Running head: CARE WITHOUT COVERAGE 1

Care without Coverage:

Health Screenings for Uninsured Populations
Kakra Agyen
University of South Florida

Care without Coverage:

Health Screenings for Low-Income Populations
When it comes to health screenings, uninsured and low-income adults
in United States needs are unmet. This population group has substantially
worse health outcomes compared to insured and high-income adults. One of
the main reasons this population is at risk for poor health status is the lack of
insurance. Many research done on this subject has shown correlation
between lack of insurance coverage and poor access to quality health care
(Kaiser Family Foundation (KFF), 2015). Thus, to help improve the quality of
health, a health policy will be created. This health policy aids to increase
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coverage for the uninsured population through the assistance of the

Affordable Care Act (ACA) as well as, to create new provisions that will
increase awareness and rate of health screenings.
The following statistics shown below will compare and contrast data
between Florida (state) and its county (Lake) in 2013. Lake County, located
in central Florida, is 19.3% urban and home to 301,019 inhabitants. In
contrast to its state, Florida has high population density of 19,057,542 and
low (8.8%) urban geography (County Health Ranking, 2013). Walt Disney Co.
(Walt Disney World), Florida Hospital (Avent Health System) and Wal-Mart
Stores Inc. are Florida's three major employers. Florida Hospital Waterman,
Leesburg Regional Medical Center, and South Lake Hospital are top
employers for Lake County (Lake County, 2014). Major healthcare systems in
Florida were Florida Hospital Orlando, UF Health Shands Hospital, and Tampa
General Hospital (Best Hospital, n.d.). Major healthcare systems in Lake
County were Florida Hospital Waterman, Leesburg Regional Medical Center,
and South Lake Hospital ("Lake County," 2014).
After analyzing garnered data, Lake County revealed to be less
populous and more rural than its state. Furthermore, Lake County showed no
diversity in its employers, as the three major corporations also comprised of
the top three employers in healthcare.
According to United States Office of Disease Prevention and Health
Promotion (n.d.), there are five determinants of health that make the social
determinants of health (SDOH). They include economic stability; education;
social and community context; health and health care; neighborhood and
built environment. Under each of the determinants, there are sub-areas that
make up SDOH. First area to be explored under economic stability
determinant is poverty. In Lake County, 10.4% of families were below
poverty level; whereas, 11.9% of families were below poverty level in Florida.
The data shows families below poverty line in Lake to be slightly less (1.5%)
than Florida (Florida Department of Health, 2013). Although the percentage
difference may seem insignificant, it does play in socioeconomic factors in
terms of standard living and health.
Second determinant will be education. High school graduation, in
addition to, language and literacy are the sub-areas to be explored. To
compare which population group greater than age 25 with high school
diplomas, data was retrieved from Florida Department of Health. Florida
Department of Health (2013) revealed 86.9% Lake County population with a
diploma and 86.1% for Florida. Thus, Lake County is 0.8 % above the
average state level of adults graduating with high school diplomas than
Florida. Language and literacy were also compared to see the percentage of
non-English speakers greater than age five in both populations. When
comparing the rate of non-English speakers, Lake County population (10.0%)
had 1.7% fewer non-English than Florida 11.7% population (Florida
Department of Health, 2013).
Lastly, access to health care and primary care will be examined
though health and health care determinant. When comparing access to
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health care centers or primary care providers in Lake County and Florida, the
ratios were quite vast. Ratio of population to primary care physicians (PCP) in
Lake County was 1,593:1 and in Florida 1,439:1. Ratio of population to
dentist in Lake County was 2,546:1 and Florida 2,049:1. The ratio of
population to mental health providers in Lake 9,609:1 and 3,372:1 for
Florida. Moreover, the percentage of population who could not see doctor
due to cost in Lake County was 14% and Florida 16% (County Health
Ranking, 2013).
To ascertain health concerns of Lake County, evidenced data was
garnered though The County Health Rankings and Roadmaps. The data was
then compared to the 2013 National benchmark to determine what were
strengths and weaknesses of Lake County. The first strength
Lake County showed to have was a higher rate (74%) of Mammogram
screening, which is 1% increase than the national benchmark of 73%. Second
strength was the adult obesity rate. Compared to the national benchmark,
the obesity rate is 1% lower (26%) than Lake County rate of 25. Although this
may seem as a weakness, it shows that Lake County is striving to be at the
national level. Lastly, water safety is in both Lake County and national levels
were equal (0%) percentage (County Health Ranking, 2013). This shows that
drinking water safety is strictly regulated in local and state levels.
Areas of improvement for Lake County were its rate of uninsured
population. In 2013, 22% of the county's adults were uninsured, which
compared to national benchmark of 11%, is double the rate of uninsured
civilians. Adult smoking rate in Lake County is another weakness. Lake
County accounted for 16% adult smoking, which is a 3% increase than the
national benchmark of 13% in 2013. Lastly, the rate for adult obesity was
26%, which is 1% higher than the national benchmark of 25% (County Health
Ranking, 2013).
The leading health indicator that needs to be improved is the rate of
uninsured populations. United States Department of Health and Human
Services (HHS), Healthy People 2020 (2016) states a person's access to
health services has a profound impact in his or her health, yet almost one in
four Americans do not have a primary care physician or health center where
they can receive regular medical services. Moreover, one in five Americans
(children and adults under the age of sixty-five) do not have medical
insurance. It has been shown that those who lack insurance are susceptible
skip routine medical care due to cost, and are more at risk for serious health
conditions (HHS, Healthy People 2020, 2016).
Determinants of health is part of Healthy People 2020 (2016) four
foundational health measures. It is a tool used to determine an individuals
health and health outcomes based on several categorized factors: policy
making, social factors, health services, individual behavior, biology and
genetics. The interrelations between these factors helps nurses create
interventions are tailored to target health issues.
It is known that some biological and genetic factors impact certain
populations than others. These biological factors include, but not limited to
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age, sex, race, gender, family history, and inherited conditions (Office of
Disease Prevention and Health Promotion, n.d.). All of the factors are utilized
in the assessment process to collect data from client and client's family. Take
for example, a low income African American household that has a history of
sickle-cell and cardiovascular disease. Due to the disparities this family
faces, they may be unable to screen for risks, and are often seen in late
stages where modifications and pharmacological interventions are not viable.
That is why screenings for disease is important in populations who are prone
to these biological factors but do not have the means to do so.
Access to health services is another priority in determining health
because it dictates the comprehensive care an individual receives, as well as,
the quality of health care services. Availability of the health system is
dependent on additional factors: awareness, affordability, acceptability,
appropriateness, and adequacy of the service. These indicators are
frequently assessed in communities especially in vulnerable communities
because it is essential to validate if individuals or populations are receiving
proper care (Truglio-Londrigan & Lewenson, 2013). The well-being of an
uninsured person depends on their ability to access health services. This
means without coverage, they are at a disadvantage to early detection of
diseases, preventable treatments; and a higher risk premature death and
poor quality of life (Berenson, Doty, Abrams, & Shih, 2012).
Poor health outcomes are often made worse by interaction between
individuals and their physical environment (Office of Disease Prevention and
Health Promotion, n.d.). The environmental factor falls under the social
determinant of health. It includes the physical determinants or the condition
of the environment in which an individuals are born, live, learn play, work,
and age. Adults who earn below the poverty line often do not live in best
neighborhood that promotes health. Urban areas are more exposed to toxic
substances and other physical hazards that pose a threat to health.
Furthermore, in rural places such as Lake County, there are less available
PCP to patients. Because rural areas tend to be underdeveloped and
understaffed, it may be difficult to receive proper health services (Truglio-
Londrigan & Lewenson, 2013).
The type of behavior an individual exhibits plays a role in plays in his or
her health outcome. An individual that engages in a negative behavior, take
for example a young adult who smokes cigarettes and has asthma, is more
likely to experience asthma exacerbations due to negative effects of
smoking. Thus, individual behavior is a priority of health because without
positive changes, health can deteriorate. However, disparities can present in
populations and influence an individual's behavior. Indicators of disparity
include race or ethnicity, sex, sexual identity, age, disability, socioeconomic
status, and geographic locations. All these contribute to the person's ability
to receive coverage and obtain good health (Truglio-Londrigan & Lewenson,
2013).
Population Diagnosis: Uninsured population increased risk for poor
health outcome related to lack of health screening as evidenced by prolong
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diagnosis of diseases and treatment, worsening chronic diseases, and high

