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Context: Cardiovascular disease (CVD) is the leading cause of mortality for US women; lack of health insurance contributes to poor control of risk factors and increased mortality. Health coaching including motivational interviewing can support primary and secondary CVD prevention, but among uninsured women, improving health outcomes is dependent on successfully reaching priority populations., Objective: We evaluated the implementation and reach of health coaching with motivational interviewing among clients in the Illinois WISEWOMAN Program (IWP), a CVD screening and risk-reduction program for uninsured women aged 40 to 64., Intervention: Following CVD screening, motivational interviewing is offered to all IWP clients via four 30-min one-on-one health coaching sessions to offer personalized guidance on setting and achieving health behavior goals., Setting: Our analysis included clients from the eight community-based Illinois agencies that implemented IWP from 2019 to 2023., Design and Measures: We assessed client demographic and baseline health characteristics among all IWP clients, those who participated in health coaching by attending at least one session, and those who completed health coaching by attending at least three of four sessions. We also assessed health coaching participation and completion by agency and examined agency-specific associations between client characteristics and health coaching participation and completion., Results: Among IWP enrollees (n = 3094), 89.7% participated in at least one health coaching session but only 31.4% completed health coaching by attending at least three sessions. Over 90% of IWP clients participated in at least one health coaching session at 4 IWP agencies. Further, over 85% of health coaching participants completed health coaching at four agencies. Across agencies, no client-level characteristics were consistently associated with health coaching participation or completion., Conclusions: High motivational interviewing participation rates support its acceptability among uninsured women, but agency-level community-level barriers likely prevent client engagement in multiple sessions. Reducing CVD risk requires working with partner agencies to address barriers to reaching the priority population., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc.)

Background: Colorectal cancer (CRC) is the second leading cause of cancer deaths in the USA. Although a number of CRC screening tests have been established as being effective for CRC prevention and early detection, rates of CRC screening test completion in the US population remain suboptimal, especially among the uninsured, recent immigrants and Hispanics. In this study, we used a structural equation modelling approach to identify factors influencing screening test completion in a successful CRC screening program that was implemented in an uninsured Hispanic population. This information will enhance our understanding of influences on CRC screening among historically underscreened populations., Methods: We used generalized structural equation models (SEM) utilizing participant reported information collected through a series of surveys. We identified direct and indirect pathways through which cofactors, CRC knowledge and individual Health Belief Model constructs (perceived benefits, barriers, susceptibility, fatalism and self-efficacy) and a latent psychosocial health construct mediated screening in an effective prospective randomized CRC screening intervention that was tailored for uninsured Hispanic Americans., Results: Seven hundred twenty-three participants were eligible for inclusion; mean age was 56 years, 79.7% were female, and 98.9% were Hispanic. The total intervention effect was comparable in both models, with both having a direct and indirect effect on screening completion (n = 715, Model 1: RC = 2.46 [95% CI: 2.20, 2.71, p < 0.001]; n = 699, Model 2 RC =2.45, [95% CI: 2.18, 2.72, p < 0.001]. In Model 1, 32% of the overall effect was mediated by the latent psychosocial health construct (RC = 0.79, p < 0.001) that was in turn mainly influenced by self-efficacy, perceived benefits and fatalism. In Model 2, the most important individual mediators were self-efficacy (RC = 0.24, p = 0.013), and fatalism (RC = 0.07, p = 0.033)., Conclusion: This study contributes to our understanding of mediators of CRC screening and suggests that targeting self-efficacy, perceived benefits and fatalism could maximize the effectiveness of CRC screening interventions particularly in Hispanic populations., (© 2022. The Author(s).)

Background: The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003 to remove financial barriers and to promote equitable access to health care services. Post implementation has been characterized by increases in access and utilization of services among the insured. The uninsured have been less likely to utilize services due to unaffordability of health care costs. In this study, we explored the experiences of the insured members of the NHIS, the uninsured and health professionals in accessing and utilizing health care services under the NHIS in the Hohoe Municipality of Ghana., Methods: Qualitative in-depth interviews were held with twenty-five NHIS insured, twenty-five uninsured, and five health care professionals, who were randomly sampled from the Hohoe Municipality to collect data for this study. Data was analyzed using thematic analysis., Results: Participants identified both enablers or motivating factors and barriers to health care services of the insured and uninsured. The major factors motivating members to access and use health care services were illness severity and symptom persistence. On the other hand, barriers identified included perceived poor service quality and lack of health insurance among the insured and uninsured respectively. Other barriers participants identified included financial constraints, poor attitudes of service providers, and prolonged waiting time. However, the level of care received were reportedly about the same among the insured and uninsured with access to quality health care much dependent on ability to pay, which favors the rich and thereby creating inequity in accessing the needed quality care services., Conclusion: The implication of the financial barriers to health care access identified is that the poor and uninsured still suffer from health care access challenges, which questions the efficiency and core goal of the NHIS in removing financial barrier to health care access. This has the potential of undermining Ghana's ability to meet the Sustainable Development Goal 3.8 of universal health coverage by the year 2030., Competing Interests: The authors have declared that no competing interests exist.

The COVID-19 pandemic has led to record unemployment claims and a weakened U.S. economy. This column reviews results of past research to examine how a recession might affect behavioral health and the treatment of mental and substance use disorders and suggests potential policy solutions. Despite increases in suicide and substance use, losses in employment-related health insurance could dampen treatment seeking. Federal, state, and local officials should be vigilant regarding suicide prevention. Individuals who lose employee insurance coverage should be protected through insurance marketplaces and Medicaid outreach and enrollment. Public and private coverage of telehealth, which has already been expanded, should continue beyond the pandemic. Federal support for community behavioral health organizations should continue to offset state and local budget cuts and ensure provision of needed treatment. The capacity of social services should be expanded as well as systems that facilitate client connection to social services.

Purpose of Study: Explore the perceptions of primary care physicians (PCPs) from community health care centers (CHCs) in Franklin County, Ohio, regarding factors that contribute to their inability to consistently provide sustainable asthma management services to their uninsured patient population., Primary Practice Setting: Asthmatic patients are not consistently receiving sustainable asthma management in CHCs in Ohio. Primary care physicians in CHCs play a pivotal role in closing health care gaps for asthmatic patients. To minimize the barriers that impede the efforts of PCPs to control asthma for their uninsured patients, asthma disease management programs that include case management services in CHCs in Franklin County, Ohio, are needed., Methodology and Sample: A convenience sample of 4 PCPs from 2 CHCs in Franklin County, Ohio, was interviewed face-to-face. Interviews, direct observation, and previously published research were the sources of data utilized for this study., Results: Results indicated that 75% of participants did not use standard guidelines while treating their patients. Physician time constraints and access to affordable medication were identified as some of the barriers to providing sustainable asthma management services., Implications for Case Management: Asthma is a complex chronic disease. Disease case managers not only are capable of coordinating health care services for a variety of patient populations but are also effective in managing complex diseases such as asthma for disadvantaged populations. Evidence-based case management models are needed to support PCPs in CHCs. Without the inclusion of asthma-specific case managers as part of the care delivery structure, CHCs may continue to provide subpar disease management services for uninsured asthmatic patients.

