To Be Healthy, Live Among the Wealthy?

If you want to be healthy, then be wealthy. Or at least live in a wealthy county.

That’s the obvious message you get from combining the recently released County Health Rankingswith poverty and income data from the 2010 U.S. Census.

Source: US Census and County Health Rankings, 2012

But if you look closer, you see something else.  It’s not just that poorer people are less healthy than their wealthier counterparts. 

People are less healthy where too few resources are invested in public health.

Earlier this month, the 2012 County Health Rankings were released by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation.  In the release, Dr. Risa Lavizzo-Mourey, President and CEO of RWJF, said that “where we live, work, learn, and play has a big role in determining how healthy we are and how long we live.”

She’s right.

The poorest counties – as measured by the percentage of people living below the poverty level – are usually home to the least healthy people.  And the wealthiest counties – as measured by income – are home to the healthiest.

That much isn’t news.  We’ve known for a long time about the relationship of poverty to poor health. 

But we usually think about that relationship in terms of individuals – the poorer the individual, the worse his or her health status is likely to be.

The county-level data suggest that we look at the relationship in another way – as a community problem.

Then we discover something more.

The poorest counties often have both the least healthy residents and some of the poorest public health infrastructures in their state. 

Consider these examples from three different states.

• The three poorest counties in America – Ziebach (the only county in America where over 50% of the population lives in poverty), Todd, and Shannon – are in South Dakota.  Of the 59 South Dakota counties in the County Health Rankings, they are at the bottom, placing 53^rd, 58^th, and 59^th, respectively.
• Owsley County, Kentucky, is also one of the nation’s poorest counties.  It is the poorest county in Kentucky, and it ranks last in the state’s county Health rankings.
• South Carolina’s Allandale County is one of the poorest counties in America.  It, too, ranks last in its state county health rankings. 

What do they share besides poverty and poor health?

The North Dakota communities are worst off.  They have very limited governmental infrastructure and services.  All are Native American reservations.  Two don’t even have a County Seat. 

Owsley County shares its health department with six other rural southeastern Kentucky counties.  The regional health department covers a geographical area larger than some states, and its central office is located over an hour away from Booneville, the Owsley County Seat.

Allandale County also lacks its own dedicated public health infrastructure, sharing public health services with several other South Carolina counties.

Is it poverty or poor public health infrastructure that matters most? 

That’s hard to say, but poorer public health infrastructures are common in relatively poorer counties in wealthier states – even when those counties are well-off compared to the nation as a whole.

• Windham County, though relatively wealthy by national standards, is Connecticut’s poorest county.  It also ranks 7^th of Connecticut’s eight counties in health. 
• And Washington County, Maine, is Maine’s poorest and least-healthy county. 

What about their public health infrastructures?  Unlike many Connecticut cities, none of Windham County’s fifteen towns has its own public health department.  Public health services are delivered through three regional health districts shared by several communities. And in all of Washington County, there are just two district offices of the Maine Health and Human Services Department.

So it appears that poor health may go hand in hand with poverty because economically disadvantaged communities often don’t take care of their public health infrastructure – not just because poorer individuals often don’t take care of their health.

Florida is home to one of the exceptions that may prove the rule.  DeSoto County is Florida’s poorest county.  But DeSoto ranks in the top half – 28^th – of Florida’s 67 counties in health.

Why?  It may be because of DeSoto County’s strong public health infrastructure.  Its residents have better-than-average access to diabetes screening and better-than-average low birth weight numbers.  Behind these achievements are a diabetes screening program housed in a county-run primary care clinic and a county-run women’s health clinic.

Living well isn’t always about how much wealth an individual has to spend for a healthy life.  It’s often about how much a community is willing and able to spend for healthy lives.

Jim Hurley's Forgotten AIDS Message

Thirty years ago, AIDS was a total mystery to us.

Six years into what CDC already termed an epidemic, 358 AIDS cases in twenty states had been confirmed and 136 people had died.  No one knew why.

Several people I knew were probably already infected with HIV.  I learned this only as they died over the next few years.  One was a popular Connecticut Congressman, Stew McKinney, who was a moving force behind federal funding for services for homeless people.  Another was a lawyer named Jim Hurley.

I first met Jim when we were high school debaters. 

His school debated against my school at several local and regional debate tournaments.  I remembered him as bright, easy-going, and friendly.

We reintroduced ourselves during our first year in college, when we crossed paths in his dormitory one day.  He hadn’t changed much.  He was personable, still friendly, and happy to exchange a few stories about Catholic high schools and debating.

I transferred to Wesleyan and lost track of him after that.  I became active in Connecticut politics and government after college, and Jim went to law school.  With his skill set, he must have been a very good lawyer.

Our paths crossed just one more time, but not in person. 

The next time I saw him, it was years later on a videotape that was played in 1987 at an AIDS conference at Central Connecticut State University.  On tape, he still looked pretty much the same as I remembered him.  But he was 34 years old and dying of AIDS.    

