y, with increased health problems comes increased premiums and limited benefits.  Private market premiums increase sharply with age and a significant amount of the policies place restrictions on pre-existing health problems.  Premiums for this age bracket are nearly twice as high as rates for people ages 35 to 54 (Simantov, 2001).  There is an estimated 3.2 million older adults between the age 55 and 65 lacking health coverage (Johnson, 2001).  This number may increase as number of employers offering retiree health plans follows a decreasing trend (Simantove, 2001).

As individuals become older and develop increased health problems, there is an increased need for long-term prescription medication.  This trend has implications on the health expenditures of elderly individuals because prescription medication is the fastest growing health care expenditure in the United States (Hellander, 2001).  Spending has risen almost 24% annually, from $12 billion in 1980 to $51.9 billion in 1994. This has been due mainly to an increase in the number of medications prescribed, and an increase in the cost of the medications prescribed. Although there has been a drop in the amount of prescription drug expenditures paid out-of-pocket and in full from 66% in 1980 to 42% in 1994, prescription drugs continue to account for the largest component of out-of-pocket medical costs (Mott & Kreling, 1998). Although most large and medium sized companies offer some coverage for prescription medication coverage, many of those employed in small firms and Medicare do not provide prescription medication coverage. Even for those with prescription medication coverage, co-payments can range from 20 – 50%.  This cost barrier provides a significant barrier for the majority of elderly individuals and can lead to compliance issues and problems managing chronic illness.

           

Chronic Illnesses

            Due to the nature of chronic illnesses, individuals suffering from these conditions are likely to need protection against high medical expenses incurred over many years. The authors of a study comparing chronically ill individuals with healthy individuals in Indiana found that the presence of a chronic illness decreased the probability of insurance coverage by 2 to 8 percent and increased the probability of being underinsured by 3 to 7 percent (Stroupe, Kinney & Kniesner, 2000). Those with chronic illnesses are especially vulnerable to being under- or uninsured due to medical underwriting practices. Insurance companies, using a practice called experience rating, may set premiums or terms of coverage based on age, gender, occupation, and health status. Waiting periods, upper limits on the amount of money the policy will pay, and exclusion of coverage for certain tests and procedures may be applied to the policies of those with chronic illnesses. A practice called renewal underwriting occurs when medical conditions that employees develop are added to the list excluded conditions when a policy is renewed. Within-group underwriting occurs when less healthy individuals are selected out of the policy group for higher premiums and/ or reduced coverage. Because of higher premiums, individuals with chronic illnesses may forgo coverage (Stroupe, Kinney & Kniesner, 2000).

At worst, some underwriting practices may permanently exclude those with preexisting medical conditions. In fact, the authors of the Indiana study found that a major contributing factor to inadequate insurance among individuals with chronic illnesses was exclusion of coverage based on a preexisting medical condition. Chronic illness decreased the probability of adequate health coverage for unmarried individuals by 25 percent when exclusions were used for preexisting medical conditions. When such conditions were not used for exclusion, unmarried individuals with chronic illness were approximately 15 percent less likely to have adequate insurance coverage (Stroupe, Kinney & Kneisner, 2000).

Because of the detrimental effects of underwriting on obtaining and maintaining adequate insurance coverage, in June 1997 the Health Insurance Portability and Accountability Act (HIPPA) went into effect. The purpose of HIPPA is to limit the ability of an insurance company to permanently exclude those with preexisting medical conditions for those who already have insurance and move into a new coverage group. HIPPA also prohibits insurance companies from increasing premiums of individuals with chronic illnesses if that individual is within a policy group. This makes it difficult for insurance companies to engage in within-group underwriting (Stroupe, Kinney & Kneisner, 2000).

Although HIPPA is a significant health care reform policy, it does have gaps. There is no protection against the reduction of coverage for a specific chronic illness or a limit to the premiums insurers may charge. In addition, HIPPA provides no protection for those previously without health insurance. Furthermore, HIPPA is not always fully enforced. States are charged with enforcing HIPPA, however if they do not do so, the responsibility is left to the U.S. Department of Health and Human Services (DHHS). Unfortunately, DHHS resources are strained making enforcement of HIPPA difficult (Stroupe, Kinney & Kneisner, 2000).

