The archiving and publishing of the proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.
David Schmidt, MD, University of Connecticut: I commend those individuals responsible for putting together this conference and thank them for the invitation to participate. I have spent most of my professional life, which now spans 28 years, working in urban teaching settings that include Boston, Buffalo, Cleveland, and now Hartford. I believe that the quality of life and the health status of Americans who live in persistent poverty has never been worse than it is today.
Let me share with you and example that occurred the night before I left Hartford for this conference. In the middle of the night a 50-year-old black female was rushed by ambulance into our emergency room because she was experiencing incapacitating panic attacks.
She has every reason to be falling apart. Eight months ago her daughter was shot and killed by random gunfire during a gang war. She is left with two grandchildren to support. On Easter Sunday her last child, a son, died of AIDS. Tragedies similar to this occur almost daily in the cities of our nation.
Background of the Access Problem
I have been asked to provide background material which will be a challenge because today’s audience is a group of well informed experts. I plan to point out some of the major problems that exist in our current health care system and try to portray the urgent cry for change that is coming from all sectors our society. I will then focus on one suggested plan for change that is exemplified in the current Waxman-Kennedy Bill.
I will share with you my reasons for predicting that in the foreseeable future, (the next five years) virtually nothing is going to be done on the federal government level to address these major health care problems. This brings us to the central theme of this meeting: The Challenge and past Responses to the Problems of Access to Primary Health Care.
What can we or other concerned individuals do on the local and regional level to address the problems of access to primary health care by rearranging some of the resources that already exist? As a partial answer to this question I am going to describe a couple of successful defenestration projects, mention some of the noble responses from the private sector, and then look at the potential of our family medicine training programs for addressing these issues.
Impending Bankruptcy of Health Care System
As we all know, the health care system is on the verge of bankruptcy. Health care costs are out of control. Partially because of these rising costs, ready access to health care is decreasing. With decreasing access to care, the health status of our nation is deteriorating.
We are now spending over $750 a year on health care. Expressed in terms of Gross National Product, this represents 11.5 percent. There are projections that by the turn of the century this figure may be as high as 14 – 17 percent.
A comparison of the cost for medical care in the United States and Canada is important. Figures for both nations were very similar until the 1970’s. This is when Canada introduced a national financing system for medical care. From that point on, the two nations have diverged. Canadian costs have been stabilized and 8 ½ percent, while the American costs continue to rise to the current peak of 11.5 percent. I mention this comparison because we can be assured that health care planners, legislators, and business leaders are tracking these major discrepancies between two similar nations.
It is estimated that there are about 37 million people in the United States without health insurance. It is important to look at the composition of this group. Only 18 percent are non-working adults. Forty-nine percent are employed adults and 33 percent are children. Two-thirds of these individuals have salaries above the poverty level. These Americans are at great risk without health insurance. Should they experience a medical disaster, they could easily experience financial ruin as well.
Fourteen percent of the White population is uninsured. Twenty-two percent of the Black population is uninsured. Twenty-nine percent of the Hispanic population is uninsured. Twenty-five percent of all American children are currently living below the poverty level and 50 percent of all Black children live in persistent poverty.
Deficiencies in Medicaid Program
The Medicaid program was introduced in the 60’s and designed to be a safety net to provide at least minimal health care benefits for those with no other source of financing for their medical care. In recent years, the eligibility requirements have deteriorated to the point that there are some places in the South where anyone earning more than $75 a week is not eligible for Medicaid benefits.
The Robert Wood Johnson Foundation has recently demonstrated that all segments of society are having problems with access to health care in the United States. Approximately one in five Americans had no regular source of health care, and a slightly smaller percentage experienced difficulty obtaining care when needed. The average number of ambulatory visits of patients in fair to poor health was inversely related to the health insurance and economic status.
As the number of individuals in this country living below the poverty level has increased, the number of individuals receiving Medicaid has remained stable. This health coverage designed to provide minimal insurance for the poor reaches only 65 percent of the households living below the official poverty level.
In 1980, the Surgeon General set a goal for 1990 of having 90 percent of our children fully immunized by age two. Today, fewer two-year-olds are fully immunized than when that goal was set. We are moving in the wrong direction. As a nation we now rank nineteenth in the world in infant mortality. (the infant mortality rate is the number of deaths per 1000 live births at the end of the first year of life.)
