Medical Soc stuff for exam 1 (After the first quiz we took)

Variables The outcome

estimate of social mobility, life expectancy, percent of residents living below the poverty line, percent of residents living in deep poverty, and the percent of low birth weights. In addition, the PSI also collected other variables that might be associated with poverty, including whether the community was urban or not, and percent of residents with less than a high school diploma

Social causation explanation

- stress, lifestyle, living conditions, health behaviors cause illness

■ SES and environmental exposures

. Exposure to damaging agents in the environment, including lead, asbestos, carbon dioxide, and industrial waste, varies with socioeconomic status. Those lower on the SES hierarchy are more likely to live and work in worse physical environments. Poorer neighborhoods are disproportionately located near highways, industrial areas, and toxic waste sites, since land there is cheaper and resistance to polluting industries, less visible. Housing quality is also poorer for low-SES families As a result, compared with high-income families, both children and adults from poor families show a sixfold increase in rates of high blood lead levels, while middle-income adults and children show a twofold increase. Low-SES persons also experience greater residential crowding and noise. Crowding within the home appears to be more problematic for health than is area density. Noise exposure has been linked to poorer long-term memory and reading deficits and to higher levels of overnight urinary catecholomines (epinephrine and norepinephrine) among children and to hypertension among adults.

Why?

1) Healthy lifestyles are more common amongst the middle and upper classes (have knowledge and resources to support it) 2) Social class effects the opportunities a person has for a healthy life.

Risk Factors

1) Physical (poor sanitation, housing, overcrowding, extreme temperatures) 2) Chemical (environmental pollution) 3) Biological (greater exposure to bacteria, viruses) 4) Psychological (stress, lack of control) 5) Economic (low income, lack of health insurance, unhealthy jobs) .6) Lifestyle (diets, smoking, alcohol and drug use, lack of leisure-time exercise)

Well-educated people:

1) best informed about the benefits of healthy lifestyles, impact of disease, and treatment (high level of health knowledge) 2) know the advantage of preventive care or getting medical treatment when needed 3) are more likely to have well-paid and more personally satisfying jobs (less alienated labor), higher income, health insurance 4) easier access to medical care (more likely to know how to navigate the system)

SES as a Fundamental cause of Sickeness and Mortality

1. Influence multiple diseases 2. Affect these diseases through multiple pathways of risk 3. Be reproduced over time; and 4. involved access to resources that can be used to avoid risks or minimize the consequences of disease if it occurs. higher SES Persons have the resources to better avoid health problems or minimize them when they occur The degree of socioeconomic resources a person or does not have such as money, knowledge, status, power, and social connections, either protect the health or causes premature mortality. "allows one to feel in control, and feeling in control provides a sense of security and well being that is [health-promoting]." Per- sons at the bottom of society are less able to control their lives, have fewer resources to cope with stress, live in more unhealthy situations, face powerful constraints in choosing a healthy way of life, and die earlier. In addition, the low SES patients had less social support, particularly single mothers with children, less motivation to take responsibility for their treatment regions, significantly longer waits for their doctor appointments, more transportation problems in getting to the clinic, and knew less about diabetes. They were much lesser to join health clubs for exercise and eat healthily, as well as make other health tyle adjustments. Not surprising, Lutfey and Freese found that the higher SES clients in Park Clinic had significantly better glucose management, and one could e, as they do, that the cause was social.

WHO BEARS THE COSTS OF UNCOMPENSATED CARE FOR THOSE WHO LACK COVERAGE?

: Public subsidies to hospitals amounted to an estimated $23.6 billion in 2001, closely matching the cost of uncompensated services that hospitals reported providing. Overall, public support from the federal, state, and local governments accounts for between 75 and 85 percent of the total value of uncompensated care estimated to be provided to uninsured people each year

Clinics and Direct Care Programs

A Shared Destiny, provided an overview of the federal, state, and local governmental programs involved in the direct provision of personal health care services to underserved and vulnerable populations, including those Americans who lack health insurance.

Back to income cont

A second challenge is to isolate the impact of redistributive policies and separate their effects from other social and economic trends occurring at the same time. Welfare benefits. Addressing the link between income inequality and health, the Acheson Commission focused attention on tax-andtransfer benefits. In particular, they suggested increases in transfer payments, upgrading of state pensions, and measures to increase the take-up rates of existing benefits. "Policies that affect the health of the labor market are perhaps the most important medicine we can apply. Labor-market policies. Policies that affect the health of the labor market are perhaps the most important medicine we can apply, although its ingestion may raise inequality levels at the same time that we benefit from the "great American job machine."

The Components of Social Class

A social class is a category or group of people who have approximately the same amount of wealth, status, and power in a society. The various classes are ranked in a hierarchical pattern from top to bottom on the basis of how much wealth, status, and power they have relative to each other and thereby constitute a layered system of socially stratified human beings. he relevance of social inequality in daily lives of most individuals is that it determines their personal opportunities and life experiences in very powerful ways. To be poor by definition means having les: of the good things in life and more of the bad things, including more health prob lems and less longevity. This is a five-clas: model consisting of (1) the upper class (extremely wealthy top corporate executive: and professionals); (2) the upper-middle class (affluent well-educated professional and high-level managers); (3) the lower-middle class (office and sales workers, small business owners, teachers, managers, etc.); (4) the working class (skilled and higher workers, lower-level clerical workers, etc.); and (5) the lower class (less killed and unskilled workers, the chronically unemployed, etc.).

■ SES and health care.

Access to, use of, and quality of health care vary by socioeconomic status. Among adults, 40 percent of those who have not graduated from high school are uninsured, compared with only 10 percent of college graduates; more than 60 percent of the uninsured are in low-income families. Persons who lack insurance receive less medical care, including screening and treatment, than those who are covered and may receive poorer-quality care.Although the very poor may be eligible for Medicaid and persons over age sixty-five for Medicare, many "eligibles" fail to enroll In the United States, states with greater income inequality and higher mortality also have fewer primary care doctors per capita. A recent study from Canada showed higher mortality among men with less income, less education, and lower occupational status for a variety of causes of death, all of which were amenable to medical treatment

2. Providing Complementary Services to those Newly Covered by Medicaid or a QHP

Accordingly, CCPs are well-positioned to promote appropriate utilization and optimal health outcomes among the newly insured: Reaching out to current members to make them aware of and help them navigate new coverage options, including determining eligibility for Medicaid and/or premium subsidy assistance (an informal navigator role); Providing enrollment assistance for those eligible for coverage; Developing and providing complementary services such as case management and/or care coordination, which can help the newly insured use their new coverage most effectively and efficiently; and Providing social services to improve self-sufficiency.

