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Update Healthy New Jersey 2000
Second Update and Review

Priority Area 1
Increase Access To Preventive And Primary Care

Introduction

Access to primary and preventive health care services is essential to improving the health status of New Jerseyans. Preventive and primary care includes immunizations, periodic examinations, screenings, and treatment services delivered in doctors' offices, clinics, hospitals and a variety of other settings. It also includes the care received when patients first bring their problems to providers. People without access to primary care are at greater risk of death and disability since it is this care which can prevent illness from striking or stop it at an early stage when treatment is relatively simple and inexpensive.

Studies consistently show that having insurance is one of the most important prerequisites for having access to care, and Healthy New Jersey 2000 set some very ambitious targets for reducing the percentage of the population that is uninsured. Access begins, but does not end with health insurance. Providers must be available, willing and able to provide services in ways that are appropriate to the populations they serve, and people must take advantage of the available preventive and primary health services. Therefore, objectives were also set to measure what proportion of New Jerseyans have a primary care provider, as well as improvement in indicators of health status, such as life expectancy, years of potential life lost, and hospitalizations for conditions that ordinarily are manageable in primary care settings.

New Jersey has made considerable progress in preventing premature mortality. However, it is unlikely we will meet other year 2000 access to care objectives. Major initiatives currently underway to provide health insurance to uninsured children in New Jersey should significantly improve access for New Jerseyans under the age of 19.

Outlook For Reaching Specific Objectives:

Achieve target: Likely Unlikely Uncertain
1A. Reduction in the percentage of persons under age 65 with no health insurance:




total population
X



black
X



Hispanic
X

1B. Reduction in the percentage of workers under 65 and their dependents without insurance
X


1C. Increase in the percentage of residents with a primary care provider:



total population
X



black
X

1D. Reduction in hospitalizations for ACS conditions:




under 65 years
X



under 5 years
X

1E. Reduction in years of potential life lost for:




total population
X




minority population
X


1F. Increase in life expectancy for:





white population

X


minority population

X
1G. Increase in people served by fluoridated water systems
X

1H. Establishment of risk assessments in publicly funded clinics

X

Data Update

1A. Reduce the non-institutionalized, civilian population under age 65 with no health insurance coverage to:

3.0 percent in the total population
3.0 percent in the black (non-Hispanic) population
3.0 percent in the Hispanic population

Achieve target:LikelyUnlikelyUncertain
total population
X
black
X
Hispanic
X

Percent With No Health Insurance
Year Total Black Hispanic
1989
1992
1993
1994
1995
1996
1997
11.7
14.8
15.5
14.7
16.2
19.1
18.4
16.0
18.9
21.6
16.0
16.4
26.8
N/A*
25.0
27.9
29.1
27.7
28.5
29.6
N/A*
*Not available

In a trend that mirrors the national experience, there has been a substantial decline in the percentage of the population with health insurance coverage since the baseline year of 1989. During this period, the black population has consistently had a higher uninsured rate than the total population, and the percentage of Hispanics without health insurance has not been under 25 percent.

Data are derived from the Census Bureau's Current Population Survey, administered in March of each year. The survey is intended to measure a variety of socioeconomic variables nationally, including the percentage of the population that had no insurance during the entire previous year. Research suggests, however, that survey respondents may misunderstand the survey questions, and that the data reflect a combination of people uninsured for both short and long periods of time. Because the survey is designed to obtain national estimates, the sample size for New Jersey respondents is relatively small. This leads to large standard errors in the estimates, and explains at least some of the variation in the numbers from year to year. Nevertheless, there is an overall trend of increasing numbers of New Jerseyans without health insurance coverage, and the year 2000 objective is unlikely to be met.

1B. Reduce the percentage of full-time employed persons under 65 years of age and their spouses and dependents who are uninsured to:

2.0 percent

Achieve target:LikelyUnlikelyUncertain
X

Percent Uninsured
Year Percent
1988
1992
1993
1994
1995
1996
7.7
9.5
11.9
12.3
13.7
15.8

Once again, in a trend that is consistent with the national experience, the percentage of employed persons under the age of 65 and their spouses and dependents who are uninsured more than doubled from 7.7 percent in 1988 to 15.8 percent in 1996.

1C. Increase the percentage of residents who have a source of primary care to:

98 percent for the total population
98 percent for the black population

Achieve target:LikelyUnlikelyUncertain
total population
X
black
X

Percent With Primary Care Source
YearTotalBlack
1986
1995
1996
84.4
87.5
83.2
84.2
90.1
79.3

The percentage of New Jerseyans with access to primary care is hovering around 85 percent for both the total population and the black population, according to baseline data from a survey sponsored by the Robert Wood Johnson Foundation and more recent data available from the Department's Behavioral Risk Factor Surveillance System, an annual survey of adults about behaviors and activities which affect their health status. Since the sample sizes for the survey are relatively small, there is a large standard error which may account for the fluctuations. However, without an obvious upward trend, it appears unlikely that the year 2000 targets of 98 percent will be met.

