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Section II:
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Access to Care
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Priority: ACCESS TO HEALTH CARE

TABLE OF CONTENTS

  1. Health Data
  2. Unmet Needs
  3. Resources in Chautauqua County
  4. Opportunities for Action

The Healthy People 2010 goal of increasing access to care focuses on the principle that:

Access to quality care is important to eliminate health disparities and increase the quality and years of healthy life for all persons in the United States. Together with health care delivered by specialists and care received in hospital settings, these elements represent major components of the continuum of care. The public health system is important in each of these areas because it educates people about prevention and addresses the need to eliminate disparities by easing access to preventive services for people less able to use existing health services. It ensures the availability of primary care through direct funding of clinics and providers or by providing public insurance.

Issues and Trends

According to Healthy People 2010,

Access to high-quality health care across each of the components in the continuum of care must be improved to realize the full potential of prevention. For example, success in reducing the burden of heart disease and narrowing the gap in heart disease outcomes between different racial groups will depend on several factors. These factors include ensuring access to clinical preventive services, such as blood pressure and cholesterol screening; effective primary care to educate people about modifiable risk factors, such as smoking, and to manage effectively chronic conditions like hypertension; high-quality emergency services to improve outcomes of acute cardiac events; and access to rehabilitative and long-term care for heart disease patients.
Major changes in the structure of the U.S. health care system, including the increasing influence of market forces, changes in payment and delivery systems, and welfare reform, have significant implications for vulnerable and at-risk populations. In light of these systems changes, Federal, State, and local public health agencies must redouble their efforts to address access barriers and reduce disparities for these populations. It is increasingly important that health care communication and services be provided in a culturally and linguistically sensitive manner. Adequate access to health care and related services can increase appropriate patient use of the health care system and, ultimately, improve health outcomes. Consequently, measures of access across a continuum of care are an important way to evaluate the quality of the Nation's health care system (http://www.healthypeople.gov/Document/HTML/Volume1/01Access.htm).

Healthy People 2010 and Access to Health Care

The specific objectives used to establish baseline measures and evaluate progress are summarized in the following table.


