Variations in Approaches to Care

Choose a specific culture or ethnicity of an immigrant or refugee population.  

• Analyze their cultural and social norms.  
• Discuss how they experience the healthcare system in America.  
• Include an evaluation of how both the community and market-oriented approaches to health care, as highlighted in Chapter 10 of your text, can assist your chosen culture in getting the care they need.  Provide an analysis of a multidisciplinary approach that can be used to deliver the best care to your population.
• Discuss a program in your community (Houston, TX), or the nearest large community, that serves immigrants and refugees.  Are the services truly accessible to a wide population of immigrants and refugees?  Identify one approach which could improve accessibility, cost, or the quality of care for the population.

Your initial contribution should be 250 to 300 words in length. Your research and claims must be supported by your course text and at least one other scholarly source. Use proper APA formatting for in-text citations and references as outlined in the Ashford Writing Center.

Chapter 10

Effective program planning must include communication between policy makers and the individuals who make up the vulnerable populations meant to benefit from a particular program.

Policy makers and program administrators must realize that there is often a lack of communication between those creating the programs aimed at vulnerable populations and the individuals who make up those populations. Programs won’t be useful if they do not directly address the needs of the vulnerable in ways that are accessible to the vulnerable. The best way to achieve useful program design or reform is to collaborate with the population you are trying to serve. Program designers and medical practitioners can learn a lot about the needs of those they are serving simply by asking them. By having conversations with patients and community leaders, and even by asking patients and patrons to complete surveys, policy makers, program administrators, and practitioners gain insight into the needs and wants of the vulnerable populace. Only through a coordinated, collaborative effort to address the serious issues confronting vulnerable populations can the health and wellness of said population increase to resemble those who are not classified as vulnerable.

Critical Thinking

Communication can take many different forms. Communication can include everything from formal town hall meetings to informal conversations between two people. Communication does not necessarily even need to involve talking. Describe three special populations and specify a form of communication that could be used to gather information on each group.

10.1 The Community-Oriented Approach

Several social and interpersonal factors influence a person’s sense of well-being.

The key to a community-oriented approach to health policy is remembering that a person’s well-being is greatly affected by family, friends, and other social factors. In other words, discharged patients will fare better or worse depending on their individual support networks. On a larger scale, this means that health policy needs to look beyond the microlevel and consider the macrolevel factors that affect the populations being served. There are five levels of focus in community engagement: (a) the individual, (b) the social and network systems, (c) the influences of organizations to bring change, (d) the community collaborative relationships, and (e) the state and federal policies and regulations. Concepts that summarize social ecology theories relating to the efforts of community engagement in addressing this need are as follows:

health status, emotional well-being, and social cohesion, which are influenced by the physical, social, and cultural status of the individual or his or her environment different effects of the individual’s health, which includes perception and financial resources available the influence by others on the individual or group

Community-oriented health policy works to improve health outcomes by making changes on a community level. To do this, community members should be consulted about the needs of their communities and the daily risks encountered there. This goes beyond patients to include consulting those who work directly with patients, and consulting community leaders and organizers on what issues they consider important in the identified community. Once policy makers understand what the contributing factors are, they can begin to form policy to address those factors. Problems with participation often trouble these efforts. Instead of creating focus groups, policy makers can work with physicians to build relationships with patients that encourage discourse and disclosure. Improving the physician-patient relationship not only offers a way to learn the needs of the patients but is in itself an improvement of patient care.

Cross-Disciplinary Solutions

Inadequate housing, high poverty levels, and low education levels can all contribute to ill health and poor health outcomes. Housing issues may include exposed asbestos that leads to lung infections, poverty reduces accessibility to health care, and low education levels contribute to poor lifestyle habits. Though they may appear to be outside the realm of health policy, the effects these and other factors discussed in this book have on health is considerable. As such, community-oriented health policy must address all such factors.

Contributing factors to poor health can include poverty, substandard housing, and low education levels.

