Secession Fever

There’s a new disease this year along with the winter flu.  It is called Secession Fever. 

Secession Fever has reached epidemic stage across the south.  As of Monday, there were more than 25,000 cases in each of eight southern states – North Carolina, South Carolina, Georgia, Florida, Alabama, Tennessee, Louisiana, and Texas.  A ninth, Arkansas, had over 23,500.  Collectively, these states had almost 402,000 cases, and the number was still growing.

Secession Fever is a self-reportable disease.  People who have it signed a petition on the White House website.  Secession Fever is characterized by the irrational belief that the federal government does more harm than good, and that states would be better off if they seceded from the Union.

So what if these nine states did secede and form a new Southern Confederacy?  Would their citizens be better off?  Some data from the Kaiser Family Foundation and the Central Intelligence Agency suggest not.

In forming the Southern Confederacy, approximately 86 million people would find themselves living in the 14^th most populous country in the world, just behind Vietnam.  (The rest of the United States would drop from 3^rd to 4^th in population, trading places with Indonesia.)

They would find themselves worse off than they think they are.

The percentage of people living in poverty in the Southern Confederacy would be 17 percent, comparable to that in Trinidad and Tobago, Jamaica, and Turkey.  Meanwhile, the percentage living in poverty in the remaining United States would drop to 14 percent, comparable to the rate in the United Kingdom.

Life expectancy in the Southern Confederacy would also take a hit.  It would decline immediately to 77.7 years, 61^st in the world and comparable to life expectancy in Libya.  In the remaining United States, it would be almost 79 years.

That’s not all.  The health status of Southern Confederacy citizens would decline, too.

One in five residents in the Southern Confederacy would be uninsured, versus only 14 percent in the remaining United States. 

Even that high percentage would grow dramatically without the federal Medicaid and Medicare programs.  Without the federal share of Medicaid dollars, the percentage of uninsured in the Southern Confederacy would grow by at least 9 percent more, to close to 30 percent.  And without Medicare providing insurance for 16 percent of its population, the Southern Confederacy’s uninsured rate would approach 50 percent, killing off nearly every hospital and long term care provider.

Infant mortality would go up, too. 

For every one million births, 1100 more babies would die in the Southern Confederacy than in the remaining United States.  The infant mortality rate in the Southern Confederacy would be 7.5 per thousand – comparable to that found in Chile.

Disease prevention would also take a hit. 

The percentage of overweight adults in the Southern Confederacy would be over 65 percent, pushing ever higher the prevalence of diseases like diabetes, hyperlipidemia, and hypertension.

Public health would suffer, too.  The AIDS rate would grow, and the proportion of people infected with HIV in the Southern Confederacy would be similar to that found in Somalia.

Mental health services would not be spared, either. 

Nationally, we currently spend around $120 per capita on mental health services.  But in the Southern Confederacy, state mental health spending would be half that – just $61 per year.

It isn’t that people in the Southern Confederacy have better mental health status and need fewer services.  Just over one-third report being in poor mental health, just as in the rest of the country.  They’re just more likely to be ignored, neglected, or maltreated.

If there were ever a compelling argument for why we need a strong federal government, life in the Southern Confederacy is it.

Aspiring to the health standards of Somalia, Chile, Libya, Trinidad and Tobago, Jamaica, and Turkey – all nations with much to offer, to be sure – is hardly the stuff of “American Exceptionalism.”  But these nations turn out to be the real role models for those with Secession Fever.

These harsh health conditions reflect the realities of life in these southern states today.  We can argue that we can do better than this, but not if we can’t accept this reality – people are worse off in these states than in the rest of the United States.

Those with Secession Fever – and the political leaders who have fanned the flames of anti-federal sentiment for years – must be living in an alternate universe.

If you would like to schedule Paul Gionfriddo to speak to your group or organization, please email gionfriddopaul@gmail.com.