One of the points Jim made on that videotape stayed with me.  He said that it didn’t really matter how he got AIDS.  What mattered was what we would do to prevent others from getting it in the future.

By that simple standard, there are now well over a million reasons why we haven’t done enough.

There was a time when the Centers for Disease Control and Prevention tracked and reported on AIDS cases every single week.  Now we have to wait years to find data about how many people have HIV and die from AIDS.

In 2009 – the year for which most recent data are available – there were 48,100 new HIV infections in the United States, and 17,774 people died as a result of AIDS.

Last year, CDC also reported that in 2009:

• New HIV infection was as common in men as salmonella poisoning and as common in women as pertussis.
• Among all people between 15 and 24, new HIV infection was twice as common as Valley Fever – a disease well-known and frequently diagnosed in the southwest.
• Among men between 40 and 64 – the population most likely to have been directly affected by AIDS over the years – new HIV infection was more common than Lyme Disease – a disease well-known and frequently diagnosed in the northeast.

AIDS-related deaths declined dramatically when drug cocktails were introduced during the 1990s, and so we began to forget about how serious it is.  People are living longer with HIV infection than they ever did before, but HIV still shaves up to 30 years from life expectancy, and still accounts for more deaths in the under 45 population than diabetes and stroke.

The AIDS epidemic isn’t nearly as under control as we might think.

And it is worse in some places than others.  Connecticut, for example, has more new HIV infections than any other state in New England. 

But for the most part, the HIV/AIDS epidemic has moved south.

Florida leads the nation in new HIV infections, with over 5,400 in 2009 alone – nearly as many as New York City and the entire State of California, two other “ports of entry,” combined. 

HIV death rates are also highest in Florida, Louisiana and Maryland.  New York, New Jersey, Delaware, Tennessee, Mississippi, Georgia, and South Carolina are all in the next tier. 

The half million Americans who have died and the 1.2 million who are living with HIV are also evidence that Jim’s Hurley’s message was poorly heeded. 

Nearly all of them got it after he made his videotape and was featured by Newsweek Magazine in its August 1987 “Faces of AIDs” issue.

We can do better than this.  Even since the most recent HIV data were published, over 100,000 more American men, women, and children have been infected.

April is STD awareness month.  In memory of our lost friends and to save lives in the future, we must do more to eradicate this relentless and deadly disease.

April is STD Awareness Month.  To increase awareness about AIDS, please consider sharing this column with friends and colleagues.  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, please email gionfriddopaul@gmail.com.

Mitt's Plan

Imagine what a nightmare healthcare scenario might look like.

You are diagnosed with a debilitating chronic disease while young.  At first, you can’t even work because of it, and you are dependent on a family member’s insurance to help pay your medical expenses. 

Eventually, your disease goes into remission, and you find a job with health insurance.  You go off your family member’s plan.  But your employer goes bankrupt, and you’re left with no job and no insurance. 

Then you get another chronic disease.

You try the individual health insurance market, but the only insurance available to you comes from a high risk pool in which everyone else also has at least one chronic disease.  The price is outrageous, but you pay the bill as long as you can.

Eventually, you can’t afford it, and you become uninsured for a few months. 

You apply to your state’s Medicaid program for help.  You are denied because your state has already spent all the Medicaid dollars the federal government has given it for the year. 

You keep searching for work.  When you finally land a new job, you are informed by your employer that it only offers a high-deductible, catastrophic-only insurance plan.  You have to cover your basic health care needs, including annual physicals, prescription drugs, and counseling, out-of-pocket. 

At least, you think, the plan will help with recurrences of your chronic conditions.

But then you learn that as a result of your earlier lapse in coverage, the company’s insurer refuses to cover you because of your pre-existing condition.

You’re out of luck.

You might call this nightmare far-fetched.

Or you could call it Mitt’s Plan.

Mitt Romney now has a plan to repeal the Affordable Care Act if he is elected President. 

These are some of the mandates with which he would replace it:

• High risk pools for the chronically ill.  These high-cost, unsubsidized private insurance plans for the sickest among us have been around for years, but have never enrolled many people because of their prohibitive costs.
• A law to prevent insurance discrimination against people with pre-existing conditions only if they maintain continuous coverage.  If they ever have a lapse in insurance for any reason, insurers could use that lapse to deny insurance to them forever.  Eventually, this could affect nearly everyone, because over one-quarter of the population has a lapse in coverage every year. 
• A return of states to “their proper place of regulating local insurance markets” – but this would be accompanied by a new federal mandate that would gut state regulatory authority.  The federal government would mandate that out-of-state insurers could sell policies in a state that don’t meet the minimum standards set by that state.
• A Medicaid block grant to the states.  This will cap federal Medicaid spending each year.  States will be forced either to pay a larger share of long-term and indigent care costs or to cap both Medicaid payments and enrollment.
• More managed care and fewer “fee-for-service” plans.  Private insurers will be given even more power over patients and doctors to decide who is worthy of care and who isn’t – and no level of government will have the authority to put an end to this rationing of care in the interest of the consumer.

