The Uninsured and Underinsured Population Angelia Lucas HCA 305 – The U.S. Healthcare System Ashford University Instructor Marcia Kessack ,PhDc MSN/Ed RN December 15, 2014 Executive Summary The Uninsured and Underinsured Population • Explore the history • Compare the U.S. to other countries • Review the Stakeholders involved • P.P.A.C.A. implementation • Recommendations History of the Problem • In 2006, 46.6 million Americans were uninsured • More than 80% were employed or came from working families • 38.3 million adults and 8.3 million children did not have health insurance in 2006 • 39% of the uninsured are between the ages of 19 and 34 • 32% of the uninsured are between the ages of 35 and 54 • Great Recession of 2007-2009 • Higher unemployment led to less income and an increase in uninsured Americans U.S. Compared to other countries “The Cost of Health System Change: Public Discontent in Five Nations” Countries Surveyed: Australia, Canada, New Zealand, the United Kingdom, and the United States Goal: To examine public attitudes and compare data on health spending and outcomes. Analysis of the health care experiences of Americans based on their insurance status and type of plan. U.S. Compared to other countries cont’d United States results: • Out of pocket costs for healthcare is much higher in the U.S. than in 5 other countries surveyed • 8 percent of U.S. adults reported paying nothing out of pocket for health care during the same period • One of five (19%) U.S. respondents said they paid more than $1,000 in the past year • One of ten (8%) indicated they paid more than $2,000 Other Countries results: • Only 6% of New Zealanders paid more than $1,000 • United Kingdom: 44% stated they paid nothing out of pocket for medical care in the past year Stakeholders • State and Federal Government • Tax Payers • Healthcare industry State & Federal Government Initiatives • Medicaid Expansion Programs • Increase income standards to aid families with dependent children • Make other eligibility requirements more flexible • Strategies for extending private insurance • Employer mandates: Play or pay • Reducing the cost of benefits • Limit or target benefits e.g. waiving state mandate benefits • Preferred provider arrangements • Managed care Healthcare Initiatives • Charity Program for eligible patients • Uninsured discounts • Prompt Pay discounts • Participate with all major insurance carriers Patient Protection Act & Affordable Care Act of 2010 • Purpose covers the following: • Affordable rates • Quality treatment • Availability of healthcare to everyone • Issues the Act addresses: • Ensuring affordable healthcare coverage to all working people • Discounts and subsidy is provided to the eligible families • Almost 95% of Americans will be insured Patient Protection Act & Affordable Care Act of 2010 cont’d • Impact on the U.S. Health Care System • • • • Less insured number of people Premiums will remain the same for age and gender Consistency and effectiveness Subsidy provided by the state will impact businesses and low income families Recommendations • Educational resources for communities • Affordable Care Act involvement • Reduction in Healthcare cost • Medicaid Expansion Conclusion • Lack of Health insurance has been linked to: • • • • • • • • Increased morbidity Decreased access to all healthcare services Lower use of preventative care Delays in seeking out necessary care Increased rate of hospitalization Linked to developmental and education deficits for children Reductions in the workforce productivity Family and community stress References Ashford University (2014). Information on the Affordable Care Act. Retrieved on December 6, 2014 from: http://www.ashford.edu/affordablecareact.htm Cummings, Elijah (July 22, 2013). Health Care Town Hall: Purpose and Benefits of Affordable Care Acts. Retrieved on December 6, 2014 from https://cummings.house.gov/sites/cummings.house.gov/files/documents/Cummings%20Health%20Care%20Town%2 0Hall%207%2022%2013.pdf Hill, M., Granado, M., Opusunju, J., Peters, R., & Ross, M. (2011). THE IMPACT OF INCOME, PUBLIC ASSISTANCE AND HOMELESSNESS ON SEEKING MEDICAL CARE. American Journal Of Health Studies, 26(3), 174. Retrieved from http://eds.a.ebscohost.com.proxy-library.ashford.edu/eds/command/detail?vid=7&sid=cf537a14-ad61-4bad-8c168e0053c19f21%40sessionmgr4002&hid=4105&bdata=JnNpdGU9ZWRzLWxpdmU%3d#db=f5h&AN=67310840 International comparisons reveal public concerns with health systems and disparity between spending, health outcomes in U.S. (1999, Jun 28). U.S.Newswire Retrieved from