Migrant Farmworkers The nation's three million migrant and seasonal farmworkers and their families share some needs with other indigent people, but these are compounded by special hazards of farmwork, such as pesticide exposure and accidents, combined with language, mobility and other barriers to care. Migrant workers are rarely covered by Medicaid because of residency requirements or by private insurance because of the nature of their employment. They often work in rural, isolated communities where there are few providers to begin with. Those providers who are present tend to be physicians with full practices who are unable to cope with a sudden and seasonal influx of additional patients. In addition, migrants' cultures are usually vastly different from that of overburdened local providers, and they have special needs for support and facilitating services. Because of the instability of their living arrangements they are unlikely to have their health care needs met in time to prevent more serious illnesses. 29 Individuals With HIV Infections According to CDC estimates, there are one and a half million persons infected with the HIV virus, with an estimated 285,000 cases of AIDS expected by 1992. GAO believes these estimates are low-that there will be 365,000 cases by the end of 1992.30 This population has enormous needs that are straining the health care system. Primary care is an increasingly important component of caring for HIV infected persons and community-based resources are critical-particularly as the disease spreads to more inner city substance abusers, their sexual partners, and children. HIV infection poses substantial problems for the health care system because those infected are often times poor, in general bad health, homeless, and IV drug abusers. An additional problem is that providers for HIV positive patients may be limited. Doctors and nurses alike have begun to report increasing psychological and emotional strain from working with AIDS patients. Fear of becoming infected causes the health care providers to question their ethical obligation to treat HIV infected patients. 31 29 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 11-12. 30 Centers of Disease Control, Department of Health and Human Services, Public Health Reports, 103, supp. 1 (Washington, D.C.: 1988), 3. 31 Institute of Medicine, National Academy of Sciences, Confronting AIDS Update 1988 (Washington, D.C.: National Academy Press, 1988), 12. Substance Abusers Substance abuse is a major national problem which has social, economic and health consequences. There are 6.5 million abusers of illicit drugs in this country.32 Substance abuse treatment facilities and services are insufficient to meet the need, especially for the poor. In addition they are seldom integrated with primary care and other physical health services. For example, alcoholics are frequently malnourished and need nutritional therapy and counseling but may not receive them. Primary care service programs are needed to identify substance abusers, ensure their treatment by appropriate providers, and support them with comprehensive primary care, including preventive medical and counseling services. 33 Substance abusers frequently overlap with other high risk groups. For example, drug abusers are at significantly increased risk of HIV infection, substance abuse is a major problem among the homeless and there is a growing problem of substance abuse among pregnant women. It is estimated that approximately 375,000 children were born exposed to drugs in 1988.34 Many of these infants are "boarder babies,” who are ready to be released by the hospital but have been abandoned by their parents. Most boarder babies are drug exposed, and their mothers are addicts. 35 The Homeless Estimates of the number of homeless individuals vary. According to U.S. Health and Human Services documents, there are between 550,000 and 600,000 homeless people in the United States on any given night. An estimated 1.3 million to 2 million persons are homeless on one or more nights in the course of the year. Families, mostly women with children, make up 23% of the homeless population. Minorities are disproportionately represented, at 2 to 4 times their proportion of the general population. The homeless have complex health needs, ranging from trauma treatment to foot care, and have difficulty integrating into a health system designed for the housed. They are afflicted by numerous cultural, environmental, and economic barriers that inhibit the maintenance of 32 Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, "Abusers of Illicit Drugs," an Attachment to a July 6, 1989 Memorandum from Jerry Britten entitled "Paper for July 12, 1989 Meeting on Access to Health Care" (Typewritten). 33 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 13. 34 Laura Feig, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, "Drug Exposed Infants and Children: Service Needs and Policy Questions," (Washington, D.C.: January 29, 1990), 2. 