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The Effects of California Proposition 187 on Ophthalmology Clinic Utilization at an Inner-city Urban Hospital
The Effects of California Proposition 187 on Ophthalmology Clinic Utilization at an Inner--city Urban Hospital Jeffrey L. Marx, MD, 1 Allen B. Thach, MD, 1 Galen Grayson, MD, 1 Lenore P. Lowry, RN, 1 Pedro F. Lopez, MD, 1 Paul P. Lee, MD, ]D1•2 Purpose: To determine the effect on ophthalmology clinic utilization at a major public inner-city hospital of California Proposition 187 and the debate surrounding its passage. Proposition 187 was a statewide referendum passed by 63% of the electorate in the November 1994 election that would restrict social services to undocumented immigrants and require providers to report them to immigration authorities. Methods: The ophthalmology clinic volume at the Los Angeles County/University of Southern California Medical Center was analyzed from October 1 to December 31, 1993 and 1994. Results: New walk-in patients significantly decreased (P < 0.001) for a 2-month period around the election, but returned to baseline levels in December 1994. The new patient cancellation and no show rate was not affected. No change in return patient behavior was noted for general and specialty clinics. Conclusions: Proposition 187 may have caused a statistically significant decrease in new walk-ins to the ophthalmology clinics during a 2-month period surrounding the November 1994 election, but it had no measurable effect on other indicators of utilization. In addition, utilization rates returned to baseline after the implementation of Proposition 187 was stayed by the judicial system, and concern that providers would be required to report undocumented immigrants to authorities was alleviated. Ophthalmology 1996;103:847-851
The failure of patients to keep appointments creates sig nificant problems for the delivery of effective healthcare. Missed medical appointments reportedly have ranged from as low as 20% to as high as 60% in a variety of settings. t-s Failure to maintain adequate follow-up can have potentially significant health as well as economic effects for the patient and society as a whole. More importantly, concern exists for those who have poor or no access to healthcare, for whatever reason. Originally received: June 27, 1995. Revision accepted: February 16, 1996. 1 Department of Ophthalmology, University of Southern California School of Medicine, Doheny Eye Institute, Los Angeles. 2 Health Sciences Program, RAND, Santa Monica. Reprint requests to Paul P. Lee, MD, Doheny Eye Institute, 1450 San Pablo St, Los Angeles, CA 90033.
Studies have shown that being poor or uninsured is related to having worse access to healthcare and worse access results in health decrements. 6•7 For example, physicians do not immunize uninsured and underinsured children as frequently as insured children. 6 Even more pertinently, a study of the effects of the 1982 termination of MediCal (state Medicaid) benefits in California for 270,000 med ically indigent adults found that 6 months after termi nation there was a significant deterioration in patients' satisfaction with care and their health status, notably an increase in uncontrolled hypertension associated with an increased relative risk of dying by 40%. 7 Access to effective healthcare is a central tenet of pro posals to reform the current health care system. Enhanced access will improve the health and quality of life of mil lions of Americans as members of our society. At the same time, concern about the rapid growth of health care
847
Ophthalmology
Volume 103, Number 5, May 1996
costs has prompted a search for methods to reduce costs. In many areas, these two concerns come into conflict. One such example has been the debate over providing nonemergency medical benefits, paid for by taxpayers, to residents who are not in the United States through legal mechanisms ("undocumented" immigrants). The most recent estimate by the state of California shows that the state costs for Medicaid emergency services provided to illegal aliens in California is $395 million annually. 8 California Proposition 187 was a statewide referendum, approved by 63% of voters in the November 1994 election, that would deny medical, educational, and other social services to undocumented immigrants and would require service providers to report those patients to immigration authorities. For several weeks before and after the election, there was intense public scrutiny and widespread debate over the social consequences of the proposition. One ma jor concern was whether the proposition would affect healthcare use by undocumented residents before and after the referendum, despite the immediate judicial interven tion preventing its implementation until constitutional issues could be resolved. In fact, an unfortunate conse quence of the confusion about the implementation of Proposition 187 was the death of a 12-year-old boy of acute leukemia because his parents delayed getting him medical care because they were worried that their status would be questioned. 9 Therefore, in the end ofNovember and beginning of December, groups opposed to Propo sition 187 taped public service announcements in Spanish and English to urge illegal immigrants to seek healthcare. The current research examines the behavior of patients seen in the ophthalmology outpatient clinics at the Los Angeles County/University of Southern California Med ical Center, between October I to December 31, 1993, and October 1 to December 31, 1994.