The community-oriented approach involves cross-disciplinary planning and programming in order to address individual patient needs as well as to address the community factors that contribute to vulnerability. Health policy that takes a community-based approach should bring together agencies from many different specialties and fields. Health care providers, care management teams, social services officers, and community-based resource programs can be brought together to design programs and policies that improve patients’ chances of positive treatment outcomes. This can be accomplished through an ideology of comprehensive collaboration and sharing of pertinent health information across what had previously been silos or territories where information was held close to the vest.

An example of one such program would be a hospital that discharges high-risk youth with a referral to a social worker at a local youth center. The social worker could encourage the youth to participate in the activities offered at the youth center, thereby improving the youth’s social capital and ultimately improving his or her chance of positive outcomes in life as well as health. This example illustrates the care continuum from treatment (hospitalization for illness) to long-term services (youth center involvement) and addresses some needs of the vulnerable youth population. Programs at the youth center should be designed to address the needs of the people it serves. One of the best sources for information about those needs is the people being served and, in this case, adults from the relevant community.

Critical Thinking

The community-oriented approach involves cross-disciplinary planning and programming in order to address individual patient needs as well as to address the community factors that contribute to vulnerability. What this means from the perspective of the individual is that discharged patients will fare better or worse depending on their personal support networks. On the other side of the coin, how does improved patient health benefit the greater community? Do you believe the community has a vested interest in ensuring improvements in health at the level of the individual? If so, why?

10.2 The Market-Oriented Approach

As discussed in earlier chapters, the United States’ economy is built on the concept of the ideal free market, unlike the single-payer systems found in countries such as Canada and Great Britain. In other words, the U.S. health care system is market-oriented, meaning it relies on competition between care providers to strive for quality and control cost. However, it must also meet the needs of health care consumers, who may not be knowledgeable enough to know what they need because of uncertainty of health and outcomes, as well as a sense that asking questions means questioning doctors’ authority.

One disadvantage of a market-oriented health care system is that because health care is often a necessity, people have little opportunity to shop around for the best service and prices. This issue is particularly pronounced in economically depressed areas where access to health care is limited. To address this, America’s health care delivery system is evolving and may have never been so prominent an issue as during the lengthy debates over the Patient Protection and Affordable Care Act of 2010 (PPACA). Even if the health care system is part of the free market economy, governments have an interest in ensuring affordable access to all citizens for two reasons: (a) Federal and state governments fund public payer insurance plans, and (b) an unhealthy population costs the country money. As such, the way Americans finance health care, both now and in the future, is at the forefront of the debate over health care reform.

Changing the Health Care System

One of the many goals of health care reform is to achieve near-universal coverage for all U.S. citizens and a safety net for accessing health care for all people. In an attempt to do this while managing costs, state and federal governments have tried implementing incentive plans to help employers cover the cost of health insurance with tax cuts and other rewards. Other attempts have disincentivized employers from not offering health insurance to employees by fining certain businesses that don’t have employee health coverage. Business owners often rail against both methods, arguing that it should not be the responsibility of employers to ensure universal care coverage.

Health care reform strives to achieve adequate access to and coverage of health care for all people, regardless of citizenship status.

Program plans should be evaluated based on these coverage concerns, as well as how they close the coverage gaps from public to private payers by equalizing the provider reimbursement structure and the use of large risk pools to determine pricing. Plan coverage and need and effectiveness norms and definitions that dictate what procedures and services are covered at what levels for which conditions should consider the care continuum model and provide coverage for services across the entire continuum. Plans that use a community rating, which is broad population grouping for computing risks and premiums, allow for more coverage for more people at less cost. The alternative, experience rating, uses a small group of eligible people and encourages denying coverage to the most vulnerable, as they are most likely to cost the insurer money. Some plans use carve outs to cover high-risk patients and pay for some patients’ disproportionately high costs. The difficulty with these plans comes when trying to find a fair way to cover patients’ needs and offer fair reimbursement for service providers without driving up premiums.

