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PubMed2006

The rights of the medically uninsured: an analysis of social justice and disparate health outcomes.

As technological advances in the United States continue to improve the effectiveness of medical interventions, expectations among Americans of both improved health and extended life expectancy have also increased. At the same time, many of the population continue to lack the insurance necessary to access even the most basic healthcare services (Institute of Medicine, 2004; Tunzi, 2004; Saha & Bindman, 2001). With approximately 18,000 avoidable deaths attributed annually to inadequate medical coverage and 43.6 million individuals currently without insurance benefits, the need to address the disparity in access to treatment and a means of social justice in the distribution of health care is all too clear (Crispen & Whalen, 2004). As a nation relying on market mechanisms to regulate the costs and quality of available health resources (Baldor, 2003; Saha&Bindman, 2001), the welfare of society as a whole may soon be threatened by the provision of marginal services to a select minority as increasing numbers of the uninsured continue to experience less favorable clinical outcomes and higher mortality rates (Tunzi, 2004; Litaker & Cebul, 2003; Jackson, 2001; Sox, Burstin, Edwards, O'Neil et al., 1998). The author will first examine the consequences of being among the growing number of uninsured individuals in the United States. Attention will then be given to exploring the social justice issues inherent in this critical problem and evaluating these issues through the perspective of both libertarian and feminist theory. Using these theories, innovative strategies for attaining distributive justice in the provision of health care will be offered with recommendations for utilizing these alternative approaches to develop and implement future health policy.

Health Services Accessibility↗
PubMed2002

Referral of medically uninsured emergency department patients to primary care.

OBJECTIVE: To examine the impact primary care referral has on subsequent emergency department (ED) utilization. METHODS: Uninsured ED patients who reported not having a primary care (PC) provider were referred to PC services at a community health center (CHC). The number of CHC visits completed was documented and the utilization rates of hospital-based services (i.e., ED visits, outpatient clinic visits, and admissions) were compared for patients who completed a CHC visit and those who did not before and after referral. RESULTS: Of the 655 referred patients, 22% completed at least one CHC visit. Patients who completed a visit were more likely to be older, to be female, and to have a chronic medical problem (p = 0.001). The number of visits to the CHC was significantly related to the payment method. Only 19% of those who were self-pay completed three or more CHC visits, compared with 63% of those who qualified for a sliding fee or insurance (p < 0.001). There was no significant difference in pre- or post-ED utilization between those who completed a CHC visit and those who did not. The only significant difference in utilization between the two study groups was for subsequent outpatient visits. Patients who completed a CHC visit were more likely to receive outpatient specialty care (23%) compared with patients who did not (12%) (p = 0.001). CONCLUSIONS: For uninsured patients with no regular health care provider, improving access to primary care services is not enough to reduce their visits to the ED.

Community Health Services↗
PubMed1987

National policy and the medically uninsured.

Although the marketplace discipline imposed on the health care sector appears to be restraining increases in the cost of care, this haphazard and incremental "policy" is having deleterious effects on access to care by the uninsured. To help alleviate this problem within our current price-centered system, I suggest that three options be pursued: create state pools to fund indigent care; broaden insurance coverage availability through the workplace; and create medical individual retirement accounts to pay for long-term care, which would free up more funds for indigent care. We must mold our future health care system during this era of rapid change by developing a coherent policy, with input from both the private and the government sectors, to create an efficient and high-quality system that will provide needed care to all members of society.

Adolescent↗
PubMed1990

State initiatives for the medically uninsured.

Recently, Medicaid has changed in terms of both perception and reality. After a period of decline in entitlement, that trend has been reversed through both Federal mandates and an increasing role for Medicaid in dealing with the uninsured. As States and the Federal Government seek structural solutions, further eligibility expansions may be necessary, such as public subsidies of private insurance of using Medicaid as a reinsurance mechanism. Currently, there is considerable State activity in identifying such solutions. These activities have given us some ideas about what is necessary to expand coverage to more of the population. Continued demonstrations and better definitions of the respective roles of the private and public sectors are needed.

Insurance Pools↗
PubMedDate not supplied

Meeting the health care needs of medically underserved, uninsured, & underinsured Appalachians.

There is the need for critical changes in the United States health care system to meet the rising costs of health care and the massive number of people without health insurance. The Berea Health Ministry Rural Health Clinic (BHMRHC) is a nurse-managed, rural primary health care clinic that was designed to respond to the health care needs of the underserved, uninsured, and underinsured populations in a designated nine county area of Appalachian Kentucky. The process used in the development and implementation of BHMRHC is described as a model to assist in the future development of similar clinics.

Appalachian Region↗
PubMed1998

Commun-I-Care: experience in the first four years.