mortality rate. Using the Levels of Prevention Model, interventions will made
to target primary, secondary, and tertiary levels.
The goal, according to Leavell and Clark, of primary prevention is
designed to promote health via health promotion strategies and to
specifically protect the individual from disease (Truglio-Londrigan &
Lewenson, 2013). At this level, the individual is the recipient, and
intervention is implemented through health promotions, such as increasing
physical activity and dietary practices; smoking cessation; and decrease or
elimination of stress. Community members can support health promotion by
exhibiting a healthy living. Communities can put great emphasis on schools
to have courses that promote exercise and healthy eating. After school
activities such as YMCA or public gyms are another organizations that offer
free programs to children and young adults. The same concept can be
applied to academic institutions (universities and colleges) and other
community-based organizations (churches) to promote health education.
Communities can also hold food drives and pantries to help individuals who
cannot afford healthy meals.
Using the Intervention Wheel principles of outreach and health
teachings, community health nurse (CHN) can carry out this intervention by
being a liaison for organizations. For example, a K-12 school nurse can
promote healthy eating and other lifestyle modifications. CHN can work with
universities and colleges help recruit nursing and medical students,
dieticians etc. to host health events on campuses. The purpose of health
events would be to give healthy lifestyle tips through food sampling,
brochures, and pamphlets. The same technique can be utilized to target
older adults in their place of leisure, volunteer, and worship.
On an individual level, secondary level of prevention will be
implemented through screenings. The goal of this level is to decrease risk by
using screening activities and early treatment to prevent consequences of
advanced disease, (Truglio-Londrigan & Lewenson, 2013). Using the already
available system-wide health insurance created by President Barack Obama,
the Affordable Care Act (ACA) will be made available to the uninsured and
underinsured populations. The ACA coverage promises to reverse the
negative consequences the uninsured population faces by using cost-sharing
measures that will reduce out-of-pocket cost, diagnose and treat illness,
reduce chronic disease progression and lower mortality risk (Crowley & Tape,
2013). Patients eligible for free healthcare must go through enrollment
process. The enrollment process entails on whether client is under poverty
level, receives other government assistance such Medicare and Medicaid.
Thus far, the provision has been showing to increase rate of preventive care;
however, they is a significant number of people who do not understand the
process. To spread the awareness about health screenings under ACA,
government, legislators, and health care members (such as PCP, nurses, and
social workers) should continue to advocate on patients behalf. There could
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also be workshops held in medically underserved neighborhoods to help

