Job-based health insurance in 2000: premiums rise sharply while coverage grows

The business of interventional pulmonology

Interventional pulmonologists are regularly asked to perform more complicated and advanced procedures, but reimbursement for the time, effort and skill involved in these procedures has not kept up with other procedural specialties. Further changes in funding and reimbursement are likely under the Affordable Care Act. Understanding and effectively using the current system of funding for interventional pulmonology practices are imperative as we adapt to changing medical needs, legislative mandates, and reimbursement policy. This article reviews the current landscape of insurance and reimbursement in health care and anticipates some changes that might be expected from implementation of the Affordable Care Act.

Working together?

Purpose

This article aims to analyze existing and preferred labor divisions between physicians and nurses treating patients with hypertension and diabetes in managed care organizations.

Design/methodology/approach

A mail survey was conducted in 2002/2003 among a representative sample of 743 physicians employed by Israel's largest managed care health plans (78 percent response rate). A telephone survey among a representative sample of 1,369 hypertensive or diabetic patients (77 percent response rate) was also used.

Findings

Findings reveal a conspicuous gap between actual labor division and what physicians perceive to be ideal. Possible reasons for this gap are discussed and strategies for facilitating collaboration, which would improve service quality as well as work life quality for both physicians and nurses.

Originality/value

This study provides empirical data on the extent of nurse involvement in managed care organization chronic patient care, as well as comparing them to physicians' preferences regarding nurse involvement.

Implementing QA programs in managed care health plans: factors contributing to success

PURPOSE

The purpose of this paper is to identify the factors that contribute to the success or failure of quality assurance programs implemented by Israeli managed care health plans.

DESIGN/METHODOLOGY/APPROACH

An in-depth study of seven quality assurance programs was conducted, comparing successful with unsuccessful ones using the comparative "case study" method. Employing a semi-structured questionnaire, 42 program directors and professionals in the field were interviewed.

FINDINGS

A number of factors associated with the programs' success emerged. Those external to the program included: ongoing management support, resource allocation, information system support and perceived financial benefit for the organization. Internal factors included: leadership, perceived problem's importance, laying the groundwork in the field, involving field staff in planning and implementation and staff motivation.

ORIGINALITY/VALUE

The study provides insights into ways to encourage the implementation of successful quality assurance programs in the special organizational context of managed care health plans. As the implementation relies heavily on data, one important precondition is the development of computerized information systems to facilitate ongoing data collection. It is also necessary from the planning stage to take into account organizational factors that affect success.

The effect of commitment to the organization on physicians' familiarity with guidelines for diabetes in managed care organizations

Despite continuous efforts, healthcare organizations still find it difficult to influence physicians to follow clinical guidelines. Previous studies have not taken into account the organizational context of the physicians' practice. We conducted a survey of a representative sample of 743 primary care physicians employed in Israel's 2 largest managed care health plans. The findings indicated that "commitment to the health plan" and "perceived monitoring by the health plan" had an independent positive effect on familiarity with guidelines for treating diabetes. We propose that managers of healthcare organizations consider enhancing physicians' commitment to the organization as a means for increasing their adherence with clinical guidelines, thereby improving the quality of care provided to diabetic patients.

The impact of managed care on health care utilization among adults with asthma

STUDY OBJECTIVES

To compare kinds and amounts of health care used by adults with asthma in managed care and fee-for-service settings.

DESIGN

Cross-sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist-immunologists, family practitioners, and from a random sample of the non-institutionalized population.

MEASUREMENTS

Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status.

RESULTS

Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee-for-service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta-agonists, home nebulized beta-agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI -5.4, -0.1), principally because those in MC had many fewer visits to allergist-immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = -16.5, 95% CI -27.8, -5.3). The two groups did not differ significantly in the proportion with asthma-related or nonasthma hospital admissions.

CONCLUSIONS

Persons with asthma in fee-for-service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist-immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in nonasthma care.

