Required Resources Required Text 1. Burkholder, D. M., & Nash, N. B. (2013). Special populations in health care (https://ashford.instructure.com/courses/28801/external_tools/retrieve? display=borderless&url=https%3A%2F%2Fcontent.ashford.edu%2Flti%3Fbookcode%3DAUHCA430.1 3.3) [Electronic version]. Retrieved from https://content.ashford.edu/ ◦ Chapter 5: Paying for Health Care ◾ This chapter explores funding of health care for vulnerable people. ◦ Chapter 6: Accessing Health Care ◾ This chapter delves into the barriers in accessing health care. Articles 1. La Fontaine, J. (2012). Explaining suicide: An afterword. Culture, Medicine & Psychiatry, 36(2), 409-418. doi:10.1007/s11013-012-9256-0 ◦ The full-text version of this article can be accessed through the EBSCOhost database in the Ashford University Library. 2. Williams, P. J. (2012). Tragedies in waiting. Nation, 295(9/10),10. ◦ The full-text version of this article can be accessed through the EBSCOhost database in the Ashford University Library. Multimedia 1. ABC News (Producer). (2003). Healthcare casualties: The underinsured mentally ill [Television series episode]. In America’s Struggling Healthcare System. New York, NY: ABC News. Retrieved from the Films On Demand database. ◦ To view the Privacy Policy and Accessibility Statements for this source, please view the Privacy Policies and Accessibility Statements listed in your Syllabus. Recommended Resource Article 1. The Kaiser Commission on Medicaid and the Uninsured. (2011).Mental health financing in the United States (http://www.kff.org/medicaid/upload/8182.pdf) . Retrieved from http://www.kff.org/medicaid/upload/8182.pdf 5 Courtesy of Keith Brofsky/Thinkstock Paying for Health Care Learning Objectives After reading this chapter, you should be able to: •• Distinguish the benefits and shortcomings of private sources of payment for the care of vulnerable persons. •• Identify the benefits and shortcomings of public sources of payment for the care of vulnerable persons. •• Recognize the most common public payer options, and understand their eligibility requirements. •• Understand how health care is financed for people with no health insurance coverage. bur25613_05_c05_149-172.indd 149 11/26/12 2:48 PM Introduction CHAPTER 5 Introduction T he cost of health care is rising, in part because of expensive new technologies and procedures, and in part because of the market failure of the health care industry. It has been argued that deregulation of health insurers, combined with a free market health care industry, has changed health care from a service-based structure to a commodity, or a product available for purchase. America’s health care delivery system is geared toward the multibillion dollar health insurance Courtesy of Jodi Jacobson/iStockphoto industry rather than individual payers, many of whom lack the Costly new technologies and the free-market nature of the financial ability to cover health health care industry have raised the cost of health care. care expenses out of pocket, from general emergency room care to a life-threatening illness. After all, few people have $10,000 in their budgets to cover the cost of an emergency room visit for a broken arm. Americans purchase health insurance to cover medical bills, but health insurance is too expensive for many families to afford. In 2010, 64% of the American population had private health insurance for all or part of the year. That isn’t a very large majority, considering that everybody needs medical attention at some point. In that same year, 31% of the population had government-run public health insurance, and 16.3% had no health insurance at all for all or part of the year (DeNavas-Walt, Proctor, & Smith, 2011). The question across America, from Congress to kitchen tables, is how to insure all, how to tackle rising health care costs, and how to decipher a fair and equitable payee process. Critical Thinking What do you think will be the impact if health care costs are not addressed? What future problems do you predict? bur25613_05_c05_149-172.indd 150 11/26/12 2:48 PM Section 5.1 Private Payers CHAPTER 5 Self-Check Answer the following questions to the best of your ability. 1. According to a study in 2011 by DeNavas-Walt, Proctor, & Smith, what percentage of Americans had no health insurance? a. 17% b. 36% c. 42% d. 16.3% 2. What has changed health care from a service-based structure to a commodity? a. deregulation b. lack of government intervention c. high consumer demand d. high employer demand 3. America’s health care delivery system is geared toward what part of the health insurance industry? a. individual payers b. employer benefits c. the multibillion dollar segment d. children and infants Answer Key 1. d 2. a 3. c 5.1 Private Payers T he private payer sector comprises programs that provide financial access to health care, which includes insurance companies, employer-run health coverage programs, and individuals who pay for health care out of pocket. Individuals who pay for all of their health care out of pocket are rare, as the cost of health care is prohibitive. Employer-run health coverage programs are types of insurance wherein the employer company manages the plan. Most Americans with private health care coverage have insurance plans that are sold and managed by insurance companies. These plans are available for purchase individually, though 60% of employers offer health insurance as an employee incentive (The Kaiser Family Foundation [KFF] & Health Research and Educational Trust, 2011). Private payer coverage is unattainable for many of America’s most vulnerable. This is primarily due to low income. Additionally, many of America’s middle class are losing private payer health insurance due to rising premium prices and employers’ inability or unwillingness to continue offering health insurance as an employee benefit. Many employers who continue to offer health insurance benefits have had to either lower the amount of coverage available or raise the out-of-pocket amount paid by the patient, called the deductible, due to rising premiums. This section discusses private payer coverage in terms of how it is able to meet the particular problems of each vulnerable population, bur25613_05_c05_149-172.indd 151 11/26/12 2:48 PM Section 5.1 Private Payers CHAPTER 5 whether or not the coverage is adequate, and the unique issues faced by each population when trying to navigate the private payer system. Vulnerable Mothers and Children Many people cite health insurance as a strong incentive to work, but as employers omit or limit insurance coverage as a benefit, private payer insurance becomes increasingly difficult to obtain for America’s most vulnerable. According to the Forum on Child and Family Statistics (2011), 60% of America’s children had private health insurance in 2009. Private health insurers have improved preventive care coverage for children, often covering well-child visits and immunizations at no copay, or the portion of the bill that the patient is responsible for. However, coverage for care of the mother and baby during pregnancy, called prenatal care, has diminished, leaving Courtesy of Blend_Images/iStockphoto the patient responsible for an increasing amount of the assoThough insurance coverage for young children has improved, ciated medical bills. Prenatal prior to giving birth mothers are becoming responsible for covering the cost of an increasing portion of their medical care. care is increasingly expensive as malpractice insurance premiums continue to rise, causing many obstetricians to increase their rates or drop out of the practice altogether. As the cost of prenatal care rises in response to these conditions, private health insurers are increasing patient co-pays in order to meet the higher costs. Abused Individuals Injuries that occur as a result of physical abuse are often treated in hospitals and urgent care centers. Many abuse victims avoid seeing their designated general practitioners and pediatricians for fear of detection. These injury treatments, and the mental health services that many victims access to recover from abusive relationships, are covered by private payers at varying levels depending on the specifics of their individual insurance plans. bur25613_05_c05_149-172.indd 152 11/26/12 2:48 PM CHAPTER 5 Section 5.1 Private Payers Chronically Ill and Disabled Persons Private insurance coverage for chronic illnesses and disabilities varies depending on the individual insurance plan. Many insurance companies have preexisting condition clauses that make it difficult to obtain insurance coverage or that reduce coverage for specified chronic illnesses. As the cost of delivered health care rises, many insurance companies are increasing individuals’ financial responsibilities in the form of co-pays or rejecting payment of insurance claims. Although it is difficult for insurance companies to deny claims for many procedures associated with chronic illness and disability, many have reduced coverage Courtesy of Lisa Eastman/fotolia for mobility and motility aids that help with activities of daily Insurance companies have increased co-pays and decreased living (ADLs). the amount and types of procedures they will pay for in order to offset the rising costs of delivered health care. Persons Diagnosed With HIV/AIDS Antiretroviral drug therapy is expensive, and HIV/AIDS patients with compromised immune systems often need costly inpatient hospital treatment. Private health insurers have discriminated against people diagnosed with HIV/AIDS by charging them higher premiums, limiting coverage, and screening for preexisting conditions. HIV/AIDS patients benefit from managed care, as managed care plans can lower medical costs through planning, organization, and deal brokering and can help HIV/AIDS patients maximize their health insurance benefits. Recent legislation works to increase access to health care coverage for people with disabilities, chronic illness, HIV/AIDS, and mental conditions. The Patient Protection and Affordable Care Act (2010) created a Pre-Existing Condition Insurance Plan (PCIP) to provide affordable health insurance coverage to all people living with medical conditions, including those with HIV/AIDS. The act also prohibits insurers from declining coverage based on preexisting conditions, beginning in 2014. Persons Diagnosed With Mental Conditions Plan coverage for mental health services has increased in recent decades. Many private insurance plans offer some level of coverage for outpatient therapy sessions and allow intense nonresidential therapies. Mental health benefits often have higher co-pays than general practitioner benefits. bur25613_05_c05_149-172.indd 153 11/26/12 2:48 PM Section 5.1 Private Payers CHAPTER 5 On the insurer side, managed behavioral health care programs (MBHCPs) have become a common method of managing mental health costs. MBHCPs come in two basic formats: • Administrative services-only payments, which are flat monthly fees that are paid in advance, usually based on the number of enrollees, or insurance plan participants • Monthly per capita payments made by the insurer to a managed behavioral health care organization (MBHCO) that make the MBHCO liable for services costs and administration costs The monthly per capita pay structure involves contracting a network of providers to perform the services. In this form of plan, mental health services have different coverage from other medical services covered under the plan. Per capita payment plans face challenges in minimizing the tendency for high-risk patients to be excluded from coverage and for providers to unnecessarily perform covered services to increase their ability to bill. Suicide- and Homicide-Liable Persons Caucasian males have the highest suicide rates and also have the highest incidence of subscribing to private health insurance plans. Suicide ideation and planning is an aspect of major depression, which is considered a mental condition eligible for insurance coverage. As discussed, many plans do offer mental health services benefits, which may be helpful in stopping a person from committing suicide but are not useful after the fact. Persons Affected by Alcohol and Substance Abuse Most private insurance plans offer some amount of coverage for alcohol and substance abuse services. In