Access to Quality Health Care Eludes Urban Poor Despite Medicaid Coverage

BUFFALO, N.Y. -- A survey of 1,226 adult residents of a largely Puerto Rican Hispanic neighborhood in Buffalo has shown that Medicaid coverage does not guarantee access to quality health care for the urban poor.

The study, conducted by researchers in the Center for Urban Research in Primary Care at the University at Buffalo, is published in the March issue of Family Medicine.

Experts agree that the key to good health care is being able to go to a family doctor, or general physician, when sickness first strikes. Health-care providers call this having a source of first-contact care.

Using this criterion as an indicator of appropriate health-care access, the UB researchers showed that adults in this poor urban population who were covered by standard Medicaid were four times more likely to report having no source of first-contact care than people with private indemnity-type insurance.

Individuals with no insurance were six times more likely than persons with private insurance to report no first contact with a primary-care provider.

"We heard a lot during the health-care reform debate about how we don't need to worry about the poor because they are already taken care of by Medicaid, and that it was the middle-class who needed help," said Carlos R. Jaén, M.D., Ph.D., UB assistant professor of family medicine and lead author on the study.

"This study shows that having insurance is better than no insurance, but for the urban poor, standard Medicaid coverage is not sufficient to overcome many existing barriers to basic health care."

Persons who were enrolled in a Medicaid managed-care program or a health maintenance organization, on the other hand, were as likely as those with traditional insurance to identify a primary-care physician as a regular source of care, the study showed.

"These results support arguments to get the urban poor off traditional Medicaid and into managed-care plans," Jaén said.

The purpose of the study was to identify the factors that predict where people in poor urban neighborhoods will go first when they get sick, to help understand access to care among poor minority populations. Options were: no place for care, hospital emergency department, hospital-based clinic, community-based clinic and private physician.

Proposals for health-care reform recommend that patients see a primary-care physician first when they get sick. This can occur in a hospital clinic, community clinic or private office. The generalist physician can get to know the patient and provide continuity of care.

By contrast, emergency rooms, the source of health care for some inner-city residents, provide no continuity and are much more expensive than primary-care services. Persons who go first to an emergency room are considered to have no source of first-contact care.

The study showed that 9 percent of the study population went no place for care; 15 percent used hospital emergency departments; 19 percent used hospital-based clinics; 24 percent used community-based clinics and 33 percent used private physicians' offices.

Forty-nine percent of the population was Hispanic, 73 percent of whom were born in Puerto Rico; 27 percent was non-Hispanic white; 17 percent was African American and 6 percent was from other ethnic groups.

Forty-four percent of the study population was covered by standard Medicaid insurance, but more than a quarter of this group had no source of primary care. Eight percent was not covered by any type of insurance.

-- Thirty percent of males had either no place to receive care or went to an emergency room.

-- Only 12 percent of Hispanics used private physicians, but 40 percent went to community-based clinics.

-- African Americans, at 28 percent, were most likely to lack a source of primary care, compared to 23 percent for Hispanics and 21 percent for non-Hispanic whites.

-- Persons with alcohol problems were less likely to identify a primary-care site as a place where they receive care first than those who do not have alcohol problems.

"This study demonstrates the need for universal health coverage," Jaén said, "but traditional Medicaid is not the answer for an ethnically diverse, poor, urban population. We need to develop links between patients and specific primary-care providers."

Also participating in the research were Kristen S. Robillard, a third-year medical student, and Laurene Tumiel, research assistant in the UB Department of Family Medicine; C. Adriana Alvarez, M.D., UB assistant professor of family medicine; Robert O'Shea, Ph.D., UB associate professor of social and preventive medicine, and Caroline Patchel, assistant professor of criminal justice at Buffalo State College.