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S. Health Promotion and Disease Prevention in the Health Care System Because of the important role it plays in detecting, treating, and preventing diseases and injuries, the health care system is critical to implementation of the Year 2000 Health Objectives. However, according to the nearly 100 people who addressed this in their testimony, there are severe problems with access to preventive services and an unfulfilled potential role for health professionals in preventing disease and promoting the health of the U.S. population. Some witnesses digressed from the narrow focus of the objectives to the broader problems of access to health and medical care in general. Milton Roemer of the University of California, Los Angeles gets directly to the essence of the problem. Many, if not all, of the priorities of positive health activity on the national agenda can be substantially influenced by access to professional health care. To cite just a few examples, the detection of and intervention against hyperten- sion and cancer, immunization against prevent- able infectious diseases, control of obesity, or the preventive management of depression re- quire the services of physicians or other skilled health personnel. Yet some 35 to 40 million Americans do not have economic access to doctors through voluntary health insurance, Medicare, or Medicaid. A larger number lack economic and physical access to primary health care, although they may have insurance for hospitalization. Access to professional care may have very broad impacts on health promotion. Education and advice from a doctor can affect lifestyle- smoking, alcohol use, contraception, exercise, diet, stress-more effectively than the most skillful messages of mass media. We have long ago learned that almost any person is more receptive to advice on changed behavior, if this advice is offered by a health care provider who is giving treatment for a specific symptom. Prevention is more effective if it is integrated with the delivery of medical care. (#277) The Medical Care Section of the American Public 68 Healthy People 2000: Citizens Chart the Course Health Association (APHA) agrees with this assess- ment: "The goals for the year 2000 will not be attained unless all Americans have access to high quality health care." This is true across the broad range of national objectives~hether the health problem being addressed is heart disease and stroke through the control of hypertension; cancer through screening and early detection; or infant mortality through the provision of prenatal care. Consequently, the APHA Medical Care Section suggests that the Public Health Service add an additional goal for the year 2000 that "all Americans will be assured ade- quate access to quality health care." (~755J Senator Chet Brooks, Dean of the Texas State Senate, sums up the political view. From my perspective as a state legislator, our success in achieving the national health objec- tives for the year 2000 will depend to a large extent on improving access to programs and services we already have in place and on increas- ing the availability of information regarding disease prevention. For example, perhaps the greatest success in a preventive health effort with significant effect on the nation's health status was the discovery and uniform administra- tion of vaccines. The diseases we faced were so frightening and widespread, we took immediate and definitive action. Every child had access to immunizations to prevent these diseases. The results: almost a virtual elimination of debilitat- ing and life-threatening diseases such as polio, diphtheria, and smallpox. The undisputed key to this success was access. As we begin to formulate our goals for the year 2000 and beyond, we must determine why certain objec- tives for 1990 were not achieved. I suggest we look closely at our policies and programs to see whether they are accessible to the persons for whom they are intended. (#234) Clearly, the Year 2000 Health Objectives can not be achieved without full participation of health professionals and the organizations in which they work. This chapter summarizes testimony on two

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interrelated issues: the great potential value of providing health promotion and disease prevention services through the health care system, and the serious problems faced by many in gaining access to that system. Access to health care in general, and to preventive services in particular, is primarily a problem of specific populations, especially the poor and minorities, so the problems confronting these groups are discussed first. Testimony on potential contributions of the various health professionals and the settings in which they work is next, along with suggestions on strengthening their roles as providers of health education and preventive services. The next section discusses problems and solutions in the financing of health promotion and disease prevention programs, including changes in existing federal fund- ing programs and in the insurance system. The last section discusses four issues in the implementation of health promotion and disease prevention in health care settings: coordination of services, training health professionals, underserved areas, and the need for minority practitioners. PROBLEMS WITH ACCESS TO HEALTH CARE Access to health care is very unevenly distributed in the United States. As discussed in Chapter 6, the poor, the homeless, and many racial and ethnic minorities have severe problems gaining access to preventive services and even basic health care. People with disabilities have access problems of a different sort (Chapter 7~. To set the stage for the inte~ven- tions and changes called for in the latter part of this chapter, testimony on the problems faced by the poor, minorities, and the disabled is presented first. Poor and Homeless According to many who testified, today's poor and homeless represent special populations that both are large enough and include enough of America's most vulnerable citizens to warrant particular concern in the Year 2000 Health Objectives. The difficulties these people face in maintaining their health and attaining access to the medical system go beyond the obvious economic ones and include the horrendous physical and social conditions in which they must live. For these disadvantaged, issues of preventing disease and promoting good health often are secondary to the problems associated with everyday survival. According to Mary Sapp of the San Antonio Health Care for the Homeless Coalition, the number of homeless people is growing, and their ranks include families and people at the highest risk for health problems. Their needs are exacerbated by special health risks inherent in their lifestyles: exposure to the elements, poor nutrition, inadequate sanitation, lack of a place to recuperate from minor illnesses, vulnerability to violent acts, psychological stress, and alcohol or substance abuse. This group needs access to every preventive measure available to the general population and would benefit more from them than the average person. (#507) According to Harold Shoults, the Salvation Army works with the most "down-and-out, the working poor and those who "fall through the cracks in public welfare programs. Their experience, revealed in reports from Salvation Army officers around the country, is