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E C O N O M I C D I S P A R I T I E S :
A C C E S S A N D Q U A L I T Y
6 December 2005
A Widening Rift In Access
And Quality: Growing Evidence Of
Economic Disparities
Americans appear willing to pursue excellence for some
while tolerating the deterioration of care for others.
by Robert E. Hurley, Hoangmai H. Pham, and Gary Claxton
ABSTRACT:
Data from the Community Tracking Study provide a valuable perspective from which to observe how economic disparities—largely a function of different sources of coverage—influence access to medical care in the United States. Many recent investments and initiatives are focused on affluent communities and are accessible mainly to people with employer-based or Medicare coverage. For people with Medicaid or no coverage at all, access to basic care is worsening, as a result of stalled coverage expansions and service cutbacks. An improving economy could forestall further cuts and permit reversal of earlier ones, but progress in closing this rift does not appear imminent.
The widening rift between the economically well-off and the rest of American society chronicled in many sectors is increasingly apparent in the health care arena. Notable advances in technological capability, clinical performance, and administrative ingenuity found in parts of the health care system are not being evenly distributed, because of a growing inability or unwillingness to ensure equal access to high-quality care.
Medical progress comes at a high price and represents a major shift of resources into the health care sector of the economy.1 Many of these investments yield valued benefits to consumers and sustain a host of related occupations, enterprises, and industries; as a result, the country spends a growing portion of its resources in pursuit of medical excellence. Although this remains a laudable goal, it has become more challenging to guarantee that the excellence that is possible in the medical care system is available to all.
Findings from the most recent round of site visits of the Community Tracking Study (CTS) reveal sizable economic disparities associated with both the source of coverage of benefits and the geographic distribution of resources for service delivery. In this paper we examine the issue of economic disparities in access to and quality of medical care, based on the findings of CTS Round Five. The study and its methodology have been described in detail elsewhere.2
The Center for Studying Health System Change (HSC) has been conducting in-depth tracking of local market developments in twelve metropolitan markets since 1996 through on-site and telephone interviews with leaders in the principal health care sectors. The fifth round of site visits from January through June 2005 involved interviews with more than 1,000 respondents. The markets were randomly drawn from among large (Boston, Miami, Orange County, and northern New Jersey), midsize (Cleveland, Indianapolis, Phoenix, and Seattle), and small (Lansing, Syracuse, Greenville, and Little Rock) metropolitan areas.
What The Interviews Revealed
The Round Five interviews revealed trends in several areas.3 Hospitals and physicians are displaying a strong commitment to increased specialization of medical care, including acquisition and application of new diagnostic and treatment techniques and technologies, in both full-service and freestanding facilities. Competition between physicians and hospitals remains intense in many markets, and new forms of joint ventures and revenue sharing are emerging between both parties to try to repair what has become a more contentious relationship in recent years and to offer consumers better and more convenient services.
Hospitals are engaged in major construction initiatives after a decade-long lull in capital spending.4 Some projects have been undertaken to upgrade facilities to make them more suitable for providing state-of-the-art care that meets the expectations of contemporary customers—patients and physicians. Other projects involve extending services to new locations closer to more-affluent and well-insured customers. Sizable amounts are being spent for information technology (IT) to enable hospitals to address quality and safety performance gaps and to respond to incentive-based compensation initiatives being launched by private payers and Medicare. Nascent growth in new insurance product designs that engage consumers through increased cost sharing is also making hospitals and physicians more attentive to anticipating customers’ demands for quality, accommodation, and amenities. Positioning for more “consumer-driven” care is widely evident.
Juxtaposed against these examples of clinical and administrative expansions are several trends suggesting that the yields from these investments have not been evenly distributed and that in a number of instances, access to existing resources has declined. Most states are still emerging from the most severe downturn in tax revenues since World War II, and state policymakers have scrambled since 2001 to deal with huge budget shortfalls.5 Medicaid, the largest single state-level expenditure category, has borne a major portion of the cuts, but other human service programs that depend heavily on state spending, including public health and mental health, have been affected as well.
For services for the severely and persistently mentally ill, who depend almost exclusively on public financing, the past four years have had brutal consequences. Homelessness and substance abuse have worsened in many communities at the same time that state and local spending to address them has been flat or declined. Local government and charitable support for programs serving uninsured people, including undocumented immigrants, has also waned and failed to offset cuts in state funds.
