Cities and the Health of the Public

5. Access to High-Quality Health Care in U.S. Cities: Balancing Community Need and Service System Survival

85 5 Access to High-Quality Health Care in U.S. Cities Balancing Community Need and Service System Survival Dennis P. Andrulis Introduction For decades, health care in the urban United States has been a study in contrasts. Hospitals in many U.S. cities are renowned for providing the best quality of care in the world. The term centers of excellence has come to represent mostly urbanbased academic medical centers and other facilities that have developed a reputation for providing emergency services, trauma care, and complex specialty care. These service settings are the providers for many privately insured individuals from within and beyond urban borders. This portrait of access and quality, however, does not extend as broadly for the uninsured, underinsured, Medicaid recipients, many racially and ethnically diverse urban communities, immigrants, and other vulnerable populations. For these residents, responsibility for care in the nation’s cities falls primarily on a smaller, dedicated but frequently fragmented and financially fragile group of providers: public hospitals, community health centers, clinics, health departments and others that, by mission or mandate, constitute the urban “safety net” for health care. Both residents and these providers face a complex set of challenges perpetuated and exacerbated by the consequences of inadequate support, entrenched health problems, and limited access to high-quality health care. These conditions are set in the broader context of other pressing issues, such as the cost of care, including prescription drug costs, which represented 11% of all health expenditures in 2003,1 and the ever-expanding arsenal of new and expensive medical procedures; competitive pressures from managed care to slow the growth rate of health care costs; and overall increases in uncompensated care, which rose from $18.5 billion to $21.6 billion between 1997 and 2000.2 Adding to these well-recognized concerns are new uncertainties, such as capacity to respond to threats of bioterrorism. 86 Part II: Determinants of Health in Cities This chapter presents and discusses the circumstances, challenges, and needs facing the most vulnerable urban residents and the providers they rely on for care. The next section describes the characteristics of urban residents most likely to rely on the safety net services. It is followed by a description of the urban health care safety net. The fourth section identifies the challenges to access and quality of care facing vulnerable urban populations and is followed by a discussion of the pressures and forces affecting the current and future prospects of urban safety-net providers. A concluding section identifies efforts and proposes directions to insure the viability of these providers in the nation’s cities. While U.S.-focused, many of these experiences are likely to have similar implications and applications for other nations and their cities. Health Needs of Vulnerable Residents in Cities and Reliance on Safety-Net Providers The ecology of urban communities and the scope of challenges to health and health care frequently set them apart from suburban and rural areas. As a result an “urban health penalty” defines many central cities, with poverty, disease, and mortality rates well above the averages for the country. The elements that comprise “pathologies” confronting daily urban life also set the context for the challenges facing health care providers who make up the community’s safety net. The scope of vulnerable populations that are dependent on the urban health care safety net is extensive. Those with conditions or circumstances that may be seen financially or by patient profile as “less desirable” to other providers includes those with certain diseases and health conditions, low income, neglected care, and complex community concerns.3 Thus, individuals with alcohol or other drug addiction; patients with tuberculosis, HIV, or sexually transmitted diseases; and victims of violent crime, domestic abuse, or homelessness are typically very dependent on safety net institutions. Others suffer from classic inner-city problems, such as lead poisoning, carcinogens related to environmental toxins, and related conditions exacerbating asthma. Rates of diabetes, cancer, and heart disease are higher as well.4, 5, 6 The primary reasons for dependency on safety net institutions are lack of health insurance and poverty. Individuals likely to be affected include such diverse populations as the employed (especially those in low-wage positions), the un­ employed, immigrants and native residents, older individuals, those from diverse racial or ethnic heritage, and children.7, 8 In 2003, almost 45 million Americans were uninsured, an increase of 5 million since 2000. More than one-third of the poor are uninsured,9 a status that affects a larger...