Going bare: trends in health insurance coverage, 1989 through 1996.

OBJECTIVES: This study analyzed trends in health insurance coverage in the United States from 1989 through 1996. METHODS: Data from annual cross-sectional surveys by the US Census Bureau were analyzed. RESULTS: Between 1989 and 1996, the number of uninsured persons increased by 8.3 million (90% confidence interval [CI] = 7.7, 8.9 million). In 1996, 41.7 million (90% CI = 40.9, 42.5 million) lacked insurance. From 1989 to 1993, the proportion with Medicaid increased by 3.6 percentage points (90% CI = 3.1, 4.0), while the proportion with private insurance declined by 4.2 percentage points (90% CI = 3.7, 4.7). From 1993 to 1996 private coverage rates stabilized but did not reverse earlier declines. Consequently, the number uninsured continued to increase. The greatest increase in the population of uninsured [corrected] was among young adults aged 18 to 39 years; rates among children also rose steeply after 1992. While Blacks had the largest percentage increase, Hispanics accounted for 36.4% (90% CI = 32.3%, 40.5%) of the increase in the number uninsured. From 1989 to 1993, the majority of the increase was among poor families. Since then, middle-income families have incurred the largest increase. Northcentral and northeastern states had the largest increases in percent uninsured. CONCLUSIONS: Despite economic prosperity, the numbers and rates of the uninsured continued to rise. Principally affected were children and young adults, poor and middle income families, blacks, and Hispanics.     

Trends in health insurance coverage, 1989-1997.

The authors analyze trends in health insurance coverage in the United States from 1989 through 1997, using cross-sectional surveys by the U.S. Census Bureau (Current Population Survey) of 160,000 persons representative of the non-institutionalized population. Between 1989 and 1997, the number of people without health insurance increased by 10.1 million to 43.4 million. From 1989 to 1993, the proportion covered by Medicaid increased by 3.6 percentage points while the proportion covered by private insurance declined by 4.2 percentage points. Since then, private coverage rates have stabilized and Medicaid coverage has decreased. Consequently, the number and percent uninsured continues to rise. Young adults age 18-39 had the largest increase in the proportion uninsured, and rates among children have also risen steeply since 1992. While blacks had the largest increase in the percent uninsured, Hispanics accounted for 35.6 percent of the increase in the number uninsured. Low-income families constituted over half of the increase in the number uninsured, but since 1993 the middle income group had the largest increase in the percent uninsured. Northeastern states had the largest increase in the percent uninsured. Thus, despite economic prosperity, the numbers and rates of the uninsured continue to rise. Principally affected are children and young adults, poor and middle-income families, blacks, and Hispanics.     

Counting the uninsured using state-level hospitalization data

OBJECTIVE: To assess the appropriateness of using state-level data on uninsured hospitalizations to estimate the uninsured population. METHODS: The authors used 1992-1996 data on hospitalizations of newborns and of appendectomy and heart attack patients in Florida to estimate the number of people in the state without health insurance coverage. These conditions were selected because they usually require hospitalization and they are common across demographic categories. RESULTS: Adjusted for the gender and ethnic composition of the population, the percentages of uninsured hospitalizations for appendectomies and heart attacks produced estimates of the state's uninsured population 1.6 percentage points lower than those reported for 1996 in the US Census March Current Population Survey. CONCLUSION: Data reported by hospitals to state agencies can be used to monitor trends in health insurance coverage and provides an alternative data source for a state-level analysis of the uninsured population.     

Identifying risk factors for disparities in breast cancer mortality among African-American and Hispanic women

