Changes in Patterns of Health Care: Plus Forty Years

Article excerpt

POVERTY, INSURANCE, AND ACCESS TO MEDICAL CARE FOR ADULTS

Herman (1) described components of health care as he viewed them in 1969. Whereas his discussion of "hippies" may be dated, his point concerning utilization of the health care system is definitely relevant, raising "the whole question of the availability to and utilization of the medical care system by those who need it most, namely, the poor." (1) (p. 10)

The established federal poverty guidelines for 2009 state that for a family of four, the poverty level is $22 050 (2) (this is for the 48 continental states and Washington, D.C. For Alaska, the figure is $27 570; for Hawaii, the figure is $25 360 (2)). In 2007 the United States poverty rate was 12.5%. (3)

A major issue related to health care access and the poor is availability of insurance. Dorn (4) estimates that 22,000 deaths in 2006 could be connected to lack of health insurance. Kronick (5) however, questions this connection between lack of insurance and increased mortality claimed by Dorn and by others. In 2007, 45.7 million Americans lacked health insurance. (6) In June 2009, U.S. Health and Human Services Secretary Kathleen Sebelius announced that 40% of Americans classified as low-income did not have health insurance, compared to 6% of high-income Americans. (7) McCormack and colleagues (8) found that individuals at lower income levels had less knowledge about health insurance than did people at higher levels of income.

QUALITY OF MEDICAL CARE FOR ADULTS

Herman also suggested that the services provided to people of lower socioeconomic status and members of racial or ethnic minorities in clinical settings were lacking, with excessive waits and abrupt visits. (1) Washington and colleagues (9) report that members of these groups still receive lesser care than do whites and offer suggestions to practitioners to improve the care that's provided. These recommendations include hiring staff to represent the clientele: this diversity should be publicized. Also mentioned are educating the staff about the cultures of the groups that are served and surveying the patients to get their views of the services provided. (9)

Lower health literacy has also been said to be more of an issue for members of minorities. (10) Recommendations for clinicians trying to improve health literacy of their clientele include making a variety of items available in clinical settings, "such as picture books, videotapes, audiotapes or multimedia presentations and written materials using plain language." (11) (p. 220) These materials should be translated as needed. (10) This type of material would make the setting more hospitable, improving health literacy and reducing health problems. (11)

POVERTY, INSURANCE AND ACCESS TO MEDICAL CARE FOR MINORS

Herman stated that minors generally could not receive treatment without parental approval and that minors were not eligible for welfare, so they would have had difficulty paying for care) More recently, Cunningham and Kirby (12) reported that insurance coverage for children decreased from 1977 to 1987, then began to increase and had just about returned to 1977 levels by 2003. In 2004, however, the number of children without insurance increased by 1 million. (13) This figure again changed in 2007, when the number of children without insurance dropped by more than half a million: The Kaiser Commission on Medicaid and the uninsured reported that as of 2007, 8.9 million children in the United States did not have health insurance. (13) The poverty rate for minors in 2007 was 18%. (3)

On February 4, 2009, the Children's Health Insurance Program Reauthorization Act of 2009 was signed by President Obama. It went into effect April 1, 2009. (14) This program is conducted by the Centers for Medicare & Medicaid Services (14) and was instituted in 1997. (15,16)

One of the major changes from 1977 to 2001 was that the percentage of children covered by nongovernment programs dropped, accompanied by an increase in coverage by government programs; the largest percentage of uninsured children were Hispanic. …