35 Feig, "Drug Exposed Infants," 6. good health. They are typically uneducated and/or virtually dysfunctional, limiting employment possibilities. They have no insurance or very limited insurance. One-third of the homeless suffer from severe mental illness. Living conditions are hazardous, at best, and expose the homeless to additional risks of disease. Malnutrition rates are high, and immunization rates among children in homeless families are low. The result is that group shelters for the homeless pose significant public health hazards, as they are reservoirs for communicable disease (e.g., respiratory infections, TB, chicken pox). Finally, a high percentage of the homeless belong to other high-risk population groups-that is, they have AIDS, and/or alcohol and drug dependencies. Thirty-five to forty percent of the homeless have alcohol problems and between 10 and 20 percent abuse other drugs. 3 Elderly 36 The number of older Americans is growing. Only 4 percent of the population in 1900 was elderly, whereas by the year 2000, 13 percent of the population will be age 65 or older. 37. 38 The elderly require multiple health and social services. First, their health care problems can be both physical and mental. In addition to multiple chronic physical problems which are cumulative with age, a substantial portion of the elderly (18 percent) have significant psychiatric symptoms of acute or chronic mental illness, retardation or depression. 39 Many elderly, particularly the 5.7 million poor elderly, also require social/support services to address problems such as isolation and inadequate transportation to reach providers.40 CURRENT EFFORTS-EXISTING COMPREHENSIVE PRIMARY CARE PROGRAMS There are several types of subsidized service delivery programs that serve the estimated 26 million persons lacking a regular private sector primary care physician.41 These include hospital outpatient depart 36 Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services, "The Homeless," an Attachment to a July 6, 1989 Memorandum from Jerry Britten entitled "Paper for July 12, 1989 Meeting on Access to Health Care" (Typewritten). 37 Office of Disease Prevention and Health Promotion, The Facts, 181. 38 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 13. 39 National Institute on Aging, Personnel for the Health Needs of the Elderly Through the Year 2020 (Report to Congress, 1987). 40 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 13. * Aiken, Lewis, Craig, Mendenhall, Blendon, and Rogers, "The Contribution of Specialists," 1363-1370. ments, State and local health departments, schoolbased programs, and Federally funded and privately supported health centers. These programs, financed through a variety of mechanisms, are designed to effectively address the barriers already described. They do so by (1) ensuring the presence of providers and facilities, (2) offering comprehensive primary medical care, (3) providing outreach and case management, and (4) including community input. In 1987, for those Americans with family incomes of less than $10,000, 43.8 percent of their physician contacts were in a doctor's office, 19.2 percent were with a hospital outpatient department, and 20.3 percent were with clinics. This contrasts with those families with incomes greater than $35,000, in which 62.3 percent of physician contacts were in a doctor's office, while only 11.2 percent were in a hospital outpatient department, and 11.1 percent were in clinics.42 For those with Medicaid, the likelihood of receiving services from a private physician is higher. However, Medicaid recipients depend heavily on subsidized primary care programs as well since there is a shortage in many areas of primary care providers who treat Medicaid patients. For example, in Philadelphia, 23.5 percent of Medicaid recipients cite a hospital as their usual source of care. 43 Programs of the Federal Bureau of Health Care Delivery and Assistance The Bureau of Health Care Delivery and Assistance (BHCDA), within the Health Resources and Services Administration of the U.S. Public Health Service, is responsible for a group of communitybased programs providing primary care and case management to approximately six million poor and underserved persons through grants and manpower recruitment. The BHCDA programs, which together encompass 610 grantees at more than 1,500 sites, include 550 community and migrant health center (C/MHC) grantees comprising the basic delivery system; services to special populations (women of child bearing age and their infants, the homeless, substance abusers and persons with AIDS); and National Health Service Corps activities (recruitment, loan repayment and scholarships, and placement). Community and Migrant Health Centers-In 1989 C/MHCs served 5.5 million Americans and had total 42 National Center for Health Statistics, Department of Health and Human Services, Health, United States, 1988 (Washington, D.C.: Government Printing Office, March 1989), 106. 43 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 10. 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.46 State and Local Health Departments 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. * 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 49 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). 