Uninsured People Research Articles

Holistic Health Care for the Medically Uninsured: The Church Health Center of Memphis.

The Church Health Center (CHC) in Memphis was founded in 1987 to provide quality, affordable health care for working, uninsured people and their families. With numerous, dedicated financial supporters and health care volunteers, CHC has become the largest faith-based health care organization of its type nationally, serving >61,000 patients. CHC embraces a holistic approach to health by promoting wellness in every dimension of life. It offers on-site services including medical care, dentistry, optometry, counseling, social work, and nutrition and fitness education, to promote wellness in every dimension of life. A 2012 economic analysis estimated that a $1 contribution to the CHC provided roughly $8 in health services. The CHC has trained >1200 Congregational Health Promoters to be health leaders and is conducting research on the effectiveness of faith community nurses partnering with congregations to assist in home care for patients recently discharged from Memphis hospitals. The MEMPHIS Plan, CHC's employer-sponsored health care plan for small business and the self-employed, offers uninsured people in lower-wage jobs access to quality, affordable health care. The CHC also conducts replications workshops several times a year to share their model with leaders in other communities. The Institute for Healthcare Improvement (IHI) recently completed a case study that concluded: "The CHC is one of a very few organizations successfully embodying all three components of the IHI Triple Aim by improving population health outcomes, enhancing the individual's health care experience, and controlling costs. All three have been part of the Center's DNA since its inception, and as a transforming force in the community, the model is well worth national attention."

Estimating the Size and Cost of the STD Prevention Services Safety Net.

The Patient Protection and Affordable Care Act is expected to reduce the number of uninsured people in the United States during the next eight years, but more than 10% are expected to remain uninsured. Uninsured people are one of the main populations using publicly funded safety net sexually transmitted disease (STD) prevention services. Estimating the proportion of the uninsured population expected to need STD services could help identify the potential demand for safety net STD services and improve program planning. In 2013, an estimated 8.27 million people met the criteria for being in need of STD services. In 2023, 4.70 million uninsured people are expected to meet the criteria for being in need of STD services. As an example, the cost in 2014 U.S. dollars of providing chlamydia screening to these people was an estimated $271.1 million in 2013 and is estimated to be $153.8 million in 2023. A substantial need will continue to exist for safety net STD prevention services in coming years.

Uncompensated Care Burden May Mean Financial Vulnerability For Rural Hospitals In States That Did Not Expand Medicaid

The implementation of the Affordable Care Act has led to a large decrease in the number of uninsured people. Yet uncompensated care will still occur, particularly in states where eligibility for Medicaid is not expanded. We compared rural hospitals in Medicaid expansion and nonexpansion states in terms of the amount of uncompensated care they provided and their profitability and market characteristics in 2013. We found that rural hospitals in expansion states provided more dollars of uncompensated care than those in nonexpansion states and that the difference was at least partly driven by greater uncompensated costs associated with public programs such as Medicaid. We found higher dollar values of unrecoverable debt and charity care among non-critical access rural hospitals in nonexpansion states than among those in expansion states. Compared to hospitals in expansion states, those in nonexpansion states provided greater amounts of uncompensated care as a percentage of revenues and appeared to be more financially vulnerable; thus, these hospitals may be more likely to experience financial pressure or losses. Policy makers need to formulate strategies for maintaining access to care for rural populations residing in nonexpansion states.

Uso de los servicios de salud ambulatorios en la población peruana

Describe the profile of need and patterns of use of outpatient health services in populations who are enrolled and non-enrolled in a health insurance program in Peru. Descriptive cross-sectional study using data from the 2011 National Household Survey. The data were divided into five groups: persons enrolled in the Social Health Insurance (ESSALUD), Integral Health Insurance (SIS), Health Insurance of the Armed Forces and Police Force (AF-PF), Private Health Insurances (SPS) and the uninsured. People insured and enrolled in ESSALUD were more likely to use outpatient services than uninsured people and those enrolled in SIS. SIS members mainly attended health centers and small health posts (47.1%), while other insurance members mainly used hospitals and private hospitals. The uninsured used as their first choice pharmacies and drugstores (46.7%) in order to solve their health problems. In all insurances, out-of-pocket payment was made for the consultation, medications and tests. The perception of "not serious" was the main reason for not seeking care in the insured (40.0%) and uninsured (41.4%); however the lack of money showed an important difference between insured (10.6%) and uninsured (16.3%). The outpatient health services utilization profile of the Peruvian population expresses differences that relate to enrollment in and type of insurance.