1D. Reduce hospitalizations of state residents for Ambulatory Care Sensitive (ACS) conditions per 1,000 age-specific population to:

12.0 for residents under 65 years
27.0 for residents under 5 years

Achieve target:LikelyUnlikelyUncertain
under 65 years
X
under 5 years
X

Rate Of ACS Hospitalizations
Year Under 65 Under 5
1993
1994
1995
1996
18.6
18.4
18.2
17.3
35.0
32.1
35.0
31.2

Ambulatory Care Sensitive (ACS) conditions are those for which timely and effective outpatient care could have reduced the risk of hospitalization. In some cases, this care could prevent the onset of an illness or condition; in others, it could help control an acute episode or manage a chronic condition. Childhood asthma is an example of an ACS condition that should be amenable to management outside the hospital. Hospitalization rates for ACS conditions provide an indicator of how well New Jerseyans are accessing primary care. Differential targets are set for young children and adults, because a higher rate of hospitalizations for ACS conditions is expected for young children in the ordinary course of events.

The hospitalization rate for ACS conditions among the population under 65 has been slowly decreasing, while that for young children has fluctuated. In both cases, however, it is unlikely that the year 2000 targets will be achieved.

1E. Reduce the years of potential life lost (YPLL) per 100,000 population under 65
years of age to:

5,200.0 for the total population
8,900.0 for the minority population

Achieve target:LikelyUnlikelyUncertain
total population
X
minority population
X

YPLL Before Age 65
Year Total Minority
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
5,449.7
5,534.8
5,714.4
5,838.0
5,611.1
5,437.1
5,477.1
5,483.5
5,505.9
5,432.0
5,323.4
8,934.1
9,340.8
10,043.2
10,484.4
10,098.6
9,887.1
9,828.1
9,659.6
9,592.9
9,112.8
8,198.5

The YPLL rate is used to reflect trends in premature mortality. Major contributors to YPLL in New Jersey are cancer, HIV infection, injuries, and heart disease. The YPLL rate represents the summation of all the years of life not lived to a defined upper limit (in this case, age 65) by those who died during the year at ages less than the specified limit.

Since peaking in 1988, the rate of YPLL for both the total population and the minority population has been declining. For the total population, it appears that the target YPLL rate of 5,200 will be met by the year 2000. The minority population met and surpassed its objective of 8,900 years in 1995. While the outlook is good for both groups and the gap is narrowing, the minority YPLL rate remains one and a half times the rate for the population as a whole.

1F. Increase life expectancy at birth, in years to:

77.9 for the white population
75.0 for the minority population

Achieve target:LikelyUnlikelyUncertain
white population
X
minority population
X

Life Expectancy At Birth, In Years
Year White Minority
1987-1989
1988-1990
1989-1991
1990-1992
1991-1993
1992-1994
1993-1995
75.8
76.3
76.6
76.9
77.0
77.1
77.1
70.7
71.0
71.1
71.3
71.4
71.8
71.8

Based on moving three year averages, life expectancy between 1993 and 1995 has improved slightly over that in the baseline years of 1987 through 1989. This is true for both the white and minority populations, with the white population having only a minor improvement (0.2 years) over the minority population. However, whites born in 1993 through 1995 are expected to live 5.3 years longer, on average, than minorities. At the current pace of these trends, it is not certain that either population will meet its year 2000 objective.

1G. Increase the proportion of people served by community water systems providing optimal levels of fluoride to:

62.0 percent

Achieve target:LikelyUnlikelyUncertain
X

Population with Fluoride
Year Percentage
1993
1998
14.7
19.5

Based on the available data, less than 20 percent of New Jerseyans were served by optimally fluoridated water systems. The year 2000 objective is unlikely to be met.

1H. Establish health risk assessments for sexually transmitted diseases (STDs), HIV infection and vaccine-preventable and other infectious diseases, specifically hepatitis B and tuberculosis, in Department of Health funded health clinics by the year 2000.

There are no data for this objective.

