related to admissions for congestive heart failure, hypertension, and asthma. Yet even the lowest ratio, for the diagnosis of angina, showed income differences almost threefold in magnitude.

Objective 5: Reducing Morbidity and Pain through Timely and Appropriate Treatment

The primary medical concern of the 90 percent of people who see themselves as being in good health is, Will I be able to see a doctor if I become sick? One utilization indicator for this objective attempts to measure this concern by singling out healthy people who suddenly become so sick that they must reduce their normal activities. The question is whether such characteristics as insurance status, income, and race have an effect on whether medical attention is obtained. A related outcome indicator looks at the effects of delayed or inappropriate outpatient treatment for acute disease by relying on analysis of admission rates by zip code for a select group of diagnoses.

A second utilization indicator moves from medical care to dental care, a set of services that have limited insurance coverage and thus the potential for being highly income sensitive. Dental services also represent an area of personal health care in which treatment, although usually not life saving, contributes to general well-being and social functioning.

People without insurance and Medicare recipients without supplementary policies were more likely than those with private insurance to refrain from seeking medical care or advice when sick. The differences for both groups compared with those with private insurance are about 10 percentage points. The likelihood of contacting a physician decreases by about 5 percentage points at the lowest income levels for the uninsured and the privately insured. Presumably, anticipated out-of-pocket costs are deterring some of the insured from obtaining services.

People who see themselves as being in good to excellent health—the population of interest in this objective—may seek medical attention for any number of reasons. The personal health care system in some cases provides only symptomatic relief to patients for conditions that would resolve independent of any medical intervention. In other situations, however, symptoms that are not addressed in a timely fashion can evolve into acute medical problems requiring hospitalization. Mild cases of such infections as bacterial pneumonia, cellulitis, kidney diseases, and precursor conditions leading to pelvic inflammatory disease can often be managed with antibiotics in outpatient settings, preventing the disease from becoming more severe. For most of the diagnoses used in this indicator, admissions from low-income zip codes were two to five times higher than admissions from high-income zip codes.



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