Ability to obtain health care: recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey

Improving Access to Eye Care: A Systematic Review of the Literature

PURPOSE

The goals were to develop a working and inclusive definition of access to eye care, identify gaps in the current system that preclude access, and highlight recommendations that have been identified in prior studies. This manuscript serves as a narrative summary of the literature.

CLINICAL RELEVANCE

Health care disparities continue to plague the nation's well-being, and eye care is no exception. Inequities in eye care negatively affect disease processes (i.e., glaucoma, cataracts, diabetic retinopathy), interventions (surgical treatment, prescription of glasses, referrals), and populations (gender, race and ethnicity, geography, age).

METHODS

A systematic review of the existing literature included all study designs, editorials, and opinion pieces and initially yielded nearly 2500 reports. To be included in full-text review, an article had to be US-based, be written in English, and address 1 or more of the key terms "barriers and facilitators to health care," "access," and "disparities in general and sub-specialty eye care." Both patient and health care professional perspectives were included. One hundred ninety-six reports met the inclusion criteria.

RESULTS

Four key themes regarding access to eye care from both patient and eye care professional perspectives emerged in the literature: (1) barriers and facilitators to access, (2) utilization, (3) compliance and adherence, and (4) recommendations to improve access. Common barriers and facilitators included many factors identified as social determinants of health (i.e., transportation, insurance, language, education). Utilization of eye care was largely attributable to having coverage for eye care, recommendations from primary care professionals, and improved health status. Geographic proximity, age, and lack of transportation surfaced as factors for compliance and adherence. There were a variety of recommendations to improve access to eye care, including improving presence in community health clinics, reimbursement for physicians, and funding of community-based programs such as DRIVE and REACH.

CONCLUSIONS

The eye care profession has abundant evidence of the disparities that continue to affect marginalized communities. Improving community-based programs and clinics, addressing social determinants of health, and acknowledging the effects of discrimination and bias on eye care serve as ways to improve equity in this field.

Cancer diagnoses and survival rise as 65-year-olds become Medicare-eligible

BACKGROUND

A Medicare effect has been described to account for increased health care utilization occurring at the age of 65 years. The existence of such an effect in cancer care, where it would be most likely to reduce mortality, has been unclear.

METHODS

Patients aged 61 to 69 years who were diagnosed with lung, breast, colon, or prostate cancer from 2004 to 2016 were identified with the Surveillance, Epidemiology, and End Results database and were dichotomized on the basis of eligibility for Medicare (61-64 vs 65-69 years). With age-over-age (AoA) percent change calculations, trends in cancer diagnoses and staging were characterized. After matching, uninsured patients who were 61 to 64 years old (pre-Medicare group) were compared with insured patients who were 65 to 69 years old (post-Medicare group) with respect to cancer-specific mortality.

RESULTS

In all, 134,991 patients were identified with lung cancer, 175,558 were identified with breast cancer, 62,721 were identified with colon cancer, and 238,823 were identified with prostate cancer. The AoA growth in the number of cancer diagnoses was highest at the age of 65 years in comparison with all other ages within the decade for all 4 cancers (P < .01, P < .001, P < .01, and P < .001, respectively). In a comparison of diagnoses at the age of 65 years with those in the 61- to 64-year-old cohort, the greatest difference for all 4 cancers was seen in stage I. In matched analyses, the 5-year cancer-specific mortality was worse for lung (86.3% vs 78.5%; P < .001), breast (32.7% vs 11.0%; P < .001), colon (57.1% vs 35.6%; P < .001), and prostate cancer (16.9% vs 4.8%; P < .001) in the uninsured pre-Medicare group than the insured post-Medicare group.

CONCLUSIONS

The age threshold of 65 years for Medicare eligibility is associated with more cancer diagnoses (particularly stage I), and this results in lower long-term cancer-specific mortality for all cancers studied.

LAY SUMMARY

Contributing to the current debate regarding Medicare for all, this study shows that the expansion of Medicare would improve cancer outcomes for the near elderly.

Delivering UN Sustainable Development Goals’ Impact on Infrastructure Projects: An Empirical Study of Senior Executives in the UK Construction Sector

Achievement of the United Nations’ 2030 Sustainable Development Goals (SDG) is of paramount importance for both business and society. Across the construction sector, despite evidence that suggests 88% of those surveyed want to measure the SDG impact at both the business and project levels, there continues to be major challenge in achieving this objective. This paper shares the results of a qualitative research study of 40 interviews with executives from the United Kingdom (UK) construction industry. It was supported by a text-based content analysis to strengthen the findings. The results indicate that SDG measurement practices are embraced in principle but are problematic in practice and that rarely does action match rhetoric. While the research was completed in the UK, the findings have broader applicability to other countries since most construction firms have extensive global business footprints. Researchers can use the findings to extend the current understanding of measuring outcomes and impact at project level, and, for practitioners, the study provides insights into the contextual preconditions necessary to achieve the intended outcomes of adopting a mechanism for the measurement of SDGs. The international relevance of this research is inherently linked to the global nature of the SDGs and therefore the results could be used outside of UK.

Family income and insufficient medical care: A prospective study of alternative explanations

Aims: Equity of access to medical care is a central objective in socialised and national health insurance systems. Based on a national panel survey of Icelandic adults, the study examined the effects of family income on insufficient medical care and whether income-related differences were explained by overall financial strain, health-care cost burden, cultural variables or barriers related to health-system obstacles or experiences. Methods: The study used two-wave panel data from national postal health surveys of Icelandic adults aged 18-75. Insufficient medical care was assessed in terms of both reported delay/cancellation of physician care and estimated underutilisation when comparing actual and professionally recommended physician visits. Results: The study found that individuals with lower family incomes were more likely to delay or cancel a needed physician visit and underutilise medical care compared to their higher-income counterparts. High relative out-of-pocket costs, overall financial strain and negative experiences of medical care fully accounted for the disadvantaged medical access of lower-income individuals. The most important explanatory variable was out-of-pocket costs, as it affected insufficient medical care both directly and indirectly by compounding economic difficulties in the family. Attitudes, beliefs and health-related behaviours had limited effects on insufficient medical care and did not account for income-related differences. Conclusions: Poorer access to needed medical care among lower-income individuals was explained by high relative out-of-pocket costs, overall financial strain and negative medical-care experiences. Efforts to reduce income differences in access to needed medical care should address these factors.

