Mental Health, America

اضغط هنا لمشاهد الفديو كامل 

I started writing Our Health Policy Matters three and a half years ago, right after the 2010 mid-term elections.

Since then, I have written about two policy areas about which I am passionate – public health and mental health.  As I explain below, I am about to change my professional focus.  And while I will be speaking about one more than the other in the future, for me these two areas are related. Let me explain why.

Mental health and public health are first and foremost about wellness.  They are about identifying risk factors for disease and eliminating or mitigating them.

Many of the same environmental risk factors contribute to poor health, especially poor mental health.  These include poverty, violence, abuse, and neglect.  When we address or mitigate these risk factors, we improve our nation’s health and mental health together.

We often place the burden of responsibility for maintaining one’s health squarely on the shoulders of individuals.  But this is a too-narrow approach.  We cannot prevent every physical illness by eating right and exercising, nor can we prevent every mental illness by simply willing it away.

What we forget sometimes is a simple, self-evident concept about wellness – the brain is a part of the body, and there is no health without mental health.

This leads to two unintended consequences.  The first is this.  In our effort to help people understand the linkage between mental illnesses and addictions, we use a term – behavioral health – that often implies to laypeople that these illnesses are bad behavior, and nothing more.  Mental illnesses therefore seem less serious than other chronic diseases – even though they shave twenty-five years or more from life expectancy.

The second is that we divide health care and mental health care into two non-integrated treatment systems.  We know the result.  Mental health care is poorly supported.  Our community support systems are inadequate.  People with serious mental illnesses are overrepresented in the homeless population.  Our jails and prisons have become our new state hospitals.

When we ignore the importance of promoting mental health and preventing mental illness and integrating care and treatment, we underestimate the power of recovery. 

Mental illnesses can be managed, just as any other chronic conditions can.  Recovery from cancer is possible – and even the norm for many – and so, too, should recovery be the norm for many mental illnesses.

When do not put resources into prevention, integrated care, and recovery, we make mistakes.  Because mental illness is often a childhood disease and there is a long lead time between the emergence of symptoms and the receipt of appropriate care, we make two mistakes in particular.  We overburden both our educational and primary care systems.

Our educators never expected to confront – as first-line responders – such needs in their classrooms.  Our primary care providers never expected to become experts in the early identification of mental illnesses.  Yet half of mental illnesses appear by age 14, and the vast majority of medications for mental illness are prescribed by primary care providers.

This system leads to failure.  I have explained why in other columns, and in an essay I wrote in 2012 for Health Affairs.  And I have written a book about the subject – Losing Tim – that will be published by Columbia University Press in the fall of this year.

But now I have been offered an extraordinary opportunity to do something more.

In a few weeks, I will become President and CEO of Mental Health America.

MHA is a Washington, D.C. area group that has advocated for mental health for over a century.  With 228 local affiliates scattered around the nation, MHA has an extraordinary history of leadership in the modern mental health movement in America – one that I hope to continue.

I am already part of an MHA family.  My wife Pam is, and will remain, CEO of the MHA Palm Beach County affiliate – the Mental Health Association of Palm Beach County.  And my daughter Lizzie works in direct services for the MHA affiliate in Connecticut, the Mental Health Association of Connecticut.

But my professional life is about to change.  For now, this will be my last Our Health Policy Matters column. 

I’ve appreciated the platform this column has given me, and hope that I have used it responsibly.  And I’m grateful to the thousands of readers who have come to this site each month.

I hope our paths will cross often in the future.  And I hope that when you think about Mental Health America, you will always think about mental health, America.  And about the work we still need to do to make mental health the norm for everyone.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

From Twinkies To Tofu: The Ten Best Public Health Initiatives Ever

I never ate yogurt, avocadoes, or tofu until I was in my twenties.  When I first went to the dentist as an eight year old, I had twelve cavities.  And the Connecticut River smelled like raw sewage when I was a kid – because it was filled with raw sewage.

This is Public Health Week; the theme is “return on investment.”  The good news – spending on public health  (as a percentage of all health spending) has doubled in the last fifty years.  The bad news, this is still less than 3 percent of our national health budget.

Despite that meager investment, the return has been big.  Here are my top ten public health initiatives ever – or at least in my lifetime.