BackgroundThis study evaluated the risk factors associated with racial disparities in female breast cancer mortality for African-American and Hispanic women at the census tract level in Texas from 1995 to 2005.MethodsData on female breast cancer cases were obtained from the Texas Cancer Registry. Socioeconomic and demographic data were collected from Census 2000. Network distance and driving times to mammography facilities were estimated using Geographic Information System techniques. Demographic, poverty and spatial accessibility factors were constructed using principal component analysis. Logistic regression models were developed to predict the census tracts with significant racial disparities in breast cancer mortality based on racial disparities in late-stage diagnosis and structured factors from the principal component analysis.ResultsLate-stage diagnosis, poverty factors, and demographic factors were found to be significant predictors of a census tract showing significant racial disparities in breast cancer mortality. Census tracts with higher poverty status were more likely to display significant racial disparities in breast cancer mortality for both African Americans (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.95–3.04) and Hispanics (OR, 5.30; 95% CI, 4.26–6.59). Spatial accessibility was not a consistent predictor of racial disparities in breast cancer mortality for African-American and Hispanic women.ConclusionPhysical access to mammography facilities does not necessarily reflect a greater utilization of mammogram screening, possibly owing to financial constraints. Therefore, a metric measuring access to health care facilities is needed to capture all aspects of access to preventive care. Despite easier physical access to mammography facilities in metropolitan areas, great resources and efforts should also be devoted to these areas where racial disparities in breast cancer mortality are often found.     

Delayed Care and Unmet Needs among Health Care System Users: When Does Fiduciary Trust in a Physician Matter?

Objectives. To examine whether fiduciary trust in a physician is related to unmet health care needs and delayed care among patients who have a regular physician, and to investigate whether the relationships between trust and unmet health care needs and delays in care are attenuated for disadvantaged patients who face structural obstacles to obtaining health care.
Data Sources/Study Setting. The 1998–1999 Community Tracking Study (CTS) Household Survey, a cross-sectional sample representative of the U.S. noninstitutionalized population. This study analyzes adults who usually see the same physician for their health care ( n =29,994).
Study Design. We estimated logistic regression models of the association of trust with unmet health care needs and delayed care. We tested interactions between trust and barriers to obtaining care, including minority race/ethnicity, poverty, and the absence of health insurance. Control variables included patients' sociodemographic characteristics, health status, satisfaction with the available choice of primary physicians, and the number of physician visits during the last year.
Principal Findings. Patients' fiduciary trust in a physician is negatively associated with the likelihood of reporting delayed care and unmet health care needs among most patients. Among African Americans, Hispanics, the poor, and the uninsured, however, fiduciary trust is not significantly associated with the likelihood of delayed care. For unmet needs, only the uninsured have no significant association with trust.
Conclusions. Results show that trust is associated with improved chances of getting needed care across most subgroups of the population, although this relationship varies by subpopulation.     

Breast cancer detection: maps of 2 San Francisco Bay area counties.

OBJECTIVES: This study describes the incidence of late-stage and in situ breast cancer among White women, using specialized mapping techniques that reflect incidence adjusted for the population at risk, and applies these maps to characterize areas with high and low risk of breast cancer. METHODS: Data from the Surveillance, Epidemiology, and End Results (SEER) database and the US Census Bureau were used to study the geographic distribution of breast cancer at the census-tract level in 2 San Francisco Bay Area counties for the years 1978 through 1982. Sociodemographic characteristics of areas with high and low incidence of the stage-specific disease were compared by means of a linear discriminant function. RESULTS: For late-stage breast cancer, the most important variables in discriminating high-risk from low-risk areas were college education, percentage of residents over age 65, and median income. The strongest ecologic indicators of high risk for in situ breast cancer were median income and percentage unemployed. CONCLUSIONS: This study demonstrates the usefulness of census tracts and sociodemographic measures of income and education in describing in situ and late-stage breast cancer.     

The roles of teaching hospitals, insurance status, and race/ethnicity in receipt of adjuvant therapy for regional-stage breast cancer in Florida

OBJECTIVES: We examined the roles of teaching hospitals, insurance status, and race/ ethnicity in women's receipt of adjuvant therapy for regional-stage breast cancer. METHODS: Data were taken from the Florida Cancer Data System for cases diagnosed from July 1997 to December 2000. We evaluated the impact of health insurance status and hospital type on use of adjuvant therapy (after adjustment for age, race/ethnicity, and marital status). Interaction terms for hospital type, insurance status, and race/ethnicity were entered in each model. RESULTS: Teaching facilities diagnosed 12.5% of the cases; however, they cared for a disproportionate percentage (21.3%) of uninsured and Medicaid-insured women. Among women who received adjuvant chemotherapy only, those diagnosed in teaching hospitals were more likely than those diagnosed in nonteaching hospitals to receive therapy regardless of insurance status or race/ethnicity. Among women who received chemotherapy with or without hormonal therapy, Hispanics were more likely than White non-Hispanic women to receive therapy, whereas women with private insurance or Medicare were less likely than uninsured and Medicaid-insured women to receive this type of therapy. CONCLUSIONS: Teaching facilities play an important role in the diagnosis and treatment of regional-stage breast cancer among Hispanics, uninsured women, and women insured by Medicaid.     

