Category: Healthcare Reform

Public Health & Epistemologies of Ignorance

The field of public health has primarily thought about improving health by making changes for individuals. We try to get individual people to quit smoking, make dietary changes to combat obesity, and start using condoms or other safer sex practices to limit exposure to sexually transmitted infections (STIs). However, all of these interventions focus only on changes that individual people are supposed to make. They don’t think about barriers that impact an individuals ability to make these changes or other factors that could be affecting, positively or negatively, the health of individuals.

In thinking about public health interventions, we should think about a multi level analysis, including the micro level (individual), the meso level (interactional, community), and the macro level (institutional, structural). Factors at each of these levels can positively and negatively impact health; however, by only looking at the individual (the micro level), we miss a significant portion of the picture in terms of health, especially when we start thinking about health disparities.

Lisa Bowleg (2017) argues that this represents an epistemology of ignorance, specifically that the focus on the individual and on health as a characteristic solely of the individual (a very neoliberal position), “obscure[s] the role of social–structural factors (e.g., political, economic, institutional discrimination) that constrain the health of historically marginalized individuals, communities, and societies” (678). She continues to argue that “[e]pistemologies of ignorance illustrate that willful ignorance is functional (Alcoff, 2007; Mills, 1997, 2007). Neglecting the historical legacy of how race (as well as the other marginalized social positions that intersect with race) has structured social inequality for people of color in the United States serves to center the health experiences of White people as normative, “color blinds” White privilege to highlight positive health outcomes among White people as the product of their individual actions, and reifies negative stereotypes about the “irresponsible” health behaviors of people of color (Bowleg et al., 2017).” From a political perspective, she argues that this focus on the individual in public health, and in other spheres, limits the political imperative and pressure to conduct research and enact laws that would address the social-structural factors in order to alleviate health disparities.

Bowleg, L. (2017). Towards a Critical Health Equity Research Stance: Why Epistemology and Methodology Matter More Than Qualitative Methods. Health Educ Behav, 44(5), 677-684. doi:10.1177/1090198117728760

Are You Healthy? (Part 2)

Previously, I discussed changes to our model of health due to randomized control trials and the pharmaceutical industry, as discussed in Joseph Dumit’s Drugs for Life. Here are the three primary models of health as discussed by Donald A. Barr in his book Health Disparities in the United States: Social Class, Race, Ethnicity, & Health. 

The first model is the medical model or physical health model that focuses on the absence of symptoms or other signs of disease or illness. However, Barr mentions several issues with this model of health, noting “that this approach to defining health tells us what the concept of health is not. . .It does not tell us what health is” (2014, pp. 15). He expands on this later:

“What are we to make of a condition that has no abnormal symptoms? An important example of this is high blood pressure, also referred to as hypertension; persons with hypertension develop symptoms only after a number of years. Should we consider a person with somewhat elevated blood pressure to be unhealthy based on our knowledge that his blood pressure will eventually lead to further problems? What might be the consequences of labeling such a person as ‘unhealthy,’ even if he feels fine?” (Barr, 2014, p. 16)

These are the questions that Joe Dumit attempts to answer, looking beyond hypertension to guidelines about pre-hypertension and the prescriptions of statins with no understanding of when patients can stop taking them.

The second model is the sociocultural model or the model of health as functioning at a normal level. Barr looks at it in contrast to the medical model, which looks at absence, because the sociocultural model looks at the presence of an ability to function at a level that has been deemed normal (2014, p. 17). The ability to functional normally is defined in regards to one’s ability to completed five “activities of daily living (ADLs),” which are roughly, (1) eating, (2) bathing, (3) dressing, (4) using the bathroom, and (5) moving on one’s own (2014, p. 17). Of course, the entire premise of “normal functioning” is subjectively predicated on societal ideas of self-sufficiency that might vary from culture to culture or community to community.

The third model is the psychological model or the model of health as a feeling of well-being. In this model, individuals are able to assess themselves and their own health with the help of several developed measures (Barr, 2014, p. 18). However, Barr notes that these tests are often “time-specific” (Barr, 2014, p. 18). I would argue that health is always time specific and temporal. I may be healthy today, but I can quickly develop a health problem or injure myself, perhaps even resulting in a temporary or life-long disability, reaffirming the temporality of both health and disability.

According to Barr, these models can be combined to create a multidimensional model of health that presents a better picture of the health of an individual.

