Can The Poor Afford Health Care Reform?

Susan Fickling, a 41-year-old Harlem resident and Medicaid recipient, prefers getting care at the William F. Ryan Community Health Center in Manhattan to the local emergency room she used to frequent. Unlike the hospital doctors, who "had an attitude," says Fickling, Ryan's physicians are "caring and understanding." What's more, she can make an appointment at Ryan instead of waiting all day, and sometimes all night, at the hospital. The center provides full medical, dental, and mental-health services on a sliding scale. To help its many immigrant patients, staffers are bilingual. For the disabled and the very sick, the center even provides transportation.

Now, the Clinton health-care plan, unveiled on Sept. 22, threatens to cripple Ryan and the other 1,400 community health centers across the U.S. By proposing to create a new authority to provide flexible grants to the states, community-health advocates worry, the plan will undermine the health centers and other programs targeted to high-need areas. They're particularly anxious about the Administration's intention to replace their $600 million in federal funds with state block grants--money the centers may never see.

Such a move could backfire on the Administration: The centers provide the kind of primary care it is vowing to expand. "If I don't have protection from the feds in terms of funding," says Ryan's executive director, Julio Bellber, "what I have here could be wiped out in a blink of an eye."

With its guarantees of universal coverage and expanded access, the Clinton plan professes to be a boon for the poor--notwithstanding $114 billion in proposed Medicaid cuts. As now envisioned, the plan will require all insurers operating in a region to contract with clinics and hospitals that treat low-income groups. Subsidies will help the providers and allow the poor to pay their premiums. The Public Health Service will get $1 billion to $1.5 billion over five years to build health-care networks and facilities. The National Health Service Corps also will get a "significant amount of money" to encourage doctors to serve such locations, says Ira Magaziner, the top White House health-care aide.

But critics believe the Clinton plan risks hurting the institutions that have long provided care for the downtrodden--from community health centers to public hospitals--and that depend on federal subsidies to survive. They worry that the plan's budget-slashing will leave them with less than they already have, just when they're forced to compete for patients with powerful provider networks and more modern private institutions. The hospitals, in particular, are concerned about paying for care of illegal immigrants, who are excluded from the plan but can get emergency care. The plan, says Bruce Goldman, executive director of Harlem Hospital Center, "could leave us in a worse situation than we [had] in the first place."

Critics charge that the plan also leaves unanswered other tough questions affecting the poor. It doesn't completely resolve, for example, how the White House plans to fulfill its pledges of low-income subsidies and public-health funding when the financing is shaky at best. Despite provisions barring health plans from discriminating, it leaves unsettled how alliances will police them. And although it specifies that providers catering to the poor will be paid more, the plan doesn't ensure that health plans will market their services in low-income areas--and, if they do, that they will in fact provide quality services.

BEARING THE BURDEN. Managed-care providers dispute criticism that they've sought out the affluent, who tend to be healthier and thus more profitable to treat. The Kaiser Foundation Health Plan for the Southern California Region, for one, maintains hospitals and clinics in poor areas such as East Los Angeles, says Jerome Ashford, health manager for the plan. Kaiser, which has 2.2 million members, has agreed to increase its state Medicaid enrollment by 20,000, to 66,000 members, under a state push to bring low-income people into managed care. "We feel confident we bear our full share of the burden," he says.

When poor people belong to health-maintenance organizations, though, they may fare less well than other groups. A Rand Corp. study in the 1970s, still considered a valid landmark, compared fee-for-service patients with those in a nonprofit HMO. It found that poor, high-risk HMO patients reported "more serious symptoms and were even at greater risk of death." While noting that the finding is not conclusive, Rand researchers warned it raised the "possibility that poor people may suffer from the side effects of what are otherwise apparently sensible health policy reforms, even when the majority of the population gains from them."

Two recent studies, by contrast, found that Medicaid recipients in HMOs suffer "no adverse outcomes," says researcher Dr. Nicole Lurie, a University of Minnesota associate professor. But those HMOs that have had experience with such populations and provided protections that are typically unavailable in Medicaid managed-care plans. Medicaid patients studied, for instance, were not segregated into separate plans. And to prevent the plans from "skimming" the healthiest recipients through targeted marketing, independent brokers were hired to educate patients about their options among health plans and doctors.

Such findings could remain the exception so long as the Clinton plan lacks similar protections. Clintonites assert that the most important feature for the poor is the plan's basic structure: the creation of huge health alliances that will monitor care. Currently, there are no assurances that Medicaid recipients have access to a doctor and actually get care, says Paul Starr, a member of the health-care-reform task force. But because Medicaid recipients, with some exceptions, will be rolled into the alliances, he says, health plans will be accountable for providing "real access to care."

Fickling, for one, hopes the White House pulls it off. If so, she and millions of other poor Americans will no longer have to worry about having their health-care needs met--or spending the night in the emergency room.

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