The medically uninsured ("working poor") comprise roughly 10 percent of the citizens in South Carolina. These individuals are more likely than the insured to have chronic health conditions including hypertension, diabetes, and respiratory diseases. They appear to have poorer outcomes as as result of misallocation of health care resources from prevention to acute intervention. CIC is a novel program which represents an effort to coordinate the efficient utilization of existing resources to meet the non-emergent health care needs of the medically uninsured. The CIC program has enjoyed a successful beginning and, with the continued strong support of providers and sponsors, looks forward to exciting progress in the future.

Adolescent↗
PubMed2006

Community-level uninsurance and the unmet medical needs of insured and uninsured adults.

OBJECTIVE: To examine the relationship between community-level uninsurance rates and the self-reported unmet medical needs of insured and uninsured adults in the U.S. DATA SOURCES: 2000-2001 Community Tracking Study, which includes data from 60 randomly selected U.S. communities. The sample is representative of the contiguous U.S. states. STUDY DESIGN: Multilevel logistic regressions were employed to investigate whether the local uninsurance rate was related to having reported unmet medical needs within the last year. The models also included individual and community variables that could be potentially related to both community uninsurance rates and having reported unmet medical needs. PRINCIPAL FINDINGS: The community uninsurance rate was positively associated with having reported unmet medical needs, but only for insured adults. On average, a five percentage point increment in the local uninsured population is associated with a 10.5 percent increase in the likelihood that an insured adult will report having unmet medical needs during the 12-month period studied. CONCLUSION: Local health care delivery systems seem to be negatively affected by high uninsurance rates. These effects could have negative consequences for health care access, even for individuals who are themselves insured.

Adult↗
PubMed1999

Understanding health behavior and speaking out on the uninsured: two leadership opportunities.

The author reviews the growth of managed care and its transforming effect on academic medical centers. He then maintains that in this time of fundamental changes and stress, academic medical centers should not only attend to the organization and financing of the clinical enterprise and the enhancement of biomedical research capacity, but also ask how academic medicine can live up to the unique opportunities and responsibilities it has been entrusted with to improve the health of the public, particularly in two neglected areas. First, if the nation does not expand the research agenda to include social and behavioral factors involved in preventable causes of morbidity and mortality, it will fail to maximize the dividends from the generous public investment in research and fail to learn how to promote healthy personal behavior. Academic medicine can promote such behavior by increasing the science base of prevention and translating into action what is already known, including how to market that knowledge so the public will respond. Second, the number of the medically uninsured is increasing; the largest percentage are the working poor. It is becoming more difficult for teaching hospitals to continue providing a third of the nation's uncompensated care. The author shares a variety of statistics about the uninsured and their care, and maintains that academic medicine, which has been entrusted with the health of the public, can declare that the high number of the uninsured is not acceptable and is a dangerous side effect of the U.S. health care system that must be treated. Doing so will also set an example to medical students and trainees that medicine's responsibility is to all Americans.

Academic Medical Centers↗
PubMedDate not supplied

Training physicians to care for the underserved: preventive medicine residency-community health center linkages.

The population of uninsured and underinsured individuals in the United States continues to grow, compounding problems of adequate access to medical care. Some of the medical needs of this population are met by community health centers (CHCs). However, CHCs often have difficulty recruiting and retaining physicians, especially those with skills in community medicine. This article describes a general preventive medicine residency program that has been successful in preparing physicians for practice in these settings-what we call training in community-oriented preventive medicine (COPM). At the heart of COPM training are mutually beneficial relationships between CHCs and the residency program. This process has been greatly facilitated through the use of Health Resources and Services Administration (HRSA) federal training grant support to "match" funds provided by CHCs. As of July 1994, 11 residents have entered the COPM track, with eight graduates and three current residents. Thus far, all graduates have remained involved in community-based medical care and preventive medicine activities for medically underserved populations. This training arrangement can serve as a model for other preventive medicine residency programs and for CHCs interested in enhancing physician recruitment and retention. Medical Subject Headings (MeSH): community-oriented preventive medicine, medically uninsured, preventive medicine residency training, community health centers.

Clinical Competence↗
PubMed1992

Private insurance reform in the 1990s: can it solve the health care crisis?

A number of health insurance reform proposals have surfaced at the state governmental level in the United States. These include Medicaid expansion for the below-poverty or near-poverty uninsured, state subsidy to individuals and/or businesses for the purchases of health insurance, risk pools for the medically uninsurable, insurance industry-initiated reforms within the small group market, the promotion of "stripped down" insurance plans that reduce premium cost, and state mandating of employer-sponsored health insurance for the employed uninsured. All of these insurance reform proposals have serious limitations: (1) they fail to address the inequities of the underwriting principle by which older and sicker people pay more for health insurance than the young and healthy population; (2) they extend the illogical linkage of employment and health insurance; and (3) they do not slow the rate of health cost inflation nor do they contain a mechanism to finance broader health coverage through savings within the health sector. An alternative to insurance reform is the establishment of a social insurance program that brings the entire population into a single risk pool.

