The Moribund Health-Care Debate

Kevin Lewis

November 07, 2009

"In reality, the health care wrestling match is less a test of Mr. Obama's political genius than it is a test of the Democratic Party's ability to govern...What's more, health care reform is the Democratic Party's signature issue. Its wonks have thought longer and harder about it than any other topic. Its politicians are vastly better at talking about the subject than Republicans: if an election is fought over health care, bet on the Democrat every time. And for all the complexity involved, it's arguably easier to tackle than other liberal priorities. It's more popular than cap and trade, it's less likely to split the party than immigration and it's more amenable to technocratic interventions than income inequality. If the Congressional Democrats can't get a health care package through, it won't prove that President Obama is a sellout or an incompetent. It will prove that Congress's liberal leaders are lousy tacticians, and that its centrist deal-makers are deal-makers first, poll watchers second and loyal Democrats a distant third. And it will prove that the Democratic Party is institutionally incapable of delivering on its most significant promises. You have to assume that on some level Congress understands this - which is why you also have to assume that some kind of legislation will eventually pass. If it doesn't, President Obama will have been defeated. But it's the party, not the president, that will have failed." ["Don't Blame Obama," Ross Douthat, The New York Times, August 23, 2009]


Racial Prejudice Predicts Opposition to Obama and his Health Care Reform Plan

Eric Knowles, Brian Lowery & Rebecca Schaumberg
Journal of Experimental Social Psychology, forthcoming

The present study examines the relationship between racial prejudice and reactions to President Barack Obama and his policies. Before the 2008 election, participants' levels of implicit and explicit anti-Black prejudice were measured. Over the following days and months, voting behavior, attitudes toward Obama, and attitudes toward Obama's health care reform plan were assessed. Controlling for explicit prejudice, implicit prejudice predicted a reluctance to vote for Obama, opposition to his health care reform plan, and endorsement of specific concerns about the plan. In an experiment, the association between implicit prejudice and opposition to health care reform replicated when the plan was attributed to Obama, but not to Bill Clinton-suggesting that individuals high in anti-Black prejudice tended to oppose Obama at least in part because they dislike him as a Black person. In sum, our data support the notion that racial prejudice is one factor driving opposition to Obama and his policies.


Development and Validation of the Physician-Patient Humor Rating Scale

Kelly Haskard Zolnierek, Robin Dimatteo, Melissa Mondala, Zhou Zhang, Leslie Martin & Andrew Messiha
Journal of Health Psychology, November 2009, Pages 1163-1173

The purpose of this study was the development of a rating instrument to assess the use of humor in physician-patient interactions, and to compare humor use as a function of patients' socioeconomic status. The 46-item Physician-Patient Humor Rating Scale (PPHRS) was used to rate 246 audiotaped primary care interactions. Four subscales were reliable and valid, demonstrating correlations with patient satisfaction and reports of physician humor, with physician satisfaction and with separate affective communication ratings. There was a significant difference in use of humor as a function of patient socioeconomic status, such that there was greater mutual trust between physicians and high versus low income patients.


Moral disengagement and tolerance for health care inequality in Texas

Alfred McAlister
Mind & Society, forthcoming

Societies vary in their levels of social inequality and in the degree of popular support for policies that reduce disparities within them. Survey research in Texas, where levels of disparity in health and medical care are relatively high, studied how psychological mechanisms of moral disengagement relate to public support for expanding access to government-subsidized health care. Telephone interviews (N = 1,063) measured agreement with statements expressing tendencies to minimize the effects of inequality, blame its victims and morally justify limits on government help. The interviews also assessed support for general and specific policies to reduce inequality, e.g., through state-subsidized health care for lower income groups, as well as political party affiliation, ideological orientation, gender, age, education and income. Agreement with beliefs expressing moral disengagement was associated with opposition to governmental policies to reduce inequality in children's health care. Beliefs that justify the withholding of government assistance, blame the victims of societal inequality, and minimize perceptions of their suffering were strongly related to variation between and within groups in support for governmental action to reduce inequality.


Sex Roles in Health Storylines on Prime Time Television: A Content Analysis

Heather Hether & Sheila Murphy
Sex Roles, forthcoming

This study examined the role of character gender in prime time television health portrayals. A content analysis of 1,291 health-related storylines from three spring seasons (2004-2006) of the ten most popular American television programs measured the frequency of male and female characters in prominent roles and how storylines differed with the sex of the ill or injured character. Our analyses revealed a significantly greater number of male characters. Moreover, storylines with a male ill or injured character were more serious in tone, more likely to take place in a medical setting, and had higher educational value. Proportionally, there were some similarities in storylines across the sexes, however, the absolute differences are striking and may have unfortunate effects on viewers.


