UNINSURED: Study Finds Location Influences Access

      Uninsured Americans' access to health care varies widely depending on which city they live in, according to a study published in today's Journal of the American Medical Association. For instance, the study found that while more than 40% of uninsured patients in cities such as Lansing and Cleveland "reported difficulty getting care," only about 20% experienced such difficulties in Orange County, CA, and Newark, NJ (AP/Las Vegas Sun). To determine the "extent of variation across communities in the ability of uninsured persons to obtain medical care," researchers Peter Cunningham and Peter Kemper of the Center for Studying Health System Change focused on 12 metropolitan areas and conducted telephone surveys of 60,000 Americans (Cunningham/Kemper, JAMA, 9/9 issue). They found that only 15% of the variation in uninsured Americans' access to care in varying cities was due to "characteristics of the population, such as how sick people are, income, gender and race" (AP/Nando Times, 9/8) The researchers attributed the primary source of the variation to "community characteristics" such as the "prevalence of managed care and the number of safety net [health care] providers," state health care subsidies, and the "wealth and size of the community" (release, 9/8). For example, the researchers argue that uninsured patients in Orange County and Newark experience better access to care because they live in "wealthy areas ... with a higher than average supply of physicians." Consequently, physicians my feel less financially threatened and be more willing to treat uninsured patients. Indeed, they note that Newark physicians on average provided 10 more hours of charity care per month than physicians in other cities (JAMA, 9/9 issue). Cunningham also noted that "the uninsured may suffer in areas like Lansing because hospitals and health plans are engaged in heated competition," which may make providers "less willing to ... care [for] the uninsured" (Anstett, Detroit Free Press, 9/8).

Differences for Insured and Uninsured
      Paul Ginsburg, president of the Center For Studying Health System Change, noted, however, that "what is true for the uninsured is not necessarily true for those who have coverage." He said that while Orange County's uninsured patients had better access to care than those in other cities, the county's insured had "more difficulty [obtaining care] as compared to those in other communities." Cunningham suggests that this occurs because the factors affecting patients' access to care are different for those with insurance and those without. For example, while uninsured patients overwhelmingly (90%) cited cost as a determining factor in receiving care, insured patients said referrals (28%) and the system's "convenience" (33%) influenced their access to care (release 9/8). The researchers conclude, "health system changes are constraining clinicians' ability and willingness to serve uninsured persons in many parts of the country," and argue that state and local policies will continue to play an important role in mediating differences among communities in uninsured patients' access to care (JAMA, 9/9 issue). Click here to see the study abstract.