Race, Class, and Health Exam 3

Possible Causes of Rapidly Increasing Health Care Expenditures

Affordable Care Act added more mandatory services to healthcare plans, raising premiums across the board

Leading Causes of Death for Hispanics

Cancer, heart disease, accidents (unintentional injuries)

Leading Causes of death for AA/NHOPIs

Cancer, heart disease, and stroke

Differences between Asian Americans and NHOPIs

Census identified 24 subgroups of AA Census identified more than 25 subgroups of NHOPIs AA generally tend to have higher educational attainment, median household incomes, and lower rates of poverty compared to whites.

1993: Health Security Act

Clinton "A bill to ensure individual and family security through health care coverage for all Americans in a manner that contains the rate of growth in health care costs and promotes responsible health insurance practices, to promote choice in health care, and to ensure and protect the health care of all Americans." - Did not passed

Why are the Uninsured Uninsured?

Cost: too expensive -Not everyone is eligible for free or subsidized coverage -More comprehensive coverage -Immigration status They are not aware of coverage options -Didn't know that they are required to have h.i. -Didn't think the requirement applied to them Not all workers have access to coverage through their job -In 2016, 73% nonelderly uninsured workers worked at a firm that did not offer health benefits to the worker

Prevalence of Hypertension among Hispanic Subgroups

Cubans, Dominicans, Puerto Rican have the highest percentage- 32% South Americans and Mexicans have the lowest percentage-20%

Differences between Asian American Groups

Customs; languages; integration into American life and culture (acculturation); Filipinos face the highest level of perceived discrimination, followed by Chinese, then Vietnamese.

Prevalence of Stroke among Hispanic Subgroups

Dominicans have highest percentage-2.5% Puerto Ricans second highest- 2.3% Mexican have the lowest percentage-1.1%

What ACA means for big and small employers

Easier for smaller employers to offer health insurance -Big employers were now required to offer healthcare and only very small businesses (over 50 employees) aren't.

Similarities between Asian American Groups

Generally located in the western states, the Northeast, and parts of the south and Hawaii

1970-1990: Health Mantenaince Organizations and Managed Health Care Organizations

HMOs create yearly fixed prices for health insurance by containing all healthcare in one network per HMO

Benefits of Limited Acculturation among Hispanics

Limited acculturation: -Have not yet adopted health risk behaviors (including "American diet") -Have not yet had extended exposure to social stress -Have not yet had extended exposure to the physical and environmental health risks -Traditional values: Familismo, Respeto

Hispanic Subgroup Percentages

Mexican American - 63.4% (highest) Puerto Rican - 9.5% (lowest

Culturally Appropriate Care

Minorities feel most comfortable when their doctor is the same race as themselves Minority doctors are more rare, and they usually treat a large proportions of minorities -Feel more open with them, language barrier is removed

What it means to be uninsured

No stable long-term preventative care, risk of extreme financial strain if health services are needed

Consequences of Being Uninsured

No usual source of care/continual care Cannot prevent illness as easily, more trips to the ER Sick care vs wellcare -Focus on treatment of illness rather than promoting healthy lifestyles

ACA's Main Tax Provisions

Optional expansion of medicare for states, employers can cover employees children until 26, fee for being uninsured

What are the (patient's) need factors?

Patient's perceived need for health care services, including health status, the severity and duration of their symptoms

Major Health Risks and Issues among Hispanic Americans

Poverty and low income Access to healthcare and utilization -Lack of health insurance -Language barrier Occupational health HIV/AIDS About 31% of Hispanics do not have a usual source of healthcare -Due to high numbers of uninsured

2010: Patient Protection and Affordable Care Act

Pre-existing conditions cannot be considered in enrolling for healthcare

Prevalence of COPD among Hispanic Subgroups

Puerto Ricans have highest percentage- 16.8% South Americans have the lowest- 4.7%

Prevalence of Coronary Heart Disease among Hispanic Subgroups

Puerto Ricans have the highest percentage of all Hispanics- 4.9% Mexicans have the least percentage of all Hispanics-2.1%

Prevalence of Asthma among Hispanic Subgroups

Puerto Ricans have the highest percentage-35.8% Cubans have the second highest- 21.2% Mexicans have the lowest-7.4%

What are the enabling factors?

