Tuesday, October 6, 2009

WARNING: Long post

I thought I'd post my paper for my Public Health Class. It's long, like 2400 words, plus references, so if you dont' feel like reading a long essay, skip down to the next one, also posted today.

Health Campaign: Access to Healthcare in Alameda County, CA
            In part I of the Health Campaign Study (Wittstock, 2009) the topic of access to healthcare in Alameda County, California was reviewed.  In part I the realization was made that the simple provision of health care clinics open to a population regardless of the ability to pay does not equate to equal access to healthcare.  A population must do more than provide a safety-net of healthcare providers to eliminate healthcare disparities within a population.  Studies have shown that the proffered health services are lacking from accepted standards when the patient is non-English speaking (Cheng, Chen, & Cunningham, 2007).  The hours a clinic is open affects the working poor’s ability to obtain any healthcare services.  Even being covered by an insurance plan doesn’t guarantee that a person can afford the co-pays for medical treatment or pay the cost of prescriptions.  Equitable access to healthcare involves offering extended clinic hours so that working people can access both preventative and treatment healthcare for their families; making neighborhoods of equal safety and allowing all inhabitants equal access to healthy foods and safe recreation areas; making sure that the air quality is the same for all inhabitants of an area; and ensuring that all have equal access to education and employment opportunities.  Despite these findings, access to healthcare remains one of the prime indicators of a population’s health.  For this reason, access to healthcare was chosen as an initiative for Healthy People 2010, as evidenced by 17 core measures (Proctor S. , 2004).  A comparison of Alameda County, CA to the national progress towards these health goals will be the focus of this analysis.
            The 17 core measures are divided into four general topics of care: preventative care, primary care, emergency services, and long-term and rehabilitative services. The core measures are:
 Clinical preventive care
Persons with health insurance
Health insurance coverage for clinical preventive services
Counseling about health behaviors
Primary Care
            Source of ongoing care
            Usual primary care provider
            Difficulties or delays in obtaining needed health care
            Core competencies in health provider training
            Racial and ethnic representation in health professions
            Hospitalization for ambulatory-care-sensitive conditions
Emergency Services
            Delay or difficulty in getting emergency care
            Rapid prehospital emergency care
            Single toll-free number for poison control centers
            Trauma care systems
            Special needs of children
Long-term Care and Rehabilitative Services
            Long-term care services
            Pressure ulcers among nursing home residents (Healthy People 2010, n.d.)

Understandably, in an analysis of limited length, all 17 core measures cannot be examined. A closer examination will be made of two health indicators; persons with health insurance and having a usual source of medical care.
Definition of the indicators. To have apples to apples comparisons, the population in which these indicators are studied must be defined.  The Healthy People 2010 initiative defines “insurance coverage” as the percent of persons under age 65 who report health care coverage by any type of public or private health insurance (Department of Health and Human Services, n.d.). Having a source of ongoing care is defined by Healthy People 2010 as the percentage of people who report having a specific source of ongoing care.  Specifically, this question asks, “Is there a place that you usually go when you are sick or need advice about your health” (Department of Health and Human Services, n.d.). This indicator is reported in three age categories: all ages, children and youth ages 17 years and younger, and adults aged 18 years and older.  Finding data that allows a direct comparison at the local level to the national level is challenging. Of particular note is that two of the indicators for Healthy People 2010 were dropped (these are the ones listed in italics) due to the inability to identify data sources on a national level (Department of Health and Human Services, n.d.).  Data for the first of these two indicators is collected from the National Health Interview Survey (NHIS), the Center for Disease Control (CDC), and the NCHS on the national level.  At the state level the data is obtained from the Behavioral Risk Factor Surveillance System (BRFSS), the CDC, and the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) (Department of Health and Human Services, n.d.). Data to support the second of the two indicators is obtained from the National Health Interview Survey at the national level (Department of Health and Human Services, n.d.), while at the state level the information is obtained from the California Health Interview Survey via an online query system called AskCHIS (California Health Interview Survey, 2005).
            Comparison of the populations.  Alameda County, California is not a representative snapshot of the rest of the U.S.  This county has a large immigrant population made of both Hispanics and Pacific Islanders/Asians.  African-Americans make up a larger percentage of the population than in other parts of the country, as well.  The following table shows some of the demographics of the population of Alameda County compared to the U.S population.
Table 1: Population Characteristics
% of population in Alameda Co.
% of population in California
% of population in the U.S.
American Indian and Alaska Native persons
Native Hawaiian and Other Pacific Islander
Two or more races
Persons of Hispanic or Latino origin
White persons not Hispanic