http://search.proquest.com/docview/451008166?accountid=32521 Merrill, J. C. (1990). State initiatives for the medically uninsured. Health Care Financing Review, , 161. Retrieved from http://search.proquest.com/docview/196950478?accountid=32521 References cont’d. Rosenbaum, Sara (2011). The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice. Retrieved on December 6, 2014 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001814/ The Patient Protection and Affordable Care Act: Detailed Summary. Retrieved on December 6, 2014 from http://www.dpc.senate.gov/healthreformbill/healthbill04.pdf Sharan, A.D., Mehta, S., Nunley, R. M., (2008). Issues facing America: The uninsured. Retrieved on December 15, 2014 from http://www.aaos.org/news/aaosnow/feb08/reimbursement2.asp Silverman, R. (2008). Access to care: who pays for health care for the uninsured and underinsured? A symposium introduction and overview. Journal Of Legal Medicine, 29(1), 1-9. Retrieved from http://eds.a.ebscohost.com.proxy-library.ashford.edu/eds/command/detail?vid=9&sid=cf537a14-ad614bad-8c168e0053c19f21%40sessionmgr4002&hid=4105&bdata=JnNpdGU9ZWRzLWxpdmU%3d#db=c8h&AN=2009875 064 Vargas Bustamante, A., & Chen, J. (2014). The Great Recession and Health Spending among Uninsured U.S. Immigrants: Implications for the Affordable Care Act Implementation. Health Services Research, 49(6), 19001924. doi:10.1111/1475-6773.12193 Retrieved from http://eds.a.ebscohost.com.proxylibrary.ashford.edu/eds/command/detail?vid=5&sid=cf537a14-ad61-4bad-8c168e0053c19f21%40sessionmgr4002&hid=4105&bdata=JnNpdGU9ZWRzLWxpdmU%3d#db=aph&AN=9951712 3 PURPOSE AND BENEFITS OF THE AFFORDABLE CARE ACT Congressman Elijah E. Cummings’ Health Care Town Hall July 22, 2013 Governor’s Office of Health Care Reform Carolyn A. Quattrocki, Executive Director What Problem Are We Working to Solve?  U.S. spends 1.5 times more on health care than any other developed country, and 2.5 times more than the average.  $3,000 more per person than Switzerland, with comparable income.  Yet Americans die earlier and live in poorer health.  Highest rates of infant and adult male mortality, and second highest mortality rate for women;  Second highest rates of death from heart, lung, and substance use; and  Lowest probability of living to age 50.  Growth in U. S. health care spending unsustainable.  Health spending has doubled in past 30 years, rising from 9.2% of GDP in 1980 to 17.9% in 2011;  Health insurance premiums have increased 97% in the last decade. 2 Overarching Goal of Health Care Reform BETTER HEALTH AT LOWER COST FOR ALL MARYLANDERS Four Pillars of the Affordable Care Act Stronger, Non-Discriminatory Insurance Coverage Expanded Access to Health Insurance and Health Care More Affordable Insurance Coverage Cost Control and Improvement in Outcomes Bringing These Benefits To Maryland Health Care Reform Coordinating Council Established by Executive Order, March 2010 01.01.2010.07  Executive and legislative leaders in health care  Directed to examine Affordable Care Act and make recommendations to Governor and General Assembly on how State should implement reforms in ways that would work best for Maryland. Report: 16 Recommendations in 5 Categories  Health Benefit Exchange, Medicaid Expansion and Insurance Market Reforms  Health Care Delivery and Payment Reform  Public Health, Safety Net, and Special Populations  Workforce Development  Communications/Outreach and Leadership/Oversight Collaborative Approach State Agencies, Local Jurisdictions, Non-Profits and Private Sector Robust Stakeholder Process Advisory Committees Patients’ Bill of Rights Stronger, Non-Discriminatory Coverage Chapter 4 2011 Laws of Maryland Chapter 368 2013 Laws of Maryland  Young adults can stay on parents’ insurance plan until age 26; 52,000 in MD; 2.5 million nationwide.  No children denied coverage because of pre-existing condition.  No lifetime limits on benefits and harder to rescind policies when people get sick; 2.25 million Marylanders benefiting, including over one half million children.  In 2014, no exclusions for pre-existing conditions or annual limits on benefits. Patients’ Bill of Rights Stronger, Non-Discriminatory Coverage Chapter 4 2011 Laws of Maryland Chapter 368 2013 Laws of Maryland  Women no longer paying higher premiums because they are women.  