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ACCESS TO HEALTH CARE SERVICES AND MEDICAL CARE

The single greatest health care challenge facing the Puerto Rican community in the mainland is "reasonable" access to health care services. Despite a number of past and current programs by federal and state government as well as industry, there is a growing cohort of Puerto Ricans who lack any access to many basic health care and human services. This is manifested, in part, by "excess" morbidity and mortality for many diseases, and the sad fact that often times the hospital emergency ward is the routine environment in which Puerto Ricans experience the United States' health care delivery system.

The recent outbreak of measles epidemics, a preventable disease, with deaths from this disease in Puerto Rican communities, represents a very serious problem. We have a startling juxtaposition of high tech expensive medical services for many in America, while even "basic" preventive immunizations are foregone for others. While this phenomenon is not new, it is worsening.

Physician Services & Health Manpower

A growing number of Puerto Ricans have limited availability for physician services. Despite an increase in aggregate physician supply in the United States to 650,000 in 1990, the number of physicians working in underserved Puerto Rican areas in the mainland remains remarkably low. Throughout the last two decades a number of programs have targeted strategies at improving physician services for Puerto Ricans; unfortunately, these programs have had only limited success for a variety of reasons. A new direction in health care policy is essential in addressing health manpower needs for Puerto Ricans.

Certain traditional health manpower programs of the past could perhaps be revisited: for example, student loan programs and give-back arrangements for physicians working in underserved Puerto Rican areas. One of the most promising of these new strategies for the United States would be to develop a large "nurse practitioner corp." This strategy would utilize an existing cohort of culturally sensitive nurses, perhaps 50,000 of the 1.6 million nurses, who would be retrained and directed as "nurse practitioners" into underserved Puerto Rican locales. This strategy would require the implementation of programs to train, empower, supervise, and finance this labor pool.

Hospital Care & Ambulatory Services

Aggregate spending on hospital inpatient care has increased dramatically during the last two decades. Puerto Ricans, however, have not enjoyed a full return on these expenditures. The majority of acute hospital inpatient care for Puerto Ricans are for emergency generated admissions to the hospital. Hospitals have been only marginally successful at redirecting some of the large inpatient funding stream into programs designed at ambulatory and/or community based health care delivery.

Most worrisome for Puerto Ricans is the continued decline in the availability of "user friendly ambulatory health care services which incorporate culturally sensitive and, at times, bilingual programs for Puerto Ricans. Also problematic is the lack of outpatient care which, along with other social and economic factors, leads to a greater severity of illness with regards to inpatient admissions for Puerto Ricans.

Rapid expansion of ambulatory health services is needed. There are a number of strategies which may accomplish this goal. Using managed care models, redirecting and retraining groups of physician extenders and nurse practitioners into Puerto Rican areas could be effective. Moreover, significant fiscal incentives are needed to encourage outpatient health care delivery and to download certain services from the hospital based setting.

Quality of Health Services and Medical Care

The quality of medical care for Puerto Ricans is marginal. There are two major issues here: 1) the health care infrastructure, i.e. the existing base of hospital, physicians, and outpatient services, is limited when dealing with the health care needs of Puerto Ricans; and 2) inadequate services are reflected, in part, by an excess morbidity and mortality for many medical disorders found within the Puerto Rican community.

The merging of quality of care data and health outcomes research would be extremely valuable in tracking changes in health care delivery and quality or outcome. Data to measure such criteria must be developed for Puerto Ricans as well as other Hispanic communities.

Cost of Medical Care

Aggregate costs of medical care continue to increase at a much greater rate than real GNP growth. Strategies at cost containment, in the aggregate, have not been successful during the last two decades. This increasing health care bill and the lack of successful cost containment has had two serious effects on Puerto Ricans.

First, medical out-of-pocket expenditures for Puerto Ricans have increased relative to family income and have had a greater impact on Puerto Ricans compared to the nonHispanic population at large. This is due to lower average family incomes for Puerto Ricans. A second significant impact of this medical cost inflation is reflected in a decrease in relative program dollars, for those tax supported programs, which has not kept pace with demand. The impact of spiralling health care costs have been doubly serious for Puerto Ricans. Thus, significant fiscal incentives are needed to encourage outpatient care delivery, and download certain services from the hospital based setting.

AIDS and Drug Abuse

In the midst of this health care delivery strain for Puerto Ricans, comes a lethal and costly disease, AIDS. Data suggest that the AIDS pandemic is growing rapidly among the Puerto Rican population. Again, the number of AIDS cases in the Puerto Rican community is increasing for women and children in addition to substance abusers. Drug abuse continues to plague many Puerto Rican communities.

