Chronic Illness and Public Health: Evaluating Influential Intersections Between Politics and Policy

Abstract

Public health emphasizes preventing the onset of disease and detecting disease in its early stages. This focus has cultivated interest in how health information is presented and the public’s responsiveness to information regarding practices believed to promote health. The chapters composing this dissertation investigate prevention, screening, and living with chronic illness in the United States. These three papers may inform efforts to improve public health, particularly when politics and health policy influence opinions and behaviors. Chapter one investigates the political bias of the U.S. news media in its coverage of two recent controversial preventive care recommendations: the 2009 USPSTF mammography guidelines and state HPV vaccination mandates. We analyze the content and sources cited in newspaper articles and opinion pieces to determine the position towards these controversial cancer prevention practices expressed in print news. After applying a standardized measure of political slant (i.e. conservative or liberal leaning) to the newspapers we evaluated, our results demonstrate that news coverage of the 2009 mammography guidelines and state HPV vaccination mandates disproportionately mirrored the political attitudes aligned with that news outlet’s political leaning. Other than staff writers/editorial boards, the types of sources frequently authoring opinion pieces on both health policy controversies significantly differed between conservative-leaning and liberal-leaning newspapers. We conclude that policymakers and public health agencies may consider developing a political communication and media strategy for disseminating policy recommendations, especially when government health authorities are involved in contentious health debates. Chapter two uses the Truven MarketScan database to assess the impact of state breast density notification laws passed from 2009-2013 in the U.S. on the use of supplemental imaging to detect breast cancer. We studied the claims of women aged 40-64 years with employer-sponsored health insurance to identify women who underwent mammography in 2008-2014. With a differences-in-differences approach, we compare additional breast imaging (ultrasound, MRI, tomosynthesis, scintimammography, and thermography) among women living in states that implemented breast density notification laws and those in matched comparison states without notification laws. Among 2,115,917 women who underwent an initial mammography exam, rates of additional breast imaging increased in states with notification laws in comparison to control states, with larger increases in Connecticut, who mandated insurance coverage of supplemental breast ultrasounds. When compared with women in control states, rates of supplemental breast imaging increased for women in states with breast density notification laws within the first 6 months after implementation of the laws and increased further in the 6-12 months following the legislation. Our results also show that breast ultrasounds have been the predominant form of supplemental breast cancer screening, with many fewer women undergoing tomosynthesis, breast MRI, or other imaging procedures. As breast density notification laws are implemented or considered at the federal or state level, policymakers and clinicians should be aware of the potential effects on care and the cost burden associated with these laws. Chapter three examines the challenges African-American and Hispanic adults experience in multiple areas of their lives and compares the life experiences of low-income and higher income subgroups within each racial/ethnic population. We conducted a weighted analysis of survey responses from 757 African-American and 697 Hispanic participants, age 18 and older, who reported a chronic illness as the biggest health problem in their families. African Americans and Hispanics with chronic illness in their families experienced challenges with the health care delivery system, with financial/economic insecurity, and with their communities that may influence how they live with chronic disease. Low-income African Americans and Hispanics were more likely to experience financial issues and problems accessing health care. Even though the majority of respondents had health insurance, neither insurance nor income completely protected against challenges like getting health care that was needed and having enough money to pay for doctors, hospitals, or prescriptions drugs. African Americans and Hispanics living with chronic conditions also expressed significant concerns in their personal lives outside of their interactions with the health care system. These personal challenges included being treated with less courtesy or respect and serious concerns about the areas where they live, especially crime and the state of the economy. To fully address health disparities, policymakers and clinicians should consider the different challenges faced by economic subgroups within a race/ethnicity when designing proper interventions that will assist minority populations effectively manage chronic illness within their communities.