The Public Health System’s Contributions to Stigma and Discrimination in Mental Health Impacting Full Recoveries from Mental Illness- Jennifer Jolivet

Mental Health America defines mental illness as a “disease that causes mild to severe disturbances in thinking, perceptions, and behavior” and classifies disorders into 5 major categories: anxiety, mood, and eating disorders, dementias, and schizophrenia. Mental illnesses are extremely prevalent in the US with more than 54 million Americans suffering from 1 or more mental disorders (1). Mental illnesses can be extremely disabling, and they affect all genders, ages, and races. According to a report by the Surgeon General, mental disorders account for more than 15% of the overall burden of disease from all causes and slightly more than the burden associated with all types of cancer (2). Unfortunately, mental health has not been regarded as important as physical health, and people suffering from a mental illness have long been subjected to hostility, discrimination, and stigma (1). Stigma and discrimination can trace their roots back to the ideas of separating the mind from the body in terms of importance and treatment. These influences continue to affect thinking today because the public health system has not done an adequate job of changing public opinions created by past public health practices and the media. There are many ways the public health system has done an insufficient job with regard to managing mental illness, but there are 3 ways that are especially significant because they help continue stigmatization and make it difficult for people to receive treatment: People with mental illnesses suffer from stigmatization from health professionals, there is a huge disparity in access to service in the form of financial barriers to those that need help, and the public health system has not successfully combated the media’s negative portrayal of people with mental illness. The public health system has failed those with mental illness because mental illness in public health has not been treated with the same respect and concern as other diseases like cancer. Mental illnesses can have a significant negative impact on many people in the US, and due to this, mental illness is a public health problem that cannot be ignored by the public health system anymore (2).

Mental illnesses have long been associated with many negative stereotypes, including violence, dangerousness, unpredictability, uncontrollability, and craziness. The phenomena of mental illness stigma can be explained by the labeling theory. According to this theory, the self identity and behavior of an individual is influenced by societal norms. Society has established a set of rules that dictate what normal and usual behavior is, and those who violate the rules are abnormal. People with mental illnesses cannot always act the way society believes is correct and because of this, the general public views people with mental illness as having something wrong with them, allowing stereotypes to develop. The public’s attitudes on mental illness have been tracked since the 1950’s and not much has changed concerning stigmatization. In the 1950’s people viewed mental illness as a stigmatized condition and those with extreme behaviors, psychosis, were viewed as mentally ill and were stigmatized as unpredictable and violent (2, 3). A similar study by Phelan et al. (4) in 1996 revealed the public had an increased scientific understanding of mental illness. However, social stigma was stronger than what it had been in the past, especially concerning psychosis disorders like schizophrenia. In the 1950 study, 13% of the responders who defined mental illness to include psychosis stigmatized mental illness with violence, while in 1996, 31% of the responders did so, indicating people today still fear that those with mental illnesses are dangerous even though this idea is largely unfounded (2).

For a person with a mental illness, constantly being shunned and viewed differently by employers, health professionals, family, and strangers, no matter how minor it is, can take an emotional toll. Stigma causes people to distrust, fear, avoid, and discriminate against people with a mental illness. Those who suffer from a mental illness often do not seek treatment because of the embarrassment of being labeled mentally ill. There is shame, isolation, and blame due to stigma. By not seeking treatment, people do not learn ways to manage their diseases, greatly impacting their way of life. Mental disorders are biological in nature and not all can be cured, but stigmatization caused by labeling creates adverse effects in equality, treatment, and overall outcomes for people suffering from mental illness. The long term consequences of stigmatization prevent many people with mental illness from recovering and leading successful lives (5, 6, 7).

HISTORY OF PUBLIC HEALTH’S CONTRIBUTION TO STIGMATIZATION OF THE MENTALLY ILL IN THE US
Historically, mental illness in the public health system has not been treated as a “real” biological disease, and this mistreatment helped establish the stigma associated with it that continues today. Early on, philosophers, most notably Rene Descartes, taught people to separate the mind from the body because the mind was not as important or rational as the body and the mind acted out of passion. This thinking greatly influenced how mental illnesses were viewed and dealt with. In the 1700’s, people with mental illnesses were called “lunatics” and cared for by families with no medical intervention. In the 1800’s, social policy dictated that those with a mental illness be removed from society because they were afflicted with their disorder for violating physical, mental, and moral laws. The mentally ill were sent to asylums, which were often inhumane places where frequent mistreatment occurred (3). In the 20th century, asylums lost popularity, but just as inhumane events occurred. For example, in the 1920’s, many mentally ill patients were forcibly sterilized, and in the 1940’s and 1950’s, many received lobotomies to remove the damaged brain which often caused even more serious side effects like mental retardation (2, 3).

This separation of the mentally ill from the rest of the public affected the treatment of and attitudes toward the mentally ill. Treatment has evolved over the years from doing nothing to the many therapies and therapeutic drugs of today, but attitudes toward treatment are still very different compared to attitudes toward treatment for publicly accepted diseases like cancer and heart disease. One problem is the mental health field was the repository for disorders whose etiology was unknown. The mental health field in its early origins included diseases that had no scientific understanding or treatment, but as more was discovered about the disease, it was moved to more medically respected departments like internal medicine or neurology. This led many individuals both in the public and medical fields to believe psychiatry was not a part of medicine and not based on reliable science (2). This idea has slowly changed over the past few years, but mental disorders are still not treated equally in the medical community. Compared to other diseases such as cancer, obesity, and heart disease, mental disorders do not receive anywhere near the same level of respect and attention as they have. The public and medical fields view obesity, cancer, and heart disease as biological diseases with symptoms and that they are a burden and life-threatening. Treatment focuses on prevention and rehabilitation, and the public health system has launched numerous campaigns to educate people about eating healthy, exercising, and being pro-active in taking caring of oneself. Obesity no longer has the stigma once associated with it because it is viewed as a very serious disease. Mental disorders have not received this treatment. Even though they affect millions, are life-threatening, and a tremendous burden to more than just the affected person, mental illness is not considered a physical disease because they often do not kill an affected person like leukemia does. People have trouble believing the idea that the mind is just as susceptible to disease as the heart or lungs. A January 2000 article in US Today illustrates this point: under the title “Mental Disorders Are Not Diseases,” Thomas Szasz argues that medical diseases are discovered while mental diseases are invented because medical diseases occur from physical aliments and are diagnosed based on physical abnormalities in the body while mental diseases are patterns of personal conduct and diagnosed on behaviors alone (8). People still believe there is no need for medicine to be involved in mental disorders because the public health system has not done what it has for diseases like obesity: making it socially acceptable for people to get diagnosed and treated because they suffer from a real, serious disease that can affect everyone.

HEALTH PROFESSIONALS CONTRIBUTE TO STIGMA AND DISCRIMINATION
Separating mental health from overall health not only influenced the general public but mental health professionals as well. A reason the public has not significantly changed its opinions about people with mental illnesses is because health professionals themselves stigmatize. There are few studies on this issue, but those that have been conducted reveal a double standard within the field because health professionals do have negative views and discomfort about mental illnesses (9). A study showed psychiatrists have more negative stereotypes than the general public, classifying those with a mental illness as more dangerous, unpredictable, and unreliable compared to the general public. Despite being better educated about the diseases, health professionals also showed the same lack of interest as the general public did regarding social interaction with severely mentally ill, like those suffering from major depression and schizophrenia. Professionals also had different beliefs regarding major depression and schizophrenia, with schizophrenia being viewed more negatively (10). Many mentally ill people already face significant discrimination from the outside world and they do not need more from the people who are supposed to be helping them. Beside continuing the cycle of stigmatization, health professionals’ beliefs deter people from seeking treatment. If the health professionals already have negative thoughts and reactions to their patients, it is difficult to believe there will be unbiased and open dialog and treatment.

