Availability of safety net providers and access to care of uninsured persons

OBJECTIVE: To understand how proximity to safety net clinics and hospitals affects a variety of measures of access to care and service use by uninsured persons. DATA SOURCES: The 1998-1999 Community Tracking Study household survey, administered primarily by telephone survey to households in 60 randomly selected communities, linked to data on community health centers, other free clinics, and safety net hospitals. STUDY DESIGN: Instrumental variable estimation of multivariate regression models of several measures of access to care (having a usual source of care, unmet or delayed medical care needs, ambulatory service use, and overnight hospital stays) against endogenous measures of distances to the nearest community health center and safety net hospital, controlling for characteristics of uninsured persons and other area characteristics that are related to access to care. The models are estimated with data from a nationally representative sample of uninsured people. PRINCIPAL FINDINGS: Shorter distances to the nearest safety net providers increase access to care for uninsured persons. Failure to account for the endogeneity of distance to safety net providers on access to care generally leads to finding little or no safety net effects on access. CONCLUSIONS: Closer proximity to the safety net increases access to care for uninsured persons. However, the improvements in access to care are relatively small compared with similar measures of access to care for insured persons. Modest expansion of the safety net is unlikely to provide a full substitute for insurance coverage expansions.     

A partnership to reduce African American infant mortality in Genesee County,Michigan

A partnership in Genesee County, Michigan, has been working to reduce African American infant mortality. A plan was developed utilizing "bench" science and community residents' "trench" knowledge. Its theoretical foundation is ecological, grounded in a philosophy of public health as social justice, and based on the understanding that cultural beliefs and practices can be both protective and harmful. Partners agree that no single intervention will eliminate racial disparities and that interventions must precede, include, and follow the period of pregnancy. Core themes for the work include: reducing racism, enhancing the medical care and social services systems, and fostering community mobilization. Strategies include community dialogue and raising awareness, education and training, outreach and advocacy, and mentoring and support. The evaluation has several components: scrutinizing the effect of partnership activities on direct measures of infant health; analyzing changes in knowledge, attitudes, behaviors and other mediating variables thought to influence maternal and infant health; and effecting changes in personal and organizational policy and practice.     

A model plan for the uninsured: delivering quality and affordability in a limited benefit managed care safety net program in Flint, Michigan

This paper presents the background and multiyear outcome data for a limited benefit safety-net care program in Michigan. It is a possible solution for policymakers and hospital/clinic administrators to consider when evaluating plans to provide primary care for the 30 million uninsured Americans who will be affected by the Affordable Care Act.     

Exploring the limits of the safety net: community health centers and care for the uninsured

This paper explores the extent to which community health centers (CHCs) are able to manage their uninsured patient caseloads. We found that CHCs can provide primary care, medications, and medical supplies to most of their uninsured patients on site but are limited in their ability to provide diagnostic, specialty, and behavioral health services. Uninsured patients often fail to receive additional services for which they are referred, and it is much more difficult for CHC physicians to arrange specialty or nonemergency hospital care for their uninsured patients than for their insured patients.     

The vanishing health care safety net: new data on uninsured Americans.

New data obtained from the Census Bureau shows that the number of Americans without any health insurance increased by 1.3 million between 1989 and 1990, bringing the total number of uninsured to 34.7 million, more than at any time since the passage of Medicare and Medicaid 25 years ago. This increase coincided with a 10.5 percent increase in health spending, the second largest in the past three decades. The number of people covered by Medicaid grew by 3.1 million, due to a one-time expansion of eligibility mandated by Congress, but this was more than counter-balanced by a population growth of 3 million and a decrease of 1.3 million in people covered by private insurance. Had Medicaid not been expanded, the number of uninsured would have increased by 4.4 million. The increase in the uninsured affected virtually all parts of the nation. Seven states had increases of more than 100,000 persons each. Only Texas experienced a decrease of that magnitude, but still had the second highest rate of uninsurance of any state. Of the 1.3 million additional uninsured in 1990, 77 percent were male, 32 percent had family incomes in excess of $50,000 per year, and 74 percent had annual family incomes above $25,000. Fewer than 9 percent had incomes below the poverty line. The numbers of uninsured children and senior citizens fell slightly (but not significantly), while the number of uninsured working-age adults rose by 1.4 million. The number of uninsured workers in each of four of 20 major industry groups increased by more than 100,000 in 1990. None of the industry groups showed a significant decline in the number of uninsured. Among professionals, there were substantial numbers of uninsured doctors, engineers, teachers, college professors, clergy, and others, but all legislators and judges were insured. The data presented here largely predate the recession and understate current problems. In 1991 the number of uninsured will likely reach nearly 40 million. Also, these estimates are based on the number of people uninsured at a single time during 1990; a far higher number were temporarily uninsured at some point during the year. Moreover the Census Bureau survey ignores the problem of the underinsurance of at least 50 million insured Americans. Patchwork public programs are grossly inadequate to plug the holes. A national health program covering all Americans could assure access to care and contain costs.     

