Nurses Leaning Into Uncertainty

Throughout history, nurses have provided care to those in need despite the cultural circumstances or political scenarios at hand. Nursing care, like medicine, is a necessary service that simply needs to be provided in a society at all times. No matter that bullets are flying, elections are being disputed, or a pandemic is raging, nurses are there with their patients even as uncertainty rules the day.

A Pandemic "Marshall Plan"​?

When World War II ended, a massive global recovery plan was initiated, and we enjoy the positive reverberations of that plan to this day. The dawning of 2021 and the ongoing COVID-19 pandemic call for nothing less than a similar worldwide initiative. Are we truly ready to collectively embrace this humanitarian call to arms?

Homelessness: Action or Complicity?

With the recent revelations that the homeless population in New York City is now at its greatest numbers since the Great Depression, we are again face to face with a public health crisis of astronomical proportions.

The Burden of Medical Bills

A recent study released by the CDC (and reported on Medscape and other sites) states the blunt fact that 20% of American households have difficulty paying their medical bills. And the National Center for Health Statistics states that 1 in 5 Americans has lived in a family that could not pay its medical bills in the last 12 months.

The "Occupy" Movement and Healthcare

For the last several months, I have been actively supporting the now worldwide "Occupy" movement that has swept the world following the initiation of the famous "Occupy Wall Street" action in New York City. Here in Santa Fe, New Mexico, my wife and I have taken part in marches, rallies, protests and teach-ins, and the "Occupy Santa Fe" encampment continues near downtown.

Although the issues broached by "Occupiers" throughout the country are seemingly disparate and multifaceted, I believe it is only through the communication of these different voices and concerns that central themes (and possible demands) can eventually be distilled.

As a nurse and healthcare professional, I have seen the face of the healthcare system up close, and it is (still) quite broken. With innumerable for-profit insurance companies dictating what doctors can and cannot do, and tens of millions of Americans living completely without health insurance, the system eschews the notion of universal coverage and leaves millions in the proverbial dust. And since almost every industrialized country in the world has some form of universal coverage, the United States lags far behind, not only in this respect, but also in infant mortality and other important markers of health and well-being of the citizenry at large. It is a shameful state of affairs.

Just today on National Public Radio, I heard a report quoting Republican candidate Ron Paul as he railed against the notion of universal coverage. When asked if an uninsured 30-year-old with a catastrophic illness should receive expensive care in order to save his life, Paul intimated that there are other ways for these sorts of people to be cared for (such as churches and neighbors). He stated, "That's what freedom is all about---taking your own risks." Although he wouldn't directly say that society should just allow this individual to die, some members of the audience loudly proclaimed that, indeed, this uninsured American's care should not be paid for and he should be allowed to meet his (uninsured) fate. A shocking notion, especially since doctors (and Ron Paul is himself an M.D.) take an oath to "do no harm". (I have always wondered about the relative similarity between the words "Hippocratic" and "hypocritical".)

When it comes to the "Occupy" movement, my sense is that a more fair distribution of wealth, corporate responsibility (in terms of taxes, etc), economic justice (an admittedly broad and relatively ill-defined phrase), jobs, the end of war, and the initiation of broader protections (such as universal health coverage) are some of the mainstays of the movement's demands.

As autocracies around the world crumble before our eyes, it was only a matter of time until such a popular people's movement erupted from its latent slumber here in the U.S.. People can only take so much, and when the number of uninsured Americans topped 52 million just last year (40% higher than in 2001), there was no reason for Americans to not decide to speak out and demand change. And if you couple the nationwide jobless numbers with the numbers of uninsured citizens (let alone the list of companies---like Wal-Mart---who are jettisoning their healthcare coverage), the recipe for popular unrest only grows.

Rates of obesity, diabetes and heart disease are ballooning in this country, and childhood obesity and chronic illness are equally on the rise. As Americans get sicker and fatter, the nation's largest employers are cutting their healthcare coverage and leaving millions of American workers (and their families) in the lurch.

Meanwhile, the American right proclaims that "Occupiers" are dirty hippies, unemployed and looking for a handout. From my perspective, this is both unenlightened thinking and plain ignorant hyperbole. I have marched and rallied with retired schoolteachers, nurses, housepainters, unemployed laborers, and gainfully employed citizens from multiple sectors of society. Yes, some "Occupiers" are unemployed, but every unemployed protester I have spoken with simply wants a job and benefits for them and their family, and they're willing to pay taxes to get what they want. (They just want wealthy Americans and American corporations to pay their fair share.)