Health professionals also add to stigma and discrimination in the way they diagnose patients, especially with regards to culture. Mental disorders are extremely difficult to diagnosis because they rely on patients describing symptoms rather than a definitive test or x-ray. The professional has to work with what the patient describes and see how it compares to different criteria set for disorders, and clinical judgment plays a significant role in final diagnosis. Disorders lie on a continuum, so there is major room for misdiagnosis or over diagnosing (11). Even though professionals are aware of the negative aspects of being labeled mentally ill, in studies they will often misdiagnosis non-cases as being mentally ill with major depression (10). For minorities, the problems they face are increased. Schizophrenia has been shown to affect all racial groups at the same rate, yet African Americans are more than 4x more likely to be diagnosed than whites and Hispanics are 3x more likely to be diagnosed than whites (12). For Asian Americans, under-diagnosing has been suggested as a problem because of the stereotype that they are “problem free” (11). Health professionals are not examining the cultural differences that prevent people from seeking treatment, could be a reason for why treatment is not working, or could be reasonable explanation for the behavior the professional feels is “abnormal.” For example, in some cultures, it is not acceptable to look someone in the eye and a clinician could easily misinterpret this if he/she is not aware of the customs (12). These disparities make mental health treatment appear uninviting, inappropriate, and ineffective (11). If patients do not trust their doctor or believe the doctor did not really listen to what they described, it is reasonable to understand why many people do not seek treatment. The lack of effective communication is a huge problem that prevents people with a mental illness from receiving proper, successful treatment.

To combat these problems that make it difficult for the mentally ill to receive treatment, health professionals need to be better trained and understand their own biases and how they affect treatment. They have to realize how their stigmatization greatly impacts their patients and the public. Professionals also need to be more aware of the cultural differences regarding race, age, and gender, and how these factors influence diagnosis and treatment. Diagnosis and treatment need to be tailored to take into account the cultural differences that influence a patient’s behavior. Creating a treatment that is geared more toward the individual should have more positive results for the person, which in turn will show others they can have more trust in the mental health services (13).

FINANCIAL BARRIERS TO TREATMENT
Isolating mental illness from the rest of the health system has had a significant impact on treatment services for disorders. By not making mental illnesses a priority, access to treatment is severely limited. Although there are numerous and very effective treatment options available for those with mental illness, the ability to pay for them is a huge barrier that prevents many from seeking a mental health specialist. Only one third of people suffering mental illness receive treatment. A survey by the American Psychological Association found Americans cite lack of any insurance coverage (87%) and costs (81%) as the major reasons that keep them from seeking mental health services (14). Even those who have insurance do not often receive treatment because health insurance coverage is more restrictive for mental illnesses than it is for somatic illnesses. Fearing the high costs of long term care, private insurance companies either refuse to cover any mental illness treatment or place limits on coverage. These restrictions include low monetary caps on long term care, high co-payments and deductibles, and low monetary caps on annual care. Medicaid and Medicare place similar restrictions on their mental health coverage. Compared to other general health services, those seeking mental health services pay substantially more out of pocket expenses and face a greater risk of suffering a catastrophic financial loss when care costs exceed insurance limits. Economic study models describe this disparity: for a family with mental health expenses of $60,000 a year, the out of pocket cost is $27,000 while the out of pocket medical/surgery costs are $1,800 (15). Insurance companies place people with severe, chronic mental illnesses in a difficult situation where they have to decide whether they take the financial hit and pay for treatment or do not receive treatment because the money has to go somewhere else. These financial barriers prevent many people from seeking and staying in treatment. The lack of interest in making treatment accessible to more individuals with mental illnesses re-enforces the idea that mental illness is not as important as other diseases.

The public health system has to address these financial barriers that are preventing treatment. It is hard to imagine only being allowed to go to the doctor three times if one was diagnosed with breast cancer, but it does happen for those with mental illness. The Paul Wellstone Mental Health and Addiction Equity Act is currently being debated in Congress, and the public health system should be actively campaigning for the passage of this legislation. It aims to stop the discrimination in the treatment of mental illnesses by prohibiting treatment limits and increased financial requirements insurance companies impose on those receiving mental health services (16). Some states have laws that require mental health financing to be on the same level as financing for general health services, and studies indicate total health care costs barely go up. The public health system should use this information to initiate changes in the laws by educating people on the idea that better services will not be as financially burdensome as insurance companies suggest (15).

THE PUBLIC HEALTH SYSTEM IS NOT SUCCESSFULLY CHALLENGING STIGMA
The historic impact of mental illness stigma is still felt today in many ways, and the public health system has begun to realize they have to actively challenge the stigma the mentally ill continually face. They have launched many anti-stigma educational campaigns, but these actions are not enough because stigmatizing opinions are not related to knowledge. As studies show, mental health professionals stigmatize even though they are highly educated on the subject (10). The public health system is failing to use one of the most influential sources to reverse the damage of stigma: the media. The public health system fails in two ways with regards to the media: it has not prevented the media from continuously portraying the stereotypes of mental illness, and they are not affectively using the media to change public opinion. The media plays a tremendous role in stigmatization because it is the primary source of information about mental illness for many Americans. Unfortunately, the media does not always positively portray mental illness and constantly links people with mental disorders with violent behavior and provides inaccurate information on mental disorders. Newspapers overwhelming focus on the dangerousness and criminality of people with a mental illness. A study in 1994 examined 184 prime time shows and found the mentally ill characters were 10 times more violent than the general population of characters, and in crime dramas, the offender had a mental illness in over 50% of the programs. People with mental illness were also portrayed as childlike, laughable, narcissistic, and lazy (17; 18). Rarely is there a mentally ill person who is the hero of a storyline. There is no disclaimer at the end of show where a schizophrenic person was the killer saying this is not the norm. The media reinforces what the general public wrongly believes about the mentally ill, and the public health system has not done a sufficient job in challenging what the media is doing. They are not protesting what is on the shows or providing alternative positive images of the mentally ill, allowing the media to continue supporting stereotypes.

The public health system is not affectively challenging the media because it is failing to understand why the media portrays the mentally ill as it does. The public health system runs an anti-stigma ad but then the show that follows has a mentally ill person committing heinous crimes. The public health system is competing with the media rather than working with it to get more accurate information out, and they do not appear to be taking into account how influential the media is. By not understanding the types of messages the media is releasing and the reasons for it, the public health system will have a difficult time getting people to be more accepting of the mentally ill. Education alone is not going to reduce stigma because the stereotypes are too deep in the social system. The public health system has to realize that using the media to provide images that portray the mentally ill as real people is an effective way to help people overcome their stigma. This includes having characters that have different disorders not just the most feared ones like schizophrenia and showing how they really function in society as well as not always making the mentally ill the bad guy (17).

There are many examples the public health system can look at to develop a better anti-stigma campaign. For example, tobacco is an example where the media has helped change what is socially accepted behavior. In movies and television, smoking by major characters is not as common as before. Educational campaigns focus on giving the public power to demand change and take charge rather than using fear or blame. This model could be used to create messages that motivate people to stand up against stigma rather than scolding them for it. There are some examples in the mental health field as well. Drug companies have helped start to change opinions on depression. There are ads for treatment on television as often as ads for Viagra. The commercials are a step toward reducing mental health stigma by showing everyone can get depression but that with help, the person can take back control of his/her life. In addition, numerous celebrities have publicly come out and discussed their battle with depression in the media and how they sought treatment to overcome it. Celebrities help show people that everyone is susceptible to mental illness. They can also help reduce stigma by showing if they can acknowledge their problem as public figures, there should be no shame for regular people to do it as well. As Mike Wallace of 60 Minutes stated when discussing his severe depression, “there’s nothing, repeat, nothing to be ashamed of when you’re going through depression” (19). The public health system needs to model anti-stigma campaigns after these successful media interventions. The public health system can use the media to make the public aware, concerned, and interested in mental illness. By changing public opinions, this will initiate changes in public health policy that will allow better and more accessible treatment because mental illness will not be an afterthought with regards to health.

