Category Archives: At-risk and vulnerable people

Sep 26 2014
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Lack of Coverage for Undocumented Patients Puts Pressure on the Health Care Safety Net

Michael K. Gusmano is a research scholar at the Hastings Center in Garrison, New York and former president of the American Political Science Association’s Organized Section on Health Politics and Policy. After completing his PhD in political science at the University of Maryland at College Park, Gusmano was a Robert Wood Johnson Foundation (RWJF) Scholar in Health Policy Research at Yale University from 1995 to 1997.

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The nation’s 11 million undocumented immigrants constitute a “medical underclass” in American society. [1,2] Apart from their eligibility for emergency Medicaid, undocumented immigrants as a population are ineligible for public health insurance programs, including Medicare, Medicaid, the Child Health Insurance Program (CHIP), and subsidies available to purchase private health insurance under the Patient Protection and Affordable Care Act (ACA) of 2010, because they are not “lawfully present” in the United States. [3] Federal health policy does provide undocumented immigrants with access to safety-net settings, such as an acute-care hospital’s emergency department (ED), or a community health center (CHC). Since 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) has required that all patients who present in an ED receive an appropriate medical screening and, if found to be in need of emergency medical treatment (or in active labor), to be treated until their condition stabilizes. CHCs such as Federally Qualified Health Centers and other nonprofit or public primary care clinics serving low-income and other vulnerable populations trace their origins to health policy that includes the Migrant Health Act of 1962. [4]

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Sep 10 2014
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I Am Who I Am Because of You

Faith Ikarede Atte, RN, MSN, is a Future of Nursing Scholar studying for her PhD at Villanova University, supported by Independence Blue Cross Foundation. The Future of Nursing program is a project of the Robert Wood Johnson Foundation.

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There are things in life so personal and private that when one vocalizes them, there is fear of being judged. It was eleven years ago that I had a personal encounter with myself. It is admittedly odd to look back at the path that I have walked on, now overgrown and distant—yet still so close to my heart.

Eleven years ago is when I lost a sense of who I was in the eyes of society, and I had to look within myself to find my footing. It is during this time that I had arrived from Kenya, full of vigor, light spirited and quick to laughter. I was hungry for knowledge and the sky was the limit.

Little did I know that life was about to teach me a lesson. It became obvious to me that my accent was different. Most immigrants can identify with the situation of being different. The more I spoke, be it in class or in a group of people, the more I felt isolated due to reactions like, “What did you say? Speak up.  Your accent is too thick. I don’t know what you are saying.”

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Jul 29 2014
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Childhood Trauma: A Public Health Problem that Requires a Robust Response

Cindy A. Crusto, PhD, is a Robert Wood Johnson Foundation (RWJF) New Connections grantee, an associate professor of psychology in psychiatry, Yale University School of Medicine, and a Public Voices Fellow with The OpEd Project.

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Were the findings really a surprise? The recent release of the report The Burden of Stress in America commissioned by NPR, the Robert Wood Johnson Foundation, and the Harvard School of Public Health, highlights the major role that stress plays in the health and well-being of American adults. As a researcher who studies the impact of emotional or psychological trauma on children’s health, I immediately thought about the findings in the context of trauma and the associated stress in the lives of children. That trauma can include violence in the home, school, and community.

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Two decades of research has produced clear findings on this significant public health problem: Psychological trauma can have a powerful influence in the lives of children, and if not detected and addressed early, it can (and often does) have long-lasting physical and mental health effects into adulthood. Despite this strong evidence, I have encountered the sheer resistance of some advocates who work with or on behalf of vulnerable children to fully engage in this topic. Perhaps it’s because of the belief that this talk about trauma is a fad—a hot topic that will fade as soon as something “sexier” comes along.

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Jul 23 2014
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Facebook: Friend or Foe?

Linda Charmaraman is a research scientist at the Wellesley Centers for Women at Wellesley College and a former National Institute of Child Health and Human Development postdoctoral scholar. She is a Robert Wood Johnson Foundation (RWJF) New Connections grantee, examining the potential of social media networks to promote resiliency in vulnerable populations.

