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107 Presentation MODELS FOR INCREASING ACCESS: STRENGTHENING COMMUNITY HEALTH CENTERS & A NATIONAL HEALTH SERVICE CORPS JO IVEY BOUFFORD, M.D. President New York City Health and Hospitals Corporation In the past several years, the United States health care system has been under increasingly detailed, and recently increasingly visible, scrutiny by legislators, the public, and the provider community. Policy makers have had two major areas of interest. The first is the cost of care. For over a decade, a series of alphabet-soup cost-containment efforts have been implemented, from PROs (Physician Review Organizations) and HMOs (Health Maintenance Organizations ) to DRGs (Diagnosis Related Groups) and RVUs (Relative Value Units), but the costs continue to escalate. The other policy concern during the same period has been access. In the 1960s, Medicaid and Medicare were designed to address the problem of access for our most vulnerable citizens—the very poor and the elderly. Other categorical federal (and some state) government initiatives, especially in the 1960s and 1970s, aimed to fill in the access gaps by increasing the numbers of students of medicine and by directly supporting health facilities and health professionals in the most medically underserved areas of the country. But in the early 1980s, as federal spending constraints increased, the costcontainment agenda collided with the access agenda, and access lost as a policy priority. Costly acute-care hospitals faced federal pressure to decrease expenses , and in a zero-sum game, resources were not redistributed to provide incentives for primary or long-term care. At the same time, pressure increased on the categorical programs. In the case of health personnel, increased federal funding in the decade following 1973 had resulted in a doubling of the number of students in most health professions. The belief was that these personnel would trickle down into underserved areas and solve the access problem. So the federal government declared the crisis Journal of Health Care for the Poor and Underserved, Vol. 1, No. 1, Summer 1990 108______________Models for Increasing Access over, and dollars were withdrawn. As for facilities, a significant network of federally supported health centers was in place, so reduced funding meant pressure to increase productivity. Some valuable operational improvements were achieved, but the continued reduction in funds began to cut into programs and to compromise the effectiveness of this access safety net. The U.S. business community has become more and more unhappy with the costs of health insurance for its employees. State and local governments have been more stressed to fill the gap left by federal reductions in health, education, human services, housing, and an array of other programs, and the health status indicators of the population, especially certain segments of the population-the poor and minorities-continue to be an embarrassment. The drug epidemic and AIDS have catalyzed the crisis by putting more pressure on the most stressed institutions-urban teaching hospitals and public hospitals, and the most stressed populations-the poor and minorities. But AIDS and drugs are not unique to the poor. They affect mainstream Americans either directly or indirectly by drawing off resources from other, less critical public services or, as in New York, by pushing all hospitals into medical gridlock, where hospitals are at full capacity and have virtually no unoccupied beds. Further, the work of the President's AIDS Commission led to a rather public dissection of the U.S. health care delivery system and found it dominated by the acute-care hospital, and with inadequate resources and organization at the pre-hospital and post-hospital levels.1 Health policy makers and others began to ask why there were so few options for less intensive and less costly care for uninsured AIDS patients—questions relevant to all uninsured persons. Interest in national health insurance has been revitalized to the point where the issue is being discussed and debated (again) at large national meetings, though most people feel the United States will continue its incremental , sometimes patchwork approach to addressing its health care problems. So while the debate over comprehensive solutions continues, interim steps must be taken to address the continuing, severe access problem in certain areas of the country for certain vulnerable populations. This paper will review the current status...

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