The impact of National Health Insurance upon accessibility of health services and financial protection from catastrophic health expenditure: a case study of Savannakhet province, the Lao People's Democratic Republic

INTRODUCTION

Many schemes have been implemented by the government of the Lao People's Democratic Republic to provide equity in health service utilisation. Initially, health service utilisations were fully supported by the government and were subsequently followed by the Revolving Drug Fund. In the 2000s, four health financing schemes, namely the Social Security Organization, the State Authority for Social Security, the Health Equity Fund and Community-Based Health Insurance (CBHI), were introduced with various target groups. However, as these voluntary schemes have suffered from a very low enrolment rate, the government decided to pilot the National Health Insurance (NHI) scheme, which offers a flat, co-payment system for health service utilisation. This study aims to assess the effectiveness of the NHI in terms of its accessibility and in providing financial protection from catastrophic health expenditure.

METHODS

The data collection process was implemented in hospitals of two districts of Savannakhet province. A structured questionnaire was used to retrieve all required information from 342 households; the information comprised of the socioeconomics of the household, accessibility to health services and financial payment for both outpatient and inpatient department services. Binary logistic regression models were used to discover the impact of NHI in terms of accessibility and financial protection. The impact of NHI was then compared with the outcomes of the preceding, voluntary CBHI scheme, which had been the subject of earlier studies.

RESULTS

Under the NHI, it was found that married respondents, large households and the level of income significantly increased the probability of accessibility to health service utilisation. Most importantly, NHI significantly improved accessibility for the poorest income quantile. In terms of financial protection, households with an existing chronic condition had a significantly higher chance of suffering financial catastrophe when compared to households with healthy members. As probability of catastrophic expenditure was not affected by income level, it was indicated that NHI is able to provide equity in financial protection.

CONCLUSION

The models found that the NHI significantly enhances accessibility for poor income households, improving health service distribution and accessibility for the various income levels when compared to the CBHI coverage. Additionally, it was also found that NHI had enhanced financial protection since its introduction. However, the NHI policy requires a dramatically high level of government subsidy; therefore, there its long-term sustainability remains to be determined.

Oral Health Practices, Beliefs and Dental Service Utilization of Albanian Immigrants in Milwaukee, Wisconsin: A Pilot Study

There is limited information on the oral health of Albanian immigrant population residing in the U.S. This creates a hinderance to developing and implementing appropriate dental care programs for the population. This study investigated oral health practices, beliefs, dental visits and associated factors of Albanian adults living in Milwaukee, Wisconsin. Purposive and snowball sampling methods were employed. Self-administered questionnaires were used to collect data on oral health practices, beliefs, dental visits and socio-demographic information. Descriptive and multivariable logistics regression were conducted. Overall, 266 adults were recruited, 54% male, 56% have lived 10 or more years in the U.S., 95% rated their oral health as excellent/good and 87% reported having a dental visit in the last year. Age, ability to speak English, having a usual source of dental care, and reporting excellent/good oral health were associated with having a dental visit in the last year. A substantial number of Albanians adult reported a dental visit in the last year and those that did not write or read in English had lower odds of reporting a dental visit.

Public Housing Relocations and Relationships of Changes in Neighborhood Disadvantage and Transportation Access to Unmet Need for Medical Care

INTRODUCTION

Cross-sectional research suggests that neighborhood characteristics and transportation access shape unmet need for medical care. This longitudinal analysis explores relationships of changes in neighborhood socioeconomic disadvantage and trans- portation access to unmet need for medical care.

METHODS

We analyzed seven waves of data from African American adults (N = 172) relocating from severely distressed public housing complexes in Atlanta, Georgia. Surveys yielded individual-level data and admin- istrative data characterized census tracts. We used hierarchical generalized linear models to explore relationships.

RESULTS

Unmet need declined from 25% pre-relocation to 12% at Wave 7. Post-relocation reductions in neighborhood disadvantage were inversely associated with reductions in unmet need over time (OR = 0.71, 95% CI = 0.51-0.99). More frequent transportation barriers predicted unmet need (OR = 1.16, 95% CI = 1.02-1.31).

CONCLUSION

These longitudinal findings support the importance of neighborhood environments and transportation access in shaping unmet need and suggest that improvements in these exposures reduce unmet need for medical care in this vulnerable population.

Developing a research agenda for understanding the stigma of addictions Part I: Lessons from the Mental Health Stigma Literature

BACKGROUND AND OBJECTIVES

Although advocates and providers identify stigma as a major factor in confounding the recovery of people with SUDs, research on addiction stigma is lacking, especially when compared to the substantive literature examining the stigma of mental illness.

METHODS

A review of key studies from the stigma literature that yielded empirically supported concepts and methods from the mental health arena was contrasted with the much smaller and mostly descriptive findings from the addiction field.

RESULTS

Integration of this information led to Part I of this two part paper, development of a research paradigm seeking to understand phenomena of addiction stigma (eg, stereotypes, prejudice, and discrimination) and its different types (public, self, and label avoidance).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

In Part II paper (American Journal of Addictions, Vol 26, pages 67-74, this issue), we address how this literature informs a research program meant to develop and evaluate and stigma strategies (eg, education, contact, and protest). Both papers end with recommendations for next steps to jumpstart the addiction stigma portfolio. Here in Part I, we offer one possible list of key research issues for studies attempting to describe or explain addiction stigma. (Am J Addict 2017;26:59-66).

