Health Differences Among Lumbee Indians Using Public and Private Sources of Care

CONTEXT: Of 2.4 million American Indians, approximately 60% are eligible to receive Indian Health Service (IHS) benefits, leaving many to seek care elsewhere. It is unknown if their quality of care, health behaviors, and health status vary by source of care, as demonstrated for other populations. PURPOSE: The purpose of this study was to determine whether preventive services, health behaviors, and number of health conditions vary as a function of having non-IHS public versus private physicians as sources of usual care. METHODS: 1,177 Lumbee Indians, who are ineligible to receive IHS services, completed a telephone interview that included information on receipt of preventive measures, tobacco use, physical activity, breast self-examination, and medical conditions. Frequencies, chi-squares, t tests, odds ratios, and confidence intervals were used to compare variables by source of care. FINDINGS: 939 respondents (80%) had a private and 210 (18%) a public health clinic physician as their usual source of care; 28 (2%) reported having neither. Logistic regression analyses, restricted to the 1,149 participants who reported either a private or public source of care, revealed no differences in receipt of preventive services or health status by usual source of care. Smokeless tobacco use was less common among persons using private than public providers. CONCLUSIONS: Lumbees whose usual source of care was a public clinic physician did not differ in receipt of preventive services or in health status compared to their counterparts who received care from a private physician. More targeted research into health similarities and differences arising from access to public and private sources of care is warranted.     

Insurance status and access to health services among poor persons.

OBJECTIVE: We examine the relationship between health insurance status and access to care among low-income persons 65 years of age and under, taking into account their social demographic characteristics and health care needs. DATA SOURCES AND STUDY SETTING. Study groups consist of the subsamples of persons with incomes between 100 and 150 percent of the federal poverty level and those below the federal poverty level interviewed in the 1983, 1984, and 1986 Health Interview Surveys (HIS) of the National Center for Health Statistics. Sample sizes range from about 6,000 to 11,000 depending on the proportion of each study group administered the insurance supplement. STUDY DESIGN. Annual visits and whether hospitalized during a year are used as measures of access to medical care. The analysis consists of identifying predictors of use of services (i.e., health status and social characteristics) and, taking them into account, examining the relationship of insurance status to access to care. This was first undertaken on the 1983 survey; the models obtained then are replicated on the other two years of data. DATA COLLECTION/EXTRACTION METHODS. The HIS utilizes in-person interviews to gather health and medical history information from a stratified random sample of the U.S. population. Data were obtained through public use tapes distributed by the National Center for Health Statistics. PRINCIPAL FINDINGS. Results are consistent for all three years among persons in poverty. Being covered by Medicaid, in contrast to having private insurance or being without health insurance, is related to use of both ambulatory care and hospital care. The access differences for persons in poverty, regardless of their vulnerability or "risk" of requiring medical care, are marked and generally statistically significant. Among the near-poor the same findings occur, although the differences are less sharp and less often statistically significant. CONCLUSIONS. The most obvious explanation is that the poor, and to a considerable extent the near-poor, have limited access because of copayments and deductibles that are typically part of private insurance coverage. The findings raise policy questions regarding the utility of either "play or pay" employer-provided insurance or income tax deductions to increase access.     

Primary health concept revisited: where do people seek health care in a rural area of Vietnam?

The government of Vietnam is committed to promote and secure equity in access to health care for all citizens. The current rapid changes towards a market economy may challenge the government's wish for maintaining equity, especially for low income and vulnerable groups. The aim of this study was to investigate aspects of access and utilisation of health care of rural people. The study included a random sample of 1075 out of the 11,547 households in the Field Laboratory in Bavi district, northern Vietnam and a structured questionnaire was used. The results indicate that self-treatment is common practice and private providers are an important source of health services not only for those who are better off but also for poor households. The costs for health care are substantial for households, and lower income groups spent a significantly higher proportion of their income on health care than the rich did. The poor are deterred from seeking health care more often than the rich and for financial reason. As regards sources for payments, the poor relied much more on borrowing money to pay for their health care needs, while those who are better off relied mostly on household savings. A burden of high cost for treatment implies high risks for families to fall into a 'medical poverty trap'. Our findings suggest a need for developing risk-sharing schemes (co-payment, pre-payment and insurance), and appropriate allocation of scarce public resources. We suggest that the private health care sector needs both support and regulations to improve the quality and access to health care by the poor.     

What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?