Cont ^

Although health effects of relative SES occur across the whole range of the SES hierarchy, the burden is particularly great for those in poverty. Given this fact, policies intended to increase the income (and income security) of the poor should have the greatest positive impact on health outcomes

4. Operating a CO-OP

Another choice for CCPs has been to form or become part of a Consumer-Operated and Oriented Plan (CO-OP), a coverage mechanism established by the ACA. CO-OP programs can offer low-interest loans to eligible private, nonprofit groups to help set up and maintain health plans. CO-OPs are directed by their customers and designed to offer individuals and small businesses affordable, consumer-friendly and high-quality health insurance options. Starting January 1, 2014, CO-OPs will be able to offer health plans either within or outside of a marketplace.

Options that CCPs are Considering

As CCPs consider how they will evolve when states implement the ACA - with or without Medicaid expansion - in 2014, they are exploring a number of options, including: 1. Continuing to serve the uninsured in their catchment areas; 2. Providing complementary services to those newly covered by Medicaid or a QHP in their state marketplace; 3. Serving as a navigator, in-person assister, or certified application counselor in their state marketplace; and/or4. Forming a CO-OP to be offered in their state marketplace.

Cont ^^

As a rule, we intervene to protect basic physical health and safety but tend not to go further by, for example, mandating work reorganizations that promote autonomy, control, and other psychosocial factors that could affect health Recognizing the link between job control and health, the Acheson Commission did push in that direction, recommending that wherever possible, private and public employers alter management practices to increase employees' levels of control over the daily conduct of work (pacing, decision making, variety). In the U.S. context, researchers need to show that such changes in work conditions will either increase—or at least not decrease—profits; improved profits could result from increased productivity, reduced absenteeism, or reductions in medical costs.

SES and behavior/lifestyle

Behavioral factors account for about half of premature mortality, and almost all vary by socioeconomic status.49 The greatest behavioral risk for premature mortality is tobacco use. Those with less education and less income are more likely to smoke. Smoking prevalence reflects likelihood of initiating smoking as well as of quitting, and different polices are relevant for those stages of smoking. Winkleby and colleagues found that neither education nor income was associated with smoking onset. However, the more educated were more likely to try to quit, and among those who tried to quit, those with higher incomes were more likely to succeed. This suggests that efforts to encourage quitting need to be geared more strongly to those with less education and that the means of quitting need to be made more accessible to the poor Low socioeconomic status is similarly associated with more sedentary lifestyle and lower consumption of fiber and fresh fruits and vegetables.53 Patterns of alcohol use by socioeconomic status are more complex, as are the health risks related to alcohol. Moderate alcohol consumption is associated with lower mortality, while high levels of consumption increase mortality risk. Moderate drinking does not show an SES gradient, while heavy drinking is more common at lower SES levels the Acheson Commission's recommendation to increase walking and cycling needs to be translated into more specific policies that would be effective in lower-SES neighborhoods, such as special provision of bike lanes and safe, well-lit places to walk; these are more available in more affluent areas, and a general policy will not address the imbalance Characteristics of school environments such as the area provided for physical activity, available equipment, improvements, and supervision have a substantial impact on children's activity levels.57 More-affluent schools are more likely to provide these, and their availability would be addressed by local school policy

How Much Medical Care Do The Uninsured Use, And Who Pays For It?

By estimating how much medical care the uninsured use and who pays for it, this analysis seeks to determine the resources that are already in the medical care system and potentially available to help pay for expanded insurance coverage. Knowing the existing sources of payment for care will help policymakers identify where some of the money for new coverage could come from.

Physicians

By waiving or reducing their fees to uninsured patients and volunteering their time in free clinics and similar settings, physicians provide a significant amount of charity care a breakdown of charity care into that which was entirely free and that for which physicians reduced their prices. They assumed that all of the free care and one-third of the reduced-price care were provided to uninsured patients.

Impact of the Affordable Care Act on Charity Care Programs

Charity care programs (CCPs) have long played a critical role in the health care safety net - providing access to low- or no-cost health care for individuals without access to affordable health insurance due to eligibility or affordability barriers. CCPs connect the uninsured and underinsured to preventive and early treatment services to help reduce more expensive and acute care and ultimately improve long-term health outcomes and control costs. These organizations operate on a state or regional basis, serving individuals who meet eligibility criteria that may incorporate: (1) income guidelines, with limits ranging from 100 to 500 percent of the federal poverty level (FPL); (2) residency/citizenship requirements; and/or (3) the ability to participate in cost-sharing via premiums and/or co-pays. Business models and financing mechanisms vary both across and within CCPs. Funds are provided by a variety of sources, including: (1) member fees and copays; (2) employer contributions; (3) individual/ corporate/ philanthropic donors; (4) federal, state, and county sources; (5) provider subsidies; (6) sales tax levies; and (7) partnering health plans and health systems. In many cases, providers also subsidize these programs by discounting their services.

COnt ^^^

Childhood asthma incidence is rising, especially in urban neighborhoods among low-SES children, and the severity is greater among these children. environmental justice as the "fair treatment for people of all races, cultures, and incomes, regarding the development of environmental laws, regulation, and policies. Despite these actions, however, poor minorities are still at far greater risk for environmental exposure than are whites in general, or middle-class adults and children of any race and ethnicity. "SES-related health effects of social environments may be even more important than those of physical environments." In a state with lax enforcement, children living at an address where a previous instance of lead poisoning had been reported were more than four times more likely to have high blood levels than in a nearby state where statutes were strictly enforced.34 This suggests that we need to focus not only on laws but on their enforcement

cont 5

Crowded living conditions, poor diet, housing, low levels of income and education, and increased exposure to ce, alcoholism and problem drinking, smoking, and drug abuse—all combine ease the life chances of the poor. the poor still have worse health than the affluent and are treated within the framework of welfare medicine. The Patient Protection and Affordable Care Act passed by Congress in 2010 i intended to reduce the disparities in health insurance by extending coverage to a estimated 32 million previously uninsured Americans. Lack income, health insurance, and knowledge about health, cognitive abilities, the infl ence of social networks, fewer incentives and motivations for healthy behavior, a much more limited means to reach health goals have also been identified as imp tant for unhealthy behavior (Glied and Lleras-Muney 2008; Pampel et al. 2010). The lower class is likewise disadvantaged with respect to mental health. basic finding of most studies is that the highest overall rates of mental disorder found in the lower class, including schizophrenia—the most severely disabling fo of mental illness (Cockerham 2014; Muntaner et al. 2013), Anxiety and depressi disorders, however, tend to be more prevalent among the upper and middle classé yet the lower class suffers from these problems as well.