People with mental illnesses suffer beyond just their disease. Because of how they have been treated in the past, problems persist today. Mental health professionals contribute to the stigma, financial burdens prevent many from receiving treatment, and the public health system is not using the most effective way to reduce stigma. Mental illness affects millions of people, costs billions of dollars, and is just as devastating as other diseases; therefore it deserves the same level of attention and respect. The public health system is increasing its part in challenging stigma, but it needs to do more. Health professionals need to understand their role in stigma and how it negatively affects treatment. Mental health service should be financed on par with general health services. Making these changes in policies will help change public opinion because mental health will finally be viewed as an important aspect to overall health. The general public also needs to be educated on more than just the scientific aspects because people’s stereotypes are just too strong. Education that shows people the mentally ill are not as frightening as they thought they were is what will illicit changes. Using the media will be a powerful way to get this new message across because the media is what helped make the stigmatization so strong. Fighting stigma will help those with mental illness finally receive the quality treatment they deserve.

REFERENCES
1. Mental Health America. Stigma: Building Awareness and Understanding. http://www.mentalhealthamerica.net/go/action/stigma-watch.
2. Surgeon General. Introduction and Themes. In Mental Health: A Report of the Surgeon General, 1999. http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c1.pdf.
3. Link, B., Phelan, J.C., Bresnahan, M., Stueve, A., and Pescosolido, B.A. Public Conceptions of Mental Illness: Labels, Causes, Dangerousness, and Social Distance. American Journal of Public Health 1999; 89: 1328-1333.
4. Phelan, J., Link, B., Stueve, A., and Pescosolido, B. Public conceptions of mental illness in 1950 in 1996: Has sophistication increased? Has stigma declined? August 1997. Paper presented at the meeting of the American Sociological Association, Toronto, Ontario.
5. SparkNotes. Introduction to Abnormal Psychology. http://www.sparknotes.com/psychology/abnormal/intro/labelingtheory.html.
6. Link, B.G., Yang, L.H, Phelan, J.C., and Ciollins, P.Y. Measuring Mental Illness Stigma. Schizophrenia Bulletin 2004; 30: 511-541.
7. Lamb, H.R. Review of Being Mentally Ill: A Sociological Theory, 3rd ed., by Thomas J. Scheff. American Journal of Psychiatry 2002; 159: 513-514.
8. Szasz, T. Mental Disorders Are Not Diseases. USA Today (Society for the Advancement of Education). January 2000. http://findarticles.com/p/articles/mi_m1272/is_2656_128/ai_58576581.
9. Sriram, T.G., and Jabbarpour, Y.M. Are Mental Health Professionals Immune to Stigmatizing Beliefs? Psychiatric Services 2005; 56: 610.
10. Nordt, C., Rossler, W., and Lauber, C. Attitudes of Mental Health Professionals Toward People with Schizophrenia and Major Depression. Schizophrenia Bulletin 2006; 32: 709-714.
11. Surgeon General. The Fundamentals of Mental Health and Mental Illness. In Mental Health: A Report of the Surgeon General, 1999. http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c2.pdf.
12. Vedantam, S. Racial Disparities Found in Pinpointing Mental Illness. Washington Post. 28 June 2005. http://www.washingtonpost.com/wp-dyn/content/article/2005/06/27/AR2005062701496.html.
13. Surgeon General. A Vision for the Future. In Mental Health: A Report of the Surgeon General, 1999. http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c8.pdf.
14. Bossolo, L. Most Americans List Lack of Insurance Coverage for Not Seeking Mental health Services. American Psychological Association. http://www.apa.org/releases/insurance.html.
15. Surgeon General. Organizing and Financing Mental health Services. In Mental Health: A Report of the Surgeon General, 1999. http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c6.pdf.
16. Wellstone Action. End Discrimination-Help Us Pass the Wellstone Bill! http://www.wellstone.org/network/article_detail.aspx?itemID=9229&catID=2796
17. Stout, P.A., Villegas, J., and Jennings, N.A. Images of Mental Illness in the Media: Identifying Gaps in the Research. Schizophrenia Bulletin 2004; 30: 543-561.
18. Byrne, P. Stigma of Mental Illness and Ways of Diminishing It. Advances in Psychiatric Treatment 2000; 6: 65-72.
19. CBS. Depression. CBS Cares. http://www.cbs.com/cbs_cares/depression/.

Will the Commonwealth Truly Connect its Citizens to High-Quality, Safe, Effective, Timely, Efficient, Equitable and Patient-Centered Health Care?

A Critique of the Massachusetts Health Care Reform Legislation - Jahera Otieno

Health Care coverage continues to become an issue of growing importance in the US. As people begin to lose essential health insurance coverage or start having to pay for portions of their health care due of rising costs, health care coverage, or lack thereof, is becoming a topic of increasing significance. As the 2008 presidential race picks up, republican and democratic candidates alike, are sharing their attempts on how they plan address the concerns related to paying for our nation’s health. We are spending more on doctors, prescription drugs and procedures than we ever have before but there are still over 40 million uninsured persons coming from every race, culture, ethnicity and income (3). With health care costs rising to over $2 trillion in 2007, will health care really be a “good” that is accessible to all peoples? This question is one that the state of Massachusetts hopes to answer.

In 2006, Health Care Reform became law in Massachusetts, initiating a national conversation about healthcare. The legislation plans to bring about a healthier Massachusetts with everyone - individuals, government and employers - doing their part and sharing the responsibility to provide all citizens with access to quality health care. While this legislation allegedly makes health care more accessible (mainly by eliminating cost), it also requires, or mandates, that all people have coverage and no longer making it an individual choice. This reform makes Massachusetts the first state in the nation to provide all citizens, if successful, with health care, and in turn, creating a model of universal health care for our country (2,3). Massachusetts becomes the first state in the Nation providing all of it citizens, if successful, High-Quality, Safe, Effective, Timely, Efficient, Equitable and Patient-Centered Health Care (1), creating a model of Universal Health Care for our country (2,3).

As this legislation is working to provide access to hundreds of thousands of people in the state with health care, it is also setting the stage for similar legislation to happen all around the country and in our nation as a whole. In moving forward, it is important that many questions and concerns that key stakeholders have are addressed. Is this legislation truly providing an easier way for all Massachusetts’s residents to access health care? Will there be enough money to support the program while not taking away from current services? Will “affordable” health care really be affordable? With there being an increased demand those primary healthcare services being, will the quality of care that is received here remain cutting-edge or suffer? The Massachusetts Health Care Reform Legislation claims to be providing “affordable” care to Massachusetts’s residents, but its citizens still will not access to affordable health care services.

Argument I: Massachusetts Health Care Reform Legislation does not account for other barriers, outside of cost to health care.

The Massachusetts Health Care Reform Legislation claims that it will provide all it citizens with access to affordable high quality health care but there are some known implicit and explicit barriers to health care that prohibit many people from using health care services. The cost of care will always discourage people from getting regular health care, but there are also many non-financial barriers to health care like culture, race and ethnicity that may deter someone from accessing basic and preventative health care. While the legislation does address some of these issues, there are key elements that have not been addressed throughout the policy.

First and foremost, the cost of health care is the primary reason that health care is not accessed by many people. According to Bodenheimer and Grumbach, Understanding Health Policy, “Access to care has two major components. First and most frequently discussed is the ability to pay”(4). The cost of health care, and its persistent rise, is the primary reason that many do not access care and one of the primary issues addressed by the legislation. By potentially eliminating cost as the barrier to care, it is believed that people should have no major hindrance to accessing health care. Past attempts at controlling cost and political unwillingness to stop the rising cost of health care continue to promote the inaccessibility of health care for many people. For some, health care is still out of reach. The legislation included a caveat that exempts some from having to obtain health insurance coverage (5). Even with the reform aiming for universal coverage, it is still out of reach for some 60,000 people. With Massachusetts having approximately 500,000 uninsured, there is still a large portion of the population for which coverage remains out of reach (5). The cost of care needs to reach a place where care is within reach so that all can access it.

