[Congressional Record Volume 140, Number 11 (Tuesday, February 8, 1994)]
[Extensions of Remarks]
[Page E]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: February 8, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
      HEALTH REFORM MUST MEET THE NEEDS OF UNDERSERVED COMMUNITIES

                                 ______


                         HON. JOHN CONYERS, JR.

                              of michigan

                    in the house of representatives

                       Tuesday, February 8, 1994

  Mr. CONYERS. Mr. Speaker, as Congress begins the deliberative process 
on health care reform, I cannot express strongly enough the critical 
importance for consensus legislation to include measures that will meet 
the needs of America's medically underserved communities and 
populations. If Congress is sincerely interested in making health 
reform work for all Americans, it must invest in community-based health 
services for at-risk communities. If the primary and preventive health 
care needs of these populations are not met in health reform, our goal 
of cost containment will not be realized: these are exactly the people 
who end up on emergency room doorsteps in my home of Detroit and across 
the country under our current health system.
  Underserved communities desperately need health reform to deliver 
three things to them: First, the presence of a medical home that offers 
high-quality care regardless of their health or social status or their 
ability to pay for services; second, adequate numbers of highly 
trained, culturally competent health professionals to staff these 
facilities; and third, the assurance that their medical home will not 
be driven out of business due to excessive financial risk or inadequate 
reimbursement, simply because they care for those who are sickest and 
hardest to serve.
  As one of the principal authors of H.R. 1200, the American Health 
Security Act, I worked hard to see that access for the medically 
underserved was given special attention. H.R. 1200 doubles available 
funding for community, migrant and homeless health centers, and affords 
these essential providers certain payment and contracting safeguards to 
ensure their financial viability. Further, it calls for a significant 
expansion of the National Health Service Corps to ensure that our 
medical education establishment is producing the kinds of doctors our 
health system desperately needs--primary care physicians--and that they 
are trained and practice in the areas that need them most.
  I am heartened that health reform proposals from all sides of the 
political spectrum recognize that access must be expanded in 
underserved communities. Many of the proposals introduced in Congress, 
including the President's, make great strides toward reforming and 
improving the health care delivery system in areas that need it the 
most. For instance, the Chafee-Thomas bill includes over $5 billion in 
funding for community health centers; the Michel bill includes $1.5 
billion for health centers, thanks in large part to the strong support 
of our colleague Nancy Johnson.
  But none go nearly far enough in meeting the needs of the communities 
many of us in the Black and Hispanic Caucuses, and others, represent. 
As health reform legislation is developed we must work to ensure that 
the needs of these communities are met--not just because it is the 
right thing to do, but because it is what we must do to achieve cost 
containment and health reform that works for all Americans. It will be 
among the best investments health reform makes.

  Mr. Speaker, I ask to submit for the Record  a story that ran in the 
February 2 edition of the Washington Post, which details the holes that 
remain in America's health safety net. As my colleagues will note, the 
story describes the great work that community health centers across the 
country are doing to care for those Americans who have fallen through 
the cracks of our health system. I urge my colleagues to join me and 
other Members of the Black and Hispanic Caucuses in working for the 
expansion and preservation of this exemplary program in health reform.
  Thank you.

                [From the Washington Post, Feb. 2, 1994]

              Expanded Medical Safety Net Still Has Holes

                            (By Dan Morgan)