Discussion

Most Americans have either public or private health insurance, but the percentage of those without insurance has steadily risen over the past decade, reaching 43.4 million or 18.2 percent of Americans. Since almost all Americans over age 65 are covered by the federal government's Medicare program, lack of insurance is primarily a problem for those under age 65, especially the working poor and their families under age 65 were uninsured in 1997. For many years it has been the case that the majority of uninsured Americans - 79 percent in 1995 - live in families where there is at least one full-time worker. Because employers offer, and employees accept, health insurance coverage on a voluntary basis, it is not surprising that employment-based health insurance coverage has never been universal. Traditionally, small employers, particularly those with fewer than 25 employees, have been less likely to offer health insurance than their larger counterparts. Typically, they cite the cost of such insurance as a major barrier. But in the past decade, other factors have come into play, so that the percentage of Americans with employer-based coverage has actually declined, from 69.2 percent in 1987, to 64 percent in 1996. This trend has persisted even during a period of economic growth. Researchers have suggested that the primary reason for this decline is not that employers are dropping coverage, but that fewer employees are taking up coverage, due to the rapidly increasing cost. From the mid-80s until the mid-90s health care costs, including insurance premiums, rose very rapidly, at rates far exceeding the general growth in consumer prices in the nation. Employers responded in a variety of ways, including shifting in large numbers to managed care insurance plans. But their primary response has been to require employees to pay more of the overall cost of insurance premiums. In 1996, workers had to contribute an average of $1,615 per year, or about 30 percent of the total premium for family coverage. Not surprisingly, some workers, particularly those with lower wages, have chosen not to participate in employer-sponsored health plans. Between 1987 and 1996, the proportion of workers participating in employer plans to which they have access fell from 93 percent to 89 percent.1

New Jersey has not been immune to this national trend and has also experienced substantial growth in the number of uninsured over the past decade. In developing strategies to address this problem, New Jersey has decided to focus on children and has set itself the goal of ensuring that all children in the state have access to comprehensive and affordable health insurance. The first step toward achieving this goal was the launching in 1997 of NJ Kidcare, a program to provide subsidized coverage to uninsured children living in families with incomes at or below twice the poverty level ($32,900 for a family of four). Families pay at most a $15/month premium to cover their eligible children under NJ Kidcare. The state intends to expand this program on a sliding fee schedule basis, with greater involvement of employers, until affordable health insurance is available to nearly every child in the state.

___________________________
1"How Well does the Employment-Based Health Insurance System Work for Low-Income Families?", Ellen O'Brien and Judith Feder, issue paper for the Kaiser Commission on Medicaid and the Uninsured, September, 1998

New Jersey has also reaffirmed its historic commitment to maintaining access to health care for the uninsured. Under state law, every hospital in the state must provide needed care to all patients who present for treatment, regardless of their ability to pay. In 1997, legislation was enacted which increased the amount of funding available to hospitals in the state to reimburse them for providing care to the indigent. At the same time, stable funding sources, including revenues from a substantially increased cigarette tax, were identified to support charity care on an ongoing basis. A 1997 study of data from the Robert Wood Johnson-sponsored Community Tracking Study Household Survey revealed that uninsured people in the Newark metropolitan area have significantly fewer problems than do their counterparts in ten other urban areas in getting access to health care when they need it.2 This suggests that New Jersey's health care safety net is working as intended. Efforts are now underway to design a major pilot program to test ways to provide more primary and preventive care through the charity care system, using managed care principles. This pilot should begin operation in 1999.

One other way in which New Jersey mirrors national trends is in the rapid shift of those who are insured, either through employers or the Medicaid program, into managed care plans. Managed care has been the subject of much controversy, but one clear benefit of managed care is its emphasis on preventive and primary care. Under traditional indemnity insurance it was not always easy to get coverage for such care, creating financial barriers to access. New Jersey monitors the performance of managed care plans, publishing an annual report card beginning in 1997 that includes specific measures of a plan's success in delivering preventive and primary care. For example, the state looks at the percentage of children up to two years of age who have received appropriate immunizations, as well as breast and cervical cancer screenings for women and eye care screenings for diabetics. Over time, health care plans are expected to improve areas of weakness identified in the report cards.

Although it is either uncertain or unlikely that New Jersey will reach its ambitious year 2000 access targets in the areas of having a regular source of primary care, hospitalizations for ACS conditions, and improvement in life expectancy, it is encouraging that there has been some improvement in these areas. The continuing disparities between the population at large and minority populations remain a source of great concern, however. In many of the other priority areas of Healthy New Jersey 2000, reducing the disparities that result in these overall differences in health status is a major focus of the Department's efforts.

Increasing the percentage of people served by optimally fluoridated community water systems was established as an objective, because this was seen as a cost-effective means to deliver preventive dental health care to many New Jerseyans. Unfortunately, there has been no progress on this front. New Jersey's strong tradition of home rule, coupled with continuing controversies about the benefits and perceived potentially adverse effects of fluoride, has resulted in New Jersey ranking among the lowest states in water flouridation. The Department is pursuing alternative strategies to promote oral health, including education and promotion of fluoride mouth rinses and fluoride supplements in areas where the water supply is not fluoridated.

___________________________
2"Ability to Obtain Medical Care for the Uninsured - How Much Does it Vary Across Communities?" Cunningham, Peter J. And Kemper, Peter. Journal of the American Medical Association, September 9, 1998, Vol 280, No. 10, pp. 921-927.



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