Urban Health Care: Prognosis Is Cautious : Medicine: Some experts fear that many will not take advantage of the proposed reform plan. They point to a host of ingrained reasons.

WASHINGTON —  Even with the promise of universal insurance coverage in the Clinton Administration’s proposed health care reform plan, many inner-city health care providers are skeptical that it alone can address the health needs of urban residents.

Some experts say they worry that many urban residents will not take advantage of the new system for a host of reasons: lack of transportation and child care make visiting a doctor difficult, too few doctors are willing to work in impoverished communities, and many low-income urban dwellers are generally mistrustful of the medical profession.

In addition, unless urban residents are taught how to live healthier lives, an expensive and politically contentious battle to reform the nation’s health care system will have been waged for naught, said Julia Scott, executive director of the National Black Women’s Health Project.

“Even if we put clinics on every corner in America, it doesn’t mean people are going to use them,” she said. “There is a trust and education factor that has to be addressed if any health plan is going to have impact in the inner cities.”

Judith Feder, a senior official on the Administration’s health care task force, said the White House hopes its plan can indeed address such issues, in part by tying existing community health centers into any restructured federal health network.

Doing so would help ensure that both doctors and medical services are available in underserved areas, Feder contends.

“We know that it is critical that inner cities have the resources and connections to the entire new system of health care,” she said.

She also held out the possibility that as part of its health care reform plan, the federal government would support programs that would encourage the use of community health services--such as educational efforts, transportation systems and day care.

Even President Clinton has suggested that he shares the concerns of doctors and hospital administrators in the inner cities.

“The bottom line is you’ve got to have more clinics in the rural areas and in the inner cities that are accessible, . . . where they are accessible not only physically but in terms of language and culture,” Clinton said during a recent news conference.

“And, if you do it right . . . they lower the cost of health care because they keep more people out of the emergency rooms.”

But with details of the health care reform plan still uncertain, optimism and skepticism about how urban residents will fare are getting almost equal time among doctors, hospital administrators, health care analysts and community activists.

Typical is Dr. Reed Tuckson, president of Charles R. Drew University of Medicine and Science in Los Angeles, who described himself as “pragmatically optimistic” that the White House plan will help people like those who line the waiting rooms in inner-city hospitals.

However, he cautioned that the provisions that would help inner-city residents could be lost in the political wrangling certain to follow the plan’s unveiling.

“If we are going to have health reform, it doesn’t make any sense to create only the structure to care for people without creating a mechanism to prevent them from getting sick in the first place,” he said. “I am concerned about the health plan as it relates to keeping poor people healthy.”

Some experts say they worry that the Administration’s brand of reform could weaken the already-second-class system of health care that often is all that is available in inner cities.

If the proposed system of managed care being discussed by the White House comes to fruition, some community health officials say they doubt that doctors and medical services will be as abundant in impoverished neighborhoods as in more affluent areas.

In a recent speech to the Chamber of Commerce in Hawthorne, Calif., Rep. Maxine Waters (D-Los Angeles) made just that point.

“Access to decent, affordable (health) care varies, depending on the community you live in,” she said. “The ratio of doctors to the population may be perfectly fine in Los Angeles County, but you and I both know that many of those physicians are specialists rather than general practitioners, and you’ll more likely find them in Santa Monica or Beverly Hills than in South-Central or Boyle Heights.”

But it doesn’t have to be that way, said Dr. Robert E. Tranquada, the former dean of the USC Medical School and chairman of a Los Angeles County task force on health care access.

He said the Administration’s health care policy can make federal resources available to all providers and give doctors financial incentives to serve poor people.

From behind his desk as president of Greater Southeast Community Hospital in the poorest municipal district within Washington, D.C., Thomas Chapman said much more is needed than offering doctors incentives to locate in poor areas.

More to the point, he argued, is the need to “keep people healthy so they don’t use the (nation’s medical) system.”

“We have to provide primary care, health promotion and lifestyle changes to keep people from coming into emergency rooms, where they are going to receive the most expensive medical care available,” Chapman said.

Nancy Nichols, who tracks health care issues for the Harvard Business Review in Cambridge, Mass., said it is possible for the government to craft policies that encourage hospitals to focus more on the needs of their surrounding communities than on profit.

Changes in such policies could encourage inner-city residents to make better use of medical services before they are desperately needed, but it is likely they would undercut the financial interests in health care.

Dr. Kenneth Chance, director of health policy at the Joint Center for Political and Economic Studies, a liberal Washington think tank that specializes in issues involving the nation’s cities, said anything that upsets the profits in medicine is likely to face stiff political opposition or suffer practical noncompliance.

“How can we resolve the problems related to cost for health care balanced on the backs of middle-class Americans and still handle this greater problem for the millions of persons who need the care in the cities but cannot pay for it?” Chance asked. “The middle class has lost confidence in the system, and they are the ones driving the government for relief.”

He said the call for health care reform is popular because the nation’s middle class is clamoring for change, but if the measure passes and doctors sense they cannot make comparable earnings by serving poor people in urban areas, some communities may find themselves lacking health care providers.

“That is the question that faces us most squarely,” he said.