Showing papers in "Journal of Health Care for the Poor and Underserved in 1993"
TL;DR: For both men and women age 15-44, the level of black/ white residential segregation was a significant (positive) predictor of the black/white ratio of the age-standardized death rate, and the need for more-detailed studies of explanations for such variation is indicated.
Abstract: Researchers speculate that in addition to poverty, residential patterns may contribute to black/white differences in mortality rates. But few have assessed the relationship. This study reports considerable variation in the black/white ratio of age-specific all-cause mortality rates (ages 15-24 to 65-74 years) from 1982 to 1986 among the 38 U.S. Standard Metropolitan Statistical Areas (SMSAs) with populations greater than one million in 1980. The black/white poverty-rate ratio for each SMSA was a stronger predictor of variation in the black/white mortality ratio for men than for women. For both men and women age 15-44, the level of black/white residential segregation was a significant (positive) predictor of the black/white ratio of the age-standardized death rate. This analysis also identifies SMSAs containing geographic areas with unusually high or low black/white mortality ratios, and indicates the need for more-detailed studies of explanations for such variation.
82 citations
TL;DR: Whether appointments were kept or broken seemed to depend on the recency of medical attention and the perceived severity of a problem, and perceived communication difficulties with clinic personnel and long waits were important predictors of overall utilization.
Abstract: Few recent studies address how situational variables and the characteristics of clients and organizations predict whether indigent clients will keep medical appointments. In this study at a southern urban charity hospital, lack of transportation was a main reason given for not keeping the last appointment at an internal medicine clinic. In contrast, clients who kept their last appointment had higher incomes; had visited the facility for pain, infection, or follow-up after hospitalization; and had been referred to the clinic less than two weeks before their appointment. Overall, whether appointments were kept or broken seemed to depend on the recency of medical attention and the perceived severity of a problem. Implementation of a system-wide discharge-planning system resulted in fewer broken appointments. Perceived communication difficulties with clinic personnel and long waits were important predictors of overall utilization. Decentralizing care through community health clinics and adopting a more holistic approach to care may improve utilization of health care facilities.
28 citations
TL;DR: Cost of medical care was found to be a significant deterrent to obtaining follow-up for patients with Medicaid or with no insurance, and expanded access to care, along with focused discharge planning, may improve completion of follow- up for Medicaid and uninsured patients.
Abstract: As the length of hospital stays decreases, important medical problems are often deferred for follow-up after discharge. We investigated whether patients without regular physicians actually receive post-discharge care. Patients without regular physicians at the time of admission to a private nonprofit teaching hospital were surveyed by telephone one month after discharge. Forty-six percent were non-Caucasian and 53 percent had Medicaid or no insurance. Although discharge planning was documented for 97 percent of patients, only 54 percent of study participants had completed follow-up one month later and only 46 percent could identify a regular physician. Among all patients with a particular need for follow-up, Medicaid and uninsured patients were less likely to receive follow-up (p = 0.042), to identify a regular physician (p = 0.007), or to complete discharge instructions (p = 0.018). Cost of medical care was found to be a significant deterrent to obtaining follow-up for patients with Medicaid or with no insurance (p = 0.001). Expanded access to care, along with focused discharge planning, may improve completion of follow-up for Medicaid and uninsured patients.
26 citations
TL;DR: It is shown that contemporary African-Americans have the highest age-adjusted rates of cancer incidence and mortality of any racial or ethnic group in the United States and the gap between whites and blacks is widening dramatically.
Abstract: Over the past 40 years, increasing numbers of Americans have benefited from cancer prevention, early detection, and improved treatment. But a review of site-specific cancer data from 1950 to the present shows that contemporary African-Americans have the highest age-adjusted rates of cancer incidence and mortality of any racial or ethnic group in the United States. Compared to whites, blacks have significantly higher incidence rates for cancers of the lung, prostate, breast (under age 40), colon, pancreas, esophagus, cervix, larynx, stomach, and multiple myeloma. Blacks have significantly higher mortality rates for cancers of the lung, prostate, breast (all ages), colon, pancreas, esophagus, cervix, uterine corpus, larynx, stomach, and multiple myeloma. Moreover, the gap between whites and blacks is widening dramatically. These startling statistics suggest that cancer researchers and policymakers, and the institutions they represent, may not fully appreciate the black cancer experience.
21 citations
TL;DR: If the African-American cancer crisis is to be halted, the growing divergence between urgent needs and meager resources devoted to preventing, detecting, and treating cancer in blacks must be sharply reversed.