Coverage And The Hierarchy Of Access To High-Quality Care
A clear hierarchy of access to care is apparent in many communities, which closely corresponds to insurance coverage and its sponsorship. Long-standing anxiety about prospects for a “two-tier” health care system has, in fact, given way to a three-tier reality in the CTS markets (Exhibit 1).
Employer-sponsored and Medicare coverage. People with employer coverage have benefited most from the developments described earlier. Medicare has moved in close coordination with private insurers, leading the way in a number of payment practices. Renewed efforts in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 to expand Medicare beneficiaries’ enrollment in private plans will promote an even higher degree of conformity between these two sources of sponsorship.
Both private insurers and Medicare have supported intensified emphasis on specialized care in both overt and subtle ways. Although largely unintended, Medicare’s payment systems have benefited specialized, procedure-oriented care, such as cardiac and orthopedic surgery.6 Contracting with physician-owned ambulatory surgery and imaging centers is widespread among private plans and growing in most markets, which often enables physicians to capture an increased proportion of service revenues. Direct access to specialty care has become health plans’ benefit design of choice, as the primary care gatekeeping function has been jettisoned. Sizable payment differentials between primary care and specialist physicians are standard practice among health plans, especially as more specialists have clustered in large group practices that are more potent negotiating entities.
Private payment levels for providers, especially hospitals, have risen in the last two CTS rounds, providing the resources needed to undertake major construction projects. These expansions further advance the development of technologically sophisticated care that can be aggressively marketed to able-to-pay patients and their sponsors. Many of these facilities are most accessible to affluent, well-insured consumers. Likewise, hospital-specialist joint ventures flourish mainly for profitable services and populations.
Although still embryonic, performance-based incentives are also making their presence felt.7 Payers such as WellPoint (Anthem) in Indianapolis and Cleveland have led the way with incentive payment systems for hospitals. Several plans in Orange County and Boston participate in pay-for-performance (P4P) initiatives with physician groups. Tufts Health Plan in Boston, Blue Shield of California, and Aetna in Seattle and northern New Jersey have all pioneered tiered networks. Medicare has begun its own hospital incentive initiatives through the Hospital Quality Initiative and the Premier Hospital Demonstration, and it has signaled its intention to extend this to physicians and other providers.8 Believing that Medicare and private payers will increasingly link quality reporting to payment, many hospitals and some physician groups in CTS markets have felt pressured to make larger investments in IT.
Commercial health plans are heavily promoting new product designs and decision-support tools that attempt to give consumers more engagement and greater empowerment by sharing with them performance information on health care systems. The designs, with their emphasis on serving up information about provider performance variation that can be acted upon, will promote further positioning by providers to attract consumers who will have added control over discretionary care spending.
Medicaid and other state and local programs. The first half of the decade has been a difficult one for people whose care is sponsored by Medicaid and other programs funded by state and local governments. Dramatic drops in state revenues clashed sharply with rising Medicaid expenditures. Efforts to continue Medicaid (and related State Children’s Health Insurance Programs, or SCHIP) expansions that were set in motion in 1997 were “casualties of the withering fire of sustained deficits,” as one respondent phrased it. Adhering to commitments to not give up hard-won gains in eligibility, most state Medicaid agencies have used other techniques, including reducing or freezing provider payments, eliminating certain benefits, instituting copayments, setting service limits such as total inpatient days or prescriptions covered, shrinking periods of guaranteed eligibility, and narrowing the time window for reapplying for coverage renewal.
Medicaid payment reductions and freezes have exacerbated problems with access to key services such as mental health and dental care, as well as many types of specialty care. Applying copayments, eliminating benefits, and setting arbitrary limits on services is seen by some observers as “cost shirking,” which leaves providers caring for these patients in the position of either dropping them or absorbing the cost of their uncompensated care. More commonly, providers avoid undertaking care for these patients to evade such discomforting situations.
Some health plans are bearing the brunt of cutbacks in Medicaid. In Orange County, the highly regarded quasi-public authority, CalOptima, which has served Medi-Cal beneficiaries for the past decade, has been forced to spend down its reserves, as state payment rates have not kept up with service costs—it has received only one 3 percent increase in the past five years. Rates for disabled beneficiaries that were once pegged to 95 percent of Medi-Cal fee-for-service (FFS) payments have fallen below 75 percent of the cost of care. In Michigan, the prolonged economic downturn and repeated Medicaid cuts have led officials to warn the state’s fifteen health plans that it will soon request permission from the Centers for Medicare and Medicaid Services (CMS) to deviate from paying them required “actuarially sound” rates. Failure to obtain such permission could mean converting 900,000 covered lives in managed care plans back to FFS Medicaid.
