by Virginia Brennan,
editor of the Journal of Health Care for the Poor and Underserved and a faculty
member at Meharry
Medical College
in Nashville, Tennessee.
The notion of the common good underlies most of the great social programs in the United States, including everything from public schools to Social Security and Medicare (to say nothing of the very rule of law itself). A highly pragmatic form of the same notion is the foundation for any insurance program. It is the size and diverse nature of the pool of people who are insured that allows the insurer to cover the costs of those unfortunate few who end up needing to make claims. The fortunate many, in effect, underwrite the costs for the unfortunate few, if only because they fear the possibility of misfortune in their own lives. The result redounds to the common good of those in the insurance pool in that the costs borne by any individual are relatively small, but everyone has the assurance that s/he will have the resources to confront misfortune should it occur. If the only people to buy insurance are, instead, highly likely to make use of it (a phenomenon known as adverse selection), the balance required for a financially viable system is lost, and either the cost of insurance becomes prohibitive or the insurers go bankrupt.
The above reasoning underlies the surprisingly contentious issue of the individual mandate to carry health insurance that is part of the 2010 Patient Protection and Affordable Care Act (ACA). Even if the simple lesson in the structure of insurance weren't enough to justify that provision of the law, a great many more specific economic and cost projections are (see the January 7, 2011 Op-Ed piece in the Los Angeles Times by Rahul Rajkumar and Harold Pollack; also see the December 2010 Urban Institute paper on the mandate by Matthew Buettgens, Bowen Garrett, and John Holahan). Among other things, the already crippling burden of uncompensated care that falls on the nation's safety-net hospitals would decline three times as much with ACA in effect than without it. As Rajkumar and Pollack put it, the individual mandate embodies "a web of mutual obligations," the sort of web that makes possible any effective use of collective action. In this case, the payoff is that each of us individually has a good chance at staying healthy, and the nation as a whole is less burdened by the massive ethical and financial problems attendant upon the less fortunate being in much poorer health than others.
And the socio-economically less fortunate are in much poorer health than others ― socioeconomic, racial, and ethnic disparities in morbidity and mortality in the United States are sharp and of long standing. To take just one example demonstrating the stubbornness of racial and ethnic disparities, it has long been established that Black women in the U.S. suffer a higher proportion of the mortality due to breast cancer than White women, despite experiencing a lower incidence of the disease. Stacey Fedewa (from the American Cancer Society) and colleagues demonstrate that -- independent of health insurance, age, and stage at diagnosis --Black and Hispanic patients had greater risk than White patients for treatment delay for breast cancer over the recent three-year period they analyzed. Socioeconomic status (SES) is as a general rule also strongly associated with health: for example, in a forthcoming article Shawn Boykin and colleagues show that both Black and White women show inverse SES gradients for all cardiovascular disease (CVD) risk factors (i.e., higher SES is associated with lower risk of CVD). (Both articles will appear in the Feb 2011 issue of the J. of Health Care for the Poor and Underserved (JHCPU). The ACA is far and away the strongest legislation yet for reducing and eliminating such population-based disparities in health and mortality.
Happily, there is a strong (if over-burdened) pair of warhorses in the fight against health disparities: federally qualified community health centers (CHCs) and safety-net hospitals. There are over 7,900 CHCs in the United States, and 71% of those they serve have incomes below the stringent federal poverty level (FPL) ― their clients are the poorest of the poor. 66% of those served at CHCs are members of minority groups and 33% are children. In 2009, according to the Dept. of Health and Human Services, CHCs served nearly 19 million people. Most importantly, it appears that the quality of care delivered in CHCs is comparable to that delivered in other care sites (such as private physicians' offices). (See, for example, the article on chronic disease care at CHCs by Hicks, O'Malley, and Lieu in the Nov/Dec 2006 issue of Health Affairs.) The ACA has already begun to strengthen the CHC system and will continue to do so, ultimately nearly doubling the funding for CHCs nationwide.
The other warhorse in the fight against health disparities is the safety-net hospital system. Safety-net hospitals are those that will not turn sick people away regardless of their ability to pay. They play a very large and largely uncompensated role in the provision of care to the medically underserved in the United States. David Goldberg and colleagues from Rush University analyze the contributions of Chicago's public hospitals to regional health care, in an article in the February 2011 issue of JHCPU. The bottom line is that these hospitals contribute substantially more in medical services to Cook County than they are provided funds for by the county (anywhere for 1.3 to 8 times as much value in services as they receive in funding, depending on the specific service being provided). Chicago's public hospitals provide especially high volumes of diagnosis of tuberculosis, sexually transmitted infections, and cancer; care of low birth weight babies; primary care for people with HIV and diabetes; and emergency room and ambulatory care visits.
In their Commentary in the February 2011 issue of JHCPU, John Zweifler and colleagues from the University of California, San Francisco argue for thorough integration of primary care services at community health centers with specialty care services at safety-net hospitals and residency training programs. They note that provisions in the ACA now make such a leap forward in underserved care possible. Such an integration ― especially of primary care at community health centers with specialty care at safety-net hospitals ― would for the first time make a workable comprehensive system of care available for the medically underserved in the United States, a group that is overwhelmingly composed of people with very low incomes and members of racial and ethnic minority groups.
Although it suffers from festering problems stemming from population health disparities, the current U.S. health care system has the raw material to overcome them. CHCs and safety-net hospitals have already demonstrated their capacity to provide high-quality care for the medically underserved. By building up CHCs and safety-net hospitals and fostering their integration, the Patient Protection and Affordable Care Act will finally begin to heal the festering sores and allow the health care system as a whole to thrive.
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