Preventive services:  ACA requires coverage of many preventive services at no cost;  Examples include mammograms and other cancer screenings, flu shots and other vaccines, tobacco cessation programs;  Services designed for women, like well visits, contraception, breastfeeding equipment, and domestic violence and counseling;  1.2 million Marylanders covered with no cost-sharing; 554,000 on Medicare have received at no cost; 797,185 eligible. Patients’ Bill of Rights Stronger, Non-Discriminatory Coverage Chapter 4 2011 Laws of Maryland Chapter 368 2013 Laws of Maryland  Carriers’ rating factors limited to:  Age bands no greater than 3:1  Family size and geography  Tobacco use no greater than 1.5:1  Maryland Health Progress Act directs State to study whether tobacco use rating should be eliminated or narrowed.  Limits on out-of-pocket costs - $6,350 for individual; $12, 700 for family; lower on sliding scale for consumers below 400% of federal poverty level.  New 80/20 Medical Loss Ratio  141,000 Marylanders received $28 million in rebates in 2012;  Average of $340 per family. ESSENTIAL HEALTH BENEFITS: SELECTION OF STATE’S BENCHMARK FEDERAL GUIDANCE – AFFORDABLE CARE ACT  Beginning in January, 2014, all plans offered in small group and individual markets inside and outside exchanges must cover “essential health benefits.” Must cover 10 categories of mandated essential health benefits 10 • Ambulatory patient services; • Emergency services; • Hospitalization; • Maternity and newborn care; • Mental health & substance use disorder services; • Prescription drugs; • Rehabilitative and habilitative services; • Laboratory services; • Preventive/wellness services & chronic disease management; • Pediatric services, including oral and vision care ESSENTIAL HEALTH BENEFITS: SELECTION OF STATE’S BENCHMARK  HCRCC solicited stakeholder input and expert consultant’s comparative analysis, and on December 17, 2012:  Made selection of State’s small group plan as benchmark;  Retained all existing mandates in markets in which currently applicable;  Substituted more comprehensive and parity compliant federal employee behavioral health benefit;  Added adult component to existing child habilitative services benefit in parity with current rehabilitative services benefit.  HCRCC decision preserves stability in small group market while offering robust, comprehensive benefit coverage and open drug formulary. 11 Pillars II and III Expanded Access to Care and More Affordable Coverage Medicaid Expansion  MAGI - New eligibility rules based on “modified adjusted gross income” standard  Uses income tax rules regarding household composition, income and deductions;  Same standard in all states;  Same standard used to determine eligibility for subsidies in Exchange. 2013 Federal Poverty Level Guidelines  Expanded eligibility - All citizens at or below 138% of federal poverty level  No longer specific categories, e.g. pregnant women, parents, for income-based eligibility;  About $16,000 for individual;  $33,000 for family of four. Pillars II and III Expanded Access to Care and More Affordable Coverage Medicaid Expansion  Primary Adult Care (PAC) program – will convert to full Medicaid benefits 1/1/14.  75,000 currently on PAC; outreach opportunity between now and January.  Foster care – Children who age out of foster care can retain Medicaid to age 26.  Paradigm shift – new assumption that all citizens qualify for health care;  Issue no longer preventing erroneous eligibility;  Instead, in which program does the person qualify?  Federal support – for 2014-16, 100% federally funded; tapers to 90% by 2020.  One-stop eligibility and enrollment through Health Benefit Exchange. Projections  2014: 110,000  2015: 135,000  2020: 190,000 (including current PAC population) Pillars II and III Expanded Access to Care and More Affordable Coverage Health Benefit Exchange  Transparent, competitive marketplace where consumers will compare private health benefit plans based on quality and price.  Federal subsidies on sliding scale for low-income people between 133% - 400% FPL.  Small business tax credits: 50% of employer’s contribution to premium Projections  2014: 147,000  2015: 170,000  2020: 284,000 Single Person FPL Annual Income Maximum Premium (as % of income) Enrollee Monthly Share 133% $15,281 2.00% $25.47 150% $17,235 4.00% $57.45 200% $22,980 6.30% $120.65 250% $28,725 8.05% $192.70 300% $34,470 9.50% $272.89 400% $45,960 9.50% $363.85 Pillars II and III Expanded Access to Care and More Affordable Coverage Effect on Maryland’s Rate of Uninsured  750,000 Marylanders currently uninsured (12.7%); 13th among states;  By 2020, uninsured rate cut in half;  Medicaid expansion and Exchange enrollment will cover 350,000, or about 6.5%;  Remaining uninsured will be undocumented immigrants, individuals with affordability exemption, those choosing penalty, etc. Closing the Donut Hole Prescription Drug Savings to Maryland Seniors  55,107 Maryland seniors received $250 rebate in 2010.  