Stepping Back: Social Determinants of Health

by Amy Caron

We’ve been talking about healthcare delivery systems locally and by country, but let’s take it all the way back to health disparities. We’ve seen in a previous post that minority groups, racially, socioeconomically and otherwise, experience poorer health outcomes, but why? What makes some groups healthier than others?

Social determinants of health are conditions in the environments in which people live, learn, and work that affect health and quality of life. Settings, like schools, churches, workplaces and neighborhoods along with the patterns of social engagement and sense of security in those neighborhoods all have an influence on health outcomes.

The framework for examining the social determinants of health is:

Socioeconomic/political context:

• Culture
• Poverty
• Religion
• Labor market
• Education
• Social norms and attitudes

Structural context:

• Race
• Income
• Education
• Gender
• Housing
• Food

These are similar determinants we examine access to power and privilege in the Web of Oppression, so we can look at health through the same lens. The closer individuals are to the center the better the health outcomes.

When we talk about health and health outcomes, we mustn’t think narrowly. Simply supplying access to health insurance or health care services addresses only a part of the problem because oppression and health are connected. 

The issue isn’t just health insurance or how healthcare is delivered. It’s the cause behind the cause. 

 

For example, causes of infant mortality in developed countries have been found to be:

• racism-related stress and socioeconomic hardship (Giscombe & Lobel, 2005)
• high prevalence of low income among women who experience serious hardships during pregnancy (Braveman et al., 2010)
• high poverty rates and lack of access to a socialized health care system, as is the case on the United States (Tillet, 2010)
• significant correlation of high poverty rates with infant mortality rates among minority and white mothers in the US (Simms, Simms, & Bruce, 2007)
• significant correlation among poverty level, racial composition of geographic areas, and infant mortality rates (Eudy, 2009)
• high correlation of inequality and child relative poverty with infant mortality rates in rich societies (Pickett & Wilkinson, 2007).

Good health for all cannot exist in an unequal society, so healthcare cannot be seen strictly as a positive right. Infringement on life, liberty and the pursuit of happiness will and does have an impact on health and therefore supports the case for the legislation of healthcare. Because healthcare can be tied to negative rights, the need for healthcare to be seen as a human right in the United States becomes difficult to argue. Looking at this graph, it's a topic of urgency. 

Shared Savings Programs, ACOs and are they changing the healthcare industry?

By Arketa Vazquez 


According to the Center for Medicare and Medicaid a Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers (this includes private health insurance companies), who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.

The shared savings program was established by section 3022 of the Affordable Care Act. The Shared Savings Program is a key component of the Medicare delivery system reform initiatives included in the Affordable Care Act and is a new approach to the delivery of health care.

The main focus of the shared savings program was to increase value of care by providing better care for individuals, better health for population and lowering growth in expenditures.

There has been an increase in the number of people who have been affected by ACO’s since 2011.

ACO’s exist in the 50 states. With California having the most with 81 ACOs.

Many private insurance companies are looking to get involved with Shared Savings programs/ACOs to lower the cost of health care, as well a improve member experience and provide quality care. According to the Kaiser Health News, many larger private ACOs, insurers can also play a role, though they aren’t in charge of medical care. Insurance companies feel they are essential to the success of an ACO because they track and collect data on patients that allow systems to evaluate patient care and report on the results.

If insurance companies, physicians, and hospitals are involved with ACOs and Shared Saving program, can these programs truly lower the cost of health care, while truly providing quality of care to their patients or will patient care suffer at the hands of trying to lowering cost of healthcare in this the United States? 

What About the Single Payer Model? A Profile of the Healthcare System in the United Kingdom

By Natasha Galasso

In 1948 in a post World War II United Kingdom, the National Health Service was launched under Aneurin Bevan, the then minister of health.  Bevan and many of his constituents believed strongly in healthcare as a universal right that should be available to all people in need, free of charge.   A driving factor of the implementation of The National Health System was the disarray that the health system had been left in due to the Second World War, and the need of the people to access healthcare.  Healthcare, and specifically a nationalized healthcare system, was thought to be one way Britain could help beat want, disease, ignorance, squalor, and idleness (Beveridge, 1942). 

