Rachel Strausman:

Today we're gonna be talking about health. And health is such an important topic. I think, if anything, these past few years, it's made us realize that health policy is so important, which is why we're so grateful to have Dr. Lefkowitz here today to discuss health care specifically as it relates to income disparities, as well as successes and shortcomings of the health care policies that helped determine health care access today. And with that, we're so glad you're here today, Dr. Lefkowitz, thank you for joining us. Let's go ahead and get started right into our first question. So given your experience with your PhD in social ecology, what does social ecology entail and why is it important to consider when working with policy?

Dr. Lefkowitz:

I loved the field of social ecology. It was a discovery later in my adult life. And I, once I discovered it, could not imagine why wouldn't one not use social ecology for analyzing health care, health services delivery. It's a framework for analyzing individuals in relation to their environment. It comes out of earlier movements where people were looking at people in relation to this neighborhoods or their cities. That was human ecology in the1930s. Social ecology considers environment a little bit more broadly to encompass things like policy, institutional relationships, as well as interpersonal relationships. So it's really looking at the interplay of individuals with all of these different components of the environment. And so it's not looking at isolated variables. It's really integrated approach. It's not looking at one directional influence. It's looking at bi-directional influence. Individuals impact, but also are impacted by their environments. It assumes that there's change over time. It assumes that the environment is multi-dimensional and that relations between humans and their environment occur at multiple scales. This provides a really flexible as well as integrated framework for doing research that can have real world impacts on pressing social problems. And I think that's very compelling. Specifically in terms of policy. We think about policy as part of the human environment interactions then we see policy has really part of this ecology, not as a standalone. That's really important. It's also really important to understand diverse stakeholder perspectives and developing policy and where we can most effectively intervene. Social ecology,  draws from systems theory and looks at one change in the system actually produces multiple changes. So you can't just tinker with one thing without changing the whole ecology and therefore changing how the system works is really what we're looking at to achieve better health outcomes. 

Kevin Karami:

Thank you so much, Dr. think that was a really good foundation for the topic today. Going through this next question, I know you've done a lot of research on the inequities of health care system here in the United States. And specifically on various factors like income disparities, access to health care in the first place, health information and also I guess the foot to that, the amount of misinformation that existed our society and also like legal services and the opportunities that people have to actually get the care that they need. With all that said, what would you say are the biggest benefits and also the biggest detriments current policy in the US creates for low-income people who might be struggling with their health care needs. 

Dr. Lefkowitz:

That's a great question. I think benefits, I would have to say the Affordable Care Act. I think it gets a lot of bad press. But in terms of people who are low-income and low resourced, the Affordable Care Act creates access to insurance, which is one of the important components of access to care. It's necessary but not sufficient. And it is almost universal. It does exclude people who are not legal immigrants, but it is otherwise inclusive of groups of people that have been excluded historically from insurance, either through their employment which didn't offer insurance, or through income not being able to afford it, and work through pre-existing conditions which essentially precluded people from being able to access insurance afterwards. I think in particular, the Medicaid expansion component of the Affordable Care Act has been a huge benefit for low-income individuals. Increasing the access to people up to 138% of the federal poverty line. In at present 41 states in the US, including the District of Columbia. In terms of detriments, I think we have to say our health care system is really broken. It's very fragmented. And what that means, a lot of people say that But what that means is that it takes a lot of work to get access to care and that work is disproportionate if you have low-income, and why is that so, well everybody has to do that work. But if you have fewer resources, less flexibility in your job, less ability to take time off. You can't afford to take time off because you have no sick leave from your job. This is actually going to really impair your ability to get health care. So I think that what has been called admin by other scholars really increases the burden of access for those who aren't able to least afford it. I think also the state-by-state policies, while that can sometimes be a benefit, I can really disadvantaged people in certain states. Medicaid expansion being one example of that, where Medicaid is a federal state partnership, but has very loose guidelines that are interpreted by every state. Every state operates its own Medicaid program. And as a result, the benefit level, as well as the eligibility threshold vary widely from state to state. I think that it can be a forum for experimentation, but it ends up being a real disadvantage and creating inequities for people across the US. So I would say those are some of them are important, exclusions and decrements.

Rachel Strausman:

Thank you so much. Yeah, that's very important. I think when you talk about access to care, it's important to make sure that we can include as many people. But we also have to understand that once we do include people, that doesn't mean we're gonna be 100% efficient, it's going to be working 100%. So kind of going off of that, relating back to your background in social ecology. To what extent does the stigma behind people in low-income backgrounds specifically affect their access to medical treatments but also to diagnosis.

