III. THE HEALTH SECURITY ACT PERPETUATES A FRAGMENTED SYSTEM
One of the major problems with the current system is that it is a fragmented system. The current health care system is a puffed-up system providing unnecessary, indulgent services for the privileged, while basic critically needed services for the disadvantaged are rationed and often unavailable. Unfortunately, the Health Security Act continues the fragmentation of an inadequate infrastructure. Such inadequate infrastructure might not be so bad if the Health Security Act delivered on the Clinton administration's promises of universal coverage for comprehensive benefits. However, for ethnic Americans the Act provides less than universal coverage, and the benefits are not comprehensive enough.
A. Continuation of Inadequate Infrastructure
Despite the apparent importance of economics as a barrier to access to health care, the unavailability of providers and facilities from which to obtain health care is equally as devastating. Even persons with the ability to pay may not have quality health care. In fact, the more inaccessible the providers and facilities, the more likely the person will, at a minimum, delay seeking care.
Certainly, providers and facilities are not accessible if they are not located near the population they are intended to serve. Moreover, even if they are located in the community, they are unavailable if they refuse to accept patients. Both rural communities and inner city communities have significant problems with access due to inadequate infrastructure.
The Act does not require states, regional alliances or health plans to strengthen the bare-bones health care infrastructures in the nation's inner-city and rural areas. Rather, the HSA relies on temporary contracting provisions with essential community providers, grants and loans by HHS for public health and rural health initiatives, expansion of responsibility of academic health centers, and training grants for health care professionals. None of these methods will prove adequate.
1. Essential Community Providers
The HSA attempts to provide some continuity of care for ethnic Americans, as well as poor and rural communities, by requiring health care plans to contract with professional and institutional providers that have been the bulwark of the service provision for those communities. Unfortunately, the requirement for health plans to contract with essential community providers applies only for five years. While the Act contemplates the possible extension of this provision, it is uncertain and subject to the political process. Consequently, the essential community providers provisions are inadequate precisely because of the temporary nature of the protection. The historical problem of inadequate infrastructure will not be relieved in five years, especially if health care plans have to assure culturally competent care. Health care plans should be required to contract with essential community providers so long as there are an inadequate number of culturally appropriate health care providers in the community. Without such provisions, the protection of essential community providers will not be translated into culturally appropriate health care for ethnic Americans.
The HSA does provide some resources for essential community providers to become competitive participants against corporate health insurance. Furthermore, it attempts to eliminate the problem of providers who do not want to serve ethnic American communities because of a disparity in reimbursement rates. The HSA does so by creating a blended rate. To the extent that this blended rate will encourage plans and providers not to make distinctions based on reimbursement rates, it is critical to assuring equity in the system.
Nevertheless, regardless of the merit of these provisions, they are inadequate. They attempt to induce health plans by monetary incentive to focus on the provision of services to ethnic Americans, rather than requiring such behavior. Furthermore, there is no language specifying ethnic American inclusion, participation or set-asides in the grants, contracts or loans. Without such language, it is likely that those best able to serve their communities will be included in only a minimal capacity. With the temporary and waivable protections for essential community providers and the lack of specific affirmative action contracting goals, the Act gives only a superficial effort to protecting the pool of health care providers that traditionally serve ethnic Americans.
2. Public Health and Rural Infrastructure
Nothing in the HSA indicates that the public health structure for delivery of services will be preserved, expanded or revitalized. In fact, health reform shifts the emphasis away from the direct delivery of health services. Instead, it redirects the emphasis of public health to health-related data collection, surveillance and outcomes monitoring; protection of environment, housing, food and water; investigation and control of diseases and injuries; public information and education; accountability and quality assurance; laboratory services; training and education; and leadership, policy development and administration.
While these are important and necessary functions of public health, so is service delivery. The public health system developed as a result of the failure of the private sector to provide health services to the poor, to the underserved and to ethnic Americans. It is improbable that private corporations and voluntary health care organizations will build health care infrastructures in ethnic American, poor or rural communities. Thus, it is unlikely that private corporations and voluntary health care organizations can replace health care provided by the existing public health infrastructure. Apparently, recognizing this, the HSA provides for funding for community and migrant health centers, for initiatives to improve health care access, and for the development of plans and networks. Also, the Act proposes a number of measures to assure health care in medically underserved rural areas.
