Dr. Martin Luther King Jr.

The injustice described by Martin Luther King Jr. still exists in the U.S. health care system and is most evident in the nation's inner cities. The fundamental problems that beset the U.S. health care system-problems of cost, quality, and access-are not qualitatively different in inner cities but vary in intensity and scope. Similarly, current trends in health care are systemwide and are more difficult to accommodate in inner cities, where resources are already scarce and stresses to the system are becoming critical. As the gap between rich and poor in the United States continues to grow [1] and financial support of the poor by the public sector is curtailed, the American College of Physicians seeks to highlight directions and innovations for public policy on inner-city health care with renewed determination that health care problems in the United States must be solved, especially in cities, where they are most extreme.

Because of its concern for the growing problems in inner-city health care, the College commissioned Dennis P. Andrulis, PhD, to write a paper on this topic [2]. Andrulis is president of the National Public Health and Hospital Institute, whose research and education mission has focused on public hospitals, safety-net organizations, and underserved communities. Whereas an earlier paper described the serious problems of the underserved population in U.S. rural areas [3], this position paper highlights selected findings from Andrulis's report and contains specific recommendations and steps of action for the American College of Physicians.

Andrulis's in-depth review of the health status of inner-city residents documents the extreme health problems in the inner city and the inability of the health care system to provide the care that is needed. This assessment questions the will of society to address the underlying causes of poor health in inner-city residents. Poor health is often a symptom of living in poverty [4, 5]. Physicians treat patients' symptoms, but not before diagnosing the disease that causes the symptom. Similarly, we must find ways to improve delivery of health care in the inner cities while addressing the underlying causes of poor health, such as poverty, homelessness, and violence.

The health problems most commonly associated with inner cities-violence, teenage pregnancy, drug abuse, and human immunodeficiency virus (HIV) infection-do not tell the entire story. Patients who have chronic illnesses, such as tuberculosis, asthma, and diabetes (conditions that respond to the provision of primary care), also present major health care challenges. Such varied health problems require broad solutions, from prevention to primary care services to subspecialty and short-term inpatient care.

As the appropriate role of government is debated in an era of scarce resources, the future of the inner cities must not be overlooked. More than 1 in 5 of persons in the United States live in the nation's 100 largest cities. The health care infrastructure in the inner cities often serves both urban residents and citizens in nearby suburbs. The fate of the inner cities is therefore inseparable from the life of the nation.

Health Status of Inner-City Residents

The term urban health penalty describes the conditions that exist when healthier, more affluent persons leave the city and the remaining and new residents experience health problems that interact with the city's physical and economic deterioration. The poverty zones created by this deterioration, which include proportionately higher numbers of persons belonging to minority groups, become epicenters for economic decline, job loss, and major health problems [6]. Urban health problems arise from the complex interaction of socioeconomic factors, behavior, environment, and disease that is related to race and ethnicity. The medical model is inadequate in the urban environment; multifaceted approaches are needed. Andrulis's literature review summarizes the disturbing statistics on the extremely high incidence and prevalence of illness and death in the inner cities. The following list of diseases and conditions is not exhaustive but conveys the breadth of chronic and acute illness and environmental factors that, when combined, greatly affect persons living in the inner cities: tuberculosis, asthma, diabetes, renal disease, cardiovascular disease, hypertension, mental illness, cancer, the acquired immunodeficiency syndrome (AIDS), HIV infection, sexually transmitted disease, infant mortality, trauma caused by violence, and substance abuse [7, 8].

Some of these diseases and conditions are associated with poverty and are characterized by poor nutrition, inadequate and unsafe housing, exposure to violence, and lack of a social services infrastructure. Most illnesses in the inner city, such as diabetes, hypertension, and congestive heart failure, can be classified as ambulatory care-sensitive conditions. One recent study [9] found major differences in the rates of preventable hospital admissions for these conditions between low- and high-income areas. High rates of preventable hospital admissions can indicate serious access or performance problems. In this study, disparities between high- and low-income areas were identified in almost all U.S. cities. These results contrasted with those found in cities in Ontario, Canada, where "the relationship between area income and admission rates for ambulatory care sensitive conditions almost disappears" [9]. The authors concluded that universal coverage and lower levels of poverty in Canada limit preventable hospitalizations. Additional research that investigates health status in the inner cities and evaluates the effects of race, socioeconomic status, and other factors is greatly needed.