But there are a variety of other reasons, which inhibit people from accessing necessary healthcare services. First, there are major cultural and language barriers that may stop a person from accessing services. "The availability of culturally competent services can make a real difference in whether a patient comes in for care or returns for a second visit (6)." For example, if a woman can’t speak English and is being seen by a male physician, it may be an uncomfortable experience for her and stop her from seeing that doctor, or any doctor, in the future. A New England journal of medicine article states that language barriers can have deleterious effects. Patients who face such barriers are less likely than others to have a usual source of medical care; they receive preventive services at reduced rates; and they have an increased risk of non-adherence to medication (7).

Additionally, issues regarding race, may also stop a person from accessing health care. It has been shown that persons of color are less likely to receive primary health care services when compared to whites (8). According to the report from HRSA, racial and ethnic minorities face significant health disparities. Compared with white infants, infant mortality rates among blacks and Native Americans are 2.5 and 1.5 times higher, respectively. Black men less than 65 years of age have double the rate of prostate cancer compared with white men. The prevalence of diabetes is 70 percent higher among blacks and nearly 50 percent higher among Hispanics than among whites (7). On CommonHealth, WBUR’s blog, about health care in the commonwealth, Elmer Freeman talks about how it is not a matter of how you’re covered but it’s how you’re treated (9). Mr. Freeman states that while it may be unhealthy to be uninsured, health insurance is no assurance of better health, particularly for the diverse racial and ethnic minority groups across the Commonwealth (9). It is true that insurance doesn’t equal access because if a person is not comfortable accessing services, simply having insurance will not open that door.

While, the legislation has established a statewide Racial and Ethnic Health Disparities Council to track disparities data but it does not seem likely that this new legislation will achieve significant results in addresses issues that will persist in baring people for essential care. There are many issues that affect a person’s ability access to health care, regardless of having insurance. It is imperative that the commonwealth continues to watch these issues and others as they arise and work to address.

Argument II: By using the Power-Coercive Model, the MA Health Care Reform Legislation will not increase use of health care through its individual mandate.

There are a variety of strategies that Public Health professionals use when developing interventions to address health care issues. “When a person or group is entrenched in power in a social system, in command of political legitimacy and of political and economic sanctions, that a person or group can use power coercive strategies in effecting changes, which they consider desirable, with much awareness on the part of those out of power in the system” (10) and people are often aware when something is being pushed on them. The Power-Coercive Model can be effective when implementing system-wide change, but it can also make some feel powerless when an initiative, program or policy, be it beneficial or not, is being forced upon them to accept.

One particular troublesome element to the Massachusetts Health Care Reform are the individual and employer mandates. The mandate is being enforced through the use of a penalty system. By working to create change by using a mandate-penalty strategy, the state is use of a Power-Coercive technique will hopefully create state wide social change in regards to health. Unfortunately, by using the Power-Coercive technique to enact a policy that Massachusetts feels is most beneficial to all it citizens, the reform may not be as successful as hoped. The Power-coercive model places emphasis on political and economic sanctions in the exercise of power (10) and it can have a detrimental effect on the change desired. Some may fight back or simply “opt-out” of the requirement.

“A mandate is critical, however, to helping the state (MA) achieve near-universal coverage and it is hard to force people to buy coverage, especially when some people do not think they need it” (11,12). By enacting an individual mandate into the legislation, it shifts the responsibility to the person to find their own health care and “as most people in the United States rely on their employers or a government program for coverage, and individuals seeking insurance on their own are faced with a difficult, sometimes impossible, task” (11,12). Having that responsibility can be an overwhelming task, even for those who have an understanding of health care. And for some MA residents, it may just be easier and cheaper to pay the penalty than to get health insurance (14). Easier, because looking for and accessing care can be a daunting task, even for those who have their coverage paid for. And for a family that is not eligible for the free or less expensive health care coverage options, the cost to provide care simply may not be affordable and a penalty may be the only reasonably priced option.

Argument III: MA Health Care Reform Legislation will not decrease or contain the spiraling cost of healthcare in Massachusetts.

The cost of health care in America continues to rise. With the US forecasted to spend over two and a half trillion dollars on health care in 2007, the cost of basic and essential health services are slowly moving out of reach of individuals, government and employers. But there are a variety of ways to slow down these rising costs including increasing efficiency of health care delivery or limiting the resources available to the health care system (13). The health reform legislation created a Quality and Cost Council which is responsible for setting benchmarks for quality improvement and cost containment, but there was no central focus in the legislation on containing cost overall.

There is a major need for health care accountability for the rising cost of care, particularly on the part care providers. In article by Jon Hurst, he states that “we need answers and accountability from health care providers and that we need to put health care under the microscope to truly examine where the money is going for all this health care (17). As health insurance premiums could cost up to 20% of a total compensation (15), the commonwealth needs to examine where all this money is going to come from to pay for the coverage it has promised it citizens. “What we need is a revolution through which we can replace our resignation with hope -- and our disengagement with a new community-based activism driven not by partisan politics but by an unwillingness to accept a system that has become obsessed with the delivery of health care as an economic commodity at the expense of health for the American people (16). If the state is able to effectively control costs, consumers will get more value for their money while still providing exceptional care. In moving forward, ee as a commonwealth need to collaborate with all stakeholders to control these costs before they get out of hand.

Massachusetts claims that it will address concerns of all it citizens and provide High-Quality, Safe, Effective, Timely, Efficient, Equitable and Patient-Centered Health Care (1)? And while there have been many strides towards providing all citizens with health insurance, it is unlikely that it will provide the highest quality and affordable care possible. It is unlikely that all people will access health care with insurance now even if they have it or if they are being forced to use the services. According to the World Health Organization Constitution, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (18) but this is not a belief held by all. As the state moves into year two of this legislation, it will need to stay in control of the service they are providing. It will need to continue to provide affordable care to all those who need it. It will need to look closer at the beliefs, ideas and expectations of all it peoples that it had that may not have been examined closely before.

References

1. The 185th General Court of The Commonwealth of Massachusetts Chapter 58 of the Acts of 2006. An Act Providing Access to Affordable, Quality, Accountable Health Care. http://www.mass.gov/legis/laws/seslaw06/sl060058.htm
2. “Health Care Reform: An Overview”. Massachusetts Commonwealth Connector www.mahealthconnector.org/portal/site/connector/menuitem.d7b34e88a23468a2dbef6f47d7468a0c?fiShown=default
3. Lee, C. Massachusetts Begins Universal Health Care. The Washington Post. 2007 www.washingtonpost.com/wp-dyn/content/article/2007/06/30/AR2007063000248.html
4. Bodenheimer, Thomas S. , Grumbach, Kevin. Understanding Health Policy. 2001.
5. Families USA. Massachusetts Health Reform of 2006 PDF. August 2007
6. Preboth, Monica. Breaking Cultural Barriers in Health Care. American Family Physician, http://findarticles.com/p/articles/mi_m3225/is_6_61/ai_61432844
7. Flores, G. Language Barriers to Health Care in the United States. New England Journal of Medicine. 2006;355;229-231.
8. Altman, S., Doonan, M. Can Massachusetts Lead the Way in Health Care Reform? New England Journal of Medicine. 2006;354:2093-2095 M
9. Freeman, E. It’s Not How You’re Covered…It’s How You’re Treated. CommonHealth, 2007. http://www.wbur.org/weblogs/commonhealth/?p=36
10. Chin R, Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The Planning of Change (3rd edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976.
11. McDonough, J. The Individual Mandate is about to get serious. CommonHealth, 2007. http://www.wbur.org/weblogs/commonhealth/?p=238
12. Abelson, R. Mandatory Coverage Is Easier Said Than Done. New York Times. 2007 http://www.nytimes.com/2007/06/11/business/businessspecial3/11insure.html?emc=eta1&pagewanted=all
13. Controlling Health Care Cost. New England Journal of Medicine .Volume 351:1591-1593 October 14, 2004
14. Lawmakers Say Employer Mandate Key To Massachusetts Health Reform Law

http://www.medicalnewstoday.com/articles/42013.php

15. A cure for spiraling healthcare costs .By Stuart H. Altman | January 2, 2007 http://www.boston.com/news/globe/editorial_opinion/oped/articles/2007/01/02/a_cure_for_spiraling_healthcare_costs/?p1=email_to_a_friend
16. Kitzhaber, J Health care system lacks accountability. October 7, 2005. Seattle Post-Intelligencer http://seattlepi.nwsource.com/opinion/243676_codeblue07.htm
17. Hurst, J. When will we just say no to big health care. Commonhealth. 2007 http://www.wbur.org/weblogs/commonhealth/?p=223
18. Constitution of the World Health Organization.. Basic Documents, Forty-fifth edition, Supplement, October 2006

Black Death: The Failure of the Public Health Community to Support African-Americans Making End-of-Life Decisions – Sarah Baker

One year ago, I watched my grandfather die. I stood at the foot of the bed, and watched him draw each slow, raspy breath until they simply ceased. He died what many think might be a “good death”: in his bed, surrounded by his family and loved ones, with no machines, no tubes, and only a little bit of morphine now and then. Most anthropologists would say that my grandfather’s idea of a “good death,” like most health beliefs and behaviors, can be attributed to social and cultural factors (1) and applying the theory of cultural relativism we might argue that other choices at the end-of-life should be respected as my grandfather’s were(2).

