Continued increases in the numbers of uninsured US citizens, increasing premiums for those who are insured, and the debate over prescription drug coverage all have served to thrust the issue of access to health care on the national radar screen once again. Since the goal of universal health insurance seems less and less likely to be realized in the near future, much of the discussion has focused on the so-called safety net, which is the loosely knit health system that cares for those outside the traditional health care marketplace, who are primarily poor and uninsured. The mere existence of the safety net, let alone our nation's dependence on it, is evidence that the market does not distribute health care in a socially equitable manner. This often ad hoc (and unheralded) system is expected to provide access to care in geographically underserved areas and to address other barriers to care, such as social and cultural factors. With the increasingly diverse US population, additional factors include whether the patient and clinician can communicate in the same language and whether they understand and are comfortable with each other's cultures. Because of the intrinsic links among access to care, quality, and outcomes, the safety net ideally should go beyond simply providing access to provide high-quality care to those it serves. The safety net functions against a backdrop of uninsurance and underinsurance and the inability of many who need care to pay for it. These problems are not distributed evenly across the population. Rural residents are more likely than those living in metropolitan areas to be uninsured.1 Furthermore, recent increases in rates of uninsurance have affected population groups differentially. Between 1994 and 1998, the number of uninsured whites increased by 3.4% while the number of uninsured blacks and Hispanics increased by 17.4% and 21.5%, respectively.2 In addition to its shortcomings in providing affordable access to care, the market has been unsuccessful in distributing health care professionals to geographic areas according to need. Federal efforts, through community health centers and the National Health Service Corps (NHSC), have helped mitigate these market failures. In this issue of THE JOURNAL, Pathman and colleagues3 present national data about the extent of nonfederal efforts to improve the distribution of the clinician workforce. They found that in 1996, 41 states had scholarship or loan repayment programs or other mechanisms to encourage medical practice in geographically underserved areas. They report that the combined number of clinicians who practice in underserved areas as a result of such programs is at least equal to that of the federal government's NHSC. While the growth of such programs is undoubtedly a positive development, it must be put into context. The NHSC addresses only a small fraction of the unmet need, and even doubling that effort by adding those practitioners recruited by state programs still results in an inadequate number of practitioners needed for underserved areas. Indeed, the NHSC estimates the unmet need for clinicians at roughly 18,000,4 even after accounting for the practitioners identified in the study by Pathman et al. Even if the safety net had an optimal geographic distribution of health care providers, concerns about its long-term viability would remain. The Institute of Medicine5 recently identified 3 major factors that will hinder the ability of clinicians within the safety net to deliver high-quality care. First, these clinicians are likely to be disproportionately affected by the growing numbers of uninsured persons. Second, traditional subsidies that helped finance the safety net are eroding. Third, the rapid shift to Medicaid managed care has had adverse consequences for many providers within the safety net. While there is no direct evidence that the clinicians in programs studied by Pathman et al do, in fact, care for uninsured patients, it is well recognized that the areas in which they practice are more likely to have higher rates of uninsurance, so the demand to provide uncompensated or undercompensated care is likely to be greater than it is for other practitioners. If, in addition, the institutions that support these clinicians are increasingly under fiscal stress, their ability to develop or sustain an infrastructure to provide high-quality care is also threatened. Beyond geographic distribution, social and cultural factors also have long been recognized as critical components of access to care. Sex, language, and race/ethnicity are all recognized as important factors in this regard. Women's preferences for female physicians6 and the challenges of recruiting female clinicians to underserved areas are well documented.7 On another front, increasing evidence about health disparities points to differential treatment of minority patients in the health care system,8 many of whom live in rural and urban underserved areas that are dependent on the safety net. Many areas contain large ethnic populations that are unable to communicate in English and have poorly understood health care beliefs that affect health care access and quality. Pathman et al do not describe the sex or ethnic composition of clinicians recruited to practice in state-sponsored safety net programs; to what extent there is concordance between clinicians and the populations they serve is not clear. However, such factors are increasingly understood to be important for patient satisfaction and health outcomes.9, 10 From a policy perspective, it is critical to remember that the safety net is important not only to those who lack access to care, but also to the United States in general. For example, most uninsured persons are employed and constitute a workforce whose health and well-being is vital to US economic health. Furthermore, safety-net providers, supported by federal, state, and local resources, keep children immunized, enable adults to take care of their young children as well as their aging parents, treat and prevent the spread of infectious diseases, provide oral health and mental health services, and thus contribute to maintaining a strong social fabric. While not everyone is a direct user of safety-net services, the benefits of the safety net affect a range of groups and interests, including both the public and private sectors. Pathman et al3 focus on 2 of the major players state and federal governments and illustrate well how state initiatives can expand federal efforts to increase access. Such efforts are not limited to workforce policy and can be used to address multiple dimensions of access. State and local initiatives already expand access through providing health insurance to certain populations, the most notable being the State