Journal of Health Care for the Poor and Underserved

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Journal of Health Care for the Poor and Underserved
Volume 16, Number 3, August 2005

CONTENTS

Brief Communications

    Kullgren, Jeffrey T.
    Taylor, Erin Fries.
    McLaughlin, Catherine G.
  • Donated Care Programs: A Stopgap Measure or a Long-Run Alternative to Health Insurance?
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    Subject Headings:
    • Health services accessibility -- Maine.
    • Medically uninsured persons -- Medical care -- Maine.
    Abstract:
      In the absence of broad federal health care reform, interest has grown in local solutions to the problem of providing health care to the uninsured. Community-based donated medical care models have emerged as one alternative. We examine the early experience of a donated care program in southern Maine called CarePartners. Although such programs are often viewed as a short-term solution for those temporarily without health insurance, we find that CarePartners served a different role for many individuals. While clearly a stopgap measure for some enrollees, CarePartners appears to be a longer-term means for getting access to care for most enrollees.
    Keywords:
      Medically uninsured, health care accessibility, Maine, donated medical care.
    Kim, Young O. Rhee.
  • Reducing Disparities in Dental Care for Low-income Hispanic Children
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    Subject Headings:
    • Hispanic American children -- Dental care.
    • Poor children -- Dental care -- United States.
    Abstract:
      Using a social ecological model, this study examined the influences of socio-demographic factors, mother's attitudes, financial barriers, and the health care delivery system on the use of dental services for 4–8 year-old Hispanic children. Initiating dental care during the preschool years was significantly related to the mothers' beliefs and her social network's beliefs in the value of preventive dental care. The mother was almost four times more likely to continue the care if she believed that dentist visits would keep the child's teeth healthy. Extended clinic hours in the evenings also increased the likelihood of the mother's return to the dentist to continue child's care. It was not the mother's attitudes but provider availability, dental insurance (including Medicaid) and family income that were related to frequency of planned visits. The study findings can be used in improving access to care and reducing barriers for low-income, urban Hispanic children.
    Keywords:
      Access to dental care; Hispanic children; provider availability.
    Fairbrother, Gerry.
    Park, Heidi L.
    Haidery, Arfana.
    Gray, Bradford H., 1942-
  • Periods of Unmanaged Care in Medicaid Managed Care
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    Subject Headings:
    • Medicaid.
    • Children -- Medical care -- United States -- States.
    • Managed care plans (Medical care) -- United States -- States.
    Abstract:
      Churning in Medicaid has been long recognized as a problem leading to breaks in coverage. Tenure in Medicaid managed care has received less attention. Recent reports indicate that children's tenures in health plans are far shorter than tenures in Medicaid itself, but explanations for the difference are not given. In the research reported here, we conducted case studies in five states to determine difference in tenure and reasons for the difference. Our investigation showed that children were enrolled in Medicaid two to four months longer than in specific Medicaid health plans. The major reasons for the gap were retroactive enrollment in Medicaid and delays in selecting a health plan. Frequent and burdensome Medicaid renewal processes exacerbate the problem, resulting in breaks in enrollment and the need to reenroll. The task of managing the care of Medicaid children is difficult without adequate tenures in health plans.
    Keywords:
      Churning, Medicaid managed care, enrollment, short tenures, retention.
    Okoro, Catherine A.
    Young, Stacy L.
    Strine, Tara W.
    Balluz, Lina S.
    Mokdad, Ali H.
  • Uninsured Adults Aged 65 Years and Older: Is Their Health at Risk?
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    Subject Headings:
    • Preventive health services for older people -- United States.
    • Medically uninsured persons -- Medical care -- United States.
    • Health surveys -- United States.
    • Health behavior -- United States.
    Abstract:
      Some U.S. adults aged 65 years and older lack health care coverage. As a result, they may have unmet health needs and be vulnerable to excess morbidity and mortality. Due to their small numbers, little data on them exist. We used data from the 1996–2000 Behavioral Risk Factor Surveillance System, an ongoing telephone survey operated by the state health departments with assistance from the Centers for Disease Control and Prevention, to examine a representative sample of adults 65 years old and older. We found that blacks and Hispanics were disproportionately represented among uninsured older adults. Compared with their insured counterparts, the uninsured elderly experienced cost barriers to needed care, lacked receipt of an annual checkup, and did not receive preventive health screenings. Given the projected growth of the elderly population, particularly among blacks and Hispanics, it is crucial to ensure all older adults have access to preventive health services.