The Affordable Care Act and Insurer Business Practices.

The ACA’s major changes to health insurers’ practices, which include requirements for adequate and affordable health insurance coverage, have resulted in a substantial reduction in the number of uninsured people in the US.

Bridging the gap between medical settings and specialty addiction treatment.

Keywords: Alcohol misuse; care linkage; medical settings; specialty addiction treatment

Community Perceptions on the Provision of Quality Health Care in Ghana: The Case of Kassena- Nankana Mutual Health Insurance Scheme

This paper examines community perceptions on the provision of quality health care in the Kassena-Nankana District in Ghana. The paper examines the relationship between Ghana’s National Health Insurance Scheme (NHIS) and the provision of quality health care, given that quality health care is an important determinant of access to health. Using a mixed methods research design, the researchers compared the perceptions of the insured and the uninsured people with respect to their perceived quality of health care received at health facilities. While the results of the household survey suggest that there is no statistically significant difference between the quality of health care received by either the insured or the uninsured, the focus group discussions indicate that the uninsured are attended to more quickly and are given more respect. The results highlight the perception that quality drugs are unavailable. The researchers recommend adequate supplies of good quality drugs to encourage utilisation of health services.Key Words: Community, Perceptions, Quality health care, Ghana, Health Insurance

Inequitable Access to Health Services for Older Adults with Diabetes: Potential Solutions on a State Level

Diabetes is a serious global public health challenge. The cost for health services for diabetes care has increased 41% over the past 5 years. Despite escalating health expenditure, the United States continues to have higher rates of diabetes than many other developed countries. There is a need for health care reform in the United States not only in reducing health care costs but also in improving the quality of preventative care. This study presents the testing of a multilevel model investigating variables on the individual and state levels to develop a better understanding of the most important contextual pathways that can lead to providing older adults (50+) with type 2 diabetes with the recommended preventative quality care they require. The model was tested using a three-level repeated cross-sectional design with data from various existing data sources, using a national sample of 181,870 individuals aged 50 years and older. Results showed that differences in state health care systems contributed to inequitable access. Specifically, in a state where there was a higher percentage of adults 65 and older coupled with a shortage of health care professionals, the likelihood of receiving the recommended preventative quality care decreased. Also, older adults living in states with a higher percentage of people with diagnosed diabetes but with a lower-than-average annual per capita health care expenditure fared worse in receiving quality preventative care. Last, older adults in wealthy states with higher percentages of uninsured people had the lowest odds of receiving quality preventative care. Health care reform, similar to what is currently promoted by the Patient Protection and Affordable Care Act of 2010, is recommended to improve the performance of all health care systems in all states.

The importance of health insurance and the safety net in rural communities.

Access to health insurance and health care are critical for people living in rural communities, where the safety net is fragile. However, rural communities face challenges as they enroll uninsured people in the health insurance marketplace, educate newly insured individuals on how to use insurance, and coordinate care for those who remain uninsured.

THE CHALLENGES OF ACA MARKETPLACE ENROLLMENT: RESULTS FROM BIG DATA AND CAMPAIGN-STYLE TACTICS IN THE KANSAS CITY AREA

In the fall of 2013 the Health Care Foundation of Greater Kansas City (HCF) undertook a major effort to increase insurance coverage among the estimated 200,000 uninsured people in their service area. HCF took a multi-tiered approach, providing direct incentive funding for organizations to train Certified Application Counselors (CACs) and conducting outreach activities through multiple modes of contact. Throughout the open enrollment period, HCF efforts involved knocking on nearly 60,000 doors and mailing communication to 68,000 households. HCF was committed to making real-time changes to their outreach strategies in order to increase effectiveness. Short-term evaluation efforts were canceled due to low response rates and it is too soon to assess the longer term impact of HCF outreach efforts. Overall, the experience highlights the role for local entities in providing education on health insurance and federal policy and the limitations of big data campaign-style tactics for identifying the uninsured and evaluating outreach activities, particularly those using phones as the primary contact. Experience also suggests the need for close collaboration between outreach and enrollment activities.

The Affordable Care Act, health care reform, prescription drug formularies and utilization management tools.

