Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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Racial and Ethnic Disparities in Healthcare: Issues in the Design, Structure, and Administration of Federal Healthcare Financing Programs Supported through Direct Public Funding
Racial and Ethnic Disparities in Healthcare: Issues in the Design, Structure, and Administration of Federal Healthcare Financing Programs Supported through Direct Public Funding
Pages 664-698
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From page 664... ...
But in the face of a significant and ongoing health gap between minority and non-minority individuals, it is worth considering whether the manner in which public financing programs are administered has the potential to contribute to one of the nation's most sobering and enduring public health problems. This paper begins with a background and overview that briefly describe Medicare and Medicaid (and its companion SCHIP program)
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From page 665... ...
Minority patients perceive barriers and racism within the health system, and at least some research suggests that these perceptions appear to be borne out by discernible differences in how health professionals interact with minority patients (The Henry I Kaiser Family Foundation, 1999; La Viest et al., 2000; Lillie-Blanton et al., 2000; Einbinder and Schulman, 2000; Schulman et al., l999~.
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From page 666... ...
Data on access to and use of healthcare by income and insurance status suggest that Medicaid has eliminated healthcare access and utilization disparities among children and non-elderly adults, particularly when utilization data are adjusted for reduced health status; indeed, poor Medicaid beneficiaries appear to use care at rates greater than the poor with ~ At one time, dependence on Medicaid was viewed by health providers and policymakers as stigmatizing. As Medicare has become increasingly complicated and overall payment has declined in relation to the overall cost of care, anecdotal evidence suggests that reliance on Medicare (either alone or in combination with Medicaid)
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From page 667... ...
As Marilyn Moon has observed, "the rules that were established to govern Medicare did little to disrupt or change the way healthcare was practiced or financed in the United States." In his seminal history of the federal government's efforts to address race discrimination in American healthcare, David Barton Smith describes the civil rights environment in which Medicare and Medicaid were enacted, with de jure race discrimination in healthcare having only recently ended, and with Southern Members of Congress threatening to derail passage of Medicare if its funding were used under Title VI as a lever to force healthcare integration (Smith, 2 These techniques included such devices as denying admission to patients without staff physicians while simultaneously denying admitting privileges to minority physicians or physicians working at publicly funded clinics located in medically underserved communities, segregating the wards and wings of hospitals and nursing homes, placing strict numerical limits on minority patients admitted or served, demanding insurmountable pre-admission deposits (akin to a poll-tax) , and refusing to participate in certain government insurance programs, particularly Medicaid (Rosenbaum et al., 2000~.
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From page 668... ...
4 The hesitation to extend civil rights statutes to office-based health professionals on the basis of their participation in federal healthcare financing programs continues today. In 2000, the federal government released guidelines clarifying existing civil rights act standards as they apply to healthcare access among persons with limited English proficiency.
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From page 669... ...
Qualified managed care organizations, known as Medicare+Choice providers, carry out broad contractual responsibilities for the federal government. Both the Medicare statute and implementing regulations establish conditions of participation for medical care institutions and professionals; indeed, much of the Medicare legislation is devoted to the establishment of standards of participation for health professionals, hospitals, other institutions and suppliers, and the managed care industry.
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From page 670... ...
By 2025, minority persons will constitute 33% of the Medicare population, up from 15% in 1995. Figure 2 provides an overview of the health status of Medicare beneficiaries by race and ethnicity and shows that regardless of condition, minority beneficiaries are more likely to experience significant limitations in health status.
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SOURCE: Urban Institute analysis of the March 1998 Current Population Survey, prepared for The Henry l. Kaiser Family Foundation.
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Kaiser Family Foundation. ic aide d stirs e: FIGURE 4 Supplemental insurance coverage: Minority and non-minority Medicare beneficiaries.
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Figure 4 shows the healthcare financing implications of the deep poverty among minority beneficiaries. In 1995, white Medicare beneficiaries were one-and-a-half times more likely than African-American beneficiaries and twice as likely as Latino beneficiaries to have additional coverage through an employer-sponsored health plan and three times as likely to have private Medigap coverage.
