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10 Where Do We Go From Here?

Learning Objectives After reading this chapter, you should be able to: •Discuss the importance of collaboration between policy makers and vulner\ able populations.

•Explain the community-oriented approach to health care.

•Define the market-oriented approach to health care.

•Specify the role that vulnerable populations should play when developing health care programs.

•Identify policies (social and economic) for health care reform that will improve health care services accessibility, cost, and quality. Courtesy of maigi/fotolia bur25613_10_c10_259-274.indd 259 11/26/12 2:50 PM Self-Check Answer the following questions to the best of your ability. 1. The best way for program administrators to achieve useful program design or reform is to collaborate with whom? a. the population they are trying to serve b. legal counsel c. government advisors d. academic researchers Critical Thinking Communication can take many different forms. Communication can include everything from formal town hall meetings to informal conversations between two people. Communication does not necessar- ily even need to involve talking. Describe three special populations and specify a form of communication that could be used to gather information on each group.

Introduction P olicy makers and program administrators must realize that there is often a lack of communication between those creating the programs aimed at vulnerable populations and the individuals who make up those populations.

Programs won’t be useful if they do not directly address the needs of the vulnerable in ways that are accessible to the vulnerable. The best way to achieve useful program design or reform is to collaborate with the population you are trying to serve. Program designers and medical prac - titioners can learn a lot about the needs of those they are serving simply by asking them. By hav - ing conversations with patients and community leaders, and even by asking patients and patrons to complete surveys, policy makers, program administrators, and practitioners gain insight into the needs and wants of the vulnerable populace.

Only through a coordinated, collaborative effort to address the serious issues confronting vulner - able populations can the health and wellness of said population increase to resemble those who are not classified as vulnerable. Courtesy of Digital Vision/Thinkstock Effective program planning must include communication between policy makers and the individuals who make up the vulnerable populations meant to benefit from a particular program. Introduction bur25613_10_c10_259-274.indd 260 11/26/12 2:50 PM CHAPTER 10 Section 10.1 The Community-Oriented Approach 2. Declarations from those in charge will be useless because ______________. a. no one will listen b. there is no food c. those in charge have not sought the council of the masses d. those in charge do not care 3. Only through a coordinated, ____________ effort to address the serious issues confronting vulnerable populations can the health and wellness of said popula- tions increase to resemble those who are not classified as vulnerable. a. collaborative b. grassroots c. organized d. revolutionary Answer Key 1. a 2. c 3. a 10.1 The Community-Oriented Approach T he key to a community-oriented approach to health policy is remembering that a person’s well-being is greatly affected by fam - ily, friends, and other social factors.

In other words, discharged patients will fare better or worse depending on their individual support networks. On a larger scale, this means that health policy needs to look beyond the micro - level and consider the macrolevel fac - tors that affect the populations being served. There are five levels of focus in community engagement: (a) the individual, (b) the social and network systems, (c) the influences of organiza - tions to bring change, (d) the commu - nity collaborative relationships, and (e) the state and federal policies and regulations. Concepts that summarize social ecology theories relating to the efforts of community engagement in addressing this need are as follows:

• health status, emotional well-being, and social cohesion, which are influenced by the physical, social, and cultural status of the individual or his or he\ r environment • different effects of the individual’s health, which includes perception and finan - cial resources available • the influence by others on the individual or group Courtesy of iStockphoto/Thinkstock Several social and interpersonal factors influence a person’s sense of well-being. bur25613_10_c10_259-274.indd 261 11/26/12 2:50 PM CHAPTER 10 Section 10.1 The Community-Oriented Approach Community-oriented health policy works to improve health outcomes by making changes on a community level. To do this, community members should be consulted about the needs of their communities and the daily risks encountered there. This goes beyond patients to include consulting those who work directly with patients, and consulting com- munity leaders and organizers on what issues they consider important in the identified community. Once policy makers understand what the contributing factors are, they can begin to form policy to address those factors. Problems with participation often trouble these efforts. Instead of creating focus groups, policy makers can work with physicians to build relationships with patients that encourage discourse and disclosure. Improving the physician-patient relationship not only offers a way to learn the needs of the patients but is in itself an improvement of patient care.

