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Show Do We Continue a Two-Tiered Health Care System for People in Poverty? The Dilemma of Providing for the Health and Medical Needs of Utah's Most Needy Population by Allan D. Ainsworth, Ph.D. and Silvia Corral, M.D. Introduction By July of 1996 the governor of Utah intends to have 95 percent of the state's population enrolled in a managed health care program. This program will be employment-based, will have transportability within the state, and will undoubtedly bring some improvement in health care accessibility for people who are capable of maneuvering within and between currently existing health insurance plans. The governor's plan may also improve some Medicaid recipients' ability to quickly gain access to a panel of health care providers. The other 5 percent-the unsigned portion-will be caught in a medical limbo. These are people who are currently living in poverty, are partially employed, are periodically at highest risk for homelessness, and who will have the greatest difficulty enrolling and functioning in this new system. For several reasons which will be outlined below, people at risk for homelessness, both in Utah and throughout the United States, will be the most difficult population to fit into any managed care plan. Some may argue that managed care is not really designed for this portion of the U.S. population, and therefore, no plan will ever really meet the needs of marginalized peoples. If we accept this argument, then we accept that we must continue a two-tiered system in which people in or near poverty continue to be treated for their health and medical needs in a different system than the rest of the U.S. population. This article discusses some of these difficult dilemmas and offers suggestions for alleviating some of the foreseeable problems in providing for this segment of our citizenry within managed care. Background First, it might be helpful to discuss the problem of provision of health insurance coverage to people in poverty from both a national and a state perspective, since a significant percentage of Utah's homeless population comes from other states. Over 34 million people are currently living in poverty in the United States, one-fifth of whom are children. Different national studies indicate that anywhere between two and five million people are homeless in the U.S. at any given time. This is a frightening statistic when one thinks about who is affected by the condition of homelessness (Buchrach, 1982). By various estimates, about 4,500 homeless people are scattered throughout Utah on any given day. Since there is no real scientific way to accurately count those people who are living in homeless camps, temporarily doubling up with relatives because they cannot afford to pay their own rent, or living in single room occupancy (SRO) hotels, this estimate is known to be an undercount. The count for those who are staying in emergency shelters is somewhat more accurate. Those numbers in themselves are alarming. About 900 to 1,200 people stay in an emergency shelter on any given night in the state of Utah. The majority of these people originate from Salt Lake County (particularly because of the steadily increasing cost of rent in the last three years), or eventually find themselves in that county because there is a greater range of services, and because there is a greater possibility of finding employment which will lead to exiting the condition of homelessness. Salt Lake County accounts for 80 percent or more of Utah's homeless population at any one time. More than 50 percent of homeless people in Utah have lived in the state for more than six months, and are therefore considered to be Utah residents. Because of the state's geographic location there is significant interstate traffic; therefore, a large number of people travel through the state each year on their way to other states, and find themselves stranded here for at least short time periods. Utah is also known nationally for its robust economy. People come here seeking better paying jobs and better opportunities for their families. Between 9 and 11 percent of Utah citizens live at or below the poverty line. This equates to about 56,000 people who are hungry and in need of social services at any given time. It is from this population that the most at-risk people for the state of homelessness come. Current figures indicate that about 65 percent of Utah's homeless population is made up of single men. The remaining 35 percent are women and children. This ratio has changed greatly during the last ten years because more and more women and children are being forced into the condition of homelessness. Utah's Health: An Annual Review 1995 17 |