Effects of poverty and lack of insurance on perceptions of racial and ethnic bias in health care

OBJECTIVE: To investigate whether poverty and lack of insurance are associated with perceived racial and ethnic bias in health care. DATA SOURCE: 2001 Survey on Disparities in Quality of Health Care, a nationally representative telephone survey. We use data on black, Hispanic, and white adults who have a regular physician (N=4,556). STUDY DESIGN: We estimate multivariate logistic regression models to examine the effects of poverty and lack of health insurance on perceived racial and ethnic bias in health care for all respondents and by racial, ethnic, and language groups. PRINCIPAL FINDINGS: Controlling for sociodemographic and other factors, uninsured blacks and Hispanics interviewed in English are more likely to report racial and ethnic bias in health care compared with their privately insured counterparts. Poor whites are more likely to report racial and ethnic bias in health care compared with other whites. Good physician-patient communication is negatively associated with perceived racial and ethnic bias. CONCLUSIONS: Compared with their more socioeconomically advantaged counterparts, poor whites, uninsured blacks, and some uninsured Hispanics are more likely to perceive that racial and ethnic bias operates in the health care they receive. Providing health insurance for the uninsured may help reduce this perceived bias among some minority groups.     

Does the Market Value Racial and Ethnic Concordance in Physician–Patient Relationships?

OBJECTIVE: To determine if the market-determined earnings per hour of physicians is sensitive to the degree of area-level racial/ethnic concordance (ALREC) in the local physician labor market. DATA SOURCES: 1998-1999 and 2000-2001 Community Tracking Study Physician Surveys and Household Surveys, 2000 U.S. Census, and the Area Resource File. STUDY DESIGN: Population-averaged regression models with area-level fixed effects were used to estimate the determinants of log earnings per hour for physicians in a two-period panel (N=12,886). ALREC for a given racial/ethnic group is measured as the percentage of physicians who are of a given race/ethnicity less the percentage of the population who are of the corresponding race/ethnicity. Relevant control variables were included. PRINCIPAL FINDINGS: Average earnings per hour for Hispanic and Asian physicians varies with the degree of ALREC that corresponds to a physician's race/ethnicity. Both Hispanic and Asian physicians earn more per hour in areas where corresponding ALREC is negative, other things equal. ALREC varies from negative to positive for all groups. ALREC for Hispanics is negative, on average, due to the small percentage of the physician workforce that is Hispanic. This results in an average 5.6 percent earnings-per-hour premium for Hispanic physicians. However, ALREC for Asians is positive, on average, due to the large percentage of the physician workforce that is Asian. This results in an average 4.0 percent earnings-per-hour discount for Asian physicians. No similar statistically significant results were found for black physicians. CONCLUSIONS: The market-determined earnings per hour of Hispanic and Asian physicians are sensitive to the degree of ALREC in the local labor market. Larger sample sizes may be needed to find statistically significant results for black physicians.     