49,000 saved $37.5 million in 2012.  Overall savings to date: $84.1 million.  Projected savings through 2020: $400 million. ECONOMIC BENEFITS OF EXCHANGE AND MEDICAID EXPANSION Economic Stimulus  Independent analysis by Hilltop Institute at University of Maryland Baltimore County found that full implementation of the Affordable Care Act will:      generate $3 billion in additional economic activity annually; create 26,000 new jobs by end of decade; have net positive impact on State’s budget through 2020; protect safety net and other health care providers; and reduce hidden uncompensated care tax in insurance premiums. Source : “Maryland Health Care Reform Simulation Model” Hilltop Institute, University of Maryland Baltimore County (July 2012) 16 ECONOMIC BENEFIT OF EXCHANGE AND MEDICAID EXPANSION 17 Economic Benefit 2104 2015 2020 Federal Subsidies $254 Million $607 Million $1.3 Billion Increase in Funds to Providers $682 Million $1.2 Billion $2.3 Billion Increase in Health Expenditures $1.06 Billion $2.08 Billion $3.9 Billion Number of New Jobs 9,000 16,000 26,000 Reduction in Uncompensated Care $118 Million $306 Million $714 Million Additional State and Local Taxes $61 Million $140 Million $237 Million Pillar IV Cost Control and Quality Improvement: Save Money While Making People Healthier Keeping people healthy: Investments in wellness and prevention Higher quality and more efficient care delivery models: Pilots and demonstration projects with leadership from health care providers Health Information Technology: Support ongoing efforts to develop Health Information Exchange and meaningful use of Electronic Health Records Workplace Wellness and Health Care Reform  ACA creates new incentives and builds on existing wellness program policies.  Increases maximum permissible reward under health-contingent wellness programs from 20% to 30% of the cost of health coverage;  Further increases maximum reward to as much as 50% for programs designed to prevent or reduce tobacco use. 19 Health Care Delivery and Payment Reform Progress  HCRCC’s Health Care Delivery and Payment Reform Subcommittee  Identifies and supports successful clinical innovations, financial mechanisms and integrated programs underway in private sector to promote delivery system reform  Website, www.dhmh.maryland.gov/innovations  Health Quality & Cost Council  Public-private Partnership to address chronic disease management, wellness and prevention, and other quality and cost control measures    Healthiest Maryland Cultural Competency Evidence-based medicine Health Care Delivery and Payment Reform  Health Enterprise Zones (Health Improvement and Disparities Reduction Act of 2012)  Community (or contiguous cluster) of 5,000 or more residents with economic disadvantage and poor health outcomes;  4-year, $4 million/year pilot to invest in local community plans to improve primary care and address underlying causes of health disparities using direct grants, property and income tax incentives, loan repayment, and other tools;  5 HEZ designations: 1) MedStar - St. Mary’s Hospital – Greater Lexington Park; 2) Dorchester, Caroline County Health Dept.; 3) Prince George’s County Health Dept. – Capitol Heights; 4) Anne Arundel Health System – Annapolis; and 5) Bon Secours West Baltimore Primary Care Collaborative. Maryland’s Patient-Centered Medical Home Pilot Programs  State multi-payer and private single payer authorized by 2010 legislation.  State multi-payer:     5 commercial carriers, 6 MCOs, some self-funded employees, and TRICARE (7/13); 52 practices with 250,000 “attributed” patients; 330 providers; Practice transformation through Maryland Learning Collaborative; Practices must deliver team-based care with care coordinator, obtain NCQA recognition as PCMH, and report on quality and performance;  In 2012, approximately $900,000 in shared savings issued to 23 practices;  Model to be evaluated to determine whether achieves savings, increased patient and provider satisfaction, and reduced health disparities.  Two single payers authorized as of 3/13; 1.1 million patients. ACA Promotion of Accountable Care Organizations  New health care delivery model where groups of doctors, hospitals, and other providers work together to:  provide coordinated, high quality care to their Medicare patients which: o ensures care at the right time and place; and o avoids duplication or services and medical errors;  reduce the rate of growth in health care spending.  