The noise and perceived "inconvenience" of massive protests will, in my opinion, continue as the movement galvanizes a broader spectrum of Americans and gains clarity as it works internally to crystallize its main messages. And as the protests continue, those 50 million Americans still languish without health insurance, millions more look for work that cannot be found, and the corporate and political powers that be bide their time in hopes that the restless citizenry will fall back into a television-induced slumber. Aside from a nationwide campaign to taint drinking water with Ambien or Lunesta in hopes of a sleepier and more ignorant nation, the chances of this movement simply being lulled into complacency is more remote than Wal-Mart offering its workers the benefits they deserve.

Social Justice, Public Health, and the Pursuit of Happiness

The health department where I am currently employed is the recipient of a three-year social justice grant from a large national foundation. Despite a steep learning curve vis-a-vis emergency preparedness, the coordination of our local Medical Reserve Corps, and developing wellness programs for town employees, the social justice mission of our little health department is one of the most intriguing aspects of my new workplace.

When one generally thinks of public health, one thinks of communicable and infectious diseases, vaccinations, disease surveillance, and epidemiology. But I am learning that access to health care, food insecurity, and access to adequate housing can all be seen under the umbrella of public health, especially when looking at these issues through a social justice lens.

In addition to our social justice grant, our health department also boasts a Cambodian outreach worker who is responsible for outreach to the Cambodian refugee community in our area, a sizeable cohort which has varying levels of need vis-a-vis health care access and other social issues.

For American-born citizens, refugees and immigrants alike, free and equal access to adequate health care is indeed a privilege in this country, but it is a privilege that many of us prefer to view as a basic human right.

Along with housing, employment and education, my progressive heart wants to see every American have free and unfettered access to as much education as his or her heart desires; comfortable and affordable housing; gainful employment; sufficient quality and quantity of food; and high-quality and accessible health care. Call me a bleeding heart, but my personal vision of social justice includes what I see as essential components of "life, liberty, and the pursuit of happiness."

In terms of my work as a Public Health Nurse, I want to remind myself that the "public" aspect of my job entails my responsibility to the public, the people who live within the geographic area of my jurisdiction. The Human Rights Commission in our town is very active, and I see part of my duty as the PHN to reach out to this group (and others) who spend their time assuaging the suffering of our homeless, hungry, and uninsured.

Aside from the nuts and bolts (and syringes) of my work, I want to delve into the area of social justice wholeheartedly. There is nothing more worth fighting for in my book, so why not start right here at home?

Young Adults, Healthcare and the Economy

A recent study by Medco Health Solutions reveals that the current economic downturn and increasing healthcare costs are having a severe effect on young adults.

With an increasing number of young adults in their 20s and 30s living with chronic health conditions, health insurance and prescription drug coverage are no longer just issues for middle-aged and older adults. The survey further revealed that young adults are considerably less savvy when it comes to finding ways to save money on healthcare.

Other recent reports show that the prevalance of mental illness among young adults is significantly high, but only a small percentage ever actually seek treatment. With potentially 50% of young college-age adults meeting criteria for substance abuse disorders, personality disorders or other conditions, it is disconcerting that less than 25% are under active medical care.

If the lack of health insurance, the prohibitive costs of prescription medications, or exponentially increasing college tuition is keeping young adults from seeking medical or psychiatric treatment at a very vulnerable time of development and maturation, important outreach and motivational education needs to be set in motion in order to counterbalance such a trend. Whereas older adults might make healthcare expenses more of a personal economic priority in times of fiscal stress, perhaps young adults are less likely to eschew social outings, travel, and other activities in order to save money to cover their healthcare costs. This trend is worrisome since untended health maintenance issues early in adulthood can often come back to haunt the unsuspecting person in middle age.

I am not at all suggesting that young adults are categorically frivolous or laissez-faire about their health, but studies do clearly suggest that they are less likely to understand how to manipulate the economic system to their personal advantage vis-a-vis healthcare expenses. Additionally, having once been a young adult myself, health is generally not as great a priority when one is twenty-something as when one crosses the threshold into middle-age and the first half of one's life comes to a resounding close.

Universal healthcare and free higher education would most likely go a long way towards easing the economic strain on today's young adults, but I would be interested to see a study comparing the healthcare-seeking habits of European young adults (who already have free medical care and higher education) and their American counterparts. It would be revealing to ascertain if it is indeed the cost of healthcare that prevents young adults from seeking care, or if it is more of a developmental issue which is part and parcel of the maturation process.

