Social Inequality and Health Final Exam
Does Paul Farmer believe that providing quality health care to the poor is possible? If so, why?
"Biggest failure in providing health care to the poor is a failure of imagination" Not possible that we can send a rover to Mars, but not build a health care system that protects poor people Idea of "accompaniment" rather than "aid" ("I'm going to be your doctor for a long time") Great health care is possible for the poor Less expensive than erratically administered health care Can build systems for relatively limited amounts of money Important to build up the systems of health delivery - only way to bring interventions to scale
What do the terms "sex" and "gender" refer to?
"Sex" refers to biological differences between men and women "Gender" refers to social differences "Male" and "female" are sex categories; "masculine" and "feminine" are gender categories Gender is relational - gender roles and characteristics do not exist in isolation, but are defined in relation to one another and through the relationships between women and men, girls and boys
What are "racialization" processes among immigrants, and how might racialization impact health?
For Latino, Asian, Black immigrants, "becoming American" involves contending with ideologies that render them racial "minorities" Stigmatized meanings the racialized society ascribes to their specific group Limited access to opportunities, stress "Becoming White" is also a racialization process that some immigrant groups experience Associated with privilege and social mobility
What are some examples of the immigrant health advantage? (e.g., differences in life expectancy)
First pointed out by Markides and Coreil (1986) about health and mortality situation of Southwestern Hispanics Health and mortality (e.g., mortality from cardiovascular diseases, major cancers) were more similar to non-Hispanic Whites than to African Americans But their socioeconomic conditions were more similar to African Americans Explanations emphasized strong family support systems, certain health behaviors and cultural practices, health selective migration By the 1990s, there was evidence that Hispanics' life expectancy actually surpassed non-Hispanic Whites' Low mortality among the foreign-born explains some of the overall mortality advantage of both Hispanics and Asian Americans (Hummer et al. 2014) At age 65, foreign-born men and foreign-born women can expect to live 2.4 years longer than their U.S.-born counterparts The immigrant advantage narrows at older ages, but persists
How might residential segregation among immigrants (enclaves) benefit or negatively influence health?
Some research says residence in immigrant/ethnic enclaves is protective of health Sets of relationships, institutions, social resources that facilitate day-to-day survival, buffer negative effects of social disadvantage Other research suggests there are limits to how beneficial enclaves are Beneficial for some outcomes (e.g., diet, access to health care, depression), but not others (e.g., physical activity, cancer incidence) Different meanings/effects depending on generational status, language skills, SES Exposure to neighborhood disadvantage (poor housing, violence, lack of access to recreational facilities, etc.) For some, living in enclaves may reflect limited opportunities for social, economic, residential mobility New immigrant destinations often lack traditional enclaves
What happened to the uninsured rate under the Affordable Care Act?
Number of nonelderly uninsured declined from 41.1 million in 2013 to 32.3 million in 2014 Nearly all of the decline occurred among adults Uninsured rates declined most sharply for poor and near-poor people, adults aged 19-34, Hispanics, Blacks, and Asian Americans
What are the ways in which racial discrimination affects health?
Racism affects multiple health outcomes, operates through multiple mechanisms, and the pathways have changed over time Racism leads to differential access to SES opportunities and to a broad range of societal resources
What are racism and discrimination (including structural and interpersonal discrimination)?
Racism: An organized system premised on the categorization and ranking of social groups into races that devalues, disempowers, and differentially allocates desirable societal opportunities and resources to racial groups regarded as inferior. Discrimination: The process by which members of a socially defined group are treated differently (especially unfairly) because of their membership in that group Structural discrimination: The totality of ways in which societies foster discrimination, via mutually reinforcing systems of discrimination (e.g., in housing, education, employment, earnings, benefits, credit, media, health care, criminal justice, etc.) that in turn reinforce discriminatory beliefs, values, and distribution of resources Interpersonal discrimination: Directly perceived discriminatory interactions between individuals
Does race capture more than socioeconomic inequality? (Be able to identify evidence of this.)
Yes, there are large racial differences in SES Median wealth of white households is 20 times that of blacks and 18 times that of Hispanics Differences in SES account for a substantial part of observed racial differences in health BUT, SES is not just a confounder of the relationship between race and health, but part of the causal pathway linking race to health Historical and contemporary racial discrimination created and perpetuates both racial inequities in SES and racial inequality in health status In addition, there is an added burden of race, over and above SES, that is linked to poor health
Who were the uninsured in 2014, after implementation of the ACA?
