Wisconsin Department of Health Services January 2014 P-00522P Healthiest Wisconsin 2020 Baseline and Health Disparities Report Access to High-Quality Health Services

ACCESS TO CARE Background Overview of Healthiest Wisconsin 2020 Baseline and Health Disparities Report Healthiest Wisconsin 2020 objectives and indicators Rationale Key points Data Health insurance coverage among adults Health insurance coverage among youth Health care access among adults Health care access among youth Emergency room utilization Health professional shortages References Links to additional reports and resources Contacts Chapter Outline 2 Chapter outline

ACCESS TO CARE Report Overview This chapter is part of a larger report created by the Wisconsin Department of Health Services to track progress on the objectives of Healthiest Wisconsin 2020 (HW2020) and identify health disparities in the state. The full report is available at: The report is designed to address the Health Focus Areas in HW2020. Where direct measures exist, data are presented; where direct measures are not available, related information may be included. Information about populations experiencing health disparities is provided in the Health Focus Area chapters and is summarized in separate chapters devoted to specific populations. Technical notes are available at: Report overview 3

ACCESS TO CARE Report Format Full Report Format: PDF Intended use: reference document Chapters Format: Annotated PowerPoint slide set Intended uses: presentations to –Decision-makers –Service providers –Community leaders –The public Sample annotated slide Report overview 4

ACCESS TO CARE Report Outline Executive Summary Section 1: Introduction Section 2: Demographic overview Section 3: Health focus areas Section 4: Infrastructure focus areas Section 5: Data summaries by population Section 6: Technical notes Report overview 5

ACCESS TO CARE Report Outline: Detail Section 3: Health focus areas Alcohol and other drug use Chronic disease prevention and management Communicable diseases Environmental and occupational health Healthy growth and development Injury and violence Mental health Nutrition and healthy foods Oral health Physical activity Reproductive and sexual health Tobacco use and exposure Section 4: Infrastructure focus areas Access to health care Report overview 6

ACCESS TO CARE Report Outline: Detail Section 5: Data summaries by population  Racial/ethnic minority populations o American Indians o Asians o Blacks o Hispanics  People of lower socioeconomic status  People with disabilities  Lesbian, gay, bisexual, and transgender populations  Geography Report overview 7

ACCESS TO CARE Data notes Please refer to the Technical Notes chapter for a more detailed description of limitations and methods: The 95% confidence intervals are denoted by error bars. Where confidence intervals do not overlap, as shown in the example on the right, differences are statistically significant. Larger confidence intervals may indicate less reliable estimates that should be interpreted with caution. Population estimates that are considered unreliable are excluded. Misclassification of racial/ethnic groups may affect the accuracy of rates. Unless otherwise indicated, the Hispanic population may include people of various races; Whites, Blacks, Asians, and American Indians are non- Hispanic. Report overview 8

ACCESS TO CARE Factors that influence health Social determinants of health Source: University of Wisconsin Population Health Institute. County Health Rankings 2013, Report overview 9

ACCESS TO CARE Objective 1 By 2020, assure all residents have affordable access to comprehensive, patient-centered health services that are safe, effective, affordable, timely, coordinated, and navigable. Objective 1 Indicators Proportion of people with health insurance. Proportion of people with a specific source of ongoing care. Number of National Committee for Quality Assurance (NCQA) – certified medical home practices in state. Proportion of counties with more than one full-time equivalent dentist providing Medicaid services per 4,000 low-income persons. Proportion of health plan members receiving care meeting National Committee for Quality Assurance (NCQA) or Healthcare Effectiveness Data and Information Set [HEDIS] standards. Healthiest Wisconsin 2020 objectives and indicators Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Access to High-Quality Health Services Focus Area Profile. 10 HW2020 objectives

