Uninsurance,Underinsurance, and Health Care Utilization in Mexico by US Border Residents

Using data from the 2008 Cross-Border Utilization of Health Care Survey, we examined the relationship between United States (US) health insurance coverage plans and the use of health care services in Mexico by US residents of the US-Mexico border region. We found immigrants were far more likely to be uninsured than their native-born counterparts (63 vs. 27.8 %). Adults without health insurance coverage were more likely to purchase medications or visit physicians in Mexico compared to insured adults. However, adults with Medicaid coverage were more likely to visit dentists in Mexico compared to uninsured adults. Improving health care access for US residents in the southwestern border region of the country will require initiatives that target not only providing coverage to the large uninsured population but also improving access to health care services for the large underinsured population.     

Children''s Health Insurance Status, Access to and Utilization of Health Services, and Unmet Health Needs in a Rural Alabama School System

PURPOSE: This study examines the relationship between children's health insurance status and utilization of health services, establishment of a medical home, and unmet health needs over a 3-year period (1996-1998) in a rural Alabama K-12 school system. METHODS: As part of a children's health insurance outreach program, questionnaires were administered to parents of 754 children regarding health and health care access. In addition, noninvasive head-to-toe physical assessments of children were conducted on-site at 4 schools. FINDINGS: A relationship between health care utilization and insurance status was observed. Results found that insured children had 1.183 (P < .0115) times the number of medical visits as uninsured children. Among uninsured children, the time since last dental visit was 1.6 (P < .001) times longer than that of insured children. Also, insured children were 5.21 times more likely than uninsured (P < .0001) to report having a medical home. No significant differences between insured and uninsured children were found regarding unmet health needs as measured by referrals made after the children's physical assessments. CONCLUSIONS: Child health coverage is an important determining factor in the ability of families to access and utilize health care services. These findings have implications for populations in similar rural communities across the nation.     

Health Insurance Status and Eligibility Among Patients who Seek Healthcare at a Free Clinic in the Affordable Care Act Era

Free clinics provide care to over 1.8 million people in the United States every year and are a valuable safety net for uninsured and underinsured patients. The Affordable Care Act has resulted in millions of newly insured Americans, yet there is continued demand for healthcare at free clinics. In this study, we assessed health insurance status and eligibility among 489 patients who visited a free clinic in 2016. Eighty-seven percent of patients seen were uninsured, 53.1% of whom were eligible for health insurance (Medicaid or subsidized insurance premiums). The majority of these patients completed health insurance applications at their visit with the help of a navigator. A majority of patients who were not eligible for health insurance lacked citizenship status. This study highlights that a significant number of patients who visit free clinics are eligible for health insurance, and that free clinics are important sites for health insurance navigation programs.     

Expanding the Universe of Universal Coverage: The Population Health Argument for Increasing Coverage for Immigrants

As the US recession deepens, furthering the debate about healthcare reform is now even more important than ever. Few plans aimed at facilitating universal coverage make any mention of increasing access for uninsured non-citizens living in the US, many of whom are legally restricted from certain types of coverage. We conducted a critical review of the public health literature concerning the health status and access to health services among immigrant populations in the US. Using examples from infectious and chronic disease epidemiology, we argue that access to health services is at the intersection of the health of uninsured immigrants and the general population and that extending access to healthcare to all residents of the US, including undocumented immigrants, is beneficial from a population health perspective. Furthermore, from a health economics perspective, increasing access to care for immigrant populations may actually reduce net costs by increasing primary prevention and reducing the emphasis on emergency care for preventable conditions. It is unlikely that proposals for universal coverage will accomplish their objectives of improving population health and reducing social disparities in health if they do not address the substantial proportion of uninsured non-citizens living in the US.     

