health disparities, social justice, geography, food politics, medical anthropology
The U.S. Department of Health and Human Services (HHS) reports that 290,439 Michiganders signed up for health coverage that will start on February 1st.
The next enrollment period runs from February 15th – March 1st.
HHS says that about 6.5 million people have signed up or renewed their health coverage in the marketplace since November 15th.
Michigan has one of the 20 lowest uninsured rates in the country with only 11% of its population uninsured. The increase in the insured rate was largely due to the expansion of Medicaid, known as Healthy Michigan. The Census Bureau expects further increases in the insured rates across many states as a result of the Affordable Care Act (ACA).
providing Michigan [residents] health care access.”
This simple concept of increasing access to health care has gained great prominence with the passage and acceptance of the Affordable Care Act (ACA). However, this composite mission statement is often placed secondary to the corporate and monetary interests of these insurance companies. The ACA has placed great emphasis on increasing access to health care while allowing the insurance companies to profit.
In the past, the insurance companies…
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Michigan ranked among the top ten states nationwide for the most ACA enrollment sign-ups between October 1st and Aptil 19th, 2014. (Source)
The topic of America’s mental health system and the need to improve it has become a hot topics following the most recent gun violence at an elementary school in Connecticut. Most of what I have heard from the media and politicians is a broad “need to improve mental health.” It is always a very generalized statement without many specifics on how or where or to what end. It is likely that these pundits and politicians have no idea, but I think this leaves a critical gap in the mental health discussion.
“As soon as I’m finished speaking here, I will sit at that desk and I will sign a directive giving law enforcement, schools, mental health professionals and the public health community some of the tools they need to help reduce gun violence.
We will make it easier to keep guns out of the hands of criminals by strengthening the background check system. We will help schools hire more resource officers if they want them and develop emergency preparedness plans. We will make sure mental health professionals know their options for reporting threats of violence — even as we acknowledge that someone with a mental illness is far more likely to be a victim of violent crime than the perpetrator.” – President Obama 01/16/13
An article that I read noted that it was easier to buy a gun than to access mental health services in America. Why is that true?
Mental Health Services Stigma
I seems as though the mental health climate in America is very similar to the stigma associated with PTSD within military circles. With the conflicts in Afghanistan and Iraq I remember reading that soldiers wouldn’t seek out counseling for their PTSD because it was interpreted as if the soldier was unfit for service and had serious issues. This applies in both the military and civilian settings. When a soldier leaves duty they may still face stigma related to their PTSD.
Likewise, this often plays out in the civilian world. Seeking counseling is never seen as a positive endeavor. Meeting with a psychologist is a negative event in your life that you never hope to repeat and you most definitely don’t tell anyone publicly. But why?
Why Seek Mental Health Services?
What causes people to seek out mental health services? Are individuals only referred by their family doctor or sometimes do they attend because they are required?
Many people seek out mental health services as a result of substance abuse. Dealing with addictions is probably the most well recognized aspect of mental health in the US. However, there is often a high degree of stigma even for those with mental illness and addictions. Overcoming the stigma and discrimination against those in need of mental health is a huge hurdle if President Obama and others hope that mental health will be more easily accessible among the general public.
Other well known reasons for mental health services are: depression, bipolar, anxiety, and PTSD. Nearly 80% of individuals who suffer from depression say that they experienced some form of discrimination (Mental Health America). Other studies have found that racial discrimination and an individual’s level of poverty also contribute strongly to mental health. However, a recent poll has found that stigma against depression and seeking treatment for depression is decreasing.
Where are Mental Health Services Accessed?
I know for many students being on a campus makes it fairly easy to meet with a Counselor at various locations. How would individuals without easy access find and utilize mental health services. I know that individuals can go to a hospital or an emergency room if they are in immediate need of mental health services, but that can’t be the ideal method of accessing mental health.
Most people probably have no idea that they have access to preventative mental health care with their insurance, however this goes back to the stigma associated with seeking such treatment. The other major barrier to accessing mental health services is the high cost with a minimum around $100 and extensive treatment reaching over $10,000. As a result of the cost barrier, only around 7% of all adult Americans accessed mental health services (NSDUH report).
Since the majority of mental health tends to affect poor individuals this cost barrier makes it even harder to identify and treat mental health. Mental health services is included in the “essential health benefits” piece of the Affordable Care Act, but it is left up to States as to what is included. Without some serious thinking about why, how, and where individuals access mental health services – improving access will just be more political rhetoric. If we are serious about improving the mental health system then we need to be asking serious questions.
Much worry, fear, and writing has already come out about Google’s new catch-all privacy policy. I for one am not surprised that they have finally created one privacy policy for their entire suite of services. Honestly, I had already assumed that Google was sharing information across its platforms about me. The one idea that really stood out to me in Google’s new privacy policy is that items in your Gmail and Google Voice would no longer be technically private. Working in a clinical research setting at a university-based School of Medicine with clients who are ensured confidentiality, I am worried. Isn’t Google violating HIPAA in some cases by sharing this information that we believe to be private?