More common among the poor:

Crowded living conditions, poor diet, inferior housing, low levels of income and education, increased exposure to violence, alcoholism and problem drinking, smoking and drug abuse (combine to reduce life expectancy), present-orientation instead of future-orientation **Access to care is only one obstacle for the poor; they still have the worst social situations and living conditions that contribute to ill health

■ Education.

Education is perhaps the most basic SES component since it shapes future occupational opportunities and earning potential. It also provides knowledge and life skills that allow better-educated persons to gain more ready access to information and resources to promote health Marilyn Winkleby and colleagues examined how education, income, and occupation relate to risk factors for cardiovascular disease; when these were taken together, only education remained as a significant predictor To the extent that education is key to health inequality, policies encouraging more years of schooling and supporting early childhood education may have health benefits

Policy And Priorities

Eliminating health disparities will require attention to all SES components and the pathways by which they influence health. Some are already the focus of debate and action. Most states provide coverage for lower-income children under Medicaid and the State Children's Health Insurance Program (SCHIP), but we lack a national policy that ensures coverage for all children.

Need for cost-benefit analysis.

Failing to capture health improvements that may follow from reduction of inequality may mean that policies look more expensive to implement than they are if one takes health spending into account.

Comparing Public Financing of Direct Services with Insurance Programs

Finding: The costs of direct provision of health care services to uninsured individuals fall disproportionately on the local communities where they reside. On the other hand, states and localities are constrained in their ability to raise additional revenues through taxes to subsidize care for uninsured persons (Desonia, 2002). States with low per capita income or depressed economies, characteristics that are positively associated with uninsurance, experience even more fiscal stress financing care than do more prosperous states (Holahan, 2002; IOM, 2003a).

Behavioral justice.

Focusing on health behavior is potentially problematic, as it can risk "blaming the victim" if this behavior is viewed simply as a lifestyle choice. Behavior suchas cigarette use, high-fat diets, and lack of exercise is shaped and constrained by social and physical environments linked to socioeconomic status.

Implications

Given the available data, it is not possible to know definitively what factors led to the temporal differences in the relationship between poverty and the number of confirmed Covid-19 cases and deaths described above. However, given the patterns of disease transmission and level of contagion, it does seem reasonable to consider the possibility that a large part of the cause is due to a lack of testing capability in the United States. In that instance, it is possible, and given the progression of the disease, perhaps even likely that Covid-19 continued to appear in relatively high rates within poor urban counties, even as the number of available tests in those communities declined relative to more affluent areas These results also suggest that under-resourced workers in fields that have been deemed essential (e.g., public sanitation, grocery employees, delivery services) and who thus may be at particular risk may not have equal access to testing for the virus. These workers, though at elevated risk, may be without the ability to quarantine away from their families in the same manner as do health care workers, another group at higher risk for exposure to the coronavirus

cont

Homeless Americans are in even worse shape to deal with a deadly viral outbreak. "They're in large group quarters, or they're sharing other facilities like bathrooms or places like cafeterias where they eat," says Samantha Batko, a research associate in the Metropolitan Housing and Communities Policy Center at the Urban Institute.

PAYMENTS BY STATE AND LOCAL GOVERNMENTS.

Hospitals receive payments from state and local governments in the form of tax appropriations. The Medicare Payment Advisory Commission (MedPAC) treats these funds as reimbursement for care provided to uninsured patients. In 1999 hospitals received $2.7 billion in tax appropriations from state and local governments

Income

In addition to providing means for purchasing health care, higher incomes can provide better nutrition, housing, schooling, and recreation. Independent of actual income levels, the distribution of income within countries and states has been linked to rates of mortality. Although the association between income and health is stronger at lower incomes, income effects persist above the poverty level.11 Health effects at the upper part of the distribution may more strongly reflect relative status, while at the lower part they may be more linked to absolute deprivation. Redistributive policies. U.S. economic policies are a mix of those that address poverty or diminish economic disparities and those that result in increased disparity. At different points in its history, the United States has created policy tools that explicitly reduced economic inequality The prime example is the introduction of the progressive income tax in 1913. Social Security and the welfare policies developed in the 1930s also influenced the contours of inequality, although other forces acting simultaneously (for instance, the expansion of the white-collar labor force) created countertendencies. Policies that might be said to have moved the country in the opposite direction—toward wealth inequalities—include the mortgage deduction allowance built into the tax code, decreases in capital gains taxes, and local financing of education budgets (which produce more advantaged districts where wealthier families reside).

cont 3

In studies of health and illness, income reflects spending power, housing, diet, a medical care; occupation signifies job status, responsibility at work, physical actiy ity, and health risks associated with one's work; and education is indicative of person's skills for acquiring positive social, psychological, and economic resource such as good jobs, nice homes, health insurance, access to quality health care and knowledge about healthy lifestyles (Winkleby, Jatulis, Frank, and Fortma 1992:816). Scandinavian countries that have high levels of health and a greater distion of welfare benefits protecting the disadvantaged than found elsewhere, sr educated people still have the best health and lowest mortality (Eikemo, man, Bambra, and Kunst 2008).

cont ^

Individuals who do not qualify for a subsidy: The remaining 15 percent would not qualify for a subsidy in the marketplace, but would have an affordable private insurance option. Those who do not qualify for subsidies would come from higher-income families. Other uninsured exempt from the mandate for other reasons: Others who may be exempt from the individual mandate requirements include those with qualifying religious exemptions, those in a health care sharing ministry, and incarcerated individuals.

Why is education so significant?

It is because educated people, especially those with a university education, are generally the aformed about the merits of a healthy lifestyle involving exercise, no smokmoderate drinking, a healthy diet, and similar practices, along with knowing dyantages of seeking preventive care or medical treatment for health problems they need it. They are also more likely to have well-paid and more personally g jobs, giving them better control over their lives and the way they live. note that literally all the pathways from ion to health are positive and that higher education and good health generally go together found -educated people—in comparison to the less educated—are more likely to fulilling, subjectively rewarding jobs, high incomes, less economic hardship, er sense of control over their lives and their health, and healthier lifestyles. This relationship, in fact, gets stronger = life course, as less-educated persons have increasingly more sickness and ity and die sooner than the well-educated (Dupre 2007; Pudrovska 2014; and House 2000; Ross and Wu 1996).

