Health Care for the Poor and Uninsured: Strategies That Work
Nellie P. Tate, PhD, and Kevin T. Kavanagh, MD, Editors
Haworth Press, Binghamton, NY
1992, 101 pp., $24.95
This text is a compilation of papers from the Second Annual Conference on Health Care for the Poor and Uninsured (1990). The book is intended for planners, policy designers, and healthcare professionals involved in the planning and implementation of state healthcare programs that serve the medically indigent, especially children and pregnant women.
Six chapters address various aspects of maternal-child health: the increasing availability of obstetric care through utilization of nurse midwives, a maternity waiver program, the channeling of high-risk mothers and infants, the cost-effectiveness of screening selected newborns, a reduction in the infant mortality rate of blacks, and perceived barriers in the use of a comprehensive prenatal care program. The final paper explores long-term home care for the frail elderly and the needs of their care givers.
The authors of the first chapter discuss a successful program using nurse midwives in Alabama. However, they leave many questions unanswered: Was the availability of nurse midwives the main reason 89 percent of area women utilized these services? How did program administrators determine that "public health nurses did not have the time to add the case management function to their list of duties" (p. 17) and therefore that social workers should be incorporated into the prenatal care system in public health? What changed as a result of case management with social workers? What was different about the experiences of the 11 percent of clients who did not use the services?
Chapter five, which describes three demonstration projects in Tennessee aimed at reducing the infant mortality rate of blacks, also leaves many questions unanswered. Although these programs used alternative approaches to outreach and patient care and enhanced reimbursement methods, the authors do not discuss these. They instead discuss need, target population criteria, and some results and then recommend that "circumstances [surrounding insufficient care] should be analyzed" and "the issues or categories of barriers should be explored" (p. 77). Eighteen months is offered as "a relatively small time period to determine the documented impact on such a multi-dimensional problem" (p. 77). Even some initial hypotheses would have been helpful to providers and planners in this area.
Chapter six discusses a study on perceived barriers in the use of prenatal care networks. The study examined factors associated with the use of community-based networks by black women in three high-risk Chicago communities and found that "convenience factors" (job demands, travel time, and child care) did not differentiate those who used the network providers from those who did not use them. Traditionally, these factors have been viewed as influencing healthcare use. The authors do not discuss how to address the lack of private providers' specialty training. In addition, two other potentially important barriers–lack of provider respect toward patients and inadequate time with the provider during the office visit–are not explored.
Even though many issues remain unexplored, the book does present several worthwhile ideas. The authors of the second chapter describe the maternity waiver program in Alabama and offer many specific examples of their primary provider network, home visits, and ways their maternity care coordinators provide nonmedical support services.
Chapter three authors discuss a South Carolina project in which high-risk patients are channeled to designated clinics. They offer many valuable insights through a description of the problems they encountered: unavailable vital records; lack of completed risk-screening forms, computers to track repeat screenings, and home data; reimbursement issues; medical discretion in designation of high-risk infants; and lack of behavioral risk factors, travel costs, and self-selection of exemptions to channeling.
Chapter four discusses Mississippi's cost-effective model of newborn screening for phenylketonuria, hypothyroidism, and hemoglobinopathy and the value of shared regional screening with Tennessee.
The author of the final chapter focuses on persons who care for an elderly parent or grandparent. The writer reflects on 10 years of personal care-giving experience that formed the basis for establishing the not-for-profit Long Term Home Care of the Frail Elderly Foundation in New York City. Three major gaps filled by foundation programs are discussed: respite for the care giver; a centralized national outlet for training, information, education, advice, and support; and advocacy for families providing long-term home care. Two tax-law reforms that address the concerns of many families about assets and long-term care expenses are proposed.
Despite these valuable ideas, on the whole I was disappointed with the book. As a healthcare professional with experience in medical indigency issues, I had hoped to find some innovative models for approaching clients, some discussion of ideas and concepts that might be replicated or at least that would evoke further reflection. Although the papers may have been helpful to those who attended the conference, as a reader, I often felt excluded from the heart of the matter. The almost-terse discussions surrounding the programs moved me to ask, How did these programs make a difference? I found few responses. I was left wondering whether the presenters were asked follow-up questions that the editors omitted.
Sr. Sally Smolen, RSM
Program Coordinator
New Steps
Detroit