Health Policy for Diverse Populations

Defining Vulnerability and Health Risk Characteristics

There is no single consensus on how to define vulnerability and vulnerable populations, but for the purpose of health policy analysis, vulnerability is defined as the convergence of health risks. These risks manifest in three primary categories: physical health (such as having a fever or physical symptoms), mental health (such as feeling depressed), and social health (resulting in poor school or job performance). Because poor health in one dimension can be compounded by poor health in others, health needs are considerably greater for people with multiple health problems than for those with only one. Historically, the moral test of government, as stated by Hubert Humphrey, is how it treats those in the dawn of life (children), the twilight of life (the elderly), and the shadow of life (the sick, needy, and disabled). Harry S. Truman also emphasized the necessity of providing protection and security against the economic effects of sickness to ensure a full measure of opportunity for all citizens.

Following the model proposed by Andersen (1995), health risk characteristics are divided into predisposing, enabling, and need characteristics. Predisposing characteristics indicate the propensity of individuals to use care services and include demographic variables such as age, sex, and family size; social structure variables like race, ethnicity, education, and occupation; and health beliefs regarding the value of healthcare. Enabling characteristics refer to the resources available to individuals and families, such as income and insurance coverage, as well as attributes of the surrounding community that affect access to care. Need characteristics represent the specific illnesses or health needs that drive the receipt of services. Vulnerable populations experience a convergence of these factors and typically exhibit poorer health status. National attention is required because the prevalence of vulnerability is increasing, it is fundamentally linked with national resources, and it is influenced by social forces that must be remedied to achieve equity.

The Health Center Program and Community Primary Care

Health centers, also known as federally qualified health centers (FQHCs), are nonprofit, community-directed healthcare providers that have provided primary and preventive care since the 1960s. These centers serve predominantly low-income racial or ethnic minority patients in medically underserved areas. Beyond clinical care, they provide "enabling services" such as transportation, translation, and education to facilitate access. They are governed by boards consisting mainly of health center patients. As of 2020, nearly $1,400$ health centers provided care at approximately $13,000$ sites throughout all $50$ states, US territories, and the District of Columbia. These centers face challenges including economic slowdowns, shifting demographics, increasing delivery system complexity, workforce shortages, and rapid technological innovation.

Specific examples of health center impacts include the Center for Family Health in Jackson, Michigan, which became a one-stop shop for pediatrics and women's health; the Crescent Community Health Center in Dubuque, Iowa, which invested in electronic medical records; and Family Health Services in Twin Falls, Idaho, which expanded medical, behavioral, dental, and pharmacy services. In Philadelphia, the Family Practice and Counseling Network recruited dentists for pre-school cleanings, while La Clinica Health Care in Medford, Oregon, installed ultrasound machines for uninsured pregnant women. United Neighborhood Health Services in Nashville became a medical home for mothers and children, and the Will County Community Health Center in suburban Chicago utilized a mobile dental van to reach families.

My Health GPS: A Model for Multiple Chronic Conditions

The My Health GPS program in the District of Columbia represents an innovative method of addressing the needs of patients with three or more chronic conditions. This program utilizes community health workers (CHWs)—frontline professionals from underserved communities—to facilitate care and perform outreach. Under Section $2703$ of the Affordable Care Act (ACA), states can coordinate care for Medicaid enrollees using a "whole-person" philosophy. Launched in 2017 by the DC Department of Health Care Finance (DHCF), My Health GPS targeted approximately $25,000$ beneficiaries. Providers must use an interdisciplinary team including a health home manager, nurse care manager, care coordinator or social worker, licensed clinical pharmacist, and a peer navigator or CHW.

Patients are classified by acuity levels. Group 1 (lower acuity) patients have three or more conditions and receive two $25$-minute contacts per month. Group 2 (higher acuity) patients have three or more conditions plus a qualifying risk score and receive six $40$-minute contacts per month. Providers are paid on a per-member, per-month (PMPM) basis: $46\,USD$ PMPM for Group 1 and $137\,USD$ PMPM for Group 2. In the first quarter of the program, providers received a one-time incentive of $475.91\,USD$ per beneficiary for starting a care plan. By mid-2020, the program expanded to $10$ providers and over $5,000$ patients, leading to the development of the Integrated Care TA program for patients with substance use disorders.