This presents a challenge to the current health care delivery system. Targeted resources will be needed for AIDS prevention, education, and treatment for Puerto Ricans. New programs designed to halt the spread of drug abuse which utilize the resources of churches, schools and the private sector are necessary.

ADDITIONAL RECOMMENDATIONS

An emphasis on primary and preventive services (including comprehensive reproductive services) to help move the focus of the health care system away from treating illness and toward maintaining good health;

Greater services for infant care and childhood immunizations;

Support services needed by low income families and children with special health care needs. Such services may include home visiting, respite care, early intervention, social work, nutritional services, and language translation assistance;

Funding for health care providers, such as community health centers, which attend
to the needs of underserved populations;

Medical services which include mental health and substance abuse treatment services;
Support for hospitals and clinics with staff who understand the distinctiveness of the
Puerto Rican community and who are culturally sensitive to Puerto Rican issues, such
as kinship and family; and

An increase in Medicaid benefits provided to residents of Puerto Rico.

CONCLUSIONS

The problem concerning Puerto Rican health care needs in the States has reached epidemic proportions. Access to adequate health care services is the single greatest challenge facing the Puerto Rican community, particularly with regards to physician, hospital, and ambulatory care services. Notwithstanding, the quality of medical care as well as spiralling health care costs are very important issues for Puerto Ricans. The coordination of medical care, emphasis on AIDS and drug abuse, and health manpower requirements for Puerto Ricans in underserved areas can have a major impact on health services in America and thus require immediate attention.

The federal government, specifically the Department of Health and Human Services, should target strategies to address each of these issues in reducing the problems for the Puerto Rican community. Federal support and federal initiatives are needed to improve the health status of Puerto Ricans.

Once again thank you for the opportunity to submit a written statement. Any questions would be welcomed.

Please direct any questions to:
Susan Monaco

Policy Analyst

National Puerto Rican Coalition, Inc.

1700 K Street, NW, Suite 500

Washington, DC 20006

(202) 223-3915, ext. 29

CRAIG THOMAS WYOMING, AT LARGE

WASHINGTON OFFICE:

LONGWORTH HOUSE OFFICE BUILDING
WASHINGTON, DC 20515-5001
(202) 225-2311

Congress of the United States

House of Representatives
Mashington, DC 20515-5001

STATEMENT FOR THE RECORD BY THE HONORABLE CRAIG THOMAS (AL-WY)
HEARING BEFORE THE WAYS AND MEANS SUBCOMMITTEE ON HEALTH

HEALTH CARE SERVICE DELIVERY INFRASTRUCTURE
IN INNER-CITY AND RURAL COMMUNITIES

JUNE 24, 1993 10:00 Α.Χ. 1310-A LONGWORTH

Mr. Chairman, thank you for holding this vital hearing. I appreciate your dedicated efforts in addressing health care reform head on. I'm sure we can all attest to the dilemma facing both rural and urban communities, and the need to reform it cannot be understated.

Rural

Americans spend nearly $900 billion annually on health care. And despite all this expense, costs continue to skyrocket. areas, however, also face the problem of access, which can often be a greater hinderance to quality care than cost itself.

Twenty-five percent of all Americans live in rural areas. The profile of rural populations consists largely of senior citizens and citizens living below the poverty line. They are often self-employed or employed by small businesses and, as a result, are usually left out of the traditional employment-based

The occupations differ vastly from There is higher agricultural and mineral

health insurance system. metropolitan cities. excavation employment

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both highly hazardous.

Rural communities have a difficult time recruiting health care personnel. It is a known fact that practitioners must be generalists and services must be generic. Rural areas are still in the process of rearranging a basic system of care that is available and accessible to all residents.

The health care dilemma in these communities cannot be easily addressed by one "black or white" plan. Some policy experts advocate a nationalized system as the solution for universal access, while others advocate a "managed competition" approach. Neither of these systems, however, is adaptable to the circumstances confronted daily in rural areas.

In our state of Wyoming, we face a severe health professional shortage. We also encounter severe weather conditions that can change without a moment's notice, geographic boundaries that add an extra 100 miles to the drive to the nearest hospital, and virtually no public transportation. care reform to us means more than simply issuing a "health care security card".

Health

There is no set model for all states.

Each community has

its own limitations and any national plan must be flexible enough

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