    Keywords:
      Key words: Medically uninsured, aged, health behavior, access to health care, preventive health services, Behavioral Risk Factor Surveillance System.
    Rhoades, Dorothy A.
    Manson, Spero M.
    Noonan, Carolyn.
    Buchwald, Dedra.
  • Characteristics Associated with Reservation Travel Among Urban Native American Outpatients
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    Subject Headings:
    • Ambulatory medical care -- Alaska.
    • Indians of North America -- Medical care -- Alaska.
    • Health services accessibility -- Alaska.
    Abstract:
      The objectives of this study were to ascertain the extent of, and health-related characteristics associated with, travel to reservations in a low-income, urban American Indian and Alaska Native (AI/AN) population. We surveyed more than 500 AI/AN adults at a primary care clinic. Measures included time spent visiting a reservation during the past year, and sociodemographic, cultural, and clinical characteristics. More than half (52%) of the patients had not traveled, 34% had traveled up to 30 days, and 14% had spent more than 30 days traveling to reservations. Multivariate ordinal regression revealed that a strong Native American cultural identification, presence of lung disease, absence of thyroid and mental problems, and greater dissatisfaction with care were independently associated with more travel to reservations (p ≤ 0.05). This research begins to augment the paucity of information on such travel and its relationship to health status and use of health services among urban AI/ANs.
    Keywords:
      Indians, North American; Inuit; primary health care; urban population.
    Lasser, Karen E.
    Mintzer, Ira L.
    Lambert, Astrid.
    Cabral, Howard.
    Bor, David H.
  • Missed Appointment Rates in Primary Care: The Importance of Site of Care
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    Subject Headings:
    • Medical appointments and schedules -- United States.
    • Primary health care -- United States.
    • Physician and patient -- United States.
    Abstract:
      The objective was to determine whether race, language, or gender concordance between primary care providers (PCPs) and patients is associated with lower missed appointment rates in neighborhood health centers. An additional objective was to determine whether site of care is a determinant of missed appointment rates. In analyses of 74,120 follow-up visits by 13,882 patients, odds ratios for missing an appointment for patients who had language, race or gender concordance with their PCP were 0.90 (95% confidence interval [CI], 0.81–0.99), 0.84 (95% CI, 0.79–0.90) and 1.01 (95% CI, 0.95–1.07) respectively, after adjustment for age, insurance, language, individual PCP open access, sessions per week PCP in practice, and health center. Odds ratios for missing an appointment varied nearly three-fold, depending upon the particular site of care. Race and language concordance between patients and PCPs has only a modest effect on missed appointment rates. Receipt of primary care services at specific neighborhood health centers was the strongest predictor of missed appointment rates in this sample.
    Keywords:
      Missed appointments, language, race, neighborhood health centers.
    Adekoya, Nelson.
  • Infectious Diseases Treated in Emergency Departments: United States, 2001
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    Subject Headings:
    • Hospitals -- Emergency service -- Utilization -- United States.
    • Communicable diseases -- Treatment -- United States.
    • National Hospital Ambulatory Medical Care Survey (U.S.)
    Abstract:
      Emergency departments (EDs) are an important source of medical care in the United States. Information is limited concerning epidemiologic patterns of ED visits for infectious diseases. Data for 2001 from the National Hospital Ambulatory Medical Care Survey (NHAMCS) were analyzed for infectious disease visits. The NHAMCS is a national probability sample survey of visits to hospital EDs and outpatient departments of non-federal, short-stay, and general hospitals in the United States. Data are collected annually and are weighted to generate national estimates. In 2001, an estimated 19.8 million visits were made to hospital EDs for infectious diseases (rate = 71 visits/1,000 persons). Children under 15 years old made 36% of these visits and had the highest rate of visits (rate = 119 visits/1,000 persons). The rate of visits for females was 37% higher than for males (82 versus 60/1,000 persons). Although the white population had the highest volume of visits, the rate of visits for blacks was more than twice that of whites (130 versus 64 visits/1,000 persons). Laboratory tests were ordered in 84% of visits. An estimated 18% of visits to the EDs concern infectious diseases. The issue of health care access and ED use is complex and the reasons for the higher rate of visits for blacks than for whites are not fully understood.
    Keywords:
      Emergency departments, infectious diseases, National Hospital Ambulatory Medical Care.