Adult↗
PubMed2000

Uninsured status and out-of-pocket costs at midlife.

OBJECTIVE: To investigate how baseline health insurance coverage affects subsequent out-of-pocket costs and utilization of health services over a two-year period. DATA SOURCE: The first two waves of the Health and Retirement Study, a nationally representative survey of the noninstitutionalized population, ages 51 to 61 at baseline. Interviews were conducted in 1992 and 1994. Our sample consisted of 7,018 respondents who did not report public insurance as their sole source of coverage at baseline. STUDY DESIGN: We compared self-reports of physician visits, hospitalizations, and out-of-pocket health care costs, measured as payments to physicians, hospitals, and nursing homes, by type of insurance coverage at the beginning of the period. We estimated multivariate models of costs and service use to control for individual health, demographic, and economic characteristics and employed instrumental variable techniques to account for the endogeneity of insurance coverage. PRINCIPAL FINDINGS: Controlling for personal characteristics and accounting for the endogeneity of insurance coverage, persons at midlife with job-related health benefits went on to spend only about $50 per year less in out-of-pocket payments for health services than persons who lacked health insurance at the beginning of the period. However, they spent about $650 more per year in insurance premiums than the uninsured. The uninsured used relatively few health services, except when they were seriously ill, in which case they were likely to acquire public insurance. CONCLUSIONS: The medically uninsured appear to avoid substantial out-of-pocket health care costs by using relatively few health services when they are not seriously ill, and then relying upon health care safety nets when they experience medical problems. These results suggest that the main impact of non-insurance at midlife is not to place the locus of responsibility for costly health care upon individuals. Instead, it discourages routine care and transfers the costs of care for severe health events to other payers. Our findings on the high cost of employment-based coverage are consistent with evidence that the proportion of workers accepting health benefits from employers has been declining in recent years.

Age Factors↗
PubMedDate not supplied

A community-based collaboration to assess and improve medical insurance status and access to health care of Latino children.

OBJECTIVES: Despite eligibility for subsidized insurance, low-income Latino children are at high risk of being medically uninsured. The authors sought to understand and improve access to medical insurance for Latino children living in a California community of predominantly low-income immigrant families. METHODS: During the summer of 1999, trained women from the community conducted interviews in Spanish with 252 randomly selected mothers of 464 children younger than age 19. Mothers provided information about family demographics, children's medical insurance, health care access, and experiences obtaining and maintaining children's insurance. RESULTS: Most children (83.3%) were eligible for subsidized medical insurance (48.4% Medi-Cal eligible; 35.0% Healthy Families eligible). Twenty-eight percent of eligible children were not enrolled. Non-enrolled eligible children were older (median age 7) than enrolled children (median age 4) and more likely to be born outside the U.S. (22.2%) than enrolled children (4.8%). Among children ages 3-18, those not enrolled were less likely to have visited a doctor in the past 12 months (58% compared to 78.7%) and less likely to have a usual source of care (96.3% compared to 99.5%). Mothers of non-enrolled children were more likely than mothers of enrolled children to have less than seven years of education (47.8% compared to 36.4%). Families with non-enrolled children were more likely to report out-of-pocket medical expenses (84.1% compared to 53%). Families with non-enrolled children were more likely to report barriers to the enrollment process, such as problems providing required documents (39.7% compared to 15.1%), problems understanding Spanish forms (19.4% compared to 8.9%), and confusing paperwork (39.7% compared to 24.7%). Most mothers (75.9%) reported that community organizations provided very useful help with children's insurance enrollment. Almost half (48.6%) preferred to receive enrollment assistance from community organizations. Only 43.3% of mothers had heard of the Healthy Families program. CONCLUSIONS: To reach the majority of uninsured Latino children, community-based outreach and insurance application assistance are crucial. Most important, the process of applying for and maintaining coverage in Medi-Cal or Healthy Families must be simplified.

Adolescent↗
PubMed1996

Seat belt use, insurance status, and hospital bad debt.

OBJECTIVES: Previous studies have shown that not wearing a seat belt is associated with both increased injury severity and higher hospital charges. In this article, we examine whether unrestrained motorists are also more likely (a) to be medically uninsured, and (b) to leave their hospital bills unpaid. METHODS: We reviewed the hospital clinical and billing records for all occupants in motor vehicle collisions admitted to the Massachusetts General Hospital Emergency Department during a 2-month period (n = 265). Using data on seat belt use, insurance status, bad debt, admission to the hospital, driver or passenger status, age and sex, we performed simple correlation and multiple regression analyses to determine the association between (a) seat belt use and insurance status and (b) seat belt use and hospital bad debt. RESULTS: Unrestrained patients were more likely both to be uninsured and, holding insurance status and other factors constant, to generate bad debt for the hospital. CONCLUSIONS: Our findings are similar to previous studies that show that the public pays a significant share of the medical care charges associated with risk-taking behavior. Propitious selection, an economic theory, may explain such findings. It asserts that risk-taking individuals are least likely to buy insurance voluntarily and will also be the ones most likely to deliberately place themselves in dangerous situations. Our findings show that people who do not use seat belts are more likely to have outstanding hospital bills; the public effectively pays for these bills in higher taxes or insurance premiums.