It is important to note that as an individual’s number of chronic illnesses increase, out-of-pocket spending on health care services rises, even after controlling for insurance status and demographic variables. When compared to families of healthy young adults, those with a chronically ill young adult are almost three times as likely to spend over $1,000 out-of-pocket annually for medical care. Not surprisingly, chronically ill individuals without health insurance had the highest out-of-pocket expenditures and were five times less likely to seek medical care (Hwang, Weller, Ireys & Anderson, 2001). Chronically ill individuals represent a population vulnerable to inadequate insurance coverage and financial hardship due to out-of-pocket expenses. It is vital that current legislation is enforced and that policy makers are mindful of the needs of this population. 

 

Homeless

Between 1981 and 1989, it is estimated that the homeless population tripled. The generally accepted causes are a decline in affordable housing, increased use of crack cocaine, loss of long-term care for the mentally ill, and a decline in federal spending for welfare programs. For the growing number of homeless individuals, poor living conditions often worsen existing health problems (Krieder & Nicholson, 1997). Traditionally, health care for the homeless has consisted of emergency care or non-care (Elliott, 2000). When homeless individuals are compared to the general population, their health status is generally poorer. This may be due to individuals in relatively poor health at the time of becoming homeless, individuals in relatively good health initially but whose health status diminishes due to poor living conditions, or individuals who are relatively healthy and are able to leave homelessness quickly and find an improved living situation (Krieder & Nicholson, 1997).

In a study of homeless individuals in Alameda County, California, the authors found that 29% had health insurance during the entire 18-month study period.  Of these, 19% received insurance through the government in the form of Medicare, Medicaid, or the Veteran’s Administration. However, it was estimated that 65% of the homeless study participants were eligible for some type of health insurance coverage (Kreider & Nicholson, 1997). In 1997, coverage programs included: Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), and Aid to Families with Dependent Children (AFDC). SSI does not require a previous work history and recipients are immediately eligible for Medicaid. SSDI does require a substantial work history and beneficiaries are eligible for Medicare after two-years. Sixty-one percent of those in the study were eligible for SSI or SSDI based on physical disabilities, mental illness, and drug or alcohol abuse. ADFC is available for female-headed households with sufficiently low incomes. In the Alameda County homeless sample, an estimated 66% of women were eligible for this aid (Kreider & Nicholson, 1997). Clearly, active case finding and enrollment assistance for the various federal insurance programs would greatly impact the number of uninsured homeless.

The disparity between the numbers of those enrolled in an insurance program and those who are eligible is thought to be due, in part, to the fact that the mentally ill have difficulty completing the enrollment procedures for the various programs. In addition to mental illness, male gender was also negatively associated with insurance coverage. Older individuals, those with a disability, those with employment, veterans, and those who had custody of a child were more likely to have insurance coverage (Kreider & Nicholson, 1997). Not surprisingly, insurance coverage affects health care utilization for homeless individuals, with insured individuals utilizing significantly more medical services than uninsured individuals. The authors of the Alameda, California study found that universal health coverage would increase hospital admissions by 38 percent. Furthermore, alcohol and drug abuse, and mental illness would produce the strongest effects on hospital admissions (Krieder & Nicholson, 1997). 

Although increasing insurance coverage would increase hospital utilization among the homeless, alternative programs have been implemented. In Savannah, Georgia, a partnership has developed between the Union Mission homeless shelter and Memorial Health University Medical Center. A health center has been established within the homeless shelter to provide primary and respite care. Chronic and routine illnesses are managed at the center, in addition to 32 beds that provide a safe and comfortable environment for the recovery of those recently discharged from the hospital. Those utilizing the respite care services are able to be discharged from the hospital sooner and are less likely to be readmitted with complications. Within the first quarter of operation, the health center saved the hospital almost $800,000 in unnecessary emergency room visits. It is estimated that the health center will save the hospital almost $17 million annually (Elliott, 2000). This case study provides evidence that partnerships between shelters and hospitals are cost-effective and could be implemented at other sits across the country. 

 

Mental Health

            Mental health services have traditionally been underprovided in this country. A study conducted in the early 1980s showed that only 29% of those needing mental health or substance abuse treatment that year received any care. The problem is due, in part, to limited levels of insurance coverage for these services (Katz, Kessler, Frank, Leaf & Lin, 1997). It is estimated that 25% of Americans have no mental health insurance. For low-income individuals, the number without mental health coverage increases to approximately 40%. Only about 10% of highest income individuals reported lacking mental health insurance coverage. Medicaid recipients and those without mental health insurance coverage are less likely to use mental health services compared to those with full private insurance coverage. Third-party payors are often unwilling to provide mental health coverage because of fears that spending will increase on services of uncertain value and duration (Katz, et al., 1997).

