Saturday, December 20, 2008

Healthcare, Culture, and the American Economy

And here's another paper. Only God knows how I managed to write all these in the past 2 weeks...

Kelly Moltzen
Community Health & Medical Care P.11.1830.002
Professor Soffel
December 18, 2008

Healthcare, Culture, and the American Economy

The United States spends 16% of its Gross Domestic Product on healthcare – more than any other developed country in the world – yet ranks poorly in comparison to other developed countries in terms of life expectancy. There are many contributors to this paradox, most of which have to do with the fundamental structure and culture of the US healthcare system. Money funneled into the healthcare system currently overemphasizes spending on long-term care for the elderly while inadequately funding public health programs and failing to account for behavioral determinants of health. It should be noted that “virtually no one in Canada or Western Europe views the U.S. health care system as a model to emulate” (Rodwin).

The first inefficiency of the US healthcare system is that it overemphasizes spending on long-term care for the elderly. Medicare and Medicaid together account for 19% of total US government spending, but the majority of this money goes towards a small number of beneficiaries. With the number of Americans over age 65 growing due to the aging of the baby boomer generation, the United States cannot afford to continue spending excessively on this population. In 2006, ten percent of Medicare beneficiaries accounted for more than two thirds of Medicare’s $374 billion budget, while 52% of beneficiaries accounted for only two percent of expenditures (Medicare: A Primer, 2007). And while the elderly and disabled comprise 25% of total Medicaid enrollees, they account for 70% of Medicaid’s $316 billion in expenditures, leaving only 30% of the funds for the other 75% – children, parents, and pregnant women (Medicaid: A Primer, 2007).

The majority of spending on healthcare for the elderly is on nursing home care, with 44% of Medicaid spending going towards nursing homes (Medicaid: A Primer, 2007). Yet nursing homes are not the most efficient way for the elderly to be cared for, as nursing homes are a very expensive business. In addition, they are generally understaffed, do not provide optimal care, and “many elders say they would rather die than live permanently in a nursing home” (Feldman, Nadash, & Gursen). Elderly people deserve to be treated with respect, and taking away their autonomy by forcing them to live in institutionalized settings denies their “right to take risks in order to lead a preferred lifestyle” (Feldman, Nadash, & Gursen). This “medicalization of everyday life” is not only draining the US budget, but is unfair to the elderly who normally prefer to live on their own as much as they can. Therefore, less costly ways to care for the elderly should be considered, such as in continuing care retirement communities and other residential alternatives (Feldman, Nadash, & Gursen). Consumers – no matter what their age – should have a say in what type of services they will receive through personally directed care. Many elders would prefer informal care while living at home or with family members, although this can be exhaustive and financially draining to their caregivers. By providing elders a specific allotment of funds for personally directed care, they could choose to hire who they saw fit. In any case, a primary goal should be ensuring that people die with dignity (Nuland, 1995).

A more humane future for America’s elderly can be expected to encounter various barriers, principally high costs of care, no matter what options are considered. The services Medicaid purchases for the elderly (i.e. nursing homes) are primarily provided by the private sector (Medicaid: A Primer, 2007), but if money were spent instead on purchasing care in public, non-for-profit institutions, or home-based care, it might cost less. However, many people may be concerned about quality assessment in home health care and assisted living facility settings (Feldman, Nadash, & Gursen). There needs to be a shift in the mindset of Americans and the culture of the healthcare system which currently seems to be more concerned with keeping people alive than ensuring the elderly can enjoy their life and maintain social relationships, which not surprisingly seem to have beneficial effects on health (House, Landis & Umberson, 1988). Yet getting Americans to change the way they conceptualize caring for the elderly will continue to be very challenging.

Another reason for the inordinate costs of healthcare in the United States is an inadequate funding of public health programs, with less than four percent of healthcare funds going towards public health (Hunt & Knickman). Although improvements in health have historically come from public health – not medical – interventions (Conrad & Schneider, 1992), the US healthcare system has become very focused on downstream interventions, which do not get to the root of the problem (McKinlay, 1974). These are extremely cost ineffective, and there are a “large number of unnecessary procedures” with “unexplained variations in practice patterns” and “unclear answers to rudimentary questions about which treatments [are] most cost-effective” (Light). Insurance providers and Medicare will pay for expensive end-stage medical procedures such as kidney transplants, dialysis, and amputations for diabetes patients, but will not pay for primary, population-based interventions that can prevent health problems, such as health education, public service announcements, and accessible healthy food. As McKinlay observes, “we long ago surrendered control of food…to private corporations…[which] have shaped the kinds of food we eat for their greater profits,” so much that “most people now eat more processed and synthetic foods than the real thing” (McKinlay, 1974).