ACCESS TO CARE Objective 2 By 2020, assure that populations of differing races, ethnicities, sexual identities and orientations, gender identities and educational or economic status, and those with disabilities, have access to comprehensive, patient-centered health services that are safe, effective, affordable, timely, coordinated and navigable. Objective 2 Indicators Proportion of people in each population group with health insurance. Proportion of people in each population group with an ongoing source of care. Proportion of adults with and without a disability who report difficulties or delays in obtaining needed health care. Proportion of Wisconsin children who report inadequate health insurance. Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Access to High-Quality Health Services Focus Area Profile. 11 HW2020 objectives Healthiest Wisconsin 2020 objectives and indicators

ACCESS TO CARE Rationale Access to high-quality health services means universal access to affordable high- quality health services for all people in Wisconsin to promote optimal physical and mental health and to prevent illness, disease, injury, disability, and premature death. High-quality health services include the full range of health care services, including medical, dental, mental health, and long term care. Access to high-quality health services means they are available to the people of Wisconsin when, where, and how services are needed. This includes equitable access to health promotion and disease prevention services across the life span that are coordinated, culturally competent, and linguistically appropriate. To be effective in producing good health outcomes, health services must be integrated, equitable, patient-centered, safe, timely, and efficient to effectively meet the needs of diverse populations. To ensure the health and economic security of Wisconsin families, everyone in the state needs access to affordable and high-quality health services, regardless of health, employment, financial, or family status. Rationale Source: Wisconsin Department of Health Services, Healthiest Wisconsin 2020, Access to High-Quality Health Services Focus Area Profile. 12

ACCESS TO CARE Key points Adults In Wisconsin,16% of adults ages did not have health insurance coverage. o More than one in three Hispanic (35%) and low-income (34%) adults ages lacked health insurance coverage. o Lesbian, gay and bisexual adults (25%) were significantly more likely to lack coverage compared to heterosexual adults (13%). Blacks, Hispanics, and Asians were significantly more likely to be unable to obtain medical care due to cost compared to Whites. Nearly one-quarter of Black residents (23%) were treated in the emergency room in the past year, as were 27% of residents living below the federal poverty level (FPL). 13 Key points

ACCESS TO CARE Key points Adults Significant differences existed in use of and barriers to health care by population: o Sex: Males were more likely than females to not have a doctor’s visit in the past year and to not have a personal doctor. o Age: Younger adults were more likely than older adults to not have a doctor’s visit in the past year, to not have a personal doctor, and to be unable to obtain care due to costs. o Race/Ethnicity: Whites, Hispanics, and American Indians were more likely than Blacks to not have a doctor’s visit in the past year; while Blacks, Hispanics, and Asians were more likely than Whites to be unable to obtain care due to costs. 14 Key points

ACCESS TO CARE Key points o Income: Adults with low household incomes were more likely to not have a doctor’s visit in the past year, to not have a personal doctor, and to be unable to obtain care due to costs than were adults with higher incomes. o Geography: Residents of nonmetropolitan counties were more likely to not have a doctor’s visit in the past year and to not have a personal doctor than those in Milwaukee County; however, residents of Milwaukee County were more likely to be unable to obtain care due to costs. o Disability status: Among adults ages 18-64, those without a disability were more likely to not have a doctor’s visit in the past year and to not have a personal doctor than were those with a disability; however, adults with a disability were more likely to be unable to obtain care due to costs. 15 Key points

ACCESS TO CARE Youth During , an estimated 4% of children in Wisconsin ages 0-17 were uninsured. In : o Approximately one in four parents/guardians in Wisconsin felt that their child’s health insurance coverage was inadequate and one in three children did not receive both routine medical and dental visits in the past year. o About half of Wisconsin children living in households below the federal poverty level did not see a health provider for preventive medical and dental care during the past 12 months. o Compared to other children, children with special health care needs were significantly more likely to have unmet medical or dental needs. o Nearly half of Black and Hispanic children in Wisconsin did not receive coordinated, ongoing, comprehensive care within a medical home. Key points 16 Key points

ACCESS TO CARE Health insurance coverage among adults 17

ACCESS TO CARE Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by sex, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-cellphone combined dataset. Health insurance coverage among adults 18

ACCESS TO CARE Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by age, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-cellphone combined dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Health insurance coverage among adults 19

ACCESS TO CARE Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by race/ethnicity, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Health insurance coverage among adults 20