Children's Health Insurance Programs.11 States and local communities can and often do take matters into their own hands, and further approach the ideal of universal health care coverage.12 Some make insurance available and affordable to adults and families who have income above the limits for state programs and Medicaid. Others have formed networks of providers who will guarantee care for anyone who is uninsured or have used tax levies to fund universal coverage. State and local governments can complement federal efforts by creating revenue sources and encouraging partnerships to support an even wider range of activities to strengthen the safety net. In addition to leveraging policy opportunities to expand coverage and care, state and local governments also can expand their roles in influencing the nature of the health professions workforce. The number of minority medical school graduates remains far behind their representation in the overall population.13 The dramatic decline in minority medical school applicants over the past few years14 suggests that this is another area in which the health care market has fallen short, requiring new approaches and new solutions. In addition to leveraging federal efforts to promote cultural competence15 and language access,16 states and local communities also can take steps to ensure that their clinician workforce reflects the ethnic characteristics of their populations. This will require a variety of creative mechanisms including recruitment of existing practitioners, development and support of diverse applicants to health professions schools, and reexamination of medical school admissions policies to shape a workforce that meets population needs. Policy efforts also must strengthen the ability of safety-net practitioners to provide high-quality care. Many safety-net clinicians work in struggling practices that cannot afford the investment in infrastructure, such as information systems and distance technology, that can facilitate quality-improvement activities. The Community Access Program (CAP)17 is a new federal program designed to strengthen the safety net by providing resources (such as developing information systems or creating language access programs) to better integrate networks of safety-net clinicians in communities around the country. The US Department of Health and Human Services (DHHS) has received more than 200 applications for CAP and has awarded 23 grants, a testament to the level of need and interest in strengthening the safety net. The total CAP budget is $25 million for 2001, and the DHHS hopes to expand the program in the future. State and local initiatives that support similar efforts can be important complements. Finally, Pathman et al appropriately call for a mechanism to monitor programs that expand the workforce for underserved communities. This call is similar to a broader recommendation by the Institute of Medicine to do the same,5 not just for the workforce, but for all components of the safety net. Until universal access to health care in the United States becomes a reality, such an endeavor will be critical for understanding how best to strengthen and support the safety net on behalf of the entire US population. Author/Article Information Author Affiliation: US Department of Health and Human Services, Washington, DC. Corresponding Author and Reprints: Nicole Lurie, MD, MSPH, US Department of Health and Human Services, 200 Independence Ave SW, Room 716-G, Washington, DC 20201. Disclaimer: The views expressed in this article are those of the author and do not necessarily reflect those of the US Department of Health and Human Services.
REFERENCES
1. Rhoades J, Brown E, Vistnes J. Health Insurance Status of the Civilian Noninstitutionalized Population: 1998. Rockville, Md: Agency for Healthcare Research and Quality; 2000. AHRQ publication 00-0023. Also available at: http://www.meps.ahrq.gov/publicat.htm . Accessed September 26, 2000.
2. Holahan J, Kim J. Why does the number of uninsured Americans continue to grow? Health Aff (Millwood). 2000;19:188-196. MEDLINE
3. Pathman DE, Taylor DH Jr, Konrad TR, et al. State scholarship, loan forgiveness, and related programs: the unheralded safety net. JAMA. 2000;284:2084-2092. ABSTRACT | FULL TEXT | PDF | MEDLINE
4. Department of Health and Human Services. Selected Statistics on Health Professional Shortage Areas as of June 30, 2000. Rockville, Md: Health Resources and Services Administration; 2000.
5. Lewin ME, ed, Altman S, ed. America's Health Care Safety Net, Intact but Endangered. Washington, DC: National Academy Press; 2000.
6. Lurie N, Margolis KL, McGovern PG, et al. Why do patients of female physicians have higher rates of breast and cervical cancer screening? J Gen Intern Med. 1997;12:34-43. MEDLINE
7. Council on Graduate Medical Education. Tenth Report: Physician Distribution and Health Care Challenges in Rural and Inner-City Areas. Rockville, Md: Public Health Service, Health Resources and Services Administration; 1998.
8. Mayberry RM, Mili F, Vaid IGM, et al. Racial and ethnic difference in access to medical care: a synthesis of the literature. Kaiser J Family Foundation. October 1999. Available at: http://www.kff.org/content/1999/1526. Accessed September 28, 2000.
9. Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Aff (Millwood). 2000;19:76-83. MEDLINE
10. Cooper-Patrick L, Gallo JJ, Gonzalez JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583-589. ABSTRACT | FULL TEXT | PDF | MEDLINE
11. The State Children's Health Insurance Program Annual Enrollment Report, October 1, 1998-September 30, 1999. Washington, DC: Health Care Financing Administration; 1999.
12. Health Resources and Services Administration. Visioning the Future in Primary Health Care. Available at: http://www.bphc.hrsa.gov/campaign/visionfuture.htm . Accessed September 27, 2000.
13. Association of American Medical Colleges, Division of Community and Minority Programs. Minority Graduates of U.S. Medical Colleges 1950-1998, Trends. 2000. Available at: http://www.aamc.org/newsroom/reporter/march2000/minority.htm . Accessed September 28, 2000.
14. Barzansky B, Jonas HS, Etzel SI. Educational programs in US medical schools, 1999-2000. JAMA. 2000;284:1114-1120. ABSTRACT | FULL TEXT | PDF | MEDLINE
15. Closing the Gap. Office of Minority Health, Department of Health and Human Services. Available at: http://www.omhrc.gov/omh/sidebar/archivedctg.htm . Accessed September 28, 2000.
16. Prohibition against national origin discrimination-persons with limited-english proficiency.. 65 Federal Register. 52762 (2000).
17. Community Access Program (CAP). Available at: http://www.hrsa.gov/CAP/FAQs.htm . Accessed September 26, 2000.
Obligations and the Potential for Indifference and Increased Health Costs