Previous research defining the health consequences of being medically uninsured show worse access, poorer health outcomes, and higher rates of premature death as compared to their insured counterparts. Adding to this literature, the present study investigated the associative role of health insurance with personal finance health behaviors. In a representative sample of the general population, our adjusted models indicated significant relationships (both positive and negative) between being uninsured and these personal finance behaviors. Therefore, future work using longitudinal data must build upon the present study to accurately determine the relative financial risk an individual takes on by being uninsured.

Objectives: The purpose of this study was to examine the association between social norms and self-management ability among uninsured low-income primary care patients., Methods: Data were collected from adult patients at a free clinic using a self-administered survey from August to December 2018., Results: Higher levels of social norms to exercise were associated with higher levels of all aspects of self-management ability. Lower levels of social norms to use substances were associated with higher levels of all aspects of self-management ability, except for variety in self-management. Better health was associated with higher levels of investment behavior of self-management ability., Conclusions: The findings of this study suggest the association between social norms and self-management ability and its impact on health among low-income, uninsured primary care patients. Self-management ability is important for maintaining health. Providing intervention programs on self-management skills should focus on not only individual behaviors but also social norms that affect their health behaviors.

Background: Ghana implemented a national health insurance scheme in 2005 to promote the provision of accessible, affordable, and equitable healthcare by eliminating service user fees. Termed the National Health Insurance Scheme (NHIS), its active enrollment has remained low despite a decade of program implementation. This study assesses factors explaining this problem by examining the correlates of insurance status unawareness among women of reproductive age., Methods: In 2015, a random probability cross-sectional survey of 5914 reproductive-aged women was compiled in the Upper East Region, an impoverished and remote region in Northern Ghana. During the survey, two questions related to the NHIS were asked: "Have you ever registered with the NHIS?" and "Do you currently have a valid NHIS card?" If the answer to the second question was yes, the respondents were requested to show their insurance card, thereby enabling interviewers to determine if the NHIS requirement of annual renewal had been met. Results are based on the tabulation of the prevalence of unawareness status, tests of bivariate associations, and multivariate estimation of regression adjusted effects., Results: Of the 5914 respondents, 3614 (61.1%) who reported that they were actively enrolled in the NHIS could produce their insurance cards upon request. Of these respondents, 1243 (34.4%) had expired cards. Factors that significantly predicted unawareness of card expiration were occupation, district of residence, and socio-economic status. Relative to other occupational categories, farmers were the most likely to be unaware of their card invalidity. Respondents residing in three of the study districts were less aware of their insurance card validity than the other four study districts. Unawareness was observed to increase monotonically with relative poverty., Conclusion: Unawareness of insurance care validity status contributes to low active enrollment in Ghana's NHIS. Educational messages aimed at improving health insurance coverage should include the promotion of annual renewal and also should focus on the information needs of farmers and low socio-economic groups.

Background: For colorectal cancer (CRC) screening to improve survival, patients with an abnormal fecal immunochemical test (FIT) must follow-up with a diagnostic colonoscopy. Adherence to follow-up is low and patient-level barriers for suboptimal adherence have yet to be explored., Objective: To characterize barriers for non-completion of diagnostic colonoscopy after an abnormal FIT reported by under- and uninsured patients receiving care in a safety-net health system., Design: A longitudinal, cohort study of CRC screening outreach to 8565 patients using mailed FIT kits. Patients with abnormal FIT results received telephonic navigation to arrange for a no-cost diagnostic colonoscopy., Patients: Adults aged 50-64 years receiving care at a North Texas safety-net health system., Approach: Descriptive analyses characterized the patient sample and reasons for lack of follow-up after abnormal FIT over the 3-year outreach program. Thematic qualitative analyses characterized reasons for lack of follow-up with a colonoscopy after the abnormal FIT., Key Results: Of 689 patients with an abnormal FIT, 45% (n = 314) did not complete a follow-up colonoscopy. Among the 314 non-completers, 184 patients reported reasons for not completing a follow-up colonoscopy included health insurance-related challenges (38%), comorbid conditions (37%), social barriers such as transportation difficulties and lack of social support (29%), concerns about FIT/colonoscopy process (12%), competing life priorities (12%), adverse effects of bowel preparation (3%), and poor health literacy (3%). Among the 314 non-completers, 131 patients did not report a barrier, as 51% reported that that had completed a previous colonoscopy in the past 10 years, 10% refused with no reason, and 10% were never reached by phone., Conclusions: Future studies aimed at improving FIT screening and subsequent colonoscopy rates need to address the unique needs of patients for effective and sustainable screening programs., Trial Registration: NCT01946282.

Background: Unmet need for mental health services remains high in the United States and is disproportionately concentrated in some groups. The scale and nature of these disparities have not been fully elucidated and bear further scrutiny. As such, in this study, we examine the demographic, socioeconomic, and health correlates of unmet need for mental health treatment as well as the reasons for unmet need., Methods: We draw upon the National Survey for Drug Use and Health (NSDUH) from 2002 to 16 for adults aged 18 and over in the United States (n = 579,017). Using multivariable logistic regression, we simultaneously model the demographic, socioeconomic, and health correlates of unmet need for mental health treatment from 2002 to 16. We also analyse the reasons for unmet need expressed by these populations, reasons which include cost, perceived stigma, minimisation of symptoms, low perceived effectiveness of treatment, and structural barriers., Results: Major characteristics associated with increased odds of unmet need include past year substance abuse or dependence (other than hallucinogens and sedatives), fair, poor, or very poor health, being female, and an educational attainment of college or higher. With respect to reasons for unmet need, cost was most often cited, followed by perceived stigma, structural barriers, and minimisation. Characteristics associated with increased odds of indicating cost as a reason for unmet need include: being uninsured or aged 26-35. Minimisation and low perceived effectiveness are mentioned by high-income persons as reasons for unmet need. College-educated persons and women had higher odds of citing structural barriers as a reason for unmet need., Conclusions: The correlates and causes of unmet need highlight the intersectionality of individual health needs with implications on addressing inequities in mental health policy and practice.