       It's only a short cab ride from Rockville's Community 
     Clinic to some of the best that American medicine has to 
     offer: the state-of-the-art research labs of the National 
     Institutes of Health in Bethesda, the distinguished 
     specialists of wealthy Montgomery County, the teaching 
     hospitals in the District of Columbia.
       But when one of the Rockville health facility's poor, 
     uninsured patients needs more than the primary care provided 
     by its staff of low-paid nurses and moonlighting doctors, the 
     distance can be vast. So vast that Diane Cella Brusick, the 
     clinic's associate executive director, sometimes can't find a 
     doctor to send such patients to.
       ``God forbid they need an operation,'' she said. ``I get on 
     the phone and beg the local radiology groups. I beg the 
     surgeons. It's a lot of networking.'' A stress test that 
     could identify suspected coronary problems costs at least 
     $300. Occupational therapy is also expensive, and it strains 
     the clinic's limited funds.
       Such daily experiences of the nonprofit Community Clinic 
     Inc. demonstrate the big holes that still exist in America's 
     medical safety net after a decade of important but 
     incremental improvements in Medicaid, the federal-state 
     health care program for the poor and elderly.
       Between 1984 and 1990, Rep. Henry A. Waxman (D-Calif.) and 
     allies from both parties in the House and Senate pushed 
     through provisions that expanded benefits and increased the 
     number of people eligible for Medicaid. Millions more working 
     poor people, mainly pregnant mothers and young children, 
     began receiving its benefits.
       For this and other reasons explored in this series of 
     articles, Medicaid costs have exploded since 1989. Despite 
     the growing numbers of Medicaid patients, the Medicaid system 
     was left basically unchanged. Until recently, for example, 
     few states attempted to steer patients away from costly 
     emergency rooms by raising Medicaid fees to physicians, 
     assigning patients to clinics, or requiring patients to make 
     copayments.
       One result is that Medicaid expenditures for children on 
     welfare rose 17 percent a year between 1988 and 1991.
       But despite the growth in both cost and numbers in the 
     program, half of all those who are poor, as defined by the 
     federal government, still are not covered by Medicaid. About 
     two-thirds of those Americans who are uninsured--as many as 
     24 million people--are either poor or near-poor.
       ``I think Henry Waxman did an enormous service for poor 
     people, but the fact that too many still fall between the 
     cracks shows that the Medicaid system is not working,'' says 
     Rep. Ron Wyden (D-Ore.), a member of Waxman's Energy and 
     Commerce subcommittee on health and outspoken advocate of a 
     recent Medicaid reform in Oregon that some have described as 
     health care rationing.
       President Clinton's health reform plan would guarantee a 
     standard package of benefits to each American regardless of 
     his or her health record or ability to pay and would do away 
     with large parts of Medicaid. The purpose is not only to 
     control the costs of the huge government entitlement program 
     and relieve pressure on the federal budget deficit but also 
     to eliminate the stark inequities in the U.S. health care 
     system.
       These inequities are all too obvious at Community Clinic. 
     The clientele at the clinic's facilities in a remodeled 
     Victorian house in Rockville, and at branches in Silver 
     Spring, Germantown and Hyattsville, include the jobless, the 
     homeless, AIDS sufferers, the chronically mentally ill, 
     immigrants and refugees.


                           ``forget fathers''

