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OCR for page 68
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
OCR for page 70
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
OCR for page 72
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
OCR for page 73
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
OCR for page 74
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
OCR for page 75
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
OCR for page 76
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
OCR for page 77
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
OCR for page 78
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
OCR for page 79
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
OCR for page 80
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
OCR for page 81
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
Representative terms from entire chapter:
disease prevention
