Disparities

How is the right to health related to Massachusetts health reform?

Massachusetts may have world class medical facilites and state health reform, but the state also has a significant number of people who struggle to access quality heath services. PHR believes that protecting human health, regardless of class, background, gender, or race, is necessary to the preservation of human rights. Massachusetts struggles to provide equitable health services to the poor, to immigrant, and to minorities, where race disparities in health continue. As future health professionals and participants in civic discourse you have the power and skills to face these chllanges head on. With your passion and work, we can drive Massachusetts towards permanently respecting, protecting, and fulfilling the right to health for all its residents.

Cost and the AAAQ Framework

Affordability & Payment Structures

Consumers are finding their access to quality care diminished, as hospitals struggle to cover expenses, employers face mounting strains on their ability to provide insurance to their employees, and health care payment structures continue to inflate costs.

Massachusetts sports some of the highest health care costs in the US. Health insurance premiums, driven largely by these costs, have increased almost every year for the past twenty years at a pace that exceeds the annual increase in the cost of living (Recommendations of the Special Commission on the Health Care Payment System, July 2009).

• Insurance companies and employers who provide insurance are forced to shift costs for coverage onto individuals and employees, escalating out – of – pocket costs in the form of increased co – insurance, deductibles, and increasing responsibility for paying premiums. Higher out – of – pocket costs hampers the ability of individuals and families to access health care.

However, high spending levels does not guarantee quality, effective care. This is largely due to existing payment structures, which simultaneously degrade quality of care and inflate costs.

–          The current fee – for – service structure, in which doctors are paid for each service performed, rewards physicians for volume rather than overall quality and outcome. It also inflates costs as doctors order multiple and sometimes unnecessary tests and procedures, the out – of – pocket costs of which are often unmanageable for the patient.

–          Primary care providers are paid less than specialists, encouraging “brain drain” away from primary care to more specialized fields and decreasing access to primary care.

The AAAQ Framework

The right to health as defined in General Comment 14 [4] and PHR’s report “The Right to Health and Health Workforce Planning” [3] contains four inter – related and essential elements (1) Availability; (2) Accessibility; (3) Acceptability; and (4) Quality. The AAQ framework is essential both in the creation of public health policy and measuring the success of a health system.

–          Availability: Health care and public health facilities, goods and services must be both functional and available in sufficient quality.

–          Accessibility: Health facilities, goods and services must be accessible to everyone. Accessibility encompasses non-discrimination, physical accessibility, economic accessibility (affordability) and access to information.

–          Acceptability: Health facilities, goods and services must respect medical ethics and patient dignity. They must also respect the culture of individuals, minorities, people and communities, and be sensitive to gender and life-cycle requirements. Health facilities, goods and services must protect confidentiality and be designed to improve the health status of all concerned.

–          Quality: Health facilities, goods and services must be scientifically and medically appropriate and of good quality. This requires, among other things, skilled health personnel, scientifically approved and unexpired drugs and functional equipment, safe, potable water and adequate sanitation.

The role of cost and the effect of existing payment structures on the patient’s relationship with health care are important factors in the success of the AAAQ framework. The current system, in which health care is fundamentally unaffordable and fails to address patients’ needs, has an adverse effect on the ability of Massachusetts to implement the framework successfully.

See: An Act Relative to Health Care Affordability [6] [2]

See: Health Care for All’s “Campaign for Better Care [1]”

Barriers to Access

These are factors that influence different population groups’ ability to access health. Look for these factors when we discuss health inequities and their causes.

–          Lack of health insurance

• People without insurance are less likely to seek care because of costs – when they do, it is often in an emergency setting in which they can only be treated in a short term capacity.

–          Language barriers

• Prevent clear communication between patient and doctor
• Discourage patients who know little or no English from seeking care from fear of difficulties
• Prevent patients from seeking or understanding medical information that will help them make informed decisions about their health

–          Lack of educational opportunities

• Contribute to a lack of information, rendering one less able to make informed decisions about one’s health
• Decreased capacity to pursue higher paying careers that would enable one to pursue more expensive health treatments, have greater choice in what kinds of food one can buy, and live in a more healthful location.

