Out of the Box and Over the Barriers

The dichotomy facing communities as they address health care access issues is that the arena of "health" is a complex combination of financial and social interests, issues, and systems. These elements are so intertwined at the local level that to deal with one without considering the others is to ask for failure.

A community's quality of life, viability of its businesses, and integrity of its health system are interwoven. The population's health status impacts the local workforce, student performance, welfare and other safety nets, and health care costs. The health system impacts business costs and public services. Uninsured populations impact health systems, businesses, schools, public programs, and providers.

The maxim "all health is local" is as true today as it always has been. Much of our health system is determined by federal and state governments, and many health services are delivered through organizations owned and governed outside of the community. However, we still receive our health care in our neighborhoods and local communities, and each community is different from the next in its citizens, values, and organizations.

Federal and state government-designed interventions to address the uninsured focus largely on either tax cuts or entitlement programs. For instance, businesses are offered tax cuts as incentives to offer health insurances benefits, or eligibility requirements for Medicaid are revised, and new entitlements, like the CHIP program, are created. Other federal initiatives address maldistribution issues-Federally Qualified Health Centers receive special levels of reimbursement to allow higher payment to doctors who practice in under-served urban or rural locations; medical education loan forgiveness programs place doctors and nurses in underserved areas.

These externally imposed strategies address either the business of health or its social side, not both. As such, they may alter a community's uninsured programs, but they fall far short of comprehensive solutions that satisfy the financial and social concerns of a unique community. Thus, a community can play a legitimate productive role by taking charge of its own uninsured population and weaving federal, state, and local strategies into a tapestry that covers its unique population.

If you aren't yet convinced of the community's rightful place in crafting local solutions to access to health care, consider that:

• More than 1,600 communities applied for $20 million in grants offered by the U.S. government's Health Resources and Services Administration in 1999.
• Foundations and the federal government are making large amounts of money available to communities to fund innovative local strategies to address the uninsured.

Funds have been made available because there is evidence that communities are capable of addressing this complex issue. It is both the role of the privilege of each community to assert its values and determine how to address the complex issue of people lacking health insurance coverage within its unique array of local circumstances and stakeholders. It is the task of each community to integrate the social and business sides of the uninsured through local partnerships and creative local strategies. It is the role of each community to own and tend the health of its population, and to invest in its health care system. Indeed, only the individual community can do the job in the way that it needs to be done.

When we speak of the uninsured, we are speaking of people who do not have access to insurance coverage for health services. The individuals who make up "the uninsured" do not have health insurances from entitlement programs, self-purchased policies, or employer-sponsored benefits.

Providing insurance for health care addresses one element of access for these individuals-it provides financial coverage. However, there may be other barriers to obtaining health care. For instance, a community resident may have dental insurance, but can find no local dentist who accepts that insurance. That resident has cover, but not access to care.

Your community must thoroughly look at access to health care services and access to payment for insurance or coverage. But, your community also will need to address other barriers to health care access.