There has been a great deal of interest in healthcare disparities at the end-of-life as they are the invert of the disparities that exist in at other times: during the last 12 months of life African-Americans receive more intensive treatments than whites, whereas white survivors receive more intensive treatment than African-American survivors (3). African-Americans are also more likely to die in the hospital, (4) and less likely to use hospice (5). A number of researchers and popular media would argue that this difference is cultural and for a variety of historical and cultural reasons African-Americans simply prefer more aggressive treatments (6, 7). Does this mean we are simply respecting the wishes of dying African-Americans and giving them culturally appropriate treatments? Or is this disparity, like so many others, an example of a minority group receiving sub-standard healthcare from a system wrought with prejudice and uneven access? Most importantly, has the public health community succeeded in supporting and educating African-Americans in a culturally appropriate manner?

The current system of advance care planning is reliant on a communicative, trusting patient-physician relationship where a physician can clearly explain treatment options and respect a patient’s choices. African-Americans experience a number of barriers to this type of relationship. Many lack confidence in the medical community to have the necessary trust in their physicians (8, 9). Many also lack a primary care physician to advocate for them during critical periods (10). Finally, studies have shown that minority patients, including African-Americans, experience more difficulty with respect for their preferences than whites (11, 12, 13, 14). Clearly end-of-life decisions are personal choices, but they are also medical choices and the public health community needs to apply an anthropological approach to the development of education and outreach to African-American about end-of-life decisions.

TRUST & RAPPORT

In surveys of terminally ill patients, open communication with a physician is considered most important at the end of life (15). This communication has been inhibited by mistrust in the medical community built through a history of abuses. Though the Tuskegee experiment is the most often cited reason for African-American’s mistrust of the medical system, the abuses go much farther back and are far more insidious than the infamous Alabama study. Horrifying medical experiments were regularly performed on slaves, and black cadavers were almost exclusively used for dissection by medical students (16). Qualitative studies have also shown that young African Americans not familiar with the Tuskegee experiment also exhibit distrust in the medical community that is assumed from elders in their community (17).

A patient and his or her family needs to openly discuss end-of-life treatment choices and personal values and preferences with their medical team. The historical treatment of blacks in the medical system has hindered their ability to have these conversations with their physicians. Indeed, studies have shown that racial disparities are greatest for treatments that require counseling (18). Using an anthropological perspective of understanding both the behavior and the broader context in which it occurs allows us to see that these disparities in end-of-life care are not simply the effect of varying preferences across diverse groups, but instead are another effect of the lack of trust between African-Americans and their medical providers.

While work remains to overcome the issues of mistrust of the medical community, the public health community should develop other venues apart from typical medical environments where end-of-life education and communication can occur. African-Americans need to have confidence in the information they receive about medical conditions and end-of-life treatment options so that decisions are made based on personal choice and not fear or suspicion.

ACCESS

The issue of racial disparities in access to medical care takes two main forms: disparities in healthcare insurance and access to primary care physicians, and the geographic disparities that affect the type of care patients will receive when they visit their local hospitals. One recent study shows that the uninsured rates for African-Americans and Hispanics are one and a half to three times as high as that of whites. African-Americans are also more likely to use the emergency room to treat a condition that could have been treated by a primary care doctor (19). Lack of insurance and over-use of the emergency room prevent African-Americans from developing the relationships with primary care physicians that are necessary in the construction of an advance care plan that is patient-centered and takes into account the patient’s preferences and beliefs.

Care at end-of-life is also impacted by the geographic disparities that exist in the treatment of conditions, and African-Americans may not be “choosing” aggressive end-of-life treatment and instead they are passive victims of the hospital system where they are living. Barnato et al showed that the majority of observed differences in terminal ICU use among African-Americans and Hispanics were attributable to their use of hospitals with higher ICU use rather than to racial differences in ICU use within the same hospital (20). Disparities in treatment were also found to be much greater for treatments that require a measure of counseling, which are communication sensitive (21). Understanding the variation in local hospital systems is essential in understanding these statistics in the treatment “choices” that African-Americans are making. The systems that most African-Americans access are inherently different due to geographic disparities and relying on physicians and hospitals to provider the highest quality end-of-life care to African-Americans is doing a great disservice to this population.

RESPECT & UNDERSTANDING

A number of studies show minority patients perceive more bias and lack of cultural competence by providers than do whites (22). These perceptions have a direct effect on whether a patient follows advice or not, where a patient is less likely to follow the advice of a doctor if he or she perceives bias or lack of cultural competence (23). African-American patients also report more problems with respect for preferences and more problems with information and education (24). Finally, African-Americans also report the highest dissatisfaction rates with healthcare out of any group (25). This perceived racial bias and disrespect for preferences prevents African-Americans from effectively communicating with their providers, and hospitals lack the ability to effectively educate minority populations about healthcare. The claim that African-Americans simply prefer more aggressive treatment options becomes highly suspect when we view the statistics through this lens of bias and disrespect for personal preferences.

This bias, combined with reports by residents that they are unprepared to provide cross cultural care (26) and repeated studies about physicians’ cultural incompetence (27) means that there are gaping divides between African-Americans and their physicians. Individual providers need to be trained in cross-cultural communication, and hospital systems need to be better trained in how to educate these populations. Meanwhile, other channels should be employed to communicate and educate minorities about end-of-life care and treatment choices. The current system relies on physicians and hospitals to communicate end-of-life options to African-Americans, understand their preferences, and respect their choices. Providers have proven to be ineffectual in all three of these areas and thus it is up to the public health community to help fill the void.

CONCLUSIONS

Anthropological theory emphasizes that any health behavior cannot be separated from the larger social and cultural context in which they occur (28). African-Americans are operating in a system that has historically been abusive to them, does not allow them equal treatment or access to services, and has been shown to be incompetent in communicating cross-culturally. Clearly while operating in this system it is difficult to determine if their choices at the end-of-life are truly influenced by their own personal preferences and beliefs, or if they are decisions made through fear, misinformation, or lack of access to care.

The public health community has continued to let African-Americans and other minorities flounder in this system that has the odds stacked against them. While systemic changes are needed to make the healthcare system equitable for all, these changes have been en-route for years with very little effect; they are not helping the thousands of African-Americans dying in hospitals today, in pain and undergoing or foregoing treatments they may or may not want. Until these changes occur, more needs to be done to support minorities and educate them about treatment options at the end-of-life through channels that they trust, and in language that they understand.

This movement needs to come from within the black community; from local religious organizations, thought-leaders, and popular black media. The goal is not to push anyone towards one treatment option or another, but to ensure that the decisions made are well-informed decisions, as choice becomes meaningless if one does not truly understand the options. Each patient needs to understand his or her options, recognizes pros and cons, has considered his or her personal preferences, and understands how to find a provider that is best suited to these preferences.

My grandfather ostensibly could have been “saved;” he had pneumonia that went untreated. He died a “good death” not because slipped away peacefully, but because he truly understood the repercussions of the decisions he had to make, and the choice was truly the one he wanted.