Methods Patient scheduling and clinic volume for the ophthal mology clinics were obtained from the Compucare System and clinic logs at the Los Angeles County/University of Southern California (LAC+USC) Medical Center for Oc tober I 1993 to December 31, 1993, and October I to December 31, 1994. The LAC+USC Medical Center is a large public inner-city hospital with a catchment of one million people, 83% of whom are of Hispanic descent. The hospital has a strict policy of not inquiring as to the immigration status ofpatients. The County of Los Angeles Department of Health Services performed statistical sam pling of patients in the outpatient department of LAC+USC Medical Center from July to December 1993 and found a 32.89% incidence of"undocumented" aliens (personal communication, 1995). The Department ofOphthalmology is comprised of 18 residents (approximately 10 residents are assigned to the clinic on a daily basis) who see the vast majority ofpatients in both an inpatient and outpatient setting and are su pervised by a full-time faculty ophthalmologist and clinical fellows. The number of residents assigned to the clinic
848
and appointment slots were similar throughout the two studied comparison times. Oinic appointment scheduling and policy regarding new patients, scheduling return pa tients, and consultations did not change. The average wait for a new patient and return patient appointment was similar during the studied comparison times. There are approximately 40,000 outpatient visits to the ophthal mology clinic each year. Ocular diagnoses of new patients presenting to the eye clinic were surveyed recently (presented as a poster at the American Academy of Ophthalmology Annual Meeting, Chicago, 1993). The most common finding was refractive error in 133 (42%) of 317 patients. Other common, treat able conditions in 317 patients included cataracts in 49 (16%) patients, glaucoma in 23 (7.3%), macular degen eration in 13 (4.1%), and other retinal diseases, including diabetic retinopathy and cytomegalovirus retinitis, in 53 ( 17%). Results of a normal examination were found in 56 ( 18%) patients, and Ill patients had more than one disease. Patient data from four sets of time points were ana lyzed: 1. October 1 to November 30, 1993 (baseline rate); 2. December I to December 31, 1993 (baseline rate); 3. October I to November 30, 1994 (intense debate over Proposition 187 with the election on November 8, 1994, and confusion about its implementation until the end of November when public service an nouncements began); 4. December I to December 31, 1994 (Injunctions preventing implementation of Proposition 187 clearly publicized.) Utilization data were analyzed for new patients and return patients (including general and specialty clinics). The specialty clinics included diabetic retina, vitrectomy, glaucoma, cornea, contact lens, uveitis, pediatrics, and neuro-ophthalmology. The panretinal and focal photo coagulation clinics were excluded because these patients were seen in diabetic clinic on the same day and would, therefore, be counted twice. For each of the above cate gories, the number ofpatients scheduled, logged in, walked in, canceled, and did not show was recorded. The Fisher's exact test (two-tailed) was used for statistical analysis. The weather, including number ofrain days (arbitrarily defined as greater than 0.1 inch over a 24-hour period), and av erage daily temperature also were studied. Other factors such as rapid transit interruptions, major freeway damage, natural disasters, and economic influences all were ana lyzed.
Results The data for each of the four time periods listed above are presented in Tables I and 2. For the time period Oc tober I to November 30, 1993 and 1994, a significant decrease (P < 0.00 I) in new walk-in patients was noted,
Marx et al · California Proposition 187 and Ophthalmology Clinic Utilization
Table 1. Comparison of Ophthalmology Clinic Logs for October 1 to November 30, 1993 and 1994, at Los Angeles County-University of Southern California Medical Center October-November
1993
New Patients Appointments Total seen (appt +walk-in) Cancelled and no show (% of appointment) Walked in(% of total seen) Return Patients General clinic Appointments Total seen Cancelled and no show (% of appointment) Walked in (% of total seen) Specialty clinic Appointments Total seen Cancelled and no show (% of appointment) Walked in (% of total seen)
2018 1569 977 (48) 528 (34)
October-November
1994
2030 1499 926 (46) 395 (26)
3755 3895
3300 3385
1040 (28) 1180 (30)
940 (28) 1025 (30)
1236 1111
1299 1229
369 (30) 244 (22)
P*
0.08 <0.001
372 (29) 302 (25)
0.47 .1.00
0.51 0.14
• Fisher's exact test (two-tailed) was used for statistical analysis.
