Letter to the Editor on "Disparities in Health and Health Care..."

The Many Faces of Diversity: Providing Culturally Competent Care

July 30, 2003
in response to Disparities in Health and Health Care: Focusing Efforts to Eliminate Unequal Burdens

Dear Editor:

As an Adult Nurse Practitioner student completing her final clinical rotation in a free community clinic for uninsured adults aged 18-64, I was very glad to read Dr. Baldwin's article "Disparities in Health and Health Care," that is included in the topic of Diversity. Personally, I am seeing the disparities of both health and health care on a daily basis in a patient population composed primarily of African American, Latino, and Pakistani ethnic groups. For example, my clinic cannot refer these indigent patients to local cardiologists or OB-GYN specialists, because these practitioner groups refuse to accept any indigent patients. These particular specialists do not want to absorb the costs of caring for the already complex, chronic health problems of the clinic's indigent patients, problems often resulting from their previous lack of access to health care.

As a provider on the front lines of health care delivery, I, too, am seeing the disparities in health resulting from a lack of access to care as a major problem. I would like to suggest that significant improvement is needed to remove the problem of access to care, or it will continue to be an uphill battle to remedy the disparities of health care. To significantly jump-start the process facilitating access to care, we must remove the burden of obtaining health insurance, which for most people is currently tied to employment, and offer universal health care coverage. We need creative, innovative solutions to push the present system out of its current chaos.

The current literature overwhelmingly supports that the fact that disparities continue in U. S. health care. The uninsured still do not receive the same level of care as the insured (Oberlander, 2002). With increasing numbers of Americans losing work due to the current floundering economy, the number of uninsured Americans continues to rise. The Robert Wood Johnson Foundation (2003) recently reported that 75 million people in the U. S. under the age of 65 were uninsured for some period of time between 2001-2002. Nearly two-thirds of these uninsured adults do not have access to consistent medical care and make less than 200% of the federal poverty line (Kaiser Commission on Medicaid and the Uninsured, as cited by Oberlander, 2002). The United States can no longer afford to sacrifice a major portion of its citizenry to inadequate, substandard access to health care. For all the scientific and technological innovations that represent the best attributes of the U. S. health care system, a general consensus is forming that the system is broken, is not getting better, and is actually hurting the rising number of people who cannot gain consistent access to its services for lack of money. This lack of access is increasing health and health care disparities, as well as health care costs.

The debate for health care reform throughout the later part of the 20th century, including the fiasco of the 1994 Clinton Health Security Act, has currently shifted into two basic arguments: (a) continued but focused incremental reform to universal health care coverage, and (b) change to a single-payer national health insurance system. The incremental or pragmatic approach, over as long as 7 years, is based on the assumption that a single-payer system would never get through the U. S. Congress (Tooker, 2003). The idea of focused incremental reform is to improve those areas of health care coverage that can be enacted into current legislation, such as expanding existing public insurance programs or providing tax credits to the uninsured for the purchase of private health insurance (Oberlander, 2002). However, extending health care coverage incrementally will continue to increase costs and spending while creating a multi-tiered, unequal system of care delivery, unless additional resources within the existing system are found and re-allocated (Himmelstein & Woolhandler, 2003). The tax credit proposal is flawed, because the amount of proposed tax credits will not cover the cost of the insurance premiums.

The proposed single-payer national health insurance plan bases its argument on the premise that the current HMO/PPO bureaucracy consumes almost 30% of all the monies designated for health care, a layer of administrative bureaucracy that is uniquely American (Himmelstein & Woolhandler, 2003). By reducing this bulging bureaucracy, an estimated $140 billion could be saved annually, leaving more than enough funding for the uninsured and the underinsured (Himmelstein & Woolhandler, 2003). A recent study evaluating the California Health Service Plan (CHSP) has shown that a single government payer linked to public authority and accountability can effectively finance health care and significantly save on health care spending, while improving the health of the population (Shaffer, 2003). Both politically and fiscally, a national health insurance could not only improve medical care for the poor but also for the majority of insured Americans.

In conclusion, the literature reports that within the health care establishment a new push for universal health coverage could become a reality provided a common ground is built around the previous political divisiveness. For example, recent polls are showing between 1/3 to 2/3 of the American public is responsive to health care reform that includes single-payer national health insurance (Himmelstein & Woolhandler, 2003). A more vocal public discourse needs to occur to bring this issue once again to the forefront of our health care discussions. Providing universal access to health care in America would be a major step in improving and removing the disparities of both health and health care currently reflected in our U. S. health care system.

Carolyn A. Highsmith, BSN, RN
ANP Graduate Student
University of North Carolina at Chapel Hill
Winston-Salem, NC


Baldwin, D. M. (2003). Disparities in health and health care: Focusing efforts to eliminate unequal burdens. Online Journal of Issues in Nursing, 8 (1), 1-13. Retrieved February 3, 2003, from www.nursingworld.org/MainMenuCategories/OJIN/TableofContents/Volume82003/Num1Jan31_2003/DisparitiesinHealthandHealthCare.aspx

Himmelstein, D. U., & Woolhandler, S. (2003). National health insurance or incremental Reform: Aim high, or at our feet? [Electronic version]. American Journal of Public Health, 93 (1), 102-105.

Oberlander, J. (2002). The US health care system: On a road to nowhere? [Electronic version] Canadian Medical Association Journal (CMAJ), 167 (2), 163-168.

Shaffer, E. R. (2003). Universal coverage and public health: New state studies [Electronic version]. American Journal of Public Health, 93 (1), 109-111.

The Robert Wood Johnson Foundation (RWJF). (2003). Special reports: Cover the uninsured week. RWJF News & Events. Retrieved March 24, 2003, from www.rwjf.org/news/special/ctuWeek.jhtml

Tooker, J. (2003). Affordable health insurance for all is possible by means of a pragmatic approach [Electronic version]. American Journal of Public Health, 93 (1), 106-109.