Term Limits Are Bad for Your Health

It costs an average of $6,000 per person per year in federal, state, and local taxes to cover the government’s share of our national health care bill.

The three levels of government pay about 71%, or roughly $1.8 trillion, of our nation’s annual health expenditures.  It is no wonder that most rational people want policymakers to do more to bring these costs under control.

Policy leaders talk all the time about controlling health care expenditures.   This would help.

But if we actually want to reduce costs significantly, we have to invest in prevention and public health.  This is a position I’ve pushed in the past.  All it takes to understand why is to recognize that prevention and public health have been responsible for half of our increased life expectancy during the past century while absorbing less than 5% of our overall health spending.

This is old health policy news.  So why aren’t policymakers doing more in prevention?

The answer may boil down to two words – term limits.  Term limits, it seems, are bad for your health.

State legislators have a direct say in how roughly 40-45% of government health dollars are spent, and an indirect say in much more.  We now have almost twenty years of experience with term limit laws.  States that limit the terms of their state legislators do a worse job protecting the health of their people than states that do not.

Term limit legislation swept through half the nation in the 1990s as citizens sought to rein in the power of lifetime citizen politicians.  California, Colorado, and Oklahoma were the first states to enact them in 1990.  Nebraska, the 21^st, was the most recent in 2000.

There are currently fifteen states with term limits for state legislators.  California and Florida are the most prominent among them.  With just a handful of exceptions, none of them ranks near the top in my States for Your Health ranking, the Healthy State rankings (which focus on public health), or the Kids Count rankings (which focus on children and prevention). 

Only four of these fifteen term-limiting states – Colorado, Nebraska, California, and Maine – make even the top half of the States for Your Health.  Only Colorado, Maine, and Nebraska are in the top 20 in the Healthy Staterankings.  And only California, Maine, and Nebraska are in the top 20 in the Kids Countrankings.

Overall, the average ranking for the fifteen states with term limits is 31^st in all three rankings.  The average ranking for the 35 states without term limits is 23^rd.

Six states – Idaho, Massachusetts, Oregon, Utah, Washington, and Wyoming – enacted term limits and then repealed them.  Their average rank is 13^th in my rankings, 11^th in the Healthy State rankings, and 15^th in the Kids Count rankings.

The reason term limits have such a significant effect on the health of a state’s population may be because term-limited politicians don’t have the time to come up to speed on complex health issues.

Election to office or appointment to a legislative committee does not make one an instant expert on policy.  And term-limited politicians are often political lame ducks the day they get elected, with no incentive to work on issues with a long-term policy payoff.

Public health and prevention initiatives demand patience, with payoffs often measured in decades, not four two-year terms.  For example, reducing smoking prevalence from 42% of the U.S. population in 1965 to 21% in 2006 required a generation of a Surgeon General-led public education campaign, bans on smoking in public places, increased cigarette taxes, and restrictions on sales of tobacco products to minors.  Saving billions in cancer and heart disease costs required this level of ongoing effort.

It also required having in place long-term legislators with whom tobacco lobbyists had to deal.

When the top-ranked state for health, Massachusetts, passed its health reform legislation in 2006 that led to near-universal coverage in the state, two legislators who spearheaded the effort – the Speaker of the House and the President of the Senate – had been in office for 27 years and 13 years, respectively.  And in Connecticut, my second-rated state for health, the current Speaker of the House has been in office for 19 years, and the Senate President has served for 18 years.  Both have considerable achievements in health and environmental health during the past decade – long after term-limiting states would have put them out of office.

In fifteen states, term limits have led us to trust a large portion of $6,000 a year in health spending annually to people without this experience. 

And that has proven to be very bad for our health.

If you have questions about this column or would like to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

The Worst States for Your Health

Some states do a much worse job than others of keeping their residents healthy and providing for high-quality, affordable health care when their residents need it.  People usually live shorter, less healthy lives in these states than they might if they lived elsewhere.

In my last column, I described a new States for Your Health ranking, and examined the states that finished near the top.