enlightening. The "barriers to health care for our clients might be summed up in three words: access, understanding, and conditions," says Shoults. The Memphis and Dallas offices discuss access: One of our biggest problems is lack of medical insurance among the unemployed, temporarily employed, and those working for temporary labor providers. These people would have to apply for Medicaid if they got into a crisis. There is nothing for minor problems. They must present themselves to an emergency room and take what they can get there. Preventive health service is only able to take life-threatening cases. As an example, this past winter our local public hospital had to refuse inpatient care unless an individual had pneumonia in both lungs. Others deal with understanding: Barriers to access include a fragmented system and not understanding the treatment or instruc- tions. There is no continuity of service, they probably see a different physician every lime, never develop a relationship with a doctor or nurse and get little in the way of health education. Finally, there is the question of condition: The socioeconomic condition of clients creates, perpetuates, and exacerbates major health problems. Health Promotion and Disease Prevention in the Health Care System 69

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Particularly in the case of a homeless family, there are multiple needs that must be addressed. Stress related problems of the families we see today may be due to (1) unemployment or underemployment, (2) inadequate public assis- tance programs, (3) substandard housing, (4) ex- orbitant utility costs, (5) poor health care, (6) lack of transportation, (7) inadequate support systems, and (8) lack of experience and educa- tion about good parenting. Many children are being raised in a state of sheer survival. As a result, they are faced with some serious malaise: malnutrition, long-term sleep deprivation, depression, developmental lags, educational deprivation, dental and other chronic health problems; these can only bring perpetuation of the homeless syndrome. (~579) Stephen Joseph, New York City Commissioner of Health, writes that The health problems of New York inevitably reflect the conditions of poverty in which too many families live. Confronting these environ- ments means confronting the failures of our formal and informal education systems, chronic unem- ployability, the too-frequent drift into a lifetime of crime and drugs, the collapse of the nuclear family, and a worsening housing crisis." (~437) As an example of what needs to be done to prevent disease and promote the health of the home- less, consider the situation of New York City. In 1987 the city provided room for over 27,000 homeless people, including more than 5,000 families, in shel- ters, temporary apartments, and hotels. For homeless families living in hotels the infant mortality rate is twice the city average. According to Joseph, the Homeless Health Initiative is being expanded to provide essential health screening and referral services to homeless individuals and families. New York City has 25 public health nurses working in 37 hotels that house approximately 90 percent of the city's homeless; these nurses refer residents lo medical or social service agencies, and teach them about proper nutri- tion and prenatal or pediatric care. To reduce the infant mortality rate and reach women who tradition- ally have not sought prenatal or pediatric care, the Department of Health is implementing a plan in which 30 public health nurses and 35 public health advisers will work with community groups to refer pregnant women and infants to local providers of medical and social services. (~437) 70 Healthy People 2000: Citizens Chart the Course Racial and Ethnic Minorities The problems that minorities face in attaining access to health care are severe and complex (see Chapter 6~. They are caused not only by socioeconomic factors, but also by different cultural attitudes and beliefs about health and medicine. According to Daniel Blumenthal of the Morehouse School of Medicine, millions of Americans especially Blacks-lack adequate access to quality health services. The reasons for this include (1) lack of insurance (even Adequate insurance does not cover preventive services); (2) living in rural or inner-ci~ areas that are poorly served by physicians; and (3) the shortage of Black physicians. Although 12 percent of the U.S. population is Black, fewer than 3 percent of U.S. physicians are Black.t (#255) The APHA Medical Care Section reports that a substantial portion of the disparities in Black and minority health May be attributed to differences in access to health care, both preventive and curative between the two population groups. (~755) Osman Ahmed of Menarry Medical College writes that "Blacks are known to delay seeking health care within the traditional health care system, preferring to rely upon family, friends, and even spiritualists and healers, during periods of economic and emotional stress." Unique value systems? together with medical care expenses, may prevent Blacks from utilizing the health care system. Since different "loci of corduroy are operating in Blacks, different health promotion strategies should be used to reach them. Eliminating barriers to care seeking and behavior change will require new, culturally sensitive approaches to infor- mation dissemination, health planning and resources management, and may even require the in- stitutionalization of new health policies." (~269) As an example of what should be done to improve access to preventive services, Ahmed cites Meharry Medical College's "Community Coalition on Minority Health. This coalition, led by Diehard, consists of local governmental, professional, voluntary, com- munity, and religious organizations and tries to "bring together the knowledge, expertise, and resources to provide solutions." The coalition's objective is to decrease diet- and nutrition-related cancer and car- diovascular disease risk factors and hypertension in the Black community. (~269) Other minority groups have similar difficulties with access to health care. The National Coalition of Hispanic Health and Human Senices Organizations says that Hispanics are more than twice as likely to

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be without either public or private health insurance than non-Hispanic Whites or Blacks.2 Hispanic mothers are more likely than non-Hispanic Whites or Blacks to begin prenatal care in the third trimester or not at all; Hispanics are less likely to have a regular source of health care; 30 percent of Hispanics lack this, compared to 20 percent of Blacks and 16 percent of Whites. Hispanics are also less likely to receive public health messages. (~193) ~Hispanics, in particular Puerto Ricans, continue to have poorer health status, and excess morbidity and mortality compared to the majority population," according to Eric Munoz of the Long Island Jewish Medical Center in New York. Munoz suggests that this disparity is due in part to less access to health care and preventive services in particular. For example, fewer Puerto Rican women undergo breast exams and mammography, or Pap smears and gyneco- logical exams. Puerto Ricans also have inadequate detection and treatment of hypertension. (#431) People with Disabilities "Adults with chronic disabilities," write Alfred Tallia, Debbie Spitalnik, and Robert Like of