Notwithstanding the positive aspects of the public health and rural initiatives, they still present issues of concern. First, the funding of the initiatives requires special federal appropriations after the year 2000. Given political realities, it is unclear whether Congress will continue to fund special appropriations for public health initiatives as the cost of the Act becomes apparent. However, one thing is certain: in five years, the health care infrastructure needed by ethnic Americans will not be in place.
Second, the public health initiatives are just another set of grudgingly given special programs for disadvantaged and poor people. They constitute a tacit acknowledgment of the failure of this health reform, since special programs for ethnic Americans and the poor inevitably become programs that the European American middle class resent. Thus, the special programs approach preserves a multi-tiered health care system, and such a system necessarily results in an unequal and unjust system. Thus, the Act fails to create a truly universal unitary health system designed to meet the needs of all Americans. Arguably, the HSA restructures and reforms a system without changing the worst aspect of it. That is, the Act proposes a system that is a complex matrix of stigmatized special programs and categorical grants.
3. Academic Health Centers
The Act appears to be structured around the provisions of services in existing facilities. Although there are some provisions for the development of infrastructure outside of the discretionary grants by HHS, the HSA does not appear to contemplate the building of additional hospitals or clinics. This is unfortunate since prior hospital closure decisions have been made by a patently imperfect market and have affected ethnic American and poor communities disproportionately. Rather, the Act contemplates extending health care by requiring academic health centers to extend their programs in primary care to inner city and rural areas.
No doubt, these provisions could improve access to health care in ethnic American communities. But they will do so only if provisions are made for meaningful transportation and provider hours for inner city and rural residents. Furthermore, these linkages will prove beneficial only if the advisory and policymaking levels within the academic health centers are reflective of rural and ethnic American communities, and only if the academic health centers are required to provide culturally competent care.
Unfortunately, while the HSA provides incentives for academic health centers to establish outreach into ethnic American communities, they are under no requirement to provide culturally competent care or community participation. Furthermore, the financial incentives to the academic health centers produces the same stigma of making the provision of services to ethnic American communities outside the normal expectation of academic health centers. The Act should mandate that academic health centers include community-based goals that center on health, community participation and education. Furthermore, academic health centers must be forced to have ethnic Americans represented at advisory and policymaking levels within the academic health centers. Finally, academic health centers must be required to provide culturally competent care.
4. Training of Health Care Professionals
The HSA establishes the National Council on Graduate Medical Education to control nationally the number of individuals who can enroll in medical programs. Even though the Act contemplates training participants who are members of racial or ethnic minority, it does nothing to assure the viability of the primary source of black health care professionals-historically black schools. Historically black medical schools provide an irreplaceable means of providing access to culturally appropriate care to African Americans. Even though these institutions are financially and structurally threatened, the HSA makes no specific provision for sustaining or strengthening their roles.
Without sufficient measures to assure the development of an adequate infrastructure, ethnic American and poor communities face the disconcerting prospect of depending on private, competitive for-profit health providers for culturally competent health care. Access to health care requires actual services provided by physicians and hospitals. But, many physicians and hospitals are reluctant to serve ethnic Americans. Within a professional culture that is reluctant to serve ethnic Americans and poor communities, universal coverage, by itself, will not appreciably redistribute the physician supply in a way that would significantly improve access. In sum, infrastructure barriers, separate and distinct from the issue of financing, are not adequately addressed, and the promise of universal coverage is not a promise of equality of care.
B. Lack of Universal Coverage
The plan maintains a fragmented system by excluding large segments of the population, keeping them outside of the main system. Specifically, undocumented aliens, Medicare recipients, prison populations, employees of eligible corporate alliance sponsors, military personnel and families, veterans and Indians are all either excluded or kept outside of the main system.
These exclusions are problematic for several reasons. First, the exclusion of a large number of individuals threatens the financial integrity of the main health system by producing inefficiencies and duplications. Second, the exclusion of some individuals inevitably causes discrimination, because someone must determine who is not covered. Consequently, providers and facilities may use skin color or language as a de facto method of determining eligibility for citizens who do not have health security cards. Finally, a significant portion of ethnic American males will not be in the system since prison populations are specifically excluded and military personnel and veterans may opt out. This is particularly troubling because the HSA does not assure that individuals in alternative systems will receive at least the same comprehensive services.