Cross-Disciplinary Solutions Inadequate housing, high poverty levels, and low education levels can al\ l contribute to ill health and poor health outcomes. Housing issues may include exposed \ asbestos that leads to lung infections, poverty reduces accessibility to health care, and low education levels contribute to poor lifestyle habits. Though they may appear to be outside the realm of health policy, the effects these and other factors discussed in this book have on health is considerable. As such, community-oriented health policy must address all such factors.

The community-oriented approach involves cross-disciplinary planning and programming in order to address individual patient needs as well as to address the community factors that contribute to vulnerability. Health policy that takes a community-based approach should bring together agencies from many different spe - cialties and fields. Health care pro - viders, care management teams, social services officers, and community-based resource programs can be brought together to design programs and policies that improve patients’ chances of positive treatment outcomes. This can be accomplished through an ideology of comprehensive collaboration and sharing of pertinent health information across what had previously been silos or territories where information was held close to the vest.

An example of one such program would be a hospital that discharges high-risk youth with a referral to a social worker at a local youth center. The social worker could encour - age the youth to participate in the activities offered at the youth center, thereby improving the youth’s social capital and ultimately improving his or her chance of positive outcomes in life as well as health. This example illustrates the care continuum from treatment (hos - pitalization for illness) to long-term services (youth center involvem\ ent) and addresses Courtesy of nathings/fotolia Contributing factors to poor health can include poverty, substandard housing, and low education levels. bur25613_10_c10_259-274.indd 262 11/26/12 2:50 PM CHAPTER 10 Section 10.1 The Community-Oriented Approach Self-Check Answer the following questions to the best of your ability. 1. Community-oriented health policy works to improve health outcomes by mak - ing changes on what level? a. community b. macro c. micro d. individual 2. Problems with participation often trouble the efforts of policy makers. What is one of the best ways to raise participation levels? a. Talk to focus groups. b. Look at housing data (sales, property values, etc.). c. Work with physicians to build relationships within the community. d. Look at how many voters are in the area. 3. Health care providers can be brought together to design programs using what ideology? a. comprehensive collaboration b. business as usual c. keep the information we have to ourselves d. continuum of care Answer Key 1. a 2. c 3. a Critical Thinking The community-oriented approach involves cross-disciplinary planning and programming in order to address individual patient needs as well as to address the community factors that contribute to vulner - ability. What this means from the perspective of the individual is that discharged patients will fare bet - ter or worse depending on their personal support networks. On the other side of the coin, how does improved patient health benefit the greater community? Do you believe the community has a vested interest in ensuring improvements in health at the level of the individual? If so, why?

some needs of the vulnerable youth population. Programs at the youth center should be designed to address the needs of the people it serves. One of the best sources for infor - mation about those needs is the people being served and, in this case, a\ dults from the relevant community. bur25613_10_c10_259-274.indd 263 11/26/12 2:50 PM CHAPTER 10 Section 10.2 The Market-Oriented Approach 10.2 The Market-Oriented Approach A s discussed in earlier chapters, the United States’ economy is built \ on the concept of the ideal free market, unlike the single-payer systems found in countries such as Canada and Great Britain. In other words, the U.S. health care system is market- oriented, meaning it relies on competition between care providers to strive for quality and control cost. However, it must also meet the needs of health care consumers, who may not be knowledgeable enough to know what they need because of uncertainty of health and outcomes, as well as a sense that asking questions means questioning doc\ tors’ authority.

One disadvantage of a market-oriented health care system is that because health care is often a necessity, people have little opportunity to shop around for the best service and prices. This issue is particularly pronounced in economically depressed areas where access to health care is limited. To address this, America’s health care delivery system is evolving and may have never been so prominent an issue as during the lengthy debates over the Patient Protection and Affordable Care Act of 2010 (PPACA). Even if the health care system is part of the free market economy, governments have an interest in ensuring affordable access to all citizens for two reasons: (a) Federal and state governments fund public payer insurance plans, and (b) an unhealthy population costs th\ e country money.

