Health Policies and Vulnerable Populations Presentation

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Copyright 2019. Health Administration Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. CHAPTER 6 H EALT H P O L ICY FOR DIVE R S E P OP UL AT I ON S The moral test of government is how it treats those who are in the dawn of life . . . the children; those who are in the twilight of life . . . the elderly; and those who are in the shadow of life . . . the sick . . . the needy . . . and the disabled. —Hubert Humphrey Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection. —Harry S. Truman L e a r n i n g O bj e c t i v e s After completing this chapter, you should be able to ➤➤ define vulnerable populations; ➤➤ identify policy issues for racial and ethnic minorities; ➤➤ describe policy issues for those with low income; ➤➤ highlight policy issues for the uninsured; and ➤➤ discuss policy issues for vulnerable subpopulations such as the elderly, people with chronic illness, people with mental illness, women and children, people with disabilities, the homeless, and people with HIV/AIDS. 155 EBSCO Publishing : eBook Academic Collection (EBSCOhost) – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY AN: 1989456 ; Leiyu Shi.; Introduction to Health Policy, Second Edition Account: s3642728.main.ehost 00_Shi (2374) Book.indb 155 11/21/18 10:55 AM 156 Introduction to Health Policy Case Study 1 T h e H e a lt h C e n t er P r ogram Since the 1960s, health centers—nonprofit, community-directed healthcare providers, also known as federally qualified health centers—have provided primary and preventive care services to predominantly low-income, racial or ethnic minority patients in medically underserved areas (HRSA 2017, 2018). In addition to clinical care, health centers provide enabling services such as transportation, translation, and education to facilitate access to care for diverse populations. Health centers coordinate with other community services and are governed by boards made up mainly of health center patients. Health centers face significant challenges, including the following: •• •• •• •• •• •• •• Persistent economic slowdown Shifting demographic trends Shifting disease burden Increasing complexity of the healthcare delivery system Health and healthcare disparities Healthcare workforce shortage Rapid rate of technological innovation Yet health centers are making a difference in underserved communities across the United States. As of 2017, nearly 1,400 health centers provided care at more than 11,000 sites throughout all 50 states and several US territories (HRSA 2017). The National Association of Community Health Centers (2018) has chronicled stories of how health centers have provided access to affordable primary healthcare and are saving lives and taxpayer dollars. Following are several examples: •• Center for Family Health (Jackson, Michigan) became a one-stop center for women’s •• Crescent Community Health Center (Dubuque, Iowa) invested in the implementation of •• •• •• •• health, pediatrics, and related medical services. electronic medical records and in patient education. Family Health Services (Twin Falls, Idaho) undertook three expansion projects throughout Magic Valley that include medical, behavioral, dental, and pharmacy services. Family Practice and Counseling Network (Philadelphia) recruited additional dentists to provide many children with regular dental cleaning before they start school. La Clinica Health Care (Medford, Oregon) installed a new ultrasound machine to provide better medical imaging for uninsured and underinsured pregnant women. United Neighborhood Health Services (Nashville, Tennessee) became able to serve as a medical home to mothers and children. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 156 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations •• West Cecil Health Center (Cecil County, Maryland) expanded services to include more •• Westside Healthcare (northern Delaware) built a new site to expand access to more •• 157 evening hours. than 5,000 people. Will County Community Health Center (suburban Chicago) acquired a mobile dental van that provides families in the county with dental care. Case Study 2 M y H e a lt h GPS P r o g r a m C h ro n i c C o n d i ti o n s fo r P atients with M ulti ple One method of addressing the needs of patients with multiple chronic conditions involves enlisting community health workers, typically members of underserved or indigenous communities who serve as frontline healthcare professionals (Love, Gardner, and Legion 1997). The duties of community health workers range from facilitating access to care and performing outreach to improving healthcare quality and reducing costs (Witmer et al. 1995). The My Health GPS program is one of two state programs requiring community health workers to be part of the care team. Under the Affordable Care Act of 2010 (Section 2703), states may submit state plan amendments to coordinate care for people enrolled in Medicaid who have chronic conditions using a “whole-person” philosophy and integrating care across the full range of services needed (CMS 2018). In 2017, the District of Columbia Department of Health Care Finance (DHCF) launched My Health GPS, a coordinated care benefit program for Medicaid beneficiaries with multiple chronic conditions enrolled in either fee-for-service or managed care plans (DHCF 2018). The program seeks to improve outcomes and reduce unnecessary hospitalizations and emergency department (ED) visits by integrating an interdisciplinary team led by primary care. My Health GPS targeted about 25,000 beneficiaries with 3 or more chronic conditions assigned to a provider via an opt-out process (District of Columbia State Innovation Model 2017). Providers under My Health GPS must demonstrate delivery and document all home services, directly provide or subcontract for provision of services, and follow communication protocols with external health partners. Providers are also required to provide patient-centered medical home recognition, certified electronic health records, hospital and ED alerts for enrollees, 24/7 access to clinical advice, and a staffing model of qualified persons or comparable alternatives (District of Columbia State Innovation Model 2017). The preapproved staffing model for My Health GPS includes a health home manager, a nurse care manager, a care coordinator or social worker, a licensed clinical pharmacist, and a peer navigator or community health worker, with an assigned staffing ratio for each role. Beneficiaries are classified based on the severity of their conditions. Individuals with lower acuity have three or more chronic conditions (Group 1) and are expected to have two 25-minute contacts per month with a care team consisting of a nurse manager, a health home manager, and a community health worker (District of Columbia State Innovation Model 2017). EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 157 11/21/18 10:55 AM 158 Introduction to Health Policy Those with higher acuity (Group 2) have three or more conditions as well as a qualifying risk score and are expected to have six 40-minute contacts per month with a care team consisting of a nurse manager, a health home manager, a care coordinator, a clinical pharmacist, and a community health worker (District of Columbia State Innovation Model 2017). Providers are paid on a per-member, per-month (PMPM) basis. To receive the initial payment, providers must (1) inform the beneficiary of this health home benefit, (2) receive consent from the beneficiary, and (3) develop a care plan for the beneficiary. Providers must deliver at least one home health service within a given calendar month to receive a PMPM payment that month. Payments are made directly from the DHCF. Providers were paid $46 PMPM for patients with Group 1 acuity and $137 PMPM for patients in Group 2. During the first quarter of the program (July–September 2017), providers were given a onetime payment incentive of $475.91 per beneficiary for starting a care plan (District of Columbia State Innovation Model 2017). As of mid-2018, the program had not yet been evaluated, having been implemented for less than a year; however, starting in 2019, providers were to be evaluated for readmissions, preventable inpatient admissions, and avoidable utilization. T his chapter discusses healthcare policies for diverse populations and vulnerable subpopulations of people with special needs. The populations covered in the chapter include racial or ethnic minorities, the uninsured, and individuals with low income. Vulnerable subpopulations include the elderly, people with chronic illness, people with mental illness, women and children, people with disabilities, the homeless, and people with HIV/AIDS. D e f i ni n g V u l n er a b ility No consensus has been reached on how to define vulnerability and vulnerable populations. For purposes of our discussion, this chapter defines vulnerability as the convergence of health risks. Health risks can manifest in the following categories: ◆◆ Physical (e.g., having a fever or other physical symptoms) ◆◆ Mental (e.g., feeling depressed) ◆◆ Social (e.g., resulting in poor school or job performance) Because poor health in one dimension can be compounded by poor health in other dimensions, health needs tend to be considerably greater for people with multiple health EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 158 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations problems than for those with a single health problem (Hu et al. 2016; Shi and Stevens 2010; Shi et al. 2017). Health risks consist of predisposing, enabling, and need characteristics at the individual and ecological levels (see the Learning Point box titled “Definitions of Health Risk Characteristics”). Vulnerable populations, such as those presented in this chapter, experience a convergence of these health risk factors and, as a result, typically exhibit poorer health status than those without multiple risk factors. The For Your Consideration box titled “Why Should We Care About Vulnerable Populations?” lists and describes compelling reasons to focus national attention on the need to reduce the health and healthcare disparities they experience. 159 LEARNING POINT Definitions of Health Risk Characteristics The following are definitions of the three characteristics of health risks (Andersen 1995): Predisposing characteristics, which indicate the propensity of individuals to use care services: • Demographic characteristics (e.g., age, sex, family size) • Social structure variables (e.g., race or ethnicity, education, occupation) • Health beliefs (e.g., beliefs about health and the value of healthcare) Enabling characteristics: • Resources available to individuals and families for the use of services (e.g., income, insurance coverage) H e a lt h P o l i c y I s s u e s P opu l at i o n s for D iverse The following sections explore health policy issues for the following types of populations: racial or ethnic minorities, the uninsured, and people with low socioeconomic status (SES). • Attributes of the surrounding community or region that affect the availability of and access to healthcare services Need characteristics: • Specific illnesses or health needs that drive the receipt of healthcare services FOR YOUR CONSIDERATION Why Should We Care About Vulnerable Populations? Possible answers to this question include the following: • Vulnerable populations have significantly greater health needs. • The prevalence of vulnerability in the United States is increasing. • Vulnerability is influenced by social forces and therefore should be remedied by them. • Vulnerability is fundamentally linked with national resources. • Vulnerability and equity cannot coexist. What do you think? Are these points valid? Explain your answer. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 159 11/21/18 10:55 AM 160 Introduction to Health Policy R acial or E thnic M inorities The US Census Bureau (2018) estimates that more than 34 percent of the country’s population is made up of racial or ethnic minorities: Blacks or African Americans 13.3 percent Hispanics or Latinos 17.8 percent Asians 5.7 percent Native Hawaiians and other Pacific Islanders 0.2 percent American Indians and Alaska Natives 1.3 percent Identified as two or more races 2.6 percent Racial and ethnic minorities experience significant problems in accessing high-quality healthcare, leading to disparities in health status as compared with the white, non-Hispanic population. Healthcare Access regular source of care (RSC) A usual place where, or a usual provider from whom, an individual receives healthcare services. culturally appropriate The regular source of care (RSC) measure is commonly used to evaluate patient access to care. Research indicates that having an RSC increases the chances of receiving better coordinated care, better treatment for chronic and acute health conditions, fewer delays in care, and access to preventive care. Studies show, however, that members of racial and ethnic minorities are less likely than whites to have an RSC, even when accounting for SES, insurance status, and health conditions (Ailawadhi et al. 2017; Grzywacz, Hussain, and Ragina 2017; Lo et al. 2017; Shi and Stevens 2005). Hispanic adults were the least likely to have an RSC, followed by American Indians and Alaska Natives, African Americans, and Asians. Whites were shown to be the most likely to have an RSC. Similar trends were seen among children from racial and ethnic minority populations compared with children from the white, non-Hispanic population (HHS 2018a, 2018b; Irvin et al. 2018; Tai et al. 2017). Factors contributing to the lack of an RSC include the following (HHS 2018a): services Efforts by healthcare organizations and providers to increase understanding and produce effective ◆◆ Lack of health insurance coverage ◆◆ Low family income ◆◆ Language other than English spoken in the home interventions for patients by taking into account patients’ cultural and linguistic characteristics. The inability to afford care was reported as the most common reason for Hispanic adults lacking an RSC (Shi and Stevens 2005). Additional factors that limit access to care, especially for Latinos and Asians, include English language barrier, poor geographic proximity to a source of care, and lack of providers offering culturally appropriate services. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 160 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 161 Healthcare Quality Racial and ethnic minority patients are more likely to report dissatisfaction with quality of care and patient–provider interactions than white patients are. One reason is that patients from these groups commonly perceive discrimination in quality of treatment. Lack of English language proficiency not only affects access to care for racial or ethnic minorities but also contributes to disparities that racial or ethnic groups experience in receiving high-quality preventive care (Njeru et al. 2018). Health Status Racial and ethnic minorities experience disparities in perceived health status, causes of death, and health risk behaviors as compared with non-Hispanic whites. For example, the 2007 National Children’s Health Survey showed that Hispanic and African-American children were the least likely to be perceived by their parents as having “excellent” or “good” health, even after adjusting for SES and family demographics (CDC 2017d). Regarding cause of death, among all racial and ethnic groups, African Americans exhibit the highest mortality rates for homicide, stroke and coronary heart disease, and colorectal cancer, as well as the highest morbidity rates for diabetes and HIV/AIDS (CDC 2013, 2017b, 2018c). These causes of death have important implications for healthcare policy because they are preventable through law enforcement, regular screening and early detection, health education, and access to effective medications. As for health risk behaviors, American Indians and Alaska Natives have the highest smoking prevalence (CDC 2013, 2017a; Garrett et al. 2011). Additionally, Asians and Latinos are more likely than whites to live in an area with substandard air quality as compared with the US Environmental Protection Agency standard (Yip et al. 2011). Programs to Eliminate Racial and Ethnic Disparities Programs to eliminate racial and ethnic disparities in the United States operate at the federal, state, and local levels of government as well as through private organizations. Federal Initiatives The Office of Minority Health (OMH) and the Indian Health Service (IHS), both part of the US Department of Health and Human Services (HHS), are among the federal agencies that address issues related to racial or ethnic minority health. The OMH, according to its mission statement, “is dedicated to improving the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate health disparities” (OMH 2018). The IHS provides comprehensive health services to federally recognized American Indians and Alaska Natives residing in 12 Indian Health Service Areas across the United States. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 161 11/21/18 10:55 AM 162 Introduction to Health Policy State and Local Initiatives State and local programs work independently to meet the specific needs of minority populations in state, county, and municipal communities. At the same time, state programs often serve as models for federal initiatives. Two examples are Minnesota’s Eliminating Health Disparities Initiative and the California Department of Public Health Strategic Plan, both initiated in 2008. They serve large numbers of individuals, and their goals are closely aligned with the determinants of health in Healthy People 2020 (HHS 2010). Private Initiatives One example of private endeavors to eliminate disparities is the Association of Schools of Public Health, which, with the support of the W. K. Kellogg Foundation, promotes health professional involvement in racial and ethnic health disparities research (Horowitz et al. 2000). Another example is the Building Healthy Communities Initiative launched in 2010 by the California Endowment (2018), which seeks to promote long-term improvements in health status in 14 communities with high rates of health disparities through broad investment in social, environmental, and medical interventions, with a primary focus on children and youth. T he U ninsured In 2015, more than 9 percent of the US population lacked health insurance (Shi and Singh 2018). Studies show that people without health insurance face barriers to healthcare access, quality of care, and positive health outcomes (Akinlotan et al. 2017; Garfield and Damico 2012; Kenney et al. 2012; Moonesinghe, Zhu, and Truman 2011; Weissman et al. 2008). Advocates have long urged lawmakers to expand public insurance programs—such as Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP)—and have called for the improvement of the quality of care received through these programs. One primary goal of the Affordable Care Act (ACA) of 2010 was to reduce the number of uninsured Americans. Several provisions in the ACA sought to extend coverage to previously uninsured groups. Examples include the development of health insurance exchanges, which established insurance markets for individuals and small business owners, and the expansion of Medicaid to provide insurance coverage to all individuals and families with an income at or below 133 percent of the federal poverty level (Shi and Singh 2018). In 2013, the year before the major provisions of the ACA took effect, more than 44 million nonelderly people were uninsured, but by 2016, only 27.6 million were uninsured (Foutz et al. 2017). However, after the tax revisions led by President Donald Trump in 2017 eliminated the ACA requirement that all individuals have health insurance, the number of uninsured Americans began to rise again (Beaton 2018; Collins et al. 2018). By March EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 162 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 163 2018, 4 million fewer working people aged 19–64 had health insurance (Collins et al. 2018). Among lower-income adults in particular, the uninsured rate increased from 20.9 percent in 2016 to 25.7 percent in March 2018 (Collins et al. 2018). If the ACA were to be repealed entirely, as the Trump administration seeks to do—either without replacement or replaced by a plan favored by President Trump—the projected number of uninsured people would rise to about 48 to 49 percent of the population (Statista 2018). Healthcare Access Lack of health insurance increases the likelihood of delayed care by increasing the chance that the uninsured individual does not have an RSC. Uninsured children in particular suffer negative consequences. A study on young children aged 0–3 showed that uninsured children had a lower chance of obtaining needed medical care, prescription medications, dental care, and an RSC (Newacheck et al. 2002). Studies have further shown that the type of insurance that patients are covered by affects their rates of ED use and preventable hospitalization. According to several studies, individuals with public insurance are more likely than those with private insurance to use an ED instead of a physician’s office as their primary source of care (Gindi, Cohen, and Kirzinger 2012; Meisel et al. 2011; Pukurdpol et al. 2014). Healthcare Quality The association between quality of healthcare and type of health insurance has been well documented, as has the impact of insurance status on how many of recommended services an individual receives. One study found that uninsured individuals experienced more deficits in receiving preventive care and less likelihood of receiving care as the uninsured period increased (Garfield and Damico 2012; Foutz et al. 2017; Moonesinghe, Zhu, and Truman 2011; Weissman et al. 2008). This pattern was consistent across most preventive services. Furthermore, poorer access to primary care services among uninsured individuals may result in a greater number of preventable hospitalizations, which are avoidable with timely, quality primary care (Davis et al. 2018; Foutz et al. 2017). Programs to Eliminate Disparities in Health Insurance Government and community organizations are at the forefront of the national drive toward universal and more comprehensive health coverage, creating several programs to raise the number of individuals covered by health insurance. Federal programs, such as Medicare, Medicaid, and CHIP, cover nearly 40 percent of the US population. The impact of these programs has been especially noticeable in reducing the number of the uninsured among vulnerable populations. Many states are expanding Medicaid or CHIP eligibility, and these expansion programs have been credited for improved access to care and health status (Dubay and Kenney EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 163 11/21/18 10:55 AM 164 Introduction to Health Policy 2009; Holahan and Headen 2010; Howell and Kenney 2012; Sommers, Baicker, and Epstein 2012). To assist the remaining uninsured individuals, some states and private organizations have created their own programs for those who cannot afford health