Table 2. Comparison of Ophthalmology Clinic Logs for December 1 to December 31, 1993 and 1994, at Los Angeles County-University of Southern California Medical Center December
1993
New Patients Appointments Total seen Cancelled and no show (% of appointment) Walked in(% of total seen) Return Patients General clinic Appointments Total seen Cancelled and no show (% of appointment) Walked in (% of total seen) Specialty clinic Appointments Total seen Cancelled and no show (% of appointment) Walked in (% of total seen)
1036 715 550 (53) 229 (32)
1735 1723
December
1994
998 735 473 (47) 210 (29)
0.01 0.15
1608 1643
501 (29) 489 (28)
465 (29) 500 (30)
688 660
644 600
184 (27) . 156 (24)
p•
181 (28) 137 (23)
1.00 0.20
0.58 0.74
• Fisher's exact test (two-tailed) was used for statistical analysis.
849
Ophthalmology
Volume 103, Number 5, May 1996
Table 3. Weather Data Obtained from the Los Angeles Times for Daily Precipitation* and Temperature for Days in Which the Ophthalmology Clinic Was Open No. of Rain Days >0.1 in (total precipitation)
Time Period October-November 1993 December 1993 October-November 1994 December 1994
2 (0.57 1 (0.34 3 (0.61 1 (0.29
in) in) in) in)
Average High Temperature (°F)
Average Low Temperature (°F)
77.9 72.1 74.9 69.6
58.5 49.7 ~5.0
51.4
• Precipitation was considered significant if greater than 0.1 inch over a 24-hour period.
but no significant difference was noted in the number of new patients seen by appointment. In addition, there was no statistically significant difference in the new patient cancellation and no-show rate during this period. There was also no statistically significant difference in the return patient parameters. Though the total number of appoint ments declined, the rate of cancellations, no shows and walk-ins did not change between the 2 years. For December l to December 31, a statistically signif icant decrease (P = 0.01) in the new patient cancellation and no-show rate was noted, but no statistically significant change (P = 0.15) in new patient walk-ins was seen be tween 1993 and 1994. No statistically significant difference was seen in all return patient parameters. Weather data are presented in Table 3. No significant difference was noted during the time period studied. Unemployment data were obtained from the California Employment Development Department, Labor Market Information Division, and is presented in Table 4. No major changes in bus fare, bus schedules, or other trans portation issues existed during the studied comparison times.
Discussion We quantified the immediate effects of Proposition 187 and its surrounding debate on clinic patient volume at a large urban hospital serving a largely Hispanic population
Table 4. Unemployment Rate for Los Angeles County Obtained from the California Employment Development Department, Labor Market Information Division, for October through December, 1993 and 1994 Month
1993 Unemployment Rate(%)
1994 Unemployment Rate(%)
October November December
9.6 9.4 8.9
7.8 8.0 8.1
850
with a significant prevalence of undocumented aliens. During the 2 months surrounding the election, there was significant apprehension in the Hispanic and other im migrant communities in Los Angeles regarding the det rimental effects of this law on the population as a whole, especially in receiving nonemergency healthcare. Based on our conversations with patients and confirmed by findings of this study, it was apparent by the beginning of December that patients believed there was little concern they might be subjected to the criteria passed in the ref erendum. From October l to November 30, 1994, we found a significant decrease in the number of new walk in patients compared with the 1993 levels. No corre sponding change was seen in number of patients who re turned to the clinic who had been reassured that their care would continue, despite passage of the referendum. In addition, during December 1994, a return to the 1993 levels was seen with regard to new walk-in patients. (It was impossible to continue this study into January due to the Northridge earthquake in January 1994 as well as the significant rainfall and floods in January 1995.) The effect of a decrease in new walk-in patients is very difficult to determine because of the short period of time studied. A significant number of new patients presenting to the eye clinic at LAC+USC Medical Center have ocular pathologic findings, including glaucoma, diabetic reti nopathy, and cytomegalovirus retinitis. Although a survey on new walk-in patients at LAC+USC has not been per formed, we believe that patients are very similar to new patients, except for trauma that occurs in the former group. The natural history of these eye diseases is pro gressive and may result in significant visual loss. Fortu nately, the time period when patients were afraid to pres ent to the eye clinic for care was relatively brief and a substantial loss of vision from the aforementioned con ditions was not perceived. Nevertheless, as the termination of benefits to patients receiving MediCal in 1982 shows that the general health of these patients worsened and for those with hypertension, the diastolic blood pressure had risen by lO mmHg. 7 A decrease in the unemployment rate was seen between 1993 and 1994 during the studied time periods. This could result in a decreased pool of patients who need to be seen at a county facility, assuming that employed individuals