Healthy People 2010 Baselines and Targets for Access to Care
Objective2000 Baseline*2010 Target
1.1Increase the proportion of persons with health insurance.83%100%
1.2(Developmental) Increase the proportion of insured persons with coverage for clinical preventative services.NANA
1.3Increase the proportion of persons appropriately counseled about health behaviors. (All baselines are for 1995) 
 Increase in counseling on health behaviors among young persons at risk with a physician in the last year. 
1.3a(developmental) Physical activity or exercise (adults aged 18 years or older) 
1.3b(developmental) Diet and nutrition (adults aged 18 years and older) 
1.3c(developmental) Smoking cessation (adult smokers aged 18 years and older) 
1.3d(developmental) Reduce alcohol consumption (adults aged 18 years and older with excessive alcohol consumption) 
1.3e(developmental) Childhood injury prevention: vehicle restraints and bicycle helmets (children aged 17 years or younger) 
1.3fUnintended pregnancy (females aged 15 to 44 years)19%50%
1.3g(developmental) Prevention of sexually transmitted diseases (males aged 15 to 49 years; Females aged 15 to 44 years) 
1.3h(developmental) Management of menopause (females aged 46 to 56 years) 
1.4Increase the proportion of persons who have a specific source of on going care. (baseline is 1998) 
1.4aAll ages87%96%
1.4bChildren and youth aged 17 years and younger93%97%
1.4cAdults aged 18 years and older85%96%
1.5Increase the proportion of persons with a usual primary health provider77%
(1996)
85%
1.6Reduce the proportion of families that experience difficulties or delay in obtaining health care or do not receive needed care for one or more family members.12%
(1996)
7%
1.7(Developmental) Increase the proportion of schools of medicine, schools of nursing, and other health professional training schools whose basic curriculum for health care providers includes the core competencies in health promotion and disease prevention.NANA
1.8In the health professions, allied and associated health profession fields, and the nursing field, increase the proportion of all degrees awarded to members of under represented racial and ethnic groups. 
 Increase degrees awarded to underrepresented populations1996-19972010
 Health professionals, allied and associated health professional fields (for the baselines, health professionals include medicine, dentistry, pharmacy, and public health.) 
1.8aAmerican Indian or Alaska native0.6%1.0%
1.8bAsian or Pacific islander16.2%4.0**
1.8cBlack or African American6.7%13.0%
1.8dHispanic or Latino4.0%12.0%
 Nursing
1.8eAmerican Indian or Alaska native0.7%
(1995-1996)
1.0%
1.8fAsian or Pacific islander3.2%
(1995-1996)
4.0%
1.8gBlack or African American6.9%
(1995-1996)
13.0%
1.8hHispanic or Latino3.4%
(1995-1996)
12.0%
 Medicine
1.8iAmerican Indian or Alaska native0.6%1.0%
1.8jAsian or Pacific islander15.9%4.0%**
1.8kBlack or African American7.3%13.0%
1.8lHispanic or Latino4.6%12.0%
 Dentistry
1.8mAmerican Indian or Alaska native0.5%1.0%
1.8nAsian or Pacific islander19.5%4.0%**
1.8oBlack or African American5.1%13.0%
1.8pHispanic or Latino4.7%12.0%
 Pharmacy
1.8qAmerican Indian or Alaska native0.4%1.0%
1.8rAsian or Pacific islander17.5%4.0%**
1.8sBlack or African American5.7%13.0%
1.8tAmerican Indian, Hispanic or Latino2.8%12.0%
1.9Reduced hospitalization rates for three ambulatory-care- sensitive conditions- pediatric asthma, uncontrolled diabetes, and immunization-preventable pneumonia and influenza.
 Reduced hospitalization rates for three ambulatory-care- sensitive conditions (admissions per 10,000 population)19962010
1.9aPediatric asthma- persons under age 1823.017.3%
1.9bUncontrolled diabetes- persons age 18 to 64 years7.2%5.4%
1.9cImmunization-preventable pneumonia and influenza- persons aged 65 years and older 10.6%8.0%
1.10(Developmental) Reduce the proportion of persons who delay or have difficulty in getting emergency medical care. NANA
1.11(Developmental) Increase the proportion of persons who have access to rapidly responding pre-hospital emergency medical services.NANA
1.12Establish a single-toll free number for access to poison control centers on a 24-hour basis thought-out the United States.15%
(1999)
100%
1.13Increase the total number of Tribes, States, and the District of Columbia with trauma care systems that maximize survival and functional outcomes of trauma patients and help prevent injuries from occurring.5 states (1998)ALL
1.14Increase the number of states and District of Columbia that have implemented guidelines for pre-hospital and hospital pediatric care.
1.14aIncrease the number of states and District of Columbia that have implemented statewide pediatric protocols for online medical direction.18 states (1997)All
1.14bIncrease the number of states and District of Columbia that have adopted and disseminate pediatric guidelines that categorized acute care facilities with equipment, drugs, trained personal and other resources necessary to provide varying levels of pediatric emergency and critical care. 11 states (1997)All
1.15(Developmental) Increase the proportion of persons with long-term care needs who have access to the continuum of long-term care services.NANA
1.16Reduce the proportion of nursing home residents with a current diagnosis of pressure ulcers. 16 diagnosis per 1,000 residents in 19978 diagnosis per 1,0000 residents

*Except as noted.
**The Asian and Pacific islander population group has exceeded its target, which represents the minimum target based on the group's estimated proportion of the population. (http://www.healthypeople.gov/Document/HTML/Volume1/01Access.htm)

The three objectives outlined below are singled out as leading indicators to measure progress toward objectives.
1-1.Increase the proportion of persons with health insurance.
1-4a.Increase the proportion of persons who have a specific source of ongoing care.
16-6a.Increase the proportion of pregnant women who begin prenatal care in the first trimester of pregnancy.

A. Health Data

New York State Data

The percentage of New York State's uninsured population and the percentage of that population under 18 during the period from 1994 through 2003 are summarized below.

Percent of Population Uninsured in New York State, 1994-2003.