As such, the way Americans finance health care, both now and in the future, is at the fore- front of the debate over health care reform. Changing the Health Care System One of the many goals of health care reform is to achieve near-universal coverage for all U.S. citizens and a safety net for accessing health care for all people. In an attempt to do this while managing costs, state and federal governments have tried impl\ ementing incen - tive plans to help employers cover the cost of health insurance with tax cuts and other rewards. Other attempts have disincentivized employers from not offering health insurance to employees by fining certain businesses that don’t have employee health coverage. Busi - ness owners often rail against both methods, arguing that it should not be the responsibility of employers to ensure universal care coverage.

Program plans should be evalu- ated based on these coverage con - cerns, as well as how they close the coverage gaps from public to private payers by equalizing the provider reimbursement structure and the use of large risk pools to determine pricing. Plan coverage and need and effectiveness norms Courtesy of gchutka/iStockphoto Health care reform strives to achieve adequate access to and coverage of health care for all people, regardless of citizenship status. bur25613_10_c10_259-274.indd 264 11/26/12 2:50 PM CHAPTER 10 Section 10.2 The Market-Oriented Approach and definitions that dictate what procedures and services are covered at what levels for which conditions should consider the care continuum model and provide coverage for services across the entire continuum. Plans that use a community rating, which is broad population grouping for computing risks and premiums, allow for more coverage for more people at less cost. The alternative, experience rating, uses a small group of eligible people and encourages denying coverage to the most vulnerable, as they a\ re most likely to cost the insurer money. Some plans use carve outs to cover high-risk patients and pay for some patients’ disproportionately high costs. The difficulty with these plans comes when trying to find a fair way to cover patients’ needs and offer fair reimbursement for service providers without driving up premiums.

The use of insurance premiums as a means of paying for health care is problematic. Premi - ums fail to consider varying economic abilities of enrollees to pay premiums and service co-pays. Under the current methodology, health insurance premiums do little to minimize financial barriers to health care, especially in ways that seem tangible to the consumer. As health insurance premiums rise, more and more Americans are allowing their coverage to lapse. Many have also seen their office visit and pharmacy co-pays increase simultane - ously. The monthly costs associated with maintaining insurance coverage often\ seem more immediate than the risk of a catastrophic health event. People living on fixed incomes and those living in poverty have been found to be the most affected by increasing insurance premiums and co-pay costs. Payer systems that include progressive payment scales based on financial need and ability provide more equitable financial access to health care. In fact, cost sharing has been found to limit access to preventive care more than limiting the need for treatment.

While patients are struggling to afford health care coverage and services, providers are struggling to stay open or to make profits. The free market system encourages all service providers in every field to strive for profitability, often to the point of diminishing services to raise profit margins, as in the case of physician practices limiting the number of Med - icaid patients they will treat because Medicaid often does not reimburse at as high a level as private payer insurance. Even health care providers who still focus on serving patients find it difficult to run a facility when insurance companies and public payers are con - stantly negotiating prices. Many among America’s most vulnerable who use public payer health coverage have experienced a significantly diminished number of ca\ re providers who will accept public payer coverage. This is because many states have \ lowered the phy - sician reimbursement rates well below what private payers have negotiated. Under\ these terms, it is in the providers’ best interests to limit the number of public payer–enrolled patients and maximize the number of private payer–enrolled patients to increase profits.

The American public payer system relies on micro-oriented means to limiting reimburse - ment. As America struggles to solve problems with the medical care delivery system, policy makers should consider the macro-oriented means used to limit reimbursements in other countries that boast more universal coverage and accessibility.