Dr. Lefkowitz:

That's a really good question and my work is not focused on stigma per se, but I think it's important to consider to what extent people who have low-income are stigmatized in the health care system, I would say that stigma is a more serious barrier for people with disabilities or people with serious mental illness. But there's considerable overlap because people with disability or serious mental illness are disproportionately low-income. When people who have low incomes encounter the health care system, how is it that they are identified as low-income? I think it's primarily through the type of insurance. So then we have to look at what happens people with Medicaid. Now, in my research, I've heard a number of people speak quite openly and with a lot of frustration about having Medicaid, Medi-Cal in California. Doctors not wanting to treat them, not providing the same level of care, not taking the same amount of time. And this is certainly possibly related to stigma. But I think that we need to consider some other possibilities. And from a social psychological perspective, we can see that stigma is really at the interpersonal level. It's about what happens between a provider and a patient. It's also a way of talking about characteristics of the person seeking health care that becomes stigmatized in that interpersonal relationship. And certainly that's not unimportant. It suggests that access is partly a problem of bias. However, we could also see that workplace policies can seriously affect access, as I just mentioned. So it's not simply the bias, but it's the people who have Medicaid insurance are more likely to have jobs that don't provide time off or flexibility to take time off. We can also look at provider practices. So if your job does not allow you flexibility to take time off and your doctor's hours of appointments coincide exactly with your work hours. That's the problem. It's a real barrier. And another example, CMS, the Centers for Medicare and Medicaid, set the threshold for reimbursement for Medicaid services. And therefore, if the doctors perceive that Medicare and Medicaid reimbursed at too low a level, that will be a real disincentive for them, especially since there's huge paperwork burden of required by Medicaid. So all of these things which I would say are part of expanding our understanding of structural barriers. Not just looking at individual level, barriers come into play for people who are low-income. 

Kevin Karami:

It's really interesting to hear about the different layers. There exists issue in terms of low-income families and individuals getting the care they need. You briefly mentioned how stigma is very correlated and it plays a big role in terms of interpersonal relationships and how some people might think that basic policy change might be a solution. But then when you have human nature getting in the way of things, it makes it so much more difficult and challenging to solve these kinds of issues from a policy perspective. So kind of leading from the conversation we've been having, what are the most important changes that you think need to be made? In order to set us up as a society to be in a better position to advocate for and also ultimately provide people who might be from lower income backgrounds who don't have the resources or access to health care. What kind of changes are you looking at from the research perspective? 

Dr. Lefkowitz:

Well, I think universal insurance would make a tremendous difference for most of us, but especially for people who are currently without adequate access to health care. Now, other proposals that have been circulating in the last few years for Medicare for All, which is one version of a universal insurance policy. And it seems to raise all sorts of fears in this country. I actually think what people should be really scared about is getting seriously ill within our current health care system. And people tend to think that they will lose the freedom of choice about their insurance, about their health care. I actually think it's a real mistake to think that we could actually make informed choices in advance about the best health insurance for our own needs. Which is not to say that we can't think about these issues, but simply that no one can ever really anticipate what their health care needs might be in the future. You can only understand when you're in a situation and your insurance doesn't cover what you need, a drug, a procedure in order to recover from your illness. So there's a lot of concern also about the government making health care decisions. I hear a lot less discussion about insurance companies making health care decisions. That's essentially the system that we have now. Where you need prior authorization from many health care plans for many types of procedures. And it's essentially an insurance adjusters who are making those health care decisions, sometimes their life and death decisions. We've been seeing a lot of discussions in the news recently about these kinds of things. For example, UnitedHealthcare just announced that they will no longer be covering screening colonoscopies and diagnostic colonoscopies, only those that are preventive as part of preventive care, which means with the healthiest of individuals that's a very recent announcement, will have huge consequences for people with likely delay and later, later stage diagnosis of cancer. While I think universal coverage would certainly benefit individuals, would also benefit us as a society. The US spends the most per capita of any country in the world on health care. We certainly do not have the best health outcomes of any country in the world. According to recent estimates, the US spends about twice as much per person for health care every year compared to other high-income countries like France, Sweden, Canada, the UK, Australia, Japan. So we have to consider what else we could be getting for that money that we're spending on health care. And I think that Universal Health Care provides some real alternatives that we should consider. 