Advocacy Issues and Strategies for the 21st Century

The authors conducted key informant interviews with 16 disability advocacy and research leaders; half of the interviews were with leaders in shaping national disability policy during and after passage of the Americans with Disabilities Act of 1990, and half were with state and local leaders representing constituencies who had not had a visible presence at the national level. During audiotaped telephone interviews, we asked the informants to identify the top 5 advocacy priorities for the next 10 years, as well as what strategies they thought could advance the disability advocacy agenda. Two overarching themes emerged: the impact of poverty among people with disabilities and the connections among various advocacy issues. The authors discuss the 5 issues most often cited by the participants, as well as issues particular to various constituencies, and draw conclusions about what strategies would advance the disability agenda.

Trends in Care for Uninsured Adults and Disparities in Care by Insurance Status

The uninsured fare worse than the insured on various measures, yet there is little evidence regarding trends in care for the uninsured and disparities by insurance status. Given changes in the health care system and the safety net, disparities between insured and uninsured populations may be changing over time. This article considers trends in access, chronic disease control, and heart attack care by insurance status and the disparity in these measures between uninsured and insured nonelderly adults, controlling for demographic characteristics to account for potential changes in the composition of these populations. Rates for the uninsured for all outcomes have generally been stable from the mid-1990s to mid-2000s, with fluctuation in some measures over shorter periods. In addition, there is a persistent disparity between the privately insured and uninsured on access measures. The gap between the uninsured and insured has not narrowed, though disparities generally have not worsened either.

The effect of neighborhood disadvantage on the racial disparity in ovarian cancer-specific survival in a large hospital-based study in cook county, illinois

This paper examines the effect of neighborhood disadvantage on racial disparities in ovarian cancer-specific survival. Despite treatment advances for ovarian cancer, survival remains shorter for African-American compared to White women. Neighborhood disadvantage is implicated in racial disparities across a variety of health outcomes and may contribute to racial disparities in ovarian cancer-specific survival. Data were obtained from 581 women (100 African-American and 481 White) diagnosed with epithelial ovarian cancer between June 1, 1994, and December 31, 1998 in Cook County, IL, USA, which includes the city of Chicago. Neighborhood disadvantage score at the time of diagnosis was calculated for each woman based on Browning and Cagney’s index of concentrated disadvantage. Cox proportional hazard models measured the association of self-identified African-American race with ovarian cancer-specific survival after adjusting for age, tumor characteristics, surgical debulking, and neighborhood disadvantage. There was a statistically significant negative association (−0.645) between ovarian cancer-specific survival and neighborhood disadvantage (p = 0.008). After adjusting for age and tumor characteristics, African-American women were more likely than Whites to die of ovarian cancer (HR = 1.59, p = 0.003). After accounting for neighborhood disadvantage, this risk was attenuated (HR = 1.32, p = 0.10). These findings demonstrate that neighborhood disadvantage is associated with ovarian cancer-specific survival and may contribute to the racial disparity in survival.

Unmet need for medical care and safety net accessibility among Birmingham's homeless

Although homeless individuals often experience health problems requiring care, there are limitations to available research concerning the scale of their needs and the accessibility of safety net agencies to meet them. Traditional access-to-care surveys calculate unmet need among all persons queried (rather than persons needing care), making it difficult to calculate what percentage of persons requiring care actually obtain it. Additionally, no research has compared the relative accessibility of safety net programs to homeless persons in need. This cross-sectional, community-based survey assessed the prevalence of unmet need for several specific types of health care and compared the accessibility of agencies in Birmingham, AL. Substantial proportions of respondents reported unmet needs for general medical care (46 %), specialty care (51 %), mental health care (51 %), dental care (62 %), medications (57 %), and care of a child (23 %). The most commonly mentioned sites where care was sought included a federally funded Health Care for the Homeless (HCH) program (59 %), a religious free clinic (31 %), and a public hospital emergency department (51 %). The HCH program was most commonly cited as the location where care, once sought, could not be obtained (15 %), followed by the county hospital primary care clinics (13 %). In this survey, unmet need was common for all types of care queried, including primary care. Key components of the safety net, including a federally funded homeless health care program, had suboptimum accessibility.

What Explains Divorced Women's Poorer Health?: The Mediating Role of Health Insurance and Access to Health Care in a Rural Iowan Sample*

The economic restructuring in rural areas in recent decades has been accompanied by rising marital instability. To examine the implications of the increase in divorce for the health of rural women, we examine how marital status predicts adequacy of health insurance coverage and health care access, and whether these factors help to account for the documented association between divorce and later illness. Analyzing longitudinal data from a cohort of over 400 married and recently divorced rural Iowan women, we decompose the total effect of divorce on physical illness a decade later using structural equation modeling. Divorced women are less likely to report adequate health insurance in the years following divorce, inhibiting their access to medical care and threatening their physical health. Full-time employment acts as a buffer against insurance loss for divorced women. The growth of marital instability in rural areas has had significant ramifications for women's health; the decline of adequate health insurance coverage following divorce explains a component of the association between divorced status and poorer long-term health outcomes.

Divorce and women's risk of health insurance loss

This article bridges the literatures on the economic consequences of divorce for women with that on marital transitions and health by focusing on women's health insurance. Using a monthly calendar of marital status and health insurance coverage from 1,442 women in the Survey of Income and Program Participation, we examine how women's health insurance changes after divorce. Our estimates suggest that roughly 115,000 American women lose private health insurance annually in the months following divorce and that roughly 65,000 of these women become uninsured. The loss of insurance coverage we observe is not just a short-term disruption. Women's rates of insurance coverage remain depressed for more than two years after divorce. Insurance loss may compound the economic losses women experience after divorce and contribute to as well as compound previously documented health declines following divorce.

The effect of community uninsurance rates on access to health care

OBJECTIVE

To investigate the effect of local uninsurance rates on access to health care for the uninsured and insured and improve on recent studies by controlling for time-invariant differences across markets.

DATA SOURCES

Individual-level data from the 1996 and 2003 Community Tracking Study, and market-level data from other sources, including the Area Resource File and the Bureau of Primary Healthcare.

STUDY DESIGN

Market-level fixed effects models estimate the effect of changes in uninsurance rates within markets on access to care, measured by whether individuals report forgoing necessary care. Instrumental variables models are also estimated.

