Learning Objectives
• Learn the population groups facing greater challenges and
      barriers in health care access

• Understand racial and ethnic disparities in health status

• Be acquainted with the health concerns of America’s

• Appreciate the challenges faced by rural health and the

• Understand the nation’s mental health system.

• Understand the AIDS epidemic in America,
   – the groups affected by it, and
   – the services available to HIV/AIDS patients
• Certain population group at greater risk of
  – physical
  – psychological
  – social health

• Terms used:
  –   underserved
  –   medically underserved
  –   medically disadvantaged
  –   underprivileged
  –   American underclasses
     Population Groups
•   uninsured children
•   women
•   rural area residents
•   homeless
•   mentally ill
•   chronically ill
•   disabled
    Racial Ethnic Minorities
• >30% of U.S. population is minority

  – Black Americans - 12.8%

  – Hispanic Americans – 14.4%

  – Asian Americans - 4.3%

  – American Indians and Alaska Natives - 1%
  Racial Ethnic Minorities Stats
• Low birthweight is most common among
  Black Americans

• White adults drink more alcohol compared
  to other racial/ethnic groups

• Mammography use of women 40+ years
  old is:
  – greatest among white females,
  – lowest in Hispanics
Racial Ethnic Minorities Stats
– Look at Fig 11-1, page 425
– Look at Tbl 11-1, page 426
– Look at Fig 11-2 and Fig 11-3, page 427
– Look at Fig 11-4 and Fig 11-5, page 428
– Look at Tbl 11-2, page 429 - 430
– Look at Fig 11-6, page 431
– Look at Tbl 11-3, page 431
– Look at Fig 11-7, page 432
                  The Uninsured
• 9.2 – 9.7 million are children

• 46 million are non elderly

• Tend to be:
   – less educated, poor
   – working in part-time jobs and/or employed by small firms
   – younger 25-40 year olds

• Medically uninsured: employed but not covered due to:
   – employer does not offer health
   – employee does not qualify, too few hours worked
   – can’t afford

• Uncompensated care costs covered by Medicaid, federal grants
  to nonprofit hospitals and charitable organizations
• 26% covered under Medicaid
• 59% covered under private insurance
• 5-20% of children have disabilities
   – Look at Tbl 11-5, page 441
• Developmental Vulnerability
   – the rapid and cumulative physical and emotional changes that characterize
     childhood, and the potential impact that illness, injury, or disruptive family
     and social circumstances can have on a child’s life course trajectory.

• Dependency
   – children’s circumstances that require adults to take responsibility for
     recognizing and responding to their health needs.

• New morbidities
   – drug, alcohol abuse, violence, emotional disorders, learning problems
     Children and the US Health Care
• Health care for children is patchwork,
  disconnected programs

• US characterizes children’s into 3 sectors:
  – personal medical and preventive services sector
       – primary and specialty care
  – population-based community health services
       – immunization, abuse prevention, rehab, case management,
  – health related support services sector
       – nutrition, rehab, family support

• The leading providers of care in the nursing profession
   – also in allopathic and osteopathic medicine, dentistry, podiatry, and
       • Look at Fig 11-9, page 444

• Women in the US live 8 years longer than men, but they
  suffer greater morbidity and have poorer health outcomes.

• Heart disease and stroke account for a higher percentage
  of deaths among women than men at all stages of life.
       • 42% of women with heart attacks, die within the year
       • only 24% for men

• Women account for approximately half HIV/AIDS cases
• Women are more likely to be depressed than men
• Women are at substantially greater risk for Alzheimer’s
  than men

• Substance Abuse and Mental Health Services
  Administration are targeting 6 areas for attention:
   –   physical and sexual abuse of women
   –   women as caregivers
   –   women with mental and addictive disorders
   –   women with HIV/AIDS
   –   sexually transmitted disease or tuberculosis
   –   older women
                 Women and the
              US Health Care System

• Women are the principal users of the health care system, both for
  themselves and as the family care coordinator
   – Until the age groups 65-74 and 75 and older, women have higher physician
     utilization rates than men
   – hospitalization rates are comparable for men and women