Abstract: To appreciate the causes of the African-American cancer crisis, contemporary myths and perceptual gaps regarding cancer in blacks must be analyzed and placed in historical context. Since ancient times, racism has permeated western scientific, medical, and social cultures. Yet contemporary analysts typically frame a 370-year-old African-American health deficit in nonracial terms, and ignore both the metamorphosis of racism and the impact of racism on the prevention, diagnosis, and treatment of cancer; exposure to cancer-causing industrial pollutants; educational opportunities for black health professionals and policymakers, and other factors. If the African-American cancer crisis is to be halted, the growing divergence between urgent needs and meager resources devoted to preventing, detecting, and treating cancer in blacks must be sharply reversed.
19 citations
TL;DR: An inverse relationship between IPO participation and the risk of neonatal mortality in a low-income population is indicated, suggesting that large-scale prenatal care programs can be effective in improving birth outcomes.
Abstract: The development of a national program to assure access to prenatal care for all women, regardless of income, is believed to be an effective means of reducing low birthweight and neonatal mortality in the U.S. Yet scarce empirical evidence concerning the effectiveness of large-scale prenatal care programs is available. This paper summarizes an evaluation of a statewide public prenatal care program xohich grew out of the federal Improved Preg- nancy Outcome (IPO) project. Using linked birth and infant death-certificate data, andIPOprogram records from a four-year period (1985-1988), this study compares the neonatal mortality rates of participan ts of Florida s IPO program with those of a matched comparison group. The results indicate an inverse relationship between IPO participation and the risk of neonatal mortality in a low-income population. These findings suggest that large-scale prenatal care programs can be effective in improving birth outcomes.
19 citations
TL;DR: This work proposes to expand the existing network of community health centers over the next 10 years to a total of approximately 3,000, which would provide a cost-effective approach to improving provider distribution, increasing consumer input, combining personal health services with health promotion, and removing both financial and nonfinancial barriers to care.
Abstract: While a national health insurance plan is needed, this alone will not provide access for approximately 30 million persons who face geographic, cultural, language, or health care system barriers, or who live in areas with provider shortages. These barriers often coexist with lack of insurance coverage, but they also affect millions who have public, or even private, coverage. Moreover, large segments of this population suffer from health problems not adequately addressed by the traditional medical model: teenage pregnancy, AIDS, injury, substance abuse, and the like. To provide appropriate care for these underserved persons, we propose to expand the existing network of community health centers over the next 10 years to a total of approximately 3,000. Such an expansion would provide a cost-effective approach to improving provider distribution, increasing consumer input, combining personal health services with health promotion, and removing both financial and nonfinancial barriers to care. This model can be implemented either independent of or in conjunction with other health care system reform efforts.
16 citations
TL;DR: The managed care program for Medicaid participants is a team approach to link each Medicaid patient with a primary care physician responsible for coordinating medical services for the patient.
Abstract: New York City's Harlem community faces extraordinary health care needs that a failing economy has made more urgent. In an attempt to open lines of access to health care, the New York City Health and Hospitals Corporation has implemented a managed care program for Medicaid participants. The program is a team approach to link each Medicaid patient with a primary care physician responsible for coordinating medical services for the patient. We hope the managed care program will help us conserve our dwindling resources while better managing patients' services and improving access to care.
16 citations
TL;DR: Although homeless youths had somewhat more medical problems than did delinquent youths, both groups had a multiplicity of medical problems, many of which were worse than among the general adolescent population.
Abstract: Little is known about the health status and health care needs of homeless and delinquent youths. This study provides medical data (medical history and physical examination) on samples of delinquent (n=245) and homeless (n=160) youths in San Francisco, CA. Although homeless youths had somewhat more medical problems than did delinquent youths,both groups had a multiplicity of medical problems, many of which were worse than among the general adolescent population. A substantial percentage of both samples did not have adequate health care coverage. Medical services to high-risk youths should be improved by providing street outreach, public health clinics, and multiservice centers for adolescents.
16 citations
TL;DR: Two federal laws help address the problem of mental health resources available among Indian communities, including the integration of community health services into schools, the development of innovative mental and physical health programs for Native American youth, and the recruitment of more health professionals into Native American communities.
Abstract: The incidence of emotional disorders and mental illness among Native American adolescents is strikingly high. Yet despite promises of support from the federal government, the mental health resources available amonglndian communities are negligible and must be expanded. Tzoo federal laws—the Indian Health Care Amendments of 1990, and the Indian Health Care Amendments of 1992—help address this problem, including the integra- tion of community health services into schools, the development of innovative mental and physical health programs for Native American youth, and the IN MY visits to Indian country, I have been impressed with the tremendous talent, with the richness of Indian cultures, and with the great knowledge and wisdom of Indian people. But Indian people are grieving the losses they have suffered over the years—loss of traditional lands; loss of the right to practice their religions, their culture, their traditions; and losses of thousands upon thousands of lives. Given the poverty and social deprivation associated with the high unemployment in Indian country, it should not surprise us that the lives of American Indian and Alaska Native adolescents are filled with stress.