Language other than English spoken at home
High School Graduates
Bachelors Degree, or higher
Median Household Income
Median Value of owner occupied housing unit
Home Ownership rate
Persons below poverty
Persons per square mile
(U.S.Census Bureau, 2008)
% of population in Alameda Co.
% of population in California
% of population in the U.S.
Source of ongoing care
(California Health Interview Survey, 2005)(Healthy People 2010, n.d.)

Clearly, Alameda County is a far more diverse, well educated, and financially well off area than the remainder of the U.S.  Despite the education and wealth in this area, residents of Alameda county suffer from urban living, crowded living conditions, expensive housing, and the assorted crimes associated with urban living.  Alameda County is also performing slightly better than the remainder of the U.S on these two target measures to assess access to healthcare.  Unfortunately, one target is met. The goal set by Healthy People 2010 is that 100% of the population is covered by health insurance (Department of Health and Human Services, n.d.).  On the other hand, the second target has been met in California. The target for having a regular source of ongoing care is 85% (Department of Health and Human Services, n.d.).  Both Alameda County and the State have met this target, with both having rates that approach 90%.

            Community based response.  Despite Alameda County having an overall improved rate of health insurance and a source of regular care among its population, health disparities continue to exist. Drilling down in the data a bit further, huge inequities exist for health insurance coverage when examined by race. Figure 1 demonstrates the disparities in health insurance coverage, by race.

 (note figure one shows that whites have the insurance coverage, hispanics the worst. blacks and asians fall inbetween)
(Sutocky, 2008)
Figure 2 demonstrates the racial disparities in having a regular source of health care.
Figure 2
(figure 2 is similar to figure one, showing whites have more regular care, hispanics the least, blacks and asians inbetween) Refer to Sutocky on the web (in references) to see the original graphs

(Sutocky, 2008)
Alameda County sees these disparities as a serious concern. Although overall health indicators are improving for the entire population, the disparities between the races and socio-economic status are growing larger (The Alameda County Public Health Department, Office of the Director, Community Assessment, Planning, and Education (CAPE) Unit, 2006).  The county recognizes that health inequities are the result of larger social problems of “inequitable policies that continue to systematically deprive the residents of these neighborhoods of access to critical social goods such as good schools, better jobs, safe recreational space, clean air, and less crime” (The Alameda County Public Health Department, Office of the Director, Community Assessment, Planning, and Education (CAPE) Unit, 2006, pp. 4-5).  Alameda County has joined a larger initiative, the Bay Area Regional Health Inequities Initiative (BARHII) to help the cities and counties of the San Francisco Bay Area region to address health inequities in a systematic fashion, using city planning, legislation, and infrastructure change to improve health disparities in the population.  BARHII has published a guide for Public Health Departments and Planning Departments to refer to when planning strategies to improve the health in a community (Bay Area Regional Health Inequities Initiative, n.d.).  The California Health Policy Reform, a division of the Center for Health Improvement, has suggested 6 policies for cities and policymakers to follow to address health inequities:
1.       Embrace the concept of health in all policy
2.      Provide funding to encourage and support work across multiple sectors and disciplines
3.      Measure and monitor the impact of social policies on health
4.      Give voice to groups that are the most impacted by social and health inequities
5.      Develop policies that will reduce stress on individuals and families and interventions to help individuals cope better with stress
6.      Strengthen the social fabric of neighborhoods by connecting and supporting residents (Center for Health Improvement, 2009).