HEALTH INSURANCE COVERAGE,INCOME DISTRIBUTION AND HEALTHCARE QUALITY IN LOCAL HEALTHCARE MARKETS

We develop a theoretical model of a local healthcare system in which consumers, health insurance companies, and healthcare providers interact with each other in markets for health insurance and healthcare services. When income and health status are heterogeneous, and healthcare quality is associated with fixed costs, the market equilibrium level of healthcare quality will be underprovided. Thus, healthcare reform provisions and proposals to cover the uninsured can be interpreted as an attempt to correct this market failure. We illustrate with a numerical example that if consumers at the local level clearly understand the linkages between health insurance coverage and the quality of local healthcare services, health insurance coverage proposals are more likely to enjoy public support. Copyright © 2012 John Wiley & Sons, Ltd.     

Local access to care programs (LACPs): new developments in the access to care for the uninsured

Context: New, locally based health care access programs are emerging in response to the growing number of uninsured, providing an alternative to health insurance and traditional safety net providers. Although these programs have been largely overlooked in health services research and health policy, they are becoming an important local supplement to the historically overburdened safety net. Methods: This article is based on a literature review, Internet search, and key actor interviews to document programs in the United States, using a typology to classify the programs and document key characteristics. Findings: Local access to care programs (LACPs) fall outside traditional private and publicly subsidized insurance programs. They have a formal enrollment process, eligibility determination, and enrollment fees that give enrollees access to a network of providers that have agreed to offer free or reduced‐price health care services. The forty‐seven LACPs documented in this article were categorized into four general models: three‐share programs, national‐provider networks, county‐based indigent care, and local provider–based programs. Conclusions: New, locally based health access programs are being developed to meet the health care needs of the growing number of uninsured adults. These programs offer an alternative to traditional health insurance and build on the tradition of county‐based care for the indigent. It is important that these locally based, alternative paths to health care services be documented and monitored, as the number of uninsured adults is continuing to grow and these programs are becoming a larger component of the U.S. health care safety net.     

Limits to the safety net: teaching hospital faculty report on their patients' access to care

Many major teaching hospitals might not be able to offer adequate access to specialty care for uninsured patients. This study found that medical school faculty were more likely to have difficulty obtaining specialty services for uninsured than for privately insured patients. These gaps in access were similar in magnitude for public and private institutions. Initial treatment of uninsured patients at academic health centers (AHCs) does not guarantee access to specialty and other referral services, which suggests that there are limits to relying on a health care safety net for uninsured patients. AHCs and affiliated group practices should examine policies that limit access for uninsured patients.     

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.     

The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care

OBJECTIVE: To examine the extent to which health insurance coverage and available safety net resources reduced racial and ethnic disparities in access to care. DATA SOURCES: Nationally representative sample of 11,692 African American, 10,325 Hispanic, and 74,397 white persons. Nonelderly persons with public or private health insurance and those who were uninsured. STUDY DESIGN: Two cross-sectional surveys of households conducted during 1996-1997 and 1998-1999. DATA COLLECTION: Commonly used measures of access to and utilization of medical care were constructed for individuals. These measures include the following. (1) percent reporting unmet medical needs, (2) percent without a regular health care provider, and (3) no visit with a physician in the past year. FINDINGS: More than 6.5 percent of Hispanic and African Americans reported having unmet medical needs compared to less than 5.6 percent of white Americans. Hispanics were least likely to see the same doctor at their usual source of care (59 percent), compared to African Americans (66 percent) and whites (75 percent). Similarly, Hispanics were less likely than either African Americans or whites to have seen a doctor in the last year (65 percent compared to 76 percent or 79 percent). For Hispanics, more than 80 percent of the difference from whites was due to differences in measured characteristics (e.g., insurance coverage, income, and available safety net services). Differences in measured characteristics between African Americans and whites explained less than 80 percent of the access disparities. CONCLUSION: Lack of health insurance was the single most important factor in white-Hispanic differences for all three measures and for two of the white-African American differences. Income differences were the second most important factor, with one exception. Community characteristics generally were much less important, with one exception. The positive effects of insurance coverage in reducing disparities outweigh benefits of increasing physician charity care or access to emergency rooms.     

