Utilization of Health Care: The Laredo Migrant Experience GEORGE M. WALKER, JR., PHD
Abstract: In 1973, three groups of randomly selected migrant labor families resident in Laredo, Texas were enrolled in a prepaid health insurance study. A study was implemented to determine the kinds and costs of medical care used by Mexican American migrant labor families in their homebase and travel areas where financial barriers to care were eliminated or reduced. At the end of three years it was found that the
study population used ambulatory services about onehalf as much as the general U.S. population while hospital use approached regional norms. The differences between homebase and out-of-area use are highlighted, and the reported failure to use any public facilities outside of Laredo is discussed. (Am J Public Health 69:667-672, 1979.)
Introduction
A significant proportion of the migrant farm worker population is Mexican American. They make up a minority of the East Coast migrant stream but are estimated to be the majority of workers in the West Coast stream.'2 Migrant farm workers from Texas, who make up the major portion of the Central migrant stream, are predominantly Mexican American. While there is a growing and useful body of literature on the cultural aspects of Mexican American health care,3' 14 there are little health cost or use rate data. Nationwide there are three ongoing demonstration projects of prepaid health care for migrants. The first of these was the Laredo Special Migrant Health Project, serving a Mexican American population.** This report describes the Laredo Special Migrant Project in some detail and compares selected Laredo indicators with those of other studies. The Laredo Special Migrant Project (LSMP) was implemented in early 1973,*** designed to meet two major objectives: 1) to identify the costs of making comprehensive health and medical services available to enrolled migrant families are low or no cost; and 2) to determine the patterns of private and/or public sector services used by the migrants in their home base and travel areas. A key concept of the project was to provide care under a system of prepaid health
Until the late 1960s, low income families and individuals used fewer health services than those with high incomes, but several studies have found that the positive correlation between family income and the use of physician services has diminished substantially since then. 1-3 Recent literature suggests that a reduction in financial barriers has been partially responsible for increased utilization by low income groups. Research by Anderson and Benham,4 Mechanic,5 Montiero,6 Rabin, Bice, and Starfield,7 and Richardson8 show that those under Medicare and Medicaid have similar and even occasionally higher use rates than the non-poor. Where poor populations have been enrolled in prepaid group practice plans under the Office of Economic Opportunity (OEO) demonstration projects, they have utilization rates similar to those of regular plan members.9 10 It was further found that OEO groups newly registered in existing prepaid group practices had higher physician encounter rates during the first six months but that the rates leveled off to those of regular plan members after a "backlog of needs" was met.'0 A similar effect of reduced utilization over time was found by Yesalis and Bonnet" in a study of uppermiddle class registrants in a prepaid group plan in Maryland, but they suggest that "testing the system" rather than a backlog of needs caused the higher initial utilization. While the body of literature on the use of services by Medicare and Medicaid recipients, group practices, and demonstration projects for low income urban populations continues to grow, there are little comparable data available on rural populations, and virtually no published data available on the use experience of migrant farm workers under any kind of program.* Address reprint requests to George M. Walker, Jr., PhD, Associate Professor, Health Administration, School of Public Health, University of Texas, Health Science Center at Houston, P.O. Box 20186, Houston, TX 77025. This paper, submitted to the Journal July 6, 1977, was revised and accepted for publication November 1, 1978.
AJPH July, 1979, Vol. 69, No. 7
insurance.
*A search of more than 1,000 articles published in the past several years on rural, low income, and migrant health revealed no usable data for comparisons. **A second program, the El Valle Plan,'5 is conducted through Catholic Charities, Inc., of Harlingen, Texas, and is operated as a Health Maintenance Organization; it serves a Mexican-American population from San Benito, Texas. The third, the East Coast Migrant Entitlement Project,'6 sponsored through the Palm Beach County, Florida, Health Department, serves a population of Black, Anglo, and Spanish-surnamed migrants. ***The project was initially proposed by the Dallas Office of the U.S. Department of Health, Education, and Welfare in 1971. The study/service program was subsequently developed through the Laredo-Webb County Health Department, the University of Texas at Houston School of Public Health, Region VI of DHEW, and Blue Cross/Blue Shield of Texas.
667
WALKER
The Study Population The study population is made up of three groups of migrant labor families selected by use of a random numbers table from a master list of all known migrant labor families resident in Laredo, Texas. (See Appendix, Table 1). None are "illegal" or "undocumented" aliens; all are U.S. citizens. None were selected who had some other form of health insurance, including Medicare or Medicaid, or who did not qualify as migrant labor families. At the end of the third study year, there were 3,623 individuals in 624 families still enrolled and the average family size was 5.8 persons. Many original families were removed from study rolls because they no longer qualified as migrants (i.e., they had no history of work in the migrant stream for a period of two years), they could not be located for reregistration, or they had acquired some other form of health insurance. Appendix Table 2 summarizes the age and sex distribution of the combined groups at the end of each study year. The population is young, with 41.1 per cent under 15 years of age and nearly 59 per cent under 20 years of age, comparable to earlier population characteristics reported by Shenkin.'2 The combined study groups were nearly equally divided between male and female enrollees. Although no tables are presented, the Laredo migrant labor population is a poor one with approximately 83 per cent of the families reporting total annual combined family incomes of less than $5,000. Nearly 80 per cent of household heads and their spouses reported completing fewer than seven years of school, far below the statewide average in Texas and the local average in Laredo. The locations to which the Laredo migrants, as whole or partial families, traveled in search of work were widespread (Appendix Table 3). The 2,458 individuals in 479 families who went "up North" (including other areas in Texas) in search of work reported locating in nearly 290 communities in 29 different states; nearly 20 per cent of these worked in more than one location. Those who migrated averaged 122 days outside of Laredo although migration time ranged from fewer than 30 days to about 345 days. One hundred fifteen families (1,018 individuals) did not migrate during the study year and no data were available for 90 families (496 individuals) who could not be located for interview.
