are becoming increasingly sensitive to the racial and ethnic demographic changes occurring in this country. Given the prediction that, by 2050, “one of every two U.S. workers [of all types] will be African American, Hispanic, Asian American, Pacific Islander, or Native American” (IOM, 2001b), officials in both the federal and state governments face a number of challenges. One challenge is the significance of cultural competence—and perhaps cultural concordance—in the delivery of quality care. Another is the disproportionate impact of certain illnesses—hypertension, diabetes, heart disease, and asthma, for example—in certain minority groups. Still another is preparation of a health workforce to care for an increasingly diverse population.

Various efforts are underway to respond to the challenges—providing patients who have limited English skills with access to interpreters or native-speaking providers; tying health status goals and indicators to ethnicity (as in Healthy People 2000 and 2010); assessing cultural competency of providers in government-funded health settings; conducting clinical and quality studies of services provided to individuals in various racial and ethnic groups; making sure that Medicaid managed care contractors meet culturally appropriate standards; and tracking Medicaid patients relative to demographic data on ethnicity and cultural characteristics. Crucial as well are broad-based efforts to project the needs of increasingly diverse Medicare and Medicaid beneficiaries and discretionary program clients; to provide incentives to attract URMs to health professions careers; to strengthen scholarship, loan, mentoring, and other aspects that relate to health professions education and training; and to put greater emphasis on nurturing URM health professions faculty, administrators, researchers, and other health leaders.

Strategies such as multiyear authorizations and appropriations to give greater certainty to program funding, interagency coordinating councils to share information and seek common threads among compartmentalized programs, and joint efforts (such as the clinical partnership that DoD and the VA have in sites such as Albuquerque) would enhance federal responses to the demographic evolution that the United States is undergoing.

Initiation of Research and Demonstrations by CMS on URM Relationships to the Medicare and Medicaid Programs

Although DHHS’ Health Care Financing Administration (now CMS) waxed and waned over time regarding Medicare and Medicaid waiver authority, there seems to be greater receptivity at this time to demonstrations in both programs. CMS can grant waivers applicable to both Medicare and Medicaid regarding provider reimbursement, prospective payment, and social health maintenance organization projects. Under Medicaid



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