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12 September 2000

The Impact of Managed Care

But while insurance and more active community clinics might help provide continuity of care, Kathryn Phillips has discovered that it may not solve some of the other barriers to good health. In her recent work, Phillips and her colleagues have found that such things as long wait times for an appointment or unresponsive providers can decrease the quality of medical care, particularly for Hispanics and Asian-Americans.

In a study published in the July/August 2000 Health Affairs, Phillips and her colleagues describe barriers to care reported by racial and ethnic groups -- and explore the extent to which these barriers vary between those enrolled in managed care versus non-managed care plans. The study found that while most insured people express satisfaction with their care, a substantial percentage report barriers. Minorities were more likely than non-Hispanic whites to report these problems, regardless of the type of insurance, with Hispanics and Asian-Americans reporting these problems in the biggest numbers. "Race and ethnicity," says Phillips, "are among the key individual predictors of access barriers."

Phillips believes the study can be used in a number of significant ways, beyond pointing the way to more research. Most notably, she believes that we might begin using access barriers as legitimate measures of the quality of care. She also believes that access barriers might be used to measure how proposed and current policy changes differentially affect racial and ethnic groups.

Socioeconomic Status Affects All

As befits the international reputation of UCSF, the CHC's work extends across the nation and around the world. CHC director Nancy Adler, for example, heads The MacArthur Foundation Research Network on Socioeconomic Status and Health. This international group of scientists has already established that the influence of socioeconomic status goes beyond the poor or uneducated, and affects everyone, regardless of their position in the socioeconomic hierarchy.

Now, these scientists are tracing the paths by which socioeconomic factors influence health. Stress exposure is one clear path. Adler and her colleagues have shown that the lower people are on the socioeconomic hierarchy, the more that constant adaptations to stress inflict wear-and-tear on the body. The more stress-related wear-and-tear, the much higher the risk for disease and early death.

But Adler's group has also found that psychological factors may mediate this process. That is, how individuals perceive their social standing is equally or more strongly related to their physical and mental health than objective factors, such as education, income, or occupation. A recent volume of Annals of the New York Academy of Sciences, co-edited by Adler, examines in considerable detail the relationship between socioeconomic status and health in industrial nations.

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