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A Fragmented System

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Vernellia R. Randall
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One of the major problems with the current system is that it is a fragmented system. The current health care system is a puffed-up system providing unnecessary, indulgent services for the privileged, while basic critically needed services for the disadvantaged are rationed and often unavailable(122) Unfortunately, the Health Security Act continues the fragmentation of an inadequate infrastructure(123) Such inadequate infrastructure might not be so bad if the Health Security Act delivered on the Clinton administration's promises of universal coverage for comprehensive benefits. However, for ethnic Americans the Act provides less than universal coverage, and the benefits are not comprehensive enough(124) A. Continuation of Inadequate Infrastructure

Despite the apparent importance of economics as a barrier to access to health care, the unavailability of providers and facilities from which to obtain health care is equally as devastating. Even persons with the ability to pay may not have quality health care(125) In fact, the more inaccessible the providers and facilities, the more likely the person will, at a minimum, delay seeking care(126) Certainly, providers and facilities are not accessible if they are not located near the population they are intended to serve. Moreover, even if they are located in the community, they are unavailable if they refuse to accept patients. Both rural communitie(127) and inner city communitie(128) have significant problems with access due to inadequate infrastructure(129) The Act does not require states, regional alliances or health plans to strengthen the bare-bones health care infrastructures in the nation's inner- city and rural areas. Rather, the HSA relies on temporary contracting provisions with essential community providers, grants and loans by HHS for public health and rural health initiatives, expansion of responsibility of academic health centers, and training grants for health care professionals. None of these methods will prove adequate.

1. Essential Community Providers

130) Unfortunately, the requirement for health plans to contract with essential community providers applies only for five years(131) While the Act contemplates the possible extension of this provision, it is uncertain and subject to the political process(132) Consequently, the essential community providers provisions are inadequate precisely because of the temporary nature of the protection. The historical problem of inadequate infrastructure will not be relieved in five years, especially if health care plans have to assure culturally competent care. Health care plans should be required to contract with 'essential community providers' so long as there are an inadequate number of culturally appropriate health care providers in the community. Without such provisions, the protection of essential community providers will not be translated into culturally appropriate health care for ethnic Americans.

The HSA does provide some resources for essential community providers to become competitive participants against corporate health insurance(133) Furthermore, it attempts to eliminate the problem of providers who do not want to serve ethnic American communities because of a disparity in reimbursement rates(134) The HSA does so by creating a 'blended rate.(135) To the extent that this 'blended rate' will encourage plans and providers not to make distinctions based on reimbursement rates, it is critical to assuring equity in the system.

Nevertheless, regardless of the merit of these provisions, they are inadequate. They attempt to induce health plans by monetary incentive to focus on the provision of services to ethnic Americans, rather than requiring such behavior. Furthermore, there is no language specifying ethnic American inclusion, participation or set-asides in the grants, contracts or loans(136) Without such language, it is likely that those best able to serve their communities will be included in only a minimal capacity. With the temporary and waivable protections for essential community providers and the lack of specific affirmative action contracting goals, the Act gives only a superficial effort to protecting the pool of health care providers that traditionally serve ethnic Americans.
2. Public Health and Rural Infrastructure

Nothing in the HSA indicates that the public health structure for delivery of services will be preserved, expanded or revitalized. In fact, health reform shifts the emphasis away from the direct delivery of health services. Instead, it redirects the emphasis of public health to health-related data collection, surveillance and outcomes monitoring(137) protection of environment, housing, food and water(138)investigation and control of diseases and injuries(139) public information and education(140) accountability and quality assurance(141)

laboratory services(142) training and education(143) and leadership, policy development and administration(144) While these are important and necessary functions of public health, so is service delivery. The public health system developed as a result of the failure of the private sector to provide health services to the poor, to the underserved and to ethnic Americans. It is improbable that private corporations and voluntary health care organizations will build health care infrastructures in ethnic American, poor or rural communities. Thus, it is unlikely that private corporations and voluntary health care organizations can replace health care provided by the existing public health infrastructure. Apparently, recognizing this, the HSA provides for funding for community and migrant health centers(145) for initiatives to improve health care access(146) and for the development of plans and networks(147) Also, the Act proposes a number of measures to assure health care in medically underserved rural areas(148) Notwithstanding the positive aspects of the public health and rural initiatives, they still present issues of concern. First, the funding of the initiatives requires special federal appropriations after the year 2000(149) Given political realities, it is unclear whether Congress will continue to fund special appropriations for public health initiatives as the cost of the Act becomes apparent. However, one thing is certain: in five years, the health care infrastructure needed by ethnic Americans will not be in place.