Marx et al · California Proposition 187 and Ophthalmology Clinic Utilization have health insurance and would prefer to obtain health care at a private facility. The county unemployment data, however, are based on a relatively small sample size, and any conclusions from small changes in unemployment levels are, therefore, limited (personal communication, Urban Research Division, Los Angeles County Admin istration Office, 1995). Walk-in patients reflect a spontaneous decision to seek medical care and may correlate directly with a risk-benefit ratio that the patient may consider. In this case, the patient must consider the possibility of being asked to produce documents and, if they are inadequate, being sent to im migration officials. Thus, we believe that the decrease in walk-in patients who we observed may be related to the Proposition 187 referendum. The reason that we did not observe these changes in patients who returned to the clinic may reflect their comfort and familiarity with the ophthalmology clinics and their doctors. A similar comfort and familiarity may exist for new patients with scheduled appointments, because such patients are willing to provide their name and contact information. In other words, se. lection bias for those with greater confidence and less sus ceptibility to the effects of the proposition among patients with scheduled appointments may have mitigated the ef fect of the Proposition 187 debate. A prior survey has shown that patients using the ophthalmology clinic at LAC+USC Medical Center are unlikely to have other physicians; therefore, the eye clinic is the only point of contact for many of these patients (unpublished data, 1993). Proposition 187 currently is being considered by the judicial system as to its constitutionality. Its effects will be far-reaching for not only health sciences, but also ed ucational and social service issues. This report only an alyzes its effects on the ophthalmology clinic for a 3-month period at a large inner-city hospital. It will be important
to determine the sequelae of the referendum if it is upheld in the courts over a longer period of time. Clearly, this study and other similar studies are only an initial step. Additional studies on the actual health effects and consequences ofchanges in care eligibility will be needed in ophthalmology as well as other areas of healthcare delivery. Yet, as noted in the introduction, de nial of needed care and poorer access to care have been found to be associated with worse outcomes. If we truly believe that medical care has benefits, then lack of access or use of that care should result in poorer health.
References I. Wesch D, Lutzker JR, Frisch L, Dillon MM. Evaluating the impact of a service fee on patient compliance. J Behav Med 1987;10:91-101. 2. Gates SJ, Colborn DK. Lowering appointment failures in a neighborhood health center. Med Care 1976;14:263-7. 3. Oppenheim GL, Bergman JJ, English' EC. Failed appoint ments: a review. J Fam Prac 1979;8:789-96. 4. Dockerty JD. Outpatient clinic nonarrivals and cancella tions. N Z Med J 1992;105:147-9. 5. Fosarelli P, DeAngelis C, Kaszuba A. Compliance with fol low-up appointments generated in a pediatric emergency room. Am J Prev Med 1985;1(3):23-9. 6. Arnold PJ, Schlenker TL. The impact of health care fi nancing on childhood immunization practices. Am J Dis Child 1992; 146:728-32. 7. Lurie N, Ward NB, Shapiro MF, Brook RH. Special Report: termination from Medi-Cal-does it affect health? N Eng! J Med 1984;311:480-4. 8. Romero PJ. Shifting the costs of a failed federal policy: the net fiscal impact of illegal immigrants in California. Cali fornia Governor's Office of Planning and Research and Cal ifornia Department of Finance. Sacramento, CA, Sept 1994. 9. Romney L. Boy in Prop. 187 controversy mourned. Los Angeles Times Nov 29, 1994: A22 (col. 1-3).
851
The failure of patients to keep appointments creates sig nificant problems for the delivery of effective healthcare. Missed medical appointments reportedly have ranged from as low as 20% to as high as 60% in a variety of settings. t-s Failure to maintain adequate follow-up can have potentially significant health as well as economic effects for the patient and society as a whole. More importantly, concern exists for those who have poor or no access to healthcare, for whatever reason. Originally received: June 27, 1995. Revision accepted: February 16, 1996. 1 Department of Ophthalmology, University of Southern California School of Medicine, Doheny Eye Institute, Los Angeles. 2 Health Sciences Program, RAND, Santa Monica. Reprint requests to Paul P. Lee, MD, Doheny Eye Institute, 1450 San Pablo St, Los Angeles, CA 90033.
