Obtaining Health Care Research Articles

Physicians With Heart

To the Editor. —Medical News & Perspectives 1 recently ran several articles physicians whose efforts for the medically underserved have made a positive impact. Another such hero is H. Arnold Meyersburg, a psychiatrist in private practice in Kensington, Md. Almost two dozen years ago, as president of a voluntary tutoring group for children from low-income families, he became aware of their difficulty in obtaining health care in affluent Montgomery County, Maryland. Under Dr Meyersburg's leadership, perseverance, and activism, and with help from a few dedicated community leaders, Mobile Medical Care was born after a difficult labor and delivery. In April 1970, its first clinic opened in a church in Ken-Car, a low-income black community, literally on the other side of the railroad tracks. The Ken-Car citizens' association helped coordinate activities, a small foundation donated seed money, the local Red Cross chapter offered supplies and recruited nurse volunteers, and a

Health care access problems of medically indigent emergency department walk-in patients

To obtain health care access data on emergency department walk-in patients and to determine factors associated with delayed access to care. Survey of stable ED walk-in patients in the triage area. University of California Irvine Medical Center, an urban, 493-bed, noncounty, Level I teaching hospital treating 38,000 emergency patients annually. A quota of 1,000 consecutive patients derived from a representative selection of service days was included; 94% of eligible patients agreed to participate. Patients with obstetrical problems (more than 20 weeks' gestation) were excluded. Pretested health access survey, available in both Spanish and English, administered by investigator. Public aid/self-pay insurance status was significantly associated with routine use of the ED for care (P less than .003), income of less than $10,000 (P less than .0002), refusal of care by health provider (P less than .001), refusal of care at an ED (P less than .03), and delay in seeking health care (P less than .0002). Income of less than $10,000 was significantly associated with routine use of the ED for care (P less than .02), and delay in seeking health care (P less than .04). Statistical analysis done using chi 2 with continuity correction and with the binomial test for comparison of two proportions. Among stable ED walk-in patients surveyed at our facility, low-income individuals and those with public aid/self-pay insurance status were significantly more likely to use the ED as a routine source of health care, and more likely to delay in seeking needed health care, than higher income and fully insured individuals. These data should be useful to health policymakers in formulating rational, cost-effective strategies that improve access to early treatment and prevention.

Health Beliefs and Practices of Foster Parents

This study considers how foster parents and social workers contribute to the routine health care of foster children. Health beliefs and practices of foster parents, their relationship to obtaining health care for foster children, and issues of social workers' and foster parents' responsibility for coordinating and obtaining medical care are explored. Suggestions for improved coordination are tendered.

Time demands and medical ethics in women's health care

The perspectives of sociology and medical ethics are combined in this study of how the demands of women's social roles affect their efforts to obtain health care. The principles of justice, beneficence, and respect for autonomy are applied to the delivery of health care. A conflict between beneficence and respect for autonomy often leads to medical paternalism. Health care is not distributed justly in the United States, and three models of patient-practitioner interaction exist as a result of financial and time constraints on women. The first model is truly paternalistic. The second appears to be paternalistic. However, medical practitioners in this model are actually given a decision-making role by their female patients for specific issues for limited time periods. A third model exemplifies cooperation between medical professionals and patients, but this model is elusive to most women because of time constraints.

Health care utilization barriers among Mexican Americans: evidence from HHANES 1982-84.

Data from the Hispanic Health and Nutrition Examination Survey (HHANES) conducted by the National Center for Health Statistics in 1982-1984 were analyzed to document the type of barriers encountered which prevented Mexican Americans from obtaining health care, the sociodemographic subgroups most vulnerable to such barriers, and to examine the combined effects of predisposing, enabling, and need characteristics on these barriers. The findings suggest, in general, that low income groups, younger age groups, the less acculturated, those who lack health insurance coverage, those with functional limitations, and those in poorer perceived health status encounter more barriers than others, and are prevented by these barriers from obtaining health care for themselves.

