Roberta Wyn

Access to Medical Care for Low-Income Persons: How do Communities Make a Difference?

This paper considers the impact of community-level variables over and above the effects of individual characteristics on healthcare acess for low-income children and adults residing in large metropolitan statistical areas (MSAs). Further, we rank MSAs’ performance in promoting healthcare access for their low-income populations. The individual-level data come from the 1995 and 1996 National Health Interview Survey (NHIS). The community-level variables are derived from multiple public-use data sources. The out-come variable is whether low-income individuals received a physician visit in the past twelve months. The proportion receiving a visit by MSA varied from 63% to 99% for children and from 62% to 83% for adults. Access was better for individuals with health insurance and a regular source of care and for those living in communities with more federally-funded health centers. Children residing in MSA

A framework for evaluating safety-net and other community-level factors on access for low-income populations.

The framework presented in this article extends the Andersen behavioral model of health services utilization research to examine the effects of contextual determinants of access. A conceptual framework is suggested for selecting and constructing contextual (or community-level) variables representing the social, economic, structural, and public policy environment that influence low-income peoples use of medical care. Contextual variables capture the characteristics of the population that disproportionately relies on the health care safety net, the public policy support for low-income and safety-net populations, and the structure of the health care market and safety-net services within that market. Until recently, the literature in this area has been largely qualitative and descriptive and few multivariate studies comprehensively investigated the contextual determinants of access. The comprehensive and systematic approach suggested by the framework will enable researchers to strengthen the external validity of results by accounting for the influence of a consistent set of contextual factors across locations and populations. A subsequent article in this issue of Inquiry applies the framework to examine access to ambulatory care for low-income adults, both insured and uninsured.

Effects of Community Factors on Access to Ambulatory Care for Lower-Income Adults in Large Urban Communities:

This study examines the effects of community-level and individual-level factors on access to ambulatory care for lower-income adults in 54 urban metropolitan statistical areas in the United States. Drawing on a conceptual behavioral and structural framework of access, the authors developed multivariate models for insured and uninsured lower-income adults to assess the adjusted effects of community- and individual-level factors on two indicators of access: having a usual source of care, and having at least one physician visit in the past year. Several community factors influenced access, but they did so differently for insured and uninsured adults and for the two measures of access used. The findings of this study confirm that public policies and community environment have measurable and substantial impacts on access to care, and that expanded public resources, such as Medicaid payments and safety-net clinics, can lead to measurable improvements in access for vulnerable populations residing in large urban areas.

Access to Care for Low-Income Women: The Impact of Medicaid

This study was undertaken to assess how low-income women with Medicaid, private insurance, or no insurance vary with regard to personal characteristics, health status, and health utilization. Data are from a telephone interview survey of a representative cross-sectional sample of 5,200 low-income women in Minnesota, Oregon, Tennessee, Florida, and Texas. On the whole, low-income women were found to experience considerable barriers to care; however, uninsured low-income women have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts. Women on Medicaid had access to care that was comparable with their low-income privately insured counterparts, but in general had significantly lower satisfaction with their providers and their plans. Future federal and state efforts should focus on expanding efforts to improve the scope and reach of health care coverage to low-income women through public or private means.

Women’s health issues across the lifespan

This study examines differences and similarities in womens health status, health care needs, and access to care across age groups. Data are from the Commonwealth Fund 1998 Survey of Womens Health. Several age-group specific issues stand out, such as more limited access to health insurance and a usual source of care among younger women, the emergence of chronic health care problems among women in the 45-64 age group, and the presence of multiple health problems among elderly women. The analyses reveal several themes that cut across age groups, such as the relationship between poverty and health status, the importance of health insurance, and the generally limited receipt of physician information about health-related behaviors.

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

Abstract 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, Californias response to CHIP, could improve coverage for this population.

Prevalence and Correlates of Recent and Repeat Mammography Among California Women Ages 55–79

OBJECTIVE Data on repeat mammography rates are less available than for recent screening. Two large, population-based state surveys provide the opportunity to investigate repeat and recent mammography prevalence and correlates among Californias diverse population. METHODS Data were from women aged 55-79, using the 2001 and 2005 California Health Interview Surveys. The study assessed the prevalence and correlates of recent mammography (within the past two years) and repeat mammography (mammogram within the past two years and 3-11 mammograms within the past six years). RESULTS Prevalence was 82.4% (recent) and 73.8% (repeat) in 2001, and 87.1% (recent) and 77.5% (repeat) in 2005. Correlates of lower rates were insurance status, no usual source of care, being a smoker, age 65-79, being Asian with no English proficiency, being never married, and lower absolute risk for breast cancer. Especially low ratios of repeat-to-recent mammography existed for the uninsured, and those using the emergency room or with no source of care. Unexpected findings in which unadjusted results were inconsistent with multivariable adjusted results occurred for Latinas with no English proficiency and women at 200-299% of poverty level. CONCLUSIONS Several groups of women in California remain at-risk of lower mammography utilization. However, investigators should also be alert for instances where multivariable analyses seem particularly discrepant with crude rates.

Medicaid managed care and low-income women: implications for access and satisfaction

Medicaid has provided critical health care coverage to millions of low-income women for over three decades and has been a major factor in improving their access to care. Following years of rapid spending growth, state Medicaid officials—like their counterparts in the private sector—have looked to managed care to help them reign in spending without compromising access. The move to Medicaid managed care has happened with unprecedented velocity. In 1991, less than 10% of Medicaid beneficiaries were enrolled in managed care; by 1997, nearly 50% of Medicaid beneficiaries were enrolled in a managed care plan.1 The shift to managed care has had a disproportionate effect on care received by low-income women and their children, because these are the population groups that have been targeted for initial enrollment. The elderly and people with disabilities have been enrolled to a much lesser extent. Despite this fast growth in enrollment, very little is known about how low-income women fare with Medicaid managed care generally.2 Much of the research on the effects of Medicaid managed care on access for women has focused on pregnancy and birth outcomes.3–5 Only a handful have focused on managed care and its impact more broadly on women for non–pregnancy-related services. Those studies were conducted to evaluate an earlier generation of managed care and did not find Medicaid managed care to be associated with better care and improved health outcomes for women in most cases.6 – 8 In this article we examine the impact of managed care on the adult women on Medicaid, who are the main adult Medicaid eligibility category affected by the transition to managed care. We use the Kaiser/Commonwealth Five-State Low-Income Survey to compare how low-income women with Medicaid managed care differ from women with traditional fee-for-service Medicaid and low-income women with private managed care with regard to personal and