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How Much Does It Vary Across Communities?

Peter J. Cunningham, PhD; Peter Kemper, PhD

JAMA. 1998;280:921-927.

Context.— Communities differ in the way that medical care for medically indigent persons is organized and delivered, which is likely to result in differences across communities in the ability of uninsured persons to obtain medical care. Changes in the health care system, many of which are driven locally, may further exacerbate these differences.

Objective.— To examine the extent of variation across US communities in the ability of uninsured persons to obtain medical care and the extent to which health status and other characteristics of the uninsured population account for these differences.

Design.— Analysis of the 1996-1997 Community Tracking Study Household Survey.

Setting.— A nationally representative sample of the US civilian, noninstitutionalized population residing in 60 randomly selected communities. Larger sample sizes were obtained for 12 of these communities, which were randomly selected to represent metropolitan areas in the United States with more than 200000 persons.

Participants.— A total of 60446 individuals and 7200 uninsured persons.

Main Outcome Measures.— The percentage of persons who either did not obtain needed medical care in the previous year or postponed receiving needed medical care in the previous year.

Results.— Differences between communities with the highest percentage of uninsured persons reporting difficulty obtaining care and communities with the lowest percentage were more than 2-fold (41.4% vs 18.5%, P<.05). Little of the variation across communities is accounted for by differences in health status or sociodemographic characteristics of the uninsured population. The pattern of variation across communities in the ability of uninsured persons to obtain medical care is not correlated with variations in the ability of privately insured persons to obtain care (Pearson r, 0.04). Simulation results indicate that expanding private or public insurance coverage would not only increase the ability of uninsured persons to obtain medical care but would also reduce the variation across communities.

Conclusions.— If people are uninsured, where they live is an important factor in determining the difficulty they have in obtaining care. This is likely to persist given that care for uninsured persons is driven largely by state and local policy, and health system changes are constraining clinicians' ability and willingness to serve uninsured persons in many parts of the country.

From the Center for Studying Health System Change, Washington, DC.

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