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HEALTH POLICY CLASS NOTES

PROFESSORS ROBIN SWIFT AND FRANK LOMBARD


DUKE UNIVERSITY – SPRING 2007

Vanessa Villamia Sochat

CONTENTS

Medicaid ................................................................................................................................................. 3

Medicare ................................................................................................................................................. 4

Effects on Health of Location and the Environment ..................................................................................................... 6

Health Disparities Between Young and Old Veterans ................................................................................................... 7

Lack of diversity within HC professionals ...................................................................................................................... 7

The Ghost Map ................................................................................................................................................... 8

Solid Waste Sites and the Black Houston Community ................................................................................................ 11

Ethnicity and Differential Access to Care for Eating Disorder Systems ....................................................................... 12

Viral Hemorrhagic Fevers ............................................................................................................................................ 12

Health Disparities Persist for Men, and Doctors Ask Why .......................................................................................... 13

Child malnutrition in Bangladesh ................................................................................................................................ 14

HIV............................................................................................................................................................................... 14

Health Care Disparities and Cervical Cancer ............................................................................................................... 16

Medicare Part II........................................................................................................................................................... 17

Executive Summary Review ........................................................................................................................................ 18

What to do about the Uninsured? .............................................................................................................................. 21

Kant Readings.............................................................................................................................................................. 22

The vision of Change: From today to tomorrow .................................................................................................... 22

The Multiple Determinants of Health .................................................................................................................... 23

Health and Working Conditions: Hotel Room Attendants in Los Vegas ..................................................................... 23

Immunization coverage among children born to HIV infected women in Rakai District, Uganda: Effect of voluntary
testing and counseling (VCT)....................................................................................................................................... 27
Federal Safety Net for Workers .................................................................................................................................. 27

Market Failure and the Creation of a National Health Information Technology System ........................................... 29

The Value of Health Care Information Exchange and Interoperability ....................................................................... 30

Hamlet, Out of the Ashes (video) ................................................................................................................................ 31

Health Information Technology .................................................................................................................................. 31

Family Planning: A Cure to Overpopulation ................................................................................................................ 32

Barriers to HC for Hispanic Community ...................................................................................................................... 32

Kindig Reading............................................................................................................................................................. 33

Factors Contributing to Disparities in Preventative Health Care Among Lesbian Women ......................................... 34

Kindig Continued… ...................................................................................................................................................... 34

Cancer Screening Among Immigrant Women” ........................................................................................................... 36

Is Tobacco Control a Social Justice Issue? ................................................................................................................... 36

The Three Core Public Health Functions ..................................................................................................................... 38

Trends of Gonorrhea and Chlamydial Infection Among Active Duty Soldiers ............................................................ 40

Female Control of Sexuality: Use of vaginal products in south west Uganda............................................................. 41

Avian Flu ...................................................................................................................................................................... 42

Obesity and Jobs ......................................................................................................................................................... 43

Health and Access to Care for Children of US Migrants and Immigrants ................................................................... 43

Costly heart Treatment in Doubt ................................................................................................................................ 45

Aspirin and Women .................................................................................................................................................... 45

Patterns of Cancer Incidence, Mortality, and Prevalence Across Five Continents ..................................................... 46

Mental Health Care in North Carolina ........................................................................................................................ 48

PSYCHIATRIST BRIEF: Supply and distribution Psychiatrists in NC .............................................................................. 50

Discriminatory factors with HIV, Thailand ............................................................................................................. 52

Cancer Health Disparities among Asian Americans .................................................................................................... 52

Health Determinants ................................................................................................................................................... 53

Mental Health Care NC ............................................................................................................................................... 53


A Difference in Disparities: Comparison of Type I and Type II Diabetes ..................................................................... 54

Safety and Health of Working Women: Poultry Processing in the Rural South .......................................................... 54

How (and how not to) Battle the Flu – A Tale of 23 Cities .......................................................................................... 58

Teens and Substance Abuse Treatment in Tennessee ................................................................................................ 59

JANUARY 25, 2007 MEDICAID

• health care is a finite resource, a scarcity model rules decision making.


• Health care is a limitless resource, scarcity arguments are artificially created by the powerful elite to
control resources and limit access to the unworthy.

We assume that health is a scarce resource – said by Kant

Even though health care may be a limited resource, we treat it as though it is limitless because we are faced with
the moral dilemma that it is a human right to receive health care!

• almost everyone went to medical care, and talked about limits around money
• the only way to get medicine is to have money… are these assumptions correct?
• How do we invest in HC, and what do we get back? Can we make a cycle of investments so the outcome
we get back is growing faster than what we put in.
o If we can do this, we have a limitless system… it isn’t market based or commodity based.

Medically Needy – Spend Down


• idea of Medicaid: provides certain number of services to certain number of categories, old and poor,
mothers and poor, sick and poor.
• States have leeway with implementing Medicaid program. They can provide care to more people
(expand)
o They do this by covering Medically Needy people. They don’t fit in the box, but they can be cut
out at any point.
o If they take in these people, they don’t do it for free.
 Spend down is patient co-pay related with getting Medicaid. The main difference
between these patients is income.

Disability
• what is the definition of disability? By SS, it is a physical or mental impairment which prevents an
individual from engaging in any substantial gainful activity, and which has lasted or is expected to last for
12 months or result in death
• Disability is determined by the disability determinant act.
• Income limit Medicaid is 798 dollars. They look at income, assets, and health status.

NC HAS…
Medicaid for Aged (65) and older Blind and disabled, Medicaid for Long Term Care
Medicaid for women and children…
SCHIP
AAF

You can be enrolled in the Medicaid program but never receive a dollar of Medicaid service. You have to pay your
share first. Transferring money to family member = sanction
What is her spend down? 958 dollars… which will qualify her for coverage for the 6 months beginning at the point
the application was approved.

Spend down = difference between income and 798, X 6 months.

What happens if it takes her 5.5 months to pay 958 out of pocket? Then Medicaid covers half a month, then she
has ANOTHER 958 dollar spend down.

Higher costs at beginning because entering the system with higher rate of infection

Poor people give up care to pay their bills before going to government even if it means it hurts their health. If we
know that people who are minorities are more highly represented in lower income status, then what are the
implications of the law racially? What kind of biases/assumptions were made?

JANUARY 30, 2007 MEDICARE

• largest public health sector program in US ($$ and people)


• National Health insurance movements started in 1900s after WWI
o Impact German adoption of NIH
• 1936 SS Act – National Health Insurance factor dropped for fear of sinking SS act
• 1939 Wagner –Dingell
• 1948 part of democratic platform but coalition of republicans and blue dog democrats was strong enough
to block.

Medicare Part D is biggest policy issue of last couple of years – a great step forward in universal care, but huge
costs!

Medicare is BIG – and it happened slowly over time.

Medicare
• incremental strategy
o populations that are high status couldn’t afford health insurance
o Elderly
 Sympathy
 Agreement to keep medical system as is for AMA
 Focus on burden of hospital care assumed status quo (fee for service)
 Limited number of days covered to begin with
AMA powerful force in the agreement, upset about Medicaid, Medicare paid them off

Objectives
• Payment of mainstream rates to providers to provide care to the elderly so to increase amount of needed
care.
o Relieves pressure of retiring and not having work covered insurance

Why the elderly?


• couldn’t afford health insurance, low access to coverage, none to low cost coverage, have higher costs
medical stuff, they vote a lot, 54% age 65+ had hospital insurance

Medicare Structure
• >65
• Disabled and receiving Soc Sec benefits
• End stage renal disease
• Not means tested, benefits after 2 years of disability determination

Medicare A
• Hospital Insurance
o Room and board 90 days
o Nursing
o Home health
o Payroll funded primarily – by employer and employee
o Hospice care

$$$$
• payroll tax – everyone works and everyone pays, DEMOCRATIC PROCESS
• co pays with hospitalizations – different amount at different point in hospitalization
• deductible - $$$ before receive any services
• patient cost sharing hits at different point depending on services accessing

Medicare Part B
• supplementary health insurance
• Voluntary, vast majority sign up for it- monthly premiums
• Physician (diagnostic and surgical facility based) and outpatient care
o Federal tax subsidies
o Monhly premiums deducted from checks
o $100 deductible
o Medicare pays 80% UCC, patient other 20%
o Physicians may or may not decide to accept Medicare rates
 If they do, they bill medicare directly and recipient pays balance
 If not, they can change 115%

Limits?
• Catastrophic care – that extends beyond time limits
• Meds – no coverage until Medicare+ choice and now “D”
• Long term care

Medigap “buy in”


• dual eligibles – both Medicaid and medicare
• you can have someone that qualifies for both, Medicaid is last place to kick in money.
• Medigap – fill the gap between the needs and Medicare coverage
• 10 standard plans across continuum, 13 possible services
• Which plan do agents try to sell most often?