Structural or material resources -having health insurance, -ability to take sick time off from work -having access to transportation -having a pre-existing relationship with a health care provider

The Latino Paradox

The Latino Paradox Hispanic women who have immigrated to the US have a level of infant mortality that was 20% lower than Hispanic women who were born in this country Compared with US-born Hispanics, foreign-born Hispanics have -About half as much heart disease -48% less cancer -29% less high blood pressure Cancers related to infections are more common among Hispanics born in another country -Cervical, Stomach, and liver cancer

Myth of the Model Minority

The incorrect assumption/notion that Asian Americans are passive, compliant and without problems or needs.

Who most benefited most from the ACA and why?

The uninsured, under-insured, and those with pre-existing conditions. Easier on-ramp to health insurance with "Market", mandatory coverage for different sectors of healthcare, prohibits insurance companies from turning you away because of pre-existing conditions.

Effect of the Myth of the Model Minority

The very real concerns of the AA population are not taken seriously. Asian groups who are not as well as statistical norm can go ignored.

The Uninsured in 2010 & 2014

The young, illegal, and poor who would rather take the penalty and risk health than pay high premiums or who are not citizens and therefore not eligible

Why the ACA required insurance companies to include the ten essential benefits

To regulate insurance companies from denying people care for the sake of profit.

Health Care Expenditures in the U.S.

US spends 16% GDP on health care, where other developed countries spend 7%

Health Insurance Coverage Among AA

Uninsured pop: 7.5% Asian Americans are least likely to be covered by government sponsored (Medicaid, Medicare, and military HI) health insurance (22.4%)

Similarities between Asian Americans and Native Hawaiians and Other Pacific Islanders (NHOPIs)

Very diverse populations of different ethnic groups including native and foreign-born. They typically have longer life expectancies and lower mortality rates.

Did the ACA help to reduce health disparities among racial/minority groups?

Yes. "Between 2013 and 2015, disparities with whites narrowed for blacks and Hispanics on three key access indicators: the percentage of uninsured working-age adults, the percentage who skipped care because of costs, and the percentage who lacked a usual care provider. "

What are the physicians' (provider) factors that may contribute to the healthcare disparity?

effects of prejudice and bias under conditions of uncertainty

What are the patients' factors that may contribute to the health care disparity?

mistrust and personal preferences

How systems factors contribute to the health care disparity?

system based factors: barriers to care within the health system (e.g. referral patterns and access to specialty care)

Before 1940s: Beginning of Private Health Insurance

- 1930s: F.D Roosevelt wanted national health insurance. But he wanted to convince the citizens first before he took it to congress. But unfortunately, he died before he was able to accomplish anything and the task was then passed down to Truman.

1950-1960: Federal Government Efforts to Expand National Health Insurance

- 1940s-1960s: (Truman and Eisenhower) For the first time in U.S. history, Truman asked for universal health care.

Barriers of Access to Health Care and Utilization

- More likely to be without a usual source of care - Immigrants enter the country with limited English proficiency that limits obtaining quality care - Less likely to disclose their use of traditional remedies to Western physicians --> Hinder developing a trusting doctor-physician relationship --> Possible problems of complication - Problem with relying on relatives as language interpreters: difficulty maintaining the the privacy of the patient's health info -Accuracy of the translation and whether the patient is receiving good quality information about their health

Allocentrism

-A collectivistic personality attribute whereby people center their attention and actions on other people rather than themselves. / Having one's interest and attention centered on other persons. -When cultures exhibit respect for nature and emphasize collective needs over individual needs -Cultures that place great importance on respect for the wisdom of elders. -Each of these values can influence patterns of health service use, including the use of preventative health services, curative care, and long-term care for seniors.

