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Health care financing is changing rapidly in the United States. We investigated whether and how health care access is changing concurrently with changes in financing, with special attention to a minority population.We examined a longitudinal biracial (half African-American, half White) urban cohort of 3,565 individuals, aged 25-37 years old, in 1992-93 and again in 1995-96. We measured access by self-reported (1) health insurance status, (2) regular source of medical care, and (3) lack of care due to financial problems.In 1992-93, 30.3% of the cohort experienced at least one access barrier, with a decline to 26.8% in 1995-96 (P.005). However, access improved more for Whites than for African Americans; and access improved for higher, but not for lower, income groups (7% improvement for high income, vs 2% deterioration for lower income, P.01). In addition, there was an 11% to 19% absolute increase in individuals making co-payments for health care utilization across all race/sex groups, with African Americans having markedly higher proportions of cost-sharing. African-American, low income, and unemployed individuals reported more acute care, but fewer outpatient visits. Income and employment explained racial differences.While access has improved or stabilized for higher income groups, there is a widening gap according to income, accompanied by an acute care pattern for low income groups that may be both inadequate and cost inefficient.

Appointment-keeping after hospitalization is a poorly understood link between inpatient and outpatient care. We investigated how health care system and patient characteristics influence appointment-keeping after discharge from an acute care hospitalization.Prospective cohort study.Urban public teaching hospital.All 372 consecutive eligible patients admitted over a 15 week period to medicine wards.We interviewed patients during hospitalization and after discharge, searched the hospital's electronic databases, and reviewed charts. We measured medication compliance, health care access and use, health status (SF-36), previous appointment compliance, and physician recommended follow-up appointments. Main outcome was appointment adherence after discharge.Patients were primarily African American (71%), uninsured (64%), female (53%), and had a mean age of 48 years; 64% of first appointments after discharge were kept. Adjusted odds ratios (95% confidence intervals) for appointment-keeping were 3.3 (1.7, 6.5) for receiving a written appointment at discharge, and 0.50 (0.27, 0.90) for previous difficulty with obtaining health care. Readmission rates were not associated with appointment adherence.Modifiable system, as well as patient, characteristics are associated with follow-up appointment-keeping. The practice of not giving patients written appointments at the time of discharge may constitute an implicit form of "rationing by inconvenience." Further studies should also evaluate potential associations between appointment-keeping and re-hospitalization.

To determine associations among health care access, cigarette smoking, and change in cigarette smoking status over 7 years.A cohort of 4,086 healthy young adults was followed from 1985-1986 through 1992-1993. Participants were recruited from four urban sites balanced on gender, race (African Americans and whites), education (high school or less, and more than high school), and age (18-23 and 24-30). Outcome measures were smoking status at Year 7, as well as 7-year rates of smoking cessation and initiation.For each of three access barriers reported at Year 7 (lack of health insurance, lack of regular source of medical care, and expense), participants experiencing the barrier had a higher prevalence of smoking, quit smoking less frequently, and started smoking more frequently; e.g., only 15% of participants with health insurance lapses quit smoking over the 7-year period, compared with 26% of those with insurance (P0.001). Results were similar for each race/gender stratum, and persisted after adjustment for usual markers of socioeconomic status: education, income, employment, and marital status.Health care access was associated with lower prevalence of smoking and beneficial 7-year changes in smoking, independent of socioeconomic status. The possibility that this is a causal relationship has implications in the prevention of cardiovascular disease, cancer and multiple other smoking-related diseases, and deserves further exploration.

In 1991, Medicare began covering screening mammograms subject to copayment and deductible. This study evaluated the effectiveness of Medicare in removing financial barriers to screening mammography among low-income older women.In an inner-city public hospital's General Medicine Clinic, 119 consecutive, eligible, and consenting Medicare-enrolled women without known risk factors for breast cancer other than age, and no mammogram in the previous 2 years, were entered into a randomized controlled trial with follow-up after 2 months. The mean age was 71 years; 77% were black, 92% had an annual income below $10,000, and 52% had had a previous mammogram. All patients were counseled concerning indications for screening mammograms and Medicare coverage, and all were referred to a low-cost mammography facility. Sixty-one subjects were randomly assigned a voucher for a free screening mammogram at the referral facility. Obtaining a mammogram within 60 days of study entry was the main outcome measure.Of the women given vouchers, 27 (44%) obtained screening mammograms, compared with six (10%) of those without vouchers (P.001). Adjustment by multiple logistic regression confirmed this association, yielding an adjusted odds ratio of 7.4 (95% confidence interval, 2.5 to 21.4). Knowledge concerning mammography and breast cancer increased significantly overall (and within randomization groups) between initial interview and follow-up; fear did not change. For women without the voucher, the main reason for not obtaining a mammogram was financial; the main reason for women with the voucher was transportation.In a low-income, inner-city population of older women, financial barriers to screening mammography persist despite Medicare coverage.