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Health Disparities: Visions of a New Approach to Health Care

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Health Disparities: Visions of a New Approach to Health Care Frank McClellan Beck Chair Professor of Law, Co-Director Center of Health Law, Policy and Practice – PowerPoint PPT presentation

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Title: Health Disparities: Visions of a New Approach to Health Care


1
Health Disparities Visions of a New Approach to
Health Care
  • Frank McClellan
  • Beck Chair Professor of Law,
  • Co-Director
  • Center of Health Law, Policy and Practice
  • Beasley School of Law at Temple University

2
Seeing Patients Unconscious Bias in Health Care
3
The Story of Mr. Jackson
  • History of Heart Disease
  • Diabetes
  • High Blood pressure
  • Heart Attack
  • Emergency Room Visit
  • Dies 6 hours later in treatment room
  • Never seen by cardiologist at hospital

4
Life Expectancy by Race and Gender
Source CDC Vital and Health Statistics Report
October 2010, United States Life Tables by
Hispanic Origin, http//www.cdc.gov/nchs/data/seri
es/sr_02/sr02_152.pdf - study from 2006
5
Work Life Expectancy by Age, Gender and Race
ALL MEN ALL MEN ALL MEN ALL MEN ALL WOMEN ALL WOMEN ALL WOMEN
AGE 1979-80 1992-93 1997-98 1979-80 1992-93 1997-98
20 36.8 36.0 36.9 27.2 30.0 31.6
25 33.1 32.6 33.4 24.0 26.7 28.3
30 28.9 28.5 29.3 20.8 23.2 24.6
35 24.5 24.2 24.9 17.6 19.7 20.9
40 20.0 19.8 20.6 14.3 16.1 17.1