Physician reimbursement isn’t the only area where service costs are rising. It is generally believed that it is not patients but rather physicians who create high demand for expen - sive procedures and services. Because they are responsible for writing the orders, physi - cians are also consumers of health care services. Cost containment includes managing increasing physician fees and also minimizing the number of expensive servic\ es called for by physicians. Policy makers may find it difficult to balance cost containment without disincentivizing the necessary treatments of patients on Medicare and Medicaid. bur25613_10_c10_259-274.indd 265 11/26/12 2:50 PM CHAPTER 10 Section 10.2 The Market-Oriented Approach Critical Thinking The text says that government should be highly interested in solving the health care crisis because an unhealthy population costs the country money. If individuals pay for their own health care, how does an unhealthy population cost the country money?

Health maintenance organizations (HMOs) are a type of insurer that uses a prepaid sys- tem to arrange care for covered patients. Because they make prepaid agreements with providers, HMOs are often a less expensive insurance option. Prepaying helps with cost containment by insuring against rising costs for a specified amount of t\ ime, because the services are paid for before they are rendered. Because HMOs have a reasonable idea of their revenue for the year (premium dollars per member) and how many members they have to serve, prepaying allows them to keep costs down in order to make profits.

Though consumers of HMO plans have reported satisfaction with the premiums and co- pay costs associated with HMOs, they have reported less satisfaction with the standard of care received. Annual numbers on HMOs usually show that they lead in preventive care and reduced number and lengths of hospital stays. Whether that is because HMO\ patients use more preventive care or because providers are less likely to recommend expensive therapies for HMO patients is unclear.

The PPACA attempts to create universal coverage balanced with affordability. The law includes a mandate that every person must have health insurance by 2014 \ or pay penal - ties. Penalty monies should be used to help cover the costs associated w\ ith uninsured patients seeking emergency medical attention. Such cases drive up the cost of health care and health insurance for every person in the United States. With the cost of health insur - ance climbing, universal coverage can be achieved only if premiums are affordable for all people. In an attempt to harness the power of the free market and increase health insurance coverage across the nation, the PPACA created the American Health Benefit Exchanges (Henry J. Kaiser Foundation, 2010c). These marketplaces will be admin\ istrated by state governments and will provide standardization and competition in the health insurance market. The point is to make it both more affordable and easier for individuals to purchase their own health insurance instead of relying on employers and government programs. This is a market-oriented approach that relies on the free market ideal. At the time this book was written, the insurance exchanges were not yet open; it will be many years before their overall effectiveness can be measured in terms of efficiency, openness of the marketplace, and cost containment. bur25613_10_c10_259-274.indd 266 11/26/12 2:50 PM CHAPTER 10 Section 10.3 Improving Accessibility, Cost, and Quality Self-Check Answer the following questions to the best of your ability. 1. Premiums fail to consider varying economic abilities of enrollees to pay for what? a. premiums and service co-pays b. direct costs of health care c. emergency transportation fees (ambulance, etc.) d. indigent persons who use health care services 2. Because they make prepaid agreements with providers, what type of organiza - tion is often a less expensive insurance option? a. labor unions b. family health centers c. PPOs d. HMOs 3. The PPACA law includes a mandate that every person must have health insur - ance by what year or pay penalties? a. 2014 b. 2016 c. 2018 d. 2020 Answer Key 1. a 2. d 3. a 10.3 Improving Accessibility, Cost, and Quality T aking a community-oriented approach to health care policy means including com - munity members in discussions of change and in the decision-making process. This approach also recognizes that changes need to be made in the affected communities, not only in insurance and medical care provider settings. Increasing social status, social capital, and human capital also works to improve access, cost, and quality of health care received by individual patients.

Minorities and females generally make less money and receive fewer employment ben- efits than do Caucasian males. Additionally, many females, children, and the elderly find themselves lacking social power in relation to males—Caucasian males in particular.

Policy changes that work to minimize vulnerability should focus on chang\ ing the social status differences between these groups, like improving housing conditions and attract - ing businesses to create jobs in poor urban areas. Improving the ability of minorities and women to hold higher-paying jobs by improving educational opportunities is an ongoing challenge. Many low-income communities lose their best educated and most\ community- minded inhabitants to areas with more economic opportunities. Public policy that incen - tivizes businesses to locate in low-income areas in order to change a region’s economic bur25613_10_c10_259-274.indd 267 11/26/12 2:50 PM CHAPTER 10 Section 10.3 Improving Accessibility, Cost, and Quality viability improves the lives of all members of the community as more females and minorities find more opportunities within these companies.