REFERENCES

1. Edberg M. Anthropology and Cultural Theory (pp. 73-76) . In: Edberg M, ed. Essentials of Health Behavior. Sudbury, MA: Jones & Bartlett Publishers, 2007.
2. Nielson F. Cultural Relativism. Anthrobase. 5 December 2007. http://www.anthrobase.com/Dic/eng/def/cultural-relativism.htm
3. Barnato A, Chang C, Saynina O, Garber A. Influence of Race on Inpatient Treatment Intensity at the End of Life. Journal of General Internal Medicine 2007; 22(3): 338.
4. Pritchard R, Fisher E, Tenon J, Sharp S, Reding D, Knaus W, Wennberg J, and Lynn J. Influence of Patient Preferences and Local Health System Characteristics on the Place of Death. Journal of the American Geriatrics Society 1998. 46 (10): 1242–50.
5. Greiner K, Perera S, and Ahluwalia J. ‘Hospice Usage by Minorities in the Last Year of Life: Results from the National Mortality Followback Survey. Journal of American Geriatric Society 2003; 51 (7): 970–8.
6. Stein, Rob. At the End of Life, a Racial Divide: Minorities Are More Likely to Want Aggressive Care, Studies Show. Washington Post Monday, March 12, 2007; Page A01.
7. McKinley E, Garrett J, Evans A, and Danis M. Differences in end-of-life decision making among black and white ambulatory cancer patients. Journal of General Internal Medicine 1996;11(11):651–6.
8. Gamble V. Under the Shadow of Tuskegee: African-Americans and Healthcare. American Journal of Public Health 1997; 87:11, 1773.
9. Hamilton L, Aliyu M, Lyons P, et al. African-American Community Attitudes and Perceptions toward Schizophrenia and Medical Research: An Exploratory Study. Journal of the National Medical Association 2006; 98:1, 18.
10. Doty M and Holmgren A. Health Care Disconnect: Gaps in Coverage and Care for Minority Adults. The Commonwealth Fund, August 2006.
11. Hasnain-Wynia R, Baker D, Nerenz D, et al. Disparities in Health Care Are Driven by Where Minority Patients Seek Care. Archives of Internal Medicine 2007 167(12):1233–39.
12. Johnson R, Saha S, Arbelaez J, et al. Racial and Ethnic Differences in Patient Perceptions of Bias and Cultural Competence in Health Care. Journal of General Internal Medicine 2004; 19, 101-110.
13. Blanchard J, Lurie N. R-E-S-P-E-C-T: Patient reports of disrespect in the health care setting and its impact on care. The Journal of Family Practice 2004; 53:9, 721.
14. LeRoi H, Ayanian J, Orav E, et al. Is hospital service associated with racial and ethnic disparities in experiences with hospital care? The American Journal of Medicine 2005; 118, 529.
15. Steinhauser K, Clipp E, et al. In search of a good death: observations of patients, families, and providers. Annals of Internal Medicine 2000; 132:10, 825-32.
16. Gamble V. Under the Shadow of Tuskegee: African-Americans and Healthcare. American Journal of Public Health 1997; 87:11, 1773.
17. Hamilton L, Aliyu M, Lyons P, et al. African-American Community Attitudes and Perceptions toward Schizophrenia and Medical Research: An Exploratory Study. Journal of the National Medical Association 2006; 98:1, 18.
18. Hasnain-Wynia R, Baker D, Nerenz D, et al. Disparities in Health Care Are Driven by Where Minority Patients Seek Care. Archives of Internal Medicine 2007 167(12):1233–39.
19. Doty M and Holmgren A. Health Care Disconnect: Gaps in Coverage and Care for Minority Adults. The Commonwealth Fund, August 2006.
20. Barnato A, Berhane Z, Weissfeld L, Chang C, Linde-Zwirble W, Angus D, on behalf of the Robert Wood Johnson Foundation ICU End-of-Life Peer Group. Racial Variation in End-of-Life Intensive Care Use: A Race or Hospital Effect? Health Services Research 2006 41 (6), 2219–2237.
21. Hasnain-Wynia R, Baker D, Nerenz D, et al. Disparities in Health Care Are Driven by Where Minority Patients Seek Care. Archives of Internal Medicine 2007 167(12):1233–39.
22. Johnson R, Saha S, Arbelaez J, et al. Racial and Ethnic Differences in Patient Perceptions of Bias and Cultural Competence in Health Care. Journal of General Internal Medicine 2004; 19, 101-110.
23. Blanchard J, Lurie N. R-E-S-P-E-C-T: Patient reports of disrespect in the health care setting and its impact on care. The Journal of Family Practice 2004; 53:9, 721.
24. LeRoi H, Ayanian J, Orav E, et al. Is hospital service associated with racial and ethnic disparities in experiences with hospital care? The American Journal of Medicine 2005; 118, 529.
25. Doty M and Holmgren A, Health Care Disconnect: Gaps in Coverage and Care for Minority Adults, The Commonwealth Fund, August 2006.
26. Weissman J, Betancour J and Campbell E. Resident Physicians' Preparedness to Provide Cross-Cultural Care. Journal of the American Medical Association 2005; 294 (9): 1058–67.
27. Ngo-Metzger Q, Telfair J, Sorkin D, et al. Cultural Competency and Quality of Care: Obtaining the Patient's Perspective. The Commonwealth Fund, October 2006.
28. Edberg M. Anthropology and Cultural Theory (pp. 73-76) . In: Edberg M, ed. Essentials of Health Behavior. Sudbury, MA: Jones & Bartlett Publishers, 2007.

Reforming Massachusetts Health Care Reform – JoAnna N. Sullivan

The Health Insurance Reform Act, Chapter 58 of the Acts of 2006, is entitled “an act providing access to affordable, quality, accountable health care.” It states in its opening paragraph that it is “an emergency law, necessary for the immediate preservation of the public health.” With this mission in mind, the Act requires residents to obtain health insurance, with the option to purchase health care through its facilitator, The Connector (1). The Act created The Connector as a means of providing the mediation between itself and established insurance companies. The purpose of this paper is to explore the flaws of Chapter 58 by utilizing a different paradigm of social and behavioral sciences. This paper outlines the current flaws of Chapter 58 as a means to constructively identify what needs to be improved upon.

By looking more closely at the Act, public health officials will be able to effect positive change. The Act correctly labels itself as a response to an “emergency need,” however its current form only further alienates the uninsured and makes obtaining insurance increasingly difficult. The implementation of the Act threatens to leave many Massachusetts residents stranded without insurance, facing tax penalties, or underinsured.

The Act falls short in achieving its stated purpose of providing affordable, quality health care to all Massachusetts residents. In its current form, it is a power-coercive technique at changing behavior. To achieve the purpose of the Act, it is necessary to consider and include. Power-coercive strategies emphasize political and economic changes. As is well exemplified by Chapter 58, power-coercive changes often include economic sanctions imposed upon individuals for non-compliance. The political changes can also wield moral power, imposing guilt and shame on those who fail to comply, in order to enforce the mandate (2).

While power-coercion may change the institutional reality, it is less effective in changing the behavior of individuals: there is often an overestimation of the ability to change behavior through political mandate. An important characteristic of power-coercive techniques is that the power elite are solely in charge of decision-making that brings major political and economic implications. These decisions are often accepted as legitimate, appropriate political evolutions, but do not necessarily consider the multidimensional realities of the citizenry. The main technique for resistance to power-coercive forms of change is community mobilization in order to illuminate the community’s needs and demands (2).

Seat belt laws are one example of a power-coercive change. Such laws spawn great controversy; many argue in favor of their paternalism, while others object to their encroachments upon personal liberty. Passing laws that regulate behavior raises questions about government’s role in the lives of individuals. Massachusetts has a tumultuous relationship with state laws requiring seat belt use. In 1986, the Commonwealth passed a law mandating the use of seat belts, but voters later repealed it. Then in 1994, the Commonwealth again passed a law mandating seat belts but made it a secondary offense, meaning drivers could only be fined if they were first pulled over for another traffic violation. Under this law, Massachusetts remained the second lowest state for seat belt use (at 65%), only slightly above the lowest state: Mississippi (61% usage rate). It was not until 2006 that the Commonwealth voted to make not wearing seat belts a primary offense, thus making it a legitimate reason to ticket a motorist (3). However after the law was passed, seat belt use rates only rose to 66% (4).

