Running head: U.S. BIOMEDICAL MODEL OF HEALTH Last Name 1 The U.S. Biomedical Model of Health Student Name Virginia Commonwealth University
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 2 Abstract This paper explores the biomedical model of health and how it effects those of minority populations, including those of low socioeconomic status (SES). The ways in which the biomedical models focus on recovery over prevention negatively impacts minority communities and public health is analyzed within each section. Minority populations face disparities, inequalities, and barriers to access within the current model. This paper cites a need for more prevention based care providers, or primary care physicians, to combat these issues. In United States, 21% of the entire population lives in an area with an insufficient amount of primary care physicians, as Shi and Singh (2015b) noted (p.436). These areas are called Health Professional Shortage Areas (HPSA), as designated by the National Health Service Corps (NHSC). There are various organizations and acts cited, such as the NHSC, community health centers (CHC s), and the Affordable Care Act (ACA), which work to provide prevention based care throughout the country. The expansion of organizations such as these, and the shift in focus from recovery to primary care, will provide more access to care for minority individuals and positively affect the overall public health.
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 3 A woman sits in her apartment, head in hands, wondering for the life of her what she s going to do. She needs to get in to see her primary care physician, she can t keep putting it off, but she has no way to get there. She tried making an appointment, but her physicians office told her they only provide same day appointments. This wouldn t be an issue if she had a vehicle or someone to take her there, but money is tight and everyone is at work. The bus would normally be the next most reasonable option, but she lives four miles away from the closest station. Suddenly, she came to the realization that her Medicaid program provides transportation and, with a jump of both delight and relief, she went for the phone to request a ride. To her dismay, the woman on the line tells her that the transportation services require an advanced notice before they can send anyone out to get her. She explains that she is unable to provide a notice because her doctor only provides same day appointments, but she really needs to get in to see him today. The woman on the line expresses her sentiments and apologizes, but says there is nothing she can do. Defeated, she sits back down and thinks about her situation. What is she going to do? She can t just take a day off, request a ride ahead of time, and call her doctor hoping he will be able to see her. That would be a waste of time and lose her the money she needs to feed herself and her family. She considers the fact that, even if she did get in to see him, he s likely to just refer her to someone else who she will have to pay out-of-pocket. What if they don t even accept Medicaid patients? She really doesn t have the money for that right now. She sits again, with her head in her hands, and thinks, Is it even worth it? Situations such as this are happening every day to people all over the United States. In an interview analyzed by Kangovi, Barg, Carter, Long, Shannon, and Grande (2013), one patient stated, When I go to my primary, I don't have a copay. But my primary may send me to 2 or 3 specialists, and sometimes there is a copay for them. Plus time off from work to go see
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 4 them. (pp. 1198-1199). Many people simply cannot afford to get the care they need, or they are turned away due to disparities within the health system, which in the United States is based on a biomedical model. This model sees health as the absence of illness or disease (Shi & Singh, 2015a, p. 41), focusing on the function of recovery over prevention methods. Primary prevention is the function of reducing the possibility of developing an illness or disease, while recovery methods are meant to treat and cure them. Primary care physicians provide prevention methods through their practice. These physicians do this by meeting with their patients on a regular basis to check on their health and prevent the development of chronic illnesses. Specialist physicians, however, only see patients when they are showing symptoms related to their specific practice. Specialists work to cure and treat patients current conditions, making their field recovery based. Most professionals agree that increasing the amount of specialist physicians within the U.S. will not help health outcomes, but further harm them. Not only is this form of care very costly and would rise health care expenditures but, as Starfield, Shi, Grover, & Macinko (2005) saw, it would also likely to lead to greater disparities in health status and outcomes (para. 1). It was also seen that as the amount of specialist physicians in the U.S. has increased, every health indicator has reached the bottom and has worsened (Starfield et al, 2005). With less availability of primary care physicians, less prevention methods are taken in order to decrease the likelihood of developing the illnesses that specialist physicians treat. While specialist physicians require more education, and are often viewed as better quality physicians because of this, their education is focused on only one area of health care. To put it in the words of Firestein, they know a tremendous amount about almost nothing (Firestein, 2013). Because of this, many of these specialist physicians preform procedures which are nonessential, ultimately increasing costs.