Studies have shown that being poor or uninsured is related to having worse access to healthcare and worse access results in health decrements. 6•7 For example, physicians do not immunize uninsured and underinsured children as frequently as insured children. 6 Even more pertinently, a study of the effects of the 1982 termination of MediCal (state Medicaid) benefits in California for 270,000 med ically indigent adults found that 6 months after termi nation there was a significant deterioration in patients' satisfaction with care and their health status, notably an increase in uncontrolled hypertension associated with an increased relative risk of dying by 40%. 7 Access to effective healthcare is a central tenet of pro posals to reform the current health care system. Enhanced access will improve the health and quality of life of mil lions of Americans as members of our society. At the same time, concern about the rapid growth of health care
847
Ophthalmology
Volume 103, Number 5, May 1996
costs has prompted a search for methods to reduce costs. In many areas, these two concerns come into conflict. One such example has been the debate over providing nonemergency medical benefits, paid for by taxpayers, to residents who are not in the United States through legal mechanisms ("undocumented" immigrants). The most recent estimate by the state of California shows that the state costs for Medicaid emergency services provided to illegal aliens in California is $395 million annually. 8 California Proposition 187 was a statewide referendum, approved by 63% of voters in the November 1994 election, that would deny medical, educational, and other social services to undocumented immigrants and would require service providers to report those patients to immigration authorities. For several weeks before and after the election, there was intense public scrutiny and widespread debate over the social consequences of the proposition. One ma jor concern was whether the proposition would affect healthcare use by undocumented residents before and after the referendum, despite the immediate judicial interven tion preventing its implementation until constitutional issues could be resolved. In fact, an unfortunate conse quence of the confusion about the implementation of Proposition 187 was the death of a 12-year-old boy of acute leukemia because his parents delayed getting him medical care because they were worried that their status would be questioned. 9 Therefore, in the end ofNovember and beginning of December, groups opposed to Propo sition 187 taped public service announcements in Spanish and English to urge illegal immigrants to seek healthcare. The current research examines the behavior of patients seen in the ophthalmology outpatient clinics at the Los Angeles County/University of Southern California Med ical Center, between October I to December 31, 1993, and October 1 to December 31, 1994.
Methods Patient scheduling and clinic volume for the ophthal mology clinics were obtained from the Compucare System and clinic logs at the Los Angeles County/University of Southern California (LAC+USC) Medical Center for Oc tober I 1993 to December 31, 1993, and October I to December 31, 1994. The LAC+USC Medical Center is a large public inner-city hospital with a catchment of one million people, 83% of whom are of Hispanic descent. The hospital has a strict policy of not inquiring as to the immigration status ofpatients. The County of Los Angeles Department of Health Services performed statistical sam pling of patients in the outpatient department of LAC+USC Medical Center from July to December 1993 and found a 32.89% incidence of"undocumented" aliens (personal communication, 1995). The Department ofOphthalmology is comprised of 18 residents (approximately 10 residents are assigned to the clinic on a daily basis) who see the vast majority ofpatients in both an inpatient and outpatient setting and are su pervised by a full-time faculty ophthalmologist and clinical fellows. The number of residents assigned to the clinic
848
and appointment slots were similar throughout the two studied comparison times. Oinic appointment scheduling and policy regarding new patients, scheduling return pa tients, and consultations did not change. The average wait for a new patient and return patient appointment was similar during the studied comparison times. There are approximately 40,000 outpatient visits to the ophthal mology clinic each year. Ocular diagnoses of new patients presenting to the eye clinic were surveyed recently (presented as a poster at the American Academy of Ophthalmology Annual Meeting, Chicago, 1993). The most common finding was refractive error in 133 (42%) of 317 patients. Other common, treat able conditions in 317 patients included cataracts in 49 (16%) patients, glaucoma in 23 (7.3%), macular degen eration in 13 (4.1%), and other retinal diseases, including diabetic retinopathy and cytomegalovirus retinitis, in 53 ( 17%). Results of a normal examination were found in 56 ( 18%) patients, and Ill patients had more than one disease. Patient data from four sets of time points were ana lyzed: 1. October 1 to November 30, 1993 (baseline rate); 2. December I to December 31, 1993 (baseline rate); 3. October I to November 30, 1994 (intense debate over Proposition 187 with the election on November 8, 1994, and confusion about its implementation until the end of November when public service an nouncements began); 4. December I to December 31, 1994 (Injunctions preventing implementation of Proposition 187 clearly publicized.) Utilization data were analyzed for new patients and return patients (including general and specialty clinics). The specialty clinics included diabetic retina, vitrectomy, glaucoma, cornea, contact lens, uveitis, pediatrics, and neuro-ophthalmology. The panretinal and focal photo coagulation clinics were excluded because these patients were seen in diabetic clinic on the same day and would, therefore, be counted twice. For each of the above cate gories, the number ofpatients scheduled, logged in, walked in, canceled, and did not show was recorded. The Fisher's exact test (two-tailed) was used for statistical analysis. The weather, including number ofrain days (arbitrarily defined as greater than 0.1 inch over a 24-hour period), and av erage daily temperature also were studied. Other factors such as rapid transit interruptions, major freeway damage, natural disasters, and economic influences all were ana lyzed.