Arrangements for Care To determine what kinds of services would be used by the migrant population when financial barriers were reduced, it was necessary to develop a system through which both public and private systems of care would be generally available to project enrollees. It was crucial that private services be made available during migration since Laredo migrants do not meet residential qualifications for local public services in most locations worked, and there are no migrant clinics in most communities. The system also had to be acceptable to private providers in the homebase area if enrollees were to have free choice of provider. In cooperation with Blue Cross, a broad and comprehensive range of medical service 668
benefits was developed. Each selected family was issued a special Blue Cross enrollment card and a portfolio explaining the program and benefits to be presented to all private providers who might question their eligibility. With but few exceptions, the identification cards have been accepted by providers in all locations. The coverage provided includes all hospital care except elective cosmetic surgery, all emergency room care, all ambulatory care, and dental emergencies. The restrictions on benefits are a 70-day hospital stay limitation for each illness, co-payment requirements locally under certain circumstances,: and self-pay for medications except when provided in hospitals or by clinics. All payments are based on the usual, customary, and reasonable (UCR) charge profiles for each provider used by Blue Cross. Most ambulatory care in Laredo was provided by the Laredo Migrant Health Clinic. This clinic has long experience in providing a broad range of quality services to its migrant population. Indeed, the migrants view it as "our clinic." In each of the study project's years of operation, more than 60 per cent of all ambulatory encounters in Laredo were provided through the clinic. The clinic was not reimbursed by the LSMP; clinic costs were borne through the Health Department's regular Migrant Health Project budget. The project paid to Blue Cross a monthly insurance premium of $9.39 for each enrollee, to cover the specified services, including hospitalization. The premium was based on the first two years actuarial experience and, in retrospect, was not sufficient to reimburse Blue Cross for total payments made for the project year.tt The prepaid enrollment for the third year was a conversion from indemnification procedures of earlier years when Blue Cross had been directly reimbursed for payments made.
Results An ambulatory encounter is defined here as a visit to a physician, or to a health or medical worker directly supervised by a physician, and its immediately related sequelae. Mass visits, as defined by the National Health Survey,'7 are not counted as encounters. All encounter data were derived from computerized claims information processed by Blue Cross. Visits to the Laredo Migrant Health Clinic were also recorded through minor modification of normal reporting procedures. Special computer edit procedures were developed to identify single encounters that generated multiple claims or single claims which recorded multiple visits, and to correct errors in data. When the edit program "flagged" such claims, hard copies of the original forms were examined. All individual encounters for all claims submitted by private providers and all entWhere an individual goes directly to a local private physician's office, the physician is reimbursed at 75 per cent UCR. When referred from the Migrant Clinic, UCR payments are at 100 per cent. t*Blue Cross/Blue Shield of Texas had unrecovered costs of $137,989.37 for claims paid and administrative expenses for 197576. The premium for the following project year was increased by 41 per cent.
AJPH July, 1979, Vol. 69, No. 7
LAREDO MIGRANT HEALTH EXPERIENCE TABLE 1-Ambulatory Encounter Rates per 1,000 Enrollees during Yearly Study Periods Group A
Group B
Group C
Total
1973-74 1710.2 1974-75 1987.9 1975-76 2182.1
2005.1 2452.7
2600,8
1710.2 2000.4 2464.5
Period
TABLE 3-Ambulatory Encounter Rates/000 Enrollees by Age and Sex 1975-1976 Encounters
N = 728 N = 2,401 N = 3,623
NOTE: Rates based on end-of-year enrollments. Average monthly enrollments not available for first two years.
Migrant Clinic
Physician
Out-
Sex
Office
Patient
Total
0-14
Male Female Total
1380.7 1381.2 1381.0
578.2 586.5 582.1
394.9 284.1 342.0
2353.8 2251.8 2305.0
15-24
Male Female Total
567.7 1031.0 793.6
353.6 566.1 457.2
251.5 336.8 293.0
1172.8 1933.9 1543.8
25-44
Male Female Total
726.4 2076.5 1488.1
621.6 1226.5 945.0
554.0 485.3 517.3
1800.7 3788.2 2863.2
Age
TABLE 2-Ambulatory Care Rates per Enrollee by Category of Encounter, 1975-76 Encounter
Group
Laredo
Out of Area
Outpatient Hospital
A B C ALL
.2534 .2903 .2914 .2847
.0445 .0524 .1031 .0712
.3427 .3946 .3559
45-64
Male Female Total
1318.5 3585.1 2435.6
810.5 1477.2 1139.0
379.0 854.8 613.5
2508.1 5917.0 4188.1
.4608 .4637 .4837 .4709
.1613 .1319 .1915 .1603
.6221 .5950 .6752 .6312
65+*
Physician Office
A B C ALL
Male Female Total
4363.6 8333.3 5214.3
181.8 3333.3 857.1
181.8 1000.0 357.1
4727.3 12666.7 6428.6
Total
1.1413 1.3157 1.2844 1.2746
-
1.1143 1.3157 1.2844 1.2746
1060.7 1729.1 1388.9
552.1 828.6 687.8
361.2 415.4 387.8
1974.0 2973.0
A B C ALL
Male Female Total
Laredo Migrant Health Clinic
Total
.2980
NOTES: 1. Based on average monthly enrollment in each group. 2. No pub0lc clinic utilization outside Laredo reported or recorded.
counters recorded at the Laredo Migrant Clinic are included in the data analyzed.tt# During project planning, it was assumed that the enrolled population would use services at rates similar to those reported for other poverty populations'0 (4-6 ambulatory contacts annually, with high initial use leveling off after about six months). The assumption was reinforced by recent observations which tend to explode the myths of cultural resistance to scientific health care by Mexican Americans. 13' 14 However, in the three years of the project, the use of ambulatory services has been far below the national average and other reported poverty population use. The rates were recorded at low levels initially with minor increases by group and within groups for each succeeding study period, as shown on Table 1. They provide no evidence of seeking care to meet a "backlog of needs" or to "test the systems" and a consequent reduction of demand. There is a tendency to increased utilization the longer a group is covered and a tendency for each newly enrolled group to use more services than those previously enrolled. Yet utilization remains low.*
tt1Direct payments to providers by enrolled families were reimbursed at UCR levels when receipts were presented to the project office and are also included. *The rates reported in Table 1 are higher than they would be if based on average monthly enrollment since end-of-year enrollments were used in their computation. AJPH July, 1979, Vol. 69, No. 7
2464.5
NOTE: End of year enrollment figures used to determine rates. *See Appendix Table 2. Numbers very small.
Table 2 shows encounter rates for each group in 1975-76 by type and location of encounter. The differential between utilization of the Laredo Migrant Health Clinic and other sources which includes out-of-area resources is obvious. Possible explanations include: 1) as a group, the migrants are "at risk" in migration locations for about 20 per cent of each study period; 2) working migrants frequently do not seek care during working periods because if they do not work they are not paid; and 3) in many of the locations, treatment facilities are not readily available and/or knowledge about where and what they are is lacking. Notable, too, is the fact that no public clinic use was reported or recorded outside of Laredo (despite special and extended efforts to retrieve such information) after the first project year; only four out of area public encounters were recorded in 1973-74. Since the Table emphasizes the amount of care sought through the Laredo Migrant Health Clinic, it is difficult to believe that no other public clinic use occurred. The lack of such data can only be interpreted to mean that no visits were recorded or reported. Table 3 summarizes the rates by age and sex for 197576. On the average each female registered one more encounter than did each male. Males, however, generally showed a greater increase in numbers of encounters than did females over the three-year period (data not shown). Table 4 presents the rates of inpatient hospitalization in homebase and migration locations for the Laredo enrollees. Most notable is the proportionally higher utilization by enrollees in Group C in both locations. Males accounted for 62 per cent of all hospitalizations, but females had longer hospi669
WALKER
tal stays. The average hospital stay for a male enrollee was 3.90 days and for a female enrollee was 5.84 days. For all enrollees, the average hospital stay was 4.7 days (data not shown).