Public mental health services have been severely affected by state budget distress, since so much of this care is funded by state funds and federal block grants that have not increased to meet growing costs. In virtually every site, observers portray public mental health systems’ ability to care for people with chronic mental illnesses as being in serious decline and disarray. Homeless shelters and local jails are characterized as the twenty-first-century versions of the state mental hospital of fifty years ago. Many general hospitals have phased out inpatient psychiatric units because, they contend, they lose too much money serving publicly or unsponsored patients.
Local support for mental health services has also lagged, especially for crisis care, which increasingly is rendered in the emergency departments (EDs) of general hospitals. In Orange County, with a population of three million, the county mental health agency maintains a crisis inpatient unit of only ten beds. Community mental health administrators in several markets related that budget cuts and growing patient populations have prompted them to modify the definition of who can qualify as “severely mentally ill” as they align staffing supply with patient demand. In Boston, the site of some of the preeminent U.S. health care providers and insurers, informed observers use words like “appalling” and “horrible” to describe the current state of mental health services for the chronically mentally ill.
Unsponsored and unfortunate. Despite its limitations, the value of state and local coverage is most evident when one looks at those who cannot qualify for any coverage. The past success of SCHIP and Medicaid expansions means that most of the uninsured are adults. Demand for uncompensated care is increasing, particularly in communities such as Orange County, Phoenix, and Miami, where undocumented immigrant populations continue to grow rapidly (see Exhibit 1). Little Rock and Greenville are seeing smaller but notable upticks in their immigrant populations, as the composition of local labor markets changes.
Subsidies ranging from Section 330 grants to federally qualified health centers (FQHCs) to hospital taxation schemes are offsetting a portion of the cost of care to the uninsured, which is typically clustered in a few provider sites. These funds are usually adequate to buy a modicum of urgent care, but obtaining other forms of care, particularly specialty services and pharmaceuticals, is more difficult. Several communities and state medical societies have tried to address the specialty shortage by coaxing physicians to donate a limited amount of appointment time for patients who are unable to pay. Demand for these programs greatly outstrips supply in most markets. A program in Little Rock reported a 60 percent increase in the past two years in requests for assistance finding physicians who will donate care. People administering these programs suggest that physician participation is proving difficult to sustain, as “donor fatigue” sets in.
The availability of pharmaceuticals is a severe problem for the uninsured because of costs. Administrators of free clinics and community health centers (CHCs) in several markets related how carefully they guard limited drug supplies or funds for buying drugs, because just a few patients with serious or chronic conditions can deplete supplies. These facilities try to qualify patients for drug companies’ charity and discount programs, but the administrative effort involved is a major impediment. According to some clinics, it is very difficult to obtain drugs for undocumented people from some of the programs. Given the prevalence of chronic disease among many people without regular coverage, inability to obtain appropriate medications is a severe medical management handicap.
Beyond Coverage: Not Getting What Isn’t Paid For
The coverage axis provides a partial perspective on the widening disparity in high-quality care available at the community level. Subtler aspects of the rift can be seen when examining which providers deliver what care to whom, and how they get paid.
Location matters. The distribution of lower-income patients among providers has long been skewed, as delivery of the majority of care for indigent populations is clustered among a small proportion of providers, mostly at safety-net institutions.9 Concentration has been mitigated by the legal obligation all general hospitals have had, through the Emergency Medical Treatment and Active Labor Act (EMTALA), to provide at least emergency care to all patients, regardless of ability to pay—a modifying effect that had previously included physician services because of physicians’ traditionally close affiliations with these hospitals.10 Moreover, some hospitals receive disproportionate-share hospital (DSH) payments from Medicare and Medicaid for providing uncompensated care.
Evidence suggests that these lines of segregation are hardening, driven largely by the dictates of geography and channeled in part through growing disparities in access to physician care. Underlying this phenomenon is the interaction of two major trends: (1) growth of investments by both hospital systems and physicians in specialty services and relocated services, such as diagnostic testing from inpatient to outpatient settings; and (2) the recent burst of hospital facility expansions. In Indianapolis, Seattle, Phoenix, northern New Jersey, Greenville, and Miami, one or both are occurring most prominently in high-growth, affluent communities.