Accidents, Traffic↗
PubMed1998

The Oregon Health Plan: development and implementation of an innovative method of delivery of health care services to the medically indigent.

BACKGROUND: Health care for the medically indigent under the federal Medicaid system often provides care for only a fraction (ranging from 20% to 80%) of the poor who nominally qualify for care. Oregon has developed a unique system that replaces such a system with one that provides a comprehensive complement of medical care for all the poor but limits the care to conditions and procedures on a prioritized list. METHODS: The Health Services Commission, a group of physicians, nurses, and public representatives, developed a list of over 740 diagnoses-treatment pairs and, with considerable public input, prioritized them in order of importance. The principal values used to develop the list were the prevention of death and the cost of the disease and its treatment. In the final ordering of the diagnosis-treatment pairs, public health and prevention of morbidity was also considered. Cancer diagnoses, and indeed all diseases, were not singled out for special consideration in this process. The Oregon Health Plan was implemented in 1994 with funds to cover 606 of 743 listed diagnoses. Diagnoses involving cancer were nearly all covered within these 606 items. The principal exception was coverage for Curative Treatment for Cancer when the likelihood for success was less than 5%. RESULTS: The prioritized list has met its goal of comprehensive medical care for the indigent population. The number of medically uninsured Oregonians has fallen significantly, and there have been few complaints about the Plan. Cancer care has been delivered to Oregon Health Plan clients with very few complaints or appeals of decisions concerning coverage. Palliative care is provided under a number of covered lines, as are curative medical and surgical treatment. CONCLUSIONS: The Oregon Health Plan represents an alternative method for delivering medical care, including the full range of cancer care, to the indigent. As there are limited funds in all state systems, the citizens of Oregon have decided to provide care using a prioritized list to allow provision of medical care to the entire Medicaid population. Such a plan represents a viable alternative to the more common method of providing everything but only to a limited number of poor citizens.

Cancer Care Facilities↗
PubMed1987

Getting care: poor children and New York City hospitals.

In 1984, almost 10 million visits were made to New York City hospital emergency rooms and outpatient departments. Of these, nearly one-quarter were made by children. Almost nine out of ten children using hospital emergency rooms and outpatient departments were either poor or uninsured. Nearly 70 percent of emergency room visits by Medicaid-covered children in 1984 were made to voluntary hospitals, as compared with less than 40 percent of uninsured visits. Medicaid patients -- poor but uninsured -- are less likely than uninsured patients to visit the emergency room for non-urgent care. For example, in 1984, 35 percent of uninsured medical and surgical after-care visits were made to the emergency room, as compared with 13 percent of Medicaid-covered visits. The availability of primary care physicians in a neighborhood reduces the rate of outpatient department use by children covered by Medicaid, but has no affect on the utilization rates of uninsured children. Access to routine health care by uninsured children is limited by the number of municipal hospital sites, both because children seek care within their home community. More details from the study of poor children and New York City hospitals follow. Data sources and statistical methods are described in an appendix to this report.

Adolescent↗
PubMed2001

Health and service utilization patterns among homeless men in transition: exploring the need for on-site, shelter-based nursing care.

Between September 1999 and May 2000, as part of a larger faculty/student teaching project, data describing the demographic, health problem and service utilization patterns of 183 newly sheltered homeless men (mean age = 42) seeking on-site nursing clinic services were collected and analyzed. Upon arrival to the transitional shelter, 46% of the study participants were medically uninsured or received state subsidized health benefits (49%). Almost all (99%) were in recovery from substance addiction. Despite numerous self-reported health problems, 44% had no primary care provider and 35% were seen only sporadically in local hospital clinics or in emergency departments. During the study period, nurse practitioner students and faculty managed most of the residents' episodic illnesses on-site, while assisting them to secure insurance coverage and medical appointments as a prelude to independent living. This was an attempt to curtail residents' previous pattern of waiting until medical problems became serious before seeking treatment. These findings mirrored those in studies of similar populations equating on-site delivery of health care to cost reduction. Unfortunately, many nurse-managed clinics, like our study site, fail to generate data supporting nurses' clinical efficiency and cost effectiveness in caring for homeless individuals. As such, nurses' work remains invisible and underappreciated. This article argues that future studies examining nurses' work and worth in caring for homeless individuals are necessary in determining future health care service planning with this vulnerable population.

Adult↗