the private payer sector, these services are usually administered by providers that focus on patients with private insurance or the financial ability to pay out of pocket. Private sector alcohol and substance abuse programs boast nearly double the revenue per admission that public sector providers charge. Private payer programs usually limit alcohol and substance abuse program spending by capping the amount of benefit available in dollars and by limiting the number of program inpatient days and outpatient visits per enrollee, per year. State law varies on the subject, so some insurance plans offer more coverage than others. bur25613_05_c05_149-172.indd 154 11/26/12 2:48 PM CHAPTER 5 Section 5.1 Private Payers Indigent and Homeless Persons Not all homeless people are without jobs or family ties, which might account for the 4% of homeless people who reported having private health insurance in the 1996 National Survey of Homeless Assistance Providers and Clients published by the U.S. Census Bureau (U.S. Census Bureau, 1996). Another 10% reported having health coverage by means other than private and public payer organizations. Unsurprisingly, those who reported some form of private or “other” health insurance coverage (as opposed to public payer), were significantly more likely to belong to homeless families, rather than being on their own. Immigrants and Refugees Courtesy of Hemera/Thinkstock Immigrants in the United States are less likely than native-born citizens to have any type of Not all homeless people are without health health care coverage. In the private payer sector, coverage; 4% reported having private this is attributable to the fact that immigrants hold insurance, and another 10% claimed fewer white-collar jobs, which are more likely to coverage by other means. offer health care coverage benefits. Language barriers may also contribute to a lack of private insurance access because a language barrier makes it more difficult for a person to negotiate benefits with employers and insurers. Language barriers and lower incomes also make it difficult for immigrants to purchase health insurance individually. Immigrants with jobs that do offer private insurance have access equal to their native-born colleagues. Critical Thinking Many of America’s middle class are losing private payer health insurance due to rising premium prices and employers’ inability or unwillingness to continue offering health insurance as an employee benefit. How do you think this will affect the health care system? Do you think it will change demand and costs? Self-Check Answer the following questions to the best of your ability. 1. According to the 2009 Federal Interagency Forum on Child and Family Statistics, what percentage of America’s children had private health insurance? a. 60% b. 80% c. 40% d. 50% bur25613_05_c05_149-172.indd 155 11/26/12 2:48 PM Section 5.2 Public Payers CHAPTER 5 2. Beginning in 2014, what federal act will prohibit insurers from declining coverage based on preexisting conditions? a. Medicare Part D Act b. Welfare Reform Act c Patient Protection and Affordable Care Act d. Housing and Insurance Act 3. Which of the following factors makes it difficult for immigrants to purchase health insurance individually? a. nationality b. language barriers c. citizenship d. physical handicaps Answer Key 1. a 2. c 3. b 5.2 Public Payers T he public payer sector comprises government-funded programs that provide financial access to health care. These programs include Medicaid, Medicare, health care available to military veterans through the Veterans’ Administration, the Federal Employees’ Health Benefits Program, states’ employees’ health benefits programs, and the states’ Children’s Health Insurance Program (CHIP). These programs all differ in coverage and accessibility. Medicaid provides health insurance to qualifying adults, primarily those with limited income and resources. It is funded through a federal program but is administered by the states; they provide 20% to 50% of each state’s own Medicaid funding through state budgets. Approximately half of the people who receive Supplemental Security Income (SSI) also Courtesy of Stephanie Kennedy/iStockphoto receive Medicaid benefits based on eligibility due to physical and Dental care for children provided by Medicaid is funded with mental disabilities and disorders. a combination of state and federal monies. The Patient Protection and Affordable Care Act (PPACA) worked to increase access to public payer programs by changing eligibility requirements, among other program changes. In March 2012, the U.S. Centers for Medicare and Medicaid Services (CMS) announced a “final rule” on the PPACA that increases coverage and bur25613_05_c05_149-172.indd 156 11/26/12 2:48 PM Section 5.2 Public Payers CHAPTER 5 accessibility to government-funded health care plans. The final rule outlined that Medicaid eligibility would expand in 2014 to include childless adults without disabilities. It also increased the income eligibility requirements to 133% of the federal poverty level (U.S. Centers for Medicare and Medicaid Services [CMS], 2012a), which translates to $14,856 for an individual and $30,656 for a family of four (U.S. CMS, 2012a). Legislation on both federal and state levels has worked to increase Medicaid access, particularly for vulnerable women and babies. The Children’s Health Insurance Program (CHIP) is part of the Medicaid collaboration between the federal government and the states, though it is not part of the Medicaid program. CHIP provides extended eligibility and coverage for qualifying children up to age 19. CHIP coverage differs by state, but in all cases provides preventive care, hospital care, and dental care (U.S. CMS, 2012b). As of February 2011, a record 90% of children in the United States had health insurance coverage, either through private payers, Medicaid, or CHIP. However, 8 million children continue to be uninsured. Of these, 5 million are eligible for Medicaid and CHIP but are not enrolled (The Kaiser Family Foundation (KFF), 2012d). Children and the elderly are the most vulnerable subgroups in any at-risk population. Whereas children are eligible for CHIP, many elderly people are eligible for Medicare, a federally run health insurance program. Medicare also covers adults who are unable to work due to permanent disabilities. Medicare can be combined with private payer coverage, though private coverage is the consumer’s responsibility. Medicare provided health insurance coverage for 47,672,971 people in 2011 (KFF, 2012c). Medicare eligibility is based on a few factors: • You or your spouse must have worked for a minimum of 10 years in Medicarecovered employment, and • you must be age 65 or older, and • you must be a citizen or legal permanent resident of the United States. People with end-stage renal failure or disabilities may be eligible for Medicare even if they are under age 65. Some people are eligible for both Medicare and Medicaid based on income and illness or disability. These individuals are called “dual-eligibles.” Medicare offers a variety of coverage levels, referred to as “Parts.” Medicare Part A has no premium for people over age 65 and covers specified inpatient medical treatments in hospitals, skilled nursing facilities, long-term care facilities, hospice care, and other inpatient settings. Medicare Part B costs the insured person a monthly premium ($99.00 in 2012) and covers preventive care and medically necessary services. This includes some coverage for mental health therapies. People who wish to enroll in a Medicare private fee-for-service plan or a Medicare managed care plan must be enrolled in both Medicare Parts A and B. It is important to note that Medicare Parts A and B do not cover long-term residential care, dental care, and eye care. Prescription drug coverage is available through Medicare Part D. This section discusses how vulnerable populations access public payer coverage like Medicaid and Medicare (Medicare.gov, 2012). bur25613_05_c05_149-172.indd 157 11/26/12 2:48 PM Section 5.2 Public Payers CHAPTER 5 Vulnerable Mothers and Children Courtesy of Rosemarie Gearhart/iStockphoto Public health care coverage resources make it possible for high-risk mothers and their children to receive basic health care. Generally speaking, women are paid less than men, and women represent a higher percentage of the low-income population. Women also report more cost barriers to accessing health care for themselves and their children than are reported by men (DeNavas-Walt, Proctor, & Smith, 2011). This is one of the reasons that public health care programs benefit high-risk mothers and children so significantly. Medicaid and the Children’s Health Insurance Program (CHIP) are the traditional public health care coverage resources for high-risk mothers and children. These programs are state-run, so benefits coverage is vastly different depending on location. Since the Omnibus Budget Reconciliation Act of 1981 (OBRA), these programs have lost funding and eligibility requirements have tightened repeatedly. OBRA restricted tax deductions for child care expenses, work-related expenses, and earned-income credits. In doing so, many working poor who did not have health insurance through their employers were, in effect, pushed above the income threshold eligibility requirement for public payer health coverage, though their incomes did not increase. This had negative consequences on child and maternal health outcomes. The legislature responded with the PPACA in 2010, by extending the income eligibility threshold to 185% of the poverty level for families and 133% for individuals. The application process was also sped up with shortened application forms, and the programs were made more accessible by placing Medicaid administrators in locations other than just welfare offices. The Welfare Reform Act of 1996 (WRA) created the Temporary Assistance for Needy Families (TANF) program, thus limiting coeligibility between welfare and Medicaid. TANF decreased accessibility to high-risk mothers and children by demanding that mothers who could work, must work to be eligible for TANF benefits. Many women who got jobs or continued in their current employment made too much to be eligible for Medicaid, even though they were the working poor and lacked access to private health insurance. The Patient Protection and Affordable Care Act of 2010 (PPACA) expands access to coverage for all people, but high-risk mothers and babies may stand to gain the most from the expanded access (see Figure 5.1). The PPACA mandates expand private health insurance access through many qualifying employers. It also increases the income threshold eligibility requirement for Medicaid, allowing access for more of America’s working poor. bur25613_05_c05_149-172.indd 158 11/26/12 2:48 PM Section 5.2 Public Payers CHAPTER 5 Figure 5.1: Improved access to health insurance under the Patient Protection and Affordable Care Act More than half of high-risk mothers are eligible to receive coverage through Medicaid. The Henry J. Kaiser Family Foundation (KFF). (2010a). Retrieved from http://www.kff.org/womenshealth/upload/7987.pdf Abused Individuals Estimates of treatment for bone injuries, brain injuries, internal injuries, burns, poisoning, and other abuse-related ailments put the total inpatient annual cost in the United States around $20 million. Child abuse is more prevalent among low-income households (U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, 2011). As such, most of the cost of treating patients for injuries from abuse is paid for by public payer programs, namely Medicaid. Similarly, Medicare bears the brunt of the cost of treating injuries resulting from elder abuse. Chronically Ill and Disabled Persons Under the Social Security and Disability Insurance (SSDI) program, the federal government provides a financial safety net for people who become disabled. SSDI pays monthly income to eligible people who have worked enough to contribute to the SSDI program before becoming disabled. The Social Security Administration (SSA) determines eligibility by using the following criteria: • The applicant cannot do the same type of work that was done before incurring his or her disability or medical condition; bur25613_05_c05_149-172.indd 159 11/26/12 