African-American Men African-American Men African-American Men Nonwhite Men Nonwhite Men White Men White Men
Age 1992-93 1997-98 1992-93 1997-98 1992-93 1997-98
20 29.4 29.4 30.6 32.2 37.0 37.7
25 26.8 26.5 27.9 29.4 33.4 34.1
30 23.4 22.9 24.5 25.7 29.2 29.8
35 19.8 19.1 20.7 21.8 24.7 25.4
40 15.9 15.4 16.7 17.9 20.3 21.0
Nonwhite includes African-American and Hispanic origin, Asians Pacific Islanders, American Indians, and Alaskan natives Nonwhite includes African-American and Hispanic origin, Asians Pacific Islanders, American Indians, and Alaskan natives Nonwhite includes African-American and Hispanic origin, Asians Pacific Islanders, American Indians, and Alaskan natives Nonwhite includes African-American and Hispanic origin, Asians Pacific Islanders, American Indians, and Alaskan natives Nonwhite includes African-American and Hispanic origin, Asians Pacific Islanders, American Indians, and Alaskan natives Nonwhite includes African-American and Hispanic origin, Asians Pacific Islanders, American Indians, and Alaskan natives Nonwhite includes African-American and Hispanic origin, Asians Pacific Islanders, American Indians, and Alaskan natives
Source Work Life Estimates at Millennium's End
Changes over the Last Eighteen Years By James
Ciecka, Thomas Donley, and Jerry Goldman Based
on Data from the US Bureau of Labor Statistics
(1986) and Ciecka, Donley, and Goldman (1995 and
1999) http//lmi.ides.state.il.us/lmr/worklife.ht
m
6
Source CDC, NCHS, Health, United States, 2008,
Table 18 http//www.cdc.gov/nchs/data/hus/hus08.pd
f
7
Source National Vital Statistics Report, 56(16),
6/11/08 Deaths Preliminary Data for 2006, Table
8, p32 http//www.cdc.gov/nchs/data/nvsr/nvsr56/nv
sr56_16.pdf
8
Source CDC, NCHS, Health, United States, 2008,
Table 42.http//www.cdc.gov/nchs/data/hus/hus08.p
df
9
Health Care Divided Race and Healing a Nation
10
EMERGENCY ROOM VISITS and ACUTE CARE BASED ON
RACIAL DISPARITIES
11
Percentage of persons by race with at least one
emergency department visit in a 12 month period
(2007)
Source National Center for Health Statistics,
Data Brief, May 2010 Emergency Department
Visitors and Visits Who Used the Emergency Room
in 2007? Tamyra Garcia, Amy Bernstein, and Mary
Ann Bush
12
Acute Care Visits to Various Providers
Source Where Americans Get Acute Care?
Increasingly, Its Not at Their Doctors Office
by Stephen R. Pitts, Emily R. Carrier, Eugene C.
Rich, Arthur L. Kellerman
13
Average Annual Frequency of Acute Care Visits
from 2001-2004
Source Where Americans Get Acute Care?
Increasingly, Its Not at Their Doctors Office
by Stephen R. Pitts, Emily R. Carrier, Eugene C.
Rich, Arthur L. Kellerman
14
Average Annual Ambulatory Visits by Setting
Type of Visit Millions of Visits Annually 2001-2004
Routine Follow-up visits/non-illness visits 0.0
Follow-up acute visits/postoperative visits 6.2
Acute care visits 97.9
Total 104.1
Source Where Americans Get Acute Care?
Increasingly, Its Not at Their Doctors Office
by Stephen R. Pitts, Emily R. Carrier, Eugene C.
Rich, Arthur L. Kellerman
15
Emergency Department Visits Within 12 Months
Among Adults 18 Years and Older by Race/Ethnicity
Percent of adults with one or more emergency department visits Percent of adults with one or more emergency department visits Percent of adults with one or more emergency department visits Percent of adults with one or more emergency department visits Percent of adults with one or more emergency department visits
Race/Ethnicity Year Year Year Year
Race/Ethnicity 1997 2000 2006 2007
White 19 19.4 20.1 19.6
Black or African American 25.9 26.5 25.6 26.3
Hispanic or Latino 19.2 18.3 17.3 18.2
American Indian/Alaska Native 24.8 30.3 21.1 26.7
Asian 11.6 13.6 13.6 11.9
Source CDC and the National Center for Health
Statistics - Health, United States, 2009 Report,
Table 89, available at http//www.cdc.gov/nchs/dat
a/hus/hus09.pdf089
16
PA, MD and IL Hospital Emergency Room Visits Per
1,000 Population 2005-2008
Source The Kaiser Family Foundation,
statehealthfacts.org, Hospital Emergency Room
Visits Per 1,000 Population 2005-2008, available
at http//www.statehealthfacts.org/comparemaptable
.jsp?yr63typ1ind388cat8sub94
17
Freedom Riders 1961 and the Struggle for Racial
Justice
18
Gospel Choirs Psalms of Survival in an Alien
Land Called Home
19
Long Walk to Freedom The Autobiography of Nelson
Mandela
20
Unnatural Causes
  • Is inequality making us sick?
  • A four hour documentary exploring racial and
    socioeconomic inequities in health
  • California Newsreel
  • www.unnaturalcauses.org

21
Unnatural Causes Video Trailer
http//www.unnaturalcauses.org/video_clips_detail
.php?res_id80
22
Health DisparitiesCommunities of Colorare
Disproportionately Affected
23
What is a Health Disparity?Conceptual Issues
  • Inequality
  • Difference in condition, rank
  • Lack of equality as of opportunity, treatment, or
    status
  • Inequity
  • Unfair and unjust
  • Unnecessary and avoidable

24
Health Disparity in Public Health Operational
Definition
  • Quantitative measures rates, percents, means
  • The Quantity that separates a group from a
    reference point on a particular measure of health
  • Calls attention to differences in health between
    groups regardless of cause
  • Can be measured in absolute or relative terms

