Excerpted from: Sidney D. Watson, Health Care in the Inner City: Asking the Right Question, 71 North Carolina Law Review 1647 (June, 1993) (135 Footnotes) (Full Document)
MIAMI-June Kirchik, fifty-eight years old, discovered a large lump in her breast. When she went to a private hospital, she was denied treatment because she was indigent and her case was not considered an emergency. A public hospital performed a biopsy, which was positive, and gave her an appointment for treatment three weeks later. When Mrs. Kirchik arrived for treatment, however, the public hospital turned her away because she had not yet applied for Medicaid. Mrs. Kirchik tried another public hospital, but was turned away because she was not a resident of the hospital's service area. When Mrs. Kirchik's story appeared in the newspaper, the first public hospital admitted her-to a private room-four months after she had first discovered the lump. Two weeks later, Mrs. Kirchik died.
The June Kirchiks of this country seem forgotten in the current debate about health care reform. Americans keep asking: How do we contain the ever-increasing costs of health care? How do we pay for health care? We are so focused on these questions that we have narrowed our vision too much and lost sight of the real questions and the real issues.
The real question for American health care reform ought to be: How do we improve Americans' health? Especially, how do we improve the health of those, like June Kirchik, who live in the inner city, are poor and overwhelmingly minority, and who are systematically under-served by our health care establishment? This is the question we should be asking. Sadly, we are not.
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Race, poverty, and geographic inaccessibility to health care interact. As a result, an urban Black typically is sicker and in greater need of health care than a suburban white, but is less likely to be able to afford or obtain health care. Given the greater poverty among minorities, health care discrimination based on race is virtually inevitable in a system in which one must purchase health care.
Simple statistics tell a good part of the story and highlight what happens when we ask the wrong question. The poverty rate for Black families is three times the rate for white families. A third of all Black households, and almost half of all Black children, live in poverty. Nearly 30% of Black households report having no assets and more than 50% have assets of $5000 or less.
In a 1986 survey, 9% of Black Americans reported they could not get health care for “economic reasons.” Only about half of all Blacks have private health insurance; one in five have Medicaid or Medicare; and one in five have no health coverage. Blacks are “50 percent more likely than whites to have no health insurance and 5 times as likely to be covered by Medicaid.” “ Forty percent of all Medicaid enrollees are black.”
The problem is exacerbated by the story the statistics do not relate. Blacks, particularly poor, inner-city Blacks, have greater health care needs than whites. Inner-city residents are exposed to twice the environmental health hazards that suburban dwellers face-bad air, polluted water, crime, and drugs. Inner-city residents suffer from hypertension, heart disease, chronic bronchitis, emphysema, sight and hearing impairments, cancer, and congenital anomalies at a rate 50% higher than suburbanites. The rate of neurological and mental disorders in inner-city residents is nearly twice that of suburbanites.
The problem begins at birth. In this country, Black infants are twice as likely to die before their first birthday than are white infants. Babies born in America's inner cities are more likely to die than babies in Costa Rica and Jamaica. In fact, nineteen developed countries have lower infant mortality rates than the United States.
The problem is exacerbated by the dual epidemics of AIDS and tuberculosis. Both diseases disproportionately affect Blacks and Hispanics, particularly those in the inner city. Together Blacks and Hispanics account for almost half of all people diagnosed with AIDS in the United States. A primary reason for the high rate of AIDS is that minority life in the inner city is identified with poverty, massive unemployment, and rampant intravenous drug use. Blacks and Hispanics have higher rates of tuberculosis than whites because life in the inner city is more likely to create the conditions in which tuberculosis spreads-overcrowded housing, homeless shelters, and prisons.
Although minority inner-city residents have many illnesses and need more medical care than other Americans, they have less access to health care. A study of ten U.S. cities found that the number of office-based primary care physicians in poor, inner-city areas declined 45% from 1963 to 1980.
Historically, inner-city Blacks, like other poor inner-city residents, have relied on hospital emergency rooms and, where available, public outpatient clinics for care. Federal budget cuts have forced many inner-city primary care clinics to close, however, and private hospitals, once a major source of emergency primary care, have abandoned the inner city.