2:48 PM CHAPTER 5 Section 5.2 Public Payers • The applicant has been unable to adjust to other work because of the disability or medical condition(s); and • The disability has lasted or is expected to last for at least one year or to result in death (U.S. Social Security Administration, 2011). At the end of calendar year 2011, the SSA reported that 8,576,000 people were regularly receiving disability benefits under SSDI: Old-Age, Survivors, and Disability Insurance program (OASDI) (U.S. Social Security Administration, 2012a). SSDI participants are automatically eligible for Medicare after two years. Supplemental Security Income (SSI) is also managed by the federal SSA and also covers some people with disabilities. Unlike SSDI, SSI eligibility is not dependent on work history but is based on having limited means to support oneself. SSI participants immediately gain access to Medicaid in most states. Some states supplement SSI payments, increasing the benefit. Courtesy of Dean Mitchell/iStockphoto Those who have worked enough to contribute to the Social Security and Disability Insurance (SSDI) program before becoming disabled are eligible to collect monthly SSDI benefits if they also satisfy other criteria. Those receiving disability benefits under SSDI and SSI may benefit from the Ticket to Work and Self-Sufficiency program (Ticket). Ticket helps place SSI and SSDI participants in jobs, while allowing them to continue to receive benefits. Ticket participants can receive rehabilitation services without endangering their disability benefit eligibility as well. Under the Ticket program, working beneficiaries are not audited for disability qualification by the Administration; benefits can only be diminished or lost based on income eligibility requirements as workers advance their careers and if deemed no longer disabled. Ticket also allows many workers who lose income benefits from SSI and SSDI to continue Medicaid and Medicare coverage (U.S. Social Security Administration, 2012b). Many SSI and SSDI participants are covered by either or both Medicare and Medicaid. Adults over age 65 who have Medicare may also qualify for Medicaid. Medicare and private insurance plans offer limited coverage for institutionalized care, including nursing homes, and the costs associated with long-term care often drain patients’ financial resources. This has created a system in which Medicaid is the single largest payer for long-term care services. Persons Diagnosed With HIV/AIDS Public payer programs bear the brunt of medical costs for HIV/AIDS. This is partially because HIV is more prevalent among low-income populations, which utilize Medicare and Medicaid programs. Though public payer programs do limit benefits for antiretroviral bur25613_05_c05_149-172.indd 160 11/26/12 2:48 PM Section 5.2 Public Payers CHAPTER 5 drug therapies, treatments for illnesses that result from having a compromised immune system due to HIV/AIDS, such as viral infections and pneumonia, are covered. Grantfunded Ryan White clinics (see Chapter 3) are located in many public health departments to meet the specific needs of HIV/AIDS patients. Additionally, federal and state governments offer preventive programs and nonmedical support to HIV/AIDS patients, which add to the total cost of HIV/AIDS to the government. As many as 50% of people diagnosed with HIV/AIDS are estimated to receive Medicaid benefits. The number of children living with HIV/AIDS receiving public payer health coverage is estimated to be as high as 90%. In 2011, the United States federal government spent an estimated $27.2 billion in domestic and international HIV/AIDS programs and research (KFF, 2010b). Figure 5.2 shows a detailed breakdown of how the money was spent. Figure 5.2: Federal spending on HIV/AIDS programs in 2011 Expenses for care and treatment make up more than half of the spending on HIV/AIDS programs. The Henry J. Kaiser Family Foundation (KFF). (2010b). Retrieved from http://www.kff.org/hivaids/upload/7029-06.pdf Persons Diagnosed With Mental Conditions According to the Substance Abuse and Mental Health Services Administration (SAMHSA), Americans spent $135 billion on mental health and substance abuse services in 2005, which accounted for 6.1% of all health care spending. Public payer programs covered the bur25613_05_c05_149-172.indd 161 11/26/12 2:48 PM CHAPTER 5 Section 5.2 Public Payers majority of mental health costs, accounting for 58% of the total spent on mental health care. Medicaid alone covered 28% of the total spent on mental health during that year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2010). SAMHSA estimates that spending on mental health and substance abuse treatments will continue to increase but will do so at a slower pace than spending on other medical care, as there is less need for mental health and substance abuse treatments than for all other medical care combined. It is projected that overall spending on mental health and substance abuse will be $239 billion in 2014 (Levit et al., 2008). Forecasting predicts that 2014 mental health and substance abuse spending will continue to be covered by public payers at the current rate of 58% of the country’s total. Suicide- and Homicide-Liable Persons Low-income minority males have the highest homicide rate (Xu, & Kochanek, & Murphy, & Tejada-Vera, 2010). This group also represents a significant number of people who have no health care coverage or use public payer programs. As such, public programs like Medicaid are responsible for much of the cost of violent deaths. Medicaid offers limited coverage for emergency care of gunshot wounds. Many social programs that work to prevent suicide and homicide focus on children. These include Head Start, Child Abuse and Neglect Program, Foster Care programs, and Child Welfare Services. Programs that focus on adults and the elderly include block grants, social services, and community services. The criminal justice system is responsible for the vast majority of costs associated with violent crime and death. These costs are accrued through investigation of violent deaths and prosecution of offenders. Once offenders are successfully prosecuted, they enter the penitentiary system, where the government pays their room, board, and health care costs. Persons Affected by Alcohol and Substance Abuse Courtesy of Big City Lights/Fotolia More than one third of the United States’ substance abuse spending in 2005 was covered by public payers, excluding Medicaid. bur25613_05_c05_149-172.indd 162 SAMHSA (2010) reports that spending on substance abuse treatments comprised 1.2% of the nation’s health care spending in 2005. Of the portion spent on substance abuse, 52% was spent at centers that specialize in mental health and alcohol and substance abuse. State and local public payers, excluding Medicaid, paid for 36% of the nation’s substance abuse spending in 2005. Medicaid paid 21% of the cost, and private insurance paid 12%. Overall, public payers were responsible for 80% of the nation’s substance abuse medical spending. Most of this spending went to publicly owned and not-for-profit programs that mostly serve indigent people. 11/26/12 2:48 PM Section 5.2 Public Payers CHAPTER 5 There has been a shift in substance abuse treatment therapies from the 1980s to 2005. Inpatient treatments represented 56% of substance abuse treatment spending in 1986. A shift to outpatient therapies due to improved pharmaceuticals and deinstitutionalization is evident in the decrease in inpatient spending to 17% in 2005. Outpatient spending rose from 23% in 1986 to 48% in 2005 (SAMHSA, 2010). Indigent and Homeless Persons The Homeless Eligibility Clarification Act of 1986 (HECA) improved Medicaid access for indigent people. HECA mandated that a person without a mailing address or income may be denied Medicaid eligibility. Two programs that focus on connecting indigent people with available resources, such as food stamps, Medicaid, and job training, include the Health Resources and Services Administration Health Care for the Homeless department and the Department of Veterans Affairs Health Care for Homeless Veterans program. Immigrants and Refugees Access to public payer programs is restricted for immigrants for various reasons. Language barriers make it difficult for immigrants to access and apply for government programs. Some cultures prohibit the use of these programs, regardless of need. American attitudes toward immigrants, and undocumented immigrants in particular, have encouraged legislation that limits public program eligibility for many foreign-born people. The Welfare Reform Act of 1996 (WRA) stripped many immigrants of their SSI and Medicaid eligibility by declaring that noncitizen immigrants are not eligible for the programs. It went on to make all immigrants ineligible for public means-tested programs for their first five documented years in America, after which point they must declare their sponsors’ incomes on means-tested applications. State and local laws often go further, making undocumented immigrants entirely ineligible for public benefit programs. The Patient Protection and Affordable Care Act of 2010 (PPACA) improves immigrant access to health coverage only slightly. Undocumented immigrants remain ineligible for Medicaid and many other public assistance programs and are also ineligible to purchase health insurance through the insurance marketplace created by the PPACA. Under PPACA, states may waive the five-year waiting period for Medicaid and CHIP program eligibility for documented immigrants. Documented immigrants are also granted access to the health insurance marketplace, and marketplace tax benefits are not subject to the five-year waiting period for Medicaid. The PPACA grants naturalized citizens full access to Medicaid and insurance marketplace benefits that all U.S. citizens have (KFF, 2012c). Critical Thinking According to the reading, 90% of children in the United States are eligible to receive some type of health insurance, either through private payers, Medicaid, or CHIP. Do you think it is possible to provide health insurance to 90% of adults? What obstacles stand in the way? What possible solutions would you recommend? bur25613_05_c05_149-172.indd 163 11/26/12 2:48 PM Section 5.3 Uninsured People CHAPTER 5 Self-Check Answer the following questions to the best of your ability. 1. According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), Americans spent how much on mental health and substance abuse services in 2005? a. $135 billion b. $17 trillion c. $13 million d. $20 trillion 2. Which of the following social programs works to prevent suicide and homicide and focuses on children? a. Health in the Community b. KinderCare c. Head Start d. Montessori 3. Which group of immigrants is granted access to the health insurance marketplace and may not have to wait for five years? a. undocumented immigrants b. those from Cuba c. those from Canada d. documented immigrants Answer Key 1. a 2. c 3. d 5.3 Uninsured People A pproximately 16.3% of the United States population has no health insurance coverage. Children under age 18 lack health insurance at a rate of 9.3% overall and at a rate of 15.4% for those living in poverty (DeNavas-Walt et al., 2011). Uninsured people are more likely to avoid or delay seeking health care. Although there is little evidence to suggest that this lack of preventive care increases emergency room (ER) visits for the uninsured, those living below the poverty line have a significantly higher incidence of ER visits, as shown in Figure 5.3 (Garcia, Bernstein, & Bush, 2010). When uninsured people do seek medical care, they are often stuck with the entire bill. In some cases, they may be eligible for financial assistance through the health care organization where they were treated and other charities that exist to help people pay for medical treatments. Many hospitals offer financial aid programs for patients who cannot afford medical treatment. These programs are eligibility-based. When a patient cannot pay his or her medical bills and does not qualify for financial aid, the hospital absorbs some of the cost. But how? The answer here is both simple and complex. The simple answer is that the hospital absorbs the loss and passes it to others through cost-of-service increases. The complex answer is