Access to health care in the United States

Approximately 34 million people in the United States have no health insurance. Up to 80 million people have insurance inadequate to provide care for severe or long-term illness (the underinsured). In 1986, an estimated 1 million persons in the US could not obtain needed health care for financial reasons, and another 18.8 million had difficulty obtaining care. There probably are 3.2 million people with neurologic disorders among the 34 million uninsured, and more among the underinsured. Those patients probably have difficulty obtaining health care, including neurologic consultations, laboratory tests, and radiologic procedures. Congress and many state legislatures are considering various proposals to address the problems of the un- and underinsured. Several national medical professional societies have developed programs to improve access to care for their patients. The American Academy of Neurology Task Force on Access to Health Care is studying access to care for neurologic patients and will recommend a course of action to the Academy. The Task Force welcomes suggestions concerning appropriate steps to improve access to health care for patients with neurologic disorders.

Health Care for Children of Migrant Families

Migrant and seasonal/farm workers constitute a major portion of the labor force in the American food industry. By harvesting and processing farm crops, they contribute positively to agricultural communities and the American economy. Currently, the office of Migrant Health estimates that nationwide there are between 3 and 5 million migrant and seasonal farm workers and dependents. The average annual income for migrant and seasonal farm workers is well below the poverty level (US Dept of Health and Human Services, unpublished data, 1988). Because health care insurance is invariably beyond the reach of migrant family budgets, and employers of farm workers rarely provide health care benefits for their employees, these families are usually uninsured. In some cases, these families lack US citizenship or are in this country illegally, which complicates obtaining health care for their children. Medicaid enrollment is also complicated by migration because aliens must meet eligibility requirements in each state to which they migrate, and only US citizens are eligible. Because of their income and mobile life-style, migrant worker families often find that comprehensive child health care (health maintenance, anticipatory guidance, and preventive medicine) essentially is not available. Migrating families must seek health care whenever it is available. This results in a pattern of service that usually is fragmented and ad hoc. Migration not only interrupts continuity of care but it also contributes to a lack of knowledge about a community's health services and/or jeopardizes eligibility for these services by conflicting with residency requirements. Other problems that delay or prevent access to health care for the children of migrant families include language barriers and differences in culture.

A Health Policy Agenda Proposal for Including the Poor

Medicaid, the nation's major program to provide health care to low-income persons, is failing to meet the health care needs of the poor. Even though the number of poor persons without access to health insurance has grown over the past decade, 11 million persons with incomes below the federal poverty level were without any health insurance in 1988, and over 50% of the poor did not qualify for Medicaid. Although a patchwork of charity care and publicly funded health provision systems is available to some individuals in some communities, this incomplete system does not ensure access to comprehensive and consistent care for all who need it. A 1986 survey discovered that 19 million Americans encountered difficulty in obtaining health care because of financial reasons, and an estimated 1 million persons were denied care because they were unable to afford it. The failure of the program to provide comprehensive access for

Unmet needs of persons with cancer in Pennsylvania during the period of terminal care.

A stratified random sample of recent cancer deaths was drawn from the Pennsylvania death registry, and 433 family members or close friends were interviewed concerning unmet needs during the last month of life. It was estimated that 72% of persons who died of cancer in Pennsylvania experienced at least one unmet service need during this period. The most frequently reported was help with activities of daily living, estimated at 42% of cancer deaths, involving over 11,000 persons each year in the state. There were significantly more unmet needs during the terminal period, compared with just after diagnosis, in activities of daily living, obtaining health care, transportation, and problems with medical staff. Our findings indicate a need to increase a broad range of support programs during the terminal period, especially of home-care services.

Caring for the Poor

DESPITE the fact that the United States is one of the most affluent countries in the world, a significant portion of its citizens have inadequate access to medical care.1,2While the barriers to obtaining health care are numerous, perhaps the most difficult hurdle to overcome is the lack of financial resources to pay for it. Although there appears to be a growing consensus that all people should receive basic health care, there is little agreement on how to achieve or finance this goal or even how to define it.3 This report examines the individual medical practitioner's ethical obligation to treat the poor. Because much of the recent attention has focused on broader societal obligations and systematic reform, the role of the individual has been overshadowed. The American Medical Association (AMA) has long recognized an ethical obligation of physicians to assume some individual responsibility for making health care available

The health plight of rural women.

