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

2. 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

3. 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: http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522.pdf 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: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf Report overview 3

4. 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

5. 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

6. 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

7. 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

8. ACCESS TO CARE Data notes Please refer to the Technical Notes chapter for a more detailed description of limitations and methods: http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf http://www.dhs.wisconsin.gov/publications/P0/p00522y.pdf 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

9. ACCESS TO CARE Factors that influence health Social determinants of health Source: University of Wisconsin Population Health Institute. County Health Rankings 2013, http://www.countyhealthrankings.org/our-approach Report overview 9

10. 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

11. 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

12. 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

13. ACCESS TO CARE Key points Adults In Wisconsin,16% of adults ages 18-64 did not have health insurance coverage. o More than one in three Hispanic (35%) and low-income (34%) adults ages 18-64 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

14. 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

15. 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

16. ACCESS TO CARE Youth During 2008-2010, an estimated 4% of children in Wisconsin ages 0-17 were uninsured. In 2011-2012: 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

17. ACCESS TO CARE Health insurance coverage among adults 17

18. ACCESS TO CARE Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by sex, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 landline-cellphone combined dataset. Health insurance coverage among adults 18

19. ACCESS TO CARE Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by age, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 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

20. ACCESS TO CARE Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by race/ethnicity, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 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

21. ACCESS TO CARE Lack of health insurance coverage among Wisconsin adults ages 18-64, by household income, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Health insurance coverage among adults 21

22. ACCESS TO CARE Lack of health insurance coverage and Medicaid enrollment among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Health insurance coverage among adults 22

23. ACCESS TO CARE Lack of health care coverage among Wisconsin adults ages 18-64, by disability status, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Health insurance coverage among adults 23

24. ACCESS TO CARE Lack of health care coverage and Medicaid enrollment among Wisconsin adults, by sexual orientation, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Health insurance coverage among adults 24

25. ACCESS TO CARE Health insurance coverage among youth 25

26. ACCESS TO CARE Health insurance coverage among Wisconsin children ages 0-17 years, 2008-2010 Source: Wisconsin Department of Health Services, Family Health Survey, 2008-2010. Health insurance coverage among youth 26

27. ACCESS TO CARE Public health insurance coverage and inadequacy of health insurance among children ages 6-17, by race/ethnicity, Wisconsin, 2011-2012 Source: 2011-2012 National Survey of Children's Health. Note: Wisconsin estimates were only available for White, Black, and Hispanic children. Health insurance coverage among youth 27

28. 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, 2011-2012 Source: 2011-2012 National Survey of Children's Health. Health insurance coverage among youth 28

29. ACCESS TO CARE Public health insurance coverage and inadequacy of health insurance among children ages 6-17, by special health care need status, Wisconsin, 2011-2012 Source: 2011-2012 National Survey of Children's Health.. Health insurance coverage among youth 29

30. 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, 2011-2012 30 Source: National Survey of Children’s Health, 2011-2012 Health insurance coverage among youth

31. ACCESS TO CARE Health care access among adults 31

32. ACCESS TO CARE Use of and barriers to health care among Wisconsin adults, by sex, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 landline-cellphone combined dataset. Health care access among adults 32

33. ACCESS TO CARE Use of and barriers to health care among Wisconsin adults, by age, 2009-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2009-2011 landline-cellphone combined dataset. Health care access among adults 33

34. ACCESS TO CARE Age-adjusted rate of use of and barriers to health care among Wisconsin adults, by race/ethnicity, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 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

35. ACCESS TO CARE Age-adjusted rate of use of and barriers to health care among Wisconsin adults, by household income, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Health care access among adults 35

36. ACCESS TO CARE Age-adjusted rate of use of and barriers to health care among Wisconsin adults, by level of urbanization, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Health care access among adults 36

37. ACCESS TO CARE Use of and barriers to health care among Wisconsin adults ages 18-64, by disability status, 2008-2011 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Health care access among adults 37

38. ACCESS TO CARE Use of and barriers to health care among Wisconsin adults, by sexual orientation, 2009-2011 38 Source: Wisconsin Department of Health Services, Behavioral Risk Factor Survey (BRFS); 2008-2011 landline-only dataset. Health care access among adults

39. ACCESS TO CARE Health care access among youth 39

40. ACCESS TO CARE Source: 2011-2012 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, 2011-2012 Health care access among youth 40

41. ACCESS TO CARE Lack of routine preventive medical and dental care and unmet medical and dental needs among children, by poverty status, Wisconsin, 2011- 2012 Source: 2011-2012 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

42. ACCESS TO CARE Source: 2011-2012 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, 2011-2012 42

43. ACCESS TO CARE Lack of access to care within a medical home among children, by race/ethnicity, Wisconsin, 2011-2012 Source: 2011-2012 National Survey of Children's Health. Note: Wisconsin estimates were only available for White, Black, and Hispanic children. Health care access among youth 43

44. ACCESS TO CARE Lack of access to care within a medical home among children, by poverty status, Wisconsin, 2011-2012 Source: 2011-2012 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

45. 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, 2011-2012. Source: 2011-2012 National Survey of Children's Health. Health care access among youth 45

46. ACCESS TO CARE Emergency room utilization 46

47. ACCESS TO CARE Emergency room utilization among Wisconsin residents, by race/ethnicity, 2008-2010 Source: Wisconsin Department of Health Services, Family Health Survey, 2008-2010. Emergency room utilization 47