the University of Medicine and Dentistry of New Jersey, "either those who have developmental disabilities or chronic mental illness, individually and as a collective group, have a history of inadequate health care and a lack of access to quality medical services, including preventive health services." They say that deinstitutionalization of the chronically disabled from large, congregate institutions assumes the availability and accessibility of health services in the community, but services are not being delivered adequately to this population. Chron- ic disabilities are accompanied by complex needs for an array of preventive health, social, educational, vocational, and other supportive services; health services for the chronically disabled, however, tend to be targeted to specific problems, and general preven- tive health needs tend to go unattended or are poorly "coordinated." Furthermore, Tallia, Spitalnik, and Like say that the nature of chronic disabilities may create barriers to participation in a primary care setting with preventive health measures; problems include economic disadvantages due to difficulty in sustaining employment, physical access issues, difficul- ties in obtaining adequate health histories, and negative prejudicial attitudes from health care workers. (#209) HEALTH PROMOTION AND DISEASE PREVENTION IN THE HEALTH CARE SYSTEM Implementation of the national objectives for health promotion and disease prevention in medical and health care settings depends on the participation of physicians, other health professionals, and the organizations in which they work. Those who testified had many recommendations about how to make better use of health professionals in disease prevention and health promotion programs. The suggestions general- ly included changes in training programs, compensa- tion and reimbursement systems, and recruitment. Physicians Many who testified felt that physicians can play a much larger role in health promotion and disease prevention than they currently do. The evidence of their effectiveness is strong, according to witnesses. Testimony, therefore, called for enhanced training opportunities and changes in insurance payment policies to allow physicians to become more active. According to the American Academy of Family Physicians: Physicians in primary care can have a positive effect on health behaviors in very cost effective ways. For example, the simple offering by a general practitioner of advice to stop smoking to patients who come to the doctor for some reason other than smoking, results in a 5 per cent quit rate at the end of one year.3 To take advantage of the opportunities presented by physicians, the American Academy of Family Physicians makes four recommendations: 1. Insurance should cover scientifically supported disease prevention and health promotion interventions in the doctor's office and other outpatient settings. 2. Office-based systems for health risk assessment and longitudinal tracking for both screening examina- tions and health behaviors should be developed and adopted. 3. Disease prevention and health promotion curricula must be developed in medical schools and residencies and put on a par with other medical education topics. 4. Research to determine appropriate assessments and interventions, as well as their frequencies and Health Promotion and Disease Prevention in the Health Care System 71

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effectiveness, needs to be funded. (#072) Donald Logsdon reports on a series of studies funded by the insurance industry under the banner of Project INSURE, which he directs. These studies have shown that (1) physicians are interested in clinical prevention; they will effectively provide preventive services, including patient education in their practices, if they receive practice-based training and if the financial barriers to preventive care are removed; (2) such interventions can be effective in changing risk behaviors; and (3) their costs can be controlled. Therefore, Logsdon suggests that the Year 2000 Health Objectives include clinical preven- tive services provided by physicians. He also sees a need for continuing medical education programs and incentives for physicians to become more effective at preventive health services and health promotion. (#463) According to Michael Eriksen, Director of Be- havioral Research at the University of Texas M.D. Anderson Hospital: lithe potential impact of health professionals, especially physicians, in furthering our disease prevention and health promotion goals is vast. However, they were rarely included in the 1990 Objectives. The Year 2000 Health Objectives should stipulate specific health promotion objectives for each patient encounter, consistent with the guidelines being developed by the U.S. Preventive Services Task Force. Eriksen offers this example: "Smoking patients should be counseled by their physician to stop smoking during 75 percent of routine office visits." (#309) Other Health Professionals Witnesses discussed the roles that a wide range of health professionals can play in implementing health promotion and disease prevention objectives. The professional groups include pharmacists, nurses, midwives, public health professionals, and allied health professionals. In many cases, these groups are oriented to disease prevention and health promotion and are reportedly effective at it, so that minimum changes in training and funding patterns can have important effects. The American Pharmaceutical Association (APhA), for instance, urges recognition of the important role pharmacists play in health promotion and disease prevention. Their testimony addresses the following 72 Healthy People 2000: Citizens Chart the Course matters: 1. The pharmacists' role as health educators and medication counselors: Pharmacists provide education and information to patients regarding the control of high blood pressure, family planning, sexually trans- mitted diseases, poison prevention, smoking and health, nutrition and weight control, and the control of stress. 2. The role of pharmacists in promoting rational prescription drug therapy: The 1990 Objectives focus on adverse drug reactions, but counseling should be much broader and should emphasize the correct use of all medication to avoid complications. Pharmacists also play a role in assuring the quality of drug therapies on the regulatory level. 3. The need to pay all health care providers for counseling that fosters health promotion and disease prevention: Unless there are economic incentives for pharmacists (like other care providers) to provide health education, the APhA feels that their maximum effort will not be brought to bear on the problem. ,#564, Many witnesses testified about the contributions that nurses already make to health promotion and disease prevention efforts and stressed the role that they can play in implementing the Year 2000 Health Objectives. Patty Hawken, Dean of the School of Nursing at the University of Texas Health Science Center at San Antonio, says that because nurses have traditionally been the constant care giver in the communing and in the home, they are well prepared to assist with health promotion and disease preven- tion. (#501) Sharon Grigsby, President of the Visiting Nurse Foundation in Los Angeles, reports that the initial efforts of visiting nurses a century ago concentrated on the prevention of disease through education on the rudiments of good hygiene and helped reduce mater- nal and infant mortality, as well as the spread of infectious diseases. Visiting nurses have kept up with technological advances in medicine, she reports, but their historical commitment to community-based care has not lessened. Grigsby still sees a role for visiting nurses in preventing illness and disability through education. Their efforts would be most effective for vulnerable populations such as the elderly, pregnant women, and infants. f#074) Sapp reports on her coalition's goal of promoting the utilization of nurse practitioners to the fullest extent of their training and skills in all programs targeting the homeless. (~507) However, according to Hawken the number of new

