Dr. Nohad Toulan

Date of Award


Document Type


Degree Name

Doctor of Philosophy (Ph.D.) in Urban Studies


Urban Studies and Planning

Physical Description

3, x, 144 leaves: ill. 28 cm.


Urban planning, Area planning & development, Medical policy -- Oregon, Medical care -- Oregon




This study explores the effects of income, insurance, and source of medical care on access to and utilization of health services. Profiles of dental, physician, and hospital services use are developed for more than 3,500 Oregonians. Low income, lack of health insurance, and/or an inappropriate source of medical care are hypothesized to be barriers to access and utilization. Households which face one or more of these barriers are identified as falling into a "Health Policy Gap." The data for this study were drawn from a 1978 random telephone survey of 1249 Oregon households. The survey was commissioned by the State Health Planning and Development Agency in conjunction with the Northwest Oregon Health Systems Agency, the Western Oregon Health Systems Agency, and the Eastern Oregon Health Systems Agency. The questionnaire was developed by the Oregon State University Research Center. Information was collected on use of health services, insurance coverage, income, household structure, health needs, health behaviors, and health satisfaction. A behavioral model of health services utilization was constructed, dividing the independent variables according to their relative mutability or amenity to policy intervention. Income, insurance, and source of care were selected as policy variables, while other variables less under policymakers' control were labelled household characteristics. The latter were assumed to reflect a household's propensity to consume services. They included household structure, health need, residential mobility, and health behaviors. Dependent variables included measures of dental and physician visits, use of the telephone for physician advice, preventive exams, and hospitalization during the past year. Multiple techniques of analysis were employed. Cross-tabular procedures were applied to investigate the interrelationship of income, insurance, and source of care. Multiple linear regression and partial correlation methods were used to select as control variables household characteristics highly correlated to each measure of health services use. Analysis of variance and multiple classification analysis were used to develop profiles of health services use. These last techniques allowed an examination of the relationship of each policy variable and health measure while applying increasing levels of statistical control. The initial bivariate relationship was studied in isolation; it was then studied while controlling for the other policy variables, and finally while controlling for both the other policy variables as well as selected household characteristic variables. Findings support the hypotheses. Income is found to be related to insurance coverage, and insurance coverage to source of medical care, although income is not found to be directly related to source of care. Low income, lack of insurance, and an inappropriate source of medical care depress use across almost all services. However, their relative barrier effects differ by the measure of service examined. After controlling for the effects of household structure, health need, residential mobility, and health behaviors, the greatest disparity in use of dental services remains due to income, in physician services to insurance and income, and in hospital services to insurance. Clear implications arise for policymakers, whether in the public or private sectors. The low income, the uninsured, and those with an inappropriate source of care face real barriers to access. Since the relative magnitude of these barrier effects vary by the health measure examined, neither income, insurance, nor health system delivery strategies can be assumed to evenly enhance use patterns. Their effects must be separately estimated for differing measures of health services. Furthermore, the relationship between these policy variables needs detailed study before large-scale policy interventions are undertaken. Understanding the complexity of these findings for different measures of health services as well as the interrelationship of income, health insurance, and source of care is crucial in designing and implementing more effective and equitable health policies in the future.


Portland State University. School of Urban Affairs.

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