The use of insurance premiums as a means of paying for health care is problematic. Premiums fail to consider varying economic abilities of enrollees to pay premiums and service co-pays. Under the current methodology, health insurance premiums do little to minimize financial barriers to health care, especially in ways that seem tangible to the consumer. As health insurance premiums rise, more and more Americans are allowing their coverage to lapse. Many have also seen their office visit and pharmacy co-pays increase simultaneously. The monthly costs associated with maintaining insurance coverage often seem more immediate than the risk of a catastrophic health event. People living on fixed incomes and those living in poverty have been found to be the most affected by increasing insurance premiums and co-pay costs. Payer systems that include progressive payment scales based on financial need and ability provide more equitable financial access to health care. In fact, cost sharing has been found to limit access to preventive care more than limiting the need for treatment.

While patients are struggling to afford health care coverage and services, providers are struggling to stay open or to make profits. The free market system encourages all service providers in every field to strive for profitability, often to the point of diminishing services to raise profit margins, as in the case of physician practices limiting the number of Medicaid patients they will treat because Medicaid often does not reimburse at as high a level as private payer insurance. Even health care providers who still focus on serving patients find it difficult to run a facility when insurance companies and public payers are constantly negotiating prices. Many among America’s most vulnerable who use public payer health coverage have experienced a significantly diminished number of care providers who will accept public payer coverage. This is because many states have lowered the physician reimbursement rates well below what private payers have negotiated. Under these terms, it is in the providers’ best interests to limit the number of public payer–enrolled patients and maximize the number of private payer–enrolled patients to increase profits. The American public payer system relies on micro-oriented means to limiting reimbursement. As America struggles to solve problems with the medical care delivery system, policy makers should consider the macro-oriented means used to limit reimbursements in other countries that boast more universal coverage and accessibility.

Maintaining High-Quality Care

Physician reimbursement isn’t the only area where service costs are rising. It is generally believed that it is not patients but rather physicians who create high demand for expensive procedures and services. Because they are responsible for writing the orders, physicians are also consumers of health care services. Cost containment includes managing increasing physician fees and also minimizing the number of expensive services called for by physicians. Policy makers may find it difficult to balance cost containment without disincentivizing the necessary treatments of patients on Medicare and Medicaid.

Health maintenance organizations (HMOs) are a type of insurer that uses a prepaid system to arrange care for covered patients. Because they make prepaid agreements with providers, HMOs are often a less expensive insurance option. Prepaying helps with cost containment by insuring against rising costs for a specified amount of time, because the services are paid for before they are rendered. Because HMOs have a reasonable idea of their revenue for the year (premium dollars per member) and how many members they have to serve, prepaying allows them to keep costs down in order to make profits. Though consumers of HMO plans have reported satisfaction with the premiums and co-pay costs associated with HMOs, they have reported less satisfaction with the standard of care received. Annual numbers on HMOs usually show that they lead in preventive care and reduced number and lengths of hospital stays. Whether that is because HMO patients use more preventive care or because providers are less likely to recommend expensive therapies for HMO patients is unclear.

The PPACA attempts to create universal coverage balanced with affordability. The law includes a mandate that every person must have health insurance by 2014 or pay penalties. Penalty monies should be used to help cover the costs associated with uninsured patients seeking emergency medical attention. Such cases drive up the cost of health care and health insurance for every person in the United States. With the cost of health insurance climbing, universal coverage can be achieved only if premiums are affordable for all people. In an attempt to harness the power of the free market and increase health insurance coverage across the nation, the PPACA created the American Health Benefit Exchanges (Henry J. Kaiser Foundation, 2010c). These marketplaces will be administrated by state governments and will provide standardization and competition in the health insurance market. The point is to make it both more affordable and easier for individuals to purchase their own health insurance instead of relying on employers and government programs. This is a market-oriented approach that relies on the free market ideal. At the time this book was written, the insurance exchanges were not yet open; it will be many years before their overall effectiveness can be measured in terms of efficiency, openness of the marketplace, and cost containment.

