MISSOURI WATCH: WHERE'S HARRY'S HEALTH PLAN?

Although the subject may come as something of a shock to members of the General Assembly, to say nothing of thousands of other Missourians, the number one public policy issue of interest to many citizens of our state can arguably be said to be not taxes, environment, education or more jobs.

It is, instead, policies for providing health care.

If you were around when Harry Truman was proposing a national health program, you are probably tempted to exclaim, "So what else is new?" After all, the richest, most powerful nation in the world has been trying to provide health care for every citizen for more than a generation.

Well, so much is happening, or about to happen, in the health field that just about everyone, urban and outstate alike, is beginning to pay attention. But outstate residents have reason to be sensitive to current and promised (or threatened) programs, and in no small way fearful of them.

Rural health care has been the subject of numerous seminars over the years, the most recent being one held on the University of Missouri's campus at Columbia. That seminar touched on one of the fundamental obstacles of creating a health policy for persons who live in scattered regions of the state. Because of distances to be traveled, many outstate Missourians find medical service not to be readily available to them. This situation is compounded by the reluctance of physicians to practice in rural locations, and the figures certainly attest to that. Twenty-three percent of Missouri's population lives in non-urban areas but only 11 percent of physicians practice in these counties.

An issue of old standing is that rural communities especially need access to primary care, but medical students have preferred to enter specialties rather than general practice. Dr. Wayne Myers, director of the University of Kentucky Rural Health Center, notes that "primary care personnel are the backbone of rural health care." This portion of the medical-service sky may be getting brighter. As specialists are less in demand in new managed care systems, medical students may now take more interest in getting primary care training.

It happens that rural Missourians are older than the state average and therefore more likely to be in need of medical service, yet they are disadvantaged by their lower incomes. A higher percentage of outstate residents depend on Medicare financing. They have much at stake in the changes being made or proposed for this portion of America's health care delivery system. The present Medicare system can be said to discriminate against rural areas, as reimbursement rates are lower there. A leveling of the rates is essential to system reform.

An interim legislative committee is winding down a several-month study of Health Maintenance Organizations, which have been at the center of health reform efforts in the state's urban and semi-urban areas. The jury, however, is still out on whether managed care is a blessing or a curse. It gets mixed reviews in regions that have been forced to rely more and more on their delivery methods. Managed care arrangements are intended to reduce the cost of services and probably do. Defenders say they improve service; critics allege the opposite.

What is certain is that to date managed care has been nearly confined to the metropolitan areas. It has not been adopted in many outstate areas, although the small city of Bolivar in Southwest Missouri has won attention with its managed care network of 12 health clinics.

As everyone should know by now, both Medicare and Medicaid are ticketed for considerable modification. More of the responsibility for Medicaid is moving to the states, where state laws will have much to do with whether, and how, that program turns to managed care. An overriding question regarding rural health care is whether communities have the capacity for leadership in resolving care deficiencies, at a time of near turmoil in the health industry.

If HMOs will not meet the needs of outstate Missouri, then it is obvious the solutions will have to come from Jefferson City and not Washington. This is not bad, unless the state views health care as principally a fiscal problem to be resolved rather than one that provides the best care to as many Missourians as possible.

~Jack Stapleton of Kennett is the editor of the Missouri News and Editorial Service.