Another recent study [10] showed that even with universal coverage through Medicare for persons who are 65 years of age or older, race and income substantially affect mortality and use of services. Gornick and colleagues [10] found that:

"Black beneficiaries and low-income beneficiaries (white and black) have fewer visits to physicians for ambulatory care, fewer mammograms, and fewer immunizations against influenza but are hospitalized more often and have higher mortality rates (as is consistent with the relations between income and mortality in the U.S. population 25 to 64 years of age). These patterns suggest that these two groups of beneficiaries may be receiving less primary care and preventive care than either white or more affluent beneficiaries. In addition, blacks and lower-income white beneficiaries have higher rates of amputation of all or part of the lower limb and bilateral orchiectomy. This suggests that these groups of beneficiaries are at higher risk for procedures associated with less than optimal management of chronic disease."

Gornick and colleagues concluded that although Medicare was necessary to provide access to care for elderly persons, "the differential patterns of use of many specific services according to race and income indicate that the provision of health insurance alone does not suffice to promote effective patterns of use by all beneficiaries" [10].

Broad health indices in the inner cities, such as mortality rate, infant mortality rate, and overall life expectancy, remain major public health issues as well as matters of social and racial inequality. The alarming conclusions in the study by McCord and Freeman on the health status of residents in the New York City community of Harlem [11] are consistent with those drawn in studies of other impoverished areas in the United States. Mortality rates for persons between the ages of 5 and 65 years were higher in Harlem than in Bangladesh, which is categorized by the World Bank as having one of the lowest incomes in the world. In men, the rate of survival beyond the age of 40 years is lower in Harlem than in Bangladesh. A decline in the infant mortality rate was more than offset by increasing mortality rates for persons between the ages of 15 and 65 years. The high mortality rates in Harlem were attributed to cardiovascular disease, diabetes, pneumonia, influenza, homicide, drug dependency, and cirrhosis.

Health problems must be resolved within a comprehensive urban policy that addresses the root causes of poverty. The medical model alone is woefully inadequate in the inner city.

Comprehensive Public-Private Urban Initiative

To improve the health of inner-city residents, we must recognize the strong link between health status and socioeconomic factors and develop strategies to correct the underlying causes of disease. In addition, we should improve the delivery of health care to persons in the inner cities. These health care improvements must address three broad areas: coverage, providers, and public health. We must address current problems, such as inadequate housing, unemployment, lack of child care, environmental pollution, and violence. The American College of Physicians calls for a comprehensive urban partnership initiative to address all aspects of the urban penalty-social, economic, and health-related-and recommends solutions to be achieved through public-private collaborations that can be adapted to the circumstances of each community.

The urban partnership initiative must address health in the broadest sense and must emphasize prevention and primary care to eliminate the social health problems that bring persons into the health care system. The national initiative will identify new and existing federal resources that can be leveraged to target assistance to localities. It will provide guidance to states in establishing partnerships with cities to address the problems of their most distressed areas. The partnership must extend beyond government to include business and diverse citizen organizations. The initiatives would address governance (for example, urban-county mergers) and economic and social issues. Major issues to be addressed include creating employment opportunities for perpetually unemployed persons, including but not limited to welfare recipients, and providing the education, training, child care, and health coverage needed to generate lasting employment.

A package of proposals, some requiring legislation, is needed to provide a blueprint that states and cities can use to work with the private and volunteer sectors on a comprehensive strategy to meet the needs of distressed urban communities. This package can be developed by appointing a presidential commission that represents a broad cross-section of leaders from business, government, and nonprofit organizations, including foundations and religious and community groups.

The specific recommendations of the College will focus on concerns about health care issues and not the broader economic and social issues that extend beyond our organization's expertise. We will offer principles to guide the urban partnership initiative and make recommendations about the issues of coverage, providers, and public health.

Coverage

Steps should be taken now toward implementing universal coverage-a vital element in a healthy community-that targets inner-city residents. The Medicaid safety net must continue to guarantee eligibility to our most vulnerable populations [12-14].

Providers

Programs beyond universal insurance coverage should be developed to solve the health problems of the urban poor. Continuous access to appropriate primary care providers and other specialists in cost-effective settings must replace the model that is most frequently found in the inner city; this model is characterized by "hospital-dependent, crisis-oriented, episodic and fragmented" care (Thomson GE. Health care in underserved urban America: Implications for national health reform [Presented paper]. Proceedings from a conference sponsored by Columbia University; New York; 1993).

