TABLE 2-1 Percentage of the Elderly Covered Only by Medicare by Race, Selected Years

Race

1980

1984

1989

Total

22.7

20.0

16.8

Racea

White

21.0

18.5

14.7

Black

40.6

34.5

37.9

Ratio black/white

1.9

1.9

2.6

a Includes persons not covered by private insurance or Medicaid.

SOURCES: Unpublished data from the National Center for Health Statistics; National Health Interview Surveys, National Center for Health Statistics (1990c).

the context of the economic circumstances of an individual in relation to the extent of coverage in his or her specific insurance policy.

Because most elderly people are entitled to Medicare benefits, they are frequently neglected in discussions of access. But Medicare benefits are not comprehensive; consequently, most elderly also carry supplemental private insurance. As Table 2-1 illustrates, less than 20 percent of the elderly have only Medicare. The table also shows that there are some important differences by race, suggesting the potential for underinsurance of these groups and the consequent need to monitor their access problems. In addition to these long-standing issues of comprehensiveness, the effect of recent reforms, including physician reimbursement rules, on access is something that the Physician Payment Review Commission set up by Congress is planning to monitor.

The millions of Americans without health insurance coverage do not necessarily go without care. Much of their care is financed through direct service delivery programs supported by federal, state, and local budgets or is delivered by institutional and individual providers in the form of free or reduced-price services. Included are the budgets of public hospitals, health department clinics, facilities run by the Department of Veterans Affairs, and community health center clinics. A host of special programs enacted by states and localities operate as a health safety net for those who do not qualify for Medicaid. This safety net can be threatened by government budget cuts or the inability of programs to keep pace with increased demand when there are downturns in the economy.

Personal and Cultural Barriers

When population subgroups that share personal characteristics—such as education levels or attitudes—systematically underuse services that make



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