Second, the public health initiatives are just another set of grudgingly given 'special programs' for disadvantaged and poor people. They constitute a tacit acknowledgment of the failure of this health reform, since special programs for ethnic Americans and the poor inevitably become programs that the European American middle class resent(150) Thus, the 'special programs' approach preserves a multi-tiered health care system, and such a system necessarily results in an unequal and unjust system. Thus, the Act fails to create a truly universal unitary health system designed to meet the needs of all Americans. Arguably, the HSA restructures and reforms a system without changing the worst aspect of it. That is, the Act proposes a system that is a 'complex matrix of stigmatized special programs and categorical grants.(151) 3. Academic Health Centers

The Act appears to be structured around the provisions of services in existing facilities. Although there are some provisions for the development of infrastructure outside of the discretionary grants by HHS, the HSA does not appear to contemplate the building of additional hospitals or clinics. This is unfortunate since prior hospital closure decisions have been made by a 'patently imperfect market' and have affected ethnic American and poor communities disproportionately(152) Rather, the Act contemplates extending health care by requiring academic health centers to extend their programs in primary care to inner city and rural areas(153) No doubt, these provisions could improve access to health care in ethnic American communities. But they will do so only if provisions are made for meaningful transportation and provider hours for inner city and rural residents. Furthermore, these linkages will prove beneficial only if the advisory and policymaking levels within the academic health centers are reflective of rural and ethnic American communities, and only if the academic health centers are required to provide culturally competent care.

Unfortunately, while the HSA provides incentives for academic health centers to establish outreach into ethnic American communities, they are under no requirement to provide culturally competent care or community participation. Furthermore, the financial incentives to the academic health centers produces the same stigma of making the provision of services to ethnic American communities outside the 'normal' expectation of academic health centers. The Act should mandate that academic health centers include community-based goals that center on health, community participation and education. Furthermore, academic health centers must be forced to have ethnic Americans represented at advisory and policymaking levels within the academic health centers. Finally, academic health centers must be required to provide culturally competent care.
4. Training of Health Care Professionals

The HSA establishes the National Council on Graduate Medical Education to control nationally the number of individuals who can enroll in medical programs(154) Even though the Act contemplates training participants who are members of racial or ethnic minority(155) it does nothing to assure the viability of the primary source of black health care professionals- historically black schools. Historically black medical schools provide an irreplaceable means of providing access to culturally appropriate care to African Americans(156) Even though these institutions are financially and structurally threatened, the HSA makes no specific provision for sustaining or strengthening their roles(157) Without sufficient measures to assure the development of an adequate infrastructure, ethnic American and poor communities face the disconcerting prospect of depending on private, competitive for-profit health providers for culturally competent health care. Access to health care requires actual services provided by physicians and hospitals. But, many physicians and hospitals are reluctant to serve ethnic Americans(158) Within a professional culture that is reluctant to serve ethnic Americans and poor communities, universal coverage, by itself, will not 'appreciably redistribute the physician supply' in a way that would significantly improve access(159) In sum, infrastructure barriers, separate and distinct from the issue of financing, are not adequately addressed, and the promise of universal coverage is not a promise of equality of care(160)

B. Lack of Universal Coverage

The plan maintains a fragmented system by excluding large segments of the population, keeping them outside of the main system. Specifically, undocumented aliens(161) Medicare recipients(162) prison populations(163) employees of eligible corporate alliance sponsors(164) military personnel and families(165) veteran(166) and Indian(167) are all either excluded or kept outside of the main system.

These exclusions are problematic for several reasons. First, the exclusion of a large number of individuals threatens the financial integrity of the main health system by producing inefficiencies and duplications(168) Second, the exclusion of some individuals inevitably causes discrimination, because someone must determine who is not covered. Consequently, providers and facilities may use skin color or language as a de facto method of determining eligibility for citizens who do not have health security cards(169) Finally, a significant portion of ethnic American males will not be in the system since prison populations are specifically excluded and military personnel and veterans may opt out. This is particularly troubling because the HSA does not assure that individuals in alternative systems will receive at least the same comprehensive services. 122. FN122. Byrd & Clayton, supra note 69, at 21-22.

