North Carolina Rural Health Research and Policy Analysis Center (NC RHR & PAC)
The NC RHR & PAC project focuses primarily on the Federal insurance programs of Medicare and Medicaid and those programs effect on rural populations and providers.
Medicare Rural Hospital Flexibility Program Evaluation (Flex Program)
The Flex Program project is a comprehensive multi-year review of the Medicare Rural Hospital Flexibility Program, conducted in collaboration with the University of Minnesota and the University of Maine.
Rapid Response to Requests for Rural Data Analysis and Issue Specific Rural Research
The North Carolina Rural Health Research Program, in conjunction with the RUPRI Center, provides rapid rural data analysis and issue-specific rural research studies in response to emerging policy issues.
Some Completed Project Topics
- Ambulatory Care Provided to Rural Medicare Beneficiaries by Rural and Urban FQHCs, RHCs, and Acute Hospitals
This project will characterize the volume, cost, and case mix of ambulatory care provided to rural Medicare beneficiaries by rural and urban federally qualified health centers (FQHCs), rural health clinics (RHCs), and acute hospitals. The study will include urban-rural and geographic comparisons of volume, cost, and case mix by provider type.
- Do Rural Communities Have a Higher Rate of Avoidable Deaths?
Based on some estimates, roughly half of deaths are avoidable in the sense they stem from risky behavior. What is less well known is the degree to which there is a rural-urban disparity in this rate.
- Financial Impact of Reimbursing CAH Swing Bed Days at the SNF PPS Rate
This study will assess the financial impact of changing Critical Access Hospital (CAH) swing bed reimbursement from the cost-based system to the skilled nursing facility (SNF) prospective payment system (PPS).
- How Rural Communities Respond and Recover after a Hospital Closure
Current rates of rural hospital closures are the highest seen in the last few decades. What can we learn from the experiences of communities experiencing hospital closures?
Topics: Hospitals and clinics, Workforce
- Post-Acute Care for Rural Medicare Beneficiaries
This project will describe the variation in the volume, mix and financial importance of post-acute services to rural hospitals; identify hospital and community characteristics associated with variation in post-acute services provided by rural hospitals; and determine where rural Medicare beneficiaries receive post-acute services.
- Creating a Culture of Health in Appalachia: Disparities and Bright Spots
“Creating a Culture of Health in Appalachia: Disparities and Bright Spots” is an innovative research initiative that aims to identify factors that support a culture of health in Appalachian communities.
- Characteristics of Rural Hospitals at High Risk of Financial Distress
Updates the Financial Distress Index Model with current hospital and market data. Evaluates changes in risk status and geographic distribution over time. Conducts an in-depth analysis of high risk hospitals.
- Exploring Regional Differences in Rural and Urban Mortality Trends
Explores the differences in U.S. mortality rates by urban and rural location, census division, and urban and rural location within each census division. The gap in nationwide urban-rural mortality is often told as a national story, but the changes are regional. This implies different regions may need different strategies for addressing the gap.
- The Financial and Community Experience of Sole Community Hospitals in Comparison to Other Rural Hospitals
This research will investigate the financial and community experience of SCHs in comparison with other rural hospitals. The availability of alternative facilities, and the socioeconomic and demographic characteristics of SCH service areas will be compared to other rural hospital service areas.
- Can a Model Predict Financial Distress Among Rural Hospitals?
This project will extend an existing model of CAH financial distress to other types of rural hospitals. A valid model would be helpful to ORHP and state Offices of rural Health interested in predicting financial distress or closure of rural hospitals.
- How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals?
This two-year project will explore the effects of changes in insurance coverage under health reform on the following outcomes in rural hospitals: (1) bad debt; (2) charity care; (3) payer mix (Medicare, Medicaid, other); (3) financial performance; and (4) hospital revenue cycle management. Results will inform federal and state agencies, rural providers and communities as to how implementation of the Patient Protection and Affordable Care Act is impacting reimbursement and financial performance of rural hospitals, allowing the Office of Rural Health Policy to identify emerging challenges and develop strategies or policy changes needed to deal with any unintended consequences.