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). ing to get estimates of the number of young persons served. Clinics are located in 32 states and 91 communities. The number of clinics have increased five-fold since 1983. These clinics serve low-income, predominately minority youth who have limited access to other sources of health care. One-third of all school based clinic users have no health insurance. For about a half of all enrolled students, school-based health clinics are their sole or primary source of health care. A wide range of medical and counseling services are provided, including primary health care and preventive services. 54 School based health centers are funded by a variety of public and private sources. In 1989 approximately two-thirds of the funding came from public sources, including States, cities, counties, Block Grants, Medicaid, the EPSDT program, and school districts. A number of school based health programs are part of a Federally funded health center. Foundations are virtually the only source of private funding for schoolbased health clinics. In 1989, foundations provided 31 percent of total funding, down from 41 percent the previous year. Insurance payments and patient fees each year accounted for less than one percent of clinic funding. 55 THE EFFECTIVENESS AND IMPACT OF EXISTING PROGRAMS There is strong evidence that the existing comprehensive primary care programs described above have made significant inroads in reducing barriers to the receipt of appropriate health care. More evidence exists about federally funded primary care centers than about other programs. However, if characteristics of the other programs are similar, it should be possible to assume that they would share the attributes of federally funded centers. 56 The evidence described below is presented both in terms of specific ways in which each barrier is being reduced, and improvements in health status/outcome measures. Reducing Financial Barriers Subsidized primary care service delivery programs play a significant role in serving the nation's poor. 54 Claire Brindis, Dr. P.H., "A Synthesis of Recent Evaluation Findings On School-Based Health Centers," presented as part of a National Health Policy Forum Workshop (Washington D.C.: November 28, 1989), 1-2. 55 Brindis, "School-Based Health Centers," 2. 56 Bonnie Lefkowitz and Dennis Andrulis, "The Organization of Primary Health and Health Related Preventive, Psychosocial, and Support Services for Children and Pregnant Women," in Better Health for Our Children, The Report of the Select Panel for the Promotion of Child Health, Vol. IV (1981), 456. Approximately 60 percent of those served by Federally funded C/MHCs have incomes under the poverty level, and another 25 percent are between 100 and 200 percent of poverty.57 Similarly, 50 percent of those served through hospital outpatient and health departments are poor.58 These programs, by targeting to underserved groups, care for the uninsured and make Medicaid a reality for many people who, although Medicaid-eligible, lack access to a provider. Reducing Capacity/Resource Barriers C/MHCs are required to be in the underserved urban and rural areas in the United States with the most substantial shortfalls of primary care providers. In addition, evidence suggests that both urban and rural centers have increased the utilization of health services. 59, 60, 61 Similarly, hospital outpatient departments and local health departments lower access barriers by their locations in underserved areas. The NHSC scholarship and loan repayment programs attract physicians to underserved communities. Priority of selection of scholarship and loan repayment recipients goes to individuals with backgrounds and interests.compatible to practice in underserved areas, and to individuals enrolled in institutions that have a history of producing large numbers of primary care physicians and who have an emphasis on care to underserved populations. C/MHCs affiliate with hospital residency programs, especially in family medicine and other primary care specialties, in order to receive direct services from residents, recruit them as future staff members, and improve the retention of C/MHC physicians who value the hospital affiliation and its teaching opportunities. Notable examples are found in Seattle, Washington and Bronx, New York. Federal primary care programs also help build systems of care in underserved areas by collaborating with State and local health departments through State Cooperative Agreements and Primary Care Associations and local coalitions. The goal of these collaborative efforts is to ensure the availability of primary 57 The Bureau of Health Care Delivery and Assistance, "The Bureau's Unique Role," 16. 58 M.G. Kovar, "Background Paper for the Select Panel for the Promotion of Child Health," (unpublished data from the National Health Interview Survey for 1974, Washington, D.C.: 1980). 59 R.A. Reynolds, "Improving Access to Health Care Among the PoorThe Neighborhood Health Center Experience," Milbank Memorial Fund Quarterly: Health and Society 54 (Winter 1976): 47-82. 60 H. Snyder, et al., "The Effect of Provision of Medical Facilities on Use by the Migrant Workers in California," Medical Care 6 (September-October, 1968): 394-400. 61 G. Sparer and L.M. Okada, "Chronic Conditions and Physician Use Patterns in Ten Urban Poverty Areas," Medical Care 12 (July 1974): 549-560. |