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nurses is declining. The current shortage of profes- sional nurses has a critical impact on health care in the country. (#501) As the population ages, the shortage of nurses to care for the elderly will become particularly acute, says Anita Beckerman of the College of New Rochelle in New York. She suggests that federal and state governments develop programs to facilitate the entrance of prospective nursing students into the profession, perhaps through full tuition payments with service payback provisions, scholarships, grants, or capitation payments to nursing schools. (~436) Hawken suggests that encouraging groups in health care to highlight the importance of nurses in meeting national health care objectives would help ease the shortage. (#501) Mary Mundinger, Dean of the Columbia University School of Nursing, says that the major reasons for the unavailability of nurses are their low status within the medical system, low salaries, and shift work. To prevent a nursing shortage and restore nursing to a viable and useful profession, funding changes must be initiated at the federal level. These would include transferring federal resources for training physicians (who are in oversupply) to nurse training programs; using National Health Service Corps funds to bring nurses into underserved areas; finding ways to bring nonworking nurses back into the work force; and changing credentialing practices to recognize and reward nurses at the highest levels of education and practice. (#589) A number of testifiers discussed the preventive services that midwives can provide, especially high- quality prenatal care and obstetrical services. Repre- sentatives of the American College of Nurse-Midwives believe that nurse midwives can deliver quality ser- vices at low cost and would be particularly effective for low-income populations. Thus, they urge the removal of barriers to practice, such as noncompeti- tive salaries, restraint of trade by physicians, and the malpractice crisis. (#268; #292; #690) Allan Rosenfield, Dean of the Columbia University School of Public Health, reports on a shortage of well-trained public health professionals. Only a small percentage of the people working in city, county, and state departments of health and in other parts of the public health infrastructure have been formally trained in public health." f#633J Bernard Goldstein of the University of Medicine and Dentistry of New Jersey notes that one impediment to reaching the important goal of a sufficient number of trained public health professionals is the Poor geographical distribution and relative lack of outreach of our existing accredited graduate training facilities in public health." He suggests the development of easily accessible, rigorous graduate education programs. (~625J According to Keith Blayney, Dean of the School of Health-Related Professions at the University of Alabama at Birmingham, allied health professionals engage in millions of patient interactions each week and thus represent a tremendous potential for disease prevention and health promotion efforts. (#258) According to John Bruhn, Dean of the School of Allied Health Sciences at the University of Texas Medical Branch at Galveston, physician's assistants, physical and occupational therapists, dental hygienists, and other allied health professionals are in positions to provide one-on-one patient education regarding lifestyles and habits that can prevent illness. 'Teachable moments' are not limited to the physician- patient dyed." (#235J To make them a potent force for implementing the Year 2000 Health Objectives, Blayney feels that every allied health professional in the country should be cross-trained to provide patient and public education and services in the area of health promotion and disease prevention. (#258) Lisa Fleming, President of the Alabama Dental Hygienists' Association, wants to Emphasize the role that dental auxiliaries can play in the Year 2000 Health Objectives. As education and prevention professionals, dental hygienists can have a significant role in meeting these objectives. With proper educa- tion, hygienists can actively participate in educational and preventive programs to reduce dental caries, apply preventive procedures to periodontal patients, and educate the public about the prevention of accidents and oral cancer.n (#262) Health Care Settings and Organizations Health professionals, especially nonphysic~ans, general- ly work in organizations, and the policies and struc- ture of these organizations have an important effect on access to preventive services. Along these lines, witnesses discussed health promotion and disease prevention activities in hospitals, community health centers, health maintenance organizations, group practices, and long-term care facilities. The general feeling is that these facilities are interested in provid- ing more preventive services and health promotion programs, but funding patterns inhibit their ability to do so. For instance, the American Hospital Association (AMA) reports: Health Promotion and Disease Prevention in the Health Care System 73

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As chronic disease has replaced acute infectious disease as the major cause of morbidity and mortality, as the locus of care has shifted to the outpatient setting, and as the research base for broadly defined health promotion/disease preven- tion services has solidified, hospitals have expanded the range of services they offer. During the 1980s, hospitals across the United States became major providers of health promo- tion services and active partners with other local organizations in addressing community health problems. Historically, patient education has been the primary focus of hospital health pro- motion services as a complement to acute medical services. A 1979 policy statement recognized hospitals' responsibility "to take a leadership role in helping to insure the good health of their communities." According to the AHA, hospitals now have a wide variety of health promotion activities such as cardiac rehabilitation, care giver education, wellness pro- gramming, and occupational health services. Increas- ingly, hospitals are recognizing the limits of their acute inpatient and outpatient services in meeting the needs of patients with chronic conditions, and are establishing linkages with self-help/mutual aid groups. (#576) However, AHA reports that changes in hospital care more outpatient services, shorter inpatient stays, and more care of chronic than acute illness-mean that hospitals have less opportunity to offer preven- tion or health promotion education to