Benefits And Disparities of A Public Health Nurse Essay

Benefits And Disparities of A Public Health Nurse Essay

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Discussion question 1:

Social justice refers to the benefits and disparities that members of society experience (Stanhope & Lancaster, 2016). There are three theories on how one achieves social justice: egalitarian, libertarian, and liberal democratic (Stanhope & Lancaster, 2016). Egalitarianism advocates for the government ensuring equal rights and treatment by all members of society (Stanhope & Lancaster, 2016). Libertarianism recognizes the right to equality and liberty, while advocating for the right to private property and minimal to no government control or intervention, relying on individuals to determine their own fate (Stanhope & Lancaster, 2016). Liberal democratic ideology encompasses both the belief that we all have the right to liberty and equality, while recognizing, and attempting to compensate for both organic and inorganic disadvantages that are acquired from time of birth to time of death (Stanhope & Lancaster, 2016). Benefits And Disparities of A Public Health Nurse Essay

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A public health nurse should focus on promoting and ensuring wellness to all persons in a way that is cost effective, indiscriminate, and allows autonomy (Stanhope & Lancaster, 2016). This is difficult to achieve when we have documented issues of socioeconomic disparities that can be demonstrated when people are categorized by race, sex, gender, and sexual orientation (US Census Bureau, 2020). While going over our weekly reading I came across the term “assurance”. Assurance is making sure that health services are available, including to those who would not otherwise receive them (Stanhope & Lancaster, 2016). This can be a daunting initiative when dealing with some of the most marginalized segments of society (homeless, transgender, undocumented persons etc.), who frequently abstain from seeking medical treatment (Stanhope & Lancaster, 2016).

Eliminating, or even minimizing healthcare disparities, needs to extend beyond the healthcare system and into society at large. Law makers and community leaders need to work together to figure out why data shows that socioeconomic disparities are so prevalent amongst clearly defined groups. Unfortunately, listening to narrative commentary on any news channel or a simple scroll through social media shows that we aren’t making much progress on these issues. Even worse, decades of research has indicated that there is systemic racism in the U.S. health system (Feagin & Bennefield, 2014). So, what can a nurse do? Can we change the healthcare industry when this is a societal problem? I think it is important that we advocate for an ethical standard in our respective workplaces, that encompasses fair and equal treatment to not only our patients, but also our coworkers. I have witnessed obvious differences in treatment of both groups that is dependent on any number of demographic categories. I am curious if other members of the class have experienced the same. Benefits And Disparities of A Public Health Nurse Essay

Discussion Questions #2:

Does the constitution guarantee the right to pursue happiness? Nope, not in there. Does the constitution guarantee everyone the right to fairness? Again no. Who says life is fair? Why does one person get to live long enough to obtain their senior discounted coffee at McDonald’s, and the other die young? Should society bear the responsibility for the poor life choices made by its members? What the constitution does guarantee is equality under the law. The law applies to everyone regardless of skin color, religion, sex, or national origin. Equality, however, does not imply uniformity. Communism attempts to enforce uniformity on society, suppressing the rights and privileges of its members (Novak, 2019).

Health care in the United States is not equitable. With insurance provided through my job, I can acquire preventive healthcare services that are generally not provided during an ED visit. One of the roles of public health is to assure that essential community health services are available for everyone (Stanhope & Lancaster, 2016). Nurses should advocate for the disenfranchised, working to ensure that essential health care resources are available for all people, and public policy should support nursings’ efforts to provide equitable care for every member of society (Stanhope & Lancaster, 2016). Equality should not be just for the healthcare sector but for all areas of life that affect health. Healthy, fresh foods such as fruits and vegetables should be available to all at affordable prices. Community resources that support healthy activities such as parks and recreation should be available to all, regardless of what community in which they reside. Equitable does not mean free; rather, it is equitable that all members of society should share in the burden of public services (Stanhope & Lancaster, 2016). Benefits And Disparities of A Public Health Nurse Essay

As members of society, personal responsibility is necessary for law and order. Personal responsibility must be balanced with free rights. The “common good” is often spoken of as something noble, but quickly becomes totalitarianism in the hands of politicians (Novak, 2019).

