Medical Care and the

Health of the Poor

 Medical Care and the
Health of the Poor

(omell University Medical College

Eighth Conference on Health Policy

EDITED BY

David E. Rogers and Eli Ginzberg

First published 1993 by Westview Press

Published 2018 by Routledge

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Library of Congress Cataloging-in-Publication Data

Cornell University Medical College Conference on Health Policy
(8th: 1992: New York, N.Y.)
   Medical care and the health of the poor / Cornell University
Medical College Eighth Conference on Health Policy : edited by David
E. Rogers and Eli Ginzberg.
  p. cm.
Conference held in New York, N.Y., in 1992.
Includes bibliographical references and index.
ISBN 0-8133-1720-7
1. Poor—Medical care—United State—ongresses. 2. Poor—Health
and hygiene—United Stat—ongresses.   I. Rogers, David E. (David
Elliot), 1926– . II. Ginzberg, Eli, 1911– . III. Title.
[DNLM: 1. Health Policy-congresses. 2. Health Services—
congresses. 3. Medicallndigency—congresses. 4. Poverty—
congresses.   W 250C814m 1992]
RA418.5.P6C68 1992
362.1′0425—dc20
DNLM/DLC
for Library of Congress 92-49555
CIP

ISBN 13: 978-0-367-00763-8 (hbk)

 Contents

List of Tables and Figures vii

Introduction, David E. Rogers 1

1 Overview, Eli Ginzberg 3
2 Poverty and Health: Asking the Right Questions,
Victor R. Fuchs 9
3 The Politics of Health Care Inequalities, Paul Starr 21
4 Poverty, Public. Health, and Tuberculosis Control in
New York City: Lessons from the Past, Margaret A. Hamburg 33

5 Inequalities in Health, Douglas Black 43

6 Medical Care and the Poor: Focus on Hypertension

and Diabetes, Nicole Lurie 61
7 Socioeconomic Differentials in Arthritis and Its Treatment,
Mary E. Charlson, John P. Allegrante, and Laura Robbins 77

8 Making a Difference in the Health of Children,

C. Arden Miller 91
9 Health Care of the Poor: The Contribution of
Social Insurance, Diane Rowland 107
Summary, David E. Rogers 125

About the Contributors 131

Cornell University Medical College
Eighth Conference on Health Policy 133
Index 137

v
 Tables and Figures

Tables
2.1 · Indexes of Mortality and Income in England and Wales by
Social Class, 1971 12

5.1 Death Rates per 1,000 People per Year, 1971 49

6.1 Financial Barriers to Accessing Care for Hypertension and

Diabetes: Selected Studies 66

Figures
2.1 Two Versions of Two-Tier Medical Care 18

5.1 Options 52

vii
 Introduction
David E. Rogers

Over the past eight years, a series of conferences held at Cornell Uni-
versity Medical College have focused attention on certain problems caus-
ing serious pain on the U.S. health care scene. The format of these confer-
. ences has been straightforward. A small group of distinguished
individuals who have spent their professional lives working on the topic
under examination have written provocative papers articulating tlte is-
sues, their thoughts on what caused the problem, its magnitude, and po-
tential ways to mute or solve it. Those papers have then been circulated to
a small but diverse group of equally knowledgeable and committed folk
from a panoply of disciplines. Both speaker and participants have then
come together at Cornell for a vigorous two-day give-and-take. This has
resulted in a short book on the subject that generally contains recommen-
. dations for action to address the problem more forcibly.
The conferences, and the publications resulting from them, have been
well received and seem to be commanding increasing national attention.
The topics reviewed over this period have opened a window on where we
are doing poorly as a nation. They have included looks at physician sup-
ply, clinical decisionmaking and social values, problems relating to the
AIDS epidemic, and most recently the burgeoning hazards that beset
high-risk children and adolescents and interfere with their chances of be-
coming healthy adults.
This year we decided to focus on a deceptively simple issue often felt to
be the root cause of the depressing U.S. showing in many indices of
health. We titled this conference "Medical Care and the Health of the
Poor." I state the title because it was chosen with some care. Although it
has long been known that there is a strong and compelling correlation be-
tween being poor and being sick, beyond this obvious point causality rela-
tionships quickly get murky. To address these relationships, we asked
several thoughtful observers of the issues surrounding this correlation to

1
2 David E. Rogers

bring us some data. Just how tight is this correlation? Which comes first-
poverty or ill health? Which most improves health-income enhancement
or more medical care? How does poverty affect access to medical ser-
vices? More to the point, if a person gets to those services, is health im-
proved or infirmity avoided? How does schooling, housing, occupation,
nutrition, or race fit into the picture?
All of our participants have spent considerable amounts of their adult
lives working on different facets of this problem. As a matter of fact, I cal-
culated that more than 700 years of collective professional experience re-
garding these linkages were in the heads of those who participated in the
conference.
The dialogue was full of depth and intensity. I hope you, the reader, en-
joy the following chapters, Dr. Ginzberg's overview, and my summation
of where we left this subject.
Asking the Right Questions 19

Summary
In summary, there are numerous questions about poverty and health
that need to be addressed. Many of them concern the relation between
poverty and health: its extent, pattern, and explanations. Other questions
revolve around possible confounding variables such as education, which
is correlated with income and health. Still other questions focus on medi-
cal care: its efficacy in improving health, its value to the poor, the best way
to provide it. In pursuing these questions, we need to find a middle road
between a mindless optimism that ignores reality and a constricting pessi-
mism that denies the possibility of creating a more efficient and more just
society.