This week, I want to look first at why Florida, ranked first in one of the seven indicators – per capita Medicare spending on non-institution-based services – only finished 30^thoverall.

Florida’s doesn’t invest enough in public health and prevention.  It is 36^th among the states in the 2011 Kids Count rankings, and 37^th in the 2011 Healthy State rankings.  Children in poor environments for their health are more likely to develop both physical and mental illnesses as they age.  Obesity, cancers, heart diseases, and mental illnesses are all expensive, and can cut decades from life expectancy.  

Florida’s care quality rankings are much higher than its prevention rankings.  It is 11^thin the number of times its hospital programs made the U.S. News and World Report national rankings.  These high quality programs are usually found in just a few hospitals in major cities, but this is the case in most states.  It is 16^th in nurse practitioners per 100,000 residents, and 19^th best in keeping Medicaid nursing home and hospital spending under control. 

Florida is, however, is near the bottom (45^thplace) in the percentage of residents with private insurance.  That hurts.

The ten lowest ranked states either score exceptionally low in the prevention or health care rankings, or consistently low across the board: 

50. West Virginia.  The lowest-ranked state isn’t at the bottom in any individual ranking.  It is just near the bottom everywhere – 40^th in the percentage of people with private insurance, 43^rd in the Healthy State rankings, and 44^th in Kids Count.  It broke into the top half in only one ranking, the amount its Medicaid program spends on hospitals and nursing homes.  Even that may not be such a good thing.  While low Medicaid spending on institutions was considered positive in this ranking, it is also an indicator of low spending on health care in general.

49.  Louisiana. Louisiana finished next-to-last in both the Healthy State and Kids Count rankings.  That’s why it’s 49^th here, too.  On the other hand, it was 2^ndin per capita community Medicare spending, and has some quality hospital programs.  It clearly has assets on which to build.

48.  Mississippi.  Mississippi is last in the Kids Count and Healthy State rankings, and next to last in percentage of people with private insurance.  However, it is in the top ten in community-based Medicare spending and in the number of nurse practitioners per 100,000.  Both could contribute to a healthier state in the future.

47.  Oklahoma. Oklahoma is in the bottom ten in nurse practitioners, Kids Count, and Healthy State rankings.  It is also one of 18 states with no highly ranked hospital programs.

45t. Arkansas.  Arkansas’s profile looks similar to some of the others at the bottom.  It has low prevention ratings that bring down its overall ranking, but it is near the top in number of nurse practitioners and limiting Medicaid hospital and nursing home spending. 

45t. Kentucky.  Kentucky isn’t near to the bottom in any single indicator.  It is just consistently weak across the board.

44. New Mexico.  New Mexico is in last place in the percentage of people privately insured.

43. Nevada.  Nevada is in last place in the number of nurse practitioners.

42. Alabama.  Alabama ranks low in prevention and primary care rankings.

41. Montana.  Montana is as high as 25^th in the Healthy State rankings, but it lags in Kids Count and all of the health care rankings.

Two states finished last in individual rankings but did not make the bottom ten.  South Dakota was at the bottom in community-based Medicare spending per capita, but ranked 29^thoverall.  New Jersey spent the most from its Medicaid program on hospital and nursing home care, but still finished 9^th overall.

To see the complete rankings, click here.

If there is a bottom line, it is this.  Despite our discouragement with our public health and health care systems in general, people in nearly every state have at least something for which to be thankful.  And there will be better days ahead for all of us if policy leaders understand that we want them to do more for our health, not less.

Happy Thanksgiving!

The Best States for Your Health

When the Supreme Court reviews the constitutionality of the Affordable Care Act next year, it will do so against the backdrop of both a national sentiment for government to do more in the area of health and significant inequalities in access to health and health care based solely on the states in which people live.  

A new poll released last week by the Robert Wood Johnson Foundation and the Harvard School of Public Health found that 52% of Americans want government to put more resources into health. 

Only 41% gave high grades to our health care system, and only 33% gave our public health system high grades.

We would all like a more effective health and health care system.  But a better national delivery system would make a much bigger difference in some states than in others.

