Edited by Drummond Rennie, MD, and Richard M. Glass, MD
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 colleaguesArticle 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 PowerArticle, in a special communication, emphasize that
health insurance alone does not guarantee high-quality care. In a commentary,
GrumbachArticle argues for universal health care coverage in the United States.
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
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.
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 colleaguesArticle 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 LurieArticle in a related commentary, the state and federal workforces
combined still fall far short of the estimated need for clinicians in underserved
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%.
"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."
An examination of the economic and workforce resources and policy issues
that shape health care for the rural elderly.
The unmet needs of children and adolescents who require mental health
services are coming under increased scrutiny by federal health officials and
US presidential candidates George W. BushArticle and Al GoreArticle outline how each
would ensure access to health care for
For your patients: Information about premature infants.
This Week in JAMA. JAMA. 2000;284(16):2021. doi:10.1001/jama.284.16.2021