HEALTH CARE BARRIERS ACCESS AMONG MEDICARE BENEFICIARIES
B.A., California State University, Sacramento, 2008
Submitted in partial satisfaction of the requirements for the degree of
MASTER OF SOCIAL WORK at
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
HEALTH CARE BARRIERS ACCESS AMONG MEDICARE BENEFICIARIES
A Project by
__________________________________, Committee Chair
Maura O’Keefe, Ph.D., LCSW
Student: Linda Buggs-Knight
I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the Project.
__________________________, Graduate Coordinator ________________
Teiahsha Bankhead, Ph.D., LCSW Date
Division of Social Work iii
HEALTH CARE BARRIER AMONG THE MEDICARE BENEFICAIRES by
Medicare is a health insurance program signed into law in 1965 under the Social Security
Act, providing universal medical coverage for people age 65 and over or with disabilities.
It has been 75 years since the signing of Social Security Act and 45 years since Medicare became law. Since its inception there have been many changes to the program and beneficiaries face barriers in accessing Medicare services. There has been little research on knowledge of Medicare policy rules and procedures or reasons for the limited knowledge of the Medicare program. Health literacy, language and unfamiliarity with technology have been identified as obstacles accessing Medicare coverage. The purpose of this study is to examine Medicare beneficiaries’ level of understanding about the
Medicare program. Thirty individuals who are currently enrolled in the Medicare program participated in the study. The participants completed a 30 question survey designed to test their knowledge of the Medicare program and Medicare services.
Descriptive statistics were used to analyze survey results. The findings indicated that
10% understood the Medicare program while the other 90% thought they understood the
Medicare program. However after administrating a quiz on the Medicare parts A, B, C iv
and D, results showed they were not knowledgeable about the Medicare program. None of the socio demographic variables were found to be associated with knowledge of
Medicare. The implications of the study were discussed and future recommendations for social work and social policy were provided.
_______________________, Committee Chair
Maura O’Keefe, Ph.D., LCSW
This is dedicated to family members: my grandmother, Marie Harmon, and my aunt,
Samuella Oliver, who inspired me to achieve my journey. To my father and mother, Fred
F. Buggs and Maude Amelia, my sisters in Christ: Cheryl Lynn Wilson, Ida Connors, my brothers in Christ: Fred F. and my belated brother George. My beloved and precious daughter, Arcella Keys Trimble Ph.D., my grandchildren: Kaila and Kareem Trimble. My nieces: Terisa Thurman, Stacy Norman, La Rita Jackson (Lady Warriors), Kamika,
Lynna Norman, and Denise. My nephews
Leslie Thurman, Lawrence Shelby, Steven
Flowers, and Marcus Flowers. My first cousins: Victoria Sloan Ph.D., Brenda, Jackie,
Shuron, Mary, and Jerome. Also, this is dedicated to a circle of friends: Robert McHugh
(Woffee), Michael Dooley, ( The Godfather), the Wicked Wheels of Oakland and
Sacramento, Albert Clayton and family, Donald Burns, Willie Frank Knight and Anthony
Knight, John Adam Knight, Audrey Knight and Andrea , Michael and Karen Shelby, the
First 5 Sacramento field instructor, Debra Payne and the staff, Bernard and Rita Keys,
Elizabeth Harrison, Clifford Trimble, Bobby Miller and family, Charles Cason,
Katherine, Rachel and family, To a special friend: Patricia Kane, the churches: Holy
Assembly in Marina, and the New Hope Baptists Church in Salinas, the following organization: Western Services Workers Association , All of Us or None, and Life
Support Alliance. vi
We love you and we miss you
Departed: Jeffery Piece and Frank Quigley Marshall Miller, (Gary, Indiana Roosevelt class of 1968), Foster Parents: Beulah and Clifford Pryor and Foster brother: Robert
Pryor, Family: Inez Leona Keys, Shirley Bobo, Mattie and Jessie Sr. Knight, Lucy
Clayton and Albert Clayton Jr., Aggie Burns, Stephanie Stewart, Aunt Florence and
Cousin Ralph Parks, Cousin Sterling, Reverend Newman, California State University.
Sacramento, Wandarah Anderson (Division of Social Work), Carolyn Stewart (Division of Social Work) vii
I would like to acknowledge my “Lord, Jesus Christ the Savior”. Also, I want to give thanks to my advisor Professor Maura O’Keefe. I want to extend a special acknowledgment to these belated, Wandarah Anderson Ph.D., and Professor Carolyn R.
Stewart, who did encourage me to complete my mission. In addition, I would like to also acknowledge my professors: John Strother, Grace Cole, and the Division of Social Work at the California State University, Sacramento.
“The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy”.
Martin Luther King Jr
Strength to Love, 1963) viii
TABLE OF CONTENTS
Dedication .......................................................................................................................... vi
Acknowledgements .......................................................................................................... viii
List of Tables .................................................................................................................... xii
List of Figures .................................................................................................................. xiii
1. THE PROBLEM ............................................................................................................ 1
Background of the Problem .................................................................................... 2
Statement of Research Problem .............................................................................. 4
Purpose of the Study ............................................................................................... 5
Research Questions ................................................................................................. 5
Theoretical Framework ........................................................................................... 6
Application of Ecological-Systems Theory ............................................................ 8
Definitions of Terms ............................................................................................. 10
Assumption ........................................................................................................... 11
Justification ........................................................................................................... 11
Limitations ............................................................................................................ 12
Summary ............................................................................................................... 12
2. REVIEW OF THE LITERATURE ............................................................................. 14
Introduction ........................................................................................................... 14 ix
History of Social Security Act and Medicare ....................................................... 14
Amendments of Social Security Act ..................................................................... 15
Medicare (Title XIX) 1965 ................................................................................... 16
Barrier-Limited Knowledge .................................................................................. 18
Barrier-Health Literacy ......................................................................................... 23
Barrier-Income (out-of pocket expense) ............................................................... 27
Barrier-Language .................................................................................................. 28
Barrier-Unfamiliar Technology ............................................................................ 32
3. RESEARCH METHODOLGY ................................................................................... 36
Introduction ........................................................................................................... 36
Design ................................................................................................................... 37
Research Questions ............................................................................................... 38
Variables ............................................................................................................... 38
Participants ............................................................................................................ 39
Instrumentation ..................................................................................................... 40
Data Gathering ...................................................................................................... 40
Protection of Human Subjects .............................................................................. 40
Summary ............................................................................................................... 41
4. ANALYSIS OF DATA................................................................................................ 42
Introduction ........................................................................................................... 42
Demographics of Respondents ............................................................................. 42
Health Condition ................................................................................................... 45 x
Technology Familiarity ......................................................................................... 49
5. FINDINGS AND RECOMMENDATIONS................................................................ 51
Introduction ........................................................................................................... 51
Major Findings ...................................................................................................... 51
Implications for Social Work and Policy .............................................................. 54
Recommendations ................................................................................................. 55
Conclusion ............................................................................................................ 56
Appendix A. Survey Questionnaire .................................................................................. 58
Appendix B. Consent to Participate in Research .............................................................. 62
References ......................................................................................................................... 65 xi
LIST OF TABLES
1. Table 1 Social Demographics………………………………………………….44
2. Table 2 Health Condition and Disability………………………………………45 xii
LIST OF FIGURES
1. Figure 1 Understanding the Medicare Program………………………………46
2. Figure 2 Medicare Parts Quiz Results………………………………………...49 xiii
The health care industry has become a complex system, especially the Medicare program (Title XVII under the Social Security Act.) The Medicare program covers 95 percent of the nation’s aged population as well as people on Social Security with disabilities (Annual Statistical Supplement, 2007). Medicare is a public payer of healthcare services Medicare providing health insurance to the elderly, retirees and the disabled
(Medicaid and Medicare 2011). Medicare was intended to protect Americans against the
“hazard and vicissitudes of life” (Hacker, 2006). Since the Medicare program has changed and expanded, it faces many barriers for the population it serves. These populations are growing; the aged and disabled are living longer with the advancement of healthcare technology and need additional health care services. The problem is that the health care industry is not meeting the growing need of the population due to disparities such as language barriers, lack of knowledge about the health care program, lack of income, and advancements in information technology. As a result, this population is hindered from accessing and utilizing health care services.
The focus of this study is to describe some of the difficulties Medicare beneficiaries may encounter in understanding their coverage and accessing health care services. Navigating the health care system under Medicare has become a complex maze.
The researcher chose this topic to increase awareness of the difficulties Medicare beneficiaries face in the hopes that change will occur and that the transition into Medicare
2 for future beneficiaries will be less complicated.
There are many American citizens who have never worked due to disabilities or other reason who the eligible to receive Medicare. This researcher, like others, has paid into the health care system and feels entitled to receive the best health care possible when the time comes. The researcher anticipates that health care will change due to Obama’s
Health Care Reform new health policy. This will impact the health industry forcing the health administrator to reexamine social and health policies and how they can better communicate Medicare policies to the Medicare beneficiaries so they can utilized their health coverage successful.
Background of the Problem
Germany became the first nation in the world to adopt an old-age social insurance program, in 1889 by Germany's Chancellor; Otto Von Bismarck Bismarck’s idea was drafted by Germany’s Emperor, William I in 1881. William wrote:
those who are disabled from work by age and invalidity have a well-grounded claim to care from the state
Bismarck introduced the social insurance to Germany in order to both promote the well-being of workers in order to keep the German economy operating at maximum efficiency, and to stave-off calls for more radical socialist alternatives (www.ssa.gov,
2011). Bismarck was called a socialist for introducing these programs, as would
President Roosevelt 70 years later. In his own speech to the Reichstag during the 1881 debates, Bismarck said,
Call it socialism or whatever you like. It is the same to me
Seventy years later, the United States under President Roosevelt adopted a similar model. (www.ssa.gov, 2011).
The Social Security program began because of the bleak condition created by the
Great Depression in the 1930’s during which there were high unemployment and economic stress nationwide. The need to provide paid benefits and health care to
American people had become extremely important because of economic hardship. After the Great Depression many programs such as the Public Works Administration were created to provide economic stimulus such as the Works Progress Administrations which provided jobs to build roads, building, and dams giving the Americans hope and income to sustain a living (American History, 2011). The Medicare program known as Title XIX was created in 1965 under the Social Security Act. This program was designed because of limited health insurance and high cost of medical care. .
