CHAPTER 11
Health Services for Special Populations
FRAMEWORK TO STUDY VULNERABLE POPULATIONS
Vulnerability is the convergence of risk factors at both individual and ecological levels. These
risk factors could be characterized by predisposing, enabling, and need attributes (see Exhibit 11-
1).
RANKINGS AMONG RACIAL/ETHNIC GROUPS (from earlier editions)
• White (W) Black (B) Hispanic (H) Native American (N) Asian (A)
W (1) B (2) H (3) N (4) A (5)
• Fair or poor health (self-assessed) 2 4 3 5 1
Here are the rankings and percentages of people from each race/ethnicity reporting fair or poor
health in 2004 (Health, US, 2006): N (1; 16.5%); B (2; 14.6%); H (3; 13.3%); A and W (tied for
4; both reported 8.6%); I’m not sure how you wish to rank these
Here are the rankings and age-adjusted death rates per 100,000 people for each r/e category for
2003 (Health, US, 2006): B (1; 21.3); H (2; 5.9); W and N (tie for 3; 2.5); A (4; 0.7)
• Suicide 4 3 1 5 2
Here are the rankings and age-adjusted death rates per 100,000 people for each r/e category for
2003 (Health, US, 2006): W (1; 11.8); N (2; 10.0); A and H (tie for 3; 5.6); B (4; 5.2)
THE UNINSURED
• Almost one in four working American adults is uninsured.
• Those most likely to be uninsured: poor, less educated, part-time workers, those working for
small employers, young adults, minorities.
• American Indians are covered under the Indian Health Service system, but financial support of
the system has been waning.
CHILDREN
• Private health insurance and regular Medicaid coverage have shrunk.
• In 2011, 38.2% of children under the age of 18 were covered under Medicaid
• Children’s health has certain unique aspects in the delivery of health care. Among these are
children’s developmental vulnerability, dependency, and differential patterns of morbidity and
mortality.
2. Dependency—children face special circumstances in that adults generally have to recognize
and respond to their healthcare needs.
3. New morbidities—youngsters face challenges related to drug and alcohol abuse, family and
WOMEN
• Women have a greater life expectancy than men, but face greater morbidity and poorer health
outcomes.
• Compared to men, women develop more acute and chronic illnesses and resulting disabilities.
• Certain mental disorders, especially depression, are more common among women.
• Eating disorders, such as bulimia and anorexia nervosa, and dementia, such as Alzheimer’s
RURAL HEALTH
• Access to health care is one of the major problems in rural areas. Principal reasons include
poverty, long distances, lack of personal transportation, geographic maldistribution of healthcare
professionals, and closure of rural hospitals.
• Initiatives designed to alleviate access problems:
HOMELESS
• As many as 3.5 million (1.35 million children) Americans are homeless.
• 33% of the homeless are parents with children.
• 40% of homeless men are Veterans.
MENTAL HEALTH
• 25% of Americans have a mental disorder in any given year.
• Burden on health and productivity is only second to heart disease.
• Access and expenditures:
• 40% private—private psychiatric hospitals and ambulatory mental health clinics.
• 22% federal government programs—private psychiatric hospitals and ambulatory mental health
clinics that accept Medicaid and Medicare reimbursement.
THE CHRONICALLY ILL AND DISABLED
• The US health care system is primarily oriented towards treating acute illness.
• A significant number of deaths (almost 50%) are attributable to preventable chronic conditions.
HIV/AIDS
• The incidence of these conditions has continued to increase despite massive public health
efforts.
• Home health care will play a major role in the care of AIDS patients as institutionalization
becomes unnecessary except in the acute phases of illness.
• Healthcare providers in rural areas have to deal with an increasing number of infected patients
who are mostly young, nonwhite, and female. However, facilities in rural areas have fewer
resources.