Discussion It is difficult to make direct comparisons of the Laredo rates with those reported for the general U.S. population. The Laredo rates are derived from unvalidated provider data while U.S.-reported rates are based primarily on validated consumer recall data.2'3'18 Yet a cautious comparison can be made. In comparing the migrant rates with selected national rates** the overall lower rates of the migrants is obvious. However, the migrants show substantially higher emergency room use, and in free standing clinics (primarily health department clinics), Laredo males and females recorded rates four and one-half and seven and one-half times greater than their general population counterparts. The Laredo enrollees also used fewer medical services than did low income, urban populations under earlier prepaid insurance plans in New York, Washington, Oregon, and California.'0 Both the migrant and the OEO rates incorporate physician and non-physician encounters but the "OEO
TABLE 4-Rates of Inpatient Hospltalization per 1,000 Enrollees, 1975-76 Laredo
Out of Area
Total
Group A Group B Group C
93.7 104.8 137.1
16.9 20.7 39.7
110.6 125.6 176.8
TOTAL
115.8
27.6
143.4
NOTE: Rates are based on average monthly enrollments.
poor" show average rates 73 per cent to 130 per cent higher per person than the Laredo migrant. The Laredo enrollees also show lower use than a similar group of Mexican American migrant farm workers from San Benito, Texas, covered under a companion prepaid program, the El Valle Plan.'s Table 5 compares summary age/ sex rates for the two groups. When adjusted for expectations of use based on national general and poverty populations, both Chicano migrant groups continue to show low rates. When adjusted for the population under 65 years of age, the Laredo migrants' rates are even lower.
TABLE 5-Comparison of Ambulatory Rates per 1,000 Enrollees of Two Prepaid Insurance Plans for Migrants El Valle Plana
Age 0-14 15-24
25-44 45-64 65+ Total
Under 65
Sex
Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total
Number Covered
211 218 429 147 126 273 72 98 170 65 54 119 5 5 10 500 501
1,001 495 496 991
Rates
Reportedb 2,540 2,711 2,627 1,769 4,032 2,813 1,792 5,551 3,959 3,361 5,944 4,681 2,800
Laredo Special Project
Adjusted to National
Populaffond
Adjusted to Poverty Populatione
See below
2,623
780 711
1,149
2,918
(Ages 0-24) 2,731
3,730
4,226
4,839
5,038
1,619 2,453 4,099 3,303 2,419 4,553 3,503
1,411 2,403 3,696 3,151 2,362 4,222 3,406
800
1,800 2,350 3,928 3,140
Adjusted to Number Covered
509 484 993 296 340 636 248 241 489 11 3 14 1,844 1,779 3,623 1,833 1,776 3,609
Rates
Reportedc 2,354 2,252 2,305 1,173 1,934 1,543 1,801 3,788 2,863 2,508 5,917 4,188 4,727 12,667 6,429 1,974 2,983 2,464
National
Populationd
Adjusted to Poverty
Populatione See below
2,304 1,559
(Ages 0-24) 2,011
2,825
3,088
4,288
4,581
9,415 2,238 4,600 3,459 1,992 3,489 2,752
10,238 2,222 4,638 3,620 1,966 3,179 2,647
aAdapted from Catholic Charities, Confinuation Application, dated January 30, 1976; bBased on two-year average, 1973-1975; derived from unvalidated provider data; C1975-1976 project year;
dAdapted from Current Population Reports, Series P-25, No. 643, 1977; eAdapted from Current Population Reports, Series P-60, No. 106,
1975.
**See Tables 6, 9, and 13 of The Nation's Use of Health ReEdition.'8
sources, 1976
670
AJPH July, 1979, Vol. 69, No. 7
LAREDO MIGRANT HEALTH EXPERIENCE
The third prepaid insurance project suggests such low ambulatory use among migrant labor families in general. The East Coast Migrant Entitlement Project (ECMEP),'6 based in Palm Beach County, Florida, serves 755 families of about 2,000 individuals. Seventy-five per cent of the enrolled population is Black and 24 per cent is Spanish-surname. Although no age/sex use is available from ECMEP reports, they recorded average ambulatory rates of 2.21 and 2.38 encounters per person in 1975 and 1976-similar to the Texas projects' rates despite an extensive and active outreach effort in the Florida program. However, in a recent study of migrant labor family hospital experience, Enger, et al,'9 found the major difference between migrant and general populations to be that overall migrant hospital use was slightly lower, but considerably lower for males. They concluded that hospital utilization by migrant workers and its associated costs do not differ greatly from national norms, and that cost and use appear most affected by geographical location and third party payor arrangements. In short, the enrolled Laredo migrant's hospital experience, in contrast to ambulatory care, did not differ greatly from that of other hospital users in the Southwest. The assumption that the Laredo migrant would approach national norms of ambulatory use when economic barriers to care were reduced or removed was not realized. Some of the low use recorded may be due to project reliance on provider data. Yet a large number of additional claims would have to be received to make an appreciable difference in average encounter rates and, based on a review of Blue Cross/Blue Shield experience, it is not believed that many claims are outstanding. Given the relatively equivalent hospital use reported by Enger,'9 a suggested explanation is that there are fewer "worried well" among the Laredo migrants and that they use services only when they define themselves as needing professional care. Survey information presented by Shearer*** also indicated that some to many enrolled individuals did not seek care when ill, that others used selfmedications purchased in pharmacies in the U.S. and Mexico,t and that a few reported using traditional healers such as curanderos and herbalists. Others reported using some private physician services in Mexico. Such use would not be included in the low rates reported. Of greater concern to project personnel was the nonreporting of any out-of-area public clinic use for two years. In each project year, reporting forms were sent to each migrant program in the nation requesting notification if any Laredo enrollees were served; none were returned. In addition, each family was provided each year with ten stamped, addressed postal cards on which to report public facility visits. Many cards were returned, but they reported only on contacts with private providers. Unverified anecdotal evidence ***Shearer CJ: Comparability of Health Information from a Household Survey and Insurance Claims. Unpublished Master's Thesis, The University of Texas Health Science Center at Houston, School of Public Health. June 1975. tAntibiotics and non-narcotic drugs requiring prescriptions in the United States can be purchased without prescription a short walk across the international bridge in Nuevo Laredo, Tamaulipas, Mexico. AJPH July, 1979, Vol. 69, No. 7
suggests that out-of-area services provided through general public facilities and by special federal programs, i.e., Migrant Head Start among others, are preventive in nature and the migrant families see their greatest needs during migration for curative services. They may not use out-of-area public facilities because of prior experience with residential requirements, or because they believe that curative care is not available, or simply because they are not aware of what curative public services might be available when needed. In summary, the objectives of the program were to determine the kinds and coststt of health and medical care that would be used by a population of Mexican American migrant labor families where the services could be obtained at low or no cost through prepaid health insurance. During the three years of the program, ambulatory use was recorded at levels lower than expected by program personnel although hospital utilization approached regional norms. Most unexpected was the finding that no public facility use was reported or recorded out-of-area in the second two years. The data available here, derived from provider sources, strongly suggest the need for additional research into why the enrolled migrants use or do not use public or private services and why they use so few services during their times of migration.
