The Top Health Policy Stories of 2011, Part Two

Last week, I shared four of the top policy stories of the year that told us something about how health policy has been trending over the past decade or more.  This week, I’m offering four more to close out the year that tell us a little about where health policy is going in the future.

4.  Connecticut Employees Choose Health.  Back in the early days of managed care, when HMOs were not yet a four-letter word and they emphasized wellness as much as health care cost containment, they proved to be popular with members.  In August, the State of Connecticut revived the concept, giving its employees the choice of a lower cost health insurance plan that emphasized wellness or their traditional comprehensive plan.  It expected 50% to choose the new wellness plan.  But the state got a big surprise.  When the dust settled in October, 97% had opted for the wellness plan.  This will cost the state much more in the first year, but will also produce more than the $100 million in health care cost savings the state originally projected for the future.

The implication for future policy – people want do more for their health, and will if they see a direct financial benefit.

3. The Florida Legislature Puts the NRA In Charge of Medicine.  During its 2011 legislative session, the Florida legislature attracted some national attention when it decided to include the National Rifle Association (NRA) in the doctor/patient relationship.  The NRA asked the legislature to prohibit pediatricians from even asking parents if there were firearms in the house so they could counsel them about firearm safety – despite well-known evidence that children are more likely to die from unintentional injury than any other cause.  The bill passed, and the pediatricians were eventually forced to go to court to stall its enforcement.  With big lobbying organizations being allowed to sit in the doctor’s office with us, is it any wonder that people wonder whose side government is on?  

The implication for future policy – Patient privacy protections will erode if “smaller government” cedes more power to private entities.

2.  The Attack on Public Health.  After the loss of almost 30,000 public health jobs nationwide between 2008 and 2010, the Association of State and Territorial Health Officials (ASTHO) headlined an April press releasewith the words “Cuts to Essential Public Health Services Jeopardize Americans’ Health.”  The proof came in an article published in Health Affairs in August, which showed that a 10% change in public health funding changed infant death rates, as well as death rates from cancer, diabetes, and heart disease. 

The implication for future – we and our children will be less healthy tomorrow because of the cuts our policy leaders have made today.

1. The Implementation of the Affordable Care Act.  The implementation of the Affordable Care Act (ACA) was once again the health story of the year.  The public is still divided.  A plurality supports it, but the combined numbers of those opposing it either because they believe it did too little or too much comprise the majority.  Meanwhile, the law has begun to affect significant numbers of Americans.  For example, in September, CMS announced that 1.3 million Medicare recipients had received drug discounts averaging over $500 per person, and another 1.3 million had gotten a free wellness visit as a result of ACA.  And this month, the National Center for Health Statistics reported that 2.5 million young adults had insurance because of ACA provisions enabling them to stay on parents’ policies.    The election campaign and the expected May or June Supreme Court ruling on its constitutionality guarantee that this will be the story of 2012, too.

The implication for the future – government’s role in determining our health care future is going to grow, not diminish.  Policymakers will continue to struggle with our expanding $2.5 trillion health care economy and the public will continue to try to figure out whose side they’re on.

In early December, Our Health Policy Matters was averaging over 2,500 readers per month, and had recorded its 20,000^th reader – not too bad for the first year of a once-a-week column focused entirely on health and mental health policy.  I appreciate you all, especially those of you who printed and shared columns with your friends, used them with your students, and offered them to readers of your own electronic journals and web sites.

I’m always interested in your ideas about how to improve the column, and how to get it in front of more people.  Please let me know (gionfriddopaul@gmail.com) if you have any suggestions for me. 

And thank you all for engaging in the health policy debate, and my best wishes for a happy, healthy, and prosperous 2012!

The Top Health Policy Stories of 2011, Part One

Public policy attacks on public health and mental health, intrusions in doctor/patient privacy, the continuing fight over the Affordable Care Act, and our collective loss of faith in private health insurance were among the top health policy story lines of 2011.

This year, eight stories make my short list.  Not all of these stories made big headlines during the year.  But they have had, or will have, an outsized impact on our lives.

I’ll begin the countdown this week with four that capture and continue some of the major trends of the recent past.   Next week, I’ll offer four more that hint at where health policy may go in the future.

8.  The Shooting of a Congresswoman.  In January, the first big health policy story of the year was about violence and mental illness – the horrible wounding of a member of Congress, and the murder of several people around her.  As the media struggled to make sense of this, it raised once again the relationship between mental illness and violence.  What it failed to do was to report that, while this particular shooter seemed mentally imbalanced, most perpetrators of violence are not, and many victims of violence either already have mental illness, or will develop it as a result.