While considering the underlying causes of the phenomena revealed by the studies mentioned above, it is important to consider what social and economic interventions might increase access to medical care for this important population, as well as what forms of education and outreach might prove to be positively motivational to that desired end. Increased access to affordable healthcare is certainly a very good first step, and while students attending college are required by law to have health insurance, young adults who choose to not go to college---or who simply cannot afford it---are left with few economically viable options once they can no longer be covered under their parents' policies.

Young adults are our future, and it is in our best collective interest to make sure that they receive the necessary preventive healthcare that can detect chronic disease---or even the potential for such disease---long before any lasting damage is done. Healthcare should be affordable, accessible, and understandable for our young adults, and in these hard economic times, too many young people may see healthcare as a luxury that they simply cannot afford. I hope that the new administration in Washington will decrease the costs of both healthcare and higher education, ease the burden on American young adults, and simultaneously educate this population about the crucial importance of detecting chronic illness before it starts to take its toll.

As the father of a young man in his twenties, I have a vested interest in his stellar generation reaching their productive middle-age with good health, economic security, and the means to live a long, happy, healthy and satisfying life.

Obama, Daschle and Healthcare

It is now confirmed that Barack Obama has asked former South Dakota Senator Tom Daschle to serve as the administration's Secretary of Health and Human Services. While the nominee has already undergone a rigorous vetting process by the Obama transition team, he will of course face a Senate confirmation hearing after the President-Elect is inaugurated on January 20th. I will venture a guess that Daschle will be handily confirmed by the Senate, and I imagine that he is already setting his sights on a broad plan of action. Whether that plan leads to successful change in the healthcare trenches remains to be seen.

Meanwhile, a powerful bipartisan group of senators met in the offices of Edward Kennedy (D-MA) today, at the behest of Senator Max Baucus (D-MT), to begin shaping potential Democratic legislation vis-a-vis broad healthcare reform.

With 15% of the country's GDP going to healthcare and the number of American uninsured (estimated at 40 to 47 million) expected to rise as layoffs and unemployment increase in response to the economy, the stakes are high for meaningful healthcare reform.

We all know we can do better. In terms of healthcare access, funding and quality of care, the World Health Organization has ranked the United States as 37th in the world. Concurrently, our ranking in terms of infant mortality and life expectancy also continue to plummet when compared with other nations. These statistics bear out the widely accepted notion that the enormous per capita expenditures on healthcare by the United States government have fallen far short of their potential, and many other countries have somehow managed to produce far better results utilizing a percentage of what we spend here.

The battle regarding the potential benefits and pitfalls of universal healthcare is on. Yesterday on Digital Doorway, I pointed readers towards an excellent website where the arguments for and against universal government-sponsored healthcare is being argued quite cogently. This nationwide conversation will only intensify, and it remains to be seen how the Obama administration will rise to this Herculean challenge.

I am personally and professionally invested in the developments vis-a-vis healthcare reform in the United States, and I assume it will be years before we know the true successes or failures of President Obama's efforts, with support from Tom Daschle and other key players (not to mention the input of the American people, if it is heeded amidst the noise).

These next months and years will be an interesting affair, and great grist for writers, bloggers, healthcare policy professionals, pundits, and ordinary citizens alike. Meanwhile, as the conversation and debate rages, the statistics related to the uninsured and underinsured will certainly worsen. We can only hope and pray that a truly remarkable (and successful) solution is indeed within reach.

Hospitals and Consumers on the Edge

Economically speaking, times are tough all over. People are losing their jobs, the unemployment rate is rising, and retailers and consumers alike seem to be facing a lean holiday season.

On the healthcare front, a number of U.S. hospitals are now in the difficult position wherein they now must buy back debt incurred from "Variable Rate Demand Notes" (VRDNs) and other forms of loans that hospitals use to do many things, including making capital improvements to their facilities. According to some reports, U.S. hospitals may be forced to buy back up to $8 billion dollars of debt, not an easy task in these cash-strapped times.

For hospitals, the economic times are indeed challenging. Patients with outstanding bills are less likely to be able to pay on time, if at all. Many employers are scaling back health insurance coverage for their employees, thus patients are often stuck with hospital bills that they cannot afford. Additionally, the numbers of uninsured and under-insured patients is rising in most states, and charity care is becoming increasingly burdensome for hospitals and health systems that provide such services. As some patients shift to Medicaid, hospitals also understand that reimbursement rates from Medicaid and Medicare often cannot match those from some private plans, thus revenues hemorrhage from numerous economic blood vessels simultaneously.