them with enrollment process and what they qualified for under ACA.
Community health nurse can work with free agencies that promote
health screening. CHN should encourage more people to get screened and
tested in the community by working with community-based organizations
that provide free services. Health fairs have shown to bring awareness to
preventive care (Murray, Liang, Barnack-Tavlaris, & Navarro, 2014). CHN
could work with K-12 schools and provide free back-to-school screening for
students. CHN can also work with other outreach programs that promote
healthy living, such as American Red Cross, to provide services in the
community. In addition, free health clinics for the medically underserved can
help promote screenings to uninsured populations who ACA does not cover.
On an individual level, third level of prevention promotes rehabilitation
and reinforces compliance. Tertiary prevention objective is to return affected
individuals to a useful place in society and maximize use of remaining
capacities (Truglio-Londrigan & Lewenson, 2013). At this level, health
screenings are not viable and pharmacological interventions must be used.
The role of CHN will be to restore health back to an optimal level. The nurse
will treat and follow-ups on patients. CHN can also go on home visits to offer
advice to improve health and provide any assistance patient may need.
The general impact of the policy paper is to promote preventive care
though health screen awareness in Lake County. Screenings are a great tool
to use when it comes to diagnosing and treatment, but is lacked in less
affluent communities. Thus, the intent of this policy is to promote screening
in these communities and help them achieve optimal health via ACA
insurance coverage.
Health policy will target uninsured and vulnerable populations who
lack access to proper health screenings and health care. Focusing on
secondary level of prevention, the policy will use screenings as a detecting
tool for early diagnosis of disease based on risk presented. The primal goal of
screenings is to improve health by to those who otherwise would not access
to proper healthcare. In addition, the policy will help translate awareness to
actual perception of risk factors by illustrating how screenings are great in
monitoring early diagnosis for diseases (heart, kidneys, eyes etc.) and give
nurses the opportunity to educate and provide clients proper information or
referral for better care. This health policy will work conjunction to ACA and
other federal regulated health policies to improve rates of screening. ACA is
already in act; however because they are a significant amount of Americans
who are unaware of how to receive preventive care though this regulation,
the policy will work with people in these communities to help them enroll for
ACA. The goal of the policy is to: provide bridging quality of care between
those insured and uninsured by reducing financial burden by widening
coverage by improving cost-related access and encouraging uninsured
population to seek care.
The policy does not need to be enacted, it simply need to be brought
to light. To do so, the job falls unto public officials in finding ways to get more
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people insured and health care providers ensuring that patients have the
necessary coverage. The Kaiser Family Foundation (KFF) website provided
reasons why people still remain uninsured. Over 32 million nonelderly
individuals remained insured in 2014 (KFF, 2015). KFF 2014 survey (of adults
between the ages of 19-64), 48% mentioned they chose to remain without
insurance because it was too expensive. 12% of adults claimed their work
did not offer insurance or they were ineligible due to unemployment. 7%
could not receive insurance because of immigration. And, 3% opted to pay
penalty because they opposed the ACA. The remaining uninsured adults did
not apply because of lack understanding.
Reasons vary as to why an individual may oppose ACA, but the
consensus is that the cost of national health care is too great, especially
when insurance companies have to cover sick people. This in turn, increases
everyone's insurance cost (Obama Care" 2016). As stated, proponents of
ACA have a choice to opt out and purchase private insurance. Other
implication arise for poor adults in states that did not expand Medicaid and
for the immigrant population. These two groups are not necessarily against
ACA, but face challenges that is not guaranteed in enrollment process (KFF,
2015).
To reiterate, the policy the policy will work alongside ACA. The first step
is to promote awareness of this policy in Lake County. As already shown, 22%
percent of the population is without health insurance. To do so, there should
be commercials, radio announcements, health fairs and other forms of public
broadcasting to grab attention. The second step will be to use these
infomercials to grab attention in these communities. By using these
methods, nurses and other healthcare professionals can direct clients (such
as local county health departments) where they can seek help on how to
enroll. As well as, where to go if any risks are identified in screenings.
In conclusion, the policy addresses the needs of underserved
population in Lake County by providing financial assistance. The policy opens
the gateway of equal quality care and decreases the disparity gap. As a
result, overtime the policy will enhance local health and decreases
hospitalizations.

References
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Best Hospitals in Florida. U.S. News. (n.d). Retrieved from
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