Blacks in this country rank 28th below Cuba, Costa Rica, and Portugal. These embarrassing figures are exaggerated in selective cities. Infant mortality rate for Blacks in Boston exceed 25 per 1000! These rates are similar to those of Third World Countries.
The cry for change is coming form all sectors of our society. Senator John D. Rockefeller, IV, Chairman of the Pepper Commission: “There is growing recognition that the American health care system is in total crisis…we are plunging ahead in this country toward health care catastrophe.” Arnold Rellman, Editor of the New England Journal of Medicine: “The cost of our present market driven system may prove to be so high, and it’s inequities so onerous, that universal tax supported health insurance may become a far more attractive political option than many now suspect.” Lee A. Iococa: “The country needs an orderly system, and if that means some kind of national health insurance, then I’m for it.” Why is a business leader like Iococa rendering an opinion?
The private sector is paying the bill. Every Chrysler that is sold today had %530 attached to ti’s basic price in order to pay for health care insurance for Chrysler employees. This figure is four times the amount of dividends that are given to the company’s stockholders. This figure is four times greater per employee than the competition, Mitsubishi, is paying for health benefits. Over the past decade the cost of health insurance to Chrysler has increased by 700 percent.
What is happening on a national level to address these problems? St September, the American Academy of Family Physicians endorsed mandated private health insurance and Medicaid reform. This is currently embodied in the Kennedy-Waxman Bill.
The AMA has endorsed mandated private insurance and Medicaid reform. The Pepper Commission suggested mandated health insurance and Medicaid reform. Recommendations of the Pepper Commission were made by a narrow vote of ti’s members. The Secretary of Health and Human Services points out that the divergence of views on the commission reflects what is going on in the country.
There is no consensus of how to achieve the kind of health care we specifically want and how to bear the cost. There is no doubt that mandated health insurance and Medicaid reform represents a quick fix. However, I predict that even this less than optimal solution to our problem will not be accepted because of its costs. The price tag for mandated health insurance and Medicaid reform would be in excess of $3 billion for the private sector and $10 billion for the public sector per year.
It is important to compare the relative economic strengths of the United States in the 1960’s and in the 1980’s. The social reforms that were instituted in the sixties occurred when the nation was enjoying incredible prosperity. In the 1960’s, the United States had 60 percent of the world industrial production, a trade surplus and small debt. We had a heavy industry and a unionized work force.
Today, our country has 30 percent of the world industrial production, over a $100 billion trade deficit and a national debt of $3 trillion. That $3 trillion figure represents $12,000 for every man, woman, and child in the United States. Heavy industry in this country has disappeared. The new high tech jobs require a minimal level of education. Only 22 percent of our work force is currently unionized. The major strategy for cost reduction is to lower labor costs, which is being done on a large scale.
For every billion dollars of foreign investment, we lose about 25,000 jobs. There is slowly creeping into our country a Third World population who are willing to work for minimal wages. There has been a great deal of publicity recently centered around eight million new jobs which have been created in this country. IN reality, 60 percent of these jobs are with earnings off $7,000 a year or less. There are many indications that the nation’s economy will worsen and with the recession, access to health care for the persistently poor will become an even greater problem.
It is estimated that the cost to implement the Kennedy-Waxman Bill will be extremely high. This quick fix, short term solution to the problem of access would concentrate on mandated employer provided health insurance and reform of the Medicaid system. It is estimated that such a program will cost the private sector $33 billion a year, and the public sector about $9 billion or $10 billion per year. In the current economic climate, I do not believe such a bill will pass Congress.
This, then, brings us to the generic question, “What can we as individuals do on a local or regional basis to address these health care problems? What can we do with existing resources to better provide access to care for the persistently poor?” We do not have to reinvent the wheel. For the past 20 years, a number of experiments have been going on that have been very successful. The following are a few selected examples of past successful responses to the problem of access for the poor.
