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October 01, 2007

Bakke and Safety Net Medicine

by Jillanne M. Schulte

In 1978, the U.S. Supreme Court considered and rejected the assumption that diversity in medical schools would lead to more doctors willing to practice in communities lacking adequate health care facilities and practitioners. Hence, we will never know whether affirmative action would have led to greater geographical distribution of doctors. But thirty years after University of California Regents v. Bakke, 438 U.S. 265 (1978), the United States faces a significant problem: too many people with little or no access to doctors, either because they have no health insurance and cannot pay or because, in both poor sections of cities and rural areas, there simply are no doctors.

The sheer number of Americans without insurance is staggering: 16 percent according to the latest numbers of the Center for Disease Control. However, the problem is far greater because the underserved community is composed of two groups: the uninsured and the insured who still lack access to adequate health care. Across the board, minority and low-income patients are more likely to get inadequate health care and to forgo necessary medical treatment due to cost or access. Moreover, even if every minority medical student and many nonminority medical students chose to treat inadequately served communities, they would find barriers at every turn.

The Difficulties of Serving the Poor

The practice of “safety net” medicine, as it is called in the medical profession, is tantamount to modern frontier medicine. Dedicated doctors who work in underserved communities contend with numerous daily challenges: myriad cultures and languages, and insurance paperwork headaches for which they have no formal training. Unlike law schools, the vast majority of medical schools offer no programs targeting students interested in working in underserved communities. While a few pilot programs exist, they are confined to elite medical schools, such as Harvard and Boston University, with large endowed funding sources.

Doctors practicing safety net medicine are all too frequently frustrated by the complicated morass of forms and guidelines accompanying U.S. public health insurance. Few understand all of the paperwork, much less have time to handle it daily. Medicaid, the largest public health insurance program for low-income families, carries a plethora of regulations that confound doctors and patients alike. Many patients find that being insured does not guarantee access because few primary care physicians treat Medicaid patients. An American Medical Student Association publication reports that only a third of U.S. physicians maintain an open door policy for Medicaid recipients; the remaining two-thirds either refuse to see Medicaid patients or restrict the number they will treat. While the process is disenchanting for the patients, doctors often find them­selves just as muddled by insurance
intricacies, which take time away from the practice of medicine.

Other difficulties complicate the choice of safety net medicine. The cost of medical education has skyrocketed in the years since Bakke, with the average debt load for medical school graduates topping $130,000 according to the Association of American Medical Colleges. Even the most idealistic young doctors find themselves confronted by mountains of debt and are forced to make a difficult choice between low-paid primary care work for Medicaid patients and the uninsured and more lucrative job offers. Unlike the legal community, with its debt forgiveness programs for lawyers who represent the disadvantaged, the medical community offers little support for physicians who dedicate themselves to the underserved.


While the Supreme Court in Bakke clearly recognized the importance of minority access and participation in the professional medical community, short of resorting to a soothsayer, it had no means to foresee that affirmative action could have little impact on the almost unrecognizable health care system of the following decades . Affirmative action is no magic bullet for providing health care to inadequately served communities. The responsibility for providing such care falls to all medical professionals, not just those who may have racial or cultural ties to disadvantaged communities. To provide even basic health care to all members of underserved communities, the entire health care system requires an overhaul that provides the necessary support and encouragement for doctors who wish to practice safety net medicine.

Jillanne M. Schulte

Jillanne M. Schulte is a second-year law student at American University Washington College of Law in Washington, D.C., where she is a staff member of Health Law and Policy, a scholarly journal. She is interested in practicing in the field of health law.