Multiple perspectives on being uninsured and barriers to health coverage in a rural western state

The purpose of this study was to describe the impact of being uninsured and barriers to obtaining health care coverage for people in a rural state. Focus groups and in-depth interviews were conducted with uninsured people, small business owners, health care providers, and key informants (such as state health officials, business leaders, and safety net providers). Uninsured people recognize the difficulties they face trying to obtain insurance and health care because of cost and ineligibility for public programs. Health care providers are frustrated in their care of the uninsured because of inability to obtain needed resources. Small business owners struggle with decisions about whether to provide health insurance or not, and find cost the greatest barrier. The impact of uninsurance on individuals, families, health care providers, and small business owners in a rural state is great, both economically and emotionally. Comprehensive approaches must be taken to increase access to health insurance and health care.     

Covering the uninsured through TennCare: does it make a difference?

Tennessee created TennCare in 1994 to address the needs of "poor and uninsured citizens ... excluded from the health care system." Under TennCare, Tennessee implemented managed care in its Medicaid program and used savings anticipated from the switch to expand insurance coverage to uninsured and uninsurable adults and children. Our analysis of the expansion suggests that it improved access to care, reduced unmet need, and encouraged use of preventive services, particularly for children. These changes coincided with higher levels of satisfaction with care among TennCare beneficiaries.     

Access to and Use of Eye Care Services in Rural Arkansas

Context: Rural residents are more likely to be uninsured and have low income.
Purpose: To determine if rural residents in Arkansas have decreased access to eye care services and use them less frequently than urban residents.
Methods: Data from the 2006 Visual Impairment and Access to Eye Care Module from the Arkansas Behavioral Risk Factor Surveillance System (BRFSS) were used in the analysis. Adults age 40 years and older were included (n = 4,289). Results were weighted to reflect the age, race, and gender distribution of the population of Arkansas. Multiple logistic regression was used to adjust for demographic differences between rural and urban populations.
Findings: Significantly fewer rural residents (45%) reported having insurance coverage for eye care services compared with residents living in urban areas (55%). Rural residents were less likely (45%) than urban residents (49%) to have had a dilated eye exam within the past year. Among residents aged 40-64, those from rural areas were more likely than their urban counterparts to report cost/lack of insurance as the main reason for not having a recent eye care visit.
Conclusions: In 2006, rates of eye care insurance coverage were significantly lower for rural residents while use of eye care services differed slightly between rural and urban residents. Rural residents in Arkansas age 40-64 would benefit from having increased access to eye care insurance and/or low cost eye care services.     

Crowd-Out and Emergency Department Utilization

When consumers gain Medicaid, their cost of healthcare changes. The direction of this change determines how utilization changes. The previously uninsured see a stark decrease in the price of primary care after gaining public insurance. Due to charity care, they may face an increase in the price of emergency department care. The previously insured see a reduction in emergency department prices and decreased access to primary care. We examine the impact of the prior insurance status of the newly publicly insured on substitution between healthcare. We base our identification on California’s LIHP and ACA Medicaid expansions. One challenge we face is estimating crowd-out. We use machine learning techniques to predict prior insurance status based on observable covariates in cross-sectional data. We find an increase in emergency department utilization caused entirely by those crowded-out whose access to primary care has decreased. We find the opposite utilization patterns for the previously uninsured.     

Uninsured Veterans Who Will Need to Obtain Insurance Coverage Under the Patient Protection and Affordable Care Act

