ments providing direct community health services. In States with no local health departments the State Health Department is usually the primary provider of these community services. States use their own resources plus Federal monies from the MCH and Preventive Services Block Grants to provide a variety of health services. In order to receive their MCH block grant allocation, States are required to match each $4 of Federal funds received with $3 of their own funds.47 There is no matching requirement for the PHHS Block grant. Many State and local health department efforts have in the past and continue to be characterized by traditional public health activities-discrete single health services (e.g., immunizations), usually provided in clinics or dispensaries. Increasingly, though, health departments are broadening their mission to provide comprehensive primary care services. The National Association of County Health Organizations estimates that approximately 25 percent of local health departments provide organized primary care services. The Association is working to get estimates of the number of persons served by these programs. The Private Sector Philanthropic foundations and others have pioneered new approaches to building capacity and reaching high risk groups. Also, there are currently over 500 private, non-Federally funded health centers throughout the country that provide comprehensive primary care services.48 However, support for ongoing care of the indigent is increasingly unstable, and the cross-subsidies of the poor by the well-off are rapidly becoming a thing of the past. Data could not be obtained on the number of individuals who receive primary care services through private clinics and other philanthropic programs. Public and Non-Profit Community Hospitals Hospitals are by necessity the only family doctor in many urban and rural areas. Oftentimes, because private physicians are unavailable in their areas, inner city dwellers (particularly the poor and minorities) rely on hospital emergency rooms or outpatient departments as their principal source of primary care. 47 Edward R. Klebe, Congressional Research Service, The Library of Congress, "Health Services Programs for Populations in Need," (August 17, 1989), 2. 4 National Association of Community Health Centers (unpublished data, Washington, D.C.: October 27, 1989). As noted earlier, the poor are more likely than the nonpoor to see physicians in a hospital outpatient department or emergency room (19 percent of the poor vs. 11.2 percent of the non-poor).49 Also, the uninsured are more likely than any other group to use hospitals for primary care. The American Hospital Association (AHA) estimates that approximately 4.9 million uninsured persons rely on hospitals for such care.50 In 1987, 4,242 hospitals, or 68 percent of the 6,281 hospitals responding to the AHA survey, provided non-emergent primary care services through an organized outpatient department. 51 The hospitals that serve many of these patients are facing severe financial strains, jeopardizing their capacity to provide care. Services in hospital clinics are frequently episodic and disease oriented, with little continuity or coordination among the various specialty clinics, let alone with outside agencies. 52 This makes care costly and reduces effectiveness. Additional reasons that primary care delivered in hospital outpatient departments is more expensive than care delivered in a free-standing setting include: (1) lack of control by outpatient department directors over their own costs; (2) the degree to which the availability of sophisticated and expensive technology within the hospital setting encourages its utilization; and (3) the fact that "sicker" patients tend to be seen in outpatient departments. 53 Responding to these growing financial strains, as well as to the increasing numbers of people who are relying on hospitals for primary care, an unknown number of both public and not-for-profit hospitals have reorganized their outpatient departments and neighborhood clinics in recent years to provide comprehensive primary care, as opposed to episodic care, in a variety of specialty clinics or emergency rooms. School Based Programs The Center for Population Options reports that there are 150 school-based health centers operating in middle or junior high schools and senior high schools in most cities as well as in many rural areas. The number is somewhat higher if centers located adjacent to school property are included. This group is work 49 National Center for Health Statistics, Health, United States, 1988, 106. so Irene Frazer, American Hospital Association, Data submitted by memorandum to Department of Health and Human Services (Chicago, Ill.: March 23, 1990). 51 Frazer, memorandum. 52 Diana B. Dutton, Ph.D., “Children's Health Care: The Myth of Equal Access," in Better Health for Our Children, The Report of the Select Panel for the Promotion of Child Health, Vol. IV (1981), 382. 