10. From Twinkies to Tofu.  Nutrition education has come a long way in the last fifty years. Twinkies, snowballs, chocolate cupcakes, and sugary cereals “fortified” with vitamins were staples of my youth.  We knew so little about nutrition in those days.  I never ate yogurt.  I never even heard of tofu.  And an avocado never touched my lips.  We may be heavier today than we were then, but thanks to public health professionals at least we know why. (Perhaps it’s the 701 sodas we consume every year – a 26 year low!)

9. HIV/AIDS Prevention.  I lost too many friends and classmates to AIDS in the 1980s, and we had no idea how to treat it for several years after it was first identified.  But once we cut through the noise created by people who worried that it came from mosquito bites, Haitians, and kitchen utensils, public health pros found effective prevention strategies that saved millions of lives while we waited for effective treatments.

8. Water Fluoridation.  Cavities were inevitable when I was young, and lost teeth were the price we paid later – in spite of brushing.  Then we fluoridated our water and prevented tooth decay.  Not only did the public health pros save teeth; they saved lives as we reduced heart disease linked to poor oral health, too. 

7. Smoking Bans in Public Places.  Thirty years ago, I was eating in a popular Italian restaurant.  The cigarette smoke was so thick that I could barely see clearly across the room.  The owner came over to say hello.  I asked him where his “no smoking” section was.  “Wherever you’re sitting,” he replied.  He was the Chairperson of the Connecticut Legislature’s Public Health Committee.  We’ve come a long way, baby.

6. Sewer Separation.  When I was young, toilets in my home town flushed waste into storm sewers that flowed directly into the river.  No wonder the water was brown.

5. Oral Polio Vaccine.  I remember getting my dose in the school cafeteria.  Immunization came of age in my lifetime, and we now we take it for granted that our children will never get many formerly life-threatening diseases – such as polio, measles, mumps, rubella, and even influenza.

4. Air Pollution Control.  My mother used to repeat the rhyme “red sky in morning, sailors take warning.  Red sky at night; sailors delight.”  Then red skies at night just meant ozone pollution.  While we have a long way to go, we can’t say that public health pros weren’t on top of the climate change issue almost from the beginning.

3. Bike paths and running trails.  When I ran my first road race thirty years ago, there were fifty people entered.   But when I ran my first marathon ten years ago, there were over ten thousand.  Exercise has gone mainstream in the last fifty years.  Don’t believe me? Compare the lack of muscle tone on the bodies of movie stars of the 1960s to what you see today.

2. The Rise and Fall of Plastics.  My wife Pam was reminiscing recently about when we used to see pictures of garbage floating down our rivers.  Everything became disposable about the time plastics arrived.  But then we began to redeem, recycle, and re-use, saving valuable landfill (and river) space.  Now cities like Austin have banned plastic bags entirely.  Why not?  Live simpler, and we often live healthier.

1. Getting the Lead Out.  When I was young, my brothers and I used to peel the lead paint off the side of our grandfather's house for fun.  We didn’t stop until he replaced the shingles with asbestos siding.  Oh, how we long for the everyday toxins of our youth.

And if only we could see this big a return on all of our investments in the future!  

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

The 13,386 Lives Congress Sacrificed Last Week

“I will keep them from harm and injustice.”

“I will prevent disease whenever I can, for prevention is preferable to cure.”

-Classic and modern versions of the Hippocratic Oath, from MedicineNet.Com

Senator Tom Coburn of Oklahoma is a physician.  He’s familiar with the Hippocratic Oath, and has used it to explain his opposition to health care reform.

Last November, Senator Coburn famously termed a $15 billion appropriation for public health and prevention a “slush fund.”  That’s because it was paying for community tobacco control programs, immunization activities, and addiction disorder prevention and treatment services around the country. 

For information on sources, see note below

“Prevention is about focusing on an individual patient,” he commented, apparently forgetting everything he learned about epidemiology at the University of Oklahoma’s College of Medicine and at least some of the words of the Hippocratic Oath.

Public health is the basis of health promotion and disease prevention. 

It focuses on the well-being of entire populations and communities.  It gets only 3% of our total health funding according to CMS data.  It has been responsible for at least half of the increase in life expectancy in America in the last century.

Now it is going to get even less funding, because Senator Coburn’s view has prevailed. 