54% of uninsured had family income <= 200% FPL People of color make up less than 40% of U.S. population, but accounted for 55% of uninsured 73% of uninsured were in family with at least one full-time worker Only 6% of children were uninsured Non-citizens were more likely than native U.S. citizens to be uninsured 48% of uninsured said main reason they lacked coverage was because too expensive
What are "acculturation stressors" and how can these be linked with health?
Acculturation stressors include: learning a new language coping with changes in family roles protecting legal status of self and family encountering racism/discrimination
What are common explanations given for deterioration in health with time in theU.S. and across immigrant generations?
Adoption of health lifestyles more typical of Americans in their socioeconomic group (e.g., smoking, drinking, high-calorie diets, sedentary lifestyles, risk behavior) Increases in obesity and in smoking are particularly important mechanisms Strong family networks deteriorate over time and generation in U.S. Changes in family structure (e.g., increases in divorce) Discrimination (and discrimination stress) Suboptimal medical care
What are some advantages and disadvantages of the "vulnerability paradigm" described by Higgins et al.?
Advantages: Over time there was an acknowledgement that women are more susceptible/ vulnerable to HIV/ AIDS so funding was funneled to addressing gender based violence (rape, abuse), transactional sex (sex work, relationships in exchange for resources: "sugar daddy") in general promoting women's health Disadvantages: The paradigm assumes that gender disparities are unchangeable/ immutable, there wasn't action to address issues of masculinity, putting the burden of action on women Also assumes that women want to prevent HIV, but they dont have the power to do so. It ignores that men also want to prevent HIV. It ignores womens agency and pleasure in general. Assumes that men were the only ones to engage in extramarital relationships
What are the key elements of Rwanda's model for delivery of health care?
Average health care cost: $55 per person per year (US: ~ $8000 per person per year) Health considered by government to be key pillar of development (sentiment that without improving health, cannot alleviate poverty) Built robust system of primary care In addition to building hospitals and clinics, trained 45,000 community health workers Universal community-based health insurance Half of funding comes from int'l donors, half from annual premiums of < $2 per person Subsidized premiums, co-payments for those living in extreme poverty Particular attention to providing for vulnerable populations Evidence-based policy (use of health data to determine interventions)
What are some examples of disadvantages LGBT individuals experience in health? In particular, be familiar with behavioral and emotional health, HIV/STIs,physical violence/assault, and health of LGBT youth. (You do not need to memorize statistics, just be familiar with trends.)
Behavioral and Emotional LGBT individuals are more likely to experience depression, anxiety and substance misuse than non-LGBT individuals Stigma and discrimination (including lack of acceptance from family members) are correlated with higher rates of depression, anxiety, and substance use Alcohol use and smoking rates are higher among bisexual and gay or lesbian adults compared to heterosexual adults Suicidal ideation is higher among bisexual adults than heterosexual, gay, or lesbian adults HIV/STIs In recent years, new HIV infections are on the rise among gay/bisexual men In 2010, gay and bisexual and other MSM accounted for > 56% of all people living with HIV in U.S., and 2/3 of new infections Highest increase in new HIV infections seen among young Black MSM (black MSM accounted for 36% of new infections) HIV treatment rates lowest among younger men and Black men Transgender women, particularly of color, are also at high risk of HIV (studies suggest 28% are HIV positive) MSM account for 72% of new syphilis cases MSM are 17x more likely than men who only have sex with women to develop anal cancer (HPV vaccine could reduce) Physical Violence/Sexual Assault LGBT adults experience higher rates of physical and sexual violence 30% of LGBT adults reported being physically threatened or attacked in a 2013 poll One in five hate crimes is due to sexual orientation bias Bisexual women experience particularly high levels of sexual and intimate partner violence Bisexual and gay men experience higher rates of sexual violence than heterosexual men Transgender women of color are at particular risk of hate crimes, including murder Health of LGBT Youth Adolescence/young adulthood are particularly trying times for LGBT youth Youth who identify as sexual and/or gender minority experience higher rates of substance abuse, violence, discrimination, and mental illness compared to the general population ~ 40% of homeless youth are LGBT (leading reason=family rejection) 64% of LGB and 44% of transgender students report feeling unsafe at school LGB youth are four times more likely than heterosexual youth to attempt suicide 3 times as many LGB youth report ever being raped compared to heterosexual peers
Why do women live longer than men, but spend more years in poor health? (Be familiar with biological, socioeconomic, psychosocial, and health behavior explanations.)
