99
THE ROLE OF THE PRIVATE SECTOR IN ADDRESSING THE HEALTH PROBLEMS OF URBAN POOR CHILDREN* RICHARD E. BEHRMAN, M.D. Managing Director Center for the Future of Children The David and Lucile Packard Foundation Los Altos, California
B Y ALMOST ANY MEASURE, children are not doing well in this country and the situation is growing progressively worse. Private and public investment in children is decreasing as their situation deteriorates (Table I). It is not possible to address the fundamental problems of poor children without addressing the plight of their families. The poorest 20% of our families have 10% the income of the wealthiest 20% (Figure 1). Even for those above the poverty line, effective income of families with children decreases with the number of children, paralleling the rise in poverty of families with more children (Table II). The problem of inadequate health insurance coverage is disproportionately worse for children; 40% of children have no health insurance or are inadequately covered (Table III). Despite a 30% increase in public insurance over the past decade, the number of uninsured two parent working families has doubled, due to decrease in private insurance coverage (Table IV). Children are disproportionately burdened with poverty in this country. They are slightly less than a third of our population but make up 40% of the ranks of those who live in poverty (Table V). Poverty falls disproportionately on African Americans and Hispanics. However, the majority of children in poverty families are white non-Hispanics and in these families one parent works full time (Tables V and VI). Against this general background of the conditions of children in the United States, I shall now address the health problems of urban poor children. A great many private organizations, corporations, and institutions are involved in the dynamics of providing health care. In New York City they range from voluntary neighborhood organizations to multibillion dollar insurance com*Presented as part of the 1991 Annual Health Conference, Children at Risk: Poverty and Health, held by the Committee on Medicine in Society of the New York Academy of Medicine May 20 and 21, 1991.
Vol. 68, No. 1, January-February 1992
R.E. BEHRMAN E.~~~~~~~~~~~~~~~~~~~~~~~~~~~~
100
TABLE I. SELECTED MEASURES OF WELL-BEING OF CHILDREN*
SAT scores Suicide rate(%) (15-19 yr) Homicide rate (%) (15-19 yr) Arrest rate (%) (14-17 yr) Family Expenditure (%) for Children US Expenditures (ratio) Children/Adult
1960 973 3.6
1970 948 6.3
1986 905 10.2
4.0
8.3
9.5
4.7
10.4
11.8
11.2
10.4
7.4
3.9
2.4
2.1
*Modified from Fuchs, V. and Reklis, D.: options. Science. In press.
America's children, economic perspectives and policy
TABLE II. ECONOMIC STATUS OF HOUSEHOLDS*
No children
Children 1
Effective income ($) Households in poverty (%)
34,500
26,661
31,597
Number of children 3 or more 2 27,775
20,877
27 14 10 *Modified from Fuchs, V. and Reklis, D.: America's children, economic perspectives and policy 7
16
options. Science. In press.
great many private organizations, corporations, and institutions are involved in the dynamics of providing health care. In New York City they range from voluntary neighborhood organizations to multibillion dollar insurance companies. However, I shall focus on only one component of the private sector, urban nonprofit voluntary hospitals, because these organizations are at the center of the action in our major cities. These institutions could play a much more significant role than they now play in ameliorating some of the more urgent health problems of poor urban children. The Chief Executive Officers of most of these institutions in New York City see themselves, realistically, as threatened and endangered by hostile regulatory, reimbursement, cost, and competitive environments. In this context one might ask how I could possibly suggest that they and their medical staffs play an expanded leadership role in regard to the health problems of poor children. Bull. N.Y. Acad. Med.
PRIVATE SECTOR
101 101
SECTOR
TABLE III. HEALTH INSURANCE COVERAGE (MILLIONS) Children Total population Type 48-50* 150-160 Private 0 30-35 Medicare 8-9 20-25 Medicaid (+ other Public) 12-13 32-37 Uninsured *7 + million partial insurance
TABLE IV. HEALTH INSURANCE OF POOR AND LOW INCOME (TWO PARENTS)*
Employment
Uninsured
Private insurance
Private insurance employment
Public insurance
(%)
(%)
(%)
(%)
25.4 29.4
67.3 64.3
61.9 57.2
7.3 6.3
19.4 40.0
71.0 47.3
64.2 44.4
9.6 12.7
Both employed 1977 1987 One employed 1977 1987
*Modified from Cunningham, P.J. and Monheit, A.C.: Insuring the children: a decade of change.
Health Affairs 9:91, 1990.
I think that the most important threat to their survival as quality institutions is not the hostile business environment of increasing regulation, poorer payer mix, and increasing costs and competition. It is a matter of how they view
themselves. This threat is embodied in the expression "health care industry." Reflex acceptance of the idea behind this caricature of what they are a part of undermines the reason for their existence as tax free private voluntary nonprofit hospitals. They may be their own worst enemies in this failure to recognize the consequences of embracing this corporate industry indentity. The emphasis in the expression "health care industry" is on the last word, "industry." Its model is the for-profit commercial world, the backbone of material prosperity in this country. However, this model is the antithesis of the tradition of voluntary nonprofit urban hospitals. Such hospitals were founded on a tradition of altruism. Altruism is one of those wonderfully simple words that comes from the Latin for "other." Literally, altruism means "the practice of unselfish concern for the welfare of others." The leaders of these hospitals must not lose sight of this value or be apologetic Vol. 68, No. 1, January-February 1992
102
R.E. BEHRMAN
RE.