The effects of physician supply on the early detection of colorectal cancer

BACKGROUND: Policymakers question whether there is a relationship between the number and distribution of physicians and the outcomes for important health conditions. We hypothesized that increasing primary care physician supply would be related to earlier detection of colorectal cancer. METHODS: We identified incident cases of colorectal cancer occurring in Florida in 1994 (n = 8,933) from the state cancer registry. We then obtained measures of physician supply from the 1994 American Medical Association Physician Masterfile and examined the effects of physician supply (at the levels of county and ZIP code clusters) on the odds of late-stage diagnosis using multiple logistic regression. RESULTS: For each 10-percentile increase in primary care physician supply at the county level, the odds of late-stage diagnosis decreased by 5% (adjusted odds ratio [OR] = 0.95; 95% confidence interval [CI], 0.92 - 0.99; P = .007). For each 10-percentile increase in specialty physician supply, the odds of late-stage diagnosis increased by 5% (adjusted OR = 1.05; 95% CI, 1.02-1.09; P = .006). Within ZIP code clusters, each 10-percentile increase in the supply of general internists was associated with a 3% decrease in the odds of late-stage diagnosis (OR = 0.97; 95% CI, 0.95 - 0.99; P = .006), and among women, each 10-percentile increase in the supply of obstetrician/gynecologists was associated with a 5% increase in the odds of late-stage diagnosis (OR = 1.05; 95% CI, 1.01 - 1.08; P = .005). CONCLUSIONS: If the relationships observed were causal, then as many as 874 of the 5463 (16%) late-stage colorectal cancer diagnoses are attributable to the physician specialty supply found in Florida. These findings suggest that an appropriate balance of primary care and specialty physicians may be important in achieving optimal health outcomes.     

A “Medical Mission” at Home: The Needs of Rural America in Terms of Otolaryngology Care

Objectives: Describe the population, Medicaid, uninsured, and otolaryngology practice demographics for 7 representative rural Southeastern states, and propose academic‐affiliated outreach clinics as a service to help meet the specialty care needs of an underserved rural population, based on the “medical mission” model employed in international outreach clinics. Methods: A needs assessment was conducted via review of medical licensing and practice location data from state medical licensing authorities, together with population, Medicaid, and uninsured data from state health/human services departments and the US Census Bureau. Results: In all states examined, there are significantly more practicing otolaryngologists per capita in urban areas compared to rural areas (P < .05), with the exception of West Virginia, where the difference was not statistically significant (P= .33). In the majority of the states examined, there were higher rates (expressed as a percentage of total county population) of both Medicaid recipients and uninsured patients in rural counties compared to urban counties. Notable exceptions include Louisiana and West Virginia, where there are higher percentages of Medicaid patients in urban areas, and Kentucky and Tennessee, where there are higher percentages of uninsured patients in the urban areas (P < .05 for each comparison). Conclusions: Borrowing design elements from the international outreach clinics, which involve many US otolaryngologists, a similar medical mission model could be of benefit domestically. There are rural areas of the Southeast where visiting outreach clinics could improve access to otolaryngology care and facilitate effective use of existing “safety net” health care resources.     

Cancer screening among racial/ethnic and insurance groups in the United States: a comparison of disparities in 2000 and 2008

Using the National Health Interview Survey, we examined associations among race/ ethnicity, insurance coverage, and cancer screening, and assessed changes in the magnitude of disparities over the past decade. Outcomes included recent cervical, breast, and colorectal cancer screening. Rates of colorectal screening increased for all racial/ethnic groups and some insurance groups from 2000 to 2008. However, rates of Pap tests and mammograms remained stagnant, and even decreased for certain groups. Some Hispanic-White and Asian-White disparities in cancer screening were reduced or eliminated over this time period. However, in 2008 Asians continued to have lower odds of Pap tests and Hispanics lower odds of colorectal cancer screening, even after accounting for potential confounders. There were no significant changes in Black-White disparities. The uninsured continued to be at a disadvantage for all three types of cancer screening, relative to the privately insured, as were publicly insured individuals with respect to colorectal cancer screening.     

Clinical and demographic predictors of late-stage cervical cancer

BACKGROUND: Despite increasingly widespread use of the Papanicolaou smear, almost half of all women with invasive cervical cancer are diagnosed at a late stage (regional or distant). Little is known about factors associated with late-stage diagnosis of cervical cancer. OBJECTIVE: To examine the relationship of age, race, education level, income level, smoking, marital status, health insurance type, comorbidity, and residence in an urban or rural setting to late stage at diagnosis of cervical cancer. METHODS: Incident cases of invasive cervical cancer occurring in 1994 in Florida were identified from the state tumor registry (N = 852). Cases were linked with state discharge abstracts and the 1990 US census. Multiple logistic regression was used to determine the relationship between predictor variables (age, race or ethnicity, marital status, smoking status, education level, income level, insurance type, comorbidity, and urban vs rural residence) and the odds of late-stage diagnosis. RESULTS: Age, marital status, and insurance type were associated with late-stage diagnosis. Each additional year of age was associated with a 3% increased odds of late-stage diagnosis (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.05; P<.001). Being unmarried was associated with a 63% increased odds of late-stage diagnosis (OR, 1.63; 95% CI, 1.18-2.25; P=.003). Being uninsured was associated with a 60% increased odds of late-stage diagnosis (OR, 1.60; 95% CI, 1.07-2.38; P=.02). Having commercial health maintenance organization insurance was associated with a 46% decreased odds of late-stage disease (OR, 0.54; 95% CI, 0.30-0.96; P=.04). Race, education level, income level, smoking status, comorbidity, and urban residence were not associated with stage at diagnosis. CONCLUSIONS: Women with cervical cancer who are elderly, unmarried, and uninsured are more likely to be diagnosed at a late stage. These women should be targeted for cervical cancer education and screening programs.     