Trans Youth, Ethics, & Access to Healthcare

There are four primary principles for ethical decision-making in health care (respect for autonomy, 2. justice, beneficence, and non-maleficence); however, these four principles do not necessarily yield the most beneficial results for trans youth or bodies that exist in contradistinction to state controlled modes of life. Medical practice is able to manage the modes of life for trans youth, relying on non-maleficence and a paternalistic notion of future expectations to continually withhold medical intervention.

The duality of beneficence and non-maleficence has often been presented as the double effect, where a single action may have both positive and negative effects that must be weighed against one another (Veach, 2007). A common example is when providing morphine to a dying patient. The patient’s suffering will be limited, causing a beneficial effect; however, the morphine simultaneously slows the respiratory system, causing the patient to die more quickly, the harmful double effect.

In the case of trans youth, this double effect is often used as a way to withhold hormone treatment or other medical intervention because the state and the medical institution see the greater harm if trans youth “change their minds” about their gender. Further, medical professionals discuss the potential harms within a framework of compulsory reproduction. The harm of hormones is seen as an inability to reproduce later in life, which maintains the assumption that biology is destiny (Adkins, 2017).

As we approach these ethical issues, there are difficult power dynamics inherent in the biopolitical state that limits what modes of living are seen as livable. For instance, an inability to reproduce is seen as unlivable or unruly. To provide better care for trans youth, we need to deconstruct current notions about the lack of autonomy for young people broadly, and especially for trans youth.

Adkins, Deanna (2017). “Transgender medicine: A wealth of ethical dilemmas.” Presentation.

Veatch, Robert M. (2007) “How many principles for bioethics?” In R. Ashcroft, A. Dawson, H. Draper, and J. McMillan (Eds.) Principles of Health Care Ethics, Second Edition. Chichester: John Wiley & Sons.

Thank you to Dr. Marshall for the fascinating presentation!

Last week, we were excited to have Dr. Laura Marshall discuss her dissertation research with us. Her work looked at the different types of comments posted online under an article for Breitbart and for Huffington Post, both on the subject of healthcare reform. Identity seemed very important to establish in both comments sections with “othering” used as the most common social process, i.e. invalidating a differing opinion typically through name-calling and questioning of intelligence. Main distinctions between the two sets of comments included Breitbart comments focusing on personal responsibility and a distrust of government actions or programs, and Huffington Post comments emphasizing social justice and hopeful solutions.

What is the purpose of these comments sections and, ultimate goal, how can communication professionals utilize them? Dr. Marshall’s theory is that users of comments sections establish identity through “othering,” then seek or offer information within their group, and propose solutions.

Are You Healthy?

To understand whether or not your healthy, you have to first understand what it means to be healthy. It seems straightforward, but in the modern age, this is a complex question.

We might at first be inclined to think that being healthy means that you don’t have any illness or injury. But is this always true? What if you have an illness that is managed by medication? What if a person has a disability but the disability doesn’t disrupt their daily life? What if you’ve been diagnosed with pre-hypertension but have no symptoms?

Joseph Dumit, Director of Science and Technology Studies and Professor of Anthropology at the University of California, Davis, discusses various changes to our view of health and illness since the rise of the randomized control trial in his book Drugs for Life: How Pharmaceutical Companies Define Our Health (Duke University Press, 2012). He argues “that being at risk for illness is often treated as if one had a disease requiring lifelong treatments, drugs for life” (6).

Dumit discusses a few prediseases in depth, looking at pre-hypertensive, pre-diabetes, and borderline high cholesterol. “Literally, a disease-sounding syndrome is produced by correlating risk factors and naming it in such a way that it becomes common sense to think about treating ‘it’ as a disease in and of itself” (165). Hence, health becomes a matter of risk where we are all bodies constantly at risk of disease. If you have pre-diabetes, are you healthy? How do we understand our health in a risk economy of health?

This intersects interestingly with Donald A. Barr’s claim, in his book Health Disparities in the United States: Social Class, Race, Ethnicity, & Health, that despite investing so much of our economy in health, US health indexes rank rather low; “[p]erhaps, our basic assumption–that more health care will lead, necessarily, to better health–is flawed.”

