The 1,476 patients served by the I lealth Links program over the two-year period were primarily from among the working-poor and unemployed residents of Franklin County (Table 1). By self-report, just over half were employed. The vast majority (78.5%) were adults ages 20-64. Just under 2(Y/c were <19 years old, and only 2.1 % were ages 65 and older. A low level of literacy was not uncommon, judging by the fact that many patients required help in completing registration paperwork. Virtually all were Franklin County residents; fewer than 1% were homeless or from a town outside of the county All 26 towns in the county were represented in the Health Links patient population.
These demographics in part reflect the pattern of health insurance eligibility in Massachusetts. During the two-year period, anyone 65 and older was eligible for Medicare and all children younger than age 12 from low-income families were theoretically eligible for MassHealth (the state Medicaid program) or the Children’s Medical Security Program (a state-funded insurance program). More recently, age eligibility for these two programs has expanded to cover adolescents up to the age of 18.
Of the 1,476 unduplicated patients, 10.4% had gross annual family incomes >$22,000, according to self-report. These individuals did not meet the income eligibility criterion for the program but still received services because they were uninsured or underinsured.
Family size. Of those reporting family size, about half (48.2%) reported living in families of two to four people, while 41.1% reported being single, living alone; 154 individuals did not respond to this question.
Employment status of working-age adults. Just over half (54.4%) of the 1159 adult Health Links clients ages 20-64 reported being employed. Among those who were employed, 62.2% reported holding part-time jobs and 37.8% reported working full-time.
Race/ethnicity. The Health Links program collected data on “race’Vethnicity in order to comply with federal funding requirements. Ethnic identification was not reported for 12 individuals. By self-report or report of par-ents/caregivers, the overwhelming majority of Health Links clients (1320/1464, 90.2%) were “Caucasian.” According to county statistics, which use racial/ethnic categories quite different from those used by Health Links staff, 97.7% of Franklin County residents self-report as “white” (Unpublished data, Franklin Regional Council of Governments Planning Department, 1996).
Health Links saw higher proportions of minorities than exist in the general population. Specifically, by self-report, 2.5% of Health Links clients were “American Indian” (no analogous category exists in county population statistics); 1.2% were “Black American” (0.7% in the county overall); 3.1% were “Hispanic” (1.2% in the county overall); 0.9% were “Asian” (no similar category for the county overall); and 2.2% fell into the “other” category (1.2% in the county overall). Overall, 9.2% were nonwhite in a county where only 2.3% of the general population is nonwhite. It is likely that this reflects a greater racial and ethnic diversity among the low-income population than among other population groups and more poverty among racial and ethnic minority groups than among white residents of Franklin County, as elsewhere.
Recipient status for other benefits. The Health Links intake form asked patients whether they were receiving benefits from any of the following publicly funded income support or health insurance programs: MassHealth (Medicaid), Medicare, Social Security Disability or Supplemental Security Income (SSI), or unemployment compensation. A total of 208 (14.1%) reported other beneficiary status; among them were 72 with Medicaid coverage (4.9% of all patients), 38 with Medicare coverage (2.6%), 60 receiving Social Security Disability or SSI payments (4.1%), and 38 receiving unemployment compensation (2.6%).
Health care access markers. Finally, Health Links patients were asked whether they had any health insurance coverage, whether they had an ongoing relationship with a primary care provider, and whether they had been seen in the hospital emergency department within the previous two years. (See Table 1.) Not surprisingly, substantial majorities reported having no health insurance (89.9%) and no primary care provider (81.4%). Many of those who had primary care providers came to Health Links after having accumulated substantial back bills with their physicians’ offices and being told that they could not be seen again until these accounts were settled.
Questions of access to the existing system are raised by the fact that 7.5% of all patients had Medicaid or Medicare coverage. Why these patients presented to Health Links rather than going directly to a medical office is a question warranting further investigation.
One important consideration is whether there are cultural access barriers within the existing local health care delivery system independent of financial barriers. For example, during the study period no health care facility in Franklin County (including the hospital and Health Links itself) had any formal medical Spanish interpreting capacity.
Nearly 40% of patients reported having gone to the local hospital emergency department within the two years prior to their initial presentation to Health Links. An analysis of the emergency department and inpatient records of the Health Links population, had it been possible, would have been useful in beginning to sort out how many of these emergency department visits could have been avoided with access to routine primary and preventive care.