Access to Health Care in U.S: Problems and the Bottom Line

by: Dr. Golam Md. Munir

Access encompasses both the ease and timeliness with which health services can be obtained (Office of Health Care Access, 1999; Millman, 1993). Metrics of measuring access to health services include:

* Having health insurance,
* Adequate income, and
* A regular primary care provider or
* Other regular source of care (U.S. Department of Health and Human Services, 2000).
* Utilization of certain clinical preventive services, such as, early prenatal care, mammography, and Pap tests, can also indicate better access to services.
* Rate of avoidable hospital admission

Health care models:

* Purely private enterprise: Exist in poorer countries with sub standard health care dominated by private clinics for wealthier population.
* In almost all the countries, a private system exists in addition to Government health care system (such as Medicare and Medicaid in U.S). This is sometimes referred to as Two-tier health care.
* The other major models are public insurance systems:

o Social Security Health Care model where workers and their families are insured by the State.
o Publicly funded health care model, where the residents of the country are insured by the State.
o Social Health Insurance, where the whole population or most of the population is a member of a sickness insurance company.

Models for access: access to health services can be impeded broadly by:

* Affordability: Economic barriers (no insurance, poverty),
* Availability: Supply and distribution barriers (inadequate or inappropriate services or primary care providers, geographic unavailability due to difficult infrastructure);
* Unavailability of services, lack of transportation and other infrastructure), and

Language and cultural barriers.

Discussion:
_________________________

A. Insurance coverage:
____________________

* Approximately 85% of Americans have health insurance.
* Approximately 60% obtain health insurance through their place of employment or as individuals,
* Various government agencies provide health insurance to 25% of Americans.[3].
* In 2004, 45.8 million (15.7%) Americans were without health insurance [1].
* According to 2000 U.S. census data [2], the percentage of large firms (200 employees or more) offering health benefits to its retirees fell between 1988 and 2001 (excepting a spike in 1995).
* Although most types of health insurance cover common treatment services and screening and diagnostic tests, many preventive services and interventions are not covered. For example, while most health insurers will pay to treat emphysema, lung cancer, and other tobacco-related diseases, for example, few will reimburse for smoking cessation programs or medications.

B. Economic condition:

Cost is a barrier. Cost is more likely to affect persons:

* Of Hispanic ethnicity,
* To affect unmarried persons,
* Those who did not graduate from high school, were four times more likely than college graduates to experience cost barriers to health care,
* People with income under $25,000

C. Availability:

Access barrier is intense in areas where the need is high but capacity of existing providers is insufficient.

* Hispanic is less likely than non-Hispanic respondents to have health-care coverage (76.2% versus 90.6%),
* They have one or more regular personal health-care providers (68.5% versus 84.1%), or
* They have a regular place of care (93.4% versus 96.2%).
* Hispanic has needs of medical care, but can not obtain it (6.5% versus 5.0%).
* Hispanics also are significantly less likely to be screened for blood cholesterol and for breast, cervical, and colorectal cancers and to receive a influenza / pneumococcal vaccination.

D. Language factor:

Language can be an obstacle to health care access for:

* People who do not speak English and
* For the deaf and hearing impaired.

According to the 1990 U.S. Census, about nine percent of Connecticut’s population was foreign born and 15% of children and older spoke a language other than English at home. Of this group, 39% did not speak English “very well”. . According to U.S. Census Bureau, 2001, 6 percent of population is hard of hearing, and 25,500 residents are considered profoundly deaf (Connecticut Commission on the Deaf and Hearing Impaired, 2001).

The ability of Connecticut’s health care providers to communicate with non-English speaking people and is very limited. In 2001, 35 percent of total physicians and surgeons practicing medicine in Connecticut indicated that a language other than English was spoken at their practice location (Connecticut Department of Public Health, Bureau of Regulatory Services, 2001). Spanish was the most frequently spoken language.