PRINCIPAL FINDINGS

Increases in the rate of uninsurance are associated with poorer access to necessary care among the uninsured. In contrast with recent evidence, increases in uninsurance had no effect on access to care among the insured. Instrumental variables results are similar, although not statistically significant.

CONCLUSIONS

Changes in rates of insurance coverage are likely to affect access to care for both previously and continuously uninsured. In contrast with earlier studies, there is no evidence of spillover effects on the insured, suggesting that such policy changes may have little effect on access for those who are already insured.

[Unmet health care needs in Brazil: an investigation about the reasons for not seeking health care]

Herein, unmet health care needs, defined by the authors as the situation when an individual feels the need but does not seek healthcare, are studied from the data of the health questionnaires of the 1998, 2003 and 2008 rounds of the National Household Sampling Survey (Pnad). From 1998 to 2008, the percentage of the population with healthcare needs during the two weeks prior to the interview did not change, remaining at around 17%, whilst the share with unmet healthcare needs fell from 3.5% to 2.9%. There were also changes in the reasons chosen by the interviewees to justify why they did not seek healthcare. The percentage of those who said they could not afford it decreased though it is still the reason given most frequently thereby boosting the percentages of those alleging problems with the healthcare system, such as long waiting times and a lack of professionals and services. People with less income or schooling, residing in the poorer regions of the country or in rural areas, blacks, males, adults, workers, people living with other people with unmet healthcare needs or that have not been to an appointment with a doctor in the last year, and those without health plans, are less likely to seek healthcare and therefore stand a higher chance of having unmet healthcare needs.

The declining number of practicing African American dentists in Cuyahoga County, Ohio, 1970 through 2010

BACKGROUND

The authors tracked the declining number of practicing African American dentists and its relationship to the migratory patterns of the black community in Cuyahoga County, Ohio, from Jan. 1, 1970, through Dec. 31, 2010.

METHODS

The authors conducted a longitudinal study in which they used the Geographic Information System (Environmental Systems Research Institute, Redlands, Calif.) to plot the location of each black-owned dental practice in Cuyahoga County in conjunction with the black population. They calculated the ages of the dentists by using birth dates posted on the Ohio State Dental Board's Web site and divided the dentists into five age groups.

RESULTS

The study results showed that dental practice distributions followed the migratory pattern of the black population from Cleveland to the surrounding suburbs. The number of black dentists in practice decreased from 1986 through 2010 in the Cleveland metropolitan area (Cuyahoga County), and 46.3 percent of the black dentists were projected to retire by 2020.

CONCLUSIONS

These results underscore the need to increase the number of black dentists in Cuyahoga County and nationwide. On the basis of the demographic data they found, the authors expect the number of black dentists to continue to decrease if no intervening circumstances occur. Practice Implications. There were 48.8 percent fewer black dentists in Cuyahoga County in 2010 than there were in 1985. If this pattern continued until 2020, there could be a critical shortage of black dentists in Cuyahoga County.

County-level poverty is equally associated with unmet health care needs in rural and urban settings

CONTEXT

Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear.

PURPOSE

Compare the association between regional poverty with self-reported unmet need, a marker of health care access, by rural/urban setting.

METHODS

Multilevel, cross-sectional analysis of a state-representative sample of 39,953 adults stratified by rural/urban status, linked at the county level to data describing contextual characteristics. Weighted random intercept models examined the independent association of regional poverty with unmet needs, controlling for a range of contextual and individual-level characteristics.

FINDINGS

The unadjusted association between regional poverty levels and unmet needs was similar in both rural (OR = 1.06 [95% CI, 1.04-1.08]) and urban (OR = 1.03 [1.02-1.05]) settings. Adjusting for other contextual characteristics increased the size of the association in both rural (OR = 1.11 [1.04-1.19]) and urban (OR = 1.11 [1.05-1.18]) settings. Further adjustment for individual characteristics had little additional effect in rural (OR = 1.10 [1.00-1.20]) or urban (OR = 1.11 [1.01-1.22]) settings.

CONCLUSIONS

To better meet the health care needs of all Americans, health care systems in areas with high regional poverty should acknowledge the relationship between poverty and unmet health care needs. Investments, or other interventions, that reduce regional poverty may be useful strategies for improving health through better access to health care.

Universal health insurance and health care access for homeless persons

OBJECTIVES

We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system.

METHODS

We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs.

RESULTS

Unmet health care needs were reported by 17% of participants. Compared with Toronto's general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey.

CONCLUSIONS

Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.

The unmet health care needs of homeless adults: a national study

OBJECTIVES

We assessed the prevalence and predictors of past-year unmet needs for 5 types of health care services in a national sample of homeless adults.

METHODS

We analyzed data from 966 adult respondents to the 2003 Health Care for the Homeless User Survey, a sample representing more than 436,000 individuals nationally. Using multivariable logistic regression, we determined the independent predictors of each type of unmet need.

RESULTS

Seventy-three percent of the respondents reported at least one unmet health need, including an inability to obtain needed medical or surgical care (32%), prescription medications (36%), mental health care (21%), eyeglasses (41%), and dental care (41%). In multivariable analyses, significant predictors of unmet needs included food insufficiency, out-of-home placement as a minor, vision impairment, and lack of health insurance. Individuals who had been employed in the past year were more likely than those who had not to be uninsured and to have unmet needs for medical care and prescription medications.

CONCLUSIONS

This national sample of homeless adults reported substantial unmet needs for multiple types of health care. Expansion of health insurance may improve health care access for homeless adults, but addressing the unique challenges inherent to homelessness will also be required.

Rising inability to obtain needed health care among homeless persons in Birmingham, Alabama (1995-2005)

BACKGROUND

Homeless persons depend disproportionately on the health-care safety net for medical services. National reports identify financial strains to this safety net. Whether this has affected homeless persons is unknown.

OBJECTIVES

We quantified changes in the proportion of homeless persons reporting unmet need for health care in Birmingham, Alabama, comparing two periods, 1995 and 2005. We assessed whether a period effect was independent of characteristics of persons surveyed.

