PRESEENT'S COLUMN ACCESS TO HEALTH CARE I AMERICA Charles Johnson President, National Medical Association Durham, North Carolina INTRODUCTION It is a privilege, pleasure, and honor for me to be here with you this morning in commemoration of Dr Martin Luther King's birthday. As President of the National Medical Association (NMA), I am here on behalf of an organization that was founded in 1895 in Atlanta, Georgia and is the oldest existing black American professional asociation in the United States. The NMA represents over 16 000 physicians residing in all of the 50 United States as well as the Virgin Islands and Puerto Rico, who are among the primary health care providers to the medically underserved and minority populations. It occurred to me that the reason I was invited to speak to this august audience was for many reasons. The two cogent ones are: first, because I am a black male and second, because next to the military budget, health care is the second largest expense to our nation. Let me point out early on that the NMA was actively supportive of Dr King's dreams and philosophies of nonviolent solutions to the problems which beset the country and blacks in particular. We, in the NMA, recognize that Dr King's dream, "that someday we would be judged by the content of our character instead of by the content of the melanin in our skin" is still an unrealized portion of his dream. The NMA and all blacks in this country have finally come to the realization that we will have to be responsible for our own destiny and to no longer believe or depend on empty phrases and empty promises from others. The members of NMA recognize, as Dr King and other black leaders have come to recognize, that class subjugation via poverty, ghettos, lack of education, unemployment, food, clothing, shelter, and the dissolution of black families has led to most of today's chaos in our cities. This chaos has manifested itself as an increase From Duke University Medical Center, Durham, North Carolina. Delivered at the Martin Luther King Interdenominational Prayer Breakfast, Raleigh, North Carolina, January 21, 1991. Requests for reprints should be addressed to Dr Charles Johnson, Duke University Medical Center Bakerhouse, Room 281, Duke South, PO Box 3217, Durham, NC 27710. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
in homicides, drug and substance abuse, teenage pregnancies, AIDS, and other sexually transmitted diseases. We in the NMA also recognize that there is no way to remedy socially derived diseases with medications alone. That is to say that the majority of our society will eventually have to come to grips with reality. The majority of our society must recognize that it can no longer continue to ignore and postpone acting on outstanding social problems. The majority of our society must come to recognize that increasing the number of police, judges, and prisons will only lead to further imprisonment of each of us and not the criminals. It must be apparent to each of you in the audience that as more violence erupts in our cities, more bars appear on our windows and double locks on our doors. It is an established truism that injustice anywhere is injustice everywhere. Where there is no justice, there is anarchy, and we are headed in that direction if we do not begin addressing the serious injustices that continue to run rampant throughout our nation. Also remember that it is infinitely cheaper to educate and provide basic health care to every American citizen than to maintain prisoners and prison systems. The NMA recognized among its founding objectives that the nurturing of the growth and diffusion of medical knowledge and the prompt universal delivery of this knowledge to all people by means of an adequate universal health care delivery system was going to be a necessity if all citizens were to have access to health care. We are dedicated to improving the health care status of all Americans, and we are especially concerned about the plight of the poor and minority populations in this country. In the early 1960s, Dr King was and continues to remain a symbol and martyr of our American civil rights movement. Today, however, another challenge awaits us nearly 30 years later. The challenge is just as insidious as those for which Dr King died. The new challenge is to ensure that all Americans have the right and access to quality health care regardless of race or economic status.
