Accessing Health Care

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.
Courtesy of Beerkoff/Fotolia
CHAPTER 6
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
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?
Introduction
Introduction Though 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.
CHAPTER 6Section 6.1 Organizational Barriers
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 Organizational 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
CHAPTER 6Section 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).
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.
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.
Courtesy of Kati Molin/Fotolia
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.
CHAPTER 6Section 6.1 Organizational Barriers
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 difficulty walking without the use of a cane. This may mean that he or she can only access doctor’s 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. Courtesy of Getty Images/Thinkstock Often, treatment is hindered for people with mobility problems due to an inability or difficulty in getting to treatment centers.
CHAPTER 6Section 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.
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.
Courtesy of Minerva Studio/Fotolia
Inadequate staff training and lack of funds can prevent HIV/AIDS patients from receiving proper care.
CHAPTER 6Section 6.1 Organizational Barriers
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 also end up in the criminal justice system, where their health care access is limited by the institution (U.S. Bureau of Justice Statistics, 2006). Outcomes are improved for those patients who live 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).
Courtesy of WavebreakmediaMicro /Fotolia
Thorazine was used to treat mentally ill patients before antipsychotic drugs were available.
CHAPTER 6Section 6.1 Organizational Barriers
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
CHAPTER 6Section 6.1 Organizational Barriers
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 abuse rates in some communities. Culturally sensitive treatments use cultural components, like religion 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.
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%.
Courtesy of Jochen Sands/Thinkstock
Many alcohol and substance abuse programs do not holistically treat the patient, instead addressing either only the psychological symptoms or only the physical symptoms.
CHAPTER 6Section 6.1 Organizational Barriers
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?
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.
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
CHAPTER 6Section 6.2 Financial Barriers
c. in a centrally located records department d. 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 The 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.
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
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.
CHAPTER 6Section 6.2 Financial Barriers
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).
For those who do have Medicaid coverage, finding an obstetrician who accepts Medicaid patients is increasingly difficult. Progress has been made 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.
Courtesy of Carlos Santa Maria/Fotolia
In 2009, almost 25% of women of childbearing age were without insurance coverage.
CHAPTER 6Section 6.2 Financial Barriers
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 insurance may reach their lifetime coverage limits and essentially lose their private payer coverage while they apply for Medicaid and wait for Medicare 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
Courtesy of Tatiana Belova/Fotolia
The cost of treating a long-term illness is often highest in the first two years, during which time disabled people who are unable to work must wait before receiving Medicare SSDI benefits.
CHAPTER 6Section 6.2 Financial Barriers
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).
CHAPTER 6Section 6.2 Financial Barriers
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 care trauma centers that once attempted to serve low-income areas were put out of business in part by the increasing costs of treating victims of violence who 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.
Courtesy of powerofforever/iStockphoto
Violence prevention programs work to prevent violence through social and economic investments in underserved, low-income communities and in individuals.
CHAPTER 6Section 6.2 Financial Barriers
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.
CHAPTER 6Section 6.2 Financial Barriers
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 2. c 3. d
CHAPTER 6Section 6.2 Financial Barriers
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. 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. 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.
CHAPTER 6Self-Check
Self-Check Answer the following questions to the best of your ability.
1. Among PHON’s community interventions plan is an initiative to eliminate programs and access to those programs for treating patients who have suffered traumatic events. a. True b. False
2. The U.S. Conference of Mayors’ 2010 Hunger and Homelessness Survey reported that demand for emergency food assistance increased how much from 2009 to 2010? a. 4% b. 13% c. 24% d. 42%
3. Cultural acceptance is fundamental to providing quality care to which populations? a. religious b. immigrant c. minority d. pregnant female
Chapter Summary Organizational 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 read this chapter, what do you think is the root of the problem? What short-term changes would you recommend to improve access? What long-term changes would you recommend to improve access?
CHAPTER 6Additional Resources
4. In 2009, what percentage of women of childbearing age had no insurance coverage of any type? a. 8.2% b. 15.6% c. 22.3% d. 48.6%
5. How long is the waiting period for the Medicare SSDI program for disabled people who are unable to work? a. 2 years b. 7 years c. 12 years d. 15 years
6. Many health care ___________ that once attempted to serve low-income areas were put out of business by the increasing costs of treating victims of violence who were unable to pay for their care. a. substance abuse centers b. criminal justice courts c. domestic abuse victim services d. trauma centers
Answer Key 1. b 2. c 3. b 4. c 5. a 6. d
Additional Resources Visit the following websites to learn more about the topics covered in this chapter:
Information on the community-based and health care organization–based resources supported by the CARE Act
http://hab.hrsa.gov/
Healthy People, which discusses the goals of HHS for the next 10 years
http://www.healthypeople.gov/2020/default.aspx
The American Foundation for Suicide Prevention
http://www.afsp.org/
CHAPTER 6Key Terms
childbearing age The age range of highest fertility, which is 15 to 44.
compulsory Forced by legal or physical means.
electronic health records Digital databases that store patient health information, making it accessible to all of a patient’s approved providers.
epidemiology The study of how a disease moves through populations.
equity Access and coverage being the same for all people.
gynecological care Medical care specializing in the female reproductive system.
obstetricians Doctors who treat pregnant women for pregnancy.
parity Access and coverage being the same across health service types.
pathology The history of a disease.
physiological Having to do with the physical body.
psychological Having to do with the mind.
Web Exercise Research at least five (5) credible websites regarding patient profiling as described in the case study toward the end of the chapter. Write a five-page paper that does the following:
• defines and describes patient profiling • describes two specific cases of patient profiling (one positive and one negative) • identifies three positive issues and three negative issues of patient profiling • identifies your personal stand on this issue and why you took that position
Remember: All papers must meet APA format. YouTube and Wikipedia are not considered creditable sources. Citations must be included.
Key Terms

TO GET YOUR ASSIGNMENTS DONE AT A CHEAPER PRICE, PLACE THIS ORDER OR A SIMILAR ORDER WITH US NOW.