25
Populationof the United States by Race
Hispanic Origin 2008 Projected 2050
Source U.S. Census Bureau, 2008 National
Population Projections, August 14,
2008http//www.census.gov/Press-Release/www/relea
ses/archives/population/012496.html
26
Racial and Ethnic Minority Populations
  • American Indian/Alaska Native (AI/AN)
  • Asian American
  • Black or African American
  • Hispanic or Latino
  • Native Hawaiian or Other Pacific Islander (NHOPI)

27
Other Populations By . . .
  • Socio-economic status
  • Geography (urban or rural)
  • Gender
  • Age
  • Disability status
  • Risk status related to sex and gender

28
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Source CDC, MMWR, March 21, 2008 /
57(11)281-285, Trends in TB, US, 2007, Table
http//www.cdc.gov/mmwr/preview/mmwrhtml/mm5711a2.
htm
35
Source CDC MMWR, V57, SS2, March 21, 2008, p5.
http//www.cdc.gov/mmwr/PDF/ss/ss5702.pdf
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45
Landmark The Inside Story of Americas New
Health Care Law and What it Means for Us All
46
Patient Protection and Affordable Care Act of
2010 (PPACA) Advancing Health Equity for
Racially and Ethnically Diverse Populations
  • http//www.jointcenter.org/hpi/sites/all/files/Pat
    ientProtection_PREP_0.pdf

47
The Lost Art of Healing Practicing Compassion in
Medicine
48
Preventive Services Under the PPACA
  • SEC. 1001 - Providing Free Preventive Care.  All
    new plans must cover certain preventive services
    such as mammograms and colonoscopies without
    charging a deductible, co-pay or coinsurance.
    Effective for health plan years beginning on or
    after September 23, 2010.
  • SEC. 4002 - Preventing Disease and Illness.  A
    new 15 billion Prevention and Public Health Fund
    will invest in proven prevention and public
    health programs that can help keep Americans
    healthy from smoking cessation to combating
    obesity.  Funding begins in 2010.
  • SEC. 4103 - The law provides certain free
    preventive services, such as annual wellness
    visits and personalized prevention plans for
    seniors on Medicare.  Effective January 1, 2011.
  • SEC. 4106 - Improving Preventive Health
    Coverage.  To expand the number of Americans
    receiving preventive care, the law provides new
    funding to state Medicaid programs that choose to
    cover preventive services for patients at little
    or no cost.  Effective January 1, 2013.

Source Healthcare.gov, http//www.healthcare.gov/
law/about/order/byyear.html
49
Interim Final Regulations (IFR) and Preventive
Care
  • Section 1001 of the Affordable Care Act amending
    section 2713 of the PHS Act, along with a set of
    interim final regulations (issued by the Internal
    Revenue Service, DHHS, and the Department of
    Labor on July 19, 2010 to implement provisions of
    health care reform) require that a group health
    plan and a health insurance issuer offering group
    or individual health insurance coverage provide
    coverage for the recommended preventive services
    without cost-sharing requirements for
  • Evidence-based items or services that have in
    effect a rating of A or B in the current
    recommendations of the United States Preventive
    Services Task Force (Task Force) with respect to
    the individual involved.
  • 2. Immunizations for routine use in children,
    adolescents, and adults that have in effect a
    recommendation from the Advisory Committee on
    Immunization Practices of the Centers for Disease
    Control and Prevention (Advisory Committee) with
    respect to the individual involved.

50
IFR and Preventive Care Continued
  • 3. With respect to infants, children, and
    adolescents, evidence-informed preventive care
    and screenings provided for in the comprehensive
    guidelines supported by the Health Resources and
    Services Administration (HRSA).
  • 4. With respect to women, evidence-informed
    preventive care and screening provided for in
    comprehensive guidelines supported by HRSA (not
    otherwise addressed by the recommendations of the
    Task Force). The Department of HHS is developing
    these guidelines and expects to issue them no
    later than August 1, 2011.