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If you were stressed out and wanted to vent to your friends about it, how would you let them know? Would you pick up the phone and talk, or text? Would you set up time to grab coffee or go for a brisk walk? Or would you post to Facebook why your day just couldn’t get any worse?

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As I logged into the recent RWJF/NPR/Harvard School of Public Health-sponsored Stress in America discussion, I identified with the panelists who were dispelling stereotypes about “highly stressed” individuals being high-level executives or those at the top of the ladder. Instead of finding work-related stress as a top concern, as is often played out in the media and popular culture, the researchers were finding that individuals with health concerns, people with disabilities, and low-income individuals were experiencing the highest levels of stress. The panelists talked about the importance of qualities like resiliency and the ability to turn multiple, competing stressors into productive challenges to overcome, and the integral role of communities in shaping, buffering, and/or exacerbating stress.

We often consider our communities as living, working, playing in close physical proximity. But what about the online spaces? What about our opt-in networked friendship circles ... our cyber-audience who sign up to read our posts with mundane observations, proud revelations, and the occasional embarrassing photos?

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Nov 19 2013
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Childhood Lead Exposure: Piling Disadvantage onto Some of the Country’s Most Vulnerable Kids

Sheryl Magzamen, PhD, MPH, is an assistant professor in the College of Veterinary Medicine and Biomedical Sciences at Colorado State University and an alumna of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program (2007-2009). She recently published two studies exploring the link between early childhood lead exposure and behavioral and academic outcomes in Environmental Research and the Annals of Epidemiology. She discusses both below.

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Human Capital Blog: What are the main findings of your study on childhood lead exposure and discipline?

Sheryl Magzamen: We found that children who had moderate but elevated exposure lead in early childhood were more than two times as likely as unexposed children to be suspended from school, and that’s controlling for race, socioeconomic status, and other covariates. We’re particularly concerned about this because of what it means for barriers to school success and achievement due to behavioral issues.

We are also concerned about the fact that there‘s a strong possibility, based on animal models, that neurological effects of lead exposure predispose children to an array of disruptive or anti-social behavior in schools. The environmental exposures that children have prior to going to school have been largely ignored in debates about quality public education.

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Jul 26 2013
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One Public Health Nurse’s Full Circle Journey

Cassandra Standifer, BSN, PHN-NFP, is a public health nurse working in the Nurse Family Partnership program in Renton.

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When I think about public health, I don’t think only of my nursing practice. I think about where I came from and how I got here. When I sit with my clients I can see in their situations my own mother, my aunt, my cousins and myself.

I work with first-time teen moms in a program called the Nurse Family Partnership.  Today I met my client, Sarah*, at her transitional housing. As I sat outside waiting for her, I thought back to 1990 when I was seven years old and living with my mother and sister in transitional housing. My mother was addicted to cocaine and attempting recovery—again. Transitional housing was an improvement from the hotel we had been living in, but I was well aware, even then, that there had to be something better out there than this halfway house.

During our home visit we chatted about Sarah’s daughter.  She exclaimed, “She has eight teeth on the bottom and eight teeth on the top, no cavities!”

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Jan 2 2013
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Housing is Health Care

Kelly Doran, MD, is an emergency physician and a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholar at Yale University. This post is part of the "Health Care in 2013" series.

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Around this time of year I think a lot about my friend Hank.  He is one of only two people to whom I reliably send a Christmas card each year, and just as reliably I receive a holiday package from him containing thoughtfully chosen gifts.

When I first met Hank he was homeless, living out of a van he parked near Golden Gate Park in San Francisco.  Hank had multiple serious chronic medical conditions, and the homelessness certainly did not help any.  He was very sick and, sadly, though he was barely 50 years old I thought he had maybe five years left, tops. Well, 10 years have passed and Hank is still ringing in the New Year… in his own apartment.  This is no Christmas miracle, but rather a predictable result of supportive housing.

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Dec 26 2012
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Focus on Economic Inequality in 2013

Fenaba Addo, PhD, is a Robert Wood Johnson Foundation Health & Society Scholar at the University of Wisconsin. This post is part of the "Health Care in 2013" series.