that the high rates everyone pays through the system are charged at such a high rate to pay for the service and all those services the hospital will never get paid for. The insurance companies absorb the cost of this and pass the rest to the populace through the bur25613_05_c05_149-172.indd 164 11/26/12 2:48 PM Section 5.3 Uninsured People CHAPTER 5 use of insurance premiums. So those with insurance pay for that service in a snowball chain and thereby end up paying for it twice. Large insurance pools spread this out a little further, where it is shared more equally. Figure 5.3: Prevalence of emergency room visits by poverty level Emergency room visits per year decrease the farther a person moves above the poverty level. CDC/NCHS, National Health Interview Survey. (2010). Retrieved from http://www.cdc.gov/nchs/data/databriefs/db38.pdf Vulnerable Mothers and Children Women of childbearing age have a particularly high incidence of having no health care payer coverage. Only 64% of America’s pregnant women are estimated to have any amount of coverage for pregnancy and childbirth expenses, whether they have insurance or not. This is partially due to health insurance plans that do not cover pregnancy expenses, and partially due to the fact that one-quarter of pregnant mothers lack health insurance of any type when they become pregnant. These women are often low income, of minority ethnicity, young mothers, and unwed. Obstetricians and other women’s health service providers can provide these women with information and access to resources, including the Program for Children with Special Health Care Needs, which supports providers who care for these high-risk mothers. Through programs like this, the uninsured rate decreases to 15% by the time of delivery. bur25613_05_c05_149-172.indd 165 11/26/12 2:48 PM Section 5.3 Uninsured People CHAPTER 5 Abused Individuals As abusive offenders are often under- or unemployed, it stands to reason that many offenders and victims of abuse have no health insurance coverage at all. It is thought that abused individuals may also avoid seeking public payer coverage for fear of being found out. No data is available on the number of uninsured abused individuals or the reasons they are uninsured. Chronically Ill and Disabled Persons Chronically ill and disabled people may have difficulty obtaining health insurance due to preexisting conditions exemptions. The Patient Protection and Affordable Care Act works to create access for these individuals by diminishing insurers’ ability to decline coverage based on preexisting conditions. Public payer programs are available to the most chronically ill and disabled, who are unable to work due to their conditions. However, a great many are able to work but unable to work full time or maintain gainful employment because they have limited functioning. Low wages and jobs that do not offer medical coverage benefits make it difficult for those who do not qualify for public payer programs to obtain private health insurance. Persons Diagnosed With HIV/AIDS Around 29% of HIV/AIDS patients lack health insurance. Many lose coverage due to losing employment when they become very ill. Others have their coverage canceled, or cannot get coverage, due to health insurance company exclusions. Some public payer programs are available, however, some people with HIV/AIDS who receive Social Security and Disability Income benefits may not be eligible for government health care programs because their incomes are too high. Persons Diagnosed With Mental Conditions Lack of health insurance is particularly problematic for those with severe, chronic mental conditions. According to the National Alliance on Mental Illness (NAMI) and SAMHSA, one-fifth of all patients with serious mental illness are uninsured (National Alliance on Mental Illness [NAMI], 2007). The truth is that these patients need a great amount of inpatient and outpatient therapies. Many are prescribed costly pharmaceuticals to help stabilize their conditions. Drug compliance can be difficult to maintain in this bur25613_05_c05_149-172.indd 166 Courtesy of kmiragaya/fotolia According to the National Institute for Mental Health and the National Center for Health Statistics, psychiatric patients have a 2% higher incidence rate of being uninsured than other medical patients. 11/26/12 2:48 PM Section 5.3 Uninsured People CHAPTER 5 vulnerable group, and lack of health insurance to offset the price of mental health drugs exacerbates the compliance problem when uninsured patients cannot afford to have their prescriptions filled. Suicide- and Homicide-Liable Persons Mental health therapy is often cost prohibitive for uninsured suicide-prone people and homicide-prone people, both victims and offenders, pose a particular strain on the public health system. Young African American and Hispanic males are both homicide-prone and have high uninsured rates. Emergency room visits for gunshot wounds are expensive. Many hospitals offer financial aid for patients who qualify. For those who don’t, the bills for treatment can lead to financial ruin. Persons Affected by Alcohol and Substance Abuse Most Medicaid and private insurance plans limit coverage of substance abuse treatments. State Medicaid coverage of substance abuse therapies differs on scope and price coverage. An estimated 13% of the total cost for treatment is paid directly by patients in the private sector. Because low-income, vulnerable populations have a higher incidence of substance abuse, it follows that the majority of patients treated for substance abuse either are on public health plans or have no insurance at all. Indigent and Homeless Persons The majority of homeless people and many indigent people lack health insurance of any kind. However, many are eligible for Social Security and Disability Insurance (SSDI) and Medicaid. Although the Welfare Reform Act of 1996 tightened eligibility requirements, making it more difficult for many people to qualify for SSDI, Medicare, and Medicaid, the Patient Protection and Affordable Care Act worked to widen eligibility requirements to cover more people. Even with increased eligibility, the safety net of services for the homeless has large gaps in access and coverage. Connecting the homeless with medical coverage services continues to be extremely difficult. Immigrants and Refugees Many immigrants and refugees hold low-paying jobs that do not offer health insurance as a benefit of employment. The language barriers and low incomes make it difficult for them to find private health insurance on their own. Many make too much to qualify for public payer coverage but cannot access private payer coverage through work. Undocumented immigrants cannot get health insurance because they lack the necessary documentation, such as a Social Security card. The U.S. Department of Health and Human Services data shown in Figure 5.4 illustrates that Hispanics are disproportionately represented among the uninsured, as they compose 14% of the American population but represent 30% of the total number of uninsured in America (U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2005). bur25613_05_c05_149-172.indd 167 11/26/12 2:48 PM Section 5.3 Uninsured People CHAPTER 5 Figure 5.4: Portion of uninsured as compared with portion of the total population Blacks and Hispanics are uninsured disproportionately to the percentage of the American population they represent. Department of Health and Human Services. (2005). Distribution of the uninsured and total U.S. population by race/ethnicity in 2004. Retrieved from http://aspe.hhs.gov/health/reports/05/uninsured-cps/ib.pdf Critical Thinking Many hospitals and insurance agencies pass on the cost of caring for uninsured patients. How effective is this policy, and what changes might be made to improve it? Self-Check Answer the following questions to the best of your ability. 1. What proportion of pregnant mothers lack health insurance of any type when they become pregnant? a. 64% b. 50% c. 25% d. 15% bur25613_05_c05_149-172.indd 168 11/26/12 2:48 PM Chapter Summary CHAPTER 5 2. What percentage of HIV/AIDS patients lack health insurance? a. 17% b. 20% c. 29% d. 42% 3. An estimated 13% of the total cost for treatment is paid directly by patients in the private sector who suffer from what condition? a. HIV/AIDS b. at-risk pregnancies c. PTSD d. substance and alcohol abuse Answer Key 1. a 2. c 3. d Case Study: Thinking Outside the Cash Box at St. Jude Children’s Research Hospital For America’s uninsured, and even those with public or private health insurance, catastrophic medical events can create financial hardship. Many hospitals offer financial aid services for families that cannot afford to pay for treatments. Some have hospital foundations that are used to cover these expenses. Of these, St. Jude Children’s Research Hospital is a shining example. St. Jude treats approximately 7,800 pediatric patients per year. The 78-bed research hospital sees critically ill children, mostly on a recurring, outpatient basis. Among its many accomplishments is the creation of treatment protocols that improved the survival rate for acute lymphoblastic leukemia, the most common cancer type among children, from 4% in 1962 to the current 94% survival rate (St. Jude Children’s Research Hospital, n.d.). St. Jude’s daily operating cost is $1.7 million for research and patient treatments (St. Jude Children’s Research Hospital, n.d.). Absolutely none of that money comes from the patients’ families’ pocketbooks. St. Jude is bankrolled by the hospital foundation, which exists almost entirely thanks to public donations. Through fund-raising efforts, St. Jude’s foundation is able to continue to treat patients without billing directly to families, and further research lifesaving cures for catastrophically ill children. Chapter Summary T he United States spends more per capita, meaning for each person, on health care than any other nation at $8,086 per person (Centers for Disease Control and Prevention [CDC], 2011). For the sake of comparison, the United States spent $7,538 per capita on health care in 2007, Norway spent $5,003 per capita in that same year, and the United Kingdom (which has a single-payer health care system) spent $3,129 per capita on health care in 2007 (KFF, 2011b). In 2009, spending on health care accounted for 18% of the gross domestic product (GDP) in the United States. As health care costs continue to increase, America struggles to find a way to mitigate the problem of growing costs while creating affordable coverage for everybody. bur25613_05_c05_149-172.indd 169 11/26/12 2:48 PM Self-Check CHAPTER 5 A small majority of Americans have private payer health insurance, usually provided through employers. For those who do not have affordable access through employer benefits plans, health care costs limit access to providers. Public payer programs like Medicare and Medicaid exist to provide affordable coverage to many Americans. However, many argue that these programs are a burden on the country’s budget. Private plans and public programs still do not cover all Americans, and the working poor and immigrants often fall through the cracks in America’s health care delivery system. Critical Thinking Considering the amount the United States spends on health care each year, what changes could be made to increase access to health insurance for the working poor and immigrants? Would increased spending be an effective way to address this deficit? Can you think of other possible solutions to this problem? Self-Check Answer the following questions to the best of your ability. 