Dennis P. Andrulis

Access to Care Is the Centerpiece in the Elimination of Socioeconomic Disparities in Health

The Institute of Medicine defines access to health care as the timely use of personal health services to achieve the best possible outcomes [1]. Achieving the objectives implied in this definition for socioeconomically disadvantaged populations has come to represent a serious, continual, and somewhat time-worn objective in the United States. Without a national health insurance program, society has tacitly accepted a piecemeal, incremental approach to improving the health care circumstances of these populations. Such an approach has shifted the focus of efforts to states, in which substantial variation in the percentage of persons without insurance for at least 12 months (the definition of long term) belies a concurrent variation in insurance policies; in 1995, this rate ranged from 2.9% in Hawaii to 17.1% in Louisiana [2]. At the same time, many continue to believe that if the financial barriers to health care could be lowered or eliminated, we could greatly reduce differences in the quality of health care as well as health care outcomes across socioeconomic groups. But would leveling the differences created by financial inequity really eliminate major disparities, or is this a shibboleth that masks more complex, deep-seated concerns that would continue to perpetuate great inequality in health care access and health status? This paper supports the contention that action that successfully decreases financial barriers across socioeconomic groups will go a long way toward the substantial reduction of socioeconomic disparities in health. In so doing, it draws on selected reports from the vast literature that lead to these conclusions and puts in context the great health care benefit that could be derived from a leveling of financial differences. Poverty, Lack of Insurance, and Health Adversity The literature is replete with studies linking problems with health care access, differences across socioeconomic groups, and health consequences. As we approach the 21st century, reports indicate that the consequences of such disparities are increasing. For example, a summary report on children who live in poverty, a population with large numbers of uninsured, profiled the familiar litany of adverse consequences, including greater likelihood of receiving lower-quality care and dying in infancy [3]. Moreover, as many as one in four children-the same proportion of children growing up in poverty in the United States-may face these and other adverse circumstances. Between 1979 and 1994, the number of children younger than 6 years living in poverty increased from 3.5 million to 6.1 million. A 1997 report from the Center for Studying Health Systems Change also shows that disparities remain large and that their adverse impact may be growing [4]. This survey-based study of almost 44 000 persons conducted in 1996 and 1997 found a familiar pattern: Families classified as low income were more likely than any other group to report decreased access to health care within the past 3 years. More than twice as many uninsured persons (43%) reported reduced access compared with persons who had private insurance (21%). In contrast, elderly persons, who are eligible for Medicare coverage, were the least likely to report reduced access. Investigations of avoidable hospitalizations and emergency department use among uninsured persons and across socioeconomic groups show how this situation plays out in our health care system. An examination of California hospital discharge data found that, among other factors, poverty was correlated with higher rates of preventable hospitalization. The report also concluded that uninsured persons are likely to have greater difficulty than privately insured patients in accessing inpatient care [5]. A 1997 report using National Hospital Discharge Survey data found that the number of potentially avoidable hospitalizations was far greater in middle-income and low-income populations than in the wealthiest populations; children were also affected by socioeconomic disparities in access. These findings led the authors to comment on the striking class and racial differences in rates of potentially avoidable hospitalization [6]. Using National Medical Care Utilization and Expenditure Survey data, Spillman [7] found that the rate of nonemergency care for uninsured children was only 70% of the rate for those who were insured and that much less money was being spent on the uninsured population for inpatient and ambulatory care. According to the National Center for Health Statistics, nonurgent cases accounted for more than 50% of the 90 000 000 visits to U.S. hospital emergency departments in 1992 [8]. Emergency departments are a well-established source of access to persons of lower socioeconomic status, who most often have no other recourse for care [9, 10]. This aspect of our health care system sets us apart from other countries as well, with the related consequences