Equally troubling for hospitals, borrowing is exceedingly difficult, despite dire need for improvements to facilities, upgraded IT equipment and systems, and rising labor costs. With increased costs of utilities, food, supplies, and health insurance premiums for their own workers, hospitals also understand that many patients will continue to cancel or postpone many elective surgeries and procedures that bring much needed revenue to hospitals' bank accounts. With consumers charged co-pays of $200 to $400 for elective procedures such as colonoscopies and vasectomies, hospitals face a serious decrease in such procedures which are much less costly since they generally involve a stay of less than 12 hours from registration to discharge.

From The Wall Street Journal to regional news outlets in the mid-West, the signs all seem to be the same: hospitals are in for a difficult season as the economic belt tightens on the healthcare industry.

As a self-appointed advocate for the uninsured and vulnerable in this country, I am seriously concerned that an enormous cohort of Americans currently face a significant decrease in the availability of affordable preventive healthcare in all regions of the country, not to mention access to many specialists and other providers.

Overall, my fear is that the availability of free and low-cost care will suffer in the current economic climate, and patients in need of care will need to travel further and further afield in search of providers willing to see them, a burden that may keep numerous people from seeking medical attention at all. When access to medical attention is limited, it is frequently the uninsured and under-insured who are left in the healthcare dust, and there are millions of children who will fall into this unfortunate group as their parents simply struggle to make ends meet.

There will be much for the new Obama administration to consider when assessing the current (horrible) state of the American healthcare system. As impatient as we all are for change, it may be many months before any improvements are even suggested for fixing healthcare in this country.

Meanwhile, as hospitals struggle with their bottom line and millions of uninsured Americans struggle to stay healthy, we all must hope that there is still a possibility that the damage, as extensive as it may seem, can still be undone. And as for those millions of uninsured children out there, it should never get any worse than this.

Hispanics and the U.S. Healthcare System

(Note: This is my fourth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)

The Hispanic population of the United States is growing exponentially, and the Pew Hispanic Center chronicles and tracks the collective successes and challenges of this burgeoning American demographic.

According to the Pew Center, the Hispanic population of the United States---currently the largest minority group in the country---will triple between 2005 and 2050, with non-Hispanic whites poised to themselves become a minority by 2050, certainly the largest projected demographic shift of the 21st century.

Taking these statistics into consideration, it is disturbing to learn that a recent Pew Hispanic Center study reveals that 1 out of 4 Hispanic Americans does not have a regular healthcare provider. Additionally, a similar number of Hispanic respondents reports receiving no medical attention or information from any member of the healthcare system in the previous year.

The Pew study, carried out in partnership with the Robert Wood Johnson Foundation, reveals that "the groups least likely to have a usual health care provider are men, the young, the less educated and those with no health insurance." The study results also clearly show that Hispanics who are less assimilated into American society---including those who are foreign-born, recent immigrants, and/or those who speak only Spanish---are less likely than their more assimilated counterparts to report having a regular medical provider.

Interestingly, when pressed for reasons why they lack regular healthcare providers, 41% of respondents simply said they lacked a provider because they are rarely sick. And a majority of Hispanic study subjects---83%, in fact---report obtaining the majority of their health information from television. Additionally, 79% states that they are acting on the information obtained from television and other media sources, changing diet and exercise practices solely based on reports and advertisements.

In terms of those Hispanics who have indeed received medical care in the last year, 77% reported their care as "good" or "excellent". However, 25% of those respondents who received health care over the last five years reports receiving poor treatment within the mainstream American health care system. The report continues by stating, "those who believe that the quality of their medical care was poor attribute it to their financial limitations (31%), their race or ethnicity (29%) or, the way they speak English or their accent (23%)".

Some other surprising findings also were revealed in the study results:

--45% of Hispanics without a regular health care provider actually have health insurance

--Half of the respondents without a regular provider have at least a high school education

--Many Hispanics without a health care provider were born here in the United States

--60% state that they received health care advice from family and friends in the last year

--A "slight majority" of those without a usual provider are "English-dominant or bilingual"

Following the release of the study, the headlines trumpeted the news: Many Hispanics Shut Out of U.S. Health Care System, Latinos Turn to TV for Health Advice, 25% of Hispanics Don't Visit Doctor Regularly, among other declarative statements meant to inform the public of the results of the study in simplistic and less-than-nuanced terms.