Pitfalls
• policies increase in premium as beneficiary ages, costing more as risk increases and more over time than
the more steady priced plans
• catastrophic only coverage
rd
• selection by 3 party coverers
• HMOs proliferation – increase in choice, decrease out of pocked costs premium variance by age (O)

Medicare Risk Program


• HMOs cover for capitated rate
• Foster costs savings
• Healthier enrollees – savings of 20%, but real?
• Reduction of length and intensity not frequency hospitalizations – why??
• More preventive services

Satisfaction surveys: bias, those disenroll are often not caught in the surveys… allow the safety valve for those not
satisfied

Medicare Catastrophic Coverage


• Reagan, coverage expansion to all sements to prevent the catastrophic impact of long term disease
o Cap to payments by beneficiaries (2000)
o Too much expanded program form congress including progressive tax and virtually all cost
sharing covered
o Opponents: drug companies, concern from those who didn’t like beneficiary financing

Physician Containment
• pressure from hospitals through PPS
• limits on balance billing (amount over UCC)
• increases in beneficiary cost sharing premiums, deductibles, co pays

EFFECTS ON HEALTH OF LOCATION AND THE ENVIRONMENT

• health is affected by location  environment  health


• Childhood diseases related to environmental problems cost Minnesota 1.5 billion per year. Based on
national research on childhood athsma, cancer, lead poisioning, birth defects, and neurobehavioral
disorders

SRI LANKA study


• increased neonatal mortality, birth deformities, cardiac illness

PURPOSE
• assess impact of pollution of community health residents in SRI LANKA

BACKGROUND
• neither area had public water supply or public sewage disposal
• control area similar to industrial zone in other areas

HEALTH DISPARITIES BETWEEN YOUNG AND OLD VETERANS

Health care coverage among veterans


Having health insurance or receiving care from VA hospital

-Younger vets lack coverage


1.7 million vets lacked HC coverage
.2% WWII and Korean lacked coverage
8.7% Vietnam vets lacked coverage
12.1 % Persian golf and “other” lacked coverage

Veterans w/o coverage more likely to hold jobs or have HS degrees

Health Implications
- 15% lacking coverage have disabling chronic illness
- Vets age 25-64 without coverage 5X more likely to refuse treatment/medication than those covered

Limited Government Resources


• 1996 eligible to receive treatments at VA hospitals
• Vets placed in 8 categories enrollment, enrollment halted for priority 8 vets

LACK OF DIVERSITY WITHIN HC PROFESSIONALS

• 25% US population, vs 9% HC personnel


• Language barriers
• Minorities get lower quality care than whites
• Minorities feel excluded
• Improves research agenda
• More minorities in leadership positions
• Affirmative action

THE GHOST MAP FEBRUARY 1, 2007

Differences between Public health and medical approach in solving problem:

Public Health Medical


More community basis More individual basis
A lot more social context
About prevention More about treatment
Organizational/logistical considerations more scientific, regardless of situation
Sociologists perspective physicians perspective
Access to healthcare More individualized
About policy About treatment
Dynamic static reactive
Political

Medical Model Approach to New Diseases


• identify symptoms and create case definition
• find evidence markets of disease presence
• ID causality
• Study and outline natural history
• Treat
• Cure or autopsy

Public Health Approach to new Diseases


• systematic investigation of affected populations (registries mapping)
• Identification of common characteristics and confounding variables
• Development/testing of hypotheses of causality
• Determination of natural history
• Once causality determined, strategies to prevent spread
• Prevention activities, quarantine, education

How Beliefs Affect Perception


• attribution of causality
• focus on particular populations
• attribution of risks
• observers learning style (VAK)
• Tyranny of expertise
• Pressure for quick solutions
• Biases

Empiricism
• the doctrine that knowledge derives from experience
• medieval practice and advice based on observation and experience in ignorance of scientific findings

Cholera spread from India around the world


• find old maps of transmission for HIV/cholera for paper! Where infections originate and how spread

Key Contributions of Snow and Whitehead


• familiar with neighborhood
• personal access to households
• willingness to reject prevailing theories of causality
• observation
• data collection and recording

Colsilience
• the agreement of two or more inductions draw from different sets of data.

Contained geographic area, growing in population


Scientist looking for causality
Germ theory
Role of contaminated water
Observed populations versues affective populations

st
21 century plagues
Blood versus feces
Virus vs. bacteria
Roles played by environmental degradation, war, travel, population changes, TRAVEL is scariest.

People are getting in contact with isolated populations that may have disease, but now all populations are
combining and spreading disease

Political price to pay by raising people’s awareness of disease, who reports the disease.

st
21 century plagues
• chronic disease epidemics
• how do we provide treatment for a long period of time?

What are my first questions about news?


• What is population that has it? (65+)
• What is stage of disease
• Access to fresh fruits and veggies (is it economic or educational?)
• Look at cities vs. rural
• Trends, at what rate increasing
• What programs in place to deal with obesity in future
• A lot of coffee and cigarettes in Spain, Argentina

London 1854, talks about the night soil men who clean out the cesspools and men that dispose of dead bodies as a
thriving business that developed on its own, that actually paid very well.

Talked about how waste was recycled, or put back into the soil to yield more crops and consequently more people
that they can feed. Then on a larger basis how one organisms waste is another’s fuel. All thanks to
microorganisms... we are completely reliant on bacteria and have a symbiotic relationship with them. Talked
about why in rainforests that’s why by the time you get to soil there aren’t a lot of nutrients… they all get
absorbed/used by the life in the higher levels. Square cm skin 100,000 bacteria

• Next to Thames River, broad st, area called golden square

• Water closets flushed waste into cesspools – overflow

• More potential with overflowing to sneak into water supply

People often linked the odors of cesspools, filth with disease, which isn’t always the case. Dickens and Engels tied
corpses with malignant diseases. (Craven’s field) With cholera it was tied to the stink in the air.

• London population: 2.4 million

Thomas and Sarah Lewis had baby Lewis that was first sick with cholera, broad st, 1840’s sick in 1854, outbreaks
48-49 (50,000 lives)

Henry Whitehead- clergyman went to Oxford – was first thinking about socioeconomic factors, like what floor
person lives on, looking at theory that people succumb to fear of disease, but knew someone with incredibly
strength and courage, can’t be that, he made connection between drinking Broad street water and getting sick
days later, but also skeptical because had seen people get better by drinking broad street water. Stuck to
elevation theory… was skeptical of removing pump handle.

Cholera: bacterium with a single cell that harbors DNA. No organelles or cell nuclei. Need between 1 million and
100 million to be infected. A cup of water could have 200 without being cloudly. They take up house in the small
intestine, protein called TCP helps reproduce really quickly, release toxin that causes cells to release water rapidly,
so person dies of dehydration really quickly. Waste products accumulate in blood. Means “roof gutter” didn’t do
well in past because humans live so far apart and don’t come in contact with each others waste

John Snow successful English doctor, acted as investigator, ether/chloroform in operations. Noticed you could be
with infected people and not get sick, or completely avoid them and get sick, so there must have been another
cause. Came up with waterborne theory of spreading in first outbreak, that it must be some agent that is
swallowed and not miasma theory – people get sick from stench. He went around and asked people about their
water, and took samples. Not sure if he led people on to his theory in talking to them… a bias. DIDN’T investigate
drinking habits of residents who had SURVIVED the outbreak,
Looked at houses supplied by Lambeth vs S&V water
Wanted to make connection between drinking/not drinking from pump and dying/living
The sewer men were like canary in the mine – couldn’t have been smell because these guys were really healthy!

William Farr: revolutionized statistic use in public health, published in weekly publication, calculated deaths by
elevation and concluded that more people on higher floors die, so it must be the smells! Very stubborn in his
views… helped bring about the practice of getting rid of cesspools and disposing of in Thames… even through
cholera outbreak highly supported this, which led to mix of disease and water that hurt the city… he stuck to view
that smell made people sick, distributed Clorox/bleach to deal with

Edwin Chadwick: in public health, responsible for big government today… said that all smell is disease, and made
elaborate plan to basically deliver cholera bacteria into mouths of londoners

Edmund Cooper first drew street map with black bar by death at each house to disprove that came from Plague pit
where corpses where disposed… presented to Board of health, but connection between pump and deaths was lost
because there was TOO much data. Then snow made his map after, came up with veronai diagram, cells with
points. Map played role in convincing Whitehead to investigate waterborne theory, and figure out that it was baby
lewis

Questions I have:

We’re a lot more technologically advanced now, but what are common views/things that are accepted in out
health system that we are either wrong about, or looking at in the wrong way, or can be greatly improved in some
way?

Interesting the conflicting interests of cities – great for implementing something like a waste disposal system
because we have more people closer together, but not so great in terms of terrorism.

SOLID WASTE SITES AND THE BLACK HOUSTON COMMUNITY

• waste problems are still issues today!


• Differential access to public services is implicit racism

3 Issues

* Relationship between racial composition neighborhoods and location of waste facilities


* Minority schools more near disposal places?

Found
• incinerators in predominantly black neighborhoods
• mini incinerators as well
• all 5 landfills in predominantly black neighborhoods

Did they look at who is operating or working for landfills? Is it possible the landfill brought the people?
Predominantly white people making decisions, didn’t want it in THEIR neighborhood. What about real estate
prices?

Should the neighborhood be compensated for this? (parks)

ETHNICITY AND DIFFERENTIAL ACCESS TO CARE FOR EATING DISORDER SYSTEMS

• prevailing societal and clinical stereotypes of eating disorders


o ethnicity
o socioeconomic status
o gender
• looked at access to care between ethnic and non ethnic minority women
• does it affect access to care?
• 1.2 % needed urgent evaluation, most of participants were Caucasian women
• 76% met criteria for clinically significant symptoms
• No correlation between ethnicity and severity of symptoms
• Before this study, found that Caucasians were 10 times more likely to have been diagnosed than any
other ethnic group.
• So eating disorder numbers don’t differ among ethnicities, but Caucasians are more likely to be
diagnosed.
• Did they look at care seeking behavior?