53 Marsha Gold, "Hospital-Based versus Free-Standing Primary Care Cost," The Journal of Ambulatory Management, 2 (1) (February 1979). revenues of $1.12 billion, of which 45 percent came from Federal grants. The remainder came from patient payments on a sliding fee scale and insurance collections (42 percent) and State, local and other support (13 percent). The Comprehensive Perinatal Care Initiative-This program provided $20 million in each of FYs 1988 and 1989 to over 200 C/MHCs for the purpose of enhancing outreach and case management activities during pregnancy and the first year of life. These services have reached approximately 100,000 mother/infant pairs. The Health Care for the Homeless ProgramThrough this program $60 million in FY 1988 and 1989 was awarded to 109 community-based organizations who offered primary care services to homeless populations. Roughly 231,000 homeless people were served in 1988, the first year of operation, with approximately 400,000 persons being served in 1989. Substance Abuse-In FY 1988 BHCDA awarded $3.8 million to 43 projects to combine primary care with special services for substance abusers. In FY 1989 $9 million was provided in a collaborative effort with the National Institute of Drug Abuse to 21 community-based organizations, to integrate primary care services with substance abuse treatment. Under this program approximately 21,000 persons were seen for both substance abuse and primary care services. AIDS-In FY 1989, under an inter-agency agreement between the Centers for Disease Control and BHCDA, three CHCs were funded to participate in an AIDS prevention and treatment program. In FY 1990 more than $10 million will be available to expand the AIDS treatment and prevention program to as many as 20 centers located in high risk communities. The National Health Service Corps-NHSC helps recruit and retain physicians and other health professionals in areas with shortages of these providers. It previously relied on a scholarship program which obligated recipients to serve in a shortage area. The scholarships were dramatically reduced, beginning in 1981. The NHSC now operates a small scholarship program, a program to recruit providers who serve in return for payment of their educational loans, and demonstration grants to develop state loan repayment programs. It also aids C/MHCs and freestanding sites in retaining existing providers and recruiting privately. FY 1989 funding for the NHSC was approximately $49 million. There were approximately 2,400 physicians providing primary care, mostly although not exclusively in C/MHCs. Forty-two new scholarships were awarded in FY 1989. Federal Block Grant Programs There are two Federal Block Grant programs that help support primary care services to underserved populations—the Maternal and Child Health Services (MCH) Block Grant, and the Preventive Health and Health Services (PHHS) Block Grant. Under these Block Grant programs, Federal dollars are channeled to State Health Departments, with approximately 25 to 30 percent being allocated by the States to local health departments. In FY 1989 $465.3 million was allotted under the MCH Block Grant and $84.3 million was awarded under the PHHS Block Grant. 44, 45 Ways in which State and local health departments use these monies to address barriers to accessible care are described later in this paper. Programs of the Indian Health Service The Indian Health Service (IHS) is the principal Federal health resource for the one million American Indians and Alaska natives living on or near Federal reservations or in traditional Indian Territory. The IHS provides primary care services through the operation of 66 health centers, 5 school health centers, and approximately 100 smaller health stations and satellite clinics. Additional clinics are managed by tribes through contracts with the IHS. They operate 73 health centers, 2 school health centers, and approximately 250 smaller health stations and satellite clinics. The IHS also contracts with Indian Health Organizations in 33 urban reservations with an estimated Indian population of 380,000. These projects provide services ranging from outreach and referral to direct provision of primary care. In FY 1988, over 1 million people received primary care services through these combined programs of the Indian Health Service. State and Local Health Departments 46 Each State has an established Health Department vested with the primary responsibility for public health. There are nearly 3,000 local health depart 44 Budget Appropriations Act, 1989. 45 Conference Report on the Department of Labor, Health and Human Services, Education, and Related Agencies, Appropriated Bill 1990, (101– 354). Centers for Disease Control, Preventive Health Services Block Grant (Washington, D.C.), 27. 