       More than half of the 7,000 mostly poor patients who use 
     Community Clinic's facilities do not qualify or have not 
     applied for Medicaid. The clinic will provide care for a 
     family of four with an income of $26,800 a year or less, well 
     above the Medicaid cutoff. Medicaid generally does no accept 
     able-bodied adults, except impoverished pregnant women. 
     ``Forget fathers,'' said one clinic worker.
        Community Clinic has doctors and nurses to provide the 
     uninsured with primary care. But difficulties arise when 
     uninsured patients have more complicated problems requiring 
     the services of a specialists--a problem that comes up ``20 
     times a week,'' Brusick said.
       In those cases, she said, the clinic relies on a network of 
     physicians, organized by the Catholic Archdiocese of 
     Washington, who provide charity care for the homeless, as 
     well as occasional help from the specialists at NIH, Howard 
     University and Johns Hopkins Hospital.
       Clinic workers boast about last summer's coup: getting a 
     local brain surgeon to administer a magnetic resonance 
     imaging scan to a woman with a suspected brain tumor. He 
     charged the clinic for the cost of the dye instead of asking 
     a fee that can run as high as $1,700. The diagnosis, an 
     inoperable brain tumor, ruled out the need for further tests.
       But the system doesn't always function smoothly. Carl E. 
     Snyder, an unemployed drywall installer, was referred by the 
     Rockville clinic to a dermatologist last year after a doctor 
     diagnosed psoriatic arthritis accompanied by joint and skin 
     diseases. Snyder, a 53-year-old Silver Spring resident with a 
     Hemingwayesque beard streaked with red and gray, said that he 
     had worked since he was 14 but couldn't in 1993. Last spring 
     and summer he had so little strength in his wrists and thumbs 
     that his wife had to unscrew the tops on the medicine bottles 
     he keeps in his second-floor bedroom.
       A private dermatologist declined to take him on as an 
     uninsured patient, Snyder said, asking him: ``What am I 
     supposed to do?''
       And although ``markedly disabled,'' according to a report 
     on his case written by a clinic physician, Snyder couldn't 
     qualify for Medicaid, which is available to adult males only 
     if they are permanently disabled. The Montgomery County 
     Department of Social Services advised him last May 1 that his 
     disease was not sufficiently disabling to allow him to get 
     the benefits.
       Medicare, the other big government health care program, 
     also provides disability benefits for persons who have paid 
     Social Security taxes. But the Social Security Administration 
     turned Snyder down for these benefits on July 2. Regional 
     Administrator Larry G. Massanari, citing an earlier medical 
     report, wrote: ``Although you may experience discomfort, the 
     evidence shows you are still able to move about and to use 
     your arms, hands, and legs in a satisfactory manner * * * you 
     can use your arms and hands for basic grasping and handling. 
     Although you say you have a skin condition, medical evidence 
     shows that this is not disabling.''
       For much of the spring and summer, Snyder made do with 
     painkilling medicines and applications of olive oil on the 
     red blotches on his arms. Finally, a clinic physician wrote 
     him a prescription for methotrexate, a drug that requires 
     regular blood testing to monitor possible liver damage. 
     Snyder bought the pills with his own money, he said, but in 
     October he stopped having the blood tests. He said he 
     couldn't pay the bill for the tests himself, and didn't want 
     to run up a larger bill with Community Clinic, which had paid 
     for some of the tests. ``I don't want the humiliation of 
     waiting to be told they [the laboratory] won't do it because 
     I owe money,'' he said.
       In late November, the clinic staff was urging him to apply 
     for a new state program, the Disability Assistance Loan 
     Program, which provides medical help for those who are 
     temporarily incapacitated, Finally last month, Snyder 
     received word that he had qualified as disabled under the 
     federal Supplemental Security Income program, making him 
     eligible for Medicaid.
       ``I'm still not sure the system's going to work,'' he said 
     yesterday.
       Shifts in the Maryland Medicaid program last year may have 
     increased pressures on facilities that treat the uninsured, 
     such as Community Clinic.
       In 1992 and 1993, about 220,000 Maryland Medicaid patients 
     were enrolled in a new managed care system called Maryland 
     Access to Care. MAC assigns these Medicaid clients to a 
     primary care physician, health maintenance organization or 
     clinic, among them Community Clinic. The goal is to save 
     money by having routine illnesses treated by a doctor or 
     clinic, rather than in a hospital emergency room.
       But to increase Medicaid payments enough to attract primary 
     care physicians into the program, the state made economies 
     elsewhere. Early this year, about 27,000 uninsured people, 
     mostly adults, were cut from a state-financed medical 
     assistance program and thrown on the mercy of charity clinics 
     and hospital emergency rooms.
       The jury is still out on whether MAC will save money for 
     the state.


                          A Degree of Security

       However imperfect Medicaid may be for those who qualify, it 
     provides a degree of security the uninsured can only dream 
     of.
       And while the uninsured may increase the budgetary problems 
     of an institution like Community Clinic, its difficulties 
     have been somewhat assuaged since 1989, when Medicaid began 
     increasing federal payments to such ``federally qualified'' 
     clinics.
       According to Community Clinic director J. Mark Langlais, 
     Medicaid will cover about a third of its 1993-94 budget of 
     $1.6 million, supplementing funds from Maryland, Montgomery 
     County, the communities of Rockville and Gaithersburg, the 
     federal McKinney program for the homeless, and fees paid by 
     patients.
       Last year, Langlais said, Medicaid funds provided a 
     financial cushion that enabled his facilities to see an 
     additional 1,000 children in families with no health 
     insurance. (Medicaid currently covers few non-disabled 
     children over age 10.)
       The waiting room of the clinic in Silver Spring 
     conveniently adjoins the local office of the Maryland 
     Department of Social Services, where families apply for 
     Medicaid. One day last summer a woman who had just returned 
     to the Washington area from Florida applied for Medicaid at 
     the Social Services window, then crossed the waiting room to 
     seek treatment for her 16-month-old son. A ``touch of scarlet 
     fever'' was diagnosed in the child.
       The women's husband, an aircraft mechanic who had been laid 
     off from his job in Florida, was still looking for work in 
     this area and she was making $200 a week as a receptionist. 
     ``We usually do for ourselves, but with two kids you need 
     medical assistance,'' she said. Medicaid, she added, would 
     cover care for the children until her husband found stable 
     employment and private insurance.
       Under the Clinton plan, the part of the Medicaid program 
     that pays the routine doctor, hospital and pharmacy bills of 
     the poor would be eliminated, although Medicaid's long-term 
     care of the elderly and disabled would continue with few 
     changes.
       By ``mainstreaming'' Medicaid recipients into the same kind 
     of private health plans and health maintenance organizations 
     used by the rest of the population, the proposal would 
     largely eliminate distinctions between insured and uninsured, 
     Medicaid and non-Medicaid patients.
       In the Clinton plan, premiums of the poor and the near-poor 
     for the basic package of benefits would be subsidized, and 
     health plans would have to accept their share of these 
     patients. Children in low-income families would be entitled 
     to extra medical and social services beyond those in the 
     standard package.
       In theory, this would do away with the stigma that Medicaid 
     coverage still has for many as a ``poor person's program'' 
     that many physicians have shied from. The fees that hospitals 
     and physicians would get for treating the poor would be the 
     same as those for treating others, which is not the case 
     today. Although the rates that state Medicaid programs pay 
     physicians for treating Medicaid patients are supposed to be 
     sufficient to ensure that covered services are available, it 
     hasn't always worked that way.
       The late Rep. Ted Weiss (D-N.Y.) told a House subcommittee 
     in 1990 that 85 percent of physicians in his state did not 
     participate in Medicaid. Health care advocates cite red tape 
     and low reimbursement rates as the main reasons why doctors 
     have been unwilling to see patients who hold Medicaid cards. 
     A recent survey of Medicaid enrollees by the Kaiser Family 
     Foundation found that one in five Medicaid enrollees had been 
     turned away by a doctor.