Original Papers

    Willging, Cathleen.
    Waitzkin, Howard.
    Wagner, William.
  • Medicaid Managed Care for Mental Health Services in a Rural State
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    Subject Headings:
    • Rural mental health services -- United States.
    • Medicaid.
    • Managed care plans (Medical care) -- United States.
    • Health services accessibility -- United States.
    Abstract:
      State governments throughout the country increasingly have turned to managed care for their Medicaid programs, including mental health services. We used ethnographic methods and a review of legal documents and state monitoring data to examine the impact of Medicaid reform on mental health services in New Mexico, a rural state. New Mexico implemented Medicaid managed care for both physical and mental health services in 1997. The reform led to administrative burdens, payment problems, and stress and high turnover among providers. Restrictions on inpatient and residential treatment exacerbated access problems for Medicaid recipients. These facts indicate that in rural, medically underserved states, the advantages of managed care for cost control, access, and quality assurance may be diminished. Responding to the crisis in mental health services, the federal government terminated New Mexico's program but later reversed its decision after political changes at the national level. This contradictory response suggests that the federal government's oversight role warrants careful scrutiny by advocacy groups at the local and state levels.
    Keywords:
      Medicaid, managed care, health care economics and organizations, access to health care, public policy, mental health.
    Gill, James M.
    Fagan, Heather Bittner.
    Townsend, Bryan.
    Mainous, Arch G.
  • Impact of Providing a Medical Home to the Uninsured: Evaluation of a Statewide Program
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    Subject Headings:
    • Community health services -- Utilization -- Delaware.
    • Medically uninsured persons -- Medical care -- Delaware.
    Abstract:
      Lack of health insurance and a regular source of care (RSOC) are associated with suboptimal health care. This study examined the impact of a statewide program called the Community Healthcare Access Program (CHAP), which provided a RSOC for uninsured persons in Delaware. This cohort study used survey data to compare health care utilization from baseline to six months after enrollment in CHAP. The 795 eligible enrollees had significant increases in Pap tests, mammograms, breast exams, cholesterol tests, sigmoid/colonoscopy and influenza immunizations but not stool blood tests or pneumococcal immunizations. There was a significant decrease in the proportion with emergency department visits but not hospitalizations, and there was a significant improvement in satisfaction with care. Delaware's CHAP program is associated with significant improvements across many measures of health care utilization and represents a successful and financially feasible method for states to improve health care for their uninsured populations.
    Keywords:
      Uninsured, access to care, regular source of care, preventive care, Emergency Department visits, hospital admissions.
    Hartley, Heather.
    Seccombe, Karen.
    Hoffman, Kim.
  • Planning for and Securing Health Insurance in the Context of Welfare Reform
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    Subject Headings:
    • Insurance, Health -- United States.
    • Public welfare -- United States.
    • Medicaid.
    • Children -- Medical care -- United States.
    Abstract:
      Previous research indicates that 25% to 50% of former Temporary Assistance to Needy Families (TANF) recipients and approximately 15% to 30% of their children become uninsured after the expiration of the one-year transitional Medicaid coverage they receive when leaving welfare. Using data from 90 face-to-face interviews, this paper explores the expectations, plans, and coping strategies of TANF leavers in Oregon who are in the middle of this year of transitional coverage. The paper examines (1) the information available to these individuals, (2) their planning and expectations about securing health insurance, and (3) their perceptions of opportunities for obtaining jobs that provide insurance. The paper shows that while TANF leavers often assume their Medicaid coverage will continue after the transitional year, many lack complete information about this. Many respondents have no active plans for securing health insurance. Even those who do have sufficient information to plan for the end of the transitional year may find themselves having to make stark choices (e.g., sacrificing income in order to keep coverage). Policy recommendations are presented.
    Keywords:
      Health insurance, welfare reform, Medicaid, coping behavior.
    Ojeda, Victoria D.
    Brown, E. Richard.
  • Mind the Gap: Parents' Citizenship as Predictor of Latino Children's Health Insurance
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    Subject Headings:
    • Medically uninsured persons -- United States.
    • Hispanic American children -- Medical care.