patients. Also, work force shortages, especially in nursing, and inade- quate resources or reimbursement may prevent health care professionals from offering the range of educational efforts called for in the 1990 Objectives, such as counseling in safety belt use, nutrition education, physical fitness regimens, and stress-coping skills. Given the lack of progress toward some key objectives such as infant mortality among minorities and the lack of access to private health insurance, fit is perhaps time to elevate financing for preventive services to the status of an objective if risk reduction and health status objectives are to be achieved for all populations." (#576) The National Association of Community Health Centers reports that these centers present a good opportunity for implementing the objectives in poor and minority communities. Clients of these centers are largely poor, minorities, women, and children, and the illnesses reported are preventable if diagnosed 74 Healthy People 2000: citizens Chart the Course early. For example, among the top 10 diagnoses reported at community health centers around the country were hypertension, upper respiratory infec- tions, pregnancy, and diabetes. (~635) Health maintenance organizations (HMOs) have Several distinct advantages" that enable them to efficiently deliver preventive and health promotion services, according to David Sobel of the Permanente Medical Group in Oakland, California. (#780) 1. Their financial incentives are such that the organization benefits from the implementation of efficient, cost-effective preventive services. 2. Large HMOs and group practice models can achieve economies of scale and efficiency in delivering these services through such mechanisms as health education centers, group classes, and telephone tapes or advice nurses. 3. Centralized medical records and patient profiles provide outstanding opportunities for evaluation of health promotion initiatives. But, Sobel cautions that even the physicians who work in HMOs may not be skilled or comfortable in providing health education and counseling. Thus, to be successful, HMOs must define and specie a basic benefit package of prenatal, immunization, and age-related periodic health evaluation services to assure consistency; use nonphysician health professionals, such as nurses, nurse practitioners, dietitians, and pharmacists, to provide health education and prevention services; and include self-care education to help people understand when to seek medical and preventive care, and when or how to use self-treatment safely. (#780J FINANCING HEALTH PROMOTION AND DISEASE PREVENTION PROGRAMS IN THE HEALTH CARE SYSTEM Many testifiers identified problems with financing health promotion and disease prevention programs as an obstacle to implementing the national objectives. Robert Black of Monterey, California, states, "Health promotion and disease prevention have been the stepchild of the American health care system and there is no incentive or reward for keeping people healthy. The financial structure needs complete revision and arrangement differently than it is present- ly conceived." (#796J Some saw the problem in the context of a larger

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concern about overall health expenditures in the United States, and proposed changes in Medicare and Medicaid or in already existing federal grant programs. Most of those who testified on these issues, however, proposed major changes in the financing of health care, including a national health insurance policy. According to the APHA Medical Care Section, "Access to health care for those most in need of care has actually been reduced since the Surgeon General's goals were first published. This is because of cutbacks in the several programs that have been established to increase access for the underprivileged and because of increasing corporatization of health care." f#755) William Hagens, a senior research analyst for the Washington State Legislature, said that the number one health problem facing Olympia and all other state capitals is the question of financing. At a time when access to health care for low-income people is declin- ing and costs are rising, there is the feeling that all the money spent is not contributing to happier, healthier people. Therefore, it is important that no new program be added, but that those already on the books be implemented more aggressively. Hagens feels that people must to be taught to be more responsible for their own health, and that prevention activities by businesses should be expanded. (~694J Federal Funding Programs Many witnesses suggested that already existing federal funding programs could do more to finance health promotion and disease prevention, and to improve the access to health care generally. In particular, testifiers addressed the possibilities of changing Medicare reimbursement policies for preventive services; increasing the coverage of Medicaid to include more poor people and more services, especially maternal health services; and better coordinating block and categorical grant programs with the national objec- tives. Medicare. A number of speakers suggested that Medicare should cover more health promotion and disease prevention services. Paul Hunter of the American Medical Student Association/Foundation, for instance, says that Medicare should reimburse at least 50 percent of the costs of the following preven- tive services: "health screenings, health-risk apprai- sals, immunizations, nutrition counseling, stress reduction, injury prevention, alcohol and drug abuse counseling, smoking cessation, and medication use.n (~612) Medicaid. A number of witnesses suggested changes in the Medicaid system to improve access to preven- tive services for the poor. These proposals ranged from changes for specific services, especially prenatal care, to an overall expansion of the number of people insured and the services covered. Milton Arnold of the American Academy of Pediatrics, for example, says that adequate prenatal care is the single most important factor in reducing infant morbidity and mortality, and he calls for more complete Medicaid reimbursement for it. With better prenatal care, he says, many of the 40,000 deaths that occur annually to babies in their first year of life can be prevented. However, he cites a General Account- ing Office (GAO) report that found insufficient prenatal care for women of all races, ages, and economic groups, but especially for low-income minorities.5 According to the GAO report, 81 percent of privately insured women surveyed received adequate prenatal care compared to 36 percent of those who qualify for Medicaid and 32 percent of uninsured women.6 The American Academy of Pediatrics would like to see prenatal care made available to all pregnant women early in pregnancy; Medicaid can help meet this goal by providing a regularly updated list of approved and reimbursable services and procedures and by improving reimburse- ment and paying claims promptly. (~678) Other witnesses complained that Medicaid is not realizing its potential. The APHA Medical Care Section says that "the Medicaid program still does nothing to improve access to health care for the majority of low-income Americans. The program actually covers less than half of all persons living in poverty; even those who are technically covered are often unable to find a physician who will accept Medicaid patients. (#755) Judith Glazner of the Denver Department of Health and Hospitals says that federal and state cutbacks in the early 1980s resulted in some of the poor becoming ineligible for Medicaid; she recom- mends that all states be required to use the same Medicaid eligibility standards. (#377) The Health Polipy Agenda for the American People, a collabora- tive effort of nearly 200 health, health-related, busi- ness, government, and consumer groups to promote health sector change, recommends that 1. Medicaid be revised to establish national standards that result in uniform eligibility, benefits, Health Promotion and Disease Prevention in the Health Care System 75