Last week, his Congressional colleagues – in approving what was described as the last significant piece of legislation like to pass this year – agreed to cut $5 billion from the public health fund.  (Senator Coburn voted against the final bill, but not because it cut public health funding.)

We now know how many lives that $5 billion cut to public health will cost. 

This is because of an article written by Glen Mays and Sharla Smith and published last July in Health Affairs.  In that article, the authors showed that increasing spending on public health reduces infant deaths and deaths from cancers, heart disease, diabetes, and other chronic illnesses. 

They found that a 10% difference in public health funding is associated with a 6.9% difference in infant deaths, a 3.2% difference in heart disease deaths, a 1.4% difference in diabetes-related deaths, and a 1.1% difference in cancer deaths.

The CMS tally of U.S. spending on public health in 2010 was $78 billion.  A $5 billion dollar cut represents 6% of that total.

So that 6% cut this year will be associated with the following:

• 1,077 additional infant deaths;
• 7,831 additional deaths from heart disease;
• 617 additional deaths attributed directly to diabetes;
• 3,861 additional deaths from cancer.

Let’s be clear.  Mays and Smith were careful to point out that we can’t say that lower public health spending causes more deaths – but the association is real.  The amount of disease and death go up as public health spending goes down.

There are two levels of irony in the vote.

The first is that, before this happened, Mays and Smith cited the public health fund as evidence of Congress’s increasing awareness of the value of public health.  So much for awareness.

The second is that Congress decided to use the $5 billion to pay physicians to see Medicare patients who suffer from conditions like heart disease, cancer, and diabetes.

Physicians needed that so-called “doc fix.” Congress caused the problem way back in 1997 when it adopted a Medicare reimbursement formula with a flaw. 

Ever since the flaw became apparent a decade ago, Congress has plugged the reimbursement hole it created one year at a time, kicking the solution another year down the road.  After ten years of kicking, the hole is so large that doctors’ reimbursements would have been cut by 27% without the plug.

Kaiser Health News has an excellent summary of the doc fix dilemma on its web site for those who want to read more about it.  Because Congress won’t fix it for good, doctors are forced to waste their time and money lobbying for a fix every year.

Physicians are undoubtedly relieved that they came out okay again this year, but I seriously doubt that most of them would have wanted the money to be taken from public health.  After all, they’ve all sworn the same Oath as Senator Coburn.

But here’s the important question.  When Congress is able to afford $40 billion in oil and gas tax subsidies over the next ten years for hugely profitable companies, how come, when our health and well-being is concerned, it has to be either/or – and at the expense of thousands of lives?

Note on Source Data for Lives Lost Calculations:  Sources for numbers of deaths attributable to cancer, diabetes, heart disease, and infant mortality were websites of national chronic disease advocacy organizations and U.S. Government (CDC).  Death calculations were made by OHPM using the one-year death total for the most recent year available (usually 2010) and applying a 6% change factor.  The implicit assumptions is that if the 6% cut were to become annualized, so too would the annual number of increased deaths.

If you have any 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.

The Contraception Exception

In arguing last week for the “contraception exception,” did Catholic Bishops – whose compassion for human beings is generally second to no one’s – really mean to open the door to those who would deny people access to other needed prevention services?

To recap, the Obama Administration announced that birth control had to be a part of employer-based health insurance plans.  Contraception is considered preventive health, and the Affordable Care Act mandates this and many other prevention services be offered free of charge.

The Catholic Bishops objected strongly.  They are morally opposed to birth control, and argued that, as an employer, the Church should not be compelled to pay for prevention services it deems immoral.

The Obama Administration then announced a compromise.  No religious institution would be required to pay for contraception services in its health insurance plan, but insurers would still have to cover the services for women who wanted them.

On Friday, it appeared that Catholic leaders would accept the compromise. 

Cardinal-designate Timothy M. Dolan, who heads the U.S. Conference of Bishops, called the Administration’s announcement “a first step in the right direction” of “preserving the principle of religious freedom.”

But by Saturday the U.S. Conference had issued a strong statement declaring that “the only complete solution to this religious liberty problem” was “to rescind the mandate of these objectionable services.”

Some commentators have taken a cynical view about the Bishops’ statement, arguing that they’re out of touch with the 99% of U.S. women who have used birth control. 

In the past, governments have preserved access to ethically controversial services, including contraception, abortion, and capital punishment, while assuring that no one with an objection had to pay or participate.