Biological Explanation: Estrogen helps reduce women's risk of heart disease Testosterone puts men more at risk of life-threatening conditions Women have more robust immune system Provides passive immunity during pregnancy, protective antibodies to infants during nursing But also puts women at greater risk of autoimmune disorders BUT these biological differences cannot explain why the gender health gap varies over time/place/social group, or increased morbidity for women other than autoimmune disorders Women's social disadvantage (e.g. role stress, role conflict, economic disadvantage) diminishes some of their biological advantage Socioeconomic Explanation: • Women earn less money than men for similar work (in 2015, 80 cents for every dollar earned by men) •... and more often also provide for a child or parent • Women occupy fewer positions of power in most occupations • Women more likely to work part-time, and to engage in domestic and unpaid labor • Influences women's access to disease prevention, health care, treatment; exposure to chronic stress; decreased feelings of personal control and self-esteem; depression Psychosocial Explanation: Women more likely than men to experience stressful life events and chronic stressors in everyday life "Second shift" and work/family conflict Increased stress at work and less decision-making power/control in workplace Gender discrimination Gender-based violence Women often have stronger support networks, which can enhance their well-being However, women less often cared for by male spouse when ill compared to men's receipt of care from female spouses (gendered norms of caregiving); women also more involved in the health needs of other family members/friends Health Behaviors Explanation Men are generally exposed to more harmful behavior than women Fewer preventive healthcare visits; less seatbelt and helmet use; more drinking, smoking, and drug use; less healthy diet Experience more unintentional injuries But, men engage in slightly higher levels of regular exercise Rates of suicide/homicide are more than twice as high among men than women But women experience higher rates of sexual and domestic violence than men Women comprise over ¾ of victims of sexual assault and rape Intimate partner violence makes up 20% of all nonfatal violence against women, 3% of nonfatal violence against men
What factors (biological and social) make women more vulnerable to HIV than men (Higgins et al.2010)?
Biological Factors: Women are exposed to infectious fluids for longer periods during intercourse than men Women face increased risk of tissue injury during intercourse; cells lining surface of cervix may be especially susceptible to HIV infection (young women at particular risk because of ectopy) Women are more likely than men to harbor untreated sexually transmitted infections Forced sex is linked with vaginal or anal tears, which can expedite disease transmission Social Factors: Unequal power dynamics in heterosexual relationships (makes pressing for condom use difficult) Sexual double standard that gives men greater license to engage in sexual activity, and to do so with multiple partners Socioeconomic vulnerability Gender-based violence and non-volitional sex Conceptualization of condoms as antithetical to trust, love, fidelity
What are the pathways through which residential segregation influences health?
Constrains the socioeconomic advancement of minorities by limiting educational quality and employment Increases minorities' exposure to unfavorable neighborhood environments, including crime, environmental hazards, inferior municipal services, "food deserts," lack of quality health care, etc.
What is the Healthy People Program? Which Healthy People 2020 goal is most closely focused on social determinants of health?
Create social and physical environments that promote good health for all.
What are the limits of cultural explanations for deterioration in health over time and immigrant generation? (Viruell-Fuentes et al. 2012)
Discrimination, residential segregation "Racialization": become a minority when after immigrating the US, in country of origin wasn't the case, can also work to make immigrant a member of the dominant racial group Cultural explanations typically assume that as immigrants shed cultural characteristics presumably associated with their country of origin, and adopt those of the receiving society, their health changes for the worse Presumption of individual-level cultural changes Ignores factors like residence in low-income communities, institutional patterns of unequal treatment, racialization processes, etc. Risks essentializing and homogenizing ethnic and/or immigrant groups, perpetuating racial/ethnic stereotypes
What does access to health insurance look like in immigrant families?
Foreign-born parents and their children are more likely to be uninsured due to job type, lower incomes, and restrictions on eligibility for public insurance Also, financial and language barriers Immigrants' eligibility for public health insurance is dependent on federal and state policies 81% of children of immigrants were born in the U.S. and are U.S. citizens, but 30% are unauthorized or living with a parent not in the U.S. legally - unauthorized parents of U.S. citizen children may forgo public health insurance Also important to note that many immigrant families are of "mixed status" - members have different statuses "Lawfully present" immigrants are eligible to buy health insurance on the ACA Marketplace, unauthorized immigrants are not (see next slide on CA) Immigrants who are "qualified non-citizens" are generally eligible for coverage through Medicaid and CHIP (but may have to wait 5 years after receiving "qualified" status, depending on state rules) Unauthorized immigrants are eligible for emergency care under Medicaid if meeting certain requirements Pregnant women are eligible for CHIP in some states, and some states use local funds to provide Medicaid and CHIP to other groups (e.g., lawfully present immigrants without qualified status, undocumented kids) Family members not eligible for Marketplace, Medicaid, or CHIP coverage can apply for coverage for dependent family members who are eligible, without being asked if they have eligible status
What are common explanations given for the immigrant health advantage?