Medicare Shared Savings Program  Uses 33 performance measures for patient safety, preventative health services, care for at-risk populations, care coordination, and patient experience;  If the cost of care is below the anticipated cost, ACO receives portion of savings.  Maryland ACOs – 9 approved by CMS to date covering every region of State 23 MARYLAND ACOs • • • • 24 APPROVED JULY 2012 Accountable Care Coalition of • Maryland, Hollywood, MD, 109 • physicians Greater Baltimore Health Alliance • Physicians, partnerships between hospital and ACO professionals, 399 physicians. Maryland Accountable Care Organization of Eastern Shore, National Harbor, 15 physicians. Maryland Accountable Care Organization of Western MD, National Harbor, ACO group practices and networks of individual ACO practices, 23 physicians. APPROVED JANUARY 2013 AAMC Collaborative Care Network Lower Shore ACO - Med-Chi Network Services Three ACOs overseen by Universal American – Maryland Collaborative Care LLC, serving Carroll, Montgomery, Frederick, Calvert and Anne Arundel. – Northern Maryland Collaborative Care LLC, serving Baltimore and Washington metro areas. – Southern Maryland Collaborative Care LLC, serving Montgomery, Prince George’s, and Anne Arundel. State Innovation Models Award Community-Integrated Medical Home     CMS initiative to develop, implement and test new payment and delivery models; Maryland received $2.37 million “Model Design,” 6-month planning award; Opportunity for “Model Testing” award up to $60 million over 4 years. Community-Integrated Medical Home (analogous to “Accountable Care Community”)  Integration of multi-payer medical home with community health resources;  Four components – primary care, community health, strategic use of new data, and workforce development;  Governance structure and public utility to administer payment and quality analytics processes (analogous to concept of “wellness trust”);  Use of expanded Local Health Improvement Coalitions, community health workers, and data and mapping resources for “hot-spotting” high utilizers.  Stakeholder engagement planning process with payers, providers, and local health improvement coalitions from April to September, 2013. Maryland’s Health Information Exchange  Chesapeake Regional Information System for our Patients (CRISP) is State-designated HIE;  State invested $10 million in startup costs to leverage $17.3 million in federal assistance;  Maryland is first state to connect all 46 acute care hospitals to common platform; 41 hospitals providing some clinical data;  Launched ENS (patient hospital encounter notifications system) in late 2012; Goal: Interconnected, consumer-driven electronic health care system aimed at enhancing quality and reducing costs. 26  sends out 12,000 notifications a month to primary care clinicians when patients seen in hospital;  State also using HIE to map hot spots of preventable hospitalizations and poor outcomes. Workforce Development  EARN program (Employment Advancement Right Now)   2013 bill which provides grant dollars to match Marylanders seeking new or better jobs with the workforce needs of Maryland employers. Businesses, government, and educational institutions will create training programs for jobs in high-demand fields, including health care.  SIM Model Design planning   Use of community health worker Identification of best practices and inventory of training models  Workforce Advisory Committee  Educators, practitioners, and other stakeholders to recommend and help support workforce development initiatives, including: o Training to increase diversity and align with new care delivery models; o Workforce data collection, analysis, and reporting. o Licensing and credentialing – identify opportunities to streamline, reduce barriers, and make more efficient.  Upcoming analysis of supply and distribution of allied health professionals in addition to physicians, e.g. psychologists, physical therapists, physician assistants, nurse practitioners. TELEHEALTH  Telehealth: use of electronic information and telecommunications ies to technologies to support long-distance clinical health care, patient and l healthprofessional health-related education, public health, and health administration.  Leading challenges include:  Developing interoperable networks capable of communicating/connecting to CRISP;  Determining actual cost-effectiveness and appropriate Medicaid reimbursement.  