Socioeconomic inequalities in health dynamics: A comparison of Britain and the United States

Peggy McDonough, Diana Worts & Amanda Sacker
Social Science & Medicine, forthcoming

Drawing on theory and research on the fundamental causes of health, the life course, and the welfare state, we investigate previous social inequalities in dynamic self-rated health for working-aged Britons and Americans. We use data from the British Household Panel Survey and Panel Study of Income Dynamics (1990-2004) and a mixture latent Markov model to test a theoretical model of health as a discrete state that may remain stable or change over time. Our contributions are threefold. First, our finding of three distinctive types of health processes (stable good health, stable poor health, and a "mover" health trajectory) represents a more differentiated profile of long-term health than previously shown. Second, we characterize health trajectories in structural terms by suggesting who was more likely to experience what type of health trajectory. Third, our more differentiated picture of dynamic health leads to a more nuanced understanding of comparative health: Although the health advantage of Britons was confirmed, our results also indicate that they were more likely to experience health change. Moreover, the socioeconomic gradient in long-term health was steeper in the US, raising provocative questions about how state policies and practices may affect population health.


Public Responses to Health Disparities: How Group Cues Influence Support for Government Intervention

Elizabeth Rigby, Joe Soss, Bridget Booske, Angela Rohan & Stephanie Robert
Social Science Quarterly, December 2009, Pages 1321-1340

Objective: To examine whether public support for government intervention to address health disparities varies when disparities are framed in terms of different social groups.

Method: A survey experiment was embedded in a public opinion poll of Wisconsin adults. Respondents were randomly assigned to answer questions about either racial, economic, or education disparities in health. Ordered logit regression analyses examine differences across experimental conditions in support for government intervention to address health disparities.

Results: Health disparities between economic groups received the broadest support for government intervention, while racial disparities in health received the least support for government intervention. These differences were explained by variation in how respondents' perceived and evaluated health disparities between different social groups.

Conclusion: Efforts to garner public support for policies aimed at eliminating health disparities should attend to the politics of social diversity, including the public's disparate perceptions and evaluations of health disparities defined by different social groups.


Do Health Insurance and Residence Pattern the Likelihood of Tubal Sterilization among American Women?

Loretta Bass & Nicole Warehime
Population Research and Policy Review, April 2009, Pages 237-249

American women have increasingly opted for tubal sterilization or tubal ligation surgery in recent decades. While research has begun to examine the unequal access to health care in the United States, little research has considered how this may impact whether women opt for a tubal ligation surgery. We first profile women with and without tubal ligations using bivariate analysis of the most recent data available, a nationally representative sample of 7,643 women from the National Survey of Family Growth, Cycle 6 (NSFG, Public use data file, 2002). We then use logistic regression models to examine the relationship between having tubal ligation and two focal variables: (1) type of health insurance (Medicaid compared with private, government or military, and no health insurance), and (2) rural or urban place of residence. We find that women on Medicaid are nearly twice as likely to have had a tubal sterilization compared with women who have private health insurance coverage. Also, women on Medicaid are substantially more likely to have a tubal sterilization than women with government or military insurance and women with no health insurance (26% and 36%, respectively). Further, we find that women living in rural areas are nearly twice as likely to have a tubal sterilization, compared with women in urban or suburban areas, all else being equal.


Changing the Way the Elderly Live: Evidence from the Home Health Care Market in the United States

Chiara Orsini
Journal of Public Economics, forthcoming

I examine how decreases in government coverage of home health care visits to the elderly in the United States have affected their living arrangements. Specifically, I exploit geographic variation in the Medicare Home Health Care reimbursement rate that arose as a result of legislation passed in 1997 and I identify its impact on the living arrangements of older Medicare beneficiaries. I find that less generous reimbursement policies lead to a greater fraction of elderly giving up independent living. Baseline-model estimates suggest that a decline in reimbursement of one visit per user leads to a 0.98 percent increase in the fraction of elderly Medicare beneficiaries living in shared living arrangements, that is, living with somebody else, rather than alone or with only the spouse. This estimate implies that a decline in reimbursement of 5.1 visits per Medicare beneficiary increases the fraction of elderly that live in shared living arrangements by 1.12 percentage points. Such an increase is consistent with the time-series increase in the fraction of elderly that live in shared living arrangements between 1997 and 2000.


Cultural Beliefs About a Patient's Right Time to Die: An Exploratory Study

Henry Perkins, Josie Cortez & Helen Hazuda
Journal of General Internal Medicine, November 2009, Pages 1240-1247

Background: Generalist physicians must often counsel patients or their families about the right time to die, but feel ill-prepared to do so. Patient beliefs may help guide the discussions.

Objective: Because little prior research addresses such beliefs, we investigated them in this exploratory, hypothesis-generating study.

Design and Subjects: Anticipating culture as a key influence, we interviewed 26 Mexican Americans (MAs), 18 Euro-Americans (EAs), and 14 African Americans (AAs) and content-analyzed their responses.