As Kaiser Health News pointed out in a February 8^th blog, over half the states required coverage of contraception services before the passage of the Affordable Care Act, and twenty of those had some form of exemption for religious institution employers.

The Bishops’ Saturday statement breaks new ground in demanding that a prevention “mandate” be rescinded. 

It has the potential to change the way we make public policy regarding both prevention and health care services in ways the Bishops themselves would not support.

Historically, we have protected most religious objections to health care treatment.  But we haven’t allowed a religious organization to run roughshod over nonbelievers.  Jehovah’s Witnesses, for example, can refuse blood transfusions, but they can’t deny them to a non-believer. 

But it is a prevention service to which the Bishops seek to deny access, not a health care treatment service. 

The Bishops argue that this is just about their rights under the first Amendment to the Constitution, which reads in part “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof.”  

However, we also have a Ninth Amendment which reads:  “The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.”   In other words, the Church’s First Amendment rights don’t come at the expense of someone else’s Ninth Amendment rights.

So then everyone must be given the opportunity to maintain their health by accessing whatever prevention services they need, consistent with their own religious and secular beliefs – unless we do not have a Constitutional right to health.

That last part is the door the Bishops – who also support universal health care – have now cracked open.

By creating a Constitutional objection to some prevention services under the Affordable Care Act, they are inviting others with less life-affirming goals to make theology-based Constitutional objections to other prevention services, too.

There are policy leaders in this country who don’t believe that people have a “right” to health.  They see health care as a commodity, subject to the whims of the free market.  They don’t support insurance mandates – for contraception, prenatal care, child health, or anything else.  You can already see them piously wrapping themselves in the Bishops’ cloaks. 

It is a slippery slope for Bishops – who on Saturday also reiterated their support for “access to life-affirming healthcare for all” – to cast their lot with these “unchristian” people. 

If the Bishops are true to their beliefs, they will speak out in the coming days as forcefully to these policy leaders as they did to the President – about why they supported health care for all in the first place.

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.

A Dime's Worth of Difference in 2012

With the Iowa caucuses finally behind us, the Presidential campaign of 2012 now begins in earnest, and will dominate our news and lives for the next year.  I predict we will hear words like "Obamacare," “Romneycare,” “government takeover,” and “individual mandate” (usually in sentences following the word “repeal”) until we can’t stand it anymore.

If this is to be our fate in the New Year, then perhaps we can take some comfort in knowing that the debate probably won’t make a dime’s worth of difference about where most of us get our health care over the next few years or how we pay for it.

This is because the 2010 Affordable Care Act and the individual mandate were not really health reform.  They were efforts to preserve health insurance as we know it, by getting more people who can afford it to purchase private insurance, and more who cannot onto the Medicaid public insurance program.

So maybe we should take a minute between caucuses, primaries, and the general election to imagine what real health reform in America would look like in 2012.

It isn’t hard.  We just have to keep in mind a few facts.

First, governments already pay approximately $1.8 trillion of our roughly $2.5 trillion annual national health care bill.  Individuals pay another $300 billion out-of-pocket.  These numbers aren’t going down, whether the Affordable Care Act is upheld or repealed by the Supreme Court in June.

Second, there is plenty of money in our health system to delivery high quality health care to everyone who needs it.  We just need to target it to prevention as well as treatment.

Third, for the relatively small amount of money they put into the system, insurance companies have been given an outsized role in determining when, where, and how our health care is delivered.

Fourth, we woefully underfund our most important health services.  Public health and prevention activities have accounted for half of the gains in life expectancy during the last century, but receive far less than 5% of health care funding. 

And fifth, we criminalize instead of preventing and treating much of mental illness, and have made jails our nation’s largest mental health institutions.

With those facts in mind, we should acknowledge what real health reform isn’t.

It is not Romney’s or Obama’s “individual mandate” to buy private health insurance people don’t want and won’t trust.

It is also not Ron Paul’s notion of leaving people to fend for themselves in some non-existent “health care marketplace.”  No civilized nation does this and we are not going to be the first.

Here’s what a true American health reform – one that would result in healthier citizens, better access to care when it is needed, lower long term costs of care, and better quality – would look like.

1.       We would rebuild our health care delivery system around the federalized funding that already dominates health financing.  Medicare would be our basic national health insurance program, and be available to everyone.