                          patients' transition

       Many of Community Clinic's patients would fit easily into a 
     new health care system in which everyone would be enrolled in 
     a health plan on more or less equal terms, Langlais said.
       But for others, he cautioned, the transition might not be 
     so easy. ``The question is whether the Clinton plan will 
     really take care of a lot of the people we see. Some are 
     socially unacceptable in a doctor's office. Some are 
     manipulative. Some have been burned by the system. A doctor's 
     office doesn't necessarily take into account social, cultural 
     and language needs.''
       Patients served by the clinic in Rockville include some who 
     are chronically mentally ill and difficult to work with--such 
     as the woman who hurled epithets at the office staff one 
     recent day while she was waiting to be seen by a clinic 
     doctor.
       The clinic doesn't ask to see immigration papers of those 
     who show up, but the staff is aware that many patients are 
     illegal immigrants--a group that would not be eligible for 
     the national benefits package in the Clinton plan.
       Langlais said he also worries that health maintenance 
     organizations and health plans will still find ways to 
     discourage utilization by low-income families with many 
     medical and social problems.
       Several Community Clinic patients covered by medicaid 
     switched earlier this year to an HMO that handles Medicaid 
     patients. Now they want to switch back to Community Clinic, 
     according to administrator Michael J. Mercurio of the Silver 
     Spring facility. Mercurio recalled a situation in which the 
     HMO wasn't able to set up an appointment for a child with 
     fever for two days. The mother brought the child to Community 
     Clinic. But the HMO refused to authorize treatment. So the 
     mother paid Community Clinic a small out-of-pocket fee for 
     seeing the child.
       The future of clinics such as Langlais's under the new 
     system is uncertain. ``We have the expertise to handle this 
     population, making sure there's follow-up, that people get to 
     their doctor, that we get back the results of tests. But will 
     the health alliances incorporate us in the mix? I don't 
     know.''
       There is also the larger question of whether health reform 
     automatically will translate into better care for the poor. 
     In theory it should.
       But the General Accounting Office reported in 1991 that 
     there was ``little evidence that Medicaid coverage alone can 
     improve the rates of early prenatal care utilization,'' It 
     cited a study in Tennessee that found ``no concomitant 
     improvements in the use of early prenatal care, birth weight, 
     or neonatal outcomes'' following the expansion of Medicaid 
     coverage in the 1980s.
       According to Lois Moore, president and chief executive 
     officer of the Harris County hospital district in Houston, 30 
     percent of the women whose babies are delivered at the 
     hospitals she runs have had no prenatal care--even though 
     most have Medicaid or would be eligible for it.
       Daniel H. Hawkins Jr., research director at the National 
     Association of Community Health Centers, said that outreach 
     services and health facilities where the poor need them did 
     not keep pace with the expansion of Medicaid eligibility in 
     the 1980s.
       ``We brought them [new Medicaid enrollees] into the system 
     without changing that system. We got them past the financial 
     barrier; now we've got to tackle the more complicated 
     problem: How can we provide care without the financing eating 
     us for lunch?''

                          ____________________