Screening of "In Sickness and In Wealth" from the documentary Unnatural Causes (MOVIE)

Lack of health care is not the main cause Social conditions tend to be more powerful than our genes. the way society is to organize is bad for our health Think of the environment. Food available, working conditions, air quality. Some people to 3 five or ten years sooner than others The lower the grade of employment the higher the worst health problems occur The higher income the more people reported good health The lower tends to have less good health College graduates live about 2 in half years longer than high school graduates Education and income can be a marker of how long a person can live Corels can call various areas of the brain to shrink and affect the memory of a person. It is about where you are located at in the class hierarchy The accumulation of stress is determined by class Stress hormones go up it invades the connections within the brain and the development. (Chemically damaging)

Indirect Pathways

Marcia Angell has observed that income, education, and occupation are powerful yet mysterious determinants of health; they are not likely to have a direct effect but serve as proxies for other determinants Pathways by which socioeconomic status influences health should be those that affect health more generally, including those identified by McGinnis and Foege.24 They used data from a broader analysis of the relative impact of four inputs to health: biological determinants, health care, environmental exposure, and behavior and lifestyle

The Remaining Uninsured Post-ACA Implementation

Medicaid opt-outs: A group likely to remain uninsured includes individuals who become eligible for Medicaid but do not enroll, perhaps due to: inadequate outreach by the Medicaid program; their unfamiliarity with or disinclination to enroll in a government-sponsored program; or the perceived stigma of being a Medicaid beneficiary. It is expected that these Medicaid-eligible individuals -- mainly low-income, young single adults without dependents -- will compose roughly 36 percent of the uninsured Marketplace opt-outs: Almost eight percent of the estimated remaining uninsured individuals would qualify for coverage in the marketplace, but will opt to not fulfill the requirements of the individual mandate. These individuals would be mostly younger (median age of 33) single adults without children (61 percent), with moderately low incomes (median 280 percent of FPL). Undocumented immigrants: Undocumented immigrants would make up roughly 25 percent of the remaining uninsured. In 2007, this population accounted for one in seven of the uninsured, but going forward it will represent a larger proportion of the total uninsured population due to the overall decline in the uninsured.11 More than half (54 percent) of families in this group will have incomes under 138 percent of FPL. Legal residents who qualify for an affordability exemption from the individual mandate: Legal residents of fewer than five years who are not eligible for Medicaid qualify to purchase coverage in a marketplace if their income is below 400 percent of the FPL and they do not have affordable coverage under their employer. Many of these individuals will be exempted from the individual mandate because the premiums associated with purchasing coverage will exceed eight percent of their family income. It is expected that 16 percent of legal residents will not have an affordable insurance option.

Equality of care and the social gradient in mortality: The British Experience

Mortality rates remained higher for the lower classes. Despite free health care, financial hardship in Britain today means going without holidays and not having adequate clothing or regular access to fresh fruits and vegetables (Dolan 2007). Britain's experiment failed to reduce health disparities precisely because living conditions and lifestyles could not be equalized; the environment of poverty and poor nutrition continued to adversely affect lower-class health. observed in a study of working-class men in the British city of Coventry, men with the lowest incomes and poorest living condi tions experienced stress and anxiety related to their treatment by other people Their low social position not only blocked educational and employment oppor tunities, but they also reported disdainful treatment from welfare agencies an persons in more privileged positions that often left them feeling frustrated an lacking in self-worth. The Black Report provided strong evidence that the lower a person is on social scale, the less healthy that person is likely to be and the sooner he or she expect to die but the upper classes continued to live longer than anyone else. This ed even though over time the lower classes began using medical services more e middle and upper classes. Medical care alone was unable to overcome the ese effects of living conditions and negative lifestyles though it obviously had = effects. This outcome underscores the importance of the social determinants

WHO BENEFITS FROM INCREASED SPENDING?

Most of the money for uncompensated care goes to hospitals, which deliver about two-thirds of such care. If all people were fully insured, hospitals would be the biggest beneficiaries, after the uninsured themselves, since they provide the majority of uncompensated care. Physicians, however, account for more than half of the private subsidies that underwrite the cost of uncompensated care. They too would benefit substantially from expanding insurance coverage to all Americans. "Most of the money for uncompensated care goes to hospitals, which deliver about two-thirds of such care."

Who would become eligible for Medicaid and who would remain uninsured?

Nationally, the uninsured are diverse in age and race/ethnicity. If states choose to expand Medicaid eligibility under the ACA, it is estimated that among the newly eligible: About half will be under age 35; 35 percent would be between the ages of 35 and 54; and over 10 percent between the ages of 55 and 64.4 Just over half will be white, male, childless adults, although race and ethnicity estimates will likely vary greatly across states. There will be about 4.6 million women of reproductive age.5

■ Occupation

Occupational status is a more complex variable, and its measurement varies depending on one's theoretical perspective about the significance of various aspects of work life. One aspect is simply whether or not one is employed, since the employed have better health than the unemployed have. there is evidence that being unemployed and the length of unemployment affect health status. However, some types of benefits for the unemployed can buffer the adverse effects on health Entitlement benefits appear to reduce some negative health effects, while means-tested benefits do not.18 Threat of unemployment and job insecurity can affect health as well. Ralph Catalano and Seth Serxner found elevated rates of low birthweight in geographic locales threatened with high rates of unemployment.19Anticipation of plant closings or other job threats have been linked to increases in blood pressure, although these increases may not become chronic 1 Lower-status jobs expose workers to both physical and psychosocial risks. They carry a higher risk of occupational injury and exposure to toxic substances. In addition, job strain and lack of control over work are greater the lower one's occupational status. In the Whitehall study of British civil servants, differences of coronary heart disease incidence by occupational grade were largely accounted for by differences in job control

DISCUSSION

One somewhat unexpected result of this study was the apparent change over time in the relationship between poverty and the number of confirmed Covid-19 cases. There are a number of possible explanations that could be responsible for this shift. Certainly one possibility is that the disease simply became relatively less prevalent in these counties over time. Under that scenario, poor urban areas would see relatively fewer cases because the virus simply did not infect residents in those areas to the same extent that it did in relatively more affluent less urban communities. A second possible explanation for the results presented above is that mitigation efforts such as sheltering in place and physical distancing had the desired effect more strongly in poorer, more urban counties than in relatively more affluent areas. However, there is some evidence that many jobs deemed to be essential, such as sanitation workers, operators of public transportation, and grocery store employees are relatively less well paid than those individuals who can work from home (Gray and Moore, 2020).