Covering the uninsured in 2008: current costs, sources of payment, and incremental costs

People uninsured for any part of 2008 spend about $30 billion out of pocket and receive approximately $56 billion in uncompensated care while uninsured. Government programs finance about 75 percent of uncompensated care. If all uninsured people were fully covered, their medical spending would increase by $122.6 billion. The increase represents 5 percent of current national health spending and 0.8 percent of gross domestic product. However, it is neither the cost of a specific plan nor necessarily the same as the government's costs, which could be higher, depending on plans' financing structures and the extent of crowd-out.     

The uninsured, the working uninsured, and the public

Recent opinion surveys show a high level of public support for the current employer-based health insurance system. Many Americans are not aware that this system is endangered or that the number of uninsured persons is growing. The public appears to favor a two-track system for the working uninsured--strengthening the existing employer-based system and developing a parallel system for those without employer coverage.     

Public housing relocations in Atlanta,Georgia, and declines in spatial access to safety net primary care

This analysis investigates changes in spatial access to safety-net primary care in a sample of US public housing residents relocating via the HOPE VI initiative from public housing complexes to voucher-subsidized rental units; substance misusers were oversampled. We used gravity-based models to measure spatial access to care, and used mixed models to assess pre-/post-relocation changes in access. Half the sample experienced declines in spatial access of ≥79.83%; declines did not vary by substance misuse status. Results suggest that future public housing relocation initiatives should partner with relocaters, particularly those in poor health, to help them find housing near safety-net clinics.     

UCHP: a case study of access for the medically uninsured

Utah Community Health Plan (UCHP) is one of fifteen Robert Wood Johnson Foundation Programs for the uninsured. The experience of UCHP is similar to the other nine demonstration programs for the uninsured who have actually enrolled individuals: offering premium subsidies to uninsured small employers is an ineffective way to expand coverage among the working uninsured.     

Don't let the numbers fool you. While the latest statistics show the number of uninsured dropped in 2007, safety net providers aren't celebrating

While the number of the uninsured dropped in 2007, safety net providers say that doesn't tell the whole story. "Many of these folks have such poorly constructed insurance policies ... that most of their healthcare expenses end up as bad debt anyway," says John Bluford, left, of Truman Medical Centers.     

Increasing access to care for the uninsured: considering the options in California counties

We interviewed California county health agency staff and administered a 58-county survey in 2002 and 2004 to inventory programs designed to improve access to care for the uninsured, and to assess county ability to meet the needs of California's uninsured during slow economic periods. Most counties have established means to connect people to existing public insurance programs and services have been expanded. Growth in new health care insurance programs for children and modest growth for adults are apparent. Counties pursue funding opportunities by a variety of strategies (e.g., leveraging of existing funding to secure new funds such as federal Healthy Community Access Program (HCAP) grants). While counties vary in their resources, political will, and barriers to care, they share a strong commitment to access to care. The implications of local efforts for state and federal policymaking are significant. In the absence of federal or state reform, county initiatives, particularly children's coverage expansions, may coalesce into state-level reform. Second, the state may move closer to access to health care for all as it recognizes the complementarity of county programs.