1. In 2010, 64% of the American population had private health insurance. a. True b. False 2. The Patient Protection and Affordable Care Act created a Pre-Existing Condition Insurance Plan (PCIP) that will begin in what year? a. 2016 b. 2015 c. 2014 d. 2018 3. To be eligible for SSDI, the Social Security Administration requires that a. the applicant’s medical condition or disability is very severe. b. the applicant is unable to perform the same type of work that he or she did before incurring the medical condition. c. the applicant’s medical condition has lasted for at least six months. d. the applicant’s income is at or below the poverty line. 4. What available resources exist for homeless people through the two federal programs Health Resources and Services Administration Health Care for the Homeless department and the Department of Veterans Affairs Health Care for Homeless Veterans? a. community outreach b. service animals c. Medicaid d. faith-based programs bur25613_05_c05_149-172.indd 170 11/26/12 2:48 PM CHAPTER 5 Web Exercise 5. What makes it difficult for those who do not quality for public payer programs to obtain private health insurance? a. low wages b. jobs that do offer insurance c. understaffed government housing offices d. preexisting conditions 6. _________________ and low incomes make it difficult for foreign-born people to find private health insurance on their own. a. Language barriers b. Immigration regulations c. The Welfare Reform Act d. The Patient Protection and Affordable Care Act of 2010 Answer Key 1. a 2. c 3. b 4. c 5. a 6. a Additional Resources Visit the following websites to learn more about the topics covered in this chapter: The SSA’s website explains disability benefits. http://www.ssa.gov/dibplan/index.htm St. Jude’s website http://www.stjude.org/stjude/v/index.jsp?vgnextoid=f87d4c2a71fca210VgnVCM1000001e 0215acRCRD Shriner’s Hospital for Children http://www.shrinershospitalsforchildren.org/ Web Exercise Using the Internet, locate three local health care foundations that benefit patients. Create a 10-slide PowerPoint presentation that covers your findings. Be sure to include the following: •• contextual information (who, what, where) •• history of foundation •• mission or belief of service bur25613_05_c05_149-172.indd 171 11/26/12 2:48 PM CHAPTER 5 Key Terms •• population served •• funding sources/types •• any affiliations (corporate, such as McDonald’s or Wendy’s, or noncorporate, such as Shriner’s, Knights of Columbus, Masons, Rotary, etc.) As always, spelling, grammar, and readability are important. Key Terms Children’s Health Insurance Program (CHIP) Administered under the Medicaid services umbrella, CHIP provides extended eligibility and coverage for qualifying children up to age 19. commodity A product available for purchase. co-pay The portion of a patient’s bill for which he or she is responsible at the time a medical service is provided. Medicare A federally run health insurance program for people age 65 and over, and those unable to work due to permanent disabilities. per capita For each person. prenatal care Care of the mother and baby during pregnancy, including ultrasounds, gestational diabetes screening, and obstetric and gynecological care. enrollees Insurance plan participants. private payer sector Programs that provide financial access to health care, which includes insurance companies, employer-run health coverage programs, and patients who pay for health care out of pocket. insurance claims Bills sent to the insurance company to pay for a covered patient’s health care services rendered. public payer sector Government-funded programs that provide financial access to health care. Medicaid A health insurance program funded with state monies, which provides health insurance to qualifying low-income adults. Social Security and Disability Insurance (SSDI) program A federal government that provides a financial safety net, in the form of monthly income checks, for people who become disabled and who have worked enough to contribute to the SSDI program before becoming disabled. deductible The portion of expenses a person must pay out of pocket before an insurer pays any expenses. bur25613_05_c05_149-172.indd 172 11/26/12 2:48 PM 6 Courtesy of Beerkoff/Fotolia Accessing Health Care Learning Objectives After reading this chapter, you should be able to: •• Identify where access barriers originate. •• Examine the organizational barriers to accessing health services as experienced by vulnerable populations. •• Explain the financial barriers to accessing health services as experienced by vulnerable populations. •• Consider ways to improve access to health care. •• Explain the politico-social forces affecting access to health care. bur25613_06_c06_173-194.indd 173 11/26/12 2:49 PM CHAPTER 6 Introduction Introduction T hough institutionalized racial segregation ended decades ago, many would argue that Americans continue to be segregated by socioeconomic class. Economic status determines where people live and attend school, and even where they go to the doctor. Vulnerable populations face access barriers to health care in both financial and organizational forms. For example, many physicians do not accept patients on Medicaid, and many who do limit the number to a certain percentage of their practices or a certain number of appointments per week. This creates an organizational barrier to health care access for Medicaid recipients. At the same time, many lowincome people struggle to find the money to pay for services that aren’t covered by Medicaid or the co-pays on the services covered by their employers’ insurance, thereby creating a financial barrier to access. As more physicians abandon small private practices in favor of joining large health care conglomerates where they can improve reimbursement rates and lower malpractice insurance rates, and more people receive Medicaid or Medicare, reliable access for the vulnerable becomes increasingly tenuous. Courtesy of Sheri Armstrong/Fotolia Though a patient may be covered by Medicaid, many are unable to take full advantage of that coverage because of physician-imposed limits and restrictions. Critical Thinking The text states, “More physicians abandon small private practices in favor of joining large health care conglomerates.” Do you think that these larger corporations would be more willing to accept Medicaid patients and thus increase accessibility? Self-Check Answer the following questions to the best of your ability. 1. Which populations face access barriers to health care in both financial and organizational forms? a. vulnerable b. naturalized citizens c. employed d. school-age children bur25613_06_c06_173-194.indd 174 11/26/12 2:49 PM Section 6.1 Organizational Barriers CHAPTER 6 2. Many physicians limit the number of what types of patients to a certain percentage of their practices or to a certain number of appointments per week? a. HIV/AIDS b. elderly c. those on Medicaid d. charitable cases 3. Many low-income people struggle to find the money to pay for what services covered by their employers’ insurance? a. enrollment fees b. wage taxes c. political contributions d. co-pays at medical facilities Answer Key 1. a 2. c 3. d 6.1 Organizational Barriers O rganizational barriers to health care access for America’s most vulnerable include health care deserts with a limited number of health care locations in poor, urban areas; understaffed health care offices in vulnerable areas that are unable to meet the needs of the number of patients in the area; cultural gaps between providers and patients in low-income regions; and fear. Fear, in fact, creates a two-sided access barrier. On the provider side, many practitioners choose not to locate their practices in poor regions for fear for the safety of the staff, fear of lawsuits from socioeconomically disadvantaged individuals seeking to take advantage of physicians’ malpractice insurance, and fear of financial hardship caused by too many patients who cannot pay their medical bills. On the patient side, fear creates an access barrier due to fear of an inability to pay for services, fear of intrusion into their lives, and fear of a health care delivery system that is populated by practitioners who cannot relate to vulnerable patients’ struggles. Each vulnerable population experiences organizational barriers to access differently; these varied experiences will be explored in greater detail in the next few sections. Vulnerable Mothers and Children The effects of organizational barriers for high-risk mothers and babies begin before conception. Many women do not receive gynecological care—medical care specializing in the female reproductive system—from their family doctors. This means that many women, regardless of socioeconomic class, must act as an informational go-between among their multiple medical providers, carrying test results between doctors’ offices and remembering to provide complete medical histories from memory. Without electronic health records, which store a patient’s health data in a digital database that is accessible by all of a patient’s authorized providers, the delivery system for women’s health care remains disjointed and difficult to maneuver. Vulnerable mothers often lack access to appropriate gynecological care and reproductive health counseling, which increases the risk of bur25613_06_c06_173-194.indd 175 11/26/12 2:49 PM CHAPTER 6 Section 6.1 Organizational Barriers unplanned pregnancies. They often seek prenatal care later in their pregnancies than those with stronger support systems. Many women with incomes below 200% of the federal poverty level report not seeking health care due to an inability to take off work during clinic hours. Others report that physical access to health care is restricted because they lack transportation to get to doctors’ offices (Ranji & Salganicoff, 2011). Courtesy of Kati Molin/Fotolia Many of the organizational barriers to accessing health care faced by women can be mitigated by extending clinic hours and locating services along public transportation routes and in low-income urban and rural areas. Unfortunately, national trends have been in the opposite direction. Instead of locating their offices in lowincome areas, many physicians are moving out of them (U.S. Health Resources and Services Administration, 2012). The number of doctors who treat pregnant women for pregnancy, called obstetricians, is also diminishing. Those who remain increasingly give up small, independent practices in favor of joining large for-profit health care conglomerates. By doing so, they are able to minimize malpractice insurance premiums and their individual liability (U.S. Health Resources and Services Administration, 2012). Many of the large hospitals that do provide obstetric care are located in more affluent areas, where private payers and patients are better able to pay higher fees for medical care. This, of course, creates an organizational barrier for vulnerable mothers, who must find appropriate transportation to access these areas. Many women with incomes below the poverty level are not able to seek health care because of an inability to leave work during regular clinic hours. Abused Individuals Organizational barriers to health care for abused individuals reside in a fragmented treatment system that includes a menagerie of medical and mental therapies, as well as intervention from social services and the criminal justice system. Law enforcement, educators, and doctors are often the first reporters of domestic abuse of women and children (Child Welfare Information Gateway, 2012). Their reports of suspected abuse are made to government social services agencies including Child Protective Services (CPS). Once a report is made, social workers investigate, and if severe abuse or neglect is present, the process of removing the victims from the home and the rehabilitation of families begins. A breakdown in the reporting process occurs when school and medical center staff are poorly trained in recognizing the symptoms of abuse and have reservations about the ramifications of reporting suspected abuse. bur25613_06_c06_173-194.indd 176 11/26/12 2:49 PM Section 6.1 Organizational Barriers CHAPTER 6 Adult victims of domestic violence can be more difficult to remove from an abusive situation than are children. Legally, CPS social workers can remove a child from an abusive situation if they deem it to be necessary. However, social workers from agencies like Adult Protective Services (APS) cannot forcibly remove an adult who does not want to leave or declines to leave for fear of retribution from the abuser. The criminal justice system gets involved in punishing offenders of child, intimate partner, and elder abuse and is often the only line of defense for an adult victim of domestic violence. This does not necessarily mean that reported offenders are arrested or jailed. The criminal justice system also facilitates restraining orders and orders of protection. Among the community organizations and