The U.S. Patient Protection and Affordable Care Act (hence, Affordable Care Act, or ACA) was signed into law on March 23, 2010. Goals of the ACA include decreasing the number of uninsured people, controlling cost and spending on health care, increasing the quality of care provided, and increasing insurance coverage benefits. This manuscript focuses on how the ACA affects pharmacy benefit managers and consumers when they have prescriptions dispensed. PBMs use formularies and utilization control tools to steer drug usage toward cost-effective and efficacious agents. A logic model was developed to explain the effects of the new legislation. The model draws from peer-reviewed and gray literature commentary about current and future U.S. healthcare reform. Outcomes were identified as desired and undesired effects, and expected unintended consequences. The ACA extends health insurance benefits to almost 32 million people and provides financial assistance to those up to 400% of the poverty level. Increased access to care leads to a similar increase in overall health care demand and usage. This short-term increase is projected to decrease downstream spending on disease treatment and stunt the continued growth of health care costs, but may unintentionally exacerbate the current primary care physician shortage. The ACA eliminates limitations on insurance and increases the scope of benefits. Online health care insurance exchanges give patients a central location with multiple insurance options. Problems with prescription drug affordability and control utilization tools used by PBMs were not addressed by the ACA. Improving communication within the U.S. healthcare system either by innovative health care delivery models or increased usage of health information technology will help alleviate problems of health care spending and affordability.

Sexually transmitted disease clinics in the era of the affordable care act: is it time to tear down the walls?

Sexually transmitted disease clinics in the era of the affordable care act: is it time to tear down the walls?

An estimated $84.9 billion in uncompensated care was provided in 2013; ACA payment cuts could challenge providers.

Millions of uninsured people use health care services every year. We estimated providers' uncompensated care costs in 2013 to be between $74.9 billion and $84.9 billion. We calculated that in the aggregate, at least 65 percent of providers' uncompensated care costs were offset by government payments designed to cover the costs. Medicaid and Medicare were the largest sources of such government payments, providing $13.5 billion and $8.0 billion, respectively. Anticipating fewer uninsured people and lower levels of uncompensated care, the Affordable Care Act reduces certain Medicare and Medicaid payments. Such cuts in government funding of uncompensated care could pose challenges to some providers, particularly in states that have not adopted the Medicaid expansion or where implementation of health care reform is proceeding slowly.

NIMH Fosters ‘Practice-Ready’ Solutions to Integrating Primary, MH Care

Research at the interface of mental health and primary care should focus on generating knowledge that decision makers need and incorporating practice-based evidence.

The Association of Lacking Insurance With Outcomes of Severe Sepsis

Patients with severe sepsis have high mortality that is improved by timely, often expensive, treatments. Patients without insurance are more likely to delay seeking care; they may also receive less intense care. We performed a retrospective analysis of administrative database-Healthcare Costs and Utilization Project's Nationwide Inpatient Sample-to test whether mortality is more likely among uninsured patients hospitalized for severe sepsis. None. We used International Classification of Diseases-9th Revision, Clinical Modification, codes indicating sepsis and organ system failure to identify hospitalizations for severe sepsis among patients aged 18-64 between 2000 and 2008. We excluded patients with end-stage renal disease or solid organ transplants because very few are uninsured. We performed multivariate logistic regression modeling to examine the association of insurance status and in-hospital mortality, adjusted for patient and hospital characteristics. We performed subgroup analysis to examine whether the impact of insurance status varied by geographical region; by patient age, sex, or race; or by hospital characteristics such as teaching status, size, or ownership. We used similar methods to examine the impact of insurance status on the use of certain procedures, length of stay, and discharge destination. There were 1,600,269 discharges with severe sepsis from 2000 through 2008 in the age group 18-64 years. Uninsured people, who accounted for 7.5% of admissions with severe sepsis, had higher adjusted odds of mortality (odds ratio, 1.43; 95% CI, 1.37-1.47) than privately insured people. The higher mortality in uninsured was present in all subgroups and was similar in each year from 2000 to 2008. After adjustment, uninsured individuals had a slightly shorter length of stay than insured people and were less likely to receive five of the six interventions we examined. They were also less likely to be discharged to skilled nursing facilities or with home healthcare after discharge. Uninsured are more likely to die following admission for severe sepsis than patients with insurance, even after adjusting for potential confounders. This was not due to a hospital effect or demographic or clinical factors available in our administrative database. Further research should examine the mechanisms that lead to this association.