A major failing of the system that delivers health care to the urban poor is the dearth of appropriate health care providers. On a national level, fewer physicians are providing care in urban areas. A study [15] of 10 urban areas between 1963 and 1980 found a 45% decline in the availability of office-based primary care in poverty-stricken areas.

To address the dearth of providers in the inner city, the College recommends the following measures.

1. Leverage all appropriate government and institutional resources to produce an adequate number of primary care physicians and other providers who are willing to practice in underserved inner-city areas [16].

2. Create incentives to change medical school recruitment and education and residency training. Medical school recruitment policies, curricula, and clerkship programs must be retooled to address the health needs of inner-city residents. Medical schools must accelerate recruitment of qualified members of minority groups, especially black and Hispanic persons, and must make changes in curricula that expose students to delivery of health care in the inner city [17].

3. Provide substantial fiscal incentives to attract individual providers to inner-city locations.

4. Deploy financial incentives and technical assistance to safety net providers who are being squeezed by reductions in public funding and competition for insured patients that have been brought on by the changing health care marketplace [18].

5. During a transitional period, require managed care organizations to contract with essential community providers (for example, those who serve low-income populations, such as community health centers) if the managed care organizations are serving persons in underserved, inner-city locations and are financed in whole or in part with federal funds.

6. Carefully scrutinize in advance all mergers, buyouts, and conversions involving nonprofit hospitals and insurance plans by an objective representative of the public (for example, the state attorney general or an insurance commissioner) to evaluate potential effect on the communities served by these nonprofit organizations. Community participation and vigilance are necessary to ensure that charitable resources remain dedicated to maintaining the well-being of the community [19].

Public Health Initiatives and Community Involvement

Inner cities are greatly affected by many of the nation's most critical public health problems: tobacco, abuse of drugs and alcohol, teenage pregnancy, and violence. The most promising solution to these problems lies in prevention and education, and important roles must be played by the government, health care providers, communities, and individuals. The following are the College's recommendations for addressing these problems.

Tobacco

The College strongly supports the regulation of tobacco as a drug by the U.S. Food and Drug Administration and initiatives to regulate tobacco sales and advertising to minors.

Drug and Alcohol Abuse

The College strongly recommends the continuation of federal programs that support biomedical research, prevention, and treatment related to mental health and alcohol and substance abuse. Research and block grants given to states for mental health and substance abuse and treatment should be evaluated for their applicability and responsiveness to inner-city drug problems.

Teenage Pregnancy

The College supports community- and school-based programs that address the growing social and economic consequences of teenage pregnancy, which is a cause for concern both nationally and in the inner city. Support should be increased for federal, state, and local family-planning grants that provide important educational and clinical services.

Violence

The American College of Physicians reaffirms its call for legislative and regulatory measures to limit the availability of firearms, including restrictions on the sale and possession of handguns and legislation to ban the sale, possession, and manufacture of all automatic and semiautomatic assault weapons for civilian use. (American College of Physicians. Firearm injury prevention. In preparation.) The College encourages its members and other physicians to educate themselves about the clinical signs of domestic and other forms of violence and to educate their patients about the dangers of possessing firearms and about reducing the risk for injury. Coordinated, community-wide efforts on violence prevention should involve hospital emergency departments, local law enforcement agencies, schools, and individual physicians.

Short-Term Improvements to Existing Programs

Medicaid issues will be debated in the 105th Congress because of the pressure to reduce federal and state funding and to transfer power to the states. The dramatic changes made to welfare programs in 1996, which ended the guarantee of benefits after decades of providing it, will affect Medicaid coverage for thousands of recipients, especially immigrants, many of whom reside in inner cities. We must be vigilant in advocacy for Medicaid to guarantee coverage and make improvements that ensure quality care for persons of greatest need in our underserved urban locations.

Medicaid Improvements for the Inner City

Medicaid reform presents unique challenges in the inner-city environment. Medicaid-managed care has been introduced in urban environments through Section 1115 waivers; the results have been mixed and have provided some valuable experience to apply in other states. (Section 1115 of the Social Security Act authorizes research and demonstration projects related to Medicaid and other federal programs and has been generally used by the states to expand eligibility to low-income and uninsurable populations through savings from Medicaid-managed care plans. Section 1915[b], another waiver authority, is drawn more narrowly and is used by states to restrict the providers from whom a recipient receives Medicaid services. Managed care programs can be set up under Section 1915[b] but cannot apply to populations that do not receive Medicaid.)