Notes

1. See J. L. Palmer, T. Smeeding, and C. Jenks, "The Uses and Limits of Income
Comparisons," inJ. L. Palmer, T. Smeeding, and B. Boyle Torrey, eds., The Vulnerable
(Washington, D.C.: Urban Institute Press, 1988), pp. 9-27.
2. V. R. Fuchs, "Toward a Theory of Poverty," in Task Force on Economic Growth
and Opportunity, The Concept ofPoverty (Washington, D.C.: Chamber of Commerce
of the UnitedStates,1965), pp. 71-91.
3· A. Smith. The Wealth of Nations (New York: Random House, Modem Library
edition, 1937), p. 821.
4· 0. Andersen, "Occupational Impacts on Mortality Declines in the Nordic
Countries," in W. Lutz, ed., Future Demographic Trends in Europe and North America
(New York: Academic Press, Harcourt Brace Jovanovich, 1991), p. 46.
5· J. Callthorp, "The 'Swedish Model' under Pressure," International Journal of
Quality Assurance in Health Care (forthcoming).
6. Callthorp, ''The 'Swedish Model'," p. 13.
7· See, for example, A. J. Fox, Social Class and Occupational Mobility Shortly Before
Men Become Fathers, OPCS Series LS No. 2 (London: HMSO, 1984); J. Stern, "Social
Mobility and the Interpretation of Social Class Mortality Differentials," Journal of
Social Policy 12(1983):27-49; and M. E. J. Wadsworth, "Serious Dlness in Childhood
and Its Association with Later Life Achievement," in R. G. Wilkinson, ed., Class and
Het~lth: Resetlrch and Longitudinal Data (London: Tavistock, 1()86).
8. R. G. Wilkinson, "Socioeconomic Differences in Mortality: Interpreting the
Data on Their Size and Trends," in Wilkinson, ed. Class and Het~lth, p. 10.
9· R. Carr-Hill, "The Inequalities in Health Debate: A Critical Review of the Is-
sues," Journal of Social Policy 16(1987):527.
10. See, for example, M. C. Berger andJ. P. Leigh, "Schooling, Self-Selection, and
Health," Journal of Human Resources 24(1989):435-455; P. Farrell and V. R. Fuchs,
"Schooling and Health: The Cigarette Connection," Journal of Health Economics
1(1982):217-230; M. Grossman, "The Correlation Between Health and Schooling,"
inN. E. Terleckyj, ed., Household Production and Consumption (New York: Columbia
20 Victor R. Fuchs

University Press for NBER, 1976); and D. S. Kenkel, "Health Behavior, Health
Knowledge, and Schooling," Journal of Political Economy 99(1991):287-304.
11. R. Auster, I. Leveson, and D. Sarachek, "The Production of Health: An Ex-
ploratory Study," Journal of Human Resources 4(1969):412-436.
12. M. Grossman, "The Correlation Between Health and Schooling."
13. V. R. Fuchs, "Time Preference and Health: An Exploratory Study," in V. R.
Fuchs, ed., Economic Aspects of Health (Chicago: University of Chicago Press, 1982),
pp. 93-120; and A. Bandura, "Self-Efficacy Mechanism in Physiological Activation
and Health-Promoting Behavior," in J. Madden N, ed., Neural Biology of Learning,
Emotion and Affect (New York: Raven Press, 1991), pp. 229-269.
14. B. C. Vladeck, "Unhealthy Rations," The American Prospect (Summer 1991):
102.
15. For other explanations by economic theorists for tied transfers, seeN. Bruce
and M. Waldman, "Transfers In Kind: Why They Can Be Efficient and
Nonpaternalistic," American Economic Review 81(1991):1345-1351.
16. SeeS. Coate, S. Johnson, and R. Zeckhauser, "Robin-Hooding Rents: Exploit-
ing the Pecuniary Effects of In-Kind Programs," (Cambridge, Mass.: Harvard Uni-
versity, March 1992, mimeo).
17. V. R. Fuchs, "From Bismarck to Woodcock: The 'Irrational' Pursuit of Na-
tional Health Insurance," Journal ofLaw and Economics 19(1976):347-359.
18.V. R. Fuchs, "NationalHealthlnsuranceRevisited," Health Affairs 10(1991):1-
11..
19. Personal communication from Ruth Watson Lubic, December 9, 1991.
Politics of Health Care Inequalities 31

standard of care for the poor is no different from the standard available to
the majority.

Summary
Let me see if I can pull together the threads of the preceding argUment.
In answer to the question "How much inequality in health care can a
democratic society tolerate?" I have given two answers. First, from a his-
torical perspective, mass exclusion clearly has been too much inequality
for democratic societies to accept, but, as the U.S. case illustrates, democ-
racy does not immunize a society against minority exclusion from basic
coverage and equal access. Second, democratic principles, at least as I un-
derstand them, argue not only against minority exclusion but also against
what I have described as narrow-based, multitier coverage. Yet broad-
based universalism should not be regarded as the only acceptable answer.
By minimizing inequalities at the bottom, even if allowing for privileges
at the top, broad-based, multitier coverage seems to me to achieve the
chief democratic interests.

Notes
1. D. Rae et al., Inequalities (Cambridge, Mass.: Harvard University Press, 1981).
2. L. Sirowy and A. Inkeles, "The Effects of Democracy on Economic Growth and
Inequality: A Review," in A. Inkeles, ed., On Measuring Democracy: Its Consequences
and Concomitants (New Brunswick, N.J.: Transaction, 1991), pp. 125-156.
3· I. S. Falk et al., The Incidence of Illness and the Receipt and Costs of Medical Care
Among Representative Families (Chicago: University of Chicago Press, 1932), pp. 103,
281,283.
4· G. St. Perrot, E. Sydenstricker, and S.D. Collins, "Medical Care During the De-
pression," Milbank Memorial Fund Quarterly 12(April1934):99-114.
5· For a more extended discussion of the data and the transition from mass to mi-
nority exclusion (which I formerly termed mass inequality and marginal inequality),
seeP. Starr, "Medical Care and the Pursuit of Equality in America," in President's
Commission for the Study of Ethical Problems in Medicine and Biomedical and Be-
havioral Research, Securing Access to Health Care (Washington, D.C.: Government
Printing Office, March 1983), vol. 2, Appendices, 2-22.
6. P. Starr, The Social Transformation ofAmerican Medicine (New York: Basic Books,
1982), Book 2, Chapter 1.
7· P. Starr, "Health Care for the Poor: The Past Twenty Years," inS. Danziger and
D. Weinberg, eds., Fighting Poverty: What Works and What Doesn't (Cambridge,
Mass.: Harvard University Press, 1986), pp. 1o6-132.
8. For a more extended discussion of these issues, seeP. Starr, "The Middle Class
and National Health Reform," The American Prospect 6(Summer 1991):7-12.
9· H. Taylor and U. E. Reinhardt, "Does the System Fit?" Health Management
Quarterly 12(1991):2-10.
32 Paul Starr

10. On the "specialness" of health care, seeN. Daniels, Just Health Care (Cam-
bridge: Cambridge University Press, 1<}85); and K. J. Arrow, "Uncertainty and the
Welfare Economics of Medical Care," American Economic Review 53(Dececember
1963)=941-¢8.
11. A. C. Enthoven, Health Plan: The Only Practical Solution to the Soaring Cost of
Medical Care (Reading, Mass.: Addison-Wesley,198o); and A. C. Enthoven, "Man-
aged Competition: An Agenda for Action," Health Affairs (Summer 1<}88):25-47.
12. On the limitations of Enthoven's competitive model, seeS. B. Jones, "Can
Multiple Choice Be Managed to Constrain Health Care Costs?" Health Affairs (Fall
1<}89):51-59·
Tuberculosis Control in New York City 41

tion of energy and resources at all levels. At a very minimum, we should

learn from the past.

