Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, February 23, 1992 TAG: 9202240191
SECTION: EDITORIAL PAGE: D-3 EDITION: METRO
SOURCE: DONALD R. STERN, M.D.
DATELINE: LENGTH: Long
A MAZE OF A SYSTEM
HOW important is your health insurance to you? Those health-insurance and pharmacy cards in your wallet are resources that are foreign to families in poverty.Such families instead find themselves struggling through a complex system of categories, criteria and eligibility standards, and a maze of a health-care system that is piecemeal, fragmented and prejudiced against the poor. In many cases, the system is so difficult to access that many children go without basic health-care services; their disease conditions mature; and they end up in emergency rooms or hospitalized or dead.
At the national, state and local levels, we do not have a clear vision of what needs to be done, so there is no clear direction for use of limited resources.
Social problems lie at the heart of the nation's child-health performance. In Roanoke today, approximately 70 percent of the black live births are to single women, and approximately 25 percent of the white live births are to single women. The 24,000 divorces in Virginia last year involved 13,000 children. More and more, the "family" in poverty is a financially stressed single woman with children.
In 1991, the Children's Defense Fund reported that "poverty affects child health in two ways. First, poverty exposes children to living conditions that threaten their health. Inadequate housing, sanitation, food, and medical care all are associated with poverty and all have a major impact on child health. Secondly, poverty deprives families of the resources they need to cope with childhood illnesses and disability when it does strike."
In 1990, the National Center for Children in Poverty reported that poor parents face significant barriers to obtaining health care for their children. Major reasons include lack of health insurance, rising cost of job-related insurance, high cost of health care, restricted Medicaid coverage, decreasing participation in Medicaid by primary-care physicians and lack of services availability.
Part of the problem is connecting needs with resources. Federal resources are available to states in several programs whose ability to provide services has been inhibited by political compromise. A massive administrative structure has been built for each of these programs to keep people out who do not meet specific eligibility criteria. Any of us who are serious about meeting people's health-care needs find ourselves consuming additional health-care dollars struggling to get people into the system.
Health care for the poor is like an obstacle course. If the course is rigorous enough, competitors are unable to complete it. That's basically what our health-care system does to many children, and they opt out.
The Medicaid eligibility process alone is such a barrier that 50 percent of the children who may qualify in most states never make it through. This frequently means that kids go without basic health-care services until a condition reaches a level that the parent feels compelled to seek services regardless of cost.
They go to the emergency room, which ultimately costs us all a lot more than an ambulatory office visit would have cost. Also, a child's disease may have reached the point that more medical intervention and possibly hospitalization are required. We all pay the cost, whether it is through our tax dollars for Medicaid or increased health-insurance premiums due to increased hospital costs to offset indigent debt.
Part of the solution is local: using available resources in an effective, efficient manner.
There are some 22 pediatricians and 72 general/family practitioners in the Roanoke Valley. In Roanoke city, basic health care for indigent children is available through the city Department of Health. The city Health Department's School Health Program is another local initiative. It screens children for a variety of conditions and refer those with abnormal findings, yet only about 50 percent of those kids found with abnormalities have documentation of proper medical follow-up.
The Virginia Department of Health also manages a Child Development Clinic, and a Children's Specialty Services clinic under a different administrative structure.
The Roanoke Valley CHIP Program, which provides access to medical care by a private physician, case management and family-support services is a partnership with the Roanoke Health Department, Alleghany Health District, Total Action Against Poverty, the private medical community and Blue Cross/Blue Shield. It is a local idea started by local people, supported by local compassion and concern for children. Funding is from wherever we can get it, including foundations, "in-kind" support, and state, local and federal revenues.
The Bradley Free Clinic, another strategy to address the health-care needs of the poor, uses a different model for providing access to basic health care and is open four to six hours per week for clinic services. The Children's Medical Center at Community Hospital is another resource.
These programs are efforts to resolve the health-care system's deficiencies. They are not really changing the system, but are efforts to provide some basic health-care services and to channel kids to expert health-care providers when needed.
A system is needed that guarantees basic health-care services to all children. We need either to enhance these creative local efforts or to change the system itself - to eliminate the piecemeal fragmentation and eligibility obstacle-courses, with all their administrative overhead, and to provide universal access to health care for all children regardless of ability to pay.
The Governor's Task Force on Child Health has recommended enhancements to the current health-care system to improve children's access. This proposal looks similar to Roanoke CHIP Program, but the financial structure is unclear.
The Children's Defense Fund report noted above, a June 1991 Government Account Office report and a 1991 National Center for Children in Poverty report recommended universal coverage for personal health services, a national health plan that includes comprehensive health insurance for children.
Those concerned about rationed health care in a national system must recognize that we are already rationing health care. It is not based on need or efficiency or effectiveness. It's based on the ability to pay.
Donald R. Stern, M.D. is health director of the Roanoke Health Department.