Telemedicine in Maryland  Medicaid reimburses for telemental health services in rural geographic areas;  2013 legislation expanded Medicaid reimbursement to cardiovascular or stroke emergencies, where procedure is medically necessary and specialist is not on duty;  Bill also directed continued study of telemedicine through Telemedicine Task Force to identify opportunities to use telehealth to improve health status and health care delivery, with final report and recommendations due December, 2014;  DHMH supports expanding to “hub and spoke” model that connects primary care to specialists, and continues to study “store and forward” and “home health telemonitoring” for cost-effectiveness. 28 QUESTIONS www.healthreform.maryland.gov carolyn.quattrocki@maryland.gov 29 American Journal of Health Studies: 26(3) 2011 THE IMPACT OF INCOME, PUBLIC ASSISTANCE AND ON SEEKING MEDICAL CARE HOMELESSNESS Mandy Hill, DrPH Misha Granado, MPH, MS Jasmine Opusunju, MSEd Ronald Peters, DrPH Michael Ross, PhD, Dr.Med.Sc. Abstract: Objective: To assess gender differences and determine whether economic determinants are correlated to delayed medical care among this population. Methods: A survey was administered to 215 Houston residents recruited from clinics and club/ bars locally in 2005. Descriptive statistics and a logistic regression were utilized. Results: Participants with a history of homelessness (OR=2.21), particularly women (OR=3.03), men with income (OR=.09), and men with public assistance (OR=16.33) were more likely to delay medical care. Discussion: Gender differences between economic determinants and willingness to sustain physical health exists. Future interventions should aim to improve medical care access in spite of economic pitfalls. INTRODUCTION Mortality and minimal survival rates disproportionately impact African Americans above any other ethnic or racial group in the United States (American Cancer Society, 2009). Distinctly different from other American nationalities, African Americans not only lead in health disparities, but also lead in three major areas: homelessness, unemployment, and public assistance use. Firstly, homeless families comprise 41% of the homeless population; however, African Americans make up 42% of that population (National Coalition for the Homeless, 2009). Although African Americans make up a mere 11% of the general population, this minority group represents 40% of homeless Americans (Public Broadcasting Network, 2007; National Coalition for the Homeless, 2009). Amidst a national recession, 43.6 million Americans live in poverty; however, African Americans are still experiencing poverty to a much larger degree compared to Caucasian counterparts (DeNavas-Walt, 2010). According to national data, African Americans have had the lowest median household in comparison to other races on average from 1967-2009 (DeNavas-Walt, 2010). Secondly and similar to poverty rates, African Americans are projected to be the most affected by growing unemployment rates in comparison to other American ethnic groups, and currently have an unemployment rate of 56%, doubling the national average (Dorsey, 2010; United States Department of Labor, 2010). Thirdly, the use of public assistance among African Americans is disproportionately high considering this is a minority racial group; however, the use is significantly lower than Caucasian, majority counterparts, according to the latest figures available (Bennett, 1995). Among these factors that promote underutilization of needed health care, African Americans are leading comprehensively. According to a study assessing barriers preventing African Americans from seeking preventive screenings, particularly colorectal screenings, African Americans reported unawareness, fear, lack of transportation, lack of insurance, dislike for medical settings, inconvenience, apprehension of physicians, and indifference as barriers to screening (Good, Niziolek, Yoshida, & Rowlands, 2010). Lack of transportation and lack of insurance are indicators of low income and an unemployment status. In addition, the absence of economic stability fuels delays and hinders preventive measures like early detection and treatment of preventable diseases (Gelberg, 1996). Unemployment is a major contributor to economic instability and African Americans lead the nation in unemployment rates, as these rates among African Americans have increased from 12.1 to 16.2%, while the US unemployment rate is 10% (United Mandy Hill, DrPH, Assistant Professor, University of Texas Health, Medical School. Misha Granado, MPH, MS, University of Texas Health, Medical