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PubMed1998

The states and health care reform: the road traveled and lessons learned from seven that took the lead.

During the past decade, an area of major policy activity among the states has been that of health care reform. As of May 1993, seven states--Florida, Hawaii, Massachusetts, Minnesota, Oregon, Vermont, and Washington--had progressed the furthest in enacting comprehensive statutes designed to expand health insurance coverage and slow the growth of health care costs. This article reviews the activities of these states to achieve health care reform and the lessons learned from those activities. The analysis focuses specifically on identifying the common problems addressed and determining the common factors that maximized states' opportunities for success. In all, some nine lessons are identified that have relevance for other states wishing to follow a similar road to reform. Most important among these are a "window of opportunity" for policy action, having entrepreneurial leadership to push the reform agenda forward, and support from key stakeholder interests. If these conditions of opportunity, policy entrepreneurship, and stakeholder commitment are met, a state can move forward in addressing key aspects of its health care reform agenda.

Florida↗
PubMed2002

Hospice care for patients with advanced lung disease.

Hospices are organized programs of support services for patients in the advanced stages of a terminal illness and their families. Although hospices serve dying patients regardless of diagnosis, limited available evidence suggests that these programs are relatively underutilized by patients dying of nonmalignant lung diseases. One explanation may be a lower awareness of hospice eligibility criteria and services among pulmonologists than oncologists. The unpredictability of death from advanced lung disease is another likely reason. Certain limitations on federal and private insurance coverage for patients with advanced lung disease probably contribute as well. For those patients who do enroll, hospice offers expert palliation of physical, psychological, social, and spiritual distress, as well as practical support for home care needs, hospitalization for short-term control of symptoms, and inpatient respite care for relief of home caregivers. Hospice workers view dying as an active phase of life filled with the pursuit of goals that patients and family members wish to complete before or shortly after the end of life. This article reviews hospice care in the United States with particular attention to eligibility criteria and services available for patients who are dying of an advanced lung disease. Specific recommendations are offered for referring respiratory disease patients to hospice programs.

Combined Modality Therapy↗
PubMed2006

Health care access among individuals involved in same-sex relationships.

OBJECTIVES: We used data from the National Health Interview Survey to compare health care access among individuals involved in same-sex versus opposite-sex relationships. METHODS: We conducted descriptive and logistic regression analyses from pooled data on 614 individuals in same-sex relationships and 93418 individuals in opposite-sex relationships. RESULTS: Women in same-sex relationships (adjusted odds ratio [OR]=0.60; 95% confidence interval [CI]=0.39, 0.92) were significantly less likely than women in opposite-sex relationships to have health insurance coverage, to have seen a medical provider in the previous 12 months (OR=0.66; 95% CI=0.46, 0.95), and to have a usual source of health care (OR=0.50; 95% CI=0.35, 0.71); they were more likely to have unmet medical needs as a result of cost issues (OR=1.85; 95% CI=1.16, 2.96). In contrast, health care access among men in same-sex relationships was equivalent to or greater than that among men in opposite-sex relationships. CONCLUSIONS: In this study involving a nationwide probability sample, we found some important differences in access to health care between individuals in same-sex and opposite-sex relationships, particularly women.

Adolescent↗
PubMedDate not supplied

Do enrollees in 'look-alike' Medicaid and SCHIP programs really look alike? State Children's Health Insurance Program.

The State Children's Health Insurance Program (SCHIP), passed by Congress in 1997, has been implemented by states in many different forms, thus creating many natural experiments about insurance coverage for low-income children. In Georgia, SCHIP children are enrolled in a Medicaid look-alike program, PeachCare for Kids, with nearly the same administrative rules and providers as in the Medicaid program. Comparing the experiences of PeachCare and Medicaid children thus allows us to examine the impact of population differences on utilization and satisfaction. We find that Medicaid children, controlling for many demographic characteristics, report both less use of services and lower satisfaction with services used. Evidence presented here supports three possible explanations for these differences: Medicaid families are less familiar with and supportive of systems requiring use of an assigned primary care physician, the families face more nonprogram barriers to using care, and physicians have different responses to the two programs.

Attitude of Health Personnel↗
PubMed2003

Patient perceptions of professionalism in dentistry.