E. Cultural factor:

Cultural differences between Hispanics and other minorities and health care providers affect health-related behaviors in certain minority groups:

* lack of knowledge about Western medicine,
* fear of public institutions (based on experiences with discrimination),
* modesty about their bodies, and
* The belief in minority women that their own needs are secondary to those of their husbands and children (True and Guillermo, 1996).
* Hispanics have less knowledge about cancer. Cancer is increasing among Hispanics [4], and cancer screening, an essential component of early detection and treatment.
* Many non-Western women do not go directly to a physician when they are ill. Instead, they first attempt to treat themselves, and if that fails, they follow the recommendations of friends, family, and in some cases, alternative or folk healers (Bayne-Smith, 1996).
* Many health problems of minority women thus go unreported and unrecognized, in part because the women do not communicate the problems, but also because providers cannot relate to the women’s cultural norms (Bayne-Smith, 1996).
* Lesbians are less likely than heterosexual women to seek health care and more likely to encounter barriers in access to care and preventive services. For example, many women who have sex only with women believe they do not need Pap tests, and confusion even exists in clinical practices about whether lesbians should be offered cervical smears routinely (Bailey et al., 2000).

? Do Medicare and Medicaid contribute to barriers to access so far we think about the delinquencies in reimbursement?
? Does it anyway refer to the question of availability of health care providers?

The U.S Health care ranking is very poor in relation to other industrialized nations in health care despite having

* the best trained health care providers and
* the best medical infrastructure

The ranking are as bellow:

* 23rd in infant mortality,
* 20th in life expectancy for women and 21st for men
* 67th in immunization, right behind Botswan
* Rank below Canada and a wide variety of industrialized nations on outcome studies on a variety of diseases, such as coronary artery disease, and renal failure.

The ranking is poor because, the access barrier is intense in U.S. Access to Health care. Difficulty in accessing to health care to 30% Americans is based on the ability to pay (disparity is directly related to income and race) [5].

Managed care organizations spend 20 % of their premium behind administration while it is only 3% in Medicare. Moreover, Managed care covers 60% of the population while Medicare and Medicaid cover 25%. About 17% of U.S population is uninsured of which, two-third has trouble accessing/paying for health care. As Medicaid covers mainly uninsured population, therefore, we may presume that high administrative cost of care providers and quickly decreasing reimbursement rate in Medicaid is a major cause of access barrier to minorities and disadvantaged so long we bark on ‘availability’ of care.

The bottom line:

Possible options to remove access barrier

* Reducing fundamental socio-economic inequities (almost absent in U.S),
* Expanding insurance coverage,
* Expanding access to Public health (preventive) services that reduce risk factors to chronic diseases and injuries.
* Prompt and effective primary care in a doctor’s office or other outpatient setting, followed by proper management can reduce the need for hospitalization for many medical conditions, such as asthma, dehydration, urinary tract infections, and perforated or bleeding ulcers (Foland, 2000; Office of Health Care Access, 2000). These conditions are referred to as “ambulatory care sensitive” hospital admissions.
* When early care is delayed or foregone, the result is often “avoidable” or “preventable” hospitalizations which can indicate:
o problems with access to primary health care services or
o Inadequate outpatient management and follow-up, because Three out of four “avoidable” hospital admissions occur through emergency rooms (Foland, 2000).
* Health Literacy and removing cultural barrier by social services and public health programs: Many patients lack the reading and comprehension skills helpful for maintaining a healthy lifestyle and to function in the U.S. health care system. These deficits result not only from poverty and low educational attainment, but also from differences in language and culture. Because of the inability of patients to read and understand health-related information:
o infants are being born with birth defects,
o diseases are being diagnosed at advanced stages, and
o Medications are being taken improperly.
* Removing cultural barriers to lifestyle and medication that have proven effective for controlling weight, blood pressure, cholesterol, and blood sugar should help reduce the large inequities in chronic disease.
* Universal health care (single or multi payer).

Sources:

1. "Income, Poverty, and Health Insurance Coverage in the United States: 2004." U.S. Census Bureau. Issued August 2005.

2. Cunningham P, May J. "Medicaid patients increasingly concentrated among physicians." Track Rep. 2006 Aug;(16):1-5. PMID 16918046.

3. LS Balluz, ScD, CA Okoro, MS, TW Strine, MPH, National Center for Chronic Disease Prevention and Health Promotion, CDC 2002.