School. Jasmine Opusunju, MSEd, University of Texas Health, School of Public Health. Ronald Peters, DrPH, University of Texas Health, School of Public Health. Michael Ross, PhD, Dr.Med.Sc., University of Texas Health, School of Public Health. Corresponding Author: Mandy Hill, DrPH, 6431 Fannin JJL 420, Houston, TX 77030, email: mandy.j.roberts@uth.tmc.edu -174- Hill, Granado, Opusunju, Peters, & Ross Stated Department of Labor, 2010). The increased burden of unemployment among African Americans contributes to the lack of available resources need to maintain and manage one’s health care needs. Lack of consistency in ascertaining care creates difficulty in chronic disease management (Runser, 2003); thus, contributing to poor health. Conditions associated with unemployment, low income, and public assistance utilization, such as an uninsured/underinsured condition, disproportionately affect African Americans by approximately 20% more than Caucasians (Institute of Medicine Report, 2002; Schneider, Zaslavsky, & Epstein, 2002; National Center for Health Statistics, 2003; Weinick, Zuvekas, & Cohen, 2000). In a study reviewing medical records of 4,694 African Americans, health care settings for medically underserved had a higher prevalence and exhibited less control of diseases commonly plaguing communities; thereby, contributing to morbidities within this racial/ethnic group (Sheats et al., 2005). The restraint on health care access caused by low income reduces preventive service utilization and timely treatment. Combined effects of low income and public assistance create a rich environment for delayed medical care. Low income and public assistance are likely a result of unemployment. The ‘disconnect’ between job existence and stability is often minimized or ignored (Runser, 2003). Understanding this disconnect brings clarity to the combined effect exacerbating poor health outcomes among African American populations vulnerable to an uninsured/ underinsured condition. Patients without insurance are more likely to delay medical care compared to insured patients; thus, uninsured patients present with more advanced staged diseases, contributing to higher health care costs (Runser, 2003). Delaying diagnosis correlates with advanced stage disease and a higher probability of mortality (Runser, 2003).. In the case of breast cancer, uninsured women are at a 30-50% increased risk for mortality in comparison to a privately insured population (Kellerman, 2002). Understanding the rationale behind delayed medical care requires an in depth look into contributing factors. Prevalence of delayed medical care among homeless populations suggests homelessness as a contributing factor. During the 1980’s, this population tripled in size due a decrease in the availability of affordable housing, a spike in crack/cocaine use, minimal mental health care coverage, and budget cuts at the federal level for public assistance (Kreider & Nicholson, 1997). The physical environment resulting from homelessness contributes to poor health. Homeless individuals heavily overuse the emergency departments at hospitals instead of clinics, and private medical services because they lack insurance and care needed is urgent (Schanzer, Dominguez, Shrout, & Caton, 2007). Health care among homeless populations is either emergent or nonexistent (Elliott, 2000). In a study of 974 homeless women residing in homeless shelters, 25% had a history of mental illness, ~50% were African American, ~33% had no usual source of care, ~ 50% were uninsured, and ~ 50% had a history of STIs (Gallagher, Andersen, Koegel, & Gelberg, 1997). These findings suggest the interaction of factors potentially related to health care utilization within homeless populations. Unemployment, low income, and ethnicity has a causal association with health care usage (Runser, 2003). Given the correlation of these three variables to the health care access, these relationships were further explored among an at-risk African American population located in the Houston metropolitan are via the Cases and Places study sample. An assessment of a multivariate ‘economic’ effect on delayed medical care is applied to this population. POPULATION This surveillance study offers a secondary analysis to the cross-sectional data set collected through the “Cases and Places” study between 2004 and 2005 at the University of Texas, School of Public Health located in Houston, Texas. The questionnaire consisted of 119 questions and was administered to 215 research adults subjects, a majority African American