Ways to Make our Society More Equal

-Addressing social and economic conditions -Improving the physical environment -Improving access to appropriate and effective health and social services -Reducing barriers to adopting healthy lifestyles

Programs that May Promote Equal Employment (Occupational) Opportunities

-Affirmative Action, Pellet Grants, Head Start -Equal opportunity and diversity programs -EEOC - Equal Employment Opportunity Commission (EEOC) is a federal agency that administers and enforces civil rights laws against workplace discrimination. EEOC investigates discrimination complaints based on an individual's race, children, national origin, religion, sex, age, disability, sexual orientation, gender identity, genetic information, and retaliation for reporting, participating in, and/or opposing a discriminatory practice.

Addressing Racial Discrimination in the Health Care System

-Civil Rights Act -Department of Health and Human Services' Office of Civil Rights -National Institute on Minority Health and Health Disparities

Random Prevalences of Disease among Hispanic Subgroups

-Hispanics have lower death rates than whites from most of the 10 leading causes of death except two conditions: diabetes and liver conditions -Percentage of all ages in fair or poor health - 10.1% -Puerto Ricans have a disproportionally high prevalence of asthma, HIV/AIDS, and infant mortality -Mexican Americans have a higher prevalence of diabetes and chronic liver disease

Health Insurance Coverage among NHOPIs

-Native Hawaiians and Pacific Islanders are more likely to be uninsured and more likely to be on Medicaid than both Asians and non-Hispanic whites

Ten Market Place Essential Benefits Under ACA

-Outpatient care—the kind you get without being admitted to a hospital -Trips to the emergency room -Treatment in the hospital for inpatient care -Care before and after your baby is born -Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy -Your prescription drugs -Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more. -Your lab tests -Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease. -Pediatric services: This includes dental care and vision care for kids

The Kaiser Family Foundation, Massachusetts Health Care Reform: Three Years Later

-Passed in 2006, the Massachusetts law imposes an individual mandate for the purchase of health insurance and calls for shared responsibility in financing coverage. This has caused an unprecedented increase in the number of people in the state that have health insurance. -Individual mandate: all residents were required to purchase health insurance coverage or be fined. -Employer Requirements: employers with 11 or more employees are required to make a "fair and reasonable" contribution toward health insurance coverage for their employees or pay a "fair share" contribution. -Health coverage was subsidized for individuals with income 300 percent of the federal poverty level: Commonwealth Care -Demand for care in underserved communities has increased -Community health centers and safety net hospitals play a crucial role in caring for the newly insured and the uninsured. -Recommendation that the state shift from a fee-for-service system in which health care providers are paid per visit and procedure to a system where providers work together to share the responsibility for the patient's care.

What are the predisposing factors?

-Patient's inclination to use health services such as patient's attitudes, cultural beliefs, prior experiences and perceptions -Assuming that the enabling factors are equal (same health insurance coverage), a person's decision whether or not to utilize health services is based on the patient's perception of need for health services

Quadango, Why the U.S. has no National Health Insurance: Stakeholder mobilization against the welfare state

-Proposes a theory of stakeholder mobilization as the primary obstacle to national health insurance: Powerful stakeholder groups such as the American Medical Association, insurance companies, and employer groups have been able to defeat every effort to enact national health insurance. -"The power of the state must be limited", so " it is easy to regard the welfare state as a threat to liberty" -Failure of national health insurance in the United States could be due to the lack of a working-class movement and labor-based political party: "Power resource theory"- views the welfare state as a product of trade union mobilization. -Another main impediment to health care reform is the diffusion of political power amongst the branches of government. -Five major structural changes established by physicians: --1. The emergence of an informal system based on the physicians' needs for referrals and hospital privileges --2. Blocking the construction of new medical schools and restricting the number of students admitted. --3. Expulsion of profit-making enterprises that could extract the surplus labor from physicians --4. Exclusion of any organized purchasers that could offset the market power of physicians --5. Establishment of specific spheres of authority and the rejection of any policy or plan that failed to respect their professional sovereignty. -The greatest challenge to physicians' autonomy came from third-party financiers of medical care -National health insurance was revived in 1945 under President Harry Truman (Poen 1979). As the Truman administration geared up to promote national health insurance, the American Medical Association (AMA) launched a "National Education Campaign" to prevent its passage and to promote private health insurance. -Racism and the Red Scare provided a potent framework for defaming national health insurance and demonizing its proponents -From the New Deal to the 1970s, the most vehement opponents of national health insurance were physicians. Fearful that government financing of health services would lead to government control of medical practice, they mobilized against this perceived threat to professional sovereignty. -The changing composition of the anti-reform coalition, dominated first by physicians, then by insurers, has obscured the persistence of stakeholder mobilization as the primary impediment to national health insurance.

