Perspectives on health and social policy

M6920September 4, 2001

Columbia University School of Nursing M6920, Fall, 2001

T E X T V E R S IO N O R G A N IZ A T IO N A L C H A R T

> C O M M E N T S & S U G G E S T IO N S < > P R IV A C Y P O L IC Y < >F R E E D O M O F IN F O R M A T IO N A C T <

L A S T R E V IS E D : T U E S D A Y , S E P T E M B E R 2 8 , 1 9 9 9 Attitude toward government:

Society is produced by our wants, and government by our wickedness; the former promotes our happiness positively by uniting our affections; the latter negatively by restraining our vices. . . . government even in its best state is but a necessary evil.

• Thomas Paine, Common Sense, 1776

Columbia University School of Nursing M6920, Fall, 2001

What is policy?

A decision on how to allocate resources to accomplish a purpose

Ideally, it is deliberately adopted after a review of alternatives, and it is intended to be followed.

Columbia University School of Nursing M6920, Fall, 2001

Health policy decisions

are supposed to support health direct response when health is

threatened direct response to treat or cure illness response when beneficiary of current

policy is threatened organize and pay for intended benefits

Columbia University School of Nursing M6920, Fall, 2001

Social policy decisions

are about our life as a community• education • housing• recreation • work

affect how groups relate to one another affect the economic welfare of groups

Columbia University School of Nursing M6920, Fall, 2001

Policy actors

the body politic the intended beneficiaries the stated beneficiaries the managers or organizers the decision-makers

Columbia University School of Nursing M6920, Fall, 2001

Time and place

may be immediate, short term or long term

may be neighborhood, city, state, region, nation, global

Columbia University School of Nursing M6920, Fall, 2001

Population perspective

“Vulnerable population” is for some reason at higher risk of problems, even though • not all members of the population will

experience the problem, and • others outside the population will experience

the problem

Columbia University School of Nursing M6920, Fall, 2001

Possible reasons for vulnerability

Social prejudice• racism• age-ism• able-ism• genderism

geography economics

Columbia University School of Nursing M6920, Fall, 2001

Healthy People 2000 Targets

46%

18%

10%

26%

RightDirection

WrongDirection

No Change

No Data

51%

30%

3%

16%

Total Population Total Population (319 Targets)(319 Targets) Special Populations Special Populations (210 Targets)(210 Targets)

Columbia University School of Nursing M6920, Fall, 2001

Special populations are defined by

Race/Ethnicity Gender SES Disabilities

Columbia University School of Nursing M6920, Fall, 2001

0

20

40

60

80

100

1936

946

1956

1966

1976

1986

1996

Year

Ave

rag

e ag

e at

dea

th

Both Sexes

Male

Female

Changes in life expectancy

Columbia University School of Nursing M6920, Fall, 2001

74%

18%

8% ContinuouslyInsured

CurrentlyUninsured

CurrentlyInsured, but notall of past year

Commonwealth Fund, Summer, 1999

Women’s insurance status

Columbia University School of Nursing M6920, Fall, 2001

0% 20% 40% 60%

% r

ep

ortin

g b

arrie

rs to c

are

CurrentlyUninsured

CurrentlyInsured, but notall of past yearContinuouslyInsured

All Women

Commonwealth Fund, Summer, 1999

Insurance and barriers

Columbia University School of Nursing M6920, Fall, 2001

3%

40%

45%

1%

11%

In Community,Under 18In Community,18-64In Community,65 and overNursing Home,under 65Nursing Home,65 and over