Objectives. We examined the number and clinical needs of uninsured veterans, including those who will be eligible for the Medicaid expansion and health insurance exchanges in 2014.Methods. We analyzed weighted data for 8710 veterans from the 2010 National Survey of Veterans, classifying it by veterans’ age, income, household size, and insurance status.Results. Of 22 million veterans, about 7%, or more than 1.5 million, were uninsured and will need to obtain coverage by enrolling in US Department of Veterans Affairs (VA) care or the Medicaid expansion or by participating in the health insurance exchanges. Of those uninsured, 55%, or more than 800 000, are likely eligible for the Medicaid expansion if states implement it. Compared with veterans with any health coverage, those who were uninsured were younger and more likely to be single, Black, and low income and to have been deployed to Iraq and Afghanistan.Conclusions. The Patient Protection and Affordable Care Act is likely to have a considerable impact on uninsured veterans, which may have implications for the VA, the Medicaid expansion, and the health insurance exchanges.The Patient Protection and Affordable Care Act (ACA)1 represents one of the most significant overhauls of the US health care system and is expected to affect millions of uninsured people across the country. Military veterans constitute a particularly important segment of the population because of their service to the country, access to US Department of Veterans Affairs (VA) health care, and other special benefits after their service. However, little has been written on the potential impact of the ACA on the health and health care of veterans.2 Although the VA operates an integrated national health care system that offers free or low-cost services to eligible veterans, many veterans are not enrolled in VA health care, and some are ineligible. Enrollment in VA health care satisfies the ACA’s requirement for insurance coverage, but eligibility for VA health care is determined on the basis of a complex system of priorities, mostly based on service-connected disability, income, and age, and it generally requires a military service discharge that is other than dishonorable (i.e., honorable, general).One study estimated that only 13% (3.6 million) of veterans report receiving some or all of their health care at the VA, and the vast majority (> 20 million) receive no health care from the VA.3 Most veterans thus rely on non-VA health care and are covered by various private or other public forms of health insurance, including Medicare and Medicaid. A small, albeit important, minority of veterans have no health insurance coverage. Estimates based on data from 1987 to 2004 showed that 7.7% of veterans were uninsured (including having no VA coverage), which equates to nearly 1.8 million veterans and represents 4.7% of all uninsured US residents.4Lack of health insurance coverage is an important problem because it can hinder access to effective health care, including needed medical visits, preventive care, and other services, and it can ultimately lead to poor health, premature mortality, and high medical costs.5,6 Being uninsured is a growing problem in the United States that the ACA addresses by requiring virtually all legal US residents to have health insurance. The ACA includes various provisions to help US residents, including veterans, accomplish this.One major provision that is optional for states to implement is the expansion of Medicaid coverage to all individuals aged 18 to 65 years with incomes at or below 138% of the federal poverty level. Although not all states will implement this expansion, and the number of participating states is currently unknown, many poor, uninsured adults will be able to obtain Medicaid coverage in states that implement the Medicaid expansion. Uninsured adults who have incomes above the Medicaid expansion limit or who live in states that do not implement the Medicaid expansion will have to purchase health insurance and may participate in the health insurance exchanges.A second major provision of the ACA is the creation of health insurance exchanges in each state whereby individuals may purchase competitive health insurance plans that are eligible for federal subsidies, but those subsidies are only available to those with income above the federal poverty level. Both of these major ACA provisions are planned for implementation in 2014 and will introduce a variety of coverage options for US residents, including veterans.There has been little study of uninsured veterans and no study of the potential impact of the ACA on veterans in general. Moreover, most data that exist on veterans are based on VA data, which only contain information about veterans who use VA health services and do not include information about those who are uninsured or not covered by VA health care. However, 1 population-based study7 has provided some evidence that a substantial number of veterans are uninsured (particularly those younger than 65 years) and that many uninsured veterans are in poor health, often forego needed health care because of costs, and have equal or worse access to health care than other uninsured adults in the general population. As the country moves toward a new era of health care with the ACA and continues to engage in conflicts in the Middle East, the impact of the ACA on the health care of veterans needs to be considered.We used a recent nationally representative survey of veterans to (1) describe the proportion and characteristics of veterans who are currently uninsured because they will likely be required to obtain coverage under the ACA; (2) determine, among those who are uninsured, who will likely be eligible for the Medicaid expansion; and (3) compare the sociodemographic and health characteristics of those who are uninsured and likely eligible for Medicaid expansion (LEME), those who are uninsured and not LEME, and those who currently have health insurance coverage. The results provide information about the number and health characteristics of veterans who will likely be affected by different provisions of the ACA and inform planning efforts for the VA and states that implement the Medicaid expansion and health insurance exchanges.     