At all steps in health planning, the public is invited to comment at public hearings and other community events held at community centers; at community gathering spots, such as churches and recreation centers; and schools.  Without input from the people affected by the inequities, the suggested solutions may only add to the problem.
            Economic Factors. Naturally, economics plays a big factor in health equities and in health insurance provision.  In former times a majority of working people received health benefits through the employer.  Economic times have changed. In California over 90% of the workers are employed in firms with less than 50 employees.  Of this 90% of the workforce, only 24% have employer based health plans (California Healthcare Foundation, 2008).  Providing one’s one health insurance is very costly. Single-person health plans cost $4906 annually, on average, while family plans cost $13,427.  In order to save on initial costs, 8% of the population nationally have chosen high-deductible health plans with a health savings spending account option across the nation, but only 4% of the population have chosen this option in California (California Healthcare Foundation, 2008).  California is also leading the way with domestic partner benefits, which are offered by 57% of firms that offer health benefits.  Oddly enough, not every employee eligible for health benefits chooses to accept the benefits. Of the workers eligible to receive health benefits, only 83% elected to enroll in a health plan.  One factor affecting this rate is the rapid increase in health plan costs, which have doubled since 2002. Employees are expected to pay a portion of premiums and higher co-pays with most of the plans offered (California Healthcare Foundation, 2008).  The high cost of healthcare both in the purchase of insurance and the purchase of healthcare services has driven many employees to drop insurance coverage and do without.  Contrary to popular belief, 60% of the uninsured in California have incomes over $50,000 annually and hold down full-time jobs (California HealthCare Foundation, 2008).  
Alameda County has invested in supporting health clinics that provide services to its population regardless of a person’s ability to pay. Fully 31 health or dental clinics provide services to the community without regard to a person’s ability to pay.  This financial burden is supported by federal funds via Medicare and Medicaid payments to the clinics, from state income taxes, local sales taxes, and Proposition 10 funds (a sin tax on cigarette sales). These health clinics do not function as traditional health providers, rather they attempt to provide a “medical home”; a place where a regular source of healthcare may be obtained for the entire family.  The clinics try to provide “a culturally competent, high quality care [that] includes support services such as transportation, child care,[and] interpreters” (Alameda County Public Health Department, 2008, p. 126).  The county recognizes that having a healthy population improves the quality of life for the entire population and is willing to finance these beliefs.
Social Marketing.  A moderate investment in social marketing has been made by Alameda County to promote its health clinics and its provision of healthcare to its entire population. The predominant medium is found in small billboards placed at bus stops that are visible to both patrons of public transportation and to other users of the public roads. These advertisements promote calling a toll free number for health services if a woman finds she is pregnant and without healthcare.  Truthfully, this author has never seen another piece of social marketing by Alameda County promoting its public health causes aside from the bus advertisements.  An improvement certainly may be made in this area.