Rachel Strausman:

Yeah, I think that's a very good point that you bring up. That the US, as we're spending significantly more money than other countries, we're not getting anywhere near what they're getting in terms of health outcomes. And so there's definitely a disparity there. So with that being said, what would you say are the most impactful policies today in the US that determine health care access as it is. 

Dr. Lefkowitz:

This is a question I really enjoy thinking about because there are some things that are both obvious and less obvious in terms of what's currently available and working. Again, the Affordable Care Act. Although the final version when it was passed, has some unfortunate gaps that could be significantly improved. I think that it's under appreciated in this country for what it did accomplish. So I'll just mention a couple of ways that it enables health care access in addition to its almost universal inclusion, first, decouples health insurance from employment. Although the majority of Americans still obtain health insurance through their employers, this creates huge inequities. 1  employer is not equal to another employer. Big employers are able to offer a bigger benefit packages. So there's huge disparities in terms of what the employer is offering the employee. As well as many workers, including most essential workers, who are working in low-wage jobs and have no benefits whatsoever. So it's really important to have an option for health insurance for people who cannot obtain insurance through their employment. Second, and this is also really important. The ACA removes the barrier to insurance of having a preexisting health condition. Now most of my research has been on cancer and seeing what happened to people historically when they got diagnosed with cancer before passage of the ACA is truly eye-opening. So many people who when they get cancer diagnoses cannot work through their treatment or cannot work continuously through their treatment. And in the past, they would often get fired from their jobs. And then they found that with a pre-existing cancer diagnosis, they could not obtain health insurance at all, or the insurance was prohibitively expensive. So if we think today about how many in the people in the US have had COVID-19, that's most people in the US that would be considered a preexisting condition under a pre ACA circumstances. And we know that the ACA is constantly under attack. So if in the future, people who had, had a COVID infection developed health problems that could be linked to that infection, then they would be excluded from health insurance. And this is currently the case for millions of Americans. Estimates range from 20 million upwards who currently are living with long COVID. Second policy that I think has really been tremendous, although it has many flaws as well, is the Family and Medical Leave Act of 1993, the FMLA. So this allows eligible employees to take up to 12 weeks of job protected leave to take care of either themselves with a health condition or a family member. Now it's unpaid leave. That's one of the problems because not everyone can afford to take unpaid leave, but it does provide important job protection during that leaf, which means on returning to work, you can't be fired and you should be reinstated to the same job or a comparable job. It's there's some other things about what makes an employee eligible. It does exclude many people, many more people than are excluded from the Affordable Care Act. But nevertheless, the job protection afforded help some individuals to retain employment that otherwise might lose their jobs and therefore their employer related the employer sponsored health insurance. Now, a third policy that we might not think of as something that enables access, but I certainly do is state disability insurance. In California, we're really lucky to have State Disability Insurance Program, SDI. And it covers short-term partial income replacement up to 52 weeks, again for eligible employees. But we're one of only five states in the US, including Puerto Rico, that offer a State Disability Insurance Program. And this goes back already to 1946. So it's been a long time that we've had access to this. So it's a state level program, but the state does not pay for it. It's administered through california's Employment Development Department, but paid for through payroll deductions. So if you work for an employer that does payroll deductions, you are likely paying into the SDI program and can make use of it if you have serious illness that requires taking time off work. So we can see how this SDI program works hand in hand with FMLA. If you qualify for both programs, then you can have some partial up to about 60% of your full pay reimbursed while you're taking unpaid leave. Finally, I do want to mention exciting recent development in Colorado. Colorado Senate Bill 23-002 to was just signed into law on May 10 of 2023. And this is the first time ever that Medicaid will reimburse for community health services. Community health services provide a huge amount of neighborhood level health education and patient navigation that helps, especially low-income individuals in low resource communities navigate health care. And this is first, and hopefully a model that other states will emulate. And eventually we'd like to see federal level legislation that would pay for these services. 

Kevin Karami:

That's all really great to hear and it's interesting to hear what the US hasn't done. I know we've been talking a lot about what we should be doing, but it's still nice to hear that, and especially that on that last point about Colorado, I think that's really inspiring. I know it's only a state-level policy, but it's still really great to hear that there's at least some action being done. Kind of going off of this question. What kinds of state-level policies? And I know you mentioned a couple of here including the Colorado one. Are there any other state-level policies that have been passed, weather in California or beyond that you think should be considered and potentially may be implemented on the national level? 