insurance but whose income level makes them ineligible for Medicaid or CHIP. For example, Kentucky is one of a few southern states that have expanded Medicaid under the ACA, extending Medicaid eligibility to many people who are too poor to purchase individual market coverage yet too “rich” to qualify for traditional Medicaid eligibility. Benitez, Creel, and Jennings (2016) found that Medicaid expansion raised accessibility of coverage and affordability of healthcare for populations experiencing financial constraints in using medical care. In an attempt to improve access to healthcare for all of its people, Minnesota created the Health Care Homes program as part of the state’s health reform initiative. The program links primary care with prevention and wellness, self-management, and community services (Minnesota Department of Health 2018). Minnesota has also attempted to provide crucial mental health services through its Medicaid program (see the For Your Consideration box titled “Minnesota’s Measuring Adolescent Depression Screening and Treatment in Medicaid”). Because states have broad flexibility in defining their public health role, state-level public health policy throughout the United States varies widely. State governments might pursue any of several strategies in relation to the uninsured (Bowman and Kearney 1988; Brace 1993; Coughlin and Zuckerman 2005; Dye 1966; Erikson, Wright, and McIver 1993; IHPP 1995). First, they may choose to do little regarding uninsurance, enacting few or no reforms and relying on the national government to remedy the problem. Although such inaction is inexpensive in the short run, it provides no assurance that something will be done to mitigate the inadequacy of insurance coverage, as even national policies can be expected to provide, at best, variable solutions to uninsurance across states. Second, states might choose a mix of state-based and market-based reforms to create a balanced policy portfolio. A balanced set of policies might provide some benefits: Relying on state-based policies would ensure that coverage is provided to certain blocs of the population and provide a fallback in the event of rising unemployment, which would lead to a reduction in employment-based coverage. By contrast, market-based policies would limit the state’s financial obligations during times of economic prosperity. Third, states may follow purely state-based or purely market-based policy strategies. With a state-based policy portfolio, states assume large financial risk but receive great assurance that citizens will receive coverage through active state intervention. With a market-based policy focus, legislatures may claim credit for both addressing uninsurance and improving the business climate, and the state assumes little financial risk (Glied and Gould 2005; Hall 2000). However, the suitability of this approach is related to the incentives offered to business and the insured. It is one thing for employers to offer insurance benefits, but it is another to make those benefits truly accessible to employees. Passing such policies might address a political imperative to take action while not adequately addressing the uninsurance problem. Alternatively, selling state-based EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 164 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 165 FOR YOUR CONSIDERATION Minnesota’s Measuring Adolescent Depression Screening and Treatment in Medicaid Depression among adolescents has demonstrated an increasing trend over time. Major depressive disorder among adolescents increased by 37 percent—from 8.7 percent in 2005 to 11.5 percent in 2014 (Mojtabai, Olfson, and Han 2016). Tasked by 2008 state health reform law, the Minnesota Department of Health established a statewide system of clinical quality measures to apply across coverage types and demographic characteristics (Honsberger and King 2017). In partnership with MN Community Measurement, a nonprofit organization focused on improving quality of healthcare in Minnesota through measurement and public reporting, the Minnesota Statewide Quality Reporting and Measurement System was established. The system requires quality reporting from all physician practices and health centers in the state. The development of these statewide measures was supervised by a committee of providers, health plans, and consumer representatives, who made recommendations and approved measures and reporting policies, and examined issues regarding data collection (Honsberger and King 2017). To address the issue of measuring adolescent depression within the state, the Statewide Quality Reporting and Measurement System developed a specific measure to determine the rate of screening for depression among adolescents in a clinical setting. To develop a meaningful quality measure, the Statewide Quality Reporting and Measurement System established the denominator of eligible adolescents—people aged 12–17 who received a well visit—and identified a reliable measure of individuals screened. The numerator of eligible adolescents chosen consisted of those who were screened using validated mental health tools in their medical record. To increase the accuracy of the measure, adolescents previously diagnosed with other mental health conditions were excluded (Honsberger and King 2017). Implementation was facilitated by provider support from MN Community Measurement to meet reporting standards via informational webinars, data submission guides, and technical assistance (Honsberger and King 2017). The Minnesota Department of Health Early and Periodic Screening, Diagnostic Treatment provided additional training in mental health screening and services for clinics and providers (Honsberger and King 2017). After a pilot study in 2013 to test the data-collection process and validate the data, the Statewide Quality Reporting and Measurement Systems launched the statewide measure and collected data for the 2014 measurement year from providers in January 2015 (Honsberger and King 2017). Preliminary results showed that fewer than half of adolescents in the state were screened for depression or other mental health conditions, and approximately 10 percent of those screened were identified as possibly having a mental health condition (Smith and Ghere 2015). Rates of screening for adolescent depression increased in follow-up years (Honsberger and King 2017). The study showed that Statewide Quality Reporting and Measurement Systems may have a positive influence on preventive care quality measures of importance in public health, such as screening for depression among adolescents. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 165 11/21/18 10:55 AM 166 Introduction to Health Policy strategies in the modern era may be politically untenable, even if the ultimate effects were beneficial for providing more broad-based insurance coverage (Holahan and Ghosh 2005). P eople with L ow S ocioeconomic S tatus SES is defined by several factors, the most common ones being income level, educational level attained, and occupational status. Those with lower SES typically face greater barriers in accessing healthcare than those higher on the SES scale. For people of lower SES who are able to receive care, their overall health status and quality of care are still typically inferior to those for people of higher SES. Healthcare Access SES has shown greater impact than race or ethnicity on access to healthcare. According to an analysis of the California Health Interview Survey (Brown et al. 2007), poor adults are more than twice as likely to lack an RSC as their counterparts who are not poor. Those with higher levels of education were more likely to maintain an RSC and to seek care at a doctor’s office instead of at community clinics and EDs. Healthcare Quality Several studies examined the link between SES and healthcare utilization. Women with lower educational levels were less likely to report receiving Pap tests and mammograms (Monnant 2014), and women with low household income had lower utilization rates for influenza vaccinations, cervical and colon examinations, and bone densitometry (Earle et al. 2003). Regarding SES and healthcare quality, low levels of income and education showed a negative effect on physicians’ perceptions of patients, which in turn adversely influenced physicians’ selection of treatments and recommendations (Van Ryn and Burke 2000). Health Status Low income, low educational level, and low occupational status have long been associated with high health risks, poor health status, and high mortality rates (see, e.g., Cutilli et al. 2018; Singh et al. 2017; Syme and Berkman 1976). Individuals living in poverty were four times more likely to report fair or poor health status than those who were not impoverished (i.e., those with incomes greater than 200 percent of the federal poverty level). Furthermore, the percentage of adults aged 55–64 with functional limitations also increases as income level decreases, with a nearly sixfold difference between the highest and lowest income levels (Minkler, Fuller-Thomson, and Guralnik 2006). EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 166 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 167 In a study of the relationship between SES and mental health, the Centers for Disease Control and Prevention (CDC) found that high-income individuals were two to three times more likely to report frequent mental distress than were low-income individuals (APA 2005). Low-income adults also showed a high prevalence of health risk behaviors (e.g., physical inactivity, smoking, smoking during pregnancy, short breast-feeding period). The effect of SES on disparities in mortality rates has also been documented. For example, the 2017 Health, United States report showed that infant mortality rates, communicable disease mortality rates, and HIV mortality rates among men are closely associated with educational level (NCHS 2017). A 2011 study found that states with the highest proportions of residents whose incomes were less than 200 percent of the federal poverty level had an amenable mortality rate (defined as death “before age 75 from complications of conditions that might be avoided by timely effective care and prevention”) twice as high as states with lower poverty rates (Schoenbaum et al. 2011). Programs to Eliminate Socioeconomic Disparities Programs to eliminate disparities based on SES in the United States are operated at the federal, state, and local levels of government as well as by private organizations. Federal Initiatives Often referred to as the “healthcare safety net,” federal programs to address SES disparities have focused on increasing access to care for low-income populations. Federal programs for specific low-income subpopulations include the Public Housing Primary Care program, the Health Care for the Homeless program, and Head Start, which helps disadvantaged preschool-aged children acquire basic math and reading skills. Unlike federal programs that focus on reducing economic and geographic barriers to healthcare, Head Start is the only federal program that invests directly in increasing educational level—an often overlooked contributor to SES disparities in healthcare. State and Local Initiatives A notable state program is South Carolina’s Welvista program, a public–private nonprofit partnership founded in 1991 that offers free or low-cost primary care, free prescription services, and free pediatric dental care to uninsured low-income people (Welvista 2018). Services are provided by volunteer health professionals, pharmaceutical companies, hospitals, and laboratories, and a number of corporate