The authors of one study sought to compare the utilization of mental health services in the United States to that of Ontario, Canada, where there are no explicit limits on inpatient or outpatient psychiatric care (Katz, et al., 1997). Overall, about 9% of Americans reported at least one mental health visit, compared to about 7% of Ontario residents. More specifically, it was found that individuals in the United States with lower mental health morbidity were more likely to receive care compared to Ontario. Conversely, those in Ontario with higher mental health morbidity were more likely to receive care compared to those in the United States. After controlling for mental heath morbidity, the lowest income residents of Ontario were more likely to utilize mental health services. It is hypothesized that this is due to greater vulnerability to psychosocial problems and a less social support in the lowest income individuals (Katz, et al., 1997). This finding indicates that lowest income individuals in the United States are not receiving adequate mental health care due to an increase in the need for mental health services and a decreased likelihood of mental health care coverage.

            Parity legislation is one proposed solution for increasing the availability of mental health coverage for the 10.2% of Americans who have general medical health insurance, but not mental health care coverage (Katz, et al., 2000). The Mental Health Parity Act of 1996 is a federal act that requires insurers to provide the same mental health care coverage, including annual or lifetime limitations, as they would for physical illnesses. As of 1998, 20 states had adopted parity legislation (Levin, Hanson, Coe & Taylor, 1998). Although this legislation increases mental health care coverage for the insured, it may lead insurers to more aggressively manage care in an effort to control costs. Cost increases may cause employers to reduce benefit packages or drop health care coverage altogether (Zuvkas, 2000). However, Maryland and Rhode Island both reported a less than one percent increase in total plan costs under parity legislation. In fact, Texas found a 48% decrease in mental health and substance abuse costs after parity legislation was enacted (Levin, et al., 1998). Because of the minimal increase in cost, it is unlikely that individuals would lose health insurance coverage due to parity legislation. Therefore, legislators should be encouraged to adopt such policies.

 

Employed Uninsured(medically indigent)

            The phenomenon of employed, but uninsured individuals continues to constitute a major challenge in the United States. In 1997, 71% of uninsured families had at least one family member employed full-time (Blumberg & Nichols, 2001). Of the uninsured workers, almost 50% were either self-employed or employed by companies with fewer than 25 workers. Of those with incomes below $10,000, approximately 31% were uninsured, compared to 5% of those with annual incomes above $40,000 (Long & Marquis, 2001). Americans, in general, feel that the provision of health insurance is very important. In one study, 64 percent of employees with employer-based health insurance indicated that they chose health insurance over other benefits such as a pension, paid leave, and life insurance (Blendon, Young & DesRoches, 1999). Being employed, but uninsured has been attributed to making individuals feel afraid, powerless, and vulnerable both physically and financially (Orne, Fishmon, Manka & Pagnozzi, 2000). 

            One study examined the characteristics of low-wage workplaces in the provision of health insurance. Low-wage workplaces were defined as those in which at least two-thirds of employees are low-wage workers, that is earning less than $7 an hour or less than $14,000 annually in 1997. It was found that less than one-third of workers in low-wage workplaces were enrolled in an employer-provided health plan, compared to two-thirds of workers in other businesses (Long & Marquis, 2001). Compared to 87% of employees in other workplaces, only 60% of employees in low-wage establishments had employers who provide insurance. It is also important to note that only 67% of workers in low-wage workplaces are eligible to enroll in their employer’s insurance plan, compared to 86% of other workers. Often employers require employees to work at least 30 hours per week to be eligible for insurance benefits. Thus, those working multiple part-time jobs are excluded from coverage. Furthermore, workers in low-wage workplaces are more likely to face waiting periods after being hired before being eligible for insurance coverage. In addition to waiting periods, the greater turnover of employees in low-wage workplaces further exacerbates the number of uninsured workers (Long & Marquis, 2001).