I am not the first to write about Google’s new privacy policy in relation to HIPAA (Health Insurance Portability and Accountability Act). The most important piece in understanding Google’s policy in regards to HIPAA is that Google says that it is not bound by HIPAA.
“Unlike a doctor or health plan, Google Health is not regulated by the Health Insurance Portability and Accountability Act (HIPAA), a federal law that establishes data confidentiality standards for patient health information.” (via Google)
This is unfortunately true. If you visit the Health and Human Services (HHS) website those bound by HIPAA are health care providers, health plans, and health care clearing houses. Google is none of these entities, so therefore it gets by. There is no way that any court of law would hold Google accountable in a HIPAA related case. Google is a private company that offers free services to users. By using their services, you don’t necessarily have the rights to control what happens to the services.
“if you’re not paying for something, you’re not the customer; you’re the product being sold” (via lifehacker.com)
Many, including Congress, have come out against Google’s new privacy policy and especially as it relates to HIPAA and health information. Representative Mary Bono Mack worries that Google could track sensitive health information.
“[…] say you do a Google search for cervical cancer and you forget to sign out. Are you being tracked across all of the other products, and if so, that’s a violation of HIPPA. We’ve gone to great lengths in our society to protect people’s medical information. That question was raised.”
Google’s response is that those individuals can use Google services, like Google Search, without having to log in to their account. However, if you are also a Gmail user and maybe you email with your doctor’s office then Google has that information more directly linked to your personal data. Does Google violate HIPAA in that case? No, because they say (to paraphrase), ‘you don’t want us to track you, then don’t login.’
For individuals, the solution is to diversify online services or stop using Google. If you don’t want your information tracked and collected by one entity start using a different email service, use Word instead of Google Docs, and if you don’t want information linked to your specific Google account, don’t login and search for everything you want to know about. That isn’t to say that other companies don’t also track and collect our data, but at least it won’t all be in one place. The hard part is that Google is good at what it does and for many, myself included, it will be hard to let go of the ease of Google services.
For Practitioners the story is more convoluted. I work for a clinical research grant where clients are ensured of the confidentiality of their information, however I am a Google user; a dedicated citizen of the Google Nation. I love their services and the ease of connecting the information that I want to use. As a result I use Gmail to communication on sensitive client matters with my Supervisors and I use Google Voice to talk and text with the clients. With the new Google privacy policy, all this information fair game for them to index and share across their platforms.
Based on the correspondence between Google and Congress as well as their stated policy that they aren’t bound by HIPAA, the responsibility falls on the shoulders of the health practitioners. In our clinical research program every client gets a number to ensure the confidentiality of their data. I use client numbers with everything that I do on Gmail and Google Voice, but sometimes background information about clients is sent to my Gmail that could reveal their identities.
Recently the School of Medicine where I am working hosted a workshop for researchers to benefit from Google tools, such as Google Docs. I emailed the individual in charge of the workshop to ask how Google’s new privacy policy might affect the way researchers use Google services. The individual seemed to be less concerned than I and said she understood it as a, “take it or leave it” policy. If you are a researcher dealing with private health information and bound by HIPAA, then there are serious implications for using Google tools for your research project. Google may state that it is dedicated to the privacy between sender and recipient, but that doesn’t mean that your data isn’t fair game for Google to catalog and use for their own purposes.
The solution for practitioners is: Don’t use Google services or share confidential information within Google services because you have no way of ensuring confidentiality.
Health statistics undoubtedly show the shortage of health workers and doctors around the world. Recently I wrote about the growth of hospitals in Detroit and the huge loss of primary care physicians. This is a health issue that is often associated with countries of the “developing” world, but the USA is facing a health shortage of a different kind: access to primary care.
Health financing has had the greatest effect on disparities in health care coverage as well as the structure of the health care system. Through our health care system, physicians have been incentivized to specialize as opposed to be a general medical practitioner. As technology has made medicine more efficient, it has not reduced costs, so “fees remained high, while the time and effort required to perform […] declined (Starr, 1982). The result was an increasing income disparity between physicians who specialized (Specialists) and primary care physicians (PCPs).
The advent of federal support for health care drove the income disparities between Specialists and PCPs. In 1946, the Hill-Burton Hospital Construction Act put $4 billion into the expansion of hospitals as opposed to ambulatory services (Starr, 1982). Ambulatory care services represent the single largest contributor to the increase of hospital expenditures and to decreased performance of the health care system in both the USA and many developing countries (Karpiel, 1994). In 1965, the start of Medicare and Medicaid allowed private insurance companies to continue their practice of providing higher reimbursements to procedural Specialists than to PCPs. Primary care was further marginalized when Medicare developed a policy that linked its teaching payments to a hospital’s level of inpatient, not outpatient, services. Medicare began giving extra payments to hospitals for residency training, pushing many hospitals to increase inpatient care in order to receive higher payments.