DESIGN

Analysis of two surveys conducted with identical methods among representative samples of homeless persons in 1995 (n = 161) and 2005 (n = 161).

MEASUREMENTS

Report of unmet need (inability to obtain care when needed) was the dependent variable. Two survey periods (1995 and 2005) were compared, with multivariable adjustment for sociodemographic and health characteristics. Reasons for unmet need were determined among the subset of persons reporting unmet need.

RESULTS

Unmet need for health care was more common in 2005 (54%) than in 1995 (32%) (p < 0.0001), especially for non-Blacks (64%) and females (65%). Adjusting for individual characteristics, a survey year of 2005 independently predicted unmet need (odds ratio 2.68, 95% CI 1.49-4.83). Among persons reporting unmet need (87 of 161 in 2005; 52 of 161 in 1995), financial barriers were more commonly cited in 2005 (67% of 87) than in 1995 (42% of 52) (p = 0.01).

CONCLUSION

A rise in unmet health-care needs was reported among Birmingham's homeless from 1995 to 2005. This period effect was independent of population characteristics and may implicate a local safety net inadequacy. Additional data are needed to determine if this represents a national trend.

Guideline implementation for breast healthcare in low- and middle-income countries: breast healthcare program resource allocation

Breast cancer is serious public health problem in countries of all resource levels. Although major advances in the detection and treatment of the disease have occurred in higher income settings, similar progress has been slow or scarce in most low- and middle-income countries (LMCs). The poorer outcomes in LMCs may relate to the limited capability of their healthcare systems (HCS) to provide successful early detection, diagnosis, and treatment of breast cancer. Impediments to better outcomes include insufficient numbers of appropriately trained healthcare workers, limited access to screening/treatment facilities, inadequate supplies of necessary drugs, and timeliness of treatment after diagnosis. Clearly, these HCS deficiencies are broader than the scope of the Breast Health Global Initiative (BHGI) and are not unique to the issue of breast cancer. To address issues in HCS that hinder the delivery of breast health services, the BHGI Healthcare Systems and Public Policy Panel explored the HCS structures and function needed to operate a breast care program (BCP). Like with all BHGI guidelines, those proposed by this panel were expressed in terms of 4 strata of resource levels: basic, limited, enhanced, and maximal. The current report describes the issues and questions related to HCS that are important to consider when designing, implementing, and measuring the performance of a BCP. Health ministers, other policymakers, healthcare personnel, administrators, and anyone else involved in developing a BCP can use and adapt this framework to improve outcomes and ensure the more effective use of resources.

Dental utilization for Medicaid-enrolled adults with developmental disabilities in Iowa residential care facilities

The goal of this study was to evaluate the dental utilization of Medicaid-enrolled adults in Iowa residential care facilities (n=1423). Medicaid enrollment and claims files for 2003 were used, as well as information from the Iowa Department of Inspections and Appeals. Dental utilization was defined as having any dental visit during 2003. Of the residents, 74.1% utilized at least one dental service in 2003. Residents in facilities that were part of smaller organizations, and younger residents, were more likely to have had a dental visit. Of those with a visit, over 80% received a preventive service but this declined with age. Despite additional barriers, dental utilization was generally good for Medicaid-enrolled residents of residential care facilities in Iowa. Residents in smaller facilities of smaller organizations received more personalized care. Older residents were less likely to have a parent involved, were more likely to be edentulous, and sought care less frequently.

Uninsured vs. Insured Population

This study identified the underlying demographic and socioeconomic factors associated with insurance status among nonelderly Americans (age 19-64), as well as compared health care utilization between insured and uninsured. Data from the Community Tracking Study 1996-1997 Household Survey were analyzed. Approximately 74 percent of uninsured Americans are nonelderly Americans. Among the nonelderly Americans, about 17 percent are uninsured. Our findings show that insurance status varies significantly by region, age, race, gender, marital status, income, education, employment status, and health status. Also, the insured nonelderly Americans were found to have better access to health care than the uninsured nonelderly.

National health surveys and the behavioral model of health services use

National health surveys have played an important role in the development of health services research. They have contributed to the advancement of concepts, methods, and the policy relevance of the field. One product of these surveys was the Behavioral Model of Health Services Use. This article documents a 75-year legacy by reviewing the series of national studies that have given to the form and function of health services research. It further examines the Behavioral Model through 40 years of considerable application and alteration.

Psychotherapy in the Veterans Health Administration: Missed Opportunities?

Informed by data on the dose-response effect, the authors assessed use of psychotherapy in the Veterans Health Administration (VA). The authors identified 410,923 patients with newly diagnosed depression, anxiety, or posttraumatic stress disorder using VA databases (October 2003 through September 2004). Psychotherapy encounters were identified by Current Procedural Terminology codes for the 12 months following patients' initial diagnosis. Psychotherapy was examined for session exposure received within the 12-month follow-up period and time (in days) between diagnosis and treatment. Of the cohort, 22% received at least one session of psychotherapy; 7.9% received four or more sessions; 4.2% received eight or more sessions; and 2.4% received 13 or more sessions. Delays between initial mental health diagnosis and initiation of care averaged 57 days. Patient variables including age, marital status, income, travel distance, psychiatric diagnosis, and medical-illness burden were significantly related to receipt of psychotherapy. Treatment delays and general underuse of psychotherapy services are potential missed opportunities for higher-quality psychotherapeutic care in integrated health care settings.

Analyzing Location-Based Accessibility to Dental Services: An Ohio Case Study

Oral health is important to overall health. Therefore, dental services should be available and accessible in order for patients to receive care.

OBJECTIVE

This study aims to identify regional inequities in dental provider location and suggest an innovative methodology that could be useful in establishing new dental facilities that are geographically accessible.

METHODS

Using a census of dentist locations for the state of Ohio in 1998, geographical accessibility to dental care was analyzed. A geographic information systems (GIS)-based model to evaluate the regional distribution of dentists was developed. In this article, it is applied to estimate the number of new dental facilities needed based on the geographical proximity or distance to nearest dentist or dental facility. Results are interactively displayed and mapped with GIS for visualization.