Originally the Medicare program benefit was designed for the primary worker to have health coverage when he or she retired at age 65. Benefits were to be based on payroll tax contributions, the tax contributions would be placed in an insurance fund so that the worker would be able to have health insurance from 65 on. In order to be eligible for the Medicare benefits, the worker must have a payroll contribute of a period of 40 quarters or 10 years. It provided health insurance for retirees, disabled workers, their spouse and dependent children and for certain decease survivors. As the Medicare program began to expand in coverage and benefits, increasing availability to needy participants, the program also became increasingly complicated. Amendments to the Medicare program and additional changes contributed to the confusion.
In addition to people living longer there was an increase in eligible immigrants.
Amendments included those that provided for survivor and dependent benefits. In the
1970’s, automatic cost of living adjustments for Social Security recipients to protect the benefits from losing value to inflation and expansion coverage to two additional high risk group which included the disabled person and a person who suffers from end-safe renal disease.(www.ssa.gov. 2011).
In 2003, the Medicare Prescription Drug Improvement and Modernization Act into law, allowing the elderly and the people living with disabilities a prescription drug benefit. The new healthcare reform signed by President Obama, March 30, 2010 is another amendment that will change how health care policies will gives everyone health coverage under the Patient Protection and Affordable Care of 2012.. The new health reform will impact Medicare beneficiaries and how the Medicare will change making the health care system a complex and difficult to understand (www.ca.ili.org/healthreform,
Statement of Research Problem
The Medicare program has become so complicated that few people understand its rules and coverage. Barriers such as lack of understanding of program rules and coverage impacts access to health care services. Medicare beneficiaries’ knowledge of program rules and regulations has received little attention because of consist changes in
Medicare policies. This creates barriers affecting Medicare beneficiary’s health care. It is important to address these because as a person who paid into the Medicare system, we
5 want to be able to transition from our old health care plan into the new without any disruption.
Purpose of the Study
The purpose of this study is to examine Medicare beneficiaries’ knowledge of the
Medicare program as well as barriers that may impede their health care access.
Specifically, this study examines Medicare beneficiaries’ knowledge of their coverage, health literacy, possible language barriers as well as their familiarity with information technology.
The secondary purpose is to increase awareness of the Medicare programs’ problems and possibly bring about social change. According to Blau (2008), change in social polices generally arise out of conflict and tension. It is hoped that increasing awareness of the problem with result in more people being concerned and taking political action to improve the communication between the Medicare beneficiaries and Medicare services
This study investigates the following research questions:
1) How knowledgeable are Medicare beneficiaries regarding Medicare coverage?
2) What factors are associated with greater knowledge of the program?
Ecological-systems theory emphasizes the importance of the relationship between people and the systems in which they function. This approach defines the behaviors and strengths of individuals and identifies the support system that surrounds them.
Ecological-systems theory is a combination of two theories, ecological theory and systems theory. Ecological theory may help to explain how people’s knowledge of their health benefits affects their utilization of health care services. Grief (1986) states that systems theory explains the specific interactions that are taking place when systems are joined together. This theory postulates that a change in one person signals a change in others who have contact with that person. This theory also identifies the social worker as an important part of the client’s system.
The ecological-systems theory explains human system functioning. Specifically, it emphasizes the following: what factors are associated with less informed subject about the Medicare program. First, it presents human beings as systems interacting with each other in context. Humans are described as complex beings, including biological, psychological, social, and cultural aspects. Second, this theory emphasizes the importance of human system connections and “the process by which people continually shape their environments and are shaped by them over time” (Germaine, 1983, p. 115).
Third, this theory shows the interaction that is developed in response to internal and external forces. These evolutionary changes are affected by the contextual influences.
Along with social groups, organizations, and institutions, contextual influences include cultural identities, race, ethnicity, socioeconomic, and gender. Fourth, ecosystem theory
7 analyzes the behaviors of individuals with regard to adapting to situations. Fifth, this theory shifts the focus from individual pathology to the possibility of a broken or out-offunction ecological system. Individuals respond differently to internal and environmental situations. If an individual is not succeeding in one environment, he/she may thrive in another. Finally, there are many options for change within individuals and their environment. Thus, it is important to focus on the strengths and abilities of individuals and apply them to their environment. Miley (2004) states the strength approach is an essential tool for the ecological-systems theory.
There are three main reasons to use the ecological-systems perspective as a guide for this study. First, because it is an integrative approach, the ecological-systems approach draws from the strengths of many other theories. Second, the behavior of individuals, families, groups, organizations, communities, and their interconnected relationships are considered. Third, the view of the ecosystem concentrates on how people care for their health living in their environment. By focusing on the problems of the client within their environment or situation, the practitioner adapts a more accepting view of the client instead of focusing on their deficiencies. According to Bronfenbrenner
(1989), the ecological-systems theory also involves three levels of systems, which consist of the microsystems, mesosystems, and macro systems.
Microsystems are the broader influences of culture, subculture, and social structure (Hutchison, 2003). Mesosystems is the local Social Security Office where the
Medicare beneficiaries ally and get Medicare information. Another mesosystems is the hospitals, the clinics and the health care provider and the health care worker who
8 provides services to the public. From the macro system the Medicare program is funded through the federal government to insure health care coverage for the eligible person
From an ecological-systems perspective, individuals play an important part in shaping their own lives, but are restricted by the environmental forces and health conditions (Miley, O’Melia, & DuBois, 2004). This is particularly relevant to the present study because it helps the social worker to understanding the nature of health insurance and the impact it has on Medicare beneficiaries’ having a significant element of social work practice.
Application of Ecological-Systems Theory
Ecological-Systems theory guides this study in a number of ways. Medicare beneficiaries are viewed at the center of series of concentric circle from the micro level to the macro level each of which affect the individual. On the micro level individuals rely on the government to assist them through the Medicare system process. The micro system involves assessing clients’ biological, psychological, and social attributes in relation to their own health. Instead of focusing on the pathology, dysfunction, symptoms, disease, and diagnosis using other models, a strength-based approach will highlight the positive aspects of clients and help identify the resources that will be beneficial their environment (Roberts & Green, 2002).
The second level is the mesosystem. This level involves interrelationships between people in most areas of their life. These relationships include family members, neighbors, friends, and acquaintances with whom they interact on a daily basis. The mesosystem level also includes the doctors and hospital in their community. As a social
9 worker, it is important to utilize these individuals, because they can be an enormous source of information regarding the strengths and weaknesses of the client and the social supports and barriers that affect their lives in the medical world. The social worker is also a part of the client’s mesosystem as an advocate to insure the client receives quality medical attention.
The third level is the exosystem. Although this level does not directly affect the client, there is an indirect influence. The ecosystem level consists of institutions, organizations, such as health care providers and Department of Mental Health maintenance, the Social Security Administration and other clinical agency to assist them with health care benefits. In order to help our client receive medical coverage, the clients need help navigating through the paper work and red tape that may hinder the client from receiving good medical treatment.
The final level of the ecological-systems theory is the macro system. This includes all the State and Federal level politics, policies, economics, guidelines, and laws that govern a client within the system. This level also encompasses the client’s culture, subculture, and social regulation (Hutchison, 2003). At this level, it is important for social worker to advocate for the political equality, civil rights, and welfare of our clients.
It is important that the social workers understand their clients with regard to the healthcare system and the client as an individual. As a social worker, I’m concern about social justice and advocate for social inequality for the ones who are unable to fight for themselves. This study will show social inequality among the Medicare beneficiaries concerning their health care.
Definitions of Terms
The following terms are used throughout this project:
Medicare beneficiaries are defined as a person who eligible to receive Medicare benefit.
Medicare (Title XVII) is health insurance program designed under the Social
Security Act in 1965 that reimburses hospitals and physicians for medical care provided to qualifying people who are 65 or older, under age of 65 with certain disabilities and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). Medicare has four parts: Part A, B, C and D.
Social Security Act of 1935 was created during the Great Depression during the economic clasped. It is a federal funded government program that provides cash benefits to program whom that have retired, unemployed, or unable to work.
Health Insurance is insurance against the risk of incurring medical expenses. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity.
The Center of Medicare and Medicaid is a federal agency within the United States
Department of Health and Human services that administers the Medicare program.
Social insurance is defined an insurance program approved or mandated by a government to provide economic assistance.
Amendment is defined as change to legal document or alteration to a motion, bill, or constitution. The Social Security Act has had a total of 20 amendments since
Health Literacy is is an individual's ability to read, understand and use healthcare information to make decisions and follow instructions for treatment.
Out-of-Pocket Expense is defined as an expense incurred and paid for by an individual for personal use. It is a financial expense that the person paid that is not coverage under their health plan coverage.
Information Technology is defined as a development, installation, and implementation of computer systems and applications.
The assumptions to be considered in this study include: 1) Subjects in the study are presumably able to understand and have no apparent challenges to their cognitive ability. 2) Aside from English being a second language, with certain subjects, there are no other issues regarding the subjects’ cognitive ability. 3) Financial resources may hinder clients from seeking medical treatment. 4) Accessibility to online sources for information may be limited
The ethical standard in the National Association Social Worker responsible of social worker to the client is to pursue the understanding cultural competence such as understanding the concept of culture and appreciated the strengths inherent in all diverse
12 culture. Social work ethical responsible to the social work practice in a broader society is encourage and assist public involvement in formulating social policies and to see fair and equal access to resources and opportunities to support policies to improve the human conditions and promote social justice ((Kirts-Ashman, Hull 2006).
The study had limitations. One of the limitations was the sample size. There were
30 Medicare participants that were convenience who participated in the study. The researcher only accessed participants from Adult Day Care centers in Sacramento, Ca.
The findings cannot be generalized to other areas or Medicare beneficiaries. The scales selected for this study have validated on a small sample of Medicare beneficiaries. The survey which was written in English would require the participants must know and understand English in order to take the survey.
Chapter One covers the history and principle of with the Medicare program and complication of accessing Medicare services for Medicare beneficiaries. The topic of this study and to bring awareness to the public regarding barriers to healthcare access among
Medicare beneficiaries included Medicare program, implementation of Medicare, the design, theoretical framework, definitions of terms, assumptions, and justifications.
Chapter Two reviews the literature on Medicare Program and its origins.
Specifically covers an historical perspective of Social Security Act, and the amendment of Social Security (Medicare (Title XIX), barriers such as limited knowledge, health
13 literacy, income (out-of Pocket expense), language and unfamiliar technology Medicare beneficiaries have faced in both accessing and utilizing services.