Health Selective Immigration: Immigration is selective of healthier people Conflicting evidence about the extent to which this is important (more important for Black immigrants than Hispanics, for men than for women, for people who migrate at older ages) Return Migration or "Salmon-Bias" Effect: Propensity to return to country of origin after illness Most important for immigrants from Latin America Cultural "Buffering" Better behavioral risk profile: diet, smoking, alcohol consumption, exercise, use of preventative care Social norms and social networks: "Familism" Immigrant enclaves: evidence is mixed, speculation that might be most beneficial to older people
What are examples of policies Marmot et al. suggest to tackle inequities of power, money, and resources?
Health equity in all policies, systems, and programs: Coherent action across government agencies (e.g., finance, education, housing, employment, transportation, health) E.g., legislation for mandatory wearing of helmets by cyclists; trade policy that is consistent with health recommendations on fruit and vegetable consumption Involvement of civil society, private sectors Assessment of results of all policies/programs for health equity Fair financing: Progressive taxation Combatting tax evasion (e.g., use of offshore financial centers) Fair allocation of resources between geographical regions and ethnic groups Greater debt relief Increase of global aid and improvement in quality Market responsibility: Public sector provision of health care, education, water, sanitation Regulation of tobacco, processed foods, alcohol Gender equity: Promote equity and make discrimination on the basis of sex illegal Create gender equity units in central divisions of government Close gaps in education and skills and support economic participation by women Invest in sexual and reproductive health services leading to universal coverage Acknowledge economic contributions of housework, care work, voluntary work Political empowerment: Socially inclusive framework for policy making (bring traditionally marginalized groups to the table) Good global governance: Multilateral system in which all countries engage with equitable voice Make health equity a global development goal
What are some examples of variation in the immigrant health advantage by race/ethnicity and/or country of origin (see slide 24 of Class 13 lecture slides for summary)
Hispanics: most studied group (particularly Mexican immigrants) Hispanic mortality advantage is feature of foreign-born Mexicans and foreign-born Other Hispanics, not Puerto Ricans or Cubans (Palloni and Arias 2004) Puerto Rican second generation less healthy than other second generation groups Blacks: Similar trends to Hispanics (evidence immigrant advantage is even larger) Immigrant advantage greatest among African-born, followed by Caribbean born Singh et al. (2013) estimated that life expectancy of black immigrants was 7.4 years higher than US-born blacks around 1999-2001 Caribbean-born Blacks lose much of health advantage relative to US-born Blacks after about 20 years in the United States; African-born immigrants maintain health advantage for longer Asians/Pacific Islanders: Least studied, but also similar trends
What are the "Three Principles of Action" recommended by Marmot et al. (2008) to reduce health inequities?
Improve the conditions of daily life Tackle the inequitable distribution of power, money, and resources globally, nationally, and locally Measure and understand the problem and assess the results of action (also includes developing a workforce trained in the social determinants of health, and raising public awareness about the social determinants of health)
What are some of the barriers to health care utilization among immigrant families?
Immigrant children use less medical care than non-immigrants, and annual medical expenditures per capita substantially lower Financial impediments to health care use: out-of-pocket costs, lack of paid sick leave Nonfinancial barriers: Language, low levels of health literacy Immigrant families often use community-based health centers, Federally Qualified Health Centers, and non-profit health centers, and sometimes turn to complementary and alternative medical providers
What is the immigrant health paradox?
Immigrants tend to be of lower SES yet exhibit better health than natives Immigrants live longer and experience better health than US-born non-Hispanic Whites Cause-specific mortality examples: 20% lower cancer mortality rate, 16% lower heart disease mortality rate, 18% lower kidney disease mortality rate, 24% lower liver cirrhosis mortality rate But on average, immigrants have less education, lower income than US-born Whites Therefore, paradoxical that immigrants have better health and mortality profiles Research has focused primarily on immigrants from Latin America, but increasingly looks at immigrants from Asia and Africa
What does contemporary interpersonal racial discrimination look like?
Implicit racism Contemporary racism as largely aversive Aversive racist lacks explicit racial prejudice (has sympathy for those who were victimized by past injustices, is committed to principles of racial equality), but has implicit biases favoring one group over another Discrimination is not experienced by the perpetrator as intentional Research suggests that almost 70% of Americans have implicit biases that favor Whites over Blacks; pattern is also evident for Asians, Hispanics Evidence of continuing racial discrimination in hiring, renting apartments, purchasing homes and cars, obtaining mortgages, accessing medical care, and applying for insurance
How has the Affordable Care Act impacted LGBT access to health care?