Hospital expansions in affluent areas have the potential to worsen disparities when they reflect a differential investment of resources between poorer and wealthier communities.11 Institutions serving poorer populations begin with major disadvantages; they are less likely to have sufficient capital or the financial health to obtain debt financing to invest in new building. In New Jersey, for example, the suburban St. Barnabas and Atlantic hospital systems have ample ability to finance hundreds of millions of dollars’ worth of expansion projects, while three inner-city hospitals serving lower-income populations had to close during the past two years, and more closures are anticipated in similar communities.
Priorities matter, too. The effect of new facilities in affluent areas and investment in specialty services on the supply of physician services is also evident. Newer facilities might more easily attract qualified physician staffs. But many physicians, particularly specialists, are becoming less dependent on their traditional affiliations with existing general hospitals. With new, alternative sources of revenue such as facility fees from surgery and diagnostic centers and the ability to concentrate patient care responsibilities at these freestanding facilities, specialists no longer have the same need to take ED call or to maintain admitting privileges at multiple hospitals, especially those serving lower-income patients.
From physicians’ perspectives, these new arrangements allow them to maintain or improve incomes and lifestyles after a period of substantial financial pressures in private practice, while avoiding the opportunity cost in both time and reimbursement, and the perceived higher malpractice risk of caring for poorly insured patients.12 These motivated one large orthopedic surgery group in Phoenix to drop their admitting privileges at one of the market’s largest hospitals.
A different perspective on priorities is the concerted effort by some facilities such as public academic health centers (AHCs) to alter their perceived role as primarily safety-net providers because of the opportunity costs they incur in both reputation and economic terms. The University of Arkansas for Medical Sciences and University of California, Irvine, medical centers are two examples of institutions that have struggled to control the amount of routine inpatient care provided to people without coverage, to enable the institutions to provide more-intensive care commensurate with their specialized capabilities and to achieve center-of-excellence status with selected payers and consumers. They hope that this, in turn, will result in improved payer mix and competitive position.
Unfavorable payer mix for both hospitals and physicians can perpetuate second-class status. Budget cuts have made Medicaid payment rates even less competitive, especially to specialty service providers, who are seeing increased demand by privately insured and Medicare patients. Moreover, incentive-based compensation is largely unknown in FFS Medicaid and exists on only a limited basis among health plans in Medicaid. Safety-net providers are also well aware that performance-based compensation schemes among private payers typically do not provide for socioeconomic adjusters necessary to equalize differences in patients’ access to care and allow for fair comparisons. Without such adjustment, providers already stressed with lower or no reimbursement for care of the poorly insured or uninsured face the threat of widening disparities in resources compared with their counterparts caring for Medicare or privately insured patients.
The Fault Line Runs Through The ED Floor
Interviews conducted with ED directors provided a glimpse of what some characterized as “ground zero” for the economic disparities influencing access to high-quality care and also a microcosm of many of the ills afflicting the health care system. EMTALA obligates EDs to evaluate and stabilize all patients who seek care. This open door is subject to exploitation, and the ED directors interviewed decried the extent to which patients and competing providers, including private physicians, rely on this policy to use EDs for care that should be available elsewhere. In some cases, this is an act of “dumping,” as patients are sent from private facilities to public EDs, where they can obtain a consultation or a needed prescription, or be referred to an outpatient clinic. In other cases, it reveals the frustration of community-based primary care providers who, knowing that they will be unable to find office-based specialty care for a Medicaid or uninsured patient, send such patients to the ED because the hospital has a call list of available specialists who will see patients in the ED.
But the call lists themselves are becoming problematic, as specialists’ economic ties and loyalties to full-service facilities have been weakened, resulting in serious difficulties in getting specialty coverage for poorly insured or uninsured patients. In northern New Jersey, Seattle, Phoenix, Miami, and Little Rock, hospitals reported increased difficulty staffing physician ED call schedules for specialists, including neurosurgeons, cardiologists, and general surgeons, and some are resorting to employing specialists or paying them extra to take ED call. One Phoenix-area hospital reported paying each of its neurosurgical groups $10,000 per week to be available for trauma care, in addition to their regular per patient reimbursement.