falling squarely on those who have difficulty meeting their health care costs. A survey-based comparison of perceived access to health care among residents in the United States, Canada, and Germany conducted in 1994 and 1995 found that persons in the United States were most likely to report difficulties in obtaining and paying for their health services [11]. In particular, the U.S. group reported greater likelihood of financially based access problems. In all, 20% of the U.S. group reported serious problems in paying medical bills in the past year. In addition, an estimated one third of the uninsured U.S. group reported financially based access problems, and almost two thirds reported delaying care because of such problems. Significant differences were found for access to specialists, diagnostic tests, and overall medical care. Breaking the Link between Poverty and Lack of Access To Improve Health Outcomes Obviously, many factors influence the health of individual persons, regardless of whether they are poor. Nonetheless, the ability to substantially improve access for low-income populations through elimination of financial barriers is probably a sine qua non when it comes to eliminating disparities in health status. The health care literature provides important evidence of the financial leveling effect-or the lack thereof-by two measures: health care utilization and health care outcomes. For example, in an international study of children and health care utilization, Casanova and Starfield [12] found that when access to primary care is leveled across income strata, no significant differences by income appeared for rates of ambulatory care-sensitive conditions, such as asthma. The implication drawn from this finding is that the ability to use a primary care practitioner may obviate worsening of a treatable condition that if left unaddressed, would probably require more urgent care. A survey-based examination of the link between access and insurance in the Seattle-King County area found that being insured was the strongest predictor for having a regular source of care and was strongly correlated with ease of access to care. Moreover, when uninsured persons became eligible for Medicaid, their health care access improved (although it never reached the levels seen with private insurance) [13]. An examination of patterns of inpatient, out-patient, and related health care status among 346 persons who were previously uninsured and became enrolled in a Kaiser managed care program found patterns of utilization similar to those seen in a commercially enrolled group [14]. In addition, the costs of care for this previously uninsured group were not substantially greater than those in the commercially enrolled group. A review of 1987 data from the National Medical Expenditures Survey and the Survey of Income and Program Participation from 1984 to 1988 found that persons receiving Aid to Families with Dependent Children who received Medicaid coverage were significantly more likely to use both inpatient and outpatient services than they would if they had been uninsured [15]. Other evidence of the value of access comes from research examining health-related quality-of-life outcomes for HIV-infected low-income and medically indigent persons [16]. Using interviews on access from 196 public hospital clinic patients participating in the HIV Outcomes Study, the authors found significantly better quality-of-life outcomes (such as freedom from pain and improved social and cognitive function) among persons who were in moderate physical and mental health and had greater access to services than those of similar health but with poorer access (access measures were based on Medical Outcomes Study responses). Several studies have documented the adverse effect of lack of health insurance on outcomes and quality of care. A 1991 report by Hadley and colleagues [17] comparing privately insured and uninsured hospital patients according to admission, use of resources, and discharge outcome found that with few exceptions, persons without insurance had a greater likelihood of dying in the hospital. A 1993 study by Franks and associates [18] found lack of health insurance to be more highly correlated with death among adults who were followed over several years. A report on birth outcomes in ethnic minority women suggests the positive outcome that can be derived from reducing financial access barriers [19]. For eligible Medicaid recipients, a New Jersey initiative increased the number of prenatal visits available; increased provider reimbursement; and enhanced other service support, including follow-up after pregnancy, case coordination, and health education. Program evaluation found an increase of almost 56 g in mean birth weight and a 3.7% reduction in the likelihood of having a low-birth-weight infant. Because low birth weight is associated with more problems in children, the ability to increase perinatal weight through improved access to health care implies healthier outcomes for a population of con

