Module 5 Overview Healthcare Policy 1. History and Social Construction of U.S. Health Care A. Health: A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. B. Health care: right or privilege? • Health insurance: A type of insurance coverage that pays for certain healthrelated expenses incurred by the insured. a. Relatively modern invention. b. Not discussed in the United States until Theodore Roosevelt’s presidency. c. Idea gained momentum in 1930s, when rising costs made health care inaccessible for low-income and middle-class Americans. • Some have argued that health care is a right and should be available to all through systems such as compulsory health insurance. • Sheppard-Towner Bill: Passage represented the beginning of federal support in an American health program. Led to creation of child welfare departments in more than 30 states. • Franklin Roosevelt in his State of the Union Address to congress outlined adequate medical care as a right that all Americans should have. • Professional organizations influence policy and how we talk about health. For example, note the AMA opposition to proposals for health insurance. • Medicine versus public health: a. Are we concerned with the health of individuals of the health of populations? b. Public health approach is associated with seeing health care as a right. • Children’s Health Insurance Program was created based off of President Clinton’s proposal to reform the health care system. C. Mental health • Mental health: A person’s condition with regard to their psychological and emotional well-being. • Historically, people with mental health issues were likely to end up in institutions, prison, or on the streets. Care was often inhuman and cruel, with physical or chemical restraints. • Mental illness has been criminalized or used as a tool of power. a. Justification for lobotomies, imprisonment, restriction from getting married, and sterilization. b. Eugenics: Procedures that are designed to “improve” the human population by increasing desirable characteristics and decreasing undesirable characteristics, primarily through manipulation of reproduction. • The National Mental Health Act of 1946 created the National Institute of Mental Health. • Diagnostic and Statistical Manual of Mental Disorders: The handbook used as the authoritative guide to the diagnosis of mental disorders. D. Substance use • “Alcoholism” entered the medical language in the 1800s, reflecting treatment of alcoholism as a disease rather than a criminal offense. a. Treatments included detoxification, inpatient treatment, and continued care supervised by a community physician. b. Some of these treatments unfortunately included the use of other drugs as part of the “recovery” process. • Prohibition and other efforts to criminalize all use of alcohol and other drugs decreased the availability of treatment. a. Prohibition: Efforts and movements to criminalize the use of substances such as alcohol or other drugs, often refers to the movement in the United States between 1929 and 1933 to prevent the making and sale of alcohol. b. Harrison Act of 1914 moved dealing with substance use from public health arena to criminal justice system. c. These were particularly used to target African American men. • Next wave of substance use treatment: Minnesota Model. a. Medication-assisted treatment (MAT): Treatment for substance use that combines behavioral therapy and medications. b. Harm reduction: Strategies and policies that aim to minimize negative health, social, and legal aspects associated with drug use in a nonjudgment manner. • Opioid epidemic: Case study of Fred Coulter v. Purdue Pharma. 3. Current Health Policy A. Introduction • Disparity in spending between the U.S. and other countries.: In 2016, health care spending per capita in the U.S. was 20% more than the next highest country. • Health care is provided by fragmented set of providers and insurers. • Underinsured: Individuals or families who have access to some health care that does not fully meet their needs. B. Health care and inequality • Causes of inequality include limited access to preventive care, racialized healthcare practices, access to health providers, and lack of empirical research that examines health considerations of non-White populations. • Social determinants of health: The conditions in which people are born, grow, live, work, and age. Examples: employment and working conditions; social exclusion; income; and gender, racial, and sexual inequality. Racism results in significant health disparities. C. The Affordable Care Act (ACA) • Inclusion of essential health benefits that all health plans must cover was expected to lead to increased expenses by insurers. Essential health benefits: According to ACA, those procedures and services that must be covered by insurance. • • Designed to expand Medicaid to cover a larger pool of individuals. Implementation of the ACA is complex. It relies on legislation that has been changed by Congress several times. D. Medicare • Most universal health insurance program in the United States. • It was designed to cover adults over the age of 65 when it was enacted as an expansion to the Social Security Act in 1965. • There are four major parts: a. Part A covers hospital and nursing facility care. b. Part B covers doctor visits and outpatient services. c. Part C covers HMOs. d. Part D covers prescription drugs. E. Medicaid • The nation’s single largest social safety net program. • Recipients of Medicaid are diverse. • Structured by a set of federal requirements, which allow states discretion about how to provide services within those guidelines. • Funding for Medicaid comes from both the federal and the state governments. • Reimbursement rates: Payments that health-care providers receive in exchange for services rendered to patients. • Hurdles to care: Stigma, access to transportation, lack of care outside of usual business hours, and lack of enforcement by state Medicaid oversight agencies. F. Veterans’ health • The Veterans Administration (VA) was established in 1930. • It expanded in 1944 after the passage of the Servicemen’s Readjustment Act and became a cabinet-level Department of Veterans Affairs in 1989. • Veterans’ facilities offer care to veterans who need physical health care, mental health care, substance use services, long-term care, and care to those who are homeless or at risk of homelessness. 