But what do these findings mean? What do we actually take away from the study results? Is there something in American society---or American health care, in particular---that has to change? With Hispanics carrying a disproportionately significant burden of diabetes and other chronic illnesses when compared to other segments of the population, it is in our best interest as a nation to address these disparities in a meaningful way. Whether we want to believe it or not, a lack of preventive health care on the part of such an enormous demographic will eventually have a widespread economic impact on society as a whole, with everyone eventually paying the price in one form or another.

Considering the climate towards immigrants since 9/11/01, it is this writer's fear that xenophobic Americans who rely on a "they should all speak English" anthem will use the results of this and other studies to defend their position that immigrants must conform, assimilate, and master the English language as a means to fuller participation and representation within the larger society. While all immigrants do indeed assimilate to some extent as they enter a new culture, the fact that Hispanics will be a majority of the population of the United States in less than 40 years underscores the notion that a broader view of this situation must be taken in order to fully embrace the coming demographic shift and its implications for health and health care in America. Websites like Optimos Medicos and other sites geared towards the Hispanic community indeed do their part to help bridge these gaps and cultural/linguistic divides. 

In my work as a nurse care manager for inner city Latinos over the course of the last decade, I have witnessed first-hand how culturally appropriate health care can be delivered to under-served populations despite barriers of language, education, and socioeconomics. However, the Pew/Robert Wood Johnson data suggests that there is more than simple socioeconomic factors which deter Hispanics from seeking regular preventive health care. When extrapolated, the data demonstrates that a large percentage of Hispanics---whether educated, English-speaking, foreign-born or not---have a relative tendency to eschew regular preventive health care, relying instead on the media, a perceived lack of acute or chronic illness, family and friends, and intermittent urgent care, in order to meet their health care needs.

It is my contention that the Pew findings necessitate a great deal of soul-searching for public health officials, Hispanic and Latino consumer groups and community leaders, government officials, as well as a broad spectrum of insurers, regulatory bodies, medical providers, health care systems, and others. I would venture a guess that Hispanic community leaders, clergy, popular entertainers, and other recognized figures of authority and cultural significance would be most likely to succeed vis-a-vis a public relations campaign urging Hispanics to obtain and utilize regular preventive health care. Additionally, it would behoove state and federal governments to invest in such a campaign with the knowledge that pennies invested in preventive health care now will save many dollars in the care of the chronically ill in the future.

So, what might a public relations campaign look like in order to reach Hispanics? Obviously, since such a large percentage of Hispanics report obtaining (and utilizing) health care information from television and radio, I would suggest a massive bilingual ad campaign targeting all segments of the Hispanic community. Highly esteemed popular entertainers and other prominent figures could be recruited as spokespeople for the campaign, providing a familiar and respected face for the project.

Above and beyond spokespeople and television ads, I picture a nationwide body of trained outreach workers (volunteer and otherwise), fanning out within their communities, educating their fellow community members about the value of preventive health care. These workers would be armed with literature, contact information for culturally sensitive medical providers accepting new patients, and other resources about what types of preventive health care are most highly recommended. Currently existing outreach infrastructures could be utilized in order to reach deeper into neighborhoods and social circles without duplicating efforts, dove-tailing with other outreach teams already actively involved in their communities.

Just as the gay community pulled together in the early days of the AIDS epidemic, educating one another about prevention and treatment options, stemming the tide of the epidemic, the Hispanic community could, with the appropriate resources, reach out within its own population in an attempt to bring more individuals into the fold. Coupled with a sustained, savvy and intelligent media campaign, major inroads could be made vis-a-vis enrolling Hispanics into primary care.

Considering the breadth of the issue and the potential challenges it presents, many arguments could be made that such a campaign is doomed to failure, and that the economic resources do not exist for such a massive outreach effort. And with no mandate for universal health care in this country, uninsured Hispanics would still be left in the dark. However, if one considers the potential impact of of an aging population of Hispanic citizens in 2050, burdening the economy and the society with undetected and untreated chronic illness, there is no question in my mind that millions of dollars in health care costs would be saved over the course of the next generation.

Preventive health care is an investment, and if we are truly a multicultural and tolerant society of immigrants and the descendants of immigrants, we have an opportunity to show our true colors, embracing the health of our Hispanic brothers and sisters as our own, investing in their---and our---collective future.

The Pew/Robert Wood Johnson study demonstrates what may indeed be a crisis of faith on the part of Hispanic Americans vis-a-vis the mainstream health care system in this country. However, the Chinese symbol for "crisis" is also the symbol for "opportunity", and this is one opportunity that we as a society should not miss.