VIRAL HEMORRHAGIC FEVERS

Emerging Disease: Infections that are appearing for the first time, rapidly increasing in incidence and range
• when germs and humans come together

Hantavirus: Sin nombre


• from contact with deer mice, at four corners
• rise in mouse population
• human population grew as well

Human activity is responsible for abrupt appearance of supposedly new pathogen


• mobility (travel) makes easier

zoonotic: reside in animal or insect host, dependent on for survival


Arenaviruses;
Lassa Fever biggest virus
o rodents
o person to person contact
o sexual contact
o contaminated needles

Bunyaviruses
Spread by contact with infected insect or animal
o mosquitoes
o ticks
o rodents

Filoviruses
Reservoir of diseases isn’t known
o person to person contact
o contaminated needles and syringes
o sexual contact
o contact with nonhuman primates

Flaviviruses
Insects responsible
o mosquitoes
o ticks

Rift Valley Theater


• zoonosis, so primarily affects animals, occasionally humans
• sheep academic, Kenya, mosquitoes (eggs can last for a long time in dry conditions)

epizootic: epidemic animal disease

HEALTH DISPARITIES PERSIST FOR MEN, AND DOCTORS ASK WHY

• The main focus is on women’s health


• Men live shorter lives, die at higher rates, and are more at risk for some diseases
• Possible explanations shorter life
o Lifestyle
o Tendency to go to doctor later
o Biological determinants
o Riskier and more aggressive behavior
o Higher rates depression
• women’s advocates oppose, men have been focus of medical research
• men die at an earlier age and at a greater rate, except for Alzheimer’s
• Need further research to look at XX vs XY
• Want to look at upbringing (don’t ask for help, take care of it yourself)
CHILD MALNUTRITION IN BANGLADESH
• problem in Africa, southeast Asia
• Health consequences: proclivity poor life style, growth faltering 6 months
• Social inequalities dictate pattern of malnutrition
o ¾ kids in poor class homes
o 45% nation below poverty line
• no matter what price rice is, consumption is the same
o when price goes up, disposable income is down
o less diversified diet

HIV

• First cases in homosexual men in Los Angeles


o Also found lethal cancer in these men
• CDC included homosexuality, but didn’t know causal agent
• Thought was chemical cause – bad “poppers” in disco
• How did it get here?
o Resorts in Haiti
o Patient 0 was European flight attendant? (no proof)

• Gay bars, PDF was illegal… 1969 Stonewall riot, then sexually more accepted in 70’s, emergence gay
neighborhoods in cities, and sexual liberation  bath houses
• Epidemiologists missed that HIV was also appearing in intravenous drug users and women and infant
(partners)
• Took until 82 or 83 to figure out that was blood borne and sexually transmissive
• Retrovirus: HIV is first that we know of, it inserts viral RNA into hosts cells DNA, so all of daughter cells has
HIV in new cells, becomes virus factory
o Immune system amounts a response, but it isn’t strong enough to win in lifetime
o Policy issue about what to do with American blood supply, should donors be screened?
 Blood banks didn’t want to spend money
• Ari Rubenstein noticed infants were being born and dying with immune system failure… they would start
out healthy and rapidly decline, 1984
• Frame, Luke Monenue, IDd retrovirus responsible for HIV
• Robert Gallo in US sure that was variant of leukemia causing retrovirus
o Once discovered could create test to screen
o Development of AIDS takes 4 years, then live 12-18 months and die of infection/cancer

o 1987: AZT monotherapy, a drug that beats back virus


 Putting on earlier lets virus build up immunity to AZT so doesn’t improve treatment,
actually does worse
 Costly and bad side effects
o Concorde?
• 1994: cocktail hit pipeline- protease inhibitor drugs, helped people dying gain weight and go back to work.
• Ryan White: adolescent with hemophilia did education at school about AIDS, activist. Became national
icon for courage in face of HIV
o Kennedy created mechanism to publicly fund care
 Patients going in hospital didn’t have health insurance, costly, couldn’t pay
 1985 federal funds made available to do
• Testing
• Surveillance
• Public education
• Pamphlet mailed to every house in the US

1986: Senate passes Ryan White care Act: designed to bring resources to most affected cities
Title I grants/funds

AZT: added other titles. (Title II) and AIDS drug assistance program, ADAP
• III impact on women and children grew, created new title for them,
• IV created early intervention clinics (before gets chronic)

Trend
• find vaccine
• push for treatment drugs by advocacy of affected populations
• there was action by the local communities, they were stigmatized, but politically powerful (educated,
wealthy)
• Were we spending money on prevention? Started in 1985, but prevention messages are messy. They
didn’t want kids in HS learning about condoms, safe sex, intercourse, etc.
o Didn’t want to teach drug users safe injection
o Mistaken belief: EDUCATION = PERMISSION

Theories that HIV was present in regions of Africa and people were immune
• When drugs came out, prevention was for people who can’t afford treatment attitude
• Problem of epidemic: expression is different in every patient, immune systems fail in different ways
because of different exposure from birth
o So disease is not predictable
o We have treatment failures because there isn’t anything more to treat with
o Drugs demand high level of adherence, most humans aren’t that adherent to therapy

HUBRIS moments:
• thought we had conquered infections diseases before HIV
• stigma against population affected, homosexual men, so harder for researchers to see other people
affected
• some public policy officials took stand that HIV is “god’s revenge”
• how we manage, test, look for viruses has changed because of HIV, our understanding cell function,
classification of viruses,
• found HIV virus all come from same family
• POLICY INNOVATIONS
• idea that we can distribute drugs to large population, create public attitude that people need wrap
around services, linking people up with care resources
• specialists vs generalists:
• politically, pub pol, scientifically, there are similarities between cholera and HIV. With Cholera we could
engineer a response: clean water and sewer systems. It is hard to engineer response for behaviorally
linked infection.

HEALTH CARE DISPARITIES AND CERVICAL CANCER

• procedures distributed unevenly


• Disparities in Cervical cancer
o Race
o Socio-economic stuff
• Cervical Cancer
o Easily Detected
o Cheap treatment
o If caught early, can be cured
• Study in Michigan
o Looked at women enrolled in and not enrolled in Medicaid
o So decreasing number women in Medicaid would increase costs
o Expand screening programs

What are HC services that are purely necessary? (everyone should have)
Immunizations (MMR)
Emergency Room/Urgent Care
Pre-natal care
Eye Correction
Psychiatry

Which HC services should be considered pure luxury and expendable?


Plastic surgery
End of life care/procedures
Annual Checkups/physical
Lasik Eye Surgery
Dermatology

What were criteria?


Necessity: should government provide to everyone?
Luxury: not provided by government
Cost effectiveness
Moral/ethical responsibility
It’s important to define rules up front of what we are using to evaluate criteria – this is why it’s so hard to do this in
the real world, it’s uncomfortable to distribute resources. We have to create rules that maybe we don’t benefit
from. Thus we have an unequal distribution. This is why TRUE HC reform is so hard.

MEDICARE PART II

Federal program
Universal
Doesn’t have federalist flavor like Medicaid
Implemented with medical providers input
HC providers less dissatisfied working with Medicare than Medicaid patients – we have the same system
everywhere, it is safe stable payer system
Late 90’s government cut Medicare distribution rates, hospitals start going out of business
Done to contain costs
Medicare lowered reimbursements to around costs of services – hospitals had been using extra to
subsidize care to uninsured.

Hospitals like Medicare because it is predictable, does a lot of services, one system, reimbursement flow is
reasonable.

Medicare Choice
Late 90s (1997) attempt to contain costs, managed care – Medicare Advantage
HMO system for Medicare, employees, that has pharmaceutical coverage
It was under utilized, and lower out of pocket costs, volume is important, but people didn’t jump on it
For older population, limiting provider choice was emotional… people want to go to their doctor

Part D

Prescription Drug Payment


No coverage outpatient prescription drugs parts A and B
People talking about absence drug coverage
Republicans said we couldn’t afford it
Democrats pushing for it, were going to make it an issue
Created opportunity for Bush to create Part D
Rising drug costs is a burden to seniors
There was political pressure for a solution (voters moving into retirement age)

Medicare Modernization Act


Left wasn’t happy about tiered approach – people without access
The Donut Hole… gap in coverage, caused because of tension/budget issues
Estimated over 60 billion in 2006
Relies on private insurance companies to administer plans
Is notoriously risk averse!
Anyone who can get Medicare can enroll in Part D
It is for anyone who is eligible for Medicare
Illegal for insurance companies to steer clients into plan based on how their qualify for Medicare

There is only one enrollment, during a short period every year


Penalty for late enrollment
Dual eligibles are covered better, can switch plans every month
No change to Medicaid, but dual eligibles are moved into Part D, so lowers costs for states
Bush told people to talk to pharmacists, and they freaked out! There wasn’t a network of educated
providers to help people use system… fell on family members, churches, etc.
People were pretty happy first 4-6 months with coverage, paying less out of pocket, premiums
predictable.
BUT THEN people hit the donut hole… concession between means test people and those who wanted to
provide a lot of coverage – created system so that if REALLY sick with highest drugs, will get good coverage, but
there must be a cost sharing element. Wanted everyone to get something (rich vs poor). So wanted COST
SHARING and COVERAGE for really sick people. In middle have to pay out of pocket about 3100.