and community providers are involved (Welvista 2018). A local initiative for the uninsured is TeleKidcare in Kansas City, Kansas, established through a partnership between the Kansas University Medical Center and a local school EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 167 11/21/18 10:55 AM 168 Introduction to Health Policy district consisting of elementary schools as well as middle and high schools (KansasHealthMatters 2018). Videoconferencing technology allows providers to conduct physical exams and provide acute care and mental health services to schoolchildren in need of medical assistance. Private Initiatives One example of a privately funded program addressing SES disparities is Interact for Health, which awards grants to improve health in Cincinnati, Ohio, and surrounding counties (Interact for Health 2013, 2018). Another example of addressing SES disparities has to do with employment opportunities provided by the private sector (Thornton et al. 2015). Employment can positively affect health through its provision of resources. In addition, because employers typically provide health insurance, the employed experience better access to health care than the unemployed do. Research indicates that employment and income gains led to increases in life expectancy between the mid-1960s and mid-1970s, and these increases were larger for blacks than for whites and greater for black women than for black men (Kaplan, Ranjit, and Burgard 2008). Research examining employment interventions for women of low SES and for people with severe mental illness suggests that employment interventions can be effective in reducing health disparities in these particularly vulnerable populations (Kneipp, Kairalla, and Sheely 2013; Luciano, Bond, and Drake 2014). H e a lt h P o l i c y I s s ues f or V ulnera ble S u bpop ulati o ns This final section of this chapter takes a closer look at health policy issues for each of the following vulnerable subpopulations: the elderly, people with chronic illness, people with mental illness, women and children, people with disabilities, the homeless, and people with HIV/AIDS. T he E lderly For the elderly, primary care and health policy concerns broadly revolve around the following: ◆◆ Containing costs of care ◆◆ Reforming the health delivery system to better serve the growing elderly population ◆◆ Improving quality of life as far as possible into old age Cost Containment Healthcare costs can be daunting for any American. For the elderly in particular, costs are often prohibitive to seeking care. According to the AARP Public Policy Institute, more than EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 168 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 169 25 percent of US adults aged 50–64 (who are not yet eligible for Medicare), as well as nearly 40 percent of older adults covered by a public insurance plan (e.g., Medicare, Medicaid), spent a significant amount of their disposable income (at least 10 percent) on healthcare (Smolka, Purvis, and Figueiredo 2009). Costs increased for patients with at least one chronic disease, and especially for many elderly patients, who have a much higher disease burden (with two or more diseases). A Medicare patient with a single chronic health condition sees, on average, four physicians per year (Bodenheimer, Chen, and Bennett 2009). Patients with five or more chronic conditions see, on average, 14 different physicians per year, and a higher number of chronic conditions seems to be related to a higher number of providers seen. After the ACA was implemented, overall US healthcare spending increased further, reaching $3.3 trillion in 2016, with out-of-pocket healthcare costs incurred directly by consumers rising by 3.9 percent—the fastest growth rate since 2007 (Johnson 2017). Any out-of-pocket healthcare costs for typical elderly individuals is significant, whether covered through public insurance, insured through a private health plan, or paid out of pocket due to lack of insurance. And healthcare costs for the elderly are on the rise, mainly due to higher numbers of chronic diseases per patient in an overall aging population (Bodenheimer, Chen, and Bennett 2009). The number of people aged 85 or older, who have the most multiple chronic conditions, has been projected to grow from 5 million to 21 million from 2005 to 2050, substantially increasing the number of high-cost patients (Bodenheimer, Chen, and Bennett 2009). Most efforts to rein in these expenditures will require major health system reforms. Quality of Life According to Bodenheimer, Chen, and Bennett (2009), the most proactive methods to raise the quality of life for the elderly are to provide effective, low-cost preventive treatments designed to lower risk for adverse health outcomes throughout the patient’s life. If policies were implemented earlier in life to reduce behavioral risk factors, such as smoking, the rise in chronic diseases might slow, and the resulting lower disease prevalence would improve quality of life (Barile et al. 2015; Bodenheimer, Chen, and Bennett 2009). The relationship between quality of life and absence of disease may not be absolute. Even with the increase in chronic diseases, many people younger than age 85 experience delays in the onset of limitations and disabilities, in part due to early diagnosis, better treatment, and more effective amelioration of prevalent diseases (Christensen et al. 2009). This finding suggests that a highly functioning health services system is crucial to improving the quality of life for everyone by its potential to help postpone disability. Service Availability The availability of assistive technology, specialized facilities, and customized services may be adding further distance between disease and disability, as are indirect changes such as EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 169 11/21/18 10:55 AM 170 Introduction to Health Policy housing, transportation, structural improvements for people with disabilities, women’s empowerment, and other social issues (Christensen et al. 2009). Improved funding and coordination of government and private programs to address these issues would simplify the process of obtaining necessary care and improving health outcomes for many elderly patients (Reinhard, Kassner, and Houser 2011). The ACA and the Elderly Many experts believe that the current system of healthcare administration in the United States is less than optimal. Issues such as high costs, insufficient focus on prevention, recurring medical mistakes, and a sense of discord among stakeholders are pervasive, especially for the elderly. The ACA attempts to address several of these challenges. One study found that changes in how healthcare providers are paid through Medicare and Medicaid create more incentives to focus on preventive care and coordinate care across providers and facilities while also reducing growth in healthcare spending and providing better value for public payers (Thorpe and Ogden 2010). Reducing hospital readmissions, improving the monitoring of controllable chronic diseases (such as diabetes and hypertension), and helping community health teams coordinate care among physicians and organizations will improve the healthcare delivery system. These modifications are expected to simplify the system, making it more patient centered and better able to serve the changing needs of US patients, particularly the elderly (Bodenheimer, Chen, and Bennett 2009; Thorpe and Ogden 2010). As the US population ages, it faces unique issues, especially in healthcare cost, treatment coorFOR YOUR CONSIDERATION dination, and quality of life, concerns which may Injury Prevention and Control move to the forefront of the health policy agenda. Injury prevention is a key area of healthcare gaining increased attention (see the For Your Consideration Among the various events that can cause injuries are incidents such box titled “Injury Prevention and Control”). as car crashes, fires, falls, drownings, poisonings, and assaults. The growing recognition of the costs of injuries to a person and to society and of their predictability and preventability helped promote the development of programs for injury prevention and control in local and international health organizations. For example, The Joint Commission (2015) issued a Sentinel Event Alert on preventing falls and fall-related injuries in healthcare facilities—injuries that can be particularly dangerous for the elderly—and offered an array of suggestions and tools to address this issue across healthcare settings (Joint Commission 2015). P eople with C hronic I llness Chronic diseases are the leading cause of death, disability, and healthcare costs in the United States. According to the CDC, half of all adults have a chronic disease, 70 percent of deaths are associated with chronic diseases, and the majority of healthcare costs are due to treating chronic diseases (Dietz, Douglas, and Brownson 2016). EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 170 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 171 Chronic conditions are on the rise worldwide. In the United States, the primary care system needs to be overhauled to accommodate the dramatic rise of chronic disease patients, requiring innovation to provide high-quality care and meet their needs (Kimura, DaSilva, and Marshall 2008). Patients with chronic illness in the United States experience less organized care at a higher cost (Schoen et al. 2009; Thorpe and Philyaw 2012). Every year, 86 percent of healthcare costs go toward care for chronic illness and mental health disorders (Schoen et al. 2009; Thorpe and Philyaw 2012). Uninsured patients who have chronic conditions face a double burden. According to a 2008 study of the National Health and Nutrition Examination Survey, conducted by the CDC National Center for Health Statistics (Wilper et al. 2008), 11.4 million Americans aged 18–65 were living with at least one chronic health condition. According to the study (Wilper et al. 2008), the uninsured faced barriers to care and were more likely not to have visited a health professional (22.6 percent of uninsured vs. 6.2 percent of insured) and not to have a standard care site (26.1 percent vs. 6.2 percent), but if they did FOR YOUR CONSIDERATION have a standard care site, it was more likely to be an CDC and Chronic Disease Programs ED (7.1 percent vs. 1.1 percent). Failing to receive appropriate, timely primary care can lead to worse health outcomes, which can be especially serious in In response to the health and financial burden of chronic diseases, patients already suffering from a chronic condition. the CDC leads national efforts to prevent and control chronic dis- eases and their risk factors (e.g., tobacco use, poor nutrition, lack of Addressing the Burden of Chronic Disease The burden of chronic illness is borne both by patients, who experience frustration, high costs, and poor health outcomes, and by the healthcare system, which often cannot provide appropriate, effective, and efficient care. Policy changes with a focus on chronic illness can significantly ease that burden. Programs that test various approaches to chronic care have been introduced in the United States, but none has been accepted on the scale required for major change (Shortell et al. 2009). National policies addressing chronic diseases should take these attempts into account to control cost and improve care for the chronically ill (see the For Your Consideration box titled “CDC and Chronic Disease Programs” and the Learning Point box titled “Combating Chronic Diseases”). physical activity, excessive alcohol