Access to CarePHHE 461
1
Housekeeping (1)
Quiz 2 online (available Mar 20-22)
Materials: since last exam through Access to Care
module
Exam 2
Week of March 24
Study guide posted
Doodle poll to determine date of exam
Materials: since last exam through Access to Care
module
2
Housekeeping (2): DB This Week
Provide an example of health care disparities (i.e., barriers to
health care or health status differences across racial/ethnic,
gender, sexual orientation, socioeconomic groups) that you
have witnessed or have personally experienced.
For this question, make sure to post on at least 2 different days
of the week, and respond to a peer in at least one of your
posts.
Each post should be at least 75 words, and be free of
grammatical/spelling, punctuation errors. The assignment is
due Sunday, March 22 @ 11:59 PM.
3
NIU Career Services Remote
Assistance
For assistance, email CareerServices@niu.edu with your
name, major, email address, phone number, the best time
to reach you, and the topic you’d like to discuss with our
staff.
We’ll have staff available remotely form 8:30 a.m. to 4:30
p.m., Monday through Friday, who will reach out to you to
respond to your career concern
4
Internship & Job Fairs (1)
Career Hotspot
Visit the Career Hotspot table for quick and convenient
help from NIU Career Services. Get your resume, cover
letter, or LinkedIn profile reviewed and learn to use
Huskies Get Hired to access over 1,500 internship/job
openings.
Wednesday, March 25, April 1, April 8, April 15, April 22
at 11:00 AM to 1:30 PM
Founders Memorial Library, 71 North, Lower Level
217 Normal Rd, DeKalb, IL 60115
5
Internship & Job Fairs (2)
2020 NIU Health and Wellness Fair
The Employee Assistance Program and
Recreation Services
Wednesday, April 1st
Holmes Student Center, Ballroom (on the main
floor)
10:00 a.m. to 1:00 p.m.
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LeadingAge Illinois – CANCELLED
LeadingAge Illinois is one of the largest and most
respected associations of providers serving Illinois
older adults.
The LAI annual conference is March 17 – 19 at
the Schaumburg Convention Center. This is a great
opportunity to get a glimpse into the industry, meet
people, and attend fantastic educational sessions.
Free student registration; fill out the attached form
and send to info@leadingageil.org
Julie Boggess, MPA, LNHA
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Instructor/Interim Director of Gerontology
815 753-6339
Career Services
NIU Career Services, 220 Campus Life Building
815-753-1641
www.niu.edu/careerservices
www.niu.edu/careerservices/huskiesgethired
Search jobs, upload resume
Practice interviews online 24-7
www.perfectinterview.com/niu
Record & review your responses to typical
8
interview questions
Schedule a Perfect Interview session: 815-753-
Lecture Overview
Economic barriers
Non-economic barriers
Health care disparities
Race/ethnicity
Culture/acculturation/language
Gender
Sexual orientation
Educational level
Issues in homeless medicine
9
Access to Care: Economic Barriers
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10
Access to Care
Not just determined by health insurance coverage
Insured patients face noneconomic barriers
Language
Culture
Health care beliefs
Care seeking behavior
Educational status
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Economic Barriers
Insurance coverage
What is covered? Anything not covered adds to out-
of-pocket costs which can become a barrier to care
Outpatient and inpatient care?
Prescription drugs?
Mental health services?
What are the copays and deductibles?
12
The Uninsured (1)
Fluctuations in uninsured
50.7 million (prior to 2010)
Just under 26 million (2016)
27.9 million (2018)
Safety net providers
Free clinics
Federally qualified health centers
Hospital emergency departments
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The Uninsured (2)
Why?
High costs of insurance
No insurance through job
In states with no Medicaid
Income above ACA cutoff for assistance
Undocumented immigrants are ineligible
for Medicaid or Marketplace coverage
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The Underinsured
Lack coverage specific types of health
care
Insured w/ significant medical
expenses, medical insurance,
deductibles
5-10% of salary
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Kovner & Knickman (2011)
Who Are the Uninsured? (1)
Older adults – low (1.8%)
Medicare program coverage
Young adults
Difficulty receiving Medicaid
In some states, limited to PWDs, pregnant women,
unemployed parents
Part-time workers
Retail, service, construction, agricultural sectors
Varies by state
Ranges: MA, IA, RI – 9% uninsured to TX, NM – 20%
uninsured
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Who Are the Uninsured? (2)
Typical profile uninsured person:
Young adult, low-wage job, working for small
employer in the retail services sector.
Particularly for small businesses, offering
insurance can be prohibitively expensive
Affordable Care Act – employers with 50+
employees must provide insurance or pay a
penalty
Businesses with adverse outcomes
Uninsured mothers: begin prenatal care later
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Impact of Economic Barriers to Care: System
Costs
Negative effects to society as a whole
1. Greater use of
2.