13 citations
TL;DR: HealthPASS, a program of capitated managed care for 82,000 Medicaid enrollees in a defined geographic area of Philadelphia, Pennsylvania, is administered by Healthcare Management Alternatives, Inc.
Abstract: HealthPASS, a program of capitated managed care for 82,000 Medicaid enrollees in a defined geographic area of Philadelphia, Pennsylvania, is administered by Healthcare Management Alternatives, Inc. (HMA), a minority-owned corporation, under a multiyear contract with the Commonwealth of Pennsylvania. HMA has striven to improve care to this low-income community by mounting innovative campaigns to encourage early access to health care, ongoing health education, and aggressive outreach and follow-up, in addition to specific projects designed to reduce infant mortality, expand Head Start, and bolster pediatric care. The program has been judged independently to provide high-quality service cost-effectively.
TL;DR: While the incidence of neurological impairment in African-Americans exceeded that of whites, predominantly white nursing homes offered more sophisticated care, suggesting the need to review the means by which comprehensive nursing home care may be expanded in the African-American community.
Abstract: In this pilot study, 288 elderly African-American and 482 white residents of 10 nursing homes in Wayne County, Michigan, were compared for neurological impairment. The frequency of diagnosis of neurological impairment was equivalent for African-American and white males, but greater for African-American females than for white females. Cerebral vascular accident (CVA, or stroke) and nonspecific dementia were the most common neurological diagnoses for all groups. For males but not females, there was a statistically significant difference in the causes of neurological impairment, with more African-Americans diagnosed as having CVA, and more whites diagnosed as having nonspecific dementia. While the incidence of neurological impairment in African-Americans exceeded that of whites, predominantly white nursing homes offered more sophisticated care. This suggests the need to review the means by which comprehensive nursing home care may be expanded in the African-American community.
TL;DR: This study finds some evidence that the ROCI program has led to an increase in the satisfaction that physician participants feel toward the prenatal care available at the local health department, and that participants are increasing their provision of obstetrical care to Medicaid patients compared to other physicians in the state.
Abstract: Rising malpractice insurance rates have led to a decrease in the number of physicians who provide rural obstetrical care. North Carolina has responded with the Rural Obstetrical Care Incentive (ROCI) Program, which provides up to $6,500 per year to physicians who provide obstetrical care to the rural poor in conjunction with a local health department. This study finds some evidence that the program has led to an increase in the satisfaction that physician participants feel toward the prenatal care available at the local health department; that participants are increasing their provision of obstetrical care to Medicaid patients compared to other physicians in the state; and that the percentage of women delivering after receiving inadequate prenatal care is decreasing in the original ROCI counties, at a time when other rural counties are experiencing an increase in this measure. Other states should consider the ROCI program as one aspect of a rural health strategy.
TL;DR: Evaluation of aspects of a demonstration outreach project designed to encourage use of a Community Health Center in Orangeburg, South Carolina shows that this type of outreach effort can identify specific needs for primary health care services in a poor under served community, and can enhance community access to Medicaid.
Abstract: Outreach using personal contact was a cornerstone of the federally funded Community Health Center (CHC) movement of the 1960s. Funding cuts and changes in federal policy have led to the discontinuation of this activity in most CHCs. This paper assesses aspects of a demonstration outreach project designed to encourage use of a CHC in Orangeburg, South Carolina. The evaluation shows that this type of outreach effort, which includes door-to-door canvassing, can identify specific needs for primary health care services in a poor underserved community, and can enhance community access toMedicaid,althoughthefinancialimpactofbringingpoorpatientsintoCHCs by means of this type of outreach is relatively low.
TL;DR: Community and migrant health centers have been shown to increase access to health care, improve health status, and reduce health care costs in communities that they serve, and can play an important role in providing for underserved communities under any program of national health care reform.
Abstract: Community and migrant health centers (CHCs) have been shown to increase access to health care, improve health status, and reduce health care costs in communities that they serve. Thus CHCs can play an important role in providing for underserved communities under any program of national health care reform whose aim is universal, affordable access. To benefit the poor, such a plan should be federally administered and progressively financed, with comprehensible enrollment procedures, easy paperwork, and clearly delineated limits and benefits.
TL;DR: Six prescriptions will help: universal early childhood education; comprehensive health and family life education; parental support; reinforcement of male responsibility; comprehensive school-based clinics; and opportunities for higher education.
