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This Week in JAMA
JAMA. 2000;284:2021.
ACCESS TO CARE
A JAMA THEME ISSUE
Edited by Drummond Rennie, MD, and Richard M. Glass, MD
Uninsured US Adults Have Unmet Health Needs
Prior studies have indicated that lack of health insurance is associated with serious adverse clinical consequences, belying beliefs that uninsured people are able to obtain care from safety-net providers. In this analysis of data from national surveys in 1997 and 1998, Ayanian and colleagues (SEE ARTICLE) found that 14% of adults aged 18 to 64 years were uninsured and 9.7% had been uninsured for 1 year or longer. Uninsured adults, especially those in poor health, were 2 to 3 times more likely than insured adults to report that they could not see a physician when needed in the past year because of cost. Adults who had been uninsured for more than 1 year were least likely to report having received a routine checkup by a physician during the prior 2 years or appropriate preventive services. Eisenberg and Power (SEE ARTICLE) , in a special communication, emphasize that health insurance alone does not guarantee high-quality care. In a commentary, Grumbach (SEE ARTICLE) argues for universal health care coverage in the United States.
Comprehensive Follow-up Care for High-Risk Infants
Care of high-risk infants after nursery discharge is often fragmented and typically does not include care for acute illnesses. Broyles and colleagues assigned very-low-birth-weight infants born at a public hospital to receive either routine care (well-baby care and care for chronic conditions) or comprehensive care (routine care plus care for acute illnesses). Between nursery discharge and 1-year adjusted age, the total number of illnesses resulting in death or admission to a pediatric intensive care unit was significantly less in the comprehensive-care group than in the routine-care group. Clinic visits and telephone contacts with clinic staff were more frequent in the comprehensive-care group; hospital admissions were similar. Overall, the estimated mean cost per infant for all care was $6265 for comprehensive care and $9913 for routine care.
(SEE ARTICLE)
Primary Care in the United States
In this analysis of data from national surveys on ambulatory care, Forrest and Whelan found that the US population made 1.3 primary care visits per person in 1994. Compared with white, non-Hispanic persons, Hispanic persons made 20% fewer primary care visits per person, and black, non-Hispanic persons made 33% fewer visits per person. Most primary care visits occurred in private physicians' offices, even among ethnic minorities and persons with no insurance or Medicaid. Rates of primary care visits made to physicians' offices, however, were lower for ethnic minorities than for white persons, whereas rates of primary care visits to community health centers and hospital outpatient departments—traditional safety-net providers—were much higher.
(SEE ARTICLE)
State Programs Provide Care in Underserved Areas
State initiatives to encourage health care practitioners to work in underserved areas are less well known than similar federal programs, as the National Health Service Corps. Pathman and colleagues (SEE ARTICLE) identified 82 nonfederal programs in 41 states operating in 1996 that provided financial support to physicians and nonphysician primary care practitioners in exchange for service in underserved areas. The number of primary care clinicians (1676) serving in these state programs was about equal to the number serving in federal programs. Nevertheless, notes Lurie (SEE ARTICLE) in a related commentary, the state and federal workforces combined still fall far short of the estimated need for clinicians in underserved areas.
Access to Substance Abuse Treatment After Capitation
In the early 1990s, as part of the Oregon Health Plan, Oregon more than doubled its population of Medicaid-eligible persons and required Medicaid recipients to enroll in a prepaid health plan. In May 1995, the Oregon Health Plan implemented a capitated chemical dependency benefit, integrating it with the primary care benefit. Deck and colleagues found that after implementation of the capitated benefit, the percentage of Medicaid-eligible persons admitted to substance abuse treatment programs increased by about 40%.
(SEE ARTICLE)
A Piece of My Mind
"In a world of externally managed medicine, making personal contact with our patients never seemed more important. Isn't that why we became physicians?" From "My Name Is Jack."
(SEE ARTICLE)
Contempo Updates
An examination of the economic and workforce resources and policy issues that shape health care for the rural elderly.
(SEE ARTICLE)
Medical News & Perspectives
The unmet needs of children and adolescents who require mental health services are coming under increased scrutiny by federal health officials and professional groups.
(SEE ARTICLE)
Invited Commentaries
Bush, Gore Pledge to Improve Access to Care
US presidential candidates George W. Bush (SEE ARTICLE) and Al Gore (SEE ARTICLE) outline how each would ensure access to health care for all Americans.
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(Photo credits: Bush-Cheney 2000, Inc; Gore/Lieberman, Inc.)
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JAMA Patient Page
For your patients: Information about premature infants.
(SEE ARTICLE)
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