51
Examples of Grade A and B Recommendations of the
United States Preventive Services Task Force
Topic Text Grade
Screening and counseling to reduce alcohol misuse The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse (go to Clinical Considerations) by adults, including pregnant women, in primary care settings. B
Screening for high blood pressure The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 and older. A
Screening for breast cancer (mammography) The USPSTF recommends screening mammography for women with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older. B
Screening for cholesterol abnormalities men 35 and older The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders. A
Screening for cholesterol abnormalities men younger 35 a The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. B
Source Healthcare.gov, www.healthcare.gov/center/
regulations/prevention/regs.html
52
Consumer Assistance Programs under the PPACA
  • Section 1002 - States that apply can receive
    federal grants to help set up or expand
    independent offices to help consumers navigate
    the private health insurance system.
  • These programs will also collect data on the
    types of problems consumers have, and file
    reports with the U.S. Department of Health and
    Human Services to identify trouble spots that
    need further oversight.
  • Goal is to help consumers
  • file complaints and appeals
  • enroll in health coverage
  • get educated about their rights and
    responsibilities in group health plans or
    individual health insurance policies.

Source Healthcare.gov, http//www.healthcare.gov/
law/about/order/byyear.html
53
At Hospitals, New Methods with a Focus on
Diversity
  • Going beyond hiring interpreters and offering
    translated paperwork to improve care
  • Example nurse tells Latino patients at diabetes
    nutrition classes to avoid white bread, but does
    not mention tortillas, a staple of their diet
  • Blood sugars levels remained high until she asked
    them to bring in samples of food they ate at home
  • Source N.Y. Times, 9-6-10

54
Provisions of the Patient Protection and
Affordable Care Act Expanding Community Health
Centers
  • SEC. 10503 Community Health Centers and the
    National Health Service Corps Fund to provide
    for expanded and sustained national investment in
    community health centers appropriates new
    funding between fiscal years 2011-2015
  • 7 billion for services (to be increased to 11
    billion under the Presidents new proposal)
  • 1.5 billion for the construction and renovation
    of CHCs
  • 1.5 billion for the National Health Service
    Corps (which will place approximately 15,000
    primary care providers in provider-short
    communities)

Source Text of H.R. 3590 Patient Protection and
Affordable Care Act, available at
http//www.govtrack.us/congress/billtext.xpd?bill
h111-3590
55
Provisions of the Patient Protection and
Affordable Care Act Expanding Community Health
Centers Continued
  • SEC. 5508- Increasing Teaching Capacity
    authorizes a new Title VII grant program for the
    development of residency programs at health
    centers and creates a new Title III program that
    provides payments to community-based entities
    that operate teaching programs, appropriate 125
    million from 2010-2012 to carry this out
  • SEC. 5601 Spending for Federally Qualified
    Health Centers
  • 2.9 billion 2009-2010
  • 3.9 billion 2010-2011
  • 4.9 billion 2011-2012
  • 6.4 billion 2012-2013
  • 7.3 billion 2013-2014
  • 8.3 billion 2014-2015

Source Text of H.R. 3590 Patient Protection and
Affordable Care Act, available at
http//www.govtrack.us/congress/billtext.xpd?bill
h111-3590
56
KEY PROVISIONS OF THE PATIENT PROTECTION AND
AFFORDABLE CARE ACT CONTINUED
  • SEC. 3501. HEALTH CARE DELIVERY SYSTEM RESEARCH
    establishing the functions of the Center for
    Quality Improvement and Patient Safety of the
    Agency for Healthcare Research and Quality, among
    them is to make the research findings of the
    Center available to the public through multiple
    media and appropriate formats to reflect the
    varying needs of health care providers and
    consumers and diverse levels of health literacy