ACKNOWLEDGMENTS The research was conducted partially under DHEW Grant No. 06-H-000113-13. Maurice A. Click and Christopher Bosman-Clark were the project programmers and made orderly a mass of disordered data, translating claims information into encounter information.
REFERENCES 1. Bice TW, Eichorn RL and Fox PD: Socioeconomic status and use of physician services. Med Care 10:261-271, 1972. 2. Age Patterns in Medical Care, Illness, and Disability. U.S. Department of Health, Education, and Welfare, PHS, HRA, Na-
3.
4.
5. 6.
7. 8. 9.
10.
tional Center for Health Statistics. Series 10-70. Washington, DC, U.S. Government Printing Office, 1972. Health: United States 1975. U.S. Department of Health, Education, and Welfare, PHS, HRA, National Center for Health Statistics, DHEW Publication No. (HRA) 76-1232. Washington, DC, U.S. Government Printing Office, 1975. Anderson R and Benham L: Factors Affecting the Relationship Between Family Income and Medical Care Consumption, in Klarman HE, (Ed): Empirical Studies in Health Economics. Baltimore: The Johns Hopkins Press, 1970. Mechanic D: Sociology and public health: perspective for application. Am J Public Health 62:146-151, 1972. Montiero LA: Expense is no object: income and physician visits reconsidered. J Health and Soc Behavior 14:99-115, 1973. Rabin DL, Bice TW, and Starfield B: Use of health services by Baltimore Medicaid recipients. Med Care 12:561-570, 1974. Richardson WC: Measuring the urban poor's use of physician services in response to illness epidodes. Med Care 12:561-570, 1974. Greenlick MR, Freeborn DK, Colombo TJ, et al: Comparing the use of medical care services by a medically indigent and a general membership population in a comprehensive prepaid group practice program. Med Care 10:187-200, 1973. Sparer G and Anderson A: Utilization and cost experience of low income families in four prepaid group-practice plans. N Engl J Med 289:67-72, 1973.
t4Data about program costs are available upon request from the
author.
671
WALKER
APPENDIX TABLE 2-Enrollment Totals at End of Each Study Year
11. Yesalis CE, III and Bonnet PD: The effect of duration of membership in a prepaid group health plan on the utilization of services. Med Care 14:1024-1036, 1976. 12. Shenkin BN: Health Care for Migrant Workers: Policies and Politics. Cambridge, Ballinger Publishing Co., 1974. 13. Farge EJ: La Vida Chicana: Health Care Attitudes and Behaviors of Houston Chicanos. San Francisco, C&E Research Associates, 1975. 14. Weaver JL: Mexican American health care behavior: a critical review of the literature. Soc Sci Q 54:85-102, 1973. 15. Continuation Application (unpublished). Catholic Charities, Inc., Harlingen, January 30, 1976. 16. East Coast Entitlement Project: Report After Two Years Experience. Palm Beach County, Florida, Health Department. August 1977. 17. Health Interview Survey Procedure, 1957-1974, Ntional Center for Health Statistics, DHEW, Series 1, No. 11, 1975. 18. The Nation's Use of Health Resources: 1976 Edition. U.S. Department of Health, Education, and Welfare. PHS, HRA, National Center for Health Statistics, DHEW Publication No. (HRA) 77-1240. Washington DC, U.S. Government Printing Office, 1976. 19. Enger I, Pindus NA, Marling CW, et al: Cost and Utilization: Migrant Hospitalization Program. Geomet Report No. HF-593, Final Report to Office of Planning, Evaluation, and Legislation, Health Services Administration, DHEW. January 1977.
APPENDIX TABLE 1-Family Enrollments at Beginning and End of Each Study Year* Beginning Year Number of Families
GROUP A 1973-74 1974-75 1975-76 GROUP B 1974-75 1975-76 GROUP C 1975-76
Number of Individuals
Study Year Sex
1973-74
1974-75
1975-76
0-14
Male Female Total
169 155 324
526 478 1,004
780 711 1,491
15-24
Male Female Total
117 102 219
371 319 690
509 484 993
25-44
Male Female Total
39 60 99
165 214 379
296 340 636
45-64
Male Female Total
52 34 86
176 146 322
248 241 489
65+
Male Female Total
-
4 2 6
11 3 14
TOTAL
Male Female Total
377 351 728
1,242 1,159 2,401
1,779 3,623
Age
1,844
APPENDIX TABLE 3-Combined Groups-Average Days in Migration and States to Which Migrated during Study Year
Ending Year Number of Families
Number of Individuals
State
Alabama Anrzona 100 96 94
760 702 659
96 94
91
728 659 615
334 290
1,999 1,742
290 267
1,742 1,595
300
1,571
266
1,413
*In addition to individuals in families no longer in the study because their families lost enrollment eligibility, 91 individuals were dropped from Group A over three years, 148 were dropped from Group B over two years, and 48 individuals were dropped from Group C. Of the 287 individuals dropped, 190 (66 per cent) no longer qualified because they married and began new families not eligible for enrollment. The number of individuals also reflects newborns added to eligible families.
Califdmia Colorado Connecticut Florida Idaho Illinois Indiana Kansas Maryland
Michigan Minnesota Missouri Montana Nebraska Nevada New Mexico New York North Dakota Ohio
Oregon Pennsylvania Tennessee Texas Utah Washington Wisconsin Wyoming Unknown
TOTAL
Number of Individuals
1
16 129 181 8 28 174 109 108
Number of
Days
71 858
18,932 17,415 1,224 1,602 23,963 15,196
Average Days Migration
71 54 147 96 153 57 138 139
8,926
83
120 876 20,042
120 125 99
39,300
81
310 1,015 12,187 825 840 4,383 42,901 4,452 1,585 87 50 35,463 6,337 4,395 26,938 9,839 61
44 78 90 75 84 115
1 7 203 488 7 13 136 11 10 38 392 70 21 3 1 360 45 28 335 148 1
3,072a
300,193
109 64 75 29 50 99 141 157 80 66 61 122.13
aTotal number is greater than the number of only those who migrated (2,458) since some individuals worked in more than one state.