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My New Year's resolution for the U.S. health care system and population health is that there is more sustained attention to the fragile economic state of many of America’s families and households, especially as we continue to climb out of this most recent Great Recession. I say this in light of the strong empirical evidence that economic inequality continues to be inextricable linked to health disparities within our country. I also believe it is especially important at this moment in U.S. history, given the increasing calls to balance the federal budget by defunding social safety net programs— in particular those that provide social insurance to America’s most economically vulnerable populations.

A significant portion of the U.S. population is still either unemployed or underemployed.  Many Americans remain deeply concerned about health care costs or the threat of financial instability due to health-related problems. The passage and implementation of the Affordable Care Act was a positive step to ensure proper health care coverage for those previously shut out of private health insurance markets, such as young adults and individuals with pre-existing health conditions. It would be naïve, however, to think that just one policy will provide the economic security U.S. households need to be productive workers and active consumers.

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Aug 3 2012
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A Doctor Delivers Multiple Acts of Human Kindness to Homeless Women

Roseanna H. Means, MD, is the founder of Women of Means, which provides free medical care to homeless women in the Boston area, a clinical associate professor at Harvard Medical School, and an internist on the attending staff at Brigham and Women’s Hospital in Boston.  She is a 2010 Robert Wood Johnson Foundation Community Health Leader.

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The prolonged recession of the last four years has hit many people hard.  My work is taking care of homeless women, which I have done for the past 20 years.  I lead a team of volunteer physicians and part-time paid nurses who provide free walk-in care to women and children in Boston’s shelters.  We fill in the gaps left by larger, more bureaucratically rigid systems that put unrealistic and unattainable expectations on those who are disabled by extreme poverty, mental illness, trauma, and cognitive dysfunction.

I designed a program of “gap” care that brings health care to them. We act as the communication and advocacy bridge between the shelter/street world and the hospitals and health centers.  Gap care is part of a continuum that I feel has an important role to play in health care access for vulnerable populations.

Here is a glimpse of our work.

Walking into one of the women’s shelters on a recent morning, I see a woman standing glumly in line for coffee, her hands chapped and shaky, her face pale and dry, a blanket heaped around her shoulder, pouring hot liquid into her body before staking out a cot where she can sleep for a few hours, let her guard down, away from the doorway where she was prey to drunk men who jumped her, raped her and stole her stuff.

She is hungover.  She drank to escape the horror of having been attacked.  She has been on and off the wagon so many times we have all lost count.  She’s also been raped and stabbed more times than any of us can remember.  She doesn’t go to the police any more.  She’s just one more homeless woman who has been raped, a “nobody”; just more paperwork.  I give her a hug and remind her that I love her no matter what.  I know that she has a library of negative and self-loathing messages in her head.  Mine is the one that can break through that chatter and give her a shred of self-respect.

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May 21 2012
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Improving on Success: Why the Nurse-Family Partnership Model is a Work in Progress

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David Olds, PhD, is founder of the Nurse-Family Partnership, a Robert Wood Johnson Foundation 40th Anniversary Force Multiplier that provides maternal and early childhood health programs for at-risk, first-time mothers. He is a professor of pediatrics at the University of Colorado School of Medicine, where he directs the Prevention Research Center for Family and Child Health.

When I finished my undergraduate degree in Baltimore in 1970, I went to work at an inner-city day care center, hoping that I might help poor preschoolers get off to a great start and have a better chance of succeeding in school and becoming productive, healthy citizens. But I soon realized that for many children in my classroom, it was already too little, too late. One little boy had been exposed to alcohol during pregnancy and was pretty profoundly developmentally compromised—he couldn’t communicate with words. Other children were being abused or neglected, so it was clear to me that parents’ prenatal health and parenting behaviors were part of the solution for low-income children.

I would have been out of touch, however, to think that all that was needed was for parents to do a better job of caring for their children. Our center was in a poor, inner-city neighborhood, where poverty, crime and a lack of adequate housing were undeniable influences for families. It was clear that parents wanted the best for their children, but their own personal histories and the social and material stressors weighing on them often made it really hard for them to protect themselves and their children. And this was happening in countless communities across the country.

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