Notes
1. K. Brudney andJ. Dobkin, "Resurgent Tuberculosis in New York City," Ameri-
can Review of Respiratory Diseases 144(1991 ):745--749.
2. New York City Department of Health, Annual Tuberculosis Report (1979).
3· L. Reichman, "The U-Shaped Curve of Concern," American Review of Respira-
tory Diseases 144(1991):741--742.
58 Douglas Black

because of their greater need. But they also partly fail to take up preven-
tive services, whether these are provided by their family doctor or by
community or hospital clinics. This is at least partly due to problems with
transportation and loss of wages. We recommended a strengthening of
community and general practitioner services to improve both access and
quality. We also made a number of recommendations for research, many
of which-in some contrast to our recommendations for expenditure,
which we considered to be directly beneficial-have been taken up, some
of them even with the support of government agencies.

Summary
There is evidence of an association between socioeconomic deprivation
and ill-health. It seems clear that ill-health can lead to descent in the social
scale and that socioeconomic deprivation, however caused, can have seri-
ous adverse effects on health. The second of these processes appears to be
quantitatively the more important. If that is so, the problem of socially de-
termined ill-health calls primarily for social or welfare measures; but
medical measures can also make an important contribution.

Notes
1. K. Popper, The Open Society and Its Enemies (Lqndon: Routledge and Kegan
Paul, 1945).
2. P. Townsend and N. Davidson, Inequalities in Health: The Black Report (London:
Penguin Books, 1982).
3· M. Whitehead, The Health Divide: Inequalities in Health in the 19Bos (London:
Health Education Council, 1987); and Townsend and Davidson, Inequalities in
Health.
4· R. G. Wilkinson, ed., Class and Health (London: Tavistock, 1986).
5· L. Fallowfield, Quality of Life: The Missing Dimension in Health Care (London:
Souvenir Press, 1990).
6. Townsend and Davidson, Inequalities in Health.
7· Whitehead, The Health Divide.
8. V. Carstairs and R. Morris, Deprivation and Health (Aberdeen, Scotland: Aber-
deen University Press, 1991).
9· D. L. Crombie, Social Class and Health Status: Inequality or Difference, Occasional
Paper 25 (London: Royal College of General Practitioners, 1984).
10. Whitehead, The Health Divide.
11. Whitehead, The Health Divide.
12. M.G. Marmot, M. J. Shipley, and G. Rose, "Inequalities in Death Specific Ex-
planations of a General Pattern?" Lancet, i(1984):1003-o6. ·
13. N. Hart, "The Social and Economic Environment and Human Health," in W.
W. Holland, R. Detels, and G. Knox, eds., Oxford Textbook of Public Health, 2nd ed.
(Oxford: Oxford University Press, 1991).
Inequalities in Health 59

14. Townsend and Davidson, Inequalities in Health.

15. Townsend and Davidson, Inequalities in Health.
16. Whitehead, The Health Divide.
17. T. McKeown, The Role of Medicine: Dream, Mirage or Nemesis (Oxford:
Blackwel1,1979).
18. R. H. Charlton and R. Velez, "Some International Comparisons of Mortality
Amenable to Medical Intervention," British Medical Journal i(1986}:t95-301.
74 Nicole Lurie

health outcomes, others are likely to affect the health of diabetics and hy-
pertensives by changing the organizational climate in which care occurs.
The poor continue to be affected by these changes. Because they begin
with a higher burden of illness and have worse outcomes, they deserve
special attention.

Notes
1. T. J. Thorn and W. B. Kannel, "Downward Trend in Cardiovascular Mortality,"
Annual Review of Medicine 32(1981):427-434; M. Feinleib, "The Magnitude and Na-
ture of the Decrease in Coronary Heart Disease Mortality," American Journal of Car-
diology 54(1g84):2c-6c; National High Blood Pressure Education Program Working
Group on Risk and High Blood Pressure, "An Epidemiological Approach to De-
scribing Risk Associated with Blood Pressure Levels," Hypertension 7(1985):641;
Hypertension Detection and Follow-Up Program Cooperative Group, "Five-Year
Finding of the Hypertension Detection and Follow-Up Program: 1. Reductions in
Mortality of Persons with High Blood Pressure Including Mild Hypertension,"
JAMA 242(1979):2562-2571; C. Sempos, R. Cooper, M. G. Kovar, and McMillen,
"Divergence of the Recent Trends in Coronary Mortality for the Four Major Race-
Sex Groups in the United States," American Journal of Public Health 78(1g88):1422-
1427; G. W. Comstock," An Epidemiologic Study of Blood Pressure Levels in a Bira-
cial Community in the Southern United States," 65(1951):271-315; N. B. Shulman,
"End-Stage Renal Disease in Hypertensive Blacks," Journal of Clinical Hypertension
3(1987): 85s-88s; and S. G. Rostand, G. Brown, K. A. Kirk, E. A. Rutsky, and H. P.
Dustan, "Renal Insufficiency in Treated Essential Hypertension," New England Jour-
nal ofMedicine 320(1g8g):684-688.
2. Shep Cooperative Research Group, "Prevention of Stroke by Antihyperten-
sive Drug Treatment in Older Persons with Isolated Systolic Hypertension: Final
Results of the Systolic Hypertension in the Elderly P, Journal of the American Medical
Association 265(1991):3255-3264.
3· V. A. Cardinale, ed., Red Book (Medical Economics Company).
4· H. Rifkin, and D. Porte, Jr., eds., Diabetes Mellitus: Theory and Practice (Elsevier
Press, 1990).
5· P. J. Farley, "Who Are the Underinsured?" Milbank Memorial Fund Quarterly/
Health and Society 63(1985):476-503.
6. N. Lurie, M. F. Finch, and B. Dowd, "Who Are the Uninsured in Minnesota?"
A Report to the Minnesota Health Care Access Commission, 1990.
7· R. M. Andersen, L. A. Aday, C. S. Lyttle et al., "Ambulatory Care and Insur-
ance Coverage in an Era of Constraint, Center for Health Administration Studies."
Continuing CHAS Research Series No. 35 (Pluribus Press, 1g87).
8. D. Rowland and B. Lyons, "Triple Jeopardy: Rural, Poor, and Uninsured."
Health Services Research 23(1989):975-1004.
9· D. Hartley and N. Lurie, "Urban/Rural Differences in Access and Insurance"
(unpublished ms.).
10. Mortality and Morbidity Weekly Review, Mortality Patterns-United States,
1988.
Hypertension and Diabetes 75