            However, even when low-wage workplaces offer insurance coverage, eligible employees often do not enroll. Low-wage workplaces tend to offer less coverage, contribute a smaller amount towards the premium, and contribute a smaller share towards covering the employee’s family (Long & Marquis, 2001). A closer examination of those who decline health insurance found that compared to those who were not offered insurance, those who declined were more likely to have had insurance within the past year. Counterintuitively, those who declined insurance were more likely to be in poor health and to have had difficulty accessing the health care system, compared to those who were not offered coverage. It is hypothesized that people in the study who declined health insurance did so because they perceived a low value to insurance if they foresaw paying high out-of-pocket fees (Blumberg & Nichols, 2001). Family income has also been hypothesized as a factor in that many low-wage employees would rather accept a slightly higher wage than insurance coverage (Long & Marquis, 2001).

            When asked about possible solutions for providing coverage to the employed, but uninsured, 21% of Americans surveyed supported a national health care system. Two of the most recent policies put forth to alleviate the burden of the uninsured among the employed are: 1) mandating employers to provide insurance or 2) the provision of a system of individual tax credits to enable employees to purchase insurance. One-third of participants in the survey favored one of these two plans (Blendon, Young & DesRoches, 1999). However, a study examining the decision to purchase insurance by uninsured workers found that a 60% premium subsidy would only induce one-quarter of eligible families to purchase insurance (Marquis & Long, 1995). When discussing funding of such plans, it is important to consider that barely half of Americans in 1999 expressed a willingness to pay increased taxes or premiums to provide coverage for the uninsured (Blendon, Young & DesRoches, 1999).

 

Racial and Ethnic Minorities

            Income is a variable most associated with insurance coverage. However, among low-income individuals, whites are more likely to be uninsured compared to minorities. This is due, in part, to the fact that greater proportions of low-income minorities are enrolled in government insurance programs or are partially insured through private payors. Whites, however, are more likely to be privately insured compared to minorities (Shi,  2001). In 1999, 11% of non-Hispanic whites were uninsured, compared to 21% of blacks, 33% of Hispanics, and 21% of Asians (Hellander, 2001).

            Unfortunately, very little is known about the insurance status of specific minority groups. Hispanics are one of the fastest growing ethnic groups in the United States, growing at 58% per year compared to 16% of for the African-American population and 3% for the white population. Compared to 5.9% of the white population, 14.7% of the Hispanic population currently has an annual income less than $10,000 per year. Lower socioeconomic status puts individuals at risk for inadequate insurance coverage and a decreased ability to pay out-of-pocket expenses (Ruiz, 2002). Of the 11 million uninsured Hispanic families, nine million have at least one employed family member (Hellander, 2001). The growth rate of this population, combined with a lower socioeconomic status and a large number of uninsured, but employed, individuals indicates a need for policy development to increase the number of insured Hispanics. In addition, more research is needed in terms of assessing the numbers of uninsured and underinsured Hispanics as a group and also as subgroups, including Mexican Americans, Puerto Ricans, Cuban Americans, Dominicans, Salvadorans, etc. (Ruiz, 2002).

            Asian Americans and Pacific Islanders are comprised of over 50 different ethnic groups. Rates of poverty vary widely among the groups. For example, in 1990 over 60% of Hmong were living below poverty compared to 7% of Japanese Americans. Asian Americans and Pacific Islanders are more likely than whites to lack health insurance, however specific information about this group is not known because Asian Americans and Pacific Islanders have historically been labeled as “other” in epidemiological and health studies (Ro, 2002). It is important that future research and policy development clearly delineate this group from other ethnic and racial minorities. Aside from socioeconomic factors, both Hispanics and Asian Americans/ Pacific Islanders are at increased risk for being uninsured due to language and cultural barriers that increase the difficulty associated with understanding eligibility, completing forms, etc.              

 

SOLUTIONS:

 