ACA Takeaway
TERMINOLOGY
• AIDS—Stands for acquired immune deficiency syndrome. It is a fatal disease believed to be
caused by the human immunodeficiency virus (HIV). HIV is an unusual type of virus, called a
retrovirus, which causes immune system suppression, leading to AIDS. Individuals infected with
HIV generally develop antibodies within a short period of time but may exhibit no symptoms for
treatment regimens.
• Developmental vulnerability—Refers to the rapid and cumulative physical and emotional
changes that characterize childhood, and the potential impact that illness, injury, or untoward
family and social circumstances can have on a child’s life-course trajectory.
• Disability—Refers to impairment of bodily functions, and therefore the restrictions of
performing activities of daily living.
• Mental health system in the United States is composed of two subsystems, one primarily for
individuals with insurance coverage or money, and one for those without. Patients without
insurance coverage or personal financial resources are primarily treated in state and county
mental health hospitals, or in community mental health clinics. Patients with insurance coverage
or the personal ability to pay receive care from both inpatient and ambulatory mental healthcare
REVIEW QUESTIONS
1. How can the framework of vulnerability be used to study vulnerable populations in the
United States?
This framework calls for attention to the convergence of vulnerability attributes. People who
experience a combination of risk factors are likely more vulnerable and therefore ought to be
2. What are the racial/ethnic minority categories in the United States?
3. Compared with white Americans, what are the health challenges faced by minorities?
Minorities are more likely to be economically disadvantaged than whites. They fall behind in
health status despite progress made during the past few decades. Blacks in particular, compared
4. Who are the AAPIs?
AAPI stands for Asian Americans and Pacific Islanders. Compared to blacks, Hispanics, and
Native Americans, AAPIs have relatively small numbers. However, AAPIs constitute one of the
fastest growing minorities in the United States. In education, income, and health, AAPIs form a
5. What is the Indian Health Service?
The Indian Health Service is a federal agency responsible for the health of Native Americans
since 1955. It operates hospitals and outpatient facilities and negotiates contracts with
6. What are the health concerns of children?
7. Which childhood characteristics have important implications for health system design?
Among the unique characteristics of childhood that have important implications for health
system design are children’s developmental vulnerability, dependency, and differential patterns
2. Which health services are currently available for children?
Personal medical and preventive health services— These services are generally delivered in
private and public medical offices, hospitals, and laboratories. Population-based community
health services—These provide services such as immunization delivery and monitoring
3. What are the health concerns of women?
Women suffer greater morbidity and poorer health outcomes and have a higher prevalence of
4. What are the roles of the Office on Women’s Health?
The Public Health Service’s Office on Women’s Health (OWH) is dedicated to the achievement
of a series of specific goals that span the spectrum of disease and disability. These goals range
5. What are the challenges faced in rural health?
The challenges faced in rural health include poverty or poor economic conditions, lack of
6. What measures are taken to improve access to care in rural areas?
Various measures have been taken to improve access to care in rural America, including the
7. What are the characteristics and health concerns of the homeless population?
The homeless population consists of single men (43%) and single women (17%), and families
with children (39%). About 40 percent of all homeless men are war veterans. The economic
8. How is mental health provided in the United States?
Mental health services are provided through public (primarily for patients without insurance) and
private resources (primarily for patients with insurance) in both inpatient and outpatient
9. Who are the major mental health professionals?
10. How does AIDS affect different population groups in the United States?
In 1994, the death rate from HIV infection per 100,000 population among persons 25–44 years
was almost four times as high for black men as for white men and nine times as high for black
women as for white women. In 2004, males and blacks continued to have significantly higher
11. Which services and policies currently combat AIDS in America?
Through the Medicaid waiver program, states may design packages of services targeted at
specific populations, such as the elderly, the disabled, and those who test HIV positive. For HIV-
positive people, the waiver is designed to provide alternatives to care in acute care hospitals. The
12. What is the impact of the ACA on vulnerable populations?
ACA is expected to significantly reduce the number of uninsured Americans and results in
enhanced insurance coverage for those previously inadequately insured. The removal of