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 5 The biomedical model also focuses on market justice, which is for the economic good, with only some aspects of social justice. With the main focus on the economic good, public health gets taken into lesser account. Public health, as defined by Shi and Singh (2015a) is to assure conditions in which people can be healthy (p. 48). In order to promote good public health, actions such as the creation of a safe living environment and the provision of easy access to health care must be taken. While the health system developed in America, public health was not seen to be one of the country s main concerns. Shi and Singh (2015a) saw that this biomedical model of health came from American beliefs and values such as: an advancement in science, the champion of capitalism, entrepreneurial spirit and self-determination, concern for the under privileged, and free enterprise as well as a distrust in government (pp.62-63). When looking at these values one can see the emphasis on the individual as opposed to the entire population, which has a major effect on the delivery of health care and subsequently the population. Based on recent studies that analyze the efficiency of the biomedical model, the evidence shows that this model decreases public health and increases health disparities for those of minority populations. The US Census Bureau released information on March third of 2015 relating to population projections until 2060, looking at size, age, race, sex, nativity, and Hispanic origin. Within this report the Bureau stated that the minority population was at 38% in 2014 and likely to rise to 56% by 2060 (para. 3). Evidence shows that these populations face poor access and various barriers to healthcare, causing them to have poorer health and to be seen as more vulnerable. During 2011, as cited by Shi and Singh (2015b), the rate of uninsured without a regular source of healthcare was 53% (p. 429). Because of this and the costs of care, these individuals are reported to access health care less often. This is an issue also seen in rural
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 6 populations, which have significantly less access to care due to the geographical maldistribution of physicians. As Meyers, Gibbs, Thacker, & Lafile (2012) found, About 19% of the state's population must travel more than 30 minutes to visit a doctor, and in rural areas, the travel time significantly increases when the doctor is a specialist. (p. 347). The authors specify that the travel time to get to specialist physicians increases in rural areas because it has been seen that there are less specialist physicians in rural areas in comparison with metropolitan areas. Though there are more specialist physicians in the U.S. than primary care physicians, they are unequally distributed. Within the United States, 21% of the entire population lives in an area with an insufficient amount of primary care physicians, as Shi and Singh (2015b) noted (p.436). These areas are called Health Professional Shortage Areas (HPSA), as designated by the National Health Service Corps (NHSC). The NHSC is an organization which works to provide health professionals to these areas, but as the evidence denotes, there are still many areas without proper care. Some say that the socioeconomic factors and inequalities that minority groups face have more of an impact on their health than that of the healthcare system. This is a factor that Shi and Singh (2015a) discuss when reviewing Blum s Model of Health Determinants, where it is seen that the medical care determinate is the least important in effecting health. This is an idea shared by Rebecca Onie, which can be seen in her statement: Social determinants-factors such as income, education, and the home and community environment-have far more influence on a person's health than does the health care system (Onie, 2012). This idea has led many people to believe that it is the fault of the individual for having poor health, that if they simply got a better job they could afford insurance and more health services. This ideology, however, is false due to the circumstances these individuals face. The health care system and the capitalistic nature of the
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 7 United States does not provide many opportunities for minority groups, mainly those of lower income, to obtain basic needs or rise above than their current situation. While it may be true that the intersection of various minority identities decreases the likelihood of having good health, this is due to the health system and American society itself. The factors these individuals face create less access to care, which is a problem with care inclusiveness and institutional discrimination, not solely the factors and inequalities on their own. Though there are certain programs made to help, such as Medicare and Medicaid which provide benefits to the elderly, disabled, and indigent, the health system does not make it easy for vulnerable individuals to become and remain healthy. The number of inequalities and disparities that minority groups face increases under the biomedical model of health. While the ideals of cultural competence and cultural sensitivity are put into place to make sure health providers are aware and respectful of people s differences, avoiding negative attitudes and incorporating these differences into their care, it is true that some providers let their biases get in the way of their performance. This is an unacceptable and unfortunate side effect of societal influences and institutional discrimination. These influences often put down minorities in a variety of ways, labeling them as lesser beings, making them more vulnerable. Because of this institutional discrimination, minority populations face more barriers to access and disparities within the many facets of healthcare, such as cost of care. This fact can be observed from the costs that different groups incur, such as those between men and women. As observed by Shi and Singh (2015b), women, who require only slightly more care then men, are charged more than men in all forms of care. The care that women receive is often more extensive and thorough, raising the costs they face and making them more likely to forgo care until it is absolutely necessary (p.433). Also in relation to increasing costs, as noted previously,