Current Policy

            Welfare and economic reform has played a role in establishing the current health care situation of many of the uninsured.  In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), also known as the welfare reform law, replaced Aid to Families with Dependent Children (AFDC) with the block grant program Temporary Assistance for Needy Families (TANF).  This law separated the link between Medicaid and cash assistant welfare.  Under the new legislation states are required to provide Medicaid coverage to all families meeting income and structure guidelines that had applied to the state’s AFDC program.  In general, these policy changes have decreased the number of Medicaid enrollees.  In addition, since 1988 states have been required to provide Transitional Medicaid Assistance to all families that had left AFDC due to increased income. Despite these extensions of health care coverage, many women and children become uninsured.  It was found that after one year of leaving welfare 49 percent of women and 29 percent of children were uninsured.  It is hypothesized that few women take up Medicaid because of the stigma attached to the coverage, complexity of Medicaid eligibility rules, and complicated application procedures (Garrett& Holahan, 2000). For those who obtain employment after leaving welfare, only a third receive private health insurance through their employer. This is especially problematic considering that in 32 states, a parent working full-time for minimum wage will exceed the income requirements of Medicaid (Hellander, 2001).  These factors contribute to the large population of medically indigent, those working people who do not qualify for Medicaid and do not have insurance.  Economic reform introduced by the Balance Budget Act of 1997 contributed to changes in Medicaid eligibility, the use of Medicaid managed care, and cost-based provider reimbursements.  Both the use of Medicaid managed care and the elimination of cost-based provider reimbursements has had significant financial impact on safety net providers.  These changes in the governmental

            The recent implementation of the Health Insurance Portability and Accountability Act of 1996(HIPAA) has the potential provision the help some insured maintain their coverage.  The Act limits insurance company’s ability to use preexisting conditions as a means of denying coverage; thus, guaranteeing the renewability of insurance.   The provision of medical savings accounts(MSA) within the act allowed for the start up of MSAs for up to 750,000 people as a trial demonstration of the system. 

            There has been a focus from the current presidential administration to strengthen the nation’s current health care safety net.  Many of the problems affecting the current safety net stem from change in revenue streams from welfare reform and the BBA of 1997.  Addressing these changes and expanding support in answer to these changes is essential to the survival of the national safety net.  The administration has put forth the Healthy Communities Access Program to further address the issue of the uninsured.  The President hopes to increase support to the National Health Service Corps(NHSC) that has served to bolster the number of providers serving in MUAs.  Some of President Bush’s campaign promises to improve Medicare and to provide tax credits as an incentive for the uninsured to buy insurance have been deemed too expensive following September 11 and the economic downturn (Scott, 2001). 

 

Support of national safety net

            As explained previously in this chapter, there are various financial and structural pressures on the nation’s safety net.  There are many possible policy changes that could be implemented to relieve and address some of these pressures.  The effects of Medicaid policies need to be addressed.  Medicaid managed care has shifted Medicaid patients away from safety net providers which has caused serious changes in revenue streams.  This change in revenue has forced the safety net to adapt, but without federal help or pressure placed on the managed care system this may possible jeopardize the continued ability of these groups to function.  The effect of the BBA of 1997 and its change of financial subsidy requires a change in federal programs and an evaluation of current support.  Are these subsidies adequate to maintain the current level of care provided by our national safety net?  In light of the growing health care needs of the uninsured, does more federal financial support need to be addressed the maintenance of these groups?  Finally, federal government should provide incentive for the integration of safety net providers with the hopes of increasing collaboration, financial diversity, and the effectiveness of care provided.  There are some successful models that have formed collaborations between public hospitals, community health centers, and local health departments to form an efficient and effective network of provision.  Establishing an organized system or process of continued assessment and evaluation of the safety net system will be important to its continued sustainability and projected vision for the future.  This evaluation may need to come in the form of federal oversight.  Policy geared towards supporting the nation’s safety net is essential to its ability to meeting the needs of the nation’s uninsured.

 

Tax Credits

Several organizations have supported the implementation of employer tax subsidies in order to initiate and expand coverage for low-wage workers.  This proposal has encountered criticism for the limited amount of uninsured who would be covered (less than 50%) and for the benefits it would provide to private insurance companies (Hellander, 2001).

 

Innovative State Health Programs

Oregon Health Plan

In 1994, Oregon implemented an innovative new health plan with the goal of providing universal care within the state.  The basis of the Oregon Health Plan(OHP) was the realization that the current system of providing comprehensive care to a limited number of people could be converted to providing limited coverage for prioritized health care services to all of the population.  Three populations were targeted: high-risk individuals above the poverty line (within 100 percent of the federal poverty line), medically indigent through mandated expansion of employer benefits, and Medicaid-eligible individuals not already enrolled.  Health care services were prioritized by the Health Services Commission and formed into a comprehensive Prioritized List of Services.  This list was determined by quantification of mortality and public health risk and budgeting these concerns to the funds available.  The entire process was a participatory, public decision-making process that involved input from health care professionals, social workers, community leaders, and the community.  The OHP has been successfully implemented, but it has continued to struggle to maintain the initial projected goals in light of market pressures.