ACCESS TO CARE Lack of health insurance coverage among Wisconsin adults ages 18-64, by household income, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Health insurance coverage among adults 21

ACCESS TO CARE Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by level of urbanization, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Health insurance coverage among adults 22

ACCESS TO CARE Lack of health care coverage among Wisconsin adults ages 18-64, by disability status, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Health insurance coverage among adults 23

ACCESS TO CARE Lack of health care coverage and Medicaid enrollment among Wisconsin adults, by sexual orientation, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Health insurance coverage among adults 24

ACCESS TO CARE Health insurance coverage among youth 25

ACCESS TO CARE Health insurance coverage among Wisconsin children ages 0-17 years, Source: Wisconsin Department of Health Services, Family Health Survey, Health insurance coverage among youth 26

ACCESS TO CARE Public health insurance coverage and inadequacy of health insurance among children ages 6-17, by race/ethnicity, Wisconsin, Source: National Survey of Children's Health. Note: Wisconsin estimates were only available for White, Black, and Hispanic children. Health insurance coverage among youth 27

ACCESS TO CARE Public health insurance coverage and inadequacy of health insurance among children ages 6-17, by highest education level of adult in household, Wisconsin, Source: National Survey of Children's Health. Health insurance coverage among youth 28

ACCESS TO CARE Public health insurance coverage and inadequacy of health insurance among children ages 6-17, by special health care need status, Wisconsin, Source: National Survey of Children's Health.. Health insurance coverage among youth 29

ACCESS TO CARE Percentage of children who have a medical home and percentage of children who have problems getting specialist care, by disability status, Wisconsin, Source: National Survey of Children’s Health, Health insurance coverage among youth

ACCESS TO CARE Health care access among adults 31

ACCESS TO CARE Use of and barriers to health care among Wisconsin adults, by sex, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-cellphone combined dataset. Health care access among adults 32

ACCESS TO CARE Use of and barriers to health care among Wisconsin adults, by age, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-cellphone combined dataset. Health care access among adults 33

ACCESS TO CARE Age-adjusted rate of use of and barriers to health care among Wisconsin adults, by race/ethnicity, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Note: Estimates that are unreliable (based on Relative Standard Error or small sample size) are not shown; this means an estimate may not be presented for every population group. Health care access among adults 34

ACCESS TO CARE Age-adjusted rate of use of and barriers to health care among Wisconsin adults, by household income, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Health care access among adults 35

ACCESS TO CARE Age-adjusted rate of use of and barriers to health care among Wisconsin adults, by level of urbanization, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Health care access among adults 36

ACCESS TO CARE Use of and barriers to health care among Wisconsin adults ages 18-64, by disability status, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Health care access among adults 37

ACCESS TO CARE Use of and barriers to health care among Wisconsin adults, by sexual orientation, Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); landline-only dataset. Health care access among adults

ACCESS TO CARE Health care access among youth 39

ACCESS TO CARE Source: National Survey of Children's Health. Note: Wisconsin estimates were only available for White, Black, and Hispanic children. Lack of routine preventive medical and dental care among children, by race/ethnicity, Wisconsin, Health care access among youth 40

ACCESS TO CARE Lack of routine preventive medical and dental care and unmet medical and dental needs among children, by poverty status, Wisconsin, Source: National Survey of Children's Health. Note: Estimates were not available for all groups. FPL is the Federal Poverty Level, based on household size and income. Health care access among youth 41

ACCESS TO CARE Source: National Survey of Children's Health. Health care access among youth Lack of routine preventive medical and dental care and unmet medical and dental needs among children, by special health care need status, Wisconsin,

ACCESS TO CARE Lack of access to care within a medical home among children, by race/ethnicity, Wisconsin, Source: National Survey of Children's Health. Note: Wisconsin estimates were only available for White, Black, and Hispanic children. Health care access among youth 43

ACCESS TO CARE Lack of access to care within a medical home among children, by poverty status, Wisconsin, Source: National Survey of Children's Health. Note: FPL is the Federal Poverty Level, based on household size and income. Health care access among youth 44