57
KEY PROVISIONS OF THE PATIENT PROTECTION AND
AFFORDABLE CARE ACT (H.R. 3590)
  • SEC. 5002. DEFINTIONS Health Literacy (the
    degree to which an individual has the capacity to
    obtain, communicate, process, and understand
    health information and services in order to make
    appropriate health decisions)
  • SEC. 5307. CULTURAL COMPETENCY, PREVENTION, AND
    PUBLIC HEALTH AND INDIVIDUALS WITH DISABILITIES
    TRAINING emphasizing collaboration between
    several groups (e.g. community-based
    organizations, licensing and accreditation
    schools, health professional societies) to adopt
    culturally competent measures
  • SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL
    INTERNAL MEDICINE, GENERAL PEDIATRICS, AND
    PHYSICIAN ASSISTANTSHIP preference and priority
    in awarding grants or contracts to qualified
    applicant accredited schools of medicine will go
    to those who provide training in culturally
    competency and health literacy (as one of other
    considerations)

58
Cultural Competency Statutes
  • California
  • New Jersey
  • Massachusetts

59
CULTURAL COMPETENCEY ACCREDITATION STANDARDS
  • Medical Schools
  • Nursing Schools
  • Continuing Medical Education
  • Continuing Nursing Education

60
Human Experimentation
  • Tuskegee Syphilis Study
  • Jewish Chronic Hospital Case
  • Johns Hopkins Lead Study case Grimes v. Kenney
    Kreiger Institute, Inc. 782 A. 2d 807 (Md.
    2001)(court holds researchers have special duty
    to children and parents cannot consent to
    non-therapeutic research that poses a risk of
    harm to their children

61
PROBLEM FOR GROUP DISCUSSION
  • 70 year old African American Male refuses to see
    orthopedic surgeon, stating I do not trust
    white doctors and I believe that whatever happens
    now is Gods will. I have led a good life.

62
Summary of Statutes and Accreditation Standards
  • Informative source https//www.thinkculturalheal
    th.hhs.gov/

63
LIAISON COMMITTEE ON MEDICAL EDUCATION
  • STANDARDS for Accreditation of Medical Education
    Programs Leading to the M.D. Degree
  • ED-21 must demonstrate an understanding of the
    manner in which people of diverse cultures and
    belief systems perceive health and illness and
    respond to various symptoms, diseases and
    treatments.
  • ED 22 must learn to recognize and appropriated
    address gender and cultural biases in themselves,
    in others, and in the process of health care
    delivery
  • http//www.lcme.org/functions2010jun.pdf (last
    visited Aug. 27, 2010).

64
The Importance of Poor Health Literacy
  • Poor health literacy is a stronger predictor of
    a persons health than age, income, employment
    status, education level, and race.
  • Report on the Council of Scientific Affairs, Ad
    Hoc Committee on Health Literacy for the Council
    on Scientific Affairs, American Medical
    Association, JAMA, Feb 10, 1999).

65
Health Literacy A Prescription to End Confusion
66
EXTENT OF LOW HEALTH LITERACY
  • 90 million U.S. adults have low health literacy
    (nearly half of all U.S. adults)
  • The average annual health care costs of persons
    with very low literacy (described as reading at
    the grade two level or below) may be four times
    greater than for the general population
  • 75 of U.S. persons with chronic physical or
    mental health issues are in the limited literacy
    category
  • One study of Medicare enrollees found that 34
    percent of English speakers and 54 percent of
    Spanish speakers had inadequate or marginal
    health literacy
  • A study of patients 60 years and older at a
    public hospital found that 81 percent could not
    read and understand basic materials such as
    prescription labels and appointments

Note Healthy People 2010 defines Health Literacy
as the degree to which individuals have the
capacity to obtain, process, and understand basic
health information and services needed to make
appropriate health decisions Sources Healthy
People 2010 (Chapter 11), Health Communication,
U.S. Department of Health and Human Services
National Network of Libraries of Medicine, Health
Literacy http//nnlm.gov/outreach/consumer/hlthlit
.html
67
PAYING FOR THE COST OF LOW HEALTH LITERACY (1998
STUDY)
Dollars in Billions
Source National Academy on an Aging Society,
Health Literacy Fact Sheet Low Health Literacy
Skills Increase Annual Health Care Expenditures
by 73 Billion http//www.agingsociety.org/agingso
ciety/publications/fact/fact_low.html
68
THE 2003 NATIONAL ASSESMENT OF ADULT LITERACY
(NAAL) SURVEY
  • First large-scale national literacy study to have
    a component specifically designed to measure
    health literacy in adults and provide a separate
    health literacy score
  • Conducted with a nationally representative sample
    of 19,000 adults aged between 16 years and older
  • Adult performance measured on a range of
    health-related tasks (e.g. understanding dosing
    instructions for medication)
  • The NAAL definition of functional health
    literacy the ability of U.S. adults to use
    printed and written health related information in
    English to function in society, achieve ones
    goals, and to develop ones knowledge and
    potential (does not measure the ability to
    communicate orally)