The Oregon Health Plan has been successful in several of their initial goals, but not in all.  OHP has been able to lower the number of uninsured from 18 percent in 1990 to 10 percent in 1999.  The number of uninsured children is now 21 percent and the emergency room use has declined almost 10 percent(Office of the Oregon Health Plan Policy and Research, 1999).  Despite these successes, the plan has met some difficulty.  The continued climb of pharmaceuticals has increased the OHP spending by 112 percent over the last six years.  In light of these rises, the state has called for federal subsidies.  The initial hope of mandating employee insurance benefits was never implemented.  The plan has met severe criticism from some parties about the rationing nature of the Prioritized List of Services as the plan has had to drop some health benefits and preventive services as the cost increases.  Consequently, the plan has continued to evolve.  It has also been continuously revisited and streamlined, with the establishment of lower cutoff points (i.e. less coverage) and the enforcement of stricter eligibility requirements (i.e. no full-time college students or individuals with more than $5000 in assets).  Ultimately, the OHP has been innovated and explored some of the possible solutions to uninsured in America.

TennCare

In 1994, Tennessee implemented TennCare, a new managed care system with the goal of increasing coverage.  They targeted three populations: uninsurable individuals(high-risk conditions), Medicaid eligibles, and the medically indigent.  Through TennCare, the state contracts with ten managed care organizations (MCOs) to provide care to clients.  The MCOs use the gatekeeper system to provide care that enhances continuity of care.  Copayments are not required for preventive services, encouraging health promotion and disease prevention.  TennCare has also developed a quality assurance program that focuses on prevention and access and measures have been taken to assure that TennCare’s growth is congruent with that of state revenues. 

Overall, there has been a decrease in the number of uninsured in Tennessee, but there also is much concern throughout the state of whether the program will be able to continue to deal with the increase cost of health care.  As of 1997, the number of enrollees was 1.2 million and the number of individuals receiving care who had previously been uninsured or uninsurable was over 400,000 (Long & Kirsch, 1997).  Consequently, the cost per capita has increased 50 percent over a 5 year period(U.S. Census Bureau, 2001).  Due to pressures from the federal government in terms of subsidies, there has been a great deal of political debate on whether to change back to the old system of Medicaid or to maintain the current system.  As one can see, even these new, innovative health care systems are finding it very difficult to address the issue of the uninsured.  Yet, even in their problematic aspects, they offer the possibility of change and the opportunity to serve as learning points for future solutions.

 

Universal Health Care System

 

There have been many proponents of instituting a national health care system that will provide insurance for all Americans.  This system would be similar to the health care programs in many other developed countries.  I will refer you to the chapter within this on-line text for further details of this possible solution. 

 

Further information(Websites):

            -US Dept. of Health and Human Resources:  http://www.os.dhhs.gov/

            -The Urban Institute:  http://www.urban.org/

            - Institute of Medicine:  http://www.iom.edu/iom/iomhome.nsf?OpenDatabase

            - Covering the Uninsured:  http://covertheuninsuredweek.org/

            - Covering the Uninsured:  http://covertheuninsuredweek.org/

 

General References:

            - Kellerman, A., Coleman, Mary.  Care Without Coverage:  Too Little, Too Late.  Report by Institute of Medicine, May 2002.

            - Lewin, E., Altman, S.  American’s Health Care Safety Net:  Intact but Endangered.  Institute of Medicine.  Washington, DC  National Academy Press, 2000.

 

References

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3.       Blendon RJ, Young JT,  DesRoches CM. The uninsured, the working uninsured, and the public. Health Affairs 1999; 18 (6): 203 – 211.

4.       Blumberg LJ, Nichols LM. The health status of workers who decline employer-sponsored insurance. Health Affairs 2001; 20 (6): 180 – 187.

5.       Bureau of Primary Health Care.  1998.  Uniform Data System.  Bethesda, MD:  Bureau of Primary Health Care/Health Resources and Services Administration, U.S. Department of Health and Human Services.

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12.   “Getting Less Care?  Report from Families U.S.A.”  (March 2001).  Families USA.

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16.   Holahan, J., Spillman, Brenda.  Health Care Access for Uninsured Adults:  A Strong Safety net is Not the Same as Insurance.  Report by The Urban Institute, January 2002.

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