Abstract: America's children are stalked by race- and income-based inequities that demand our attention. Health care reform efforts that respect the needs of the entire child can diminish these inequities. Six prescriptions will help: universal early childhood education; comprehensive health and family life education; parental support; reinforcement of male responsibility; comprehensive school-based clinics; and opportunities for higher education.
TL;DR: The Clinton Administration's approach, rooted in broad-based participation and multisector planning, is consistent with international models and promises long-overdue recognition that health problems in underserved communities stem from poverty—not the poor.
Abstract: The startling health disparities between whites and racial and ethnic minorities in the United States are partly the result of six major assumptions about health promotion that permeated the Reagan and Bush Administrations. These assumptions, which placed the responsibility for maintaining health on individual Americans, are consistent withpolicymakers reliance on market forces to address social issues. While this model may serve persons with a continuum of options and resources to elicit change, it does not benefit the underserved. In contrast, the Clinton Administration's approach, rooted in broad-based participation and multisector planning, is consistent with international models and promises long-overdue recognition that health problems in underserved communities stem from poverty—not the poor.
TL;DR: There is still a great need for community-based preventive and primary care programs with outreach and family support services, and traditionally underserved populations continue to be at increased risk.
Abstract: To date, Hawaii is the only state to have implemented near-universal health insurance The cornerstone of this program is the country's only requirement that employers provide health insurance for all employees who work at least 20 hours per week Combined with low unemployment, voluntary modified community rating by health insurers, and expanded Medicaid and Medicare, this employer mandate has been part of a patchwork mechanism that insures upwards to 95 percent of the state's population Indeed, by adding a state-sponsored gap group-insurance program, Hawaii may now insure in excess of 95 percent of its population The program has generated good health outcomes, good consumer satisfaction, and relatively modest overall health care expenditures But for all that near-universal insurance provides, there is still a great need for community-based preventive and primary care programs with outreach and family support services In addition, traditionally underserved populations continue to be at increased risk Both funding reform and continued infrastructure development must occur to achieve universal access to care
TL;DR: The Oregon Health Plan introduces a rational plan for expanding services to the entire population of the state, while acknowledging the limitations of funding resources.
Abstract: The Oregon Health Plan addresses the needs of 450,000 Oregonians presently without health insurance, among them 120,000 living in poverty who are not now Medicaid-eligible. This is accomplished by expanding eligibility for Medicaid to individuals and families with incomes at 100 percent of the federal poverty level. T0 help expand access within the limitations of the state budget, certain services, determined to be of limited value or effectiveness, are not covered for payment. This concept of rationing health care reimbursement stands in contrast to existing mechanisms of rationing employed by every state and the nation. The Oregon Health Plan introduces a rational plan for expanding services to the entire population of the state, while acknowledging the limitations of funding resources.
TL;DR: This editorial chronicles how one grassroots program, begun by volunteer mothers and one community health nurse, developed into a partnership for primary health care that advocates and empowers the entire community.
Abstract: Current strategies for initiating and operating community health programs rely on one of two approaches. One is a predetermined, operational process. The other comes from the grassroots, beginning with involvement of the recipients of the program. This editorial chronicles how one grassroots program, begun by volunteer mothers and one community health nurse, developed into a partnership for primary health care that advocates and empowers the entire community. In the end, the editorial challenges community health organizers to ask whom their programs are empowering--the community or the organizers themselves?
TL;DR: To insure that reform initiatives benefit the underserved communities within which public hospitals operate, reform initiatives should be evaluated against 10 criteria that emphasize prevention and primary care, community health education, cost control, tort reform, and community values.
Abstract: Health care reform proposals may affect public hospitals in a number of ways. To insure that such proposals benefit the underserved communities within which public hospitals operate, reform initiatives should be evaluated against 10 criteria that emphasize prevention and primary care, community health education, cost control, tort reform, and community values.
TL;DR: The authors report several strategies that a community-based coalition has used to improve indigent care in one county and how such advocacy efforts can substantially improve the availability of local services.
Abstract: Because no national health program assures entitlement to basic services, advocates must cope with barriers to access on the local level. The authors report several strategies that a community-based coalition has used to improve indigent care in one county. Research strategies have involved short-term investigations of barriers to needed services. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor. Legal strategies have involved the participation of attorneys who represent clients unable to receive care. Although such advocacy efforts do not guarantee access, they can substantially improve the availability of local services.
TL;DR: To protect the interests of underserved Americans, fair and rational health care reform must embrace 10 principles that include universal and comprehensive coverage and mandatory cost containment.