use) through its National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). Specifically, NCCDPHP focuses on the following (CDC 2018a): • Tracking chronic diseases and their risk factors through surveys and research • Improving environmental strategies to make healthy options easier for people to choose • Strengthening healthcare systems to deliver prevention services that keep people well and diagnose diseases early • Connecting clinical services to community programs that help people prevent and manage their chronic diseases NCCDPHP supports various programs at the national, state, and community levels in the areas of cancer, diabetes, heart disease and stroke, smoking and tobacco use, and chronic diseases, as well as community health, nutrition and physical activity, oral health, population health, and reproductive health (CDC 2018a). EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 171 11/21/18 10:55 AM 172 Introduction to Health Policy LEARNING POINT Combating Chronic Diseases Cancer National Breast and Cervical Cancer Early Detection Program (NBCCEDP): Breast cancer is the most common cancer among women, and cervical cancer is the leading cause of cancer mortality among women in the United States. Breast cancer screening with a mammogram and cervical cancer screening with a Pap test reduce mortality rates from these cancers (CDC 2014). NBCCEDP has provided timely breast and cervical cancer screening and diagnostic services to low-income, uninsured, and underserved women in more than 11,000 primary care clinics since the early 1990s (DeGroff et al. 2016). Evidence suggests that NBCCEDP screening for breast cancer has lowered breast cancer mortality among uninsured and underinsured low-income women. However, another study reveals that the US-affiliated Pacific islands face significant barriers to implementing NBCCEDP screening for cervical cancer (Hoerger et al. 2011; Senkomago et al. 2017). Colorectal Cancer Control Program (CRCCP): In 2015, the CDC provided $23 million in funding to the American Cancer Society, universities, state primary care associations, local health departments, and selected nonprofit organizations to implement the CRCCP over a five-year period. CRCCP grantees partner with health systems and clinics to implement four main evidence-based interventions—patient reminders, provider reminders, provider assessment and feedback, and reducing structural barriers—and other supporting activities (including media, community health workers, patient navigation, and provider education) to increase rates of screening for colorectal cancer (CDC 2018b). Tangka and colleagues (2017) analyzed the extent to which the CRCCP program model resulted in funding going toward implementation of the interventions recommended by the Guide to Community Preventive Services. Their findings revealed that all 29 CRCCP grantees carried out media activities, and more than 90 percent used client reminders, provider assessment feedback, or patient navigation. However, grantees spent one-third of their total budget on broad-based recommendations instead of targeted education on evidence-based strategies by the Community Guide (Tangka et al. 2017). Diabetes National Diabetes Prevention Program (DPP): Established by the CDC, the DDP is a partnership that brings public and private sectors together to offer evidence-based, affordable interventions in communities to prevent type 2 diabetes. Some of the primary partners include federal agencies, state and local health departments, community organizations, public and private insurers, healthcare professionals, employers, and businesses that focus on wellness. The overarching goal of the DPP is to enable partner organizations to build a workforce that can effectively deliver and implement CDC-recommended programs for lifestyle change through EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 172 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 173 LEARNING POINT Combating Chronic Diseases (continued) organizations nationwide, as well as to increase referrals to and participation in the program (CDC 2018e). Heart Disease and Stroke Paul Coverdell National Acute Stroke Program: This program was established by the CDC in 2001 to build a high-quality system of care to improve care for patients who have experienced a stroke and to save lives. The stroke system of care aims to improve care and support for patients throughout their journey of care—from the first symptoms of stroke, emergency medical services (EMS), hospital care, and rehabilitation to follow-up with outpatient providers to prevent stroke complications and recurrences. Together, EMS agencies, hospitals, and healthcare organizations collect and analyze data about stroke patients and care, and they share best practices to improve patient care. Through the Coverdell Program, the CDC funds nine state health departments that partner with many hospitals, EMS agencies, healthcare facilities, and community services (CDC 2018f ). Hospitals have been recruited by states since 2007 to join the Paul Coverdell National Acute Stroke Registry Program. By 2012, more than 213,500 patients had been treated and benefited from improved quality of care in more than 300 participating hospitals across the United States (CDC 2015a). Sodium Reduction in Communities Program (SRCP): Strong scientific evidence has proved the health benefits of reducing dietary sodium intake. SRCP is a national program administered by the CDC’s Division for Heart Disease and Stroke Prevention. Grantees in SRCP across the United States partner with local organizations that serve or sell food, such as schools and work sites, to implement strategies for reducing sodium intake as recommended by the Dietary Guidelines for Americans. The CDC funds eight communities to collaborate with food industry partners to make lower-sodium foods more available and accessible, and the CDC monitors and measures their effectiveness (CDC 2018g). In addition, SRCP has developed several evidence-based toolkits such as Partnering with Food Service to Reduce Sodium: A Toolkit for Public Health Practitioners to reduce sodium intake and maximize program impact. Also, award recipients of SRCP, such as the Los Angeles County Department of Public Health and the Philadelphia Department of Health, work at the community level toward meeting SRCP’s short-term goal of facilitating environmental changes that make lower-sodium foods more available and accessible as well as its long-term goal of bringing sodium intake levels down to recommended limits (Mugavero et al. 2012; Welsh et al. 2014). Although the CDC has published the official Sodium Reduction in Communities Program Outcome Evaluation Toolkit, researchers need to conduct more evaluation studies to assess the outcome and impact of SRCP programs (CDC 2018g). (conti nu ed) EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 173 11/21/18 10:55 AM 174 Introduction to Health Policy LEARNING POINT Combating Chronic Diseases (continued) Community Health Programs National Implementation and Dissemination for Chronic Disease Prevention: This national program supports three community capacity-building awardees (American Heart Association, American Planning Association, and National WIC Association), and two dissemination and training awardees (Association of State and Territorial Directors of Health Promotion and Public Health Education, and Society for Public Health Education). Both types of awardees develop strategies and technical assistance to maximize their collective impact, raise local and national awareness of community health workers, and ensure that the communities they serve can increase their capacity and achieve sustainable improvements even after funding for the program ends (CDC 2017c). Racial and Ethnic Approaches to Community Health (REACH): To reduce racial and ethnic health disparities in the United States, the CDC initiated REACH as a national program that funds state and local health departments, universities, community-based organizations, and American Indian tribes. The awardees use these funds to plan and implement local, culturally appropriate programs to resolve health issues among such federally classified racial and ethnic groups as African Americans, American Indians, Hispanics/Latinos, Asian Americans, Alaska Natives, and Pacific Islanders. Beyond providing funding, the CDC also offers technical support from experts to the REACH awardees (CDC 2017e). The REACH program has successfully established community ownership. As a result, various REACH grantees across the United States have initiated local community health programs to address the needs and expectations of their local communities. For example, the Community Asthma Initiative is a program that addresses asthma disparity at Boston Children’s Hospital, which reduced hospitalization rates for children by 80 percent, and yielded $1.73 of return on investment per dollar spent a year after the program began. The Medical University of South Carolina launched a Community Diabetes Education Program, which reduced the frequency of amputation and yielded cost savings. The University of Alabama at Birmingham has trained 170 community health advisers to advocate for mammography screening and reached more than 3,000 women, which ultimately reduced the mammography screening disparity significantly, from 18 percent to 3 percent (CDC 2015b). Tips from Former Smokers: In 2012, the CDC launched the first paid national campaign for tobacco education—Tips from Former Smokers, known more commonly by the shorthand Tips. The Tips campaign profiles real people living with serious health effects from smoking and secondhand smoke exposure. It features compelling stories of former smokers living with smoking-related diseases and disabilities as well as nonsmokers who suffered from exposure to secondhand smoke. With a focus on health issues caused by or associated with smoking and exposure to secondhand smoke, the primary goal of the Tips campaign has EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 174 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 175 LEARNING POINT Combating Chronic Diseases (continued) been to raise public awareness of the health damage caused by smoking and exposure to secondhand smoke (CDC 2018h). Tips has demonstrated significant impact. As of 2017, an estimated 1.83 million smokers had tried to quit smoking, and 104,000 smokers had actually quit smoking. Nonsmokers reported having conversations with family or friends about the harm of smoking and showed an increased knowledge of smoking-related diseases. Smokers who had watched Tips ads showed a greater intention to quit smoking within the next 30 days or next six months, and there was a close relationship between exposure to the ads and intention to quit. More important, since the launch of the Tips campaign, the call volume of national “quitlines” dramatically increased, registering 92.7 percent higher than the two-week baseline period (CDC 2018h). Some chronic diseases cause chronic pain, which in some cases may be treated with medications containing opioids. However, overdependence on such narcotics can create further problems for patients who become addicted to them (see the Critical Concept box titled “The Opioid Crisis”). P eop le with M ental I llness Mental health has become an increasingly important public health issue in the United States. Based on the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition (DSM-IV) classification system, half of Americans are estimated to be affected by a mental disorder in their lifetime, and a quarter of Americans are affected in any given year (Kessler and Wang 2008). In 2005, 27 percent of those younger than age 65 with Medicare coverage were considered mentally disabled (Goldman, Glied, and Alegria 2008). Mental health disability is rising, and in 2018, about one in five US adults was living with some degree of mental illness (MHA 2018). These statistics reveal serious health concerns. Poor mental health is associated with increased risk for early mortality, and many mental disorders exhibit an early-age onset that leads to a lifetime of healthcare needs (Goldman, Glied, and Alegria 2008; Kessler et al. 2008). However, in the early twenty-first century, only 41.1 percent of Americans with a DSM-IV-recognized mental disorder were treated for that disorder (Wang, Lane, and Olfson 2005). In fact, mental health care in the United States has traditionally suffered from marginalization. Only recently has the focus on mental health shifted from specialized, inpatient marginalization A process in which a person or an idea is pushed aside in favor of another. A marginalized subject typically receives few resources and little attention. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 175 11/21/18 10:55 AM 176 Introduction to Health Policy CRITICAL CONCEPT The Opioid Crisis Among the greatest drug-related concerns for Americans today is the opioid crisis. Every day, more than 115 Americans die from an overdose of some form of opioid, including prescription pain relievers, heroin, and synthetic opioids (CDC 2018i). According to the CDC, prescription opioid misuse causes the United States an economic loss of $78.5 billion per year, including the actual costs of healthcare, addiction treatment, enforcement of criminal justice, and the opportunity cost of lost productivity (Florence et al. 2016). In response, several cities, counties, and states have filed lawsuits against pharmaceutical companies over the opioid crisis (Noguchi 2017). Many observers argue that the pharmaceutical industry started and perpetuated the opioid crisis by encouraging the overprescription of pain pills by doctors, leading to higher rates of overuse, abuse, and addiction. An investigation by the Washington Post and 60 Minutes found that the Ensuring Patient Access and Effective Drug Enforcement Act of 2016 removed the authority of the US Drug Enforcement Administration (DEA) to block suspicious narcotic shipments from drug distribution companies, thereby worsening the problem of easy access to drugs (Higham and Bernstein 2017). The investigation also reported that political action committees contributed at least $1.5 million on behalf of the pharmaceutical industry to the 23 lawmakers who sponsored or cosponsored the four versions of the bill (Higham and Bernstein 2017). The DEA and government officials argue, however, that the DEA has effective methods to curb inappropriate narcotic transactions. treatment options to treatment integrated into the broader healthcare system; a 2012 study found that most mental health patients are identified in the primary care system, and because primary care physicians often report difficulties in obtaining mental health care referrals for their patients, mental health care provided in a primary care setting could improve health outcomes (Kessler 2012). Consistent with this finding, a recent study on veterans’ health found that the US Department of Veterans Affairs (VA) Primary Care–Mental Health Integration services increased accessibility to mental health care for primary care VA clinic patients as used in place of non-primary-care-based mental health specialty visits—without increasing acute care use or costs (Leung et al. 2018). In the course of this shift toward integration into primary care, general practitioners have become far more involved in mental health care than in the past. By the early twentyfirst century, 22.8 percent of mental health patients were being treated solely by a general health medical professional, higher than the percentage seen by any type of specialist (Wang, Lane, and Olfson 2005). This trend, while indicative of better integration of mental health services with general medicine, may also reflect a shortage of specialized mental health professionals. A survey of general EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 176 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 177 practitioners found that 66.8 percent had difficulty obtaining a referral for their patients to any mental health specialist (Cunningham 2009), and another analysis detected unmet patient need for mental health professionals in 96 percent of all counties in the United States (Thomas et al. 2009). Evidence also indicates that the mental health services rendered by general practitioners are of lower quality than those provided by mental health professionals, with only 12.7 percent of general practitioner visits resulting in “treatments that exceeded a minimum threshold of adequacy,” compared with 48.3 percent of visits to specialists (Wang, Lane, and Olfson 2005). This need for increased numbers of mental health professionals may be exacerbated by a major legislative development in mental health care: the passage of federal and state mental health parity laws. On a national level, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 requires equal coverage in group health insurance plans for mental health and physical health benefits (Cunningham 2009). Several states followed with their own similar policies. Despite these policies, disparities in care between mental and physical health continue, as do disparities between Americans with mental health disorders and those without. The ACA was expected to expand coverage and thus diminish barriers to adequate mental health care. However, the issues mentioned, if left unexamined and unaddressed, will continue to prevent progress in mental health care delivery in the United States (Bartels, Gill, and Naslund 2015). W omen and C hildren According to the US Census Bureau (2018), in 2017, 50.8 percent of the US population was female, and nearly 23 percent of the population was aged 17 or younger. Both women and children face unique health issues that deserve policy attention, and maternity and childbirth present yet another set of concerns. Women Women’s health is an emerging field centered on health issues and concerns that disproportionately affect women. For instance, women tend to live longer, yet also report more physically and mentally unhealthy days each month, and have higher rates of chronic conditions in old age than men (MCHB, HRSA, and HHS 2013; Strobino, Grason, and Minkovitz 2002). Women—especially those who are poor—are less likely to meet minimum physical activity recommendations than men are. Women are also more likely than men to be obese and report more activity limitations (MCHB, HRSA, and HHS 2013; Strobino, Grason, and Minkovitz 2002). In 2009, 36.6 percent of female-headed households were classified as food-insecure, and 15 percent of all women experienced food insecurity—placing them at increased risk EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 177 11/21/18 10:55 AM 178 Introduction to Health Policy for health problems caused by poor nutrition (MCHB, HRSA, and HHS 2013; Strobino, Grason, and Minkovitz 2002). Of those adults who receive aid through the Supplemental Nutrition Assistance Program (SNAP), 64.4 percent were women (MCHB, HRSA, and HHS 2013; Strobino, Grason, and Minkovitz 2002). These factors, combined with disparities perpetuated by the limitations of women’s traditional roles as caregivers and by economic inequality, call for increased attention to women’s health issues. Children The health issues faced by children are continuing to rise. For example, chronic conditions in children have increased dramatically in the twenty-first century; in 2007, more than 7 percent of children had a chronic condition that limited their function to perform basic daily activities, as compared with 1.8 percent in 1960 (Perrin, Bloom, and Gortmaker 2007). High-prevalence chronic conditions among children now include obesity (affecting 18 percent of children and adolescents aged 18–25, as compared with 5 percent in the early 1970s), asthma (9 percent of children and adolescents, double the percentage for the 1980s), and attention deficit hyperactivity disorder (ADHD, affecting 6 percent of schoolage children), and poverty is associated with an increased risk for many chronic conditions (Perrin, Bloom, and Gortmaker 2007; Wijlaars, Gilbert, and Hardelid 2016). Particularly, conditions such as asthma and ADHD have increased at a disproportionately higher rate among children living in poverty (American Academy of Pediatrics 2016). As children become greater consumers of medical care, the quality of care they receive increases in importance. A medical record analysis conducted by Mangione-Smith, DeCristofaro, and Setodji (2007) shows that, on average, children seeking medical care received only 46.5 percent of the services recommended or prescribed by a healthcare provider—a reminder that merely expanding access to health services, a primary policy focus for many years, does “not deliver necessary services [and] will not result in optimal outcomes.” Maternity and Childbirth Pregnancy and childbirth can lead to both temporary and permanent health conditions, including maternal mortality (Misra and Grason 2006). Receiving proper prenatal care is essential for good neonatal health in the United States, but preventive care must be obtained early and continued throughout pregnancy. For example, folate, a substance that helps prevent adverse fetal outcomes such as spina bifida, must be present in adequate levels early on in pregnancy. Thus, women must be able to obtain adequate levels of this nutrient even before conception (Misra and Grason 2006). Considering that 42 percent of the births in the United States in 2008 were reported as unintended, ensuring this level of preventive care is difficult (MCHB, HRSA, and HHS 2010). EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 178 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 179 Women from racial or ethnic minorities receive prenatal care at lower rates than non-Hispanic white women do (MCHB, HRSA, and HHS 2010). In 2015, 6 percent of pregnant women in the United States received late or no prenatal care (Kids Count Data Center 2018). Pregnant women who received inadequate prenatal care, and lacked education related to the purpose of such care, experienced an increased risk of providing poor nutrition to their unborn baby. In turn, this practice may increase the risk of the child being diagnosed with obesity, asthma, or ADHD. Maternal cigarette smoking during pregnancy is among the most-documented risks for asthma, obesity, and ADHD in children. Alcohol use during pregnancy introduces serious risks as well (Perrin, Bloom, and Gortmaker 2007). Although considerable progress has been made in improving prenatal care, and thus the health of women and children, these gains have not been evenly distributed. Health disparities between women and children of different ethnic, racial, and socioeconomic groups still exist, and primary care for these groups has great potential for additional improvement. P eop le with D isabilities As the US population ages, more people will experience disabilities and need specialized care. The groundbreaking 1991 Institute of Medicine (IOM) report Disability in America and the follow-up 1997 IOM report Enabling America highlighted disability as a topic of public health action and scientific inquiry (IOM 1991, 1997). IOM predicted substantial growth in the