Access to health care can be defined in many ways, including by insurance status, number of physician visits in the last year, and treatment interventions once an individual is in the health care system. Furthermore, access can relate to whether the patient's health care is satisfactory, comprehensive, and meeting the overall needs of the patient from a social, cultural, spiritual, or other perspective.
Individuals from communities of color are more likely to be uninsured than non-Hispanic whites. Over one-third of Hispanics (37%) are uninsured. They are three times more likely to be uninsured than non-Hispanic whites. Nearly one-fourth of African Americans and one-fifth of Asian Americans and Pacific Islanders (AAPI) (Veenstra and Higashi, 2000) and American Indian/Alaskan Natives (AI/AN) are uninsured (Henry J. Kaiser Family Foundation, 2002).
Among preschool age children, 8% of AAPI and Hispanic children did not have a physician visit in the past year compared to 5% of whites and African American children. For school age children (6-17 years), Hispanics AI/ANs, and AAPIs are one-and-a-half to two times more likely not to have visited a physician in the last two years compared with African Americans and whites. One of the reasons that African American children are covered at a higher rate than AAPI and Hispanic children is because of the safety net of Medicaid, for which some AAPI and Hispanic children are not eligible because of their immigrant status and their parents' fear of applying for their native-born children. Other families are uninsured because of working in small businesses or being self-employed. Hispanic, AI/AN, and AAPI children are two to three times as likely as white and African American children to lack a usual place of care (Henry J. Kaiser Foundation, 2002).
The picture is even grimmer for adults. One-third of Hispanic and AAPI men in fair and poor health have not visited a doctor in the past year. Hispanic, African American, and AAPI women in fair or poor health are also less likely to have visited a physician than non-Hispanic white men (Henry J. Kaiser Foundation, 1999).
The level of care also may be inadequate. Many uninsured individuals receive their care through "safety net" providers such as community health centers and public hospitals, which usually have limited budgets and are facing competition from Medicaid managed care providers. Many who are on Medicaid today will be ineligible in the short term and will become uninsured (Lewin and Altman, 2000).
1. Access to Pharmaceuticals. Lack of access to drugs often leads to declines in health status (Lurie et al., 1984). This decline is explained by increased ambulatory care visits to obtain medications and the shifting of care to provider settings, such as hospitals and nursing homes, where prescription drug reimbursement is available (McCombs et al., 1994). The cost of prescription drugs and drug utilization vary considerably among individuals (Doonan, 2001). The poor, uninsured, and elderly have reduced access to drugs and rely on safety net providers for pharmaceuticals (Committee on the Changing Market Managed Care and the Future Viability of Safety Net Providers, 1999). With few exceptions, Medicare does not cover outpatient prescription costs. Consequently, older Americans spend three times as much of their income on drugs as the general population. Thirty-five percent of seniors do not have prescription drug coverage, and many with coverage have high deductibles and caps on total dollar coverage. The three out of ten standard Medigap policies that offer prescription drug coverage are very expensive (Doonan, 2001).
Medicaid has become the largest single purchaser of prescription drugs. In 1995, Medicaid provided coverage to 15.8% of Americans, including women, children, the elderly, and individuals with disabilities. A disproportionate percentage of minority populations were on Medicaid. For example, in 1997, 19% of African Americans were on Medicaid (Mayberry, 1999). To control utilization, several states limit the number of prescriptions that a beneficiary can have filled per month or per year. Although many of these programs allow for exceptions (e.g., life-threatening illnesses) or provide some mechanism to allow for review and considerations, some do not. Federal law allows states to impose limits on all such drugs in a therapeutic class, the maximum or minimum quantities per prescription, and the number of refills, if such limitations are necessary to discourage waste (Scholesberg and Jerath, 1999). Many states impose copayments for prescription drugs, ranging from fifty cents to five dollars. Certain categories of individuals, such as pregnant women, children, and the elderly, cannot be charged a copayment. In addition, states may require prior approval of prescription drugs before they are dispensed for any medically accepted indication (Scholesberg and Jerath, 1999).
A few studies have examined the impacts of Medicaid and non-Medicaid copayments on drug utilization and health care costs. In a 1993 study, Reeder et al. noted an 11% decrease in prescription use after South Carolina established a 50-cent per prescription copayment. This increase was significantly greater than in Tennessee, a comparison state with no copay-ments (Reeder et al., 1993). Another study using survey data from the 1992 Medicare Beneficiary Survey found that elderly and disabled Medicaid beneficiaries who live in states with prescription drug copayments have lower prescription drug utilization than their counterparts in states without copayment, and three-fourths of the difference was directly attributed to copayment policies. The study predicted that Medicaid copayments reduce annual prescription drug utilization by 15.5% (Stuart and Zacker, 1999).
These findings are also supported by a study of non-Medicaid HMO members as a whole; a $1.50 copayment was associated with an 11% decrease in drug utilization (Harris and Stergachis, 1990). Similarly, persons in high coinsurance plans in the RAND Health Insurance Experiment reduced their use of most medications by 50-70% compared with plans with copayments. Lower income was related to greater reductions in prescription drug use (Lohr et al., 1986). Some state Medicaid plans also use prescription caps that limit the number of prescriptions that may be written for a person. Prescription caps are associated with a reduction in the utilization of prescription drugs (Soumerai et al., 1994; Martin and McMillan, 1996; Soumerai et al., 1997), especially by Medicaid beneficiaries who used multiple prescription drugs. Prescription limits are also associated with an increase in nursing home admissions for Medicaid beneficiaries with chronic illness (Soumerai et al., 1994). In a subsequent study of disabled Medicaid beneficiaries with schizophrenia, prescription caps led to increased community health center visits, increased use of emergency mental health services, and increased days of hospitalization (Scholesberg and Jerath, 1999).
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