The Association of State and Territorial Directors of Nursing (ASTDN) has long
espoused the values of health equity and social justice. In May 2006, the
Association convened its members and an invited panel of community experts in a
series of explicit learning opportunities and conversations to revive and rededicate
ourselves as state-level public health nursing leaders to the elimination of health
inequalities and disparities in the United States and its Territories. Many of the
concepts and suggestions described as Public Health Nursing roles, responsibilities
and obligations were identified through that and subsequent discussions.
Purpose
This paper is an outgrowth of ASTDN’s commitment to the elimination of health
disparities and the achievement of health equity for all, and underscores the
important role public health nurses play in eliminating inequities in health. Its
purpose is to inspire public health nurses to serve as leaders and major contributing
forces in the elimination of health inequities in the United States and its Territories.
The nursing profession was one of the early innovators in the recognition of the
importance of culture in health with its recognition of transcultural nursing. Our
values of health equity and social justice evolved out of direct experience, witnessing
the visible and sometimes deadly hardships experienced by resident and
undocumented populations at the turn of the 20th Century. Visible and deadly
hardships persist today, some obvious and some insidious, most notably black infant
mortality, escalating rates of chronic diseases and the impact of the social gradient
on quality of life.
Despite the enormity of the challenges that public health nurses face every day, it is
imperative that public health nurses continue to move forward and develop
successful evidence-based strategies and approaches in their practice settings. The
incremental steps taken may not seem to make a difference in the present but could
be the foundation for the achievement of health equity in the future. Public health
nurses have always been and must continue to be catalysts and change agents. We
may just be the “continuing expression of an ideal.”
This paper is a call to public health nurses across the United States and its Territories
that we may find our voices, renew our commitment to the elimination of health
2
inequities, and help build durable public policy that promotes and protects health for
all and assures conditions that support safe and healthy communities.
Definitions
For the purposes of this position paper, ASTDN based it definition of health
disparity from Carter-Pokras and Baquet in the seminal publication entitled: “What
is a Health Disparity?” (2002). Benefits And Disparities of A Public Health Nurse Essay
According to Carter-Pokras and Baquet, most dictionaries define disparities as
inequalities, a “condition of being unequal.” Taking this to the next level, inequities
represents a judgment – Is the inequity unjust or unfair? One must factor-in not
only “who is deciding what is avoidable and unjust, and how it is decided.” Thus,
“disparity in the context of public health and social science, therefore has begun to
take on the implications of injustice, but nonetheless may be distinguished from the
general term ‘inequality.’ A health disparity should be viewed as a chain of events
signified by a difference in: (1) environment, (2) access to, utilization of, and quality
of care, (3) health status, or (4) a particular health outcome that deserves scrutiny.
Such a difference should be evaluated in terms of both inequality and inequity, since
what is unequal is not necessarily inequitable.” (Carter-Pokras, Baquet, 2002)
ASTDN is defining health equity as an ideal state marked by fairness and the
achievement of optimal health and wellbeing for all populations, where disparities in
health status are eliminated across populations by race, ethnicity, gender,
geography, disability, religion, sexual preference and mental status. Health equity
may be viewed as an equal and fair distribution of health and wellbeing.
Public health nurses in the United States and its Territories need to be aware that
research on health disparities and health equity is an emerging and evolving body of
work and currently lacks agreement on common definitions. This body of work is led
by notable researchers, institutions, and organizations that include the USDHHS
Office of Minority Health, the National Institutes of Health, the Association of State
and Territorial Health Officers, the National Association of City and County Health
Officials, and the Kaiser Permanente Institute of Health Policy, to name a few. At
this writing, work continues to resolve conceptual differences in the definitions of
health disparity and health inequality. The current incomplete condition of research
should not dissuade public health nurses in their efforts to assure health equity.

Executive Summary
1. What are health and health care disparities?
Health and health care disparities refer to differences in health and health care between groups that are closely linked with social, economic, and/or environmental disadvantage. Disparities occur across many dimensions, including race/ethnicity, socioeconomic status, age, location, gender, disability status, and sexual orientation.

2. Why do health and health care disparities matter?
Disparities in health and health care not only affect the groups facing disparities, but also limit overall gains in quality of care and health for the broader population and result in unnecessary costs. Addressing health disparities is increasingly important as the population becomes more diverse. It is projected that people of color will account for over half (52%) of the population in 2050. Benefits And Disparities of A Public Health Nurse Essay

3. What is the current status of disparities?
Although the Affordable Care Act (ACA) lead to large coverage gains, some groups remain at higher risk of being uninsured, lacking access to care, and experiencing worse health outcomes. For example, as of 2018, Hispanics are two and a half times more likely to be uninsured than Whites (19.0% vs. 7.5%) and individuals with incomes below poverty are four times as likely to lack coverage as those with incomes at 400% of the federal poverty level or above (17.3% vs. 4.3%).