REVIEW OF THE LITERATURE
This review of literature will focus on the barriers Medicare beneficiaries face trying to access Medicare services. Previous studies have shown that access to health care has become a complicated process. After briefly outlining the history of the Social
Security Act and Medicare (Title XIX), this chapter will examine barriers that Medicare beneficiaries’ face, such as limited knowledge of the Medicare program, lack of health literacy, and unfamiliarity with technology.
History of Social Security Act and Medicare
Faced with unprecedented economic dislocation during the Great Depression in
1935, President Franklin D. Roosevelt saw the need and opportunity for an economic security bill to address unemployment and old age insecurity (see http://ssa.gov/history/fdrsign, 2010). President Roosevelt established the Committee on
Economic Security (CES), chaired by a social worker and the first woman cabinet member Secretary of Labor Frances Perkins. The CSE report provided the basis for the
Social Security Act of 1935 of which President Roosevelt said “We can never insure one hundred percent of the population against one hundred percent of the hazards and vicissitudes of life, but we have tried to frame a law that will give some measure of protection to the average citizen and his family” (see http://ssa.gov/history/fdrsign, 2010).
In the United States, Social Security refers to the program that provides cash benefits to retired and disabled workers, their spouses and dependent children, and certain survivors
15 of deceased workers. Social Security is sometimes used to describe the Old Age,
Survivors and Disability Insurance and Medicare program (Mizrahi et al. Social Security
Program, 2008). This social insurance approach to economic security protects against identifiable risk that could overwhelm the finances of individuals and families or loss of income due to death of a parent or spouse, disability, health care expense, retirement, or workplace injury (Mizrahi et al., 2008). Social security represents an ideal, a value to be achieved by a civilized society seeking to provide widespread basic protection against what Franklin D. Roosevelt called “the vicissitudes of life.” (See http://ssa.gov/history/fdrsign, 2010).
Amendments of Social Security Act
The amendment of the Social Security Act expands the protection to include retirees, domestic workers, farmers and women. Since the signing of the Social Security
Act of 1935, many changes in the economy and society have resulted in amendments to
Social Security. Incremental expansion from 1935 to 1975 brought about many changes to Social Security (Social Security, 2010). In 1950 Social security’s established social insurance as the nation’s dominant means of protecting older Americans against loss of income in retirement, including employed domestic workers and farm workers (Social
Security Act, 2010). Another amendment allowed women the right to receive social security benefits in 1956. The amendment also gave women the right to accept permanently reduced retired worker benefits between the ages of 62 and 64. In 1965,
Medicaid (Title XVII) and Medicare (Title XIX) were passed into law. Today, Medicare
16 is the largest public payer of health-care services in the nation, serving a population of
1.9 million people (Social Security Act, 2010).
Medicare (Title XIX) 1965
Social Security refers to the program that provides cash benefits to retired and disabled workers, their spouse and dependent children and certain survivors of deceased workers (Social Security, 2010). In 1965, the Social Security Act established the Health
Insurance Program (Title XVIII) which became known as Medicare (Title XIX) and was signed into law by President Lyndon B. Johnson (www.socialsecurity.gov/history/orghist,
2010). Medicare operates as a single-payer health care system. Medicare is administered by the federal government through the Center of Medicare and Medicaid Service.
Funding is provided through a combination of general funds, including payroll deductions and funds of the federal government (Center of Medicare and Medicaid
Service, 2010). The Medicare program covers over 30 million elderly and disabled people (CMS, 2010).
Medicare eligibility eventually was expanded into parts. Medicare has four primary parts: inpatient hospital insurance (Medicare Part A) ; supplemental medical insurance that helps pay for outpatient hospital, home health, skilled nursing facility, and hospice care (Medicare Part B);and Medicare Advantage called Medicare + Choice allows Medicare beneficiaries to purchase additional insurance (Medicare Part C); and prescription medication (Medicare Part D) (Social Security Act, 2010). According to the
Center for Medicare and Medicaid Service (2010), American citizens and permanent residents are usually eligible for Medicare under one of the following criteria:(a) they
17 have reached age 65, and they or their spouse had contributed payroll taxes to Social
Security disability for 40 quarters (10 years), (b) they are under 65 years of age and have received Social Security Disability Income or Railroad Retirement Board Disability payments for 24 months, (c) they are diagnosed with end-stage renal disease requiring dialysis or kidney transplant, or (d) they are diagnosed with amyotrophic lateral scleroses
Lou Gehrig’s disease (CMS,2010). The Medicare program has several components and therefore, understanding the Medicare program has been a challenge for many Medicare beneficiaries. This researcher will examine the relationship between the Medicare program and the barriers that Medicare beneficiaries’ face.
One of the barriers that eligible Medicare beneficiaries face is limited knowledge about the Medicare program and how to access medical information, while other
Medicare beneficiaries have no idea about their health care.
Harris-Kojetin, Uhrig, Williams, Bann, Frentzel, McCormack, Mitchell and West
(2007) conducted a research study that raises the question of whether Medicare beneficiaries realize they have adequate knowledge about the Medicare program. The purpose of this study was to educate working at white males who plan to transition from an HMO to the Medicare program. There were thirty-four participants with an average age of sixty-five. The participants were white, well-educated males. The study was conducted to educate people approaching age 65 about their Medicare health plan options, and to incorporate information on the quality of care and services provided by other health plans. Each organization present did a presentation given by Human
Resource personnel. Human Resource personnel explained to the participants how to understand their Medicare options by giving them “different choose with care products and how they were developed” (Harris-Kojetin et al, 2007). This focus group was given information by a human resource employee explaining their Medicare and health insurance. After the presentation, the participants were confused about the Medicare program and their benefits. Human Resource employees were unable to give the participants' out-of pocket expenses or and explain their eligible status. An interview was conducted with the participants after the presentation. The participants felt that the company should have brought in a representative from the Social Security office. The
19 findings indicate that working Americans were baffled and discontented about the
Medicare information; they felt the company did not provide accurate information about their future benefits. The other challenge was the confusion about the coordination of benefits. This is relevant because in response to these findings the research group developed the “Choose with the Care Part 1” program to educate the participants about the basics of Medicare and how Medicare works. This study proves that even working, educated people have difficulties understanding their options in the health care system.
Another study conducted by Bann, and his colleagues (2004) examined the
Medicare-related knowledge and information gathering of beneficiaries who received decision-making help from a caretaker. The purpose of this study was to evaluate the
Medicare knowledge and information-gathering of beneficiaries who received help with the insurance decision. Data was drawn from the 2000 Medicare Curry Beneficiary
Survey (MCBS). A national sample of 14,000 or more non institutionalized Medicare beneficiaries interviewed every 4 months for up to 4 years. Participants were administered questions on health insurance, service utilization, experiences, and their knowledge of the Medicare program. Total of 11,987 beneficiaries’ and 1,401 proxies completed the MCBS survey. The MCBS surveys computed beneficiaries’ awareness and uses of information sources, in understanding of the Medicare program and their confidence in decision-making about Medicare. Results indicated that beneficiaries who received help with health insurance decisions have lower knowledge of the Medicare programs and are less likely to use the information sources than beneficiaries who make their own decisions. Sixty-eight percent of beneficiaries made their own health insurance
20 decisions. Twenty-four percent received help, and nine percent was so disabled that their
MCBS surveyed response was conducted by proxy. According to Bann et.al. (2004), the beneficiaries who receive help with their insurance decisions may have limited Medicare knowledge and may not be aware of the resources that could help them. The result from this study suggests the need for further education, and outreach directed at all Medicare beneficiaries and their decision helpers.
Hibbard et al. and colleagues (2001) examined how Medicare beneficiaries make informed choices about health care and health coverage. More than half of the Medicare population has difficulty using comparative health plan information after the information is presented. According to Hibbard et al (2001) making these decisions require skill in making decision basic on the data given. Older adult sought less information when it comes to their health care. The study compared the skills of Medicare beneficiaries and non Medicare beneficiaries in ability to interpret information and determine whether using information is related to their attitudes or other factors making in decision about health care choices. Participants were 65 and older Medicare beneficiaries, and non
Medicare beneficiaries ages 18 to 64. Participants in both groups reviewed the same information and completed tasks related using to making health plan decisions. In delegating health plan decisions the findings showed five predictor variables used in the study are: the degree to which plan choice is viewed as burdensome; the desire to delegate a health plan choice to experts; the desire for choice and seeking decision assistance from a “knowledgeable person”; and a screening index based on age, education and self related health issues (Hibbard et al., 2001). The findings indicated
21 striking differences between the Medicare beneficiaries and the younger sample in the ability to use information accurately. Medicare beneficiaries made 25% more errors compared than to the younger sample with 9%. The results indicated that the elderly consumer has much more difficulty accuracy using comparative information about their health plan than the non elderly. Given that the larger proportion of the Medicare population was having difficulty using the comparative information, they suggested an investigating an approach to make the information easier to understand and more accessible to lower skilled beneficiaries, identifying those most in need and providing assistance, and finally simplifying the task of beneficiaries in Medicare decision making by having fewer types of plan designs to choose from ( Hibbard et at, 2001). Medicare beneficiaries need more information and support during their transition from their health plan to the Medicare program.
Another study conducted by Greenwald, McCormack, Uhrig and West examined past research indicated that Medicare beneficiaries have limited knowledge about
Medicare and related health options programs. Most beneficiaries have an understanding at least some the concept related to Medicare (Greenwald et al., 2006). This study reviewed the factors that limit Medicare beneficiaries’ knowledge of health options and suggested that knowledge readiness to engage in making health care decision. The researchers suggested that the knowledge gained depends on the level of income. There were 1,673 participants ages 65 and over that took part of a telephone survey in five geographic county regions in Kansas City. Only 61% responded to the telephone survey.
Knowledge of the Medicare program was scored based on a 22-item scale. The scale
22 indicated that education was the factor that correlated the highest with knowledge and income was second (Greenwald et al., 2006). The finding indicated that lower education the less knowledge Medicare beneficiaries about the Medicare services. Another factor that showed having higher education the beneficiaries would have better knowledge about the Medicare program as a result received better care.