123. FN123. See infra part III.A.

124. FN124. See infra part III.B.

125. FN125. See generally Arnold S. Relman, Controlling Costs by 'Managed Competition'-Would It Work?, 328 New Eng. J. Med. 133 (1993).

126. FN126. See generally Randall, supra note 79, at 146-60; Sidney D. Watson, Health Care in the Inner City: Asking the Right Question, 71 N.C. L. Rev. 1647 (1993).

127. FN127. One-quarter of the U.S. population, about 65 million persons, resides in rural areas. Rural Americans face unique health needs which require access to local health care. Charles Marwick, Educating Farmers, Physicians Who Treat Them, About Rural Life's Potential Health Hazards, 261 JAMA 343 (1989); Ross M. Mullner et al., New Report Cites Rural Health Problems, Needs, 107 Pub. Health Rep. 486 (1992); Ross M. Mullner et al., Rural Community Hospitals and Factors Correlated with Their Risk of Closing, 104 Pub. Health Rep. 315, 316 (1989) (hereinafter Mullner et al., Rural Community Hospitals). However, rural Americans do not have access to as many or as wide a range of health care services as suburban Americans. The health care of rural Americans is restricted both because of the lack of medical providers and the lack of health care facilities. In 1986, rural areas had 44% fewer physicians than cities. C. Neil Bull & Share DeCroix Bane, Growing Old in Rural America: New Approach Needed in Rural Health Care, 365 Aging 18, 20 (1993); cf. David A. Kindig & H. Movassaghi, The Adequacy of Physician Supply in Small Rural Communities, 8 Health Aff. 63-76 (1989); Joseph P. Newhouse et al., Where Have All the Doctors Gone?, 247 JAMA 2392, 2393 (1982); William B. Schwartz et al., The Changing Geographic Distribution of Board-Certified Physicians, 303 New Eng. J. Med. 1032 (1980). Very small rural counties had 112 fewer physicians per county than the national average. Shawn Tully, America's Painful Doctor Shortage, 126 Fortune 103 (1992). In fact, in 1992, the Department of Health and Human Services estimated that more than 100 U.S. counties had no physicians. Id. The shortage of providers is so severe that in some communities essentially all medical practices are closed to new patients. Id. Many communities have no training programs and find it extremely difficult to recruit providers. Stephen J. Pearson, Health Care for Uninsured and Underinsured Children: Letter to the Editor, 145 Am. J. Dis. Child 1085 (1991). In 1988, there were 2,549 rural community hospitals. David G. Whiteis, Hospital and Community Characteristics in Closures of Urban Hospitals, 1980-1987, 107 Pub. Health Rep. 409 (1992) (citing American Hospital Association, Hospital Statistics, 1989-90 (1990)).During a seven year period, estimates of hospital closures ranged from 161 to 200. See Bull & Bane, supra, at 20 (reporting 190 rural hospital closing between 1981 and 1988); Tully, supra, at 103 (reporting over 200 hospitals closed between 1987 and 1992); Mullner et al., Rural Community Hospitals, supra, at 318 (reporting 161 hospital closings between 1980 and 1987).

The reasons for rural closings are complex, and include the disproportionate impact of Medicare's prospective payment system on rural hospitals. However, the lack of available physicians is another story. Many rural communities are unable to replace physicians who retire or leave. 'You can have a physician without a hospital, but you cannot have a hospital without a physician.' Emily Friedman, Analysts Differ Over Implications of More Hospital Closings Than Opening Since 1987, 264 JAMA 310, 313 (1990). Other health services are also in short supply, including nursing homes, allied health care professionals, nurses, health technology personnel, dentists, physical therapists, pharmacists and opticians. In fact, inpatient psychiatric services are 'virtually nonexistent' in rural communities. Bull & Bane, supra, at 21. Thus, a rural person's ability to obtain (e)qual(ity) health care is severely impaired by the serious lack of infrastructure for the delivery of care.

