OBJECTIVES. This study analyzed data on US residents reporting that they were unable to obtain needed care. Inadequately immunized children and women inadequately screened for breast or cervical cancer were also examined. METHODS. Data from the 1987 National Medical Expenditure Survey was analyzed. RESULTS. A total of 6,375,000 (90% confidence interval [CI] = 6,039,000, 6,711,000) people could not get hospitalization, prescription medications, medical equipment/supplies, or emergency, pediatric, mental health, or home care. Although the uninsured were more likely to forego care unavailable, three quarters of those unable to obtain services were insured, and 46% (90% CI = 42.4%, 49.6%) had private coverage. Of those reporting the reason why they failed to obtain care, 65.1% (90% CI = 61.7%, 68.6%) listed high costs or lack of insurance, including 60.7% (90% CI = 57.1%, 64.3%) of the privately insured. More than a third of women had not had a breast examination in the previous 2 years, a fifth had not had a Pap smear within the previous 4 years, and half had never had a mammogram (ages 50-69 only). Of children 2 to 5 years old, 35.1% (90% CI = 31.5%, 35.7%) were inadequately immunized. Medicaid recipients had measures of access to care similar to those of the uninsured. CONCLUSIONS. Many US residents--most of whom have insurance--are unable to obtain needed care, usually because of high costs.

We studied 458 consecutive patient transfers from 14 ty studied, transfer is a common and potentially dangerous medical private hospitals to a public hospital emergency room during a sixintervention which appears to reinforce racial and class inequalities month period. The transferred patients were predominantly male, of access to medical care. (Am J Public Health 1984; 74:494-497.) young, and uninsured, and included large numbers of minority group members. We established criteria to identify patients at high risk for adverse effects of transfer and reviewed the clinical records of the 103 patients meeting these criteria. We judged that transfer resulted Introduction in substandard care for 33 of these patients, either because theyLittle is known about the transfer of patients between were at risk for life-threatening complications in transit or because hospital emergency rooms. Anecdotal reports suggest that such transfers are common, may be hazardous, and dispro- Of the 458 patients transferred to the emergency department, 272 (53 per cent) were admitted to the hospital, 22 of whom required intensive care. Thirty-two patients (7 per cent) were referred to the Department of Psychiatry, 9 (2 per cent) were taken into custody by judicial authorities, and 27 (6 per cent) were transferred to other institutions for further care. The study population of 458 patients with 272 admissions represented 2 per cent of emergency room visits and 6.5 per cent of all hospital admissions at Highland General.Half of the patients had suffered traumatic injuries; 8 per cent were thought to have taken drug overdoses; and 5 per cent had alcohol withdrawal syndromes.Each of the 14 private hospitals in Alameda County with an emergency room transferred at least 11 patients to the county hospital. The 12 private hospitals with full emergency services were responsible for 91 per cent of the transfers, with four of these accounting for 55 per cent of all transfers. Sixty-six per cent of patients were transported by ambulance, and the remaining 34 per cent provided their own transportation.Seventy-nine (31 per cent) of the White patients transferred were insured, while 90 (44 per cent) of the non-White patients had health insurance (Chi square df 1 = 7.5, p<.01). Clinical EvaluationOf the 103 patients whose charts were reviewed, only one patient was explicitly transferred for a medical indication, a service not available at the original hospital. In 11 cases, physicians indicated that the patient was transferred because of inability to pay. In no case did a physician or nurse accompany the patient during transfer.In 33 cases (24 males and 9 females), transfer was judged to have jeopardized the patient. Fourteen (42 per cent) of those jeopardized were non-Spanish surnamed Whites, while this group accounted for 56 per cent of nonjeopardized transfers (Chi square df 1 = 2.35, p=.12). Twenty-eight (85 per cent) of those imperiled by transfer were uninsured, a significantly greater proportion than the 62 per cent uninsured among tho...

OBJECTIVES. We compared US and Canadian health administration costs using national medical care employment data for both countries. METHODS. Data from census surveys on hospital, nursing home, and outpatient employment in the United States (1968 to 1993) and Canada (1971 and 1986) were analyzed. RESULTS. Between 1968 and 1993, US medical care employment grew from 3.976 to 10.308 million full-time equivalents. Administration grew from 0.719 to 2.792 million full-time equivalents, or from 18.1% to 27.1% of the total employment. In 1986, the United States deployed 33,666 health care full-time equivalent personnel per million population, and Canada deployed 31,529. The US excess was all administrative; Canada employed more clinical personnel, especially registered nurses. Between 1971 and 1986, hospital employment per capita grew 29% in the United States (mostly because of administrative growth) and fell 14% in Canada. In 1986, Canadian hospitals still employed more clinical staff per million. Outpatient employment was larger and grew faster in the United States. Per capita nursing home employment was substantially higher in Canada. CONCLUSIONS. If US hospitals and outpatient facilities adopted Canada's staffing patterns, 1,407,000 fewer managers and clerks would be necessary. Despite lower medical spending, Canadians receive slightly more nursing and other clinical care than Americans, as measured by labor inputs.

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