11. S. J. Kittner, L. R. White, K. G. Losonczy, P. A. Wolf, and J. R. Hebel, "Black-

White Differences in Stroke Incidence in a National Sample: The Contribution of
Hypertension and Diabetes Mellitus." '
12. N. B. Shulman, B. Martinez, E. Brogan et al., "Financial Cost as an Obstacle to
Hypertension Therapy," American Journal ofPublic Health 76(1'}86):1105.
13. D. D. Rutstein, W. Berenberg. T. C. Chalmers, C. G. Child, A. P. Fishman, and
E. B. Perrin, "Measuring the Quality of Medical Care: A Clinical Method," New En-
gland Journal ofMedicine 294(1976):582-588; and J. Billings and V. Harrelblad, "Use
of Small Area Analysis to Access the Performance of the Outpatient Delivery Sys-
tem in New York City" (Lyme, N.H.: Codman Research Group, 1989).
14. A.M. Epstein; C. Gatsonis, and J. S. Weissman, "Is There a Link Between In-
surance Status and Poor Health Outcomes? Rates of Avoidable Hospitalizations in
Massachusetts and Maryland."
15. E. S. Fisher, C. Fleming, H. Sox, G. Goodman, and E. Hamilton, "Monitoring
the Effectiveness of Medical Care in Meeting Public Health Needs in Northern New
England: A Population-Based Approach Relying on Administrative Databases"
(Paper presented at the annual meeting of the Health of the Public, September
1991).
16. N. Lurie, N. B. Ward, M. Shapiro, and R. H. Brook, ''Termination from Medi-
Cal: Does It Affect Health?" New England Journal ofMedicine 311(1984):48o.
17. N. Lurie, N. B. Ward, M. Shapiro, C. Gallego, R. Vaghaiwalla, and R. H. Brook,
''Termination from Medi-Cal: One Year Later," New England Journal of Medicine
314(1'}86):1266-1268.
18. S. D. Fihn and J. B. Wicher, "Withdrawing Routine Outpatient Medical Ser-
vices: Effect on Access and Health," Journal ofGeneral Internal Medicine 3(1988):356-
362.
19. A. B. Bindman, D. Keane, and N. Lurie,"A Public Hospital Ooses: Effects on
Access to Care and Health Status," Journal of the American Medical AssociaHon
264(1990):~2904.
20. A. L. Stewart, R. D. Hays, and J. E. Ware, "The MOS Short-Form General
Health Survey: Reliability and Validity in a Patient Population," Medical Care
26(1988):724--?'32.
21. S.D. Sacerdote, "Impact of Budget Cuts on Diabetic Control in Urban Adult
Diabetes Oinic," Diabetes Care 11(1988):302-303.
22. J.P. Newhouse, W. F. Manning, C. N. Morris, L. L. Orr, N. Duan, E. B. Keeler
et al., "Some Interim Results from a Controlled Trial of Cost Sharing in Health Insur-
ance," New England Journal ofMedicine 305(1981):1501-1507·
23. R. H. Brook, J. E. Ware, and W. H. Rogers, "Does Free Care Improve Adults'
Health?: Results from a Randomized Controlled Trial," New England Journal ofMedi-
cine 309(1983):1426-1434; and N. Lurie, W. Manning, C. Peterson, G. Goldberg, C.
Phelps, and L. Lillard, "Preventive Medicine: Do We Practice What We Preach?"
American Journal of Public Health 77(1987):8o1-8o4.
24· E. B. Keeler, R. H. Brook, G. A. Goldberg et al., "How Free Care Reduced Hy-
pertension in the Health Insurance Experiment," Journal of the American Medical As-
socilltion 254(1985):1926-1931.
76 Nicole Lurie

25. Epstein, Gatsonis, and Weissman, "Is There a Link Between Insurance Status
and Poor Health Outcomes?"
26. I. S. Udvarhelyi, K. Jennison, R. S. Phillips, and A. M. Epstein, "Comparison
of the Quality of Ambulatory Care for Fee-for-Service and Prepaid Patients," Annals
J'flnternal Medicine 115(1991):394-400.
27. C. Coffey, N. Lurie, I. Moscovice, M. Finch. and J. Christianson, "Manage-
ment of Hypertension and Diabetes in Medicaid Elderly: Does HMO Enrollment
Make a Difference?" Clinical Research 32(1991):2.
28. N. Lurie, I. Moscovice, M. F. Finch, and J. Christianson, "HMO vs. Fee-for-
Service Care: Are Outcomes Different for the Medicaid Elderly?" (unpublished
ms.).
29. D. A. Freund and R. E. Hurley, "Managed Care in Medicaid: Selected Issues
in Program Origins, Design, and Research." Annual Review of Public Health
8(1987):137-163.
30. D. E. Rogers, R. J. Blendon, and T. W. Maloney, "Who Needs Medicaid?" New
England Journal ofMedicine 309(1983):1426-1434; ~d K Erdman and S. Wolfe, "Poor
Health Care for Poor Americans," Public Citizen (1987).
31. S. B. Soumerai, J. Avorn, D. Ross-Degnan, and S. Gortmaker, "Payment Re-
strictions for Prescription Drugs Under Medicaid: Effects on Therapy, Cost, and Eq-
uity, New England Journal ofMedicine 317{1987):55<>-556.
32. E. Ginzberg and M. Ostow, "High-Tech Medicine and Rising Health Care
Costs," Journal of the American Medical Association 263(1990):182<>-1822.
33· E. Ford, R. Cooper, A. Castaner et al., "Coronary Arteriography and Coro-
nary Bypass Surgery Among Whites and Other Racial Groups Relative to Hospital-
Based Incidence Rates for Coronary Artery Disease: Findings from NHDS," Ameri-
can Journal of Public Health 79(1991):437-440; M. B. Wenneker and A. M. Epstein,
"Racial Inequalities of Procedures for Patients with Ischemic Heart Disease in Mas-
sachusetts," Journal of the American Medical Association 261(1989):253-257; and J. Z.
Ayanian and A. M. Epstein, "Differences in the Use of Procedures Between Women
and Men Hospitalized for Coronary Heart Disease," New England Journal of Medi-
cine 325(1991):221-225.
34· B. L. Kasiske, J. F. Neylan II, R. R. Riggio et al., ''The Effect of Race on Access
and Outcome in Transplantation," 324(1991: 302-307; and C. M. Kjellstrand and G.
M. Logan, "Racial, Sexual and Age Inequalities in Chronic Dialysis," Nephron
45(1987):257-263.
35· M. Durbin, "And Equal Transplants for All" (Paper presented at the Robert
Wood Johnson Clinical Scholars meeting, Miami, Florida, 1988).
36. H. G. Welch and E. B. Larson, "Dealing with Limited Resources: Oregon
Health Decision to Curtail Funding for Organ Transplantation," New England Jour-
nal ofMedicine 319:171-173.
37· B. Sumner, K Peterson, A. Pheley, E. Benavides, and N. Lurie, "Discounted
Care for the Uninsured: Does It Hit the Target?" (unpublished ms.).
38. J. Wylie-Rosett, S. Engel, G. D'Eramo et al., "Delivery of Diabetes Care to
Low-Income Patients: Assessment of a Federally Funded Pprogram."
39· S. H. Kaplan, S. Greenfield, and J. E. Ware, Jr., "Expanded Patient Participa-
tion in Medical Care: Effects on Blood Sugar and Quality of Life in Diabetes," Jour-
nal of General Internal Medicine 3(1988):448.
86 M. E. Charlson, J. P. Allegrante, & L. Robbins

