IV. THE HEALTH SECURITY ACT MAINTAINS A CULTURALLY INCOMPETENT SYSTEM BASED ON ILLNESS CARE
A person does not have meaningful access to health care if that person is not provided health care within the context of his or her cultural background. Merely providing a person with a piece of paper (insurance) or a provider does not mean that that person will receive health care that assists in improving the person's health status. For centuries, Americans indulged in the fantasy that all persons (native Americans, immigrants and slaves) blended into one great melting pot to become Americans. While it is true that there are unique American cultural similarities that cut across all groups, this country has always had a diverse population of races, ethnic groups, subcultures and religions.
That diverse mix will continue. By the end of this century, 39% of the population will be from foreign-born parents. At the same time, 50% of all Americans will be either African American, Hispanic American, Asian American or Native American. America is a micro-world reflecting (the) cultural diversity of the entire world.
A. The Perpetuation of European American Culture
The medical care system is a representation of one subculture-the middle-class, middle-aged, European American. The system focuses on individual autonomy rather than family involvement. It assumes a basic trust in the health care system instead of distrust. It relies on a western European American concept of communications. It is built on a western European concept of wellness, illness and health care. Consequently, the more a patient differs from the cultural prototype (middle-class, middle-aged, European American) the more likely the person will not have meaningful access to health care.
Merely providing financial coverage for health care does nothing to assure that ethnic Americans will have access to care that is culturally competent. One barrier to culturally competent care is physicians' own negative perceptions about ethnic Americans. This barrier exists in part because the health care system is designed around the cultural needs of middle-class European Americans. Ethnic Americans and poor individuals seem less compliant and more difficult to care for because they have differing needs and problems in accessing care. The problem, however, is not poor patients or ethnic Americans, but the health care system's inability to provide effective care to diverse populations. If increased compliance and improved health status are the goals, then the health care system must be flexible enough to match a community's cultural, ethnic, lifestyle and socioeconomic needs.
The HSA does little to address the issue of assuring culturally competent care. For instance, despite the fact that ethnic Americans respond well to community-based health education programs, the Act fails to require health plans to provide such activities. Furthermore, it fails to require removal of the barriers to the effective utilization of such services. Rather, the Act permits, but does not require, states to provide financial incentives to ensure that health plans provide for extra services such as interpreting services. Finally, since the HSA never explicitly defines disadvantaged groups, the scope of the incentives is indeterminate.
Health care requires interaction between the patient seeking care and the provider. When individuals do not understand, speak or read English, they may avoid contact with the health care system. Although some Americans do not understand English well enough to be able to talk with their physicians, the Act does not require that health care plans address these language barriers. Language barriers can defeat the provision of health care if essential information cannot be conveyed. Consequently, although universal coverage makes it easier for many ethnic Americans to seek and obtain effective health services, language barriers will continue to inhibit their use of the health care system, unless the system is required to restructure itself to address those concerns.
B. Ineffective Comprehensive Coverage
The HSA's univeral coverage does not cover many of the services needed by poor Americans. For instance, it does not cover eyeglasses or hearing aids, and provides that no person 18 years or older can receive prevention, diagnosis or treatment of dental disease before January 1, 2001. These items may be of marginal expense to middle-income persons, but to the poor they are not only expensive but they are also essential corrective treatment.
The Act also provides insufficient comprehensive coverage for mental health and substance abuse. Although the Act covers inpatient and residential mental illness and substance abuse treatment, intensive nonresidential mental illness and substance abuse treatment, and outpatient mental illness and substance abuse treatment, these services are available subject to significant limitations. Given the serious significant mental health and substance abuse problems in ethnic American and poor communities, basic mental health services are inadequate. In addition, the proposal to phase-in mental health benefits over five years is particularly troubling since political changes may result in the non-delivery of benefits.
While the evidently cut-throat competition of a health care market will make ethnic American patients fair game, the HSA fails to assure that ethnic American communities have providers who can provide culturally competent care. Nor does the Act anticipate the need to direct the regional alliance and health plans to develop culturally competent policies for the treatment of ethnic Americans. While there is a generalized list of Uniform Conditions of Participation for health plans to be established by the National Health Board, these conditions are oriented to management, contract conflict resolution, financial and marketing. They are not patient- or service-oriented. More specifically, they do not require plans to show that they have the infrastructure to assure services to all population groups. To assure that health plans do serve the needs of ethnic Americans and poor communities, an additional conditions of participation should be added: to require health care plans to decrease the health status deficits of ethnic and disadvantaged Americans; to provide culturally competent care; and to prohibit adherence to rules, regulations and laws that discriminate on the based of race, class, ethnicity, language, gender or sexual preference.
While the Act certainly has a number of provisions that are beneficial to ethnic Americans, one wonders why the only sections which mention culturally appropriate care are those which provide for financial incentives, training of providers, and the funding of school-based health clinics. Why doesn't the HSA require health care plans to provide culturally appropriate care? Its failure to do so assures that the private sector will not provide culturally appropriate care to ethnic Americans.