RESULTS

Four hundred thirteen of 1,008 zip codes in Ohio did not have dentists. Using a service standard of S = 5 (all zip codes without dentists must be within 5 miles of a zip code with a dentist), 307 zip codes were not served by dentists. With a standard of S = 10, only 45 zip codes in Ohio were not served by dentists, with only 24 additional offices needed to be located to allow accessibility to a dentist within 10 miles.

CONCLUSIONS

Using GIS and geographical techniques to reveal and solve the potential locational inequities in accessibility to dental care, this work links oral health policy with geographical techniques.

Disparity in prenatal care among women of colour in the USA

OBJECTIVE

To describe the disparity in prenatal care among women of colour in timing of initiation of prenatal care and total number of prenatal visits.

DESIGN

A retrospective, descriptive design.

SETTING

A large, urban university midwifery faculty practice.

PARTICIPANTS

439 healthy women at term (37-42 weeks gestation) with a vertex singleton pregnancy, and an essentially uncomplicated prenatal course. One clinic, the university facility, provided full-scope services. The other four community clinics, all outside the university in the larger metropolitan area, were designed to provide care to low-, under-, and uninsured pregnant women.

MEASUREMENTS

Timing of initiation of prenatal care and total number of prenatal visits were examined in relation to demographic variables, including race, education, age, marital status, method of payment and clinic sites.

FINDINGS

Significant differences in initiation of prenatal care and total number of prenatal visits were documented. The non-Hispanic white women at the university hospital clinic, with high school or college degrees and insurance or Medicaid, were more likely to visit prenatal clinics. Examination of association between timing of initiation of prenatal care and demographic variables showed significant differences in race and education.

KEY CONCLUSIONS

This study reflects the difficulty in access to care faced by women of colour. When comparing 1997 national survey findings with those of a 2001 study, about 40% of the 50 States and the District of Columbia showed an increase in the frequency of women receiving late care or no care; additionally, a disparity in access to prenatal care between non-Hispanic white and non-white women was noted in most of these areas.

IMPLICATIONS FOR PRACTICE

The number of births to women of colour delivered by midwives has rapidly increased in recent years. Also, the numbers of babies born to women of colour is anticipated to surpass 50% in the next few decades. Considering the increased proportion of births to women of colour, special attention to promote early prenatal care for these populations is needed. Recruitment and retention efforts for non-white midwives, regular education for cultural competence of midwives, and provision of culturally and linguistically appropriate care for women of colour should be considered.

How much health insurance is enough? Revisiting the concept of underinsurance

There is little consensus on what constitutes adequate health insurance coverage. The concept of a lack of adequate coverage, or underinsurance, is a matter of ongoing debate. A measure of adequate coverage is of critical importance as the nature of health insurance products evolves. Changes to health coverage include more direct out-of-pocket spending by consumers and a reduction of covered benefits. This article updates and extends an earlier review of underinsurance measurement published in 1993. We present a conceptual approach to measuring underinsurance and provide a review of the empirical findings obtained from the application of these approaches. A discussion of the limitations in the selection of a measurement approach includes a review of the extant data sources used. We recommend a national effort to develop a consistent approach to monitor changes in the economic and structural dimensions of health insurance coverage with a concerted effort to define and measure underinsurance.

Unmet Service Needs of Persons With Traumatic Brain Injury

OBJECTIVES

Assess unmet needs of persons with traumatic brain injury (TBI) 1 year after hospital discharge; compare perceived need with needs based on deficits (unrecognized need); determine major barriers to services; evaluate association of needs with satisfaction with life.

PARTICIPANTS

Representative sample of 1830 community-dwelling persons with TBI aged 15 years and older.

MEASURES

Perceived and unrecognized unmet needs, barriers to receiving services, and satisfaction with life as a function of met service needs.

RESULTS

35.2% of participants reported at least 1 unmet need, 51.5% had unrecognized needs, 47% reported at least 1 barrier to receiving help. Receipt of services significantly increased satisfaction with life.

CONCLUSIONS

Many persons experiencing TBI report having unmet service needs 1 year after hospital discharge.

Access to health care: does neighborhood residential instability matter?

Many Americans do not have access to adequate medical care. Previous research on this problem focuses primarily on individual-level determinants of access such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed medical care, however, has not received much attention. We address this gap in the literature by investigating the association between neighborhood residential instability and access to health care. Using individual-level data from the 2000 Medical Expenditure Panel Survey and block-group level data from the 2000 decennial census, we find that individuals who live in neighborhoods with high residential turnover have worse health care access than residents of other neighborhoods. This association persists even when the prevalence of poverty, the supply of health care, and a variety of individual characteristics are held constant. We offer explanations for these findings and suggest directions for future research.

Perceived Barriers To Mental Health Service Use Among Individuals With Mental Disorders in the Canadian General Population

BACKGROUND

Eliminating barriers to care is important for improving health service use. However, the barriers to mental health care have not been well investigated.

OBJECTIVES

This study was designed to provide information about the barriers to mental health service use and to identify clinical factors associated with perceived barriers among individuals with depressive-, anxiety-, and substance use-related disorders in the communities.

DESIGN

A cross-sectional analysis using data from the Canadian Community Health Survey-Mental Health and Well-being was instituted.

SUBJECTS

Participants with depressive-, anxiety-, and substance use-related disorders in the past 12 months, assessed by the World Mental Health-Composite International Diagnostic Interview, were included (n = 4094).

RESULTS

In participants with mental disorders, 19.5% reported barriers to mental health service use. The percentage of perceived barriers due to acceptability was higher than those for barriers due to accessibility and availability. Participants with comorbid mental disorders were more likely to have experienced barriers than those with one disorder in both mental health service users and in the nonusers. Role impairment was a significant factor predicting barriers to care, overall and in the service nonusers, in the groups having anxiety disorders only, having any depressive or anxiety disorders, and having any alcohol or drug dependence.

CONCLUSIONS

Clinical characteristics play an important role in perceiving barriers to mental health care. Future efforts should pay particular attention to the needs of those with chronic and severe mental health problems and focus on improving the effectiveness of mental health services.