128. FN128. Ethnic Americans and poor Americans who live in inner cities are similarly affected by the lack of infrastructure. As in rural communities, many hospitals and primary care clinics have been forced to close. Boger, supra note 75, at 1330. Many hospitals have abandoned the inner city and moved to more lucrative suburban areas. Between 1980 and 1989, of the 508 general acute care hospitals that closed, 256 were urban. Friedman, supra note 127, at 310. Hospital closures left many communities stripped of any available resource. For instance, the 'entire north side of St. Louis, parts of Philadelphia, and even sections of New York City are virtually devoid of hospital care.' Id. at 313. Although surviving hospitals often maintain that patients may find 'a safe harbor there,' the reality is that disabled individuals and individuals 'with linguistic, cultural, geographic, or finanical access problems are less able to find substitute care.' Id. (quoting Alan Sager, Associate Professor at the Boston University School of Public Health).

The inadequate infrastructure also has to do with the lack of physicians practicing in the inner city. This lack of infrastructure is due both to physicians who have moved their practices from inner city communities and to the shortage of physicians trained in primary medicine. See generally Watson, supra note 126, at 1649-50. In 1961, 50% of U.S. doctors were primary care providers; by 1990 that figure had dropped to 33%. Marc L. Rivo & David Satcher, Improving Access to Health Care Through Physician Workforce Reform, 270 JAMA 1074-78 (1993). In a study performed by the Council on Graduate Medical Education, projections indicate that the number of primary care providers will continue to decline. John M. Eisenberg, Economics, 270 JAMA 198-200 (1993). The lack of providers and facilities from which to obtain health care is equally as devastating as economic barriers, and providing universal coverage will not, by itself, remove all infrastructure barriers.

129. FN129. See infra notes 137-51 and accompanying text.

130. FN130. Basically, each health plan must enter into a provider participation agreement with essential community providers. HSA s 1431(a). The agreement provides that the plan shall make payment to the provider. Id. s 1431(c). The participation agreement between the health plan and an essential community provider shall provide that the health plan agrees to treat the provider at least as favorably as other providers. Id. s 1431(b). In particular, the agreement must be similar with respect to the scope of services for which payment is made by the plan to the provider, the rate of payment for covered care and services, the availability of financial incentives, limitations on financial risk provided, assignment of enrollees, and access by the provider's patients to providers in medical specialties or sub-specialties participating in the plan. Id. Essential community providers are not merely any providers serving in underserved areas but those that have been certified by HHS. The Act provides that any of the following health care providers or organizations can be certified as an essential community provider: a migrant health center; a community health center; a homeless program provider; a public housing provider; a family planning clinic; an Indian health program; an AIDS provider under the Ryan White Act, 42 U.S.C. s 300ee-3 to -12 (1991); a maternal and child health provider; a federally qualified health center; a rural health clinic; a provider of school health service; or, a community practice network. Id. s 1582(a)(1)-(11). Other categories of health care providers and organizations may also be certified as essential community providers. Id. s 1583(a). An essential community provider who is aggrieved by the failure of a health plan to fulfill a duty imposed by the HSA may commence a civil action against the plan. Id. s 5240(a). If the court finds that the health plan has failed to fulfill its duty, the essential community provider may recover compensatory damages, other appropriate relief, and reasonable attorney's fees, including expert fees. Id. s 5240(b), (c).

131. FN131. Specifically, it applies during the five-year period beginning with the first year in which any health plan is offered by an alliance. Id. s 1432(a).

132. FN132. The Act authorizes the preparation of recommendations regarding essential community providers, including studies that assess the definition of essential community providers, the sufficiency of the funding levels for providers, the effects of contracting requirements relating to such providers, the effects of contracting requirements on such providers, health plans, and enrollees, the impact of the payment rules for such providers, and the impact of national health reform on such providers. Id. s 1432(b). Congress will decide whether and to what extent to continue requiring the health care plan to contract with essential community providers. Id. s 1432(c).