ATLANTA-Grady Memorial Hospital in downtown Atlanta turned away ambulances twenty-three times in 1990 because it had no beds available.
The waiting time for an appointment to receive treatment for AIDS is six months.
Between 1937 and 1977, 210 private hospitals with 30,000 hospital beds in fifty-two of the largest cites in the country either closed or relocated. A disproportionate number of these hospitals were located in neighborhoods where Blacks constituted at least 60% of the population. The hospitals that closed served the patients whom other hospitals were reluctant to serve, in areas where few doctors were willing to practice. The facilities that closed served twice as many minority patients and twice as many Medicaid patients as the hospitals that remained open. The private hospitals that remained behind often limited the number of Medicaid and Medicare patients treated, disproportionately excluding Black patients, who, as stated earlier, are five times as likely as whites to be covered by Medicaid.
NEW YORK-New York City's six public hospitals have a 97% occupancy rate, and many private hospitals have closed their emergency rooms to keep out uninsured patients. The results are witnessed at Bellevue Hospital where patients wait as long as two days to be treated in the emergency room.
At New York City's public hospitals, it takes six weeks to get a first appointment at an AIDS clinic, and two months for an appointment at City Hospital's general medicine clinic. Women wait up to three months for prenatal care and four months for gynecological care.
Most public hospitals in urban areas are located in the inner city and are the primary care providers for inner-city, poor minorities. These public facilities are grossly underfunded and suffer from rapidly deteriorating conditions, overcrowding, long waits for emergency treatment, staff shortages, and outdated equipment. Patients with private insurance avoid these decaying inner-city public hospitals and choose newer, less crowded, more patient-friendly private facilities-the same ones that are more likely to limit the number of Medicaid and Medicare patients they treat.
The result is America's segregated health care system. The Black, poor, inner-city resident receives treatment at overcrowded, underfunded, disproportionately Black public hospitals. Those with private insurance, who are disproportionately white, receive care at more modern, better-equipped, and better-staffed private hospitals.
NEW ORLEANS-“When sixty-four year old Marie Barnett arrived at Charity Hospital suffering from piercing pains in her arm and chest, she needed the constant medical care and high-tech attention of an intensive care unit. Unfortunately, the ... unit ... was full,” half its beds had been converted to storage closets because of a lack of money to pay for nurses to staff the unit. Mrs. Barnett was put on a regular ward, “without special equipment to monitor her condition or extra staff to respond quickly to problems. A few hours later, she had a second heart attack”-finally earning a place in one of Charity's six intensive care beds. At Charity, New Orleans' only public hospital, the sick and poor, who are overwhelmingly Black, wait six months for a routine outpatient clinic appointment, pipe leaks are left unattended and nearly half of its 920 beds have been taken out of service since 1986 because of a budget stalled at 1985 levels.
Compounding the problem, few urban Blacks who need care receive it, because the care provided by public hospitals effectively is rationed by the inconvenience and waiting time inherent in these overcrowded and understaffed facilities. A worker employed at an hourly-wage job forgoes a hypertension checkup because the wait to be seen in a crowded public clinic would cost her a day's pay-three months later she dies of a heart attack. A teenage mother assumes that prenatal care is not particularly important when she is informed that she must wait eight weeks for her first appointment-the baby she delivers is twice as likely to die.
The care that public hospitals provide, moreover, is generally the more expensive, in-patient variety because overcrowding and underfunding prevent patients from obtaining preventive and primary care. A vicious circle develops: overcrowding and long waits cause patients to delay necessary care, which causes health conditions to worsen; more serious conditions, in turn, require more intensive and more expensive treatment, which, to close the circle, increases demand on the limited resources of the public hospitals. The consequences are needless suffering and death as many poor patients do not receive any medical care until they are beyond help.