This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households. There is growing evidence of households being pushed into poverty or forced into deeper poverty when faced with substantial medical expenses, particularly when combined with a loss of household income due to ill-health. Health sector reforms in LMICs since the late 1980s have particularly focused on promoting user fees for public sector health services and increasing the role of the private for-profit sector in health care provision. This has increasingly placed the burden of paying for health care on individuals experiencing poor health. This trend seems to continue even though some countries and international organisations are considering a shift away from their previous pro-user fee agenda. Research into alternative health care financing strategies and related mechanisms for coping with the direct and indirect costs of illness is urgently required to inform the development of appropriate social policies to improve access to essential health services and break the vicious cycle between illness and poverty.     

The health care of poor persons living in wealthy areas

This paper describes the problems inherent in targeting new health care initiatives to disadvantaged communities rather than to disadvantaged persons in the 100 wealthiest counties in the United States. The barriers to care experienced by such persons are generally comparable to those of other poor persons. Deprivations in access to care appear to be caused by poverty per se and not by the characteristics of the places in which the poor live. It is suggested that per capita income not be used as a criterion for the allocation of health care resources. The actual number of poor persons in a geographic area is a better criterion for determining the need for public health care programs.     

Health care provider choice: the North West Province of Cameroon

Health care is provided in many developing countries free of any charge at the point of delivery. This is attributed to the fact that health care is one of the basic human rights. While modern health care in public health units is free, patients in rural areas continue to use either self-care, traditional healers or both. In Cameroon, the idea of integrating traditional and modern medical practices is discussed by both traditional and medical practitioners. However, it is not very clear what influences the household's choice of one or the other. Within a health district, where there are many providers, the question as to whether or not there is a possibility of choice open to all is posed. This article reports on a study undertaken in a rural health district that shows that there are many factors that influence the choice of health care. Among these factors is quality of care which is the most important factor influencing the choice of health care provider. As quality of care increases in governmental health centres, their choice probability also increases. Other factors include: the time spent seeking treatment; household income and size; distance; and, cost of health care. Those with higher incomes tend to choose private health units and those with larger families tend to choose government health units. Other socio-cultural factors, difficult to model, appear to also influence the choice of providers. It is concluded that since household income influences the choice of private health units, policies targeting poverty alleviation should be instituted in the rural areas to provide households with income. This will enable them widened access to private health care and enable government to redeploy its scarce resources to maintain and extend services to needy areas.     

Optimizing Distribution of Pandemic Influenza Antiviral Drugs

We provide a data-driven method for optimizing pharmacy-based distribution of antiviral drugs during an influenza pandemic in terms of overall access for a target population and apply it to the state of Texas, USA. We found that during the 2009 influenza pandemic, the Texas Department of State Health Services achieved an estimated statewide access of 88% (proportion of population willing to travel to the nearest dispensing point). However, access reached only 34.5% of US postal code (ZIP code) areas containing <1,000 underinsured persons. Optimized distribution networks increased expected access to 91% overall and 60% in hard-to-reach regions, and 2 or 3 major pharmacy chains achieved near maximal coverage in well-populated areas. Independent pharmacies were essential for reaching ZIP code areas containing <1,000 underinsured persons. This model was developed during a collaboration between academic researchers and public health officials and is available as a decision support tool for Texas Department of State Health Services at a Web-based interface.     

Physician visits, hospitalizations, and socioeconomic status: ambulatory care sensitive conditions in a canadian setting

OBJECTIVE: To determine whether rates of physician visits for ambulatory care sensitive (ACS) conditions are lower for people of low-socioeconomic status than of high-socioeconomic status in an urban population with universal health care coverage. DATA SOURCES/STUDY SETTING: Physician claims and hospital discharge abstracts from fiscal years 1998 to 2001 for urban residents of Manitoba, Canada. The 1996 Canadian Census public use database provided neighborhood household income information. The study included all continuously enrolled urban residents in the Manitoba Health Services Insurance Plan. STUDY DESIGN: Twelve ACS conditions definable using 3-digit ICD-9-CM codes permitted cross-sectional and longitudinal comparison of ambulatory visits and hospitalizations. Neighborhood household income data provided a measure of socioeconomic status. DATA COLLECTION/EXTRACTION METHODS: Files were extracted from administrative data housed at the Manitoba Centre for Health Policy. PRINCIPAL FINDINGS: All conditions showed a socioeconomic gradient with residents of the lowest income neighborhoods having both more visits and more hospitalizations than their counterparts in higher income areas. Six of nine conditions with a sufficient N showed individuals living in the lowest income neighborhoods to have significantly more ambulatory visits before hospitalization for an ACS condition than did those in the most affluent neighborhoods. Many conditions showed a gradient in rate of hospitalization even after controlling for the number of ambulatory care visits. CONCLUSIONS: In the Canadian universal health care plan, the poor have reasonable access to ambulatory care for ACS conditions. Ambulatory care may be more effective in preventing hospitalizations among relatively affluent individuals than among the less well off.     