48. ACCESS TO CARE Emergency room utilization among Wisconsin residents, by poverty status, 2008-2010 Source: Wisconsin Department of Health Services, Family Health Survey, 2008-2010. Emergency room utilization 48

49. ACCESS TO CARE Emergency room utilization among Wisconsin residents, by level of urbanization, 2008-2010 Source: Wisconsin Department of Health Services, Family Health Survey, 2008-2010. Emergency room utilization 49

50. ACCESS TO CARE Health professional shortages 50

51. 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

52. 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

53. ACCESS TO CARE References 1.University of Wisconsin Population Health Institute. County Health Rankings, 2013. http://www.countyhealthrankings.org/our-approach http://www.countyhealthrankings.org/our-approach 2.Center for Urban Population Health. Milwaukee Health Report, 2011. http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf http://www.cuph.org/mhr/2011-milwaukee-health-report.pdf 3.LaVeist TA, Gaskin DA, Richard P (2009). The Economic Burden of Health Inequalities in the United States. Joint Center for Political and Economic Studies. http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic% 20Burden%20of%20Health%20Inequalities%20in%20the%20United%20States.pdf http://www.jointcenter.org/sites/default/files/upload/research/files/The%20Economic% 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):1057–1059. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/ 5.Wisconsin Department of Health Services (DHS). Healthiest Wisconsin 2020. http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf http://www.dhs.wisconsin.gov/publications/P0/P00187.pdf 6.Centers for Disease Control and Prevention (CDC). Health Care: See Why Being Insured Matters. http://www.cdc.gov/features/vitalsigns/HealthcareAccess/http://www.cdc.gov/features/vitalsigns/HealthcareAccess/ 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). http://www.annemergmed.com/webfiles/images/journals/ymem/FA-PTCheung.pdf http://www.annemergmed.com/webfiles/images/journals/ymem/FA-PTCheung.pdf 8.Kaiser Commission on Medicaid and the Uninsured. Next Steps in Covering Uninsured Children. Findings from the Kaiser Survey of Children’s Health Coverage. http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7844.pdf http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7844.pdf 53 References

54. ACCESS TO CARE 9.CDC. Regular Check-Ups Are Important. http://www.cdc.gov/family/checkup/http://www.cdc.gov/family/checkup/ 10.United States Department of Health and Human Services (HHS). The 2011 HHS Poverty Guidelines. http://aspe.hhs.gov/poverty/11poverty.shtmlhttp://aspe.hhs.gov/poverty/11poverty.shtml 11.Data Resource Center for Child and Adolescent Health. Indicator details. http://www.childhealthdata.org/browse/survey/results?q=2507&r=1 http://www.childhealthdata.org/browse/survey/results?q=2507&r=1 12.RAND Corporation. The Evolving Role of Emergency Departments in the United States. http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_ RR280.pdf http://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR280/RAND_ 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 2011. National Center for Health Statistics. May 2012. Available from: http://www.cdc.gov/nchs/nhis/releases.htm http://www.cdc.gov/nchs/nhis/releases.htm 14.Wisconsin Department of Health Services (DHS).Wisconsin Health Facts: Poverty and Health, 2010 Results from the Wisconsin Family Health Survey. http://www.dhs.wisconsin.gov/publications/p0/p00381.pdf http://www.dhs.wisconsin.gov/publications/p0/p00381.pdf 15.DHS. Wisconsin Primary Care Office: Number of Dentists Needed to Reduce Significant Shortages for Medicaid Members. http://www.dhs.wisconsin.gov/publications/p0/p00368.pdf http://www.dhs.wisconsin.gov/publications/p0/p00368.pdf 16.DHS. Wisconsin Primary Care Office: Number of Psychiatrist FTEs Needed to Reduce Significant Shortages for the Resident Population. http://www.dhs.wisconsin.gov/publications/p0/p00376.pdf http://www.dhs.wisconsin.gov/publications/p0/p00376.pdf 54 References

55. ACCESS TO CARE Links to additional reports and resources Wisconsin Health Facts: Poverty and Health, 2010. http://www.dhs.wisconsin.gov/publications/p0/p00381.pdf http://www.dhs.wisconsin.gov/publications/p0/p00381.pdf Wisconsin Health Insurance Coverage, 2010. http://www.dhs.wisconsin.gov/publications/p4/p45369.pdf http://www.dhs.wisconsin.gov/publications/p4/p45369.pdf Wisconsin Primary Care Programs. Maps and data. http://www.dhs.wisconsin.gov/health/primarycare/maps.htm http://www.dhs.wisconsin.gov/health/primarycare/maps.htm 55 Links

56. 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 Email: Ann.Buedel@dhs.wisconsin.govAnn.Buedel@dhs.wisconsin.gov Wisconsin Primary Care Programs Traici Brockman, MPH Coordinator Office of Policy and Practice Alignment Division of Public Health Wisconsin Department of Health Services Email: Traici.Brockman@dhs.wisconsin.govTraici.Brockman@dhs.wisconsin.gov 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 Email: Anne.Ziege@dhs.wisconsin.govAnne.Ziege@dhs.wisconsin.gov 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 Email: Elizabeth.Oftedahl@dhs.wisconsin.govElizabeth.Oftedahl@dhs.wisconsin.gov Contacts