Medicare Catastrophic Coverage

Reagan: coverage expansion to all segments

Prospective Payment System

NJ 1978; attempt to curb hospital costs feds 1984


Financing by DSG- diagnosis related groups

Physician Containment

EXECUTIVE SUMMARY REVIEW

• 2004: 1.3 million elderly people didn’t have health insurance


• If people receive adequate primary care, wouldn’t get serious (expensive) health problems
• Without proper healthcare
o Workers not as productive (chart shows people connected to small business)
o School kids not up to par
o Economic strain on HC institutions in NC
• residents are absorbing these extra costs in taxes and higher premiums
• Four fifths of uninsured fall into one or both of these groups…
o Working for small business
o Below federal poverty level
• 78% of uninsured work full time, or are in a family with full time workers
• Primary reason lacking coverage is COST (say 55% of uninsured in NC)
o 3,400/year for employee in NC
o 8,400/year for family
• ESI (employee sponsored insurance) rate is decreasing because insurance premiums are rising, so small
businesses are cutting health benefits because they can’t afford them
• Blue Cross Blue Shield of NC will cover anybody regardless of condition, etc
• 19% non-elderly people in NC get health insurance from Medicaid, Medicare (public programs)
• Lack of insurance –caused by—rising premiums  rising costs all health care
• 1/3 increase in spending caused by
o Heart disease
o Mental disorders
o Pulmonary disorders
o Cancer
o Trauma

Smoking, heavy drinking, and obesity can lead to these

Many employers are using case management to help employees with high costs

Recommendations
• grant to get background of uninsured and explore policy options
o realized not one option would address full problem or satisfy all stakeholder groups
o Decided on: market-based reform efforts, private-public partnerships, and public initiatives
 There is conflicting interest between providing care for more uninsured AND restraining
health spending for employers, uninsured families, gov
• Thought about limited benefit packages and cost sharing

GOAL: All NC residents have health insurance that meets their basic healthcare needs
Five Priority Recommendations

1 Additional state funding to support and expand the healthcare safety net, to
provide healthcare services to the uninsured;
2 Promotion of personal responsibility for leading a healthy lifestyle and the
inclusion of healthy lifestyle promotion in state policies;
3 Development of a limited-benefit Medicaid expansion for low-income parents;
4 Creation of a subsidized health insurance product targeted to small employers
with 25 or fewer employees, low-income sole proprietors, and low-income
individuals who had not previously offered health insurance coverage; and
5 Creation of a high-risk pool for individuals with pre-existing health conditions.

We need to do SOMETHING because everyone gains from a healthier workforce


• so government needs to subsidize insurance for those who can’t afford it
• people need to get insurance, so employers should help employees pay for it
• agents can market new products to employers

Trends in Healthcare Costs

Individual incentive to live healthy lifestyles


o education
o support
o resources
• chronic diseases  access to care
• increased premiums for risky behaviors

Providers, employers, school, gov incentive for healthy lifestyle

• insurers develop product that rewards (financially) healthier behavior


• providers provide information
• employers and schools create health conscious working space/attitude
• public health continue to promote healthy lifestyle practices
• communities and governments should provide healthy environment (paths, parks, etc)

Healthy NC program for lower income workers


• covers prescription drugs and mental health
• premiums should be 30% lower than in private market
• program must be marketed to encourage competitive prices

Study to look at impact of small group reform


• look at problems small businesses face when trying to get HC benefits for employees
• private insurance companies should sell basic health insurance packages, tack on more coverage for
increased premium
• must expand Medicaid to cover more people, pregnant women and people below 200% FPG
• 1115 waiver to develop limited benefit package
• Have sliding scale premium based on income, reduce premiums for being in non-smoking program, etc.
• Give HRA (health risk assessment) to Medicaid individuals with following up coaching/counseling to
o Determine health risks of population
o Identify costs
o Identify cost savings of implementing wellness initiatives

High Risk Pool


• ineligible Medicare, Medicaid, COBRA
• rejected from private insurer because of health problem
• 6 months open enrollment
• Offer different packages
• Financed through
o Premiums and cost sharing of individuals
o By state for individuals with income below 300% FPG

HIV changed hospital policy with regard to Infection Control/Precaution!

Question: I’ve been thinking a lot about the balance between individual and local or government
responsibility towards an individuals health. And obviously you want to have programs that encourage healthy
behavior on an individual level, and I’m not sure there is an answer to this question, but what is the distribution of
the individual’s responsibility to take care of her or himself versus the government’s responsibility to do it.
Because I feel like with all the technology and medicines etc we are moving more away from prevention of a lot of
diseases, which maybe can be prevented with a healthy lifestyle, towards the government being responsible for
treating the disease, that arguably could have been prevented if the individual took better care of him or herself.

Do you think that the accessibility and availability of a medicine or service as a quick fix to so many
diseases that result from poor lifestyle choices decreases an individual’s incentive for healthy behavior that might
prevent the disease in the first place? And thus increases costs and skyrockets demand?

WHAT TO DO ABOUT THE UNINSURED?


From the perspective of Durham county

• Have to provide context for people to make best personal choices (not get HIV, diabetes) it is
responsibility of society and individual
• How do we provide access to HC resources that enables better decision making?

Objectives

• understand the multidimensional nature of local policy options for covering the uninsured
• Understanding structure and dynamics of financing care for the uninsured
• Analyze local policy options within the context of
o Multiple stakeholder interests
o State/federal policy directions

What you need to know about the uninsured..


• More and more of them – 45 million and counting
o Most are lower income (at or below 200% federal poverty level, 20,000 single individual, 40,000
family of four)
o Most are older and in working families
• continued decline of employer-sponsored coverage
o still over 50%, but has been slipping from 2/3
• Feds and states wrestling with Medicaid costs
• States vary greatly – Medicaid programs and what they are doing about the uninsured
o Two extremes – Massachusetts and North Carolina
 There is a Federal match that goes with Medicaid, but states structure programs
differently.
 Mass: more aggressive in spending to increase coverage long before health reform plan
passed. North Carolina is a conservative coverage state.
KANT READINGS

Chapter 1

Our Outcomes are Lower than Expected

There isn’t a good correlation between expenditures and health, so spending more won’t necessarily make us
healthier

How is our health care system being improved now?

Managed care programs, and consolidation of health care services. Maybe what we are going through
now is HC reform, just without the legislation behind it.

THE VISION OF CHANGE: FROM TODAY TO TOMORROW

Presentville 2007:
• Financed privately and publicly
• Rising number of people uninsured
• Moving towards hospital systems and group practices over individuals
• We are measuring costs and quantity, but not quality

Healthopolis 2020:
• health benefits paid in annual capitation based on need/health status
• benefits to health care systems that improve over time
• all health care systems are finished consolidating
• payment made to health plans is based on HALE (health adjusted life expectancy)
• ? – is this book like a policy proposal?
• Ineffective programs have been reduced, and there is substantial cost savings
• This money given to small business employers… number of employees without health benefits dropped
close to zero
• Private-public dialogue = health outcome trusts, established to allocate resources effectively

A Realistic Vision

• current system is very political, new system will be purchasing population health framework

Taking Our Temperature: How healthy are we?

Health: presence or absence of disease


• complete mental, physical, and social well being
• we are living longer = healthier?
• We have a really hard time measuring quality of care, which should be big factor in determining our
health

Structure: basic inputs (materials, etc) needed for health care services
Process: is procedures and intervention for converting structure into health care outcomes
Outcome: ultimate achievement of system

So when we are trying to judge health care quality, we are paying too much attention to process and too little to
outcome.

THE MULTIPLE DETERMINANTS OF HEALTH

• we are NOT obtaining maximum health benefits from our investments

How does ___ affect health status…

Role of Medical Care:


• diagnostic/disease intervention processes
• medical measures responsible for only 3.5 % disease decline in the US
• we need to provide improvements to most people possible with resources available

Expanded Model for Determinants of Health

• Socioeconomic Determinants
o Higher socioeconomic status = lower morbidity

Better Educated and Healthier?

• higher education = lower mortality rates

HEALTH AND WORKING CONDITIONS: HOTEL ROOM ATTENDANTS IN LOS VEGAS

• Impact of lean staffing and increased service demands/higher level of competition on health of workers.
Nobody has looked at the quality of life of these workers, and asked if it could be an better
o Increased physical workloads
o Low income
o Low skill utilization and job control
o Little chance of skill advancement
• Housekeeping/service jobs is biggest growing sector – can’t be outsourced
o Low wage
o 75 billion dollar industry
o 1.1 million workers
Study Goals

• describe working environment: organizational and biomechanical risk factors


o study wants to develop a survey instrument for measuring health quality
o compare 5 different types of hotels, and make comparisons between San Francisco and Los
Vegas

• guest room attendants play huge role in designing study – so it meets their specific needs
o they have largest incentive to improve their quality of lives!

Study Results and Conclusion


• Limited Job Potential: promotion not probable, not satisfied with job, little job security,
• Physical workload has increased in last five years
o Correlated with improvement of hotel (more features, Jacuzzis, etc), more rooms
• current physical workload and time pressure
o current jobs are physically demanding
o more assignments during the day
o limited in time to finish quickly because people come back to their rooms
• high levels of work stress
o correlation between job stress and disease
o there isn’t enough social support from employers to offset the stress
• lower levels of general health and higher levels of pain
o even though Los Vegas workers are younger
o workers in Los Vegas are more tired than those in Los Angeles, have less energy and vitality,
lower than average in the US population
• elevated blood pressure
o 40% of attendants versus 25% for all of US population
• high rates of work related disability, and under-reporting of injury
o high medical costs
o discouragement by medical providers
o punitive action by employer
o so there are Barriers at work to showing/expressing/dealing with illness – shouldn’t be this way!

• there is an association between poor working conditions, poor health, and elevated levels of pain

In summary: time pressure, high workload, low job control, high psychological demand, and high job stress
increase the risk of health or severe pain in employees at Las Vegas hotels

Outlook: Potential for improving health status of hotel room attendants:

• health status of room cleaners is below the national average


• workload and work organization can be designed in ways that can reduce the burden of illness and
disability for these workers
What is OSHA doing about immigrant worker safety?