- How Have Changes in Insurance Coverage Under Health Reform Affected Uncompensated Care and Financial Performance in Rural Hospitals? (Year 2)
The second year of this two-year project will explore the effects of changes in insurance coverage under health reform on the following outcomes in rural hospitals: (1) bad debt; (2) charity care; (3) payer mix (Medicare, Medicaid, other); and (4) financial performance.
- Policy Analysis Using the Financial Distress Model: Does Medicaid Expansion Affect the Risk of Hospital Financial Distress and Closure?
This study will build on the 2014-15 approved project entitled “Can a Model Predict Financial Distress among Rural Hospitals?” The newly developed model uses current financial performance and market characteristic data to assign rural hospitals to one of four categories of risk of financial distress. The study will use Medicare Cost Report data for 2014, if available. Otherwise, simulation will be used to estimate the effects on financial distress.
- Rural Health Clinics: Medicare & Medicaid Profile (Year 2)
Year 2 of a project developing a longitudinal data collection/tracking mechanism of key RHC Medicare claims data and cost report elements. RHC Medicaid data for a sample of states also will be requested and analyzed to determine utilization patterns and identification of potential quality metrics.
- What Would be the Financial Consequence of Eliminating Low Volume Hospital Payments?
Analysis will include comparison of the long-term profitability of LVHs to other rural hospitals and estimation of the potential profitability consequences of eliminating the payment classification altogether.
- 21st Century Rural Hospital: Outpatient Services and Access to Care
The rural hospital has changed dramatically with hospitals becoming increasingly outpatient-centered. This project is designed to inform policymakers about rural hospitals’ provision of outpatient care, including publication of a Primer, detailing the variability in outpatient services provision by key characteristics that can be used to examine the potential impact of proposed policy changes on patients’ ability to access different services.
- Early Rural Experiences of Changes to Medicaid
This project will 1) develop baseline state-level snapshots of rural enrollment in Medicaid and 2) estimate and model enrollment expansion in each state. We will also conduct a baseline provider key informant interviews in late 2013 to gauge expected effects, with follow up interviews in Summer 2014 as a sentinel warning system of early effects of changes to Medicaid in order to inform timely policy development.
- Identifying Limitations of PPS Reimbursement for Rural Hospitals
This project will investigate the potential financial and access consequences of returning rural hospitals to PPS payment. Characteristics of the hospitals and communities at highest risk of adverse consequences will be identified.
- Rural Health Clinics: Medicare & Medicaid Profile
This study builds on our work with the 2009 RHC Medicare claims. This project will result in the development of a longitudinal data collection/tracking mechanism of key RHC Medicare claims data and cost report elements (provider-based cost reports only at this point in time). RHC Medicaid data for a sample of states will be requested and analyzed to determine utilization patterns and identification of potential quality metrics.
- What Does it Cost to Operate a Rural Free-Standing Emergency Department (RFED)?
In recent months, there have been numerous media reports of rural hospital closures and the adverse effect on communities. In the face of hospital closure, one alternative for maintaining access to healthcare is a rural free-standing emergency department (RFED).
- What Happens after Acute Inpatient Care is No Longer Provided by a Rural Hospital?
This project will investigate the precursors to closure of acute inpatient care by rural hospitals and the post-closure configuration of health care services in the community.
- Comprehensive Study of Swing Bed Use in Rural Hospitals
This project will comprehensively address questions about how swing beds are used by rural hospitals. Questions to be answered include whether decision about use are driven by patient need, community resources, hospital operational concerns or some combination of these factors; the cost implications of swing bed use in critical access hospitals to the Medicare program; and whether patients served in swing beds differ in meaningful ways from those in skilled nursing facilities.
- Early Rural Experiences of Changes to Medicaid: Year 1
In January 2014, some states will expand eligibility through the Medicaid program, while other states will not. Because rural residents are likely to be disproportionately affected by Medicaid expansion, understanding this interstate variation has important policy implications.
- Patterns of Care in Small Rural Areas: Implications for New Models of Care Provision and Payment such as Bundled Payments and Accountable Care Organizations
This study will describe usual patterns of care in rural areas to determine whether rural areas are part of a single service area, or whether smaller communities utilize services from a variety of larger hubs. The results of this analysis will inform a thought piece on how the concepts of bundled payments and Accountable Care Organizations might play out in small rural areas and whether small rural communities can be assigned to a single service area without major disruption of current patterns of care.