Background: High patient out-of-pocket (OOP) spending for medical care is associated with medical debt, distress about household finances, and forgoing medical care because of cost in the USA., Objective: To examine the national prevalence of medical financial hardship domains: (1) material conditions from increased OOP expenses (e.g., medical debt), (2) psychological responses (e.g., distress), and (3) coping behaviors (e.g., forgoing care); and factors associated with financial hardship., Design and Participants: We identified adults aged 18-64 years (N = 68,828) and ≥ 65 years (N = 24,614) from the 2015-2017 National Health Interview Survey. Multivariable analyses of nationally representative cross-sectional survey data were stratified by age group, 18-64 years and ≥ 65 years., Main Measures: Prevalence of material, psychological, and behavioral hardship and hardship intensity., Key Results: Approximately 137.1 million (95% CI 132.7-141.5) adults reported any medical financial hardship in the past year. Hardship is more common for material, psychological and behavioral domains in adults aged 18-64 years (28.9%, 46.9%, and 21.2%, respectively) than in adults aged ≥ 65 years (15.3%, 28.4%, and 12.7%, respectively; all p < .001). Lower educational attainment and more health conditions were strongly associated with hardship intensity in multivariable analyses in both age groups (p < .001). In the younger group, the uninsured were more likely to report multiple domains of hardship (52.8%), compared to those with some public (26.5%) or private insurance (23.2%) (p < .001). In the older group, individuals with Medicare only were more likely to report hardship in multiple domains (17.1%) compared to those with Medicare and public (12.1%) or Medicare and private coverage (10.1%) (p < .001)., Conclusions: Medical financial hardship is common in the USA, especially in adults aged 18-64 years and those without health insurance coverage. With trends towards higher patient cost-sharing and increasing health care costs, risks of hardship may increase in the future.

Background: The Rio Grande Valley (RGV) and Laredo regions located along the Texas-Mexico border consist of seven counties with a population of approximately 1.5 million people and a high uninsured rate (33.5%). Cervical cancer mortality in these border counties is approximately 30% higher than the rest of Texas. The RGV and Laredo areas were studied to better understand the state of access to cervical cancer prevention services along the Texas-Mexico border., Methods: Data on the population served and the services provided were analyzed to determine the gap between cervical cancer screenings recommended versus those received. Through interviews, we gathered the perspectives of 16 local stakeholders regarding cervical cancer screening for underserved individuals in the region., Findings: It is estimated that 69,139 uninsured women aged 21-64 years in the RGV/Laredo per year are recommended to undergo cervical cancer screening with Papanicolaou (Pap) and/or human papillomavirus (HPV) testing, but only 8941 (12.9%) Pap tests are being performed by the Federally Qualified Health Center (FQHC) serving uninsured women in these regions. Systemic barriers identified include insufficient provider clinical capacity, the high cost of healthcare, and uncertainty about government funding sources. Patient barriers identified include inadequate knowledge on navigating the local healthcare system, low health literacy, lack of money and childcare, an inability to miss work, limited transportation, and fear of deportation., Conclusion: Decreasing the disparity between cervical cancer screening services provided and those recommended requires addressing the barriers, identified by local experts, which prevent uninsured women from accessing care. These challenges are being addressed through ongoing programs and collaborations.

Background: Wisconsin currently has a 6.4% uninsured rate. In Milwaukee, it is not known what proportion of the currently uninsured may be eligible for health insurance and why those eligible have not enrolled., Methods: Anonymous surveys were distributed at a free/low-cost health clinic in Milwaukee to ask their attendees why they remain uninsured., Results: Fifty-one percent of respondents cited insurance being "too expensive" as the primary reason for lacking health insurance. Additionally, 56% of respondents appeared to misunderstand their Medicaid eligibility, while 69% appeared to misunderstand their Affordable Care Act (ACA) Marketplace eligibility., Discussion: A majority of respondents misunderstood their eligibility for ACA subsidies, indicating that additional efforts are needed to educate uninsured Milwaukee residents to maximize health insurance coverage., (Copyright© Wisconsin Medical Society.)

Objective: The purpose of this study was to examine cardiovascular disease-related health beliefs and how they are influenced by knowledge and a sense of community among uninsured primary care patients., Method: This study was a cross-sectional study using a self-administered paper survey (January to April 2016). The study population included medically uninsured US-born English speakers, non-US-born English speakers, and Spanish speakers., Results: Medically uninsured adults utilizing a free clinic (N = 374) participated in the survey. Increasing knowledge about major risk factors for developing cardiovascular disease helped enhance levels of perceived severity of cardiovascular disease and benefits of healthy diet and physical activity. Spanish speakers reported higher levels of perceived severity of cardiovascular disease but lower levels of knowledge compared to US-born or non-US-born English speakers., Conclusion: Spanish speakers may need different approaches to promote cardiovascular disease prevention due to their higher levels of perceived severity of cardiovascular disease but lower levels of cardiovascular disease-related knowledge compared to English speakers. Developing a healthy "community" in a clinic setting may be effective to promote cardiovascular disease-related health for underserved populations.

Objectives: Underserved populations are at risk of low cancer risk awareness. The purpose of this study was to examine cancer risk awareness and lifestyle issues among uninsured primary care patients in the United States., Methods: Data were collected using a self-administered survey from May to July 2017 of adult free clinic patients (N = 506) who spoke English or Spanish., Results: The following factors were associated with higher levels of cancer risk awareness: higher educational attainment, better self-perceived health, and having a family history of cancer. More than 40% of free clinic patients reported a family history of cancer. Contradictory findings existed between perceived diet quality and perceived weight., Conclusions: The intersection of cancer risk awareness and lifestyle issues among underserved populations is a vital topic to improve cancer prevention and promote screening uptake. Continued research is needed to understand which types of cancer underserved populations are cognizant of developing. In addition, because community-level interventions are effective in increasing cancer risk awareness, 3 research is needed to determine ways in which health education programs focused at cancer risk awareness directed to underserved populations can be effectively implemented and evaluated.

We sought to assess if electronic messaging/reminders could increase human papillomavirus (HPV) vaccine completion among adolescents and HPV knowledge among their parents. The study was conducted in two clinics in eastern North Carolina from March 2014-March 2016. Participants included English-speaking and/or Spanish-speaking, uninsured or Medicaid-insured parents and their children (ages 9-17). Intervention participants received text/email appointment reminders and education messages and controls received standard-of-care. The final sample included 257 parent-child dyads. Most identified as Black (60%) or Hispanic (28%). Completion rates for intervention and control groups were similar for HPV dose 2 (65% vs. 65%) and HPV dose 3 (35% vs. 30%), respectively. Although knowledge change was higher for the intervention group, this difference was not statistically significant. Those who reported provider vaccine recommendation were 1.8 times more likely to complete the series. Electronic reminders to promote vaccine completion were not effective in this population. More research is needed.