Health Reform Holds Both Risks And Rewards For Safety-Net Providers And Racially And Ethnically Diverse Patients

The Affordable Care Act of 2010 creates both opportunities and risks for safety-net providers in caring for low-income, diverse patients. New funding for health centers; support for coordinated, patient-centered care; and expansion of the primary care workforce are some of the opportunities that potentially strengthen the safety net. However, declining payments to safety-net hospitals, existing financial hardships, and shifts in the health care marketplace may intensify competition, thwart the ability to innovate, and endanger the financial viability of safety-net providers. Support of state and local governments, as well as philanthropies, will be crucial to helping safety-net providers transition to the new health care environment and to preventing the unintended erosion of the safety net for racially and ethnically diverse populations.

The Changing Landscape of Hospital Capacity in Large Cities and Suburbs: Implications for the Safety Net in Metropolitan America

An analysis of trends in hospital use and capacity by ownership status and community poverty levels for large urban and suburban areas was undertaken to examine changes that may have important implications for the future of the hospital safety net in large metropolitan areas. Using data on general acute care hospitals located in the 100 largest cities and their suburbs for the years 1996, 1999, and 2002, we examined a number of measures of use and capacity, including staffed beds, admissions, outpatient and emergency department visits, trauma centers, and positron emission tomography scanners. Over the 6-year period, the number of for-profit, nonprofit, and public hospitals declined in both cities and suburbs, with public hospitals showing the largest percentage of decreases. By 2002, for-profit hospitals were responsible for more Medicaid admissions than public hospitals for the 100 largest cities combined. Public hospitals, however, maintained the longest Medicaid average length of stay. The proportion of urban hospital resources located in high poverty cities was slightly higher than the proportion of urban population living in high poverty cities. However, the results demonstrate for the first time, a highly disproportionate share of hospital resources and use among suburbs with a low poverty rate compared to suburbs with a high poverty rate. High poverty communities represented the greatest proportion of suburban population in 2000 but had the smallest proportion of hospital use and specialty care capacity, whereas the opposite was true of low poverty suburbs. The results raise questions about the effects of the expanding role of private hospitals as safety net providers, and have implications for poor residents in high poverty suburban areas, and for urban safety net hospitals that care for poor suburban residents in surrounding communities.

U.s. Hospital Care for Hiv-infected Persons and the Role of Public, Private, and Veterans Administration Hospitals

Hospitals are a major provider of medical care for human immunodeficiency virus (HIV)-infected persons. Although utilization and patterns of care profiles in public and private hospitals have been evaluated for acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), one of the most costly and common severe complications of AIDS, information from Veterans Administration (VA) hospitals has not been reported previously. This article reports on inpatient care for PCP patients by obtaining data from VA, private, and public hospitals. Cost and resource utilization data were obtained from reviews of medical records, claims, and provider bills from 26 non-VA hospitals and 18 VA hospitals in 10 cities in the United States. Data on severity of illness, patterns of care, and outcomes for PCP were obtained from medical record reviews from 2,174 PCP cases treated in 82 non-VA and 14 VA hospitals in five U.S. cities. Estimates were made of the average costs and the rates of use of diagnostic tests, anti-PCP medications, and intensive care units for samples of public hospital, private hospital, and VA patients with PCP. With mean charges for a single PCP episode of

Reducing Racial and Ethnic Disparities in Disease Management to Improve Health Outcomes

14,500 to

Public hospitals and substance abuse services for pregnant women and mothers: implications for managed-care programs and Medicaid.

16,060, PCP remains one of thea most costly complications of AIDS. Although the severity of PCP illness at admission was greatest at public hospitals, the intensity of care was lowest: for frequency of cytologic diagnosis (48% at public, 62% at VA, and 66% at private hospitals), bronchoscopy (45% at public, 60% at VA, and 66% at private hospitals), and intensive care unit use (11% at public, 22% at VA, and 19% at private hospitals). In-hospital mortality rates for PCP also differed in the three types of hospitals (20% at public, 24% at VA, and 18% at private hospitals). Patterns of PCP care differ among VA, public, and private hospitals. Future studies on the HIV epidemic should include data collected from uniform data sources from VA hospitals, in addition to public and private hospitals, to provide insight on the processes of care and outcomes for HIV-infected persons.

Integrating racially and ethnically diverse communities into planning for disasters: the California experience.