133. FN133. The HSA provides for regional alliances to encourage the development of plans to serve areas that have inadequate health services. In particular, a regional alliance may encourage the establishment of new health plans in an area that has inadequate health services. Id. s 1329(b). Health alliances may encourage the development of community plans by organizing health providers to create a plan, by providing assistance with setting up and administering such a plan, and by arranging favorable financing for such a plan. Id. Furthermore, the Act authorizes the use of federal funds to improve the infrastructure for urban and rural medically underserved populations. Id. s 3411. In particular, the funding is to be used to facilitate transition to a system in which medically underserved populations have an adequate choice of community-oriented providers and health plans; to promote the development of community practice networks and community health plans that integrate health professionals and health care organizations supported through public funding with other providers in medically underserved areas; to support linkages between providers of health care for medically underserved populations and regional and corporate alliance health plans; to expand the capacity of community practice networks and community health plans in underserved areas by increasing the number of practice sites and by renovating and converting substandard inpatient and outpatient facilities; to link providers in underserved areas with each other and with regional health care institutions and academic health centers through information systems and telecommunications; and to support activities that enable medically underserved populations to gain access to the health care system and use it effectively. Id. Finally, the Act allows HHS to make grants and to enter into contracts with consortia of providers for the development of qualified community health plans and qualified community practice networks. Id. s 3421.

134. FN134. See infra notes 144-50 and accompanying text.

135. FN135. HSA s 1351(a).

136. FN136. Minority 'set-aside' is a term that refers to both public and private sector efforts to reserve a predetermined percentage of benefits and opportunities for racial minorities. Set-asides are most often associated with public construction dollars, where a general contractor working on a public building project must devote a certain percentage of the bid price to minority sub-contractors. See Richmond v. J.A. Croson Co., 488 U.S. 469 (1989) (minority set-asides for municipal contractors); Fullilove v. Klutznick, 448 U.S. 448 (1980) (federal minority set-aside program in construction industry); see also Wygant v. Jackson Bd. of Educ., 476 U.S. 267 (1986) (formula for preserving employment for minority teachers during district-wide layoffs); Cliff Hocker, Richmond Enacts New Set-Aside Law, Black Enter., Aug. 1993, at 24.

137. FN137. The health-related data collection, surveillance and outcome monitoring function of public health provides for regular collection and analysis of information on key dimensions to ensure timely awareness, decisions and interventions related to epidemics, emerging patterns of disease and injury, prevalence of risks to health, and outcomes of personal health services. HSA s 3312(b)(1).

138. FN138. The public health functions related to enforcement focuses on air pollution, including indoor air, exposure to high lead levels, water contamination, handling and preparation of food, sewage and solid waste disposal, radiation exposure, radon exposure, noise levels and abatement, and consumer protection and safety. Id. s 3312(b)(2).

139. FN139. The public health functions that focus on investigation and control of diseases and injuries include improvements in emergency treatment preparedness, cooperative activities to reduce violence levels in communities, activities to control the outbreak of disease, exposure related conditions and other threats to the health status of individuals. Id. s 3312(b)(3).

140. FN140. The public information and education function of public health focuses on mobilizing communities and motivating individuals to reduce risks to health such as tobacco use, abuse of alcohol and other drugs, sexual activity that increases vulnerability to HIV infection and sexually transmitted diseases, inadequate nutrition, physical inactivity and childhood immunization. Id. s 3312(b)(4).

141. FN141. The accountability and quality assurance focus of public health functions includes monitoring the quality of personal health services furnished by health plans and providers of medical and health services in a manner consistent with the overall quality of care monitoring activities undertaken under Title V of the Health Security Act and monitoring communities' overall access to health services. Id. s 3312(b)(5)

142. FN142. Laboratory services include the provision of individual testing and pathology services (including the system of state laboratories that screen for metabolic diseases in newborns), providing toxicology assessments of blood lead levels and other environmental toxins, diagnosing sexually transmitted disease and tuberculosis requiring partner notification, testing for cholera and other infections or food-borne diseases, and monitoring the safety of water and food supplies. HSA s 3312(b)(6).

143. FN143. The training and education function of public health focuses on ensuring adequate training with special emphasis on public health professionals such as epidemiologist, biostatisticians, health educators, public health administrators, sanitarians and laboratorians. Id. s 3312(b)(7).

144. FN144. Leadership, policy development and administration activities focus on defining health goals, standards and policies, and the development of health coalitions. Id. s 3312(b)(8).