Source Sheida White, Assessing the Nations
Health Literacy Key Concepts and Findings of the
National Assessment of Adult Literacy (2008)
69
NAAL FINDING OF PERCENTAGE OF ADULTS AT EACH
HEALTH LITERACY LEVEL BY RACE/ETHNICITY
Source Sheida White, Assessing the Nations
Health Literacy Key Concepts and Findings of the
National Assessment of Adult Literacy (2008)
70
KEY PROVISIONS OF THE PATIENT PROTECTION AND
AFFORDABLE CARE ACT (H.R. 3590)
  • SEC. 5002. DEFINTIONS Health Literacy (the
    degree to which an individual has the capacity to
    obtain, communicate, process, and understand
    health information and services in order to make
    appropriate health decisions)
  • SEC. 5307. CULTURAL COMPETENCY, PREVENTION, AND
    PUBLIC HEALTH AND INDIVIDUALS WITH DISABILITIES
    TRAINING emphasizing collaboration between
    several groups (e.g. community-based
    organizations, licensing and accreditation
    schools, health professional societies) to adopt
    culturally competent measures
  • SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL
    INTERNAL MEDICINE, GENERAL PEDIATRICS, AND
    PHYSICIAN ASSISTANTSHIP preference and priority
    in awarding grants or contracts to qualified
    applicant accredited schools of medicine will go
    to those who provide training in culturally
    competency and health literacy (as one of other
    considerations)

71
KEY PROVISIONS OF THE PATIENT PROTECTION AND
AFFORDABLE CARE ACT CONTINUED
  • SEC. 3501. HEALTH CARE DELIVERY SYSTEM RESEARCH
    establishing the functions of the Center for
    Quality Improvement and Patient Safety of the
    Agency for Healthcare Research and Quality, among
    them is to make the research findings of the
    Center available to the public through multiple
    media and appropriate formats to reflect the
    varying needs of health care providers and
    consumers and diverse levels of health literacy

72
KEY PROVISIONS of the PATIENT PROTECTION AND
AFFORDABLE CARE ACT CONTINUED
  • SEC. 3506. PROGRAM TO FACILITATE SHARED
    DECISIONMAKING REQUIREMENTS FOR PATIENT DECISION
    AIDS - Patient decision aids developed and
    produced pursuant to a grant or contract shall
    present evidence about the risks and benefits of
    treatment options in a form and manner that is
    age-appropriate and can be adapted for patients,
    caregivers, and authorized representatives from a
    variety of cultural and educational backgrounds
    to reflect the varying needs of consumers and
    diverse levels of health literacy

73
TITLE VI OF THE CIVIL RIGHTS ACT OF 1964
  • No person in the United States shall, on the
    ground of race, color, or national origin, be
    excluded from participation in, be denied the
    benefits of, or be subjected to discrimination
    under any program or activity receiving federal
    financial assistance.
  • Lau v. Nichols (1974) - the Supreme Court
    interprets language discrimination as equivalent
    to national origin discrimination

74
Title VI of the Civil Rights Act of 1964
  • Alexander v. Sandoval (2001) a class action
    suit against the Alabama Department of Public
    Safety for requiring that all state drivers
    license tests be administered in English only a
    divided Supreme Court held private individual
    actions to enforce the disparate impact
    regulations promulgated under Title VI are
    prohibited
  • A huge blow to equitable health care by
    undermining the ability to address systemic
    discrimination that takes place in the health
    care system