Correlation of the ratio of metastatic to non-metastatic cancer cases with the degree of socioeconomic deprivation among Texas counties

Background  

Previous studies have demonstrated that cancer registrations and hospital discharge rate are closely correlated with census data-based socioeconomic deprivation indices. We hypothesized that communities with higher degrees of socioeconomic deprivation tend to have a higher ratio of metastatic to non-metastatic cancer cases (lung, breast, prostate, female genital system, colorectal cancers or all types of cancers combined). In this study, we investigate the potential link between this ratio and the Wellbeing Index (WI) among Texas counties.     

Delayed diagnosis of cancer with emphasis on oral cavity cancers.

Delayed diagnosis of cancer and, of oral cavity cancers in particular, is of crucial importance for the clinical management, costs of care and unfavourable outcome. Many scientists have studied the causes of delayed diagnosis to find solution of the problem. However, only few studies of this kind have been performed in Bulgaria, especially for oral cavity cancers. The aim of this overview was to summarize and analyze publications on problems and causes of delayed diagnosis of cancer in general and, of oral cavity cancers in particular. The literature search was made in different databases such as MEDLINE, BIOSIS, INTERNET, etc. More than 100 relevant items of information were extracted but only 22 of them were found suitable and further analyzed. The analysis of the literature has revealed the importance of recognizing the warning signals and causes of delayed diagnosis in cancer in general and in oral cavity cancers in particular. For instance, survival of patients with squamous cell carcinoma of the tongue (Dx:141) was related to delayed diagnosis (20% of patients survive more than 5 years and 71%--only 2 years after diagnosis). The problems of delayed diagnosis in patients with multiple neoplasm of the oral cavity (Dx:143-145) and with nasopharyngeal carcinoma (Dx:146-149) were also discussed (96.6% of patients were in stage III at diagnosis). This overview has summarized problems in and stressed the main aspects of delayed diagnosis of cancer in general. It has also denoted hints in delayed diagnosis of cancer of the oral cavity and their relevance to the clinical management, outcome and costs of care for such patients. The latter has been considered of primary importance for general practitioners, dentists and specialists in public health medicine.     

How Do Racial/Ethnic Groups Differ in Their Use of Neighborhood Parks? Findings from the National Study of Neighborhood Parks

The current study examined racial/ethnic differences in use of parks and park facilities and features and self-reported park use and perceptions. We conducted observations in a nationally representative sample of 193 neighborhood parks in 27 US cities over a 1-week period between April and August of 2016 using the System of Observing Play and Recreation in Communities (SOPARC). To determine the propensity of different racial/ethnic groups to use parks relative to expectation based on their representation in the surrounding neighborhood, we calculated the percentages of park users of each race/ethnicity and compared these to the percentages of racial/ethnic groups residing in the neighborhood within a 1-mile radius of the park based on 2010 U.S. Census data. In the same parks, we administered an intercept survey to assess park users’ self-reported use and perceptions of the park (N?=?1872). We examined racial/ethnic differences in self-reported use and perceptions of parks using GEE models that adjusted for several individual- and park-level covariates. Hispanics comprised a disproportionate percentage of observed park users. Racial/ethnic groups generally did not differ in their self-reported park use and perceptions, except for the social context of park visits. In adjusted models, Hispanics had significantly higher odds of visiting with a child family member (OR?=?1.44) and lower odds of visiting alone than non-Hispanic whites (OR?=?.55). Findings highlight Hispanics’ greater propensity to use parks and indicate that parks may serve a communal purpose for Hispanics that they do not serve for other racial/ethnic groups.     