government departments that address domestic violence, there is little overlap and partnership in programming, as independently involved organizations often focus on different aspects of the abuse. For example, many programs that exist for treating child victims of abuse do not address the needs of the adults in the relationship. Most battered women shelters will accept children, although having children may alter a woman’s ability to remain at the shelter due to shelter rules about the length of time a child may be housed or individual childcare issues such as keeping the children in their enrolled schools. More cooperation is needed between the disassociated agencies that are in place to address the needs of abused individuals. Chronically Ill and Disabled Persons Organizational barriers for chronically ill and disabled individuals revolve around physical access to programs and providers, as well as program eligibility requirements and an uncoordinated selection of programs. People with mobility problems may have difficulty simply getting to treatment centers. This is particularly true for low-income disabled and chronically ill patients who statistically lack social capital, which can be thought of as the number of relationships a person has and/ or the number of social networks a person belongs to, all of which provide resources and support. For example, a person in an advanced stage of multiple sclerosis (MS) may have diffiCourtesy of Getty Images/Thinkstock culty walking without the use of a cane. This may mean that he Often, treatment is hindered for people with mobility problems or she can only access doctor’s due to an inability or difficulty in getting to treatment centers. offices that have parking structures within reasonable walking distances. Additionally, without a friend or relative who can help navigate the walk from the parking structure to the office, he or she may find the trip too arduous to complete on his or her own. bur25613_06_c06_173-194.indd 177 11/26/12 2:49 PM CHAPTER 6 Section 6.1 Organizational Barriers Even when an individual is eligible for particular programs—whether that be caretaker respite programs, meal delivery programs, home visits, and transportation services— these programs may not be available in his or her area. Often, coordination is lacking when services are available, which creates a barrier to access. Individual community programs and government programs operate independently, and each often has its own focus. For example, a meal delivery program may not offer caretaker respite. In these situations, it is up to the individual person to find available resources and enroll in needed programs. Persons Diagnosed With HIV/AIDS HIV/AIDS patients face organizational barriers to health care access in many different forms. Limited space is designated in long-term centers specifically for HIV/AIDS patients; staff is sometimes undertrained in HIV/AIDS care; some medical staff may purposefully limit their contact with HIV/AIDS patients for fear of contracting the disease or for other personal reasons; and the sparse number of community support services is often underfunded and has long waiting lists. Ways of counteracting these barriers include improved staff training on the history, or pathology, of HIV/AIDS; its epidemiology, which refers to the distribution and prevalence of disease in a population; and best practices for HIV/AIDS–related patient care. Courtesy of Minerva Studio/Fotolia Improved financial access to antiretroviral drugs would continue to lower the number of HIV/AIDS patients in need of long-term care, and improved funding for community-based resources would help shorten waiting lists. One of the most important public health initiatives to have been enacted in recent years is the federally funded Ryan White Comprehensive AIDS Resources Emergency (CARE) Act program, which works to improve access to health care and community resources for low-income HIV/ AIDS patients. The act provides grants and additional funding to secure the success of HIV/ AIDS treatment and prevention programs in underserved areas. (For more information on the community-based and health care organization– based resources supported by the CARE Act, visit http://hab.hrsa.gov/.) Improved access to general care providers and preventive counseling among those most at risk for contracting HIV would work to lower the number of new infections. Among homeless intravenous drug abusers, access to preventive care and treatments is severely limited. Without functional inpatient care, homeless and intravenous drug abusers who have HIV/AIDS find it difficult to maintain treatment compliance, as physical and financial access barriers make it difficult to obtain medication and maintain treatments plans. Inadequate staff training and lack of funds can prevent HIV/AIDS patients from receiving proper care. bur25613_06_c06_173-194.indd 178 11/26/12 2:49 PM Section 6.1 Organizational Barriers CHAPTER 6 Persons Diagnosed With Mental Conditions Before the first antipsychotic drug, Thorazine, was used to treat mentally ill patients, America’s most severely mentally ill were regularly housed in government-run institutions (Torrey, 1997). Ten years after Thorazine became common in psychological therapy, Medicaid was created to improve health care access for low-income individuals. The combination of these two events, in tandem with a shift in social ideology regarding forced institutionalization and involuntary care, created an atmosphere wherein physicians were encouraged to deinstitutionalize mental health care for the most severely affected. By the 1990s, most of America’s long-term care facilities for the severely mentally ill were no longer in service. Now, the onus of inpatient care of severely mentally ill patients rests on nursing care facilities, the criminal justice system, and the diminished number of specialized long-term inpatient care centers that treat mental illness. Housing is perhaps the most pressing health care access problem for individuals with severe mental conditions. Without proper housing, they are liable to suffer the myriad negative health outcomes of homelessness. Some of these patients Courtesy of WavebreakmediaMicro /Fotolia also end up in the criminal justice system, where their health care access is limited by the institu- Thorazine was used to treat mentally ill tion (U.S. Bureau of Justice Statistics, 2006). Out- patients before antipsychotic drugs were comes are improved for those patients who live available. with their families, but access is often limited to community resources for the caregivers of mentally ill patients. If there is a lack of community resources, the strain on caregivers may be overwhelming; as a result, patients may end up having to leave their homes. More funding for community support programs and resource organizations like the National Alliance for the Mentally Ill (NAMI) may lead to increased access and improved outcomes. Many of these same support programs can also help create positive outcomes for people with mental conditions who live independently, in board and care homes, group homes, and veterans’ housing. The Surgeon General’s 1999 report on mental health in the United States reflected that social attitudes that encourage a microlevel personal view of mental health that put all the responsibility of care on the individual negatively affect funding proposals that would support mental health services (National Institute of Health, 1999). Legislation increasing financial support of mental health programs, and increasing coverage for mental health therapies, could change social opinions and raise awareness of the existence of a vulnerable population living with mental conditions. Resourcing staff who once worked in longterm care institutions for the mentally disturbed to train new staff in community-based programs would increase those programs’ ability to effectively help psychiatric patients (Koyanagi & Bazelon, 2007). bur25613_06_c06_173-194.indd 179 11/26/12 2:49 PM Section 6.1 Organizational Barriers CHAPTER 6 Suicide- and Homicide-Liable Persons Suicidal and homicidal behaviors stem from a mix of mental health problems and socioeconomic inequality. As such, the programs in place that work to lower suicide and homicide rates are uncoordinated. Programs on violence prevention exist in the fields of physical health, mental health, community-based support programs, education, social services, criminal justice, and public health and wellness. Initiatives range from suicide hotlines to school assemblies about violence prevention to support group therapies. The federal initiative, Public Health Objectives for the Nation, 2020 (PHON), addresses suicide and homicide by working to reduce the following (U.S. Healthy People, 2012): • suicide rate • number of adolescent suicide attempts • number of people experiencing major depressive episodes in both adolescent and adult categories PHON attempts to meet these goals by doing the following: • increasing the number of primary care facilities offering mental health treatment services • improving access to mental health services for children • increasing screening for mental health problems in juvenile residential facilities • increasing depression screening in primary care settings • improving treatment methods for people with both mental health disorders and substance abuse behaviors Although clinical interventions are important for treating individual patients, community interventions have a greater effect on homicide and suicide rates on a macro level. One of PHON’s community intervention plans is an initiative to improve programs and access to those programs for treating patients who have suffered traumatic events. Improved training for hospital social workers, emergency room staff, physicians, and educators will increase the recognition of adults and youth who are prone to violence or are subjected to violence, and get them into prevention programs faster. Improving local economies and living conditions in low-income areas may also reduce the overall number of attempted homicides and suicides by reducing stress on the people who populate those areas. Persons Affected by Alcohol and Substance Abuse Alcohol and substance dependence has both physiological and psychological components. Physiological dependence on a substance is evidenced primarily by the development of physical symptoms (withdrawal symptoms) when the substance is no longer consumed. Psychological dependence, on the other hand, manifests as a desire, or “craving,” for a substance. Although effective treatment for alcohol and substance abuse must address both the physiological and psychological aspects of a person’s addiction, some treatment programs address only one or the other. This means that patients are sometimes forced to coordinate two kinds of care in order to address their chemical dependencies. In some circumstances, both physiological and psychological therapies are offered in tandem bur25613_06_c06_173-194.indd 180 11/26/12 2:49 PM Section 6.1 Organizational Barriers CHAPTER 6 under the umbrella of one provider organization. Many patients are under treatment as mandated by social services or the criminal justice system. These patients often lack the means to seek out the best possible treatment options for their particular circumstances, and instead receive the minimum mandated care. Alcohol and substance abuse programs are improved by increasing awareness of the socioeconomic struggles that lead to higher drug Courtesy of Jochen Sands/Thinkstock abuse rates in some communities. Culturally sensitive treatments use Many alcohol and substance abuse programs do not cultural components, like religion holistically treat the patient, instead addressing either only the psychological symptoms or only the physical symptoms. and cultural-based social norms, to encourage and empower the patient to continue treatment and make the necessary physical and emotional changes that can keep them from relapsing. Treatment centers can also reduce organizational barriers by hiring bilingual staff and locating in underserved areas. Indigent and Homeless Persons Homeless individuals are far more likely to lack a regular family doctor. Many avoid seeking care unless absolutely necessary. When medical care does become an immediate need, homeless persons without a regular physician often end up at urgent care centers and hospital emergency rooms. Social attitudes about homeless people often lead to their being met with negativity and hostility. Many homeless people report being sent away from some medical care clinics to seek treatment elsewhere. Transportation difficulties make it difficult for this vulnerable population to move from clinic to clinic seeking medical treatment. bur25613_06_c06_173-194.indd 181 Courtesy of Brand X Pictures/Thinkstock Between 2009 to 2010, a lack of health care and increasing rates of reckless behavior have raised demand for emergency food assistance by nearly 24%. 