This week, Our Health Policy Matters unveils a new ranking of the states that reflects which states invest most effectively in our health and health care. 

It was created by combining four existing rankings and three new ones.  It includes mental health as well as health, the work of other health professionals in addition to doctors, and availability of community care as well as quality institutional care.  It ultimately rates the states based on how good they are at simultaneously:     

• keeping their children and adults healthy; and 
• taking care of their residents when they are sick or have chronic conditions; and 
• providing for both health and health care at a price their residents can afford. 

Taking everything into account, here are the ten best States for Your Health, and why:

1. Massachusetts.  Massachusetts is the only state with five top five finishes among the seven rankings.  It takes good care of its children, invests in wellness and prevention, has many top-rated hospital programs including one of the highest rated mental health facilities in the country, and insures its population well.  Where health and health care are concerned, every state should want to be more like Massachusetts.
2. Connecticut.  Connecticut is near the top in six of the seven rankings.  Its children, working adults, and elders all thrive on a rich set of high-quality prevention and health care services. The only ranking in which it did not excel was one that measured affordability – the high amount its Medicaid program historically spends on hospital and nursing home care. 
3. New Hampshire.  New Hampshire rates as the best state in the nation in three of the individual rankings I combined – the 2011 Kids Count child health and well-being rankings, and two Kaiser Family Foundation State Health Facts rankings – the number of nurse practitioners per 100,000, and the percentage of people who are privately insured.
4. Vermont.   Vermont is number one in the Healthy State rankings and in keeping its Medicaid hospital and nursing home costs under control.  It has figured out that the best way to control Medicaid spending is to keep its population healthy.
5. Utah.  Utah proves that good health is a conservative value.  It takes good care of its children, promotes healthy lifestyles among its residents, and is home to a high percentage of residents with private employer-based insurance – a key measure of affordability.
6. Minnesota.  Strong in the prevention and public health rankings, Minnesota is also home to a top hospital.  It gives its residents access to quality public health and quality health care at the same time.
7. Washington.  Washington cracked the top ten in only one individual ranking, so it may be a surprise that it is ranked so high when they are all combined.  But it does just about everything well compared to other states, and isn’t close to the bottom in any category. 
8. Hawaii.  Hawaii scores high in prevention and keeps Medicaid institutional spending under control.  It doesn’t have any of the top rated hospital programs.  If it did, it would rank even higher.
9. New Jersey.  New Jersey does especially well by its children and its elders, and is in the top ten in three individual categories.  But it is an expensive state for Medicaid recipients to get sick in, and a lot of that money goes to hospitals and nursing homes. 
10. Wisconsin.Like Washington, Wisconsin is consistently in the top half of the individual rankings.  If its residents were able to spend relatively more of their Medicare dollars on community services and less on institutional ones, it would move up.

There are two states that topped individual rankings that didn’t make the top ten.  California, according to US News and World Report the best state in the nation to find high quality hospital programs, tied for 15^th.  Florida, first in per capital Medicare spending on community services, finished 30^th. 

To see the full ranking of all the states, click here.

Next week:  More about why Florida finished where it did, and a closer look at the ten states that finished near the bottom.

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, email gionfriddopaul@gmail.com.

Note: Here are the rankings I used, the reasons I used each of them, and a link to the 

original data: 

• the 2011 Healthy State Rankings and the 2011 Annie E. Casey Foundation Kids Count state rankings – to measure the effectiveness of public health and overall prevention (including mental illness prevention) activities; 
• the Kaiser Family Foundation (KFF) State Health Facts ranking of the percentage of people with private employer-based insurance – to measure health care access and affordability for workers and families; 
• the KFF State Health Facts ranking of the number of nurse practitioners per 100,000 residents – to measure support for non-physician providers and high quality primary care;
• To measure quality of care and medical professional development, I calculated and ranked the states by the number of times a hospital in a state was included in the 2011 U.S. News and World Report rankings of best hospitals in the country across specialties, including mental health and overall rankings of children’s hospitals (33 states had at least one hospital mention);
• To measure the availability of community-based services for elders, I used the most recently available data from the Centers for Medicare and Medicaid Services reporting per capita state spending in each state on Medicare minus hospital and nursing homespending;
• To measure the effectiveness of state intervention to keep people with disabilities in their homes and out of institutions and as a measure of affordability, I used CMS data to calculate per capita state spending on Medicaid hospital and nursing home care as a negative measure.