Commonwealth Fund, Summer, 1999

Long term care population

In Millions

Columbia University School of Nursing M6920, Fall, 2001

0

10

20

30

40

50

60

70

80

Percen

tag

e

WhiteAll MinorityBlackHispanic

MMWR, January 14, 2000

AIDS Cases/ MSM

Columbia University School of Nursing M6920, Fall, 2001

AIDS Cases Reported in 1999 and Estimated 1999

White, not HispanicBlack, not HispanicHispanic

Asian/Pacific IslanderAmerican Indian/ Alaska Native

*Includes 120 persons with unknown race/ethnicity

4%

1%

71%

12%13%

AIDS Cases

N=46,400*

PopulationN=277,200,000

<1%1%

32%

47%19%

Columbia University School of Nursing M6920, Fall, 2001

Impact of welfare reform

In 1995, 88% of poor children received food stamps; in 1998, 70%

From 1995-1997, average incomes of poorest 20% of female headed families fell• 2 million families, 6 million people• drop of $580 per family; below 3/4 of

poverty line

Columbia University School of Nursing M6920, Fall, 2001

Welfare Reform and Insurance Coverage

0%

10%

20%

30%

40%

50%

60%

70%

% uninsured (below 200% FPL)

Adults belowpoverty

Children belowpoverty

Adults 100-200%FPL

Children 100-200%FPL

Families USA Chartbook

Columbia University School of Nursing M6920, Fall, 2001

2000 Poverty Guidelines

1 $ 8,3502 11,2503 14,1504 17,0505 19,9506 22,850Each additional Add $2,900

Size of Family Income Guideline

Columbia University School of Nursing M6920, Fall, 2001

Poverty in New York City

10,34414,15016,478

46,83650,600

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

Income

Welfare & foodstamps, family of 3

Federal povertylevel, family of 3

Full-time minimumwage

Self-sufficiencywage/Queens, familyof 3Median NYC familyof 3

NY Times. 9/13/2000. Pg. B1

Columbia University School of Nursing M6920, Fall, 2001

% non-elderly uninsured

0

5

10

15

20

25

30

US NY State NY City

1990

1998

United Hospital Fund, March, 2000

Columbia University School of Nursing M6920, Fall, 2001

%Uninsured by race, ethnicity

0

5

10

15

20

25

30

35

1990 1998

WhiteAfrican-AmericanHispanic

United Hospital Fund, March, 2000

Columbia University School of Nursing M6920, Fall, 2001

Public coverage for children

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1994 1995 1996 1997 1998 1999

MedicaidCHP

United Hospital Fund, March, 2000

Columbia University School of Nursing M6920, Fall, 2001

Percentage of Medicare Recipients, by age

0%

10%

20%

30%

40%

50%

60%

70%

80%

65-74 75-84 85 and up

MenWomen

Columbia University School of Nursing M6920, Fall, 2001

Medicare Recipients with Income $10,000/yr.

0%

10%

20%

30%

40%

50%

60%

65-84 85 and up

MenWomen

Columbia University School of Nursing M6920, Fall, 2001

Income disparity

Top 1% (2.7 million people) has as much to spend as the bottom 40% (100 million people)

The top 1/5 has 50.4% of income. The top 1/5 has had a 15% income

increase while the bottom 1/5 has had a 10% income increase

Columbia University School of Nursing M6920, Fall, 2001

CBO analysis:

1997: 49 million lowest earners equal top 2,500,000 after tax $$

2000: 100 million lowest earners equal top 2,700,000

Bottom 4/5 (217 million) earn 50% 9/10 of growth since 1977 went to top 1%

($515,600 after tax average income)

Columbia University School of Nursing M6920, Fall, 2001

HP2010: a policy example

The development of national health objectives is almost a policy-setting process

The model builds on an the determinants of health model

The national goals attempt to minimize threats to the health of vulnerable populations.

Columbia University School of Nursing M6920, Fall, 2001

Columbia University School of Nursing M6920, Fall, 2001

Questions for this course:

What current policies are having a positive impact on health?

What current policies are having a negative impact on health?

What policy conflicts affect our ability to improve health?

What do I want to do to have an impact on policies?

Columbia University School of Nursing M6920, Fall, 2001

Next week:

Determinants of health Vulnerable populations in the

Unites States