The continuing trend – Our jails are our nation’s largest mental health institutions, and will remain so until we invest more in prevention and treatment of mental illness.   

7.  The End of the Iraq War.  The War in Iraq may have ended this month, but its health effects will be with us and our veterans for many years to come.   A GAO report released in Octobergot little mainstream media attention, but was blunt in its description of the effects of this war and others on veterans’ mental health.  The 2.1 million unique veterans who received mental health treatment in the five year period between 2006 and 2010 represented over 30% of the veterans who received any type of health care.  The fastest-growing groups of veterans receiving mental health treatment during this period were the 213,000 Iraq and Afghanistan veterans with mental health needs.  And 38% of all Iraq/Afghanistan veterans who received health care during that time required mental health care. 

The continuing trend – So long as we remain at war, veterans’ health and mental health services will need to be expanded significantly throughout the foreseeable future, and, as taxpayers, we will need to pay for them.

6.  The Death of the CLASS Act.  What does it say when the first major provision of health reform to be killed off in a bipartisan way was the one provision that had enjoyed bipartisan support for a generation?  There are at least two things about long term care most of us don’t want to face.  The first is that most of us will need it someday.  The second is that practically none of us can afford it on our own.    Rather than coming up with a meaningful public/private partnership to pay for it after almost thirty years of trying, the Administration and Congress quietly killed CLASS in October, choosing once again to keep the current, broken system in place.  This is the one where we first impoverish people when they get old and sick, and then let government pay the whole bill.

The continuing trend – Medicaid will remain the default payer for long term care.  Costs will continue to skyrocket, we’ll all continue to complain, and long term care insurance won’t gain a greater foothold in the market any time soon.   

5.  Low PCIP Enrollment Numbers.  The most compelling evidence in 2011 that we may have finally lost our faith in private insurance was found in the late summer reports of the low enrollment in the Pre-Existing Condition Insurance Program (PCIP).  This is a program that eligible uninsured people were supposed to embrace, because it pretty much guaranteed that it would pay out far more for their health care than it collected in premiums, saving each of them lots of money.  But when only 30,000 of the 4 million eligible people enrolled as of July, most of the rest seemed to be saying that they would rather take their chances on permanent financial ruin than insurance.  Or that they were already so impoverished by illness that they no longer had anything to lose.

The continuing trend – If the health insurance industry cannot restore our trust, even the people who need it most will opt out, relying only on safety net government funding.

Next week:  The final Our Health Policy Matters column of the year looks at four more big stories of the year, and their implications for the future. 

Echoes of Scrooge

Except for summertime humidity, the Florida and Connecticut “climates” don’t have a lot in common. 

For example, Connecticut has one of the best climates for health and health care, while Florida’s is in the bottom half.  On the other hand, Florida has one of the best business tax climates, while Connecticut’s is near the rear.

Their political climates are also polar opposites.  Florida’s governor is a Republican, and its Legislature is overwhelmingly Republican.  Connecticut’s governor is a Democrat, and its legislature is overwhelmingly Democratic.

And the difference in their policy climates is reflected in the way they handled their 2011 budget crises.  Connecticut raised taxes and cut spending, while Florida just cut spending.  As a result, Connecticut’s budget now balanced.  Florida, meanwhile, extended its crisis by another year.  And its Governor has just proposed cutting $2 billion from health services alone in his proposed new budget.

But for two states with so little in common, their emerging 2012 Medicaid cost containment strategies are remarkably similar echoes of the ghost of Ebenezer Scrooge.

They both want to “decrease the surplus population” of needy people on the program.  Florida is targeting kids; Connecticut young adults.

In Florida, Health News Florida reported last week that nearly 800,000 Florida residents could be forced off of Medicaid because of a new co-pay Florida has asked the Federal Government to approve.  The vast majority would be children. 

While he awaits the decision of the Feds, Florida’s governor is also proposing massive cuts in Medicaid reimbursements to a host of safety net hospitals.  Jackson Memorial Hospital in Miami would be cut by $133.5 million, Memorial Hospital in Ft. Lauderdale would be cut by $58 million, Shands Hospital in Gainesville would be cut by $52 million, Miami Children’s Hospital would lose $35 million, and Tampa General would be slashed over $32 million. 

Shands, Jackson Memorial, and Tampa General all have been ranked among the best hospitals in the country by U.S. News and World Report.   This would greatly limit poor people’s access to them.

Meanwhile, in Connecticut CT News Junkie reported that a “reduction in health care benefits, asset tests, and a potential cap on enrollment” are all under consideration by the Department overseeing its Medicaid program.