The purpose of this study was to examine how patients perceived the professionalism of University of Minnesota School of Dentistry students, faculty, and staff. Professionalism is defined by the authors as an image that will promote a successful relationship with the patient. Patients within comprehensive care clinics were asked to assess physical attributes and behaviors of the dental care providers using a questionnaire. The patients read statements dealing with characteristics of the dental care providers and responded as to whether they agreed, were neutral, or disagreed with the statement. The surveyed population consisted of 103 males and 97 females, 64 percent of whom lacked insurance coverage. Fifty-one percent of the patients were between the ages of forty-four and sixty-nine, but the overall age distribution was dispersed over a range of eighteen to one hundred. Our research found that all dental care providers displayed a professional appearance as well as behavior. The attire of the dental care provider affected the comfort and anxiety levels of patients, as did first impressions of both students and faculty. Most patients reported that students and faculty displayed effective time management and used appropriate language during the appointment. Finally, hairstyle, makeup, and jewelry appeared to have little effect on patients' opinions of the various dental care providers.

Adolescent↗
PubMedDate not supplied

ABMT and breast cancer: what have we learned?

The debate regarding the efficacy of and insurance coverage for ABMT for breast cancer has been raging since the widespread dissemination of ABMT in the early 1990s. Underlying the debate was the expectation that the results of randomized clinical trials would finally provide scientific data to resolve the frequently emotional controversy. Unfortunately, the results of these eagerly awaited trials failed to show a significant impact in patients with either metastatic breast cancer or those at high risk for metastatic disease. ABMT, as it is now offered, will not provide the breakthrough that was anticipated or a substantial benefit to the majority of patients. Research on ABMT may have evolved from the initial expectation that the trials would confirm a positive to more modest expectations that trials will disprove a negative. The promising results of early trials still require confirmation through randomized controlled trials, and participation in such clinical trials is vitally important.

Bone Marrow Transplantation↗
PubMed2002

The personal costs and convenience of screening mammography.

BACKGROUND: Few studies have examined the impact of women's personal costs on obtaining a screening mammogram in the United States. METHODS: All women obtaining screening mammograms at nine Connecticut mammography facilities during a 2-week study period were asked to complete a questionnaire. Facilities included urban and rural fixed sites and mobile sites. The survey included questions about insurance coverage, mammogram payment, and personal costs in terms of transportation, family care, parking, and lost work time from the women's perspective. RESULTS: The response rate was 62% (731 of 1189). Thirty-two percent of respondents incurred some type of personal cost, including lost work time, family care, and parking. Women incurring personal costs were more likely than those without personal costs to attend an urban facility (46% vs. 23%, p < 0.01) and be under the age of 50 (40% vs. 26%, p < 0.01). Overall, 61% of women listed convenience and 17% listed cost as a reason for choosing a mammography facility; 23% reported that cost might prevent them from obtaining a future mammogram. CONCLUSIONS: One third of women obtaining mammograms may be incurring personal costs. These personal costs should be considered in future cost-effectiveness analyses.

Adult↗
PubMed1999

Benefit limits in managed behavioral health care: do they matter?

More than half of Americans with insurance coverage for mental health services are enrolled in plans that carve out behavioral health care services with a vendor specializing in the management of these services. However, utilization management has not taken the place of benefit limitations. Do benefit limits matter? This article reports the percentage of enrollees in managed behavioral health care carve-out plans that encounter benefit limits. Estimates are provided on the impact and savings of imposing benefit limits on enrollees in unrestricted plans. Costs to eliminate benefit limits are estimated to be very small. This study finds that benefit limits do matter but only to a very small number of plan enrollees. Furthermore, the results of this study show that for inpatient limits, children are especially vulnerable. These issues have important implications for discussions about the impact of managed care in mental health and for discussions concerning parity legislation.

Adult↗
PubMedDate not supplied

The community need index. A new tool pinpoints health care disparities in communities throughout the nation.