75
Health Insurance Coverage
Health Insurance Coverage and Population
Characteristics-all Ages, Medical Expenditure
Panel Survey Home, http//www.meps.ahrq.gov/mepswe
b/data_stats/summ_tables/hc/hlth_insr/2009/t1_a09.
htm.
76
Uninsured Persons and Uninsured Rate Between
1987-2009
50.7 million
16.7
Source New England Journal of Medicine, Health
Policy and Reform, Data Watch Sept. 22, 2010
U.S. Census Bureau, Current Population Survey,
1988-2010 Annual Social and Economic Supplements
77
Uninsured Rates for the Nonelderly by
Race/Ethnicity
Note 1.Nonelderly 0-64 years of age,
2.Insufficent data available for PAs uninsured
nonelderly other category Source The Kaiser
Family Foundation, statehealthfacts.org,
http//www.statehealthfacts.org/comparetable.jsp?i
nd143cat3
78
Distribution of Nonelderly Uninsured by
Race/Ethnicity (2008)
Note 1. Nonelderly ages 0-64 years of age 2.
Insufficient data for Pennsylvanias other
race/ethnicity category of nonelderly uninsured
3. Persons of Hispanic origin may be of any race
all other racial/ethnic groups are
non-Hispanic Source The Kaiser Family
Foundation, statehealthfacts.org,
http//www.statehealthfacts.org/comparebar.jsp?ind
138cat3
79
HEALTH CARE DECISION-MAKING LEGAL RIGHTS AND
DUTIES
  • PATIENT AUTONOMY
  • PHYSICIAN AUTHORITY
  • THIRD PARTY PAYER POWER
  • PATIENT TRUST

80
REALITY OF DECSIONMAKING
  • PROVIDERS SET STANDARD OF CARE
  • INSURERS SET STANDARD OF CARE
  • PATIENT AUTNTOMONY LIMITED BY ACCESS AND KNOWLEDGE

81
PATIENTS KNOWLEDGE AND VALUES
  • HEALTH LITERACY
  • VALUES CULTURAL, RELIGIOUS ECONOMIC
  • INFLUENCE OF FAMILY
  • INFLUENCE OF CHURCH
  • INFLUENCE OF MEDIA
  • INFLUENCE OF GOVERNMENT

82
Three Important Books
  • James Jones, Bad Blood
  • Anne Fadiman, The Spirit Catches You and You Fall
    Down
  • Rebecca Skloot, The Immortal Life of Henrietta
    Lacks

83
LAW OF INFORMED CONSENT
  • Canterbury v. Spence, 464 F.2d 772 (D.C. Cir.
    1972)
  • Patient has a right to know risks, benefits
    alternatives
  • Autonomy Patient has a right to make decisions
    others consider irrational or unreasonable

84
INFORMED REFUSAL
  • Truman v. Thomas, 611 P. 2d 902 (Cal. 1980)
  • Patient refuses pap smear
  • Patient dies from cervical cancer
  • Family sues patients family doctor who
    recommended pap smear but did not explain risk of
    not having the test done
  • Court rules doctor had duty to advise of risk of
    harm associated with refusing test

85
Key Sources
  • Institute of Medicine Report Unequal Treatment
    Confronting Racial and Ethnic Disparities in
    Health Care (2002), Edited by Brian Smedley,
    Adrienne Stith, and Alan Nelson
  • CDC Health Disparities and Inequalities Report
    2011, MMWR, Vol 60 available at
    http//www.cdc.gov/mmwr/pdf/other/su6001.pdf
  • Institute of Medicine Health Literacy A
    Prescription to End Confusion (2004)
  • Patient Protection and Affordable Care Act, a
    study of key provisions available at
    http//www.jointcenter.org/hpi/sites/all/files/Pat
    ientProtection_PREP_0.pdf
  • The Kaiser Family Foundation, www.statehealthfacts
    .org
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