Prior to the creation of the National Health System, the British healthcare system was a mix of public and private institutions, the latter run by councils or charities.  Due to this mainly privatized history, the idea of centralizing the healthcare system faced opposition by members of the medical community as well as politicians.  During these initial debates, which took place in the early 1940s, there were proposals for the extension of health insurance (similar to the idea of the Affordable Care Act) instead of the complete restructuring of the healthcare system.  These proposals were eventually defeated in favor of a centralized, state run healthcare system, funded through general taxation. 

The Nation Health System was founded on three principles that remain at its core today.

• That it meet the needs of everyone
• That it be free at the point of delivery
• That it be based on clinical need, not ability to pay

 The aim of the NHS was to promote:

"The establishment of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness”  (1946 NHS Act).

Although the healthcare system in the United Kingdom is not without its issues, the fundamental values on which it was formed have become ingrained in British society.  The debates are no longer if access healthcare should be the right of every citizen, but about how the current system can be improved to better serve its citizens.  Perhaps it is because of this focus that the UK has been ranked to have the #1 healthcare system in the world by the Commonwealth Fund based on Quality Care, Access, Efficiency, Equity, and Healthy Lives.

Do you believe it is it too late for the United States to have a paradigm shift in its healthcare system? 

Germany: Health Care for All!

The German state has been regarded as an exemplary state for the health care it provides its citizens. The German Health Care System dates back to 1883 when chancellor Otto von Bismarck proposed this universal health model. Germany and many other European countries adopted this system.  

 

 

 

 

 

   
                           







































The German health care system is composed of Statutory Health insurance and Private Health Insurance.  The majority of Germany's almost 83 million citizens are enrolled in "sickness funds" or not for profit insurance companies, there are over 162 not for profit companies that provide easy access for the population. The government pays for all children and unemployed or welfare recipients. Employed people making below the relatively high income threshold, about $60,000 per year, share contributions to their sickness fund with their employer.

The wealthy?

Those earning more than $65,000 per year have the option of purchasing private insurance. As of 2013 in German, 76.8% of health care is government funded and 23.2% is privately funded according to the World Health Organization.

Is Health Care a Human Right in Germany? Yes.

According to the 2010 Human Rights Report, Germany declares as follows:

 

Section 6 Discrimination, Societal Abuses, and Trafficking in Persons

The constitution prohibits the denial of access to housing, health care, or education on the basis of race, ethnicity, gender, religious affiliation, age, sexual orientation, disability, language, or social status, and the government effectively enforced these provisions in practice.

 

 

Can the United States follow a similar low cost health care model? How can people in the U.S. voice their rights to achieve low cost health care?

By Edlira Qatipi
 

Healthcare: Can it be a Human Right in the US?

By Amy Caron

There are many dimensions of health disparities in the United States. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status and environment all contribute to one's ability to maintain overall wellness. Access to quality education, nutritious food, clean water and air, housing, and safe neighborhoods all contribute to good health, in addition to access to health care services regardless of income or insurance. The social determinants of health or the conditions in which people are born and live are mostly responsible and create extreme differences in health status within and between populations.

According to the Center's for Disease Control Health Disparities and Inequalities Report US 2013:

• Rates of premature death from stroke and coronary heart disease were higher among non-Hispanic blacks than non- Hispanic whites.
• Infant mortality rate for non-Hispanic black women was more than double that of non-Hispanic white women in both 2005 and 2008.
• Among persons with asthma, attacks were more frequently reported for children than adults, adults with incomes <250% of the poverty level than adults with incomes >450% of the poverty level. 
• Rates of blood pressure control among adults with hypertension were lowest among Mexican Americans, persons without health insurance, and those born outside of the US.
• Diabetes prevalence was highest among males, persons 65 and older, non-Hispanic blacks and those of mixed race, Hispanics, persons with less than a high school education, those who were poor and those with a disability.
• During 2010, two to five Hispanic adults and one of four non- Hispanic adults were classified as uninsured.

According to a study by the Commonwealth Fund in 2012, 41% of adults reported they had a hard time paying their bills, even with insurance and had been contact by a collection agency or had to change their way of life in order to pay for medical bills. A Kaiser Family Foundation poll showed that 28% of middle income families (income between 30-75k) stated they were having a serious problem paying for health care or health insurance.

Overall the United States is quickly becoming the worst healthcare system in the world among developed nations. Our healthcare expenditures are the highest among this group at about 15.3% (Organization for Economic Cooperation and Development). We spend inefficiently according to the Congressional Budget Office that estimated that nearly 5% of that spending did not improve health outcomes and our prescription prices are about 35-55% higher than in other developed countries. In addition to the lack of price controls or regulations on pharma companies to control drug pricing.