–          Geographic Location

• Location may have a greater distance from nearest hospital or “safety net” location and may have a greater distance from public transportation that can transport one to a hospital or “safety net” location.
• Location may have lower quality of housing, higher rates of violence, more trash in the streets, higher pollution rates, and less proximity to fitness centers or healthy and high quality food (“a food desert”). These are all underlying determinants of health that are vital to achieving one’s highest attainable standard of health.

Low Income Individuals and Families in Massachusetts

A family or individuals living close to 300% federal poverty level are likely to fluctuate over and under that line over the course of a year. When they fluctuate over they still may not earn enough to afford health insurance coverage, and are therefore exempt from the individual mandate to purchase health coverage. This often results in a lack of health insurance.

– When a family’s income fluctuates around the 300% FPL, the children cycle on and off SCHIP / Medicaid coverage, leaving coverage gaps.

– Because women are more likely than men to be low income, on average earning 77 cents for every dollar earned by a man in Massachusetts, they are also more vulnerable to the coverage gap that results when they earn slightly too much to qualify for subsidized care but do not purchase insurance.

See: An Act to Assure Continuity of Health Coverage for Children [5]

Another barrier providing coverage to low – income individuals and families is existing affordability standards.

–          MA requires residents to purchase health insurance coverage if it is affordable to them, but only takes into account the cost of health insurance premiums in relation to income.

–          This narrow definition of affordability should be expanded to include factors such as co – pays and deductibles so that residents are purchasing insurance that is truly affordable to them and paying more manageable levels of out – of – pocket costs.

See: An Act Relative to Health Care Affordability [6] [2]

Racial and Ethnic Disparities in Coverage and Access to Care

Racial and ethnic health inequities are dependent upon a web of interrelated factors, some of which are included in our list of basic barriers to health access. In Boston, Black and Hispanic residents are more likely to have low incomes than White residents. Lower economic status inflicts upon populations such barriers to health as:

–          More likely to be low income and therefore be more vulnerable to a lack of health  insurance.

–          Lower quality / less healthful housing

–          Less healthful geographic location

–          Lower rates of employment and educational opportunities

–          Language barriers: In Boston, 28.5% of Asian residents and 23.5% of Latino residents speak little to no English as compared to 2.6% of White residents (BCPH Disparities Data Report [9] (PDF).).

–          Racism and the stress associated with it (an underlying determinant of health)

The disproportionate levels of health barriers for Black, Latino, and Asian residents amount to discrimination. The pervasiveness, and codependent nature, of these factors indicate that a solution beyond health care coverage is needed to address health inequities in order to respect, protect, and fulfill the right to health and the right to freedom from discrimination for all Massachusetts residents.

See: An Act to Eliminate Racial and Ethnic Health Disparities in the Commonwealth [8]

See: Food Policy Council Bill [7]

Barriers to Health Care and Access for Legal Immigrants

Legal immigrants, regardless if they are income eligible, must undergo a five year waiting period before participating in federal health care plans such as Medicaid that are incorporated into Massachusetts health policy.

–          These individuals are currently covered by the Commonwealth Care Bridge, which        provides income eligible legal immigrants who have lost their coverage due to the federal waiting period. However, this plan fails to cover vital areas such as dental care and is only a short term solution to the problem.

–          Legal immigrants who must undergo this waiting period are, from the inception of their residency in the US, marginalized into lower incomes and inferior health outcomes from having to pay more out – of – pocket costs for health care, facing barriers to accessing important health care services not covered by CommCare Bridge, and being more likely to use Health Safety Net services which provide less comprehensive and more short – term care.

Reforming these laws would not provide federal coverage for undocumented immigrant adults. It should, however provide legal immigrants with the following:

–          Subsidies to legal immigrants as they do for legal citizens, with no discriminatory barriers or waiting periods.

–          Elimination of the five year waiting period that prevents legal immigrants from receiving federal Medicaid coverage.

–          Access to affordable children’s health insurance regardless of immigration status.

See: An Act Strengthening Health Care Reform [10]