145. FN145. Id. ss 3401, 3402.

146. FN146. Id. s 3411. The funding is intended to provide a program of grants, contracts and loans and will 'facilitate transition to a system in which medically- underserved populations have an adequate choice of community- oriented providers and health plans.' Id. It will do so by promoting 'the development of community practice networks and community health plans that integrate health professionals and health care organizations supported through public funding with other providers in medically underserved areas.' Id. It is also intended 'to support linkages between providers of health care for medically underserved populations and regional and corporate alliance health plans. The funding will be used to expand the capacity of community practice networks and community health plans in underserved areas by increasing the number of practice sites and by renovating and converting substandard inpatient and outpatient facilities.' Id. It will also 'link providers in underserved areas with each other and with regional health care institutions and academic health centers through information systems and telecommunications.' Id. Finally, it will be used 'to support activities that enable medically underserved populations to gain access to the health care system and use it effectively.' Id.

147. FN147. Id. s 3421. The funding is intended to remove barriers to health care and to assist communities that include a substantial number of individuals who have a limited ability to speak English to assure culturally competent care. Id. s 3421(d), (e).

148. FN148. The Act attempts to ensure health care for rural Americans by requiring alliance areas to serve rural areas, by providing investment in rural infrastructure, by creating incentives to expand rural community-based networks and plans, by providing investments for the development of the health workforce, and by providing for the expansion of the rural public health system. The Act recognizes rural health clinics as essential community providers. See supra note 130. In addition, the HSA allows HHS to make grants to establish rural information and referral systems, and it allows HHS to make grants to carry out activities to provide rural health care. Id. s 3132. The Act authorizes funding for projects to train more primary care physicians and physician assistants, including expanding the supply of physicians with special training to serve in rural areas. Id. s 3062. Finally, The Act amends the Social Security Act's Anti-Fraud and Abuse provisions to allow more favorable provisions for rural providers. The HSA amends s 1877(d)(2) of the Social Security Act, which limits physician self-referrals, 42 U.S.C. s 1395nn(d)(2) (1988 & Supp. V 1993), by allowing exceptions for rural physicians where at least 85% of their services are furnished in rural areas, rather than 'substantially all.' HSA s 4042(e). Section 1877(e)(4) (relating to physician recruitment) is amended to limit the exception to entities located in rural areas, areas with a shortage of health professionals, or an entity in which 85% of patients are members of medically underserved populations. Id. s 4042(f)(4).

149. FN149. The Act provides appropriation for the development of qualified community health plans and practice groups, and community and migrant health centers through fiscal year 2000. Id. ss 3412(a), 3401(b).

150. FN150. Byrd & Clayton, supra note 69, at 22.

151. FN151. Byrd & Clayton, supra note 69, at 24-26. As noted by one author:

Arranging care for those who are least well off is a matter of how best to integrate them into a system of universal access. . . . (S)pecial attention should be paid to the impact on the least well off. Will the proposed system work for them? Will it address, for example, the higher rates of disease and disability among those of lower socioeconomic status? Does it recognize and take into account flawed educational and transportational infrastructures, cultural and linguistic barriers, the stigmatization of certain diseases and lifestyles and so forth? Reform in light of the intrinsic value of helping the least well off means starting reconstruction, so to speak, from the bottom up rather than from the top down.

Dougherty, supra note 73.

152. FN152. Friedman, supra note 127, at 5 (quoting Robert Van Hook, Executive Director of the National Rural Health Association).

153. FN153. Regional and corporate health alliances must ensure that health plans enter into sufficient contracts with academic health centers to ensure that enrollees receive the specialized treatment expertise of such centers. HSA s 3131(a). More importantly, HHS has the authority to 'make grants to (academic health) centers for the establishment and operation of information and referral systems to provide the services (to rural health plans).' Id. s 3132(a). Furthermore, HHS may make grants to academic centers to carry out activities which provide the services to residents of urban communities who otherwise would not have adequate access to such services. Id. s 3132(b).

154. FN154. HSA s 3011. The HSA designates the specific composition of the National Council. Unfortunately, nothing in the Act requires the appointment of ethnic Americans. Id. s 3001.

In the case of each medical specialty, the National Council shall designate for each academic year the number of individuals nationwide who are authorized to be enrolled in eligible medical programs. Id. s 3012(a). Specifically, the Act requires that the percentage of individuals enrolled in primary health care is not less than 55%. Id. s 3012(b)(1). Furthermore, for each medical specialty, the National Council is authorized to make annual designations for periods of three academic years. Id. ss 3012(b)(1), 3013. In making the designation, the National Council shall consider the incidence and prevalence of the diseases, disorders or other health conditions with which the specialty is concerned, the number of physicians who will be practicing in the specialty in the academic year, and the number of physicians who will be practicing in the specialty at the end of the five-year period beginning on the first day of the academic year. Id. s 3012(d)(1).

