Wednesday, November 14, 2007

Barriers to Serving Vulnerable Populations

Anyone interested in the politics and ethics of health care resource allocation should read Christine Ferguson’s recent Health Affairs article “Barriers to Serving the Vulnerable: Thoughts of a Former Public Official.”

Ferguson writes from her experience in numerous state and federal public health roles, including seven years as director of human services in Rhode Island and two years as commissioner of public health in Massachusetts. The question she asks is -- why is it so difficult to fund services for vulnerable populations?

In Ferguson's view, the problem isn't just money. She believes that the chronic budget problems have two generally unspoken issues in the background: “[1] policymakers’ perceptions and biases about vulnerable populations and [2] their disbelief in the likelihood of a successful outcome once a service or treatment is offered.”

With regard to 'biases about vulnerable populations" Ferguson writes that public and private decision makers divide vulnerable populations into three categories: " (1) those with health care problems that are the equivalent of an 'act of God,' such as most forms of cancer, premature birth...(2) those with health care problems that are viewed as being their own fault, resulting from behavior that could be reversed...such as the obese, substance abusers, prisoners, the homeless...and (3) the offspring of parents who made 'bad' choices, such as illegal immigrants...My observation has been that the first group is considered 'deserving'; the second, clearly 'undeserving'; and the third, the children of the undeserving, occupying a middle ground."

In other words, Ferguson believes that the centuries old distinction between the "worthy" or "deserving" poor and the "unworthy" and "undeserving" poor is alive and well in health policy and governance.

In addition to the unspoken sentiments about the worthiness/unworthiness of vulnerable populations, Ferguson describes "cynicism about whether treatment will lead to a successful outcome...(1) the belief that on an individual basis, seldom will an intervention or service lead to a successful outcome...and (2) the belief that on a population wide basis, the number of people who fall into a given vulnerable group is never reduced..."

Ferguson has no magic bullets to propose. She makes four policy recommendations to those who are concerned with the needs of vulnerable populations. First, to be open to new program approaches. Simply advocating for more of the same "demonstrates a lack of appreciation of the very real problems faced by decision makers..." Second, the biases that policy makers hold need to be confronted openly and discussed. Third, criteria for success must be realistic. Finally, advocates should identify the ways in which health programs impact dimensions like productivity, educational attainment, and quality of life, as well as the direct impacts on health.

I beat the drums for Ferguson's article because of its experience-based realism, not simply for the recommendations she makes, sound as they are. There is a tendency to approach resource allocation issues too much from the head and too little from the heart. I believe that Ferguson is correct in identifying bias about populations and despair about success as major underlying barriers to meeting the needs of the underserved. To achieve more equitable allocation of our health resources we have to address these deep attitudinal factors. Simply marshaling more facts and raising our voices won't do the job.

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