Emergency rooms
Hospital outpatient clinics
Community-based clinics
Financial impacts
Providers (e.g., hospitals) covering the uninsured
must cover the costs of unreimbursed care
Cost-shifting to other payers (e.g., to patients with
health insurance paying higher reimbursement rates)
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Raising costs of services above actual costs in order to cover
the unreimbursed care
State Initiatives to Improve Health
Care Access
Near-universal coverage initiatives
Massachusetts
Mandate for all to have health insurance coverage
Insurance exchange for individuals to buy insurance if it is not
covered by employer
Maine
Premium subsidies with new insurance products for persons
below 3 times the poverty rate
Vermont
Requires employers to contribute to worker health insurance
coverage
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Effects Patient Protection & Affordable Care
Act (2010)
Insurance available for individuals with pre-existing
conditions started in 2014
Health care exchanges available for individuals to buy
health insurance started in 2014 (if not covered by
employer)
Expand Medicaid for non-Medicare eligible individuals
under age 65 (including adults without dependent
children) in 2014
Participating states
Incomes up to 138% of the federal poverty level
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▪ Effective Sept 23rd, 2010:
▪ Banned lifetime caps on most health benefits
▪ Restriction on annual coverage limits
▪ Adult children can remain on parents’ health insurance policies up
Current Status of Affordable Care
Act (2020)(1)
President Trump and Republicans in Congress have
pledged to repeal and replace the Affordable Care Act
Advocated for several unsuccessful proposals in
Congress in 2017
As part of the Tax Cuts and Jobs Act of 2017, Congress
eliminated the Affordable Care Act’s tax penalty for
most people who are not covered by health insurance
effective in 2019
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Current Status of Affordable Care
Act (2020)(2)
On Dec. 14, 2018, a federal judge in Texas ruled that
this change to the law’s individual mandate makes the
entire law unconstitutional, though that decision has
no effect as the case works its way through the
appeals process
Twenty Republican-led states, along with individual
plaintiffs, sued in February 2018 to abolish the ACA.
Argued that the individual mandate is unconstitutional
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because the Congress in 2017 zeroed out the penalty
associated with not having insurance, and as a result,
the rest of the Affordable Care Act must fall with it
Current Status of Affordable Care
Act (2020)(3)
After presidential election, the Supreme Court will
rule on this case to abolish the Affordable Care Act
(2010)
The court will allow 33 state hospital associations to
file a legal brief supporting Democratic attorneys
general and the U.S. House of Representatives’
argument that the rest of the Affordable Care Act
should be preserved even if the individual mandate is
found unconstitutional
25
Current Status of Affordable Care
Act (2020)(4)
The Trump administration has no replacement plan
Professor Nicholas Bagley: “”You can’t craft an ACA
replacement overnight. It takes years of diligent work
with stakeholders, legislators and policy experts. The
Trump administration has exhibited zero interest so far
in doing any of that work.”
26
Access to Care: Noneconomic Barriers
27
What Affects Access to Care?
In addition to economic barriers, there are
other noneconomic barriers to care:
Language
Culture
Health care beliefs/beliefs about health
care system
Educational levels
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Health Disparities (1)
Population-specific differences in the prevalence of
disease, outcomes of care, and access to health
services.
e.g., differences in health outcomes, health status
by
Gender
Race/ethnicity
Socioeconomic factors
29
Health Disparities (2)
Health care access affected by
Economic factors
Income
Insurance status
Noneconomic factors
Language
Health literacy
30
Health Disparities (3)
If mortality rates for Whites and African Americans
were the same
>> 83,570 fewer deaths among African Americans each
year.
For new AIDS cases, in comparison to Whites:
African Americans are 10 times more likely to develop
AIDS
Hispanics are 3 times more likely to develop AIDS
Children of poor families half as likely to receive
dental care.
31
Health Disparities (4)
Black, American Indian, and Alaska Native (AI/AN)
women
Two to three times more likely to die from
pregnancy-related causes than white women
This disparity increases with age (CDC MMWR,
2019)
Death rate for African-Americans declined 25
32
percent between 1999 and 2015 (CDC MMWR,
2017)
Significant health disparities between black and
white Americans remain, with black life
expectancy still nearly four years less than that of
whites (CDC MMWR, 2017)
Removing Economic Barriers Doesn’t
Erase All Barriers
Pregnant women on Medicaid delayed prenatal care,
Compared with those with commercial insurance.
Late detection of breast cancer was comparable for
uninsured and Medicaid patients.
33
Health Disparities by …
Race/ethnicity
Culture/acculturation/language
Gender
Sexual orientation
Educational level
34
Race/Ethnicity (1)
Large racial/ethnic disparities in
Health status
Utilization services
Preventive care (i.e., influenza immunizations); diagnostic
procedures (i.e., X rays, mammograms); surgical procedures (i.e.,
coronary bypass)
Health outcomes
Race/ethnicity & socioeconomic status
intertwined:
Some differences because of socioeconomic conditions
35
But, differences persist when insurance status &
socioeconomic status controlled for
Race/Ethnicity (2)
Why do differences persist?
Racial bias of the US health care system?
A study of referral candidates for cardiac
catheterization
White men were more likely than women
and African Americans to be referral
candidates
Attitudes towards the health care
system?