Health Benefits In 2003: Premiums Reach Thirteen-Year High As Employers Adopt New Forms Of Cost Sharing

This paper reports changes in job-based health insurance from spring 2002 to spring 2003. The cost of health insurance rose 13.9 percent, the highest rate of increase since 1990. Employers required larger contributions from employees for the monthly cost of health insurance. Separate copayments and deductibles for hospital services have become commonplace, and provider networks have broadened. There was no change in the percentage of employers offering health plans to their workers. Employers indicate little confidence in any future strategies for controlling health care costs.

Changes in health insurance and payment for substance use treatment

Based on data from the National Household Survey on Drug Abuse in 1994 (N = 10, 158) and 1998 (N = 12,892) alcohol- or drug-using subsamples (aged 18-64) were compared to see if postwelfarereform reports of having employer-paid health insurance increased and Medicaid decreased by 1998 and affected participation in substance use treatment. By 1998, respondents were more likely to report having employer-paid insurance but reported source of payment for substance use treatment did not differ by year. In 1998, privately insured respondents were less likely to know if they had coverage for substance use treatment than in 1994. Of privately insured in treatment, 24% did not know if insurance covered treatment; most of these said they paid for treatment out-of-pocket. Despite reported increases in employer-paid insurance, uncertainty about its coverage of substance use treatment also increased and was associated with reports of not using it to pay for treatment.

Health promotion: causes, beliefs and measurements

This investigative study summarizes the five most prevalent healthcare models and seven instruments to help the reader determine which model is the most effective in measuring health-related ideas and behaviors in subjects of varying populations. Their significance to the science and art of health promotion and analytical techniques are also reviewed. The purpose of the study is to consider varying arguments and apply them to abstractions of health promotion activities that readers may be contemplating.

Perceived need and receipt of outpatient mental health services. Factors affecting access in Israeli HMOs

The finance and provision of care have been suggested as variables that affect the utilization of mental health services. This study compared perceived need and receipt of outpatient mental health services in a staff-model health maintenance organization (HMO) and in three HMOs with preferred provider organization (PPO) arrangements. A national random phone survey (n = 1,394) of perceived need for and receipt of mental health assistance was conducted in Israel in 1995. Health care is provided by four HMOs that differ in mental health benefits, utilization management (i.e., prior authorization and referral requirements), and availability of mental health services (i.e., pool of providers and geographic dispersal). About one-quarter of the respondents had perceived a need for help at some time in their life. Significantly fewer respondents from the HMO with a small pool of providers got help (20%) than respondents from the other HMOs, which had almost identical rates of obtaining care (40.3%, 37.3% and 40.3%). Providing generous outpatient mental health care benefits does not appear to increase the proportion of persons in need who get help. However, severely limiting the availability of services does reduce the proportion of persons getting care. Implications for regulating insurers are discussed.

Upstream or downstream. Determinants of consumer willingness to recommend an HMO

Understanding the attributes that explain an HMO members' willingness to recommend a health plan is considered by many to be critical in a competitive managed care market. The study reported in this article examines the relationship between provider panel composition on overall willingness to recommend a health plan. Our results indicate that a strong association exists between an HMO member's available choice of primary care physician and recommendation of their primary care physician with overall HMO members' recommendation of the health plan. Interestingly, a member's recommendations of hospitals and specialists did not influence HMO member's willingness to recommend a health plan.

Disparities in women's health and health care experiences in the United States and Israel: findings from 1998 National Women's Health Surveys

OBJECTIVE AND METHODS

Using data from bi-national 1998 surveys of adult women in the U.S. and in Israel, this article examines health, access, and care experiences among women in two countries with very different health care systems. We examine how well each country's system serves those vulnerable due to lower socio-economic status. The Israeli health care system-characterized by universal coverage for all its residents-relies on a system of competing health funds that employ many features typical of U.S. managed care plans. The analysis explores the extent to which such a system helps to equalize access experiences with contrasts to the experiences of U.S. women.

FINDINGS

We find that U.S. and Israeli women report similar rates of disability and chronic conditions with prevalence of health problems sharply higher for low income and less educated women. We also find disparities in access: women in both countries reported unequal access experiences by education and income. In Israel, these experiences appear to be linked to health plan structural features rather than cost barriers.