According to a study by Fitzpatrick, Powe, Cooper, Ives and Robbins that examined barriers to accessing Medicare, primary barriers included a lack of responsiveness to patient concerns, medical bills, and transportation among the Medicare beneficiaries. The method used to evaluate barrier in the study were the questionnaires designed by Cardiovascular Health Study (CHS). Participants included 5,888 men and women aged 65 and older. Participants were randomly selected from Medicare eligibility lists in four communities. Data revealed problems of access among beneficiaries to receive quality services. Finding indicated the problem was the physical barrier such as shared cost, preventive care and transportation which preventive the Medicare beneficiaries from accessing quality health care. Another problematic factor was the doctor of responsive to concern patient health concerns. There were not following up appointment schedule, unless the patient requested it. As a result, an individual which visits the physician office was more likely to be younger, female and white., have an supplement medical insurance and higher income than a person who is over 65 of age, then a non white female with no supplement medical insurance. Another is cost for medical doctor visit and transportation. Cost to visit the doctor could the decision of
Medicare beneficiaries, whether to see the doctor or not. Reliable transportation is
23 another problematic factor that is a barrier for most Medicare beneficiaries. If the beneficiaries’ transportation is not reliable, or they are unable to travel across this affects their ability to keep their appointment. Data collected to evaluated access and barriers for
Medicare beneficiaries provides insight about the lack of responsive to the doctor, shared cost of medical visit and lack of transportation. The study reported radical disparities in the medical services among Medicare beneficiaries, and the out-of pocket.
One area where knowledge is particularly limited among beneficiaries is health literacy. According to the National Literacy Act of 1991, health literacy is defined as the inability to read, understand, and act on health information. This is a rising public health issue that affects all ages, gender, ethnicities and income levels. However, lack of language skills, education, and a low level of familiarity seems to be common a trait shared by people with low health literacy. The researcher shows that most consumers need help to understand health care information regardless of their level of reading. The strategy is to address low literacy skills examine one is the ability to complete forms, follow medication instructions, and interact with the provider (Public Policy Institute,
2010). According to Public Policy Institute 2010, there is the correlation between literacy and health care decision. Health expects to recognize the importance of literacy and health literacy (PPI, 2010). A study conducted using Test of Functional Health Literacy in Adult (TOFHLA) with Medicare beneficiaries over the age of 65 to test reading comprehension and numeric skills. The study indicated that patient with inadequate functional health literacy were more likely to report poor health than were patient with
24 adequate reading skills (Baker et al1997) and that adults with low literacy skill are hard to identity. Patient may be reluctant to reveal their difficulties to provide because of embarrassment or shame as the result this can lead to poor health services for the participants. The health of 90 million people in the United States may be at risk because of difficulty some patient experience in understanding and acting upon health information
(Social Security, 2010).
Morgan, Teal, Hasche, Peterson, Byrne, Paterniti and Virnigl (2008) examined the relationship between a global measure of Medicare program familiarity and a broad set of measures of actual and perceived healthcare access. Medicare beneficiaries face a number of difficulties in acquiring and using information about their Medicare benefits.
As a result, beneficiaries’ reported limited availability of materials that provides information about choices under Medicare, as well as a lack of knowledge regarding state-based and federally funded counseling programs. According to Morgan et al. (2008)
, “Health literacy is broadly conceptualized as ‘‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”. Research examining the association between knowledge about Medicare and measures of healthcare access and use has been limited
(Morgan et.al, 2008). According to the Medicare Current Beneficiary Survey (MCBS)
2009, items associated with aggregated costs of care, and knowledge of emergency department (ED) and physician office visit copayments, and knowledge of pharmacy benefits had been linked to using of those services. Knowledge about or familiarity with
Medicare benefits has not been linked to indicators of healthcare access or to satisfaction
25 with healthcare access. This study examined the relationship between self-reported measures of Medicare program familiarity and reported actual and perceived healthcare access, using data from a survey of white, black, and Hispanic Medicare beneficiaries.
The Centers for Medicare and Medicaid Services (CMS) approved the study methods. A mailed survey was conducted during the fall of 2004 White, Black, and Hispanic
Medicare beneficiaries (Morgan et, al, 2008). In this study Medicare beneficiaries indicated feeling unfamiliar with the Medicare system based on delayed care because of multiple emergency department
ED) visits, poor healthcare access, and cost of prescription medications. The beneficiaries who reported feeling unfamiliar with
Medicare had to struggle to access their health care. The findings of the suggested that beneficiaries’ familiarity with the Medicare program may contribute to that inconsistency by mediating beneficiaries’ ability to access care. This poorer familiarity with Medicare may affect beneficiaries’ ability to access needed care effectively, may lead them to delay or avoid seeking care, and ultimately may have a negative effect on their healthcare quality and outcomes (Morgan et al 2008).
Hanchete, Ash, Gazmanararian, Wolf, and Pasasche-Orlow, (2008) found in their study that approximately 90 million American adults is estimated to lack the literacy skills needed to use the health-care system. Limited health literacy is an independent risk factor for worse health status, hospitalization, and mortality (Hanchate et al., 2008). The
National Health Interview Sample (NHIS) is an in-person, nationally representative annual survey covering many healths related, demographic, and socio-economic measures .
Participants in the Prudential Medicare Study are HMO enrollees; those in the
NHIS include Medicare and HMO as well as Fee-for-Service enrollees. As these two types of NHIS enrollees may differ in terms of health literacy, socioeconomic status, and health indicators, they also examined the differences in imputed literacy scores in these cohorts separately (Hanchate et al. 2008). There were 2,824 participants in the Prudential
Medicare Study. The method the researchers used for the Prudential Medicare Study assesses the S-TOFHLA score, leading to a “reference standard” classification of 25% of people with inadequate literacy. The Prudential Medicare Study used data to derive a
Demographic Assessment for Health Literacy (DAHL) score, and imputed inadequate literacy to the 25% with the lowest DAHL scores. The Prudential Medicare Study concluded that social demographics are a factor that contributes to health literacy in adults. The DAHL was examined for how closely its association with the various health status measures approximates the association of the S-TOFHLA with that measure in the
Prudential Medicare Study
Besides the DAHL, which uses four SES indicators (age, sex, race, and education), they also examined an “education only” model, as well as models that added measures to the DAHL, including difficulty in reading and understanding forms at doctor visits, seeking help for reading forms at doctor or hospital visits, reading newspapers, and current employment status (Hanchate et al.2008). Finding indicated the S-TOHFLAbased health literacy score ranged from 0 to 100, with a mean of 73 and standard deviation of 26 in the Prudential Medical Study (Hanchete et.al 2008). White women aged 65–69 with more than 12 years of schooling receive a mean DAHL of 91.3, the highest possible imputed score. A participant with less schooling of older age, and other
27 races and ethnicities result in lower imputed health literacy. The lowest possible imputed literacy score is 15.6 found among Black males 85 or older with fewer than nine years of schooling (Hanchete et al. 2008).
Barrier-Income (out-of pocket expense)
Other barrier Medicare beneficiaries face is a lack of income due to having lost their job, disability, retirement or loss of spouse. Medicare beneficiaries’ income affects their ability to pay for their doctor visit, medication and other health supplies that are needed. Studies show that a lack of income is a barrier to accessing quality health care for most Medicare beneficiaries.
Havrada et. al examined how low income Medicare beneficiaries have a high outof-pocket medication expense that discourages adherence to treatment regimens. The
Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created a temporary drug discount card program to assist with medication expenditures for eligible beneficiaries. The purpose of this study was to examine low-income eligible participants living under the 150% of the federal poverty line (FPL) who subsidizes drug coverage. There were 137 participants without prescription coverage receiving (MMA) assistance from pharmaceutical companies for medication. Patients were stratified into three categories according to income, household size, and the federal poverty line as defined in the new Medicare Act signed by President George W. Bush in 2003. The researcher used pharmaceutical companies for the cohort and FLP categories to measure the result. Findings showed a base overview of benefits of the Medicare prescription drug, if the beneficiaries FPL 150%guideline income of $13,965 and asset $10,000 with
28 household of one, the monthly premium cost of sliding scale to $35 with $50 as the result the Medicare participant is unable to afford medication, or to seek medical services.
Thirty seven million Medicare beneficiaries are projected to enroll in the Medicare program (CSM, 2010). It is estimated that 11 million seniors are eligible for low-income benefits of the sustainable medical drug program, and the remainder will receive no assistance. The report states that estimated 2.37 million Medicare beneficiaries will qualify for low-income subsides but will be ineligible because of excessive assets. This study provides evidence that Medicare program barrier based on income, household size and FPL guidelines strengthen for barriers that Medicare beneficiaries face.
As the U.S. population ages, and immigration continue at its current pace, the need for policy remedies is likely to grow. Data from the 2000 United States Census reveals that about 2.3 million people 65 or older do not speak English or do not speak it very well (US Census, 2010).
Ponce et al. and his colleagues (2006) examined language barriers to health care access among Medicare seniors in California from 2001 to 2003. Researchers demonstrated that children and adults with Limited English Proficiency (LEP) experience difficulties accessing health care (Ponce et al., 2006). Language barriers can decrease the quality of care and patient fulfillment. The study collected two years of data (2001 and
2003) from California Health Interview (CHIS) administered by Center of Health Policy
Research. This data source used a health survey questionnaire and interviews either with an interpreter or a family member. The survey interview was conducted in English,
Spanish, Cantonese, Mandarin, Korean, Vietnamese and Khemer. There was a total of
18,948 participants in the study ages 65 and older. The purpose of the interview questions was to gauge the participant’s understanding of their health care coverage. Data analyzed in health care access in three measures; having a usual source of care; receipt of a mammogram among females; and receipt of a fecal occult blood test for colorectal cancer. The finding for having a usual source of care was 97%. There was a high rate of
79% for female mammogram receipt and 24% low rate of a receipt for an annual fecal occult blood test. The independent variable was the three language usage cohort; the individuals reported speaking no English (LEP), bilingual and English only. Results from this study indicate that LEP clients were likely to have a limited source of care compared to those who spoke English. Factors are due to poor health, low income, and not understanding medical term or treatment compare to Medicare beneficiaries who speak
English. Medicare beneficiaries with LEP were less likely to have a limited source of health care due to the language barrier. A Language barrier can reduce the quality of care
(Ponce et al 2006).
Another study submitted by the New Hampshire Advisory Committee identified why Limited English Proficient (LEP) participants have difficulty accessing health care.
In the New Hampshire Advisory Committee study the clients linguistically appropriate services and health providers receive quality care (NHAC, 2005). The investigation was assigned to the New Hampshire Advisory Committee to research the issue (New
Hampshire Advisory Committee, 2005). According to the US Census 2000, 98,088 New
Hampshire residents over the age of 65 other than English are spoken (NHAC, 2005).