ACCESS TO CARE Lack of access to care within a medical home and problems getting specialist care among children, by special health care need status, Wisconsin, Source: National Survey of Children's Health. Health care access among youth 45

ACCESS TO CARE Emergency room utilization 46

ACCESS TO CARE Emergency room utilization among Wisconsin residents, by race/ethnicity, Source: Wisconsin Department of Health Services, Family Health Survey, Emergency room utilization 47

ACCESS TO CARE Emergency room utilization among Wisconsin residents, by poverty status, Source: Wisconsin Department of Health Services, Family Health Survey, Emergency room utilization 48

ACCESS TO CARE Emergency room utilization among Wisconsin residents, by level of urbanization, Source: Wisconsin Department of Health Services, Family Health Survey, Emergency room utilization 49

ACCESS TO CARE Health professional shortages 50

ACCESS TO CARE Number of full-time equivalent dentists needed to reduce significant shortages for Medicaid members, by county, 2009 Source: Wisconsin Department of Health Services, Primary Care Office, Shortage Designation Program. Health professional shortage areas 51

ACCESS TO CARE Number of full-time equivalent psychiatrists needed to remove significant shortages for the resident population, by county, 2011 Source: Wisconsin Department of Health Services, Primary Care Office, Shortage Designation Program. 52 Health professional shortage areas

ACCESS TO CARE References 1.University of Wisconsin Population Health Institute. County Health Rankings, Center for Urban Population Health. Milwaukee Health Report, LaVeist TA, Gaskin DA, Richard P (2009). The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf 4.Thomas JC, Sage M, Dillenberg J, Guillory VJ (2002). A Code of Ethics for Public Health. Am Journal of Public Health. 92(7):1057– Wisconsin Department of Health Services (DHS). Healthiest Wisconsin Centers for Disease Control and Prevention (CDC). Health Care: See Why Being Insured Matters. 7.Cheung PT, Wiler JL, Lowe RA, Ginde AA. (2012). National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries. Annals of Emergency Medicine. 60(1) Kaiser Commission on Medicaid and the Uninsured. Next Steps in Covering Uninsured Children. Findings from the Kaiser Survey of Children’s Health Coverage References

ACCESS TO CARE 9.CDC. Regular Check-Ups Are Important United States Department of Health and Human Services (HHS). The 2011 HHS Poverty Guidelines Data Resource Center for Child and Adolescent Health. Indicator details RAND Corporation. The Evolving Role of Emergency Departments in the United States. RR280.pdf RR280.pdf 13.Gindi RM, Cohen RA, Kirzinger WK. Emergency room use among adults aged 18–64: Early release of estimates from the National Health Interview Survey, January–June National Center for Health Statistics. May Available from: Wisconsin Department of Health Services (DHS).Wisconsin Health Facts: Poverty and Health, 2010 Results from the Wisconsin Family Health Survey DHS. Wisconsin Primary Care Office: Number of Dentists Needed to Reduce Significant Shortages for Medicaid Members DHS. Wisconsin Primary Care Office: Number of Psychiatrist FTEs Needed to Reduce Significant Shortages for the Resident Population References

ACCESS TO CARE Links to additional reports and resources Wisconsin Health Facts: Poverty and Health, Wisconsin Health Insurance Coverage, Wisconsin Primary Care Programs. Maps and data Links

ACCESS TO CARE Contacts 56 Family Health Survey Ann Buedel Research Analyst Office of Health Informatics Division of Public Health Wisconsin Department of Health Services Wisconsin Primary Care Programs Traici Brockman, MPH Coordinator Office of Policy and Practice Alignment Division of Public Health Wisconsin Department of Health Services Behavioral Risk Factor Survey Anne Ziege, PhD Behavioral Risk Factor Survey Coordinator/Project Director Office of Health Informatics Division of Public Health Wisconsin Department of Health Services National Survey of Children’s Health Elizabeth Oftedahl, MPH CYSHCN Epidemiologist Maternal and Child Health Program Division of Public Health Wisconsin Department of Health Services Contacts