The reason is because its caseload is growing too quickly.  In 2010, Connecticut was the first state to shift 45,000 state-only medical assistance program clients – many young adults – to Medicaid under a provision of the Affordable Care Act.  The Federal Government paid 60% of the cost and the state saved millions.   But the number of people signing up for the program has grown to 70,000 in the last eighteen months, erasing the savings.

So Connecticut has sent a letter to the Federal Government asking permission to change the eligibility requirements for the program and the benefits package.

Even though Connecticut acknowledges in the letter that the poor economy is a reason for the unexpected growth in the program, its solution, like Florida’s, is to deny some of its neediest people access to care.

So here’s the question that both Florida and Connecticut must answer.

If they make these cuts, where do they think these people will go, and who do they think is going to pay the bill?

Workhouses, a favorite of Scrooge’s?  Prisons, which are already the largest mental health providers in the country? 

Or perhaps they want them to go to the hospitals from which Connecticut took $32 million in 2011 and Florida wants to take millions more in 2012? 

Of course, in both states there are good, local alternatives to cutting and slashing, and wishing and hoping that poor people will recover from disease and disability on their own. 

Connecticut could offer the same wellness and disease management program to these Medicaid recipients as it offers its 50,000 state employees.  The State projects that it will save over $100 million this way – close to what it hopes to save in Medicaid cuts. 

And Florida could stop slashing public health and prevention – which already took a $56 million hit in 2011 – and instead increasefunding to local public health departments by 10%, giving them the flexibility to spend the new dollars anyway they want.

A Health Affairsarticle this past summer showed that this approach leads to reductions in cancers, heart disease, and infant deaths (here’s a link to a related article and chart I created from the data).   

Wouldn’t these cost-saving options be preferable to a Scrooge-like denial of care to desperate children and destitute young adults? 

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.

Socialized Medicine in America

If there were an award given for the worst health policy exaggeration of 2011, it might well go to Newt Gingrich, Mitt Romney, Rick Perry, and a chorus of others who call the Affordable Care Act “a government takeover of health care.”

They make this charge to capture votes from a constituency that fears what life would be like if we had “socialized medicine.” 

The problem with the rhetoric is this.  It isn't true.  If you look at who pays the bill, the United States already has socialized medicine. We just get less for our money than practically anyone else in the world.

According new data from the Organisation for Economic Cooperation and Development (OECD), no other country spends close to what our government alone does on health care.  Right now, the total government share of our annual per capita health care bill is around $6,000, or over 70% of the total. 

Norway is next most expensive, but its total per capita bill is $5,352.  The government share is $4,501.  In Denmark, the government pays only $3,696 annually, and in the United Kingdom, our poster child for socialized medicine, it pays just $2,933.

There are more relevant comparisons to make, too.  According to OECD, the Canadian government’s share of its annual health care bill is 71% - exactly what ours comes to when you add in all our government costs (the OECD does not in its data reporting, which makes our government share – though still second-highest among the nations – look artificially small).  Health care costs much less in Canada than it does here, however.  The Canadian government spends only about half ($3,080 per capita) as much as ours on health care.

What are we getting for all this government spending?  Fewer doctor visits, shorter hospital stays, and less access to mental health care.

We get an average of 3.9 visits to doctors each year here, compared to 7.7 in Germany, 5.5 in the United Kingdom, and 5.5 in Canada.  People in Italy, Switzerland, and Denmark also get more doctor visits than we do.

Our average length of stay for an acute care hospital visit is 5.4 days.  In Canada, they get 7.7 days, in Germany and Switzerland, they get 7.5 days, and in the United Kingdom, they get 6.8.

And we share 2 psychiatric care beds for every 10,000 people.  Canada has 4, Germany has 5, Denmark and the United Kingdom have 6, and Switzerland has 10.

Perhaps we need less health care because we’re healthier in America. 

Only 16% of our population smokes every day, the same percentage as in Canada.  This compares favorably to Norway, Germany, and the United Kingdom, where over 20% of the population are daily smokers.

And while we consume almost 9 liters of alcohol per person per year, citizens of Germany, the United Kingdom, Switzerland, and Denmark all consume far more alcohol than we do.

But if we take better care of ourselves, have shorter hospital stays, and fewer doctor visits, shouldn’t our overall cost of care be lower, not higher, than other countries’? 

Could we be paying for quality?

We have access to a lot of medical technology, but not so much more as to explain why the cost of care is so high here.  For example, we have more MRI machines than any other country in the world, but countries like Greece, Iceland, Korea, and Finland are all beginning to catch up with us. 

