-
Chapter 12. Health Care for the Poor: For Whom, What Care, and Whose Responsibility?
- Russell Sage Foundation
- Chapter
- Additional Information
330 / Chapter 12 Health Care for the Poor: For Whom, What Care, and Whose Responsibility? Katherine Swartz A mericans’ efforts to help poor people obtain medical care have evolved as the country has grown richer and as medicine has become capable of increasing life expectancy and improving quality of life. That evolution has not been a direct path of increased generosity toward poor people. Instead, it reflects a mix of philosophical beliefs, greater understanding of the links between health and ability to work, and swings in the economy that have made Americans alternately more and less willing to help pay for poor people’s medical care. Since the late 1940s, when the share of Americans with employer-sponsored, private health insurance started to grow rapidly, the primary approach to helping poor people obtain medical care has been to make public health insurance available to a growing share of the poor. Underlying this approach is the assumption that if poor people have health insurance, physicians and other providers of medical care will provide the same services to poor people as they do to middle-class people. But as experience with public insurance has grown, it has become clear that poor people face barriers to obtaining health care beyond simply their ability to pay for it. Many poor areas of the country have a shortage of physicians and nurses, and not all physicians and other medical care providers are willing to treat people with public insurance coverage. Many poor people are unaware of symptoms of medical need or do not know how to explain the symptoms to medical personnel. Others face language or cultural difficulties when seeking care. As understanding of these barriers has increased, efforts to help poor people with health care have expanded to include more funding for community health centers, public health clinics, language translators, and educational programs about health issues specifically targeted at groups of poor people. These public policy efforts, however, have been secondary to expanding health insurance coverage for lowincome people. The dramatic increase over the past fifty years in medicine’s ability to increase life expectancy and improve quality of life (especially for people with chronic conditions) has made disparities in access to health care particularly troubling. There is no doubt that poverty is a contributing factor to poor health outcomes. Poor people have lower life expectancies, a higher prevalence of chronic illnesses and health conditions, and more unmet health needs than do people with middleclass and high incomes. But the causal path between poverty and poor health outcomes is complex. Other factors correlated with low income, such as low education, the inability to speak English, and living in areas with high levels of pollution, also contribute to poor health (Lillie-Blanton et al. 1999; IOM 2003). Equally important, the link between poverty and poor health does not go in one direction (Smith 1999). Poor health is a contributing factor to low incomes and poverty. People with chronic medical conditions frequently are poor because they cannot work, and people who suffer a sudden decline in health—an accident, stroke, or cancer diagnosis—often become poor owing to a job loss. Moreover, people with such health problems often have problems accessing medical care because there are not enough medical providers nearby or they are not good advocates for themselves—and then they remain poor because they cannot work. The fact that people in poor health often have low incomes as a result of their health problems is an increasingly important driver of efforts to expand eligibility for public insurance. This is especially the case in efforts to increase coverage of children. As we have come to appreciate how poor health can affect learning, which in turn is related to a person’s productivity and earnings, awareness has grown that investing in improving access to health care pays off in areas beyond health outcomes. Thus, the recent history of public policies to help poor people obtain health care is an evolving mix of efforts to address the reasons why poor people have poor health. Some policies increase the availability of public insurance, and other initiatives are targeted at addressing language and cultural problems particular to the poor and increasing the supply of medical providers (especially those knowledgeable about the difficulties facing poor people). This chapter focuses on the recent history of public policies intended to help the poor obtain health care, including the concerns now surrounding public insurance. The first half of the chapter provides a brief...