Government to Reduce Poverty: Current Safety Net Programs

-SNAP, TANF, Social Security, medicare, medicaid -Earned Income Tax Credit -Section 8 Housing: Housing Assistance

Fiscella, Inequality in Quality: Addressing Socioeconomic, Racial and Ethnic Disparities in Health Care

-Socioeconomic position appears to be the more powerful determinant of primary health care use in the US over race/ethnicity→ in the US, lower socioeconomic position is associated with lower overall health care use, even among those with health insurance. -In general, blacks receive less intensive hospital care than their white counterparts. Latinos receive fewer mammograms, pap smears, vaccinations, prenatal care, etc, than whites. -Ethnic minorities report lower health care satisfaction and greater discrimination. -5 principles for addressing disparities in health care quality: --1. Disparities must be recognized as a significant quality problem. --2. The collection of relevant and reliable data are needed to address disparities. --3. Performance measures should be stratified by socioeconomic position and race/ethnicity. → For example, instead of simply reporting overall rates of Papanicolaou test screening among eligible women, MCOs should also report separate rates by socioeconomic position and race/ethnicity --4. Because the socioeconomic position and race/ethnicity of enrollees affect existing performance measures. Population-wide performance measures should be adjusted for socioeconomic position and race/ethnicity. --5. An approach to disparities should account for the relationships between both socioeconomic position and race/ethnicity and morbidity. -There are a number of challenges to implementing these proposals. These include leadership (Obtaining commitments from key players to these proposals will be challenging.), absence of relevant data, privacy and data collection concerns, misuse of data, and organizational inertia and resistance.

Aronson, Unhealthy Interactions: The Role of Stereotype Threat in Health Disparities

-Stereotype threat is the unpleasant psychological experience of confronting negative stereotypes about race, ethnicity, gender, sexual orientation, or social status. -When interactions between care providers and their patients are stressful, unpleasant, or disrespectful, patient health often suffers. → Members of disadvantaged groups such as African Americans, Latinos, the poor, and others appear to be particularly at risk. -Research demonstrates the existence of unconscious or unintentional bias on the part of the health care providers toward cultural minorities and show its contribution to racial disparities in health care outcomes. -Stereotype threat: a disruptive psychological state that people experience when they feel at risk for confirming a negative stereotype associated with their social identity. -Racial differences in academic performance are, to a significant degree, influenced by the nature of situations and by the way individuals respond to them. -The experience of stereotype threat does not require any actual prejudice or bias— implicit or explicit—to be manifested; targets can feel devalued by their interaction partners merely as a function of interacting across racial, ethnic, or other social identity divides. Thus the minority patient can feel a sense of threat without ever encountering unfair or unkind treatment.

Actions to Reduce Health Disparities in the U.S.