The example of seat belt laws shows the disjunction between a power-coercive regulation and actual personal behavior change. The Massachusetts law did not have much, if any, impact on the increase in seat belt use. Similarly, a power-coercive technique to mandate health insurance is not the most appropriate method. The overarching mandate of Chapter 58 fails to identify and address key impediments to its stated goal of coverage for all residents. There are other ways to more effectively accomplish its goal.

The implementation of such a complex and consequential law necessitates the use of Political Economy Theory. Political Economy Theory appreciates the multidimensional realities of the citizenry and the political and economic issues that have an important bearing on an individual’s actions. An individual’s sociopolitical and economic realities dictate behavior more heavily than outside influences such as government mandates. Political Economy Theory redefines the health coverage inequity as a product of larger social relations: such as socioeconomic status, class, ethnicity, and gender. The problem, here a lack of insurance, is a part of an individual’s trajectory of risk that is shaped by these factors and ultimately dictates (or predicts) a person’s access to care and subsequent health status. Solutions must identify and combat these social, political, and economic risk factors (5).

The Act does nothing to address existing social and economic obstacles. The Act assumes that the uninsured do not have health insurance simply because they don’t have access to it. Chapter 58 provides “access” to this coverage, however, the solution is not as simple as just providing the product and expecting the consumers will follow. The Act does not address issues of cost and cultural, language, or social barriers to coverage and care. There is no appreciation for such differences in either the law or its current implementation. Political Economy Theory identifies barriers to coverage and care.

Many obstacles compel people to remain uninsured. When deciding between food and shelter or health coverage, most, if not all, people choose the former. It is the responsibility of healthcare corporations, especially The Connector, to provide options that do not make this an “either-or” decision but rather allow people to be able to cover themselves and their families. The use of Political Economy Theory more efficiently addresses the obstacles of the population.

Chapter 58 would also benefit from a complete use of Social Marketing Theory. Social Marketing Theory identifies the four “P’s”: product, price, place (accessibility), and promotion (5). The Connector and the Commonwealth have accomplished the first and last Ps: product and promotion, however, they have not worked toward providing the remaining two. Coverage is the product and it is promoted vigorously through television advertisements. However, the price is not controlled nor is it appropriate for the target consumer. Additionally, as discussed in the other arguments, “place” or accessibility and availability are not fully appropriate for the target consumer. Multiple impediments to access to coverage exist, including cultural, language, and political barriers. With a full implementation of Social Marketing Theory, the Act may be a better system of providing coverage to consumers.

Social and cultural limitations of the Act

Chapter 58 is an individual mandate on coverage, which does not distinguish between the individuals who can or cannot afford to buy coverage. The ecological nature of health status and likelihood to be covered are parallel barriers to comply with Chapter 58. The Act must address these barriers in order to more completely accomplish its purposed mission. This section looks at who remains uninsured and their barriers to coverage.

There are systematic aspects of the Act that exclude many of the most needy groups from access. Among some populations, for example Latinos, there is a distinct resistance to buy coverage because of a general fear and mistrust of the government. For individuals who are not citizens, there is a fear that the process of applying for subsidized insurance will be a detriment in the process of obtaining citizenship. Additionally, among this population, the cultural ideal of pride inhibits some from seeking government assistance (10).

Chapter 58 does not address other social obstacles to obtaining coverage. Homeless individuals cannot get coverage without a birth certificate, however, a permanent address is required to receive their birth certificate (3). The media-advertising blitz has not reached many at risk populations so some people are not aware of the opportunities available to them. Also, middle class individuals do not have the means to pay premiums of $200-$900 per month for health coverage through The Connector (before co-payments and deductibles) (10).

For some individuals who qualified for free care prior to Chapter 58, there is resistance to now buy coverage after having previously received free care from some hospitals. Hospitals, especially those that cater to poor populations, lose subsidized funds under Chapter 58 since the Act it requires all residents to have coverage, therefore supposedly negating the need for free care. The free care pool was $600 million of funds allocated to needy hospitals. Now this money is going to subsidize health plans. Some hospitals are still providing free care, especially since there are still a large number of uninsured people in the state. Now the hospitals are not receiving state funds to cover costs left unpaid (10, 11).

The lack of funds is perilous for some health care providers. Hospitals need compensation for the care they give to those who are un- or underinsured. Caritas Carney, a community hospital in Dorchester, is facing major changes or closure if it does not receive more revenue. It has primarily focused on providing free or subsidized care for over 150 years and it received state funding for doing so. However, under Chapter 58, all residents are supposed to be covered thus negating the need for state funding for free care (11). If the Commonwealth is withdrawing money, forcing hospitals to close or reallocate care, more people will be priced out of receiving care.

It is important to use community mobilization techniques to increase the numbers of people who sign up for coverage, as well as to demand appropriate prices. Community mobilization is focused on grassroots activism that fosters community change. In the aftermath of a power coercive political mandate, it is important to empower the community to promote the change that is available. Since many barriers to health are ecological, it is necessary to systematically define the at-risk communities, assess and work with the communities’ established capacity to mobilize, and most importantly understand the community agenda (5). Some grassroots organizations have made important advances in connecting with individuals (10). However, politicians and public health practitioners must better understand the agendas, values, and needs of these communities.

A complete use of Social Marketing Theory can allow Chapter 58 to be more effectively implemented. Social Marketing Theory needs the complete implementation of the four “Ps”: product, price, place, and promotion. The previous arguments show how the lack of the middle two “Ps” (price and place) is stunting the Law. For the homeless and non-English speaking residents, the media blitz is not helpful; therefore the Act has lost its last “P” (promotion) in these populations as well. If there were cost control, easy applications for people, and universal promotion, Chapter 58 would be much more visible and accessible to all Massachusetts residents, thus making it innately more sustainable.

By looking at the barriers to obtaining coverage, the implementation of Chapter 58 would be more appropriate. In order to do so, it is necessary to use a Social Marketing Theory and community mobilization. Social Marketing Theory delineates and addresses the necessary methods to approach such a complex mandate with a disciplinary approach. Community mobilization involves the community and established grassroots organizations that are essential in implementing the Act. This approach is more suitable and comprehensive than the current bottom line power-coercive technique.

Success could leave the State in the red

Chapter 58 is a major political feat in the attempt to accomplish health care for all. However, in its primary stages, there were major oversights that ultimately put the State and the people at risk. The inaccurate numbers of the uninsured and the uneven distributions of wealth of those who have applied for coverage put the State in financial peril. Without the proper numbers, measuring success is extremely difficult.

The reform architects used inaccurate statistics when calculating the number of the uninsured in Massachusetts. Census numbers indicate that 651,000 Massachusetts residents are without insurance; estimates put this number without insurance at 950,000 if undocumented residents are also included. However, the Census number is 65% higher than the figure used by Commonwealth officials when drafting the law and allocating the moneys to implement it. The Massachusetts health reform planners did not account for over 500,000 people because it conducted surveys over the phone, done in English and Spanish, therefore leaving out those people who speak neither of those languages. In addition, it excluded people without a landline, including many young adults who use only cell phones. According to other surveys 44% of phoneless adults are uninsured (7, 8). These particular populations are at high risk for being uninsured.

Now that the law has been implemented, new applications for insurance only constitute one quarter of the people who were previously uninsured. Additionally, job based coverage has decreased substantially since passage of the Act’s, so the increase in numbers of insured may be nullified by the number of people losing coverage from private employers (8). The increase in insured individuals may not be as successful as it appears.