Because prevention and health care each account for approximately 50% of the gains in life expectancy over the last century, I gave the two prevention-oriented rankings – the Healthy State and Kids Count rankings  – a combined weight equal to that of the other five.  

Veterans Dazed, Not Dazzled, By Mental Health Care

Nearly 2.1 million veterans received mental health care from the Veterans Administration between 2006 and 2010.  According to a Government Accountability Office report released in October, 1.2 million veterans received mental health treatment in 2010 alone.

Almost 30% of the 7.2 million veterans who received treatment from the VA received mental health treatment.  So did 38% of Iraq and Afghanistan (“OEF/OIF”) veterans.  Many more probably needed it. 

The GAO report shows how pervasive mental illness is among veterans, and how co-occurring mental illnesses overwhelm both veterans and their service delivery system.

Younger veterans and reservists are especially affected.

We now have over 22 million living American veterans, but only 4 million served during World War II or the Korean War.  Seven million served during the Vietnam War, and almost 6 million are OEF/OIF veterans. 

OEF/OIF veterans accounted for 12% of all those receiving VA mental health services in 2010, a three-fold increase in just five years.  The GAO said this was expected “because of the nature of OEF/OIF veterans’ military service – veterans of this era typically had intense and frequent deployments.” 

Another October 2011 report entitled Losing the Battle: The Challenge of Military Suicide quantifies the tragic effect of this.  We lost 33 active and reserve duty Army personnel to suicide in July 2011 alone, and veterans – less than 10% of our population – account for 20% of all suicides in America.

There are three reasons why we lose so many veterans to suicide.  They are

• Traumatic brain injury, resulting in disability;
• Chronic pain from bodily injury; and
• Post Traumatic Stress Disorder (PTSD).

PTSD is far and away the most significant of these reasons.  I wrote about this in an earlier column.  As both the GAO report and the chart accompanying this column show, nearly half of the veterans receiving VA mental health care in 2010 had PTSD.  Most had at least one other mental health diagnosis, too.

It is a national failure that we don’t do a better job of identifying suicide risk factors and intervening earlier.

VA screening protocols may be part of the reason.  The authors of Losing the Battle report that returning veterans have historically been discouraged from admitting to mental health problems as they fill out their post-deployment screening forms.  As a result, the GAO reports the VA now “requires veterans treated in primary care settings to be screened for mental health conditions such as PTSD, depression, substance abuse disorders, as well as a history of military sexual trauma.”

And it turns out that veterans are more dazed than dazzled by the mental health care they are offered.

They avoid it, the VA told the GAO, because of stigma, lack of understanding about available services, logistical challenges accessing health services, and concerns about the quality of VA care.

• Mental illnesses are stigmatizing largely because many people still believe that they are “behavioral” weaknesses, not serious and life-threatening diseases that can shorten life expectancy by 25 years.
• Many also believe that services are only for people who are severely mentally ill.  They avoid seeking care for fear they will be labeled “whiners” and “psychosomatics.”
• Veterans, reservists, and non-veterans have logistical challenges in accessing services.  The VA does not have a full complement of mental health providers.  At least those they have get paid.  Major insurance companies are cutting reimbursements to community mental health providers, so patients who find providers outside of the VA often can no longer afford the out-of-pocket cost.
• It is impossible to have a quality mental health care system unless non-mental health professionals don’t just screen for – but are trained in managing – mental illnesses.

A 2009 SAMSHA reportfound similar reasons given by the 5.1 million civilians who also reported unmet mental health needs.