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As a matter of federal law, state welfare agencies bear final legal responsibility for Medicaid eligibility determinations, but the law permits any state agency to act as the responsible "single state agency"6 for overall program accountability purposes.7 6 42 U.S.C.
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These groups consist of "AFDC-related" families with children, certain former welfare recipients, elderly and disabled recipients of Supplemental Security Income, certain low-income Medicare beneficiaries (for Medicare cost sharing only) , and "poverty level" pregnant women and children.
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As a result, Medicaid beneficiaries continue to rely disproportionately on publicly supported systems of care such as public hospitals, health centers, and public health agencies.
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Federal Medicaid law affords states considerable discretion in the design and operation of their state programs. As a result, state plans varyat times dramatically in who qualifies for coverage, the level and range of services to which individuals are entitled; participation rules for providers and provider compensation; and methods of administration, such as enrollment procedures, service delivery, and quality oversight.
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From page 678... ...
State plans can adopt significant "amount, duration, and scope" limitations on classes of covered benefits. So other than in the case of children, states are relatively free to adopt any definition of medical necessity they choose as long as it meets minimum tests of reasonableness.20 However, the basic Medicaid entitlement has been interpreted to mean that coverage decisions conducted by state agencies and their contractors (such as managed care entities, home health agencies, and long-term care institutions)
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Kaiser Family Foundation. nursing home care, and over a third of all funds received by such "core" safety net providers as public hospitals and federally funded health centers (Rosenbaum and Rousseau, 2001; IOM, 2000~.
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Kaiser Family Foundation. SCHIP: In 1997, Congress amended the Social Security Act to add a new Title XXI program known as the State Children's Health Insurance Program (SCHIP)
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Federal law permits states to establish separate SCHIP programs that stand apart from Medicaid not only in terms of their benefit packages and cost sharing rules, but also in terms of their organization and service delivery arrangements. SCHIP contains no minimum standards regarding the relationship between the administration of a Medicaid plan and a separately administered SCHIP plan.
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Medicare policies regarding conditions of participation and their impact on low income Medicare beneficiaries; 2) Medicare policies that potentially underlie the problem of racially disparate health outcomes among similarly insured Medicare beneficiaries; 3)
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As a result, the federal power to set conditions of Medicare participation has failed to address the issue of lowincome Medicare beneficiaries, who risk serious access barriers unless they can locate providers that also participate in and will accept Medicaid as a supplemental source of payment for uncovered deductibles and coinsurance and necessary but uncovered services. Only a small proportion of all Medicare-participating physicians and managed care organizations also participate in Medicaid.
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2. Medicare administration issues underlying racial disparities in health outcomes among similarly insured Medicare beneficiaries Much of the literature on race-based health disparities focuses on disparate access to certain types of treatment among similarly situated hospitalized beneficiaries and other beneficiaries undergoing medical treatment (U.S.
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Although Medicaid contains a number of specific requirements related to program administration, states also have broad latitude in how 27 Indeed, in discussing specialist referrals with physicians in practice at federally funded community health centers, the author has heard on innumerable occasions about the difficulties these physicians have in locating specialists who will accept and aggressively manage their referrals as a result of financial and other considerations.
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From page 686... ...
The leader in this effort to transform Medicaid from a "welfare piggyback" program to a true public insurance program has been Medicaid, whose program now serves individuals without access to employer coverage, as well as persons who need subsidization in order to secure benefits available through their employers. States that have taken active steps designed to produce destigmatizing program structures that move Medicaid away from welfare and toward a more neutral public insurance stance are Oregon, Tennessee, Arizona, and Rhode Island.
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From page 687... ...
We'll come and get you."' The consultant said that one way of discouraging Medicaid patients while welcoming private pay patients whose insurance policies often reimburse at higher rates, is to give Medicaid patients the most inconvenient appointment times while saving the most popular appointment slots for private pay patients. 28 Low rates, whether set for physicians, pharmacies, managed care organizations, nursing homes, home health agencies, or other health suppliers have several potential effects, all of which fall with disproportionate impact on minority patients.
