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Americans) who were ever without coverage during a part of 1987.

About 36 million people were uninsured in the first quarter of 1987. (This figure includes the 25 million who were uninsured all year and 11 million who were uninsured at the start of the year but obtained coverage before the end of the year.)

Seventeen percent of the population under 65 was uninsured in the first quarter of 1987 compared to 14 percent (26.5 million) a decade earlier.

Only 64 percent of uninsured Americans under age 65 used any health services in 1987, compared to 87 percent of those with private insurance and 83 percent of those with public coverage (Medicaid, CHAMPUS, or Medicare).

Average total health expenditures for uninsured persons less than 65 who used health services were $915 in 1987 compared to $1,316 for privately insured persons and $2,619 for persons with public health insurance.

Uninsured Minorities

The number of uninsured whites was 28 percent higher in the
first quarter of 1987 than 1977. During the same time
period, the number of uninsured blacks nearly doubled from 4
to 7 million and the number of uninsured Hispanics increased
three-fold from 2 to 6 million.

Blacks and Hispanics accounted for half of the increase in the uninsured over the decade.

Twenty-four percent of blacks under age 65 and 34 percent of Hispanics were uninsured in the first quarter of 1987, compared to 14 percent of whites.

Only 53 percent of uninsured blacks under age 65 and 55
percent of uninsured Hispanics used any health services in
1987, well below the national average (84 percent) and lower
than the percent of uninsured whites who used any services
(69 percent).

Average total health expenditures for uninsured blacks under
age 65 who used health services were $1,454 in 1987,
comparable to the national average of $1,420 for all persons
less than 65 who used health services. In contrast, average
total health expenditures for uninsured whites and Hispanics
were much lower, $896 on average for the former and $514
for the latter.

Uninsured Children

The proportion of children without insurance coverage increased from 13 percent in 1977 to 18 percent in 1987, almost entirely due to reductions in public coverage (mainly Medicaid).

Fully one-third of uninsured persons are under age 19.

While 93 percent of privately insured children under age 6 used any health services in 1987, only 81 percent of uninsured children used any services.

Average total health expenditures for uninsured children under age 6 who used health services were $954 in 1987. Average total health expenditures for privately insured children ($1,098) were somewhat higher. In contrast, average total health expenditures for publicly insured children ($2,566) were almost three times larger than uninsured children and two and a half times that of insured children.

Uninsured Poor (Poor anything below poverty line)

The proportion of poor persons without insurance nearly doubled from 23 percent in the first quarter of 1977 to 39 percent in 1987.

The majority of the uninsured (62 percent) are in families with incomes equal to 200 percent of the poverty line or less. Those in poverty account for nearly one-third of all uninsured persons.

Only 63 percent of uninsured under age 65 persons in poverty used any health services in 1987, compared to 79 percent of the poor with either private or public coverage.

Average total health expenditures for uninsured persons under age 65 in poverty averaged $1,008 in 1987. In contrast, poor persons with private insurance had average total expenditures of $1,627, while those with public coverage had average total expenditures of $2,946, three times the average of the uninsured poor.

The Uninsured in Nonmetropolitan Areas

Persons who reside outside of metropolitan areas (outside of SMSAs) are slightly more likely to be without coverage (20 percent of the population under age 65) than residents of metropolitan areas (17 percent).

About a quarter of the uninsured live outside of SMSAs.

Only 65 percent of the uninsured under age 65 residing outside of metropolitan areas used any health services in 1987, compared to 86 percent of nonmetropolitan residents with private insurance and 85 percent of nonmetropolitan residents with public insurance.

Average total health expenditures for uninsured persons
under age 65 in nonmetropolitan areas were $579 in 1987
compared to $1,017 for privately insured persons in
nonmetropolitan areas and $2,336 for publicly insured
persons in nonmetropolitan areas.


Question. One of AHCPR's mandates is developing clinical practice guidelines, which we hope will provide information about what treatments are effective and which ones don't work.

Can you give us an update on what your agency has done so far in this area, and what practice guidelines will be developed in FY 1992?

Answer. The Agency for Health Care Policy and Research (AHCPR) currently has seven panels in process and is initiating an eighth panel on HIV treatment. The panels are: prediction, prevention, and early treatment of pressure sores in adults; management of acute post operative pain; diagnosis and treatment of depressed outpatients in primary care settings; urinary incontinence in the adult; visual impairment due to cataracts in the aging eye; delivery of comprehensive care in sickle cell disease; and diagnosis and treatment of benign prostatic hyperplasia (BPH).

Two of the of the panels, pain management and benign prostatic hyperplasia, are beginning the peer review process of their draft guidelines. The panel on urinary incontinence has completed the peer review process. The peer review process consists of the panels sending drafts of the guidelines they have developed and the supporting evidence to external reviewers with a wide range of relevant backgrounds to review critically all aspects of the development process. This process takes approximately one month and is followed by pilot testing of the guidelines by various types of practitioners who utilize them in their own setting in patient management for two to three months. The feedback from pilot testing will be utilized by the panels in making any necessary changes in the guidelines prior to release and dissemination. The urinary incontinence, pain management and BPH panels should finish their guidelines in the Fall and the other four guideline panels are expected to complete their guidelines before the end of the calendar year.

