Seeking Access
What keeps people
 from getting needed care?
 
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Do-it-yourself access

Few clinicians have direct control over public policy. But with some effort, nurses and allied health professionals can have an impact on access issues if they speak up, experts say.

"Providers are on the front lines," said Mark Rukavina, deputy director for programs and policy for The Access Project, a Boston-based organization funded by the Robert Wood Johnson Foundation that studies access issues nationwide. "They're the people delivering the care and can be very effective spokespeople for change and documenting problems and what's working and what's not working as well."

A lot of times, health professionals are just trying to keep their clinic's doors open, acknowledged Lisa Hasegawa, a public health analyst for Community Voices for Immigrant Health, a joint project of La Clínica de la Raza and Asian Health Services in Oakland, Calif. Though they might not have time to change national or state policies, she said, "they're probably the most informed and best people to be informing [others] what needs to change in the system."

They can also work to make their own facilities more accessible, particularly to those with limited English proficiency, said Linda Okahara, community service director for Asian Health Services. "Managers and administrators should walk through the whole system of trying to access care from the very beginning, in terms of just even calling up for an appointment," she suggested. Then ask yourself, "What are the glitches? What are the challenges of just trying to get basic needs communicated?"

Even if changes can't be made immediately, at least you'll have a sense what needs to be done to improve access, she said.

~ Anne Federwisch, OTR
   

By Anne Federwisch, OTR
Illustration by Hal Pham
September 2, 1999

The best health care in the world is of no use to people who can't access it. And barriers to care affect more than just the individual's health. Ultimately, lack of access becomes a problem for the entire community by affecting public health and straining public funding, experts say.

Blocking the way

"Lack of availability of insurance is one of the barriers to accessing health care," said Afaf Meleis, PhD, RN, FAAN, a professor in the department of community health systems in the School of Nursing at the University of California, San Francisco. Forty-three million Americans lack health insurance, according to most estimates, and another 31 million are underinsured. In Texas, between 4 and 5 million people-about a quarter of the state-lack health insurance, according to Texas Department of Health Commissioner William Archer, MD.

"There is also the barrier of a non-caring system, of a system that is becoming very legalistic and very cost-driven," Meleis added. "Before we ask people what's wrong with them and what can we do, we ask them what insurance they have and are they really eligible to have care. That acts as a barrier."

People with limited English proficiency (about 32 million nationwide) often face additional obstacles, Meleis said. Because of the language barrier, many don't realize that they are actually eligible for insurance, she said, while others can't maneuver through the confusing, fragmented healthcare system.

But even some who know they are eligible for services don't sign up, Archer said. "There's a sort of self-independence in Texas-'I don't want the government to help me.' So a lot of families won't even enroll in Medicaid, even though they might be eligible," he said.

Lisa Hasegawa, a public health analyst with Community Voices for Immigrant Health, a joint project of La Clínica de la Raza and Asian Health Services in Oakland, Calif., agreed. She said that many immigrants don't want to tap into government healthcare benefits for fear of being dubbed a public charge, which could jeopardize their chances of sponsoring relatives' immigration to the United States. "In order to sponsor your relative, you need to show a certain financial viability," she explained. "If you have used government services that are means tested, then in the past it was unclear as to how that would be counted against you."

In May, the Immigration and Naturalization Service issued a clarification "saying that all healthcare benefits are free and clear from any public charge determination," Hasegawa said. However, many immigrants are still unaware of the recent ruling.

Why communities should care

"For people with limited income, health is a luxury," Hasegawa said. "Health care is something they will put off until they absolutely have to go into the doctor." Generally, that doctor is in the ER, said Chris Esperat, PhD, FNP, RN, graduate program director for the nursing department at Lamar University in Beaumont, Texas. "The emergency room in essence becomes the entry point into the healthcare system," she said.

The ER is a costly alternative to preventive primary care, Meleis said. If people could access health care in a timely manner, they could prevent costly complications-a definite boon to their own health, and a financial savings to the community as well, she said. For example, the cost of prenatal care and immunizations is minuscule compared to the cost of complications of pregnancy and preventable diseases.

Community innovation

The ultimate solution could well begin in individual communities, rather than at the national policy level, said Mark Rukavina, deputy director for programs and policy for The Access Project, a Boston-based organization funded by the Robert Wood Johnson Foundation that studies access issues nationwide. "Communities are very innovative," he said. "These are little laboratories for change."

One community program that's increasing access to health care is the Ubi Caritas Clinic, a nurse-managed clinic in Beaumont, said Esperat, who serves as the project director. "Before we had this clinic, there really was no healthcare clinic here," she said. "The only health-related clinic available was a veterinary service."

A family nurse practitioner provides primary care services, and nursing faculty from Lamar University offer case management. Patients are charged on a sliding scale based on income and family size, but no one is denied care because of an inability to pay. The clinic also accepts Medicaid, Medicare, and most insurance.

Esperat said that outreach efforts have been successful because the clinic is geographically accessible, mirrors the community's ethnic make-up, focuses on prevention, and emphasizes continuing care through case management.

Currently funded by grants from the federal government and Episcopal Health Charities, Ubi Caritas is working toward getting a viable mix of insured and uninsured patients so the clinic will be sustainable once the funding runs out, she said.

"People are happy these people are being taken care of," Esperat said. "The hospitals are happy that we're treating these patients so that they don't turn up in their emergency rooms and drain the resources there." And the clients themselves, she said, feel they've finally got an entry point into the healthcare system so they can make health more of a priority and, consequently, less of an emergency.