Catholic Healthcare West, San Francisco (CHW), has developed a national Community Need Index (CNI) in partnership with Solucient, an information products company, to help health care organizations, not-for-profits, and policymakers identify and address barriers to health care access in their communities. The CNI aggregates five socioeconomic indicators long known to contribute to health disparity--income, culture/language, education, housing status, and insurance coverage--and applies them to every zip code in the United States. Each zip code is then given a score ranging from 1.0 (low need) to 5.0 (high need). Residents of communities with the highest CNI scores were shown to be twice as likely to experience preventable hospitalization for manageable conditions--such as ear infections, pneumonia or congestive heart failure--as communities with the lowest CNI scores. The CNI provides compelling evidence for addressing socioeconomic barriers when considering health policy and local health planning. The tool highlights health care disparities between geographic regions and illustrates the acute needs of several notable geographies, including inner city and rural areas.Further, it should enable health care providers, policymakers, and others to allocate resources where they are most needed, using a standardized, quantitative tool. The CNI provides CHW with an important means to strategically allocate resources where it will be most effective in maintaining a healthy community.

Community Health Planning↗
PubMed2005

Racial variations in treatment and outcomes of black and white patients with high-risk non-ST-elevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?).

BACKGROUND: Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non-ST-segment elevation acute coronary syndromes (NSTE ACS) and how different treatments affect outcomes. METHODS AND RESULTS: Using data from 400 US hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative, we identified black and white patients with high-risk NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes). After adjustment for demographics and medical comorbidity, we compared the use of therapies recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS and outcomes by race. Our study included 37,813 (87.3%) white and 5504 (12.7%) black patients. Black patients were younger; were more likely to have hypertension, diabetes, heart failure, and renal insufficiency; and were less likely to have insurance coverage or primary cardiology care. Black patients had a similar or higher likelihood than whites of receiving older ACS treatments such as aspirin, beta-blockers, or ACE inhibitors but were significantly less likely to receive newer ACS therapies, including acute glycoprotein IIb/IIIa inhibitors, acute and discharge clopidogrel, and statin therapy at discharge. Blacks were also less likely to receive cardiac catheterization, revascularization procedures, or smoking cessation counseling. Acute risk-adjusted outcomes were similar between black and white patients. CONCLUSIONS: Black patients with NSTE ACS were less likely than whites to receive many evidence-based treatments, particularly those that are costly or newer. Longitudinal studies are needed to assess the long-term impact of these treatment disparities on clinical outcomes.

Black or African American↗
PubMed2002

Children of working poor families in California: the effects of insurance status on access and utilization of primary health care.

We examined the effects of health insurance on access and utilization of health care among children of working poor families. These children experience strong access barriers yet have not been studied systematically. 1,492 children in California under 19 years old who had workforce participating parents and a subset of full-time year round working families earning below 200% of poverty were examined from the 1994 National Health Interview Survey. Thirty-two percent of children of working poor families were uninsured in California compared with 26% nationwide. Difficulties in accessing a regular care source and obtaining after-hour care were markedly higher in California. Full-time year round work did not increase insurance coverage and worsened access to a regular source of care. Uninsured children in California were far more likely than insured children to face access barriers and less likely to see a physician in the previous year. Between privately and publicly insured children, the gap in access and utilization narrowed markedly. Health insurance is critical for children in working poor families. Healthy Families, California's response to CHIP, could improve coverage for this population.

Adolescent↗
PubMed2007

Palliative care in the inner city. Patient religious affiliation, underinsurance, and symptom attitude.

Many barriers, including being uninsured or having less than comprehensive health insurance coverage, reduce access to palliative and end-of-life care by inner city minorities. Medicaid or Medicare coverage alone can limit options for pain and symptom management, especially when late referrals make it more difficult to achieve symptom control. Patient affiliation with a religion could offset perceived difficulties with pain medication as well as negative pain and symptom attitudes. Data were analyzed from the most recent assessments of 146 African Americans and Latinos enrolled in an outpatient palliative care unit of an inner city hospital. Fifty-seven percent were receiving palliative care for cancer. Compared with other patients, patients with a religious affiliation did not differ regarding pain medication stress. Uninsured patients with a religious affiliation reported more hopeful pain and symptom attitudes, while patients with a religious affiliation covered only by Medicaid reported less hopeful pain and symptom attitudes. More hopeful pain and symptom attitudes by religious-affiliated, uninsured patients may reveal adequate coping, yet also conceal problem domains. Conversely, less hopeful attitudes by religious-affiliated patients covered only by Medicaid serve as clues to coping difficulties and problem domains. Palliative care programs should carefully consider how to integrate religious support networks as pipelines for program referrals and potential partners for care. Cancer 2007. (c) 2006 American Cancer Society.