• report published outlining details of work related Mexican worker deaths


• in actuality level of work related death has decreased by 8% since 2002, thanks to OSHA

REAL STORY
• OSHA takes credit for any distinguishable favorable trend in the data, but the real story is a grim one.
• It has currently been an issue addressed in the media, so it is finally getting some attention
• There IS an increasing trend of workplace death in the immigrant population
o CAUSES
 Lack of knowledge about safety and health hazards
 Language barrier
 Exploitation (we make immigrants do most dangerous work)
 Intimidation (fear of the migra, and won’t know to call OHSA)

• OK, so OHSA has been trying to “reach out” to Hispanic workers, form groups for communication, etc.
• They claim that more information is available to Hispanics about work safety, heath hazards, etc, and
training course through the web and similar publications
o OK, there is info on the web, but how available is it to the workers?
o Printed materials are outdated, and given sometimes only to employers
o A lot of Spanish people can’t actually read Spanish (or English)
o The only training being done is through a program that Bush is trying to eliminate

• Hispanic workers are not familiar with government agencies that could assist them
• Hoffman Plastics decision: undocumented immigrants are not entitled to back wages
o But everyone is entitled to safety, regardless of status!

• so there isn’t any link between OSHA research/work and the small trend in dropping Mexican immigrant
worker deaths
o maybe Mexican born workers have been in the US longer and have experience and aren’t as
willing to take risks as they were before?

What can OSHA and others do to improve plight of immigrant workers in the United States?
• Establish building grants program for community based organizations, so that workers can get local,
personal training
o The main issue is trust
o Workers go to co-workers, friends and family more often than employers
o These organizations would speak their language and not turn them in the MIGRA
o OSHA needs to be funding these organizations! But they are ignoring them
• do more research, public hearings, and establish a clearinghouse for information!
o OSHA needs to hire more people that speak a foreign language

• problem is preventing punishment/retaliation against immigrant workers that attempt to use their OSHA
rights.
o Should be fines for health/safety violations and criminal activity

Bottom Line: more money and more innovative programs by OSHA to hire more immigrant employees from
foreign countries.
February 20, 2007

IMMUNIZATION COVERAGE AMONG CHILDREN BORN TO HIV INFECTED WOMEN IN RAKAI


DISTRICT, UGANDA: EFFECT OF VOLUNTARY TESTING AND COUNSELING (VCT)

• Does knowledge of HIV status affect immunization rates among children (with HIV positive versus
negative numbers)
• Outcomes
o Fully immunized
o BCG
o Etc

• Only 34% of children were fully immunized at 35 months


• Lower immunization rates among kids with HIV+ mothers
o Especially for vaccines you get later
• Mother knowing HIV+ status doubled the risk of her under-immunizing her child
• Some weren’t immunized because they were HIV+ themselves
• Children 4X as likely to be under-immunized if HC hard to access

Higher immunization rates with…


• higher education levels
• majority tribe
• higher socio-economic status

FEDERAL SAFETY NET FOR WORKERS

Superfund: hold polluters responsible for pollution!


What about the workers who have to clean up these sites?

• Number of people that die while working, 2005: 5,702


o How many become injured? 4.9 million
 Every 2.5 seconds someone gets ill because of job
• Occupational Safety and Health Administration OSHA
• Holes in safety net: reportable injuries that happen DURING work… so they had women who broke arm
wait until end of day to go to hospital
o Insurance premiums go up if reported, there are costs to employer that reduces incentive to
report injury
• Tradeoff: if she’s covered by worker’s comp, she can’t press charges
Safety Net Organizations
OSHA: occupational safety and health administration
• formed by OSHA Act
• established 1970, nobody looking out for safety of workers until then
• under Nixon
• OSHA sets minimum standards for worker safety, and enforce them
o They fine you, sometimes, if you don’t follow them
• general duty clause
o responsibility of employer to provide workplace free of all recognized hazards

• Mine Safety and Health Administration (MSHA): mine workers most dangerous profession in country.
Make a lot of money, so union is more powerful

• NIOSH: National Institutes of Safety and Health

• scientists figuring out how much is bad for you, recommend equipment
o they set recommended exposure level
o then OSHA makes a permissible exposure level, that is usually higher than recommended
exposure level

• Congress setting laws, companies, employers, insurance companies, advocate groups, all working
together to decide on levels of exposure
o Insurance companies want levels to be high so they don’t have to file claims for people who are
injured

• Chemical Safety Board: investigates causes of disasters in chemical related environments

• Industrial commission: workers comp people. (early 1900’s)


o Schools were created during industrial revolution to provide skilled, trained workers to work in
plants. Learned skills necessary for work in plant. The industrial commission was started for the
same reason
o People were suing companies for getting injured due to lack of training.
o The industrial commission assigns a dollar value per body part, and for a life! Only 2200!

• There is a federal OSHA act, but each state has the option for creating its own plan
• A lot of people don’t have a choice about their jobs

How do our fatality rates compare with the rest of the world?

US: 4 deaths/100,000 workers


Belgium: 3.3
Finland 2.1
Norway: 1.6
UK .8 (our rate is five times greater)
Portugal: 8.7
Canada: 7.1

How well are we protecting workers?

Number fatal work injuries, latinos: 1992: 275 deaths/year. Now 625. But there are a lot more latinos in the
country in general, BUT when we account for increases in population, trend holds.
• is there a decrease in death rates for non-latino (white workers, etc)
• service sector is increasing (lots of latinos)
• OSHA celebrating, rates went down 2004-2005, BUT rates of Hispanic and black workers killed in 2005
fatalities INCREASED
• Contract workers may not be counted in numbers, how can we even trust the numbers? A single event
can skew the numbers!

You knew what it was when you walked in the door!


• employers do not translate risk into higher compensation
o they look for certain populations to engage in this high risk work

DOT-GOV: MARKET FAILURE AND THE CREATION OF A NATIONAL HEALTH INFORMATION


TECHNOLOGY SYSTEM

• when the market fails, government has to step in


• The HC marketplace has failed to implement IT because of
o Problems unique to HC
o Business strategy problems typical of fragmented industries
 (but there seems to be a huge movement going on to consolidate HC, so we are dealing
with this one?)
o Technology standardization problems

• Implementing a system would reduce costs and increase quality

• It seems like we need an open access system that can bring up any individual’s information with
o There would be large start up costs, and then low marginal costs, and huge benefits!

• Problems without the system


o Inaccurate transfer of information / miscommunication
o Slow

Purpose of the Paper


1) illustrate how the failure of the health care IT market is rooted in economic problems unique to health
care and business strategy problems typical of fragmented industries
2) to show how this failure is exacerbated by US reliance on the zigzag market forces to generate technology
standards for infrastructure development
3) to suggest ways in which the deferral government can and should intervene
• a private business isn’t going to jump in and solve this problem – it already would have been done by now
• The HC system will stay like this forever because bad quality is good for business
o Less information about a patient = more services = more billed to health insurance
• Exceptions to the inefficient, sneaky system
o Kaiser Permanente Health Plan
o Veterans Health Administration
 Vertically integrated (responsible for financing and delivery of care)
 Business models
• Own their own hospitals
• Employ and control workflow of physicians
• Members do not jump in and out of plans

Health Care is a Prisoner’s Dilemma


• there is a dominant strategy to not absorb huge costs of implementing a system like this at the risk no one
else will jump on the train, financially
• No single HC organization is large enough in size to fix this problem alone

Cost of building national HIT system: 276 billion (so this would have been a percentage of what we’ve wasted in
Iraq, right?)

Solutions for Government… because it’s a big player in Health care, purchases ½ US HC
• Mandatory conversion of all government-payer transactions to systems based on new clinical data
standards
• Parallel mandatory conversion of providers transactions with government payers to systems based on
new clinical data standards
• Safe harbor for hospitals purchases of the new system for physicians

What is a policy wonk?

Inadequate transmission of patient information across a continuum of care environments precedes a fatal
outcome

• It is very common to have lack of coordination in care


o I saw this first hand! How scary that this article is about a woman who died from a bowl
obstruction because of that… too close to home for me.

THE VALUE OF HEALTH CARE INFORMATION EXCHANGE AND INTEROPERABILITY

• this paper did a cost benefit analysis of a fully standardized electronic system
o value over year is 77.8 billion
Overview of Study
Data and Methods
• used literature review, experts, analytic framework, software model, and projection of costs.
• Basically, the costs outweigh the benefits in implementing a HIEI Health care electronic information
exchange and interoperability
o Limitations? HC organizations aren’t used to this system now
o A lot of costs might be inaccurately predicted

Overall Message: the government needs to step in to really make this happen!

VIDEO: HAMLET, OUT OF THE ASHES

• women made comment that the smell was so awful, job was terrible and she wanted to quit, but she
stayed for money for her family- this is something we talked about in class
o also another woman stated that she was single with two kids and she would deal with
harassment

• they never have a fire safety drill


• 19/25 were single mothers – I would speculate that a large percentage of the people working there could
fall under this category… were poor and desperate to care for their children and therefore would put up
with the horrible treatment
• 10,000 Americans lose lives on job every year
• It was interesting that no males were interviewed… they seem to be minority working in factory, but I
would think with that many interviews they would have at least one!

Guest Speaker

HIT

HEALTH INFORMATION TECHNOLOGY


• moving data from one source to another

HER: Electronic health record – broader scope of data


• electronic medical record: strictly limited to medical data

Group 2:

• community based managers/social workers


• biographical info
• Health -> psychological -> addictions  disabilities

Fragmentation
• 40,000-50,000 medical errors per year lead to death
• Medicine as an art and science  standardization
• Standards of care and not telling HIV patients that they have Hepititis C

Surveillance/research/inter-exchange of information

$80 billion dollars saved per year

A difficulty for small practices, already know their patients well  must hire person

3 Dirty Secrets of Health Care

Bad quality is good for business


On organization is unnecessary medical product or service is anothers revenue stream
Paper may kill, but obfuscation pays

MARCH 6, 2007 FAMILY PLANNING: A CURE TO OVERPOPULATION

Focus on Egypt

The Study

Does access to family planning services have an effect on use of interuterine devices (IUDs)

• 8,845 married women, 15-49 years old


• Used index to measure quality of family planning services

Why Egypt?