4. Villar HV, Menck HR. The National Cancer Data Base report on cancer in Hispanics: relationships between ethnicity, poverty, and the diagnosis of some cancers. Cancer 1994; 74:2386--95

5. The Case for Universal Health Care in the United States http://cthealth.server101.com/the_case_for_universal_health_care_in_the_united_states.htm, The Case For Single Payer, Universal Health Care For The United States Outline of Talk Given To The Association of State Green Parties, Moodus, Connecticut on June 4, 1999-By John R. Battista, M.D. and Justine McCabe, Ph.D.

About The Author

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Putin's Nation State Model

by: John Stanton

On February 8, 2008 President Vladimir Putin of Russia made an extraordinary speech at the Expanded Meeting of the State Council. The 13 page speech was titled Russia’s Development Strategy to 2020. The document is a template, a guide for the creation of the 21st Century Flex-State. A State with strong, even aggressive leadership that seeks to keep its story, its history, its people alive and prosperous in an era of competitive globalization where information about any organization, any individual, in any country is nearly impossible to hide. It is a bold, even historical document about Russia’s experience with a method of US economic torture called The Shock Doctrine (see Naomi Klein’s book of the same name), and its trials and tribulations with low birth rates and dismal healthcare. It is astonishingly open.

More than anything, though, it’s about the long-term. It is about country and national interest coming first, agency second.

Putin recognizes that only The State has the authority to wield power to protect the national interest, play referee when financial markets convulse, and ensure that a nation’s infrastructure, its culture, its people and its security come first. After all, those are the critical components of The State. It is vital that, as much as possible, The State should attempt to remain unincorporated. “We have rid the country of the harmful practice that saw state decisions taken under pressure from commodities and financial monopolies, media magnates, foreign political circles and shameless populists, a practice that was not only detrimental to our national interests but that cynically ignored the basic needs of millions of people,” said Putin.

According to Goldman Sachs, Russia has become a “remarkable” performing member of the BRIC’s (Brazil, Russia, India, and China) with its economy growing at an annual rate of 6.8 percent. Even so, according to Putin, much remains to be done and Russia can’t borrow and spend its way to national prosperity and security. In short, Putin’s “non-democratic” plan, much maligned in the world’s mainstream media, is working.

Putin’s Way

The American people would do themselves a big favor by reading his speech. The entire US economic, political, military, and diplomatic apparatus--presidential candidates included—would do their country a great service by taking the time to understand and heed the message behind the words. That message is clear: The State exists to serve the interests of the people. The State will not fade away, it can’t. Indeed, Evolutionary Psychology teaches that human beings are hierarchical creatures that in groups need structure, discipline, and unitary purpose. The State should be the guardian of the national psyche and not the captains of industry.

According to Putin, “Our children will no longer have to pay our old debts. The state foreign debt has shrunk to 3 percent of GDP – one of the lowest ratios in the world. What choice can there be between the opportunity to become a leader in economic and social development, a leader in ensuring our national security, and the threat of losing our economic standing, losing our security and ultimately even losing our sovereignty? Russia must become the country offering the best life, and I am sure that we can achieve this goal, not by sacrificing the present for some radiant future, but by working day by day to improve people’s lives.

The transition to an innovative development path calls above all for large-scale investment in human capital. Human development is the main goal and essential condition for progress in modern society. This is our absolute national priority now and in the future. Russia’s future and our success depend on people’s education and health and their desire to improve themselves and make use of their skills and talents. I am not saying this because presidential elections are just around the corner. This is not a campaign slogan. This is vital for our country’s development. Russia’s future depends on our citizens’ enthusiasm for innovation and on the fruit of the labors of each and every individual.

Political parties must not forget their immense responsibility for Russia’s future, for the nation’s unity and for our country’s stable development. No matter how fierce the political battles and no matter how irreconcilable the differences between parties might be, they are never worth so much as to bring the country to the brink of chaos. Irresponsible demagogy and attempts to divide society and use foreign help or intervention in domestic political struggles are not only immoral but are illegal. They belittle our people’s dignity and undermine our democratic state. Russia’s political system must not only be in accordance with our national political culture but should develop together with it. Then it will be both flexible and stable.”