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 8 increasing the amount of specialist physicians in an area will increase the costs of care, making it nearly impossible for minority individuals to attain it. The focus for these physicians and the system itself is on high paying individuals, due to the central idea of market justice and capitalism. Those who are willing and able to pay exorbitant amounts will receive the most care while those of lower income face more barriers and disparities within the biomedical model. The increasing amount of barriers that this model creates is an issue that many organizations have tried to tackle and attempted to fix. Community Health Centers (CHC s) were created as a result of President Johnson s War on Poverty, their main goal being to decrease the health disparities that effect minorities and those of lower income (Adashi et al, 2010). These centers work to provide care for all, but their main patient base and focus is with those of minority populations. These centers provide transportation, similar to Medicaid which also serves the indigent population. CHC s are often placed in medically underserved areas, working to combat the shortage of primary care for these areas. This is a function similar to that of the National Health Service Corps, which works to place physicians in underserved areas, or HPSA s. Onie (2012) stated that the Health Leads organization is also working to expand to those areas with less access to care in order to provide their services to more low income individuals. It can be seen that each of these organizations works to expand access to care and provide for patients in need. In addition to the work of these organizations, Gostin (2012) cited that the ACA has been working to expand Medicare and Medicaid since its implementation. These programs work to not only provide easier access to care for indigent, disabled, and elderly populations, but also work to make the care they receive more affordable. Some may assume that the issue of health disparities has been resolved by all of the different organizations working to combat them. Each of these organizations, however, faces
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 9 barriers in its goals. As the situation beginning this essay shows, Medicaid transportation can be very unreliable. The requirement of an advanced notice can provide issues for many individuals. Similarly, the transportation that CHC s provide is also not easily accessed due to the fact that many areas still do not have these centers. Citizens within these areas cannot make use of this transportation, nor the centers themselves. While organizations such as the National Health Service Corps have been working to decrease the number of HPSA s in the U.S., there are currently still around 18,300 health professionals needed to eliminate them (HRSA, n.d.). The Health Leads organization faces the need for expansion as well, as it only operates in about six cities within the U.S. ( Creating a new model, 2012, p. 2795). While these organizations work to improve the issues facing minority individuals, expansion is needed in order to completely eliminate them. In relation the ACA s work to expand Medicare and Medicaid, Gostin (2012) noted that the U.S. Supreme Court has ruled that the ACA cannot expand by threat of taking away federal funding to state programs. This means that states are able to choose whether they expand these programs or not, which can have a severe negative impact on the populations in need. It was also noted that in the 2010 Healthy People initiative (a ten year plan made to set goals to be accomplished by the end of that ten year period) the plan sought to decrease disparities but saw that 80% of its objectives remained the same and 13% of the others increased (Shi &Singh, 2015a, p. 70). The evidence shows that disparities facing minority individuals continue to increase, even given the organizations created in an attempt to decrease them. The increase in these disparities, mainly less access to care, is also a factor which decreases public health significantly. Adashi and colleagues(2010) cited that while CHC s were created to help decrease the amount of disparities minorities face, in 2009 the Government Accountability Office (an organization which watches federal government spending) saw that
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 10 43% of medically underserved areas still do not have a CHC (para. 5). This issue is not uncommon for organizations which serve the purpose of decreasing disparities and aiding those in need. The areas that are most commonly effected by limited access are rural, and as Slusky (2006) states, they must be able to provide the basics, like high quality health care (p. 4). If people are unable to access basic care, their conditions will worsen, a point which most professionals agree with. However, limited access is not the only disparity which lowers the public health, as Shi and Singh discovered. These authors observed that when it came to population health, the greater the wage gap in a certain area, the less likely the area was to have good health. Shi and Singh (2015a) contributed this to a lack in social cohesion and more psychological stress (p. 53). When communities do not come together to support one another, and do not work to provide programs for those in need due to the fact that the majority of their community can afford it, those in need suffer poorer health. Because of the conditions they face, low socioeconomic status individuals and minorities are likely to use care less often, negatively impacting their health. In a study using interviews to analyze why patients of lower income are more likely to utilize emergency services, Kangovi and colleagues (2013) stated that these individuals use preventative care and ambulatory services about 45 percent less than those of higher status (p. 1196). This under usage is due to a plethora of reasons including limited access, misinformation, and assumptions on the usefulness of these services. Onie (2012) observed, during her time in medical practice, that patients would often sacrifice their health to obtain basic needs such as food and shelter and vice versa. These people are forced to choose between what they can afford and what is more important. This can be seen in many low income families where parents will often choose to provide for their children as opposed to seeking care for their health conditions. Shi and Singh (2015a) stated that providing