-Take explicit measures to eliminate unconscious racial and ethnic bias as a cause of health disparities -Monitor patterns of care to identify disparities when they exist -Strengthen the physician-patient relationship, especially when they are from differing backgrounds (cross-cultural education) -Increase the racial and ethnic diversity of the medical profession and other health professions -Assure access to care through universal health insurance

Programs that May Reduce SES Disparities

-Tax returns, healthcare subsidies for near poverty line -Equal Educational opportunities act: 1974 -Equal educational opportunities --Head Start --Affirmative Action --Pell Grants -Harlem Children's Zone (Promise neighborhood)

Koh, Translating evidence into practice to reduce health disparities: A social determinants approach

-The 2008 World Health Organization Commision on Social Determinants of Health urged that gaps in health are attributed to political, social, and economic factors that should be closed in a generation. -Those who are poor and have a low socioeconomic position suffer disproportionately from poor health outcomes. -Roots of health disparities include living environment, education, employment, and many other social factors -The NIH defined health disparities as "the quantity that separates a group from a specified reference point on a particular measure of health." -RE-AIM Model: Reach: participation rate and representativeness of participants, Efficacy/Effectiveness: effect of an intervention on specified outcomes, Adoption: number and representativeness of setting and interventionists, Implementation: quality and consistency with which intervention is delivered, Maintenance: how long intervention holds up at both the individual and organizational level. -Translating the evidence of health inequities into practice requires research that bridges the gap between discovery and delivery. -To date, 166 countries have both signed and ratified this treaty, committing their governments to adopting a comprehensive range of measures to combat the health and economic effects of tobacco. In the United States, the National Cancer Institute has committed to developing community-academic networks to address cancer disparity issues, connecting resource-rich institutions with community resources. -In 1948, the WHO (world health organization) defined health as ''a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.'

Editorial, Ending racial and ethnic health disparities in the USA

-The US Department of Health and Human Services has been having meetings nationally where the federal officials discuss the best ways to address health inequalities with state officials and communities. -Although racial and ethnic minorities represent a third of the US population, more than half of the country's 50 million uninsured citizens are from ethnic minorities. -Ethnic minorities have poorer overall health and experience more severe forms of serious illness which shortens their life expectancy. -The lack of access to care and low quality of care in minority populations is also reflected in infant outcomes. → Stillbirth rates in African-Americans are double the rate of whites, and infants born to African-American women are 1.5 to 3 times more likely to die than are infants born to non-African-American women. -Many adult Americans are not proficient in English! → need to create online national registry of interpreters that hospitals and doctors would use when dealing with nonEnglish speakers.

Smedley, Unequal Treatment- Confronting Racial and Ethnic Disparities in Health Care

-There is increasing evidence that even after socioeconomic differences are accounted for, race and ethnicity remain significant predictors of the quality of healthcare received. → Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients' insurance status and income, are controlled. -They found evidence that stereotyping, biases, and uncertainty on the part of healthcare providers can all contribute to unequal treatment. -Broad sectors—including healthcare providers, their patients, payors, health plan purchasers, and society at large—should be made aware of the healthcare gap between racial and ethnic groups in the United States. -Economic incentives should be considered for practices that improve provider-patient communication and trust, and reward appropriate screening, preventive, and evidence-based clinical care. -The healthcare workforce and its ability to deliver quality care for racial and ethnic minorities can be improved substantially by increasing the proportion of underrepresented U.S. racial and ethnic minorities among health professionals

Cultural Competence

-Understanding a patient's culture, their beliefs, attitudes, and how it may affect their healthcare decisions/outlooks -Understanding other people's culture as a physician in order to better treat your patients. Including their cultural behaviors, habits, and trends.

Barriers of Access to Health Care and Utilization among Hispanics

-Uninsured population- 19.6% -Language Barrier --About 1 in 3 do not speak English well --About 40% reported that they have hard time speaking with or understanding the doctor b/c of language barrier ---Less likely to understand diagnosis, medication, special instructions and plans for follow up care --30% reported that even with interpreter, they still do not fully understand the doctor -Central Americans (28.2%) and Mexicans (21.5%) have the highest percentage of uninsured -Cubans (13.9%) and Puerto Ricans (8.5%) have the lowest percentage of uninsured

Does race/ethnicity affect the way physicians treat patients? Why?

-Yes, unconscious bias causes less procedures to be recommended, pain killers to be withheld, and worse/cheaper medicine to be offered -Unconscious bias has the same effects as conscious racial biases

1965: Implementation of Medicare and Medicaid

1965: Great Society (LBJ)