Nearly 60,000 Uninsured And Low-Income People With HIV/AIDS Live In States That Are Not Expanding Medicaid

Health insurance gives people living with HIV/AIDS access to medical care, including antiretroviral therapy, which in turn can dramatically improve health and reduce the risk of HIV transmission. Yet many people living with HIV/AIDS remain uninsured. The Affordable Care Act (ACA) seeks to decrease the number of uninsured Americans in part by extending Medicaid coverage to individuals with incomes of up to 138 percent of the federal poverty level. However, many states are not moving forward with this expansion. Using national HIV surveillance data and data from the National Health Interview Survey, we estimated that nearly 115,000 uninsured, low-income people living with HIV/AIDS would be eligible for Medicaid if all states adopted the expansion. Of these, nearly 60,000 live in states not moving forward with the Medicaid expansion. States' decisions about whether or not to participate in the expansion are likely to have important consequences for the health of this population and the evolution of the HIV epidemic.

Incorporation of Socioeconomic Status Indicators into Policies for the Meaningful Use of Electronic Health Records

Socioeconomic status (SES) has an important effect on health. Individuals with lower SES experience more chronic disease, are less likely to receive preventive care, and have shorter life expectancies. As the Affordable Care Act is implemented and increasing numbers of previously uninsured people gain access to health care, the imperative to recognize patients' SES and develop health initiatives that account for the social determinants of health increases. Health care providers across the nation are adopting electronic health records (EHRs). Policies such as Meaningful Use offer opportunities systematically to incorporate the collection of standardized SES indicators into EHRs in ways that improve health, increase the understanding of the relationship between SES and health, and inform future policies. This paper examines the use of SES indicators in research, national surveys, and federal programs and finds adding an income question is the most feasible and optimal SES indicator for the inclusion in EHRs.

Interdisciplinary HIV care in a changing healthcare environment in the USA

HIV remains a complex disease that requires comprehensive, coordinated care to ensure optimal outcomes. In the USA, interdisciplinary models of care have developed over time to optimize treatment outcomes. These models may be increasingly important in an era of healthcare reform in the USA. A qualitative study of nine clinical sites funded by the Ryan White HIV/AIDS Program (RWHAP), the federally funded “safety net” program for uninsured and underinsured people living with HIV, was undertaken to identify components of successful models of interdisciplinary HIV care. Findings suggest that these include: (1) patient-centered, one-stop-shop approaches with integrated or co-located services; (2) diverse teams of clinical and nonclinical providers; (3) a site culture that promotes a stigma reducing environment for clients; (4) the availability of a comprehensive array of medical, behavioral health, and psychosocial services; (5) effective communication strategies, including electronic health records (EHRs); and (6) a focus on quality. The importance of RWHAP funding in sustaining these programs is highlighted.

A New Day Dawns For Workforce Redesign

A New Day Dawns For Workforce Redesign

Early Evidence From California on Transitions to a Reformed Health Insurance System for Persons Living With HIV/AIDS

Many uninsured people living with HIV/AIDS (PLWHA) will obtain managed health insurance coverage when the Affordable Care Act (ACA) is implemented in January 2014. Since 2011, California has transitioned PLWHA to Medicaid managed care (MMC) and to the Low-Income Health Program (LIHP). To draw lessons for the ACA implementation from the transitions into MMC and the LIHP. Surveys about clients and services provided before and after the transition to MMC and the LIHP were sent to 43 HIV service providers. Usable responses were obtained from 18 (42%). Although total client loads were similar in the pre- (January 2011) and posttransition periods (June 2012), many clients transitioned from fee-for-service (FFS) Medicaid to MMC. Over this period, responding agencies served 43.5% fewer PLWHA in FFS Medicaid, whereas the share of PLWHA covered by MMC rose from 16.9% to 55.5%. Managed care covered a smaller number of services than either FFS Medicaid or Ryan White sites. Ryan White providers reported that 53% of the clients they served in January 2011 had transitioned to the LIHPs. Nonetheless, they continued to provide services to many of these clients, and Ryan White caseloads did not decline. PLWHA enrolled in the MMC continue to depend on Ryan White sites to supply the full range of services that will allow them to take full advantage of increased access to care under ACA.