- Rural Hospital Mergers and Acquisitions – Who is Being Acquired and What Happens Afterwards?
This study compares the financial and market characteristics of recently acquired rural hospitals to other rural hospitals and investigates the post-acquisition change in services and financial performance of these hospitals. This study will inform rural advocates, federal and state agencies, and regulators as to how mergers and acquisitions (M&As) of small rural hospitals affect access to care for Medicare beneficiaries, and the potential financial consequences of M&As to small rural hospitals.
- Use of Rural Health Clinics by Medicare Beneficiaries
Determination of Medicare beneficiaries utilization of available RHCs and development of a descriptive profile of Medicare beneficiaries who utilize RHCs including both geographic and diagnostic elements and a comparison to Medicare beneficiaries who utilize FQHCs.
- Community and Financial Experience of Medicare Dependent Hospitals in Comparison to Other Rural Hospitals
This research will investigate the community and financial experience of Medicare Dependent Hospitals in comparison with other rural hospitals. Analysis of the financial experience will include comparison of the long-term profitability of MDHs to other rural hospitals, estimation of the potential profitability consequences of eliminating the payment classification, and estimation of the potential consequences of maintaining the payment classification but failing to update the base year from which costs are trended forward.
- Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research
Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research
- Importance of Surgery to Rural Hospital Financial Condition and Market Share
This study explores the provision of surgical services in rural hospitals and its relationship to financial performance. The percentage of rural hospitals that offer surgical services and the number that have discontinued surgical services over the last decade will be described, and, for those that have discontinued services, the impact on financial condition will be explored.
- Mini-Studies to Inform Health Reform Efforts
Rural health care systems are far more vulnerable to changes in federal health care policy than are those in urban areas. The purpose of this project is to conduct rapid turnaround mini-studies that will be essential to maintain an effective rural voice in both the ongoing adjustments to current policies and the development of new policies.
- Factors Associated with Provision of Ambulance Services by Rural Hospitals
This two-part study will use existing national data to determine how many hospitals have regularly offered ambulance services as well as how many have recently acquired or discontinued such services. In-depth interviews with selected rural hospital administrators will explore the factors related to a hospital’s decision regarding these important health care services.
- Medicaid and SCHIP Participation in Rural and Urban Areas
This project examines state-level Medicaid and SCHIP participation rates for children in rural and urban areas. It also updates the State Profiles of Medicaid and SCHIP in Rural and Urban Areas web site and documents changes in program characteristics relevant to rural areas over the past few years.
- Rural Emergency Department Preparedness for Pediatric Care
While many large cities have dedicated children’s hospitals or facilities with pediatric emergency departments, many general hospitals do not have either the equipment necessary to provide optimal pediatric emergency care nor staff that is specifically trained in the care of pediatric emergencies. This project will use secondary data analysis and semi-structured interviews with emergency room directors in order to address how the availability of pediatric services, expertise and supplies in U.S. emergency departments differs between urban and rural facilities, and to determine which factors impede the availability of pediatric services, expertise, and supplies in rural emergency departments.
- Rural Medicaid and CHIP Mini-Studies
Medicaid and the Children’s Health Insurance Program (CHIP) are important sources of health insurance coverage in rural communities and it is likely that the importance of Medicaid/CHIP will grow as job-based health insurance coverage continues to erode and policymakers pursue the goal of expanding coverage. This project is composed of three mini-studies that: 1) Update our State Profiles of Medicaid and CHIP in Rural and Urban Areas website, adding information on Medicaid Disproportionate Share Hospital (DSH) payments to rural hospitals; 2) Analyze trends in Medicaid/CHIP enrollment in rural and urban areas over the past two to three years; and 3) Explore the future role of CHIP given increasing levels of childhood poverty.
- Rural-urban Comparison of Hospital Financial Performance by Medicare Payment Classification
This project will compare the financial performance of rural and urban short term general hospitals by Medicare payment classifications (PPS only, Medicare dependent hospitals, sole community hospitals, rural referral centers, and critical access hospitals).
- Volunteerism in Rural EMS
Semi-structured telephone interviews will be used to examine issues facing rural EMS services that have converted or are considering converting from volunteer services to paid services. Respondents will be queried regarding their conversion or consideration of conversion and the effect on their ability to recruit and retain personnel, their relationship with other agencies such as fire departments and hospitals, and the overall availability of EMS services.
