Health Affairs, 26, no. 5 (2007): 1303 doi: 10.1377/hlthaff.26.5.1303 © 2007 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

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Health System

PROLOGUE

Vulnerable Populations And The Health System

The failure of health reformers to overcome these challenges is a perennial source of recrimination and gnashing of teeth. But if the sources of ill health lie largely in economic inequality, the environment, genetics, and personal behavior, how can the health system be expected to deliver remedies? What good would it do, for example, to shift primary responsibility for paying for care either to government or to individuals? Neither of these simplistic scenarios comes near to the roots of the problem of protecting the health of the most vulnerable. Why blame the health system for uninsurance and poor health habits among low-wage workers instead of investigating the deterioration of public education? It may be that health system performance continues to fall short because we continue to look for answers in the wrong places.

The startling variety of viewpoints in the five papers in this section might be attributable to the far-flung origins of the liabilities that patients bring with them through the clinic or hospital door. To begin with, credit Mark Pauly and José Pagán with a holistic approach in their analysis of the communitywide effects of uninsurance—specifically, the negative impact of large coverage gaps on quality and access to care for the insured. Gregg Bloche next offers a penetrating examination of the risks that low-income and disadvantaged workers may face from high-deductible insurance coverage; Katherine Baicker and colleagues follow with an equally articulate explication of the advantages that reduced premiums may confer in high-deductible plans. Although cost-control policies are designed to make care affordable, Geoffrey Joyce and colleagues find that caps on pharmaceutical benefits—and by implication, the doughnut-hole gap in Medicare Part D—put chronically ill patients at risk for higher out-of-pocket liabilities and potential disruptions of therapy. Finally, Barak Richman argues creatively that policies designed to improve access for disadvantaged populations such as the mentally ill may have perverse consequences if disparities in service use by income and race persist as these policies are implemented.

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