Effects of physician supply on early detection of breast cancer

BACKGROUND: There are few studies examining the effects of physician supply on health-related outcomes. We hypothesized that increasing physician supply and, in particular, increasing primary care supply would be related to earlier detection of breast cancer. METHODS: Information on incident cases of breast cancer occurring in Florida in 1994 (n = 11,740) was collected from the state cancer registry. Measures of physician supply were obtained from the 1994 AMA Physician Masterfile. The effects of physician supply on the odds of late-stage diagnosis were examined using multiple logistic regression. RESULTS: There was no relation between overall physician supply and stage of breast cancer of diagnosis. Each 10th percentile increase in primary care physician supply, however, resulted in a 4% increase in the odds of early-stage diagnosis (adjusted odds ratio = 1.04, 95% confidence interval = 1.01-1.06). CONCLUSIONS: The supply of primary care physicians was significantly associated with earlier stage of breast cancer at diagnosis. This study suggests that an appropriate balance of primary care and specialty physician supply might be an important predictor of health outcomes.     

Does the Vaccines for Children Program Influence Pediatric Nurse Practitioner Referral of Disadvantaged Children to Public Vaccine Clinics?

Objective: Concerns about financial barriers to vaccination led to the creation of the Vaccines for Children (VFC) program, which provides free vaccines to states for disadvantaged children. Our objective was to understand the effect of free vaccine and insurance on pediatric nurse practitioners' (PNPs) likelihood of referring children to public vaccine clinics. Although referral from the medical home to public vaccine clinics is preferable to not vaccinating, there are disadvantages, including the potential for windows of inadequate protection and fragmentation of care. Methods: A standardized survey was conducted by trained personnel using computer-assisted telephone interviewing. We interviewed a national random sample of primary care PNPs in 1997. Results: In 1997, 252 of 271 (93%) directly contacted PNPs were interviewed. The percentage of respondents receiving free vaccines was 82%. Among PNPs not receiving free vaccines, the percentages stating that they were likely to refer insured, Medicaid insured, and uninsured children to public vaccine clinics were 7%, 27%, and 67%, respectively. In contrast, among PNPs receiving free vaccines, only 46% would refer an uninsured child and 10% a Medicaid child. Conclusions: Most respondents received free vaccine supplies in 1997. Based on current PNP data and previous physician data, most clinicians who do not receive free vaccine supplies are likely to refer uninsured children to public vaccine clinics. In contrast, clinicians who receive free vaccine supplies are much more likely to vaccinate uninsured and Medicaid-insured children.     

Use of skin and oral cancer examinations in the United States, 1998

BACKGROUND: Findings from previous surveys suggest low utilization of oral cancer examinations, even though this examination is noninvasive. The purpose of this analysis is to compare the use of an oral cancer examination (OCE) and a skin cancer examination (SCE) in the past 12 months within the United States. Both exams are noninvasive and include a visual component. METHODS: Weighted data from the Adult Prevention Supplement of the 1998 National Health Interview Survey (NHIS) for adults 40 years of age or older were analyzed using SAS and SUDAAN. A ratio compared the percentage reporting an OCE (%OCE) with the percentage reporting a SCE (%SCE). RESULTS: The percentage having an OCE in the past year (13.8%) was very similar to the percentage having a SCE (13.5%) during that same period. With increasing age group, the %OCE/%SCE ratio varied inversely from 1.60 (C.I. 1.42-1.78) among persons 40-49 years to 0.62 (C.I. 0.55-0.69) among persons 70+ years. The ratio was similar in whites and blacks, males and females, and Hispanics and non-Hispanics. There was a positive gradient in the ratio by education and family income. CONCLUSIONS: Overall, less than 15% of the population is receiving either of these examinations, although the American Cancer Society recommends both of them on an annual basis for individuals 40 years of age and older. To increase detection of these cancers at early stages, extensive educational and media campaigns for the public and providers identifying risk factors and the availability of and the need for these examinations are required.