Health insurance coverage among persons with AIDS: results from a multistate surveillance project.

To determine factors associated with health insurance coverage among persons with acquired immunodeficiency syndrome (AIDS), we interviewed 1958 persons 18 years of age or older who were reported to have AIDS in 11 states and cities. Overall, 25% had no insurance, 55% had public insurance, and 20% had private insurance. Factors associated with lack of insurance varied by current employment status. Employed persons with an annual household income of less than $10,000 were 3.6 times more likely to lack insurance than employed persons with a higher income. Unemployed persons diagnosed with AIDS for less than 1 year were two times more likely to lack health insurance than unemployed persons diagnosed for a longer time. Making insurance available to persons identified as most likely to lack insurance should improve access to care for persons with AIDS.     

The effects of child-only insurance coverage and family coverage on health care access and use: recent findings among low-income children in California

OBJECTIVE: To compare the extent with which child-only and family coverage (child and parent insured) ensure health care access and use for low income children in California and discuss the policy implications of extending the State Children's Health Insurance Program (California's Healthy Families) to uninsured parents of child enrollees. DATA SOURCES/SETTING: We used secondary data from the 2001 California Health Interview Survey (CHIS), a representative telephone survey. STUDY DESIGN: We conducted a cross-sectional study of 5,521 public health insurance-eligible children and adolescents and their parents to examine the effects of insurance (family coverage, child-only coverage, and no coverage) on measures of health care access and utilization including emergency room visits and hospitalizations. DATA COLLECTION: We linked the CHIS adult, child, and adolescent datasets, including the adolescent insurance supplement. FINDINGS: Among the sampled children, 13 percent were uninsured as were 22 percent of their parents. Children without insurance coverage were more likely than children with child-only coverage to lack a usual source of care and to have decreased use of health care. Children with child-only coverage fared worse than those with family coverage on almost every access indicator, but service utilization was comparable. CONCLUSIONS: While extending public benefits to parents of children eligible for Healthy Families may not improve child health care utilization beyond the gains that would be obtained by exclusively insuring the children, family coverage would likely improve access to a regular source of care and private sector providers, and reduce perceived discrimination and breaks in coverage. These advantages should be considered by states that are weighing the benefits of expanding health insurance to parents.     

Innovative health service delivery models in low and middle income countries - what can we learn from the private sector?

Background  

The poor in low and middle income countries have limited access to health services due to limited purchasing power, residence in underserved areas, and inadequate health literacy. This produces significant gaps in health care delivery among a population that has a disproportionately large burden of disease. They frequently use the private health sector, due to perceived or actual gaps in public services. A subset of private health organizations, some called social enterprises, have developed novel approaches to increase the availability, affordability and quality of health care services to the poor through innovative health service delivery models. This study aims to characterize these models and identify areas of innovation that have led to effective provision of care for the poor.     

Outpatient care utilization in urban Kerala, India

CONTEXT: Kerala is characterized by a high density of public and private health infrastructure. While less inequality in access has been reported in this Indian state, few studies have looked at problems found within cities. Escalation of costs of private services and reduced public investments could generate some inequalities in access for the poor. OBJECTIVE: To assess factors associated with utilization and source of outpatient care in urban Kerala, and to discuss policy implications with regards to access to care. METHODS: A multilevel analysis of individual and urban characteristics associated with utilization and source of outpatient care was conducted using data from a 1995-96 survey by the National Sample Survey Organisation on health care in urban Kerala. RESULTS: There is a high level of utilization (83.6%) of allopathic medical services. Controlling for illness severity and age, utilization thereof was lower for the very poor (OR 0.13 [0.03; 0.49]), inhabitants of medium towns (OR 0.20 [0.05; 0.70]), and inhabitants of cities with a lower proportion of permanent material (pucca) houses (0.21 [0.06; 0.72]). Among all users, 77% resorted to a private source of care. Utilization of a private provider was less likely for the very poor (OR 0.13 [0.03; 0.51]) and individuals from casual worker households (OR 0.54 [0.30; 0.97]), while it was more likely for inhabitants of cities from both low public bed density districts (OR 4.08 [1.05; 15.95]) and high private bed density districts (OR 5.83 [2.34; 14.53]). Problems of quality and accessibility of the public sector were invoked to justify utilization of private clinics. A marked heterogeneity in utilization of outpatient care was found between cities of various sizes and characteristics. CONCLUSION: This study confirms high utilization of private outpatient care in Kerala and suggests problems of access for the poorest. Even in a context of high public availability and considering the health transition factor, relying on the development of the private sector to respond to increasing health care needs could create inequalities in access. Investing in the public urban primary care system and ensuring access to quality health care for the poorest is warranted.     