Behavioral Health and Mental Healthcare Reform

Behavioral health encompasses mental health and substance use disorders. It is estimated that as of June 2020, $40\%$ of American adults lived with these disorders, a figure that grew during the COVID-19 pandemic. Mental health literacy, defined by the American Medical Association as "knowledge and beliefs about mental disorders which aid their recognition, management, and treatment," remains low in the US. Public health spending on these issues has dropped significantly, with total expenditure on public health falling from $45\%$ in 1960 to only $15\%$ in 2010. Furthermore, patients in the public mental health system die $25$ years earlier than the general population.

Systemic issues such as fragmentation, stigma, and workforce shortages hinder care. While the early 20th-century "mental hygiene" movement sought to move away from asylum-based care, it lacked preventive measures. The Epidemiological Catchment Area Survey found that more than one in four individuals had a diagnosable mental disorder annually, yet fewer than half received treatment. Vulnerable populations face additional barriers; more than $30\%$ of Black people, $20\%$ of Latinx people, and $23\%$ of Indigenous people reported avoiding medical care due to discrimination. Behavioral health outcomes are additionally influenced by nutrition, socioeconomic disparity, and early childhood experiences. Primary care integration is essential, as underserved populations are more likely to seek mental health services in primary care settings than in specialized mental health settings.

Health Policy Issues for Racial or Ethnic Minorities

According to the 2020 US Census Bureau, nearly $40\%$ of the population consists of racial or ethnic minorities: Blacks or African Americans ($13.4\%$), Hispanics or Latinx people ($18.5\%$), Asians ($5.9\%$), Native Hawaiians and Pacific Islanders ($0.2\%$), American Indians and Alaska Natives ($1.3\%$), and those identified as two or more races ($2.8\%$). These groups face significant disparities in access, quality, and health status. A common measure of access is the Regular Source of Care (RSC). Studies show that minorities are less likely to have an RSC than whites, even when accounting for income and insurance. Contributing factors include low family income, language barriers, and a lack of culturally appropriate services.

Disparities in health status are stark: African Americans exhibit the highest mortality rates for homicide, stroke, coronary heart disease, and colorectal cancer, and the highest morbidity for diabetes and HIV/AIDS. American Indians and Alaska Natives have the highest smoking prevalence. Programs to resolve these issues include the federal Office of Minority Health (OMH) and the Indian Health Service (IHS), which serves $574$ federally recognized tribes. State initiatives like Minnesota’s Eliminating Health Disparities Initiative and California’s Strategic Plan serve as models. Private initiatives include the Building Healthy Communities Initiative by the California Endowment, which invests in social and medical interventions across $14$ historically marginalized communities.

Policy Issues for the Uninsured and Socioeconomic Status (SES)

The number of uninsured Americans was $10.3\%$ in 2020 and fell to $8.9\%$ in 2021, largely due to the ACA. However, after individual mandate requirements were eliminated in 2017, the uninsured rate among lower-income adults rose from $20.9\%$ in 2016 to $25.7\%$ in 2018. President Biden expanded eligibility to $400\%$ of the federal poverty level (FPL) to strengthen the ACA. Lack of insurance leads to delayed care and a higher reliance on emergency departments (EDs) as a primary source of care. States manage the uninsured through varying strategies: inaction (relying on the federal government), balanced (mix of state-based and market-based), or purely state-based or market-based reforms.

Socioeconomic status (SES) is determined by income, education, and occupation. SES often has a greater impact on healthcare access than race. Poor adults are more than twice as likely to lack an RSC. Those at lower income levels have a sixfold higher rate of functional limitations between ages $55\text{ and }64$. States with high poverty rates (incomes less than $200\%$ of the FPL) have amenable mortality rates twice as high as wealthier states. Programs like South Carolina’s Welvista offer free primary care and prescriptions to the uninsured, while Kansas’s TeleKidcare used videoconferencing to provide services in schools. One Community Health in Oregon and Washington offers the "Steps to Wellness/Pasos Hac Salud" course to address high rates of diabetes and obesity among Hispanic residents.