BACKGROUND The NMA primary care providers are painfully aware 197
of the disparity between the health status of uninsured and underinsured minority populations in comparison to the general population of this nation. We view first hand disproportionately higher rates of infant mortality, cancer, heart disease, AIDS, and other diseases, particularly among the indigent segment of the minority community. In 1985, the Report of the Secretary's Task Force on Black and Minority Health (better known as the Heckler Report) indicated that 60 000 excess deaths among blacks and minorities could have been prevented if they had received health care received by most nonminorities The National Institutes of Health in November 1990 brought forth statistical data to show that the lifespan for blacks had continued to decrease despite the lengthening lifespan for the majority population. Health care must become more accessible in both costs and availability to all citizens in this great nation. Let me point out to you that the NMA was the only national medical group to support the establishment of Medicare in 1965 which was signed into law by President Lyndon B. Johnson. The other national medical groups did not initially support Medicare and still do not have plans to make health care accessible to all Americans. The cost of health care continues to rise three times faster than the consumer price index. Last year health care costs consumed $600 to $650 billionapproximately 12% of the gross national product (GNP). Other countries, however, have stabilized the share of their GNP spent on health care while the pace of the United States' health care costs has accelerated in recent years. Inflation, adjusted by per capita spending, for health care grew by 4% per year from 1970 to 1980, and by 4.6% per year from 1980 to 1986. The Health Care Financing Administration estimates that health care costs will reach 15% of the GNP by the year 2000, which translates into approximately $1.5 trillion, a number that most of us would find difficult to write and even nore difficult to pay. According to the Bureau of Labor Statistics, 1 million Americans annually lose their health insurance. It is estimated that 37 million Americans have no insurance-one third or more than 12 million of them are children. These 37 million Americans represent a segment of our population that has increased by 25% since 1980. An additional 26 million Americans will have no insurance for substantial periods of time. There are also 60 million Americans who have inadequate insurance to fully accommodate their needs. Those of us today who are adequately insured during a recession and an uncertain economic future may only be a heartbeat from losing our coverage, or alternatively, if 198
we had to be admitted to the hospital for a long period of time, our entire economic status would be easily destroyed. Virtually all Americans are at risk; however, it is the low- and middle-income families who are subject to the greatest threat. The numbers of underinsured and uninsured are unfortunately expected to increase during the 1990s as employers struggle to curb skyrocketing medical costs is by reducing staff and cutting benefits. Let me say again that the middle class has and continues to be disenfranchised from health care by what in economic terms in called "cost shifting," which really means that the way health care institutions recoup their red-ink losses is by increasing the premiums to the middle class. Both the middle class and corporate America are now rebelling because the cost of health care has gotten completely out of control. Some reasons for increases in the underinsured and uninsured population can be attributed to Medicaid's failure to keep pace with the number of people below the poverty level, and high unemployment during the Reagan era, as well as the current recession, followed by shifts in employment away from manufacturing to low-paying service sector jobs. The growth in the number of small businesses, which frequently do not provide adequate insurance, along with the part-time workers who generally do not receive any insurance, also contributes to the increase in the uninsured population. While nearly all the uninsured are poor, not all are poor enough to qualify for Medicaid. Today, Medicaid covers only 45% of those below the poverty line, compared with 66% a decade ago. The health care economy is inflationary because it is dominated by fee-for-service payment of doctors and hospitals by third-party intermediaries with what are generally perceived to be open-ended sources of finance. A fee-for-service system does not allow a budget to be set in advance from which providers could manage the care of patients as related to the costs. Without a budget, providers do not have any incentive to find and use medical practices that produce the same health outcomes at less cost. It is the hope of the federal government that the new system, the resource based relative value scale which is to be introduced in 1992, will help in making specific budgets in advance.
SIGNIFICANCE OF THE PROBLEM In September 1990, the Department of Health and Human Services released a report entitled Healthy People 2000: National Health Promotion And Disease Prevention Objectives. According to the report, over the course of the 1990s, the profile of the American JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
popultion will change. Barring any unforeseeable events, the demographic contrasts between 1990 and 2000 will be evident if not dramatic. Based on the best information available: * By the year 2000, the overall population of the United States will have grown about 7% to nearly 240 million people. * The American population will be older, continuing the aging trend of the present century with a median age of more than 36 years, compared with 29 years in 1975. By the year 2000, the 35 million people over age 65 will represent about 13% of the population, in contrast to 8% in 1950. The population of those over age 85 will have increased approximately 30% to a total of 4.6 million. * Additionally by 2000, it is estimated that economic expansion will create up to 18 million new jobs, but the number of young job seekers will decline due to a shift in birth rates, reflecting changes in racial and ethnic populations, the entry rate of blacks, Hispanics, Asian-Pacific Islanders, and American-Indians into the workforce will be higher than for whites. Although 10 years in the history of the nation may seem to be a conparatively short time, it is long enough to alter population patterns in ways that are of great importance to current and future decision-makers seeking to design an effective program of health promotion and disease prevention. This nation has within its power the ability to save many lives lost prematurely and needlessly, via effective health care planning and program implementation.
HEALTH CARE ACCESS INITIATIVES With such grim and depressing statistics, you may be asking yourself what, if anything, is being done about this situation. Legislators on the state and national levels have been studying many of the problems that I have outlined.
State Initiatives Last year, legislation was introduced in the North Carolina General Assembly addressing the issue of health insurance coverage. Other states such as Oregon and Pennsylvania have passed heath care reform proposals that allow access to health care for all. It is too soon, however, to judge whether these recent enactments will begin to effectively address the health care concerns I have mentioned this morning.