672
AJPH July, 1979, Vol. 69, No. 7
Abstract: In 1973, three groups of randomly selected migrant labor families resident in Laredo, Texas were enrolled in a prepaid health insurance study. A study was implemented to determine the kinds and costs of medical care used by Mexican American migrant labor families in their homebase and travel areas where financial barriers to care were eliminated or reduced. At the end of three years it was found that the
study population used ambulatory services about onehalf as much as the general U.S. population while hospital use approached regional norms. The differences between homebase and out-of-area use are highlighted, and the reported failure to use any public facilities outside of Laredo is discussed. (Am J Public Health 69:667-672, 1979.)
Introduction
A significant proportion of the migrant farm worker population is Mexican American. They make up a minority of the East Coast migrant stream but are estimated to be the majority of workers in the West Coast stream.'2 Migrant farm workers from Texas, who make up the major portion of the Central migrant stream, are predominantly Mexican American. While there is a growing and useful body of literature on the cultural aspects of Mexican American health care,3' 14 there are little health cost or use rate data. Nationwide there are three ongoing demonstration projects of prepaid health care for migrants. The first of these was the Laredo Special Migrant Health Project, serving a Mexican American population.** This report describes the Laredo Special Migrant Project in some detail and compares selected Laredo indicators with those of other studies. The Laredo Special Migrant Project (LSMP) was implemented in early 1973,*** designed to meet two major objectives: 1) to identify the costs of making comprehensive health and medical services available to enrolled migrant families are low or no cost; and 2) to determine the patterns of private and/or public sector services used by the migrants in their home base and travel areas. A key concept of the project was to provide care under a system of prepaid health
Until the late 1960s, low income families and individuals used fewer health services than those with high incomes, but several studies have found that the positive correlation between family income and the use of physician services has diminished substantially since then. 1-3 Recent literature suggests that a reduction in financial barriers has been partially responsible for increased utilization by low income groups. Research by Anderson and Benham,4 Mechanic,5 Montiero,6 Rabin, Bice, and Starfield,7 and Richardson8 show that those under Medicare and Medicaid have similar and even occasionally higher use rates than the non-poor. Where poor populations have been enrolled in prepaid group practice plans under the Office of Economic Opportunity (OEO) demonstration projects, they have utilization rates similar to those of regular plan members.9 10 It was further found that OEO groups newly registered in existing prepaid group practices had higher physician encounter rates during the first six months but that the rates leveled off to those of regular plan members after a "backlog of needs" was met.'0 A similar effect of reduced utilization over time was found by Yesalis and Bonnet" in a study of uppermiddle class registrants in a prepaid group plan in Maryland, but they suggest that "testing the system" rather than a backlog of needs caused the higher initial utilization. While the body of literature on the use of services by Medicare and Medicaid recipients, group practices, and demonstration projects for low income urban populations continues to grow, there are little comparable data available on rural populations, and virtually no published data available on the use experience of migrant farm workers under any kind of program.* Address reprint requests to George M. Walker, Jr., PhD, Associate Professor, Health Administration, School of Public Health, University of Texas, Health Science Center at Houston, P.O. Box 20186, Houston, TX 77025. This paper, submitted to the Journal July 6, 1977, was revised and accepted for publication November 1, 1978.
AJPH July, 1979, Vol. 69, No. 7
insurance.
*A search of more than 1,000 articles published in the past several years on rural, low income, and migrant health revealed no usable data for comparisons. **A second program, the El Valle Plan,'5 is conducted through Catholic Charities, Inc., of Harlingen, Texas, and is operated as a Health Maintenance Organization; it serves a Mexican-American population from San Benito, Texas. The third, the East Coast Migrant Entitlement Project,'6 sponsored through the Palm Beach County, Florida, Health Department, serves a population of Black, Anglo, and Spanish-surnamed migrants. ***The project was initially proposed by the Dallas Office of the U.S. Department of Health, Education, and Welfare in 1971. The study/service program was subsequently developed through the Laredo-Webb County Health Department, the University of Texas at Houston School of Public Health, Region VI of DHEW, and Blue Cross/Blue Shield of Texas.
667
WALKER
The Study Population The study population is made up of three groups of migrant labor families selected by use of a random numbers table from a master list of all known migrant labor families resident in Laredo, Texas. (See Appendix, Table 1). None are "illegal" or "undocumented" aliens; all are U.S. citizens. None were selected who had some other form of health insurance, including Medicare or Medicaid, or who did not qualify as migrant labor families. At the end of the third study year, there were 3,623 individuals in 624 families still enrolled and the average family size was 5.8 persons. Many original families were removed from study rolls because they no longer qualified as migrants (i.e., they had no history of work in the migrant stream for a period of two years), they could not be located for reregistration, or they had acquired some other form of health insurance. Appendix Table 2 summarizes the age and sex distribution of the combined groups at the end of each study year. The population is young, with 41.1 per cent under 15 years of age and nearly 59 per cent under 20 years of age, comparable to earlier population characteristics reported by Shenkin.'2 The combined study groups were nearly equally divided between male and female enrollees. Although no tables are presented, the Laredo migrant labor population is a poor one with approximately 83 per cent of the families reporting total annual combined family incomes of less than $5,000. Nearly 80 per cent of household heads and their spouses reported completing fewer than seven years of school, far below the statewide average in Texas and the local average in Laredo. The locations to which the Laredo migrants, as whole or partial families, traveled in search of work were widespread (Appendix Table 3). The 2,458 individuals in 479 families who went "up North" (including other areas in Texas) in search of work reported locating in nearly 290 communities in 29 different states; nearly 20 per cent of these worked in more than one location. Those who migrated averaged 122 days outside of Laredo although migration time ranged from fewer than 30 days to about 345 days. One hundred fifteen families (1,018 individuals) did not migrate during the study year and no data were available for 90 families (496 individuals) who could not be located for interview.
Arrangements for Care To determine what kinds of services would be used by the migrant population when financial barriers were reduced, it was necessary to develop a system through which both public and private systems of care would be generally available to project enrollees. It was crucial that private services be made available during migration since Laredo migrants do not meet residential qualifications for local public services in most locations worked, and there are no migrant clinics in most communities. The system also had to be acceptable to private providers in the homebase area if enrollees were to have free choice of provider. In cooperation with Blue Cross, a broad and comprehensive range of medical service 668
benefits was developed. Each selected family was issued a special Blue Cross enrollment card and a portfolio explaining the program and benefits to be presented to all private providers who might question their eligibility. With but few exceptions, the identification cards have been accepted by providers in all locations. The coverage provided includes all hospital care except elective cosmetic surgery, all emergency room care, all ambulatory care, and dental emergencies. The restrictions on benefits are a 70-day hospital stay limitation for each illness, co-payment requirements locally under certain circumstances,: and self-pay for medications except when provided in hospitals or by clinics. All payments are based on the usual, customary, and reasonable (UCR) charge profiles for each provider used by Blue Cross. Most ambulatory care in Laredo was provided by the Laredo Migrant Health Clinic. This clinic has long experience in providing a broad range of quality services to its migrant population. Indeed, the migrants view it as "our clinic." In each of the study project's years of operation, more than 60 per cent of all ambulatory encounters in Laredo were provided through the clinic. The clinic was not reimbursed by the LSMP; clinic costs were borne through the Health Department's regular Migrant Health Project budget. The project paid to Blue Cross a monthly insurance premium of $9.39 for each enrollee, to cover the specified services, including hospitalization. The premium was based on the first two years actuarial experience and, in retrospect, was not sufficient to reimburse Blue Cross for total payments made for the project year.tt The prepaid enrollment for the third year was a conversion from indemnification procedures of earlier years when Blue Cross had been directly reimbursed for payments made.