health policy are clear: We need a policy that enables a greater number of
people with arthritis-related functional impairment and disability to gain
the benefit of treatment. In the absence of such a policy, our society can ex-
pect to continue paying for increasingly costly long-term care and custo-
dial services.
Our society has been slow to grapple with the socioeconomic dispari-
ties that once again increasingly characterize the delivery of and access to
medical care. As health care professionals, we need to recommit ourselves
to the principles of social justice and equity. If we do not, we risk forsak-
ing an entire generation of Americans whose social station we allow to de-
termine their potential for a quality life. Until we have a system of health
care that is accessible to all, the numbers of people with severe arthritis
and related disability will continue to increase.

Notes
1. D. Williams, "Socioeconomic Differentials in Health: A Review and Redirec-
tion," Social Psychology Quarterly 53(1990):81-99.
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tality and Morbidity in Rheumatoid Arthritis," Journal of Chronic Disease
38(1CJS5 ):973-984.
Socioeconomic Differentials in Arthritis 87

11. A. Epstein, R. Tsem, J. Tognetti, C. Begg, R. Hartley, E. Cumella, and J.

Ayanian, "The Association of Patients' Socioeconomic Characteristics with the
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21. Mitchell, "The Importance of Age."
22. T. Pincus, J. Mitchell, and R. Burkhauser, "Substantial Work Disability and
Earnings Losses in Individuals Less Than Age 65 with Osteoarthritis: Comparisons
with Rheumatoid Arthritis," Journal of Clinical Epidemiology 42(1989):449-457·
23. E. Yelin, "The Myth of Malingering: Why Individuals Withdraw from Work
in the Presence of illness," Milbank Memorial Fund Quarterly 64(1986):622-649.
24· J. Lubben, P. Weiler, and I. Chi, "Gender and Ethnic Differences in the Health
Practices of the Elderly Poor," Journal ofClinical Epidemiology 42(1989):725-733.
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cial Support and Health (New York: Academic Press, 1985).
26. W. Ruberman, E. Weinblatt, J. Goldberg, and B. Chaudhary, "Psychosocial In-
fluences on Mortality After Myocardial Infarction," New England Journal ofMedicine
311(1984):552-559; and W. Ruberman, E. Weinblatt, J. Goldberg, and B. Chaudhary,
"Education, Psychosocial Stress and Sudden Cardiac Death," Journal ofChronic Dis-
ease 36(1983): 151-16o.
88 M. E. Charlson, f. P. Allegrante, & L. Robbins

27. D. Zuckerman, S. Kasl, and A Ostfeld, "Psychosocial Predictors of Mortality

Among the Elderly Poor," American Journal of Epidemiology 119(1984):41o-423.
28. P. Nicassio, K. Wallston, L. Callahan, M. Herbert, and T. Pincus, "Measure-
ment of Helplessness in Rheumatoid Arthritis," Journal of Rheumatology
12(1985):462-467.
29. L. Callahan, R. Brooks, and T. Pincus, "Further Analysis of Learned Helpless-
ness in Rheumatoid Arthritis Using a Rheumatology Attitudes Index," Journal of
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30. J. Parker, K. Smarr, S. Walker, K. Hagglund, S. Anderson, J. Hewett, A
Bridges, and C. W. Caldwell, "Biopsychosocial Parameters of Disease Activity in
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31. G. Parkerson, L. Michener, L. Wu, J. Finch, L. Muhlbaier, K. Magruder-
Habib, J. Kertesz, N. Clapp-Channinig, D. Morrow, A. Chen, and E. Jokerst," Asso-
ciations Among Family Support, Family Stress and Personal Functional Health Sta-
tus," Journal of Clinical Epidemiology 42(1989): 217-229.
32. L. A Aday, "Economic and Noneconomic Barriers to the Use of Needed Med-
ical Services," Medical Care 18(1975):447-456.
33· I. Rosenstock, "Why People Use Health Services," Milbank Memorial Fund
Quarterly 44(1966):94-124; and M. Becker, ed., "The Health Belief Model and Per-
sonal Health Behavior," Health Education Monographs 2(1974):324-508.
34· R. Andersen and J. Newman, "Societal and Individual Determinants of Med-
ical Care Utilization," Milbank Memorial Fund Quarterly 51(1973):95-124; and N.
Roos and E. Shapiro, "The Manitoba Longitudinal Study on Aging: Preliminary
Findings of Health Care Utilization by the Elderly," Medical Care 19(1981):644--656.
35· P. Denson, S. Shapiro, and M. Einhorn, "Concerning High and Low Utilizers
of Service in a Medical Care Plan and the Persistence of Utilization Levels Over a
Three-Year Period," Milbank Memorial Fund Quarterly 37(1959):217-250; J. Mullooly
and D. Freeborn, "The Effect of Length of Membership upon the Utilization of Am-
bulatory Care Services," Medical Care 17( 1979):922--936; T. Wan and L. Gray, "Differ-
ential Access to Preventive Services for Young Children in Low-income Urban Ar-
eas," Journal of Health and Social Behavior 19(1978):312-324; and J. Alpert, M.
Heagarty, L. Robertson, J. Kosa, and R. Haggerty, "Effective Use of Comprehensive
Pediatric Care," American Journal of Diseases of Children 116(1968):529-533·
36. R. Blendon, L. Aitken, H. Freeman et al., "Uncompensated Care by Hospitals
or Public Insurance for the Poor," New England Journal of Medicine 314(1986):116o-
1163; and D. Rogers, R. Blendon, and T. Moloney, "Who Needs Medicaid?" New En-
gland Journal of Medicine 307(1982):13-18.
37· R. Blendon, L. Aitken, H. Freeman, and C. Corey," Access to Medical Care for
Black and White Americans: A Matter of Continuing Concern," Journal of the Ameri-
can Medical Association 261(1989):278-281.
38. R. Hayward, M. Shapiro, H. Freeman, and C. Corey, "Inequities in Health
Services Among Insured Americans: Do Working-Age Adults Have Less Access to
Medical Care Than the Elderly?" New England Journal of Medicine 318(1988):1507-
1512.
39· D. Rogers, R. Blendon, and T. Moloney, "Who Needs Medicaid?"
Socioeconomic Differentials in Arthritis 89

