Healthcare Coverage, Access, and Utilization in the Unincorporated US Territories of Guam, Puerto Rico, and the Virgin Islands Open Access
Pao, Alexander (2012)
Published
Abstract
Introduction: National healthcare reforms such as the 2010 Patient Protection and Affordable Care Act rarely extend to the unincorporated US territories, where healthcare disparities may be masked by nationwide statistics. This study investigates whether healthcare coverage predicts access and utilization in Guam, Puerto Rico (PR), and the Virgin Islands (VI) relative to the US states (DC inclusive). Further, we examined factors associated with access/utilization to inform community-based healthcare interventions in the unincorporated territories.
Methods: We analyzed the 2010 BRFSS data for access to and utilization of healthcare across five factor domains: socio-demographics, lifestyle/behavior, social and emotional support, self-reported health, and history of diagnosed conditions. Multiple logistic models estimated weighted odds of healthcare access/utilization outcomes attributed to lack of coverage across the four subpopulations, adjusting for each factor domain.
Results: Compared to the US states, residents in Guam and VI were more likely to be uninsured and lack a usual source of healthcare, whereas reverse associations were found in PR. Cost barriers were more prevalent in unincorporated territories than in the states, even for the highly-insured PR population (92% coverage). Controlling for factor domains had varying effects across each territory's healthcare access/utilization outcomes. After adjusting for all five factor domains, health insurance was a significant predictor of all access/utilization outcomes in PR, VI, and the states, and was also a significant predictor of having a usual healthcare provider in Guam. The fully adjusted cost barrier OR among those lacking coverage (95% CI): 1.15 in Guam (0.53-2.47), 5.51 in PR (3.20-9.49), 3.95 in VI (2.27-6.87), and 5.41 in the states (5.06-5.79).
Discussion: Having healthcare coverage strongly improves the likelihood of access/utilization, even in the unincorporated territories. This relationship was partially accounted for by poor social and emotional support and mental health in Guam, mental health coverage and physical limitations in PR, and socio-demographic disparities in VI, highlighting the need for interventions with cultural and social relevance. To fully address national healthcare disparities, the unincorporated territories should be included in future reform efforts and discussions.
Table of Contents
TABLE OF CONTENTS
1. Chapter I: Background/Literature Review...1
a. Healthcare coverage, access, and
utilization
b. US healthcare reform
c. The argument for healthcare reform in the territories
d. Purpose of the study
2. Chapter II: Manuscript
a. Introduction...9
b. Methods...11
c. Results...14
d. Discussion...19
e. References...27
f. Tables...34
g. Figures...43
3. Chapter III: Summary, public health implications, possible future directions...47
4. Appendices
a. Appendix A: Associations between experience
of a medical cost barrier and factor domain covariates, by US
subpopulation...50
b. Appendix B: Associations between having a usual healthcare
provider and factor domain covariates, by US
subpopulation...53
c. Appendix C: Associations between performance of an annual
routine checkup and factor domain covariates, by US
subpopulation...56
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