Confused and Confusing

President Reagan gave his first speech on the AIDS epidemic almost twenty-five years ago on May 31, 1987.  This was after 36,058 Americans had been diagnosed with AIDS, 20,849 had died, and over a quarter of a million had been infected with HIV.

For years, he had been criticized for ignoring and underfunding the worst public health crisis of the late 20^thcentury.  

So he began his speech with a joke:

“A charity committee approaches the wealthiest man in town for a contribution.  ‘Our book shows that you haven’t contributed any money this year,’ they tell him.  ‘Does your book also show that I have an infirm mother and a disabled brother?’ he replies.  ‘Why no,’ they say, ‘we didn’t know that.’ ‘Well, I don’t give them any money.  Why should I give any to you?’”

The bad joke was an inadvertent punctuation mark on a presidency too fondly remembered by both republicans and democrats today.

On matters of health, Reagan took us backwards.  He was neither in touch with the nation’s growing needs nor successful in addressing them.

His inattention to the AIDS catastrophe in particular and public health in general were just two examples.

He also helped create a new generation of chronically homeless people when he significantly cut federal mental health funding as part of the Omnibus Budget Reconciliation Act of 1981.  During his two terms as President, he also cut funding for safety net community health centers by over 25%.

Suggesting that Reagan would be too liberal by today’s GOP standards – as both some progressives and conservatives have done – is too liberal a stretch where health policy is concerned.

It was the Bushes who were progressives by today’s standards. 

Both delivered on campaign promises to expand the government’s role in health.

“Compassionate conservative” George W. Bush doubled funding to community health centers during his term and added a prescription drug benefit to Medicare.

And George H.W. Bush significantly expanded the federal Medicaid program.

Long before blogging, those of us who wished to express our opinions publicly used the “Letters to the Editor” forum in our local newspapers.  When I was in the Connecticut Legislature in the 1980s, I communicated regularly with my constituents through my local newspaper.

Here’s something I wrote about presidential health policy in October 1988: 

“When health insurance is necessary to pay for health care, how do we ensure that everyone has access to affordable insurance?  Both presidential candidates talk about this.  Governor Dukakis believes that the answer lies in the private sector, in all employers providing health insurance to their employees.  Vice President Bush believes that the answer lies in the public sector, in expanding the state and federal financed Medicaid program.  I know this looks like a classic role reversal, but solutions to health care dilemmas defy ideology.”

You can read the full text of what I wrote here.  If you do, you’ll be either fascinated or fatigued by how little health policy progress we have made in the last 25 years. 

Today, Mitt Romney, another former governor from Massachusetts, has a position on health care more similar to Michael Dukakis than to either Reagan or Bush.

Dukakis wasn’t very persuasive arguing for the private sector solution then, and Romney hasn’t been very persuasive arguing for it now – possibly because both headed a state with a long and solid reputation for making significant public investments in health.

At least President Barack Obama, the most vocal Democratic opponent of the individual mandate in 2008 who is now its leading proponent, recognized the importance of government funding for health when he said this past weekend:

“I refuse to pay for another millionaire’s tax cut by eliminating medical research projects into things like cancer and Alzheimer’s disease.  I refuse to pay for another tax cut by… eliminating health insurance for millions of poor and elderly and disabled Americans on Medicaid.”

But this hasn’t stopped President Obama from initiating or agreeing to multiple raids on public health funding.

Are you confused by all this?  You should be.  Presidents and presidential candidates have long taken confused and confusing positions on health policy with dire consequences for the public’s health.

Need some evidence?  Connecticut had over 250,000 uninsured people when I wrote my letter back in 1988.  Today, it is one of the states with the lowest percentage of uninsured people.  It has 384,000 uninsured.  Mental illness prevalence is up, autism is epidemic, obesity and its related effects have skyrocketed, and HIV still infects over a million Americans.

And our children, we all know by now, could be the first generation to live shorter lives than their parents.