The heightened awareness of substantial racial and ethnic disparities in health outcomes has major implications for how healthcare providers effectively manage health conditions among diverse populations. This report identifies five dimensions that address the major causes of disparities that can exert significant influence over the success and quality of the patient-physician relationship, treatment plans, and health outcomes. These five dimensions are (i) biological and genetic influences; (ii) differential access to care; (iii) quality of care disparities; (iv) clinical-patient perceptions and realities; and (v) language and communication barriers.Recommended disease management actions for health practitioners and healthcare organizations focus on promoting more effective interactions between both the patient and the physician in the clinical encounter, methods for improving patient understanding, and education and information to improve treatment adherence and outcome. Educational strategies include: adapting existing protocols in the clinical setting; using communities, the internet and other sources of information; recognizing the importance of racial and ethnic concordance; and assuring competent communication and interpretation in the clinical encounter. Governments also perform several critical functions in addressing racial and ethnic disparities, such as setting the tone and offering leadership, guidance and support for practitioners and their healthcare settings.Ultimately, effective disease management will require practitioners, as well as healthcare organizations and agencies to integrate knowledge and actions around the multiple causes of ethnic and racial disparities into clinical regimens through training, on-site services and resource development.

Strategies to increase enrollment in children's health insurance programs: A report of the New York Academy of Medicine

Although an increasing proportion of the US population receives health services through managed care, pregnant women and mothers eligible for Medicaid who are involved with alcohol or other drugs are often excluded from these programs due in large part to lack of information on costs, service needs, and service use. To develop such information policy, service settings, and managed-care plans, the project conducted a national survey using a provider group with experience in caring for this population, the member universe of the National Association of Public Hospitals and Health Systems. The survey requested detailed information on hospital system information, current managed-care arrangements, outcome measurements, financing, service priorities, and service availability. The 81% response rate (n = 95) identified 35 hospital systems providing services to an average of 998 women in 1997. The majority of these systems (69%) reported coordinating care for these patients, but only 26% reported they computerize patient charts. Most use at least one indicator to measure effectiveness, and 50% use at least four. Counseling/education and transportation were seen as key support services, but many acknowledge they are not reimbursed for critical services such as nutrition education. The discussion highlights the need to provide formal support for core support services, to assist in care coordination and provide incentives for developing more sophisticated information, and to specify related services in the state Medicaid contract language.

Measuring progress in meeting healthy people goals for low birth weight and infant mortality among the 100 largest cities and their suburbs

OBJECTIVES Racially/ethnically diverse communities suffer a disproportionate burden of adverse outcomes before, during and after a disaster. Using California as a locus of study, we sought to identify challenges and barriers to meeting the preparedness needs of these communities and highlight promising strategies, gaps in programs, and future priorities. METHODS We conducted a literature review, environmental scan of organizational Web sites providing preparedness materials for diverse communities, and key informant interviews with public health and emergency management professionals. RESULTS We identified individual-level barriers to preparing diverse communities such as socioeconomic status, trust, culture, and language, as well as institutional-level barriers faced by organizations such as inadequate support for culturally/linguistically appropriate initiatives. Current programs to address these barriers include language assistance services, community engagement strategies, cross-sector collaboration, and community assessments. Enhancing public-private partnerships, increasing flexibility in allocating funds and improving organizational capacity for diversity initiatives were all identified as additional areas of programmatic need. CONCLUSIONS Our study suggests at least four intervention priorities for California and across the United States: engaging diverse communities in all aspects of emergency planning, implementation, and evaluation; mitigating fear and stigma; building organizational cultural competence; and enhancing coordination of information and resources. In addition, this study provides a methodological model for other states seeking to assess their capacity to integrate diverse communities into preparedness planning and response.

Trends in community mental health programming.

9 Nationwide, 4.7 million children 18 years and under are eligible for, but not enrolled in, Medicaid. 9 Over 770,000 New York State children (approximately 15%) are uninsured. 9 Among uninsured children in New York State, 37% are estimated to be Medicaid eligible, and in 1999, an estimated 27% will be eligible for Child Health Plus. 9 Nearly three-quarters of uninsured children in New York City are eligible for, but not enrolled in, Medicaid or Child Health Plus.