Perspectives on health and social policy M6920 September 4, 2001

Columbia University School of NursingM6920, Fall, 2001 Attitude toward government: l Society is produced by our wants, and government by our wickedness; the former promotes our happiness positively by uniting our affections; the latter negatively by restraining our vices.... government even in its best state is but a necessary evil. Thomas Paine, Common Sense, 1776

Columbia University School of NursingM6920, Fall, 2001 What is policy? l A decision on how to allocate resources to accomplish a purpose l Ideally, it is deliberately adopted after a review of alternatives, and it is intended to be followed.

Columbia University School of NursingM6920, Fall, 2001 Health policy decisions l are supposed to support health l direct response when health is threatened l direct response to treat or cure illness l response when beneficiary of current policy is threatened l organize and pay for intended benefits

Columbia University School of NursingM6920, Fall, 2001 Social policy decisions l are about our life as a community education housing recreation work l affect how groups relate to one another l affect the economic welfare of groups

Columbia University School of NursingM6920, Fall, 2001 Policy actors l the body politic l the intended beneficiaries l the stated beneficiaries l the managers or organizers l the decision-makers

Columbia University School of NursingM6920, Fall, 2001 Time and place l may be immediate, short term or long term l may be neighborhood, city, state, region, nation, global

Columbia University School of NursingM6920, Fall, 2001 Population perspective l “Vulnerable population” is for some reason at higher risk of problems, even though not all members of the population will experience the problem, and others outside the population will experience the problem

Columbia University School of NursingM6920, Fall, 2001 Possible reasons for vulnerability l Social prejudice racism age-ism able-ism genderism l geography l economics

Columbia University School of NursingM6920, Fall, 2001 Healthy People 2000 Targets Total Population (319 Targets) Special Populations (210 Targets)

Columbia University School of NursingM6920, Fall, 2001 Special populations are defined by l Race/Ethnicity l Gender l SES l Disabilities

Columbia University School of NursingM6920, Fall, 2001 Changes in life expectancy

Columbia University School of NursingM6920, Fall, 2001 Commonwealth Fund, Summer, 1999 Women’s insurance status

Columbia University School of NursingM6920, Fall, 2001 Commonwealth Fund, Summer, 1999 Insurance and barriers

Columbia University School of NursingM6920, Fall, 2001 Commonwealth Fund, Summer, 1999 Long term care population In Millions

Columbia University School of NursingM6920, Fall, 2001 MMWR, January 14, 2000 AIDS Cases/ MSM

Columbia University School of NursingM6920, Fall, 2001 AIDS Cases Reported in 1999 and Estimated 1999 White, not Hispanic Black, not Hispanic Hispanic Asian/Pacific Islander American Indian/ Alaska Native *Includes 120 persons with unknown race/ethnicity 4% 1% 71% 12% 13% AIDS Cases N=46,400* Population N=277,200,000 <1% 1% 32% 47% 19%

Columbia University School of NursingM6920, Fall, 2001 Impact of welfare reform l In 1995, 88% of poor children received food stamps; in 1998, 70% l From , average incomes of poorest 20% of female headed families fell 2 million families, 6 million people drop of $580 per family; below 3/4 of poverty line

Columbia University School of NursingM6920, Fall, 2001 Welfare Reform and Insurance Coverage Families USA Chartbook

Columbia University School of NursingM6920, Fall, Poverty Guidelines Size of Family Income Guideline

Columbia University School of NursingM6920, Fall, 2001 Poverty in New York City NY Times. 9/13/2000. Pg. B1

Columbia University School of NursingM6920, Fall, 2001 % non-elderly uninsured United Hospital Fund, March, 2000

Columbia University School of NursingM6920, Fall, 2001 %Uninsured by race, ethnicity United Hospital Fund, March, 2000

Columbia University School of NursingM6920, Fall, 2001 Public coverage for children United Hospital Fund, March, 2000

Columbia University School of NursingM6920, Fall, 2001 Percentage of Medicare Recipients, by age

Columbia University School of NursingM6920, Fall, 2001 Medicare Recipients with Income  $10,000/yr.

Columbia University School of NursingM6920, Fall, 2001 Income disparity l Top 1% (2.7 million people) has as much to spend as the bottom 40% (100 million people) l The top 1/5 has 50.4% of income. l The top 1/5 has had a 15% income increase while the bottom 1/5 has had a 10% income increase

Columbia University School of NursingM6920, Fall, 2001 CBO analysis: l 1997: 49 million lowest earners equal top 2,500,000 after tax $$ l 2000: 100 million lowest earners equal top 2,700,000 l Bottom 4/5 (217 million) earn 50% l 9/10 of growth since 1977 went to top 1% ($515,600 after tax average income)

Columbia University School of NursingM6920, Fall, 2001 HP2010: a policy example l The development of national health objectives is almost a policy-setting process l The model builds on an the determinants of health model l The national goals attempt to minimize threats to the health of vulnerable populations.

Columbia University School of NursingM6920, Fall, 2001

Columbia University School of NursingM6920, Fall, 2001 Questions for this course: l What current policies are having a positive impact on health? l What current policies are having a negative impact on health? l What policy conflicts affect our ability to improve health? l What do I want to do to have an impact on policies?

Columbia University School of NursingM6920, Fall, 2001 Next week: l Determinants of health l Vulnerable populations in the Unites States