Results The data for each of the four time periods listed above are presented in Tables I and 2. For the time period Oc tober I to November 30, 1993 and 1994, a significant decrease (P < 0.00 I) in new walk-in patients was noted,
Marx et al · California Proposition 187 and Ophthalmology Clinic Utilization
Table 1. Comparison of Ophthalmology Clinic Logs for October 1 to November 30, 1993 and 1994, at Los Angeles County-University of Southern California Medical Center October-November
1993
New Patients Appointments Total seen (appt +walk-in) Cancelled and no show (% of appointment) Walked in(% of total seen) Return Patients General clinic Appointments Total seen Cancelled and no show (% of appointment) Walked in (% of total seen) Specialty clinic Appointments Total seen Cancelled and no show (% of appointment) Walked in (% of total seen)
2018 1569 977 (48) 528 (34)
October-November
1994
2030 1499 926 (46) 395 (26)
3755 3895
3300 3385
1040 (28) 1180 (30)
940 (28) 1025 (30)
1236 1111
1299 1229
369 (30) 244 (22)
P*
0.08 <0.001
372 (29) 302 (25)
0.47 .1.00
0.51 0.14
• Fisher's exact test (two-tailed) was used for statistical analysis.
Table 2. Comparison of Ophthalmology Clinic Logs for December 1 to December 31, 1993 and 1994, at Los Angeles County-University of Southern California Medical Center December
1993
New Patients Appointments Total seen Cancelled and no show (% of appointment) Walked in(% of total seen) Return Patients General clinic Appointments Total seen Cancelled and no show (% of appointment) Walked in (% of total seen) Specialty clinic Appointments Total seen Cancelled and no show (% of appointment) Walked in (% of total seen)
1036 715 550 (53) 229 (32)
1735 1723
December
1994
998 735 473 (47) 210 (29)
0.01 0.15
1608 1643
501 (29) 489 (28)
465 (29) 500 (30)
688 660
644 600
184 (27) . 156 (24)
p•
181 (28) 137 (23)
1.00 0.20
0.58 0.74
• Fisher's exact test (two-tailed) was used for statistical analysis.
849
Ophthalmology
Volume 103, Number 5, May 1996
Table 3. Weather Data Obtained from the Los Angeles Times for Daily Precipitation* and Temperature for Days in Which the Ophthalmology Clinic Was Open No. of Rain Days >0.1 in (total precipitation)
Time Period October-November 1993 December 1993 October-November 1994 December 1994
2 (0.57 1 (0.34 3 (0.61 1 (0.29
in) in) in) in)
Average High Temperature (°F)
Average Low Temperature (°F)
77.9 72.1 74.9 69.6
58.5 49.7 ~5.0
51.4
• Precipitation was considered significant if greater than 0.1 inch over a 24-hour period.
but no significant difference was noted in the number of new patients seen by appointment. In addition, there was no statistically significant difference in the new patient cancellation and no-show rate during this period. There was also no statistically significant difference in the return patient parameters. Though the total number of appoint ments declined, the rate of cancellations, no shows and walk-ins did not change between the 2 years. For December l to December 31, a statistically signif icant decrease (P = 0.01) in the new patient cancellation and no-show rate was noted, but no statistically significant change (P = 0.15) in new patient walk-ins was seen be tween 1993 and 1994. No statistically significant difference was seen in all return patient parameters. Weather data are presented in Table 3. No significant difference was noted during the time period studied. Unemployment data were obtained from the California Employment Development Department, Labor Market Information Division, and is presented in Table 4. No major changes in bus fare, bus schedules, or other trans portation issues existed during the studied comparison times.