Percent of Population Uninsured in New York State, 1994-2003
US Census Bureau, 2004 Current Population Survey, Annual Social and Economic Supplement

The percentage in both groups of uninsured persons is below the average of the previous four years in each case. For persons in the under 18 group, the 2003 average (9.4%) is the lowest of any year, with the exception of 2001 when the percentage was 9.3%. For all persons, the 15.1% uninsured in 2003 is the lowest of any previous year.

The chart below from BFRSS compares uninsured persons in New York to those nationwide during the period from 1990 to 2002. With the exception of several years in the mid-nineties, the New York median % is higher than the national median % to varying degrees.

Figure 2. No Health Insurance Nationwide versus New York


A recent study of Upstate New York by Univera based on the 2000-2004 Current Population Survey data and entitled The facts about Upstate New Yorkers Without Health Coverage: An Update from the 2004 U.S. Census (https://www.excellusbcbs.com/download/files/1fsuninexcellus.pdf) reveals a number of facts about health insurance that are, to an extent, more relevant to Chautauqua County, since New York City and environs are separated from upstate counties:

Working Residents Without Coverage: Employer-Sponsored Insurance on the Decline
  • During 2002-2003, employment-based health coverage dipped slightly and government coverage rose both in upstate and in the downstate regions.
  • Employer-sponsored coverage for upstate adults continues to be more than 13 percentage points higher than for adults living downstate, and the proportion with government-based coverage is nearly three percentage points lower in upstate compared to downstate. In the downstate region, roughly 59 percent have employment-based coverage compared to 72 percent of those living in upstate.
Uninsured rates: Upstate versus Downstate New York: 1 2001-2003 (three-year average)
  • Between 2001 and 2003, the average annual uninsured rate for upstate New York was 9.9 percent versus 18.6 percent downstate.
  • The total uninsured rate is generally lower than the rate among 18-64 year olds because those under age 18 and over age 65 more often receive government-sponsored insurance through Child Health Plus and Medicare.

Figure 3. Upstate's Uninsured

How Does Upstate New York Compare to the Rest of the Nation?
Uninsured rates in upstate New York are markedly below the U.S. average. Since 2000, the national uninsured rate has steadily increased from 14.2 percent to 15.6 percent in 2003. During this time, upstate's uninsured rate remained between nine and 11 percent. Upstate New York, with a population of approximately 6.3 million, has a greater number of residents than 37 individual U.S. states. Yet, only five states have an uninsured rate that is lower than the upstate rate.

*Population figures are Census Bureau estimates for July 1, 2002, revised as of May 2004.

Regional Patterns: Significant Variations Across the State Uninsured rates by Upstate New York MSA and age group: 2001-2003 (three-year average)

Within New York State there are significant variations in the uninsured rates by region. The differences in the numbers of uninsured in key upstate metropolitan statistical areas (MSAs) are striking. From 2001 to 2003, the average uninsured rate among adults in upstate New York ranged from roughly 10 percent in the Albany/Troy/Schenectady area to 20 percent in the Binghamton region. In the Jamestown area, more than 14 percent of adults were uninsured during this time. *Schoharie County excluded **Cayuga County excluded

Overall, according to this study, a three year average (2001-2002) reveals that only five states have a lower percentage of uninsured persons than Upstate New York (9.9%), and only eight states have a lower percentage than New York as a whole (15.5%).

Figure 4. Regional Patterns: Significant variations across the state

Note that on that on this chart the city of Jamestown has a higher percentage of persons 18-64 uninsured than upstate New York as a whole.

Chautauqua County Data

1. Insurance Coverage

Data from the 1999 Western New York Adult Health Risk Assessment is somewhat outdated, but is the most comprehensive available, since it is based on a substantial sample, and allows for comparisons with other Southern Tier counties and with the Western New York Region. The following tables are excerpted directly from this report.

Of all Chautauqua County adults 15.6 were uninsured in 1999, compared to 11% of Western New York adults.

Percentage of Chautauqua County, Western New York,
and United States Adults that are insured.
Figure 5. Percentage of Chautauqua County, Western New York, and United States Adults that are insured

Chautauqua County adults between 18 and 44 years of age are uninsured at a higher rate than are older individuals. The uninsured prevalence rate for men aged 45 to 64, is higher than women in the same age group, 14% to 10%, respectively.