Socioeconomic inequalities in access to health care: examining the case of Burkina Faso

The past decade has recorded remarkable interest in socioeconomic inequalities in health care. A multivariate analysis of the World Health Survey data for Burkina Faso was conducted using STATA. This included questions on household economic factors, perceived need, and access to health care. Poverty was defined using Principal Components Analysis. There was no significant difference in perceived need on the basis of poverty or gender. The less poor accessed health care more than the poor, but this difference was significant only among males. Respondents who lived in urban areas accessed health care more than those in rural areas, but this difference was significant only among females. We argue that health care financing arrangements affect self-reported need and access to health care. Even when they perceive need, the poor do not access care, probably because of cost, exacerbated by non-availability of readily accessible health care facilities.     

Use of clinic versus private family planning care by low-income women: access, cost, and patient satisfaction.

Use of private physicians versus public family planning facilities by poverty level and near poverty level women was examined by means of a sample survey conducted in low-income areas of Los Angeles County. Utilization differed by race/ethnicity, with Hispanics more likely to go to federally subsidized family planning clinics (primarily county-run), Whites and Blacks to private physicians. Private family planning offers easier access, greater convenience, and higher satisfaction, albeit at almost double the cost. Clinic usage is influenced by lack of a regular source of medical care and lack of insurance coverage more than poverty level per se. Clinic patients report greater patient education regarding contraceptive methods, but less general medical care during clinic visits. They are more likely than private patients to express a desire for a different source of family planning care.     

Integrating microfinance and health strategies: examining the evidence to inform policy and practice

INTRODUCTION: Single solutions continue to be inadequate in confronting the prevalent problems of poverty, ill health and insufficient health system capacity worldwide. The poor need access to an integrated set of financial and health services to have income security and better health. Over 3500 microfinance institutions (MFIs) provide microcredit and financial services to more than 155 million households worldwide. Conservative estimates indicate that at least 34 million of these households are very poor by the definition in the Millennium Development Goals, representing around 170 million people, many in remote areas beyond the reach of health agencies, both private and governmental. A small but increasing number of MFIs offer health-related services, such as education, clinical care, community health workers, health-financing and linkages to public and private health providers. REVIEW OF EVIDENCE: Multiple studies indicate the effectiveness of microfinance and its impact on poverty. A small but growing number of studies also attempt to show that MFIs are capable of contributing to health improvement by increasing knowledge that leads to behavioural changes, and by enhancing access to health services through addressing financial, geographic and other barriers. While these studies are of uneven quality, they indicate positive health benefits in diverse areas such as maternal and child health, malaria and other infectious disease, and domestic violence. While more rigorous research is needed to inform policy and guide programme implementation to integrate microfinance and health interventions that can reliably enhance the well-being of the poor, there is useful evidence to support the design and delivery of integrated programmes now. CONCLUSION: Worldwide, current public health programmes and health systems are proving to be inadequate to meet population needs. The microfinance sector offers an underutilized opportunity for delivery of health-related services to many hard-to-reach populations.     

Variation in the ecology of medical care

BACKGROUND: We wanted to quantify how the location in which medical care is delivered in the United States varies with the sociodemographic characteristics and health care arrangements of the individual person. METHODS: Data from the 1996 Medical Expenditures Panel Survey (MEPS) were used to estimate the number of persons per 1,000 per month in 1996 who had at least 1 contact with physicians' offices, hospital outpatient departments, or emergency departments, hospitals, or home care. These data were stratified by age, sex, race, ethnicity, household income, education of head of household, residence in or out of metropolitan statistical areas, having health insurance, and having a usual source of care. RESULTS: Physicians' offices were overwhelmingly the most common site of health care for all subgroups studied. Lacking a usual source of care was the only variable independently associated with a decreased likelihood of care in all 5 settings, and lack of insurance was associated with lower rates of care in all settings but emergency departments. Generally, more complicated patterns emerged for most sociodemographic characteristics. The combination of having a usual source of care and health insurance was especially related to higher rates of care in all settings except the emergency department. CONCLUSION: Frequency and location of health care delivery varies substantially with sociodemographic characteristics, insurance, and having a usual source of care. Understanding this variation can inform public consideration of policy related to access to care.     

