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Public Health and Health Insurance as a Public Good: Part 3

October 30, 2013

IMGP3157While the media has given a lot of coverage to citizens complaining about having to pay for health insurance for pregnancy when they are men or have wives past child-bearing age/interest, or for pediatric care, or birth control–the story being lost is the one about health insurance as a public good. If all citizens have access to a certain level of care, then all citizens should achieve a certain level of health, and that should be good for all of us, the public good associated with health insurance and the public’s health.

Of course, we hear these arguments in other contexts. There are people who don’t have children who don’t want to pay for public schools. People who don’t use the interstate system not wanting to pay for maintenance of the interstate system. So it seems to be a very old tune, but the words for the new verse haven’t been rehearsed very well. Without telling more about how sharing the cost of paying for a level of health care aims to benefit all of us, complaints get heard and the argument for the ACA gets lost.

Likely, over time, debates will unfold as data collects to support or fail to support ACA’s benefits for society. Will we improve on some of the major health indicators, such as infant mortality rate–with the U.S. ranking 30th on a recent list []. That is the hope. It will likely take some discussion and some effort to work toward achieving such aims. And some revision of the ACA. A foundation of understanding related to its purpose is a good place to start.

Public Health in the U.S., Public Good, and the Affordable Care Act: Part II

October 20, 2013

IMGP3159Most of us learn at a very young age what “medical doctor” means. Far fewer of us learn what “public health” means. Our nation’s public health system functions largely as a backdrop to promote the well-being of all of us in the U.S.  As a member of the Institute of Medicine–IOM–committee that wrote the report, “Who Will Keep the Public Healthy: Educating Public Health Professionals for the 21st Century,” []  this reality emerged time and again, as we discussed and debated the roles that the public health force play.

I often teach Korean and Chinese graduate students who look to the U.S. for a model for public health and how to organize and deliver it in their countries where policies are newer and emerging.We tend to take for granted that someone has inspected the safety and health of restaurants where we eat, the meat and produce that we buy to consume, and the water quality coming into our work sites and homes. These “luxuries” sometimes become more salient when we visit outside the boundaries of the U.S.  In reality, these illustrate ways that our health is being safeguarded, not only for our individual well-being but for the health of all of us–with inoculations required for public school one of the most recognized acts taken for this aim.

The public good is served when actions are taken to protect and promote the health of each one of us as individuals in order to reduce the likelihood that any one of us will contribute to the illness of others and/or incur costs linked to the poor health of others. This principle frames some of the actions taken as part of the Affordable Care Act but has not been emphasized or clearly explained.


The Public Good, Public Health, and the Affordable Care Act: Part 1

IMGP3169October 10, 2013.

Political discourse related to naming access to health care as a priority shows expansion to the underserved and needy during the era of the Great Society, when Presidents Kennedy and Johnson expanded the social welfare and services system. During this era, the arguments in support of an economic model to support the government’s role in health and health care extended well beyond the need to keep a work force healthy. They included powerless groups, such as the elderly, who needed government assistance. They also included migrant farmworkers who harvest much of the nation’s food but often lack access to health care. Edward Murrow first exposed the conditions in which these laborers exist in the documentary, “Harvest of Shame.”    

My first doctoral student to complete her degree as my advisee told me about her mother’s labors in harvesting the nation’s crops in the fields of California. Her mother died at a young age from cancer likely the result of pesticide exposure during those long hours of harvesting.

From a social justice side, it seems only fair to provide care to the nation’s harvesters of food. When that assertion did not work, evidence that a harvester’s poor health and poor sanitation habits–failure to wash hands, for example–could contaminate the food supply was brought forth. This argument relates to public health and the public good, such that safeguarding the health of those who harvest our food benefits everyone’s health. Too little discussed in conversations about affordable health care are the issues related to public health and the public good.    

Social Justice, the Unemployed, and the Affordable Care Act: Part 5

 October 5, 2013

IMGP3133A fourth event shaping the government’s role in naming access to health and care as political priorities was the Great Depression, 1929-1941. Unemployed workers were unable to pay for their own health care. Because so many workers were unemployed, this led providers’ incomes to fall. Middle class citizens began to rely on public hospitals, and state and local health departments to receive health care. In turn, doctors began providing more services through these venues. Doctors charged the welfare departments. State welfare departments in turn charged the federal government. This cost-shifting system was supported by political priorities established in debates at the federal level and then by passage of such policy as the Social Security Act in 1935.

President Truman expanded Social Security and recommended national health insurance in 1949. He continued to work toward it unsuccessfully until 1953, a year before I was born. Nonetheless, an economic model based on commerce as the stimulus to support a government role in health care access made a transition to a government role in health care access for the needy or underserved with the initial stimulus being the unemployed. 

Social Justice, Workers and Congress, and the Affordable Care Act: Part 4

IMGP3160September 30, 2013

It didn’t take long for efforts associated with covering costs associated with worker’s health care to become burdensome. In 1927, the Congressional Committee on Costs of Medical Care proposed Health Maintenance Organizations [HMOs] as a strategy aimed at providing affordable health care to all citizens. A minority report written by doctors and adopted by the American Medical Association, however, took the position that HMOs would hurt the quality of health care. As a result, the Committee’s recommendation was not seriously considered.