Why are race and ethnicity important regarding health?

People from minority groups are more likely to live and work in disadvantaged socioeconomic circumstances that have a powerful negative influence on health.

Living in poverty

People living in poverty (lowest SES) have the greatest exposure to risk factors for ill health.

cont

Public subsidies for coverage make health insurance financially more feasible for lower-income persons and families, yet many who are eligible are not enrolled in public programs or cannot afford to take up workplace offers. The change in the financial circumstances of persons without health insurance who gained health insurance would also depend on how their care-seeking behavior changed.

Does Racism Play a Role in Health Inequities? Video

Racism is a Signiant indicator to people who is not obvious and obvious towards Poorer quality care and less intensive care for blacks and minorities Implicit bias is a indicator It existing with care providers and effects the care towards patients 70% has a antiblack bias Normal americans reflecting the message about race they recivied Negative implicit bias without be consciously aware please will be treated differently

Most commonly used measure of social class:

SES = income + occupation (prestige) + education Income---> spending power, diet, medical care, housing Occupation--> work health risks, status/control, stress, physical activity Education---> health knowledge, health insurance, income

SES and social environment

SES-related health effects of social environments may be even more important than those of physical environments. Isolation and lack of engagement in social networks are strong predictors of health. The socially isolated have relative risks of mortality ranging between 1.9 to almost 5 times greater than those with better social connections.Patterns of social interaction also affect disease risk. For sexually transmitted diseases, transmission is more rapid in high-risk networks, which are often clustered in poorer areas, thus putting lower-SES persons at greater risk for exposure. Those with greater social cohesion and social capital have lower rates of homicide as well as lower overall population mortality. The literature on social capital has not yet explained why neighborhoods with similar demographics differ on social cohesion and trust, or established whether social capital is stabl

Strong analyses needed

Scientists need to show the causal pathways, demonstrate how much alteration in underlying inequalities is needed to affect health outcomes, and evaluate the economic and social benefits. As Michael Marmot points out, policies or interventions that target "upstream" effects (for example, income distribution) would have the broadest impact but would be the most difficult to evaluate.

cont 1

Social class is a much stronger predictor of good health than race. This approach was based on differences in employment relationships- (such as decision-making autonomy and job security) and work conditions as promotion opportunities and influence over the planning of work) that commonly used a seven-class model. The ESeC was designed for use in all countries of the European Union eatures a ten-class model: (1) large employers and higher grade professional, agerial, and administrative occupations; (2) lower grade professional, mana- and administrative occupations, and higher grade technical and supervi- occupations; (3) intermediate occupations (such as higher grade white-collar Kers); (4) small employers and self-employed occupations, not including agri- are; (5) self-employed occupations, including agriculture; (6) lower technical supervisory occupations; (7) lower services, sales, and clerical occupations; lower technical occupations; (9) routine occupations with low job security, no eer prospects, and closely supervised work; and (10) no occupation and long- 2 unemployment. The concept of SES is derived from ideas about social stratification put forward by Weber ([1922] 1978). he pointed out that there was more to social stratification tha wealth alone and observed that status and power are important as well.

ABSTRACT

Socioeconomic status (SES) underlies three major determinants of health: health care, environmental exposure, and health behavior. In addition, chronic stress associated with lower SES may also increase morbidity and mortality. ReducingSES disparities in health will require policy initiatives addressingthe components of socioeconomic status (income, education, and occupation) as well as the pathways by which these affect health.

PRIVATE FUNDING OF HOSPITALS' UNCOMPENSATED CARE.

Some hospitals with large uncompensated-care burdens and small surpluses may allocate the entire surplus to offset uncompensated care, while others may have surpluses well in excess of their uncompensated-care load.

How does SES relate to health and illness?

Studies have shown education to be one of the strongest predictors of good health.

3. Providing Consumer Assistance

The ACA requires that state insurance marketplaces establish a grant program to fund navigators to assist consumers in using the marketplaces. Navigators are required to: (a) maintain expertise regarding the marketplace; (b) provide information to consumers in a fair, accurate, and impartial manner; (c) facilitate QHP selection; (d) refer consumers to other resources; and (e) provide information in a culturally diverse and linguistically accessible manner. The law requires that each marketplace select at least two types of entities to be navigators, at least one of which must be a community- or consumer-focused non-profit. States operating a state-based marketplace or participating in a partnership model will have the option of designing an inperson assister program. Assisters will have the same role as navigators, but are not required under the law. Marketplaces also have the option of using certified application counselors to help people understand and enroll in health options.

■ Challenges in each domain.

The Acheson Commission gave priority to policies that would improve the health of women of child-bearing age and children to minimize the impact of inequality early in life. Policies that support early childhood programs have been supported largely on the basis of social outcomes such as school achievement and lower delinquency rates; demonstrating the health benefits of such programs (and their associated cost savings) may add a rationale for their support

Poverty and Covid-19: Rates of Incidence and Death in the United States During the First 10 weeks of the pandemic

The Covid-19 pandemic in the winter and spring of 2020 represents a major challenge to the world health care system that has not been seen perhaps since the influenza pandemic in 1918 The emergence of the Covid-19 virus across the world, beginning in late 2019, has put the health care systems of many nations under a great deal of stress such as Italy and Spain, this stress has brought health care to the breaking point, resulting in a large number of deaths. In other nations, including Singapore, Korea, and Germany, the number of per capita deaths has been very low in comparison. In each of these countries, the widespread availability of testing, followed by contact tracing has been credited with the relatively low mortality figures, and slowed spread of the virus indicates that workers with lower levels of education are less likely to work from home, suggesting that they therefore may also be less able to physically distance than those with higher levels of education. In turn, these individuals may be faced with the choice between staying home and not getting paid, or going to work and increasing their risk of becoming infected with the virus. In addition, these people may also have less access to testing and treatment resources, if experience with influenza is any guide (Ompad et al., 2007; Logan, 2009). Considering all of these issues together, Covid-19 presents under-resourced Americans with a set of unique and potentially very dangerous challenges. In addition, policy makers who are struggling to deal with the effects of the pandemic across the nation at large may not have the resources to focus on this particularly vulnerable portion of the population.