Rice-Minded Arrogance

Much of the world’s mainstream media outlets focused their attention on the last two pages of Putin’s remarks in which he bluntly, but not surprisingly, indicated that Russia would respond to further military encroachments by the United States--and its NATO partners--by re-engineering its national security apparatus to counter US/NATO plans to encircle the Russian Federation with a ring of tripwire military bases. With its hand forced, Putin said that “Russia has a response to these new challenges and it always will.” He went on to say that “The use of new technology calls for a rethinking of strategy in the way our Armed Forces are organized. After all, new breakthroughs in bio-, nano-, and information technology could lead to revolutionary changes in weapons and defense.”

Officials from the US State Department, the Pentagon, US defense industry--and the many think tanks/interest groups they rely on--have carefully deconstructed and reconstructed President Putin's comments on national defense.

Their considered—and predictable--recommendations on Putin's remarks reads something like this: The US national security strategy of provoking Russia, and much of the rest of the planet, has been successful. Said provocation has produced additional and in some cases unforeseen threats, as the Putin speech demonstrates. Therefore, the out-year budget planning is already dated and inadequate for the previously anticipated threat scenario. To meet new and as yet undefined threats posed by the Russians—and the world—an increase in funding requests next year is an absolute certainty. We must lobby the US Congress and convince the US public that an increase in program funding for all the US military services and their contractors is essential to counter this new Russian belligerency and other threats we cannot at this time predict.

Right on schedule, the marketing campaign kicked-off. On February 13, 2008, US Secretary of State Condoleezza Rice had this to say about Putin. “The unhelpful [remarks] and really, I will use a different word; reprehensible rhetoric that is coming out of Moscow is unacceptable.”

Unacceptable? Who does she think she’s talking to?

Soviet Model or Chinese Communist Model

Rice’s flippant statement is yet another example of the F***! You! US national security policy—an in-your-face mandate to corporatize and militarize The State for neocolonialist ends. This incendiary national policy has been wonderful for those who want to turn The State into a for-profit enterprise. As such, when Putin talks tough--because US national security strategy compels him to—he ends up providing the rationale for US corporatists/militarists who want to perpetually develop and market new weapons platforms, increase the centralization of national security systems to monitor public opposition, and use The State to justify shady practices (retroactively too!) from preemptive intervention and torture to US central bank policies that sanction Wall Street’s appetite for the Roulette Wheel.

It’s tough to gage whether those in power in the USA--and the many who are now seeking elected and appointed office--want to turn the US State into capitalist version of the former Soviet Union or today’s Communist China with its capitalist face. Perhaps they want the best of both. Whatever designs they have, this much is certain:

1.) the continued corporate takeover—encouraged by the three branches of the US government—of The State’s social, education, infrastructure and security functions, to include resource assets;

2.) increased militarization of the US economy;

3.) bigger defense budgets for kinetic overkill platforms for land, sea, space that ignore William Lind’s Nth Generation Warfare principles and consume a greater percentage of US GDP;

4.) unprecedented expansion and centralization of domestic surveillance and homeland security activities;

5.) widening income disparity and increases in cost-of-living;

6.) ignorance of America’s story--its good, bad, and ugly history—as it has struggled to live up to the ideals embodied in the US Declaration of Independence and US Constitution;

7.) loss of national and global identity;

8.) painful economic collapse/financial insolvency—a dramatic replay of the Soviet Union’s end—that terminates the American Nation State;

9.) violent anarchy as The State fails, the population disperses and pledges allegiance to whatever group or individual can provide food, shelter, clothing and security.

Putin offers a sensible means to avoid a nasty end.

About The Author

John Stanton is a Virginia based writer specializing in national security and political affairs. His most recent book is Talking Politics with God and the Devil in Washington, DC. Reach him at cioran123@yahoo.com.

The A-Z of Global Warming: Deforestation

by: Simon Rosser

Deforestation is basically the loss or destruction of forest habitat, primarily as a result of the action of human beings.

It is the single largest source of land- use greenhouse gas emissions, and accounts for around 18 -20% of global greenhouse gas emissions.

We know from a previous article, trees and vegetation act as sinks or stores for carbon dioxide, one of the most important greenhouse gases. Stored carbon taken out of the atmosphere by photosynthesis through decades of growth is released back into the atmosphere as vegetation and trees are cut down and burnt, or, as unburned organic matter slowly dies. This process contributes to atmospheric CO2 levels.