Loans and Scholarships On the national front, on November 6, 1990, the JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 3
Disadvantaged Minority Health Improvement Act was signed into public law 101-527. This act highlighted the glaring need to increase the number of minorities in the health care profession to serve many of the underserved and indigent communities. Blacks, Hispanics, and Native Americans represent approximately 20% of the population of the nation; however, these minorities constitute only 7% of physicians, 4% of dentists, and 6% of nurses practicing in the United States. Specifically, black physicians constituted 0.6% in 1890, 2.7% in 1930, and 3.0% in 1990. You can see that in this baseball game we have never left home plate, since the ratio of black physicians to white physicians has not changed in 60 years. You might find it of interest to know that in the late 1 800s there were 14 black medical schools in this country. The Leonard School of Medicine was a part of Shaw University and graduated over 400 black physicians until it, along with the 11 other black medical schools, were closed as a result of the 1914 Flexner Report calling them inadequate. As a result of the Leonard School of Medicine, the Old North State Medical Society was founded in 1887 and therefore antedated the NMA. I am pleased to report that last year the congress passed legislation authorizing increased funding to the National Health Service Corps. The corps is an extremely valuable program that can help alleviate the severe shortage of health care professionals serving the corps and minority populations. The NMA has a special interest in increasing the number of minorities in the health professions. The NMA, along with representatives of the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), and the American Association for the Advancement of Science have formed a special task force on the black and minority applicant pool in an attempt to address the significant deficiency in the provision of health care to the minority and medically underserved populations of this country. Last year, we began efforts to identify and alleviate factors that will not only increase the numbers of qualified blacks and minorities in the applicant pool, but also increase the recruitment, training, and retention of minorities in the medical and other health professions. The NMA has and continues to demand that the number of black physicians be brought to parity with white physicians in this country. Black and minority medical school graduates have been more likely to serve the medically indigent and underserved populations, especially the minority populations whose disparate health status has been well 199
documented. The AAMC medical student graduation questionnaires have indicated that this trend has and will continue. Therefore, parity for black physicians is a necessity rather than just a dream unfulfilled.
Pepper Commission Six members from the US House of Representatives and six members from the US Senate, along with three Presidential appointees comprised the Pepper Commission, which was charged to develop a proposal to expand access to health care and to provide long-term care insurance for Americans who are currently underinsured or uninsured. The NMA testified before the Pepper Commission, and several of our recommendations were incorporated in its final proposal. In March 1990, the Pepper Commission released its proposal which recommended that universal access be provided to 30 million Americans who are inadequately insured, and another 20 million who are uninsured. The proposal establishes two categories. The first category, characterized as universal access to health, includes a benefit package that creates insurance reform and provides access to health care systems to 50 million Americans. The second category establishes a provision for nursing and home care for the disabled. The Pepper Commission proposal also would: 1. require employers with 100 or more employees to provide health insurance, 2. make important changes to private insurance, and 3. convert medicaid into a new public insurance program conforming to the Medicare reimbursement schedule. It is estimated that implementation of the Commission's proposals will cost about $66 billion, which the commission hopes to phase in over a 5-year period. By the fifth year, all Americans who do not have insurance today would have insurance under this system. It is now up to the Congress to propose legislation based on the Commission's recommendations.
Senate Labor and Human Resources Committee Hearing More recently, on January 10, 1991, Senator Edward Kennedy, Chairman of the Senate Labor and Human Resources Committee, held a series of hearings on health care and the American family, Congressman Richard Gephardt, Majority Leader of the House of Representatives, stated that "It is time for Congress to make a commitment to ensure universal access to
necessary and appropriate health care." He further reported that within the next few weeks, the Speaker of the House, Congressman Tom Foley, will announce that health care legislation will be a priority on our agenda for the 102nd Congress. As you may know, there had been several legislative initiatives introduced in the last Congress pertaining to the issue of access of health care for all Americans. It is imperative, however, that we all make an effort to educate our business, associates, friends, neighbors, and family, and most important alert our elected officials to the urgency of the lack of health care accessibility for all. In doing so, it is essential that we start with our own community but quickly spread that word to the news media, Congress, the executive branch, and every responsible unit of government. The NMA has been in the forefront in addressing many of the issues affecting uninsured and underinsured Americans. We reaffirm our position that affordable basic health care is a human right for all citizens and that the NMA supports a national health program that provides coverage to all Americans, regardless of income, race, sex, or ethnic origin and provides access to primary quality care with high professional standards. During Martin Luther King Jr's time, his priority was to address the urgent cry of his people for equality and liberty within our country. But before his untimely death, he sought to address various types of injustices that were ravaging the black and minority communities-a ravaging that resulted in hundreds of deaths caused by crime, drugs, and finally the disproportionate impact of the war in Vietnam. If Dr King were alive today, he would recognize that a priority for the 1990s is saving lives that are being squandered by an absence of adequate, effective, and timely health care. The miracles of modern medicine and our capacity of saving lives is phenomenal. As long as we deny access to these technical miracles, we are perpetrating a new form of genocide on the minority and indigent population of our nation. Let us first recognize the virulent and destructive impact of the lack of access to health care as a result of our inaction. We must rededicate ourselves to saving lives in a less dramatic but urgently needed arena by providing the wherewithal to secure basic health care services for all Americans. We at the NMA look forward to working with you to ensure that health care for all Americans will be achieved during the decade of the 1990s.
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