Medical Care and Public Health Research Paper

  

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PART
VI
Medical Care and
Public Health
CHAPTER
25
Is the Medical Care System a
Public Health Issue?
Public Health Issues?
Even in an ideal world, where public health functioned perfectly, there would be a need for
medicine. The medical system provides preventive care: immunizations against infectious
diseases, monitoring of pregnancies and provision of “well-baby care” to ensure that children
develop normally, testing of adults for risk factors (such as high cholesterol and blood pressure)
that lead to cardiovascular disease, and secondary prevention measures—screening for early
detection of diabetes and cancer, for example, and early interventions to correct problems. Even
people with the healthiest lifestyles get sick or injured. Medical care saves lives and prevents
suffering and disability and, therefore, must be considered necessary for public health.
443
444
IS
THE
MEDICAL CARE SYSTEM
A
P U B L I C H E A LT H I S S U E ?
Medical care is even more necessary when public health is not functioning perfectly. There
are many gaps in the public health system because of a lack of resources, lack of political will,
and the emergence of new health threats. Also, competing values in society lead people to behave in unhealthy ways. The medical system is called upon to deal with the consequences of
failures in public health. Doctors are asked to repair the damage when an unvaccinated child
contracts an infectious disease, when a community is sickened by water or food contaminated
because of deficiencies in sanitary practices, when someone is injured in a motor vehicle
accident caused by a drunk driver, or when a smoker develops cancer after years of exposure to
tobacco smoke.
The fact that medical care can and does make a difference in people’s health raises a number
of fundamental social questions. Who is responsible for providing medical care when it is
needed? Medical care is expensive, and the costs have been rising dramatically over the past several decades. Who should pay for that care? Vastly greater sums of public money are spent each
year on medical care than on public health measures aimed at preventing disease and disability.
Is that a rational allocation of resources? Should U.S. citizens have the same right to medical
care as they have to education in childhood? And, if there are limits on the community’s responsibility for providing medical care, how should those limits be determined?
The medical profession has fought governmental involvement in addressing these questions,
regarding itself as the ultimate authority over all matters of health.1 However, public health concerns have repeatedly forced government action on a piecemeal basis to challenge medicine’s
sovereignty. Public health has always seen a role for itself as the provider of last resort, offering
needed medical care to people who cannot afford to pay for it. This is part of the assurance
function that the Institute of Medicine identified as one of public health’s core functions (see
Chapter 1). Government regulation has also been necessary to set standards for the practice of
various healthcare services, to discipline medical professionals when they are thought to be acting unethically or incompetently, and to set policy when ethical dilemmas have arisen that transcend the individual sickroom.
When Medical Care Is a Public Health
Responsibility
Some forms of medical care are more important to the health of the community than others.
Medical treatment of communicable diseases is particularly important because of the possibility
that one sick individual could infect many others. Consequently, public health has taken a major interest in all aspects of infectious disease control, from the early days when quarantines
were the only effective way of controlling epidemics, to immunization programs, to the provi-
WHEN MEDICAL CARE IS
A
P U B L I C H E A LT H R E S P O N S I B I L I T Y
445
sion of free medical treatment for those who do not have health insurance and cannot afford to
pay for care. City and county health departments have traditionally operated clinics for diagnosis and treatment of infectious diseases. Today, the threat of re-emerging tuberculosis is taken
seriously enough that, for example, the New York City Department of Health provides a program of directly observed therapy (see Chapter 10) in which public health nurses are sent to
track down patients and make sure they take their medicine. The fact that AIDS is a communicable disease accounts, at least in part, for the major investment that the federal and some state
governments have made not only in research, but also in providing treatment for patients.
A second area in which communities have an undisputed interest in the universal availability
of medical care is the provision of emergency services. Emergencies are by definition unpredictable and can strike individuals at any time and in any place. In an increasingly mobile society, heart attacks and motor vehicle crashes may occur when people are far from home, with no
family or friends present to provide first aid or call the doctor. It is in the interest of everyone to
save lives first and ask questions later. Beginning with the Highway Safety Act of 1966, the federal government began to pressure states and localities to develop procedures for providing
quick access to emergency care. Since then, in accordance with federal standards, communities
have developed 911 phone-response networks, trained emergency medical technicians, dispatched ambulances using a centralized system, regulated the availability of hospital emergency
rooms, identified trauma centers, and provided evacuation helicopters in rural areas. Still, the
quality and the effectiveness of emergency response systems vary considerably in different parts
of the country.2
A number of federal and state laws require that emergency rooms provide treatment to any
patient that arrives with a life-threatening condition until he or she is stabilized, regardless of
ability to pay. When the emergency situation has passed, however, many hospitals transfer poor
and uninsured patients to public or charity hospitals. Some states have laws that prohibit hospitals from denying admission based solely on inability to pay, but in many parts of the country
hospitals can and do turn away patients for financial reasons. Once medical treatment is under
way, however, a patient’s rights are greatly enhanced. There are laws against “abandonment,”
and hospitals cannot simply discharge patients because they are poor and uninsured.