CONCLUSION

The findings indicate that achieving more equitable access to health care requires attention to non-financial as well as financial barriers to care. Despite the lack of financial barriers to care in Israel, administrative controls typical of managed care organizations appear to make health care systems difficult to navigate for low income and less educated women. The finding that disparities in health persist in a country with universal coverage indicates that improving women's health will require attention to broader social influences on health as well as improving access to health care.

Managing costs, managing benefits: employer decisions in local health care markets

OBJECTIVES

To better understand employer health benefit decision making, how employer health benefits strategies evolve over time, and the impact of employer decisions on local health care systems.

DATA SOURCES/STUDY SETTING

Data were collected as part of the Community Tracking Study (CTS), a longitudinal analysis of health system change in 12 randomly selected communities.

STUDY DESIGN

This is an observational study with data collection over a six-year period.

DATA COLLECTION/EXTRACTION METHODS

The study used semistructured interviews with local respondents, combined with monitoring of local media, to track changes in health care systems over time and their impact on community residents. Interviewing began in 1996 and was carried out at two-year intervals, with a total of approximately 2,200 interviews. The interviews provided a variety of perspectives on employer decision making concerning health benefits; these perspectives were triangulated to reach conclusions.

PRINCIPAL FINDINGS

The tight labor market during the study period was the dominant consideration in employer decision making regarding health benefits. Employers, in managing employee compensation, made independent decisions in pursuit of individual goals, but these decisions were shaped by similar labor market conditions. As a result, within and across our study sites, employer decisions in aggregate had an important impact on local health care systems, although employers' more highly visible public efforts to bring about health system change often met with disappointing results.

CONCLUSIONS

General economic conditions in the 1990s had an important impact on the configuration of local health systems through their effect on employer decision making regarding health benefits offered to employees, and the responses of health plans and providers to those decisions.

The role of public employers in a changing health care market

Public employers provide health insurance coverage to nearly 16 percent of all U.S. workers. Their reactions to rapidly rising premiums can have an important effect on local markets for health insurance because of their size, their visibility, and their reflection of public policy. However, public employers are constrained in their responses by tight budgets set by elected officials and statutes regarding due process, public input, and public accountability. As insurance markets consolidate and premiums continue to increase, public employers face tough choices regarding employee benefits.

Quality measurement and accountability for substance abuse and mental health services in managed care organizations

OBJECTIVES

To analyze managed care organizations' (MCOs') use of behavioral health quality management activities using nationally representative survey data.

MATERIALS AND METHODS

The primary data source is the Brandeis Survey on Alcohol, Drug Abuse, and Mental Health Services in MCOs. Using a sampling strategy designed for national estimates, we surveyed 434 MCOs in 60 market areas (response rate = 92%) regarding their commercial products' behavioral health services in 1999. Of these, 417 MCOs reported clinically oriented information for 752 products. We investigated the use of four behavioral health quality management activities: patient satisfaction surveys, clinical outcomes assessment, performance indicators, and practice guidelines. chi tests and logistic regression were used to determine effects of product type (HMO, PPO, point-of-service) and behavioral health contracting arrangement (specialty contract, comprehensive contract including general medical and behavioral health, internal provision).

RESULTS

Three-quarters of products used patient satisfaction surveys (70.1%), performance indicators (72.7%), and practice guidelines (73.8%) for behavioral health. Under half (48.9%) assessed clinical outcomes. HMO products were most likely, and PPOs least likely, to conduct activities. Quality activities were significantly more common among specialty-contract products. Logistic regression showed significant negative effects on quality activity use for PPO and POS products compared with HMOs. For clinical outcomes, specialty- and comprehensive-contract arrangements had significant positive effects. There were interactions between product type and contract arrangement.

CONCLUSIONS

Most commercial managed care products use patient satisfaction surveys, performance indicators, and practice guidelines for behavioral health, whereas clinical outcomes assessment is less common. Product type and contracting arrangements significantly affect use of these activities.

Association between health insurance coverage of office visit and cancer screening among women

BACKGROUND

Little is known regarding the nuances of insurance benefit design that may affect the receipt of clinical preventive services.

OBJECTIVE

To evaluate whether differences in insurance coverage of physician office visits influences the receipt of cancer screening in women who have full coverage for the screening services.

