Current and Proposed Financing of Health Care for the Poor: Second-Best Solutions

48 Presentation CURRENT AND PROPOSED FINANCING OF HEALTH CARE FOR THE POOR: SECOND-BEST SOLUTIONS ELI GINZBERG, Ph.D. Director Conservation of Human Resources Columbia University Since I prefer not to load this paper with a large volume of data but rather to focus on conceptual clarifications and policy alternatives, I shall start by setting forth my basic preconceptions: • Lack of money (insurance) prevents sizable numbers of poor persons from seeking health care services. • This monetary/insurance barrier means that many untreated conditions worsen progressively. As a result, when the patient can no longer avoid seeking treatment, the costs are higher than they would have been had treatment been sought earlier. • In most instances, health care involves a relationship between a physidan , or other health professional, and the patient. Since most physicians are self-employed, they prefer to practice in locations where there is a suffidently large concentration of middle- or upper-income families to assure that they can earn a reasonable livelihood under conditions to their liking. Hence, most physicians avoid practidng in areas with large concentrations of poor people. • In an effort to economize in their use of public funds, many states have set Medicaid reimbursement rates for physidans who treat the poor at such low levels that many practitioners are reluctant or refuse to treat them. • A number of states have also placed limitations on the duration and types of hospital or ambulatory care for which they will reimburse for Medicaid patients. • Poor people, by virtue of their inadequate incomes, often pursue lifestyles that are dysfundional for their health, and as a result, require lengthier and more intensive treatment than more affluent members of the community. •Since poverty is frequent among radal or ethnic minorities, these poor are doubly handicapped. Racism and cultural and language barriers exacerbate Journal of Health Care for the Poor and Underserved, Vol. 1, No. 1, Summer 1990 Ginzberg 49 the difficulties of many blacks and Hispanics in obtaining access to the health care system. The problem is aggravated for minorities who live in rural areas that lack an adequate health care infrastrudure. • While I acknowledged earlier that lack of finandng blocks the access of some millions of poor people to the health care system when they need it, by far the major deprivation that the poor suffer is the inferior quality of the care to which they have access. My sub-title, "second-best solutions," requires explanation: why secondbest rather than best solutions? Let me state the basic premises for my choice of this limited objective. • Our nation is strongly committed to a relatively weak system of government and is accordingly averse to expanding the responsibilities of the federal and the state governments for providing broadly needed and desired sodal goods or services. I see no early change in this basic orientation. • The distribution of income in the U.S. is becoming more, not less, skewed. Accordingly, it is even less likely that our sodety will make any substantial progress in the near to middle term toward providing the poor with access to medical care equal in quality to that received by the well-insured population. • Regional and subregional differences in standard of living and in public and philanthropic infrastructure are so great that it is difficult for the federal government to legislate a single level of benefits for all benefidaries. The best that one can hope for is that the federal government will establish a minimum standard that the more affluent states are free to (and will) exceed. • The medical profession and the acute care hospitals, which are greatly influenced by the medical profession, are in a unique position to determine the structuring and restructuring of health care services: how they are delivered, to whom, and under what conditions. It is wiser to elidt the cooperation of the medical profession in the processes of change than to assume that its members can be coerced into going along. • The increasing restiveness of the public and private payers for health care with the unremitting rise in their outlays suggests to me that the margins for their agreeing to provide more liberally for the poor or underserved are limited. Given these realities, I believe...