Although most U.S. citizens do not have a general right to medical care, there are several exceptions, including veterans and prisoners. The hospitals and clinics of the Department of
Veterans Affairs (VA) were designed to treat war-related injuries, but they also serve as a safety
net for low-income veterans who do not have other sources of medical care. Funding for the VA
system is chronically inadequate, however, and the agency has tightened its criteria for eligibility; except for those with combat injuries, only the poorest veterans can be served. Many veterans suffer from psychiatric disabilities or have substance abuse problems—conditions that the
446
IS
THE
MEDICAL CARE SYSTEM
A
P U B L I C H E A LT H I S S U E ?
VA has special expertise to treat.3 Prisoners are entitled to medical care because, as wards of the
state, they are unable to seek care on their own. The courts have ruled that to deny them care
would be the cruel and unusual punishment forbidden by the Constitution.4 The medical care
provided in prisons, however, is often substandard.
The Conflict Between Public Health and the
Medical Profession
Most Americans get health insurance as part of an employee benefit package. The insurance
covers the worker and his or her family. This approach to paying medical bills became
dominant after World War II, when unions bargained actively to obtain health benefits for
workers. The arrangement satisfied most groups over the next three or four decades. Workers
and their families could receive necessary medical care without worrying about cost; doctors
and hospitals were happy because they could provide care as they saw fit and not worry about
getting paid; unions took credit for forcing employers to provide the benefits; employers did
not object because the cost at first was modest and the benefits inspired loyalty in their workers.
Traditional health insurance, the kind of insurance provided by most employers until quite
recently, is like car insurance. Regular premiums are paid to the insurance company to cover the
worker and his or her family. When covered individuals get sick, they go to the doctor or other
medical provider of their choice, and that provider then sends them bills for services rendered.
The patients pay the bills and are reimbursed by the insurance company. Sometimes the policy,
like many car insurance policies, calls for a deductible that the patient must pay first before the
insurance kicks in. Sometimes the patients must also pay a flat fee or a fixed percentage of the
remainder of the bill, called a copayment. This way of paying for medical care is called “fee-forservice.” The fee-for-service approach permits doctors to make decisions about a patient’s care
with no consideration of cost. As discussed in Chapter 26, this freedom has led to escalating
medical costs and increasing numbers of uninsured citizens whose access to care is limited.
The medical profession has strongly resisted efforts to be included in the domain of public
services. Since the end of the 19th century, with the discovery of bacterial causes of diseases,
public health has claimed the prevention and treatment of infectious disease as its responsibility,
and doctors have resisted that claim. While tolerant of public health’s efforts at cleaning up the
environment, private practitioners regarded diagnosing and curing sick people as their domain.
Early in the 20th century, they fought reporting requirements for cases of tuberculosis and
venereal disease, and they opposed the creation of public health clinics and centers, which they
T H E C O N F L I C T B E T W E E N P U B L I C H E A LT H
AND THE
M E D I C A L P R O F E S S I O N 447
perceived as an attack on their economic interests. This struggle continued throughout the century, and although public health has had some victories, the medical establishment has been
able to prevent the United States from providing for its citizens the public assurance of needed
medical care.1
Still, there is a long history of providing charity care for the nation’s poor. Often, treatment
was provided by part-time volunteer physicians who combined their services with research and
the teaching of medical students. This practice began in the late 18th century, with the establishment of free dispensaries in eastern cities, many of them connected with medical schools.
These services were controversial. Private practitioners were suspicious that free care was being
provided to those who could afford to pay for it, and there was great concern about “dispensary
abuse.” The poor, on the other hand, were distrustful of the dispensaries, where they were
forced to wait hours for hasty and superficial attention.1
In the early 20th century, city health departments began setting up clinics for the control of
infectious diseases and the prevention of infant mortality. Baby clinics emphasized the teaching
of hygienic practices and promotion of improvements in child care, diet, and living patterns.
Clinics for tuberculosis and venereal disease provided diagnosis and advice about hygiene and
diet but left treatment to private physicians, who objected strongly when they felt that the clinics were trespassing on their territory. The New York City Department of Health ran into trouble when its diagnostic bacteriologic laboratory began producing diphtheria antitoxin, selling it
to drugstores, and making it available to poor patients for free, prompting complaints of socialism and unfair competition that forced it to cease all sale of the antitoxin. Despite the early opposition of the medical profession, however, an uneasy truce has evolved that allows city and
county health departments to provide treatment for the poor, often under the uncomfortable
conditions that prevailed in the old dispensaries.1
Community health centers provide another source of basic medical care for the poor. These
centers are supported by federal grants as well as by payments by public and private health insurance for services provided. There are about 1200 community health centers in the United
States. They are located in inner cities and isolated rural areas where there are shortages of medical and social services. Community health centers provide primary and preventive care to people who might otherwise not be able to afford it. Services may be paid for by government
programs (see the next section), or patients may pay a fee based on a sliding scale according to
income. Community health centers serve as an important safety net for low-income families;
the numbers served have been increasing, and in 2008 they served about 21 percent of lowincome uninsured persons.5
448
IS
THE
MEDICAL CARE SYSTEM
A
P U B L I C H E A LT H I S S U E ?