And we are in a tight competition with this same set of countries in the availability of other technology.  We have less radiation therapy equipment available to our population than Iceland, fewer mammogram machines than Greece, and not as many CT Scanners as Korea. 

Of course, we don’t usually compare our health care to that in Iceland, Korea, Finland and Greece – and we shouldn’t.  Iceland’s annual total per capita health care expenditure is $3,538, Finland’s is $3,226, Greece’s is around $3,000, and Korea’s is $1,879.

So why is socialized medicine such a mess in America? 

It isn’t, and won’t ever be, on account of the Affordable Care Act’s phantom “government takeover.” 

It’s more likely because politicians pretend that private insurers play a bigger role in financing health care than they do, and give them too much power over transactions between patients and providers.   

And – unlike other countries with socialized medicine – it’s because we treat health care more as a commodity off which private businesses should profit than a public service we all need.

That’s what exaggerating politicians are really defending.

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

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.

Cain Not Able

Herman Cain’s ascendant Presidential campaign brings into focus the limited health policy thinking that has dominated the campaign so far. 

Here are our current major health policy challenges:

• Reversing the trend toward lower investments in the public health and prevention activities that have accounted for half of our increased longevity in the last century;
•  Assuring fair coverage of the chronic conditions, including mental illness, cardiovascular disease, and cancers, that affect 60% of our population;
• Giving even the uninsured 16% of our population access to high quality, comprehensive, integrated primary, specialty, and hospital care; and
• Figuring out how best to pay for all this.

Despite the urgency of these challenges, the current health policy debate can be condensed into a four word sound bite – “Repeal Obamacare Individual Mandate.”

Here are the specifics of what the candidates have been talking about the past couple of weeks.

Mitt Romney and Newt Gingrich are fighting over whether Romney got the idea for the “individual mandate” from Gingrich or the Heritage Foundation.  (Both, it seems, from their exchange in the last debate.)

Ron Paul wants to abolish our health care system in its entirety and replace it in part with free care “as a charitable benefit provided by doctors” for all poor people.

Rick Perry’s first national health policy headline came when he advocated eliminating the Medicaid program that pays for long-term nursing and home care for elders and people with disabilities.  His last came this past weekend when he questioned Hawaii’s vital statistics record-keeping – at least where Barack Obama’s birth certificate is concerned.

And Herman Cain, the self-proclaimed a “problem solver,” solved his business’s financial problems in part by helping to pay for health insurance for only 17% of his employees.

As Cain’s sketchy health care plan shows, his plans for what he would do for the other 83% are few and far between.   

First, he wants to sell insurance across state lines.  The Affordable Care Act already will permit this, but there’s a catch.  The only policies that could be sold across state lines must meet minimum coverage standards. 

He opposes this.  So when he favors selling insurance across state lines, he doesn’t care if it actually covers anything for which you might need insurance, such as cancer, heart disease, mental illness, comprehensive primary care, drugs, or even most hospital stays. 

Second, even though it would violate his 9% flat tax proposal, he wants to allow individuals who buy insurance to be able to deduct it from their income tax.    

Why?  So that businesses could eliminate group health insurance from their employee benefits package – as Cain himself did – and let employees pay for the more expensive individual plans on their own.

Third, he wants to expand the use of health savings accounts, into which individuals and families would have to deposit their own money to cover the thousands of dollars of deductibles in the stripped down insurance policies that would flood the market if his “across state lines” plan passed.

They might get a tax deduction for this – if he violated his 9% flat tax policy again – but that’s just another way of shifting even more of the cost of health care to individuals and the federal government. 

Citizen Cain refers to these proposals as “patient-centered” reforms.  But patient-centeredness involves most everything that is absent from “Cainsian” health economics. 

It is about promoting health and well-being and improving access to affordable, quality care, not making insurance companies more profitable.

At least Cain offers a plan on his web site, unlike family-first candidate Rick Santorum.  And in a nod to Michele Bachmann, Cain did acknowledge in a recent debate – without mentioning her – that he lifted much of his health plan from legislation co-sponsored by Bachmann (HR3400) in 2009.

Herman Cain talks a good game about the “sacred patient-doctor relationship,” but his slapped-together health plan is little more than a slap in the face to people with serious health and wellness needs.  There’s nothing in it about wellness, prevention, or chronic disease management.  There’s nothing about access and quality. 

It’s all about stringing together a few of the worst proposals for individuals, families, and taxpaying citizens, and dressing them up as an alternative to the Affordable Care Act. 

Even raising Cain to new poll heights won’t make him able to sell this.   

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