• Egypt is largest producer and consumer of pharmaceuticals in MENA region


• Large population, over 70 million, growing at 2%, expected to increase by 50% by 2025 (more people
being born versus fewer people dying)

• Quality of family planning services correlated with use of contraceptives

• Population growth rate down from 3%... how can they attribute the access to family planning care?

• How is it a disparity?

• Empower women, over 1/3 not educated and 58% from rural areas

BARRIERS TO HC FOR HISPANIC COMMUNITY


• language barrier can impact effective HC
• asked patients about their verbal/language skills
• controls had excellent language skills/ no translators

KINDIG READING

Health Determinant: Something that helps to set or direct your level of health function (demographic, genetic,
behaviors, education, social, environmental, and social factors) All of the things that when combined with me,
facilitate or inhibit my health status.

Education in the 80’s was a BAD thing for HIV. A lot of education is based on political things

Social class is another health determinant: higher class feels entitlement to HC. Class is how others perceive you
as well, people make assumptions about behaviors, ability to pay, etc.

Behaviors: smoking, nutrition, seat-belts, sleep


Location of food distribution on a population level: access to fresh fruits and vegetables, costs of
nutrition,

Biological: what are you born with? Energy level, likelihood of heart disease, every single person has a different
set of health determinants than everyone else. What is it that exists in my biological, behavioral, social construct
that creates a structure that my health lives in? Some health determinants we don’t want to share with people!
Paper must show I understand something in each domain…
Health is status in which we function in our lives… NOT medical status

Focus on emotional/mental status of being a student at Duke


Think about constructs, what are important to me, and that’s what I write about… what shapes, drives health
status that will become important. Then think about how this relates to the HC system.
March 8, 2007

MULTISYSTEM FACTORS CONTRIBUTING TO DISPARITIES IN PREVENTATIVE HEALTH CARE


AMONG LESBIAN WOMEN

- 2 million lesbians in US
- Goal of study to figure out WHY disparities exist, and change for future

Multisystem Ecological Model

- Authors talked about…


o Client system factors (orientation does not equal behavior)
o Still at risk for sexually transmitted infections
o Higher rates other behaviors that might increase risk certain cancers
o Many attribute hesitancy to seek care because of negative past experience
- Standards of care based on heterosexuality
- Women must go through coming out process with each provider
- Lack of awareness and sensitivity

Health Care System Factors


- Institutional biases
- Not sufficiently trained to deal with lesbian patients
- Lesbians less likely to have insurance coverage

Implications
- Responsibility of system and HCP’s to change the environment

Tuberculosis

- 1.6 million die per year

Differential Decline TB incidence in NYC


- 1992 peak epidemic in US
- 14.3% TB cases in nation are in NY… why? Population density?
- Multi Drug Resistant TB: resistant to two potent drugs.
- US born patients two times as likely to have resistance

KINDIG CONTINUED…

Purchasing Population Health – presents model for changing how we deliver HC

• Shift away from fee for service – instead we pay for health
• More social and environmental awareness
• Current cost containment efforts cut costs but don’t say anything about health
• Emphasizes addressing outcomes of system in general, holding providers accountable for outcome
measured by health
• Measure by standardizing – HALE – gives each person a score that determines whether or not to provide
health care. Looks at outcomes as far as function.
• Target health care delivery to people who have the least – but we don’t see it that way
o What motivation does he propose for us to take care of these people?
 Cost effectiveness
 Reward for health outcome improvements
• If you can improve health of subpopulation over time, we’ll give you more
money! MARKET BASED INCENTIVE to provide better health care to
populations that start with worst health status.

• Creating economic incentive to decrease disparities


• Is everything capable of being market-ized?

So resources distributed away from wealthier populations to lower health status populations
• ? What is the moral response that HC is being rationed away from those who need it the most, to those
who may not get as much benefit ?
March 20, 2007

THE ROLES OF CITIZENSHIP STATUS, ACCULTURATION, AND HEALTH INSURANCE IN BREAST


AND CERVICAL CANCER SCREENING AMONG IMMIGRANT WOMEN”

35.7 million immigrants in US households, 1/3 latinos, 2/3 asians


Less likely to seek screening and most lack health insurance

Subject of Study – specifically looked at latinas

Role of citizenship status and acculturation

• Look at screening by pap smear and mammography


• Significant different regarding US citizen women and immigrants
• Initiatives: non discrimination based on citizen status, insurance coverage

Scott – Director of Epidemiology

IS TOBACCO CONTROL A SOCIAL JUSTICE ISSUE?

NH is smoke free!

• tobacco outweighs other risk factors for causing death


• at one point NC produced ¼ of world’s cigarettes!
• Industry master at marketing toward women – weight loss
• Ronald Reagan used to recommend, doctors
• Advertising tried to address fuss/controversy
• Now advertising is primarily for younger audience, African Americans
• We had American Tobacco District
• If you want to impact who smokes, get to age 18, then likelihood falls
• In NC, use of tobacco products in HS products is falling, white is going down faster than black and Hispanic
• Most preventable causes of death are due to tobacco
• Men smoke more than women, youth are the most price sensitive

Paradigm for Tobacco Control

• Minor’s access
• Advertising

Cessation Activities
Prevention Activities
Clean indoor air
Regulation/liability
Price/Economic

Bar Hopping Study

Went to a bunch of bars, etc and compared indoor air quality


Found that air quality is 5X worse than establishments that completely ban smoking

Peeing section/non peeing section  swimming pool, haha


Ban  what’s the economic impact?
March 26, 2007

THE THREE CORE PUBLIC HEALTH FUNCTIONS

Assessment
• Monitor  ID problems
o Water, diabetes, disease screening and immunizations
• Diagnose and investigate
o Medical examiners, TB, HIV
• Evaluate services
o Data management, health needs assessment

Policy Development
• Develop
o Housing, health, safety
• Enforce laws and regulations
o Food, license, hazardous material inspections
• Research for new solutions
o Recycling, health needs survey/assessment, observe other programs

Assurance
• Connect people and HC
o Early screening programs,
• Assure PH workforce
o Bio-emergency meetings, food service worker safety course, training
• Inform, educate, empower people about health issues
o Education and programs
• Mobilize community partnerships
collaborate with business, HC providers, etc

Introduction

Social Contract:
• rule of law
• peace among citizens
• protect human life

we are a violent nation, yet we have these values!

Surgeon’s General’s Workshop on Violence and Public heath (1985) encouraged health professionals to respond to
violence

Is violence a public health issue?


Do research on:
• child abuse
• rape and sexual assault
• spouse abuse
• homicide

the numbers are growing, so research and policy is necessary to strengthen our nation
TRENDS OF GONORRHEA AND CHLAMYDIAL INFECTION DURING 1985-1996 AMONG ACTIVE
DUTY SOLDIERS AT A UNITED STATES ARMY INSTALLATION

• military personnel higher risk for STDS


o Because of prostitutes!
o Especially deployed soldiers, contact with sexual workers
• what about during peacetime, in comparison to citizen population?
• Yes, it’s a problem, but crude incidence is decreasing
• Implied when talked about missing private HC, Is being in the military tied to socioeconomic status, which
could be another influence

Silverman
What are the police powers that the government should hold over health?

(and why)

• Infectious Diseases: quarantine (respiratory)


• Mandate vaccinations
• Temporarily shut down institution
• Right to control USE of drug, but not completely banish it because tied to business, economy
• Making something illegal makes it socially unacceptable – social stigma
• Government can play role in education and warn people about things!
• Government regulation of sanitary standards
• Monitoring environmental factors
• Speed limit?
• Have to find balance between health and utility
• Put tax on unhealthier foods… fat tax
• Does there HAVE to be a benefit to other people?

FEMALE CONTROL OF SEXUALITY: ILLUSION OR REALITY? USE OF VAGINAL PRODUCTS IN


SOUTH WEST UGANDA

ABC approach: abstinence, be faithful, condoms

Differences in health status among distinct segments of the population, including differences in gender, race,
ethnicity, education, disability, etc,

The disparity: HIV associated with men, women get overlooked

• Women have a greater chance of infection


• In Uganda, woman’s lack of control… have multiple partners for economic reasons (rape?)
• STIGMA against using condoms
• There is an importance of secrecy and control over protective measures – so ability to use product
without partner knowing is important
AVIAN FLU

Public Health Problem Solving Avian Flu Preparedness

Three kinds of Flu

• seasonal flu: what comes every winter, respiratory illness, vaccine available
• avian (bird) flu: H5N1
• Pandemic flu: global outbreak, easily spreads from person to person

Things we should know…

• large number of deaths


• we are on the brink
• All countries will be affected (travel and food)
• Medical supplies inadequate
• 18-40 most affected
• H5N1 concentration most prominent in asia

Group Assignment

How can communities respond to the avian flu?

th
Look at response plans, look for gaps, condense work into 10 minute presentation: April 10

Avianflu.gov

My group: Group 2

Plan

Everyone read intro, purpose, and scope

People’s Roles in Presentation


• intro and conclusion person
OBESITY AND JOBS

• Steeper gradient for women than men with obesity and job status
• Obesity = socioeconomic disadvantage
• Obesity = low levels of education as well
• People doing manual labor have MORE likelihood of being obese
• Reasons for trend:
o Uncertain about productivity of obese workers
o Men run hiring processes, looking for attractive women

HEALTH AND ACCESS TO CARE FOR CHILDREN OF US MIGRANTS AND IMMIGRANTS

• We have history of removing poor children – we apply our standard, even if the person might be living
better than they ever had!
• Treating patients in clinic everyday doesn’t have as large effect as actually going in and informing policy
members what needs to be changed in living conditions, etc. There is a connection between policy and
clinical medicine… use research as a TOOL to answer questions of policy makers.