Discussion We quantified the immediate effects of Proposition 187 and its surrounding debate on clinic patient volume at a large urban hospital serving a largely Hispanic population
Table 4. Unemployment Rate for Los Angeles County Obtained from the California Employment Development Department, Labor Market Information Division, for October through December, 1993 and 1994 Month
1993 Unemployment Rate(%)
1994 Unemployment Rate(%)
October November December
9.6 9.4 8.9
7.8 8.0 8.1
850
with a significant prevalence of undocumented aliens. During the 2 months surrounding the election, there was significant apprehension in the Hispanic and other im migrant communities in Los Angeles regarding the det rimental effects of this law on the population as a whole, especially in receiving nonemergency healthcare. Based on our conversations with patients and confirmed by findings of this study, it was apparent by the beginning of December that patients believed there was little concern they might be subjected to the criteria passed in the ref erendum. From October l to November 30, 1994, we found a significant decrease in the number of new walk in patients compared with the 1993 levels. No corre sponding change was seen in number of patients who re turned to the clinic who had been reassured that their care would continue, despite passage of the referendum. In addition, during December 1994, a return to the 1993 levels was seen with regard to new walk-in patients. (It was impossible to continue this study into January due to the Northridge earthquake in January 1994 as well as the significant rainfall and floods in January 1995.) The effect of a decrease in new walk-in patients is very difficult to determine because of the short period of time studied. A significant number of new patients presenting to the eye clinic at LAC+USC Medical Center have ocular pathologic findings, including glaucoma, diabetic reti nopathy, and cytomegalovirus retinitis. Although a survey on new walk-in patients at LAC+USC has not been per formed, we believe that patients are very similar to new patients, except for trauma that occurs in the former group. The natural history of these eye diseases is pro gressive and may result in significant visual loss. Fortu nately, the time period when patients were afraid to pres ent to the eye clinic for care was relatively brief and a substantial loss of vision from the aforementioned con ditions was not perceived. Nevertheless, as the termination of benefits to patients receiving MediCal in 1982 shows that the general health of these patients worsened and for those with hypertension, the diastolic blood pressure had risen by lO mmHg. 7 A decrease in the unemployment rate was seen between 1993 and 1994 during the studied time periods. This could result in a decreased pool of patients who need to be seen at a county facility, assuming that employed individuals
Marx et al · California Proposition 187 and Ophthalmology Clinic Utilization have health insurance and would prefer to obtain health care at a private facility. The county unemployment data, however, are based on a relatively small sample size, and any conclusions from small changes in unemployment levels are, therefore, limited (personal communication, Urban Research Division, Los Angeles County Admin istration Office, 1995). Walk-in patients reflect a spontaneous decision to seek medical care and may correlate directly with a risk-benefit ratio that the patient may consider. In this case, the patient must consider the possibility of being asked to produce documents and, if they are inadequate, being sent to im migration officials. Thus, we believe that the decrease in walk-in patients who we observed may be related to the Proposition 187 referendum. The reason that we did not observe these changes in patients who returned to the clinic may reflect their comfort and familiarity with the ophthalmology clinics and their doctors. A similar comfort and familiarity may exist for new patients with scheduled appointments, because such patients are willing to provide their name and contact information. In other words, se. lection bias for those with greater confidence and less sus ceptibility to the effects of the proposition among patients with scheduled appointments may have mitigated the ef fect of the Proposition 187 debate. A prior survey has shown that patients using the ophthalmology clinic at LAC+USC Medical Center are unlikely to have other physicians; therefore, the eye clinic is the only point of contact for many of these patients (unpublished data, 1993). Proposition 187 currently is being considered by the judicial system as to its constitutionality. Its effects will be far-reaching for not only health sciences, but also ed ucational and social service issues. This report only an alyzes its effects on the ophthalmology clinic for a 3-month period at a large inner-city hospital. It will be important
to determine the sequelae of the referendum if it is upheld in the courts over a longer period of time. Clearly, this study and other similar studies are only an initial step. Additional studies on the actual health effects and consequences ofchanges in care eligibility will be needed in ophthalmology as well as other areas of healthcare delivery. Yet, as noted in the introduction, de nial of needed care and poorer access to care have been found to be associated with worse outcomes. If we truly believe that medical care has benefits, then lack of access or use of that care should result in poorer health.
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