“Primary care brings promotion and prevention, cure and care together in a safe, effective and socially productive way at the interface between the population and the health system. The features of health care that are essential in ensuring improved health and social outcomes are person-centeredness, comprehensiveness and integration, and continuity care, with a regular entry into the health system, so that it becomes possible to build an enduring relationship of trust between people and their health care providers.”
“Primary Health Care – Now More Than Ever”
World Health Organization (WHO) Annual Report 2008
In a 2008 survey of Michigan physicians, 34% identified themselves as PCPs, which follows the national trend that two thirds of physicians are Specialists (Michigan Physician Profile, 2009). The report showed that numbers had not changed since 2005 and the number of PCPs entering the workforce equaled those leaving the workforce. The report also highlighted the rising costs of medical education and the debt that many young physicians will carry into the workforce. With this high level of indebtedness, why wouldn’t younger physicians look towards becoming a Specialist as opposed to a PCP with fewer financial incentives? A friend of mine studying to become a doctor noted that many of her colleagues were having conversations about whether to go into primary care or to specialize. Unfortunately the system seems to choose the path for young doctors as opposed to giving young doctors the choice to go into a medical field that they enjoy.
Health care reform has represents a huge win for those fighting for increased access to care along with the Affordable Care Act (ACA) providing a positive framework for many living in poverty. However, the largest reform may have been one that was minimally addressed by the ACA, including 10% bonuses for PCPs under Medicare and $300 million to recruit PCPs for underserved areas. I don’t think 300 million today goes as far as 4 billion did in 1946, nor does a 10% bonus equalize decades of subsidies for Specialists. The health care reform added $11 billion in support for community health centers, but some of that was cut in the 2011 budget deal. The inability of the current health care system to keep up with this new rising demand for PCPs on top of the increase of chronic diseases and an aging population that lives longer, represents the need for reform in our health care financing not just access to health care.
We have a health system that has subsidized specialized care for too long, taken health care to large technology driven hospitals, and limited the ability for new, young doctors to infuse our health system with much needed passion. The real health care reform should have included increasing support for primary care facilities (no cuts) and more for training.
If we want all people to be able to access health care affordably then we need to provide them with the necessary health workforce that can meet them where they are. For many urban poor the Emergency Department (ED) has become their primary care facility. Many individuals working in health care finance world note the cost of ED visits is covered by the premiums of the insured (roughly $1200-$2000/ year) .
Its exciting to see widespread support for increasing access for the uninsured, its amazing to see funding to bolster primary care facilities, but if we are going to have young doctors who aren’t living paycheck to paycheck, then there needs to be a concerted effort to get doctors into those primary care facilities and greater incentives to join the growing trend in supporting community health through primary care.
I caught a recent news brief from the Detroit News reporting from the Mackinac Policy Conference put on by the Detroit Regional Chamber of Commerce and was surprised by the headline.
“Outsource to Detroit”
That’s a bit different than Chrysler’s “Imported from Detroit” tagline. I’ve been following this idea and imagery of Detroit. I’ve written previously about how misinformed the image of Detroit is, some critics call this “ruin porn,” while others (some academic professors) call Detroit Michigan’s “third world” city.
For these reasons I am not too surprised to read a headline that is generally associated with sending jobs to developing countries (“third world”). The article highlights the growth of businesses moving into downtown Detroit because of the low cost of office space and the surplus of technical talent. The technical talent may be reference to wider metro Detroit and the many existing technology companies, but I know that I often see billboards in Detroit promoting web and technology job opportunities.
In an interview with Tim Bryan, GalaxE Solutions, the CEO said,
“A hundred percent of the work we’re doing in Detroit is health-care related and is coming from outside Michigan. It validates our model to outsource to Detroit.” […] enable[ing] GalaxE to serve customers for roughly the same cost as operating from Brazil.
I would not call this outsourcing, since the primary idea with outsourcing is that the job leaves the USA for another country where business is cheaper. There are plenty of examples of companies shifting locations because of varying economic climates in different States. Case in point, GM moving production from Michigan to Tennessee because of different business regulations and tax breaks. Brazil is an up and coming developing economy with its hand in many international markets – is it bad to be like Brazil?
Detroit is quickly becoming an technology hub for Michigan, which is an amazing reversal from its manufacturing past, as well as innovating for better health care. Wayne State University School of Medicine is leading incredible research projects to improve health care along with the Detroit Medical Center’s (DMC) nine specialized hospitals, Henry Ford Health System, and Michigan State University’s College of Osteopathic Medicine.
If this is the future for Detroit, then things are looking good. This is an excellent example of economic growth in a downturn via two growing industries: health care and technology. If Detroit lawmakers play the cards right, everyone in Detroit could get the best of both worlds: job creation and city revitalization. These are important steps to pay attention to for a better Michigan future.
Alex B. Hill 