As public policy is often lack- ing in improving social status for America’s most vulnerable, many minority groups have found power through grassroots social movements, which are commu- nity changes that begin with the people. The Women’s Suffrage movement is an example of a grassroots movement that affected public policy change in favor of the group who initiated it. The Women’s Suffrage movement in the United States caused the addi - tion of the Nineteenth Amend - ment to the U.S. Constitution, which gives all women the same eligibilit\ y and right to vote that were previously only enjoyed by men. Similarly, the Civil Rights movement improved the social status of minorities by outlawing racial segregation and discrimina - tion. The Occupy Wall Street of 2012 movement offers an example of a contemporary social movement that worked to raise the social status of all Americans who cannot boast large amounts of wealth. Policy makers can learn from these grassroots movements and use that information to improve social status and thereby health care access for America’s most vulnerable populations.

Policy Changes to Improve Social Capital Social capital is also linked to health care cost, quality, and access. Policies are needed that respond to the changing American family. Increasing numbers of households have only one parent or two parents of the same gender. Legal marriage is being replaced for many couples with cohabitation, sometimes called mingling—living with a sexual part- ner without getting married, often still having children together. For some groups, such as same-gender couples, public policy has focused more on restricting social capital than on improving it, with states making state constitution amendments that ban marr\ iage between people of the same gender.

Public policy does best when it focuses on improving social capital rather than diminish - ing it. Strengthening family units builds stronger communities. But social capital doesn’t end at the front door. Social capital extends well into the community and includes all the people that make up a person’s support network, whether extended \ family, friends, or neighbors. Public policy that works to strengthen families and communities through improved family medical leave, parental leave, improved access to child care services, and improved access to caregiver resources makes it easier for individuals to contribute to their communities. Policy investments in social capital double as inv\ estments in access Courtesy of Hemera/Thinkstock Salary and employment benefits are just one area in which minorities and females receive less than their Caucasian male counterparts. bur25613_10_c10_259-274.indd 268 11/26/12 2:50 PM CHAPTER 10 Section 10.3 Improving Accessibility, Cost, and Quality to health care, as social capital is a major factor in overall health and access to c\ are. As with efforts to improve social status, efforts to improve social capital are most successful when community residents are actively involved in identifying the needs present in the community and in program development. Not only does this involvement offer insight that program developers may otherwise lack, but involving community members in \ the development process also helps energize the community to use the program once it is established.

Social capital levels are directly tied to investment in human capital. Strong family ties help keep children in school and help parents maintain employment. Multi-adult house- holds have more working power to contribute to the household income, and increased income opens doors to health care access as well as education and other opportunities.

Policy Changes to Improve Human Capital Public policy focusing on investing in the growth of human capital is lacking. By nature, community-oriented policies support programs and institutions that provide for grow - ing human capital. Early childhood education programs are an example of school-based investments in human capital. These programs, like Head Start, have been found to greatly improve the chances of students continuing through high school by improving early literacy scores and providing access to other resources, including some health care services. Basing fam- ily resource centers and clinics in schools increases access to these resources and improves the human capital of the entire family. Simply increasing fund - ing for public education works to narrow the gaps in educa - tion available in different com - munity settings. Programs that improve the education received at public schools in economi - cally depressed areas invest in the human capital of the students, as better education provides for better job opportu- nities later in life.