Even when specialty consultation is available during an ED visit, follow-up care is a persistent problem for uninsured patients who are subsequently discharged. In one public AHC, an ED medical director, board-certified in both emergency medicine and internal medicine, set up his own follow-up clinic because he was unable to get colleagues in specialty departments to provide timely follow-up appointments. Senior executives in this and other AHCs acknowledged, regretfully, that clinical departments commonly allocated appointment slots based on referred patients’ type of coverage.
The ED is particularly vulnerable to being a dumping ground for the chronically mentally ill. One ED medical director contended that as far as he could see, EMTALA is not being applied to this population at many hospitals, because they routinely turn such people away. Another noted that law enforcement officials often insist on admitting disruptive or intoxicated people to the ED so that officials can get on to other more pressing business, because no crisis or detoxification facilities are readily available. Such patients present serious security and management burdens for busy EDs and contribute further to the sense of overload and “controlled chaos” found in many of them.
Can The Trajectory Be Altered?
There are indications that the trajectory of unequal access and care can be altered. Most states indicate that their revenue pictures are finally improving, which has enabled them to consider restoring some of their recent budget cuts. In Massachusetts, the economic upturn, coupled with an urgent need to reconfigure Medicaid and safety-net care funding, has stimulated a vibrant debate about universal coverage for state residents.13 In California, the dismal state of services for the chronically mentally ill, who constitute much of the state’s homeless population, triggered sufficient community concern that a targeted tax proposition was passed to generate an estimated $600 million in new revenues each year to support service innovation.14 And in northern New Jersey, a market that exhibits many trends that threaten to worsen disparities in access and quality, the state is increasing its uncompensated care fund, most recently with a series of controversial tax assessments including a 3.5 percent tax on the revenues of privately owned ambulatory surgical centers and a 6 percent gross receipts tax (the first of its kind in the United States) on physicians for cosmetic medical procedures, with respondents predicting a chilling effect on the development of new ambulatory surgery centers.
In other states, Medicaid enrollment has grown, despite budget distress, to offset gaps in private coverage worsened by the recession. In politically conservative Arizona, the Arizona Health Care Cost Containment System (AHCCCS), through repeated expansions, has grown from covering 200,000 in 1984 to covering more than one million, or nearly 20 percent of the state’s population; unlike in most Medicaid programs, payment rates to providers in Arizona are maintained on a par with Medicare rates. At the local level, well-crafted, community-anchored limited-benefit programs such as the Wishard Health Advantage program in Indianapolis and the Ingham Health Plan in Lansing have grown by picking up people who have lost coverage as a result of unemployment or unaffordability.
But the cost of Medicaid for states remains a source of great anxiety.15 Without major reform, the program’s long-term financing seems an unsustainable burden on most states. However, current discussions of federal-driven reform, including those led by the Medicaid Reform Commission, raise the possibility that the redesigned Medicaid program will either pay for less by reducing benefit packages or services or pay for fewer by shrinking eligible populations, or both. Any combination of those scenarios will, at best, lead to greater shifting of costs to private plans and providers or, at worst, shift more people into the lowest level of the coverage hierarchy described earlier.
Continued erosion in private insurance and further hollowing out of benefit packages for those with private insurance, which result in varying degrees of underinsurance, also place added pressure on public sponsors of care.16 The growing number of undocumented people to be cared for, mainly by already-stretched safety-net providers, intensifies pressure on providers who are least able to cross-subsidize care. Finally, despite quixotic litigation regarding billing and collection practices for the uninsured, and policymakers’ “saber rattling” about greater accountability by not-for-profit institutions to earn their tax-exempt status, it seems reasonable to expect that most private providers of medical care will continue to engage in payer-mix management as well as medical management.17 The ED, and the crucial doorstop role of EMTALA, remains the exception that proves the general rule that equal access to care is not guaranteed throughout the health care system.
There is every reason to expect that Americans will demand and receive more and better health care, shifting more resources into the health care sector. However, not all will be able to afford this care, and there is growing evidence that U.S. society is prepared to tolerate trading off pursuing excellence for some, at the expense of deteriorating care for others.
This research was conducted as part of the Center for Studying Health System Change’s (HSC’s) Community Site Visit project, which is funded by the Robert Wood Johnson Foundation. The authors gratefully acknowledge the leadership of Paul Ginsburg and Cara Lesser and the assistance and support of all of their colleagues on the Round Five research teams.
