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HSA 3111: Healthcare for Special Populations

2Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest

Topics

• Special Populations• Ethnic Divisions• The Uninsured• Children• Women’s Health Issues• Rural Health Issues• Homelessness• Mental Health Issues• HIV / AIDS“These population groups are more vulnerable than the general population and experience greater barriers in access to care…”

Text, p. 428



Special Populations

• “Special Populations” as used in the text refers to– Identifiable groups– Having challenges achieving the average level of

health• Special medical needs• Difficulty obtaining healthcare

– Higher levels of vulnerability



Special Populations (cont.)

• It is critical in the chapter to look at the causal relationship between the groups and the challenges– We must not assume (without investigation) that

the identifying characteristic of the group is the cause of the challenge

– The true causal relationship is the issue that must be addressed

– Focusing on the identifying characteristic of the group may not lead to effective remedial programs



Special Populations (cont.)

• What sorts of population identifiers does the chapter use?– Ethnic– Insured vs. uninsured– Age (children, adults, the elderly)– Gender– Rural vs. urban– Homeless– The Chronically ill– HIV/AIDS Sufferers



Ethnic Divisions

• Consider the divisions in Tables 11-1—11-4 and Figures 11-1—11-8– How many of the disparities in outcomes are

attributable to access to medical care?– How many are attributable to lifestyle?– Are there inherent characteristics of any ethnic

group that create healthcare challenges• Independent of income• Independent of education• Etc.



Ethnic Divisions (cont.)

• Additional Data*

• What data would we need to see to determine causality of health disparities?

2009 Income and Insurance DataWhite NH Black Asian Hispanic

Avg. Income $54,460 $32,584 $65,469 $38,039 % No Health Insurance 12.0% 21.0% 17.2% 32.0%

NH = Non Hispanic

* Source: Income, Poverty, and Health Insurance Coverage in the United States, U.S. Bureau of the Census http://www.census.gov/prod/2010pubs/p60-238.pdf




• Asian American Populations– Staggering heterogeneity in this population group– Wide variation in immigration waves by country or

origin• First generation immigration waves• Eighth (or more) generation waves




• Native Americans– 2.9 million in 2005 (< 1% of the population)– Share characteristics of rural HC (later)– Twice as likely to be poor, unemployed, and have

no college degree as others where they live– Native Americans have special funding sources for

HC improvement• But population growth is overwhelming

resources



The Uninsured

• In 2009 50.7 million (16.7%) of Americans were uninsured (Census Bureau)

– Most of the uninsured are neither unemployed nor poor enough to qualify them for federal or state programs such as Medicaid. (p. 442)

– Only 1/10 of uninsured people are uninsured by personal choice

– Most uninsured do not have access to or cannot afford employer-sponsored health insurance



The Uninsured (cont.)

• Impact of no insurance on healthcare– Chronic underutilization of existing resources– “Systematic barriers” to HC

• 42% report no regular HC provider• Few resources to pay medical bills• Managed care reducing available of free or

reduced cost care– 47% of uninsured reported postponing HC in one

year → Worsening condition when treated– Uninsured increase the cost of HC for the insured



Children

• The demographics of HC for children span the issues already discussed– Income– Ethnicity-specific factors– See Table 11-5 for impact on childhood

vaccination rates



Children (cont.)

• Impacts of diminished HC for children– Impaired learning with long-term social

consequences– Lower vaccination rates have population

consequences– Lack of sick-child care means more sick children

are sent to school → More sick children



Children (cont.)

• Political Issues– Children don’t vote– They are dependent on other champions– SCHIP (Balanced Budget Act of 1997) created

additional matching funds for uninsured child HC• Works like Medicaid• Higher income threshold for eligibility• States must pay for federal matching dollars• Only applies to uninsured children

– Violence against children being treated with increasing vigor by society



Women’s Health Issues

• Note the overwhelming morbidity differences between men and women– Higher death rates after heart attack or stroke– 25% more activity-restricted days/year than men– 34% more bed-ridden days/year than men– 2-3 times more likely to suffer from anxiety

disorders or major depression than men– Higher incidence of Alzheimer’s disease among

older women than older men• But women living an average of eight years

longer than men



Women’s Health Issues (cont.)