Better opportunities are key to building human capital on an individual level. How- ever, many American families find that it is increasingly difficult to raise a family on one income and that the salaries commanded by high school diplomas are no longer enough to lift a family out of poverty. Economic development partnerships—like those in which state and local governments offer business incentives in terms of tax breaks and even investment cash to businesses willing to locate within their geogra\ phic regions— can help improve the overall economy of an area and provide more opportunities for Courtesy of iStockphoto/Thinkstock Public policy is needed to focus on investing in the growth of human capital. Early childhood education programs like Head Start are examples of school-based investments in human capital and offer educational, health care, and nutritional resources. bur25613_10_c10_259-274.indd 269 11/26/12 2:50 PM CHAPTER 10 Section 10.3 Improving Accessibility, Cost, and Quality Critical Thinking When communities invest in the growth of human capital, they provide avenues to elevate social status and social capital for not just the very poor, but the entire community. How does increasing social status, social capital, and human capital increase the benefits to special populations? How can helping one or two special populations in a community lead to the betterment of the community as a whole?

higher income. Such partnerships are often forged between city governments and busi- nesses, but these partnerships do not prosper if they aren’t supported by the community.

Policy makers should invite the active participation of community residents and leaders to make sure that community interests are properly represented when such partnerships are formed.

Policy and program recommendations for improving human capital include encouraging low-income housing development by the private sector, as opposed to low-income hous - ing being the sole responsibility of government. In this way, local businesses can grow while providing for a community need. Similarly, improving access to supportive housing for people experiencing homelessness, people diagnosed with HIV/AIDS, the chronically ill and disabled, refugees, and others in need creates a safety net for these individuals that enables them to increase their own human capital by holding jobs and accessing other resources.

Paradigm shifts are also still needed in order to create true equality between Caucasian men, minorities, and women in the workplace. The minimum wage is reviewed on an ongoing basis by state and national governments. Raising the minimum wag\ e usually meets with resistance, and has both positive and negative economic ramifications. Ot\ her economically based changes that would improve human capital for America’s most vul - nerable include improving enforcement of child support payments and expanding the earned income tax credit for families.

Self-Check Answer the following questions to the best of your ability. 1. Minorities and females generally make less money and receive fewer employ - ment benefits than whom? a. Caucasian males b. Asian females c. Pacific Islanders d. Native Americans bur25613_10_c10_259-274.indd 270 11/26/12 2:50 PM CHAPTER 10 Section 10.3 Improving Accessibility, Cost, and Quality Case Study: Changes in Health Care as a Result of Gender Neutrality How long does a woman normally stay in a hospital after giving birth to a child?

In 1980, the average stay was 3.8 days, according to the Centers for Disease Control and Prevention (CDC) (2010c). This average dropped to 2.1 days in 1995, but rose again to 2.4 days in 1997. The Orga - nization for Economic Cooperation and Development (OECD) tracks the same data and reported that in 2010, the average stay was again at 2.1 days, after dipping to 1.9 for much of the latter 2000s (Organiza - tion for Economic Cooperation and Development [OECD], 2011). Given the historically short duration of the average hospital stay for pregnant women, it may be difficult to imagine a woman giving birth and then staying in the hospital for over a month. But that’s just what happened to a woman named Wendy during World War II.

Wendy checked herself in to the hospital with symptoms of childbirth and went through 16 hours of labor. Her son, Rob, was born on a bright Monday morning but would not see the outside world until he was a month old because Rob’s father Harold, who was fighting in the South Pacific at the time, was not able to check Wendy and Rob out of the hospital. The law of the land during that period stated that the father, or a male relative, had to check a new mother out of the hospital. A frantic search for Harold’s brother began, but the brother had just started boot camp in Florida, and the Army did not release him until after the four-week training process had concluded. After that, Harold’s brother drove from Florida to the hospital in Kentucky and signed the papers releasing Wendy and Rob from the hospital.

Could this happen today? Of course not. The current laws and public policies related to health and health choices have changed to such a degree that women’s rights and the rights of other groups have evolved and been established to empower them to make decisions, both medical and legal, for themselves.

2. Many minority groups have found power through what type of movement? a. ethnic support group movement b. labor movement c. grassroots social movement d. professional organization 3. Early childhood education programs are an example of school-based investments in what type of product? a. human capital b. social capital c. social status d. social networking Answer Key 1. a 2. c 3. a bur25613_10_c10_259-274.indd 271 11/26/12 2:50 PM CHAPTER 10 Critical Thinking Top-down and bottom-up change can both effectively improve societies. Top-down changes tend to originate at the federal or state government level, whereas bottom-up changes can originate at the community or even individual levels. Can you think of examples of a top-down and bottom-up change?