Speaking a different language and having a difficult time communicating in English with health care providers resulted in poor health care. This report study shows several problems. One is the language barrier between the LEP and the health provider in accessing health services. Complaints were being made by citizens who because of limited English Proficiency because LEP clients do not communicate proficiently in
English, and they felt discriminated against (NHCA, 2005). For example, one study found the language barrier as significant as a lack of insurance due to the failure to access health care services by Latinos. A case study of a migrant worker from Mexico was committed to a psychiatric hospital and diagnosed as paranoid schizophrenic. The psychiatrist spoke to him in Spanish and English at one point; the man became agitated.
The psychiatrists concluded that the man had been hallucinating. After two years confined into an institution, they discovered the man spoke only Trique. With the help of a Trique interpreter, the psychiatrists diagnosed him as mentally sane and discharged him. More than $100,000 was wasted in unnecessary treatment (NHAC, 2005). Culture plays an important part in language barriers. Failure to provide professional care to those with LEP is a barrier to accessing the quality health care services.
Another researcher confirmed that the use of non-professional interpreters, whether a family member or untrained health cares staff is a potentially dangerous practice with miscommunication between the health care provider and the client. One study conducted using a taped exam of 70 Spanish speaking children in emergency rooms utilizing inaccurate translations resulted in negative consequences in this situation the client may resist treatment or not fully understand the medical term (NHAC, 2005).
Another study showed that the Hmong language has no word for cancer resulting in confusion when the doctor addresses treatment. Results indicated that with English speaking health providers and limited English proficient (LEP) patient, a professional medical interpretation service helps bridge the communication gap better than the untrained family members or bilingual staff people. Findings concluded that the health care providers in New Hampshire realize there is a growing need to make services accessible to those clients who do not communicate well in English. Despite this awareness, the need is only partially met and many of LEP, deaf and hard of hearing residents of the state continue to suffer from limited access to health care because of a lack of interpreters.
Spanish speaking Medicare beneficiaries can encounter to be the barrier a significant proportion of adults in the United States had difficulty navigating the health care system and managing personal health care issues (Lee, Stucky, Lee, J, Rozier and
Bender, 2010). Their study intended to compare health literacy test for Spanish-speaking and English-speaking populations. Researchers created an easy-to-use health literacy test, the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), for Spanish speakers. The field test was conducted with 202 English-speaking and 201
Spanish-speaking participants recruited from the Ambulatory Care Center at the
University North Carolina. Participants in the study had to meet the following special criteria: (1) be fluent in either English or Spanish; (2) be age 18 or older but not over 80 years old; (3) without obvious signs of cognitive impairment; (4) without vision or hearing problems; and (5) showing no sign of drug or alcohol intoxication (Lee et al,
2010). In taking this test, examinees are asked to read aloud of 18 medical terms and then associate each term to another similar word for comprehension. Results indicated even though the words were identified in Spanish SAHL result. It identified individuals with low health literacy scores. Spanish-speaking participants recognized the words but did not understand the meanings compared to English-speaking participants. Finding show most Spanish-speaking Medicare beneficiaries face barriers due to lack of understanding provided instructions, taking medications and understanding their health needs.
Technology is expanding in the health care field. More people are using technology to get many of their health questions answered. Hospital is expanding their database to the internet and today, Medicare beneficiaries can access their lab results, make an appointment, order medication, and communicate with their doctor using the internet. Medicare was introduced on the web in 1987, allowing members to fill out retirement forms, and other Medicare. (See http//:Socialsecurity.gov). Most elderly beneficiaries do not have computer training or familiarity with computer usage, causing difficulty in accessing online.
Zionts, N., Apter, J., Kuchta, J. and Greenhouse, P. (2009) conducted a study based on the need for Librarian to teach the public how to use the computer. According to a market survey, the public library is the first place many turn to when seeking health information (Zionts et. al. 2009). Health Information Fellowship offers training to librarians in the Pittsburg public library to help ensures the consumers have access to computers. The purpose of this is to obtain a certification, in order to assist the consumer
33 on how to locate health information electronically, which requires a degree of technical savvy and baseline health care knowledge that many people do not have. According to the American medical Association, poor health literacy is “a stronger predictor of a person’s health than age, income, employment status, education and race” (Zionts, 2009).
This study describes the barriers to locating health information, which includes access limitation and the inability to evaluate received information. Linn et.al, writing in Health
Promotion Practice 2004, found that two-third adults visit a library yearly.
Borman and McKenzie (2005) looked at the barriers in the reference transaction between librarian and consumer. Their study found that 20 percent of total reference requests in the public library were on health related issues. Among the barriers, the consumer health information found was that some librarians reported spending significant time with consumer health information. The barrier for consumers according to Borman et al. (2005) is that the consumer may encounter a staff member who was not comfortable providing information or the consumer is unaware of the service offered by the library staff member.
Lorence and Park (2006) examined different age groups and their access to the computer and the Internet as health information resources. According to Lorence et. al.
(2006), millions of people are using the internet seeking health information. Technology has expanded throughout the years making information available, and it continuing to grow. There were 3,099 participant computer users, 2,488 computer user who use internet services and 1,509 online users ranging from the ages 18 to over 50, both males and females. The method used to obtain this study was a tracking survey dataset with a set of
34 questions that tracked the answers from 2000 to 2002. Results indicate 58.1% of the older people used computers on an occasional basis, whereas 86.2% of younger people accessed the computer regularly (Lorence et. al. 2006). The lack of access to web-based health information for the elderly is low even thought the internet access has to increase.
How to get the elderly to use the computer needs further study. Unfamiliar technology can be a barrier in accessing health care information and Medicare update news.
Harris and Wathen (2007) wrote “If My Mother Was Alive I’d Probably Have
Called Her” examine how women living in a rural Canadian county excess the internet for health information. Women are using the internet for medical information and medical assistants. Harris et al. (2007) expanded their internet study. They found that most of the women interviewed to seek information from a wide variety of sources, including the internet. Harris and Wathen proposed that merely expanding the availability of Internet-based health information. Rather than helping the local libraries becomes a health information resource, it would be a better strategy because of librarians ‘potential to provide “an empathetic, listening ear. Harris et al. (2007), discussing the barriers due to lack of skills and access, trust in sources, pointing out that public libraries could have a role in facilitating consumer access to health information. Twenty one librarians express an interest in the initiative program from the city of Pittsburg. They engage in eleven course module for eleven sessions that was design around core value of Perfecting
Patient Care (PPC) center around the consumer needs. The reading assignments accounted for roughly one hour per week of reading time; topics included oncological issues, death and dying, Medicare, community resources, senior issues, pharmacological
35 issues, and health careers. The final project was the development of an algorithm for a consumer health information interview. Participants also spent time outside the session on journal assignment reflecting on pervious Consumer Health Information Specialist
(CHIS). The outcome of this study gave the twenty librarian experience handling challenges and addresses ethical issues, interpretation and recommendation health information for the consumers. Since the study, the librarian meets quarterly to implement a new goal and discuss their process, they continue to find new ways to collaborate with the consumer and be of assistance to help access the internet.
Conclusion of review of literature shows that Medicare beneficiaries face many barriers to access the Medicare services. The Center of Medicaid and Medicare Services
(CMS) have to advance in technology in an effort to educate the Medicare beneficiaries, is it effective. Millions of dollars are spent each year on Medicare commercial about prescription, health equipment, selling supplemental insurance to educate the public about Medicare services. Despite all the effect to reach out to the Medicare beneficiaries, the review of literature shows the barrier still remind.
According to Kaiser Fast Fact (2011), Medicare enrollment has increased significantly over the last 50 years. The number of Medicare beneficiaries more than doubled between 1966 and 2000 and is projected to double again to 80 million by 2030.
It is estimated that in 2010 the Medicare program covered an estimated 47 million people, included in that numbers are 39 million Americans ages 65 years and older and 8 million people with permanent disabilities that are less than 65 years old. With the vast growth of the aged U.S. population, the Medicare beneficiaries continue to face barriers to accessibility and utilization of Medicare services.
The intent of this study was to determine if there are barriers preventing Medicare beneficiaries from receiving quality health care. This study specifically investigated
Medicare beneficiaries’ limited knowledge of Medicare program, lack of health literacy and unfamiliarity with technology (computer skills). This chapter explains the research design, research questions, and instrumentation the researcher utilized to conduct the study. In this chapter the reader will find explanation on the study’s participants, methods used for the protection of human subjects, specifics on the variables studied and data analysis techniques used to draw conclusions and make recommendations regarding this topic.
A quantitative design was chosen in order to investigate the preceding questions.
There are several advantages and disadvantages in using a qualitative approach. On the positive side it provides depth and detail not found in most quantitative methods (Rubin
& Rubin, 2005; Robson, 2002). This method is, in many ways, is more flexible then a descriptive type method and therefore allows for unexpected results (Royse, 1997).
Quantitative data is efficient and makes it easier to test hypotheses. With the quantitative method the findings are not as simple to generalize (Royse &Robson 1997) and there is greater tendency for researcher bias (Robson, 1997) therefore, making this method generally less respected in academia (Royse, 1997). However, this researcher found that the most appropriate method to examine the subject’s knowledge about the Medicare program is the quantitative method.
According to Rubin and Babbie (2001) this type of study draws focus on the quantitative aspect of human nature in order to describe, explain, predict and control behavior. The method used is quantitative research is inductive involves the development of generalizations from the observation. This researcher examined Medicare beneficiary’s humanism ideology logic of “entitlement”. Medicare is program that most Medicare beneficiaries have paid into this insurance over a period of time with the hope having health insurance after their retirement or before the participant becomes disabling. The impact of not being able to understand and utilized their health plan is baffling to most beneficiaries.
The questions addressed in this study were: 1) How knowledgeable are Medicare beneficiaries about the Medicare program? 2) What factors are associated with greater knowledge of the program?
A variable explains or causes something is independence variable and a variable explaining or change is called dependence variable (Rubin, Babbie, 2008) the dependence variables are Medicare beneficiaries who’s unable to access and utilized the Medicare services due to barriers. Survey questionnaire numbers 20 through 23 asked the participants “What services does Medicare A, B, C and D provides?” in order to tests the Medicare beneficiaries’ knowledge about their health coverage. The independent variable will examine social demographic such as age, gender, education, income and
English their first or primary language to see if this has an impact on the Medicare beneficiaries’ limitation in accessing their health care.