All poor women have difficulty obtaining needed health services due to their poorer health status and lesser ability to pay for services. Rural poor women have additional conditions imposed on them by the isolation of the rural environment from resources commonly available in urban areas, such as public transportation to services and the availability of a wide range of health resources. Strategies to address the health plight of rural women must first and foremost address their poverty. Strategies must also include a coherent national and state rural health policy that recognizes rural health as a distinct part of the larger health system.

Health care delivery models: Emerging trends in the delivery of health services

Rising costs, a higher proportion of elderly in the population, proliferation of high technology and increased knowledge about efficient and effective service provision have all led to increased cost-consciousness in the health system. Historically, regulatory approaches have provided equity of access and funding, but for controlling costs they have now become inappropriate because they leave the mix of services untouched. In the future, regulatory approaches may make more use of guidelines and algorithms for care (the "soft" regulatory route), or they may directly control the supply of providers and other resources in the health system (the "hard" regulatory route). An alternative is the competition approach which allows choices by consumers on where to obtain health care based on the efficiency with which those services are provided. The danger in this approach is the potential for equity to be compromised; this may be addressed by combining the regulatory and competitive approaches.

A Navajo health consumer survey.

The findings of a health consumer survey of 309 Navajo families in three areas of the Navajo Reservation are reported. The survey shows that access to facilities and lack of safe water and sanitary supplies are continuing problems for these families. The families show consistent use of Indian Health Service providers, particularly nurses, pharmacists and physicians, as well as traditional Navajo medicine practitioners. Only incidental utilization of private medical services is reported. Extended waiting times and translation from English to Navajo are major concerns in their contacts with providers. A surprisingly high availability of third-party insurance is noted. Comparisons are made between this data base and selected national and regional surveys, and with family surveys from other groups assumed to be disadvantaged in obtaining health care. The comparisons indicate somewhat lower utilization rates and more problems in access to care for this Navajo sample. The discussion suggests that attitudes regarding free health care eventually may be a factor for Navajo people and other groups, that cultural considerations are often ignored or accepted as truisms in delivering care, and that the Navajo Reservation may serve as a unique microcosm of health care in the U.S.

New health professionals and older persons.

Because the number of aged persons in the population is increasing and localized maldistributions of health care manpower persist, it has been suggested that new health professionals might provide health services for older persons who would otherwise face problems in obtaining health care. In this study, the authors tested the degree to which older persons know about and are accepting of care by new health professionals. They found that older persons know less about and accept less NHP care than do younger persons, although they are still mostly accepting of such care. In addition, older persons are more satisfied with their current care providers. Taken together, these findings indicate that older persons do not currently provide a source of expressed demand for NHP services.

The Medicare-Medicaid Amendments

The provisions of PL 92-603, which made its way through Congress in 1972 as H.R.I, are many and varied. Title II, which changed Medicare and Medicaid extensively, is probably most significant to nurses. Its major provisions would * Establish professional standards review organizations, * Encourage the increased use of health maintenance organizations, * Establish cost-sharing mechanisms whereby medically indigent patients are required to pay a portion of the cost of services which were formerly free, * Provide new coverage for disabled persons and patients needing long-term kidney treatment, * Modify the rules for the use of extended care facilities, * Set penalties for those states failing to provide screening examinations for children and family planning services for mothers who receive aid to families with dependent children, and * Encourage the use of a wider variety of health care personnel, including nurse practitioners. Cursory examination of the amendments may well leave the observer with some confusion about their overall intent. The first and major theme in the amendments is one of economy. The second major theme is less obvious, but nevertheless important. Significant efforts are made to extend coverage and to make the procedures for obtaining health care more rational. These steps to improve the operation of Medicare and Medicaid can, with a little imagination, be described as steps toward an eventual national health care plan.