46 Indian Health Service, Public Health Service, Department of Health and Human Services, “Justifications of Budget Estimates to OMB" (Vol. III), 1, 56, 73. ments providing direct community health services. In States with no local health departments the State Health Department is usually the primary provider of these community services. States use their own resources plus Federal monies from the MCH and Preventive Services Block Grants to provide a variety of health services. In order to receive their MCH block grant allocation, States are required to match each $4 of Federal funds received with $3 of their own funds.47 There is no matching requirement for the PHHS Block grant. Many State and local health department efforts have in the past and continue to be characterized by traditional public health activities-discrete single health services (e.g., immunizations), usually provided in clinics or dispensaries. Increasingly, though, health departments are broadening their mission to provide comprehensive primary care services. The National Association of County Health Organizations estimates that approximately 25 percent of local health departments provide organized primary care services. The Association is working to get estimates of the number of persons served by these programs. The Private Sector Philanthropic foundations and others have pioneered new approaches to building capacity and reaching high risk groups. Also, there are currently over 500 private, non-Federally funded health centers throughout the country that provide comprehensive primary care services.48 However, support for ongoing care of the indigent is increasingly unstable, and the cross-subsidies of the poor by the well-off are rapidly becoming a thing of the past. Data could not be obtained on the number of individuals who receive primary care services through private clinics and other philanthropic programs. Public and Non-Profit Community Hospitals Hospitals are by necessity the only family doctor in many urban and rural areas. Oftentimes, because private physicians are unavailable in their areas, inner city dwellers (particularly the poor and minorities) rely on hospital emergency rooms or outpatient departments as their principal source of primary care. 47 Edward R. Klebe, Congressional Research Service, The Library of Congress, "Health Services Programs for Populations in Need," (August 17, 1989), 2. 48 National Association of Community Health Centers (unpublished data, Washington, D.C.: October 27, 1989). As noted earlier, the poor are more likely than the nonpoor to see physicians in a hospital outpatient department or emergency room (19 percent of the poor vs. 11.2 percent of the non-poor).49 Also, the uninsured are more likely than any other group to use hospitals for primary care. The American Hospital Association (AHA) estimates that approximately 4.9 million uninsured persons rely on hospitals for such care.50 In 1987, 4,242 hospitals, or 68 percent of the 6,281 hospitals responding to the AHA survey, provided non-emergent primary care services through an organized outpatient department. 51 The hospitals that serve many of these patients are facing severe financial strains, jeopardizing their capacity to provide care. Services in hospital clinics are frequently episodic and disease oriented, with little continuity or coordination among the various specialty clinics, let alone with outside agencies. 52 This makes care costly and reduces effectiveness. Additional reasons that primary care delivered in hospital outpatient departments is more expensive than care delivered in a free-standing setting include: (1) lack of control by outpatient department directors over their own costs; (2) the degree to which the availability of sophisticated and expensive technology within the hospital setting encourages its utilization; and (3) the fact that "sicker" patients tend to be seen in outpatient departments. 53 Responding to these growing financial strains, as well as to the increasing numbers of people who are relying on hospitals for primary care, an unknown number of both public and not-for-profit hospitals have reorganized their outpatient departments and neighborhood clinics in recent years to provide comprehensive primary care, as opposed to episodic care, in a variety of specialty clinics or emergency rooms. School Based Programs The Center for Population Options reports that there are 150 school-based health centers operating in middle or junior high schools and senior high schools in most cities as well as in many rural areas. The number is somewhat higher if centers located adjacent to school property are included. This group is work ** National Center for Health Statistics, Health, United States, 1988, 106. 50 Irene Frazer, American Hospital Association, Data submitted by memorandum to Department of Health and Human Services (Chicago, Ill.: March 23, 1990). $1 Frazer, memorandum. 52 Diana B. Dutton, Ph.D., "Children's Health Care: The Myth of Equal Access," in Better Health for Our Children, The Report of the Select Panel for the Promotion of Child Health, Vol. IV (1981), 382. 