Uninsured Latin American immigrant women are at increased risk for vaccine preventable diseases, such as cervical cancer; yet gaps in vaccine coverage persist. The purpose of this study was to explore vaccine-related knowledge, attitudes and decision-making for tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, meningococcal conjugate vaccine (MenACWY), and human papillomavirus (HPV) vaccine among uninsured Latin American immigrant mothers of adolescent daughters. A purposive sample of 30 low-income, uninsured, predominantly Latin-American immigrant mothers of adolescent daughters aged 13-17 were recruited from two academic-community managed health clinics in Virginia. From March-September 2016, data were collected through in-person, semi-structured interviews, in English or Spanish. For data analysis, conventional content analysis was employed. The majority of participants self-identified as Hispanic and had less than a high-school level education. Key themes included: general acceptance of vaccines; associating vaccines with prevention/protection; minimal vaccine hesitancy; and lack of knowledge regarding vaccine-preventable diseases, vaccines recommended for adolescents, and adolescent daughters' vaccination history. Doctors' recommendation, school requirements, and the media were key influencers of vaccination. Mothers were the primary decision-maker regarding vaccine uptake among their adolescent daughters. Findings highlight the need for efforts to help uninsured Latin American immigrant mothers better understand vaccines, and provide linkages to affordable, accessible vaccines among under-resourced populations.

The rates of colorectal cancer (CRC) screening in the U.S. remain below national targets, so many people at risk are not being screened. The objective of this qualitative research project was to assess patient and provider knowledge and preferences about CRC screening modalities and specifically the use of the fecal immunochemical test (FIT) as a first line screening choice. Nine focus groups were conducted with a medically underserved patient population and qualitative interviews were administered to their medical providers. Thematic analysis was used to synthesize key findings. Both providers and patients thought that the FIT would be a good option for CRC screening both as an individual choice and for an overall program approach. The test is less expensive and therefore more readily available for patients compared to colonoscopy. Overall, there was consensus that the FIT offers a reasonably priced, simple approach to CRC screening which has broad appeal to both providers and patients. Concerns identified by patients and providers included the possibility of false positives with the FIT which could be caused by test contamination or failing to perform the test properly. Patients also described feelings of disgust toward performing the FIT and difficulties in following the instructions. Study findings indicate provider and patient support for using the FIT for CRC screening at both the individual and system-wide levels of implementation. While barriers to the use of the FIT were listed, benefits of using the FIT were perceived as positive motivators to engage previously unscreened and uninsured or under-insured individuals in CRC screening.

We conducted a randomized controlled trial, enrolling low-income uninsured adults in Virginia (United States), to determine whether cash incentives are effective at encouraging a primary care provider (PCP) visit, and at lowering utilization and costs. Subjects were randomized to four groups: untreated controls, and one of three incentive arms with incentives of $0, $25, or $50 for visiting a PCP within six months of group assignment. We used the exogenous variation generated by the experiment to obtain causal evidence on the effects of a PCP visit. We observed modest reductions in non-urgent emergency department visits and increased outpatient visits, but no reductions in overall costs. These findings in utilization are consistent with the expectation that PCPs offer an alternative to the emergency department for non-emergent conditions. Total costs did not decline because any savings from avoiding the emergency department were offset by increased outpatient utilization., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Churn, defined as a change in plan or a gap in insurance, is a problem in the United States that usually occurs as the result of changing life circumstances. Recent health reform perpetuates - rather than alleviates - churn because low- and middle- income individuals experience frequent changes in eligibility status. Our research asked: how common is churn in the non-group market and what are the health, financial, and emotional impacts on Rhode Island residents? This article draws examples from 31 life-history interviews and 188 enrollment observations conducted at Rhode Island's health insurance exchange from 2014-2017. The findings demonstrate that churn persists, despite state efforts to maximize enrollment, and causes poor health outcomes, financial insecurity, and increased stress. We argue that efforts to reform health insurance enrollment policies should be grounded in qualitative understandings of why people lose coverage and should seek to minimize barriers to maintaining continuous coverage.

Purpose: To describe and compare the prevalence of mental health access, preference, and use among pediatric cancer survivors and their siblings. To identify factors associated with mental health access and use among survivors., Methods: Six hundred ninety-eight survivors in the Childhood Cancer Survivor Study (median age = 39.4; median years from diagnosis = 30.8) and 210 siblings (median age = 40.4) were surveyed. Outcomes included having mental health insurance coverage, delaying care due to cost, perceived value of mental health benefits, and visiting a mental health provider in the past year., Results: There were no differences in mental health access, preferences, and use between survivors and siblings (p > 0.05). Among respondents with a history of distress, most reported not having seen a mental health provider in the past year (80.9% survivors vs. 77.1% siblings; p = 0.60). Uninsured survivors were more likely to defer mental health services due to cost (24.6 vs. 8.4%; p < 0.001). In multivariable models, males (OR = 2.96) and survivors with public (OR = 6.61) or employer-sponsored insurance (ESI; OR = 14.37) were more likely to have mental health coverage., Conclusions: Most childhood cancer survivors value having mental healthcare benefits; however, coverage and use of mental health services remain suboptimal. The most vulnerable of survivors, specifically the uninsured and those with a history of distress, are at risk of experiencing challenges accessing mental health care., Implications for Cancer Survivors: Childhood cancer survivors are at risk for experiencing high levels of daily life stress that is compounded by treatment-related sequelae. Integrative, system-based approaches that incorporate financial programs with patient education about insurance benefits can help reduce some of the financial barriers survivors face.

Uninsured and unprepared travelers to countries with endemic tropical diseases pose great health-care burdens and financial risks on returning to the United States. We discuss the delayed presentation of an uninsured U.S. traveler returning from West Africa with severe malaria who required intensive care measures to save his life. Despite being critically ill on his return, he sat rigoring on his couch taking antipyretics for 3 days, while he applied for insurance on the Affordable Care Act website and waited for approval because he was fearful of the costs of seeking care. He also had limited access to affordable pretravel consultation and prophylactic medications and did not take them because he had no insurance. Average fees for a malaria hospitalization cost $25,789; however, this patient accumulated fees nearing $300,000-and his care was reimbursed by emergency Medicaid with $39,000, because his newly accepted insurance did not cover his hospitalization. This patients' experience in the U.S. health-care system with a deadly tropical disease exemplifies the need for affordable universal coverage of pretravel consultation and malaria prophylaxis. In this uncertain political time and the recent removal of the health insurance mandate, along with the White House and Congress wanting to reform health care, this case supports the American Society of Tropical Medicine and Hygiene (ASTMH) statements showing the need for funding of tropical medicine education, research, and public health services for travelers, not cuts to important agencies and insurances that keep our country safe from imported deadly tropical diseases.

