More than one in three Latino/a and just under one in five African Americans – are uninsured. In comparison, only about one in eight Whites lacks health insurance.Four in 10 low-income Americans do not have health insurance, and half of the nearly 46 million uninsured people in the United States are poor. About one-third of the uninsured have a chronic disease, and they are six times less likely to receive care for a health problem than the insured. In contrast, 94% of upper-income Americans have health insurance.What are your thoughts about this disparity? (10 points)
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Chapter 13: Health Care Choices
Section 13.1 Understanding your Health Care Choices
Developing Health Literacy
The U.S. Department of Health and Human Services (HHS) defines health literacy as
“The degree to which individuals have the capacity to obtain, process, and understand
basic health information and services needed to make appropriate health decisions.” In
a recent report by the HHS, improved consumer health literacy was determined to be an
important component of health communication, medical product safety, and oral health.
Health literacy includes the ability to understand instructions on prescription drug
bottles, appointment slips, medical education brochures, doctor’s directions and consent
forms, and the ability to negotiate complex health care systems. Health literacy is not
simply the ability to read. It requires a complex group of reading, listening, analytical,
and decision-making skills, and the ability to apply these skills to health situations.
Health literacy varies by context and setting and is not necessarily related to years of
education or general reading ability. A person who functions adequately at home or
work may have marginal or inadequate literacy in a health care environment. With the
move towards a more “consumer-centric” health care system as part of an overall effort
to improve the quality of health care and to reduce health care costs, individuals need to
take an even more active role in health care related decisions. To accomplish this
people need strong health information skills.
Skills Needed for Health Literacy
Patients are often faced with complex information and treatment decisions. Some of the
specific tasks patients are required to carry out may include:





evaluating information for credibility and quality,
analyzing relative risks and benefits,
calculating dosages,
interpreting test results, or
locating health information.
In order to accomplish these tasks, individuals may need to be:




visually literate (able to understand graphs or other visual information),
computer literate (able to operate a computer),
information literate (able to obtain and apply relevant information), and
numerically or computationally literate (able to calculate or reason numerically).
Oral language skills are important as well. Patients need to articulate their health
concerns and describe their symptoms accurately. They need to ask pertinent
questions, and they need to understand spoken medical advice or treatment directions.
In an age of shared responsibility between physician and patient for health care,
patients need strong decision-making skills. With the development of the Internet as a
source of health information, health literacy may also include the ability to search the
Internet and evaluate websites.
according to the American Medical Association, poor health literacy is “a stronger
predictor of a person’s health than age, income, employment status, education level,
and race.” In Health Literacy: A Prescription to End Confusion, the Institute of Medicine
reports that ninety million people in the United States, nearly half the population, have
difficulty understanding and using health information. As a result, patients often take
medicines on erratic schedules, miss follow-up appointments, and do not understand
instructions like “take on an empty stomach.”
Vulnerable populations include:





Elderly (age 65+) – Two thirds of U.S. adults age 60 and over have inadequate or
marginal literacy skills, and 81% of patients age 60 and older at a public hospital
could not read or understand basic materials such as prescription labels
Minority populations
Immigrant populations
Low income – Approximately half of Medicare/Medicaid recipients read below the
fifth-grade level
People with chronic mental and/or physical health conditions
Reasons for limited literacy skills include:




Lack of educational opportunity – people with a high school education or lower
Learning disabilities
Cognitive declines in older adults
Use it or lose it – Reading abilities are typically three to five grade levels below the
last year of school completed. Therefore, people with a high school diploma,
typically read at a seventh or eighth grade reading level.
The relationship between literacy and health is complex. Literacy impacts health
knowledge, health status, and access to health services. Health status is influenced
by several related socioeconomic factors. Literacy impacts income level, occupation,
education, housing, and access to medical care. The poor and illiterate are more
likely to work under hazardous conditions or be exposed to environmental toxins.
Economic Impact of Low Health Literacy
In addition to the effects of low health literacy on the individual patient, there are
economic consequences of low health literacy to society. After adjusting for health
status, education level, socioeconomic status, and other demographics factors, people
with low functional literacy have less ability to care for chronic conditions and use more
health care services.
Why Does Health Literacy Matter?
Every day, people confront situations that involve life-changing decisions
about their health. These decisions are made in places such as grocery and
drug stores, workplaces, playgrounds, doctors’ offices, clinics and hospitals,
and around the kitchen table. Obtaining, communicating, processing, and
understanding health information and services are essential steps in making
appropriate health decisions; however, research indicates that today’s health
information is presented in ways that are not usable by most adults. “Limited
health literacy” occurs when people can’t find and use the health information
and services they need.


Nearly 9 out of 10 adults have difficulty using the everyday health information that is
routinely available in our healthcare facilities, retail outlets, media and communities.
Without clear information and an understanding of the information’s importance,
people are more likely to skip necessary medical tests, end up in the emergency
room more often, and have a harder time managing chronic diseases like diabetes
or high blood pressure.
Who Does Limited Health Literacy Affect? Who is affected?
People of all ages, races, incomes, and education levels can find it difficult to obtain,
communicate, process and understand health information and services. Literacy skills
are only a part of health literacy. Even people with strong reading and writing skills can
face health literacy challenges when •



They are not familiar with medical terms or how their bodies work.
They have to interpret or calculate numbers or risks that could have immediate
effects on their health and safety.
They are voting on a critical local issue affecting the community’s health and are
relying on unfamiliar technical information.
They are diagnosed with a serious illness and are scared or confused. They have
health conditions that require complicated self-care.
Health Promotion and Self Care
Ideally we adopt behaviors and practices that promote health and prevent chronic
disease. Through education and health promotion we learn behaviors and practices to
manage our own basic health care. Health promotion involves education, policy, and
support that helps us to make health choices and promote positive behavior and selfcare. Self-care and health promotion involve the following:




health prevention practices, which help limit our need for formal interventions; we
manage minor health concerns informally using self-care.
primary prevention such as brushing our teeth, breast and testicular self exam,
vaccinations, etc.
managing uncomplicated injuries or illnesses with self diagnosis and treatment
using home remedies and OTC drugs.
Self Care versus Formal Care
The World Health Organizations defines self-care in the following way:
‘Self-Care is what people do for themselves to establish and maintain health, and to
prevent and deal with illness. It is a broad concept encompassing hygiene (general and
personal), nutrition (type and quality of food eaten), lifestyle (sporting activities, leisure
etc), environmental factors (living conditions, social habits, etc.) socio-economic factors
(income level, cultural beliefs, etc.) and self-medication.’
Self-care improves as we come to know our body and pay attention to the signals it
gives us so we can take appropriate actions. Self-care helps us rely less on formal
medical intervention. When we are more knowledgeable about our body and health
issues we are better able to make better decisions about self-care and seeking formal
care.
Examples of self-care are:
1. Recognition of symptoms or conditions that occur frequently but may not require a
doctor’s visit
2. Performing monthly breast and testicular self-exams
3. Learning first aid for common, uncomplicated injuries and conditions
4. Checking blood pressure, pulse, and temperature
5. Using home pregnancy tests, ovulation kits and HIV test kits
6. Doing periodic checks for blood cholesterol
7. Using home stool test kits for early colon cancer detection
8. Using self-help books, tapes, websites, and videos
9. Benefiting from relaxation techniques, including meditation, nutrition, rest, and
exercise
Formal Care: Health care professionals often need to be consulted if there is a serious
accident or injury, severe trauma, sudden onset of symptoms, or if any symptoms are
unusual and recur over time. Formal Care is accessing a local provider through a
community or privatized hospital, clinic or medical practice. Formal Care is best and
most effective when you are an active participant and informed. A partnership between
the patient and health care provider is desirable. The goal should be an exchange of
information and coordination on interventions and solutions. Formal Care is enhanced
through health literacy.
Section 13.2 How to Read Health News
If you’ve just read a health-related headline that has caused you to spit out your
morning coffee (“Coffee causes cancer” usually does the trick), it’s always best to follow
the Blitz slogan: “Keep Calm and Carry On”. On reading further, you’ll often find the
headline has left out something important, such as, “Injecting five rats with really highly
concentrated coffee solution caused some changes in cells that might lead to tumors
eventually. (Study funded by The Association of Tea Marketing)”.
The most important rule to remember is: don’t automatically believe the headline. It is
there to draw you into buying the paper and reading the story. Would you read an article
called, “Coffee pretty unlikely to cause cancer, but you never know”? Probably not.
To avoid spraying your newspaper with coffee in the future, you need to analyze the
article to see what it says about the research it is reporting on. Consider the following
questions to help you figure out which articles you’re going to believe and which you’re
not.
Does the article support its claims with scientific research?
Your first concern should be the research behind the news article. If an article touts a
treatment or some aspect of your lifestyle that is supposed to prevent or cause a
disease, but doesn’t give any information about the scientific research behind it, then
treat it with a lot of caution. The same applies to research that has yet to be published.
Is the article based on a conference abstract?
Another area for caution is if the news article is based on a conference abstract.
Research presented at conferences is often at a preliminary stage and usually hasn’t
been scrutinized by experts in the field. Also, conference abstracts rarely provide full
details about methods, making it difficult to judge how well the research was conducted.
For these reasons, articles based on conference abstracts should be no cause for
alarm. Don’t panic or rush off to your doctor.
Was the research in humans?
Quite often, the “miracle cure” in the headline turns out to have only been tested on
cells in the laboratory or on animals. These stories are regularly accompanied by
pictures of humans, which creates the illusion that the miracle cure came from human
studies. Studies in cells and animals are crucial first steps and should not be
undervalued. However, many drugs that show promising results in cells in laboratories
don’t work in animals, and many drugs that show promising results in animals don’t
work in humans. If you read a headline about a drug or food “curing” rats, there is a
chance it might cure humans in the future, but unfortunately a larger chance that it
won’t. So there is no need to start eating large amounts of the “wonder food” featured in
the article.
How many people did the research study include?
In general, the larger a study the more you can trust its results. Small studies may miss
important differences because they lack statistical “power”, and are also more
susceptible to finding things (including things that are wrong) purely by chance.
You can visualize this by thinking about tossing a coin. We know that if we toss a coin
the chance of getting a head is the same as that of getting a tail – 50/50. However, if we
didn’t know this and we tossed a coin four times and got three heads and one tail, we
might conclude that getting heads was more likely than tails. But this chance finding
would be wrong. If we tossed the coin 500 times – i.e. gave the experiment more
“power” – we’d be more likely to get a heads/tails ratio close to 50/50, giving us a better
idea of the true odds. When it comes to sample sizes, bigger is usually better. So when
you see a study conducted in a handful of people, treat it with caution.
Did the study have a control group?
There are many different types of studies appropriate for answering different types of
questions. If the question being asked is about whether a treatment or exposure has an
effect or not, then the study needs to have a control group. A control group allows the
researchers to compare what happens to people who have the treatment/exposure with
what happens to people who don’t. If the study doesn’t have a control group, then it’s
difficult to attribute results to the treatment or exposure with any level of certainty.
Also, it’s important that the control group is as similar to the treated/exposed group as
possible. The best way to achieve this is to randomly assign some people to be in the
treated/ exposed group and some people to be in the control group. This is what
happens in a randomized controlled trial (RCT) and is why RCTs are considered the
“gold standard” for testing the effects of treatments and exposures. So when reading
about a drug, food or treatment that is supposed to have an effect, you want to look for
evidence of a control group, and ideally, evidence that the study was an RCT. Without
either, retain some healthy skepticism.
Did the study actually assess what’s in the headline?
This one is a bit tricky to explain without going into a lot of detail about things called
proxy outcomes. Instead, bear in mind this key point: the research needs to have
examined what is being talked about in the headline and article. (Somewhat alarmingly,
this isn’t always the case.)
For example, you might read a headline that claims, “Tomatoes reduce the risk of heart
attacks”. What you need to look for is evidence that the study actually looked at heart
attacks. You might instead see that the study found that tomatoes reduce blood
pressure. This means that someone has extrapolated that tomatoes must also have
some impact on heart attacks, as high blood pressure is a risk factor for heart attacks.
Sometimes these extrapolations will prove to be true, but other times they won’t.
Therefore if a news story is focusing on a health outcome that was not examined by the
research, treat it with a pinch of salt.
Who paid for and conducted the study?
This is a somewhat cynical point, but one that’s worth making. The majority of trials
today are funded by manufacturers of the product being tested – be it a drug, vitamin
cream or foodstuff. This means they have a vested interest in the results of the trial,
which can potentially affect what the researchers find and report in all sorts of conscious
and unconscious ways. This is not to say that all manufacturer-sponsored trials are
unreliable. Many are very good. However, it’s worth seeing who funded the study to sniff
out a potential conflict of interest.
Should you “shoot the messenger”?
Overblown claims might not necessarily be due to the news reporting itself. Although
journalists can sometimes misinterpret a piece of research, at other times the
researchers (or other interested parties) over-extrapolate, making claims their research
doesn’t support. These claims are then repeated by the journalists.
Given that erroneous claims can come from a variety of places, don’t automatically
assume they come from the journalist. Instead, use the questions above to figure out for
yourself what you’re going to believe and what you’re not.
How and Where to Find Reliable Health Information on the Internet
The Healthfinder website (http://www.healthfinder.gov (Links to an external site.)) is the
federal government’s gateway for reliable information from U.S. government agencies
and other organizations. The site displays selected resources of consumer health and
human services information. Here is an example of a source that has been reviewed
and found reliable and credible: MedlinePlus Guide to Healthy Web Surfing
The Social Life of Health Information
Where do you go for health information? According to the Pew Research Center, most
people seek information from doctors, nurses, and other health professionals first but
the Internet and peers are also a significant source.
The Pew Research Center conducted a telephone survey in 2010 to find out how
Americans are getting their health information.
“The survey finds that, of the 74% of adults who use the internet:





80% of internet users have looked online for information about any of 15 health
topics such as a specific disease or treatment. This translates to 59% of all adults.
34% of internet users, or 25% of adults, have read someone else’s commentary or
experience about health or medical issues on an online news group, website, or
blog.
25% of internet users, or 19% of adults, have watched an online video about health
or medical issues.
24% of internet users, or 18% of adults, have consulted online reviews of particular
drugs or medical treatments.
18% of internet users, or 13% of adults, have gone online to find others who might
have health concerns similar to theirs.


16% of internet users, or 12% of adults, have consulted online rankings or reviews
of doctors or other providers.
15% of internet users, or 11% of adults, have consulted online rankings or reviews
of hospitals or other medical facilities.
Of those who use social network sites (62% of adult internet users, or 46% of all adults):



23% of social network site users, or 11% of adults, have followed their friends’
personal health experiences or updates on the site.
17% of social network site users, or 8% of adults, have used social networking sites
to remember or memorialize other people who suffered from a certain health
condition.
15% of social network site users, or 7% of adults, have gotten any health information
on the sites.”
Section 13.3 Health Care Choices: The Affordable Health
Care Act (ACA)
Health care choices in the United States can be broadly divided into two main
categories: public health care (government-funded) and private health care (privately
funded). The two main publicly funded health care programs are Medicare, which
provides health services to people over 65 years old as wel …
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