Critical Thinking

The text says that government should be highly interested in solving the health care crisis because an unhealthy population costs the country money. If individuals pay for their own health care, how does an unhealthy population cost the country money?

10.3 Improving Accessibility, Cost, and Quality

Taking a community-oriented approach to health care policy means including community members in discussions of change and in the decision-making process. This approach also recognizes that changes need to be made in the affected communities, not only in insurance and medical care provider settings. Increasing social status, social capital, and human capital also works to improve access, cost, and quality of health care received by individual patients.

Salary and employment benefits are just one area in which minorities and females receive less than their Caucasian male counterparts.

Minorities and females generally make less money and receive fewer employment benefits than do Caucasian males. Additionally, many females, children, and the elderly find themselves lacking social power in relation to males—Caucasian males in particular. Policy changes that work to minimize vulnerability should focus on changing the social status differences between these groups, like improving housing conditions and attracting businesses to create jobs in poor urban areas. Improving the ability of minorities and women to hold higher-paying jobs by improving educational opportunities is an ongoing challenge. Many low-income communities lose their best educated and most community-minded inhabitants to areas with more economic opportunities. Public policy that incentivizes businesses to locate in low-income areas in order to change a region’s economic viability improves the lives of all members of the community as more females and minorities find more opportunities within these companies.

As public policy is often lacking in improving social status for America’s most vulnerable, many minority groups have found power through grassroots social movements, which are community changes that begin with the people. The Women’s Suffrage movement is an example of a grassroots movement that affected public policy change in favor of the group who initiated it. The Women’s Suffrage movement in the United States caused the addition of the Nineteenth Amendment to the U.S. Constitution, which gives all women the same eligibility and right to vote that were previously only enjoyed by men. Similarly, the Civil Rights movement improved the social status of minorities by outlawing racial segregation and discrimination. The Occupy Wall Street of 2012 movement offers an example of a contemporary social movement that worked to raise the social status of all Americans who cannot boast large amounts of wealth. Policy makers can learn from these grassroots movements and use that information to improve social status and thereby health care access for America’s most vulnerable populations.

Policy Changes to Improve Social Capital

Better Community Based Care

Social capital is also linked to health care cost, quality, and access. Policies are needed that respond to the changing American family. Increasing numbers of households have only one parent or two parents of the same gender. Legal marriage is being replaced for many couples with cohabitation, sometimes called mingling—living with a sexual partner without getting married, often still having children together. For some groups, such as same-gender couples, public policy has focused more on restricting social capital than on improving it, with states making state constitution amendments that ban marriage between people of the same gender.

Public policy does best when it focuses on improving social capital rather than diminishing it. Strengthening family units builds stronger communities. But social capital doesn’t end at the front door. Social capital extends well into the community and includes all the people that make up a person’s support network, whether extended family, friends, or neighbors. Public policy that works to strengthen families and communities through improved family medical leave, parental leave, improved access to child care services, and improved access to caregiver resources makes it easier for individuals to contribute to their communities. Policy investments in social capital double as investments in access to health care, as social capital is a major factor in overall health and access to care. As with efforts to improve social status, efforts to improve social capital are most successful when community residents are actively involved in identifying the needs present in the community and in program development. Not only does this involvement offer insight that program developers may otherwise lack, but involving community members in the development process also helps energize the community to use the program once it is established.

Social capital levels are directly tied to investment in human capital. Strong family ties help keep children in school and help parents maintain employment. Multi-adult households have more working power to contribute to the household income, and increased income opens doors to health care access as well as education and other opportunities.