Individuals of some races/ethnicities may not prefer or
36
be informed adequately to use the formal medical
Culture/Acculturation/Language (1)
Not well understood
Particularly affects Hispanic/Latino and Asian
Americans & immigrant populations
Because of?
Distrust of the formal American medical system
Different concepts disease & illness from their culture
Unfamiliarity with the US health care system
Perceived provider disrespect
Concerns about immigration status
Language barriers
37
Culture/Acculturation/Language (2)
Disparities because of acculturation?
Acculturation: assimilation in new culture;
change in cultural behavior
How measure acculturation?
By language proficiency
Can acculturation negatively affect health status?
Limited family connections (in home country)
↑ consumption of processed foods while living in the US
38
Health Disparities with the Gay, Lesbian,
Bisexual, Transgender Population
Poorer health status & poorer health behaviors than
with the heterosexual population
Poorer physical health status
Poorer mental health status
Higher incidence of
Depression
Suicide
More likely to engage in negative health behaviors
Smoking
Binge drinking
Substance abuse
Eating disorders
39
Gender
1.
Women historically have been excluded from
clinical trials related to new drugs & procedures
2.
Physician gender can affect practice patterns &
service utilization.
3.
Some research indicating that female physicians are more
likely to prescribe pap smears & mammograms
Restricted access to family planning & abortion
services
–
–
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Doctors therefore are less likely to prescribe drugs because
of limited research on efficacy of drugs for women
Greater effects on low-income women
Anti-abortion efforts
Education (1)
Low parental educational levels is related to
Lower use well-baby and preventive services
Low education levels linked to
Lower rates breast cancer screening
Lower rates usage of preventive services
Greater difficulty following medical regimes
More likely missed appointments
41
Education (2)
Functional health literacy
Affects reading, writing, and computational skills
as a patient
Reading prescription labels
Following diagnostic test instructions
Understanding treatment directions; not doing so may
have fatal consequences
Take medications on an empty stomach
Return for follow-up visit
Follow instructions gastrointestinal radiological
exam
42
The Homeless – Access to Care (1)
Definition:
An individual who lacks a fixed, regular, and adequate
nighttime residence
3.5 million Americans experience homelessness each
year
Street medicine:
Collaboration of professionals delivering health care &
related services to people living on streets or in austere
environments
43
The Homeless – Access to Care (2)
Some barriers of the homeless to health
care services:
Limited financing/lack of health care
insurance
Stigma
Transportation
Competing survival priorities
44
Barriers: Stigma (1)
Societal stigma: homeless are assumed to be
Lazy
Drug abusers
Mentally ill
The homeless may expect such stigmatization from
Health care providers
Other patients
45
Barriers: Stigma (2)
Physicians have historically been seen as
having
Position of power, status
Some physicians may see the homeless as
Challenging
Dangerous
Morally suspect
Unworthy
46
Barriers: Finances, Insurance
Not eligible for Medicaid
If childless, not pregnant (prior to 2014)
Often not eligible for Medicare
Not elderly, not disabled
Except in some cases where state has a waiver
Difficulties affecting enrollment in health care
services
Unaware of services (e.g., Veterans)
Identification problems
47
Barriers: Lack of Transportation &
Survival Priorities
Financial problems >>
Lack of access to public and personal
transportation
Survival priorities contributes to poor health
status
Food >> malnutrition
Water >> dehydration
Shelter >> frostbite/burns
Safety >> victimization/violence
48
Hygiene >> wound infection
Survival Priorities Compete with
Medical Care
The homeless have survival priorities which may
take precedence over seeking out health care
services
Time priorities:
They must find place to stay/sleep which may affect time available
to stand in lines for medical care services
Safety concerns:
They may be concerned that their belongings may be stolen during
a medical visit
Financial decisions:
They are more likely to prioritize obtaining food rather than
treatment/medications
49
Barriers: How Affect Access to Care
for Homeless
Some of the ways
Stress-related depression
Decline in individuality and self-esteem
Fear of arrest
Mistrust traditional health care system
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How Homeless Medicine Addresses Barriers
Clinicians involved in medicine for the homeless
may affect the following to break down barriers
seeking health care services
Break down traditional practitioner power roles &
empower the patient
Foster patient-physician collaboration
Provide free services when possible
No transportation needed: services come to homeless
Working in coordination with social services which can
help to:
Find housing
Provide food, clothing, etc.
51
Employment preparation services
Wrap-Up
Economic barriers
Non-economic barriers
Issues in homeless medicine
52
Provide an example of health care disparities (i.e., barriers to health care or health status differences
across racial/ethnic, gender, sexual orientation, socioeconomic groups) that you have witnessed or have
personally experienced.
Response at least 75 words.
A big health care disparities that involves race/ethnicity is the fact that minority women are likely to be
under cared for. We are more likely to be told nothing is wrong or we are overacting. I have experienced
this firsthand. I have a hard time breathing and I get shortness of breathe from doing somethings as
simple as putting on lotion. Every time I tell my doctor, I don’t feel like she is taking it serious. I have
been trying to find another doctor, but with my insurance it is hard. – Cooper
Response at least 75 words.
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