Results An ambulatory encounter is defined here as a visit to a physician, or to a health or medical worker directly supervised by a physician, and its immediately related sequelae. Mass visits, as defined by the National Health Survey,'7 are not counted as encounters. All encounter data were derived from computerized claims information processed by Blue Cross. Visits to the Laredo Migrant Health Clinic were also recorded through minor modification of normal reporting procedures. Special computer edit procedures were developed to identify single encounters that generated multiple claims or single claims which recorded multiple visits, and to correct errors in data. When the edit program "flagged" such claims, hard copies of the original forms were examined. All individual encounters for all claims submitted by private providers and all entWhere an individual goes directly to a local private physician's office, the physician is reimbursed at 75 per cent UCR. When referred from the Migrant Clinic, UCR payments are at 100 per cent. t*Blue Cross/Blue Shield of Texas had unrecovered costs of $137,989.37 for claims paid and administrative expenses for 197576. The premium for the following project year was increased by 41 per cent.
AJPH July, 1979, Vol. 69, No. 7
LAREDO MIGRANT HEALTH EXPERIENCE TABLE 1-Ambulatory Encounter Rates per 1,000 Enrollees during Yearly Study Periods Group A
Group B
Group C
Total
1973-74 1710.2 1974-75 1987.9 1975-76 2182.1
2005.1 2452.7
2600,8
1710.2 2000.4 2464.5
Period
TABLE 3-Ambulatory Encounter Rates/000 Enrollees by Age and Sex 1975-1976 Encounters
N = 728 N = 2,401 N = 3,623
NOTE: Rates based on end-of-year enrollments. Average monthly enrollments not available for first two years.
Migrant Clinic
Physician
Out-
Sex
Office
Patient
Total
0-14
Male Female Total
1380.7 1381.2 1381.0
578.2 586.5 582.1
394.9 284.1 342.0
2353.8 2251.8 2305.0
15-24
Male Female Total
567.7 1031.0 793.6
353.6 566.1 457.2
251.5 336.8 293.0
1172.8 1933.9 1543.8
25-44
Male Female Total
726.4 2076.5 1488.1
621.6 1226.5 945.0
554.0 485.3 517.3
1800.7 3788.2 2863.2
Age
TABLE 2-Ambulatory Care Rates per Enrollee by Category of Encounter, 1975-76 Encounter
Group
Laredo
Out of Area
Outpatient Hospital
A B C ALL
.2534 .2903 .2914 .2847
.0445 .0524 .1031 .0712
.3427 .3946 .3559
45-64
Male Female Total
1318.5 3585.1 2435.6
810.5 1477.2 1139.0
379.0 854.8 613.5
2508.1 5917.0 4188.1
.4608 .4637 .4837 .4709
.1613 .1319 .1915 .1603
.6221 .5950 .6752 .6312
65+*
Physician Office
A B C ALL
Male Female Total
4363.6 8333.3 5214.3
181.8 3333.3 857.1
181.8 1000.0 357.1
4727.3 12666.7 6428.6
Total
1.1413 1.3157 1.2844 1.2746
-
1.1143 1.3157 1.2844 1.2746
1060.7 1729.1 1388.9
552.1 828.6 687.8
361.2 415.4 387.8
1974.0 2973.0
A B C ALL
Male Female Total
Laredo Migrant Health Clinic
Total
.2980
NOTES: 1. Based on average monthly enrollment in each group. 2. No pub0lc clinic utilization outside Laredo reported or recorded.
counters recorded at the Laredo Migrant Clinic are included in the data analyzed.tt# During project planning, it was assumed that the enrolled population would use services at rates similar to those reported for other poverty populations'0 (4-6 ambulatory contacts annually, with high initial use leveling off after about six months). The assumption was reinforced by recent observations which tend to explode the myths of cultural resistance to scientific health care by Mexican Americans. 13' 14 However, in the three years of the project, the use of ambulatory services has been far below the national average and other reported poverty population use. The rates were recorded at low levels initially with minor increases by group and within groups for each succeeding study period, as shown on Table 1. They provide no evidence of seeking care to meet a "backlog of needs" or to "test the systems" and a consequent reduction of demand. There is a tendency to increased utilization the longer a group is covered and a tendency for each newly enrolled group to use more services than those previously enrolled. Yet utilization remains low.*
tt1Direct payments to providers by enrolled families were reimbursed at UCR levels when receipts were presented to the project office and are also included. *The rates reported in Table 1 are higher than they would be if based on average monthly enrollment since end-of-year enrollments were used in their computation. AJPH July, 1979, Vol. 69, No. 7
2464.5
NOTE: End of year enrollment figures used to determine rates. *See Appendix Table 2. Numbers very small.
Table 2 shows encounter rates for each group in 1975-76 by type and location of encounter. The differential between utilization of the Laredo Migrant Health Clinic and other sources which includes out-of-area resources is obvious. Possible explanations include: 1) as a group, the migrants are "at risk" in migration locations for about 20 per cent of each study period; 2) working migrants frequently do not seek care during working periods because if they do not work they are not paid; and 3) in many of the locations, treatment facilities are not readily available and/or knowledge about where and what they are is lacking. Notable, too, is the fact that no public clinic use was reported or recorded outside of Laredo (despite special and extended efforts to retrieve such information) after the first project year; only four out of area public encounters were recorded in 1973-74. Since the Table emphasizes the amount of care sought through the Laredo Migrant Health Clinic, it is difficult to believe that no other public clinic use occurred. The lack of such data can only be interpreted to mean that no visits were recorded or reported. Table 3 summarizes the rates by age and sex for 197576. On the average each female registered one more encounter than did each male. Males, however, generally showed a greater increase in numbers of encounters than did females over the three-year period (data not shown). Table 4 presents the rates of inpatient hospitalization in homebase and migration locations for the Laredo enrollees. Most notable is the proportionally higher utilization by enrollees in Group C in both locations. Males accounted for 62 per cent of all hospitalizations, but females had longer hospi669
WALKER
tal stays. The average hospital stay for a male enrollee was 3.90 days and for a female enrollee was 5.84 days. For all enrollees, the average hospital stay was 4.7 days (data not shown).