Policy Changes to Improve Human Capital

Public policy focusing on investing in the growth of human capital is lacking. By nature, community-oriented policies support programs and institutions that provide for growing human capital. Early childhood education programs are an example of school-based investments in human capital. These programs, like Head Start, have been found to greatly improve the chances of students continuing through high school by improving early literacy scores and providing access to other resources, including some health care services. Basing family resource centers and clinics in schools increases access to these resources and improves the human capital of the entire family. Simply increasing funding for public education works to narrow the gaps in education available in different community settings. Programs that improve the education received at public schools in economically depressed areas invest in the human capital of the students, as better education provides for better job opportunities later in life.

Public policy is needed to focus on investing in the growth of human capital. Early childhood education programs like Head Start are examples of school-based investments in human capital and offer educational, health care, and nutritional resources.

Better opportunities are key to building human capital on an individual level. However, many American families find that it is increasingly difficult to raise a family on one income and that the salaries commanded by high school diplomas are no longer enough to lift a family out of poverty. Economic development partnerships—like those in which state and local governments offer business incentives in terms of tax breaks and even investment cash to businesses willing to locate within their geographic regions—can help improve the overall economy of an area and provide more opportunities for higher income. Such partnerships are often forged between city governments and businesses, but these partnerships do not prosper if they aren’t supported by the community. Policy makers should invite the active participation of community residents and leaders to make sure that community interests are properly represented when such partnerships are formed.

Policy and program recommendations for improving human capital include encouraging low-income housing development by the private sector, as opposed to low-income housing being the sole responsibility of government. In this way, local businesses can grow while providing for a community need. Similarly, improving access to supportive housing for people experiencing homelessness, people diagnosed with HIV/AIDS, the chronically ill and disabled, refugees, and others in need creates a safety net for these individuals that enables them to increase their own human capital by holding jobs and accessing other resources.

Paradigm shifts are also still needed in order to create true equality between Caucasian men, minorities, and women in the workplace. The minimum wage is reviewed on an ongoing basis by state and national governments. Raising the minimum wage usually meets with resistance, and has both positive and negative economic ramifications. Other economically based changes that would improve human capital for America’s most vulnerable include improving enforcement of child support payments and expanding the earned income tax credit for families.

Critical Thinking

When communities invest in the growth of human capital, they provide avenues to elevate social status and social capital for not just the very poor, but the entire community. How does increasing social status, social capital, and human capital increase the benefits to special populations? How can helping one or two special populations in a community lead to the betterment of the community as a whole?

Case Study: Changes in Health Care as a Result of Gender Neutrality

How long does a woman normally stay in a hospital after giving birth to a child?

In 1980, the average stay was 3.8 days, according to the Centers for Disease Control and Prevention (CDC) (2010c). This average dropped to 2.1 days in 1995, but rose again to 2.4 days in 1997. The Organization for Economic Cooperation and Development (OECD) tracks the same data and reported that in 2010, the average stay was again at 2.1 days, after dipping to 1.9 for much of the latter 2000s (Organization for Economic Cooperation and Development [OECD], 2011). Given the historically short duration of the average hospital stay for pregnant women, it may be difficult to imagine a woman giving birth and then staying in the hospital for over a month. But that’s just what happened to a woman named Wendy during World War II.

Wendy checked herself in to the hospital with symptoms of childbirth and went through 16 hours of labor. Her son, Rob, was born on a bright Monday morning but would not see the outside world until he was a month old because Rob’s father Harold, who was fighting in the South Pacific at the time, was not able to check Wendy and Rob out of the hospital. The law of the land during that period stated that the father, or a male relative, had to check a new mother out of the hospital. A frantic search for Harold’s brother began, but the brother had just started boot camp in Florida, and the Army did not release him until after the four-week training process had concluded. After that, Harold’s brother drove from Florida to the hospital in Kentucky and signed the papers releasing Wendy and Rob from the hospital.

Could this happen today? Of course not. The current laws and public policies related to health and health choices have changed to such a degree that women’s rights and the rights of other groups have evolved and been established to empower them to make decisions, both medical and legal, for themselves.