NOTES
1. C. Smith et al., “Health Spending Growth Slows in 2003,” Health Affairs 24, no. 1 (2005): 185–194.
2. P. Kemper et al., “The Design of the Community Tracking Study: A Longitudinal Study of Health System Change and Its Effects on People,” Inquiry 33, no. 2 (1996): 195–206.
3. C. Lesser, P. Ginsburg, and L. Felland, “Initial Findings from HSC’s 2005 Site Visits: Stage Set for Growing Health Care Cost and Access Problems,” Issue Brief no. 97 (Washington: Center for Studying Health System Change, August 2005).
4. G.J. Bazzoli et al., “Does U.S. Hospital Capacity Need to Be Expanded?” Health Affairs 22, no. 6 (2003): 40–54.
5. D.J. Boyd, “The Bursting State Fiscal Bubble and State Medicaid Budgets,” Health Affairs 22, no. 1 (2003): 46–61; and V. Smith et al., States Respond to Fiscal Pressure: A Fifty-State Update of State Medicaid Spending Growth and Cost Containment Actions, January 2004, http://www.kff.org/medicaid/7001.cfm (accessed 23 August 2005).
6. L.P. Casalino, K.J. Devers, and L.R. Brewster, “Focused Factories? Physician-Owned Specialty Facilities,” Health Affairs 22, no. 6 (2003): 56–67.
7. M.B. Rosenthal et al., “Paying for Quality: Providers’ Incentives for Quality Improvement,” Health Affairs 23, no. 2 (2004): 127–141.
8. Medicare Payment Advisory Commission, “Strategies to Improve Care: Pay for Performance and Information Technology,” Chapter 4 in Report to the Congress: Medicare Payment Policy (Washington: MedPAC, March 2005).
9. P.J. Cunningham and H.T. Tu, “A Changing Picture of Uncompensated Care,” Health Affairs 16, no. 4 (1997): 167–175.
10. Emergency Medical Treatment and Active Labor Act, 42 U.S.C. 1395dd, http://www.emtala.com/law/index.html (accessed 23 August 2005).
11. D. Andrulis and L. Duchon, Hospital Care in the 100 Largest Cities and Their Suburbs, 1996–2002: Implications for the Future of the Hospital Safety Net in Metropolitan America, August 2005,
http://www.downstate.edu/urbansoc_healthdata/report_new.pdf (accessed 23 August 2005).
12. H.H. Pham et al., “Financial Pressures Spur Physician Entrepreneurialism,” Health Affairs 23, no. 2 (2004): 70–81.
13. See, for example, L. Blumberg et al., Building the Roadmap to Coverage: Policy Choices and the Cost and Coverage Implications, June 2005, http://roadmaptocoverage.org/pdfs/BCBSF_Roadmap2005.pdf (accessed 9 November 2005).
14. R.M. Scheffler and N. Adams, “Millionaires and Mental Health: Proposition 63 in California,” Health Affairs Web Exclusive, 3 May 2005, http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.212 (accessed 23 August 2005).
15. National Governors Association and National Association of State Budget Officers, Fiscal Survey of the States, June 2005, http://www.nga.org/Files/pdf/FSS0506.pdf (accessed 23 August 2005).
16. C. Schoen et al., “Insured but Not Protected: How Many Adults Are Underinsured?” Health Affairs Web Exclusive, 14 June 2005, http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.289 (accessed 23 August 2005).
17. M. Veazey, “A Growing Crisis: Scruggs Lawsuits Highlight the Problem of Caring for Poor, Uninsured,” Modern Healthcare 35, no. 34 (2005): 32; and Senate Finance Committee, “Grassley Asks Non-Profit Hospitals to Account for Activities Related to Their Tax-Exempt Status,” Press Release, 25 May 2005,
http:// finance.senate.gov/press/Gpress/2005/prg052505.pdf (accessed 23 August 2005).
Bob Hurley (rhurley{at}hsc.vcu.edu) is an associate professor in the Department of Health Administration, Virginia Commonwealth University, in Richmond. Hoangmai Pham is a senior health researcher at the Center for Studying Health System Change (HSC) in Washington, D.C. Gary Claxton is a vice president at the Henry J. Kaiser Family Foundation in Washington, D.C. Hurley and Claxton are senior consulting researchers at HSC.
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DOI: 10.1377/hlthaff.w5.566
©2005 Project HOPE–The People-to-People Health
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