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Medicare waivers alone are insufficient to improve use of primary care by poor and elderly blacks

In 1979, the Health Care Financing Administration granted Medicare waivers to five cities to implement a demonstration called the Municipal Health Services Program (MHSP), which set up MHSP clinics similar to community health centers. The purpose was to provide more primary and preventive care services to inner city, elderly, Medicare enrollees by eliminating financial barriers that may have limited access to services.

The waiver eliminated payment of part-B deductibles and coinsurance that Medicare patients usually must pay and covered ancillary services not normally covered by the Medicare program, such as prescription drugs, dental services, and optometry. Despite these incentives, the clinics set up by the waiver were not able to overcome the tendency of black elderly urban patients to use less primary care than their white counterparts.

Other barriers to primary care for racial minorities may need to be addressed, such as assistance with transportation and child care, expansion of office hours, and reduction of waiting time, suggests Jayasree Basu, Ph.D., of the Center for Primary Care Research, Agency for Healthcare Research and Quality.

During the 1987-1989 study period, the 14 MHSP clinics provided better access to Medicare patients who were poor enough to also be eligible for Medicaid than to patients who were not eligible for both programs. Among those eligible for both programs, MHSP clinics provided better access to care to minority patients than to white patients.

However, patients who were eligible for both programs also used more ancillary services than all Medicare patients and those who were eligible only for Medicare. Half of patients eligible for both Medicare and Medicaid compared with 44 percent of all Medicare patients used clinics solely for ancillary care. This suggests a lower propensity among poor Medicare beneficiaries to use clinics for primary care services than for ancillary services. For instance, 72 percent of poor Medicare patients compared with 78 percent of all Medicare patients who visited primary care doctors at the MHSP clinics saw them more than twice during 1987-1989.

Overall, whites and minorities accounted for 37 percent and 63 percent of visits for ancillary care and 56 percent and 44 percent of visits for primary care, respectively.

More details are in "Access to primary care: The role of race and income," by Dr. Basu, in the April 2001 Journal of Health & Social Policy 13, pp. 57-73.

Reprints (AHRQ Publication No. 01-R043) are available from the AHRQ Publications Clearinghouse.

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