Statewide oversight of managed care organizations has often been inadequate for both the broad issues of quality and availability of care and the more narrowly drawn issues related to marketing and enrollment abuses. Many commercial managed care organizations are not experienced in providing services to low-income populations. In contrast, community providers, such as departments of public health and community health centers, have experience with providing outreach services, patient education, transportation, and multilingual services. The successful expansion of managed care in the inner city requires effective collaboration between managed care organizations that have expertise in financial information systems and community providers who have clinical and outreach expertise.

Some federal standards governing the expansion of managed care through Section 1115 waivers and other programs should uniformly apply to all plans, regardless of whether they serve beneficiaries in inner cities. These standards include requirements for a basic benefits package, financial solvency, adequate numbers and types of providers, actuarially sound capitation rates, and other quality features. In the inner city, special needs and conditions exist that necessitate additions or modifications. The College makes the following recommendations for federal standards.

1. Require managed care organizations to provide special services that are essential in inner-city environments, such as primary care services that are geographically accessible (providing transportation when necessary), after-hours availability of primary and urgent care, outreach services, and self-care education. Managed care organizations must have linguistic and cultural competence and must be able to coordinate interaction with other social services, such as nutrition programs. Capitation rates would reflect the additional cost of providing specialized services and the savings from reduced emergency department and other hospital costs.

2. Restrict direct marketing and encourage enrollment and education through independent brokers to eliminate "cherrypicking" and to provide objective information, thereby enabling enrollees to choose the health plans that meet their health care needs.

3. Provide case management for persons with HIV infection, AIDS, or other serious illnesses.

4. Include risk-adjustment mechanisms to protect plans with a higher-than-expected number of patients who have HIV infection, AIDS, or other costly diseases and conditions.

Consideration of the Medicaid issue, first linked in legislation with welfare, was postponed until the 105th Congress, despite the direct effect of insurance coverage on the transition from welfare to employment. Because the jobs that are filled by persons moving from welfare to employment are unlikely to provide insurance, the next phase of welfare and Medicaid reform must address ways to maintain insurance coverage during this transition.

Implications of Welfare Reform for Inner-City Health Care

The recently enacted welfare reform bill, designed to "end welfare as we know it," saves $16 billion per year in federal funds. By converting Aid to Families with Dependent Children to a block grant called Temporary Assistance to Needy Families, enrollment and eligibility of the current Aid to Families with Dependent Children and Supplemental Security Income populations are limited. Funds for the food stamp program also are reduced. Consistent criticisms of the welfare reform effort have been that inadequate attention has been paid to the creation of jobs and the provision of child care and that cutbacks will increase the number of poor persons. A recent Urban Institute analysis [20] estimates that 2.6 million more persons will fall below the poverty line, including 1.1 million children, as a result of this legislation. Even when more positive assumptions about how many welfare recipients will find employment after their benefits are eliminated are used, the number of persons who will eventually live in poverty is not dramatically changed because many of the jobs will pay below-poverty wages.

Because poverty is so strongly linked with poor health status, the effect of welfare reform on poverty is of great concern to the College. The College strongly encourages Congress to carefully monitor the effect of welfare reform and to make mid-course corrections if adequate jobs are not available and poverty increases. We support the elimination of fraud and abuse in the food stamp program but believe that nutrition programs, especially those targeted to children, are essential components of the safety net for the urban poor. As an adjunct to the proposal to provide a tax credit for employers who hire welfare beneficiaries, additional incentives should be created for employers to provide jobs with health care coverage.

Conclusions

At a conference in the summer of 1993, when health care reform was still alive, Gerald E. Thomson, MD, now immediate past president of the College, said that "With all the advances in science, technology, and the care of patients, the health of people living in our nation's inner-city areas is extraordinarily poor. ... It tears at our consciences and is a source of national and international disgrace." (Thomson GE. Health care in underserved urban America: implications for national health reform [Presented paper]. Proceedings from a conference sponsored by Columbia University; New York; 1993.) Since then, the most modest efforts at health care reform have been extraordinarily difficult to achieve and none has been targeted to help underserved persons in U.S. cities. Reductions in federal funding mean that states and localities have more responsibility for the ever-increasing needs of their most vulnerable citizens. Individual persons and communities are being asked to provide more services than are feasible. The American College of Physicians believes that that the problems of inner-city health care and the contributing social and economic disparities must be returned to the national agenda. A positive, first step toward that goal would be to begin bipartisan discussions on how to structure that debate. We offer the framework of the urban partnership initiative-a comprehensive public-private collaboration to address all aspects of the urban penalty-as a starting point for developing solutions to inner-city problems.