Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Response to Scott M. Matheson Lawrence S. Lewin Larry Lewin commented on the well-considered and constructive con- ceptual framework that Governor Matheson presented for thinking about the role and responsibilities of the federal and state governments in relation to the issue of access. He underscored the innovative and productive role that states are currently playing in trying to ameliorate the critical problem of the uninsured and underserved. Mr. Lewin stressed the importance of not equating the provision of universal health insurance coverage with universal access to appropri- ate and timely health care services for all Americans. While the expansion of health care insurance remains an important national objective, delivery systems must be put in place to address the special problems of such vulnerable groups as disadvantaged mothers and chil- dren, the homeless, substance abusers, and those for whom language and cultural barriers may impede access to care even when insurance is available. The major innovations in fashioning delivery systems respon- sive to the special needs of vulnerable target groups have come from the states and localities, not from the federal government. A remaining unmet need in this area continues to be adequate provision of primary and preventive outpatient services. Mr. Lewin referred to a study that his firm had recently completed that looked at 30
the health care patterns of various socioeconomic groups in Washing- ton, D.C. One of the major findings of the study was that lack of sufficient outpatient and outreach services often prevented low-income groups from using the health care system appropriately or cost-effec- tively. Even with national health insurance, local delivery systems must be in place to address the needs of special populations and special service requirements. States can play a key role in improving Medicaid and, with the assistance of the federal government, make this critical program for the poor more equitable in its eligibility and benefits structure. States also have a major responsibility for assuring that the increasingly competi- tive forces in our health care system not exacerbate the access problem. Today competition among hospitals and other provider groups is eroding the implicit subsidies that have in years past made possible the provision of services to the medically indigent. In the absence of universal access, incentives must be maintained for hospitals and physicians to preserve and strengthen their commitment to charity care. Policies and programs to further these worthwhile objectives can best be formulated at the local level. In order to broaden access to affordable health care, more attention will need to be focused on developing minimum benefit standards, a package of services that is adequate, of high quality, and cost-effective. Some level of economic discipline will have to be exercised. There is a natural tendency to begin with a streamlined package of services and proceed to "X-mas tree" it in order to get all the provider groups on board. More research, demonstrations, and consensus building need to be conducted in this crucial area. As Governor Matheson stated, the importance of enhancing the scope of managed care must also be part of this overall effort. Improving the safety net for our less fortunate citizens is a chal- lenge that is surely not beyond our reach. Although discussions like the one we are having this evening will not lead to a magic solution, they play a critical role in informing and energizing the debate, in strength- ening the resolve to turn words into actions. 31