Background: Quality of life can be used to measure the effect of intervention on health related conditions. Health insurance contributes positive effect on availability of medical supplies and empowerment of women and children on financial healthcare. Therefore, the study was aimed to measure the impact of Community-Based Health Insurance on HRQoL and associated socio-demographic factors., Methods: A comparative community based cross-sectional study was employed. Data was collected by trained enumerators using World Health Organization QoL-BREF tool from a sample of 1964 (982 CBHI insured and 982 un-insured) household heads selected by probability proportional to size. A descriptive summery, simple and multiple linear regression analysis was applied to describe the functional predictors of HRQoL. The study was ethically approved by IRB of Wolkite University., Results: The HRQoL score among CBHI insured family heads was 63.02 and 58.92 for un-insured family heads. The overall variation in HRQoL was explained due to; separated marital condition which reduced the HRQoL by 4.30% than those living together [ β  = - 0.044, 95% CI (- 5.67, - 0.10)], daily laborer decreased HRQoL by 7.50% [ β  = - 0.078, 95% CI (- 12.91, - 4.10)], but employment increased by 5.65% than farmers [ β  = 0.055, 95% CI (2.58, 17.59)]. QoL increased by 6.4 and 6.93% among primary and secondary level educated household heads than those household heads who could not read and write [ β  = 0.062, 95% CI (0.75, 4.31)] and [ β  = 0.067, 95% CI (1.84, 7.99)], respectively. As family size increased by one households' head, HRQoL decreased by 18.21% [ β  = - 0.201, 95% CI (- 2.55, - 1.63)], as wealth index increased by one unit, HRQoL decreased by 32.90% [ β  = - 0.306, 95% CI (- 5.15, - 3.86)] and QoL among CBHI insured household heads increased by 12.41% than those un-insured family heads [ β  = 0.117, 95% CI (2.98, 6.16)]., Conclusions: The study revealed that significant difference in quality of life was found among the two groups; health insurance had positive effect on quality of life. Triggered, the government shall expand the scheme into other similar areas' and further efforts should be made on the scheme service satisfaction to ensure its continuity.

Background: Patients with little or no health insurance are frequently readmitted to the hospital, yet few previous studies have listened to patients' explanations of why they returned to the hospital after discharge. Enhanced understanding of patient perspectives may facilitate targeted services and improve care., Methods: We enrolled 18 patients with Medicaid or no insurance during a hospital readmission within 30 days in a major metropolitan area, and conducted semi-structured qualitative interviews to explore the impact of patients' experiences around readmission using a grounded theory approach., Results: We identified five themes contributing to readmission: (1) therapeutic misalignment; (2) accountability; (3) social fragility; (4) access failures; and (5) disease behavior. Medical conditions were complicated by social influences and insufficiently addressed by our health system. Patients understood the need to manage their own health but were unable to effectively execute care plans because of competing life demands and compromised relationships with health providers., Conclusions: Our study using interviews of readmitted Medicaid and uninsured patients revealed complex illnesses complicated by social instability and health system failures. Improved patient-provider trust and shared decision-making, while addressing social determinants and expanding care coordination with community partners, provide opportunity to better meet patients' needs and decrease hospital readmission in high-risk patients.

Objectives: Patients' perceptions of how they are treated in their interactions with the healthcare system represent important and valid measures of healthcare quality that may influence health utilization, outcomes, and costs. Perceived discrimination or the sense of being treated unfairly is an important patient perception known to adversely affect health, but the relation of such perceptions to health-seeking behaviors related to low-acuity emergency department (ED) use is unclear. The objectives of this exploratory study were to describe the prevalence and nature of perceived discrimination or perceived unfair treatment (PD/PUT), and to examine the association of PD/PUT with healthcare utilization among adult safety-net patients in the southwestern United States who sought ED treatment for low-acuity conditions., Methods: Cross-sectional survey data were collected via self-administered questionnaires completed by adult safety-net patients who were uninsured or covered by Medicaid and who sought ED treatment for low-acuity conditions (N = 310). We used descriptive statistics to describe PD/PUT in the healthcare experiences reported by study participants. We used logistic regression to examine the association between PD/PUT and participants' likelihood to seek health care from ED and non-ED settings., Results: Thirty-eight percent of study participants reported PD/PUT, most frequently attributed to insurance status (being uninsured or covered by Medicaid). Participants who reported PD/PUT in their ability to access medical care or to obtain health insurance were significantly more likely to be frequent (vs nonfrequent) ED users (odds ratio [OR] 3.80, P < 0.001) and to use multiple (vs 1) EDs (OR 3.79, P < 0.001) during a 12-month period. Participants who reported PD/PUT while receiving medical care were more likely to have received care in ED and non-ED settings, as compared with EDs only (OR 2.02, P = 0.012)., Conclusions: A substantial proportion of this sample of adult safety-net patients in the Southwest reported experiencing PD/PUT in their healthcare interactions and most frequently attributed such perceptions to their insurance status. Although this study does not establish a causal link between PD/PUT and utilization of care in specific settings, it highlights the need to better understand the underlying causes of PD/PUT across multiple delivery settings and to clarify the extent to which such experiences may influence patients' healthcare-seeking behaviors. Federal and state policies that aim to maintain or expand health insurance coverage for safety-net populations should consider the role of health insurance status in driving perceptions of being discriminated against or treated unfairly.

This study addresses health literacy among patients at a free clinic in Syracuse, NY. Researchers conducted chart reviews of 600 patients and qualitative interviews with 22 patients and 7 providers. Most clinic patients had a high school, or higher, level education and no difficulty with reading comprehension. Nevertheless, a majority had at least some difficulty with comprehending and following through on health information. For many interviewees, the greatest difficulty was completing the required forms for entitlement programs. The findings demonstrate that low health literacy may occur even among well-educated patients and recommend that health literacy be assessed for all patients.