4. What are key initiatives to address disparities?
The ACA’s coverage expansions and funding for community health centers increased access to coverage and care for many groups facing disparities, and other provisions explicitly focused on reducing disparities. At the federal level, the Department of Health and Human Services is engaged in a range of actions to implement its 2011 action plan to eliminate racial and ethnic health disparities. States, local communities, private organizations, and providers also are engaged in efforts to reduce health disparities, which increasingly encompass a focus on social factors influencing health. Benefits And Disparities of A Public Health Nurse Essay

5. What are current challenges to addressing disparities?
Recent policy changes and current priorities may lead to coverage declines moving forward. Beyond coverage, there are an array of other challenges to addressing disparities, including limited capacity to address social determinants of health, declines in funding for prevention and public health and health care workforce initiatives, and ongoing gaps in data to measure and understand disparities.

1. What are health and health care disparities?
Health and health care disparities refer to differences in health and health care between groups. A “health disparity” refers to a higher burden of illness, injury, disability, or mortality experienced by one group relative to another.1 A “health care disparity” typically refers to differences between groups in health insurance coverage, access to and use of care, and quality of care. Health and health care disparities often refer to differences that are not explained by variations in health needs, patient preferences, or treatment recommendations and are closely linked with social, economic, and/or environmental disadvantage. The terms “health inequality” and “inequity” also are used to refer to disparities. Benefits And Disparities of A Public Health Nurse Essay

A complex and interrelated set of individual, provider, health system, societal, and environmental factors contribute to disparities in health and health care. Individual factors include a variety of health behaviors from maintaining a healthy weight to following medical advice. Provider factors encompass issues such as provider bias and cultural and linguistic barriers to patient-provider communication. How health care is organized, financed, and delivered also shapes disparities. Moreover a broad array of social and environmental factors affect individuals’ health and ability to engage in healthy behaviors (Figure 1).4

Figure 1: Social Determinants of Health

Health and health care disparities are commonly viewed through the lens of race and ethnicity, but they occur across a broad range of dimensions. For example, disparities occur across socioeconomic status, age, geography, language, gender, disability status, citizenship status, and sexual identity and orientation. Federal efforts to reduce disparities focus on designated priority populations who are vulnerable to health and health care disparities, including people of color, low-income groups, women, children, older adults, individuals with special health care needs, and individuals living in rural and inner-city areas.5,6,7 These groups are not mutually exclusive and often interact in important ways. Disparities also occur within subgroups of populations. For example, there are differences among Hispanics in health and health care based on length of time in the country, primary language, and immigration status.8,9 Research also suggests that disparities occur across the life course, from birth, through mid-life, and among older adults. Benefits And Disparities of A Public Health Nurse Essay

2. Why do health and health care disparities matter?
Addressing disparities in health and health care is important not only from an equity standpoint, but also for improving health more broadly by achieving improvements in overall quality of care and population health. Moreover, health disparities are costly. Analysis estimates that disparities amount to approximately $93 billion in excess medical care costs and $42 billion in lost productivity per year as well as economic losses due to premature deaths.12

It is increasingly important to address health disparities as the population becomes more diverse. It is projected that people of color will account for over half (52%) of the population in 2050, with the largest growth occurring among Hispanics (Figure 2). There also are wide gaps in income across the population. As of 2018, the richest 20% of households have an average income of $234,000, nearly 17 times the average income of $14,000 for the bottom 20% of households (Figure 3).13 Benefits And Disparities of A Public Health Nurse Essay

Figure 2: Distribution of U.S. Population by Race/Ethnicity, 2016 and 2050

Figure 3: Gaps Between Average Annual Income of Richest and Poorest Households in the United States, 2018

What is the current status of disparities?
Despite overall improvements in population health over time, many disparities have persisted and, in some cases, widened.14 People of color and low-income individuals historically have faced greater barriers to accessing care, including a higher uninsured rate, compared to Whites and those at higher incomes.15 Data also show that disparities in some health outcomes, such as heart disease mortality rates among Blacks and diabetes mortality rates among AIANs, have widened over time.16