• Women have historically had “less attachment to the labor market” and therefore less anchoring to employer-sponsored health insurance– More likely to work part time with no benefits– More susceptible to losing benefits through

divorce• Poorer women who may have been eligible for

Aid To Families with Dependent Children saw this assistance decoupled from Medicaid



Women’s Health Issues (cont.)

• Reproductive Health– Insurance plans have been very slow to add

contraceptives to covered medications or treatments

– Erectile dysfunction treatments were more widely covered

– Some states are forcing insurance plans to cover family planning

– Women face higher out-of-pocket costs because of non-covered reproductive health costs



Rural Health Issues

• Rural populations also share characteristics we have seen before– Increased incidence of poverty– Ethnic distributions with attendant income issues– Farmers often self-employed small businesses

with no employer-sponsored HC• A risky profession



Rural Health Issues (cont.)

• Some new HC issues– Dispersed populations make access to HC and

HC delivery more difficult– Lack of population density affect HC market

• Difficult to attract physicians• Fewer specialists• Hospital funding impacted




• Numerous programs developed to address rural HC issues– National Health Service Corps provides physicians

for underserved areas– Health Professions Shortage Areas

• Provide increased Medicare payments• Other federal and state benefits

– Medically Underserved Areas • Receive federal support for HMOs serving

underserved areas• Receive C/MHC funding (next slide)




• Rural programs (cont.)– Community and migrant health centers

• Cover medically underserved areas• Provide primary care and preventive services• Different provisions for community vs. migrant

care centers– Rural health clinics act supported underserved

areas in various ways including special reimbursement programs



Homeless Health Issues

• Homelessness is a multifaceted issue – Approximately 1% of the population will be

homeless in a given year– 39% are children– 33% of the overall homeless population are

families with children– 1/2 have not graduated from high school– 20% have some sort of income maintenance– 26% have some health insurance– Federal help prohibited to individuals with no

physical street address



Homeless Health Issues (cont.)

• Other challenges to healthcare access– Overlap other population groups and share the

same issues• Low income • Children• Women

– Large numbers with mental health difficulties– Mobility impedes longitudinal care– Large numbers with substance abuse difficulties– Greater risk of assault– Exposure to weather and unsanitary conditions




• Use of the healthcare system– Underutilize ambulatory care– Over utilize hospitalization– But still use high proportion of outpatient services– Lack transportation




• Remedial programs– Federal Health Care for the Homeless Program– Community health centers with private and

government support– Mental health programs for homeless– Homeless families program– Most programs rely on outreach

• Actively seeking out the population at risk• Address barriers to healthcare



Mental Health Issues

• One in five Americans has a mental disorder in any one year

• Huge numbers of people do not receive the help they need for their conditions

• Multiple causes– Medical ‒ Psychological

• Barriers to treatment– Stigma ‒ Awareness– Lack of supply ‒ Inadequate delivery– Financial barriers ‒ Lack of individualized

treatment



Mental Health Issues (cont.)

• Providing mental health care– Most mental health care is provided in the general

medical sector– Overall care consists of multiple components

• Primary care providers• Specialty mental health services• General counseling services• Non-medical advisors• Specialty inpatient facilities




• Mental health care for the uninsured– State hospitals– Community and county mental health clinics– Local governments are providers of last resort

• Mental health care for the insured– Growing infrastructure of treatment facilities– National chains of facilities




• Managed care and mental health services– Traditional MC programs often limit MH services– Providers are responding to multiple pressures– Governments moving to MC programs for serviced

MH populations– Specialized MC mental health services

organizations have developed in response to • Needs• Cost pressures

– Apply MC principles to MH case management



HIV / AIDS

• HIV / AIDS transitioned from an always fatal condition to one which can be managed for many patients– Treatments require

• Early diagnosis• Complex treatments

– Patient self-management• Expensive medication



HIV / AIDS (cont.)

• Complexity places burdens on traditionally underserved groups– Economically challenged– Undereducated– Uninsured– Mentally or emotionally challenged



HIV / AIDS (cont.)

• Social impacts– Acute stages of advanced AIDS in the uninsured– Likelihood of developing drug resistant strains– Infected children– Inequitable impacts on ethnic groups that share

contributing challenges to infection and treatment– Shifting patterns of infection

• Women becoming equal opportunity victims– AIDS stigma

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