Introduction: The collaborations between dental care providers and other health care providers are especially needed for underserved populations. There is a deficit of research focused on underserved populations who utilize a safety net facility such as a free clinic in the United States. The purpose of this study is to examine the association between health-related beliefs and oral health behaviors among uninsured adults utilizing a primary care free clinic providing oral health care., Methods: Uninsured primary care patients utilizing a free clinic (N = 585) participated in a self-administered paper survey in May and June, 2016., Results: More than 60% of free clinic patients reported a perceived need for dental treatment. Free clinic patients who brush their teeth more than once a day reported better perceived general health compared with those who do not brush their teeth more than once a day. Free clinic patients who had perceived a need for dental treatment reported worse perceived general health compared to those who did not report dental needs., Conclusions: The results of this study indicate a pressing need for the further development of dental care services at safety-net clinics. By including dental care in health promotion programs, it will have positive impacts not only on oral health but also on a healthy lifestyle and the general health of underserved populations utilizing a safety-net clinic. The implementation and evaluation of the integrated health programs, which include primary care and oral health care together, would be beneficial to reduce oral health disparities.

Context: Publicly funded family planning providers are well positioned to help uninsured individuals learn about health insurance coverage options and effectively navigate the enrollment process. Understanding how these providers are engaged in enrollment assistance and the challenges they face in providing assistance is important for maximizing their role in health insurance outreach and enrollment., Methods: In 2014, some 684 sites participating in California's family planning program were surveyed about their involvement in helping clients enroll in health insurance. Weighted univariate and bivariate analyses were conducted to examine enrollment activities and perceived barriers to facilitating enrollment by site characteristics., Results: Most family planning program sites provided eligibility screening (68%), enrollment education (77%), on-site enrollment assistance (55%) and referrals for off-site enrollment support (91%). The proportion of sites offering each type of assistance was highest among community clinics (83-96%), primary care and multispecialty sites (65-95%), Title X-funded sites (72-98%), sites with contracts to provide primary care services (64-93%) and sites using only electronic health records (66-94%). Commonly identified barriers to providing assistance were lack of staff time (reported by 52% of sites), lack of funding (47%), lack of physical space (34%) and lack of staff knowledge (33%); only 20% of sites received funding to support enrollment activities., Conclusions: Although there were significant variations among them, publicly funded family planning providers in California are actively engaged in health insurance enrollment. Supporting their vital role in enrollment could help in the achievement of universal health insurance coverage., (Copyright © 2017 by the Guttmacher Institute.)

Despite healthcare reform, a large population in the United States is without healthcare coverage. The Surgery for People in Need (SPIN) program offers free outpatient surgical procedures to working, uninsured adults. Taking nearly one year to construct, the program has been operational for three years and has performed 22 procedures. Free surgery programs can improve healthcare access by providing interventions to patients who otherwise have no outlet for surgical care., Competing Interests: No competing interests declared., (Copyright the Association for Perioperative Practice.)

Young adults have low rates of outpatient service utilization and higher rates of emergency service use compared to older adults. This study explored pathways to crisis service use for uninsured young adults who accessed emergency psychiatric treatment. Participants were 55 young adults (ages 18-25) who were on an inpatient short-term stabilization unit and had qualifying diagnoses for outpatient services (bipolar, major depression, or schizophrenia). Semistructured qualitative interviews were conducted to understand decision-making and the events that led to service use. A team of coders used an open coding approach to develop a codebook and participated in iterative discussions of coded text to generate results presented. Themes across 3 dimensions were identified. Participants formed the intention to seek treatment through the interaction of escalating symptoms, triggering events, and motivating factors. Intention was translated to actualized service use through individual and systemic facilitators. Natural supports and service systems influenced the entire process. Findings highlight the importance of understanding motivating factors to better engage young people in treatment and including their support systems in efforts to increase awareness of problems and treatments. Systemic barriers identified suggest the need for enhanced coordination of care across systems such as drug and alcohol treatment, homeless services, and criminal justice and for ready access to outpatient services to reduce crisis psychiatric service use. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Lifestyle interventions have shown to be effective in improving health status, health behaviors, and self-efficacy. However, recruiting participants to health education programs and ensuring the continuity of health education for underserved populations is often challenging. The goals of this study are: to describe the attendance of health education programs; to identify stages of change to a healthy lifestyle; to determine cues to action; and to specify factors affecting perceived benefits and barriers to healthy food choices and physical activity among uninsured primary care patients. Uninsured primary care patients utilizing a free clinic (N=621) completed a self-administered survey from September to December of 2015. US born English speakers, non-US born English speakers, and Spanish speakers reported different kinds of cues to action in attending health education programs. While self-efficacy increases perceived benefits and decreases perceived barriers for physical activity, it increases both perceived benefits and perceived barriers for healthy food choices. The participants who had attended health education programs did not believe that there were benefits for healthy food choices and physical activity. This study adds to the body of literature on health education for underserved populations., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

This paper examines first-generation Korean immigrants' barriers to healthcare in the US and their strategies for coping with these issues by analyzing survey data from 507 Korean immigrants and in-depth interviews with 120 Korean immigrants in the New York-New Jersey area. It reports that more than half of Korean immigrants have barriers to healthcare in the US, with the language barrier being the most frequent response, followed by having no health insurance. Korean immigrants are not passive, but rather active entities who display coping strategies for these barriers, such as seeing co-ethnic doctors in the US, seeking Hanbang (traditional Korean medicine) in the US, and taking medical tours to the home country. However, their coping strategies are far removed from formal US healthcare as their behaviors are still restricted to the informal healthcare within the ethnic community or home country. This study methodologically and theoretically contributes to the literature on immigrants' healthcare behaviors by using a mixed-method approach and developing a specific framework for one particular immigrant group., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

A sociologist chronicles how uninsurance and health reform have affected one Texas family for over a decade., (Project HOPE—The People-to-People Health Foundation, Inc.)

Obesity is associated with a number of chronic health problems such as cardiovascular disease, diabetes and cancer. While common prevention and treatment strategies to control unhealthy weight gain tend to target behaviors and lifestyles, the psychological factors which affect eating behaviors among underserved populations also need to be further addressed and included in practice implementations. The purpose of this study is to examine positive and negative emotional valence about food among underserved populations in a primary care setting. Uninsured primary care patients (N = 621) participated in a self-administered survey from September to December in 2015. Higher levels of perceived benefits of healthy food choice were associated with lower levels of a negative emotional valence about food while higher levels of perceived barriers to healthy food choice are related to higher levels of a negative emotional valence about food. Greater acceptance of motivation to eat was associated with higher levels of positive and negative emotional valence about food. Spanish speakers reported greater acceptance of motivation to eat and are more likely to have a negative emotional valence about food than US born or non-US born English speakers. The results of this study have important implications to promote healthy eating among underserved populations at a primary care setting. Healthy food choice or healthy eating may not always be achieved by increasing knowledge. Psychological interventions should be included to advance healthy food choice.