2.       Medicaid would become a federal program like Medicare, and cover only long term care needs including chronic mental illnesses.  There would be no means-tested eligibility. States would not have to pay for it or administer it, so they could lower their state taxes accordingly.

3.       Private insurers, which are already such a small part of the overall health financing market, would play a role to which they are more suited.  They could offer supplemental insurance products covering first-dollar deductibles, co-pays, and additional, discretionary consumer services (like private hospital rooms and gourmet meals) at whatever prices they could get, for whatever profit they could make. 

4.       The Medicaid program could still require that people spend down a considerable portion of their own resources before it covered the remainder of long term care costs.  But we should allow everyone to set up tax-deferred long term care savings accounts to use for themselves, members of their families, or anyone else they designate.

5.       We would double the percentage of health dollars in public health and prevention over the next ten years.

How could we finance such as system of care?  The reality is that this system probably wouldn’t cost us any more than the current one does, and would probably cost less.

Of course, we won’t get this reform, but we can dream.  And I’d much prefer such a real policy debate about health reform in 2012 to the one we’re scheduled to receive – Mitt Romney attacking the individual mandate he invented and Barack Obama defending the individual mandate he opposed. 

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.

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.

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.

Public Health Spending Prevents Deaths

If you are as grateful as I am that the nonstop coverage of debt ceilings and deficits is behind us for a while, and want to talk about something even Congress should be able to agree is worthwhile, then just repeat after me these two magic words. (No, not those two!)

The words are "public" and "health."  There is a new article out entitled Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths. 

Source:  Mays and Smith, Health Affairs, 7/11

The article has been published online by Health Affairs, and is in the August 2011 edition of the print journal.  It was written by Glen Mays and Sharla Smith.

Spending on public health has long been one of our government’s great success stories.  It keeps our water clean, our air free of pollution, our food pure, our children immunized, and our homes and neighborhoods free of lead, rats, and violence.  It also promotes our health. 

I wrote in a previous column about what this means for individuals like you and me.  Our life expectancy in America grew by 30 years during the last century.

The Health Affairs article makes it clear that public health is still getting the job done today.

Here’s the bottom line.  When more money is spent on public health, death rates go down.  When less money is spent on public health, death rates go up. 

It can’t be much clearer than that.  The authors studied public health expenditures and death rates in a number of communities between the years of 1993 and 2005. 

Local health departments whose spending increased by an average of 10% per year during those years experienced significant declines in infant deaths, deaths from heart disease, deaths from diabetes, and deaths from cancer.

These declines were not inconsequential.  For each 10% increase in public health funding, there was a decrease of 3.2% in deaths from heart disease, a decrease of 1.4% in deaths from diabetes, and a decrease of 1.1% in deaths from cancer.

There was also a 6.9% decrease in infant deaths.

These percentages may seem small, but consider this.  In a county of one million people, a 10% increase in public health funding per year for twelve years means a decrease of over 1,000 deaths from heart disease alone. 

These are not avoided deaths among people who had heart attacks and were saved by advanced medicine.  These deaths usually occur among people who seem healthy.  If it weren’t for public health, these thousand people wouldn’t be playing with their children and grandchildren, walking and jogging along our streets, working at jobs, dining in our restaurants, shopping in our stores, and even serving as elected or appointed officials.   

It seems a no-brainer to invest in public health.  However, one-third of local health departments actually had their funding reduced during the twelve year time period of the study.  The communities they serve had an increase in deaths equivalent to 430 for every one million people.

We’ve all heard how tight our public budgets are as public officials work to reduce spending.  Can we afford to save this many people through public health?

The short answer is yes, and the longer one involves some embarrassment that we don’t try harder.  The average community spends about $40 per person per year on public health.  Increasing this expenditure by 10% would average out to $4 per person per year, about the cost of one movie rental or one beer per year.  

Local people have also already delivered a message about this to state and federal officials.  They don’t mind giving up a movie rental or a beer every year to save 1,000 lives. 

In states where counties or cities control their own local health departments, the authors note that public health spending is 24% higher than it is in states where the states themselves control the local health departments.  It turns out that local people are willing to give up a movie rental and a beer for public health.