- Assessing the Impact of Transfer of Pharmacy Services for Dual Eligible Beneficiaries to Medicare Part D
This project will focus on the implementation of the new Part D benefit for those dually eligible for Medicare and Medicaid. The study will examine the impact on rural dual eligibles and their local pharmacies of the transfer to Part D coverage. The project is a joint undertaking with the RUPRI Center, taking advantage of unique data sets held at each center, the analytical and programming resources of both centers, and the ability to conduct qualitative analysis in multiple states efficiently.
Topics: Medicaid and CHIP, Medicare Part D, Pharmacy and prescription drugs
- Critical Access Hospital Conversion Tracking
Information regarding new CAH conversions will be gathered from Flex coordinators and CMS, and added to the CAH management information dataset that is housed at UNC. Flex coordinators will also be queried regarding topics of interest to the coordinators, the monitoring team, and the federal Office of Rural Health Policy.
Topic: Critical Access Hospitals
- Developing a Financial Performance Measurement System for Critical Access Hospitals
This project uses research and expert opinion to select dimensions and indicators of financial performance, develop appropriate bases or methods of peer comparison, investigate the relationship between quality of care and financial performance, and identify characteristics of high performing CAHs.
Topics: Critical Access Hospitals, Healthcare financing
- Move Toward Clinical Doctorates in the Allied Health Professions: Implications for Rural Areas
Allied health occupations play a major role in health care delivery and comprise a significant proportion of the health care workforce in the United States. Researchers have found empirical evidence of allied health shortages in many states. Given the longstanding history of health professional shortages facing rural areas, there are concerns that the existing and impending shortages in allied health professions may be particularly acute in rural areas. This study will synthesize information on allied health professions, such as credentialing requirements and wage comparisons, with telephone and in-person interviews of rural health care employers, educators, and practitioners in order to assess the degree of alignment between community needs for allied health care services and existing and proposed certification and educational training for these health care providers.
Topics: Allied health professionals, Workforce
- Quality and Financial Status of Critical Access Hospitals: A Preliminary Analysis
The purpose of this project is to continue to investigate the relationship between CAH financial performance and quality of care. The University of Minnesota (UMN) and the University of North Carolina (UNC) will jointly develop hypotheses related to the finance-quality link and statistical models suitable for testing hypotheses.
Topics: Critical Access Hospitals, Healthcare financing, Quality, Rural Hospital Flexibility Program
- Rural Hospital Flexibility Performance Monitoring Project- Grant Years 2003-2008
Under contract with the federal Office of Rural Health Policy, the Rural Health Research Centers at the Universities of Minnesota, North Carolina, and Southern Maine are cooperatively conducting a performance monitoring project for the Medicare Rural Hospital Flexibility Program (Flex Program). The monitoring project will assess the impact of the Flex Program on rural hospitals and communities and the role of states in achieving overall program objectives, including improving access to and the quality of health care services; improving the financial performance of Critical Access Hospitals; and engaging rural communities in health care system development.
Topics: Critical Access Hospitals, Rural Hospital Flexibility Program
- Describing Geographic Access to Physicians in Rural America Using Statistical Applications in GIS
This study will use a geographically weighted regression to assess the influence of distance and travel time on the distribution of physicians in rural America. The ultimate goal of the study will be to improve our measures of access by identifying the extent to which border resources can be considered in indices of access.
Topics: Health services, Physicians
- Occupational Mix Differences Across PPS Hospitals: Analysis of Hospital Occupation Mix Survey Data and Implications for Rural Hospital Payments
This study addresses the occupation-mix adjustment that has recently been added to the computation of the area wage index used to adjust Medicare prospective rates for all institutional healthcare providers. The study will review the policy objectives as well as the mechanics of the adjustment, and then analyze the data from the most recent occupation-mix survey to obtain a better understanding of occupation mix differences across labor markets and hospital types.
Topics: Hospitals and clinics, Medicare Prospective Payment System (PPS), Workforce
- Rural Emergency Medical Services: Workforce and Medical Direction
This two year study will examine the status of medical direction for rural EMS systems and the nature of the challenges and impediments to obtaining adequate medical direction in rural areas across the country. In addition, the study will address issues surrounding the recruitment and retention of paid and volunteer staff for rural EMS systems.