GOP Bill Halts in Senate

Remember back in May when the GOP health bill passed in the House? The momentum stopped there.
The Senate failed to pass a GOP-proposed Health Law yesterday. Senate Majority Leader Mitch McConnell says they’re going to try again early next week, though it doesn’t seem like this will be a promising attempt either. Analysts attribute this to many deep-rooted factors:  the Republican party as a whole not unified behind an action plan other than repealing the ACA, the taking away of funding and resources without a viable exchange, and a severe lack of public hearings and drafting.
Provisions included in a draft of the bill last week including capping funding for Medicaid, and giving states the power to opt out of insurance regulations substantiated in the Affordable Care Act. This fielded much opposition from more moderate Republicans. They cite problems  such as too “deep cuts” to Medicaid, and an insufficient means to account for the expenses of changing the insurance system. This opposition was especially strong in Republican states like Ohio that had expanded Medicaid under the ACA.
Now, Republican Senators are working on re-drafting a “repeal and delay” bill that would phase out aspects of the ACA over a two year time frame–a version of this bill passed in 2015. Of note, the draft of this bill to be debated does not include an amendment proposed by Senator Ted Cruz. According to a report conducted by the Department of Health and Human Services, this amendment might actually result in broader coverage and lower premiums. The quality and correctness of this report is already under great criticism by healthcare and insurance analysts.
Sources: The New York Times, Kaiser Health News

Caring for Our Veterans

On Memorial Day we remember the men and women who have served our country as part of the U.S. military. After concluding their service, military veterans often face substantial physical and mental health issues that require medical care. Many of these veterans choose to seek care through the Department of Veterans Affairs (or facilities with which the department contracts). According to the U.S. Department of Veterans Affairs, “The Veterans Health Administration is America’s largest integrated health care system with over 1,700 sites of care, serving 8.76 million Veterans each year.” When coordinating services and care within such a massive health care system, it is inevitable that challenges arise.

 

Last year, the U.S. Government Accountability Office issued a report outlining the current issues facing the veteran health care system. Because of the many issues that they identified, including risks associated with timeliness, cost-effectiveness, quality, management, and oversight, the GAO placed VA Health Care on the 2015 High Risk List. This list included other pressing national issues such as Federal Oversight of Food Safety, and Managing Climate Change Risks.

 

Some improvements have already been made to the VA health care system. Most notable is the Veterans’ Access to Care through Choice, Accountability, and Transparency Act of 2014, which was signed into law in order to expand survivor benefits and educational opportunities and to improve care for veterans. The law also sought to address the need for increased accountability, transparency, and recruiting of high quality medical professionals at VA facilities. At that time, President Obama also announced 19 new executive actions to improve mental health services for the military, veterans, and their families.

 

Despite these initiatives, it is clear that more work still needs to be done to ensure that those who have served are not returning home to face the further danger of inadequate medical care.

What can healthcare learn from Uber?

Reports and news stories about the wastefulness of the U.S. healthcare system abound, but the healthcare industry may be able to combat some of that waste by embracing the growing trend of collaborative consumption or a shared economy. This new economic model is rapidly gaining traction in other industries, especially the travel and hospitality industries, where companies like Uber, Lyft, and Airbnb are changing the way that people think about consumption by tapping into unused resources and creating peer-to-peer sharing networks.

In the Robert Wood Johnson Foundation’s Pioneering Ideas podcast, Rachel Botsman, coauthor of the book What’s Mine Is Yours: The Rise of Collaborative Consumption, explained the concept of a collaborative economy and identified the potential future role it could play in the healthcare industry.

Botsman posits that the growing waste, broken trust, unnecessary complexity, and redundancy in the medical field could be mitigated by a shared economy model. Some other unused or underused resources that could be tapped into with a sharing economy model include things like excess food, unused gym memberships, and the skills and knowledge of retired health care workers.

In addition, some hospitals have already created peer-to-peer networks in which expensive medical equipment can be shared with or rented to other hospitals that need them.  Because each hospital does not need to invest the hundreds of thousands of dollars to purchase their own device, it removes waste from the system and allows new technology to be adopted and utilized more quickly and efficiently, which can mean better and more affordable care for patients.

Botsman attributes the growing popularity of collaborative consumption to the rise in peer trust that is beginning to surpass the trust people have in traditional companies, as well as people’s increasing expectation and demand for two-way interactions. These ideas echo some of the underlying principles in the growing healthcare trends of patient empowerment and shared decision making.

 

What are some health or healthcare issues that you think could be addressed by a shared economy system? Share your thoughts in the comments!

The Costs and Benefits of Full-Time Employment: ACA Challenges

As the enrollment deadline for health coverage through the Affordable Care Act (ACA) has recently passed, more Americans will be eligible to receive heath care that is affordable and consistent, regardless of their pre-existing conditions. Obviously, this is a plus for many on the consumer side of the spectrum, but what does it mean for struggling employers now having to pay more to offer coverage to more of their workers?