The resulting nightmare isn’t far-fetched.  Candace Brown is already living most of it every day. 

Candace Brown is a nurse.  She was diagnosed with Crohn’s Disease when she was 30.  She wasn’t able to work for three years, but was covered on her father’s insurance.  Her disease finally went into remission, and she found a job with health insurance.  However, she lost both the job and her insurance when the company went out of business.

Then she was diagnosed with depression, and struggled to find insurance afterwards because of her two pre-existing conditions.  She finally found a plan that would accept her, but it now costs $1,200 a month. 

She describes herself as “financially drained.”

I imagine she sometimes feels physically drained as well.

At least she hasn’t yet had to deal with being uninsured, but even that hasn’t come without stress.  She’s afraid to let her coverage lapse to qualify for the Pre-existing Condition Insurance Program (PCIP) - which Romney also would repeal.

The only nightmares Candace has avoided so far – because they won’t be legal unless Mitt’s Plan becomes law – is a non-entitlement Medicaid long term care program someday and being dumped by her current insurer.

But Candace is a realist, and that’s why she is counting the days until ACA takes full effect.  

Note: Candace Brown's story was published and made available by Florida CHAIN at the link provided in the column.  More information about the work of Florida CHAIN can be found using the link.  If you have questions about this column or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Anna Brown's Death

Anna Brown was 29 years old when she died suddenly last September.

She left two small children. 

Sometimes, the tragic and untimely death of a young mother commands our attention.  Anna’s death in Missouri drew a little national interest just last week. 

She died alone on a concrete jail cell floor.  It happened just a few minutes after she was arrested for trespassing.  She refused to leave a hospital emergency room while she was in agonizing pain.   

Anna Brown was homeless, had mental illness, and was on Medicaid.  Hospital officials thought she was a drug-seeker.  They were wrong. 

According to news reports, a morning fog blanketed St. Louis on September 20, 2011 – the day Anna died.  She spent much of her final day going from emergency room to emergency room begging for care.  She started at St. Louis University Hospital complaining of pain in her leg.  She was evaluated and released with a prescription for painkilling medication. 

Unsatisfied with her care, she went next door to Cardinal Glennon Children’s Medical Center.  There clinicians found tenderness in her leg, but explained that they could not treat her because she was not a child. 

Her pain was so bad that she could not walk.  So she was transported by ambulance to a third hospital, St. Mary’s, where she was diagnosed with a sprained ankle. 

But Anna Brown was afraid something more serious was wrong with her.  So when St. Mary’s said she could go, Anna Brown refused.

That’s when St. Mary’s had her arrested for trespassing.  

A police officer later reported that “they thought that she was a drug seeker.”  The police wheeled her out of the hospital in handcuffs.

When she arrived at the jail, she was having trouble breathing.  Officers placed her on the floor of her cell and left her alone.  She died within fifteen minutes of undiagnosed blood clots in her leg that traveled to her lungs.

What a tragedy.

It was compounded by others in Anna Brown’s life.   

She had lost her house a couple of years earlier to a tornado.  She lost her job shortly thereafter.  When she could no longer afford to pay her heating bills, her service was discontinued and she took to building fires in her apartment to keep her children warm.

Child protective services found out, and the state removed her children from her care.

Her mother took in the children, and reported that the family court gave her a choice – she could care for Anna’s children or Anna, but not both.  She was forced to choose her grandchildren over her daughter.

So Anna became homeless.  At the time of her death, she was using city shelters and frequenting a drop-in center for people with mental illness.  Contrary to the assumptions of the clinicians who examined her on her last day of life, she was not using drugs.

Too much of Anna’s story isn’t uncommon. 

We have all read reports about patients with mental illness “flooding” hospital emergency rooms because of state cutbacks to mental health services.

These usually suggest that patients choose emergency rooms for non-emergency health reasons because they have no place else to go. 

In defending its actions just last week – a full six months after Anna Brown’s death – St. Mary’s Hospital sounded this theme.  It issued a statementthat read in part “the sad reality is that emergency departments across the country are often a place of last resort for many people in our society who suffer from complex social problems that become medical issues when they are not addressed.”

That statement may be true.  But Anna Brown wasn’t suffering from “complex social problems” when she showed up at St. Mary’s. 

She was suffering from neglect of her medical condition.  That neglect didn’t begin at St. Mary’s; it just ended there.

And we are mistaken if we think this doesn’t happen every day in every state in the nation.

Medicaid emergency room co-pays, cuts to mental health and substance abuse treatment, inadequate funding to combat homelessness, and anti-loitering laws are all just symptoms of this neglect.

Anna Brown died from blood clots, but she also died because too many people looked past her suffering and saw a caricature of a homeless, mentally ill patient, and jumped to a conclusion about what they think such a patient represents.

Anna Brown may have visited far too many emergency rooms on the day she died, but the fault wasn’t hers.  And she and her loved ones paid the price.   

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, please email gionfriddopaul@gmail.com.