disabled elderly population between 1997 and 2027 (IOM 1997). At the same time, the number of children and young adults facing disability is rising as survival odds increase for once-fatal birth and childhood conditions and as chronic conditions in the young become more common (Iezzoni 2011; Wijlaars, Gilbert, and Hardelid 2016). Combined, these trends have led to significant, increasing levels of disability in the United States. The World Health Organization estimated that the United States lost 41.372 million disability-adjusted life years (DALYs) in 2004 (McKenna et al. 2005). The DALY measure has been used since the mid-1990s to capture the true health burden caused by disability, combining measures of both the years of life lost to disabling conditions and the quality of life lost over the years spent living with a disability (McKenna et al. 2005). DALYs measure the number of life years lost to disability only for people living with disability, yet the effects of disability are also felt by those who care for the disabled and by society as a whole. In addition to the underlying issues of poor socioeconomic, educational, income, and employment outcomes, people with disabilities in the United States encounter a health system characterized by discrimination and barriers to accessing care. Although many years have passed since the Americans with Disabilities Act went into effect in 1990, “inaccessible facilities, equipment, and communication systems still compromise healthcare experiences for individuals with disabilities in the United States. . . . The barriers that disabled patients confront represent quality problems and also heighten patients’ sense of stigmatization, disenfranchisement, and demoralization” (Kirschner, Breslin, and Iezzoni 2007). disability-adjusted life years (DALYs) A measure of the loss of healthy life. The DALY measurement is intended to capture the economic, social, and functional realities that a person with a disability faces and the corresponding loss in health status and quality of life. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 179 11/21/18 10:55 AM 180 Introduction to Health Policy Although more large-scale research needs to be conducted in this area, studies that have been done so far suggest that far lower rates of preventive care are provided to people with disabilities. According to Iezzoni (2011), only half of women with a severe disability had received a recommended mammogram or Pap test, compared with almost three-quarters of women without any disability who had received a mammogram and more than 80 percent of women without any disability who had received a Pap test. Approximately half of Americans with disabilities are eligible for governmental assistance, such as Medicaid or Medicare, and many more have private coverage. State and federal government spending on individuals with disabilities totaled more than $400 billion in 2008, and patients with disabilities accounted, on average, for almost three times more healthcare expenditures each year than for patients without disabilities (Kirschner, Breslin, and Iezzoni 2007; Livermore, Stapleton, and O’Toole 2011). These expenditures were predicted to only rise, especially after the ACA expanded Medicaid to cover a greater number of Americans with disabilities and prohibited refusal of insurance due to preexisting health conditions in the private market. T he H omeless Homeless people in the United States are among the most marginalized groups in society; however, their health needs are not marginal. A study published in the first decade of the twenty-first century revealed that up to 3.5 million people each year experience homelessness in the United States, and 700,000 people are classified as homeless on any given night; furthermore, 7 percent of US residents will experience homelessness at least once in their lives (Reid, Vittinghoff, and Kushel 2008). Additionally, many more Americans will face housing instability, a precarious position that, while less drastic than homelessness, predisposes them to several risk factors that can lead to worse health outcomes (Reid, Vittinghoff, and Kushel 2008). Homeless and housing-unstable people are subject to much higher resource competition than most of the general population, and health issues that others would consider absolutely critical may be sidelined by the homeless in favor of more basic needs such as food and shelter (Kidder et al. 2007). As a result of reduced healthcare, the homeless experience significantly higher rates of morbidity and mortality, greatly reduced access to healthcare (especially preventive services), and, therefore, much higher rates of hospitalization and self-reported poor health than the broader population does (Baggett et al. 2010; Kidder et al. 2007; White et al. 2018). Several studies have attempted to identify factors that increase ambulatory and preventive care utilization among the homeless. First and foremost, housing situations with greater stability have been shown to increase the amount of healthcare received, especially ambulatory care (Kushel, Vittinghoff, and Haas 2001). The Housing First program was developed in response to these findings, and it realized positive results in reducing ED visits and hospitalizations among the chronically homeless population in several cities, by providing necessary, no-strings-attached housing (Kertesz and Weiner 2009). A recent EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 180 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 181 study revealed that becoming housed is a key facilitator of reduced ED utilization and that efforts to provide housing for homeless adults may also greatly decrease ED use (Moore and Rosenheck 2017). Another factor, the lack of insurance among the homeless population, was analyzed by Reid, Vittinghoff, and Kushel (2008), who suggested that health outcomes would improve with better insurance options or with options to receive regular care. An earlier study found that health services utilization by the homeless did not increase greatly with either housing stability or insurance coverage alone and, instead, was associated with better community ties and social support. Increased community support was, in turn, correlated with housing stability (Stein et al. 2000). Overall, homelessness in the United States is a complex and poorly understood issue. Yet ignoring the health problems faced by homeless or housing-insecure people will only exacerbate an already difficult societal situation. Many innovative and comprehensive approaches to improving the health outcomes of the homeless are being developed. The Boston Health Care for the Homeless program, a leading outreach program, works to integrate care across the medical spectrum and to create housing situations that provide continuous services and preventive care (O’Connell et al. 2009). The Homeless Outreach and Proactive Engagement initiative launched in the San Fernando Valley around Los Angeles in 2016 (Walton 2016). The program connects Los Angeles Police Department officers with the city’s Sanitation Department, mayor’s office, city attorney’s office, and the Los Angeles Homeless Services Authority to identify encampments for homeless people and help them transition into permanent housing. P eop le with HIV/AIDS In the relatively short time since the disease was recognized, AIDS has dramatically changed the lives of millions of people, their communities, and the US healthcare system (see the Learning Point box titled “HIV/AIDS in the United States”). Although there have been marked improvements in the prevention and care of HIV and AIDS, more than 35,000 people contract the virus each year (CDC 2018c). At the end of 2015, about 1.1 million people in the United States were living with a diagnosed HIV infection (CDC 2018c). A major factor in the continued high number of transmissions is that 14 to 15 percent of the people infected with HIV do not know that they are HIV-positive (CDC 2018c; KFF 2018b). Impact on HIV/AIDS Subpopulations Current health disparities in the United States are also reflected in the trends in AIDS infection. Men who have sex with other men (a category referred to as MSM) constitute only 2 percent of the US population yet accounted for 68 percent of new HIV infections in 2015 (KFF 2018b). Although the proportion of women who are HIV-positive or have AIDS is EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 181 11/21/18 10:55 AM 182 Introduction to Health Policy significantly lower than that of men, the disease has become more prevalent in the female population over time, and research shows that more barriers to care exist for women than for men (KFF 2014). Minorities also carry a disproportionate share of HIV is the abbreviation for human immunodeficiency virus; the that health burden; African Americans accounted term AIDS is derived from acquired immune deficiency syndrome. for 43 percent of HIV diagnoses although they HIV is a retrovirus that infects the human body and, over time, comprise only 12 percent of the US population destroys the immune system, leading to AIDS. A person who has (KFF 2018a). The HIV diagnosis rate for African AIDS is typically in the final stages of HIV, after the immune system becomes unable to defend itself. HIV is transmitted by having sex Americans in 2016 was double the rate for Latiwithout a condom; by sharing syringes, needles, or drug works; and nos and eight times higher than for whites (KFF through pregnancy, childbearing, or breast-feeding. 2018a). The CDC identified the first AIDS cases in the United States in As with other health conditions and dis1981. Since then, 1.7 million US residents have become infected eases, socioeconomic factors also influence the rate with HIV, and more than 700,000 have died from AIDS, leaving of HIV acquisition. Lower SES is associated with more than 1.1 million people in the United States living with HIV/ higher AIDS mortality, and infection prevalence is AIDS today (CDC 2018c, 2018d; KFF 2018b). higher among Americans with less education, lower incomes, and higher unemployment rates (KFF 2018a; Rubin, Colen, and Link 2010). Even as the demographic profiles of HIV-infected residents have evolved, those living with AIDS still face discrimination, reduced access to care, and other disparities that greatly affect health outcomes. LEARNING POINT HIV/AIDS in the United States Implications of Advances in Treatment People infected with HIV/AIDS fare better today than they did at the beginning of the twenty-first century, thanks to the discovery and widespread use of new treatment options, particularly antiretroviral drugs used in combinations of multiple drug classes. These therapies are only effective, however, if administered early and continuously over the course of the infection. For those patients who have access to expert medical care and powerful drug “cocktails,” these advances “have transformed HIV/AIDS from a terminal illness to a chronic disease,” whereas those with limited means may still face a bleak outcome (Lubinski et al. 2009). The barriers that inhibit HIV-positive people from accessing lifesaving medications are significant; the most important among them is the lifetime health costs associated with the diagnosis. In 2006, the total costs of treating HIV and AIDS per person were estimated to be more than $385,000, of which 73 percent was spent on antiretroviral medications (Schackman et al. 2006). The estimate of lifetime HIV treatment costs was $379,668 (Schackman et al. 2006). Assuming that an individual has access to these treatments, by 2006, the average patient’s life expectancy