Community, Service, and Policy Strategies to Improve Health Care Access in the
Changing Urban Environment
A B S T R A C T
Urban communities continue to face formidable historic challenges to improving public health. However, reinvestment initiatives, changing demographics, and growth in urban areas are creating changes that offer new opportunities for improving health while requiring that health systems be adapted to residents’ health needs.
This commentary suggests that health care improvement in metropolitan areas will require setting local, state, and national agendas around 3 priorities. First, health care must reorient around powerful population dynamics, in particular, cultural diversity, growing numbers of elderly, those in welfare– workplace transition, and those unable to negotiate an increasingly complex health system. Second, communities and governments must assess the consequences of health professional shortages, safety net provider closures and conversions, and new marketplace pressures in terms of their effects on access to care for vulnerable urban populations; they must also weigh the potential value of emerging models for improving those populations’ care. Finally, governments at all levels should use their influence through accreditation, standards, tobacco settlements, and other financing streams to educate and guide urban providers in directions that respond to urban communities’ health care needs. (Am J Public Health. 2000;
American Journal of Public Health
Dennis P. Andrulis, PhD, MPH
Improving the health of residents of the nation’s urban areas has been a formidable and continuing struggle to meet complex and varied needs with limited resources. Entrenched chronic conditions such as asthma, diabetes, and cancer; infant mortality and child morbidity; drug abuse; violent crime; and health-risk behavior have been accompanied by chronic health system problems of difficult access to and inconsistent quality of care. These circumstances intersect with inner-city environments, requiring providers to recognize not only the specific medical challenge but also the complex social context within which individuals work and live.
Despite these long-standing conditions, cities are not stagnant, isolated enclaves, doomed to face ever-growing challenges to the health of their citizens. As this commentary discusses, recent research has demonstrated that access to effective health-related interventions can improve the lives of urban residents. Moreover, several health and social dynamics suggest both new opportunities and emerging concerns that demand reconsideration of the nation’s health care policy and programs as they relate to health and health care in urban areas. The composition of many of these communities is changing, with the aging of the population, metropolitan area sprawl, and growing cultural diversity altering the terrain.
Overlaying these changes are other contrasting dynamics. For example, many cities are witnessing an urban renaissance of sorts.
One need look no further than Harlem, where the Walt Disney Co is planning to build a multimillion-dollar complex that will transform a neglected area into a major shopping district, to see that areas less attractive to business are becoming economically fashionable. In contrast, the economic distance between rich and poor has rarely, if ever, been greater, and it has been accompanied by steady increases in the numbers of uninsured individuals throughout the 1990s. Moreover,
efforts to improve the health of urban residents face new uncertainties: the fallout from welfare reform and work-fare initiatives; the promise of increased employment and, with it, questions about employer-based coverage of health care for low-wage workers; the increasing role of managed care in both private insurance and Medicaid; and questions about the fate and