    • Citizenship -- United States.
    Abstract:
      Parents' citizenship appears to be correlated with high rates of uninsurance and low rates of job-based insurance among Latino citizen children in families headed by citizens and non-citizens. Few studies have examined the direct relationship between parents' citizenship and children's insurance status. Data for U.S.-born Latino and non-Latino white children ages 0–18 years in working two-parent households obtained from the March 2001 Current Population Survey were analyzed. Results from logistic regressions were adjusted for a design effect to account for survey design. After controlling for other sociodemographic and employment characteristics, only Latino children in families headed by non-citizen couples are more likely to be uninsured and less likely to have employer-based insurance than others in the dataset. Even controlling for non-citizen parents' duration in the U.S., citizenship status of the head of household predicts children's coverage. Latino children are more likely to have health insurance if they have at least one citizen parent. Continued and varied efforts are needed to promote coverage among U.S.-born Latino children.
    Keywords:
      Uninsured, employer-based insurance, Latino, health insurance, children, citizenship, U.S.-born.
    Lin, Chyongchiou Jeng.
    Davitt, Joan K.
    Meit, Michael.
    Schwartz, Myron.
    Marainen, Jonas.
    Davis, Lisa.
    Leon, Joel, 1948-
  • The Financial Impact of Interim and Prospective Payment Systems on Home Health Providers in Rural Communities
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    Subject Headings:
    • Home care services -- Prospective payment -- Pennsylvania.
    • Medicare -- Pennsylvania.
    • Rural health services -- Pennsylvania -- Finance.
    Abstract:
      The objective of the study was to examine the financial impact of the interim payment system and prospective payment system (PPS) on home health agencies (HHAs) in rural communities. Data sources used included a survey of administrators in all rural HHAs in Pennsylvania and financial and utilization data provided by 10 rural HHAs in Northwest Pennsylvania. The results of survey showed that, under the PPS, 40% of the HHAs reported financial vulnerability and 24% expressed concern that the fiscal uncertainties arising from the PPS threatened their continued operation. Two prospective analyses were conducted to examine how HHAs would be further affected by payment rate changes implemented in October 2002 and April 2003. The Medicare margin in rural Pennsylvania was 23.3% during the period from October 2000 to June 2002. This margin was slightly higher than the free-standing home health Medicare margin (21.6%) reported in analyses conducted by the Medicare Payment Advisory Commission (MedPac). However, this Medicare margin did not include hospital-based HHAs. The payment rate changes implemented in 2002 and 2003 would increase the proportion of care episodes that incur financial losses, assuming service provision remains constant. As of April 2003, the proportion of all episodes with loss would rise to 46.9%, the proportion of low-utilization payment adjustment (LUPA) episodes with loss would rise to 91.1%, and the proportion of non-LUPA episodes with loss would rise to 40.2%. New payment mechanisms are profoundly affecting the finances of rural HHAs and the use of home health services by Medicare beneficiaries.
    Keywords:
      Home health agency, interim and prospective payment systems, Medicare.
    Cheng, Tyrone.
  • The Impact of Welfare Reforms, Health, and Insurance Status on Welfare Recipients' Health Care Access
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    Subject Headings:
    • Public welfare -- United States.
    • Insurance, Health -- United States -- States.
    • Welfare recipients -- Medical care -- United States -- States.
    • Health services accessibility -- United States -- States.
    Abstract:
      This study explores ways in which welfare reforms have affected utilization of four health services (physician visits, hospital care, prescription medication, and dentist visits) and the impact of health insurance on these services. A secondary data analysis of a nationally representative sample of 1,259 non-elderly adult current and former welfare recipients shows that use of health services is significantly affected by state-specific welfare policy, health insurance, and race/ethnicity, when other variables are controlled. More restrictive state welfare policies were variously associated with lower likelihood of using dental care, visiting a physician and using prescriptions. Non-Hispanic whites in the sample were more likely than members of other racial/ethnic groups to use prescriptions; Hispanics were less likely than non-Hispanic whites to visit physicians or dentists. The proportion of respondents reporting fair or poor health was three times as great as the estimated proportion of non-elderly adults reporting fair or poor health in the general population. Policy implications are discussed.
    Keywords:
      Welfare reforms, welfare recipients, health care access.

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