Health reforms may still slight inner-city poor Managed care groups are reluctant to move into disadvantaged areas

April 02, 1993|By Knight-Ridder News Service

WASHINGTON -- For millions of working poor in America's inner cities, health reform could create a bewildering paradox: They would get health insurance, but they still may lack ready access to quality care.

Despite assurances from the Clinton administration, experts on minority health fear that a revamped medical system could perpetuate second-class medical care in the inner city.

The reason: Inner-city residents are not likely to fit smoothly into President Clinton's "managed competition" strategy, which envisions a system dominated by health plans like today's health maintenance organizations.

A central problem is that most HMOs cater to suburban, middle-class America, and many lack the facilities, experience, and even the desire to operate in the inner city.

"There has been no competition for the uninsured, the homeless, the lower-income, ethnic minority populations and the mentally ill," said Dr. Richard Butcher, president of the black-oriented National Medical Association. "It is unreasonable to expect a middle-class [health care] delivery system to embrace these populations."

According to congressional figures, only 22 percent of HMOs participate in Medicaid, the federal-state health insurance program for the poor.

HMOs have stayed away because Medicaid reimbursement rates are low and because poor people tend to have more health problems.

"They feel inner-city areas carry a greater risk," said Ellis Bonner, president of Comprehensive Health Services, a Detroit HMO that mostly serves Medicaid beneficiaries. "By and large, they have not been inclined to do business in the inner city."

Unless that changes, health reform could have the unintended consequence of locking in a two-tiered system.

"Choice will be restricted greatly, as few managed care plans will want to locate in inner-city neighborhoods," said Rep. John Conyers, D-Mich., who favors a government-run national health system like Canada's.

"Neighborhoods will be red-lined from health care as sure as they're red-lined from bank loans."

In the last few years, many states have tried to get Medicaid

beneficiaries into HMOs as a way to hold down costs. And more recently, the HMO industry has begun an effort to reach out to minorities.

Nevertheless, fewer than 2 million of 28 million Medicaid beneficiaries are in HMOs.

Two states, California and Michigan, account for 41 percent of the beneficiaries in HMOs. Long-established Medicaid HMOs, like Detroit's Comprehensive Health Services, remain the exception.

What's more, Medicaid HMOs don't usually serve many private-pay patients, raising concerns that Medicaid patients are getting a lesser standard of care. Several Medicaid HMOs have had highly publicized quality problems.

White House officials say that the president's experience as governor of Arkansas and first lady Hillary Rodham Clinton's involvement in the Children's Defense Fund have made them acutely aware of the problems minorities have in getting quality health care.

They caution against prejudging the reform plan based on how managed competition would work in theory. "We are not slavishly following any theory," said Bob Boorstin, a spokesman for the health reform task force.

Mr. Clinton's plan is likely to contain other provisions aimed directly at helping inner cities, such as more money for community health centers.

Some activists are urging the administration to consider opening veterans hospitals and clinics to people in poor communities.

But the ivory-tower image of the White House health task force is not reassuring to minorities. Jane Delgado, president of a national Hispanic health network and an adviser to the task force, says there is widespread distrust of government experts who claim to know what's best for minority communities.

The experts "can tell you 50 ways to get a date, but they've never been kissed," said Ms. Delgado.

"If you come and slap something into the inner city without the community being a part of it, there's no way that the community will accept it."

One problem that health reform could address is the issue of lower reimbursement for treating the poor.

Under managed competition, Medicaid would be eliminated as a separate program.

Instead, the government would pay premiums for the poor to insurance purchasing co-ops that would also represent the non-poor and many businesses.

The co-ops would use their purchasing power to negotiate rates with different health plans, and they would be able to compensate for the higher costs of serving the poor.

But even if financing problems can be resolved, delivering care to poor people will still require a certain expertise.

Detroit's Mr. Bonner said HMOs have to organize differently to operate successfully in the inner city. They need large social work departments, more mental health and substance abuse services, and aggressive programs to make sure pregnant women and young children receive routine preventive care.

Some HMOs may not want to take on those challenges.

Tom Chapman, president of a hospital and health care network that serves inner-city Washington, predicts that the transition to a new system will be "very slow and very difficult.

"The medical system is fundamentally passive," said Mr. Chapman. "It waits for people to present problems, and then takes care of those problems in a miraculous way. We need to have a system that reaches out, and that requires a different mindset."

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