Hypothesis prediction is called variable. To test the one of more hypotheses the hypothesis is developed to predict relationships among variables. It suggests that a change in one variable is likely to be associated with a change in another variable (Rubin,
Babbie 2008). A variable explains or causes something is independence variable and a variable explaining or change is called dependence variable (Rubin, 2008). To test the one of more hypotheses the deduction method is used. The researcher begins with a theory and then drives one of more hypotheses from it for testing. (Rubin, 2008).
The participants were recruited from an Adult Day Care center in Sacramento,
CA. The study consist 19 females and 11 males which total of 30 individuals who are able to read and write without assistance and ranged in age from 55 and older. The majority of participants were African American, Hispanic, Chinese and Latino. All the participants are currently receiving Medicare benefits. The participant either lived with family members or lived alone. Even though the study was conducted at the Adult Day
Care center, the snowball sample method was utilized because the study was open to anyone who met the criteria. The sample size will ensure that a factor analysis by which questions that were answered is reliable. According to Babbie (2008), snowball sampling is appropriate when the members of a special population are difficult to locate. The senior’s population is hard to locate due to sickness, transportation or locations. Other considerations for the population studied are that most of them identify English as their first language, reside in senior housing or live with family members. They attended the
Adult Day Care center because of minimal physical disabilities that inhibit common daily activities, like walking and driving. Excluded from this study are people who have severe physical disabilities, developmental delays and mental health disorders. Also excluded from this study are those who have payees and/or designees that make decisions regarding their healthcare on their behalf.
The data was gathered by using a questionnaire consisting of 30 questions focused on surveying Medicare beneficiaries’ knowledge about their current health care insurance and the Medicare program in general. The questionnaire also surveyed the participant’s ability to access digital information via computer and internet mediums. There were no validity and reliability because the researcher created the questionnaire.
A survey questionnaire was distributed to each participant to complete. Having the study conducted at Adult Day Care center allows the research to gather the information needed to complete the study in single sitting. A flyer was displayed in the facility explaining the study, including the dates and times the study would be conducted at the location. For other participants who participated at other locations, special arrangements were made to meet them at convenient, secure locations. The participants were informed that the study would take approximately 30 minutes to complete. The informed consent form was explained and given to each participant for signature and any questions were clarified prior to starting the survey (see Appendix A). The data will be analysis using Predictive Analytics Software (PASW) statistic.
Protection of Human Subjects
Prior to the start of data collection, a human subject’s application was submitted and approved by the California State University, Sacramento, and Committee for the
Protection of Human Subjects from the Division of Social Work. This application was
41 approved with a “minimal” risk category, with an approval number 10-11-087. This application included the informed consent form used throughout the study. The informed consent was read by each participant. There was no identifying information gathered in the survey. The questionnaires and informed consent forms were stored separately to further ensure anonymity and confidentiality for the subjects. After signing the signature page, participants were given a copy of the information. This explained the voluntary and confidential nature of the interview.
This chapter described the research methods utilized for this study. A description of the quantitative research design used in this study was provided. In addition, sections on instrumentation, sample design, data gathering methods, and protection of human subjects were included. In the next chapter, the results of the data gathered are presented.
ANALYSIS OF DATA
The previous chapter 3 discussed the design, subjects and data gathering procedures of this study. The purpose for this chapter is to present the reader with the results of the analyzed quantitative data collected by the researcher. Findings are discussed in seven sections: 1) Demographics; 2) Health Condition; 3) Medicare
Coverage; 4) Medicare Resources; 5) Medicare Knowledge; 6) Test of Medicare Parts and 7) Technology Familiarity.
Demographics of Respondents
The final sample included 30 participants who are Medicare beneficiaries as presented in Table 1. The age ranged from 49 to 84 with a mean age of 64. Forty percent
(n = 15) identified as male, fifty percent (n = 12) as female, while 3 respondents identified as transgender or 10% of the sample.
Single never married people represented 23% percent (n = 7) of the sample while
30% (n = 9) represent married. Thirteen percent (n = 4) identified as widowed while
33% (n = 10) identified as divorced or separated.
The levels of education of report are a high school diploma or GED and some high school equally distributed at 27% (n = 8). Over 26% (n = 6) of the respondents reported some college education or AA degree. However, 7% (n = 2) report earning a college degree.
African-Americans made up 33% (n = 10) of the study sample representing the greatest number of respondents in this research. Hispanics made up 20% (n = 6),
Caucasians made up 23% (n = 7), Asians represented 17% (n = 5) of the study sample and 7% (n = 2) of the respondents identified as American Indian.
Data on income was reported as follows: 37% (n = 11) of the respondents had between
$10,000 and $15,000 per year. Those who had between $15,001 and $20,000 as well as between $20,001 and $40,000 were equally distributed at 20% (n = 6) for both income groups. Twenty-three percent (n = 7) of respondents reported income less than $10,000 per year.
The study found that 33 % (n = 10) of the respondents lived alone while 53% (n =
16) live with either a spouse of family member. The remaining 13% (n = 4) live with a friend or other arrangement.
Sixty percent (n = 18) reported English as their primary language while 40% (n =
12) reported Spanish or another language as the primary language spoken and understood.
49 to 84
Single and never been Married
Some High School
High School Diplomas/GED
$10,001 to $15,000
$15,001 to $20,000
$20,001 to $40,000
With family members
With regards to health conditions as presented in Table 2 7% (n = 2) excellent health while 27% (n = 8) reported good health. Interestingly, 50% (n = 15) stated their health was in fair condition. The remaining participants reported a poor health status.
With regard to being disabled, 23% (n = 7) reported that they are not disabled while a large majority, or 77% (n = 23), reported being disabled.
Health Condition and Disability
Excellent 2 6.7% Yes 23 76.7%
Good 8 26.7% No 7 23.3%
Fair 15 50 %
Total 30 100%
Poor 5 16.7%
Total 30 100%
Participants were asked about their general understanding of the Medicare program as presented in Table 3. Seventy percent (n = 22) were “knowledgeable or “very knowledgeable” of the program. Thirty percent (n = 9) believed they were “somewhat knowledgeable” about the Medicare program. None of the respondents reported “none” or “minimal knowledge” of the program.
Understanding the Medicare Program
Participants were also asked if they understand the four parts of the Medicare program presented in Table 4. Interestingly, 93% (n = 28) stated they do not understand the four parts of the Medicare program indicating the sample group has a general understanding of the Medicare program but lack understanding of how the four parts, A,
B, C and D specifically function.
With regard to the question of what Medicare services the respondents were covered under, only 7% (n = 2) of the respondents were covered under all four parts of the Medicare program; 50% (n = 15) were covered with Part D for prescription drug plans only and the remaining respondents (n = 15) were covered under a variation of Part
A (hospitalization), Part B (medical insurance) and Part C (Medicare Advantage) plans.
With regard to the question of enrollment in Medicare Advantage + Choice, one respondent reported not understanding this survey question, 33% (n = 10) indicated they are not enrolled in this program and 63% (n =19) stated they are enrolled in this program sometimes called Part C.
With regard to the question of how long each had been on the Medicare program
60% (n = 18) reported participation in the program for 3 years or less. Those participating
6 to 10 years was 23% (n = 7) while 17% (n = 5) had 15 to 20 years of participation in the Medicare program.
Respondents were asked why they applied for Medicare from a list of options: retirement, disability, renal disease or other reason. Ten percent (n = 3) of the respondents chose other reasons for their initial application while 40% (n = 12) chose retirement eligibility and 50% (n =15) chose disability as the reason for participating in
48 the Medicare program. No participants stated renal disease as the reason for Medicare application.
Participants were asked if they received a general information booklet from
Medicare that describes basic program coverage information. Seventeen percent (n = 5) did not receive a booklet of information while the remaining participants, 83% (n = 25) did receive booklet material regarding the program.
With regard to resolving personal problems with the Social Security office a vast amount of respondent, 73% (n = 22) reported that they utilized the telephone, 17% (n =
5) used online/internet resources and 7% (n = 2) utilized mail services. One study participant did not respond to this question and no respondents reported walking in to an office to resolve personal problems.
The sample group was nearly split when responding to having an advocate or family member support when speaking with a Social Security representative. Sixty percent (n = 18) reported they had an advocate or family member support and the other
40% (n = 12) do not report having either.
Test of Medicare Parts A, B, C and D
Respondents were asked questions to test their ability to identify the four parts of the Medicare program as presented in Table 4. Twenty-seven percent (n = 8) answered the question correctly as hospitalization while 37% (n = 11) answered the question correctly as doctor visits. Another 33% (n = 10) answered Advantage + Choice correctly and 27% (n = 8) answered prescription drug coverage correctly. Only one respondent answered all four questions correctly.
Medicare Parts Quiz Results
Respondents were asked if they own computers and if there is internet access associated with this access. Approximately 60% (n = 18) have a computer but a mere 7%
(n = 2) have internet access.
Respondents were asked if they sent information via internet regarding Medicare.
More participants have participated in the program online than who have current internet access. Thirty seven percent (n = 11) responded “yes” this survey question and the remaining 64% (n = 19) “no”.
Notably, 90% (n = 27) felt “comfortable” or “very comfortable” with accessing online information regarding Medicare. Three respondents, 10%, either were
“uncomfortable” or “not sure” how they felt regarding online access to Medicare information.
In contrast with the overwhelming comfort level in accessing Medicare information online, 73% (n = 22) did not trust the privacy and security of the internet when accessing personal beneficiary information while 27% (n = 8) trust the internet site’s privacy and security protocols when accessing personal information.
This chapter discussed findings from data analysis regarding Medicare beneficiaries’ knowledge of the program. Although some findings were illustrated in context of this chapter, major findings will be discussed in the following chapter.
Included will be limitations to this study and recommendations for increasing understanding this complex program for those who utilize it for maximum benefits.
FINDINGS AND RECOMMENDATIONS
This chapter summarizes the study findings. The primary purpose of this study was to determine how knowledgeable Medicare beneficiaries are about the Medicare program and what socio demographic factors are associated with greater knowledge of the program. The secondary purpose was increase awareness of the program and highlight that the Medicare program is a complex health system that is difficult to understand. This chapter also discusses the implications for social work and social policy, and discusses future recommendations.