Topics: Emergency medical services and trauma, Workforce
- Rural Hospital Participation in the 340B Drug Discount Program
The 340B drug discount program enables certain types of safety net organizations to obtain deeply discounted medications, at prices below the ‘best price’ typically offered to Medicaid agencies. This study used telephone interviews and mail surveys to explore the experiences that rural hospitals have had in seeking 340B eligibility status.
Topics: Hospitals and clinics, Pharmacy and prescription drugs
- State Facts about Medicaid: Rural Specific Data
This project will develop state-specific fact sheets which will include information on the groups covered (and income eligibility), structure of the state’s SCHIP program, services covered, delivery system, some provider payment information for certain safety net providers, and percentage of the state’s rural and urban population that are enrolled in Medicaid. Additional information comparing urban and rural areas of the state will be provided, when available. The rural and urban comparisons will include total numbers of Medicaid recipients, Medicaid expenditures, and enrollment in different types of managed care plans.
Topics: Medicaid and CHIP, Rural statistics and demographics
- Community Impact Assessment
This project will evaluate the impact of the Flex program on local communities. Activities will focus on identifying the ways in which the program could have a measurable effect, as well as the ways in which Flex program coordinators intended to affect community health. A briefing paper that integrates information on scope of services, networking, and quality will be produced. Additionally, case studies will be conducted in six CAH communities.
Topics: Critical Access Hospitals, Networking and collaboration, Rural Hospital Flexibility Program
- Financial Performance of Critical Access Hospitals, Pre- and Post-Conversion
Making use of the financial indicators developed by project staff, the focus of this project is a longitudinal analysis of the dimensions and indicators of financial performance. Descriptive analyses are used to capture changes in all dimensions of financial performance pre- and post-conversion.
Topics: Critical Access Hospitals, Healthcare financing, Medicare Prospective Payment System (PPS), Rural Hospital Flexibility Program
- Premium Assistance Programs: Exploring Public-Private Partnerships as a Vehicle for Expanding Health Insurance to Rural Uninsured
This project examines the experience of states that have implemented premium assistance programs in rural areas to determine whether there are certain design features or certain types of rural communities where these programs may be more feasible.
Topics: Private health insurance, Uninsured and underinsured
- Rapid and Flexible Analysis of Data from Centers for Medicare and Medicaid Services
Project staff will provide rapid and flexible analysis of Centers for Medicare and Medicaid Services (CMS) data in response to requests from Office of Rural Health Policy (ORHP) staff. Work will be ongoing throughout the contract year, with the design of individual products determined in response to ORHP staff needs.
Topics: Medicare, Rural statistics and demographics
- Access to Health Care for Young Rural Medicaid Beneficiaries
This study examined access to health care among rural children ages 0-17 who are enrolled in some type of Medicaid managed care program, and will compare this access across types of programs and, within program type, to that of urban beneficiaries.
Topics: Children and adolescents, Health services, Medicaid and CHIP, Oral health, Transportation
- Impact of The Medicaid Budget Crisis on Rural Communities: A 50-State Survey
The impact of the Medicaid budgetary crisis on rural communities across the US will be assessed through a 50-state survey of state Medicaid agencies, state Offices of Rural Health and state rural health associations.
Topic: Medicaid and CHIP
- Role of Intensive Care Units in Critical Access Hospitals
This project will examine the role that intensive care units (ICUs) play in Critical Access Hospitals (CAHs). The number and geographic distribution of CAH with ICUs will be described, and types of services provided in these units discussed.
Topics: Critical Access Hospitals, Health services
- Special Study of EMS Issues
This study will focus on state, community, and hospital level initiatives designed to build the infrastructure to support EMS service capacity and encourage the integration of these services into the rural healthcare infrastructure in the areas of quality improvement, financing, staffing, medical control, and networking and integration.
Topics: Critical Access Hospitals, Emergency medical services and trauma, Networking and collaboration
- Trends in Swing Bed and Skilled Nursing Facility Use in Rural Hospitals, 1996-2003
This study will examine trends in the distribution of skilled nursing facility (SNF) services in rural hospitals during a period of dramatic change in Medicare reimbursement, most notably the transition from cost-based reimbursement to SNF prospective payment system (PPS).