In 2010, President Obama asked the Secretary of Health and Human Services to identify steps to improve LGBT health Affordable Care Act (ACA, a.k.a. "Obamacare") Individuals can no longer be denied insurance due to pre-existing conditions (e.g., HIV, mental illness, transgender medical history) Prohibits discrimination based on sex, sex stereotypes, and gender identity in any health program receiving federal funds Requires health insurers to cover same-sex married spouses (does not apply to employers) Requires that insurance plans cover recommended preventive services, including screenings for HIV, STIs, depression Calls for inclusion of routine data collection and surveillance on health disparities
What are some examples of ways that immigration policies can influence immigrant health?
Increasingly restrictive immigration policies in United States Produce messages and practices that racialize and construct immigrants as undesirable others, threats to the nation Limit access to health/social services for immigrants Impact the fundamental causes of disease by shaping access to life opportunities like access to higher education, well compensated employment opportunities Engender chronic stress Effects of anti-immigrant policies likely extend to documented immigrants and U.S.-born co-ethnics because of heightened racialization of anyone perceived to be an immigrant
Why the "added burden of race," over and above SES? What explanations does the Williams 2012 article give for this added burden?
Indicators of SES are not equivalent across race - Blacks and Hispanics have lower earnings than Whites at comparable levels of education, less wealth at every level of income, etc. Exposure to adversity over the life course - Minorities are more likely than Whites to have experienced low SES in childhood/early adversity Racism Reduced access to good and services, including health services•Increased exposure to traditional stressors like unemployment•Discrimination as a chronic stressor itself•Internalized racism Residential segregation by race Note: It is not generally about genetic predispositions!
What do Marmot et al. suggest should be done to understand the problem and evaluate action?
Institute basic data systems to monitor health disparities, social determinants Increase funding for research on social determinants of health (majority of health research funding is biomedically focused) Invest in education and training in social determinants of health for health and medical personnel and policy makers
What are institutional and cultural racism (including examples of each), and what are some of the ways in which they affect health?
Institutional: Discriminatory policies or practices carried out by institutions (state or nonstate) Examples: Segregation: Physical separation of the races in racially distinctive neighborhoods/communities Black-white segregation: perpetuated through individual actions, institutional practices, and governmental policies Forced removal and relocation of American Indians to reservations Incarceration: Inordinately high levels of incarceration of minorities in United States Racial disparities in criminalization and investigation of certain behaviors (e.g., racial profiling), discrimination in prosecution and sentencing Immigration policies: Rank racial groups; exclude, segregate, and place in detention some racial populations; limit the rights/privileges of those deemed dangerous or undesirable Cultural: Racism deeply ingrained in American culture Images and ideas in contemporary popular culture continue to devalue, marginalize, and subordinate non-White racial populations Blacks and other minorities negatively stereotyped: not all that much change over time Whites view all minority and racial groups more negatively than themselves Blacks viewed more negatively than any other group Hispanics viewed twice as negatively as Asians Examples: Basically the stereotypical portrayal of any race on contemporary media
Do health inequalities between men and women reflect biological sex differences, societal gender differences, or the interplay between the two?
Interplay between the two
What are examples of policies Marmot et al. suggest to improve daily living conditions?
Invest in early child physical, cognitive, emotional, and social development ("equity from the start") "Healthy places, healthy people" - Living conditions (housing, resources, transportation, planning for healthier choices in food, ability to avoid substances and alcohol) "Fair employment and decent work": Living wage & Reduce exposure to hazards and work-related stress Social protection throughout life: Social protection systems that allow a healthy standard of living below which nobody should fall because of circumstances beyond his/her control Universal health care: Finance health care systems through general taxation or mandatory universal insurance, Focus on primary health care, and Invest in training and retaining health workers
In what ways do stigma and discrimination impact the health of LGBT people?
Lack of research directed towards LGBT issues Exposure to discrimination Exposure to violence Poor clinical care Inadequate attention to health concerns of LGBT people Lack of attention to LGBT health issues Lack of knowledge/insensitivity to cultural concerns of LGBT people
What was the health insurance coverage landscape right before the Affordable Care Act? Who was and was not covered?