The health of schoolchildren has been a public health concern since the late 19th
century. To control the spread of communicable diseases, cities began to employ medical
inspectors to examine children who showed signs of illness and exclude them from school if
they had a communicable disease. School doctors and nurses also began testing children for eye
problems and other physical impairments that might interfere with learning. Because of the
opposition of the medical establishment, they were not allowed to provide medical treatments.
With the development of effective vaccines, the law began requiring that children be immunized—by their private physicians or in public clinics—before they started school, and the
threat of epidemics in the schools has receded. In some cities, school health programs treat
minor problems; sometimes they merely send notes recommending treatment home to parents.
It is a source of frustration to public health practitioners that there is no integration of school
health programs with medical services, leaving many children with health problems that are
repeatedly diagnosed but untreated.1
Throughout the 20th century, there have been repeated attempts in the United States to
provide some kind of national health insurance plan to ensure that everyone would have
access to needed medical care. During this period, most industrialized countries were setting
up such programs, some of them run by the national government, others more loosely
organized. Germany established the first national system of compulsory sickness insurance in
1883. Over the next thirty years, Austria, Hungary, Norway, Serbia, Britain, Russia, and the
Netherlands followed Germany’s example. Canada implemented a national health insurance
plan in the 1970s.1
In the United States, efforts to establish a national health program were made before World
War I but were derailed by the war. Another attempt was made during the 1930s as part of
President Franklin D. Roosevelt’s New Deal, but health insurance was not included in the
Social Security Act. After World War II, President Harry S. Truman proposed a single health insurance system that would apply to everyone; again the attempt failed. Each time, the medical
profession opposed governmental involvement in medical care as “socialized medicine,” and
various other political interests joined to defeat the proposals.1
In 1965, a significant victory over the medical establishment’s opposition was achieved under President Lyndon Johnson: legislation for Medicare, which provides insurance for the elderly, and Medicaid, a welfare-type program for the poor, were passed. These programs were
designed to remedy what people considered the main problems with employer-based insurance:
it stopped when a worker retired, and it left the poor and unemployed out of the system.1
Medicare, created in 1965 as a mandatory insurance program for people over the age of 65,
is part of the Social Security system. (Younger people who are entitled to Social Security because
of disability are also eligible for Medicare.) Workers pay into the system through deductions
from their paychecks; employers pay a tax on their payroll; and workers are entitled to benefits
T H E C O N F L I C T B E T W E E N P U B L I C H E A LT H
AND THE
M E D I C A L P R O F E S S I O N 449
when they reach retirement age. The Medicare program has two parts: Part A, which covers
hospital insurance, and Part B, which pays doctor bills and other outpatient costs. Virtually all
people are automatically enrolled in Medicare Part A when they reach age 65. Part B is voluntary and requires participants to pay a monthly premium. Medicare is much like traditional
health insurance, in that most doctors and other providers are paid on a fee-for-service basis.
Like private insurance, the patient is required to pay deductibles and copayments. In 2003, legislation was passed that created a new Medicare prescription drug plan. The new benefit, which
became effective in 2006, is optional and requires an additional monthly premium. Medicare is
discussed further in Chapter 28.
Medicaid was created, also in 1965, as a welfare program for the poor, with costs shared by
the federal government and the states. Eligibility is determined by income and varies from one
state to another. Medical bills are paid directly by the state or local government to the provider,
usually at a low, fixed rate for each service. Alternatively, states may fund managed care companies to cover Medicaid patients, as discussed in Chapter 26.
In the early 1970s, President Richard Nixon tried to expand these programs, proposing a national plan to cover everyone, but his efforts were derailed by the Watergate scandal. No further
efforts were made until President Bill Clinton was elected in 1992, promising to provide health
insurance for all; his proposal was also defeated. However, because of increasing concern about
the problem of children without access to medical care, President Clinton and Congress negotiated a program called the Children’s Health Insurance Program (CHIP). This is a joint federal–
state program, similar to Medicaid, which expands coverage to children in families that earn too
much to qualify for Medicaid, usually up to 200 percent of the federal poverty level.6 Now,
President Obama has vowed to reform the healthcare system to ensure that all Americans will
have medical insurance, and Congress is attempting to come up with a plan. Whether this attempt will succeed remains to be seen.
Pending the outcome of the current efforts, the United States remains the only industrialized
nation, except South Africa, that does not have a national plan ensuring medical care for all its
citizens. In 2008, over 20 percent of the American population ages 18 to 64 had no health
insurance.7 For many of these people, there is no guaranteed access to health care except for
emergency care. While most public health advocates believe that the government should ensure
access to basic medical care for anyone who needs it, the American political system has not
supported that view. Clinical medicine, always more prestigious and more well financed than
public health, has been able to fend off public health’s attempts to integrate medical treatment
into a rational system that would maximize the health of all Americans. However, in response
to increasing evidence that the U.S. healthcare system is dysfunctional, as discussed in Chapter
26, even the American Medical Association has endorsed President Obama’s efforts to change
the system.8

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