The ACA led to large coverage gains for many groups facing disparities. The ACA created new coverage options, including a Medicaid expansion and health insurance marketplaces. Following enactment of the ACA in 2010, there were large coverage gains across racial and ethnic groups, with the sharpest increases after implementation of the Medicaid and marketplace expansions in 2014 (Figure 4).17 Groups of color experienced larger coverage gains compared to Whites as a share of the population, which narrowed percentage point differences in uninsured rates between groups of color and Whites.18 However, most groups of color remained more likely to be uninsured compared to Whites as of 2018. Moreover, the relative risk of being uninsured compared to Whites did not improve for some groups. For example, Blacks remained 1.5 times more likely to be uninsured than Whites between 2010 and 2018, and the Hispanic uninsured rate remained over 2.5 times higher than the rate for Whites.19 Lower-income individuals also experienced large coverage gains that narrowed percentage point differences in uninsured rates for poor (<100% of the federal poverty level, FPL) and near-poor (100-299% FPL) individuals compared to those at higher incomes (400% FPL and above). Relative disparities by income also narrowed. For example, in 2010, the uninsured rate for poor individuals was five times higher than the rate for those at higher incomes (400% FPL or above) (30.3% vs. 6.0%), while in 2018, it was four times higher (17.3% vs. 4.3%). However, low-income groups remained more likely to be uninsured than those at higher incomes. Benefits And Disparities of A Public Health Nurse Essay

Figure 4: Uninsured Rates for the Nonelderly Population by Race and Ethnicity, 2010-2018

Beginning in 2017 and continuing in 2018, coverage gains stalled and reversed for some groups. The uninsured rate for the total nonelderly population increased from 10.0% in 2016 to 10.4% in 2018.20 This reversal in coverage trends eroded some of the progress achieved in reducing uninsured rates for Whites and Blacks as well as for groups with incomes above the poverty level (Figure 5).

Figure 5: Change in Uninsured Rate among the Nonelderly Population by Selected Characteristics, 2016-2018

Many groups continue to face significant disparities in access to and utilization of care.21 For example, among nonelderly adults, Hispanics, Blacks, and American Indians and Alaska Natives are more likely than Whites to delay or go without needed care (Figure 6). Moreover, nonelderly Black and Hispanic adults are less likely than their White counterparts to have a usual source of care or to have had a health or dental visit in the previous year.22 Low-income individuals also experience more barriers to care and receive poorer quality care than high-income individuals.23 Disparities in access and use also occur across other dimensions. For example, individuals living in rural areas face a range of barriers to accessing care.24

Figure 6: Share of Nonelderly Adults Who Did Not Receive Care or Delayed Care in the Past Year by Race/Ethnicity, 2018 Benefits And Disparities of A Public Health Nurse Essay

Additionally, some groups are at higher risk for health conditions and experience poorer health outcomes compared to other groups. For example, Blacks and American Indians and Alaska Natives are more likely than Whites to report a range of health conditions, including asthma and diabetes; American Indians and Alaska Natives also have higher rates of heart disease compared to Whites.25 Health disparities are particularly striking in AIDS and HIV diagnoses and death rates (Figure 7).26 Infant mortality rates are higher for Blacks and American Indians and Alaska Natives compared to Whites,27 and Black males have the shortest life expectancy compared to other groups.28 Low-income people of all races report worse health status than higher income individuals.29 Further, research suggests that some subgroups of the LGBT community have more chronic conditions as well as higher prevalence and earlier onset of disabilities than heterosexuals.30

Figure 7: HIV or AIDS Diagnosis and Death Rate per 100,000 Among Teens and Adults by Race/Ethnicity

3. What are key initiatives to eliminate disparities?
Major recognition of health and health care disparities began nearly two decades ago. Two Surgeon General’s reports in the early 2000s showed disparities in tobacco use and access to mental health services by race and ethnicity.31,32 The first major legislation focused on reduction of disparities, the Minority Health and Health Disparities Research and Education Act of 2000,33 created the National Center for Minority Health and Health Disparities, and authorized the Agency for Healthcare Research and Quality to regularly measure progress on reduction of disparities. Soon after, the Institute of Medicine released two seminal reports showing racial and ethnic disparities in access to and quality of care. Benefits And Disparities of A Public Health Nurse Essay

The ACA included provisions that advanced efforts to reduce disparities.36 The ACA’s broad coverage expansions and increased funding for community health centers improved access to coverage and care for many groups facing disparities. Other ACA provisions explicitly focused on reducing disparities, such as creating Offices of Minority Health within HHS agencies to coordinate disparity reduction efforts. The ACA also promoted workforce diversity and cultural competence, increasing funding for health care professional and cultural competence training and education materials, and strengthened data collection and research efforts. Moreover, the ACA included prevention and public health initiatives and created the Prevention and Public Health Fund. It also permanently reauthorized the Indian Health Care Improvement Reauthorization Extension Act of 2009.