53 Marsha Gold, "Hospital-Based versus Free-Standing Primary Care Cost," The Journal of Ambulatory Management, 2 (1) (February 1979). Case management of primary, specialty and inpatient services combined with other social and support services can make the health care system more effective for everyone but are particularly important for the poor and underserved. Among the services needed are those relating to eligibility determinations for health financing, mental health, substance abuse, runaway youth, infant day care, child abuse and neglect, welfare programs, nutrition, family planning, housing, transportation, labor practices, correctional programs, and legal services. Although these services are typically available through multiple organizations, local agencies often lack adequate personnel, materials, or knowledge of other programs to make referrals or other coordination efforts, such as arranging for co-location of services. The problem is exacerbated in rural areas, where the physical facilities that house necessary services are geographically dispersed, thus complicating integration of service delivery. In addition, a multiplicity of eligibility requirements, and multiple sites for needs-determination procedures complicate the ability to access services. Finally, rivalries among different disciplines and organizations can fragment provider responsibility. This inability to integrate services means that those least able to do so must grapple with the most "red tape" and barriers to receiving care. 10 Cultural/Social Barriers Oftentimes, language, racial, educational, behavioral, environmental and attitudinal differences impose special barriers to effective delivery of health and social services. Health care professionals may lack necessary skills, such as language training, health education, and training in the provision of preventive services, or may be insensitive to cultural differences.11 For many population groups, individual, family, and community behavior patterns can affect the pursuit of appropriate care in a timely fashion. As an example, one-third of the women in the U.S. do not receive adequate prenatal care, of which the highest proportion are black, Hispanic, poorly educated, low-income, unmarried, and/or teenaged.12 Fear or lack of knowledge is often a barrier to care for these women, who are twice as likely as those who receive prenatal care to have a low-birth weight baby.13 Fi 10 William White, consultant to the Bureau of Health Care Delivery and Assistance, Department of Health and Human Services, "Draft Report prepared for the Subcommittee on Community Based Health and Social Services, White House Task Force on Infant Mortality" (1989), 9. 11 William Gorham, Delivery of Health Services for the Poor, U.S. Department of Health and Human Services (Washington, D.C.: December, 1967), 257. 12 Gold, Kenney, and Singh, Blessed Events and the Bottom Line: Financing Maternity Care in the United States (New York: The Alan Guttmacher Institute, 1987), 14-16. 13 Gold, Kenney, and Singh, Blessed Events, 14-16. nally, exposure to environmental toxins or hazards, such as lead, also influence pregnancy and other health outcomes. 14 HOW GROUPS ARE AFFECTED BY THESE BARRIERS There are numerous population subgroups that experience barriers to the receipt of care. A disproportionate share of those facing the barriers described above are poor and minority. In addition, there are smaller, frequently overlapping subgroups who are disproportionately poor or minority and who also face their own unique hurdles to accessible care. The Poor The Robert Wood Johnson Foundation found in a recent study that lack of accessible care is largely a · problem of the poor. Specifically, access to health care showed marked improvement from the 1950s to 1982, when the gap between rich and poor was closing. Unfortunately, since 1982 this gap has widened, reducing access to care among the poor. For example, the adult poor below the age of 65 had 30 percent fewer ambulatory visits per person in 1986 than in 1982. The widening gap is due to financial barriers (i.e., increasing lack of health insurance) as well as nonfinancial barriers (e.g., maldistribution of resources, logistical and lifestyle barriers).15 The impact of the nonfinancial barriers is noted by a recent study showing that among insured adults, the poor are 4.4 times as likely as those who are not poor to have needed medical services but not to have received them. 16 There are approximately 32 million Americans with incomes below the poverty line. 17 The poor are less likely than the non-poor to have private medical coverage or medical coverage through their workplace. One-half of the 31.8 million people who lack health insurance have incomes below 150 percent of the poverty level. Populations in this group include pregnant women and infants, children, and other uninsured per 14 Department of Health and Human Services, "Facts on Infant Mortality and Access to Prenatal Care" (unpublished information distributed on Child Health Day, Washington D.C.: 1989). 15 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 8. 16 Rodney A. Hayward, M.D., Martin F. Shapiro, M.D., Ph.D., Howard E. Freeman, Ph.D., and Christopher R. Corey, M.A., "Inequities in Health Services Among Insured Americans," New England Journal of Medicine (June 9, 1988): 1507. 17 Jane Koppelman, National Health Policy Forum, The George Washington University, Poverty and the Underclass: Priorities for the Next Decade, Issue Brief No. 511 (Washington, D.C.: 1989), 2. sons such as the working poor, who are not eligible for Medicaid but have no private insurance. Nationwide, Medicaid reaches fewer than half the poor, and even fewer of the employed poor. In fact, fear of losing Medicaid's protection may be an incentive to remain unemployed, thus perpetuating the poverty cycle. 