Adaptation, Psychological↗
PubMed2005

Are rates of functional limitations associated with access to care? A state-level analysis of the national survey of children with special health care needs.

OBJECTIVES: Health-related services and compensatory mechanisms have a potential role in minimizing functional limitations and increasing quality of life among children with special health care needs (CSHCN). We examined whether rates of functional limitations among CSHCN in the 50 states and District of Columbia were associated with state-level characteristics that reflect access to such services among CSHCN. METHODS: We aggregated child-level survey data from the National Survey of CSHCN to create 51 state-level estimates of the proportions who had functional limitations, had >/=1 unmet health needs, and lacked medical insurance coverage. State-level information about Medicaid spending per child enrollee in federal fiscal year 2000 was obtained from The Henry J. Kaiser Family Foundation website. We examined correlations between the percentages of CSHCN having functional limitations and each of the other state-level variables, and conducted multiple regression analyses that examined these associations while controlling for the statewide percentages of children living in poverty. RESULTS: The proportions of CSHCN with functional limitations were higher in states with higher rates of uninsured CSHCN (r = .49; p < .0001) and higher rates of CSHCN with unmet health needs (r = .62; p < .0001). Proportions of CSHCN with functional limitations were unrelated to per child Medicaid spending. These findings were robust when we controlled for percentages of children in poverty across states. CONCLUSIONS: Fewer unmet needs for health-related services are associated with lower statewide rates of functional limitations in CSHCN. As health care costs increase and state revenues decrease, CSHCN are at increasing risk of losing access to required services. Were this to happen we might expect an increase in the proportion of CSHCN who experience significant functional limitations. Thus, a key challenge is to provide CSHCN access to the amount and quality of health-related care they require to achieve their potential.

Child↗
PubMedDate not supplied

Disparities in oral health and access to care: findings of national surveys.

In this background paper, sociodemographic variables, including age, race, family income, sex, parental education, and geographic location, have been used to characterize the dental status of US children and their access to dental services. Because tooth decay, or dental caries, remains the preeminent oral disease of childhood and national data is available on dental office visits, tooth decay has been used as the primary marker for children's oral health, and visits to the dentist is the marker for care. In general, children from low-income families experience the greatest amount of oral disease, the most extensive disease, and the most frequent use of dental services for pain relief. Yet these children have the fewest overall dental visits. Paradoxically, children in poverty-those living in households with annual gross incomes under $16 500 for a family of 4-or near poverty-those in family households with incomes between $16 500 and $33 000-also have the highest rates of dental insurance coverage, primarily through Medicaid and SCHIP. For those most affected, dental disease is consequential for their growth, function, behavior, and comfort. The twin disparities of poor oral health and lack of dental care are most evident among low-income preschool children, who are twice as likely to have cavities as are higher income children. Medicaid-eligible children who have cavities have twice the numbers of decayed teeth and twice the number of visits for pain relief but fewer total dental visits, compared to children coming from families with higher incomes. Fewer preventive visits for services such as sealants increase the burden of disease in low-income children. These disparities continue into adolescence and young adulthood, but to a lesser degree. Disparities in oral health status and access to dental care are also evident when comparing black, Hispanic, and Native American children to white children and when comparing children of parents with low educational attainment to children of parents with higher educational attainment. The fastest growing populations of children are those that currently have the highest disease rates and the lowest amount of dental care. If the strong correlation between these subpopulations and dental diseases continues, caries rates are likely to rebound after longstanding declines, and the stress on publicly financed dental care will likely increase.

Adolescent↗
PubMed2002

Do regular dental visits affect the oral health care provided to people with HIV?

