Miami-Dade County faces a challenge -- one in five residents lacks health insurance. Half of the uninsured work full- or part-time, most for small employers. In South Florida, small firms drive the economy in good times and suffer in bad times. Right now, times are tough, and people -- working or not, insured or uninsured -- are vulnerable. They trust that healthcare will be available when they need it.
Miami-Dade is also fortunate. The Public Health Trust, with its flagship facility, Jackson Memorial Hospital, is committed to providing quality healthcare to all residents of Miami-Dade. Funded in part with public funds from property taxes and a half-percent sales tax, the Public Health Trust is the county's public safety-net provider. The many other hospitals in the county, both not-for-profit and for-profit, also shoulder a financial burden in providing healthcare to the uninsured, largely without financial compensation.
But more can be done. In an earlier study, RAND, a nonprofit research and policy analysis institution, found disparities in geographic access to hospital care. The uninsured who live in the western and southern areas of the county were much more likely than their insured neighbors to travel beyond their local hospital facilities, even in emergencies, to go to Jackson for medical care. By law, all hospitals are required to provide healthcare to emergency cases, regardless of ability to pay. However, there are limits to hospitals' ability to provide such uncompensated care.
RAND was asked by Community Voices Miami, an initiative funded by the W.K. Kellogg Foundation to improve access to healthcare for the underinsured and uninsured in the county, to examine the governance of public funds for healthcare in Miami-Dade. This report, released in May, explains how improved governance can lead to better accountability and performance and, ultimately, more trust.
Among the recommendations we offer, the most important concerns separating the provision of services from the development and implementation of health policy for the county. Currently, the Public Health Trust oversees the $1 billion-plus operation of the various Jackson Health System facilities and has a major role in developing countywide policies for providing healthcare to those without insurance.
This dual role puts the trust in an awkward situation: Should it collaborate with other hospitals and perhaps share some public funds or look inward and adjust its facilities and services to better provide for all in Miami-Dade?
In separating these functions, the board of directors of the Jackson Health System would continue its role in governing the operations and instituting mission- and outcome-oriented polices to guide management of the various public facilities. A new board of directors for a health-policy agency would focus its efforts on the efficient allocation of public funds and development of services for the uninsured. The new health-policy agency should also be allocated resources to give it the authority and the means to effect change. When services and policy are separated, the potential for innovation and collaboration among all hospital and healthcare providers can be realized, and health-policy planning and implementation can be guided by what is best for the county's residents.
Good governance goes beyond separating these two functions. The boards themselves, and the Miami-Dade County Commission, need to take an active role in providing oversight and guidance. The boards should be of reasonable size, and members should bring the expertise needed to make sound, objective decisions. Attention should be paid to avoid actual or potential conflicts of interest.
The boards should be held accountable to county commissioners and residents. Routine practices, such as audits and inventories, should be put in place. Annual reports to the community detailing their efforts and progress toward fulfilling their missions should be made available.
Improvement in the governance and, by extension, the operation of publicly funded healthcare facilities is possible. What is needed now is the will to change.
Catherine A. Jackson is a senior health economist at RAND. For more information, contact Dr. Joe Greer, Community Voices Miami Principal Investigator, at 305-962-1761.
This commentary originally appeared in The Miami Herald on June 10, 2003. Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.