Evaluation of a primary health care program for the poor

This paper examines the success in implementing a major program involving a partnership between public and private providers to deliver primary health care services to the poor. In 1985, the 69th Texas Legislature passed the Primary Health Care Services Act, authorizing the Texas Department of Health to contract for or directly provide primary health care services in those parts of the state that are medically underserved and have large numbers of people in poverty. This paper evaluates the potential impact of the projects with respect to access and cost. The study revealed that the basic concept of allowing local public and private providers to develop projects reflecting their community's unique needs and resources was successful. The approach lead to a wide variety of different types of projects, but the basic goals and activities of the projects are consistent with the legislation. The evaluation identified three major program areas that could be improved: (1) patient monitoring and follow-up to ensure the accessibility of the priority primary care services, (2) the need for the development of projects in other high need areas of the state, and (3) greater efficiency in service delivery.Charles E. Begley, Ph.D. is an Assistant Professor at the School of Public Health, The University of Texas Health Science Center at Houston, P.O. Box 20186, Houston, Texas 77225.Lu Ann Aday, Ph.D. is an Associate Professor at the School of Public Health, The University of Texas Health Science Center at Houston.Roy McCandless is a Faculty Associate, Center for Health Policy Studies, School of Public Health, The University of Texas Health Science Center at Houston.The research on which this paper is based was supported by the Bureau of Dental and Chronic Disease Prevention, Texas Department of Health. The authors wish to acknowledge the substantial contributions of Margaret Frank, M.H.S. and Kiyoko Parrish, M.P.H., Faculty Associates with the Center for Health Policy Studies, in the development and conduct of this research.     

Report on a seminar on financing and service delivery issues in caring for the medically underserved

Current national activities directed toward improving access to health care and assessing the potential effectiveness of various financing and service delivery strategies were reviewed by an invited group of 39 public and private sector health policy experts. Health care access problems of the medically underserved population were defined and a range of strategies for addressing them were presented. The seminar was held at Columbia, MD, July 6-7, 1988, sponsored jointly by the Robert Wood Johnson Foundation and the Health Resources and Services Administration, PHS.     

Assessing spatial and nonspatial factors for healthcare access: towards an integrated approach to defining health professional shortage areas

This research considers both spatial and nonspatial factors in examining accessibility to primary healthcare in Illinois. Spatial access emphasizes the importance of geographic barrier between consumer and provider, and nonspatial factors include nongeographic barriers or facilitators such as age, sex, ethnicity, income, social class, education and language ability. The population and socioeconomic data are from the 2000 Census, and the primary care physician data for the same year are provided by the American Medical Association. First, a two-step floating catchment area method implemented in Geographic Information Systems is used to measure spatial accessibility based on travel time. Secondly, the factor analysis method is used to group various sociodemographic variables into three factors: (1) socioeconomic disadvantages, (2) sociocultural barriers and (3) high healthcare needs. Finally, spatial and nonspatial factors are integrated to identify areas with poor access to primary healthcare. The research is intended to develop an integrated approach for defining Health Professional Shortage Areas (HPSA) that may help the US Department of Health and Human Services and state health departments improve HPSA designation.     

Insurance, income, and access to ambulatory care in King County, Washington.

OBJECTIVES. We studied simultaneous effects of income and insurance on access measures in an indigent population, focusing on Medicaid and the marginal effects of increasing income. METHODS. Surveys were distributed in waiting rooms of county clinics and welfare offices. Models examined insurance (private, Medicaid, or none), income (to twice the poverty level), single-parent status, age, gender, and presence of a regular source of care; first-order interactions were evaluated. RESULTS. In terms of ease of access, postponing care, and having a regular source of care, uninsured respondents fared worst and Medicaid recipients were at an intermediate level. However, relative to those with private insurance, Medicaid recipients had four times the odds, and uninsured respondents twice the odds of being denied care. Income had no consistent effect; however, older, poorer people may have greater problems. For preventive services, income was significant, while differences between Medicaid and private insurance were generally not significant. CONCLUSIONS. Except for denial of care, access for indigent people is improved by Medicaid but remains worse than the access of those with private insurance. Income had variable effects, but support for income criteria used for public insurance eligibility was not found.