Conclusion.  California, and Alameda County in particular, has made progress in attaining two of the Healthy People 2010 objectives. 89.1% of the population of Alameda County is covered by a health insurance plan and 89.7% of the population can identify an ongoing source of medical care.  Of interest, 30% of the users of Alameda County safety-net clinics are holders of private health insurance, who chose to use the unique services of the Alameda County clinics despite having other choices for care.  The clinics provide care that is culturally sensitive, which is attractive to the multicultural population of this geographic area.  Simple access to healthcare, however, does not equate to health equities.  Many factors determine a person’s health status. Unfortunately, those who are not born White suffer many impedances to good health, including having access to healthy foods, recreational areas, lower crime rates, and overall higher stress levels. Until the other determinants of health are addressed, the population of the U.S. may never enjoy real health equities.
Alameda County Public Health Department. (2008, August). Life and Death from Unnatural Causes: Health and Social Inequity in Alameda County. Retrieved September 20, 2009, from Alameda County Public Health Department: http://www.acphd.org/AXBYCZ/Admin/DataReports/00_2008_full_report.pdf
Bay Area Regional Health Inequities Initiative. (n.d.). Healthy Planning Guide. Retrieved September 21, 2009, from Bay Area Regional Health Inequities Initiative: http://www.barhii.org/resources/downloads/barhii_healthy_planning_guide.pdf
California Health Interview Survey. (2005). AskCHIS. Retrieved October 4, 2009, from California Health Interview Survey: http://www.askchis.com/main/DQ3/output.asp?_rn=0.3471033
California Healthcare Foundation. (2008, December). California Employer Health Benefits Survey. Retrieved October 5, 2009, from California Healthcare Foundation: http://www.chcf.org/documents/insurance/EmployerBenefitsSurvey08.pdf
California HealthCare Foundation. (2008). Snapshot: California's Uninsured. Retrieved October 5, 2009, from http://www.chcf.org/documents/insurance/UninsuredSnapshot08.pdf
Center for Health Improvement. (2009, July). Calfornia Health Policy Reform. Retrieved 5 2009, October, from Center for Health Improvement: http://www.chipolicy.org/pdf/6166.HealthInequities2009.pdf
Cheng, E. M., Chen, A., & Cunningham, W. (2007). Primary Language and Receipt of Recommended Health Care Among Hispanics in the United States. Journal of General Internal Medicine , 22 (2), 283-288.
Department of Health and Human Services. (n.d.). Healthy People 2010 Operational Definition. Retrieved October 4, 2009, from Center for Disease Control: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Datasets/DATA2010/Focusarea01/O0101.pdf
Department of Health and Human Services. (n.d.). Healthy People 2010 Operational Definition. Retrieved October 4, 2009, from Center for Disease Control: ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Datasets/DATA2010/Focusarea01/O0104a.pdf
Department of Health and Human Services. (n.d.). Midcourse review Healthy People 2010: Modifications to objectives and subobjectives. Retrieved October 4, 2009, from Healthy People 2010: http://www.healthypeople.gov/data/midcourse/html/focusareas/FA01Modifications.htm
Healthy People 2010. (n.d.). 1: Access to Quality Health Services. Retrieved October 4, 2009, from Healthy People 2010: http://www.healthypeople.gov/document/html/volume1/01access.htm
Healthy People 2010. (n.d.). Access to Quality Health Services. Retrieved October 4, 2009, from Healthy People 2010: http://www.healthypeople.gov/Document/HTML/Volume1/01Access.htm
Proctor, S. (2004, October). Racial and Ethnic Disparities in Selected Healthy People 2010 . Retrieved October 4, 2009, from Center for Disease Control: National Center for Health Statistics: www.cdc.gov/nchs/ppt/hpdata2010/apha04/s_proctor_apha04.ppt
Sutocky, J. (2008). Healthy People 2010 Leading Health Indicators: California Update. Retrieved October 4, 2009, from California Department of Public Health: Center for Health Statistics: http://ww2.cdph.ca.gov/pubsforms/Pubs/OHIRhp2010LeadingHealthIndicator2008.pdf
The Alameda County Public Health Department, Office of the Director, Community Assessment, Planning, and Education (CAPE) Unit. (2006). Alameda County Health Status Report, 2006. Retrieved October 4, 2009, from Alameda County Department of Public Health: http://www.acphd.org/AXBYCZ/Admin/DataReports/00_chsr2006-final.pdf
U.S.Census Bureau. (2008). Fast FactsAlameda County, CA & U.S Fast Facts. Retrieved October 4, 2009, from U.S. Census Bureau: http://quickfacts.census.gov/qfd/states/06/06001.html
Wittstock, S. (2009). Health Campaign Study- Part I: Access to Healthcare in Alameda County. University of Phoenix, Healthcare Sciences, Phoenix, AZ.

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