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and adequate payment mechanisms for services across jurisdictions; and 2. Medicaid eligibility standards be expanded to include the medically indigent and payments be related to their ability to pay. (#583) Block Grants. A number of state and local health officers suggest that federal block grant funds should be an important tool in financing prevention activities called for in the objectives. Mark Richards, Secretary of Health for the Commonwealth of Pennsylvania, says that all recipients of block and categorical grant funds should demonstrate clearly how they will help meet the appropriate objectives. (#387) Thomas Halpin and Karen Evans of the Ohio Department of Health say that federal preventive health and health services block grants were crucial to the success of the objectives in Ohio and should continue with the Year 2000 Health Objectives. (#129) Diana Bonta suggests using Title X family planning grants to implement family planning objec- tives. (#024) Maternal and child health block grants and the Special Supplemental Food Program for Women, Infants, and Children (WIC) can help improve access to early prenatal care and other services for pregnant women, infants, and children. (#044) Health Insurance Many witnesses called for some form of national health insurance system that would pay for preventive services, saying that without major changes in the current system, from which many are disenfranchised and which provides little preventive care for those who are covered, it will be difficult to make progress in the Year 2000 Health Objectives. Although some witnesses felt that a national health system or at least a national health insurance system is the only answer, others proposed changes in the existing private insurance system. According to Rosenfield: There should be a much greater emphasis on disease prevention/health promotion as a num- ber one national health priority with adequate funding at federal, state, and local levels. Health care financing in this country remains a tragic problem for an unacceptably large per- centage of the population. As the only Western nation without some form of national health insurance or health service, a sizable percentage 76 Healthy People 2000: Citizens Chart the Course of our population is either unserved or under- se~ved. The problem is greatest for the unin- sured working poor, the homeless, and the poor generally. A national health insurance program remains an urgent, if misunderstood, national priority. (#633j Derrick Jelliffe of the University of California, Los Angeles goes further: Until the country has some form of national health insurance coverage or other national health system enabling preventive and curative health services to be available to all economic levels in the country, the rest of the delibera- tions on the objectives border on the farcical. Unless one is careful, a potpourri of fragmented programs of limited extent and coverage may emerge in the usual sort of way. There is no way that the country can move from being a second-class nation as far as health services are concerned until a national health coverage has been achieved. (~271) "Millions of people are going without needed medical care, both therapeutic and preventive, because of financial barriers," writes Marjorie Wilson of Olympia, Washington. It is time for us to stop Band-Aiding a sick medical system. It is time now to start im- plementing a comprehensive national health plan. In addition to preventing serious condi- tions caused by neglect of early diagnosis and treatment, the national health plan should provide other preventive services such as: (1) primary prevention of mental conditions, early screening, and tertiary prevention for symptom control; (2) age-related health screening for all citizens with emphasis on the very young and the very old; (3) mammograms, Pap smears, and cholesterol and diabetic screening, as risk re- lated; (4) health education in the community, the workplace, and the schools for healthy living; and (5) environmental and personal changes for injury prevention. (~346) Members of the Society of Teachers of Family Medicine at a hearing on the national objectives suggested the following objective: "The number of Americans not covered by health insurance, currently 37 million, should be reduced by at least half~nd

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preferably more; alternatively, more- than 95 percent of Americans should have health insurance that covers 90 percent of hospital and 80 percent of outpatient costs, Including primary and secondary prevention, as recommended by the U.S. Preventive Services Task Force." (#143) According to Glazner, insurance coverage is a key factor in gaining access to preventive health care, and lack of insurance particularly affects the young, the old, and the poor. Without health insurance, low-income families must rely on a frequently fragmented and diff~cult-to-use public system of health care. Regular preventive care, including prenatal care, immunization, and well-child care, is sometimes difficult to get, and its availability may not be well understood. Only when families do not have to make a choice between food on the table and a visit to the doctor or clinic will adequate care for those most at risk be pro- vided. Because health insurance in the United States is largely employment based, The practical focus of increasing insurance coverage at this time must primarily be on employers that don't provide health insurance and on the insurers themselves." (~3 77) Thus, Glazner suggests adding a new category to the objectives, Improvement of Economic Access to Health Care." Its aim would be to reduce the num- ber of Americans not covered by public or private insurance programs, including Medicare and Medicaid, to less than 7.5 percent (a reduction of 50 percent), and she suggests a number of specific changes in legislation and regulation to achieve this goal. (#377) The Health Policy Agenda for the American People also is addressing the current insurance sys- tem, especially its coverage. 