Delayed care and unmet needs among health care system users: when does fiduciary trust in a physician matter?

OBJECTIVES

To examine whether fiduciary trust in a physician is related to unmet health care needs and delayed care among patients who have a regular physician, and to investigate whether the relationships between trust and unmet health care needs and delays in care are attenuated for disadvantaged patients who face structural obstacles to obtaining health care.

DATA SOURCES/STUDY SETTING

The 1998-1999 Community Tracking Study (CTS) Household Survey, a cross-sectional sample representative of the U.S. noninstitutionalized population. This study analyzes adults who usually see the same physician for their health care (n = 29,994).

STUDY DESIGN

We estimated logistic regression models of the association of trust with unmet health care needs and delayed care. We tested interactions between trust and barriers to obtaining care, including minority race/ethnicity, poverty, and the absence of health insurance. Control variables included patients' sociodemographic characteristics, health status, satisfaction with the available choice of primary physicians, and the number of physician visits during the last year.

PRINCIPAL FINDINGS

Patients' fiduciary trust in a physician is negatively associated with the likelihood of reporting delayed care and unmet health care needs among most patients. Among African Americans, Hispanics, the poor, and the uninsured, however, fiduciary trust is not significantly associated with the likelihood of delayed care. For unmet needs, only the uninsured have no significant association with trust.

CONCLUSIONS

Results show that trust is associated with improved chances of getting needed care across most subgroups of the population, although this relationship varies by subpopulation.

Access to healthcare services among persons with osteoarthritis and rheumatoid arthritis

OBJECTIVE

Persons with osteoarthritis and rheumatoid arthritis frequently require access to a broad range of healthcare services. The purpose of the current study was to examine the healthcare access experiences of these two populations.

DESIGN

Mail surveys were completed by 409 adults with self-reported osteoarthritis or rheumatoid arthritis who were recruited through a variety of recruitment strategies such as advertisements placed in arthritis publications, internet sources, and physician referrals.

RESULTS

Participants self-reported not obtaining needed health care at high rates for several service domains, including mental health services (42%) and rehabilitation therapies (39%). The most frequent reasons for not obtaining services included lack of service coverage by the health plan and high costs. Type of arthritis was predictive of the ability to obtain primary doctor services.

CONCLUSIONS

The United States healthcare system continues to focus on treating acute disorders and has yet to adapt to the growing prevalence of chronic illness and disability. Changes will be needed in both healthcare financing and delivery structures to promote access to specialized services such as mental health services and rehabilitation therapies for persons with osteoarthritis and rheumatoid arthritis.

Uninsurance and health care access among young adults in the United States

OBJECTIVE

Young adults who are 19 to 24 years of age are the most likely age group to be uninsured in the United States, yet little is known about how uninsurance might affect health care access among young adults. The objective of this study was to describe the association between health insurance status and health care access among young adults while controlling for other determinants of access to care.

METHODS

We conducted a cross-sectional analysis of data from 11,866 19- to 24-year-old respondents who completed the National Health Interview Survey between 1998 and 2001. We present percentages and adjusted relative risk of young adults who in the previous year delayed or missed medical care because of cost, did not fill a prescription because of cost, had not spoken to a health professional, or identified no usual source of health care.

RESULTS

Among the young adults studied, 27% of women and 33% of men were uninsured. After potential confounders were adjusted for, the uninsured remained at significantly higher risk for reporting delayed or missed medical care (women: adjusted relative risk [95% confidence interval]: 3.24 [2.72-3.82]; men: 4.31 [3.44-5.34]), not filling a prescription because of cost (women: 3.27 [2.55-4.16]; men: 4.05 [2.78-5.81]), having no contact with a health professional (women: 2.54 [2.01-3.09]; men: 1.60 [1.43-1.77]), and having no usual source of health care (women: 3.45 [3.05-3.90]; men: 2.27 [2.06-2.48]) relative to privately insured peers. Women with Medicaid did not differ significantly from privately insured women in these measures.

CONCLUSIONS

Uninsured young adults were significantly more likely than privately insured peers to report barriers to obtaining needed care, having no contact with a health professional, and identifying no usual source of health care. Given the high rates of uninsurance among young adults, additional study is needed to examine how these barriers affect the immediate and future health of the young adult.

Failure to seek needed medical care: results from a national health survey of Icelanders

The study focuses on access to outpatient medical care in Iceland--a socialized health care system. As in other systems of this sort, equal access to needed services (equity) is a fundamental principle. Despite governmental claims that access to health services is "easy" and "roughly equal", the study indicates substantial and rather extensive variations in equity of care. More specifically, younger individuals, the non-widowed, the economically troubled, individuals with inflexible daily schedules, the chronically ill, those who had incurred high out-of-pocket costs relative to their family income, and those who didn't have a physician care discount card, were more likely than others to postpone or cancel an MD visit they thought they needed. Furthermore, younger age, economic troubles, chronic medical conditions, no family physician, and no physician care discount card, were all related to under-utilization, based on medical specialist criteria of recommended medical care for symptoms. Although the results show that access problems originate in part outside the health care system, they also suggest revision of current health policy, in order to adequately address existent inequities in service delivery.

The effect of the availability of charity care to the uninsured on the demand for private health insurance

The economic reasons why some people do not obtain health insurance are unclear. In this paper, I test the hypothesis that the availability of charity care to the uninsured reduces the likelihood of obtaining private coverage. I utilize variation in the availability of charity care across the different markets in the Community Tracking Study's Household Survey (CTS-HS) using an "access to care" measure of the uninsured's cost-related difficulties in obtaining medical care, to both aggregate across the various "safety net" providers and control for its potentially endogenous supply. I find evidence supporting this hypothesis for low-income people, in both the individual market and the employment-based group market. I also estimate a joint model of offer and take-up decisions for the group market sample and find that the availability of charity care reduces low-income workers' offer rates but not their take-up rates.