40. A. Hindman, D. Keane, and N. Lurie, "A Public Hospital Closes: Impact on
Patients' Access to Care and Health Status," Journal of the American Medical Associa-
tion 264(1990): 2899--2904·
41. L. A. Aday and R. Anderson, "The National Profiles of Access of Medical
Care: Where Do We Stand?" American Journal of Public Health 74(1984):1331-1339·
42· H. Valkenburg, "Epidemiology Considerations of the Geriatric Population,"
Gerontology 34(Supplement 1)(1<)88):2-10.
43· J. Hadley, E. Steinberg, and J. Feder, "Comparison of Uninsured and Insured
Hospital Patients: Condition on Admission, Resource Use and Outcome," Journal of
the American Medical Association 265(1991):374-379.
44· E. Ford, R. Cooper, A. Castaner, B. Simmons, and M. Mar, "Coronary Arteri-
ography and Coronary Bypass Survey Among White and Other Racial Groups Rel-
ative to Hospital-Based Incidence Rates for Coronary Artery Disease: Findings
from NHDS," American Journal ofPublic Health 79(1<)89):437-440; and M. Wenneker
and A. Epstein, "Procedures for Patients with Ischemic Heart Disease in Massachu-
setts," Journal of the American Medical Association 261(1<)89): 253-257.
45· E. R. Greenberg, C. G. Chute, T. Sukel, J. A. Baron, D. H. Freenman, J. Yates,
and R. Korson, "Social and Economic Factors in the Choice of Lung Cancer Treat-
ment," New England Journal ofMedicine 318(1<)88):612-617.
46. A. Smith, "Social Factors and Disease: The Medical Perspective," British Med-
ical Journal294(1987):881-883.
47· N. Johanson and C. R. Charnley, "Low Friction Arthroplasty: Past Develop-
ments and Current Practice, Contemporary Orthopedics 19(1<)89):467-471; W. Harris,
J. MCarthy, and D. O'Neill, "Femoral Component Loosening Using Contemporary
Techniques of Femoral Cement Fixation," Journal of Bone and Joint Surgery
6¢(1<)82):1o63-1o67; and C. Ranawat, B. Rawlins, and V. Harju, "Effect of Modem
Cement Technique on Acetabular Fixation on Total Hip Arthroplasty: A Retrospec-
tive Study in Matched Pairs," Orthopedic Clinics of North America 19(1<)88):599--603·
48. W. Harris, "Total Joint Replacement," New England Journal of Medicine
297(1977):65o-652; and J. Noble and R. Chilton, ''Total Knee Replacement: Getting
Better All the TIDle," British Medical Journal303(1991):26<r261.
49· A. William, "Economics of Coronary Artery Bypass Grafting," British Medical
Journal291(1985):326-329.
50. W. Felts and E. Yelin, "The Economic Impact of the Rheumatic Diseases in the
United States," Journal of Rheumatology 16{1<)89):867-884.
104 C. Arden Miller

Finally, we must establish beyond any doubt that children are

wanted-both by their families and by the larger society. A society that
neglects and fails its children, as ours does in so many ways, can scarcely
expect parents to provide supportive nurture. A search for successful so-
cial interventions on behalf of children's health yields rich evidence about
programs that work. What fails to work is indifference to that evidence.
What will work is a mobilized national will to help children and their fam-
ilies. It should be an important part of any national program to reform sys-
tems of health care financing and access.

Notes
1. D. T. Ellwood, Poor Support: Poverty in the American Family (New York: Basic
Books, 1988); and L. B. Schorr, Within Our Reach: Breaking the Cycle of Disadvantage
(New York: Doubleday, 1988).
2. R. H. McKey, L. Condelli, H. Ganson et al., The Impact ofHead Start on Children,
Families, and Communities, DHHS Pub. No. (OHDS) 85-31193 (Washington, D.C.:
Government Printing Office, 1985).
3· L. V. Klerman, Alive and Well? A Research and Policy Review of Health Programs
for Poor Young Children (New York: National Center for Children in Poverty, School
of Public Health, Columbia University, 1991).
4· Select Committee on Children, Youth, and Families, U.S. House of Repre-
sentatives, Opportunities for Success: Cost-Effective Programs for Children Update
(Washington, D.C.: Government Printing Office, 1~).
5· Select Committee, Opportunities for Success; and Klerman, Alive and Well?
6. U.S. Public Health Service, Healthy People 2000: National Health Promotion
and Disease Prevention Objectives, DHHS Pub. No. (PHS) 91-50212 (Washington,
D.C.: U.S. Public Health Service, 1991).
7· American Academy of Pediatrics, Report of the Committee on Infectious Diseases
(Elk Grove, Ill.: American Academy of Pediatrics, 1991); and Public Health Service,
Healthy People 2000. ·
8. Klerman, Alive and Well?
9· E. E. Werner, J. M. Bierman, and F. E. French, The Children of Kauai (Honolulu:
University of Hawaii Press, 1971).
10. William T. Grant Foundation Commission on Work, Family, and Citizenship,
The Forgotten Half Pathways to Success for America's Youth and Young Families (Wash-
ington, D.C.: William Grant Foundation Commission, 19BS).
11. The Infant Health and Development Program, "Enhancing the Outcomes of
Low-Birth-Weight, Premature Infants: A Multisite, Randomized Trial," Journal ofthe
American Medical Association 263(1990):3035-3042.
12. L. B. Williams and W. F. Pratt, "Wanted and Unwanted Childbearing in the
U.S. 1973-88," Advance Data, National Center for Health Statistics 189(1990):1-8.
13. Williams and Pratt, "Wanted and Unwanted Childbearing."
14. R. B. Gold and D. Daley, "Public Funding of Contraceptive, Sterilization, and
Abortion Service, Fiscal Year 1990," Family Planning Perspectives 23(1991): 204-211;
The Health of Children 105

