Welcome to my Why Health Communication Matters BLOG
October 30, 2013
While 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 [http://www.cbsnews.com/news/us-has-highest-first-day-infant-mortality-out-of-industrialized-world-group-reports/]. 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.
October 30, 2013
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Where is “public health” in the credentialing? While being a civil engineer to work on safe and quality water issues makes sense, many of the issues discussed go beyond the scope of what a civil engineer learns. The passion described for the work being done best fits education in public health. I recommend that the requirements for jobs and internships throughout the US PHS Commissioned Corps site be updated to include requirements related to public health training. These would reflect the IOM report discussed in the last post.
October 20, 2013
Most 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,” [http://www.iom.edu/Reports/2002/Who-Will-Keep-the-Public-Healthy-Educating-Public-Health-Professionals-for-the-21st-Century.aspx] 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.
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.
October 5, 2013
A 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.
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 [http://thomas.loc.gov/cgi-bin/cpquery/?&sid=cp113l8f0T&r_n=hr173.113&dbname=cp113&&sel=TOC_22349]. 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 [http://jeffduncan.house.gov/legislative-work/fact-or-fiction/fact-or-fiction-do-members-congress-get-free-health-care].
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 http://www.proquest.com/en-US/catalogs/collections/detail/American-Association-for-Labor-Legislation-38.shtml].
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 [http://www.ssa.gov/history/corningchap1.html]. 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.
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 http://usmilitary.about.com/cs/healthcare/a/medicalcare_4.htm 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: http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/03/uninsured-veterans-and-family-members.html — 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: http://www.militarytimes.com/article/20130926/BENEFITS06/309260025/Affordable-Care-Act-No-impact-Tricare-some-coverage-isn-t-equal. 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.
As President Obama took on the health care issue, his overall aim appeared to be to address access to health care for those who do not have it. This includes some of our most vulnerable citizens, ranging from children living in poverty to the elderly who lack the resources for care. This President, as others before him, sought to promote the dignity of citizens through the provision of health care and to exercise social justice in ways that represent ideals expressed in the Declaration of Independence—promoting “life, liberty, and the pursuit of happiness.”
The U.S. Constitution, which was adopted in 1787 as the supreme law of the newly formed national government for the thirteen states, does not endow Americans with a protected right to health care. This was a conclusion reached by the U.S. Supreme Court but one that finds itself at odds with other republics where a level of health and health care are explicitly guaranteed [see Poland, for example—p. 3 of http://www.ehma.org/files/Benefit_Report_Poland.pdf].
The reasons for an absence of reference to health and health care in the U.S. Constitution likely reflect both the desire to avoid government intervention—related to the very foundation leading to the formation of this nation–and the practical reality that medicine was in its infancy at that time. Thus, there was not much anyone, let alone government, could do to promote the health of individuals. Family comprised the primary unit of both social and economic life, and family assumed the role of caring for sick and injured members.
Very early on, these realities conflicted with the fact that merchant seamen, who acted on behalf of the welfare of all U.S. citizens, became ill and/or disabled in the performance of their duties. Thus, it was only “just” to pay for their health care. In accord with this premise, Congress passed an act to provide for merchant seamen’s medical care in 1798. Congress used the authority of Article I, Section 8 of the U.S. Constitution to support this policy. It empowers the federal government to regulate commerce with foreign nations and to tax for the general welfare as a means to that end. The health and well-being of individual seamen was not the argument used to support a role for government in providing health care. The need for a government role in health and health care resided in a focus on promoting commerce. Government efforts to provide health care, however, were squarely on the table, beginning a path toward where we are today.