DESIGN

Cohort study of women enrolled in fee-for-service (FFS) or Preferred Provider Organization (PPO) health plans, where FFS plans have less generous office visit coverage, for the period 1995 to 1997.

SETTINGS AND PARTICIPANTS

General Motors Corporation's employees and their dependents.

MAIN OUTCOME MEASURES

Papanicolaou and mammography rates in women aged 21 to 64 years (n = 139,294) and 52 to 64 years (n = 56,554), respectively.

RESULTS

Compared with FFS plans, enrollees in PPO plans were significantly more likely to obtain a Papanicolaou smear and mammogram (adjusted relative risk [RRa] = 1.22; 95% CI, 1.21-1.24; and RRa, 1.17; 95% CI, 1.15-1.18, respectively). The association was more pronounced among hourly individuals (RRa, 1.27; 95% CI, 1.26-1.29 for Papanicolaou smears; RRa, 1.17; 95% CI, 1.16-1.19 for mammograms) than among salaried individuals (RRa, 1.10; 95% CI, 1.08-1.12 for Papanicolaou smears and RRa, 1.10; 95% CI, 1.06-1.12 for mammograms), corresponding to a greater differential in office visit coverage among the hourly group.

CONCLUSIONS

Benefit structure appears to have an important effect on receipt of cancer screening in women. The findings highlight the need to ensure that future reforms of the health care system do not adversely affect the use of preventive services.

Bargaining health benefits in the workplace: an inside view

Before contract negotiations in 1999, the author served on an "issue-based" health benefits committee of faculty union representatives and university administrators. Although the committee solicited estimates from health insurers regarding the impact of higher copayments on monthly premiums, in subsequent negotiations, the projected cost savings did not lead to changes in coverage or copayments. The explanations offered are (1) national or regional employers may be reluctant to raise employees' health benefit copayments when labor markets are tight; (2) collective bargaining, particularly when other, nonmonetary issues are being bargained, may lead to results different from those from a strictly competitive model; and (3) employers with market power in the product market may shift these highest costs to consumers through higher prices.

Effect of managed care insurance on the use of preventive care for specific ethnic groups in the United States

BACKGROUND

Ethnic disparities in access to health care is a persistent problem in the US. Despite the broad implementation of managed care, there is little information that specifically addresses how this type of coverage may affect ethnic disparities.

OBJECTIVES

To examine the effect of managed care insurance on the use of preventive care for different ethnic groups.

RESEARCH DESIGN

Observational cohort using the 1996 Medical Expenditure Panel Survey.

SUBJECTS

Adults with health insurance who report their ethnicity as white, black, Hispanic, or Asian/Pacific Islander.

MAIN OUTCOME MEASURES

(1) Mammography within the past 2 years for women between 50 and 75 years of age; (2) clinical breast exam within the past 2 years for women between 40 and 75 years; (3) Papanicolaou smear within the past 2 years for women between 18 and 65 years; and (4) cholesterol screening within the past 5 years for men and women older than the age of 20 years.

RESULTS

Hispanic people enrolled in a managed care plan report higher rates of mammography, breast exam, and Papanicolaou smear compared with Hispanic people with fee-for-service insurance. For example, the adjusted predicted probability of a mammogram for Hispanic women with managed care was 85.6% compared with 72.4% for Hispanic women with fee-for-service coverage (risk difference: 13.2%; 95% CI for the risk difference 0.7%-25.7%). White persons with managed care are also more likely than white persons with fee-for-service coverage to receive mammography and cholesterol screening. Managed care is not associated with less preventive care for any ethnic group.

CONCLUSIONS

In this nationally representative household survey, it was found that managed care is associated with greater use of some preventive care for Hispanic persons and white persons than fee-for-service insurance. Despite a focus on prevention, the benefits of managed care are not apparent for black persons or Asian/Pacific Islanders.

Tracking Medicaid managed care in rural communities: a fifty-state follow-up

This study updates a 1997 study examining implementation of rural Medicaid managed care programs. Most states operate Medicaid managed care programs for their beneficiaries, but the types of programs vary across urban and rural settings. Over the past four years the number of rural counties covered by Medicaid managed care, including fully capitated programs, has grown, although primary care case management (PCCM) remains the predominant program type in rural areas. Health plan withdrawals from rural areas have led some states with rural capitated programs to provide financial incentives or develop alternative approaches, such as enhanced PCCM programs.