population. METHODS UT Health’s Center for the Protection of Human Subjects approved the Cases and Places Study, HSC-SPH-03-085, which implemented a behavioral and environmental surveillance for gonorrhea (GC) transmission among high-risk populations (M. Ross, personal communication, December 1, 2006). Participants were either index patients with GC identified in two local clinics (n=57 women) over a 12 month period, or men (n=66) and women (n=92) recruited at two local clubs/bars via a recruitment card. The two clinics and two bars were selected based on location in an effort to ascertain participant data representative of the Houston metropolitan area. Those recruited via the second method were later interviewed at a scheduled appointment with a researcher and offered the option to receive a GC test. Participants were consented and interviewed. Upon completion of the interview, incentives ($30-$40 for a 30-minute interview) were dispersed for time and designed to offset transportation or childcare costs. Standardized instructions were used in survey administration. The importance of the study, as well as the procedures in place to assure confidentiality, was explained to participants. There were potential subjects who refused to participate; however, data to -175- American Journal of Health Studies: 26(3) 2011 calculate refusal rates were not recorded. Measures: The categorical, outcome variable, ‘delayed medical care’, had a yes/no option inclusive of the following responses: don’t know, refuse to answer, and not applicable. ‘Delayed medical care’ examined participant’s tendency to delay medical care within the last 12 months. Categorical, independent variables included gender, age, race, education, income, public assistance, and a history of homelessness. Gender: Participants were identified as either women or men. Age: Participants were included into one of four age categories: 18-19 years, 20-25 years, 26-30 years, or 31 years of age and older. Race: Participants were categorized into one of four race options: African American, Hispanic or Latino, White, or other. Education: Participants’ education level completed was defined by one of four options: Elementary school, Junior high, High school or GED, or college. Income: Income on a monthly basis, encompassing all sources of income, included two categories: none and $1-$3,001 and over. Public assistance: Public assistance, assessing participant receipt of public assistance (inclusive of food stamps, TANF, SSI, etc.) had a yes/no response format. A history of homelessness: A history of homelessness had a yes or no response format. RESULTS A frequency analysis performed on demographic variables included gender, age, race, education completed, income, and symptoms of depression (Table Table 1: Frequency Analysis of Demographic Variables Examined in the Cases and Places Study (n=215) Variable Gender Categories of Variable Total N (%) Cases N (%) Places N (%) Women 149 (69.3%) 57 (100%) 92 (58.2%) Men 66 (30.7%) 0 (0%) 66 (41.8%) 18-19 12 (5.6%) 7 (12.3%) 5 (3.2%) 20-25 56 (26.0%) 30 (52.6%) 26 (16.5%) 26-30 25 (11.6%) 6 (10.5%) 19 (12.0%) 31 and older 122 (56.7%) 14 (24.6%) 108 (68.4%) African American 210 (97.7%) 56 (98.2%) 154 (97.5%) Hispanic or Latino 1 (.5%) 1 (1.8%) 2 (1.3%) White 3 (1.4%) 0 (0%) 1 (.6%) Other 1 (.5%) 0 (0%) 1 (.6%) Elementary school 1 (.5%) 0 (0%) 1 (.6%) Junior high 31 (14.4%) 1 (1.8%) 30 (19.0%) High school or GED 156 (72.6%) 46 (80.7%) 110 (69.6%) College 27 (12.6%) 10 (17.5%) 17 (10.8%) None 23 (10.7%) 12 (21.1%) 11 (7.0%) $1 - $3,001 and over 177 (82.3%) 43 (75.4%) 134 (84.8%) Yes 62 (28.8%) 21 (36.8%) 41 (25.9%) No 153 (71.2%) 36 (63.2%) 117 (74.1%) Yes 36 (16.7%) 4 (7.0%) 32 (20.3%) No 179 (83.3%) 53 (93.0%) 126 (79.7%) Age Race Education Completed Income (monthly) Public assistance History of homelessness -176- Hill, Granado, Opusunju, Peters, & Ross Table II: Bivariate Analysis of economic-based independent variables as they relate to delayed medical care Independent variable Gender stratification Income 1 History of homelessness 2 .31 .60 .44 9.60 .00* 1.42 .23 Women .03 .86 Men 9.16 .00* 4.36 .04* Women 1.74 .19 Men 3.23 .07 Women 1.46 .23 Women .05 .83 Women .09 .77 6.01 .01* Women .00 .97 Men 9.60 .00 1.32 .25 Women .01 .93 Men 9.16 .00* 7.26 .01* Women 4.28 .04* Men 3.23 .07 History of homelessness Public assistance 1.04 Men 1 2 p-value Women Public assistance1 Income2 Pearson’s ϰ2 Income 3 Public assistance3 History of homelessness 3 * - significant at the p
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