and S. K. Henshaw and J. Van Vort, "Abortion Services in the United States, 1987
and 1988," Family Planning Perspectives 22(1990):102-1o8,142.
15. A. E. Waller, S. P. Baker, and A. Szocka, "Childhood Injury Deaths: National
Analysis and Geographic Variations," American Journal of Public Health
79(198g):}1Q-}15.
16. Select Committee on Children, Youth, and Families, U.S. House of Repre-
sentatives, Abused Children in America: Victims of Officilll Neglect (Washington, D.C.:
Government Printing Office, 1987).
17. S. J. Zuravin, "Unplanned Childbearing and Family Size: Their Relationship
to Child Neglect and Abuse," Family Planning Perspectives 23(1991):155-161.
18. National Center for Health Statistics, Health Aspects of Pregnancy and Child-
birth, United States 1982, DHHS Pub. No. (PHS) 99-1992 (Hyattsville, Md.: U.S. Pub-
lic Health Service, 1988).
19. E. F. Jones, J.D. Forrest, S. K. Henshaw et al., "Unintended Pregnancy, Con-
traceptive Practice, and Family Planning Services in Developed Countries," Family
Planning Perspectives 20(1g88):53-67·
20. Jones, Forrest, Henshaw et al., "Unintended Pregnancy."
21. S. K. Henshaw, "Induced Abortion: A World Review," Family Planning Per-
spectives 16(2)(1ggo):59""76·
22. H. P. Verbrugge, ''Unrecorded Comment, Conference on Child Health in
1990: The U.S. Compared to Canada, England and Wales, France, the Netherlands,
and Norway," Pedilltrics 86(6, part 2)(1990).
23. B. C. Williams and C. A. Miller, Preventive Health Care for Young Children: Find-
ingsfrom a 1o-CountryStudyand Directions for U.S. Policy (Arlington, Va.: National
Center for Clinical Infant Programs, 1991).
24· S. Goodwin, "Child Health Services in England and Wales: An Overview,"
Pedilltrics 86(6, part 2) (1ggo):10}2-1036.
25. H. P. Verbrugge, "Youth Health Care in the Netherlands: A Bird's Eye View,"
Pedilltrics 86(6, part 2) (1990):1044-1047·
26. W. Tietze and K. Ulferman, "An International Perspective on Schooling for
4-Year-Olds," Theory into Practice 28(1989):~.
27. P. Moss, "Childcare and Equality of Opportunity," Consolidllted Report to the
European Commission (Brussels: Commission of the European Communities, 1g88).
28. I. T. Hill and J. M. Breyel, Caring for Kids (Washington, D.C.: National Gover-
nors' Association,1991).
29. C. Berman, P. Biro, and E. S. Fenichel, Keeping Track: Tracking Systems for High-
Risk Infants and Young Children (Arlington, Va.: National Center for Clinical Infant
Programs, 198g).
30. D. G. Richards and C. J. Roberts, "The 'At Risk' Infant," Lancet
7518(2)(1¢7):711-71}.
31. S. L. Kagan and E. F. Zigler, "Early Schooling: A National Opportunity?" inS.
L. Kagan and E. F. Zigler, eds., Early Schooling: The National Debate (New Haven,
Conn.: Yale University Press, 1987).
32. J. Lombardi, "Head Start: The Nation's Pride, a Nation's Challenge. Recom-
mendations for Head Start in the 19905," Young Children September(1990):22-29.
33· McKey et al., The Impact ofHead Start.
106 C. Arden Miller

34· P. P. Olmsted, "Early Childhood Care and Education in the United States.
Chapter XV," in P. P. Olmsted and D.P. Weikart, eds., How Nations Serve Young Chil-
dren (Ypsilanti, Mich.: High Scope Press, 1989). ·
35· Lombardi, "Head Start."
36. Lombardi, "Head Start."
37· F. North, Jr., "Health Services in Head Start," in Project Head Start: A Legacy of
the War on Poverty (New York: Free Press, 1979).
38. A. J. Kahn and S. B. Kamerman, Income Transfers for Families with Children: An
Eight-Country Study (Philadelphia: Temple University Press, 1983).
39· S. Orr and S. James, "Maternal Depression in an Urban Pediatric Practice: lm·
plications for Health Care Delivery," American Journal ofPublic Health 74(1984):363-
365·
40. R. K. Leik and M.A. Chalkley, "Parent Involvement: What Is It That Works?"
Children Today 19(1990):34-37·
41. Schorr, Within Our Reach.
The Contribution of Social Insurance 121

Notes
1. R. Stevens and R Stevens, Welfare Medicine in America: A Case Study ofMedicaid
(New York: Free Press,1974), pp. 19-56.
2. Stevens and Stevens, Welfare Medicine in America.
3· K. Davis and C. Schoen, "Health, Use of Medical Care, and Income," in Health
and the War on Poverty: A Ten-Year Appraisal (Washington, D.C.: Brookings Institu-
tion, 1976), pp. 18-48.
4· Stevens and Stevens, Welfare Medicine in America.
5· E. R Brown, "Medicare and Medicaid: The Process, Value and Limits of
Health Care Reforms," Journal ofPublic Health Policy (September 1983): 335-356.
6. K. Davis, "Achievements and Problems of Medicaid," Public Health Reports
(Washington, D.C.: U.S. Department of Health, Education, and Welfate)910uly-
August 1976), pp. 309-316.
7· Davis and Schoen, "Health, Use of Medical Care, and Income," pp. 18-49.
8. Brown, "Medicare and Medicaid," pp. 335-356.
9· Davis and Schoen, "Health, Use of Medical Care, and Income," pp. 18-49.
10. Stevens and Stevens, Welfare Medicine in America; Brown, "Medicare and
Medicaid," pp. 335-356.
11. Davis and Schoen, "Health, Use of Medical Care, and Income," pp. 18-49.
12. D. Rogers, R. Blendon, and T. Moloney, "Who Needs Medicaid?" New En-
gland Journal ofMedicine 307Guly 1, 1982):13-18.
13. K. Davis and R. Reynolds, "The Impact of Medicare and Medicaid on Access
to Medical Care," in R. N. Rosset, ed., The Role of Health Insurance in the Health Ser-
vices Sector (Washington, D.C.: Brookings Institution, 1977), pp. 391-425; R. W. Wll-
son and E. L. White, "Changes in Morbidity, Disability, and Utilization Differentials
Between the Poor and the Nonpoor: Data from the Health Interview Survey: 1964
and 1973," Medical Care 15(August 1977): 636-646; P. Newacheck, "Access to Am-
bulatory Care for Poor Persons," Health Services Research 23(August 1988):401-419;
Rogers, Blendon, and Moloney, "Who Needs Medicaid?" pp. 13-18; K. Davis,
"Achievements and Problems of Medicaid," pp. 309-316.
14. Rogers, Blendon, and Moloney, "Who Needs Medicaid?" pp. 13-18.
15. J. Kaspar, "Health Status and Utilization: Differences by Medicaid Coverage
and Income," Health Care Financing Review 7(1986):1-17i P. Newacheck and B.
Starfield, "Morbidity and Use of Ambulatory Care Services Among Poor and Non-
Poor Children," American Journal of Public Health 78(1988):927--935·
16. J. Kleinman, M. Gold, and D. Makuc, ''Use of Ambulatory Medical Care by
the Poor: Another Look at Equity," Medical Care 19{0ctober 1981):1011-1029; Davis
and Reynolds, "The Impact of Medicare and Medicaid on Access to Medical Care,"
pp. 391-425; Newacheck, "Access to Ambulatory Care for Poor Persons," pp. 401-
419; Davis,"Achievements and Problems of Medicaid," pp. 309-316.
17. E. M. Howell, "Low Income Persons' Access to Health Care: NMCUES Med-
icaid Data," Public Health Reports 103(1988): 507-516.
18. G. R. Wllensky and M. L. Berk, "Health Care, the Poor and the Role of Medic-
aid," Health Affairs (1982):93-1o6; M. Rosenbach, "The Impact of Medicaid on Phy-
sician Use by Low-Income Children," American Journal of PubliC Health 79(Septem-
122 Diane Rowland