18 Minorities There are 60 million members of minority groups (blacks, Hispanics, Native Americans, and Asian Americans), a disproportionate percentage of whom are low income. Thus, they are likely to face access problems related to poverty, as well as additional barriers arising from location in the inner city, discrimination, and other socio-economic and cultural factors. 19 For example, researchers Janet Mitchell and Rachel Shurman found that, controlling for other factors, obstetricians were less likely to participate in Medicaid in counties with high minority populations. The same was not true for surgeons or general practitioners, causing speculation as to whether it was the prospect of continuing and frequent contact with patients that led to the difference. Mitchell and Shurman also noted that many doctors have expressed a willingness to treat the poor in a public clinic or outpatient department for a few hours a week, but not in their own offices, where their private patients might be uncomfortable. 20 The impact of these non-financial barriers on minority populations is demonstrated by the fact that among insured, working age adults, blacks are 1.7 times as likely as whites to need medical services but not to receive them. Similarly, Hispanics with a medical illness are 2.2 times as likely as whites not to have seen a physician within the past year.21 As a result of financial as well as nonfinancial barriers to care, there are significant gaps in health status between minorities and the rest of the nation. Specifically, in virtually every measure of health status (e.g. life expectancy, death rate, infant mortality rate, and the prevalence of coronary and cerebrovascular disease), minorities, particularly blacks and Hispanics, are significantly worse off than whites. 22 18 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 9. 19 President's Commission Report, 83-86. 20 Janet B. Mitchell and Rachel Shurman, "Access to Private Obstetrics/ Gynecology Services under Medicaid," Medical Care, 22 (11) (November 1984): 1034. 21 Hayward, Shapiro, Freeman, and Corey, "Inequities in Health Services," 1507. 22 Office of Disease Prevention and Health Promotion, U.S. Public Health Service, U.S. Department of Health and Human Services, Disease Prevention/ Health Promotion: The Facts, (Palo Alto, Calif.: Bull Publishing Company, 1987), 198, 202. High Risk Pregnant Women and Their Infants In 1988, the provisional infant mortality rate in the United States was 9.9 deaths within the first year per 1,000 live births. The rate for black infants was nearly twice that. In 1987 the black infant mortality rate (17.9 per 1,000) was at the same level as the white rate had been 25 years earlier. Although the U.S. rate is better than ever, 21 nations have lower rates. 23 There has been a troubling slowdown in the rate of decline in infant mortality observed in the 1980s. During the 1970s, the rate declined by 4.9 percent per year for whites and 4.1 percent per year for blacks. In 1987, the black infant mortality rate declined by less than 1 percent for the third year in a row. The white infant mortality rate declined by 3.6 percent. 24 Worse yet, in 1987, the black fetal death rate increased by 2.7 percent, the first increase since the 1960s. White fetal death rates decreased by only 1.6 percent.25 The rate of progress has slowed primarily because factors associated with increased risk of infant death, such as low birth weight and lack of access to prenatal care, have shown no improvement in recent years. 26 The importance of prenatal care is demonstrated by the fact that women who get insufficient prenatal care have double the risk of having a low birth weight baby, and give birth to babies that are three times more likely to die in infancy.27 In 1980, low birthweight infants represented less than seven percent of all newborns in the United States, but accounted for sixty percent of all babies who died in infancy.28 Many pregnant women experience a combination of the financial, organizational, and cultural barriers described above. They are particularly affected by lack of providers, exacerbated by the fact that some physicians are no longer practicing obstetrics, in part due to the cost of liability insurance. Lack of coordination among health and social services also has a significant impact on low-income pregnant women, who are illprepared to visit numerous locations in search of needed services. For example, services under the Special Supplemental Food Program for Women, Infants, and Children (WIC) are often not provided in conjunction with prenatal care. 23 White House Task Force on Infant Mortality, Draft Report, "Infant Mortality in the United States," (Washington, D.C.: October 29, 1989), 3. 24 White House Task Force, Draft Report, 3. 25 White House Task Force, Draft Report, 4. 26 White House Task Force, Draft Report, 3. 27 Office of Disease Prevention and Health Promotion, The Facts, 134. 28 Congress of the United States, Office of Technology Assessment, Healthy Children: Investing in the Future, OTA-H-345 (Washington, D.C.: Government Printing Office, February 1988), 6. |