Laura WoodyardProfessor Owen BordaPublic Health in the 21st CenturyCritical Discourse Analysis pg. 212-267

The Health Care Delivery SystemIn a report geared toward providing recommendations to the public and private sector, and politicians who have the capacity to address and implement change within the American health care system, the Institute of Medicine addresses the "issues of access, managing chronic disease, neglected health care services, and the capacity of the health care delivery system to better serve the population in terms of cultural competence, quality, workforce, financing, information technology, and emergency preparedness" (212) The IOM committee addresses the "responsibility of the health care system to recognize and play its appropriate role within the intersectoral public health system, particularly as it collaborates with the governmental public health agencies" (212). The committee uses persuasive discourse in order to argue and appeal to their audience, emphasizing the current need for reform to improve the health care sector due to deterioration of quality of services, increasing cost of care, and other challenges faced under the current configuration. As a critical discourse analyst, the committee is aware of their societal role to argue through scholarly discourse, influenced by social structure and social interaction, the importance of their research intent. They satisfy critical elements, effectively addressing a social problem that is entangled in political issues - access to health care and its role in individual and community health - from a multidisciplinary approach.

The committee proposes that the structure and incentives of health care are "technology and procedure driven and do not support time for the inquiry and reflection, communication, and external relationship building typically needed for effective disease prevention and health promotion" (213). This parallels advancements within 21st Century society, a fast-paced, technology and procedure driven culture looking for next-day results and time-efficient, cost-effective production methods. Such trends leave less room to build in-depth relationships that might provide guidance and insight beneficial to public health prevention campaign initiatives. Additionally, this results in a decrease in stable foundational markers and thus sets up campaigns for potential failure from the onset, resulting in wasted financial resources, lowered moral, consumption of time, energy, and resources, and impairment of "the ability of governmental public health agencies to perform other essential tasks. The committee's purpose is to make aware these issues, but not necessarily offer recommendations or solutions to solve the problems in the economic and structural instability of the US health care system, rather focusing on issues with more pertinent implications for the effectiveness of the public health system in promotion of overall national health - narrowing in on insurance's role in providing quality health care through collaborative efforts between these private sector groups and "governmental public health agencies and organizations in the personal health care delivery system" (214).

The committee believes that health care is not the holy grail in determining health status but is an important aspect, with studies showing health insurance coverage being associated with better health status. Regular care, screenings, and effective treatments are all more likely with health coverage, whether insurance is provided privately through employment-based groups or individual policies, or publicly through governmental programs. However, those who are uninsured or underinsured compromise their health. As an alternative, if the underinsured cannot access mainstream health care services, they may seek safety-net providers - a service that the committee discusses and later endorses the recommendations from America's Health Care Safety Net: Intact but Endangered (IOM, 2000). Ultimately, the committee believes its report should act as a guidance; they do not believe they were "constituted to make specific recommendations about health insurance"

(218). They seem to be trying to remain as objective as possible in order to inform the readers about the complex issues surrounding the failure of solving the health care reform efforts over the past 30 years. The committee does state that "both the scale of the problem and the strong evidence of adverse health effects from being uninsured or underinsured make a compelling case that the health of the American people as a whole is compromised by the absence of insurance coverage for so many. [And that] assuring the health of the population in the twenty-first century requires finding a means to guarantee insurance coverage for every person living in this country" (219). With this statement, it is evident that the committee is subjective toward a reform policy governed toward investment in the uninsured and underinsured populations. They highlight the gravity of need for coverage for these Americans to assure the health of the entire American population in the future, almost saying that the country is only as strong as its weakest link and that by bringing forth and addressing its weakest link, it will create a stronger, healthier nation. The committee uses it power of influence as an instigator of change, putting pressure on the federal government to lead the "national effort in weighing the various choices available that could be implemented into a stale health care plan that could achieve results" (219).

The committee discusses the increased coverage of clinical prevention services by insurance companies. Their regard for this is a positive one, especially implicating it in age-related groups, older populations, children, genetically inherited and high-risk populations, those in need of mental health services, substance abuse populations, and oral hygiene services across all generations. The committee highly recommends, bolding the text in the report to emphasize the importance of their point, that "all public and privately funded insurance plans include age-appropriate preventative services as recommended the US Preventative Services Task Force and provide evidence-based coverage of oral health, mental health, and substance abuse treatment services (230-231).

The committee was able to make recommendations as well as able to point out disparities in the health care systems as a way to instigate improvements. They indicate that health care quality declines amongst certain racial and ethnic minority populations - possibly due to bias, discrimination and stereotyping at the individual, institution, and health system level - though it should not differ in principle "because of such characteristics as gender, race, age, ethnicity, income, education, disability, sexual orientation, or place of residence" (231). Such disparities compound adverse health effects of other disadvantages faced by minorities, including lower incomes and education, less healthy living environments, and a greater likelihood of being uninsured. The committee takes the stance to urge the health care system and policy makers in the public and private sectors to carefully consider interventions identified in their report Unequal Treatment (IOM, 2002) in order to eliminate disparities in health care. In doing so, they are not only offering a way of improving the health care system, but also, in a way, they stand by their image as a leader in public health research and ask policy makers to look upon them as a key investigator, and a venerable, reliable committee that provides significant data on core issues in the health care sector.

