Access Now: Improving Access to Specialty Healthcare for the Low-income Uninsured

Abstract

Seventeen percent of non-elderly Americans were uninsured in 2007. Sixty-five percent of the uninsured have a family income below 200 percent of the federal poverty level. The uninsured receive less preventive care, fewer diagnostic services, less therapeutic care, and are usually more severely ill at presentation. The uninsured have poorer disease-specific and general mortality and morbidity, which is partially explained by decreased access to care and medical care use. Thus, the physical and emotional health of the uninsured suffers due to decreased use of and access to medical services. Lack of insurance affects also burdens families and communities. Families without health insurance are twice as likely to spend over five percent of their income on out-of-pocket health care. In 2005, approximately $43 billion was spent on uncompensated medical care for the uninsured. An estimated$65 to $130 billion is lost annually due to the uninsured's poorer health and reduced lifespans. Thus, the health consequences of uninsurance present a significant burden to patients, family, and communities. The burden of care for the uninsured further falls disproportionately on primary care providers. In minority populations, 45.6 percent of low-income uninsured physician visits are with family physicians. In comparison, 30.1 percent of insured physician visits are with family physicians. Since the uninsured present more severely ill and advanced disease, family physicians are caring for sicker patients that often would be better served by more specialized care. In a study of children with a chronic condition or disability, Kuhlthau and colleagues found that 16.9 percent of the uninsured saw a specialist while 28.3 percent of the privately insured saw a specialist. Szilagyi and colleagues found a 5-fold increase in specialty visits after patient enrollment in an insurance program. Uninsured dialysis patients are three times more likely to be referred late to nephrologists than their insured counterparts. The uninsured's decreased access to specialists leads to worse outcomes for patients with hypertension, heart attacks, cancer, trauma, ruptured appendices, liver disease, and patients on ventilator support. Many communities have safety nets that are intended to provide care for their low-income uninsured. Generally, this includes some combination of emergency departments, health departments, free clinics, and charity care from other private providers. Safety nets are mainly composed of primary care providers and lack specialty care providers. While the specialty needs of the uninsured are known, few models to address this problem are described in the medical literature. In this program plan and evaluation paper, I first explore what models exist to address the lack of specialty care for the uninsured. I then describe a recently begun program in Richmond, Virginia and outline a plan for its growth and evaluation.Master of Public Healt