Journal of Health Care for the Poor and Underserved

Journal of Health Care for the Poor and Underserved
Volume 15, Number 1, February 2004

CONTENTS

Association of Clinicians for the Underserved (ACU) Column

    Rhee, Kyu.
  • Creating A National, Transdisciplinary Community of Clinicians Who Serve the Underserved
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    Subject Headings:
    • Physicians (General practice) -- Supply and demand -- United States.
    • Health services accessibility -- United States.
    • Medically underserved areas -- United States.
    • Association of Clinicians for the Underserved.

Guest Editorials

    Maupin, John E.
    Schlundt, David G.
    Warren, Rueben C.
    Miller, Stephania.
    Goldzweig, Irwin.
    Warren, Hershell.
  • Reducing Unintentional Injuries on the Nation's Highways: Research and Program Policy to Increase Seat Belt Use
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    Subject Headings:
    • Traffic safety -- United States.
    • Automobiles -- Seat belts -- Law and legislation -- United States.
    Abstract:
      Death, disability, and injury from motor vehicle accidents constitute a public health crisis. The goal of this paper is to describe how Meharry Medical College's Center for Community Based Research plans to address this problem. A model of how high-risk groups are influenced to engage in behaviors that increase risk for traffic crashes is articulated. Five strategies for reducing risk for motor vehicle morbidity and mortality are identified: 1) influencing the individual at the point of decision; 2) mobilizing communities and coalitions to support individual and systems changes; 3) modifying environmental factors to modify behaviors; 4) changing laws and public policy; and 5) working towards the elimination of underlying causes. The Center for Community Based Research's promotion of seat belt use, based on each of these five strategies, is described. Addressing the public health crisis resulting from death and injury on the nation's roads and the excess risk faced by minority groups in this country will require the coordinated efforts of many groups. This work must be driven by research, the outcome of which will be a reduction in preventable injury, disability and premature death.
    Keywords:
      traffic accidents, injury, disparities, participatory research, mortality.
    Washington, William N.
  • Collaborative/Participatory Research
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    Subject Headings:
    • Participant observation.
    • Research institutes -- United States.
    • Community and college -- United States.
    Abstract:
      Collaborative (or, participatory) research involves a working relationship between at least one academic institution's research unit and one community-based organization. The community-based organizations of interest are those from and representing underserved communities. Barriers to collaboration, approaches to overcoming such barriers, and principles for the maintenance of good collaborative research relations are given. Representatives of the underserved and academic research units tend to interact in a collaborative/participatory relationship by means of formal committees. How the degrees of power of the underserved on such committees might be understood is discussed in terms of a model from Arnstein's 1971 article and the value of participation for the underserved is discussed.
    Keywords:
      collaborative research, participatory research, academic research, citizen participation, underserved, power.

Brief Communications

    Fairbrother, Gerry.
    Jain, Aparna.
    Park, Heidi L.
    Massoudi, Mehran S.
    Haidery, Arfana.
    Gray, Bradford H., 1942-
  • Churning in Medicaid Managed Care and Its Effect on Accountability
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    Subject Headings:
    • Managed care plans (Medical care) -- United States -- States.
    • Medicaid.
    • Poor children -- Medical care -- United States -- States.
    Abstract:
      There is concern that churning in Medicaid excludes children from the accountability system for managed care because they may not meet the one-year continuous enrollment requirement. This study explores the effect of churning in measuring childhood immunization coverage rates under the current accountability system. Data were collected from administrative databases at the Centers for Medicaid and Medicare Services and 12 states with high Medicaid managed care penetration. On average in the 12 states only 39% of the children enrolled in one specific managed care plan met the continuous enrollment requirement. However, Centers for Medicaid and Medicare Services data showed that 78% of children were enrolled in Medicaid (but not the same plan) continuously for 12 months. Both plan-specific rates and overall Medicaid rates varied greatly across the states. Policies that result in churning mean that many vulnerable children fall outside of the accountability structure intended to assure that they receive necessary services.
    Keywords:
      accountability, Health Plan Employer Data and Information Set, Medicaid managed care, churning, immunizations.
    Geller, Stephanie.
    Taylor, Buck M.
    Scott, H. Denman.
  • Free Clinics Helping to Patch the Safety Net
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    Subject Headings:
    • Medically uninsured persons -- Middle West.
    • Health services accessibility -- Middle West.
    • Clinics -- Middle West.
    • Free Clinics of the Great Lakes Region -- History -- 20th century.
    Abstract:
      For the uninsured and underinsured with few funds, there are a limited number of health care options. To assist in filling this hole in the safety net, hundreds of free or volunteer-based clinics have been established across the country. Although these clinics have existed for years, little data on them exist. In 1999, a mail survey was sent to free clinics in seven Midwestern states. Findings from this survey show that, in a single year, these 106 clinics provided medical, dental, and pharmaceutical services to over 200,000 patients, suggesting that free clinics nationwide are caring for a substantial number of our nation's uninsured. The survey paints a picture of free clinics, the populations they serve, and the services they provide. Given the lack of options for the uninsured and underinsured, free clinics deserve continued recognition, support, and assistance from policy makers, health care providers, and the philanthropic community.
    Keywords:
      access to health care, medically uninsured, medically underinsured, voluntary workers, data collection, Midwest.