? – Should we alter health system to accommodate immigrants?


? – health care for immigrants vs children of immigrants?
? – Should they ever NOT be treated as citizens for public health related benefits? When DON’T they have
standing?

• Migrants may or may not intend to stay, want work


• Immigrants intend to STAY
• More unaccompanied women are migrating
• 12% US population (37 million) are foreign born!
o 30% are unauthorized migrants
o 31% are naturalized citizens
o 28% legal permanent residents
o 7% refugees
o 3% temporary legal residents
• 20% children in US have at least one immigrant parent
• Welfare Reform: if not foreign born, (legal permanent resident) CANNOT receive benefits first five years!
First tying of citizenship to who receives benefits
• Newborns and Medicaid…
• There is little research about HC for migrant children
o Are children who NEED HC actually getting it?
o Western thinkers are independent, we decide when we need care! We are rational… immigrants
may think that THEY don’t determine need, it’s the doctors that determine it.
o Difference between having fever and having fussy baby
o Working cross culturally, we have standard practices that may not be applicable to another
culture! Have to consider these things! Maybe with a survey when it is translated, bring it BACK
to the population and see if it translated correctly
o Taking off time from work is American concept, “ask to leave”
rd
o African American and Mexican 3 generation are the two populations that don’t trend towards
better socioeconomic status (still look like first generation immigrants)
• There is an independent effect of nativity of parent on health care access
• People with only one foreign born parent do better than those with two foreign born
o Citizenship hasn’t affected this analysis

When looking at access to care


• Nativity of parent is critical
• Citizenship status isn’t that important, but the longer you stay, the worse HC children gets

Hispanic Health Paradox:

• We select for health by immigration – so we pull out the healthiest group (over time develop illnesses)
• They start to think differently about own health
• Salmon hypothesis: immigrants come to country and when get older, will go back to country of origin
• Infant mortality is low amongst Hispanic women compared to African American, but likely due to
selection.
April 2, 2007

COSTLY HEART TREATMENT IN DOUBT

• We have treatment with expectation that we will be fixed.


o Expensive heart surgery = taking medicine and changing behavior!
o Found that taking pills is equal to having expensive surgery
o But treatments are highly profitable, cost 35,000 dollars
o Patients that had heart arteries cleared and took medicine lived no longer than those who just
took medicine.
o 2300 patients at 50 hospitals across the country
 Funded by drug companies as well… do they benefit more?

• we look at medicine as somehow inferior to expensive procedures (because it is old fashioned?), but this
isn’t the case!
• Drugs work on the entire circulatory system, while angioplasty just works where operated
• Angioplasty is one of 10 most common procedures in hospitals
• Interventional cardiologists get paid 500,000 per year, largest increase in salary… so do they have
incentive to do surgery even if drugs could have equal effects?
• But we don’t like idea of leaving an artery just blocked!

ASPIRIN IS GOOD FOR WOMEN, TOO, STUDY SAYS

• 24 year study 80,000 women


• Taking aspirin: 25% lower chance of death
• 38% lower risk of death cardiovascular disease, 12% cancer
• 50 cents/ week, no larger benefit from high doses
• Aspirin also prevents stroke in women
• At risk women and older women got most benefit!
• The length of the study makes the results compelling, BUT the study was observational because the
women chose to take the aspirin, which is problematic.
PATTERNS OF CANCER INCIDENCE, MORTALITY, AND PREVALENCE ACROSS FIVE
CONTINENTS

Introduction
• number and rates of incidence
• mortality,
• prevalence of cancer

Methodology
• statistical analysis pre-existing data, 2002
• identified regional disparities

Results
• number of new cases in each region
• highest incidence of specific cancers
• lung cancer
• breast cancer

Reasons
• lung cancer
o cigarette smoke
o occupational hazard
o indoor exposure
o genetic susceptibility
• breast cancer
o screening
o chemoprevention
o treatment

Solutions
• behavioral interventions
o education
o increase screening and early detection strategies
o Vaccinations against HPV and HBV
• Public health policy
o Occupational safety
Epidemiology takes rigorous quantitative methods and does detective work/logical thinking to try and figure out
what is causing unusual patterns of disease.

• surveillance systems
• CDC is national coordinating industry
• Outbreak investigations
April 3, 2007 Public Health Reading

MENTAL HEALTH CARE IN NORTH CAROLINA

• we spend 71 billion a year on mental health treatments


• gap between what we know how to do and what we actually do because of…
o declining financial support mental health/substance abuse in private/public sector
o viewed as discretionary, so cut out!
o No consistent mandate to insurers to provide mental health – led to mass cuts in spending,
because they don’t have to!
• 1988 – 1998, value of general HC benefits decreased by 11.5%
• Same period behavioral HC benefits decreased by 54.7 %
• As proportion total HC costs, behavioral HC decreases from 6.1 to 3.2%
• Patients pushed into public sector care, increased burden on mental HC services
o So can’t treat low-fee patients, they wind up in emergency rooms!

• 20% of population experiences mental health illness during year, and there are treatments!
o Mental illnesses rank first amongst causing disability in US
o But they are STIGMATIZED and face disparities
o The problem is that they aren’t looked at as legitimate illnesses

• Presiden’t commission mental health did study and found that


o 5-7% adults/year have serious mental illness
o 5-9% children have serious mental disturbances

• Challenges
o Financing
o Quality of care

North Carolina’s Public Mental HC System

• state operated services


• Area Programs
• Private, non-profit, and for profit services

• State division mental health disabilities operates

o Psychiatric hospitals
o Developmental disability centers
o Alcohol and drug rehab centers
o Private agencies have expanded in past decade

• NC has lagged behind in…


o Deinstitutionalization
o Medicaid expansion
o Managed care
o Shift to local mental health authorities
 Led to organizational and financial problems!
• 1990’s – mental HC system teetering on collapse!
o Carolina Alternatives, Medicaid for children, terminated because wasn’t cost neutral
o Increasing demands services and decreased reimbursement rates
o State was updating standards and changing requirements that would be very expensive to
implement

Mental Health Reform in NC

• Public Consulting Group determined that 4 hospitals beyond saving, and should be replaced by new ones,
580 million dollar project
o Wanted to move towards county operated model
• original model created in 1960’s had federal-local partnership that bypassed states.
o Reagan transferred funding to states, and now states had dominant role.
o States slowly downsized
o Problems like Medicaid made it harder, financing is tough
o PCG = ?
o LME = local management entity: purchase services from broad array of providers- so we shifted
to privatized care!
o MD/DD/SAS: state division of mental health, developmental disabilities, and substance abuse
services
• new legislation, reform, passed by Dept Health and Human services 2001

The Promise and Pitfalls of mental Health Reform in NC: Managing a Privatized System

• Privatization (LME’s)
o increase administrative efficiency
 separates management and oversight from admin. Of services
 private sector providers want to be more efficient so they are going to want new
technologies, etc. = increased competition = weed out bad ones = low cost and high
quality care

But does privatization


1) promote innovation?
2) Enhance quality?
3) Lead to competition?
4) Fragment care?
5) Co-op advocates?

Promoting Innovation vs. Maintaining accountability

• There are low reimbursement rates and high demands, so little time for training – hard to get expertise
and resources
Enhanced Provider Quality

• want to enhance quality by making providers compete on value, not price – but it’s hard to keep track of
which providers have good quality AND it is arguable there won’t be competition for under-funded
services

Competition vs Continuity of Care

• it is inconvenient for a consumer to have to switch between providers, and may be disruptive

Co-opting the advocates

Financing the Reformed System

• who is the population most in need?


• Can we rely on Medicaid funding?
• Most fragile piece of financing plan is bridge funding – we lose our hospital safety net
o In NC we’ve been downsizing on hospital beds to reinvest in community services
 NC has lost about 500 beds

Clinical capacity and workforce needs

• shortage mental HC workers


• training needs, money isn’t there, and people aren’t there

Leadership

• we need leadership from the governor, Dept health, etc.


• we need to convince people that mental health is a viable investment

PSYCHIATRIST BRIEF: SUPPLY AND DISTRIBUTION PSYCHIATRISTS IN NC

• 1/3 adults have mental disorder during year period


• Barriers to care
o Inadequate insurance coverage
o Stigma of mental illness and treatment
o Poor financial resources
o Not enough psychiatrists

Study finds that…


• maldistribution of psychiatrists, and growing population = shortage for adult and child pshchiatrists
• not even enough primary care providers!
Why should NC take stock psychiatry workforce now?

