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.  

For a Less Healthy State, Cut Business Taxes

In a recent column, I wrote about the importance of public health spending in reducing the death rate. 

What other public policy strategies also lead to a healthier state?

Chart shows positve healthy state rank relationship to health spending, negative to business tax climate. 

There are quite a few.  I compared several other state rankings with the most recent state health rankings published earlier this year. These included health care spending per capita, per enrollee Medicaid spending, Medicaid spending for people with disabilities, Medicaid spending on children, and state mental health agency spending.  I also looked at rankings in per capita income, household income, the percentage of people with private health insurance, and business tax climate.  

It turns out that a higher state ranking in eight of the nine areas is related to a higher state health ranking.  In only one area – business tax climate – did a higher ranking predict a lower state health ranking.

Like spending on public health, more generous health care spending – including safety net spending – is a strong indicator of a healthier state.  The healthiest state, Vermont, was 8^th overall in per capita health care spending.  Massachusetts, the second healthiest state, ranked second in Medicaid spending for people with disabilities.  Maine, which topped the state list in mental health spending, was the eighth healthiest state overall. 

The strongest indicators of a healthier state among the five areas of health spending were Medicaid expenditures on behalf of people with disabilities and the state’s ranking in per capita mental health spending. 

The next strongest was overall Medicaid spending.  Behind this were overall health care spending per capita and Medicaid per capita spending on children. Spending more on children generally means better prevention, and spending more on health care usually means better health care.  Both contribute to a healthier population. 

Some people might argue that there are economic factors at play here.  After all, wealthier people are healthier than poor people, so it stands to reason that higher per capita income would be a much better predictor of a state’s health ranking than entitlement spending would be. 

Higher per capita income is, in fact, related to a higher healthy state ranking.  Eighteen of the states in the top 25 in the healthy state rankings are also in the top 25 in per capita income.  However, a state’s per capita income ranking is no better a predictor of the state’s health ranking than is its overall spending on Medicaid.

Put another way, a state’s spending on mental health and disabilities services is a better indicator of a state’s health ranking than is its per capita income.

Another economic factor – the state’s ranking in the number of people who are privately insured in the state – is strongly related to the state’s health ranking.  The more people on private insurance, the healthier it is for a state. 

So it turns out that there are many policy decisions state legislators can make to improve the health of the people of their states.  They can spend more on Medicaid, put more state resources into mental health services, get more people on private insurance, increase minimum and living wage standards, and make sure that health care providers are plentiful and paid decently for their services.

Most states are doing exactly the opposite today. 

Some are even taking it one step farther.  They are cutting business taxes in an effort to improve their business tax climate.

However, the better the business tax climate ranking, the lower that state’s health ranking seems to become.

Nevada, for example, has the 4^th best business tax climate, but it was the 47^th healthiest state.  Florida has the 5^th best business tax climate, but it was the 37^th healthiest state.  The least healthy state, Mississippi, had the 21^st best business tax climate. 

Chart shows poor relationship of business tax climate to per capita income and private insurance rankings.

There is a reason why so-called “business tax expenditures” don’t translate into a healthier state.  It is that these don’t appear to improve a state’s economy. 

A better business tax climate ranking is related to lower, not higher, per capita income, and has no effect at all on the state’s ranking in the number of people who are privately insured.

A good business tax climate does not have to lead to a poor state health ranking.  New Hampshire, for example, is the third healthiest state and has the seventh healthiest business tax climate.  But it also prioritizes health and worker benefits.  It is in the top tier of state per capita mental health and Medicaid spending, its per capita income is high, and its employers are tops in providing private health insurance to workers.

We can have a healthier population working within the constraints of bad economic times.  We just have to stop knee-jerking about entitlements and taxes, focus our attention on what works, and invest in our people again.

Column note:  The two charts accompanying this blog may be difficult to interpret because of the number of state data points on them.  I added the liner trend lines to simplify them.  Trend lines that move in the same direction as the line to which they are being compared (the healthy state ranking in the first chart and the business tax climate in the second) have a positive relationship to it; flat lines have no relationship and those moving in the opposite direction have a negative one.  For further reference, I have created a new page with a table (see the “State Rankings” tab) of all the state rankings I used.  The sources for the rankings and the charts are on that page.

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