Landscape before ACA Employer-based insurance: Most people obtained health insurance coverage as a job benefit But not all workers had access to or could afford employer-sponsored coverage: In 2013, 57% of firms offered employee coverage (down from 66% in 2000) Workers in low-wage and small firms were less likely than others to be offered coverage Health insurance premiums and employees' share of premiums doubled between 2000 and 2013 Public health insurance: Medicaid and CHIP were important sources of coverage for low-income children and people with disabilities; coverage for non-parent adults without disabilities limited •In 2013, Medicaid and CHIP covered 19% of people < 65 Non-group policies: Very few people were covered by non-group health insurance policies •5% of people < 65 in 2013 (premium expense not shared with employer, so quite expensive; people with existing health problems could be charged high rates or denied coverage) Uninsured 41.3 million non-elderly people lacked health insurance Nearly all elderly were insured by Medicare Individuals with low incomes had higher uninsured rates than those with higher incomes Adults were more likely than children to be uninsured People of color were more likely than Whites to be uninsured Non-citizens (legal and undocumented) were three times more likely to be uninsured than citizens Insurance coverage varied by state
What is the "double jeopardy" for minority children that I discussed in class? (Be familiar with racial/ethnic disparities in access to advantaged neighborhood environments)
Large fraction of black and Latino children consistently experience "double jeopardy" - living in poor families and in poor neighborhoods On average, 16.8% of black children and 20.5% of Latino children live in poor families and in high-poverty neighborhoods (neighborhoods with poverty rate > 20%) By contrast, 1.4% of white children experience double jeopardyDisparities in access to advantaged neighborhood environments: Average white child lives in neighborhood with poverty rate of 7.2%, compared to 21.1% for black and 19.3% for Latino children Neighborhoods with 20% poverty rate or higher are generally regarded as "high poverty" Typical poor white child lives in neighborhood with poverty rate of 13.6%, compared to 29.2% for black and 26.2% for Latino children In most cities, worst-off white children live in better neighborhoods than majority of black and Latino children
What are some of the obstacles to gaining knowledge about LGBT health?
Methodological Large-scale random surveys don't often collect and analyze data on sexual orientation, gender identity Large-scale random surveys often don't identify enough gay, lesbian, and (particularly) transgender individuals Social desirability bias in reporting of sexual orientation, sexual behavior, and gender identity Data collected are often from smaller, non-representative studies (may be biased) National Health Interview Study (NHIS) began including question on sexual orientation in 2013 survey Homophobia/heterosexism Defining LGBT issues as marginal (need not be active or intentional) Constructing LGBT issues as exotic or difficult to study, or as too political or too sensitive Lack of data on LGBT population has led to neglect of important health issues!
How widely has the Medicaid expansion been implemented, and what is the "coverage gap"?
Originally, when ACA was passed there was supposed to be a Medicaid expansion in all states but was taken to the supreme court and ruled a state decision Was supposed to cover everyone below 138% of the poverty line ACA expanded Medicaid to adults with incomes ≤ 138% of poverty line But 2012 Supreme Court ruling made expansion a state option As of November 2015, 30 states and DC adopted Medicaid expansion About 3 million poor uninsured adults fall into "coverage gap" in states not expanding Medicaid (incomes > Medicaid eligibility limits, but < minimum for Marketplace premium tax credits) Undocumented immigrants remain ineligible for Medicaid (documented immigrants often must wait 5 years to be eligible)
What are the key provisions of the Affordable Care Act?
Passed in 2010; most provisions went into effect in January 2014 Mandatory coverage of pre-existing conditions Extension of dependent coverage to age 26 Prohibition of lifetime limits of coverage Prohibition of discrimination due to pre-existing conditions or gender Requirements for all individuals to obtain insurance coverage or pay a penalty (controversial—but done to broaden the pool of policyholders to include more healthy Americans) Health Insurance Marketplaces established for purchasing private insurance; premium tax credits for Marketplace coverage for many with incomes between 100-400% of FPL Free coverage of certain preventive care services (without charging deductible, co-pay, or coinsurance) Investment in community health centers Expansion of Medicaid for adults with incomes at or below 138% of poverty
In Healthy People 2020, what are the 5 Key Areas of Social Determinants of Health?
Poverty, employment, food security, housing stability High school graduation, enrollment in higher ed, language/literacy, early childhood ed/development Access to healthy foods, quality of housing, crime and violence, environmental conditions Access to health care, access to primary care, health literacy Social cohesion, civic participation, discrimination, incarceration
What are the 3 stages of migration laid out by Perreira and Ornelas (2011), and can immigrant children's health be impacted at each stage of migration?