The Food and Agriculture Organisation of the United Nations (FAO) who are the leading source for information on the status of the worlds forests define forests as, "land with a tree canopy of greater than 10%, and an area of more than half a hectare". The organisation defines deforestation as, " the conversion of forest to another land use or long term reduction of the tree canopy cover below the minimum 10% threshold."

Land change and co2.

Land use changes are driven almost entirely by emissions caused through deforestation, which is highly concentrated in a few countries. Indonesia contributes approximately 30% of land use CO2 emissions with Brazil around 20%. It is estimated that about 80,000 acres or 32,000 hectares are being lost every day. This is the equivalent of about 117,000 km2, (45,173 sq miles) each year.

Total world rainforest cover is now about 6 million km2, (2,316,602 sq miles), which equates to about 5% of Earth's land surface. Only a few thousand years ago, rainforests covered about 12% of the worlds land surface, around 15.5 million km2, (6 million sq miles). A quick calculation reveals that if forest cover is being lost at the rate of 117,000 km2 a year, then it will only take in the region of 51 years for the world's rainforests to be destroyed! (6,000,000 divided by 117,000).

Destruction at this level would lead to the release of vast amounts of CO2 into the atmosphere, further thickening the CO2 "blanket" that surrounds our planet and no doubt lead to an increased warming of the atmosphere.

Between 2000 and 2006 Brazil lost nearly 150,000km2, (57,915 sq miles) of forest, an area the size of Greece, and since 1970 over 600,000 km2, (231,660 sq miles) has been destroyed.

It is now estimated that almost 20% of the Amazon has been destroyed, which is considerably alarming when one considers that the Amazon rainforest represents about 50% of the worlds tropical rainforests.

There are various causes for deforestation, and they include, Cattle ranching, Activities of farmers, fires, mining and road construction and of course logging and commercial agriculture.

It's not entirely fair to blame the developing nations for all the deforestation however. Whilst countries like Brazil and Indonesia may be the main culprits now, up until the early 20th Century emissions of CO2 through land use changes came from developed nations. It's a natural step for developing nations to clear forest-land for agriculture and habitation. The fact is that as developed nations have already deforested many areas long ago, there is more pressure on developing nations to preserve what is left. Of course population growth is another major factor which will be discussed in a later chapter. Another significant point is that trees in topical forests typically hold on average about 50% more carbon per hectare than trees outside the tropics. Therefore deforestation in these areas causes greater amounts of CO2 to be released into the atmosphere than deforestation outside of the tropics.

Future of the forests.

Remarkably when talking about land use change emissions, countries such as the USA, Europe and China were in the year 2000 net absorbers of CO2 as a result of their aforestation (planting new forests) and reforestation (re establishing old forest areas) programs. However, the planting of one tree does not offset the damage caused by the removal of another, as trees absorb CO2 very slowly. It could take 100 years for a growing tree to recover all the CO2 released when a mature tree is cut down!. For this reason, carbon offset programs which suggest planting a tress to offset co2 produced are pretty worthless, due to the time it would take for that tree to remove co2 from the atmosphere.

There is some good news however, as in 2006 the Brazilian government announced a sharp drop in deforestation. Loss for the year 2005/6 was 13,100 km2, (5,057 sq miles) down more than 40% from the year before. Its too early to say whether this is a declining trend, or just one good year out of the pervious eight where deforestation levels were all in excess of 16,000 km2, (6,177 sq miles).

As the worlds forests are being destroyed, huge amounts of CO2 are being released back into the atmosphere. The forests that were once able to absorb and store this potent greenhouse gas, will no longer be standing which will push CO2 levels up higher, thereby contributing to the warming of Earth's climate.


Copyright (c) 2008 Simon Rosser

About The Author

Simon Rosser

A lawyer by profession, I felt inspired to write The A-Z of Global Warming book, published in June 2008, after viewing Al Gore's documentary, An Inconvenient Truth in Nov 2006. Based on the most upto date scientific information, this Deforestation extract gives a flavour of the books content. To pre-order the book from Amazon goto http://www.amazon.co.uk/Z-Global-Warming-Simon-Rosser/dp/0955809207/ref=sr_1_9?ie=UTF8&s=books&qid=1206442671&sr=1-9