Percentage of Chautauqua County Adults that are Uninsured, by Age Group.
Figure 6. Percentage of Chautauqua County Adults that are Uninsured, by Age Group

Suburban adults have a slightly higher prevalence rate, 16.2, than rural adults in Chautauqua County, 14.2, as the table below indicates.

Percentage of Chautauqua County Adults that are Uninsured, by Urban Designation.
Figure 7. Percentage of Chautauqua County Adults that are Uninsured, by Urban Designation

The next table from the same assessment compares Chautauqua County to other Southern Tier counties and to the WNY Region in general, and breaks the uninsured population down by an under 65 age group, Black racial group membership, full time employment, income below $10,000, and several additional factors.

Access: Insurance Status
Figure 8. Access: Insurance Status

Blacks, adults under 65, workers employed full time, and persons receiving Medicare are all uninsured at a rate higher than the overall prevalence rate of 15.6%. Differences between Chautauqua and other Southern Tier Counties are generally small, but differences with the Western New York Region are generally greater.

The following data are based on the first quarter results of the 2004 BRFSS Survey conducted by the Bureau of Chronic Disease Epidemiology and Surveillance. Data were collected between May and July of 2004, and so may be affected by seasonality. Data are based on 464 cases, and must be regarded as preliminary and tentative. For this reason, both weighted and unweighted data are presented.

Weighted Frequencies Chautauqua County
Figure 9. Weighted Frequencies Chautauqua County


Based on the weighted data, the percentage of uninsured persons has decreased to 11.13% from 15.6%.

The 2010 target for the leading indicator to increase the proportion of persons with health insurance to 100% has not been met based on 1999 data that show an insured rate of 84.4%. This survey is in the process of being repeated, and more recent data will be available in the near future. According to preliminary 2004 data, the rate may now be closer to 90%.

2. Medicaid/Self-Pay Birth Percentage per 100 Live Births

Medicaid/Self-Pay Birth Percentage per 100 Live Births data are reported below for the period from 1993 to 2002 by single year, 3 year average, and upstate New York collectively, and also for the 2000 - 2002 period by comparison to other Western New York Counties and to the Region as a whole. The 2001 and 2002 rates for Chautauqua, 32.7 and 32.8 respectively, are the lowest during the ten year period, and the 2001 three-year average is the lowest of the eight three-year averages.

Chautauqua County Medicaid/Self-Pay Birth Percentage per 100 Live Births
Figure 10. Chautauqua County Medicaid/Self-Pay Birth Percentage per 100 Live Births

Medicaid/Self-Pay Birth Percentage per 100 Live Births
Figure 11. Medicaid/Self-Pay Birth Percentage per 100 Live Births

As the table below shows, the Chautauqua County three year average of 34.2% is higher than the Regional average, 21.2%, but lower than the state average of 41.3%, and lower than the percentages for Cattaraugus (36.1%) and Allegany (48.3%) Counties.

MEDICAID/SELF-PAY BIRTHS - PERCENTAGE PER 100 LIVE BIRTHS
Figure 12. Medicaid/Self-Pay Births - Percentage Per 100 Live Births


3. Access to Primary Care Source

The following tables are excerpted from the 1999 Western New York Health Risk Assessment Survey.

As the first table indicates, 9% of Chautauqua County residents and 6% of the Western New York population does not have a regular source of care. This is a lower rate than the nation as a whole, 16%, but higher than the Western New York rate of 6.4%.


Percentage of Chautauqua County, Western New York, and United States Adults with No Regular Source of Health Care
Figure 13. Percentage of Chautauqua County, Western New York, and United States Adults with No Regular Source of Health Care

Individuals between 18 and 44 years of age are somewhat more likely to have no access to care those 45-64. And men age 45-64 are slightly more likely to have no regular source of care than women in this age range.


Percent of Chautauqua County Adults With No Regular Source of Health Care, by Age Group
Figure 14. Percent of Chautauqua County Adults With No Regular Source of Health Care, by Age Group

In Chautauqua County, rural adults were more likely than suburban adults to be without a regular source of health care.