The uneven distribution of people who are signing up for coverage is putting the Commonwealth at financial risk. Ninety-four percent of new enrollees are under 150% of the poverty level and therefore pay only a fraction of the insurance while six percent of enrollees bought private plans with no subsidy (6,9). Costs exceed premiums, violating a key principle of community rating insurance. The Commonwealth is faced with uneven distribution of wealth in its enrollees, which forces prices to rise in order to pay for everyone’s coverage. This will cause an “underwriting death spiral” that will lead to a decrease in healthy, wealthier members who are supposed to offset costs of subsidies. As prices go up, healthier and/or wealthier individuals, who use care less, feel overcharged, and will opt out of coverage because they think it is too expensive and/or they are not at risk. This causes prices to go up again, as an attempt at offsetting the monies lost from the loss of healthier individuals; and so the “underwriting death spiral” continues.

In order to improve upon the Act’s current state, it is important to use Social Marketing Theory. When applying Social Marketing Theory, it is apparent that the product and price are directly affected by the disparity of new enrollees. The State is now burdened by the numbers and types of enrollees because it has done little to universally promote (the third “P”) in order to make the Law sustainable. If Social Marketing Theory were more properly implemented, the State would have a larger pool of applicants and a more equal distribution of need and payers. Chapter 58 is dependent upon the single payments from individuals. However if the majority of enrollees are subsidized, it is difficult to sustain the program. Therefore, it is necessary to reach more individuals to equilibrate the coverage payments.

Prohibitive costs for the individual

Chapter 58 does nothing to control costs. As a power-coercive technique to change the institution, there are no power-coercive mandates for maintaining sustainable costs for the individual. The State made the decision to universally cover its residents first, before addressing costs. There are no programs or corporate initiatives to contain cost. Under this program, the populations most at risk are those being financially punished. By addressing the costs, the Act will be more appropriate for all Massachusetts’ residents. This section outlines the cost needs of the citizenry and the organizational changes necessary for a more proper implementation of the Act.

The populations of people who are signing up pose major problems to the stability and maintenance of the Act. Insurance groups control costs by charging members a similar amount so that the healthy members, who do not use much care, off set the cost of sicker individuals who use more care than the average. A similar equilibrium is sought when supplying subsidized insurance alongside full payer insurance. Individuals who pay the full ticket price offset the amount lost by the company for supplying subsidies to the individuals who cannot pay the full price.

Chapter 58 gives little assistance to the already struggling middle class in Massachusetts. The premiums and co-payments options available are extreme barriers to those in the near-poor group and those in the middle class (8). Faced with either the loss of a personal tax exemption (a penalty of approximately $150 – 250) or possibly $10,000 in health insurance premiums and fees, the struggling middle class may opt to remain uninsured (10). There are often more pressing needs facing individuals, such as food and shelter. This can make the yearly “penalty” of approximately $200 preferable to exorbitant monthly payments.

There is no current incentive for insurance companies to control costs and provide an appropriate, affordable option to the middle class, families, and older consumers (8). Chapter 58, Section 16L solely focuses on quality and cost control for the practitioners (1). However, for a law that was championed for being a provider of affordable insurance to all, it does little to insist on controlling the cost to the consumer. The past year has shown that providers are not controlling prices. As Alan Sager stated, “the law does nothing to control cost (6).” There are no regulations stipulating how prices should be outlined to consumers, and this is the basis of why it is so difficult to effectively achieve the mission of Chapter 58.

Prices are not reasonably appropriate for the consumer. For example, the Connector’s prices are 4.5% higher than comparable private insurance companies. This excess cost goes towards administrative and organizational costs. The establishment of an enterprise like The Connector, in its current state, is just an additional middleman in health coverage. Rather than praise the Act for providing any coverage option to those who are uninsured, a feasible option must be established for those in desperate need of coverage (1, 6). The lack of cost control brings back the need for proper Social Marketing Theory. An important “P” (price) is not being accurately addressed. Without appropriate costs, individuals cannot buy insurance, which leaves the Commonwealth with a disproportionate number of subsidized buyers and legislation that has not completed its mission.

The Connector is not meant to be a profitable corporation, therefore organizational changes must occur in order to better provide coverage. Organizational change demands that a corporation assess and improve group dynamics, encourage and promote shared goals, identify the impediments to change within the organization, and involve the individuals in identifying and implementing new policies. The Connector was created with the purpose of providing affordable coverage to Massachusetts residents (1). However, in its current state, it does not accomplish this. Changes are necessary to ensure that the corporation works towards its established “goals.” This organization is innately not a “normal” corporation that has the luxury of seeking the most profitable means. Rather it was created to provide coverage to residents. It must return to its proposed mission.

Social Marketing Theory reemerges as a necessary part of enacting the Act. The Theory emphasizes price as an important part of implementing a financial intervention. With Chapter 58, there are major financial implications but, unlike other products in the market, healthcare costs have not yet changed with the market. There are no cost controls for healthcare costs, although the market may dictate the need. Without power-coercive techniques to control cost in this power-coercive mandate, costs will skyrocket, further punishing the consumers.

Implications for the Future

Chapter 58 is an ambitious step toward combating the pervasive issue of uninsured members of our community. 200,000 people have become insured under the mandate. However, in order to maximize its effectiveness, there are important changes necessary to improve its current state. There are problematic results of the large disparities in the new realities borne by this Act.

It is improper to continue to handle this law with kid gloves so as to not disrupt the current state of “progress” and blindly celebrate it as a victory. Health care is not progressing; rather the Act further alienates the middle class from coverage and puts the state into financial danger, and perpetuates cultural insensitivity and isolation. Additionally, there will be an ever-growing number of underinsured residents. Underinsurance has detrimental implications on the health care system and economy.

The Massachusetts process has major implications for other states and the nation. It is our responsibility to appropriately, accurately, and effectively carry out the Health Insurance Reform Act, and no longer tolerate excuses about its “acceptability” in the current political climate. There are still changes that can help improve Chapter 58’s efficacy in the Commonwealth. In order to do so, it is essential to open up the public psyche to more creative methods of approaching the situation.

References

(1) Massachusetts Senate and State of Representatives. Chapter 58 of the Acts of 2006: An act providing access to affordable, quality, accountable health care. Boston, MA. (Accessed 10 October 2007 at http://www.mass.gov/legis/laws/seslaw06/sl060058.htm)

(2) Chin R. and K. Benne. General Strategies for Effecting Changes in Human Systems. (pp. 22-45). In: Bennis, etal, ed. The Planning of Change. New York, NY: Holt, Rinehart and Winston, 1976.

(3) Helman, S. House approves seat belt law. The Boston Globe. 20 January 2006 (Accessed 13 November 2007 at http://www.boston.com/news/local/massachusetts/articles/2006/01/20/house_approves_seat_belt_scrutiny/?page=1)

(4) National Highway Traffic Safety Administration. Traffic Safety Facts: Seat Belt use in 2006. Washington, DC: National Center for Statistics and Analysis. January 2006. (Accessed 13 November 2007 at www.nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/RNotes/2007/810690.pdf)

(5) Edberg, M. Essentials of Health Behavior, Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.

(6) Zapler, M. State finds universal health care vexing. Oakland Tribune. Oakland, CA. 12 October 2007 (accessed 25 October 2007 at http://findarticles.com/p/articles/mi_qn4176/is_20071012/ai_n21051797)

(7) Kaiser Family Foundation. Medicaid Fact Sheet for Massachusetts and United States. Washington, DC: Kaiser Family Foundation. http://www.kkf.org/mfs/medicaid.jsp?rl=MA&r2=US&x-8&y=13)

(8) Woolhandler S. and D. Himmelstein. Health Reform Failure. Boston Globe. 17 September 2007.

(9) Flanagan J. Massachusetts mandatory health insurance purchase law is no model for California. US Newswire. Washington, DC: 12 October 2007. (Accessed 25 October 2007 at http://www.bio-medicine.org/medicine-news-1/Massachusetts-Mandatory-Health-Insurance-Purchase-Law-is-No-Model-for-California-3593-1/)

(10) Dembner A. State boosts effort to reach the uninsured. The Boston Globe. 27 October 2007.

(11) Krasner J. Carney may be sold or shuttered. The Boston Globe. 24 October 2007.