AMA Journal of Ethics^®

The Death of Bessie Smith by Edward Albee, presents the playwright's version of the last hours of the famous blues singer's life. It is a disturbing play: Smith is a black woman in 1930s America who has been in a terrible car accident and is taken by her boyfriend to the nearest hospital. The drama centers around Smith's boyfriend's pleading with hospital staff to allow the black woman to be admitted to the whites-only hospital. His pleas fall on deaf ears, and Bessie dies en route to a black hospital. When I first saw the play in high school I was dumbfounded—could this have happened in America? Could anything like it happen today?

Barriers to health care come in many forms. Racial disparities in care are still far more prevalent than many of us would care to admit. Infant mortality for African Americans is twice that of Caucasians.¹ Rates of diabetes are higher in minority populations than in Caucasians, with rates for African Americans, Latinos, and Native Americans at 70 percent, 100 percent, and 200 percent higher, respectively.² Inequalities in health insurance coverage, poverty, geographic isolation, and language barriers, all affect an individual's access to health care. As cited in several of this month's articles, 45 million Americans are presently without health insurance. How do these people obtain care? What do they forego?

In this installment of Virtual Mentor we explore some of the challenges to access. We do not pretend to cover the issue in its entirety; there are simply too many aspects of the problem to touch on them all in a single volume. Rather, we have tried to concentrate on what we see as the general themes, with an emphasis on legislative and political trends that we believe will have the greatest impact in the coming years.

Of those Americans who are covered by health insurance, nearly a third are enrolled in the government-sponsored programs Medicare and Medicaid.³ Given the importance of these 2 programs, we have devoted considerable space to them. Much of the policy forum discusses how recent and proposed legislative changes to Medicare and Medicaid will affect those covered by these programs.

Our op-ed section looks at some current proposals for health care financing—Health Savings Accounts (HSAs), income-based tax subsidies, and government-administered health care. Which of these will improve coverage for the currently uninsured? Moreover, which are likely to be endorsed by the American people and enacted by the legislature? Medicine and society outlines the state of the medical "safety net"—the community health clinics and public hospitals that provide the majority of care for the uninsured. Another medicine and society contributor gives us insight into barriers to care that refugees and other immigrants face when they enter the US system. An international perspective on access to life-saving HIV medications reminds us that we are members of a global community, and, as such, we have responsibilities that extend beyond our own borders. And finally, in medicine and education, one doctor recounts his experiences teaching medical students at a homeless clinic in Denver, discussing his belief that physicians can learn the importance of providing charity care if they are exposed to it early in their careers.

To return briefly to Bessie Smith: the real details of her death are somewhat obscure, but Edward Albee appears either to have been mistaken or to have invoked poetic license in his rendition. Most historians agree that she was taken by ambulance from the crash scene, and that no ambulance driver would have attempted to take her to a white hospital at that point in American history. She was taken directly to a black hospital and died some hours after being admitted. We no longer have hospitals segregated along racial lines, but a recent New York Times article suggests that we now may be segregating along other lines: the article documents an uninsured man who refused to go to the hospital after becoming short of breath because his bill there was already so high that the hospital was garnishing his wife's wages. Later that day, his wife came home from work and found him dead.⁴ Although we have undoubtedly come a long way toward improving access to health care in the past 70 years, with Medicaid and Medicare being notable examples, it appears that we still have a long, long way to go.