• Women work more part-time jobs than men, receiving lower wages,
  and having interruptions in their work histories;
   – they are at a higher risk to be uninsured
   – Women are more likely to be covered as dependants under their husbands’ plans

• Women are twice as likely to be covered under Medicaid because the
  program is linked to Aid to Families with Dependant Children (AFDC)
                    Office on
               Women’s Health (OWH)
•   Dedicated to disease and disability

•   Coordinates and implements a comprehensive women’s health agenda
    on research, service delivery, and education across the agencies on
    Public Health Service

•   Responsible for implementing the National Action Plan on Breast Cancer
    (NAPBC), a major public-private partnership dedicated to improving the
    diagnosis, treatment, and prevention of breast cancer through research,
    service delivery, and education.

•   Working to prevent physical and sexual abuse, as stated in the Violence
    Against Women Act of 1994.

•   The Women’s Health Initiative, supported by the NIH, is occurring in more
    than 50 centers across the country. It is the largest clinical trial conducted
    in US history.
     – Focusing on major causes of death and disability among women
              Rural Health

• Poor access by:
  – poverty, long distances, topography,
    weather, availability of health care and
• Measures to improve rural health care:
  1) The National Health Service Corps
  2) Health Manpower Shortage Areas
  3) Medically Underserved Areas
  4) Community and Migrant Health Centers
  5) The Rural Health Clinics Act
  6) Rural Managed Care
                 1) The National Health
                       Service Corps

• Created in 1970

• To recruit and retain physicians in shortage areas

• A scholarship and loan repayment program
   – targeted doctors, dentists, nurse practitioners, midwives, and
     mental health professionals who serve a minimum of two years
     in underserved areas.

   – Since 1972 over 27,000 have been placed in medically underserved
2) Health Professional  Shortage
           Areas (HPSA)

• The Health Professions Educational Assistance
  Act of 1976 provided for HPSAs

• Three different types of HPSAs:
  – geographic area, population groups, and medical

• DHHS designated 1955 primary care physician
  shortage areas
  – 68% were in rural areas
           3) Medically Underserved
                Areas (MUA)
• Developed to support the:
  – federal health maintenance organization grant program
  – community health center and rural health clinic programs

• Factors in designing MUAs:
  – available health resources related to area size and
    population, health indices, care and demographics

• The Index of Medical Underservice was developed
  comprising four variables:
  –   Percent of population below poverty income levels
  –   Percent of population 65 + years old
  –   Infant mortality rate
  –   Primary care physicians / 1,000 population
 4) Community and Migrant Health
• Service to low income populations on a
  sliding-fee scale
• Serve 16 million patients per year:
  – 22% black
  – 34% Hispanic
  – 4% other minorities

• Offers primary and prevention
• Hard to attract physicians here
 5) The Rural Health Clinics Act

• Created due to concerns that isolated rural
     communities could not generate revenue to
  support physician services
• A reimbursement mechanism to create financial
      viability and ability to receive Medicare and
      Medicaid reimbursement
• Midwives, Physician Assistants, Nurse
  Practitioners do not need physician oversight
• There are over 3000 currently operating
      6) Rural Managed Care
• Gives physicians :
  – consultation opportunities
  – continuing education units
  – coverage for time off

• Faces demographic, geographic, and
  infrastructure challenges
• Health care needs in rural areas are as great or
  greater than in urban areas
• Physicians, hospitals, leadership, and
  governance usually in short supply
  – contributes to lack of access
                The Homeless

• Est 3.5 million people are without a home
   –   Single men – 43%
   –   Single women – 17%
   –   Children under 18 – 39%
   –   Families with children – 33%

• A multifaceted problem related to personal, social,and
  economic factors
   – Homeless adults and children, have a high prevalence of
     untreated acute and chronic medical, mental health, and
     substance abuse problems
   – At a greater risk of assault and victimization