Topics: Aging, Hospitals and clinics, Long-term care, Medicare Prospective Payment System (PPS)
- Analysis of the Cesarean Section Rates in Rural Hospitals
This project will describe the practice patterns for deliveries in rural hospitals. Cesarean section rates in rural hospitals will be compared to urban hospitals and the national rate.
Topics: Hospitals and clinics, Maternal health
- Analytic Capacity to Respond to Changes in Medicare and Medicaid, Data Assistance to Policy Staff at the Federal Office of Rural Health Policy, and Production of Short Policy Briefs
This project will produce short policy briefs on a variety of topics related to proposed and enacted changes in Medicare and Medicaid, as requested by policy staff at the federal Office of Rural Health Policy.
Topics: Legislation and regulation, Medicaid and CHIP, Medicare
- Changes in the Supply, Distribution, Workload and Reimbursement Patterns of Pharmacists in Rural Areas
This study will examine the supply, distribution, workload, and reimbursement patterns of pharmacists in rural areas. The study will also examine pharmacy licensure data in rural vs. urban areas to study trends in pharmacy ownership patterns.
Topics: Pharmacy and prescription drugs, Workforce
- Rural Hospital Closures, 1990-2000: Community Profiles and Economic Indicators Before and After the Event
This study investigated the economic impact of hospital closures in non- metropolitan counties, taking into account the economic characteristics and employment trends that may have preceded the event.
Topic: Hospitals and clinics
- Unmet Needs for Health Care Services: An Analysis of Children with Special Health Care Needs in Rural Areas
This project will study whether parents of children with special health care needs (CSHCNs) who live in rural areas are less likely to perceive the need for routine and specialty medical care than their metropolitan counterparts, and whether CSHCNs that live in rural areas face a greater risk of having unmet needs for health care services than their metropolitan counterparts.
Topics: Children and adolescents, Disabilities, Health services, Oral health
- Factors Contributing to Unit Cost Instability in the Low-Volume Hospital
Topics: Hospitals and clinics, Medicare Prospective Payment System (PPS)
- Information Technology Engineering Support for Health Resources and Services Administration Data Systems/Geospatial Data Warehouse, GIS Technologies, GEMS Support and General Office of Information Technology Systems Support
- Labor Costs and the Area Wage Index in Skilled Nursing Facilities
Topics: Hospitals and clinics, Long-term care, Workforce
- Medicaid Managed Care in Rural Areas: Innovative Case Management Strategies
Topics: Care management, Medicaid and CHIP
- National Rural Hospital Flexibility Program Review
Topics: Critical Access Hospitals, Rural Hospital Flexibility Program
- Analysis of Options for Criteria to Determine Underservice
- Analysis of Options for Revisions to the Criteria for Designation for Medically Underserved Areas (MUAs) and Health Professional Shortage Areas (HPSAs)
- Arguing for Rural Health: Justice and Fairness in Advocating for Rural Health Policy
Topic: Legislation and regulation
- Background Paper on Skilled Nursing Facilities in Rural Areas
Topic: Long-term care
- Evaluation of the Medicare Rural Hospital Flexibility Program
Topics: Critical Access Hospitals, Rural Hospital Flexibility Program
- Evaluation of the Rural Hospital Flexibility Act and the Critical Access Hospital Program
Topics: Critical Access Hospitals, Rural Hospital Flexibility Program
- Rural Population and Providers: Mapping the 2000 Census
Topics: Rural statistics and demographics, Workforce
- Tracking the Implementation of Medicaid Managed Care in Rural Areas
Topic: Medicaid and CHIP
- Describing the Health Care Infrastructure in Rural Towns
Topics: Federally Qualified Health Centers (FQHCs), Hospitals and clinics, Physician assistants, Physicians, Rural Health Clinics (RHCs), Rural statistics and demographics
- Impacts of Multiple Race Reporting
Topic: Minority health
- Rural Hospital Wages and the Prospective Payment System Wage Index: 1990-1997
Topics: Hospitals and clinics, Medicare, Medicare Prospective Payment System (PPS), Workforce
- Rural Informal Safety Net: The Development of a Research and Evaluation Design and a Preliminary Assessment
Topics: Health services, Uninsured and underinsured