'rhe Health Policy Agenda has developed a "basic benefits package" to serge as the foundation for private health insurance plans and for public programs that finance health care. The package includes the following prevention and health promotion activities: maternal and child care, dental examination and teeth cleaning, immunizations, and periodic medical examinations. (#583) IMPLEMENTATION WITHIN THE HEALTH CARE SYSTEM Witnesses also identified four interrelated implementa- tion issues especially relevant to assuring access to preventive services: coordination of services, training of health professionals, underserved areas, and the lack of minority practitioners. Coordination of Services Helen Farabee, representing the March of Dimes Birth Defects Foundation, suggests as an objective that "by 2000, all pregnant women and infants should have access to and at least 95 percent shall receive quality care and case management from a coordinated and comprehensive system of public and private health-care providers.n According to Farabee, recent efforts in Texas have (1) expanded services, to make prenatal care available in every county; (2) instituted a comprehensive managed care program for pregnant women with high-risk conditions; and (3) tried to better coordinate services that should be targeted toward the poor, such as the WIC program, family planning programs, infant care programs, and early childhood intervention programs. (#289) George Silver of Yale University writes of the need "to focus on the inadequacies, inefficiencies, uncon- trollable inflation of cost, and evidence of poor quality plaguing the U.S. medical care system" in order to meet the Year 2000 Health Objectives. However, in implementing programs, he emphasizes the need to start with a state, rather than a full-scale national, program because the nnational tradition in connection with social policy has always been to start with a state model." ('t510) Training of Health Professionals Many testifiers identified training issues as key in realizing the potential of health professionals, espe- cially physicians, in implementing the objectives. One issue is the necessity for more specialists in preventive medicine. Other witnesses called for better integra- tion of the knowledge and skills needed for health promotion and disease prevention in the basic educa- tion of all health professionals. William Scheckler of the University of Wisconsin, Health Promotion and Disease Prevention in the Health Care System 77

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for instance, notes a decline in choice of prirna~y care careers by medical students, despite an increasing need for such specialists. He suggests that training grants in these areas be increased, residency programs in primary care be promoted, and medical schools be encouraged to emphasize primary care. f#l94J The American Occupational Medicine Association (AOMA) makes a similar suggestion about training more specialists in occupational medicine. (~071) The Society of Teachers of Family Medicine (STFbI) calls for a 25 percent increase in the number of residency graduates in family medicine and general preventive medicine who plan to emphasize clinical preventive medicine in their practice, as well as development of a clinical preventive medicine fellow- ship to meet this objective. (~118) The Association of Preventive Medicine Residents agrees with this approach and recommends creation of a specific objective dealing with the training of health professionals in disease prevention and health promo- tion, with emphasis on training physicians in preven- tive medicine. Although shortages of preventive medicine specialists are predicted, the federal govern- ment has cut funding for preventive medicine residencies in recent years; thus, the association recommends that this funding be restored at least to the earlier level. (~560) The other approach suggested in testimony is incorporation of health promotion and disease preven- tion material into the general medical curriculum. Sue Lurie of the Texas College of Osteopathic Medicine points to the importance of prevention in the training of physicians and physician's assistants. She feels that integration of specific topics into the existing curriculum is the most effective approach and that increasing the clinical training of physicians in outpatient settings would increase their focus on preventive health care. (#136) The AOMA recom- mends that broad-based orientation courses in occupa- tional medicine be established in the curriculum of all schools of medicine and osteopathy. (#071) The STF}4 calls for a 25 percent increase in the cur- riculum time spent in medical schools and primary care residency programs on health promotion and disease prevention. (#118) The National Board of Medical Examiners sets certification standards for practicing physicians and develops tests to evaluate current medical education and practice. It reports that the major priority areas of the 1990 Objectives are covered in the examination and that the "educational imperative" of the Year 2000 Health Objectives will be reflected in new examinations. 78 Healthy People 2000: Citizens Chart the Course Thus, setting appropriate objectives will have some impact on medical practice. #221) The National Council for the Education of Health Professionals in Health Promotion (NCEHPHP) suggests that students of medicine, nursing, dentistry, and the allied health professions be adequately prepared to intervene effectively with those patients at risk and to organize health promotion/disease prevention services. Therefore, those respon- sible for the education, training, and certification of health professionals must develop goals and objectives to assure that health promotion and disease prevention becomes an integral part of the repertoire of skills of those charged with the responsibility of providing health care. The NCEHPHP also addresses specific recommenda- tions for the health professions curriculum, academic institutions and faculty, accreditation, certification and licensure, and continuing education. (~169) Underserved Areas According to some witnesses, the problem is not a shortage of health professionals but rather their distribution. Many inner cities and rural areas have few physicians or other health professionals; further- more, according to witnesses, the primary federal program for addressing this problem, the National Health Service Corps, is insufficient. The solutions proposed involve the medical education system, reimbursement, and substituting one kind of profes- sional for another. According to the APHA's Medical Care Section, Millions of Americans who live in rural or inner-city areas lack access by reason of living in these areas. The National Health SeIvice Corps, which offered one approach to this problem, has been all but phased out over the last several years." (~755) Donna Denno, representing the American Medical Student Association, says that the health objectives cannot be attained without a consistent health care work force available to implement them, particularly to serve the indigent in health manpower shortage areas. Despite reports of a physician surplus, the manpower shortage is increasing, particularly of primely care physicians in underserved regions. The steps Denno lists to address the problems include funding the National Health Service Corps, exposing medical students to health manpower shortage areas