Congress initiated a program for its own health care in 1928. In response to a number of elected lawmakers collapsing and even dying while on duty that year, Congress asked the Navy to provide a physician for the Capitol. The Office of the Attending Physician provides some basic care to members at a cost of about $500 a year, the same rate that has been in place since 1992.  The budget for the Office of the Attending Physician is more than $3 million []. There are several Navy doctors providing the care, together with more than a dozen registered nurses. The budget also includes a pharmacist, an ambulance available at the steps of the Capitol building, plus first-aid stations that staff members may use, and the x-ray and lab equipment available for care. In addition, care for families of Congress comprises choices much like all of us must make [].    


Social Justice, Workers, and the Affordable Care Act: Part 3

IMGP3152September 25, 2013

In the first two decades of the 20th century, middle class progressives realized that the American industrial society’s working-class citizens suffered ill health and injury through no fault of their own. Work places were often unsafe, causing injury to workers and their ability to work. In recognition of these facts, a number of economists formed the American Association for Labor Legislation (AALL) in 1905 for the purpose of studying labor conditions and labor legislation [see].

The AALL group advocated for health reforms in industry and sought compulsory health insurance. Initial efforts to argue the merits of such legislation focused on workmen’s compensation. This strategy aimed to provide access to care for workers injured on the job.

Woodrow Wilson joined the AALL []. He included their social insurance plank in the 1912 Progressive party’s platform. In 1915, the AALL published a model health insurance bill in legislative language to be considered by State legislatures, with California, Massachusetts, and New Jersey supporting the proposal out of the 12 States that discussed it. As debate continued within the States, so did opposition to a proposal for government health insurance. AALL leaders assumed that such reform would be viewed as beneficial to all. The stage was set for health insurance to dominate conversations about health care.

Social Justice, Military, and Affordable Care Act: Part 2

IMGP3125September 20, 2013

Other early federal debates led to the provision of health care to the armed forces, naming the public good and satisfaction of economic aims to support the government’s role. It was argued that a healthy army and navy were necessary for national defense. The patchwork of care for the U.S. military covers decisions relating to those who serve, have served, and their families [see for a summary]. Lost in the conversation about the uninsured and the Affordable Care Act is the data about our nation’s veterans. They comprise a very large group of the uninsured. Here is the estimate from the Robert Wood Johnson Foundation: — 1.3 million veterans plus their families [about another 1 million] have no access to health care.

How does the Affordable Care Act affect military families? An analysis that includes comparisons between Tricare and ACA requirements appears at: It appears that the ACA will require more coverage than Tricare offers in various instances.

As for veterans and their families, if their income levels fall within Medicaid guidelines, they may receive care through an ACA Medicaid-expansion option. That depends upon their State’s buy-in, however, so it remains unclear whether this group of hundreds of thousands will find a path to care or not.   

Patient-Centered Outcomes Research Institute News on My Birthday

IMGP3168September 10, 2013

Nothing I enjoy more than a walk along a creek or stream and gathering fall foliage. In this case, it is cattails. A great way to spend a birthday.

At the same time, an announcement came into my email about the approval of 114 million dollars to support patient-centered outcomes research. The Affordable Care Act introduced this new research institute as part of its overall mission. Each of us will contribute one dollar to the initiative as part of the plan to fund its activities. I am not yet sure why a new institute was needed in addition to the National Institutes of Health which often includes patient centered outcomes research. I haven’t heard any real public discussion about this new initiative to fund research. You can check it out here:

I will continue to ponder the meaning of another institute as part of the Affordable Care Act and share any insights I gain. Please do the same.

Happy 80th Birthday to my Dad today! I am so blessed…

June 22, 2013

117_1754Today is Dad’s 80th birthday. We live too far apart to be together on many of these big life event days, and this is one of those days where a chat on the telephone just doesn’t quite do it. I am thinking about Dad and there are really so many thoughts but most of all, I just feel blessed to have a dad who shares his spirituality and his passion for nature, which really go hand- in- hand. He shares with me how the Lord has provided for him in immeasurable and unseen ways, and in concrete ways–as when a bike part broke on a ride out in the desert, only to turn the next bend walking his bike and finding in the path, something that would work to patch a repair, making it possible to ride again.

Some of you may know that I dedicated my ‘Talking about health’ book to my dad. And I observed that he always told me, “If it is important to you, then do it.” Along with that advice, he guided me to expect to work hard to do those important things. And he set an example of working hard.

Dad served in the Air Force during the Korean War and the Vietnam War. He was a crew chief on a B-52 bomber. After retirement from the Air Force, he worked for a civilian airport as a facilities and systems maintenance technician. Among my many inherited gifts from him, I love working with my hands in the garden and with wood. I am never afraid to pick up a tool and use it, whether I use it the correct way or not. I have mixed colors of stain to match old woodwork, refinished antique trunks, and repurposed screen doors as art above my fireplace. I know I do these things because Dad’s wood-working skills stir in me.   

Dad is not much of one for going to the doctor or for taking medication or having surgery. When he had to have open heart surgery, as I describe in the “Talking about health’ book, he did not let it stop him from being at his grandson’s wedding. He knew before my youngest sister knew that there would be a new granchild in the family–one that he had to heal for so he could take her fishing. And today, at the age of 80, he is enjoying conversations with his five children and looking ahead to a family BBQ tomorrow. Happy Birthday, Dad!