Subject: Who Will Serve Poor Urban Residents?
Date: Published: 4/16/93 (130 lines)
Source: Wall Street Journal. Copyright Dow Jones & Co. Inc.

    Politics & Policy:
    ...While Some Poor Urban Residents
    Ask if Anyone at All Will Serve Them
    ----
    By Hilary Stout
    Staff Reporter of The Wall Street Journal

    WASHINGTON -- Alain Enthoven, the father of managed competition,
 was briefing House Ways and Means staffers on the virtues of the
 competitive new health-care system President Clinton wants to adopt.
 Jon Sheiner, an aide to Rep. Charles Rangel, had a question.
    "Who's going to want to compete for Mr. Rangel's constituents?"
    It's a good question.
    Mr. Rangel, a New York Democrat, represents some of the poorest
 neighborhoods in New York City, including Harlem.  It is a district
 with extraordinary health problems:  crack babies, drug addicts,
 HIV-positive intravenous drug users, homeless people, street
 violence, AIDS and tuberculosis.  It is a health insurer's nightmare,
 particularly because Mr. Clinton has said he wants to outlaw
 insurance companies' practice of adjusting premiums according to
 individuals' medical risk.
    The health plan the president will unveil next month aims to
 generate more competition in the medical market by setting up huge
 networks around the country to buy health coverage for everyone in a
 region.  Their huge consumer muscle, the theory goes, will control
 prices and improve quality for everyone.
    But will it?
    "There has been no competition for the uninsured, the homeless,
 the lower-income, ethnic minority populations and the mentally ill,"
 according to Richard Butcher, president of the National Medical
 Association, the nation's oldest group of African-American
 physicians.  "It is unreasonable to expect a middle-class delivery
 system to embrace these populations," he told the Clinton
 administration's health-reform task force last month.
    In Harlem, there are fewer than 50 practicing physicians, serving
 a neighborhood with a population of 300,000, according to Eugene
 McCabe, president of North Star General Hospital there.  "It could be
 as little as 25," he says.  Nationally, there are more than 200
 doctors for every 100,000 people.  Most Harlem residents get care
 from hospital emergency rooms, like North General's, where half of
 the emergency room patients have no health insurance.
    At first glance it looks as if the people of the inner cities,
 who are often poor and either uninsured or on the federal-state
 Medicaid program, will benefit more than anyone from the Clinton
 health system.  After all, the president wants to guarantee health
 coverage for everyone, by forcing all employers to contribute a
 substantial portion of the cost of health coverage for their workers
 and by having the government subsidize the purchase of private
 coverage for the low-income unemployed.
    But the end result, some people worry, could be a two-tier
 system, where people in the inner cities can join the same networks
 of doctors and hospitals that the well-off people use, but don't
 have real access to them.  How is a single mother with an all-day job
 in Mr. Rangel's district, for example, going to get to see a
 specialist on Madison Avenue?
    The administration's health task force and its staff have spent
 many hours on such issues, and Hillary Rodham Clinton, the task
 force chairwoman, has been peppered with questions about them in
 meetings with the Congressional Black Caucus and other groups.
    Politically, the outlook for the inner cities could be critical
 to the Clinton plan's success on Capitol Hill.  The chairmen of key
 congressional panels come from urban states or districts.  Daniel
 Patrick Moynihan, chairman of the Senate Finance Committee is from
 New York; Dan Rostenkowski, chairman of the House Ways and Means
 Committee, represents a Chicago district; Edward Kennedy, chairman
 of the Senate Labor and Human Resources Committee represents
 Massachusetts.
    "You want to make certain that the services on K Street are
 available to the people in Anacostia," says Judith Feder, co-chair
 of the working groups advising the task force, referring to the posh
 downtown Washington business corridor and the blighted southeast
 corner of the city.
    To that end, the task force is considering a number of measures
 to prevent a kind of health-insurance redlining.
    Most importantly, it will probably require that any health plan
 competing for a regional health alliance's business will have to be
 prepared to serve all residents of the region.  That means, for
 example, a health-maintenance organization on Madison Avenue would
 have to have facilities in Harlem.  Most likely, according to the
 system Ms. Feder describes, it would mean that the Madison Avenue
 HMO would contract for services or have a "referral arrangement"
 with established community health centers, public health clinics and
 hospitals in Harlem.  Any health plan "would be required to have that
 arrangement," she says.
    For the most part advocates for the poor applaud such measures.
 But they say it is also important to develop systems sensitive to
 and geared to the special needs of poor urban communities.
    "We just don't have a system in place that is culturally
 competent and sensitive, that is located in our neighborhoods, that
 is user-friendly," says Tom Van Coverden, executive director of the
 National Association of Community Health Centers, which has about
 600 federally funded health organizations with some 1,400 delivery
 sites in urban and rural areas nationwide.  For example, he says,
 it's important to have a facility "with comprehensive services under
 one roof ...so poor people aren't running all around town for
 tests and services," and with extended hours to serve working people
 unable to take off time from jobs.
    Administration officials say they want to build on the health
 care systems already in place in the inner cities by pumping more
 money into the community health center system of federally funded
 clinics for inner-city and rural communities and by strengthening
 the National Health Service Corps, which helps finance medical
 students' education in return for a pledge to serve in rural or
 inner city areas for a certain number of years.
    North Star General's Mr. McCabe wants to set up a provider
 network linking his hospital to doctors and community health centers
 in the area, geared specifically toward bringing more primary and
 preventive care to the residents of Harlem.  But administration
 officials say they haven't decided whether to allow a plan geared
 solely to an inner-city population, fearing that could foster a kind
 of segregated medicine.
    Mr. McCabe says, "We don't want to continue a situation that some
 people have described as two-tiered medicine.  On the other hand I
 think the population we're describing has special kinds of needs
 that have to be recognized from experience and commitment to the
 area.  Initially ...you could have the same standards for
 everyone, but the emphasis for getting people to access the system
 has to be locally focused."
    (See related article:  "Politics & Policy:  Health-Care Proposals
 Based on Competition Are Viewed With Skepticism in Rural Areas..."
 -- WSJ April 16, 1993)

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