Main Results: Nearly all subjects regardless of ethnic group or gender said God determines (at least partially) a patient's right time to die, and serious disease signals it. Yet subjects differed by ethnic group over other signals for that time. Patient suffering and dependence on "artificial" life support signaled it for the MAs; patient acceptance of death signaled it for the EAs; and patient suffering and family presence at or before the death signaled it for the AAs. Subjects also differed by gender over other beliefs. In all ethnic groups more men than women said the time of death is unpredictable; but more women than men said the time of death is preset, and family suffering signals it. Furthermore, most MA women-but few others-explicitly declared that family have an important say in determining a patient's right time to die. No confounding occurred by religion.

Conclusions: Americans may share some beliefs about the right time to die but differ by ethnic group or gender over other beliefs about that time. Quality end-of-life care requires accommodating such differences whenever reasonable.


End-of-Life Treatment Preferences Among Older Adults: An Assessment of Psychosocial Influences

Deborah Carr & Sara Moorman
Sociological Forum, September 2009, Pages 754-778

We explore the content and correlates of older adults' end-of-life treatment preferences in two hypothetical terminal illness scenarios: severe physical pain with no cognitive impairment, and severe cognitive impairment with no physical pain. For each scenario, we assess whether participants would reject life-prolonging treatment, accept treatment, or do not know their preferences. Using data from the 2004 wave of the Wisconsin Longitudinal Study (N = 5,106), we estimate multinomial logistic regression models to evaluate whether treatment preferences are associated with direct experience with end-of-life issues, personal beliefs, health, and sociodemographic characteristics. Persons who have made formal end-of-life preparations, persons with no religious affiliation, mainline Protestants, and persons who are pessimistic about their own life expectancy are more likely to reject treatment in both scenarios. Women and persons who witnessed the painful death of a loved one are more likely to reject treatment in the cognitive impairment scenario only. Consistent with rational choice perspectives, our results suggest that individuals prefer treatments that they perceive to have highly probable desirable consequences for both self and family.


Patient Satisfaction and Physician Productivity: Complementary or Mutually Exclusive?

Craig Wood, Robert Spahr, John Gerdes, Zahra Daar, Randall Hutchison & Walter Stewart
American Journal of Medical Quality, November 2009, Pages 498-504

Motivating physicians to increase productivity and maximize patient satisfaction may result in conflicted behavior, raising questions about whether one must be sacrificed for the other. To determine if high satisfaction (measured by Press Ganey patient satisfaction survey) can be achieved while maintaining high productivity (measured in McGladrey relative value units, MRVU), longitudinal data collected from January 2002 to July 2004 were modeled using repeated measures regression. A total of 136 000 patient-completed satisfaction questionnaires evaluating 417 physicians were collected for analysis. Patient confidence (positively correlated; P = .001) and physician/patient time (inversely correlated; P = .001) were associated with higher physician productivity. Increases in MRVU were associated with decreases in patient perceptions of time with the physician (P = .003). The relationships between patient satisfaction and physician productivity were relatively small, suggesting that they are not necessarily incompatible and that both can be improved simultaneously.

The Rise and Impact of Nurse Practitioners and Physician Assistants on Their Own and Cross-Occupation Incomes

John Perry
Contemporary Economic Policy, October 2009, Pages 491-511

There has been a dramatic increase in the authority granted to nurse practitioners (NP) and physician assistants (PA). This "expanded" authority has changed who can provide health-care services and has weakened the control physicians have traditionally held over the provision of medical services. These changes in regulation have varied by occupation, state, and year and provide variation that can be exploited to empirically measure the individual and collective impacts of changes in NP authority and PA authority on practitioner incomes. It is found that changes in NP and PA regulatory authority do impact the labor markets of all three practitioner categories. NPs having greater practice authority brings physician incomes down, has differential impacts on PA incomes, and improves their own earnings, other factors held constant. PAs having increased authority has a downward effect on NP earnings, a positive impact on physician income, and little impact on their own incomes.


Adoption And Spread Of New Imaging Technology: A Case Study

Joseph Ladapo, Jill Horwitz, Milton Weinstein, Scott Gazelle & David Cutler
Health Affairs, November/December 2009, Pages w1122-w1132

Technology is a major driver of health care costs. Hospitals are rapidly acquiring one new technology in particular: 64-slice computed tomography (CT), which can be used to image coronary arteries in search of blockages. We propose that it is more likely to be adopted by hospitals that treat cardiac patients, function in competitive markets, are reimbursed for the procedure, and have favorable operating margins. We find that early adoption is related to cardiac patient volume but also to operating margins. The paucity of evidence informing this technology's role in cardiac care suggests that its adoption by cardiac-oriented hospitals is premature. Further, adoption motivated by operating margins reinforces concerns about haphazard technology acquisition.

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