Selected Pilot Projects
THE CALIFORNIA PROJECT FOR OB ACCESS
In the 1970’s, it was discovered that there was an increase in infant mortality in the poorer districts throughout California. Less than half of the obstetricians were taking Medi-Cal patients. Increasing the physician reimbursement had no effect on the number of physicians who would care for these patients. Therefore, the California Department of Health Services targeted 13 counties and defined a comprehensive prenatal care package.
This included a very active outreach effort to bring women into the health care system. There was a guarantee that this care would continue to until the birth of the child, regardless of eligibility requirements. Over 7,000 women received care in these comprehensive programs. When compared to women receiving conventional care, it was demonstrated that there is an increased cost of about five percent for the California OB Access Program. But for every dollar that was invested, more than $2 were saved in the area of neonatal intensive care alone. These calculations do not consider the human suffering associated with permanently damaged child.
COMPREHENSIVE SCHOOL HEALTH CARE PROGRAMS
Over 20 years ago the city of St. Paul (Minnesota) introduced a comprehensive health care program in the school system. This began with education at the seventh grade. The curriculum included family planning, prenatal classes for pregnant women, and a mother support group. The medical services included routine medical examinations, personal counseling, family planning, treatment of sexually transmitted diseases, pregnancy testing and prenatal care on the school premises.
St. Paul even established a day care component which allowed the parents to complete high school. A woman who completes high school is on welfare for an average of two years. The woman who has a child and drops out of high school is on welfare for 18 years! The day care component provided field experience with course credit for the high school’s child development classes.
The results of this program were phenomenally successful. After four years of operation, virtually all the pregnant women received early prenatal care. There was only one premature birth. There were no other low birth weight infants. There was no perinatal mortality. The postpartum drop-out rate fell from 45 percent before the initiation of the program, to only 10 percent. There were virtually no repeat pregnancies and the baseline fertility rate dropped by half.
MADISON COUNTY, NORTH CAROLINA
Madison county, North Carolina has 450 square miles of land, 17,000 individuals living in 5,000 households, a higher than average number of individuals over age 65, and a median household income that is below the poverty level.
Over 20 years ago, the Town of Hot Springs lost its last physician and none could be found to replace him. Local community leaders developed a non-profit community-owned health care program and hired nurse practitioners to provide care for the people.
Initially, the nurse practitioner was supervised by faculty from the University of North Carolina, Chapel Hill. Eventually, physicians were hired by the health care program.
Over this period of time, virtually every remaining physician in the county has retired or died and Hot Springs Health Care Program now provides total care for the county. They employ six primary care physicians, two family nurse practitioners, dentists, pharmacists, and 75 health professionals. They are the fourth largest employer in the county.
They now have four medical centers. There is a county-wide home health and hospice agency. Staff from the Hot Springs Health Program staff the county health department. Virtually every woman receives free prenatal care. The deliveries occur at the Asheville Hospital in a neighboring county. The entire county has enjoyed an incredibly low infant mortality rate: 5 per 1,000!
The six physicians provide 24-hour county call. One of the centrally located facilities is open until 9:00 pm. After that hour, if a true emergency occurs, an ambulance is sent to bring the patient to the medical facility. By organizing health care for the entire county, it is now possible to recruit young physicians to work in this rural area. The six physicians enjoy professional companionship and share night and weekend coverage. The Hot Springs Health Care Program is financially solvent. In fact, this program recently declined acceptance of federal funding.
Responses from the Private Sector
Across the country, office-based private physicians have been forced to reduce the number of Medicaid recipients they care for because of low level Medicaid reimbursements. In some areas, the introduction of primary care management for Medicaid recipients has reversed this trend.
In the State of Washington, a physician legislator sponsored a successful bill for $19 million which allowed the state to buy health care from the Puget Sound Cooperative (a closed staff HMO) for Medicaid recipients. The benefit package was somewhat reduced. This is clearly and example of rationing of health care. The “frills” were not included, such as prolonged mental health care and drug rehabilitation.
In Rochester, New York, physicians, Blue Cross/Blue Shield, and hospitals work together to create a health insurance program for low wage earners. The cost of this insurance to the individual was 50 percent the cost of regular Blue Cross/Blue Shield programs. Here, again, the benefits were trimmed. The physicians agreed to accept 65 percent of the regular and customary fee for their services.
