HD420 Unit 6 Seminar Reflection on Uninsurance Example

Not Choosing to Go Without: A Unit 6 Seminar Reflection on Reading a County's Uninsured Rate

[Student Name]

Purdue University Global

HD420: Social Determinants of Health and Health Behavior

Unit 6 Seminar Reflection

[Instructor Name]

[Date]

The county, its figures and the seminar are composite; the social determinants review, the conceptual framework and the reflective model cited are real.

The Figure

The instructor put a single line on the screen: in the composite county, [17] percent of adults aged 19 to 64 had no health insurance, compared with [9] percent statewide. The county is mostly rural, with a poultry plant, two nursing homes and many small farms and businesses.

My First Reading

When the instructor asked for first impressions, I said that insurance was available to anyone who looked for it, through employers or the marketplace, and that many people in rural areas, especially young men, decide they do not need it. I had a cousin who said exactly that. I expected the discussion to be about how to persuade people that coverage is worth buying. I even had a slogan in mind for a campaign aimed at young men, something about not gambling with their health, and I was ready to suggest it if the discussion went that way. Looking back, the slogan assumed that the problem was a mistaken belief, and that changing the belief would change the number.

How the Discussion Took It Apart

The instructor asked the group to split the 17 percent into who, exactly, was uninsured and why, using what we knew about the county.

The first group was workers at small businesses and farms. Most employers with fewer than fifty workers are not required to offer coverage, and many in the county do not. Those workers could buy marketplace plans, but a classmate who works as a benefits navigator explained that premiums after subsidies can still be high relative to their pay, and deductibles high enough that the plan feels useless.

The second group was working adults who earned a little too much to qualify for Medicaid in the composite state yet too little to afford a marketplace plan without strain. A classmate pointed out that the state's adult Medicaid limit was low, so many working adults with modest incomes fell in that space.

The third group was workers at the poultry plant and nursing homes who were eligible for employer plans but whose share of the premium for family coverage was more than a quarter of their pay.

The fourth group, smaller, was people who had lost Medicaid at renewal because of paperwork, not because they became ineligible, and had not reapplied. A classmate who works in a county benefits office described renewal letters sent to old addresses and forms that ask for pay stubs people paid in cash do not have. She estimated that in her office, about one in five people who lost coverage at renewal were still eligible.

By the end, my cousin's choice was one small piece of the picture, and most of the uninsured adults in the county turned out to be working people for whom the price, the eligibility rules or the paperwork had already made the decision.

What Changed

I had treated being uninsured as a decision. The discussion showed me that for most people it is an outcome of employer size, wages, state eligibility rules and administrative burden, the kind of upstream conditions the social determinants literature describes (Braveman & Gottlieb, 2014). Even the choice my cousin made sits inside those conditions: he works for a roofing company with six employees and no coverage, and his marketplace premium would be about a tenth of his pay.

Using Gibbs's reflective cycle helped me see that my first reading came from one story I knew well and generalized to a whole county (Gibbs, 1988). The evaluation stage of the cycle asked what was good and bad about that reading, and the honest answer was that it was vivid but unrepresentative.

What I Will Do Differently

From now on, a rate like this will prompt me to ask who makes up the number before I try to explain it. I will look for the categories, eligibility, affordability, employer size and paperwork, that sort the people behind it. I will also be careful with the word choose. A framework for action on social determinants distinguishes the structural conditions that shape options from the choices people make within them (Solar & Irwin, 2010), and most of the people in this number had few options to choose among.

A Question I Still Have

How much of the county's rate would fall if renewal paperwork alone were simplified? It seems like the cheapest change, but I do not know how large that group really is.

References

Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It's time to consider the causes of the causes. Public Health Reports, 129(Suppl. 2), 19-31. https://doi.org/10.1177/00333549141291S206

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit, Oxford Polytechnic.

Solar, O., & Irwin, A. (2010). A conceptual framework for action on the social determinants of health (Social Determinants of Health Discussion Paper 2). World Health Organization.