THE UNINSURED AND ACCESS TO HEALTH CARE
The uninsured face a variety of barriers when seeking access to health care services. Sometimes the obstacles are primarily financial. A lack of insurance coverage or the inability to pay for services out-of-pocket creates substantial difficulties for individuals seeking necessary medical treatment. At the same time, the uninsured and the underinsured can face significant non-financial obstacles, due to a variety of demographic, linguistic, cultural, and racial factors. Inadequate provider availability can also be barrier, either due to geographic isolation in the case of rural areas or a lack of transportation in urban areas.
The Uninsured Receive Less Care
A 1993 report showed that the uninsured are much less likely to use health services than either privately or publicly insured populations. In 1987, the period studied, the uninsured had lower average health expenditures than the insured, but paid a greater proportion of these expenditures out-of-pocket. Among those under age 65, health services were used by 87 percent of those covered by private insurance, 83 percent of those covered by public insurance and only 64 percent of the uninsured. Among users of health services, those with public insurance had the highest average total expenditure ($2,619), twice that of privately insured individuals ($1,316) and almost three times that of the uninsured ($915). However, the uninsured paid three-quarters of their total expenditures out-of-pocket, while the privately and publicly insured paid one-half and one-fifth, respectively.(footnote 18)
In 1994, the Robert Wood Johnson Foundation (RWJF) conducted its fourth national access to care survey. A recent article by Berk, Schur, and Cantor reported the findings in the policy journal Health Affairs. Results from earlier surveys (1982 and 1986) indicated that about 6 percent of the general population did not receive the medical care they thought they needed. Similarly, the 1994 survey also showed about the same proportion (5.7 percent) did not receive the medical or surgical care they believed they needed. However, the most recent survey also expanded the definition of care to include supplementary services, such as dental, prescription drugs, eye glasses, and mental health care or counseling. Using this more inclusive definition of care, 16.1 percent of respondents -- representing about 41 million Americans -- were unable to receive at least one necessary service.(footnote 19)
The graph on the following page shows the percentage of individuals who reported having an unmet medical need, broken out by service category.
Berk, Schur, and Cantor used the RWJF survey to examine the demographic characteristics of those who reported difficulty in obtaining care. The survey found that adults were more likely than children to have an unmet medical need. Overall, adult women had the greatest difficulty obtaining necessary services (21.4 percent), followed by adult men (15.3 percent). By comparison, 9.6 percent of children were unable to obtain care. The researchers contend this is very likely the result of the more extensive safety net available to children, both in terms of Medicaid eligibility and local programs directed to the young. In addition, as the chart below shows, minorities were more likely to have unmet needs than whites, as were individuals in poorer health compared with those in better health.
Three additional factors were significant in determining whether individuals received necessary medical services. These included income level, insurance status, and whether an individual had a usual source of care (such as a primary care provider). As one might expect, those with lower incomes had more difficulty obtaining care, as did those without a usual source of care. However, lack of health insurance was the most important correlate of unmet need. Berk and his colleagues found that the uninsured were two and one-half times as likely as the insured to have an unmet medical need.
The Uninsured Receive Care in Less Appropriate Settings
Without regular primary care providers, those without health insurance tend to forego routine preventative care. However, once a problem becomes an emergency, the uninsured can generally obtain care -- even if they cannot afford to pay for it. Unfortunately, such care tends to come late in the course of medical problems, many of which could have been prevented or treated more effectively through an earlier intervention.
According to a study sponsored by the RWJF, 16 percent of the uninsured report that their usual source of care is a hospital emergency room or outpatient department, compared with only 8 percent of the insured. In addition, by waiting until conditions deteriorate, the uninsured were much more likely to be hospitalized for an "avoidable hospital condition" or AHC. AHCs are conditions that can often be treated out of hospitals or avoided altogether. The RWJF study found that the likelihood of hospitalization from an AHC was significantly higher for uninsured adults than for privately insured adults -- even after controlling for other factors such as income.(footnote 20)
Emergency departments are both labor- and equipment-intensive and therefore such care is often two and one-half to three times more costly than visits to office-based physicians.(footnote 21) When the uninsured use these services and cannot pay the full cost, the bill is passed along to those who do pay, generally those with private insurance. In addition, there are important treatment issues; prevention efforts, continuity of care, and appropriate follow up are much more likely to occur through the use of primary care.
Where Do the Uninsured Obtain Care in Connecticut?
Despite the serious barriers to access that exist, there is a patchwork of facilities, programs and providers that serve uninsured individuals who cannot afford to pay the full cost of care. As noted earlier, many of the uninsured use emergency rooms or outpatient clinics as their principal source for health care services. Connecticut's 34 acute-care hospitals serve anyone who is admitted, regardless of insurance status or ability to pay. The 15 community health centers (CHCs) throughout the state are a major source of primary care to the uninsured. The CHCs have main sites, as well as satellite locations that include homeless health sites, school-based health centers, dental clinics, child guidance clinics, and perinatal sites. In addition, school districts (often through school-based health clinics) and local health departments offer a variety of these services, sometimes in conjunction with the CHCs. Finally, Connecticut health care providers, such as physicians and nurse practitioners, provide charity care, both at their offices and as volunteers in other settings.
Connecticut's Community Health Centers
In addition to an increase in total visits, there has also been a corresponding increase in the number of individuals that received services. In 1990, 80,000 (non-duplicated) patients were served at Connecticut's CHCs; by 1995, that figure grew to over 145,000.
CHC Use by Age
The clients served by the CHCs are predominantly young and female. In 1995, nearly 46 percent of CHC patients were children age nineteen or younger, compared with about 26.4 percent of the general population. About 23 percent of CHC patients were women between the ages 20 and 44, while men in this age range represented 14.6 percent. Another 11 percent of CHC clients were ages 45 to 64 and about 5 percent were age 65 or above.
CHC Payment and Funding Sources
Medicaid funded slightly more than half (50.4 percent) of all visits to CHCs in 1995. Self-pay clients, most of whom are categorized as "working uninsured," represented another 21.7 percent. The remaining payment sources for CHC visits included general assistance (13.1 percent), private insurance/other (10 percent) and Medicare (4.8 percent).
Because so many of their patients are uninsured, the CHCs depend heavily on government grants and contracts. The Department of Public Health provides funding to CHCs in order to help support community-based health services to uninsured and underinsured individuals. In state fiscal year 1995-96, this funding totaled nearly $4.8 million, including $1,689,552 for primary care services and $3.1 million for an expansion initiative. In addition, most community health centers receive federal funding as "community and migrant health centers" or as "federally qualified health centers" if they meet certain criteria defined by the federal government.
The recent Medicaid managed care initiative has brought about substantial changes in the financing and delivery of care to a large segment of the Medicaid population -- primarily AFDC recipients. The long-term effects of these changes on the CHCs, as traditional providers of primary care to the Medicaid and uninsured populations, remain to be seen.
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