The beginning of 2016 marked an ACA requirement that all employers with 50 or more full-time workers offer health coverage, or otherwise pay a steep penalty. In some cases, this has had unintended consequences, forcing employers to downsize, to both cut health costs and/or avoid the requirement altogether.

Some smaller employers are learning the hard way and are making staffing adjustments just to stay afloat. This is especially the case among the fast food industry, where most employers have decided to avoid the steep ACA penalty by making more of their workers part-time, precluding these employees from the option of employer-based coverage. Obviously, this isn’t doing any favors for the employees, so is cutting corners like this really worth it?

Another aspect of this situation is that when employers decide to make more workers part-time, the more workers they have to hire to do the job. As a result, there are usually scheduling headaches and frequent turnover, and as a result, many managers and business owners complain the quality of their establishments has declined.

And this makes sense. If workers who are already earning minimum wage aren’t going to be rewarded in other ways for their work, what incentive do they have to remain loyal to their employer? With less loyalty come fewer skills. It’s a problem that is unfortunately on the rise as ACA mandates — although intended to support the consumer, actually end up not only being ineffective to the employee, but also hurting the employer as well.

In the end, in many cases, the workers end up paying the most severe penalty. Workers who desire to work more hours — to be full-time — yet can’t because their employer can’t afford it. And, as a result of the workforce being flooded with part-time workers, some areas are seeing an increase in their numbers of Medicaid recipients. For many, there is nowhere else to turn, despite their desire to be independent. And for others, they say they come out better by working part-time and receiving health coverage through the state.

So, what do you think? Do you think Obamacare is fulfilling its promise to make Americans safer and more secure through health coverage, or have the unintended consequences caused more problems?

 

Photo credit: Bloomberg News

Changing Our Thinking: Quality Over Quantity for a Better Health System

For many of us covered by a health insurance plan, the thought of how much we spend on the services we receive — whether it’s a routine procedure, such as a mammogram, or a monthly medication for anxiety — is unlikely to cross our minds. The most we might think about the cost incurred lies with our copay, the reduced amount we pay for the service we utilize under our plan. Copays can vary—from $10 to $45—depending on the type of service used.

But what about the actual cost of those services and medications? What does a mammogram really cost? Surely 30 tabs of a common antidepressant don’t cost just $45. Folks without insurance might be more aware of the realities of this, although they are less likely to obtain these types of services and medications for that very reason alone — cost.

While the average cost of a mammogram is around $100, the cost of other preventative services, such as a colonoscopy, can cost upwards of around $5,000. Medicare recipients usually don’t have to feel the sting of such a bill since they’re likely to also receive a special type of coverage called Medigap, which pays for the services Medicare doesn’t cover.

But does that mean we still shouldn’t be concerned with keeping our healthcare expenditures at a minimum or is the sky the limit? And even if you are concerned, will your doctor know how much things cost before you choose to undergo them? Most physicians say they know very little about medical pricing since they received very little or no formal training at all regarding healthcare spending or cost-effectiveness when it comes to tests and treatments.

Instead, most providers were taught the American rationale of healthcare — to focus on the best treatment they can offer, regardless of the cost. But in a world where many individuals are no longer able to afford insurance coverage due to ever-rising expenditures, should our nation continue with this way of thinking? Or should we become more mindful of costs, even if we aren’t the ones bearing the burden of them?

Fortunately, the Affordable Care Act is bringing attention to the long overdue subject, forcing medical equipment companies and the pharmaceutical industry — known as Big Pharma — to take a hit through higher taxes. Those dollars are now being shifted to help fund many new enrollees to receive the coverage they need to remain healthy.

But as more people enroll, will they, too, become less likely to bear in mind the cost that remains for the services they receive? Unfortunately, for those physicians who are interested in helping their patients make informed decisions, there isn’t much help available; however, smartphones have made obtaining this knowledge easier, through apps that link to health insurers’ price databases.

But the question still remains — “Will knowing the price of a colonoscopy have any affect on those that are considering one?” Of course, I’m by no means suggesting patients and providers forego services if they are truly needed, as in cases where there’s a family history or pre-existing conditions occur. But I would like to see more concern placed on the quality of care providers give and patients receive. Making the patient more a part of his/her health plan is key to garnering an interest in what services cost and whether or not they are truly needed.

Perhaps as the ACA makes it’s way into history books and more folks get insured, we’ll see a shift in priorities, with a stronger emphasis on quality care at reduced cost, for that’s the only way we’ll truly begin to see equality for all in the game of the healthcare sector.