`ESTIMATING THE COST OF CARE FOR THE UNINSURED.

The MEPS estimates are based on the civilian, noninstitutionalized population under age sixty-five, excluding people covered by Medicare. 5 Newborns, people who died during the year, and people who were institutionalized for part of the year are included for the portion of the year that they satisfied the basic MEPS criteria for inclusion. MEPS defines expenditures as "payments made for health care services," which excludes the cost of services for which there was no explicit and identifiable payment linked to a specific patient (except for services provided by public hospitals and clinics). For example, MEPS does not count provider revenues from general government appropriations to hospitals and Medicare and Medicaid disproportionate-share hospital (DSH) payments, since they are not payments for specific patients.

The acheson commission

The analyses we have presented here suggest that multiple approaches are indeed needed to eliminate SES disparities in health. Since the relevant sectors operate somewhat independently, there may be less direct competition for priorities than occurs within domains, and it makes sense to push on as many fronts as possible. What is needed is a broad-gauged approach to the multiple determinants of SES disparities in health if we are to eliminate, or even greatly reduce, these disparities.

UNCOMPENSATED CARE TO UNINSURED PERSONS

The best available estimate of the value of uncompensated health care services provided to persons who lack health insurance for some or all of a year is roughly $35 billion annually, about 2.8 percent of total national spending for personal health care services. To the extent that individuals who lack coverage receive less effective or more costly health care than do those with coverage, the overall costs of their care will include some amount of true economic costs attributable to the condition of lacking coverage

Chronic stress.

The effects of stress were not included in the Centers for Disease Control and Prevention (CDC) analyses, and the impact is hard to quantify However, stress can affect health both directly and indirectly through its effects on health behavior. While people in all walks of life experience stress, lower-SES persons live and work in more stressful environments. Eric Brunner identified a number of factors that contribute to greater stress at lower SES levels, including economic strain, insecure employment, low control at work, and stressful life events. Some of the factors reviewed earlier, including crowding and noise exposure, low control at work, and social isolation, may affect health in part through elevated stress responses. A number of interventions developed to help people manage stress and buffer its physiological effects have been shown to reduce disease burden. In controlled trials, such programs have been shown to reduce hypertension, increase glycemic control among diabetic patients, reduce decreases in height among the elderly, increase levels of dehydroepiandrosterone (DHEA) and growth hormone, and decrease cortisol levels.

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The more years their parents own a home. The less likely they had a cold. African die early compared to their white counterparts Sanitation, Social reform, Personal income tax, Veterans got the GI bill. Most African Americans was excluded (GI bill) Had little to do to medical resonation Better housing and better education helped Behind the other countries in resources that will have the barriers of income, health, education. (wealth is more equal disbursed Empowering commutes can be a huge help to help instill hope in people.

Components Of Socioeconomic Status

The most fundamental causes of health disparities are socioeconomic disparities.Socioeconomic status has traditionally been defined by education, income, and occupation. Each component provides different resources, displays different relationships to various health outcomes, and would be addressed by different policies

State Medicaid Expansion Decisions and the Implications for CCPs

The need for charity care programs (CCPs) - which provide the uninsured with access to preventive, primary, and specialty care - will remain. These organizations must consider the implications of the size, health care needs, demographics, and expected utilization of the remaining uninsured population. This brief, informed by an affinity group of CCPs supported by Kaiser Permanente Community Benefit, examines options that CCPs are considering These include: (1) serving as a consumer assister in their state's health insurance marketplace (formerly known as an insurance exchange); (2) operating in a marketplace as a Consumer-Operated and Oriented Plan ( CO-OP); (3) continuing to provide the uninsured population in their regions with access to affordable care, albeit with program modifications; and/or (4) providing complementary services to those newly eligible for health insurance.

MEDICARE AND MEDICAID.

The use of supplemental, or upper payment limit (UPL), mechanisms is a newer approach to targeting additional funds to selected hospitals by raising their payment rates for the services they provide. As in the case of Medicaid DSH payments, there is often no net increase in state spending because of the use of intergovernmental transfers

Increases in Prices of Health Care Services and Insurance Premiums

There is mixed evidence that uncompensated care is subsidized by private payers. The impact of any such shifting of costs to privately insured patients and insurers is unlikely to be so large as to affect the prices of health care services and insurance premiums. Finally, the total burden of utilization and expenses by uninsured people has remained quite stable over the past decade or so (Taylor et al., 2001). For uncompensated care utilization by the uninsured to affect the rate of increase in service prices and premiums, the proportion of care that was uncompensated would have to be increasing as well.

CLINICS AND DIRECT CARE PROGRAMS

These providers are both privately and publicly owned, and they receive funds from all levels of government as well as from private sources, including payments from patients. While many of these clinics serve substantial numbers of low-income people, not all of their users are uninsured. For example, although 88 percent of the patients served by federally qualified health centers (FQHCs) have incomes below 200 percent of the federal poverty level, only 39 percent are uninsured.

Spending on Health Care for Uninsured Americans: How Much, and Who Pays?

Uninsured families pay for a higher proportion of their total health care costs out of pocket than do insured families, however, and are more likely to have high medical expenses relative to income Uninsured children and adults are less likely to incur any health care expenses in a year than their counterparts who have coverage. As earlier Committee reports demonstrated, this lower level of utilization is the source of one hidden cost of uninsurance—higher morbidity and mortality as a result of using fewer and less appropriate health care services. Health Insurance and Use of Services Within Families. Health insurance status affects families' relationships with health care providers and the delivery system. One way families with uninsured members manage health care expenses is by not using services People who lack health insurance for an entire year have out-of-pocket expenditures comparable to those of people with private coverage, but they also have much lower family incomes. Out-of-pocket spending for health care by the uninsured is more likely to consume a substantial portion of family income than out-of-pocket spending by those with any kind of insurance coverage. hose who did not have health insurance had substantially lower levels of wealth than those who did at the start of the study.