Abstract: To protect the interests of underserved Americans, fair and rational health care reform must embrace 10 principles. These include universal and comprehensive coverage; mandatory cost containment; equity; freedom to change jobs or to relocate; high quality; reduced paperwork; primary care; help for the underserved; consumer-oriented care; and fair financing.
TL;DR: The national mood has changed in recent years, as a consequence of a conservative belief that the federal government has become too costly and too powerful, concern over the economy and inflation, and the feeling that the nation's power has somehow been diminished by give-away social programs that weaken the national will.
Abstract: WE ARE ON THE VERGE of an historic turning point in the social philosophy of the United States. Since the Depression, we have borne witness to a growing involvement on the part of government in the social welfare system of the nation, beginning with the New Deal's work relief programs and the passage of Social Security, and coming to a climax throughout the 1960s and 1970s with the enactment of a wide variety of new social legislation dealing with civil rights, health, welfare, the handicapped, occupational safety and health, housing, and the environment. The impact of this wave of federal intervention was to make government both the regulator and principal funding source of many new and expanded social initiatives, the essential goal of which was to improve the quality of human life, particularly among people of lower socioeconomic status. In fact, two very important health programs, Medicare and Medicaid— health benefit programs for the aged and the poor, respectively—were initiated during the mid-1960s. The national mood has changed in recent years, as a consequence of a conservative belief that the federal government has become too costly and too powerful, concern over the economy and inflation, and the feeling that our power as a nation and as a people has somehow been diminished by give-away social programs that weaken the national will. Because of this shift in philosophy, there have been serious deleterious effects on the quality of life for all Americans, particularly those who are poor or near-poor. Recent budgetcutting has taken its toll on poor families, children, and the elderly—and, certainly, people of color have suffered disproportionately.
TL;DR: New Jersey's health care reform initiatives will ultimately provide for accessible preventive and primary pediatric care, with a community-based "medical home" serving as a child's gateway to the health care system.
Abstract: There is widespread agreement that the American health care system needs comprehensive reform. This kind of reform will take time, however, and millions of Americans have urgent health care needs that must be met now. This is especially true for the nation's poor children, for whom the health care "safety net" has greatly eroded in the past decade. New Jersey's health care reform initiatives will ultimately provide for accessible preventive and primary pediatric care, with a community-based "medical home" serving as a child's gateway to the health care system. In the meantime, New Jersey has established programs dealing with such urgent problems as infectious childhood diseases, lead poisoning, AIDS, and infant mortality. While in the spirit of the state's long-range planning effort, these programs are up and running now, their impact maximized in this period of budgetary constraints through coalition- and network-building.
TL;DR: This analysis found that state-purchased health policies would result in lower program costs than either an increase in county assistance programs or employer-mandated health insurance.
Abstract: In this study, several alternatives for the provision of health care to the medically indigent of Nebraska were analyzed quantitatively and qualitatively. These alternatives were: expansion of county medical assistance programs, state-purchased health insurance policies, Medicaid expansion, revenue pool to redistribute charity-care losses, all-payer rate system, mandated employer-purchased health insurance, and charity-care districts. Under four future scenarios, alternatives were ranked on the basis of program costs, a sensitivity analysis, and qualitative criteria. This analysis found that state-purchased health policies would result in lower program costs than either an increase in county assistance programs or employer-mandated health insurance. Medicaid expansion would reach fewer than one-third of the state's medically indigent. A revenue pool and all-payer rate system are the least costly alternatives but depend on the continuing good will of providers.
TL;DR: This study evaluates three programs to expand eligibility for Alabama's Medicaid program, which would increase the proportion of Alabamians with health coverage to nearly 50 percent and drop all categorical eligibility requirements and base eligibility solely on whether income is below the federal poverty level.
Abstract: Some advocates of the uninsured support expansion of Medicaid programs, while others say that expansions are simply unaffordable, especially in poor states. State-level analyses of the costs and consequences of these expansion programs are infrequent. This study evaluates three programs to expand eligibility for Alabama's Medicaid program. The first two programs would raise the Aid to Families with Dependent Children (AFDC) eligibility threshold to 50 and 100 percent, respectively, of the federal poverty level. The third program, currently not available to the states without a federal waiver, would drop all categorical eligibility requirements and base eligibility solely on whether income is below the federal poverty level. Only 10.7 and 18.3 percent, respectively, of Alabama's uninsured would gain health care coverage under the first two programs. The third program would increase the proportion of Alabamians with health coverage to nearly 50 percent. For all of these programs, front-end state costs would be largely countered by federal funding and offsets, such as reductions in uncompensated hospital care and savings realized by former uninsureds from reductions in out-of-pocket expenditures for health services.