We can begin to fix this if we do four things:

1. Commit a fraction of the resources we committed to the wars to fight the mental illnesses they have caused – in the VA and in the community, wherever veterans, reservists, and non-veterans receive services.
2. Increase training of primary and specialty care providers so they recognize, diagnose, manage, and refer patients with mental illnesses.
3. Make periodic mental health screening a part of wellness exams for everyone, starting with young children.
4. Insist that insurers honor the mental health parity mandate.

We remember the sacrifices of our veterans when we fly our flag.  We honor those sacrifices when we take care of the men and women who made them.

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The Growing Obesity Challenge

Obesity is a disease, just like cancer, heart disease, mental illness, and addiction.  That’s the message of experts at a recent Future of Medicine summit on the subject.

And there are missing pieces in the way states with some of the largest concentrations of obese residents, like Florida, Connecticut, Texas, California, New York, and New Jersey, approach the epidemic.

As recently as 25 years ago, obesity was uncommon in America.  Most states didn’t even collect data on it, and not a single state reported obesity in more than 15% of its population.  Connecticut and Florida both reported rates under 10%.

The CDC map at that link shows what has happened since.  Every state in the country quickly grew bigger. 

By 2010, in 12 states, including Connecticut, between 20% and 25% of the population was obese.  In 24 states, including Florida, between 25% and 30% of the population was obese.  In the remaining 12 states, including Texas, over 30% of the population was obese.

Why has this happened at a time when people arguably have become more health conscious than ever before?   

The reasons that are emerging from research are changing the way experts think about obesity.  If policy makers listen to the experts, then this will change the way they attack the problem, too.

According to the research, obesity is not the result of an exercise of free will to overeat, any more than drug dependence is the result of a desire to overmedicate.  Dr. Paul Kenny of the Scripps Research Institute, a member of the expert panel convened by the Palm Beach County, FL Medical Society, argued that low-quality, high calorie food is proving in laboratory studies to be nearly as addicting as cocaine.

He and others say that we must use a disease model to attack obesity.  We must prevent it whenever we can, and treat it aggressively when it is present.

Unfortunately, identifying a single cause of obesity is elusive.  Dr. Kenny suggested that no single obesity gene will be found.  Dr.Ronald Romear, a practicing pediatrician, said that “in eighteen years, I haven’t seen the thyroid as a cause” for any of the obesity in the children he treats.

Investing in prevention, therefore, is imperative, and this has become the first line of attack against obesity in the public policy arena.

The American Academy of Pediatrics and public health professionals both favor the 5-2-1-0 campaign.  Children and adults are urged:

*  to eat five servings of fruits and vegetables a day,

*  to limit television, computer, and video game play to no more than two hours a day,

*  to exercise at least one hour a day, and

*  to drink zero beverages sweetened with sugar. 

Focusing on individual behavior is important.  As I wrote in an earlier column, there are also broader, community prevention strategies for states to consider.  They could regulate the amount of sugars added to foods and drinks.  They could make an hour of physical education a mandatory part of the school day, and they could offer safe outdoor play areas in all neighborhoods.   

Aggressive treatment is also part of the arsenal against obesity when it has progressed to critical stages.

Bariatric surgeries, such as lap band and gastric bypass, are becoming more common.  Dr. Andrew Larson, a bariatric surgeon on the panel, noted that 45 state Medicaid programs pay for bariatric surgeries.

But, in the disease treatment model, what are largely being ignored by states are the treatment options between prevention and end-stage obesity surgery – primary care integration and behavioral health intervention.

Some argue that primary care providers must play a bigger role in treating obesity in its early stages.  However, primary care providers need tools and resources – including adequate reimbursement for their time – to identify and treat those at risk, and they don’t currently have them as a matter of policy.  

And with addiction at the heart of obesity, states should recognize the importance of mental health services like counseling.  They should make Medicaid coverage for counseling part of the anti-obesity campaign.   

According to a recent George Washington University publication entitled Coverage of Obesity Treatment, neither Florida nor Connecticut (nor most of the high-concentration states) does.

Some of us undoubtedly shake our heads, wondering why government should address what we see as personal choice and weakness. 

But if the experts are correct, then obesity today is no more the result of human weakness than cancer or heart disease, and it is in the public interest that we do more about it.