In This Issue

June 2006 | Bradford H. Gray

This issue of The Milbank Quarterly begins with “Race, Segregation, and Physicians’ Participation in Medicaid,” by Jessica Greene, Jan Blustein, and Beth Weitzman. Racial/ethnic disparities in health services and outcomes have been extensively documented in the United States (Institute of Medicine 2003), and many possible causes have been studied. Disparities in treatment may result if physicians’ treatment decisions are influenced by the patient’s race or if patients of particular racial/ethnic backgrounds use different service providers than other patients do. There is evidence of both (Schulman et al. 1999; Bach et al. 2004).

Physicians’ reluctance to accept patients who have Medicaid (Asplin et al. 2005), which provides insurance coverage to low-income people, has generally been attributed to the low fees the program pays to doctors in many states. Researchers have also found that physicians’ participation is related to the particular characteristics of the Medicaid population where the physicians are located. If physicians are more reluctant to participate in Medicaid in areas where disproportionate numbers of minorities reside, this can contribute to racial differences in access to and sources of care. That is the issue addressed by Greene, Blustein, and Weitzman in their article.

After discussing the theoretical and research literature about physicians and Medicaid, they examine the topic empirically. Their data on Medicaid participation come from the physician survey conducted by the Center for Studying Health System Change as part of the Community Tracking Study. They also use U.S. census data regarding the characteristics of the low-income residents of those counties in which the physicians practice. The authors looked at three possible influences on physicians’ decisions to accept Medicaid patients: the percentage of white residents and the extent of both racial and economic integration in the county. They found that physicians are less likely to participate in Medicaid in areas in which the poor are not white and in areas that are racially segregated. The study thus provides additional evidence that physicians’ choices—in this case, whether to participate in Medicaid—do contribute to the racial patterning of health services in the United States.

The Community Tracking Study is also the source of the data for the second article in this issue, “The Transition from Excess Capacity to Strained Capacity in U.S. Hospitals,” by Gloria Bazzoli, Linda Brewster, Jessica May, and Sylvia Kuo. Even though hospital occupancy rates are relatively low nationally (66 percent on average in 2003), in some of the markets that are the focus of the Community Tracking Study there is a growing belief that some hospitals’ capacity is becoming constrained. Focusing on the Boston, Cleveland, Miami, and Phoenix markets, the authors used longitudinal data and in-depth interviews to examine the reasons for these constraints. They report that the hospitals experiencing strained capacity were more likely to be teaching hospitals, to be located near hospitals that had closed, and to be in areas experiencing rapid population growth. Bazzoli and her colleagues discuss the reasons why changes in the supply of hospital services are both slow and out of sync with changes in demand. They conclude by considering implications for policy and for institutions experiencing capacity constraints.

The next article is concerned with a boundary issue in health policy. In “‘This Case Is Closed’: Family Caregivers and the Termination of Home Health Care Services for Stroke Patients,” Carol Levine, Steven Albert, Alene Hokenstad, Deborah Halper, Andrea Hart, and David Gould report on an empirical study conducted in New York City that examines what happens when stroke patients’ eligibility for insured home health services ends, usually because they are deemed as no longer needing “skilled” services or as having no potential for rehabilitation. The research team interviewed family caregivers and documented the services received by stroke patients after they returned home following their hospitalization. Levine and her colleagues found that the bulk of these patients’ care came from family caregivers, even while the patient was receiving services from a home care agency paid by Medicare, Medicaid, or a private insurer. Families usually were not prepared when the agency told them that the patient no longer met the insurers’ criteria for eligibility for services. Notably, nine months after an agency closed their cases, the number of hours of care per week had actually increased for many patients, particularly those who were not eligible for a special Medicaid program in New York. The authors conclude with recommendations for both policy and practice.

The fourth article in this issue, “Routes to Better Health for Children in Four Developing Countries” by Thomas Croghan, Amanda Beatty, and Aviva Ron, considers population health. Improving population health is particularly challenging in low-income countries. Although the death of young children is not common in industrialized countries, a study by the World Health Organization showed that between 2000 and 2003, almost 11 million children under age five died each year in the world from diseases like pneumonia, diarrhea, malaria, and neonatal sepsis caused mainly by environmental and nutritional factors.

The study described by Croghan, Beatty, and Ron in their article had three phases. First, the researchers reviewed the literature on measures of health in developing countries. Second, they examined worldwide databases to identify countries that had exhibited rapid improvements in measures of child mortality. Third, focusing on four such countries—Bangladesh, Ecuador, Egypt, and Indonesia—they sought to identify the circumstances, including relationships with donor nations, that accounted for success in improving measures of children’s health. Croghan, Beatty, and Ron found that targeted health interventions and foreign aid mattered more than did the country’s degree of economic development, good governance, and even strong health care systems. They concluded that at least from the standpoint of children’s health, international aid aimed at promoting economic growth and poverty reduction is less effective than setting health goals and supporting targeted interventions.

This issue ends with an article that answers the question, Whatever happened to health planning? In “Health Planning in the United States and the Decline of Public-interest Policymaking,” Evan Melhado reviews the long and complicated history of an approach that tried to meld expertise and public-spiritedness to rationalize health care and reduce waste by matching facilities with need. Melhado traces the planning movement from the Progressive Era, through the federal Hill-Burton program for hospital construction in the post–World War II period, and to the Comprehensive Health Planning legislation of 1966. After passage of the National Health Planning and Resources Development Act of 1974, health planning became the leading cost-containment approach of the Carter administration before being phased out early in the Reagan administration. Planning of facilities and services thereafter became the province of private providers of services operating in private markets for capital, and their success has determined the distribution and availability of services.

Melhado observes that the demise of planning has been “little lamented,” even though vestiges remain in some states’ certificate-of-need programs. He contends that the ideas behind planning and the reasons that it failed as a national policy instrument need to be understood, and that is the central task of his article. Distinguishing between soft (voluntary) and hard (tied to access to funding) planning, Melhado analyzes the history in both organizational and ideological terms and links the demise of health planning to the decline of an idealistic style of policymaking that emphasized “extramarket values” in the attempt to satisfy the public interest.

Bradford H. Gray
Editor, Milbank Quarterly


Asplin, B.R., K.V. Rhodes, H. Levy, N. Lurie, A.L. Crain, B.P. Carlin, and A.L. Kellermann. 2005. Insurance Status and Access to Urgent Ambulatory Care Follow-up Appointments. Journal of the American Medical Association 294(10):1248–54.

Bach P.B., H.H. Pham, D. Schrag, R.C. Tate, and J.L. Hargraves. 2004. Primary Care Physicians Who Treat Blacks and Whites. New England Journal of Medicine 351(6):575–84.

Institute of Medicine. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, edited by B.D. Smedley, A.Y. Stith, and A.R. Nelson. Washington, D.C.: National Academies Press.

Schulman, K.A., J.A. Berlin, W. Harless, J.F. Kerner, S. Sistrunk, B.J. Gersh, R. Dubé, C.K. Taleghani, J.E. Burke, S. Williams, J.M. Eisenberg, J.J. Escarce, and W. Ayers. 1999. The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization. New England Journal of Medicine 340(8):618–26.

Author(s): Bradford H. Gray

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Volume 84, Issue 2 (pages 235–238)
DOI: 10.1111/j.1468-0009.2006.00446.x
Published in 2006