TABLE V. DISTRIBUTION OF POVERTY*
Millions 32.5 21.5 18+ 9 2-3 13-14 (40%) 5
Total White (non hispanic) Working Rural Inner city "underclass" Children
THE ROLE OF THE PRIVATE SECTOR IN ADDRESSING THE HEALTH PROBLEMS OF URBAN POOR CHILDREN* RICHARD E. BEHRMAN, M.D. Managing Director Center for the Future of Children The David and Lucile Packard Foundation Los Altos, California
B Y ALMOST ANY MEASURE, children are not doing well in this country and the situation is growing progressively worse. Private and public investment in children is decreasing as their situation deteriorates (Table I). It is not possible to address the fundamental problems of poor children without addressing the plight of their families. The poorest 20% of our families have 10% the income of the wealthiest 20% (Figure 1). Even for those above the poverty line, effective income of families with children decreases with the number of children, paralleling the rise in poverty of families with more children (Table II). The problem of inadequate health insurance coverage is disproportionately worse for children; 40% of children have no health insurance or are inadequately covered (Table III). Despite a 30% increase in public insurance over the past decade, the number of uninsured two parent working families has doubled, due to decrease in private insurance coverage (Table IV). Children are disproportionately burdened with poverty in this country. They are slightly less than a third of our population but make up 40% of the ranks of those who live in poverty (Table V). Poverty falls disproportionately on African Americans and Hispanics. However, the majority of children in poverty families are white non-Hispanics and in these families one parent works full time (Tables V and VI). Against this general background of the conditions of children in the United States, I shall now address the health problems of urban poor children. A great many private organizations, corporations, and institutions are involved in the dynamics of providing health care. In New York City they range from voluntary neighborhood organizations to multibillion dollar insurance com*Presented as part of the 1991 Annual Health Conference, Children at Risk: Poverty and Health, held by the Committee on Medicine in Society of the New York Academy of Medicine May 20 and 21, 1991.
Vol. 68, No. 1, January-February 1992
R.E. BEHRMAN E.~~~~~~~~~~~~~~~~~~~~~~~~~~~~
100
TABLE I. SELECTED MEASURES OF WELL-BEING OF CHILDREN*
SAT scores Suicide rate(%) (15-19 yr) Homicide rate (%) (15-19 yr) Arrest rate (%) (14-17 yr) Family Expenditure (%) for Children US Expenditures (ratio) Children/Adult
1960 973 3.6
1970 948 6.3
1986 905 10.2
4.0
8.3
9.5
4.7
10.4
11.8
11.2
10.4
7.4
3.9
2.4
2.1
*Modified from Fuchs, V. and Reklis, D.: options. Science. In press.
America's children, economic perspectives and policy
TABLE II. ECONOMIC STATUS OF HOUSEHOLDS*
No children
Children 1
Effective income ($) Households in poverty (%)
34,500
26,661
31,597
Number of children 3 or more 2 27,775
20,877
27 14 10 *Modified from Fuchs, V. and Reklis, D.: America's children, economic perspectives and policy 7
16
options. Science. In press.
great many private organizations, corporations, and institutions are involved in the dynamics of providing health care. In New York City they range from voluntary neighborhood organizations to multibillion dollar insurance companies. However, I shall focus on only one component of the private sector, urban nonprofit voluntary hospitals, because these organizations are at the center of the action in our major cities. These institutions could play a much more significant role than they now play in ameliorating some of the more urgent health problems of poor urban children. The Chief Executive Officers of most of these institutions in New York City see themselves, realistically, as threatened and endangered by hostile regulatory, reimbursement, cost, and competitive environments. In this context one might ask how I could possibly suggest that they and their medical staffs play an expanded leadership role in regard to the health problems of poor children. Bull. N.Y. Acad. Med.
PRIVATE SECTOR
101 101
SECTOR
TABLE III. HEALTH INSURANCE COVERAGE (MILLIONS) Children Total population Type 48-50* 150-160 Private 0 30-35 Medicare 8-9 20-25 Medicaid (+ other Public) 12-13 32-37 Uninsured *7 + million partial insurance
TABLE IV. HEALTH INSURANCE OF POOR AND LOW INCOME (TWO PARENTS)*
Employment
Uninsured
Private insurance
Private insurance employment
Public insurance
(%)
(%)
(%)
(%)
25.4 29.4
67.3 64.3
61.9 57.2
7.3 6.3
19.4 40.0
71.0 47.3
64.2 44.4
9.6 12.7
Both employed 1977 1987 One employed 1977 1987
*Modified from Cunningham, P.J. and Monheit, A.C.: Insuring the children: a decade of change.
Health Affairs 9:91, 1990.
I think that the most important threat to their survival as quality institutions is not the hostile business environment of increasing regulation, poorer payer mix, and increasing costs and competition. It is a matter of how they view
themselves. This threat is embodied in the expression "health care industry." Reflex acceptance of the idea behind this caricature of what they are a part of undermines the reason for their existence as tax free private voluntary nonprofit hospitals. They may be their own worst enemies in this failure to recognize the consequences of embracing this corporate industry indentity. The emphasis in the expression "health care industry" is on the last word, "industry." Its model is the for-profit commercial world, the backbone of material prosperity in this country. However, this model is the antithesis of the tradition of voluntary nonprofit urban hospitals. Such hospitals were founded on a tradition of altruism. Altruism is one of those wonderfully simple words that comes from the Latin for "other." Literally, altruism means "the practice of unselfish concern for the welfare of others." The leaders of these hospitals must not lose sight of this value or be apologetic Vol. 68, No. 1, January-February 1992
102
R.E. BEHRMAN
RE.
TABLE V. DISTRIBUTION OF POVERTY*
Millions 32.5 21.5 18+ 9 2-3 13-14 (40%) 5
Total White (non hispanic) Working Rural Inner city "underclass" Children