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 11 access to primary care for these individuals has been seen to correlate with reduced mortality, increased life expectancy, and improved birth outcomes (p. 54). If all individuals are provided easy access to primary health care, mortality rates will decrease and the general public health will also improve. The biomedical model causes many low socioeconomic status individuals to overuse acute hospital care. There are many implications for this over usage, including the technological imperative within in the U.S. which causes people to desire the newest and most hi-tech technology regardless of its cost or proof of success. Because of this imperative, many believe that hospitals have higher quality of care due to the amount of technology within them. It has been seen by many health professionals, such as Starfield and Kangovi, that those of lower socioeconomic status are more likely to seek out emergency hospital services due this belief. Kangovi and colleagues (2013) provided additional reasons for this over usage including lower cost, easy access, as well as a relation to hospitals as a basis of support (p. 1198). Many of these individuals, especially those of lower income who turn to illegal means of obtaining money, end up in the hospital on various occasions because of their inadequate living conditions. It is also very common for these patients to be referred to different specialists who require co-pays, increasing costs of care, when visiting their primary care physicians. The increase in costs drives many low SES individuals to seek emergency care because it is more affordable. As Kangovi (2013) noted, patients with low socioeconomic status (SES) are at higher risk for being hospitalized for ambulatory care-sensitive conditions (p. 1196). It is important to acknowledge that the over use of hospital emergency services and technologies decreases health and increases health care expenditures. Patients who only use emergency care are likely put off care until
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 12 absolutely necessary and are unlikely to utilize primary prevention based care, causing their health to diminish. The belief that hospital care is of higher quality is one shared by many, including Slusky (2006) who stated in an article discussing the importance of rural hospitals in rural communities, Hospitals are the pillar of health care (p. 4). This statement suggests that hospitals are the most important form of care within the health system. The fact of the matter is that hospitals do not provide better quality care, nor are they the pillar of health care. Hospitals may be one of the largest institutions of care, but this does not make them the most important. The main factor driving the belief in this form of care to be of better quality, the availability of new hi-tech technology, is backed by many false assumptions. The idea that newer technology is better is untrue, due to the fact that these technologies aren t always proven to be the best form of care. What is proven is that it is very important for individuals to see their primary care physicians on a regular basis in order to prevent the development of illnesses. This is something most hospitals do not provide because of their focus on recovery and emergency based care. The over use of these facilities does not lead to positive health outcomes and, it is also noted by Shi and Singh (2015c), hospitals are the number one source of health care expenditures in the United States (p. 305). A facility which costs the public more than it provides should not be considered the pillar of healthcare. The overall focus on recovery based care over prevention based care decreases public health. The biomedical model focuses on the treatment of disease without prevention or health promotion, and as Shi and Singh (2015a) state, Preventative and health promotional efforts need to be adopted to significantly improve the health of Americans (p. 73). This sentiment is one shared by many professionals and organizations. Recovery based care focuses on the treatment
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 13 of those individuals which can afford it, as seen when specialist physicians turn away those under the Medicaid program and those who are uninsured. When these patients can t receive the care they need, their health declines. Onie, CEO of the Health Leads organization, saw the way low socioeconomic patients and minority groups were handled within health care and stated the need for a health care system, not a sick care system (Onie, 2012). Specialist physicians preform this sick care or recovery based care, and as mentioned before, the increase of these professionals will only continue to harm health outcomes. It has been seen that an increase in specialists increases mortality rate and decreases public health, while an increase in primary care physicians has the opposite affect: An increase of one primary care physician per 10,000 population was associated with a reduction of 34.6 deaths per 100,000 population at the state level (Starfield et al, 2005, para. 8). Primary care physician s focus on prevention based care and health promotion, and that this form of care has been seen to have the result of increasing health outcomes. In order to stay healthy, everyone needs to have easy access to primary care services. This is a claim that organizations, such as The National Health Service Corps (NHSC), the ACA, CHC s, and Health Leads, have agreed upon and worked to make a reality. This can be seen very well in the following statement made by the NHSC (n.d.): strengthening and growing our primary care workforce is critical to keeping this nation healthy (Sites section, para. 2). The National Health Service Corps provides benefits for those who decide to join, such as loan repayment and scholarships for those still in school. Through these incentives the organization hopes to recruit enough physicians to eliminate Health Professional Shortage Areas. As observed by Starfield (2005), increasing the amount of primary care physician s decreases death rates, increases quality of care, lowers costs, and increases positive health outcomes. The