BACKGROUND: Financial factors related to income and insurance coverage have been found to limit access to, and influence use of, oral health care services by people with human immunodeficiency virus, or HIV. METHODS: The authors determined if visiting a dentist regularly affected the oral health services provided to people with HIV when financial barriers were eliminated as an impediment to access. They analyzed dental claims data for services submitted for payment to the Minnesota Access to Dental Care Program. The analyses focused on comparisons of dental utilization patterns among 273 people classified as regular patients, or RPs, and 222 people classified as nonregular patients, or NRPs. RESULTS: RPs were found to have been provided more diagnostic and preventive care, and less restorative, endodontic, periodontic, removable prosthodontic and oral surgical treatment than were NRPs. Although the mean submitted cost per patient visit was much higher for NRPs, total mean submitted costs per patient for RPs and NRPs were not significantly different. Even though NRPs underwent fewer procedures and had fewer clinic visits than did RPs, the procedures provided to NRPs were more complex and costly. As indicated by differences in the mix of dental care services provided to RPs vs. NRPs, continuity of primary oral health care for RPs led to a better oral health result at no increase in cost over that for NRPs. CONCLUSIONS: The study findings provide substantial evidence regarding the value of regular oral health care for people with HIV. CLINICAL IMPLICATIONS: This study reinforces the need for dentists to educate and encourage people with HIV to integrate regular oral health care into the ongoing maintenance of their overall health and well-being.

Adult↗
PubMed2004

Effects of maternal characteristics on cesarean delivery rates among U.S. Department of Defense healthcare beneficiaries, 1996-2002.

BACKGROUND: National rates of cesarean birth continue a three decade-long escalation, despite widespread recognition that a reduction in the use of the procedure is a continuing appropriate public health goal, as evidenced by the Healthy People 2010 reduction targets. Nonclinical factors associated with cesarean delivery include maternal age, race, socioeconomic status, and insurance coverage. This study compared cesarean delivery rates and trends for the U.S. Department of Defense healthcare beneficiary population from 1996 to 2002 with those observed nationally, and assessed the association of these nonclinical factors with cesarean rate variation in the U.S. Department of Defense healthcare beneficiary population. METHODS: Hospital discharge and claims records for babies born in the military and civilian hospitals that comprise the Department of Defense healthcare network were used to calculate total and primary cesarean delivery rates and vaginal birth after cesarean (VBAC) rates from 1996 to 2002. Annual cesarean rates for subgroups defined by maternal age, race, and socioeconomic status were calculated to examine rate variations and rate trends within the study population. Pooled data from 1999 to 2002 were used to compare rates across socioeconomic status, stratified by age and race. Statistical significance of the differences calculated for subgroups was assessed using chi-square. RESULTS: Total and primary cesarean delivery rates among the U.S. Department of Defense population were lower than those reported nationally for every year examined. Cesarean delivery and VBAC rate trends in the national and Department of Defense populations were similar. Within the Department of Defense population, total cesarean delivery increased with increasing maternal age and was more highly associated with racial minorities relative to white women. The higher socioeconomic subgroup (defined as active duty, retired, and warrant officers and their families in this study) was generally associated with reduced cesarean delivery rates. CONCLUSIONS: Cesarean deliveries are performed less frequently for the U.S. Department of Defense healthcare beneficiary population relative to the national population. Associations between socioeconomic factors and cesarean rates reported for the national population were not apparent in the study population. The consistent pattern of rate variation across racial subgroups in the Department of Defense population suggests that factors beyond those examined in this study are needed to explain the elevated cesarean rates for racial minorities.

Adult↗
PubMedDate not supplied

Children's health coverage: a quarter-century of change.

Data from a series of medical spending surveys over the past twenty-five years show that uninsurance rates for children have fallen to levels not seen since the late 1970s (about 8 percent). Rates of uninsurance have fallen in particular for poor children. Deteriorating family economic circumstances, along with a weakened safety net, contributed to the decrease of private insurance coverage and rising uninsurance rates between 1977 and 1987. Although family circumstances have stabilized since the late 1980s, high annual increases in health insurance costs have continued to erode private coverage. Public coverage expansions have reversed the surge in uninsurance rates during 1977-1987.

Adolescent↗
PubMed2001

Health insurance and health services utilization in Ireland.

The numbers buying private health insurance in Ireland have continued to grow, despite a broadening in entitlement to public care. About 40% of the population now have insurance, although everyone has entitlement to public hospital care. In this paper, we examine in detail the growth in insurance coverage and the factors underlying the demand for insurance. Attitudinal responses reveal the importance of perceptions about waiting times for public care, as well as some concerns about the quality of that care. Individual characteristics, such as education, age, gender, marital status, family composition and income all influence the probability of purchasing private insurance. We also examine the relationship between insurance and utilization of hospital in-patient services. The positive effect of private insurance appears less than that of entitlement to full free health care from the state, although the latter is means-tested, and may partly represent health status.

Attitude to Health↗