Findings indicate the respondents were not knowledgeable about the Medicare program. Results of the quiz testing their knowledge of Medicare Parts A, B, C, and D indicated that participants scored very low. Interestingly, in answer to the question regarding Medicare knowledge, the majority (70%) indicated they were either
“knowledgeable” or “very knowledgeable” of Medicare. Thus, participants’ self perceptions were that they were knowledgeable; however, their test scores regarding what was covered under the four parts of Medicare indicated low or poor knowledge. Only one out of thirty respondents answered all the quiz questions correctly.
The researcher believes the reason why this group was so disconnected from understanding the Medicare program was because many of the respondents have some form of physical disability or cognitive disorder. Findings indicated that there was no
52 correlation between what the Medicare beneficiaries thought they knew about the
Medicare program and test scores on their knowledge of the Medicare four parts. The lack of association may be because the sample was taken at an adult day care center where the respondents depend on someone else to assist them with care. Since they are not totally self-sufficient, they are likely to rely on support persons to help with navigating the Medicare system, as well. Further, continued use of the program could have led the respondents to believe they have a greater understanding of the program and its parts, especially if they have not encountered any problems with accessing services.
The respondents in this study were fairly mixed equally between males and females; the majority had an annual income of less than $15,000 a year, live alone, their primary language is English and they identify as having fair health. However, 40% indicated their primary language was not English and low income individuals were disproportionately represented.
Study findings indicated that none of the socio-demographic variables were associated with knowledge of the program. This was interesting because these variables would be expected to influence beneficiary knowledge. However, in this study these socio demographics did not influence beneficiary knowledge. A possible reason is the study location and sample skewness. The sample was taken from one local adult day care center in Sacramento. This agency consists of seniors who are disproportionately lower income with some physical and cognitive disabilities and include many whose primary language is not English. This may partially explain their low test scores.
The researcher was able to get clearance to perform this study only at this single adult day care center which lacked variability in socio demographics. If the sample also included Medicare beneficiaries living independently either in a senior complex or their own homes or even those employed, the results may have different. The researcher believes those living a more independent lifestyle would likely be more informed of the
Medicare program. With greater variability of the sample participants both in knowledge of the program and in socio demographics, a significant correlation between socio demographics and knowledge of Medicare might have emerged.
Diversity among the sample group was difficult to achieve because the researcher was not permitted to conduct this study at certain senior centers or living assistance residences because of the Health Insurance Portability and Accountability Act (HIPAA).
The HIPAA is concerned with protection and confidential handling of protected health information (HHS.gov, 2011). The researcher contacted several senior complexes and found the senior complexes were bound by HIPAA law prohibiting the researcher from conducting the study at these sites. Another interesting finding of the study was that the vast majority of the respondents had no access to the internet. This limited access to the internet most likely negatively impacted the Medicare beneficiaries’ ability to retrieve information from the internet on Medicare. The Medicare information can be accessed on the internet by everyone. Medicare has its webpage so beneficiaries can access their personal information from home. Over half of the participants did not access the
Medicare webpage to retrieve information due to lack of trust in the technology.
Participants preferred to go their local social security office than to even talk on the
54 phone to resolve personal private issues. Further, due to certain mobility issues and the fact that they spent much of their day at the adult day care center, could explain limited knowledge of the Medicare program.
Implications for Social Work and Policy
The Medicare program is a complex program. It is continually amended and reformed. Keeping up with the changes is difficult for Medicare beneficiaries due to challenges associated with the aging process. Information is not processed as quickly as senior’s age. What the beneficiary understood may have undergone recent changes. For example, with President Obama’s Affordable Health Care, the Medicare program would exclude Medicare Part C (Advantage Choice). Also, the Social Security Administration wants to raise the age limit for beneficiaries from 65 to70 years. This will impact the retiree who plans to transition from a health maintenance organization (HMO) to the
Medicare program. It also impact retirees reaching retirement age. As a result this will force the retirees to work beyond their retirement eligibility day in order to have health insurance for them and their families. These are examples of continued changes to the
Medicare program which makes keeping up with program eligibility rules difficult to follow.
The study highlights the lack of knowledge that many Medicare beneficiaries have regarding the Medicare program. This lack of knowledge has implications for social work practice and policy at different system levels. On the micro level, it is important for social workers to have a basic understanding about the health care system so that they may be more effective in working not only with senior population but also
55 with families. If the information that was presented in this study is utilized by students of social work, then it should increase their understanding of the health care system.
Students who choose social work may not directly work with the elderly or disabled populations. However family members who are affected by this program may need an advocate when dealing with the Medicare system. It is essential that social workers be resourceful about the policies of the health care system to better service clients and families.
On the mezzo level, the findings in this study can better prepare social workers to meet the needs of this population by teaching students what health care is about and how it affects the clients. Present social work education at California State University,
Sacramento focuses on micro level practice with some macro practice. However, with one of the top reasons for teaching social workers being societal change, there should be an even greater focus on macro level work in the curriculum regarding health care. With greater knowledge of policies regarding health care reform, the future social worker would be better prepared for macro practice while learning about the health care system.
They will be better prepared to become advocates for change to policies that help rather than hinder the populations closely associated with the Medicare program. The researcher hopes the information gathered for this study will encourage further research on this topic.
The purpose of this study was to examine Medicare beneficiaries’ knowledge of the program because there are barriers to the access and utilization of the program
56 benefits. The following is a list of recommendations developed for future Medicare beneficiaries, health care providers and social workers surrounding better communication about the program:
The Medicare system should create more outreach programs to help the Medicare beneficiaries understand their health care coverage in the community.
Cultural sensitivity trainings should be a high priority concern in Medicare with regard to literacy, media and teaching.
The hospitals and clinics should hire more employees who speak more than one language to assist the doctors and the nurses.
The Center of Medicare and Medicaid services should offer computer training to help Medicare beneficiaries navigate through their web page.
Social work education programs should require the students to learn about the
Medicare system so they can better serve and understand the clients’ health needs.
At least one gerontology course should be required curriculum in graduate social work programs focusing on seniors and public health care.
Further research should be done on this topic in order to better understand the
Medicare system and to teach students how to help their parents or grandparents navigate the Medicare program. Also, further research could promote advocacy for seniors and motivation for change to better prepare future social workers.
The primary purpose of this study was to determine how knowledgeable the
Medicare beneficiaries were about Medicare program and what socio demographic
57 factors are associated with knowledge of the program. The findings from this study suggest that additional education on public health care should be done so that it can be better understood and applied. Those particularly in need would be poorer, vulnerable, and hard to reach populations such as those in this study. Education should on four areas:
1) understanding the Medicare program and its operation, 2) understanding the four parts of the Medicare program, 3) the complexities of the Medicare system as it relates to the aged and disabled and, 4) access to technology when accessing health benefits information. Increasing knowledge of the Medicare program so that participants will better understand how to increase access and utilization of their Medicare health coverage is critical.
(Please circle the letter next your answer or fill in the blank)
1 Age: ____________________________
2. Gender: (Circle one of the following)
a) Male b) Female c) Transgender d) other
3. Marital Status: (Circle one of the following)
a) Married b) Single and never married c) Widowed d) Divorced e) Separated
4. Highest Education: (Circle one of the following)
a) Some high school b) HS diploma/GED c) Some college d) AA degree
e) College degree f) Graduate degree g) Vocational training or certification
5. Race/Ethnicity: (circle one of the following)
a) Caucasian b) Black/African American c) Hispanic d) Asian
e) American Indian d) Biracial g) Filipino h) Other
6. Annual Income: (Circle one of the following)
a) Under $10,000 b) $10, 001 to$ 15,000 c) $15,001 to $20,000
d) $20,001 to $40,000 e) $40,001 and up
7. Living Arrangement :( circle one of the following)
a) Alone b) With spouse c) with Friends d) with Family members e) other
8. Is English your primary language? (Circle one of the following)
a) Yes b) No
If you answered No, what language do you read or speak? _____________________
9. What is your present health condition? (Circle one the following)
a) Excellent b) Good c) Fair d) Poor
10. Are you disabled? (Circle the following) a) Yes b) No
Are you a Medicare beneficiary? (Circle one of the following)
a) Yes b) No
12. If so, how long have you been on the Medicare program?
(Fill the blank)
13. Why did you apply for Medicare? (Check one of the following)
a) Retirement b) Disability c) Renal disease d) Other
14. Did you receive a Medicare booklet? (Circle one of the following)
a) Yes b) No
If your answer is yes, how did you acquire the Medicare booklet? (Circle one of the following)
a) By mail b) Picked up it at Social Security Office c) Internet download d) Other
15. How do you correspond with the Social Security office to resolve personal issues?
(Circle the following)
a) By phone b) Online/internet c) Walk into the Social Security office d) By mail
16. Do you have an advocate or family member support when speaking with the Social
Security representative relating to your Medicare coverage? (Circle one the following)
a) Yes b) No
17. As a Medicare beneficiary, do you believe you understand the Medicare program?
(Circle one of the following)
a) Very knowledgeable b) Knowledgeable c) somewhat d) not very knowledgeable
e) Do not understand
18. Do you understand the four parts of the Medicare program? (Circle one of the following)
a) Yes b) No c) don’t understand
19. What services does Medicare A provide? (Circle the correct answer)
a) Hospital b) Medication prescription c) Doctors visit
d) Medicare Advantage+ Choice e) Don’t know
20. What services does Medicare B provide? (Circle the correct answer)
a) Hospital b) Medication prescription c) Doctors visit
d) Medicare Advantage+ Choice e) Don’t know
21. What services does Medicare C provide? (Circle the correct answer)
a) Hospital b) Medication prescription c) Doctors visit
d) Medicare Advantage+ Choice e) Don’t know
22. What services does Medicare D provide? (Circle the correct answer)
a) Hospital b) Medication prescription c) Doctors visit
d) Medicare Advantage+ Choice e) Don’t know
23. What parts of Medicare services are you covered under? (Circle all that apply)
a) Medicare A b) Medicare B c) Medicare C d) Medicare D e) All of the above
f) Don’t know
24. Are you enrolled in Medicare Advantage +Choice? (Circle one of the following)
a) Yes b) No
25. If yes is the answer, please select one of the following below:
a) Kaiser b) Blue Cross & Blue Shield c) AARP d) other____________
26. Do you own a computer? (Select one of the following)
a) Yes b) No
If you selected yes, do you have access to the internet?
a) Yes b) No
27. Have you sent personal information relating to your Medicare benefit online?
(Circle one of the following)
a) Yes b) No
If your answer is no, explain why not _________________________________
28. How comfortable do you feel accessing your Medicare information online? (Select one of the following)
a) Very comfortable b) Comfortable c) Not comfortable d) Unknown
29. Do you trust the privacy and security of the internet when accessing Medicare benefits? (Circle one of the following)
a) Yes b) No c) Not sure
Consent to Participate in Research
Consent to Participate as a Research Subject
California State University, Sacramento
Division of Social Work
You are being asked to participate in a research project conducted by Linda Buggs-
Knight, a MSW II graduate student in Social Work at California State University,
Sacramento. The purpose of this study is to examine the barriers Medicare beneficiaries face in understanding the Medicare Program and how it impacts their quality of health care. I am hoping the results of this study will contribute to future reforms of the current program.
