Health care system reform and public health. Protecting the safety net.

The most difficult to reach underserved populations are not likely to disappear even with universal insurance coverage. Universal coverage does offer all educated and motivated individuals, including those lacking financial resources, the opportunity to seek improved health through prevention services and treatment for illness. But, it would not guarantee that uneducated and unmotivated people, substance abusers, the chronically mentally ill, people with geographic or cultural barriers to access, or other traditionally underserved populations will use or be able to use a new system more wisely. These last groups, who, for various reasons, may underuse prevention services or delay contact until disease is transmitted or illness is advanced, will continue to add costs to a reformed health care system. Care must therefore be exercised in health care system reform to provide incentives for private-sector outreach to these problem populations. Even with incentives, however, history suggests that the private sector will either avoid or have difficulty incorporating the large groups of disadvantaged patients who in the past have relied on public health services and public hospitals for their health care. The public health sector will need to maintain the capacity to provide for the health care of many disadvantaged groups with historically poor access. It becomes critical in the budgetary trade-offs inherent in health care system reform that the infrastructure of the public health system not be damaged.(ABSTRACT TRUNCATED AT 250 WORDS)