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during their training period, and recruiting minority medical students. (~717) In a more specific case, according to Lisa Kane Low and colleagues from the Michigan chapter of the American College of Nurse-NIidwives: The distribution of health care providers is a main contributor to the problem of patient access to maternity services. While major urban and resort areas have long had ample numbers of physicians, there are many areas of Michigan that have far fewer physicians than necessary and despite the ample number of providers, all women are not provided equal access to these resources. Many of the undersexed areas are rural, geographically removed from the social and professional benefits of large urban areas. However, a number of urban areas in Michigan contain ~pockets" of undersexed populations. They offer three recommendations for dealing with these problems: 1. Reestablish the National Health Service Corps or provide incentives for states to develop their own programs. 2. Reimburse certified nurse midwives and other nurses in advanced practice for services they are qualified to deliver. 3. Improve reimbursement rates for services provided to Medicaid recipients and provide parity in reimbursement for the same services provided by various health care professionals, including nurse midwives. (#628) Minority Practitioners The problems of undersexed areas often intersect with the lack of access for minority populations. A number of testifiers suggested that one solution to REFERENCES this joint problem could be found in training more minority health professionals at all levels. One testifier who calls himself Ha state health commissioner with a vision toward the new millen- nium," says that "ultimately, achievement of the nation's health objectives will depend not only on clearly articulated measures, but also on the availabi- lity of appropriately trained personnel who are repres- entative of the communities served, and who recognize the fact that health is the outcome of many complex factors, involving individual, institutional, and community behavior patterns." Objectives for the year 2000 should Include training health professionals in culturally appropriate interventions and recruiting health personnel from the communities most In need of interventions. (#599) More specifically, the APHA Medical Care Section says that "the continued shortage of Black physicians exacerbates access problems for Black Americans. (~755) Denno adds that minority physicians tend to work in health manpower shortage areas more often than their White counterparts; thus, recruiting minor- ity medical students through specific grant and loan programs would help undersexed areas. (#717J James Young, Dean of the School of Allied Health Sciences at the University of Texas Health Science Center at San Antonio, says that allied health profes- sionals have an important potential role in promoting and achieving the nation's health goals, specifically as they concern minorities. Young's recommendations include (1) increasing minority representation in the allied health professions, and assessing the incentives that exist to encourage student, faculty, and clinician entry into needed areas; (2) aggressively recruiting students from underserved communities; and (3) developing strategies and incentives to attract allied health professionals to enter practice in undersexed areas and to increase the number of minority students who practice in these settings. (#497) 1. U.S. Bureau of the Census: Statistical Abstract of the United States, 1987 (107th Edition). Washington, D.C.: U.S. Government Printing Office, 1986 2. National Center for Health Statistics: Health United States, 1984 (DHHS Publication No. [PHS3 85-1232), 1985 3. Russell MAH, Wilson C, Taylor C, et al.: Effect of general practitioners' advice against smoking. Brit Med J 2:231-235, 1979 Health Promotion and Disease Prevention in the Health Care System 79

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4. Hughes D, Johnson K, Rosenbaum S. et al.: The Health of America's Children: Maternal and Child Health Data Book. Washington, D.C.: Children's Defense Fund, 1988 5. U.S. General Accounting Office: Prenatal care: Medicaid recipients and uninsured women obtain insufficient care. Report to the Chairman, Subcommittee on Human Resources and Intergovernmental Relations, Committee on Government Operations, House of Representatives. GAO/EIRD 87-137, September 1987 6. Ibid. TESTIFIERS CITED IN CHAPTER 8 024 Bonta, Diana; Los Angeles Regional Family Planning Council 044 Corry, Maureen; March of Dimes Birth Defects Foundation 071 Givens, Austin; American Occupational Medical Association 072 Graham, Robert; American Academy of Family Physicians 074 Grigsby, Sharon; The Visiting Nurse Foundation 118 Kligman, Evan; Society of Teachers of Family Medicine 129 Halpin, Thomas and Evans, Karen; Ohio Department of Health 136 Lurie, Sue; Texas College of Osteopathic Medicine 143 Martin, Robert; Society of Teachers of Family Medicine 169 Osterbusch, Suzanne; National Council for the Education of Health Professionals in Health Promotion 193 Delgado, Jane; The National Coalition of Hispanic Health and Human Services Organizations (COSSMHO) 194 Scheckler, William; University of Wisconsin 209 Tallia, Alfred, Spitalnik, Debbie, and Like, Robert; University of Medicine and Dentistry of New Jersey 221 Voile, Robert; National Board of Medical Examiners 234 Brooks, Chet; Texas State Senate 235 Bruhn, John; University of Texas Medical Branch at Galveston 255 Blumenthal, Daniel; Morehouse School of Medicine 258 Blayney, Keith; University of Alabama at Birmingham 262 FIeming, Lisa; Alabama Dental Hygienists' Association 268 Work, Rebecca; University of Alabama at Birmingham 269 Ahmed, Osman; Meharry Medical College 271 Jelliffe, Derrick; University of California, Los Angeles 277 Roemer, Milton; University of California, Los Angeles 289 Farabee, Helen; Benedictine Health Promotion Center (Austin) 292 Wente, Susan; Jefferson Davis Hospital (Houston) 309 Eriksen, Michael; University of Texas Health Science Center at Houston 346 Wilson, Marjorie; Olympia, Washington 377 Glazner, Judith; Denver Department of Health and Hospitals 387 Richards, N. Mark; Pennsylvania Department of Health 431 Munoz, Eric; Long Island Jewish Medical Center 436 Beckerman, Anita; College of New Rochelle (New York) 437 Joseph, Stephen; New York City Department of Health 463 Logsdon, Donald; INSURE Project (New York) 497 Young, James; University of Texas Health Science Center at San Antonio 501 Hawken, Patty; University of Texas Health Science Center at San Antonio 507 Sapp, Mary; Benedictine Health Resource Center (San Antonio) 510 Silver, George; Yale University 560 Salive, Marcel and Parkinson, Michael; Association of Preventive Medicine Residents 564 Schlegel, John; American Pharmaceutical Association 576 Owen, Jack; American Hospital Association 579 Shoults, Harold; The Salvation Army 80 Healthy People 2000: Citizens Chart the Course

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583 McCarthy, Diane; Health Poligy Agenda for the American People (Chicago) 589 Mundinger, Mary, Columbia University 599 Adams, Predenck; Connecticut Department of Health Services 612 Hunter, Paul; American Medical Student Association/Foundation 625 Goldstein, Bernard; University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School 628 Low, Lisa Kane; American College of Nurse-Midwives 633 Rosenfield, Allan; Columbia University 635 White, Francine; National Association of Community Health Centers 678 Arnold, Milton; American Academy of Pediatrics 690 Carr, Katherine; American College of Nurse-Midwives 694 Hagens, William; Washington State House of Representatives 717 Denno, Donna; University of Michigan 755 Blumenthal, Daniel; American Public Health Association, Medical Care Section 780 Sobel, David; The Permanente Medical Group 796 Black, Robert; Monterey, California Health Promotion and Disease Prevention in the Health Care System 81