Access to Health Care in America (1993) / Chapter Skim
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Appendix C: Developing Indicators of Access to Care: The Case for Migrants and the Homeless
Appendix C: Developing Indicators of Access to Care: The Case for Migrants and the Homeless
Pages 199-218
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From page 199... ...
Among these populations are migrant farmworkers and their families, the homeless, undocumented workers, and others whose employment or other life circumstances necessitate frequent movement and residential shifts. This review concentrates on existing knowledge regarding access barriers and the consequent health status of migrant farmworkers and the homeless, two examples of such populations.
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From page 200... ...
Tragically, migrants and the homeless share more than the lack of a fixed address: members of both groups live in extreme poverty, have less than the national average level of education, and have a greater burden of illness, higher rates of infant mortality, and shorter life expectancies than Americans as a whole (National Migrant Resource Program, 1990; Wright and Weber, 1987~. Migrant farmworkers and their families, the single adult living on the street, and homeless families in shelters periodically become "visible." For brief periods, the news media and policymakers focus on the problems of homelessness or the plight of migrants.
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From page 201... ...
Available information about health status, access to health services, and utilization of the medical system by migrants and seasonal farmworkers and the homeless is generally derived from surveys and evaluations of specially targeted health care delivery systems (e.g., the Migrant Health Clinics and Health Care for the Homeless programs)
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From page 202... ...
The Institute of Medicine's Committee on Monitoring Access to Personal Health Services defines access as "the timely use of personal health services to achieve the best possible health outcomes." The health care needs of both the migrant and homeless populations are enormous and complex, as a consequence of poverty, environmental and occupational risks, mental health needs, and the living conditions that define and determine the existence of these groups. In turn, monitoring access, evaluating the barriers to health care, and assessing the appropriateness of services for the homeless and for migrant populations are essential to understand the complex relationships among health status, health care utilization, and outcomes.
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From page 203... ...
of the Health Resources and Services Administration quotes a figure of approximately 4 million migrant and seasonal farmworkers and their dependents; this statistic is derived by defining a migrant or seasonal farmworker as "an individual whose principal employment within the last 24 months is in agriculture on a seasonal basis." (Office of Migrant Health, 1992~. In this definition, the only difference between a migrant and a seasonal farmworker is that the migrant travels and establishes a temporary abode for employment purposes (Office of Migrant Health, 1992~.
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From page 204... ...
A number of sources quote a life expectancy of 49 years, as compared with the national average of 75 years, for migrant farmworkers, and an infant mortality rate that is 125 percent above the national average (National Migrant Resources Program and the Migrant Clinicians Network, 19904. However, literature searches commissioned by the Department of Health and Human Services in 1984, the Farmworker Justice Fund in 1985 and 1988, and one performed by a migrant health physician in 1990 revealed no published studies that included specific mortality or survival data (Rust, 19901.
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From page 205... ...
The Texan migrant health centers are considered to be "home base" or "downstream" sites, whereas the Indiana and Michigan centers are "nonhome base" or "upstream" centers. The study also looked at the demographics of the counties in which the centers were located.
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From page 206... ...
. As the author correctly notes, using proportions of clinic visits for specific diagnoses fails to provide information regarding disease incidence or prevalence; however, the variation in visits by principal diagnoses between migrants and seasonal farmworkers and their dependents and the general population suggests that migrant and seasonal agricultural workers suffer from different health problems and a greater burden of chronic diseases at a younger age than do most Americans.
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From page 207... ...
A survey of migrant health centers, conducted by the National Association of Community Health Centers in the spring of 1991, documented the remaining barriers, from the providers' perspective, after the Medicaid expansions mandated by Congress in 1989 and 1990 (National Association of Community Health Centers, 1991~. Additional barriers to receiving Medicaid benefits would surely emerge if migrants and seasonal farmworkers were queried directly.
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From page 208... ...
Almost 25 percent listed fear or lack of confidence in the medical profession as a reason for not seeking or delaying care. In the population-based study of occupational injuries among North Carolina migrant farmworkers conducted by Ciesielski and colleagues (1991)
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From page 209... ...
In 1985, the Robert Wood Johnson Foundation, the Pew Memorial Trust, and the United States Conference of Mayors established Health Care for the Homeless Demonstration Projects in 19 large cities. (Wright and Weber, 19871.
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From page 210... ...
The use of estimation techniques based on recorded diagnoses led to estimates that 38 percent of the homeless seen in the demonstration projects abused alcohol, 13 percent abused drugs other than alcohol, and 33 percent were mentally ill. During the demonstration period, the rates of tuberculosis (968 cases/100,000 population)
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From page 211... ...
In addition to general underfinancing of health care services for the poor, the report identified additional barriers to access facing the homeless: bureaucratic and scheduling issues, lack of transportation, negative perceptions on the part of providers and institutions, and the avoidance of institutions by the homeless themselves because of prior experience (Institute of Medicine, 1988~. Despite the lack of quantifiable data, no one has disputed the statements made on the original brochure for the Health Care for the Homeless Demonstration Projects: "Most homeless people do not now receive needed health services.
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From page 212... ...
The general agreement among policymakers and advocates that the homeless continue to have inadequate access to appropriate health care services has not been tested. Because no new federal money has been available for the McKinney Health Care for the Homeless program, few cities or rural areas have performed recent systematic health care needs assessments of this population group.
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From page 213... ...
and the McKinney Health Care for the Homeless programs (Section 340 of the act) should develop data systems that include clinical information necessary to assess the health status of these populations and information regarding utilization of health care services and access barriers encountered within the health care system.
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From page 214... ...
should develop a research agenda on migrant health issues that would include specific measures of access to personal health care services, including alcohol and substance abuse treatment and mental care health programs. In addition to the measures of access to these services, the research agenda must include studies that allow for calculating vital statistic rates including maternal and infant mortality, low birthweight, and age- and cause-specific mortality.
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From page 215... ...
Additional issues related to access particularly for the homeless, include the relationships among poor health status (especially mental health) , lack of access to appropriate health care services, and the precipitation or continuation of homelessness.
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From page 216... ...
Unfortunately, developing indicators for monitoring the access to health care services of migrants and the homeless cannot be divorced from the need for special studies. There exists a national commitment to providing targeted services through the McKinney Health Care for the Homeless and the Migrant Health Center programs.
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From page 217... ...
Austin, Tex.: The Program. National Migrant Resource Program and the Migrant Clinicians Network.
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From page 218... ...
1990. Health status of migrant farmworkers: A literature review and commentary.
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