Original Papers

    O'Toole, Thomas P.
    Arbelaez, Jose J.
    Dixon, Bruce W.
  • Full Disclosure of Financial Costs and Options to Patients: The Roles of Race, Age, Health Insurance, and Usual Source for Care
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    Subject Headings:
    • Health services accessibility -- Economic aspects -- Pennsylvania -- Allegheny County.
    • Insurance, Health -- Pennsylvania -- Allegheny County -- Finance.
    • Poor -- Medical care -- Pennsylvania -- Allegheny County -- Finance.
    Abstract:
      The objective was to identify factors associated with financial discussions and financial disclosure of medical costs within a low-income urban community. The method used was a cross-sectional community-based survey in Allegheny County, Pennsylvania. The survey was conducted door-to-door and at area food pantries. Two hundred and twenty six adults were interviewed. Overall, 76.1% reported having a usual source for care and 73.0% had health insurance. Thirty nine and four tenths percent reported having been asked about their ability to pay for health services; this was more common among African Americans (OR 5.2; 95% CI 1.73-15.84), those with no health insurance (OR 4.3; 95% CI 1.01-17.89), and those less than 45 years old (OR:2.9; 95% CI 1.03-8.28). Only 10.6% reported being told how much a health visit would cost. Overall, 30.1% reported their provider made payment allowances for medical bills, with white respondents 2.5 times more likely and those persons identifying an ambulatory site for care 2.6 times more likely to report this. Overall, 30.5% reported being referred to a collection agency for unpaid medical bills; this was 2.4 times more common among those individuals identifying a non-ambulatory usual site for care. Significant race and socio-economic disparities exist in discussions about and access to financial resources to pay for medical care. Expanding the availability of financial assistance is critical to improving access to health care.
    Keywords:
      race, age, health insurance, source of care, financial costs, financial options.
    O'Hara, Brett.
  • Do Medical Out-of-Pocket Expenses Thrust Families into Poverty?
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    Subject Headings:
    • Medical care, Cost of -- Social aspects -- United States.
    • Income distribution -- United States.
    • Poverty -- United States.
    Abstract:
      This paper estimates the impact of medical out-of-pocket expenses on families' well-being using the Survey of Income and Program Participation. Medical out-of-pocket expenses include the out-of-pocket costs from medical services and the family's share of health insurance premiums. Demographic characteristics, insurance status, and medical usage of the family are analyzed to determine which characteristics are most likely to impoverish a family. Families impoverished because of medical out-of-pocket expenses are far more likely to have older heads of the family, at least one family member in poor health, or some adults without health insurance. Families without at least one person who worked full time for the entire year were also likely to be impoverished. However, children in the family had little effect on the probability that the family became impoverished. This odd result is probably due to the high correlation between parental health insurance coverage and the health insurance coverage of their children.
    Keywords:
      poverty, medical expenditures, health insurance.
    Schlundt, David G.
    Warren, Rueben C.
    Miller, Stephania.
  • Reducing Unintentional Injuries on the Nation's Highways: A Literature Review
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    Subject Headings:
    • Traffic safety -- United States.
    • Risk-taking (Psychology) -- United States.
    Abstract:
      Death and injury on the nation's highways is a public health crisis, especially for youth and members of selected minority groups. The objective of this paper is to review the literature on behavioral and environmental factors that increase risk for traffic morbidity and mortality in populations at high risk. Each of the following is a risky traffic-related behavior: not wearing seat belts, not using child safety seats, not wearing bicycle or motorcycle helmets, driving after drinking, driving while fatigued or distracted, speeding, running red lights, and aggressive driving. Environmental factors that modify risk include urban sprawl, highway design, public policy, racism and economic inequality. High risk groups include youths, males, pickup truck drivers, urban dwellers, the elderly, African Americans, American Indians, and Alaska Natives.A comprehensive approach must be developed for reducing traffic-related risk of death and injury, especially in high risk populations.
    Keywords:
      safety, traffic, injury, mortality, environment, behavior, disparities.
    Adelmann, Pamela K.
  • Prevalence and Detection of Urinary Incontinence among Older Medicaid Recipients
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    Subject Headings:
    • Medicaid.
    • Urinary incontinence in old age -- United States.
    • Poor aged -- Medical care -- United States.
    Abstract:
      Low-income older adults have higher rates of many medical disorders than those with higher income, but rates of urinary incontinence have not been examined in this population. A random sample of older Medicaid recipients was interviewed (n=910) and medical records examined for the subset with urinary incontinence (n=236). Nursing home residents were randomly selected from Medicaid enrollment files (n=480). Forty-two percent of community residents reported urinary incontinence, with higher rates among women, older respondents, and whites. The medical records for only 22% of community-dwellers contained a diagnosis of urinary incontinence, compared with 77% for nursing home residents. Type of urinary incontinence was specified for 65% of diagnosed community dwellers and 7% of diagnosed nursing home residents. Urinary incontinence rates are high among Medicaid recipients compared with estimates from general population studies, but detection rates are lower for community-dwellers. Physicians may need to do more among low-income older adults in order to detect urinary incontinence.
    Keywords:
      urinary incontinence, Medicaid, low-income.
    Miller, Jane E., Ph. D.
    Gaboda, Dorothy.
    Cantor, Joel C.
    Videon, Tami M.
    Diaz, Yamalis.
  • Demographics of Disenrollment from SCHIP: Evidence from NJ KidCare
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    Subject Headings:
    • New Jersey State Children's Health Insurance Program.
    • Poor children -- Medical care -- New Jersey -- Finance.
    • Medically uninsured persons -- Government policy -- New Jersey.
    Abstract:
      The State Children's Health Insurance Program (SCHIP) provides health insurance coverage for children in low-income families. Although there is evidence of substantial disenrollment from SCHIP, few studies have examined how disenrollment varies by demographic characteristics. This study uses data from administrative records of all 41,881 children enrolled prior to April 2000 in NJ KidCare (New Jersey's SCHIP) separate state plans for families with incomes between 133% and 350% of the Federal Poverty Level. Survival methods were used to analyze disenrollment according to demographic and plan characteristics. Reasons for disenrollment were also studied. Overall, 18.9% of children disenrolled within 12 months of enrollment. Disenrollment was higher among non-Hispanic black children, children aged 1 to 5, and children without siblings in NJ KidCare than among their counterparts. Surprisingly, English speakers had the highest disenrollment rate of all language groups. Children in families with moderate income categories for whom premium contributions were required were 3 times as likely as lower-income children to disenroll, principally due to non-payment of premiums. To maximize retention in SCHIP and ensure access to care and continuity of care for low-income children, research is needed concerning why some groups disenroll more quickly.
    Keywords:
      State Children's Health Insurance Program (SCHIP), socioeconomic factors, health insurance, program evaluation, blacks.
    Shefer, Abigail.
    Smith, Philip J. (Philip James), 1951-
  • Improving the Immunization and Health Status of Children in the Women, Infants, and Children (WIC) Program
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    Subject Headings:
    • Immunization of children -- United States.
    • Health surveys -- United States -- Methodology.
    • Special Supplemental Food Program for Women, Infants, and Children (U.S.)
    Abstract:
      Maintaining enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and continued exposure of these children to immunization-promoting and nutritional benefits within the program is essential to improve the health status of this vulnerable population. Logistic regression was used to determine characteristics of 2 groups of children: those who dropped out of the program despite being eligible and those who remained in the program but were underimmunized. Of over 20,000 children 19-35 months old, 49% had participated in WIC but only 50% were still enrolled. Factors most strongly associated with dropping out of the program were older age of child; white, black, or American Indian race; living in an urban or suburban area; higher socioeconomic status but still eligible for the program; having only 1 child at home; and having mothers who were unmarried or less than 30 years old (p<0.05). Among current participants, factors most strongly associated with under-vaccination included younger age of the child; black or Asian race; moving from another state since birth; mother with less than a high-school education; and having 2 or more children under 18 years old living in the household (p<0.05). Routinely collected child/family information can be used to target outreach and immunization-promoting interventions toward children most likely to drop out of the program or to be underimmunized.
    Keywords:
      immunization; vaccination; child; poverty; socioeconomic factors; Women, Infants, and Children Program

Review

    Warren, Rueben C.
  • NDA II: The Story of America's Second National Dental Association (review)
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    Subject Headings:
    • Dummett, Clifton O. (Clifton Orrin) NDA II: the story of America's second National Dental Association.
    • Dummett, Lois Doyle.
    • National Dental Association (1932- ) -- History.

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