11/26/12 2:49 PM Section 6.1 Organizational Barriers CHAPTER 6 Financial barriers, social stigmas, and physical access barriers like limited transportation lead to an exacerbated health deficit for America’s homeless. Increased rates of unprotected sex, drug abuse, and HIV, combined with a lack of regular health care, have caused America’s homeless numbers to strain the support system that is in place to address their needs. The U. S. Conference of Mayors’ 2010 Hunger and Homelessness Survey reported that demand for emergency food assistance increased almost 24% from 2009 to 2010. Mayors reported that increasing the availability of affordable housing topped their initiatives lists as a means to mitigate a growing homeless population. Unemployment was the most cited cause of homelessness for family units. Together, increasing employment opportunities and affordable housing offer a macrolevel solution to reducing the number of America’s homeless and to reducing the need for medical care among this population. Fewer homeless puts less strain on the health care delivery system and may increase access to those still homeless by having a smaller pool of people who rely on the already small pool of funds for emergency care of the homeless. Immigrants and Refugees Naturalized citizens face fewer organizational access barriers than undocumented immigrants and refugees. Many refugees live in government-subsidized housing. Others may live in areas that are more densely populated with other immigrants. Physicians’ offices and other medical clinics are often sparse in these areas. In some cases, medical providers have the legal right to request proof of legal immigration before seeing patients. Many undocumented immigrants avoid seeking medical care for fear of deportation. Immigrants and refugees also face language barriers and cultural barriers to accessing health care. Medical providers can limit these barriers by hiring bilingual staff and training staff to understand and meet the needs of their patients based on cultural ideals and norms. For example, a physician’s office that treats a significant number of Muslim families should be familiar with acceptable behaviors related to the body, such as rules concerning clothing and disrobing in front of a person of the opposite gender, as dictated by the religion of Islam. Other cultural barriers involve differences in how health and well-being are defined. Cultural acceptance is fundamental to providing quality care to immigrant populations. Critical Thinking Many vulnerable patients have a “fear of a health care delivery system that is populated by practitioners who cannot relate to vulnerable patients’ struggles.” How do you interpret this statement? How might a practitioner overcome this fear? Self-Check Answer the following questions to the best of your ability. 1. Authorized providers can access a patient’s health data ______. a. on the Internet b. in electronic health records bur25613_06_c06_173-194.indd 182 11/26/12 2:49 PM CHAPTER 6 Section 6.2 Financial Barriers c. d. in a centrally located records department in a warehouse in Washington, DC 2. Many of the support services available to disabled people are delivered through what type of programs? a. Veteran’s Affairs b. Medicaid c. community d. state department 3. Currently, which entities are responsible for inpatient care of severely mentally ill patients? a. nursing care facilities b. private homes c. local businesses d. professional organizations Answer Key 1. b 2. c 3. a 6.2 Financial Barriers T he United States spends more on health care per capita than any other nation, and health care costs are still rising across the globe. This is partially due to America’s free market economy, which avoids regulating industry as much as possible. It is also because America is a forerunner in the development and adoption of new medical technologies and pharmaceuticals. New technologies and drugs cost more than older ones because the manufacturers price them high to help recoup the costs associated with research, development, and federal safety approval. Courtesy of George Doyle/Thinkstock Deregulation of the industry and the rapid development of new medical technologies and pharmaceuticals have resulted in the United States spending more on health care per capita than any other nation. bur25613_06_c06_173-194.indd 183 Most insurance plans include copays, deductibles, and cost sharing. These patient charges result in decreased financial accessibility to medical care, even for patients with private payer insurance. As it is difficult for patients to know what their out-of-pocket expenses will be for many tests and procedures done in physician offices, many people avoid health care treatments as much as possible. In some 11/26/12 2:49 PM Section 6.2 Financial Barriers CHAPTER 6 circumstances, patients are subject to blood tests and other procedures without an opportunity to consider the costs before they are administered. Imagine the shock of one patient who received a bill for $7,000 for a DNA test that was not covered by insurance and was done at the same time that blood was drawn for routine annual blood work. Both public and private payers limit the amount of coverage per patient. Medicaid negotiates lower reimbursement rates for physicians. Because of this, many physicians maximize the percentage of clientele with private payer insurance because private payers have higher reimbursement rates. This practice, based on financial decisions, leads to organizational barriers to care when Medicaid and uninsured patients cannot find doctors and medical clinics that will treat them. Vulnerable Mothers and Children Prenatal care is expensive, partially due to the cost of treatment, and partially due to high liability insurance premiums that obstetricians must pay to avoid financial ruin from malpractice lawsuits. When doctors pay high insurance premiums, that cost is reflected in what they charge patients for care. In 2009, 22.3% of women of childbearing age (women in the age range of highest fertility, which is 15 to 44) had no insurance coverage of any type. This was an 11% increase from that of 2008 (March of Dimes Foundation, 2010). Uninsured women are significantly less likely to seek early prenatal care because the cost of prenatal care is so high. Medicaid patients are a bit more likely to seek care earlier in their pregnancies; however, many women eligible for Medicaid during pregnancy do not get through the application process until later in the gestational period (March of Dimes Foundation, 2010). Courtesy of Carlos Santa Maria/Fotolia For those who do have Medicaid coverage, find- In 2009, almost 25% of women of ing an obstetrician who accepts Medicaid patients childbearing age were without insurance is increasingly difficult. Progress has been made coverage. to reach out to obstetricians by increasing Medicaid reimbursements to incentivize them to accept Medicaid patients. With a dwindling number of practicing obstetricians, many uninsured and Medicaid-covered pregnant women seek prenatal care at local health departments, where their care is often uncoordinated. bur25613_06_c06_173-194.indd 184 11/26/12 2:49 PM Section 6.2 Financial Barriers CHAPTER 6 Abused Individuals It is argued that the social services departments that handle domestic abuse are underfunded and understaffed. Community programs that help abused women escape bad situations often rely on grants and individual donations. These programs are nearly nonexistent for male victims of domestic abuse. Males do not report the abuse for a number of reasons; hence, a program for males will not be fruitful until reducing the stigma of male reporting becomes a public health goal. Individual financial barriers exist in many abusive relationships where the victim is dependent on the offender for financial security, housing, and insurance coverage. This dependence makes it difficult for a victim to leave or improve an abusive situation. Shelters and other programs do exist to help battered women with housing and with finding work at little or no charge. Chronically Ill and Disabled Persons Chronically ill and disabled people have expensive, ongoing health care needs. Lifetime caps on insurance benefits, cost sharing between insurance companies and patients, and patient co-pays can all add up to large out-of-pocket costs for this vulnerable population. The Medicare SSDI program for disabled people who are unable to work has a two-year waiting period, though eligible people can apply for welfare and Medicaid in the meantime (U.S. Social Security Administration, 2012c). The first few years of a chronic condition or disability are often the most expensive in terms of health care needs. For the uninsured, this two-year waiting period can lead to two years’ worth of unpaid medical bills. Those with private payer Courtesy of Tatiana Belova/Fotolia insurance may reach their lifetime coverage limits and essenThe cost of treating a long-term illness is often highest in the tially lose their private payer first two years, during which time disabled people who are coverage while they apply for unable to work must wait before receiving Medicare SSDI Medicaid and wait for Medibenefits. care SSDI eligibility. Preexisting condition clauses in health insurance policies enable insurance companies to refuse coverage for many of America’s chronically ill and disabled people, but SSDI does not have preexisting condition clauses as it is designed to help these very people. Medicare and Medicaid do cover some long-term treatments, such as nursing home care and physical rehabilitation services. However, coverage is restrictive and based on a myriad of factors, including the chances of positive outcomes from the treatments and patient ability to cover some or all of the costs. Medicare will only cover long-term care for a bur25613_06_c06_173-194.indd 185 11/26/12 2:49 PM Section 6.2 Financial Barriers CHAPTER 6 maximum of 120 days, if the patient is making marked recovery or rehabilitative strides toward some end goal. At that point, Medicaid may pick up caring for the patient if they have less than $2,000 in total assets and make less than 133% of the poverty amount for an individual. Managed care plans and health care coordinators help limit costs by coordinating care across multiple disciplines (physical therapy, home visits by nurses, and so on) and negotiating better fees for both payers and patients alike. Persons Diagnosed With HIV/AIDS Financial barriers to health care access for HIV/AIDS patients are rooted in cost of care and social stigma. As HIV/AIDS drug therapies continue to improve, patients are living longer, which increases their lifetime cost of care for HIV/AIDS treatments. New improvements in treatment therapies are expensive because pharmaceutical companies price new drugs high to recoup research and development expenses. High prices and increased longevity lead to increased out-of-pocket expenses for HIV/AIDS patients. Early detection is essential, as many patients die within two years of the onset of AIDS without antiretroviral therapy. Early treatment can also help reduce the cost of medical care by slowing the progression of the symptoms of both the primary and related illnesses. Social stigma surrounding the HIV/AIDS epidemic has led to lax regulation of insurance coverage for HIV/AIDS patients. Many private payer insurance contracts allow for preapproval testing for HIV. Still others allow for immediate cancellation of the policy if a patient becomes HIV positive. Many states allow insurers to discriminate