4. Policy Informed by Alternative Lenses and Implications A. Capitalism: A capitalist approach to health care argues that using the private market to deliver services creates a system that is more innovative, less bureaucratic, and less prone to fraud. • Capitalism: A belief system that privileges private ownership of goods and property for profit, rather than by the state. B. Managed care: A system of health decision-making by a competitive system of private actors. • Proponents highlight its cost-effectiveness, and opponents point out that it struggles to manage complex care. C. Human rights • Human rights approach looks at the positive and negative effects of health policies, programs, and practices on human rights. Human rights: Rights inherent to all human beings regardless of race, sex, nationality, ethnicity, language, religion, or any other status. • Approach examines ways in which human rights violations affect health. • This approach has the potential to add cost and time to the process of providing health care. May require significant shifts in the ways that health systems and the public think about health care. D. International alternatives: Germany, Great Britain, Switzerland, and Portugal • Germany: All citizens and permanent residents are required to obtain health insurance through a combination of public and private services and pay a mandatory contribution of 14.6% of their gross wages. • Great Britain: Health care is free and a universal service. It is offered as a public service and doctors are government employees. Private health care is also available by a network of private physicians who charge for their services. • Switzerland: Health insurance is required and quite expensive; it is offered by mostly private agencies which are regulated by the government. • Portugal: Decriminalization of drug use. Government emphasizes that they have decriminalized drug use not legalized it. 5. Opportunities for Advocacy A. Discriminatory treatment of people of color in health care • Tuskegee syphilis study: the U.S. Public Health Service withheld treatment from African American men who had syphilis without their knowledge or consent. • In Guatemala, the U.S. Public Health Service infected people with syphilis to study them. B. Nutrition programs • Access to nutritious and adequate food is an important aspect of health. U.S. policy often deals with nutrition separately from health. • WIC provides supplemental food packages to low-income pregnant women until 6 months postpartum or after giving birth and to their children until age 5. • As a part of President Lyndon Johnson’s great Society Programs in 1964, the Food Stamps program was created by the Food Stamp Act of 1964 to give agricultural surplus to poor families. • In the 1980s, the federal government began to mandate that states develop electronic benefit transfer systems (EBT) for beneficiaries to pay for their benefits with a card that looks like a credit card, making it easier and less stigmatizing for participants to use their benefits. C. Universal health care • Universal health care refers to systems that provide quality medical services to all, regardless of their ability to pay. • Single-payer health-care proposals: Access to the full continuum of physical and mental health services for all people regardless of age, race, ethnicity, religion, gender or gender expression, sexual orientation, cognitive or physical functioning, socioeconomic or immigration status, or geographic location. • Such policies are common in other countries but are still debated in the U.S. Disability Policy 1. History and Social Construction of U.S. Disability Policy A. Models of disability • The medical model assumes that disability is experienced only by the person with the disability and that it is caused by a medical problem or condition that requires some treatment or rehabilitation. • The Nagi model suggests a relativist view in which a person’s disability is defined in part by societal expectations of what people should be doing. • Social model: An approach that views the environment as a problem, rather than the person (individuals with disabilities). • The World Health Organization: The most comprehensive definition of disability. a. Disability is a result of the interaction between the individual and the environment. b. Activity: Execution of a task or action by an individual. c. Activity limitation: Difficulties an individual may have executing activities, generally focused on activities of daily living. d. Impairments: Problems in body function or structure resulting in an inability to do something that people are generally expected to be able to do. e. Participant restrictions: Problems individuals may experience in involvement in life situations. • Many U.S. disability-related policies are based on the medical model and the Nagi or functional limitations model. • Non-apparent disabilities: Disabilities that cannot necessarily be seen by others and encompass a wide range of diagnoses, including dyslexia, Crohn’s disease, chronic pain, mental illness, and attention-deficit/hyperactivity disorders. B. The early U.S. history of disability • People with disabilities had no basic human rights and were seen as a burden because of their dependence on their families and their towns. • In the early 1800s, the first classifications for mental illness were recognized: dementia, melancholy, and mania with and without delirium. • The mid-1800s saw the rise of almshouses with terrible living conditions. • Dorothea Dix fought for better living conditions and tried to overcome the stigma that people with disabilities were helpless and a burden • Eugenics sterilization laws emerged in the early 1900s: Sterilization carried out against people with disabilities in an effort to rid humans of “bad genes.” 