Background: The introduction of health insurance in Ghana in 2003 has resulted in a tremendous increase in utilization of health services. However, concerns are being raised about the quality of patient care. Some of the concerns include long waiting times, verbal abuse of patients by health care providers, inadequate physical examination by doctors and discrimination of insured patients. The study compares perceptions of quality of care between insured and uninsured out-patients in selected hospitals in Ghana to determine whether there is any unequal treatment between insured and uninsured patients in terms of quality of care, as empirical and anecdotal evidence seem to suggest., Methods: A cross-sectional survey of 818 out-patients was conducted in 17 general hospitals from three regions of Ghana. These are the Upper East, Brong Ahafo and Central Regions. Convenience sampling was employed to select the patients in exit interviews. Descriptive statistics, including frequency distributions, means and standard deviations, were used to describe socio-economic and demographic characteristics of respondents. Factor analysis was used to determine distinct quality of care constructs; t-test statistic was used to test for differences in quality perceptions between the insured and uninsured patients; and regression analysis was used to test the association between health insurance and quality of care., Results: Overall, there was no significant difference in perceptions of quality between insured and uninsured patients. However, there was a significant difference between insured and uninsured patients in respect of financial access to care. The major quality of care concern affecting all patients was the problem of inadequate resources, especially lack of doctors, lack of drugs and other basic supplies and equipment to work with., Conclusions: It was concluded that generally, insured and uninsured patients are not treated unequally, contrary to prevailing anecdotal and empirical evidence. On the contrary, quality of care is a concern of both insured and uninsured patients.

As a result of the Affordable Care Act, millions of previously uninsured individuals are facing the daunting task of selecting health insurance. In order to better understand how to reach the uninsured and support their health insurance decision making, this study examined where the uninsured collect information about health insurance and the extent to which they trust those sources and media. We analyzed secondary data on health insurance information-seeking behaviors collected from a survey of 343 uninsured individuals. The Internet, mail, and television were among the most frequently used media, though all 3 had low trust scores. Participants sought information from health care providers and interpersonal sources less frequently but trusted it more than they trusted the media. Age, gender, race, and education were predictors of use and trust of different media and sources of health insurance information. Findings suggest that strategies that pair health care professionals, lay health advisors, or community liaisons with the ubiquity of the Internet may be a strong approach for delivering quality health insurance information to the uninsured. Tailoring messages might also be effective at reaching specific subgroups of the uninsured.

Objectives: People of low socio-economic status (SES) are particularly at risk for developing stress-related conditions. The purpose of this study is to examine depression, stress, and coping strategies among uninsured primary care patients who live below the 150th percentile of the federal poverty level. Specifically, this study compares the experiences of impoverished US-born English speakers, non-US-born English speakers, and Spanish speakers., Methods: Uninsured primary care patients utilizing a free clinic (N = 491) completed a self-administered survey using standardized measures of depression, perceived stress, and coping strategies in the spring of 2015., Results: US-born English speakers reported higher levels of depression and perceived stress compared to non-US-born English speakers and Spanish speakers. US-born English speakers are more likely to use negative coping strategies than non-US-born English speakers and Spanish speakers. Perceived stress and negative coping strategies are significant predictors of depression., Conclusion: US-born English speakers, non-US-born English speakers, and Spanish speakers reported different coping strategies, and therefore, may have different needs for addressing depression. In particular, US-born English speakers need interventions for reducing substance use and negative psychological coping strategies.

Background: To sustain the long-lasting beneficial effects of subcutaneous allergen immunotherapy, the recommended duration of treatment is 3 to 5 years. Nevertheless, many patients discontinue allergy injections prematurely and therefore might not appreciate the full therapeutic benefit., Objective: To examine factors leading to premature discontinuation of subcutaneous allergen immunotherapy (cessation before completion of the recommended duration)., Methods: Patients who discontinued immunotherapy before the completion of the prescribed duration and received their final injection from January 2008 through September 2013 were contacted to identify the reason for stopping the allergy injections. Phase of treatment (escalation or maintenance) was used to measure the duration of treatment at the time of cessation and patients were grouped accordingly., Results: The study population consisted of 555 patients with allergic rhinitis and/or asthma who terminated immunotherapy prematurely. Two hundred thirteen (38%) were men and 342 (62%) were women. The following reasons were cited by patients for non-adherence to immunotherapy: requirement of copayment for allergy injections and/or payment for allergen extract by their health insurer (40%); inconvenience of travel (15%); change of residence (8%); concurrent health problems (5%); patient-perceived ineffectiveness (4%); patient-perceived lack of need to continue immunotherapy (2%); adverse effects from injection (local reaction 1%; systemic allergic reaction 0.5%); and trial of alternative medicine (0.1%). The remaining 24.4% did not provide a reason for discontinuation., Conclusion: Of the various factors, inadequate reimbursement for allergen extract and allergy injections by health insurers is the most common reason cited for non-adherence to subcutaneous allergen immunotherapy., (Copyright © 2015 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the perspectives and practices of renal sick people and their families without social insurance regarding problems faced while on dialysis treatment., Materials and Methods: A qualitative research was developed in Guadalajara, Mexico. Thirty-seven renal sick people on hemodialysis and 50 relatives participated; all affiliated to Seguro Popular. Information was gathered through individual and group interviews. Directed content analysis was carried out., Results: Renal sick people and their families face multiple difficulties while on hemodialysis treatment; nevertheless, economic ones are perceived as a priority due to treatment expenses, lack of financial resources and non-coverage of kidney disease by Seguro Popular. Multiple actions are combined in a circular searching for help process to face the economic burden., Conclusion: Hemodialysis treatment is an unbearable economic burden for renal sick people and their families without social insurance. Universal access to renal therapies should be implemented urgently.

This study compared three age groups of uninsured adults, young (26-44), middle-aged (45-64), and older (65≥), to examine heterogeneity of the uninsured. The pooled 2000-2007 Medical Expenditure Panel Survey was analyzed (N = 22,246). The findings demonstrated that the three groups were very different regarding their individual characteristics, health service utilization, and health beliefs. Compared with uninsured young adults, uninsured middle-aged individuals reported worse health statuses, paid higher out-of-pocket medical expenditures, and had more positive attitudes toward insurance and health care. Considering the policy goals of the Affordable Care Act, understanding the uninsured by age will facilitate targeted interventions to decrease the number of uninsured.