Neighborhood socioeconomic disadvantage and access to health care

Most research on access to health care focuses on individual-level determinants such as income and insurance coverage. The role of community-level factors in helping or hindering individuals in obtaining needed care, however, has not received much attention. We address this gap in the literature by examining how neighborhood socioeconomic disadvantage is associated with access to health care. We find that living in disadvantaged neighborhoods reduces the likelihood of having a usual source of care and of obtaining recommended preventive services, while it increases the likelihood of having unmet medical need. These associations are not explained by the supply of health care providers. Furthermore, though controlling for individual-level characteristics reduces the association between neighborhood disadvantage and access to health care, a significant association remains. This suggests that when individuals who are disadvantaged are concentrated into specific areas, disadvantage becomes an "emergent characteristic " of those areas that predicts the ability of residents to obtain health care.

Health care resource allocation and individuals' health care needs: examining the degree of fit

Previous studies examine associations between health system resources and an individual's use of health services, yet the importance of these resources in meeting an individual's health care needs is unclear. This paper examines the relationship between health care system characteristics, other social and economic characteristics of counties in a mid-western U.S. state and an individual's ability to meet health care needs over a 12-month period. We conclude that policy interventions are needed that look beyond health resource allocation to address problems in health care access that contribute to inequities in health.

Access to health care services among people with chronic or disabling conditions: patterns and predictors

OBJECTIVE

To examine patterns of access to a variety of specific health care services among people with chronic or disabling conditions, focusing on factors that predict access to services.

DESIGN

National survey of 800 adults with cerebral palsy (CP), multiple sclerosis (MS), spinal cord injury (SCI), or arthritis.

SETTING

Respondents were surveyed in the general community.

PARTICIPANTS

National convenience sample of adults with CP, MS, SCI, or arthritis.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Access to services from primary care doctors, services from specialists, rehabilitative services, assistive equipment, and prescription medications. Cross tabulations and logistic regression analyses were performed on survey data to examine patterns and predictors of access to health care services.

RESULTS

Only half of all respondents received needed rehabilitative services. Respondents covered by fee-for-service health plans were more likely than those covered by managed care organizations to receive needed services from specialists. Respondents with the poorest health and with the lowest incomes were the least likely to receive all health services examined.

CONCLUSIONS

People with chronic or disabling conditions often require a comprehensive array of health care services. Reform of the current health care payment and delivery structures is needed so that health care is more responsive to those with the greatest service needs.

Managed care penetration, insurance status, and access to health care

BACKGROUND

Access to health care, reflected by an ability to meet one's health needs, is influenced by individual characteristics and the environment. Although managed care activity influences healthcare prices and overall utilization, its relationship to access and its broader effects across different insurance categories has not been well studied.

OBJECTIVE

To examine the association between managed care activity and individuals' access to care, and to assess differences in this relationship by insurance status.

RESEARCH DESIGN

Cross-sectional survey of households conducted in 1998.

SUBJECTS

A sample of 15,613 adult Ohio residents.

MEASURES

Self-reported difficulties in obtaining health care, medications, supplies, or medical equipment in the past year.

RESULTS

A total of 1248 (8.0%) identified an access problem. In bivariate analyses, these problems were more common among continuously and intermittently uninsured individuals compared with those who were continuously insured during the previous 12 months (P<0.001) and also among those living in areas with more managed care (P=0.01). After accounting for other individual and environmental characteristics in hierarchical analyses, individuals residing in areas with more managed care had 28% higher odds of reporting problems obtaining care than those elsewhere (multivariate odds ratio, 1.28; 95% confidence interval, 1.04-1.58]; P=0.02). No significant interaction between managed care penetration and insurance status was observed.

CONCLUSIONS

Greater managed care activity is associated with unfavorable patterns of healthcare access despite an individual's insurance status, suggesting more pervasive effects. Unintended effects should be carefully evaluated when formulating future programs that seek to address disparities in access to care.

Primary care attributes and care for depression among low-income African American women

OBJECTIVES

We examined the association between attributes of primary care providers and care for depression, from a patients' perspective, among a sample of predominantly low-income African American women.

METHODS

Computer-assisted telephone interviews were conducted among a population-based sample of 1202 women residing in Washington, DC.

RESULTS

Respondents whose primary care physicians provided more comprehensive medical services were more likely to be asked about and treated for depressive symptoms than women whose providers were less medically comprehensive. Women who rated their providers as having more respect for them also were more likely to be asked about and treated for depression.

CONCLUSIONS

More comprehensive primary care delivery and a physician-patient relationship focused on mutual respect are associated with greater rates of physician inquiry about and treatment for depression among vulnerable women.

Reform and remembrance: the place of the private sector in the future of health care policy

Although the nation failed during the past decade to enact large-scale, structural change in government health policy, it has seen health care in the private sector remodeled dramatically during the same period. In this article I argue that a new round of equally significant changes is quite possible, this time at the hands of the national government. More specifically, I argue that for a variety of reasons, both enduring and more recently born, support for the private sector and the market in health care is relatively weak: that given likely trends in costs, demographics, and inequalities, it is likely to get even weaker; and that in the potential coming crisis of the health care system. there will be a real opportunity for seizing the agenda and winning policy battles on the part of would-be reformers pushing large-scale, public sector-oriented changes that go well beyond the recent reform efforts directed at managed care and HMOs.

Use, quality, and outcomes of care for mental health: the rural perspective

This review synthesizes empirical research in rural mental health services to identify current research priorities to improve the mental health of rural Americans. Using a conceptual framework of the multiple determinants of use, quality, and outcomes, the authors address (1) how key constructs are operationalized, (2) their theoretical influence on the care process, (3) reported differences for nonmetropolitan and metropolitan individuals or within nonmetropolitan individuals, (4) salient issues rural advocates have raised, and (5) key research questions. While the authors recognize that rurality is a useful political umbrella to organize advocacy efforts, they propose that investigators no longer employ any of the multiple definitions of the term in the literature as even intrarural comparisons have not provided compelling evidence about the underlying causes of observed outcomes differences. Until these underlying causes have been identified, it is difficult to determine which components of the nonmetropolitan service system need to be improved.