The committee continues with pointing out disparities as a way to use their sociopolitical discourse to highlight the need for social action for health care reform. They make apparent the challenge in providing clinically appropriate and cost-effective care for the chronically ill, as they concluded in their report, Crossing the Quality Chasm (IOM, 2001). The committee, though they often say they aren't providing recommendations, do so provide so recommendations, as they provide examples from their other reports and findings. Such can be seen in how they outline the five elements required in improving outcomes for chronically ill patients: (1) evidence-based planned care, (2) reorganization of practices to meet the needs of patients who require more time, a broad array of resources, and closer follow-up, (3) systematic attention to patients' need for information and behavioral change, (4) ready access to necessary clinical expertise, (5) supportive information systems. Possibly by doing

so, this takes the guess work out of the functional methodology of how to go about making such inherent improvements in the health care system especially when the government has so many different issues to address when it comes to health care reform.

The committee follows with a more general discussion of the imbalance of resources in the health care delivery system and its inability "to provide patient-centered care, to address the complex health care demands of an aging population, to absorb normal spikes in demand for urgent care, and to manage a large-scale emergency" (234). Because the system is so focused on controlling costs, the committee finds, there is less time for physician-patient interaction. And when the roots are dug up, the committee discovers that an absence of a national health information infrastructure to support research, clinical medicine, and population-level health underlies the void of support system in the insurance plans' design for integrated disease management protocols that treat chronic disease.

The committee believes in more hands on involvement on the part of governmental public health agencies as health care providers. They can fill the role as epidemiological agencies, surveilling for disease and reporting disease occurrence rates, through such agencies as the CDC and sentinel networks like the National Nosocomial Infections Surveillance system. Additionally, acting as health care providers, the committee believes the governmental public health agencies can serve as educators interacting with academic health centers and keeping them informed on current research and topics. In this way, they can stay involved in the academia realm as well as community and professional clinical arena.

There is a tremendous shortage of resources, especially health care professionals who are integral, like a main artery, supporting the infrastructural mainstay of the system, that has now become overcrowded due to changes in the industry and surge capacities. That coupled with the system's inefficiencies that characterize current insurance and care delivery arrangements, the result of good primary care is hard to come by. Even with the development of enhanced information technology and its use in hospitals, individual provider practices, and other segments of the health care delivery systems, better care is not necessarily guaranteed in the future, without an overhaul of the entire health care system, the committee points out. There needs to be more communication and collaboration in the activities and interests of the health care delivery systems and the governmental public health agencies, which the committee sees as pertinent to the success of health care reform, because failure to do characterizes the lack of communication within our nation and just how separate we are. How can initiatives be reached and how can anything - a relationship, a business, a corporation, a nation, a health care system - function without productive communication, communication is key to getting things accomplished. The operational separation of public health and health care financing programs mirrors the cultural division that characterizes medicine and public health. America is so wrapped up in technology, progress in the science and medical interventions, yet fails to understand the need for an appreciation of the fundamental determinants of health or of workings of governmental public health agencies. This only inhibits the progress in public health reform - because without solid fundamentals to provide a stable foundation, we can't pave the way for the future use of advancements in technology and in medical interventions. The resource differences and stratifications and continual existence of barriers to communication and collaborative efforts on a shared vision of healthy communities prevents progress. Efforts can be made once blinders are removed, walls are broken down, and first steps are taken to engage the other party in discussion on what matters - people's health. Not only does health care reform need to be a part of our future in order to address the needs of uninsured, underinsured, and the quality and cost of health care in America, but advocacy and public awareness campaigns need to be commenced to educate the public and private sectors on health issues, determinants of health, health prevention methods, health legislation and incentives, shortage in health industry and the positives of joining a health

career, and health agencies.

The committee finishes with recommendations that "bold, large -scale demonstrations be funded by the federal government and other major investors in health care to test radical new approaches to increase the efficiency and effectiveness of health care financing and delivery systems. The experiments should effectively link delivery systems with other components of the public health system and focus on improving population health while eliminating disparities. The demonstrations should be supported by adequate resources to enable ideas to be fairly tested" (257). In this concluding point, the committee is able to promote many of their arguments and sum up their propositions made throughout the report. As well, they are able to sell themselves, or more so, some of their other reports as "adequate resources" for fairly tested demonstrations because they have done the research for investigators and policy makers already. When it comes to funding initiatives, ultimately by asking the federal government to pay for health care, the committee seems to be asking the tax payer to take on the bill, so their supporting statement of efficiency and effectiveness of health care financing and delivery should be at the center of reform as well as the components of improving population health while eliminating disparities. They act effectively as critical discourse analyst by pointing out an area of the sociopolitical sector - health care reform - that affects culture and society and has a historical context and is in need of social action.

Work Cited

IOM (Institute of Medicine). 2000. America's Health Care Safety Net: Intact but Endangered. Washington, DC: National Academy Press.IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.IOM. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health. Washington, DC: National Academy Press.IOM. 2003. The Community. The Future of the Public's Health in the 21st Century. Washington, DC: National Academy Press, 212 - 267.