Consider one special population and a challenge that they face. Which type of change (top-down or bottom-up) do you think would be the most effective catalyst of social improvement for this group?

Chapter Summary P olicy and program designers fare best when they incite and encourage community involvement in recognizing the needs pres- ent in a given community and plan for ways to address those needs. Market-oriented approaches to improving health care access and quality focus on the way Americans purchase health care. This can be a useful tactic, as America’s health care system is based on a free market. Community- oriented programs and policies focus on mitigat - ing the factors that contribute to vulnerability.

Grassroots movements have proven effective in the past as ways for individuals to work together to incite the change and social improvements needed.

America’s health care system presents unique challenges for policy makers and consumers alike. Those seeking to effect positive change do best when they include the people they intend to help in the planning process. Improving health care quality, access, and affordability for every person saves lives in more ways than one, and the entire country benefits from improving the lives of the people. Courtesy of edbockstock/fotolia Community involvement is integral to the success of a program in a given community because those individuals are most familiar with their own needs. bur25613_10_c10_259-274.indd 272 11/26/12 2:51 PM CHAPTER 10 Chapter Summary Self-Check Answer the following questions to the best of your ability. 1. The worst way to achieve useful program design or reform is to collaborate with the population you are trying to serve. a. True b. False 2. Unfit housing, poverty, and low education levels can all contribute to what? a. crime b. food deserts c. ill health d. early childhood programs 3. One of the many goals of health care reform is to achieve ____________ for all U.S. citizens and a safety net for accessing health care for all people. a. financial stability b. near-universal coverage c. full employment d. religious freedom 4. The monthly costs associated with maintaining insurance coverage often s\ eem more ________________ than the risk of a catastrophic health event. a. distant b. immediate c. relevant d. difficult 5. America’s health care system presents unique ___________ for policy makers and consumers alike. a. challenges b. opportunities c. programs d. discussions 6. Grassroots movements have proven _____________ in the past as ways for indi - viduals to work together to incite the change and social improvements needed. a. effective b. ineffective c. illegal d. difficult Answer Key 1. b 2. c 3. b 4. b 5. a 6. a bur25613_10_c10_259-274.indd 273 11/26/12 2:51 PM CHAPTER 10 Self-Check American Health Benefit Exchanges Mar- ketplaces created by the PPACA that will be administrated by state governments and will provide standardization and com- petition in the health insurance market. carve outs Special insurance planning used to cover high-risk patients and pay for some patients’ disproportionately high costs. community-oriented approach An approach that takes into consideration that a person’s well-being is greatly affected by family, friends, and other social factors. community rating A rating utilized by insurance companies that uses a broad population grouping for computing risks and premiums. cost containment The process of managing increasing physician fees and also minimiz - ing the number of expensive services called for by physicians. experience rating A rating utilized by insurance companies that uses a small group of eligible people. grassroots social movements Community changes that begin with the people.

health maintenance organizations (HMOs) A type of insurer that uses a prepaid system to arrange care for covered patients. market-oriented An approach that relies on competition between care providers to push for quality and affordability. mingling The act of living with a sexual partner without getting married, often still having children together. Additional Resources Visit the following websites to learn more about the topics covered in this chapter:

An article on the study of a community-based participatory research (CBPR) on health care and the growing Hispanic population in North Carolina (published 2011):

http://www.implementationscience.com/content/6/1/38 An article on managed consumerism in the health care industry:

http://content.healthaffairs.org/content/24/6/1478.full Web Exercise Create a seven-minute presentation explaining the pros (advantages) and the cons (dis - advantages) of the two different systems discussed in this chapter. You are encouraged to start with the two websites listed in the Additional Resources section, but you must use at least three reputable sources for each side of the discussion.

Key Terms bur25613_10_c10_259-274.indd 274 11/26/12 2:51 PM CHAPTER 10 Key Terms