Neighborhood Disadvantage

They determined there are five features of neighborhoods that can affect health: (1) the physical environment; (2) surroundings in home, work, and play; (3) services provided to support people like schools, street and garbage pickup, police, hospitals, and health and welfare services; (4) the cultural aspects of the neighborhood such as its norms and values, economic,political, and religious features, level of civility and public safety, and networks of ; and (5) the reputation of an area that signifies its esteem, quality of material structure, level of morale, and how it is perceived by residents and nonresidents. Orderly neighborhoods are clean and safe, houses and buildings are well maintained, and residents respectful of each other and each other's property. Disorderly neighborhoods a breakdown in social order, as there is noise, litter, poorly maintained houses buildings, vandalism, graffiti, fear, and crime. Many families with children in neighborhoods are one-parent families headed by females. Ross asked whether = who live in disadvantaged neighborhoods suffer psychologically as a result their environment and found the answer to be yes. they observed that the residents in these neighborhoods lived in a stressful environment characterized by crime, incivility, and harassment and argued that the longterm exposure to these conditions impaired their physical and mental health. including the promotion of heavy drinking (Hill and Angel 2005). Other research in Chicago found that low SES on the part of the residents and their neighborhood perceptions could be correlated with negative self-rated health (Wen, Hawkley, and Cacioppo 2006) and that neighborhood effects on health extended into later life (Wen and Christakis 2006). There was also a significantly higher prevalence of hypertension in disadvantaged Chicago neighborhoods (Morenoff et al. 2007) and early risk of exposure to sexually transmitted diseases (Browning, Burrington, Leventhal, and Brooks-Gunn 2.008). found that living in disadvantaged neighborhoods reduces the likelihood of having a regular source of health services and obtaining preventive care, while increasing the probability of having unmet medical needs.

HOW MUCH DO GOVERNMENTS SPEND TO CARE FOR THE UNINSURED?

To develop estimates of what governments spend on care for the uninsured through either direct care programs or appropriations, grants, and payments to providers, we rely primarily on information from providers on the sources of their revenues that can be attributed to or justified by care to the uninsured. These estimates "get behind" the undifferentiated estimates of uncompensated care from the MEPS data and overall hospital uncompensated care from the provider data.

DISCUSSION AND POLICY IMPLICATIONs

We also estimated that governments finance most of the uncompensated care received by the uninsured, spending about $30.6 billion on payments and programs largely justified to serve the uninsured and covering possibly as much as 80-85 percent of uncompensated-care costs through a maze of grants, direct provision programs, tax appropriations, and Medicare and Medicaid payment add-ons.

STUDY DATA AND METHODS

We use two independent approaches to estimate the costs and sources of payment for care used by the uninsured, because no single data source provides complete, unambiguous, and precise information. 2 One approach uses household survey data collected by the Medical Expenditure Panel Survey (MEPS). 3 MEPS is the best available household survey for our purposes because it obtains information on services used from household respondents and then contacts providers to identify amounts and sources of payment for the respondents' care. We pooled data from 1996, 1997, and 1998 and updated each year's costs to 2001 prices The second approach uses data from various surveys of providers' revenues and expenses and from government budgets and agency reports, to determine how much care they delivered to the uninsured and to identify the sources of payment. Hospital data come primarily from the annual survey of the American Hospital Association (AHA). Estimates of uncompensated care provided by clinics are derived from information collected by government agencies that contribute to clinics' funding. Physicians' uncompensated care is inferred from recent physician surveys.

Social class

a category or group of people who have approximately the same amount of wealth, status, and power (based on Max Weber's work in 1922)

Social AND economic inequality

contribute to ill health of those at the bottom of the stratification ladder. The poor have the consequences of poverty (i.e. living conditions) as well as feeling aware of their social position. They feel undervalued and excluded because they ARE undervalued and excluded

Covid-19 Deaths

d demonstrate that there was a statistically significant interaction between percent of residents living in poverty, percent living in deep poverty, urban location, and percent low birth weight with date, indicating that their relationships with the number of deaths attributed to Covid-19 changed over time. The simple slopes for these variables at the two selected times appear in Table 12. The coefficients show that the number of deaths increased over time more quickly in those counties with higher percentages of residents living in poverty, and deep poverty, those living in urban areas, and in counties with a higher proportion of babies born at low weight. This result is consonant with the higher rates of confirmed Covid-19 cases in relatively poorer and more urban areas earlier in the pandemic, so that by the end of the study period the disease had progressed for some individuals to the point of dea

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education is not the entire story when it comes to the effects of SES ith. New research is showing that the relationship between income, educaad health changes over the life course, with income becoming more imporhealth as a person moves toward older age (Herd, Goesling, and House Kahn and Pearlin 2006; Lynch 2006). class also affects children < income and other features of their parent's SES significantly influence their o level of education, income, and eventual type of work, as seen in evidence linkir childhood adversity to poor health later in life Regardless of age or gender, people living in poverty and reduced socie economic circumstances have the greatest exposure to risk factors that produce health. These risk factors are physical (poor sanitation, poor housing, overcro ing, extreme temperatures), chemical (environmental pollution), biological (bact ria, viruses), psychological (stress), economic (low income, lack of health insurane unhealthy jobs), and lifestyle (poor diets, smoking, alcohol and drug abuse, lac of leisure-time exercise) in origin.

Another fun reading

experts are recommending that people avoid large crowds, stockpile shelf-stable foods in case they end up quarantined, and stay home from work and contact a doctor if they are ill. But there's a key problem with that advice: A lot of low-income people can't afford to follow it. Low-income jobs—line-cooks, nurse's aids, grocery store clerks, nannies—mostly can't be done remotely, and the majority of low-income jobs don't offer paid sick days. Low-income people are disproportionately more likely to be uninsured or underinsured for medical care, and for many, even stocking up the pantry can be an impossible financial hurdle. There's a secondary effect, too. As states and community health departments scramble to address the COVID-19 outbreak in the U.S., they are shutting down schools, creating containment zones, and enforcing quarantines—moves that, again, often have outsized, if unintended, downstream effects on poorer people. Many low-income children rely on free and reduced school breakfasts and lunches for their daily nutrition, for example, and low-income parents can't always afford child care when their school age kids are suddenly home all day. Limited access to healthcare is another issue that might exacerbate the spread of the virus. Even as private insurance companies, Medicare and Medicaid all vow to test symptomatic patients free of charge, 28.6 million people across the U.S. are not covered by any form of insurance at all.