based on sexual orientation, and thereby limit the number of HIV positive patients in the insurance pool. HIV/AIDS patients with public payer coverage often find that Medicare and Medicaid coverage for HIV/AIDS–related treatments is minimal. Persons Diagnosed With Mental Conditions Though federal health care laws do address the problem, there is still a parity gap between mental health treatment coverage and treatment coverage for physical health. This means that mental health services are not as available as physical health services, both in terms of geographic proximity to patients and in the ability of the existing mental health services delivery system to meet demand. Similarly, an equity gap also exists between mental and physical health services. This essentially means that patients who can afford better insurance coverage and higher out-of-pocket expenses have better access to mental health services than do those who cannot afford them. Medicaid does provide mental health benefits for qualifying patients, under which they can sometimes get more services, longer treatment duration, and good treatment from masters-level professionals—which is usually the requirement. The Patient Protection and Affordability Act of 2010 (PPACA) addresses mental health parity by expanding the applicability of federal mental health parity laws and mandating coverage for specified mental health and substance abuse recovery treatments (National Conference of State Legislatures [NCSL], 2011). bur25613_06_c06_173-194.indd 186 11/26/12 2:49 PM Section 6.2 Financial Barriers CHAPTER 6 Both public and private payer coverage is usually less for mental health services than for other services. Many plans include annual maximums in number of treatments and covered treatment costs with some federal- and state-mandated exceptions. Many also have higher out-of-pocket expenses for patients, which means that the insurer pays less of the total cost for mental health services than most do for physical health services. Medicaid in most states pays providers significantly less for mental health services than it does to physical health service providers. This has led to mental health professionals limiting the number of Medicaid patients they will accept. Suicide- and HomicideLiable Persons Violence prevention programs are historically underfunded and plagued by delivery problems. These programs work to prevent violence through social and economic investments in underserved, low-income communities and in individuals. A significant number of these programs are community-based and are financially dependent on private donations and grants. Many health Courtesy of powerofforever/iStockphoto care trauma centers that once attempted to serve low-income areas were put out of business Violence prevention programs work to prevent violence in part by the increasing costs of through social and economic investments in underserved, treating victims of violence who low-income communities and in individuals. were unable to pay for their care. As Chapter 7 illustrates, studies have found that violence prevention programs cost hospitals and trauma centers significantly less than does treating victims of violence. Persons Affected by Alcohol and Substance Abuse A significant disparity exists between alcohol and substance abuse treatments available to patients with private payer insurance and those with public payer insurance. Providers in the private sector earn more revenue while treating fewer patients. Though private payers limit the amount of coverage for substance abuse therapies, particularly inpatient treatments, patients with private payer coverage are better able to afford the out-of-pocket costs and, as such, demand higher-quality treatments. bur25613_06_c06_173-194.indd 187 11/26/12 2:49 PM Section 6.2 Financial Barriers CHAPTER 6 A benefit of these upscale treatment facilities is that many offer coordinated treatments, including both physical and mental health services, all under one roof. While private payer patients “recuperate” in these facilities, they often enjoy more comfortable accommodations than are available in institutions that serve public payer patients. In fact, many public payer substance abuse patients receive treatment under compulsory terms, meaning they are forced into treatment by social services or the court. While courts and social services are forcing people into substance abuse programs, welfare reformers have been cutting funding and eligibility for substance abuse coverage under Medicaid. The results of these cuts are that felons who are convicted of drug charges are not eligible for substance abuse program coverage in many states (when living outside of jails and prisons). This has particularly affected pregnant women who are addicted to alcohol and other drugs. However, some amount of treatment is available to jailed offenders. The Federal Bureau of Prisons has strengthened its substance abuse treatment programs in an effort to reduce relapse, improve convicts’ abilities to rejoin society, and improve the safety and social atmosphere inside penitentiaries (U.S. Department of Justice, Federal Bureau of Prisons, 2012). Indigent and Homeless Persons Most homeless people do not have any type of health insurance, and even those with insurance often cannot afford to pay their share of the cost of health services. Many different state and federal agencies (for example, Department of Health and Human Services and Department of Veterans’ Affairs) have programs in place to address the problem of homelessness and the needs of homeless people. Some of these departments offer grants to community-based services and health care clinics and professionals who are willing to treat indigent people as a significant portion of their client base. Many of these funding opportunities are administered under the Stewart B. McKinney Homeless Assistance Act of 1987, which specifically recognized the need for federal monies to address homelessness and the needs of this population. Since 1987, many agencies have had the designated funding for homeless programming cut, and recipient programs often lament the fact that the grant approval processes are unduly long and difficult to navigate. Immigrants and Refugees Financial access to health care for immigrants is similar to that of other groups in the United States. However, some immigrant and refugee members of the population encounter barriers to accessing public payer insurance because legislation like the Welfare Reform Act of 1996 decreased eligibility for nonnaturalized citizens. Undocumented immigrants have no access to public payer health care insurance in most states. Naturalized immigrants and those who qualify for public payer and private payer insurance generally have the same financial benefits and restrictions as other subscribers. bur25613_06_c06_173-194.indd 188 11/26/12 2:49 PM Section 6.2 Financial Barriers CHAPTER 6 Critical Thinking Health care tests and procedures are often performed without consulting patients on the costs and financial liabilities until after they have been rendered. Do you think it would be better if patients understood costs before services are rendered, or do you think discussing costs should be of secondary importance to the patients’ health? What do you think would be the result if health care providers were suddenly required to have patients sign off on the cost of each individual procedure before being rendered? Self-Check Answer the following questions to the best of your ability. 1. What programs are nearly nonexistent for male victims of domestic abuse? a. community support b. federal programs c. faith-based services d. public transportation to and from work 2. Many states allow insurers to discriminate against individuals on the basis of _____________________. a. a preexisting condition b. pregnancy c. sexual orientation d. immigration status 3. The Federal Bureau of Prisons has strengthened its substance abuse treatment programs in an effort to reduce what? a. occupancy b. in-prison drug use c. fetal alcohol syndrome births d. relapse Answer Key 1. a bur25613_06_c06_173-194.indd 189 2. c 3. d 11/26/12 2:49 PM Section 6.2 Financial Barriers CHAPTER 6 Case Study: Patient Profiling and Inequalities in Care as Organizational Barriers Susan was a 22-year-old Caucasian female who worked at a coffee shop. She did not have health insurance through work and had never considered checking for Medicaid eligibility. Susan and her boyfriend regularly used illicit substances, including crack, cocaine, and marijuana. When Susan became pregnant, she sought prenatal care at a local health department. Health department staff helped Susan sign up for Medicaid, and she continued with regular prenatal care at that facility. During one appointment in the third trimester, Susan’s doctor asked her if she ever had or currently used illicit drugs. Susan replied honestly and told her doctor that she had stopped using most drugs when she learned she was pregnant, though she continued to smoke marijuana and cigarettes on a regular basis. Susan later reported that the doctor nodded, took notes, and never counseled Susan on the negative effects of the use of those substances during pregnancy or offered cessation help. Weeks later, Susan gave birth to a full-term baby girl. The next morning, a physician she had never met before entered her hospital room with a social services worker. They told Susan that the doctor who had treated her at the health department throughout her pregnancy had reported Susan’s drug use to social services. They had already drawn blood from the baby to test for drug dependence, and Susan would be hearing from social services with the test results. They warned that if the baby tested positive, they were prepared to remove the infant from her mother’s care. Either way, Susan and the baby would be working with social services for the next year, or until their assigned social worker determined that there was no danger to either the mother or child. Courtesy of Stockphoto4u/ iStockphoto Susan abused drugs before and during her pregnancy and was threatened with the possibility of giving up her baby to social services. After two worry-filled days, the social worker arrived unannounced at Susan’s door. The baby had tested negative for everything and was deemed to be in good health. After six months working with her social worker, Susan was removed from the social services program after many follow-up visits and multiple negative drug tests. Susan reported feeling singled out by the doctors and social services and felt that she was punished for her honesty. Her basis for feeling singled out was that a friend of hers was simultaneously pregnant and had private payer health insurance. The friend reported never having been asked about cigarette, alcohol, or substance use or abuse history by any of her physicians or hospital staff. Part of the difference in their experiences was simply that they had different doctors. But the friend had a physician in an office that specializes in obstetric care for women with private payer insurance. It may be that Susan was profiled because she received her prenatal care at the public health department. bur25613_06_c06_173-194.indd 190 11/26/12 2:49 PM Self-Check CHAPTER 6 Chapter Summary O rganizational and financial barriers to health care are intertwined. These barriers range from the physical location of health care providers to providers’ reluctance to treat patients who have difficulty paying for treatment. Legislation that limits coverage eligibility and increases the ability of insurance companies and medical providers to deny coverage and care creates organizational barriers for both private payer and public payer patients. Some organizational barriers are created by the insurance companies’ and medical providers’ need to maximize profits. Many barriers can be overcome with legislation that improves eligibility and coverage. Still others can be overcome by targeting the social and economic problems that plague America’s most vulnerable populations. Critical Thinking This chapter discusses several issues related to the barriers faced by America’s vulnerable populations to accessing health care. Now that you have r...
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