Objective: To describe the development and implementation of a human papillomavirus (HPV) vaccine patient assistance program (PAP) for university students, and to acquire information on the number who accessed the program and completed the series., Setting: University of Texas at El Paso University Student Health Clinic Pharmacy, Fall 2011-Spring 2014., Practice Description: A community pharmacy located within the university student health clinic providing services to an underinsured student population., Practice Innovation: Existing evidence shows the benefit of using PAP in community pharmacies but is nonspecific regarding the use of PAP for vaccines in an uninsured and underinsured Hispanic student population. The implementation of this unique HPV vaccine program in a community setting aims to increase awareness, access, and rates., Main Outcome Measures: Primary measures included results from a needs-assessment questionnaire that were used to implement the HPV vaccine program. After implementation, utilization data were collected on the number of students who qualified and enrolled in the HPV PAP and the number of students who completed the HPV series., Results: The preliminary data from a needs assessment indicated that a majority (72.1%, n = 80) of students did not understand how HPV is transmitted. A total of 89 students qualified for PAP. The majority were women (81%). A total of 71 students (79.8%) received their second dose and 43 (48.3%) completed the series., Conclusions: Although pharmacists continue to provide vaccine services, minorities such as the Hispanic population continue to be underimmunized. Students may not be taking the proper precautions to prevent the acquisition of HPV. For these reasons services such as this HPV vaccine program are warranted. Pharmacists need to continue to educate and advocate on the importance of vaccines and how they prevent disease.

Objectives: The study's purpose was to examine the impact of somatic symptoms and perceived neighborhood environment on depression using a comparison among US-born and non-US-born free clinic patients., Methods: US-born English speakers (n = 99), non-US-born English speakers (n = 89), and non-US-born Spanish speakers (n = 158) 18 years old or older (N = 346) were surveyed at a free clinic that provides primary care to people without health insurance. Depression, somatic symptoms, and perceived neighborhood environment were measured using standardized instruments., Results: US-born English speakers reported higher levels of depression and a greater number of somatic symptoms than non-US-born Spanish speakers and non-US-born English speakers. Non-US born English speakers reported lower levels of depression and fewer somatic symptoms than Spanish speakers. Somatic symptoms and perceived neighborhood satisfaction were related to depression., Conclusions: Developing mental health services for patients in a free clinic setting is needed; however, because of limited financial and human resources, providing mental health services in a free clinic setting often is difficult. Community-based health promotion programs as supplements to efforts within clinical settings would be valuable in improving the mental health of free clinic patients. Future studies should implement collaborative pilot programs and evaluate health outcomes.

Mission House Clinic is a We-Care clinic that provides medical care to low income, homeless, and uninsured individuals. The Prescription Assistance Program (PAP) was created to bridge the gap between pharmaceutical companies that provide free medication and the patients at Mission House Clinic. UNF Nursing students have been involved with the PAP program since 2006. Previously, the PAP has focused on patients with respiratory diseases, hypertension, and diabetes. More recently, the population has shifted towards patients with mental health needs. The purpose of this project was to enhance the effectiveness of the PAP at Mission House Clinic and to improve upon the methods used to identify the prescription needs of the clinic population.

The Affordable Care Act (ACA) has as one of its main objectives to reduce the number of uninsured Americans. The understanding of the ACA reforms by uninsured patients will likely influence the degree of success in achieving this objective. This study assessed the basic knowledge and opinions regarding the ACA of patients at a free clinic and the impact of a brief educational intervention on respondents' knowledge and opinions. One hundred uninsured adult patients completed a brief survey about the ACA before and after viewing a video outlining the major features of the act. The study cohort initially performed worse than national polls on all knowledge questions. Significant improvement was observed after the educational video. Our study suggests a need for educational efforts directed at those individuals most likely to benefit from the ACA. We demonstrated that a brief intervention during a routine office visit may improve knowledge of the ACA.

Following the June 2012 Supreme Court ruling that states are no longer mandated to expand their Medicaid programs in 2014 as part of the Affordable Care Act, many states plan to opt out of the expansion, citing affordability as their primary concern. In response to this controversy, the present study evaluated the cost savings of expanding Medicaid coverage to include currently ineligible homeless adults with substance use disorders, a subset of the population that incurs some of the greatest societal costs and is disproportionately impacted by uninsurance. Using a time horizon of 7 years, separate analyses were conducted for state and federal governments, and then a final analysis evaluated the combined costs for the other two models. Results of the study demonstrate that, although the expansion will be associated with a net cost when combining state and federal expenses and savings, states will experience tremendous savings if they choose to participate.

Introduction: Little has been done to examine the role of student-run free clinics in patient care. In this study we examine patient perceptions of care provided by medical students in comparison to that provided by licensed physicians. Care providers were judged on perceived exam thoroughness, trust, and overall patient satisfaction., Methods: Patients were asked to complete a 37 question survey after being examined by either medical students or by a physician., Results: Differences between physicians and students were not observed for perceived thoroughness, trust, or overall satisfaction scores. Patients who reported never being married gave lower satisfaction scores (p = 0.024); however, all patients reported being satisfied with their care., Conclusions: Patients are satisfied with the care they received at the Jackson Free Clinic regardless of the provider's level of training. Patients did not report students to be less thorough in their exams than physicians. Furthermore, patients reported equal trust in students and physicians.

The paper presents a quantitative investigation on the national health insurance scheme (nhis) in dormaa municipality, Ghana: why some residents remain uninsured? Since its implementation has been a little over a decade now. The aim is to identify the obstacles to enrollment by the public which would enable policy direction to ensure that all residents are registered with the scheme. A descriptive and cross-sectional study was conducted between May and July, 2013. Both purposive and simple random sampling technique were used to select 210 respondents and data obtained through self-administered and face-to-face interviews guided by structured questionnaire. chi square (X2) test of independence was adopted to show the association between socioeconomic and demographic features and membership. Findings from the research suggest that residents' decision to enrol have significant associated with gender, education, number of children, place of residence, employment and income. It was also observed that membership is highly affected by premium level. The discussion of the findings and recommendations offered, if incorporated into the policy guideline of NHIS could maintain and at the same time increase enrollment level which would guarantee quality, accessible and affordable basic health care protection for the good people of Ghana.

By 2014, uninsured adults will be eligible for health insurance through exchanges with multiple plan options. Choosing health insurance is challenging even for those who have engaged in the process previously. We examined 51 uninsured adults' health insurance knowledge and preferences through semistructured qualitative interviews. Our sample was predominantly low-income and African American. Most had little or no experience with health insurance terminology. Those with limited health literacy skills understood less than those with higher health literacy. Many confused related insurance concepts. Non-health contexts (e.g., car insurance) aided understanding. Premiums, fixed costs, and specific coverage were rated very important to insurance decisions. Our study was one of the first to examine uninsured individuals' health insurance knowledge and preferences. Uninsured individuals may have different information needs and preferences than those studied in previous research. Clear information and familiar non-health contexts can be important strategies when communicating about the exchanges.