Results Covid-19 Cases

includes the simple slope estimates relating the poverty index to the number of cases at specific dates. For the first three dates, the relationship between the poverty index and the number of cases was negative, indicating that counties with greater levels of reported poverty had a larger number of confirmed Covid-19 cases. However, by April 1, 2020, the relationship between these two variables was positive, so that relatively more affluent counties had a larger number of confirmed cases. It is also important to note that for the earlier dates, the number of confirmed cases overall was relatively small. school diploma, whether a county was classified as urban, life expectancy, and the percent of low birth weights were all examined in this follow up analysis. As was the case for the poverty index, the main effects of date, the specific variable, and the interaction of the two were included in a mixed effects model with a random intercept. Each poverty variable was analyzed individually in order to avoid the possibility of collinearity among them

Social Gradient Thesis

inequalities in population health status are related to inequalities in social status

(Modern Diseases and the poor) The poor in industrialized nations suffer more than middle and upper classes from:

infectious disease (typical diseases of the past) Chronic diseases (greater %, longer-lasting, increased risk of death)

The Earned Income Tax Credit (EITC)

is a contemporary example of a federal policy that has raised the income of working-poor families, while welfare reform in general has pushed in the opposite direction, cutting the stipend levels for recipients.13 These interventions have affected the distribution of resources and therefore the contours of inequality, which at least in theory should leave their traces in health outcomes.

Modern Diseases and the poor

lower class, even in modern nations, suffers more from the typical diseases st human existence, such as influenza and tuberculosis, in comparison to the + and middle classes. Japan, for example, has historishown a relatively low rate of heart disease. Diet and stress-reducing activich as periodic group vacations and after-work socializing for Japanese males been thought to contribute to the low mortality rates from heart disease. Westernization of the Japanese diet is considesponsible for the replacement of stroke by heart disease as Japan's second cause of death. The result is coronary heart disease is now concentrated more among the poor. The differs that more obesity, smoking, and stress now occur in the lower class, in addi- » higher levels of blood pressure, less leisure-time exercise, and poorer diets. A healthy lifestyle includes the use of good personal such as eating properly, getting enough rest, exercising, and avoiding practices zs smoking, abusing alcohol, and taking drugs. However, the type of lifestyle romotes a healthy existence is more typical of the upper and middle classes ave the resources to support it.

Socioeconomic status

qhether assessed by income, education, or occupation, is linked to a wide range of health problems, including low birthweight, cardiovascular disease, hypertension, arthritis, diabetes, and cancer. Lower socioeconomic status is associated with higher mortality, and the greatest disparities occur in middle adulthood (ages 45-65). J. Michael McGinnis and William Foege have provided an incisive analysis of the "actual causes" of death in which they estimated the number of U.S. deaths caused by factors such as tobacco, diet and lack of activity, and toxic agents While socioeconomic status is clearly linked to morbidity and mortality, the mechanisms responsible for the association are not well understood. Identifying these mechanisms provides more options for policy remedies. Given the pervasive effects of socioeconomic status, no single policy, or even one domain of policy, can eliminate health disparities the United Kingdom, which was charged with providing policy suggestions for reducing health disparities in that country, made thirtynine recommendations, organized around key populations (such as children, older people, and ethnic minorities) and domains (such as income and tax benefits, education, and employment)

1. Continuing to Serve the Uninsured

the ACA will face a health care marketplace that is even less favorable to their needs than the current system, suggesting that efforts to connect them to care will require CCPs to change their outreach and delivery systems. This is a particular challenge given that it is unclear what the health care needs and utilization patterns of this population will be Medicaid and insurance marketplace "opt-outs": While CCPs typically screen their own program applicants for Medicaid eligibility - to avoid allocating limited program resources to those who can access lowor no-cost care elsewhere - their role in this capacity may need to be more assertive. CCPs will need to decide whether to offer coverage to those who opt out of Medicaid or marketplace coverage. CCPs can play a role in "selling" the value of Medicaid and marketplace enrollment. Undocumented immigrants: Reaching and enrolling these individuals in a charity care organization may be more difficult given linguistic challenges, cultural barriers, and/or individuals' fears of deportation. Individuals exempt from the mandate: As with undocumented populations, these individuals will still have health needs that may lead to increased utilization of the emergency department. CCPs can play a role in mitigating this avoidable, high-cost utilization by providing this population with a coverage alternative The "churn" population: For those moving in and out of eligibility for Medicaid or for marketplace-based premium subsidies, CCPs can provide "gap coverage." The relatively small increase in income that can move an individual out of Medicaid eligibility is often not enough to cover the additional costs of marketplacebased coverage, leading to the risk of a coverage gap. Within six months of enrollment, an estimated 35 percent of low-income adults could be expected to move from Medicaid to a QHP in a marketplace, or vice versa; the number rises to 50 percent over 12 months. Gaps or changes in coverage can also threaten access to consistent primary care and specialty providers, a particular issue for individuals with chronic illness requiring ongoing management.

Social Demography of Health - Social Class.pdf

there is a 20-year gap in life expectancy between the low-income blacks at the beginning of the journey and the wealthy whites at the end. In the United States, as well as in virtually all countries without exception, the wealthy are healthier and live longer on average than the poor. It is a sociological fact that the further down one goes in the social structure of a society, the worse the health of the people on that rung of the social ladder. Conversely, the higher one goes in the class structure, the better the overall level of health. socioeconomic status or social class is the strongest and most consistent predictor of a person's health and life expectancy throughout the world Even though other social demographic variables such as race, gender, and age also have important effects on health, the explanatory power of class position is evident when it interacts with these other variables to produce differences beyond those already produced.

Social selection explanation

there is a downward mobility of people with illness that puts them in the lower classes

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wealth is an objective dimension of a person's social rank based upon how muck money or property he or she possesses, status is a subjective dimension consisting o how much esteem the person is accorded by other people. Status indicates a person level of social prestige, which may or may not correspond to wealth. People with similar class standing generally have similar lifestyles Power js clearly affected by wealth and status status by wealth and power, and wealth by power and status, so all three variable are interrelated but distinct. SES consists of three variables: income, occupational prestige, and level of educa tion. The advantage of using this measure in quantitative studies is that income occupation (through the use of scales ranking occupations in terms of prestige and years of eduction can all be assigned numerical values that sort people into social classes based on their scores

CCPs at a Strategic Crossroads

while considering the above challenges, CCPs must communicate to key stakeholders that they will continue to be critical to the health safety net. Without access to health care services, the still-sizable uninsured population will pose a fiscal burden on states through costs for uncompensated care.