As the federal level, the Department of Health and Human Services (HHS) has engaged in a range of initiatives focused on addressing disparities. In 2011, HHS developed an action plan for eliminating racial and ethnic health disparities, which built on the Healthy People 2020 goal to achieve health equity and eliminate disparities.37,38,39 Since the release of the report, HHS has undertaken various efforts to implement the plan including coordinating programmatic and policy efforts to advance health equity, expanding access and quality of coverage and care, and strengthening the health care infrastructure and workforce.40 In 2013, HHS updated the national standards for Culturally and Linguistically Appropriate Services (CLAS), which seek to ensure that people receive care in a culturally and linguistically appropriate manner.41 In 2013, the Centers for Medicare and Medicaid Services (CMS) released an equity plan for improving quality in Medicare, and, in 2018, it released a new rural health strategy.42 Other CMS equity initiatives include the “From Coverage to Care” initiative focused on connecting individuals to primary and preventive services and a minority research grant program focused on designing and testing interventions that may reduce disparities in readmissions and/or patient experience. Benefits And Disparities of A Public Health Nurse Essay

States, local communities, private organizations, and providers also are engaged in efforts to reduce health disparities, which increasingly encompass a focus on social factors influencing health.44 State actions to reduce disparities vary considerably. A federal review found that 23 states or territories had a strategic plan addressing minority health or health equity and that one of the most common goals and activities of states is measure development and data collection/analysis.45 Other activities identified included Medicaid expansion, immunization programs, and chronic disease management efforts.46 The review further found that many states’ disparity reduction efforts focus on particular populations, such as children, refugees, and/or individuals experiencing homelessness.47 Private funders, local communities, managed care plans, and providers also are engaged in disparities reduction efforts.48

4. What are current challenges to addressing disparities?
As noted, there were large coverage gains following the ACA, but coverage gains stalled and began reversing in recent years. Recent policy changes and current priorities may lead to continued declines moving forward. For example, the federal government has decreased funds for outreach and enrollment assistance, Congress negated the ACA individual requirement to have coverage, CMS has encouraged and approved waivers from states to add new eligibility restrictions for Medicaid coverage, and the Department of Homeland Security made immigration policy changes that have increased fears among immigrant families about participating in Medicaid and CHIP. Further, the Trump administration is pursuing additional changes, such as supporting litigation to overturn the ACA, releasing guidance allowing states to cap federal funding for Medicaid, and adding eligibility verification requirements to Medicaid that could further curtail coverage and lead to increases in the uninsured rate. Benefits And Disparities of A Public Health Nurse Essay

Beyond coverage, there are an array of other challenges to addressing disparities, including limited capacity to address social determinants of health, declines in funding for prevention and public health and health care workforce initiatives, and ongoing gaps in data. As noted, a range of activities are underway to address disparities, and many of these initiatives encompass a focus on social determinants of health. Within the health care system, these efforts often are occurring through payment and delivery system models that focus on providing whole person care and paying for value or outcomes instead of services.49 However, the administration has begun phasing out and changing the direction of some health care payment and delivery system reforms, which may reduce resources to address social determinants of health.50 Moreover, addressing social determinants of health will require tackling issues that are beyond the health care system’s capacity to address, including large deficiencies in resources to meet social needs, such as affordable housing, and structural and institutional biases and racism. Maintaining support for public health and prevention and expanding and diversifying the health care workforce to increase access to culturally and linguistically appropriate care also underpin efforts to address disparities. However, funding for prevention and public health has been reduced through cuts to the Prevention and Public Health Fund and the President’s Fiscal Year 2021 budget includes further cuts in this area .51,52 Further, although the ACA included provisions to enhance capacity of the health care workforce, many of these provisions were time-limited and have not received continued funding. Benefits And Disparities of A Public Health Nurse Essay

The outcome of the 2020 national elections will have important implications for disparities moving forward. Democratic candidates have proposed or endorsed plans, including a Medicare-for-All option and a public option, that are designed to further expand coverage to individuals and fill in some of the remaining gaps in coverage. Several candidates have also put forth proposals to specifically target racial/ethnic and urban/rural health disparities, especially in maternal health. In contrast, the Trump Administration has pursued policies focused on restricting eligibility for Medicaid, capping funding for the program, and decreased resources for outreach and enrollment assistance. In addition, litigation challenging the ACA with support from the Trump administration is ongoing. Moving forward, whether policies continue to focus on expanding coverage or lead to roll-backs in available coverage options, including restrictions to Medicaid and/or elimination of the ACA, will have major implications for disparities.Benefits And Disparities of A Public Health Nurse Essay