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Health care policy has a major bearing on cities. American urban centers are complex social environments that are home to disproportionately large numbers of disenfranchised and marginalized groups, including the poor, people of color, and illegal and legal immigrants. In other words, despite the diversity and richness of their residents, the most vulnerable and oppressed segments of the population also live in cities. These groups are heavily impacted by health care policy, particularly reforms to public health insurance programs, funding for public health care facilities, regulations on private health care, as well as a range of other policies that both directly and indirectly impact people's health.
In developing positions on health care, the presidential candidates have focused on several core themes, including access to health care, Medicare coverage of prescription drugs and the managed care system.
John McCain argues that it is unacceptable that 43 million Americans lack health insurance coverage, but suggests building on the strengths of the current system, rather than on remedies that rely on government mandates or bureaucratic command and control measures. His solutions include using the tax code to provide employers and individuals with incentives to obtain health insurance, allowing people to pool resources to obtain health insurance, reforming the tort system and the Food and Drug Administration to eradicate impediments to service delivery, and ensuring that all children have health insurance coverage.
Like McCain, George W. Bush wants to utilize the private sector to provide health insurance. Bush promotes privatization in health care and choice among competing private sector providers. He also advocates personalized medical savings accounts. But in many ways these are piecemeal ways of coping in a system where there is no guarantee of quality health care. Bush is proposing short-term solutions so that those who are able to save a certain part of their income or afford to travel for health care would be able to afford health care.
Unlike the Republican candidates, Bill Bradley proposes health care reform that "leaves no one out." Bradley's health care proposal guarantees health insurance for every child, access to affordable health care for every adult, expands Medicare with coverage for social services and an optional prescription drug benefit, and invests in public health and prevention.
Al Gore also proposes broad health care reform, but does not emphasize as much as does Bradley universal health care. His plan would leave out millions of working adults who can't afford health care premiums. Gore's plan does, however, expand health care to millions of uninsured parents of Medicaid or CHIP-eligible children. While Bradley's plan covers prescriptions for the elderly, Gore's plan places a cap on prescription drug benefits under Medicare.
While the candidates' themes tap into important issues, there are several areas of health care policy that are particularly critical for urban areas that the candidates have largely ignored.
Emphasis on Adults
First, while health care programs for children and the elderly are vital, the group that is consistently overlooked and underrepresented in the candidates' messages is adults, notably working adults. In fact, the working adult population has been particularly hard hit by recent developments in health care policy. Increasingly, working adults do not have their health insurance covered by their employers, nor do they qualify for the benefits programs earmarked for the young and the old.
Tears in the Urban Safety Net
Secondly, the trend throughout urban areas to close down public hospitals and of large-scale mergers among private and public hospitals has meant it is increasingly difficult for those without health insurance to obtain needed services. Access to quality health care should not be a question of policy, but a right for all. This is becoming more difficult to obtain for everyone, but the impact has been greatest on the working urban poor and their families.
Managed Care
Third, while each of the candidates has commented on the patients' bill of rights, that is, the right to sue if something goes wrong with a medical procedure, they have focused far less on what can we do to ensure that nothing goes wrong in the first place.
Community Health
Fourth, although the inclusion of health care in the candidates' statements is laudable, they lack an understanding of what needs to happen beyond the clinic and hospital walls. A community-based mission, orientation, and strategies are necessary to promote the health of the population. In urban areas, safe, affordable housing, greater availability of nutritious food, adequate numbers of public parks and exercise facilities, and easy accessibility to public transportation systems and medical facilities are all crucial to promoting healthy communities and healthy lives.
The Urban Health Care Challenge
We are living in a time of unprecedented prosperity with large surpluses in the federal government's coffers. The rapidly changing world of health care, coinciding with the dynamic environments of the nation's urban areas, call for a concerted national effort to provide a sustainable system of care for all, including the historically disenfranchised population. Now is the time for our society to commit to provide for the basic health care needs of each individual, family, and community in the United States. In this way, we can truly promote sound health and full lives throughout all of America's communities, including its remarkable cities.
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