Discussion It is difficult to make direct comparisons of the Laredo rates with those reported for the general U.S. population. The Laredo rates are derived from unvalidated provider data while U.S.-reported rates are based primarily on validated consumer recall data.2'3'18 Yet a cautious comparison can be made. In comparing the migrant rates with selected national rates** the overall lower rates of the migrants is obvious. However, the migrants show substantially higher emergency room use, and in free standing clinics (primarily health department clinics), Laredo males and females recorded rates four and one-half and seven and one-half times greater than their general population counterparts. The Laredo enrollees also used fewer medical services than did low income, urban populations under earlier prepaid insurance plans in New York, Washington, Oregon, and California.'0 Both the migrant and the OEO rates incorporate physician and non-physician encounters but the "OEO
TABLE 4-Rates of Inpatient Hospltalization per 1,000 Enrollees, 1975-76 Laredo
Out of Area
Total
Group A Group B Group C
93.7 104.8 137.1
16.9 20.7 39.7
110.6 125.6 176.8
TOTAL
115.8
27.6
143.4
NOTE: Rates are based on average monthly enrollments.
poor" show average rates 73 per cent to 130 per cent higher per person than the Laredo migrant. The Laredo enrollees also show lower use than a similar group of Mexican American migrant farm workers from San Benito, Texas, covered under a companion prepaid program, the El Valle Plan.'s Table 5 compares summary age/ sex rates for the two groups. When adjusted for expectations of use based on national general and poverty populations, both Chicano migrant groups continue to show low rates. When adjusted for the population under 65 years of age, the Laredo migrants' rates are even lower.
TABLE 5-Comparison of Ambulatory Rates per 1,000 Enrollees of Two Prepaid Insurance Plans for Migrants El Valle Plana
Age 0-14 15-24
25-44 45-64 65+ Total
Under 65
Sex
Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total Male Female Total
Number Covered
211 218 429 147 126 273 72 98 170 65 54 119 5 5 10 500 501
1,001 495 496 991
Rates
Reportedb 2,540 2,711 2,627 1,769 4,032 2,813 1,792 5,551 3,959 3,361 5,944 4,681 2,800
Laredo Special Project
Adjusted to National
Populaffond
Adjusted to Poverty Populatione
See below
2,623
780 711
1,149
2,918
(Ages 0-24) 2,731
3,730
4,226
4,839
5,038
1,619 2,453 4,099 3,303 2,419 4,553 3,503
1,411 2,403 3,696 3,151 2,362 4,222 3,406
800
1,800 2,350 3,928 3,140
Adjusted to Number Covered
509 484 993 296 340 636 248 241 489 11 3 14 1,844 1,779 3,623 1,833 1,776 3,609
Rates
Reportedc 2,354 2,252 2,305 1,173 1,934 1,543 1,801 3,788 2,863 2,508 5,917 4,188 4,727 12,667 6,429 1,974 2,983 2,464
National
Populationd
Adjusted to Poverty
Populatione See below
2,304 1,559
(Ages 0-24) 2,011
2,825
3,088
4,288
4,581
9,415 2,238 4,600 3,459 1,992 3,489 2,752
10,238 2,222 4,638 3,620 1,966 3,179 2,647
aAdapted from Catholic Charities, Confinuation Application, dated January 30, 1976; bBased on two-year average, 1973-1975; derived from unvalidated provider data; C1975-1976 project year;
dAdapted from Current Population Reports, Series P-25, No. 643, 1977; eAdapted from Current Population Reports, Series P-60, No. 106,
1975.
**See Tables 6, 9, and 13 of The Nation's Use of Health ReEdition.'8
sources, 1976
670
AJPH July, 1979, Vol. 69, No. 7
LAREDO MIGRANT HEALTH EXPERIENCE
The third prepaid insurance project suggests such low ambulatory use among migrant labor families in general. The East Coast Migrant Entitlement Project (ECMEP),'6 based in Palm Beach County, Florida, serves 755 families of about 2,000 individuals. Seventy-five per cent of the enrolled population is Black and 24 per cent is Spanish-surname. Although no age/sex use is available from ECMEP reports, they recorded average ambulatory rates of 2.21 and 2.38 encounters per person in 1975 and 1976-similar to the Texas projects' rates despite an extensive and active outreach effort in the Florida program. However, in a recent study of migrant labor family hospital experience, Enger, et al,'9 found the major difference between migrant and general populations to be that overall migrant hospital use was slightly lower, but considerably lower for males. They concluded that hospital utilization by migrant workers and its associated costs do not differ greatly from national norms, and that cost and use appear most affected by geographical location and third party payor arrangements. In short, the enrolled Laredo migrant's hospital experience, in contrast to ambulatory care, did not differ greatly from that of other hospital users in the Southwest. The assumption that the Laredo migrant would approach national norms of ambulatory use when economic barriers to care were reduced or removed was not realized. Some of the low use recorded may be due to project reliance on provider data. Yet a large number of additional claims would have to be received to make an appreciable difference in average encounter rates and, based on a review of Blue Cross/Blue Shield experience, it is not believed that many claims are outstanding. Given the relatively equivalent hospital use reported by Enger,'9 a suggested explanation is that there are fewer "worried well" among the Laredo migrants and that they use services only when they define themselves as needing professional care. Survey information presented by Shearer*** also indicated that some to many enrolled individuals did not seek care when ill, that others used selfmedications purchased in pharmacies in the U.S. and Mexico,t and that a few reported using traditional healers such as curanderos and herbalists. Others reported using some private physician services in Mexico. Such use would not be included in the low rates reported. Of greater concern to project personnel was the nonreporting of any out-of-area public clinic use for two years. In each project year, reporting forms were sent to each migrant program in the nation requesting notification if any Laredo enrollees were served; none were returned. In addition, each family was provided each year with ten stamped, addressed postal cards on which to report public facility visits. Many cards were returned, but they reported only on contacts with private providers. Unverified anecdotal evidence ***Shearer CJ: Comparability of Health Information from a Household Survey and Insurance Claims. Unpublished Master's Thesis, The University of Texas Health Science Center at Houston, School of Public Health. June 1975. tAntibiotics and non-narcotic drugs requiring prescriptions in the United States can be purchased without prescription a short walk across the international bridge in Nuevo Laredo, Tamaulipas, Mexico. AJPH July, 1979, Vol. 69, No. 7
suggests that out-of-area services provided through general public facilities and by special federal programs, i.e., Migrant Head Start among others, are preventive in nature and the migrant families see their greatest needs during migration for curative services. They may not use out-of-area public facilities because of prior experience with residential requirements, or because they believe that curative care is not available, or simply because they are not aware of what curative public services might be available when needed. In summary, the objectives of the program were to determine the kinds and coststt of health and medical care that would be used by a population of Mexican American migrant labor families where the services could be obtained at low or no cost through prepaid health insurance. During the three years of the program, ambulatory use was recorded at levels lower than expected by program personnel although hospital utilization approached regional norms. Most unexpected was the finding that no public facility use was reported or recorded out-of-area in the second two years. The data available here, derived from provider sources, strongly suggest the need for additional research into why the enrolled migrants use or do not use public or private services and why they use so few services during their times of migration.