   – Exposure to harsh weather
            The Homeless
• Barriers to Health Care
   – Barriers to ambulatory services
   – High hospitalization rates

• Reasons for barriers:
   1) Individual factors
          – Competing needs
          – Substance dependence
          – Mental Illness

   2) System factors
          – Availability
          – Cost
          – Convenience
            The Homeless

• Outreach to shelters, hotels, soup lines,
  parks, bus stations

• Health Care for the Homeless
  – a federal effort for medical service
  – Robert Wood Johnson supported

• Salvation Army provides:
  – social, rehab, support, food, housing
                Mental Health
• 1 in 4 Americans have a mental disorder in a
  given year

• Industry plagued with disparities in availability
  and access
   – hinges on financial status
   – tear down the stigma, fear and the hopelessness

• Medicaid is the single, largest payer
   – States had strong emphasis on inpatient care
    Mental Health
The plan:
  1) build science base
  2) overcome stigma
  3) improve public awareness
  4) ensure supply of mental health
  5) ensure state-of-the-are treatment
  6) tailor treatment to demographics
  7) facilitate treatment
  8) reduce financial barriers
            Mental Disorders
• Managed care

  – Managed care is also expanding into mental health.

  – State and local government want to contract with
    managed care organizations to handle the mental
    health and substance abuse services covered by
Mental Health Professionals

   • Psychiatrists
     – physicians
     – postgrad training in mental health
     – have power
        • can prescribe prescriptions
        • admit patients

   • Psychologists
     – usually have doctoral degree, some
     – interpret and change people’s behavior
     – cannot issue prescriptions
             Mental Health
• Depression
  – The most common illness among primary care
     • affects approximately 14.8 million adults in the US.

  – Risk Factors
     •   History of depression,
     •   Family history,
     •   Stressful life events,
     •   Lack of social support,
     •   History of anxiety,
     •   Postpartum period,
     •   Substance abuse,
     •   Medical comorbidity,
     •   Being single,
     •   Old age,
                The Chronically Ill
                  and Disabled
• Unique challenges to our health system that is oriented
  toward acute care
• In 2005, over 90 million Americans had chronic conditions
   – 6.1% have limitations in ability to perform ADLs
   – By 2010, 141 million will have a chronic condition.
   – Chronic disease accounts for 75% of the total medical expenditure
• Chronic
   – an illness if disease or injury with long-term symptoms, 3
     or more months
• Disability
   – a person’s short-term or long term limitation / inability to
     perform tasks that were previously done unaided; a gap
                     HIV / AIDS
• July 1982, a disease was officially named:
  – acquired immuno deficiency syndrome (AIDS)
     • See Figure 11-11 (page 459)

• AIDS caused by human immunodeficiency virus

• 6th leading cause of death among people aged 25-
  44 years old in 2003
              HIV / AIDS
• Risk factors:
  –   male-to-male sexual encounters
  –   male to female sexual contact
  –   injection drug use
  –   blood product exposure
  –   perinatal transmission frm mother to infant
       • during pregnancy, delivery or possible breastfeeding

       • Look at Tbl 11-8, page 461
       • Look at Tbl 11-9, page 462
       • Look at Tbl 11-10, page 463
             HIV / AIDS
• HIV testing is anonymous or
  – Most states offer anonymous HIV testing
  – All states offer confidential testing
  – Have rapid HIV tests

• Treatment tries to slow the progression
  – HIV and opportunistic infections
     • (ie tuberculosis)
  – Includes cocktails
           Cost of HIV / AIDS

• The course of AIDS:
  – a gradual decline in a patient’s physical,
    cognitive, and emotional function and well-

• Medical care is very expensive
    • $119,000 per person on average due to inpatient care
       • Look at Fig 11-12, page 471
      Cost of HIV / AIDS
• Medicaid is primary payer

  – Medicaid waiver programs
    • packages of services
    • an alternative to institutional care

  – Ryan White CARE Act, 1990
    • federal monies to develop treatment and care
    • purpose was to give emergency assistance to
      cities affected
       – (ie testing, counseling, case management)

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