Pre-migration: Children's parents make the decision to leave the home country Migration decisions may reflect: Economic hardship Political unrest Persecution Desire to reunify with family Poverty in the country of origin can engender malnutrition, stunting, infectious diseases, etc. Family separations (e.g., because of staged migration) can engender emotional distress, behavioral problems, poor physical health Political violence is linked with post-traumatic stress, diarrheal disease, malnutrition, fractures, tuberculosis infection Migration Mobility process of migrating Whether children walk, drive, fly, or come by ship Whether children travel with a trusted family member or friend, or are smuggled Whether children experience hardship during travel, such as detainment, assault, injury, or hunger Migration experiences and health: For some, migration journey can involve severe physical and emotional hardship These hardships can engender stress, injury, illness Post-migration Most research on the health of immigrants focuses on this stage Settlement experiences Process of navigating life in a new country Changes in family economic situations, dynamics, and social roles Acculturation stressors include: learning a new language coping with changes in family roles protecting legal status of self and family encountering racism/discrimination •Racial discrimination can produce anxiety, depression, risky behaviors, poor physical health • Familism (strong family ties, trust, loyalty, mutual support) and family responsibilities like "language brokering" for parents can have positive influences on health • Family conflict, parent-child acculturation gaps, and numerous family obligations can produce stress • More "acculturated" youth have poorer health and engage in more risky behaviors • Living without legal status can engender chronic stress for children and parents • Influence of acculturation stressors may vary by state of residence: •Historically, immigrants settled in six traditional gateway states - CA, FL, IL, NJ, NY, TX •New destination states lack institutional resources, have smaller co-ethnic networks, lower access to health care Pre-migration and migration influences are critical to the first generation Post-migration influences are also critical to second and later immigrant generations
What are race and ethnicity?
Race: The group a person belong to, or is perceived to belong to, based on physical features Ethnicity: The group a person belongs to, or is perceived to belong to,based on culture, language, religion, ancestry, customs, and physical features
(Befamiliar with links between racial residential segregation and educational opportunities,employment opportunities, and exposure to unfavorable neighborhood environments)
Restricts socioeconomic mobility by limiting access to quality schools and employment Concentrates urban violence in a few "hot spots" Associated with residence in poor-quality housing and deficits in health-enhancing resources: Lower access and poorer quality of medical care Exposure to elevated levels of chronic and acute stressors Higher risk of exposure to toxic chemicals Lower access to healthy foods, safe outdoor spaces to exercise Educational opportunities In U.S., community resources determine quality of public schools Strong relationship between residential segregation and concentration of poverty Public schools with high proportions of minorities are dominated by poor children These schools have different and inferior courses, teachers that are less well trained, lower levels of student achievement compared to schools with high proportions of white children Leads to racial differences in high school dropout and graduation rates, competencies and knowledge of high school graduates, preparation for higher education, probability of enrollment in college Employment Opportunities Mass movement to the suburbs of low-skilled, high-paying jobs from urban areas where minorities are concentrated "Spatial mismatch" - minorities live in areas that do not offer ready access to high-paying entry-level jobs "Skills mismatch" - available jobs in urban areas where minorities live require levels of skill/training many do not have Some corporations explicitly use area racial composition in decisions about placement/ relocation of facilities Residential segregation also isolates minorities from role models of stable employment and from social networks that could provide job leads Effects of Place Slide 1: Beyond affecting socioeconomic mobility, segregation can affect health by creating a broad range of pathogenic residential conditions Racial segregation has created distinctive ecological environments for African Africans Most poor whites live near non-poor people, most poor blacks live in high-poverty neighborhoods Sampson and Wilson: "The worst urban context in which whites reside is considerably better than the average context of black communities" Slide 2: Lower "neighborhood quality" (e.g., less investment in infrastructure, lack of municipal services, poor housing conditions, high mobility, elevated exposure to pollutants and allergens) Poorer health behaviors (lack of safe spaces to exercise, lack of access to nutritional foods, higher costs for key amenities because companies avoid segregated urban areas, targeting of poor minority communities by tobacco/alcohol industries, high levels of stress) Lack of access to quality medical care (fewer facilities, discrimination in medical encounters based on place of residence) Crime and drug use (concentrated poverty, unemployment, single-parent households)
What is racial residential segregation, and has it decreased much in recent decades?
Segregation: The physical separation of the races in residential contexts In US, was imposed by legislation, supported by economic institutions, enshrined in housing policies, enforced by judicial system, and reinforced by real estate agents and neighborhood organizations Civil Rights Act of 1968 made discrimination in the sale or rental of housing units illegal in US, but studies document persistence of subtle and explicit discrimination in housing No immigrant group has experienced the high levels of segregation that exist for Blacks In Northern and Southern cities, levels of black-white residential segregation increased from 1860-1940, and have remained strikingly stable since US index of dissimilarity in 2000 = 0.66 (means that 66% of blacks would have to move to eliminate segregation) Values above 0.60 represent extremely high segregation Any declines in segregation have been due to reductions in the number of all-White census tracts; little impact on residential isolation of most Blacks
What is a "Health in All Policies Strategy"?