The costs and adequacy of safety net access for the uninsured in Genesee County, Michigan

This commentary examines Genesee County (Flint) Michigan to explore whether a well-structured safety net system is able to provide low-income uninsured people adequate access to care at a reasonable cost. Genessee County is one of the more economically challenged communities in the country. This commentary explores the cost and adequacy of safety net care in Genessee County under the Genessee Health Plan (GHP). The analysis compares the cost of services under GHP to the cost of the same services offered by local private insurers and Medicaid. An analysis found that GHP, Flint-area physicians, hospitals, and foundations have succeeded in providing basic medical care access to a substantial majority of their low-income uninsured citizens. The costs of care, both paid by GHP and donated by local providers, are substantially less than the estimated costs if this population were covered by full Medicaid or private insurance.     

Pennsylvania's medically uninsured population: findings from a statewide survey

Pennsylvania is currently considering legislative options to expand coverage and improve access to medical care for state residents who lack health insurance. Relevant data are presented from a telephone survey of 10,809 Pennsylvania households. Almost nine percent (8.5%) of the state's population lacks health insurance, representing over one million people. Those most likely to be uninsured are children and young adults, non-whites and the poor. A substantial number of poor people are not covered by the state's Medicaid program. The uninsured report poorer health status, more obstacled to receiving care and greater use of hospital services for primary care.     

Who will provide preventive services? The changing relationships between medical care systems and public health agencies in health care reform.

Health care reform in the United States will likely attempt to expand the health insurance coverage to uninsured groups, control costs, enhance quality, and expand access to care. Preventive services will be assigned to the medical care system, while new roles and responsibilities will be defined for public health agencies. The clinical preventive services likely required are examined in a population of 44,565 persons residing in Otsego County, New York. Expansion of preventive services to Medicaid requests and the uninsured will require considerable resource expenditure to correct the current deficit in preventive services received by these groups. Moreover, the uninsured and Medicaid recipients have high levels of risk behaviors, identifying a need for health education services effective to that population subgroup. The transfer of responsibilities for clinical preventive services to the medical care system may free up resources for public health agencies to focus on other initiatives such as disease surveillance, health education, and quality assurance. New interrelationships, some cooperative and some adversarial, are likely to emerge, due to a closer working relationship between the medical care system and public health agencies than previously seen in American health care.     

Inequities in access to medical care in five countries: findings from the 2001 Commonwealth Fund International Health Policy Survey

OBJECTIVE: To examine across five countries inequities in access to health care and quality of care experiences associated with income, and to determine whether these inequities persist after controlling for the effect of insurance coverage, minority and immigration status, health and other important co-factors. DESIGN: Multivariate analysis of a cross-sectional 2001 random survey of 1400 adults in five countries: Australia, Canada, New Zealand, United Kingdom, and United States. MAIN OUTCOME MEASURES: Access difficulties and waiting times, cost-related access problems, and ratings of physicians and quality of care. RESULTS: The study finds wide and significant disparities in access and care experience between US adults with above and below-average incomes that persist after controlling for insurance coverage, race/ethnicity, immigration status, and other important factors. In contrast, differences in UK by income were rare. There were also few significant access differences by income in Australia; yet, compared to UK, Australians were more likely to report out of pocket costs. New Zealand and Canada results fell in the mid-range of the five nations, with income gaps most pronounced on services less well covered by national systems. In the four countries with universal coverage, adults with above-average income were more likely to have private supplemental insurance. Having private insurance in Australia, Canada, and New Zealand protects adults from cost-related access problems. In contrast, in UK having supplemental coverage makes little significant difference for access measures. Being uninsured in US has significant negative consequences for access and quality ratings. CONCLUSIONS: For policy leaders, the five-nation survey demonstrates that some health systems are better able to minimize among low income adults financial barriers to access and quality care. However, the reliance on private coverage to supplement public coverage in Australia, Canada, and New Zealand can result in access inequities even within health systems that provide basic health coverage for all. If private insurance can circumvent queues or waiting times, low income adults may also be at higher risks for non-financial barriers since they are less likely to have supplemental coverage. Furthermore, greater inequality in care experiences by income is associated with more divided public views of the need for system reform. This finding was particularly striking in Canada where an increased incidence of disparities by income in 2001 compared to a 1998 survey was associated with diverging views in 2001.     

Inequities in access to health care in South Africa

Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population without imposing an unaffordable burden on individuals or households. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n = 4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.