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 14 maldistribution between primary care physicians and specialist physicians has caused many issues within the health care industry, but by increasing the amount of primary care physicians and creating easier access to this care for all, there will be an overall positive outcome for population health and health care expenditures. Another way in which the health industry could be improved for minority individuals is through the expansion and promotion of the Health Leads organization. Not only would this program significantly improve the health of those low SES individuals who cannot afford to obtain basic needs, but it would also provide experience and work opportunities for college students. The Health Leads organization was founded by Rebecca Onie and Barry Zuckerman in 1996 ( Creating a new model, 2012, p. 2796). This organizations purpose is to prescribe basic needs to low income individuals in need and assist them in obtaining these needs, continuing care to ensure the health of these individuals. Onie (2012) believes that providing basic needs, a form of prevention care which prevents disease from inadequate living conditions, is more important than that of specialty care. Unfortunately, Health Leads has only twenty three sites within six cities in the U.S., these cities including Baltimore, Boston, New York, Washington DC, Chicago, and Providence ( Creating a new model,2012, p. 2796). Diffusing this organization would improve the lives of those in need; patients would be able to work with college advocates in order to obtain the basic resources provided within their communities. Though Health Leads is a nonprofit organization, it still needs money to provide care, and is mostly funded by grants and different foundations. With some amount of federal funding, this organization would thrive and continue to aid minority populations across the country. Another organization which, with expansion, would significantly improve public health and decrease disparities for minority populations would be the Community Health Center. As
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 15 pointed out, the majority of CHC care is provided to the minority population. Adashi (2010), noted that while the country has been struggling with the facility of primary care, the government has been working on the expansion of these centers (para. 5). In fact, around forty seven million dollars has been dedicated to primary care training programs for residents, medical students, physician assistants, and dentists. (Adashi, 2010, para. 5). The funding and emphasis that the government has given to this form of care shows its importance and need for diffusion. Because these facilities provide care for all individuals, insured and uninsured, the expansion of these centers which provide primary care services to all would be very beneficial to minority populations. In regards to pay for services, these centers use a sliding scale for those uninsured individuals based on their income (Adashi, 2010). This scale allows individuals to pay based on the amount of money they make, making it more affordable and easily accessible for all. The transportation services provided also make these centers easier to access for those with no available transportation. With more focus on the expansion of these centers, more minority individuals will have access to these centers preventative services, something which would significantly affect the public health. The United States health care system, while it may be the most technologically advanced system, is one which still needs a lot of work. This system follows a biomedical model of health which creates many issues and barriers for those of minority populations. These barriers come from not only the inequalities faced by these populations, but also the problems within the health system itself such as the focus on the highest payer and discriminatory practitioners. One of the main issues with this system is its focus on recovery based care over prevention based care. Primary prevention is a necessity in creating a healthy population: it decreases mortality rates, costs, and works to prevent the development of chronic illness. With the focus being on care
U.S. BIOMEDICAL MODEL OF HEALTH Last Name 16 which only cures illness, the obvious outcome will be decreased public health and increased costs of care due to the expensive procedures needed to cure an illnesses which could have been prevented. Whether it is through organizations such as the NHSC or CHC s, the U.S. needs an increase in general practitioners, or primary care physicians. One should not assume that this also means there should be a decrease in the amount of specialist physicians, however. Though the increasing amount of these physicians decreases the public health, their services are still important for those who require them. What is needed of these physicians is their equal distribution throughout the country, as opposed to being concentrated in heavily populated areas. While the solutions provided are only a few of the ways to improve the health system, they are all important stepping stones and with a shift in focus from recovery based care to prevention based care, the United States will see a more efficient health system that does not overlook minority populations needs.
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U.S. BIOMEDICAL MODEL OF HEALTH Last Name 18 Onie, R. (2012, April). What if our healthcare system kept us healthy? [Video File]. Retrieved from https://www.ted.com/talks/rebecca_onie_what_if_our_healthcare_system_kept_us_health y Shi, L., & Singh, D.A. (2015a). Beliefs, values, and health. In C. Falivene (Ed.), Delivering health care in America: A systems approach (pp. 39-75). Burlington, MA: Jones & Bartlett Learning. Shi, L., & Singh, D.A. (2015b). Health services for special populations. In C. Falivene (Ed.), Delivering health care in America: A systems approach (pp. 415-452). Burlington, MA: Jones & Bartlett Learning. Shi, L., & Singh, D.A. (2015c). Inpatient facilities and services. In C. Falivene (Ed.), Delivering health care in America: A systems approach (pp. 291-333). Burlington, MA: Jones & Bartlett Learning. Slusky, R. 2006. An investment in rural hospitals is an investment in healthier communities. AHA News 42(5), 4-5. Retrieved from http://proquest.com Starfield, B., Shi, L., Grover, A., & Macinko, J. (2005). The effects of specialist supply on populations' health: Assessing the evidence. Health Affairs, 24, 97-107. Retrieved from http://proquest.com United States Census Bureau (2015). New Census Bureau Report Analyzes U.S. Population Projections. Retrieved from http://www.census.gov