Percentage of Chautauqua County Adults With No Regular Source of Health Care, by Urban Designation
Figure 15. Percentage of Chautauqua County Adults With No Regular Source of Health Care, by Urban Designation

The following table offers comparative estimates among three WNY counties of those with no regualr source of care by several demographic and insurance characteristics


Table IC. HRA Estimates Compared to Healthy People 2010 Goals
for Allegany, Cattaraugus, and Chautauqua Counties
Access: No Regular Source of Care
Figure 16. Access: No Regular Source of Care

In Chautauqua County, blacks, persons without insurance, those with incomes under $10,000, and individuals receiving Medicaid all have rates that exceed the overall rate of 9.2%, particularly those receiving Medicaid whose rate is 29.7%.

The 2010 target for the leading indicator to increase the proportion of persons who have a specific source of on going care to 96% has not been met based on the 1999 data that show an uninsured rate of 90.8%. This survey is in the process of being repeated, and more recent data will be available in the near future.

4. Care Received in First Trimester of Pregnancy

Another 2010 indicator involves increasing the rate of pregnant women who receive prenatal care in the first trimester. The rates for the period from 1997 to 2001 range from 69.7% in 1997 to 74.3% in 1998. The 2001 rate is 71.9%, down from 73.3% in 2000.


Figure 17. Care Received in First Trimester of Pregnancy

The 2010 target for the leading indicator to increase the proportion of pregnant women who begin prenatal care in the first trimester of pregnancy to 90% has not been met based on the 2001 data that show a prenatal care rate of 71.9%.

5. Emergency Services

Healthy People 2010 identifies a number of issues related to response to emergencies (http://www.healthypeople.gov/Document/HTML/Volume1/01Access.htm#_Toc489432817). In addition to the need for hospital and responder services, there are also barriers to access to these resources, including lack of insurance, and psychological and cultural factors that can also limit access for persons with insurance. Restrictions on coverage by some insurers are also a factor. Even when services are accessed, issues arise concerning promptness of response, training of response personnel, and availability of hospital emergency rooms and medical services.

Chautauqua County has a county Office of Emergency Services, which coordinates response services in the county, and also works with the Southwest Regional Emergency Services Council. Residents and visitors have 24 hour access to 911 services. There are also has 37 fire departments that provide ambulance service and levels of care ranging from Basic Life Support to Advanced EMT-Critical Care. Each of the four hospitals in the county has an emergency room, and the WCA Hospital is designated trauma center. Twenty-two physicians in the county list their primary specialty as emergency medicine.

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B. Unmet Needs

According to Healthy People 2010...

Limitations in access to care extend beyond basic causes, such as a shortage of health care providers or a lack of facilities. Individuals also may lack a usual source of care or may face other barriers to receiving services, such as financial barriers (having no health insurance or being underinsured), structural barriers (no facilities or health care professionals nearby), and personal barriers (sexual orientation, cultural differences, language differences, not knowing what to do, or environmental challenges for people with disabilities). Patients with disabilities may face additional barriers arising from facilities that are not physically accessible or from the attitudes of clinicians. Hispanics, young adults, and uninsured persons are least likely to have a usual source of care.

The study based on the 2000-2004 Current Population Survey data entitled The Facts About Upstate New Yorkers Without Health Coverage: An Update from the 2004 U.S. Census (https://www.excellusbcbs.com/download/files/1fsuninexcellus.pdf), identifies a number of unmet needs related to access that have more direct relevance to Chautauqua County, since the focus is specifically on upstate New York. The study lists the following barriers, all of which are addressed in the data presented previously in this assessment:

Groups are at greatest risk for being uninsured are defined by:
  • Age: those ages 18-24 are least likely to have insurance and those ages 25-34 are second.
  • Race/Ethnicity: Individuals of minority race or ethnicity, particularly those who are Black and/or Hispanic are less likely to be insured.
  • Marital Status: The uninsured rate among the single, separated and divorced are more likely to be uninsured than married persons.
  • Education: Uninsured rates for upstate New Yorkers decrease with increasing levels of education.
  • Employment Status: Uninsured rates are higher among the unemployment and among those employed part.
  • Income and Poverty Status: health coverage rates increase with increasing income levels.
  • Age and Employment: The uninsured rate among 18-24 year olds who are also unemployed is higher than for any other group.
  • Income and Employment: Whether employed full- or part-time, those incomes at or near the poverty level have higher uninsured rates than do workers with higher incomes.
  • These demographic and socioeconomic factors constitute barriers that limit access to health care for identifiable subpopulations. To the extent that these upstate data are representative of Chautauqua County, they indicate populations at greater risk to limited access and its consequences.
  • These same groups may encounter barriers to emergency service resources in the county, due to lack of insurance, slow response, or other factors that limit willingness to request emergency service.
  • It should also be mentioned that Medicaid costs in Chautauqua County, as in other New York counties, have strained the resources of county government to the point of crisis.

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C. Resources in Chautauqua County

  • CHAUTAUQUA COUNTY HEALTH NETWORK: An administrative entity whose mission is to improve the quality of health care, including people's access to services, to contain the costs of health care for the consumer while strengthening the viability of providers, and to enhance the economy by retaining and expanding health services offered by health care providers in Chautauqua county.
  • FACILITATED ENROLLMENT/MATERNAL & CHILD HEALTH SERVICES (MCHS)
  • Chautauqua Opportunities Facilitated Enrollment provides health care coverage for pregnant women and children under nineteen years of age. The coverage is either free or low-cost, depending on eligibility. Enrollers provide assistance in the application process and check an applicant's eligibility for health care coverage such as Child Health Plus, Medicaid or any Medicaid Managed Care Plan options. The enroller also handles the application, follows up on status, and makes sure the applicant receives the coverage they are eligible for.
  • Fidelis Health Plan: provides a variety of services including facilitated enrollment.
  • Community Blue HMO: provides a variety of services including facilitated enrollment.
  • PARTNERS FOR PREVENTION: mission is to improve health by preventing illness and injury and by promoting health.
  • Community Health Assessment Project: survey community members to identify the priority of needs related to access to health care.
  • BRFSS Survey- SUNY Buffalo: survey community members to factors related to access to health care.
  • JCC: Nursing Program that has graduated an average of 23 nurses per year.
  • Cover the Uninsured: a national organization dedicated to providing information and resources related to covering the uninsured. (www.covertheuninsured.com).
  • Fire departments and physicians that provide emergency services are listed in Section V.
  • Chautauqua County Department Of Social Services: Child Health Plus.

A list of all physicians and their primary and secondary specialties is provided in Section V.

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D. Opportunities for Action

Community responses to needs related to access are available from data collected by the Community Needs Assessment. Responses to all questions pertaining to access presented in the following table suggest not only needs but also opportunities for action. The first three items on this list were among the top ten of forty-nine needs examined by the assessment questionnaire. Mean scores refer to the mean for the item on a five point scale indicating how much the respondent believes county-wide improvement is needed. Higher means indicate greater need.


Figure 18. Community Assessment Project - Chautauqua County Community Need Statement Ratings By Cluster

Opportunities for action related to access to health care are derived from Healthy People 2010 suggestions (http://www.healthypeople.gov/Document/HTML/Volume1/01Access.htm) and Chautauqua County data and information.

  • Demographic and socioeconomic barriers to access are quite clear, and it is essential to increase understanding of exactly how these barriers are distributed among Chautauqua County's subpopulations.
  • Utilize existing data and collect additional health data to assess the health status of smaller geographic areas within the county.
  • Continue efforts to develop strategies to deal with rising Medicaid costs in Chautauqua County and to increase access to affordable insurance, therefore facilitating regular sources of primary care.
  • Promote recognition of the critical role of preventive services among consumers and providers.
  • Develop ongoing collection and reporting of data on the delivery of recommended services by providers and health plans.
  • Maintain and promote the further development of local prevention coalitions linking health departments, businesses, community institutions, and individuals form all local communities.
  • Improve health insurance availability, cost, and options.

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