ber 1989):122o-1226; Davis and Reynolds, "The Impact of Medicare and Medicaid
on Access to Medical Care," pp. 391-425; Howell, "Low Income Persons' Access to
Health Care," pp. 507-516; Newacheck, "Access to Ambulatory Care for Poor Per-
sons," pp. 401-419.
19. Newacheck, "Access to Ambulatory Care for Poor Persons," pp. 401-419.
20. Rosenbach, "The Impact of Medicaid on Physician Use by Low-Income Chil-
dren," pp. 122o-1226.
21. Wilensky and Berk, "Health Care, the Poor and the Role of Medicaid," pp.
93-106.
22. P. Newacheck and N. H. Halfon, "The Financial Burden of Medical Care Ex-
penses for Children," Medical Care 241(December 19&J):111D-1117.
23. Wilensky and Berk, "Health Care, the Poor and the Role of Medicaid," pp.
93-106.
24· P. Braveman, S. Egerter, T. Bennett, and J. Showstack, "Differences in Hospi-
tal Resource Allocation Among Sick Newborns According to Insurance Coverage,"
Journal of the American Medical Association 266(December 18, 1991):33oo-33o8.
25. J. Hadley, E. Steinberg, and J. Feder, "Comparison of Uninsured and Pri-
vately Insured Hospital Patients," Journal of the American Medical Association
265Uanuary 16, 1991):374-379.
26. R. Blendon, L. Aiken, H. Freeman, B. Kirkman-Liff, and J. Murphy, "Uncom-
pensated Care by Hospitals or Public Insurance for the Poor: Does It Make a Differ-
ence?" New England Journal ofMedicine 314(May 1, 1986): 116o-1163.
27. Howell, "Low Income Persons' Access to Health Care," pp. 507-516.
28. Brown, "Medicare and Medicaid," pp. 335-336.
29. K. Davis, G. Anderson, D. Rowland, and E. Steinberg, Health Care Cost Con-
tainment (Baltimore, Md.: The Johns Hopkins University Press, 1990).
30. Wilensky and Berk, "Health Care, the Poor and the Role of Medicaid," pp.
93-1o6.
31. J. Feder, J. Hadley, and R. Mullner, "Falling Through the Cracks: Poverty, In-
surance Coverage, and Hospital Care for the Poor, 198o-1982," Milbank Memorial
Fund Quarterly/Health and Society 62(1984): 544-566.
32. Kleinman, Gold, and Makuc, "Use of Ambulatory Medical Care by the
Poor," pp. 1011-1029.
33· Howell, "Low Income Persons' Access to Health Care," pp. 507-516.
34· S. Jencks and B. Benedict, "Accessibility and Effectiveness of Care Under
Medicaid," Health Care Financing Review (1990): 47-56.
35· J. Mitchell, "Physician Participation under Medicaid Revisited," Medical Care
29Uuly 1991):645-653.
36. American Medical Association, "Physician Participation in Medicaid," Phy-
sician Marketplace Update 2ijuly 1991).
37· Physician Payment Review Commission, Annual Report to Congress, 1991.
38. M. McManus, S. Flint, and R. Kelly, "The Adequacies of Physician Reim-
bursement for Pediatric Care Under Medicaid," Pediatrics 87Uune 1991):909-920.
39· Physician Payment Review Commission, Annual Report to Congress, 1991.
The Contribution of Social Insurance 123

40. Davis, "Achievements and Problems of Medicaid," pp. 309-316; Rogers,

Blendon, and Moloney, ''Who Needs Medicaid," pp. 13-18; Davis and Schoen,
Health and the War on Poverty.
41. J. Hadley, More Medical Care, Better Health (Washington, D.C.: Urban Institute,
t982).
42· N. Lurie, N. Ward. M. Shapiro, and R. ~rook, "Termination from Medi-Cal:
Does It Affect Health?" New England Journal of Medicine 311(August 16, t984):4&r
484; N. Lurie, N. Ward, M. Shapiro, R. Vaghaiwalla, and R. Brook, "Termination of
Medi-Cal Benefits: A Follow-Up Study One Year Later," New England Journal of
Medicine 314(May 8,1986):1266-1268.
43· P. Braveman, G. Oliva, M.G. Miller, R. Reiter, and S. Egerter, "Adverse Out-
comes and Lack of Health Insurance Among Newborns in an Eight-County Area of
California, t982-1986,'' New England Journal of Medicine 321(August 24; tCJ89):5o8-
512.
44· Hadley, Steinberg, and Feder, "Comparison of Uninsured and Privately In-
sured Hospital Patients," pp. 374-379.
45· D. -Rowland, B. Lyons, and J. Edwards, "Medicaid: Health Care for the Poor
in the Reagan Era," Annual Review of Public Health 9(t988):427-450i M. McManus
and S. Davidson, "Medicaid as Public Health Insurance for Children," in M. J.
Schlesinger and L. Eisenberg, eds., Children in aChanging Health System: Assessments
and Proposals for Reform (Baltimore, Md.: Johns Hopkins University Press, 1990), pp.
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46. R. Blendon, L. Aiken, H. Freeman, B. .Kirkman-Liff, and J. Murphy, ''Uncom-
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124 Diane Rowland

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