An additional note on three sources:  I took the Reagan speech anecdote from the book And the Band Played On by Randy Shilts (1988 Penguin edition). My constituent letter was published in the Middletown (CT) Press on October 7, 2008. Kaiser Health News provided the Obama quotation on May 7, 2012.  

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.

We Need Foundations to Innovate in Health Care

Implementing health reform in the states is a governmental responsibility.  But Kaiser Health News reported this week that states are turning to foundations to help them with the costs of implementing these reforms. 

Financing governmental duties has not traditionally been the role of a foundation.  Governmental programs should be implemented efficiently, but asking foundations to pay for this implementation is drawing dollars away from the most important work of foundations.

This important work involves investing resources in promising initiatives that aren’t yet “government ready.”  Foundations are uniquely equipped to provide seed funding to experimental and innovative programs before they are ready for governmental action.

On the other hand, funding governmental obligations leads to two unintended consequences. 

First, it relieves governments of their obligation to justify to the public the expenditures they need to make to implement their programs.  This always seems to lead to unrealistic public expectations about how much things costs, and problems down the road with funding them.

Second, it takes limited foundation dollars away from innovation and experimentation.  Not every foundation initiative will succeed, and that’s the point.  While some fail quietly, many have changed the way we understand and address health problems in America.  Some of the best fundamentally change American society for the better. 

To name just three recent examples that illustrate this point, consider our 30 year history with HIV/AIDS, our emerging approaches to addressing the mental health epidemic, and our understanding of health disparities across populations and regions.  

The Robert Wood Johnson Foundation created the AIDS Health Services Program in 1986, five years after AIDS was first reported in the United States.  It was also the same year that President Reagan first mentioned AIDS publically.  While government responded slowly to the crisis, the RWJF initiative flourished and was responsible for enabling the Ryan White CARE Act, which wasn’t passed by Congress for four more years.  

Foundations are also leading the way in breaking down the barriers between health care and mental health care.  Primary and behavioral health “integration” emerged as a treatment strategy in the early 1990s, nurtured along by foundation investments.  It took the federal government fifteen more years before it began to make a serious commitment to integration through passage of the Mental Health Parity Act in 2008, the Medicare Mental Health parity law in 2008, and the Affordable Care Act in 2010.

Health disparities are underreported and poorly understood.  This is because they often offer no “local angle” to a story, but can only be understood in the context of comparing one group or region to another.  Such comparisons are easily dismissed as “apples to oranges” by local policymakers.

However, a government-supported university-based study shows vast and stunning differences in the life expectancies of various racial and geographic groups in the United States that can’t be so easily dismissed. 

The complete article, authored by Christopher Murray and others, is rich in comparative data, and its conclusions are more than troubling.  Asian Americans in well-integrated counties have a life expectancy that is 15 years longer than African Americans living in urban settings sometimes just a few miles away.  Rural white Americans in the Midwest have a 7 year life expectancy advantage over rural African Americans in the south. 

Native American and African American men have life expectancies of between 60 and 70 years, but Asian American and white women living in rural areas have life expectancies well into their 80s.  These numbers are underscored by readily-available CDC data tables. 

Nevertheless, the federal government did not make a major commitment to funding specific programs aimed at tackling disparities until more than four years after this study was published.  Just recently, HHS announced its Promotores de Salud community health workers initiative, a strategy specifically designed to address health disparities in minority populations.

However, as Grantmakers in Health points out, both local and national foundations have been focused on this problem for years, leading the way by funding important initiatives looking at both populations and place as determinants of health status for many years.

At their finest, foundations lead governments to action by experimenting with differing approaches to solving emerging policy problems, and finding and promoting those that work best.

It’s government’s job to bring them to scale.  Then it can solve the underlying problems – like AIDS treatment and prevention, mental health and primary health care integration, and health disparities – it may have been too timid to address, either because it didn’t know what would work or because it didn’t know what the public would support.

Asking foundations also to take on this job of government will reduce the dollars available for innovation and experimentation.  The risk is that we miss out on finding an early solution to the next public health crisis.

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