Dr. Lefkowitz:

Well, that's a really big question. I think that again, states are often incubators for experiments and certainly CMS, centers for Medicare and Medicaid are using States as places to try out ideas and health systems within different states. So for example now there's a lot of discussion about value-based care and there's different models that have been tried out and there's always pitfalls. They work out some of the details. They have to try them out and implement them in real time, in real practices in order to see what's working and what's not I would say that one of the areas where states differ tremendously as around options for people who are undocumented. And in California, for example if you get breast cancer or cervical cancer, there are two programs. It's the breast and cervical cancer treatment program. One of them is the federal version and one of them is the state version. And the state version, it is possible for people who do not have legal immigration status to be covered for their breast or cervical cancer and treatment. The other federal program has a longer timeframe and is more expensive in the services that it covers. But at least the state level version allows people to get through cancer treatment. So this is where we see real differences. And I think that issues like legal immigration status, which are so incredibly polarized, certainly also abortion now in the post dobbs decision landscape, these are issues that we're working to see radical differences between states. 

Rachel Strausman:

Yeah, I think it's very important to highlight the issues of perceptions of health care and health care policy through not only policymakers and Important officials, but also through the general public. And branching off of that. To take a new perspective, you have a very inspiring career and you are not only an accomplished researcher and an academic, but you're also an internationally recognized documentary filmmaker and visual artists. So you have created this vast body of work on how individuals confront traumatic and life altering experiences. So given your experience with that, how important is it to bring light to these issues through the media? And what positive effects can they have towards helping inspire people to work to create lasting change? 

Dr. Lefkowitz:

I'm afraid I'm going to disappoint you in my answer on this. I spent about 15 years working as an independent documentary filmmaker. And some years after that, working primarily as a visual artist. And I believed during that time that media was an incredibly powerful way of illuminating problems and building empathy and understanding across profound differences in people's lives. It was like opening a window and letting people in to see ways of living that they would otherwise not have access to. I have somewhat revised my opinion about the media and that has a lot to do with the context in which people view media today. So I'll just say a few things that I've been thinking about. So when I started as a documentary filmmaker, people made films, not video's, not digital videos. Most often people viewed films collectively. They viewed them in classrooms and movie theaters and community centers. As a communal experience, it generates discussion, it generates social connection, a sense of shared values and commitments. I think there's an excitement that's generated with people all watching something together and then walking out afterwards with conversations continuing. If people viewed films in the privacy of their homes than it was on television and then it was often a family activity. So nowadays, I think most people are consuming media in little chunks, short YouTube videos, and even shorter TikTok videos. And this works against the kind of nuance, the complexity that indepth investigation that was possible with longer format media. It also encourages a really short attention span and impatience, and demand for everything right now. And I think that that works against really understanding how things are working today in society for health care and what needs to be changed, what's possible. I really think that complexity is missing from a lot of media. And third, if media invites viewers into the lives and problems of the people depicted, encouraging people to feel this could be me, or if this were me, how would I feel? That's a really powerful way of using media and that's certainly what I thought I was doing. But media it can also distance viewers from the lives and problems of people depicted and suggest to the viewer, oh, this would never be me. And in our politically polarized world, I fear that distance viewing is becoming more common than empathetic viewing. And that it takes more than simply a film or a television show to allow people to empathetically embrace someone else's perspective. And so in this sense, making media in today's world, I feel it's less helpful for inspiring policy change. That's not to say that important, really powerful media productions are not still being made and watched on issues of social justice. But I think for me, the trajectory out of film and out of art-making into research was a way of wanting to influence policy differently, using research as the foundation. So I don't know what your experience has been about viewing films and whether you've seen something recently that made you want to stand up and share or go out and do something? I'd be curious to hear. 

Rachel Strausman:

Yeah, I think that's actually an interesting point that you bring up, which I had never considered. I know a lot of people talk about the attention span that has changed over the years, but about how this loss of the communal viewing doesn't spark the important conversations needed to create change. And that's definitely agree with you on that. Now that media is more so viewed personally. We're not having these important conversations and hearing others people's ideas and opinions and beliefs so that we can better understand ours and those of the world around us, which I think is a great place to end because it really shows how health care and public policy both involve so many different players. They're both very interdisciplinary and to create policy that really makes sure that everyone has seen and everyone is heard. It takes a lot of work and so many different things coming together to make the perfect policy, which is why we have a lot of policies that are great in many ways, but it's just so difficult to create one ideal policy. So with that, thank you so much, Dr. Lefkowitz for joining us today. It's been an honor to have you on the podcast.

Dr. Lefkowitz:

Thank you so much pleasure talking to you.