NEW ORLEANS-Manuela Chacon is a retired hotel housekeeper who was diagnosed with diabetes. Soon after, she felt dizzy so she went to Charity Hospital's one outpatient clinic early Monday morning. After waiting more than ten hours and taking a battery of tests, Ms. Chacon was told to return the next day. On Tuesday, after a six-hour wait and more tests, she was told to return on Friday. On Friday, she got her test results: her diabetes was under control, but she needed further tests and possible treatment because her liver enzyme levels were suspiciously low. Ms. Chacon was told to come back in six weeks-the first available date when a doctor could examine her.
What Gunnar Myrdal concluded in 1944 in his seminal study of Blacks in America remains true today:
It is hard to separate the effects of discrimination from those of concentration of Negroes in those areas where medical facilities are not easily available and in those income brackets which do not permit the purchase of medical facilities in the competitive market. Discrimination increases Negro sickness and death both directly and indirectly and manifests itself both consciously and unconsciously.... Ill health reduces the chance of economic advancement, which in turn operates to reduce the chance of getting adequate medical facilities or the knowledge necessary for personal care.
In 1968 the Kerner Commission agreed with Myrdal's conclusions, but made no recommendations directed specifically at health care reform. The Commission's strategy of integrating inner-city Blacks into the suburbs was designed to increase employment opportunities for Blacks, and with better jobs would come employer-provided health care. Those left behind in the inner city would be able to obtain medical care through the new federal programs-Medicaid for the poor and Medicare for the elderly. Urban Blacks have not been able to escape to the suburbs, however. The inner city is still a ghetto bereft of health care providers and populated predominately by poor minorities unable to purchase health care in a competitive market. Many urban Blacks have not entered the job force; those who are employed often hold low-paying, nonunionized jobs that do not provide health insurance. While Medicare has provided virtually universal coverage to the elderly population, Medicaid provides insurance to only 42% of the non-elderly poor. The details of the health care crisis for inner-city minorities may have changed, but the broad outlines remain the same: few providers of health care and little money with which to purchase care from even those few.
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The best way to improve the health of minority inner-city residents is still that envisioned by the Kerner Commission: provide jobs, increase incomes, and improve socioeconomic status. Good health correlates primarily with higher socioeconomic status; poor health correlates directly with poverty. Those who live in crowded conditions run a higher risk of disease. In the inner city, this risk is aggravated “by low wages and high unemployment, inferior education systems, unstable sources of health care, substandard housing, violence, and high transportation and food costs.” To improve the health of inner-city minorities, we not only need to reduce the risk of disease, but also to increase access to jobs, better schools, adequate sources of health care, good housing, less crime, and more affordable transportation and food.
The other contributors to this Symposium identify and evaluate strategies to accomplish these socioeconomic goals. Until these goals, which will have a profound, long-term effect on minority health, are accomplished, any strategy to provide adequate health care for minority urban populations must expand beyond the narrow financing questions that predominate the political debate. Reformers need to address the larger question of how to improve American health generally and, specifically, the health of minorities in the inner city. Achieving real improvement requires addressing four issues: (1) health care financing, (2) attracting sufficient health care providers into the inner city, (3) combatting discrimination in the delivery of health care, and (4) developing new health care delivery systems responsive to the needs of inner-city residents.
My point is not that the present national debate focused on health care financing-providing the means to purchase health care-is wrong; it is, however, only the beginning. If we are serious about improving the health of inner-city Blacks and assuring that health care providers are available in the inner city, we must focus attention equally on dismantling the race discrimination that pervades health care delivery and on developing new health care delivery systems that meet the needs of poor, inner-city, minority patients.
Even with all these changes in place-universal financing, an adequate number of providers, the elimination of discrimination, and the creation of new delivery systems-access to health care probably can increase the health status of inner-city minorities only slightly. Race, geography, and economic status all play a role in the poor health status of disadvantaged minorities.
How can we best improve the health of inner-city minorities? We need not only to provide better access to health care, we also need jobs that pay a living wage and programs that deliver decent housing, adequate sanitation, and good education. Only when all of these strategies coalesce will we make real headway in the fight to improve the health of poor minorities in the inner city.
Associate Professor of Law, Mercer University Law School. B.A. 1974, University of Southwestern Louisiana; J.D. 1977, Harvard University.