The AHCPR has prepared a request for proposal to develop guidelines under contract with public or nonprofit entities. We also are in the process of developing mechanisms for the creation of standards, performance measures and review criteria based on the developed guidelines.

The AHCPR is considering the possible development of guidelines in FY 1992 for cancer pain management, low back pain, otitis media in children, congestive heart failure in the adult, management of Alzheimer's disease, management of cerebral vascular accident, and quality determinants of mammography. We will make final decisions on these conditions shortly and publish the appropriate notices in the Federal Register.

Question. Where I come from, there are quite a few solo practitioners, small hospitals, and other health care settings that are not university-based or even physician-based. I am concerned that these health care providers are most vulnerable to professional isolation, and may have the hardest time keeping up with current medical findings.


How will AHCPR ensure that the practice guidelines are disseminated to these health providers?

Answer. The Journal of the American Medical Association (JAMA) has agreed to publish all the practice guidelines. The National Library of Medicine will use its outreach efforts also for dissemination. In addition, AHCPR is developing a dissemination strategy to work with medical and allied health specialty groups, American Association of Retired Persons (AARP) and other consumer groups, business groups, and a variety of publications and the media to ensure that the guidelines reach practitioners and their patients regardless of their residence.


Question. Dr. Clinton, one aspect of your budget request is very troubling to me. It's not the end so much as the means of getting funding. I'm sure you know that we had a lot of trouble last year over whether to use funds from the 1% evaluation setaside (Section 2711) for the Agency for Health Care Policy and Research.

I had hoped the budget request would take into account the conflict over that funding method, and seek another or seek a change in the authorization, which specifies the current tap on 1% funds. Unfortunately, this isn't the case.

Knowing of the trouble we had last year, and the trouble that may lie ahead, will the Administration seek any change in the AHCPR funding authorization?

Answer. The authority for AHCPR and its major programs expires in FY 1993. The question of the funding authorization is currently under review as the administration develops its policy and legislative plans for next year. At the present time, a decision has not been made about whether the administration will seek a change in funding methods in the FY 1993 AHCPR reauthorization legislation.


Question. I have advocated in the past for a "larger gene pool" of researchers and research topics, including women, minorities, and those from more rural institutions. From the start, this Subcommittee has advocated that research topics should, to the extent possible, provide a broad base of knowledge relevant to current questions of health policy. And last year, we suggested that AHCPR should establish a Small Grants program in order to bring more new researchers into the field.

Dr. Clinton, please describe to the Committee what steps you will be taking to increase research activity on rural health issues, problems of minorities, and the question of low-income individuals gaining access to quality health care.

Answer. We have been very active within the primary care research community, specifically to increase the capacity for high quality research dealing with rural health issues, problems of

minorities, and the question of low-income individuals gaining access to quality health care.

We have recently published a research agenda for primary care, deriving in large part from our first national conference on primary care research. Research on issues related to health care of underserved, vulnerable, and minority populations are prominent in this document. On February 7, 1991 we published a program note together without the National Center for Nursing Research, reaffirming our continuing interest in supporting research targeted toward the problems of the most vulnerable rural population.

In addition, we have collaborated with the Office of Rural Health Policy within the Health Resources and Services Administration to establish a series of regional research capacity building workshops. By the end of the current fiscal year, we will have held workshops in Chapel Hill, NC, Seattle, WA, Bismarck, ND, and Tucson, AZ and Marshfield, WI. We are organizing workshops on rural and undeserved populations research at meetings of major national health organizations including the National Rural Health Association and the Association of University Programs in Hospital Administration (AUPHA).

Staff of AHCPR's extramural research Division of Primary Care are currently analyzing grant proposals submitted over the last five years to identify patterns of deficiency that have impeded successful review and funding. The results of this analysis will be incorporated into future workshops as well as ongoing technical assistance to potential investigators.

Finally, we are working closely with several minority health oriented academic institutions in increasing the capacity for research in primary care. We would expect specific strategies and institutional relationships to be identified this year for implementation during FY 1992.

Question. Do you think the "small grants" method is useful, or should we be looking at other ways of enhancing the research base and the opportunities for new researchers?

Answer. The "small grants" mechanism is one of several useful strategies for increasing opportunities for new researchers. As the Senate suggested last year, the AHCPR has expanded our small grants program. Soon we will be announcing four priority areas for funding under the small grants mechanism in FY 1991 and FY 1992. These include:

Research on health care services for

underserved/disadvantaged populations (e.g., women and minority health issues, rural health issues, methods to improve access; and costs, access, and quality of care for the uninsured/underinsured);

Research on health care services for individuals with HIV infections, (e.g., including issues of costs, access, and quality of care);

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