Takes us beyond the health sector and just the US Application of "health in all policies strategy": Incorporates health considerations into decision-making across sectors and policy areas that have not traditionally considered their impact on health (e.g., education, economic development, transportation) For example, availability and accessibility of public transportation affects access to employment, affordable healthy foods, health care, and other important drivers of health
What are some potential applications of the Rwandan model to the United States?
U.S. exceeds Rwanda in traditional health metrics (e.g., life expectancy) and hospitals and medical care surpass those in Rwanda But in U.S., health outcomes falter because many patients fall through the cracks Too much reliance on doctors and hospitals to provide care Extension of health care into the community as way to extend care and improve costs Community-based pilots in inner-city Boston, rural Mississippi Mississippi: Health Connect - purpose is to reduce admissions to Central Mississippi Medical Center Inspired by interventions in Iran ("health houses") Health houses and community health workers who are trained community members
What are the Health Insurance Marketplaces, and who is eligible for Marketplace coverage?
Undocumented immigrants are not eligible ACA established Health Insurances Marketplaces in each state where individuals and small employers can purchase insurance Designed to ensure more level competitive environment for insurers, to provide consumers with information on cost/quality to help them choose plans Federal gov't provides tax credits for people with incomes 100%-400% of FPL Limits cost of premium to a share of income Federal gov't provides cost-sharing subsidies to people with incomes 100-250% of FPL Reduces what people pay out-of-pocket to access health services Undocumented immigrants prohibited from purchasing Marketplace coverage (documented immigrants may receive tax credits)
What are the financial implications of lacking health insurance?
Uninsured do not receive health services for free or at reduced charge Uninsured often must pay "up front" before services will be rendered Being uninsured leaves people at increased risk of financial strain due to medical bills Uninsured are at risk of medical debt In 2014, 32% of uninsured adults said they were carrying medical debt (20% of those with employer-sponsored insurance) Burden on providers of uncompensated care Funds from federal gov't defray some of costs Majority of uncompensated care is provided by hospitals
How does lack of insurance influence people's access to health care?
Uninsured people are more likely than those with insurance to go without care due to cost Most uninsured do not have a regular place of care Uninsured are less likely to receive timely preventive care (leads to higher risk of being diagnosed at later stages of diseases) Many uninsured do not obtain treatments recommended by health care providers Uninsured are more likely to be hospitalized for avoidable health problems
How have recent Supreme Court decisions affected LGBT access to health care?
United States vs. Windsor (2013): Required federal government to recognize legal same-sex marriages Required federal government to extend spousal benefits to legally married same-sex couples But some benefits remained dependent on legal status of same-sex marriage in state of residence Obergefell vs. Hodges (June 2015): Resulted in legal recognition of same-sex marriage nationwide Still some question about whether private employers can legally limit spousal coverage to opposite-sex spouses
Might racism and racial residential segregation be fundamental causes of health? Do theWilliams and Mohammed and Williams and Collins articles suggest that they are? Whatabout Phelan and Link (article I discussed in class)?
Williams and Mohammed believe racism is a fundamental cause of health So do Phelan and Link because: Racism is a fundamental cause of racial differences in SES. But, racism also has a fundamental association with health independent of SES Race is related to most diseases, and association holds when SES is controlled Flexible race-related resources: prestige, power, beneficial social connections (via racial segregation), freedom Relation to health via multiple mechanisms: discrimination stress, exposure to trauma, "weathering," quality of health services, incarceration, neighborhood attributes (availability of healthy food, recreation, crime, environmental exposures) Racial inequalities in health are reproduced over time via replacement of intervening mechanisms (e.g., slavery replaced by incarceration, segregation)
Do women live longer than men on average, or do men live longer than women? What do we know about gender differences in morbidity (illness)?
Women live longer than men, but are sicker on average than men "Men die quicker, women are sicker" Gender gap varies by specific disease outcome and stage in lifecycle Younger ages: Men engage in more health-damaging behaviors than women (e.g., heavy drinking, illegal drug use, and—until recently—smoking) Increases men's risk of death at younger ages, elevates risk of later life health problems Older ages: Men tend to suffer from acute illnesses (e.g., coronary heart disease, cancer, emphysema) for relatively short periods before they die Women tend to suffer from nonfatal, chronic conditions (e.g., anaemia, arthritis, disability) that affect quality of life Elevated female morbidity rate is related to their longer length of life