155. FN155. Significantly, the HSA requires the National Council to consider the extent to which each program trains members of racial or ethnic minority groups when making allocations for eligible programs. Id. s 3013(c)(2)(A). 'With respect to a racial or ethnic group represented among the training participants, the extent to which the group is underrepresented in the field of medicine generally and in the various medical specialties,' is considered. Id. s 3013(c)(2)(B). Furthermore, the Act provides funding for primary care physician and physician assistant training. Id. s 3031(b). This includes supporting projects to train additional primary care providers and to increase the number of physicians capable of serving medically underserved rural and inner city areas. Id. The Act includes a provision for the training of ethnic Americans. Id. The programs include: supporting projects to increase the number of underrepresented minority and disadvantaged persons in medicine, osteopathy, dentistry, nursing, public health and other health professions; financial assistance for underrepresented minority and disadvantaged persons in health professions training programs; and funding for recruitment and retention of underrepresented minority and disadvantaged persons in the health professions. The funding can be used to maintain efforts to foster interest in health careers among such persons at the pre-professional level and to increase the number ofminority health professionals in faculty positions. Finally, it includes funds for training providers to supply culturally sensitive care. Id.

156. FN156. For instance, by 1980, three-fourths of all of Meharry's graduates had gone on to practice in underserved rural and inner city communities. Marsha F. Goldsmith & Charles Olson, Minority Physician Training: Critical for Improving Overall Health of Nation, 261 JAMA 187 (1989).

157. FN157. The HSA authorizes the limitation on the number of individuals who can be enrolled in medical programs. HSA s 3012(a). The Act also provides for the allocation of training spots among medical specialties. Id. s 3013(a).

158. FN158. Eli Ginzberg & Miriam Ostow, Beyond Universal Health Insurance to Effective Health Care, 265 JAMA 2559 (1991).

159. FN159.

New York City has operated a major health and hospital system . . . committed to providing care to everyone, regardless of ability to pay. Accordingly, New Yorkers may be said to have had universal coverage for almost a century. . . . (The Health and Hospitals Corporation of New York) is faced with severely overcrowded conditions stemming from significant increases in AIDS, psychiatric, and drug-abuse patients; a lack of available discharge options for patients occupying acute care beds unnecessarily; and bed closings due to shortages of key staff such as nurses and social workers.

Ginzberg & Ostow, supra note 158, at 2559.

160. FN160. Ginzberg & Ostow, supra note 158, at 2559. As reported in one newspaper:

With President Clinton trying to give all Americans health insurance,places like the Washington Free Clinic might be expected to be getting ready to go out of business. But the Clinic volunteers who work out of a transformed church choir loft are not planning to pack up anytime soon. Their patients are the ones who often fall through the cracks of the existing health care system. . . . And many of these people, even strong supporters of the Clinton health plan admit, will still be out in the cold after the plan.

Clinics for Poor Expect to Continue Being Needed, N.Y. Times, Sept. 20, 1993, at B6.

161. FN161. HSA s 1005(a).

162. FN162. Id. s 1001(d).

163. FN163. Id. s 1001(e).

164. FN164. Eligible sponsors of corporate alliances include large employer, multi- employer plan sponsors, rural electric cooperatives and rural telephone cooperative associations. A large employer is one that has more than 5,000 full-time employees in the United States. Id. s 1311(b).

165. FN165. The Act allows military personnel and families to elect the Uniformed Services Health Plan rather than a plan through a regional alliance HSA s 1004(b)(1).

166. FN166. Veterans and families may elect a veterans health plan rather than a plan through a regional alliance. Id. s 1004(b)(2).

167. FN167. The HSA permits eligible individuals to elect the Indian Health Service rather than a plan through a regional alliance. Id. s 1004(b)(3)

168. FN168. Byrd & Clayton, supra note 47, at 5.

169. FN169. A health security card is issued to each eligible individual by the alliance in which he or she is enrolled. HSA ss 1001(b), 1324, 1383.

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Professor Vernellia R. Randall
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The University of Dayton School of Law
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