Are HMO enrollees healthier than others? Results from the community tracking study

This analysis addresses the question of biased selection into health maintenance organizations (HMOs) by using recent, nationally representative data from the Community Tracking Study (CTS) to compare the health status of nonelderly privately insured persons enrolled in HMO and non-HMO plans. Contrary to the conventional view that HMOs receive favorable selection, we find among the privately insured that HMO enrollees are not healthier and may be slightly less healthy. To help understand that result, we present evidence suggesting that other factors, including cost considerations, may be more important than health when people are deciding whether to enroll in an HMO.

Differences in health care costs and utilization among adults with selected lifestyle-related risk factors

PURPOSE

This study examined the relationship between lifestyle-related health risks and health care costs and utilization in adults.

DESIGN

A 2-year prospective study with no intervention was used to compare health care utilization and costs in employees with different levels of health risks.

SETTING

Data were collected at a primarily white-collar worksite during 1994 and 1995.

SUBJECTS

Subjects included 982 employees and spouses, mean age 32.1 +/- 10.1 years.

MEASURES

Employee medical claims obtained from a third-party administrator were analyzed with respect to health care expenses and utilization. Exercise habits, stress, and overall wellness were assessed by self-report and obesity by the body mass index (BMI). Regression, regression with outliers removed, and odds ratios were used to analyze the associations.

RESULTS

Employees who were at high risk for overall wellness (2.4 times), stress (1.9 times), and obesity (1.7 times) were more likely to have high health care costs (> $5,000) than subjects not at high risk. Mean total medical costs also were greater for high-risk subjects compared to lower risk subjects for overall wellness (difference = $1,973; F = 10.65, p = .001), stress (difference = $1,137; F = 7.35, p = .007), and obesity (difference = $1,092; F = 9.09, p = .003). The exercise habits measure was not significantly associated with health care costs or utilization.

CONCLUSIONS

Results indicate that health risks, particularly obesity, stress, and general lifestyle, are significant predictors of health care costs and utilization in employed young adults.

Employer-sponsored health insurance: pressing problems, incremental changes

Despite large premium increases, employers made only modest changes to health benefits in the past two years. By increasing copayments and deductibles and changing their pharmacy benefits, employers shifted costs to those who use services. Employers recognize these changes as short-term fixes, but most have not developed strategies for the future. Although interested in "defined-contribution" benefits, employers do not agree about what this entails and have no plans for moving to defined contributions in the near future. While dramatic changes in health benefits are unlikely in the short term, policymakers may want to watch for future erosions in health coverage.

Challenges and options for increasing the number of Americans with health insurance

This paper provides an overview of the issues confronting policymakers who want to develop programs to help working Americans obtain health insurance. It sets the stage for the following 10 articles, which detail a variety of proposals to offer subsidies and financial incentives to people so they will purchase health coverage. This paper examines challenges to covering the uninsured, describes principles that should be used in assessing policy proposals aimed at this purpose, and evaluates the main strategies for coverage expansions. The evaluation of proposal categories also provides estimates of the costs and consequences of specific proposals described in the other papers.

Job-based health insurance in 2001: inflation hits double digits, managed care retreats

Drawing on the results of a national survey of 1,907 firms with three or more workers, this paper reports on several facets of job-based health insurance, including the cost to employers and workers; plan offerings and enrollments; patient cost sharing and benefits; eligibility, coverage, and take-up rates; and results from questions about employers' knowledge of market trends and health policy initiatives. Premiums increased 11 percent from spring 2000 to spring 2001, and the percentage of Americans in health maintenance organizations (HMOs) fell six percentage points to its lowest level since 1993, while preferred provider organization (PPO) enrollment rose to 48 percent. Despite premium increases, the percentage of firms offering coverage remained statistically unchanged, and a relatively strong labor market has continued to shield workers from the higher cost of coverage.