Our broken health care system impacts us all, some groups more so than others, and it's safe to say that that all would agree that the system is broken. To achieve health equity, or to eliminate all disparities and improve the health of all groups, all groups must be valued equally and society as a whole must work together to address inequalities that lead to health disparities. In the US, this is what divides us.

Brief History of Health as a Human Right in the US

In 1812, Theodore Roosevelt said "We pledge ourselves to work unceasingly in State and Nation for the protection of home life against the hazards of sickness, irregular employment and old age through the adoption of a system of social insurance adapted to American Use." In 1944, Franklin Roosevelt called for "a second Bill of Rights under which a new basis of security and prosperity can be established for all." These rights included "the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment." He died in 1945. His wife, Eleanor Roosevelt, went on to be a major contributor to the UN's Universal Declaration of Human Rights of 1948 which states:

• Article 25: Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, medical care, and necessary social services, and the right to security in the event of unemployment sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. 

This document gave way to the International Covenant on Economic, Social and Cultural Rights (ICESR). In which states:

• Article 12: States that agree to the covenant should create conditions which would assure to all medical service and medical attention in the event of sickness.
• Article 12.2 Requires parties to take specific steps to improve the health of their citizens.

President Jimmy Carter signed the Covenant, but the United States stands with Comoros, Cuba, Myanmar, Palau, and Sao Tome and Principe and has not ratified. In total, the Covenant has 164 parties. 

So why not ratify? The problem is the distinction between a "positive" and a "negative" right. 

• Positive Rights: Provide the right holder with a claim against another person or the state for some good, service, or treatment. 
• Negative Rights: Restrain other persons or governments by limiting their actions toward or against the right holder. 

Our Bill of Rights, written in the 18th Century, embodies negative rights that were designed to prevent government oppression. The ICESR leans in towards positive rights. This marks a sharp divide in the United States. 

Healthcare: Not  Human Right?

Here are some arguments:

• Health care is broad and too hard to define. It includes preventative services, health education, promotion, and treatment for established illness. But does the right to health care also mean the right to clean water, food, organ transplantation, or infertility treatment? To be considered a right, it must be easily defined. 
• Rights imply a duty on the part of others, and who/what would that be in the case of health care? Would doctors, hospitals, or governments take responsibility? This would impose an intolerable burden on others and should be seen as a provision of benefits instead. 
• As a right, health care would impose forceful obligations on taxpayers and providers. No one can "give" health care without first taking away something from someone else.  

In a nutshell, health care can't be a human right because it requires providing goods and services that don't "exist in nature" and inevitably a person's rights will be infringed upon in order to to do so. By enforcing a right to health, the government becomes legally obligated to provision the necessary services. It is at someone else's expense.

Our Constitution was written as a series of negative rights and all amendments made before the 1930's basically aim to protect the people against its government. They call for government to refrain from acting. This is the simple explanation why so many believe healthcare can't be a human right. This core value of "every man for himself" simply sums up why we rank last or close to last on measures of health.

Does Healthcare Have to be a Right?

The US is the only country among the group of wealthy nations that belong to the Organization for Economic Cooperation and Development (OECD) that does not guarantee healthcare to its people as a right. In most of Europe, healthcare must be accessible to the entire population, without discrimination, and is done do in different ways:

• Great Britain has a national health service and the government runs the hospitals and pays all staff.
• Germany and France have a mix of regulated private and public insurance companies and a law (like the ACA) that make it mandatory.
• Netherlands' mandatory health insurance coverage is provided by private insureres competing for business.
• Sweeden relies on innovative programs managed by their government to control costs and maintain the public's health.

Australia does not claim that healthcare is a human right as seen in Europe, however they still have a system of public hospitals and accessible insurance program. Japan follows suit. In these countries, healthcare is not a right per se, it just is.

In short, there are a mix of mechanisms and motivations for ensuring universal access to healthcare for all residents. In China, not an OECD member, healthcare access is a matter of law, not of rights, however healthcare coverage is growing just the same.

In the US, we spend the most and are the sickest, but we first need to define the problem to come up with solutions.

Do we need to see healthcare as the human rights issue of our time or an economic problem we need to solve?

Where can the Affordable Care Act take us and which country should we emulate?