2. Social Security Act and Disability Rights Movements Begin A. In 1960, Social Security was expanded to cover all workers with disabilities and their adult children. B. Modern disability rights movement § Began in 1960s, and was inspired by African American and women’s civil rights movements. § The first federal law to protect the civil rights of people with disabilities was Section 504 of the Rehabilitation Act of 1973 (known as Section 504). § In the late 1970s, the people who started the independent living movement at Berkeley founded the Disability Rights Education and Defense Fund. § In 1986, the National Council on the Handicapped, issued a report recommending a law to promote equal opportunity for people with disabilities. a. Their report led to the introduction of the Americans with Disabilities Act, signed into law by President George Bush in 1990. b. This movement challenged the medical model of disability. 3. Current Disability Policies A. Social Security Disability Insurance and SSI • SSI provides financial assistance to people with severe disabilities, no matter their age or work history as long as they are sufficiently disabled and meet income eligibility guidelines • Social Security also provides survivor’s benefits and retirement income. • Problems associated with SSDI and SSI: a. The definition of disability is strict, and the rules for determining whether someone qualifies are complicated. b. Neither program adequately addresses chronic illnesses that may flare up for less than a year, making people temporarily unable to work but not long enough to be eligible for SSI or SSDI. B. Section 504 of the Rehabilitation Act of 1973 and the Americans With Disabilities Act • Made it a civil rights violation for federal agencies and any agency receiving federal funding to discriminate against people with disabilities based on their condition. • Provided many of the founding principles and guidelines on which the Americans with Disabilities Act (ADA) was based. • Americans with Disabilities Act (ADA): designed to expand upon the rights that were created in Section 504 of the Rehabilitation Act. a. Title I of the ADA requires that all employers other than religious organizations, who employ 15 or more people, make reasonable accommodations in employment. b. Title II of the ADA applies to public services and transportation. c. Title III applies to public accommodations (public and private facilities used by the public, including stores, schools, etc.) C. Individuals With Disabilities Education Act (IDEA) • Two major parts: (1) designed to address the educational needs of infants and toddlers, and (2) designed to address those needs for school-aged children (K–12). • In order to be eligible for special education services under the IDEA, the disabling condition must adversely affect a student’s educational performance. D. The Patient Protection and Affordable Care Act • Prohibits discrimination by insurance companies and health care programs based on race, color, religion, sex, national origin, age, or disability. • Allows children to stay on their parents’ insurance until they are 26. • Prior to ACA, many had to forgo work opportunities to stay eligible for Medicaid, which relegated many to living in poverty in order to receive medical care. • ACA implementation varies across states. • Vocational programs: Programs designed to help people either enter or return to the workforce, sometimes referred to as Vocational Rehabilitation programs. E. Disability in the workplace and higher education • HEOA made postsecondary education more accessible and affordable for people with disabilities. • Universal design: The idea that education or workplace structures can be designed in a way that is optimal for everyone so that there is less need for adaptation to account for individual needs. • Workforce Innovation and Opportunity Act provided incentives for employers to hire more people with disabilities. 4. Policy Informed by Alternative Lenses A. Introduction • In 2006, the United Nations ratified the Convention of the Rights of Persons with Disabilities. This document was ratified by 177 countries. The United States has signed, but not ratified, this treaty. • The World Policy Analysis Center at UCLA analyzed the implementation of the Convention’s goals. • The United States provides neither constitutional protection for people with disabilities to work nor guaranteed health-care access. B. Norway: Example of a country with an excellent system for providing support for people with disabilities. 5. Opportunities for Advocacy A. Use of language • Best Buddies is an international not for profit agency that aims at inclusion for people with disabilities by advocating friendships. • They have created the Spread the Word to End the Word Campaign that tries to tackle stigmatizing language used for people with disabilities. B. Disability awareness • Advocacy activities around disability include increasing awareness of different types of disabilities and their effects and the capabilities of people with disabilities to contribute on par with others. • Advocacy groups are pushing to train law officers on disability awareness, in light of recent altercations. C. Self-advocacy: Many areas have self-advocacy groups led by people with disabilities. • Self-advocacy movement is even reaching into the schools in the form of studentled IEP meetings, and staff collaborates with students to prepare them to learn about their disability. • Person-centered planning has increased the momentum for people with disabilities to obtain services in an empowering way, as they are more likely to be involved in their care.
