Study Guide #1
This is a troubling, at times appalling, study of one family’s interaction with the American health care system. You should keep in mind as you read this book that this study is intended to document the weaknesses in the American health care system, and you should remember that the system also has strengths. We could, I suppose, also read a book about how well the American health care system works for, say, an affluent highly educated family, but I believe that is unnecessary, since many Wellesley students are quite familiar with the “good side” of American health care—its endless innovations, sophisticated technology, and high standards of treatment. The other side, the health care system used by the less fortunate, is less visible to many. My purpose in assigning this book is not to get your blood boiling (though that may be useful too), but to introduce you to some basic facts about how health care is delivered in the United States. You will use the book to learn the basics of Medicare, Medicaid, SSI and health care finance. One point I hope you will see is how incredibly fragmented and complex these programs are, even to us reading about them in a book. Imagine yourself as a sick, poor, less educated person trying to navigate the complicated bureaucratic rules in these programs, as Jackie Banes does in the book, and you get a sense of the consequences of the way the United States organizes health care finance and delivery. For the rest of the course we will have a “top-down” view of American health policy, as we study the elites (elected officials, interest groups, academics) who make health policy, but I hope you will always keep in mind the “bottom-up” story that is told here—and that all the policies and politics we examine has life or death consequences for real people. After you read each section of the book you should be able to answer the following questions:
Coverage Issues (pages 1-59) What is Medicaid? What is Medicare? How do they differ? Who in the family uses which program? (That’s a much more complex question than you might think at first!) Why didn’t Robert get treatment for his kidney condition before it became life threatening? (Again a more complex question than you might think.) How is Robert’s dialysis paid for? Why is Highland Park’s dialysis unit more posh than the one Robert uses? What are “DRG’s”? How do they affect the care given to Mrs. Jackson? What kinds of medical care aren’t paid by Medicare? If Medicare won’t pay for Mrs. Jackson’s care, where can she get coverage? What is a “Medicaid spend-down”? How does coverage vary depending on whether you are receiving standard Social Security, as Mrs. Jackson does, or SSI (Suplementary Security Income) as Tommy Markham does? According to the author, what are the consequences of a “patchwork” system of coverage like the one in the United States? Why was it important for Mrs. Jackson to be considered “disabled”? If you know anything about the new prescription drug law recently signed into law by President Bush, how would this law have helped Mrs. Jackson and her family? Discussion Question: Consider the following statements: “ In a just society, everyone would receive exactly the same level of health care coverage. Health care is a basic human right and you should not get more or less depending on your ability to pay for it.” “ Forcing everyone into the same health care system violates basic American values. We don’t provide everyone with the same house, or the same college education, why would we provide the same level of health care? Such a system would deter innovation, encourage mediocrity, and put government bureaucrats in the business of deciding whether you deserve medical treatment.” What arguments can be made for either side?
Why did Mrs. Jackson sometimes miss appointments with her primary physician? If Medicare serves everyone over 65, why do minorities and the poor seem to get worse care? (Again, a complicated question.) Why did Mrs. Jackson get Coumadin poisoning? Imagine Mrs. Jackson as an upper-class retiree, maybe a retired Wellesley professor. How do you think her medical story might be different? If you had to explain the poor outcomes of Mrs. Jackson’s medical treatments, how would you do it? (To what extent is Mrs. Jackson herself responsible?) Why is the rehabilitation center that Mrs. Jackson goes to more profitable than the hospital? How is Medicare biased toward “in-patient” psychological care? Why do emergency rooms get used for routine care? How are emergency rooms like the one the Banes family uses funded? Why is Mt. Sinai Hospital in such bad financial shape? How has it survived? What is “demarketing”? How is it used? What are its consequences? Discussion Question Based on this section of the book, suggest one reform to improve the American health care system. What is the best argument against your proposed reform? What factors might affect its political feasibility? (Who would oppose it?)
Caregiving (134-197) Who is responsible for Tommy Markham’s health? Why was Mrs. Jackson’s home care so limited? Medicaid covers nursing home care for everyone who “spends down,” and many middle-class people use this strategy successfully. Why then do many poor African-Americans have trouble getting into a nursing home? Jackie had the chance to be paid for caring for her mother. Why didn’t she sign up for it? Why didn’t Brianna get her measles vaccination?
Why isn’t most Medicaid money spent on poor children? To whom does it go? Why does being poor affect your chances of getting a transplant? Why did whites in Illinois receive transplants at higher rates than blacks?
Link and Phelan, "Fundamental Sources of Health Inequalities" The authors take issue with "risk-factor epidemiology" even though they admit that it is a major type of research in public health. What do they have against "risk-factor" epidemiology" and why do they instead favor a "fundamental cause" approach? The authors argue that socioeconomic status influences health, indeed that socioeconomic status is a more fundamental cause of health than "health behaviors". How exactly? What exactly are the implications of the authors' claims for public health policy? Discussion Question: What exactly could be said against Link and Phelan's claims?
Discussion Questions Consider the following statements: “ Although I sympathize with the Banes family, the truth is that most of their health problems are the result of bad choices they have made—poor diets, bad habits, not following doctor’s directions, not seeking medical treatment even when it was free. We could spend a lot of money treating all the problems that result, but I would rather spend the money promoting healthy life choices. Let’s use all that money on prevention and provide incentives and education to convince them to improve their health choices, rather than wasting money on treatments for diseases they never would have gotten if they had lived better.” To what extent do you agree? According to the account in this book, do poor families like the Banes have bad health because of flaws in the American health care system, or because they simply make bad health choices? (How would Link and Phelan analyze this question?)
Disparities (198-259) Why do some blacks distrust white doctors? Why does Tommy Markham distrust his doctor? Mrs. Jackson received extremely expensive high technology care at the end of her life. Why was so much spent on her in the last three months of her life compared to previous years? According to the author, how does the American health care system compare to the systems of Canada and Great Britain? According to the author, what changes in Medicaid might affect children like Brianna? Discussion Question Looking back over this story, what lessons do you draw about the American health care system? Why do you think the system is at it is? How would you change it, if you were queen or king? |