The government needs to be much more stringent in enforcing restrictions on the advertising of unhealthy food products, as the food industry has a very influential voice in Congress due to the revolving door between Congressmen and lobbyists (Nestle, 2007). While a substantial amount of money has supposedly been set aside for public health interventions in the 2008 Farm Bill (Rush, 2008), the government needs to be sure this money goes towards interventions for those with the highest risk of disease (Leviton, Rhodes & Chang). More consideration should be given to efforts such as those that took place in post-war East Germany, where decentralization and prevention were emphasized, medical stations were put in places of work, and an extensive health education program was started in public schools (Light).

While it has historically been an American tradition to rely on non-profit organizations for public health interventions (Leviton, Rhodes & Chang), they can no longer support the country’s needs by themselves. The private sector’s contribution to health expenditures has unfortunately been declining since the 1960’s (Hunt & Knickman). Overall, the private sector needs to contribute more of its resources to public health interventions – particularly the food industry and the tobacco industry, as their products cause the most harm to human health.

Public health does not get the attention it deserves because it is largely invisible, avoiding problems rather than fixing them (Knickman & Kovner). Unfortunately, American culture and Western medicine in particular tend to err towards the side of wanting to see “something being done,” even if that “something” is inefficient and unproductive. In addition, the general public often may not understand what public health comprises, “often supposing it refers to programs for the poor” (Leviton, Rhodes & Chang). It is difficult to change the mindset of the American population, to whom health advertisements appear “boring” and “largely misdirected” (McKinlay, 1974). Very often people follow “quasi-health” fads that they believe are meant to improve their health, and “to request people to change or alter these behaviors is more or less to request abandonment of dominant culture” (McKinlay, 1974). Another challenge is trying to convince education officials of the value of investing time in teaching children more health and nutrition information during the school day, as school curricula already face difficult time constraints.

A third failure of the US healthcare system is the inadequate attention that has been paid to the behavioral determinants of health. While a growing number of Americans do not have health insurance, even those who are insured still experience barriers to accessing healthcare (Billings & Cantor). Families that are eligible for services such as Medicaid may not even know what they are eligible for or how to go about using the services. This could be because of language barriers, cultural barriers, a failure of health professionals to properly explain to them the necessary procedures and paperwork, or a combination of these factors. Many immigrants may be unfamiliar and skeptical of Western medicine and may not seek it out, even when ill. Immigrants may also have fears about immigration status. Individuals who have Medicaid may not use it because of a stigma attached to it or having to wait long periods of time.

Further, research shows that ethnic minority groups use healthcare services more, but the service they are provided is of lower quality (Gabe). This is particularly true for investor-owned hospitals that evidence shows spend less of their resources on uninsured patients than do voluntary hospitals (Relman, 1991). Individuals without private health insurance – such as the uninsured or those with Medicaid – may receive sub-par treatment from physicians who do not benefit from low reimbursement rates, or may even be outright rejected by some physicians and hospitals that avoid certain types of patients in order to maximize revenues (Relman, 1991; Billings & Cantor). The uninsured may be more likely to seek care in an emergency room, either because they waited until a late stage of disease progression, or thought they would eventually be noticed there. And even once they receive attention, limitations to functional health literacy may impede proper use of prescribed medication (Billings & Cantor).

Solutions to improving access to healthcare necessitate culturally sensitive interventions. By modeling Great Britain’s National Health System, walk-in clinics that are “accessible, convenient, and customer-focused” and address social issues of underprivileged populations could be put in place, such as a nurse-led phone help line and walk-in centers with accommodating evening and weekend hours (Gabe). Special outreach by non-profits and local governments may also be needed “to take preventive and therapeutic measures out of the hospitals, clinics, and emergency rooms and deliver them to the population at highest risk” (McCord & Freeman, 1990).

Other solutions may include setting up commonwealth funds for easier access to insurance, requiring employers to contribute to their employees’ insurance, subsidizing insurance through increased taxes on health-damaging products such as tobacco and junk food, and starting programs that teach people how to manage chronic diseases effectively (Billings & Cantor). Maine, Massachusetts, and Vermont – three states where these interventions were successful – started out with comparatively low rates of uninsured individuals. Barriers exist for other states, where employer mandates and taxes may work “against states’ economic development efforts to recruit and retain jobs within their boundaries” (Billings & Cantor). Mandating employer-sponsored insurance would likely meet fierce resistance from the business community. Capitated payments and publicly funded managed care can also be considered, although Medicaid managed care could create yet more barriers for low-income patients, as the enrollment process may be too confusing, the new site may be too far away, and continuity of care may be disrupted (Billings & Cantor).

Clearly, on many levels, today’s US healthcare system developed together with American culture, bringing the capitalistic mindset along with it. Resources are limited, however, and the United States must make much wiser choices with regard to how it utilizes those resources. At the same time, bringing some humanity into the information-dominant, depersonalized domain of medicine could go a long way in improving the health of all patients. It is possible for the US to simultaneously solve its health crisis and its economic crisis, but it may be that the underlying problem is American culture: “values shape financing. They have to change before financing can change” (Light).


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