Headline writers understandably reached for the jumbo-sized type last week when Atty. Gen. John Ashcroft warned that Al Qaeda might be planning an attack in the U.S. this year.
But hardly anyone noticed when researchers from the Urgent Matters program at the George Washington University School of Public Health released a study documenting a more insidious threat to the nation's health and safety: the growing strain on the thin line of public hospitals and clinics that provide healthcare for millions of low-income and uninsured Americans.
In an election year dominated by concerns about terrorism and the war in Iraq, domestic problems such as the cost and availability of healthcare have been overshadowed. Yet the healthcare system is facing pressures similar to those that inspired President Clinton's failed attempt to ensure universal coverage a decade ago.
As costs rise relentlessly, more employers are dropping coverage and more workers are refusing it even when it is offered. Those trends — along with the employment slump that only recently appears to have ended — have pushed the number of uninsured past 43 million.
And as the number of uninsured grows, so does the pressure on the few places that care for them, particularly emergency rooms at public hospitals and federally funded health centers.
Anyone who has spent time in these institutions marvels at the creativity and tenacity they display in cobbling together funds from governments and foundations, and then stretching those dollars like gauze over a wound. But it's just as clear they are being overwhelmed by the endless need.
"We could build three of these clinics and still not meet the demand in this neighborhood," Grace Floutsis, medical director of the Clinica Monsenor Oscar A. Romero in Los Angeles' heavily Latino Pico-Union neighborhood, told me last winter.
The strain on the public healthcare safety net in Los Angeles County is particularly dire because so many of the area's employers don't provide insurance for their workers. But the problem is hardly unique to L.A.
Examining the safety net in 10 communities around the nation — from Boston to San Diego — the George Washington researchers found a dangerous squeeze. On the one hand, the providers are spending more to care for those without insurance. On the other, government cutbacks are reducing their principal source of revenue: the money they receive for treating patients covered by Medicaid and the Children's Health Insurance Program, the state-federal partnerships that fund care for millions of low-income families.
Even under these pressures, in most communities studied by the researchers the safety net institutions were providing impressive levels of primary care. But patients who needed more specialized care faced impossibly long waits to see the few specialists who would treat those without private insurance. (In a focus group, one woman trying to see a specialist said she was told there were 500 patients ahead of her.)
That drives many of those patients to seek help in emergency rooms, overwhelming those systems as well. Mental health and dental services were virtually nonexistent for those who depended on the safety net providers.
President Bush has displayed a schizophrenic attitude toward the strains on the safety net. He has significantly increased funding for federal community health centers that treat the uninsured; last week in Youngstown, Ohio, he noted the clinics served almost 30% more patients than when he took office. Yet while increasing direct grants to the centers, Bush has also pursued cutbacks in Medicaid that could undermine the very public clinics and hospitals he aims to promote.
The George Washington study, "Walking a Tightrope," points to some critical steps for reinforcing the safety net — with strengthening Medicaid and encouraging greater coordination among providers topping the list.
But another step is to ease the demand for healthcare in low-income communities through efforts to prevent disease and encourage more healthful living.
That's the focus of the Health Policy Institute launched last week by the Joint Center for Political and Economic Studies, a think tank concentrating on issues affecting African Americans. At a kickoff conference, the institute presented a series of papers arguing that expanding access alone would not solve the most pressing healthcare problems in low-income communities.
"There's no question that's a piece of the issue," says Gail C. Christopher, the institute's director. "But a larger, more relevant, more creative and effective strategy is: How do we reduce the need [for healthcare]? Looking at disease management, at education, at prevention, at strengthening communities
is an absolute imperative right now."
The institute took an important step in that direction with a series of practical recommendations.
To fight the epidemic of asthma among inner-city children, it recommended not only expanded screening but also more inspections of rental housing and improved building codes for schools and day-care centers to combat the conditions that trigger the disease. To fight the high (and growing) obesity rates among minorities, it urged more physical activity in schools and redoubled efforts to locate supermarkets and parks in inner-city neighborhoods.
Ever since Clinton's national healthcare plan collapsed, Washington has mostly gridlocked over how to expand coverage. But the studies from the Joint Center and George Washington University show that even without agreement on that overriding question, practical steps are possible to help millions of low-income families live healthier lives and receive more effective care when they need it. Ignoring that opportunity, while waiting for consensus on coverage, would be a form of political malpractice.
Ronald Brownstein's column appears every Monday. See current and past Brownstein columns at latimes.com/brownstein.
Copyright 2004 Los Angeles Times