Your participation in this research is entirely voluntary. You will not be compensated for participating in this study and you will not directly benefit from this study. However, information you provide may help increase knowledge and could help improve Medicare services in the future.
If you decide to participate in the study, you will be given a survey of 30 questions about your experience in the program. The survey will require approximately 20 minutes of your time, and will be conducted in the recreational area.
Some of the questions asked in the survey may seem personal. You are under no obligation to answer any questions that you choose not to. You may stop the study at any time with no negative consequences.
To ensure your confidentiality, no identifying characteristics will be used in this study.
Your responses to all survey questions will remain confidential. The data will be reported as a collection of all participant responses. All data collected in this study will be kept in a locked cabinet, only accessible to the single researcher, and will be destroyed at the end of the study.
If at any point while completing the survey, or any time afterward you experience discomfort or have concerns, please contact any of the services noted below. If you have any questions concerning Social Security benefits you may contact the Social Security at
If you have any questions or concerns about this research, you may contact Linda Buggs-
Knight at (916) 225-1823 or by email [email protected] You may also contact my advisor, Professor Maura O’Keefe, Ph.D. at 916-278-7067 or by email [email protected] will be given a copy of this consent form to keep.
Your signature below indicates that you have read and understand this consent form and agree to participate in this research project.
Participant Signature Date
For professional assistance in greater Sacramento County, please contact:
Social Security Administration
8581 Folsom Blvd
Sacramento, CA 95826
Phone: 887-274-5419 www.ssa.gov
Sacramento County of Mental Health
2150 Stockton Blvd.
Sacramento, CA 95817
Phone: 916 875-1000 www.sacdhhs.com
Turning Point Community Programs
3440 Viking Drive, Suite 114
Sacramento, CA 95827
Phone: 916-364-8395 www.tpcp.org
La Familia Counseling Center, Inc.
5523 34th Street
Sacramento, CA 95820
Phone: 916-452-3601 www.lafcc.com
California Health Advocates
5380 Elvas Avenue, Suite 221
Sacramento, CA 95819
Phone: 916-231-5110 www.cahealthadvocates.org
Ahmed, S., Lemkau, J., Nealeigh, N., Mann, B. (2001). Barriers to healthcare access in a non-elderly urban poor American population.
Blackwell Science Ltd Health and
Social Care in the Community
. 9(6), 445-453.
Baker, D., Gazmararian, J., Williams, M., Scott, T., Parker, R., Green, D.,(2002).
Functional health literacy and the risk of hospital admission among Medicare managed care enrollees.
American Journal of Public Health.
Bann, C. Beckman, N. (2004), Insurance knowledge and decision practice among
Medicare beneficiaries and their caregiver.
Tyzy-Mey Kousource: Medicare Care.
Borman, C., McKenzie, P. (2005). Trying to help without getting in the faces: public library staff description of providing consumer health information.
User Services Quarterly
. 45, 2.
Bronfenbrenner, U. (1989). Ecological Systems Theory.
Annuals of Child Development
Centers for Medicare & Medicaid, United States Department of Health and Human
Services. (2007). Medicare & You 2007. Publication No. 1005. Baltimore. MD.
Fitzpatrick, A., Powe, N. Cooper, L., Ives, D., Robbins, J. (2004). Barriers to health care access among the elderly and who perceives them.
American Journal of Public
. 94, 10.
Germain, C. B. (1983). Using Social and Physical Environments. In A. Rosenblatt & D.
Handbook of Clinical Social Work
. San Francisco: Jossey-
Glassman, P. (2010). Health literacy. National Network of Libraries of Medicine, New
England Region, MA. Retrieved 2010. http://nnlm.gov/outreach/consumer/hlthlit.html
Greenwald, L., McCormack, L., Uhrig, J. & West, N. ( 2006). Measures and predictors of
Medicare knowledge: A review of the literature.
Health Care Financing Review
Greif, G. L. (1986). The Ecosystems Perspective ‘Meets the Press.’
Hacker, J. (2006). The great risk shift: the assault on American jobs, families, health care and retirement and how you can fight back. Oxford Press.
Hanchate, A., Ash, A., Gazmararian, J,. Wolf, M. ,Paasche-Orlow, M. (2007). The
Demographic assessment for health literacy (DAHL): A new tool for estimating associations between health literacy and outcomes in national surveys.
General Internal Medicine
. doi: 10.1007/s11606-008-0699-5
Harris-Kojetin,L., Uhrig, J., Williams, P., Bann, C., Frentzel, E., McCormack, L.,
Mitchell, N., and West, N. (2007). The choose with care system-development of education materials to support informed Medicare health plan choices.
. doi: 10.1080/10810730601150098
Havrda, D., Omundsen, B., Bender, W., Kirkpatrick, M. (2008). Impact of the Medicare modernization act on low-income person.
Annals of Internal Medicine
. 43, 8.
Hibbard, J., Slovis, P., Jewett, J. (1997). Informing consumer decisions in health care: implications from decision-making research.
. 75, 3. doi: 10.1111/1468-0009.00061
Hoffman, E., Klees, B., Curtis, C. (2005). Brief summaries of Medicare & Medicare:
Title XVII and title XVIII of social security act. Baltimore, MD: Center for
Medicare and Medicaid.
Howard, D., Stentell, T., Gazmaraian, J (2006). Impact of health literacy on socioeconomic and racial difference in health in an elderly population. doi.10.111j. 1525-1497.2006.00530.x
Hutchison, E. D. (2003). Dimensions of Human Behavior: Person and Environment (2nd.
Ed.). Thousand Oaks, CA: Sage.
Institution for Local Government (2011). Understanding the impacts of health reform.
Retrieved from www.ca-ilg.org/healthreform
Kingson, E. (2008). Social security program. In T. Mizrahi, L. Davis. (Eds),
Encyclopedia of Social Work. (4)89-97.
Lee. S., Struck, B., Lee, J., Rosier, G., Bender, D. (2010). Short assessment of health literacy-Spanish and English: A comparable test of health literacy for Spanish and
Health Research and Education Trust.
Lorence, D, .Park, H. (2006). New technology and old habits: the role of age as a technology chasm.
Technology and Health Care.
Medicare: the official United States Government for people with Medicare. (2006).
Premium and cost information for 2007. Retrieved from www.medicare.gov/MedicareEligibility/Home.asp?dest=NAV|Home|
Miley, K.K., O’Melia, M., & DuBois, B. (2004). Generalist Social Work Practice: An
Empowering Approach. New York: Pearson.
Morgan, R., Teal, C., Hasche, J., Petersen, L., Byrne, M., Paterniti, D., Virnig, B. (2008).
Does poor familiarity with Medicare translate into worse access to health care?
The American Geriatrics Society
. Journal Compilation.
National Assessment of Adult Literacy (2010). Health Literacy. Retrieved from nces.ed.gov/NAAL/health.asp
New Hampshire Advisory Committee (2005). Language and access to health care easing barriers in New Hampshire.
Ponce, N., Penseraga, L. (2002). Language access in health care: why the policy and practice inertia?
Harvard Health Policy Review
Public Policy Institute (2006) Issue Brief, Adequate literacy and health literacy:
Prerequisites for informed health care decision making.
Rubin, A., Babbie, E. (2001). Research methods for social work. Thompson/Cole.
Pacific, CA. 4 th
Ed. Silver Spring, MD: National Association of Social Workers.
Rice, D., Fineman, N. (2004). Economic implication of increasing longevity in the United
Annual Reviews: Public Health, 2004
Riley, G., Lubitz, J. (2010). Long-term trends in Medicare payment in the last year of life.
Health research and educational trust
. doi: 10.111/J.1475-
Roberts, A.R., & Greene, G.J. (2002). Social Workers’ Desk Reference. New York:
Oxford University Press.
Robson, C. (2002). Real world research. Malden, MA: Blackwell Publishers. Second ed.
Rosenberg, M. (1965). Society and the Adolescent Self-Image. New Jersey: Princeton
Royce, D. D. (1991). Research Methods in Social Work. Chicago: Nelson-Hall.
Royse, D. (1999). Research methods in social work. Chicago, IL: Nelson-Hall. Third ed.
Rubin, A., Babbie, E. (1997). Research Methods for Social Work. Pacific Grove, CA:
Brooks/Cole. Third edition.
Shrank, W., Patrick, A., Pedan, A. Polinski, J. Varasteh, L. Levin, R, Liu, N.
Scheeweiss, S. (2008). The effect of transitioning to Medicare part D drug coverage in senior dually eligible for Medicare and Medicaid. The American geriatrics society. doi: 10.111/j.1532-5415.2008.02025.x
Social Security Administration Title II and Title XVII Programs and Medicare, Part 111,
Social Security (2010). FDR's Statements on Social Security: Presidential Statement
Signing the Social Security Act August 14, 1935. Retrieved www.ssa.gov/history/fdrstmts.html#radio
Social Security History (2010). Historical Background and development of social security. Retrieved from www.ssa.gov/history/briefhistory3.html
Social Security Online: Retrieved from www.ssa.gov/history/ottob.html
Tracy, M., Ozawa, N. (1995). Social Security. Encyclopedia of social work.
United States Department of Health and Human Services, Centers for Medicare &
Medicaid, Medicare & you 2007. Publication No. 1005. Baltimore. MD.
United States Census Bureau, (2010). The survey of income and program participation health insurance coverage among the elderly. Retrieved from www.census.gov/sipp/workpapr/wp149.pdf
Zionts, N., Apter, J., Kuchta, J., Greenhouse, P. (2009). Promoting consumer health literacy: Creation of a Health Information Librarian Fellowship.
. 49(4). 350-359.