Policy Issues for Vulnerable Subpopulations

For the elderly, health policy focuses on cost containment, quality of life, and service availability. Medicare beneficiaries live on less than $26,200\,USD$ annually and spent an average of $5,801\,USD$ on healthcare in 2017. Elderly individuals with five or more chronic conditions see an average of $14$ different physicians per year. Chronic diseases are the leading cause of death and disability in the US, with $90\%$ of the $3.4\,trillion\,USD$ in healthcare costs going toward chronic illness and mental health. The CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) focuses on four domains: surveillance, environmental strategies, healthcare system strengthening, and community-clinical links.

Specific chronic disease programs include the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which provides screenings to low-income women, and the Colorectal Cancer Control Program (CRCCP). The Paul Coverdell National Acute Stroke Program funded by the CDC has improved stroke treatment times, with patients receiving treatment within an hour of arrival increasing by $42$ percentage points from 2008 to 2019. The REACH program (Racial and Ethnic Approaches to Community Health) funds state and local initiatives, such as the Community Asthma Initiative at Boston Children’s Hospital, which reduced child hospitalizations by $80\%$. The "Tips from Former Smokers" campaign is estimated to have prevented $129,000$ early deaths and saved $7.3\,billion\,USD$ in healthcare costs since 2012.

Women, Children, Disabilities, and Homelessness

Women constitute $50.8\%$ of the population and face higher rates of stress and chronic conditions in old age. Children ($22.3\%$ of the population) have seen a rise in chronic conditions from $1.8\%$ in 1960 to $25\%$ today, including obesity at $18\%$ and asthma at $9\%$. Maternity health is a major concern, as $45\%$ of births were unintended as of 2011, which acts as an obstacle to prenatal care. For the disabled population—approximately $54$ million Americans—health status is often measured in disability-adjusted life years (DALYs), which capture the loss of healthy life. This group faces barriers in inaccessible facilities and communication; only half of women with severe disabilities receive recommended mammograms compared to $80\%$ of women without disabilities.

Homelessness affects up to $3.5\%$ million people annually. The homeless face resource competition where basic needs like shelter sideline health concerns. Housing First programs identify that becoming housed is the primary facilitator for reducing ED utilization. Finally, people with HIV/AIDS represent a significant vulnerable subpopulation. Roughly $1.2$ million people in the US live with HIV, with one in seven unaware of their status. Disparities are severe: African Americans accounted for $40\%$ of HIV cases in 2019 despite being only $13\%$ of the population. Lifetime treatment costs per person are estimated at $379,668\,USD$. The federal government spent $28\,billion\,USD$ on domestic HIV care in 2017, largely through Medicare, Medicaid, and the Ryan White HIV/AIDS Program.

Questions & Discussion

Case Study 1: Health Centers

1. How would you describe the efficacy of health centers? What are their roles in improving access to care, quality of care, and health outcomes for vulnerable populations?

2. How can health centers cope with the challenges they face?

Case Study 2: Chronic Illness

1. What are some innovative models of care delivery that target people living with chronic illnesses? How do these models differ from the status quo?

2. The care team approach is often used to provide community-based primary care, particularly to people with chronic illnesses. What is the composition of the team? Why are these individuals essential members of the team?

3. How can low-cost technology be used in community-based primary care for people with chronic illnesses? Provide illustrative examples.

Case Study 3: Behavioral Health

1. What are a few key elements lacking in the current US approach to addressing behavioral health?

2. Look into an example of a successful behavioral health program. What made it successful?

3. A common behavioral health intervention is promotion, which disseminates information on behaviors known to increase health risks in hopes that this knowledge will empower people to cease or modify this behavior. Behavioral health promotion has been shown to be mostly ineffective at addressing health inequity. Why is this?

For Discussion

1. Why should health policy focus on vulnerable populations?

2. What health policy issues do racial and ethnic minorities face? Cite examples of programs to eliminate racial and ethnic disparities in healthcare.

3. What health policy issues do uninsured US residents face? Cite examples of programs to eliminate insurance disparities.

4. What is socioeconomic status (SES)?

5. What health policy issues do people with low SES face? Cite examples of programs to eliminate SES disparities.

6. List the health policy issues for each of the following subpopulations: The elderly; People with chronic illness; People with mental illness; Women and children; People with disabilities; The homeless; and People with HIV/AIDS.