Prevalence of selected employer health insurance purchasing strategies in 1997

This paper provides information about the nationwide prevalence of selected employer health insurance purchasing strategies. These strategies include raising the share of medical costs borne by employees; the use of quality information in choosing which plans to offer; and direct contracting with provider systems. The data are primarily from the 1997 Robert Wood Johnson Foundation Employer Health Insurance Survey.

Market failure? Individual insurance markets for older Americans

This study examines the viability of tax credits and nongroup markets for covering uninsured adults ages fifty to sixty-four. We find that adults in this age group covered by nongroup plans tend to be healthier and wealthier than the average for their peers, yet more of them go without care and experience high medical bills relative to their incomes. Individual-market premiums rise steeply with age in most states and are well above employer-group rates. Costs are likely to be unaffordable for most uninsured older adults, even with large tax credits or in states with community rating. These findings indicate a need to include risk and age pooling to reach the uninsured in this age group.

Embraceable you: how employers influence health plan enrollment

Based on data from a 1999 national survey of 1,939 randomly selected employers, this paper examines the policies that affect the percentage of workers eligible for and enrolled in a firm's health plan. In 1994, 14 percent of employees worked for a firm offering cash-back payments, but fewer than 1 percent worked for a firm with income-related premiums or deductibles. The strongest determinants of eligibility rates are the waiting time for new employees before they are deemed eligible, and eligibility standards for part-time workers. The primary determinants of the take-up rate are lowest monthly employee contribution for single coverage, and the percentage of the workforce earning less than $20,000 per year.

Innovative approaches to educating medical students for practice in a changing health care environment: the National UME-21 Project

In today's continually changing health care environment, there is serious concern that medical students are not being adequately prepared to provide optimal health care in the system where they will eventually practice. To address this problem, the Health Resources and Services Administration (HRSA) developed a $7.6 million national demonstration project, Undergraduate Medical Education for the 21st Century (UME-21). This project funded 18 U.S. medical schools, both public and private, for a three-year period (1998-2001) to implement innovative educational strategies. To accomplish their goals, the 18 UME-21 schools worked with more than 50 organizations external to the medical school (e.g., managed care organizations, integrated health systems, Area Health Education Centers, community health centers). The authors describe the major curricular changes that have been implemented through the UME-21 project, discuss the challenges that occurred in carrying out those changes, and outline the strategies for evaluating the project. The participating schools have developed curricular changes that focus on the core primary care clinical clerkships, take place in ambulatory settings, include learning objectives and competencies identified as important to providing care in the future health care system, and have faculty development and internal evaluation components. Curricular changes implemented at the 18 schools include having students work directly with managed care organizations, as well as special demonstration projects to teach students the knowledge, skills, and attitudes necessary for successfully managing care. It is already clear that the UME-21 project has catalyzed important curricular changes within 12.5% of U.S. medical schools. The ongoing national evaluation of this project, which will be completed in 2002, will provide further information about the project's impact and effectiveness.

Trends in out-of-pocket spending by insured American workers, 1990-1997

This paper examines trends in out-of-pocket spending for insured workers from 1990 to 1997. Data are from the Consumer Expenditure Survey conducted by the U.S. Bureau of Labor Statistics. The survey collects detailed quarterly data on all consumer spending from logs kept each year by more than 10,000 households with job-based health insurance. During the study period, total out-of-pocket spending in constant dollars remained unchanged. Spending for medical expenses, drugs, and supplies declined by 23 percent, but this decline was offset by rising employee contributions for health insurance premiums. The shift to managed care, whose benefit structure requires less cost sharing, may have played a role in reducing out-of-pocket spending.

Assessing the impact of health plan choice

Many health policy researchers have argued that increased insurance plan choice will enhance the efficiency of the health care system. However, relatively little is known about plan choice and its association with insurance coverage and access to and satisfaction with health care. Using data from the 1996 Medical Expenditure Panel Survey, we find that 55 percent of workers had plan choice in that year. Approximately 26 percent of workers with choice obtained it through a family member. Controlling for other factors, plan choice is associated with higher levels of employment-based insurance coverage and a greater likelihood that workers are satisfied that their families' health care needs are being met.