ACKNOWLEDGMENTS The research was conducted partially under DHEW Grant No. 06-H-000113-13. Maurice A. Click and Christopher Bosman-Clark were the project programmers and made orderly a mass of disordered data, translating claims information into encounter information.
REFERENCES 1. Bice TW, Eichorn RL and Fox PD: Socioeconomic status and use of physician services. Med Care 10:261-271, 1972. 2. Age Patterns in Medical Care, Illness, and Disability. U.S. Department of Health, Education, and Welfare, PHS, HRA, Na-
3.
4.
5. 6.
7. 8. 9.
10.
tional Center for Health Statistics. Series 10-70. Washington, DC, U.S. Government Printing Office, 1972. Health: United States 1975. U.S. Department of Health, Education, and Welfare, PHS, HRA, National Center for Health Statistics, DHEW Publication No. (HRA) 76-1232. Washington, DC, U.S. Government Printing Office, 1975. Anderson R and Benham L: Factors Affecting the Relationship Between Family Income and Medical Care Consumption, in Klarman HE, (Ed): Empirical Studies in Health Economics. Baltimore: The Johns Hopkins Press, 1970. Mechanic D: Sociology and public health: perspective for application. Am J Public Health 62:146-151, 1972. Montiero LA: Expense is no object: income and physician visits reconsidered. J Health and Soc Behavior 14:99-115, 1973. Rabin DL, Bice TW, and Starfield B: Use of health services by Baltimore Medicaid recipients. Med Care 12:561-570, 1974. Richardson WC: Measuring the urban poor's use of physician services in response to illness epidodes. Med Care 12:561-570, 1974. Greenlick MR, Freeborn DK, Colombo TJ, et al: Comparing the use of medical care services by a medically indigent and a general membership population in a comprehensive prepaid group practice program. Med Care 10:187-200, 1973. Sparer G and Anderson A: Utilization and cost experience of low income families in four prepaid group-practice plans. N Engl J Med 289:67-72, 1973.
t4Data about program costs are available upon request from the
author.
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WALKER
APPENDIX TABLE 2-Enrollment Totals at End of Each Study Year
11. Yesalis CE, III and Bonnet PD: The effect of duration of membership in a prepaid group health plan on the utilization of services. Med Care 14:1024-1036, 1976. 12. Shenkin BN: Health Care for Migrant Workers: Policies and Politics. Cambridge, Ballinger Publishing Co., 1974. 13. Farge EJ: La Vida Chicana: Health Care Attitudes and Behaviors of Houston Chicanos. San Francisco, C&E Research Associates, 1975. 14. Weaver JL: Mexican American health care behavior: a critical review of the literature. Soc Sci Q 54:85-102, 1973. 15. Continuation Application (unpublished). Catholic Charities, Inc., Harlingen, January 30, 1976. 16. East Coast Entitlement Project: Report After Two Years Experience. Palm Beach County, Florida, Health Department. August 1977. 17. Health Interview Survey Procedure, 1957-1974, Ntional Center for Health Statistics, DHEW, Series 1, No. 11, 1975. 18. The Nation's Use of Health Resources: 1976 Edition. U.S. Department of Health, Education, and Welfare. PHS, HRA, National Center for Health Statistics, DHEW Publication No. (HRA) 77-1240. Washington DC, U.S. Government Printing Office, 1976. 19. Enger I, Pindus NA, Marling CW, et al: Cost and Utilization: Migrant Hospitalization Program. Geomet Report No. HF-593, Final Report to Office of Planning, Evaluation, and Legislation, Health Services Administration, DHEW. January 1977.
APPENDIX TABLE 1-Family Enrollments at Beginning and End of Each Study Year* Beginning Year Number of Families
GROUP A 1973-74 1974-75 1975-76 GROUP B 1974-75 1975-76 GROUP C 1975-76
Number of Individuals
Study Year Sex
1973-74
1974-75
1975-76
0-14
Male Female Total
169 155 324
526 478 1,004
780 711 1,491
15-24
Male Female Total
117 102 219
371 319 690
509 484 993
25-44
Male Female Total
39 60 99
165 214 379
296 340 636
45-64
Male Female Total
52 34 86
176 146 322
248 241 489
65+
Male Female Total
-
4 2 6
11 3 14
TOTAL
Male Female Total
377 351 728
1,242 1,159 2,401
1,779 3,623
Age
1,844
APPENDIX TABLE 3-Combined Groups-Average Days in Migration and States to Which Migrated during Study Year
Ending Year Number of Families
Number of Individuals
State
Alabama Anrzona 100 96 94
760 702 659
96 94
91
728 659 615
334 290
1,999 1,742
290 267
1,742 1,595
300
1,571
266
1,413
*In addition to individuals in families no longer in the study because their families lost enrollment eligibility, 91 individuals were dropped from Group A over three years, 148 were dropped from Group B over two years, and 48 individuals were dropped from Group C. Of the 287 individuals dropped, 190 (66 per cent) no longer qualified because they married and began new families not eligible for enrollment. The number of individuals also reflects newborns added to eligible families.
Califdmia Colorado Connecticut Florida Idaho Illinois Indiana Kansas Maryland
Michigan Minnesota Missouri Montana Nebraska Nevada New Mexico New York North Dakota Ohio
Oregon Pennsylvania Tennessee Texas Utah Washington Wisconsin Wyoming Unknown
TOTAL
Number of Individuals
1
16 129 181 8 28 174 109 108
Number of
Days
71 858
18,932 17,415 1,224 1,602 23,963 15,196
Average Days Migration
71 54 147 96 153 57 138 139
8,926
83
120 876 20,042
120 125 99
39,300
81
310 1,015 12,187 825 840 4,383 42,901 4,452 1,585 87 50 35,463 6,337 4,395 26,938 9,839 61
44 78 90 75 84 115
1 7 203 488 7 13 136 11 10 38 392 70 21 3 1 360 45 28 335 148 1
3,072a
300,193
109 64 75 29 50 99 141 157 80 66 61 122.13
aTotal number is greater than the number of only those who migrated (2,458) since some individuals worked in more than one state.
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AJPH July, 1979, Vol. 69, No. 7