In Orange County, California, a constituency of academic leaders and practicing physicians became an effective advocacy group for the uninsured. Orange County is known for its affluence with a mean annual income of over $48,000. However, there are 5,000 homeless, 150,000 non-documented aliens, and about 250,000 people without health insurance in that county.
The county hospital, which is owned by the medical school, attempted to insist on advance payment for their services. This advocacy group has been very effective in preventing the county hospital from decreasing patient services. IN fact, the number of women receiving comprehensive OB care at this institution has increased.
The Potential for Training Programs to Help Address
The Problem of Access to Medical Care
It is difficult to quantitate how much care for the underserved is provided by training programs. The number of residents in training is over 80,000. This person power works in institutions that add up to over 300,000 beds. This represents 60 percent of all the medical beds in the United States.
In family medicine alone, there are 380 residency programs. If an average family medicine center has 15,000 visits per year, this resource provides six million visits. I am not aware of any means of estimating what percentage of these visits are made by Medicaid recipients or patients without health insurance. Nevertheless, this must be a significantly high percentage.
I will end this presentation by focusing on a new and promising training program in East Los Angeles. Over 300,000 Hispanics live in East Los Angeles within the shadow of the affluent downtown skyscrapers. In 1985, there were only 65 elderly non-residency trained primary care physicians in this community.
The story begins a few years ago when an 8-year old boy named Hector Flores and his family moved from Mexico to the United States. No one in the family spoke English. They settled in the East Los Angeles area.
Eventually, Hector went to Stanford University and received his medical degree from the University of California, Davis. During his college and medical school days, Hector became involved with the California Chicano Medical Student Association. This group today has 12,000 pre-medical, 300 medical students, 3,000 residents, and 12,000 alumni in its membership.
In 1985, the University of Southern California was granted AHEC money to create a Hispanic education training initiative. It was decided that a new family practice residency program would be the centerpiece of this initiative. Dr. Peter Lee, the Chairman of the Department of Family Medicine at the University of Southern California, began searching for a hospital that might house such a residency program.
White Memorial Medical Center in East Los Angeles is a full service tertiary care facility that was previously the University Hospital, Loma Linda Medical School. As a university hospital, it had little community involvement and virtually none of the East Los Angeles primary care physicians had admitting privileges to the hospital. Loma Linda build an entirely new university, hospital at some distance. Suddenly this full-service hospital was left without a mission.
Dr. Sanford Bloom, who had retired from a distinguished career as the family practice residency director at Santa Monica Hospital Medical Center, agreed to do a feasibility study for the White Memorial Medical Center and later developed the curriculum and the Residency Review Committee accreditation application.
When it came time to recruit a faculty, Hector Flores seven of his friends form the Chicano Medical Association. Six of these seven physicians had their roots in East Los Angeles. Through the California Chicano Medical Association, it was easy to recruit a group of bright residents.
This is not an ordinary residency program. The Faculty and the residents have become heavily involved in the community. These Hispanic role models are trying to encourage the younger students at the elementary school level to consider health careers. They have organized a teenage pregnancy program in the high school and there is a great deal of one-to-one mentoring occurring.
The program has set up a number of satellite practices throughout East Los Angeles. At present, there are three such practices. Faculty receive 50 percent salary from the hospital and they earn the rest of their living through community practice. There is a separate practice corporation. The hospital and the practice corporation are prepared to help each resident set up a new practice in East Los Angeles upon graduation.
This is another example of crating a system in which an individual need not be isolated when providing care to the underserved. This type of arrangement provides professional companionship and a reasonable night and weekend call schedule.
At present this project is funded almost equally by the hospital, extramural grants, and patient income. Bill Burnett (through the Song-Brown Family Physician Training Act that he administers for the State of California) is helping the program create new funding methods to provide long-term viability. The areas that are being explored include a primary care capitation program with Medi-Cal and application for designation as a National Health Service Corps site.
This is an example of existing resources being brought together in a vision that has the potential of providing a sufficient number of well trained family physicians for the entire 300,000 population.
Dr Schmidt’s presentation was preceded by: The First National Conference on Primary Health Care Access. April 20-21, 1990 (Opening Remarks)
Dr Schmidt’s presentation was followed by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 2, Weaver).