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As Table 2 illustrates, because of the high concentration of minority individuals in the poorest large city neighborhoods, this refusal to participate also has its greatest adverse impact on minority beneficiaries who ultimately are starved for access in the midst of plenty. Table 2 shows the marked racial and ethnic patterns of urban poverty in the largest cities.
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From page 689... ...
Other than isolated litigation efforts designed to challenge grossly low provider payment levels, this basic requirement of the program has attracted no attention other than from the nation's governors who have periodically called for its repeal.29 The federal government has done virtually nothing with the provision, and there are virtually no guidelines that interpret how to apply the equal access requirement or what is expected in terms of state implementation (e.g., specific data collection to measure levels of access where disparities in health outcomes are pronounced, affirmative efforts to increase rates, or affirmative efforts aimed at attracting healthcare providers in high need communities)
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From page 690... ...
There is very little in the conditions of participation under these three programs that requires or finances the efforts of healthcare providers to take systematic steps to examine enrollment and utilization patterns in relation to the demographics of the communities in which they serve, and undertake affirmative steps to improve access to their services. Limited conditions of participation under federal Medicare and Medicaid managed care regulations do require that participating managed care organizations make certain efforts to address access to care in their service ar
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From page 691... ...
Despite the "equal access" provisions in the Medicaid statute (noted above) , most state contracts with managed care organizations do not expressly prohibit contractors' provider networks from engaging in what can be termed "contractually sanctioned discrimination," i.e., permitting network providers under a general duty of care to all plan members to nonetheless refuse to treat the Medicaid sponsored members of the plan (Rosenbaum et al., 1997~.
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From page 692... ...
Regulations issued by the Clinton Administration in lanuary 2001 and applicable to Medicaid managed care systems prohibit contractually sanctioned provider discrimination against Medicaid patients within Medicaid-participating managed care organizations.33 On August 20, 2001, the Bush Administration suspended these rules.34 The Administration simultaneously proposed new regulations that seek to relax certain of the requirements imposed on state agencies and managed care organizations 32 This position on the part of providers serves to at least informally dispel any notions that managed care would somehow erase healthcare access differentials based on sponsorship. Medicaid-only managed care plans are the norm in many communities, and in communities in which MCOs that do business across sponsors are in the market, separate Medicaid-only subsidiary operations may be common.
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From page 693... ...
Furthermore, by relying on general Title VI sanctions rather than expressly prohibiting patient "redlining" by member sponsorship status, the Administration essentially foregoes an opportunity to set an explicit standard designed to directly address an identified problem issue in Medicaid managed care that has the potential to hurt not only all Medicaid beneficiaries but disproportionately harm minority patients. Putting aside Title VI, the repeal of such a regulation appears to have direct implications for the enforceability of the equal access provisions of the Medicaid statute themselves.
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From page 694... ...
While money is always a problem, and can be expected to become increasingly so in an era of declining rates of government revenues, the financial problems actually pale in comparison to the two awesome political problems that arise in any restructuring discussion: the healthcare industry and state governments. Restructuring Medicare and Medicaid administration to emphasize orientation toward minority patients and beneficiaries as a condition of federal financial participation means confronting the fundamental character of both programs.
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From page 695... ...
Congress might consider extending additional levels of compensation to both state agencies and providers that take steps to orient programs toward minority patients and away from practices that result in segregation, exclusion, and denial of care. Also necessary is sufficient health services research to support the claim that certain healthcare financing decisions and service arrangements are at least associated with better (or poorer)
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From page 696... ...
2000. The Use of Community Health Centers In Countries with National Health Insurance: Evidence from the Literature.
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U.S. Civil Rights Policy and Access to Health Care by Minority Americans: Implications for a Changing Health Care System.
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From page 698... ...
Medical Care Research and Review 57 (Supplement 1~:36-55.
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