increased to 24.2 years following diagnosis with HIV or AIDS EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 182 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 183 (as compared with the average expected 6.8 years in 1998), but this greatly expanded life expectancy accounts for much of the rise in treatment costs (Schackman et al. 2006). As discussed next, the federal government pays a substantial portion of these expenses. Funding In fiscal year 2017, the US government spent $19.6 billion on HIV-related care and treatment (KFF 2017b). In 2014, Medicare covered about 120,000 people infected with HIV, nearly triple the 42,520 covered in 1997 (KFF 2016b). Medicaid covered 242,000 patients in 2011, a 14 percent increase compared with 212,900 in 2007 (KFF 2016a). The federal government spent nearly $5.8 billion in 2017 for Medicaid HIV activities (KFF 2017b), an amount which is supplemented by state funding. Medicare is the largest federal funder of HIV care and treatment in the United States, followed by Medicaid (KFF 2017b). Additional funding is provided by the Ryan White HIV/AIDS Program, a federal initiative named after a 13-year-old hemophiliac boy who was diagnosed with AIDS after a blood transfusion in 1984. White gained national fame when he fought for the right to return to school, having been barred from attending because of AIDS (HRSA 2016). The program aims to assist HIV patients who lack sufficient means to obtain treatment by disbursing discretionary funds provided by the US Congress to states, cities, not-for-profit organizations, and healthcare providers. By 2016, this program had become the third-largest source of federal funding for HIV care in the United States, providing about $2.3 billion that year (KFF 2017a, 2017b). President Trump’s budget request for fiscal year 2018 called for decreased funding of HIV/AIDS programs (KFF 2017b). Policy Initiatives Two major initiatives in US healthcare policy prior to 2017 showed the potential to lead to improved health outcomes for people with HIV/AIDS. First, President Barack Obama’s 2010 National AIDS Strategy for the United States, hailed as “the most comprehensive federal response to the domestic HIV epidemic to date,” set three targeted goals for the country to achieve over the next ten years: (1) reduce new HIV infections, (2) increase access to care and improve outcomes, and (3) reduce health disparities for HIV/AIDS (Yehia and Frank 2011). In 2015, an updated National HIV/AIDS Strategy was released, still with a view toward 2020, which added a fourth goal—to achieve a more coordinated national response to the HIV epidemic ( 2017; White House 2015). Second, accompanying this greater focus on HIV health issues were mandates set forth in the ACA. The ACA raised the income level for Medicaid eligibility and outlawed the denial of coverage due to preexisting health conditions, both of which helped HIV/ AIDS patients continue to receive lifesaving healthcare (Dawson and Cates 2017). EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 183 11/21/18 10:55 AM 184 Introduction to Health Policy Under President Trump, the federal government’s willingness to address health disparities for people with HIV/AIDS has appeared uncertain. In addition to his request for reduced funding of HIV/AIDS programs (KFF 2017b), there were indications that Trump’s desired changes in federal healthcare programs overall could result in a reduction of coverage through Medicaid and elimination of ACA protections for individuals with preexisting health conditions (Dawson and Cates 2017; Kessler and Kelly 2018; Luhby 2018), both of which would have negative repercussions for people with HIV/AIDS. Key Points ➤➤ Vulnerable subpopulations, such as racial and ethnic minorities, the uninsured, and those with low SES, typically experience a convergence of multiple health risk factors and, consequently, exhibit poorer health status than do other subpopulations. ➤➤ For the elderly, concerns about primary care and health policy broadly revolve around containing costs of care, reforming the health system to better serve a growing elderly population, and increasing their quality of life. ➤➤ The US primary care system will need to be fundamentally overhauled to accommodate the increase in the number of patients with chronic diseases, requiring new ideas on how best to provide high-quality care and meet the needs of this growing population. ➤➤ Although half of all Americans are affected by at least one mental disorder in their lifetime, mental health care in the United States has traditionally been marginalized. Case Study Questions Case Study 1 Based on your own research on health centers, answer the following questions: 1. How would you describe the efficacy of health centers? What are their roles in improving access to care, quality of care, and health outcomes for vulnerable populations? 2. How can health centers cope with the challenges they face? Case Study 2 Based on your own research on chronic illness, answer the following questions: 1. What are some innovative models of care delivery that target people living with chronic illnesses? How do these models differ from the status quo? EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 184 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 2. 185 The care team approach is often used to provide community-based primary care, particularly to people with chronic illnesses. What is the composition of the team? Why are these individuals essential members of the team? 3. How can low-cost technology be used in community-based primary care for people with chronic illnesses? Provide illustrative examples. For Discussion 1. Why should health policy focus on vulnerable populations? 2. What health policy issues do racial and ethnic minorities face? Cite examples of programs to eliminate racial and ethnic disparities in healthcare. 3. What health policy issues do uninsured US residents face? Cite examples of programs to eliminate insurance disparities. 4. What is socioeconomic status (SES)? 5. What health policy issues do people with low SES face? Cite examples of programs to eliminate SES disparities. 6. List the health policy issues for each of the following subpopulations: a. The elderly b. People with chronic illness c. People with mental illness d. Women and children e. People with disabilities f. The homeless g. People with HIV/AIDS References Ailawadhi, S., R. D. Frank, P. Advani, A. Swaika, M. Temkit, R. Menghani, M. Sharma, et al. 2017. “Racial Disparity in Utilization of Therapeutic Modalities Among Multiple Myeloma Patients: A SEER-Medicare Analysis.” Cancer Medicine 6 (12): 2876–85. Akinlotan, M., J. N. Bolin, J. Helduser, C. Ojinnaka, A. Lichorad, and D. McClellan. 2017. “Cervical Cancer Screening Barriers and Risk Factor Knowledge Among Uninsured Women.” Journal of Community Health 42 (4): 770–78. American Academy of Pediatrics. 2016. “Percentage of US Children Who Have Chronic Health Conditions on the Rise.” ScienceDaily. Published April 30. releases/2016/04/160430100357.htm. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 185 11/21/18 10:55 AM 186 Introduction to Health Policy American Psychological Association (APA). 2005. “Low Socioeconomic Status Is a Risk Factor for Mental Illness, According to a Statewide Examination of Psychiatric Hospitalizations.” Published March 6. Andersen, R. M. 1995. “Revisiting the Behavioral Model and Access to Medical Care: Does It Matter?” Journal of Health and Social Behavior 36 (1): 1–10. Baggett, T. P., J. J. O’Connell, D. E. Singer, and N. A. Rigotti. 2010. “The Unmet Health Care Needs of Homeless Adults: A National Study.” American Journal of Public Health 100: 1326–33. Barile, J. P., S. A. Mitchell, W. W. Thompson, M. M. Zack, B. B. Reeve, D. Cella, and A. W. Smith. 2015. “Patterns of Chronic Conditions and Their Associations with Behaviors and Quality of Life, 2010.” Preventing Chronic Disease 12: E222. Bartels, S. J., L. Gill, and J. A. Naslund. 2015. “The Affordable Care Act, Accountable Care Organizations, and Mental Health Care for Older Adults: Implications and Opportunities.” Harvard Review of Psychiatry 23 (5): 304–19. Beaton, T. 2018. “Uninsured Rate Among Working Adults Rises to 15.5% in 2018.” HealthPayer Intelligence. Published May 1. uninsured-rate-among-working-adults-rises-to-15.5-in-2018. Benitez, J. A., L. Creel, and J. Jennings. 2016. “Kentucky’s Medicaid Expansion Showing Early Promise on Coverage and Access to Care.” Health Affairs 35 (3): 528–34. Bodenheimer, T., E. Chen, and H. D. Bennett. 2009. “Confronting the Growing Burden of Chronic Disease: Can the US Health Care Workforce Do the Job?” Health Affairs 28 (1): 64–74. Bowman, A., and R. Kearney. 1988. “Dimensions of State Government Capability.” Western Political Quarterly 41 (2): 341–62. Brace, P. 1993. State Governments and Economic Performance. Baltimore, MD: Johns Hopkins University Press. Brown, E. E., S. A. Charles, N. A. Ponce, J. Yoon, J. Cummings, and T. Rice. 2007. “The State of Health Insurance in California: Findings from the 2005 California Health Interview Survey.” UCLA Center for Health Policy Research. Published July 1. search/pages/detail.aspx?PubID=219. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 186 11/21/18 10:55 AM Chapter 6: Health Policy for Diverse Populations 187 California Endowment. 2018. “What We Are Learning from Building Healthy Communities.” Published June 12. Centers for Disease Control and Prevention (CDC). 2018a. “Chronic Disease Prevention and Health Promotion: Programs.” Updated June 12. ———. 2018b. “Colorectal Cancer Control Program (CRCCP).” Updated June 12. crccp/index.htm. ———. 2018c. “HIV/AIDS: Basic Statistics.” Updated June 26. ———. 2018d. “HIV Among Gay and Bisexual Men.” Updated February 27. msm/index.html. ———. 2018e. “National Diabetes Prevention Program.” Updated January 16. prevention/index.html. ———. 2018f. “Paul Coverdell National Acute Stroke Program.” Updated April 10. dhdsp/programs/stroke_registry.htm. ———. 2018g. “Sodium Reduction in Communities Program (SRCP).” Updated May 9. dhdsp/programs/sodium_reduction.htm. ———. 2018h. “Tips from Former Smokers.” Updated May 23. tips/index.html. ———. 2018i. “Understanding the Epidemic.” Accessed July 5. ———. 2017a. “American Indians/Alaska Natives and Tobacco Use.” Updated September 18. www. ———. 2017b. “Diagnoses of HIV Infection in the United States and Dependent Areas, 2016.” HIV Surveillance Report 2016, vol. 28. Published November. surveillance/cdc-hiv-surveillance-report-2016-vol-28.pdf. ———. 2017c. “National Implementation and Dissemination for Chronic Disease Prevention: Awardees.” Updated April 28. dissemination/implementation.html. EBSCOhost – printed on 4/24/2022 11:33 PM via TRIDENT UNIVERSITY. All use subject to 00_Shi (2374) Book.indb 187 11/21/18 10:55 AM 188 Introduction to Health Policy ———. 2017d. “National Survey of Children’s Health.” Updated September 6. slaits/nsch.htm. ———. 2017e. “Racial and Ethnic Approaches to Community Health (REACH).” Updated November 13. ———. 2015a. Paul Coverdell National Acute Stroke Registry Program: Summary Report, 2007–2012. Accessed June 11, 2018. ———. 2015b. “REACH Program Impact.” Updated December 18. state-local-programs/reach/program_impact/index.htm. ———. 2014. Increasing Population-Based Breast and Cervical Cancer Screenings: An Action Guide to Facilitate Evidence-Based Strategies. 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J. 2009. “Beyond Parity: Primary Care Physicians’ Perspectives on Access to Mental Health Care.” Health Affairs 28 (3): w490–w5…

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