• before 2001 psychiatrist salaries not dependent on patient fees


• reform of 2001…
o called for local management entities (LME’s) to manage, and psychiatrists encouraged to link up
with them… but now we have fee for service system, and arguably it doesn’t generate enough
revenue to support psychiatrists
• providers want privately insured patients – disparity

Psychiatrists

th
• 1/10,000 people! We rank 20
• We’ve done well in the past keeping this ratio because we have a lot of in state residency programs,
recently the trend has started to decrease, so we’re starting to fall behind.
• So the closer to the medical centers we get, the better the psychiatrist ratio… the trouble is when we
move farther out.
• In last decade, 2/3 counties in NC have lost all of or had significant decrease in number psychiatrists
• Psychiatrists go to metropolitan areas because there are more people!
• Without psychiatrists, burden of managing mental illnesses falls on primary care or other health services
• 24% decline child psychiatrists past decade
April 5, 2007

You can’t understand health disparities unless you understand health determinants

DISCRIMINATORY FACTORS WITH HIV… THAILAND


• refusal of treatment
• testing without consent
• not informing the patient

Results
• no signs of discrimination
• There is discrimination in practice after being admitted to hospital because there isn’t a system to
monitor policy within population
o Quality of treatment…
o Lack of seriousness of patient consent (patient tested without knowledge)

Problems
• too small a sample
• nature of those interviewed
• doctors still don’t have knowledge about HIV/AIDS… think they will get it from getting close to people.
o There’s still a fear of condom use!
• still stigmatized to sex workers, gay men, etc.

CANCER HEALTH DISPARITIES AMONG ASIAN AMERICANS

• Differences in incidence, prevalence, and mortality of different groups in US


• Asian Americans have low cancer rates for SOME cancers, but have HIGHEST rates
For
Uterine, cervic, stomach

• Asians expected to be 8% of population by 2050 (now is approx 3%)


• 20 countries of origin, 30 ethnic groups,
o So different educations, languages, cultures, etc.

• Cancer is leading cause of death for 25-44 and 45-66 years of age! Others leading cause is heart disease.
• Asians have more cancers of infectious origins
o Eating more red meat  cancer colon
• Asian Americans have lowest screening rates
• Language is also a barrier

Why do they have lowest rate of visiting doctor?


Language and access or Pride? Belief in other types of medicine? Busier??
• we need to orchestrate efforts between government entities

HEALTH DETERMINANTS

All stereotypes are built into the HC system… society is built to provide HC easiest, etc to white men.

Every person has a concept of race put upon them that is a determinant of health

There are both positive and negative health determinants

We can’t imbue our values/health determinants on others!

MENTAL HEALTH CARE NC

We moved from publicly funded into privatized market based model with LME’s – the old system had serious
problems (stretched beyond capacity) had 39 entities each governed by own mental boards, and very different
(levels of program planning, values, goals, organization, Medicaid billing, etc) completely separate from hospitals.

Money goes from state  local communities in LME’s, they assure that are adequate services, that providers
following guidelines, etc.

Huge problem with recruitment contracted agencies, those that DO want to provide services don’t have business
plan, strategy, lots of times goes through entire funding in a couple of months
A DIFFERENCE IN DISPARITIES: COMPARISON OF TYPE I AND TYPE II DIABETES

Type I: juvenile onset, insulin pump therapy

Type II: adult onset (obesity) insulin resistance

Dealt with Hispanic community


Surveyed fasting blood glucose levels and medication taken

52% Hispanics treated with insulin


26% Caucasian treated with insulin

Hispanics have poorer blood glucose control and are more severely medicated

Controlled for education of parents


Lowest level of socioeconomic group h ad 45% more likely to have Hba1C over 8%
Found correlation between these levels and income

Therefore: Type II is more of a behavioral disease


Type I requires more money to obtain resources
Need to assist lower socioeconomic patients.
Genetic factors, education, lack of access

Future: when aid is given to the diabetic-community has to consider type

SAFETY AND HEALTH OF WORKING WOMEN: POULTRY PROCESSING IN THE RURAL SOUTH

1970: Occupational Safety and Health Act OSHA


• within dept of labor
• maintain record keeping system to monitor job related injuries and illnesses
• develop mandatory job safety standards
• There are specific standards AND general duty clauses

General Duty Clause


• Hazard that causes serious physical harm
• Recognized
• Has to be something could do to fix the problem

NIOSH
• branch of CDC
• does internal research

OSHA: regulatory
NIOSH: research
Safety and Health of Working Women Project (SHOWW)
• focused on how work contributes to health disparities

Work is good…

• health insurance
• money
• retirement benefits
• responsibility
• self worth/esteem
• less welfare burden
• increases tax base

But it’s also bad…

• physical and chemical exposure


• stress
• application of rights to medical care and wage replacement under workers’ comp

• segregated by race and sex

• African Americans have harder time finding work, more hazardous, pay less

Northeastern North Carolina


• low education
• high poverty
• high infant mortality
• sparsely populated, growth is stagnant
• few employment opportunities
• majority of population is black
• largest employer is poultry processing 2500 primarily AA workers

Poultry Processing…
• live birds get there, crated, hung on shackler, shot, throats cut, feathers removed, feet removed, rehung,
remaining feathers removed, then inspected at 90 birds a minute
• guts taken out, put into chiller, packaged as whole birds or cut up and packaged as parts, then ready to be
shipped to grocery stores

Morbidity
• from repetitive motion
• acute injury risk
• upward trend in mortalities – fire where 25 workers died

Plants in study area


• poor OSHA history, cited for repetitive motion hazards, failure to record hazards, and injury hazards.
NIOSH did health evaluation… saw 36% workers had evidence of rep. motion injury in past year
• turnover rates over 50% annually

Is this kind of employment good? What is the community gaining? Why are so many people LEAVING
employment?

• asked for help documenting health effects of employment in poultry processing

There isn’t OSHA standard for ergonomics, even though we know its an issue

Women in community reported


• symptoms attributed to other things…obesity/mental health/child care
• reported distrust of employer, and HC available at plant

Community comparison group


• women also working, but weren’t working in plant… picked same age distribution
• women never worked in plant, or at least not in last 5 years

Black women underrepresented in research studies

Had financial incentive, $40/interview

Primary outcomes of interest


• musculoskeletal symptoms (location, frequency and severity) by survey

Work exposures (postures, speed, what doing, stress levels)

Exposure assessment without access to the workplace hmmm

Created exposure variable that was index of cumulative exposure over time.
Also interested in depression (pain related to depression)
14% lost to followup
Recruited 290 women in other jobs

Analyzed data to compare changes in plant, how do poultry workers look compared to other women? Followed
over time, factors depicting development of disease over time.
99% African American, single, employed 2 months – 30 years
What department was person 30 year experience employed in?

• average wage is 17,000/year


• prevalence is what they saw in 1990!
• Increasing prevalence of symptoms and disorders with more exposure plant

Other indicators need for medical care


• 15% normal body weight
• 1% lipid lowering medication
• High prevalence of depressive symptoms
o Less than 1% on medications
o ALL women have Health Insurance through employment?

What is a $10 copay represent to someone who makes 8 dollars an hour before taxes?

So do the poultry workers have a higher prevalence of musculoskeletal symptoms than other women in their
community? YES, 2X higher

After considering other factors, do they have a higher prevalence of depression?


80% higher prevalence depression – symptoms associated with aspects of work ALL of these factors higher for
workers in poultry plant.

How do workplaces come to be in certain communities?


• 1960, poultry processing had commercial supplied family farms, 2000 less than 50, top 5 have over half
market share. Half processing done in this region in south. Reduction of labor costs = hire less
advantaged workers.

Research around these issues is difficult, potential to affect profit margin of business = TENSION

Working poor major philanthropists of this society.

Economic development area: in NC encourage promotion of industry, waiver taxes, building,etc


APRIL 18, 2007 HOW (AND HOW NOT TO) BATTLE THE FLU – A TALE OF 23 CITIES
NY TIMES

• Influenza of 1918 hit in summer, and was rampant among military camps
• Hit Philadelphia in September
• Rampant because city allowed public gatherings
o World War I parade/loan drive
o 4 months, 12,000 Philadelphians dead
o 719/100,000
o Prevented public gatherings in St. Louis, only 347 / 100,000 deaths
o EARLY ACTION SAVED LIVES

• H5N1 could do this


• Differences in death rates are directly correlated with preventative health measures
• Preventative measures EARLY in the epidemic reduced death rates by 30-50%
o Hopeful that same is true today if we don’t have an effective vaccine

• 2 week delay in response time can double or triple mortalities


• Non-pharmaceutical methods mitigated the impact most strongly

• Effective prevention program can implement controls and then control the epidemic, worry is that once
controls are lifted, epidemic will start again

o This is what happened in St Louis… reopened schools after 3 days influenza rates declining and
second wave epidemic started and children 30 to 40 percent of infections

• Study examined epidemic in 23 cities, Kansas City had most effective prevention, weren’t too late or too
early
• Most successful interventions in communities where political and health authorities broadly agreed on
what needed to be done and got significant cooperation from the public
• Tune intervention so single peak of minimal size is the result
• It is a mix between vaccine development and preventative measures
• Question of whether society is up for responsibilities that come with these measures, limitations
TEENS AND SUBSTANCE ABUSE TREATMENT IN TENNESSEE

Racial and Gender Differences in Utilization of Medicaid Substance Abuse Services among Adolescents

Health disparities are population level differences that result in different health outcomes
So we have to ID population, and population we are comparing it to
In differences to access, use, outcome

Costs US 143 billion dollars


• looked at claims and enrollment into Medicaid
o Annual utilization rate
o Age at which the first treatment was received

• Whites nearly two times as likely as blacks to use services


• Males were more likely to have had treatment, received treatment and at older age than females
• Youths 3.7 times more likely to have used substance abuse services if they were in foster care (greater
need? Or more of a support system)

Implications
• differences in willingness of different HC professionals when have problem
• different ways of dealing with them
• how diagnose and treat a problem

Local Health Policy in Rural Health

• 87 health departments, 100 counties


• We have hybrid system
o Local health department are under authority of both the state health department and local
government bodies.