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Show "A significant measure of any reform of the health care system will be that reform's impact on the neediest Americans ~ those who lack the most basic necessities, such as housing and income. Their severely limited access to the current system results in untreated illnesses, prolonging their personal economic woes and ultimately driving up the overall costs of the health care system" (NCHC, 1993). The state of being homeless also increases the risk of diseases of the extremities and of skin disorders. Trauma, especially the result of physical assaults or rapes, is quite high among homeless people. Relatively minor injuries such as foot or hand infections can become major life threatening illnesses if left untreated. Other health problems include malnutrition, parasitic infestations, dental and periodontal disease, and venereal diseases. Standing, sitting, and kneeling, rather than lying down periodically often produces swelling of the ankles and cellulitis. Further, a great number of contusions, lacerations, sprains, bruises and burns become major health concerns if they become seriously infected before the individual is able to seek health care. Prominent chronic health problems among homeless people include hypertension, cardiovascular disease, neurological disorders, podi-atric problems, cancers, and so on. Most homeless people treated at the Fourth Street Clinic, a free clinic operating on the western edge of downtown Salt Lake City, have not seen a regular physician or experienced a regular health care visit for years or even decades until they come in to address a serious infection or a persistent cough. We know that children living in poverty die earlier due, among other reasons, to poor health care. We see older individuals who have been chronic alcoholics for most of their adult lives and are now experiencing a variety of health problems, including kidney and liver malfunctions, and dementia. Many of these individuals are probably not candidates for social or work rehabilitation, but nevertheless must be cared for in the course of health care reform. Out on the streets these men (and increasingly women) are the subjects of muggings and other abuses. Finally, the staff at Fourth Street Clinic are seeing more and more people with HIV/AIDS. People with HIV status come to the clinic both as homosexuals and as intravenous drug abusers. They are on the streets because they have no other place to be. Fourth Street Clinic personnel attempt to address the initial needs of this expensive patient population and help them to move into the greater medical community, particularly in terms of support to gain eligibility to Medicaid, UMAP, and disability pro- grams. Many of these patients qualify for UMAP as the result of their status as having a "life-threatening or contagious disease," but do not find the UMAP Clinic easily accessible. Patients are only eligible for 30, 60 or 90 days, and spend a great deal of time working through the maze of paperwork necessary to maintain their eligibility. These patients often come to the Fourth Street Clinic (even though the state of Utah will pay for treatment of their specific life-threatening problems at other facilities) primarily because Fourth Street has fewer obstacles to obtaining health care. Because of the increased costs of HIV/AIDS patients, TB supervision, and the amount of time spent per homeless patient, health care costs at the Fourth Street Clinic are rising astronomically. This, of course, is happening in the entire health care industry, partially the result of people who are abusing emergency rooms in hospitals because they have no other recourse for medical care. These patients have sought health care too late because they have had little or no access to preventive health care and to health education. While the Fourth Street Clinic alleviates some of these emergency visits, the need is too great for one clinic or agency to handle. A critical perusal of Utah's Health: An Annual Review (1994) reveals a number of interesting issues concerning the provision of health care to homeless people, although this is not an official category of interest in any of the tables presented. In Section I - Data - Health Status tables, from pages 19 through 62, virtually every category is affected by homeless status. Homeless people in Utah have higher mortality rates, higher infant mortality, and higher morbidity rates than the general population. It stands to reason that a place to begin to lower health care costs is among the most needy population. Any real effort to reform health care in Utah, however, will have to include both financial and delivery system issues for homeless people. To be effective, the system will have to address health education, prevention, public health efforts, and primary care to reduce long-term costs. Easy access to care must be assured, regardless of the medical condition, residency, or culturally sensitive issues such as language. By excluding this segment of Utah's population, we must continue to provide an additional mechanism for their health care support, which means duplication of equipment, supplies, personnel, and other necessary costs to keep disenfranchised and marginalized people in another system. Issues of adverse selection and the avoidance of difficult, possibly mentally ill homeless people in the delivery system must be addressed 20 Do We Continue a Two-Tiered Health Care System for People in Poverty? |