The authors calculated that the ten percent increase in public health spending per community would increase local public health budgets by an average of only $312,000 per community each year.  Compared to the billions and trillions of dollars our elected officials have been talking about – or even the $9.2 million one hospital recently charged the estate of a dead patient – $312,000 doesn’t seem like a very big number to me. 

Public health is responsible for 50% of the gains in life expectancy in the United States during my lifetime.  We can certainly do better than to give it less than 5% of all health funding, as we do today.

Public health doesn’t need a lot to do its job.  Just 5.05% would make a measureable difference.  And 5.5% across the nation could save the lives of millions.   

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Fifty Years Later: Class, Children, Mental Illness, and Cancer

Fifty years ago, we already knew that there were environmental causes of chronic conditions like mental illness.  Had we taken them on as an American nation-building project with the zeal with which we have approached nation-building overseas, we would be a healthier country today. 

Will we do any better in the next half-century?

I’ve recently been reading a book written in 1969 about the 1968 Presidential campaign, called An American Melodrama.  It is a very long book about a very short political campaign by today’s standards.

Bobby Kennedy, for example, didn’t announce for the Presidency until March, and George Wallace – who won several southern states as a third-party candidate – didn’t pick his running mate until October.  Political scientists will find many parallels from that time to today.  One example: former Governor Romney was the early favorite for the Republican nomination.  (He never made it to the starting gate.)

It was a campaign and a time repeatedly rocked by violence, and worries about domestic terrorism consumed policymakers and the public.  About halfway into the book, the authors – without today’s benefit of hindsight – searched for an explanation for the tensions of those days.  They found it partially in a mental health study published in 1961.

It was entitled Mental Health in the Metropolis: The Midtown Manhattan Study (Volume 1).

The authors surveyed a sample of 1,660 adult residents of Midtown Manhattan.  They found that 23.4% of Midtown adults were impaired by mental illness, and 45.2% had at least moderate symptoms of mental illness.

These percentages are almost identical to the percentages of US residents today who have diagnosable mental illness in a given year (around one quarter of the population) and who will have a diagnosable mental illness in their lifetime (around one half of the population).

They believed that the high percentages of mental illnesses must be related in some way to the conditions in which people lived.

So they tested this belief, by identifying and measuring attributes of good mental health:

·         Freedom from disabling inner tension
·         Ease of social interaction
·         Feeling of adequacy in social roles
·         Capacity to accept deprivations and individual differences
·         Identification with ethical and moral values
·         Adaptability to stress
·         Healthy acceptance of self
·         Conservative handling of hostilities and aggressions

They divided the Midtown population into six socioeconomic groups, and found a direct relationship between class and mental health.  Only 17.5% of those in the highest socioeconomic group had symptoms of serious mental illness, versus 32.7% of those in the lowest group.

Arguably, their most important finding wasn’t just about class, however.  It was about child health.  They divided the adult population into the socioeconomic groups based on the socioeconomic status of their parents, not themselves.  In other words, the “class” measure was a measure of the impact of childhood socioeconomic status on adult mental health.

We know today that many of the preventable causes of adult mental illness are rooted in childhood, and socioeconomic status is the culprit in a variety of chronic diseases besides mental illness.

In its recent publication Cancer Facts and Figures 2011, the American Cancer Society devotes a special section to a description of socioeconomic status as a carcinogen.  Low socioeconomic status leads to a doubling of cancers among men and similar large increases in many types of cancer among women.

As public health professionals have been explaining for years, environmental factors linked to socioeconomic status – such as exposure to violence, abuse and neglect, poor diet, unsafe living conditions, lack of health insurance, limited educational opportunities, and increased risk of smoking – are among the causes of some of the most common chronic diseases in America – mental illnesses, cancers, cardiovascular disease, hypertension, and diabetes. 

We haven’t addressed these environmental factors adequately in the last fifty years, and we have no unified governmental vision for doing so now, either.

We’ve been too busy fighting endlessly about the role of our government at home and insufficiently about the role of our government overseas.

We celebrate Independence Day this weekend.  As we do, we should remember that we didn’t fight for our independence on foreign soil and we weren’t magically transported from 1776 to 2011 without anything happening in between.  We can explain why Americans today are less healthy than their counterparts in many other developed nations by taking notice of the conditions in which we live and how we got to this point.

We may know where we want to be in the future.  But if we stumble around in the present with no clear sense of our relatively recent past, we won't get there.

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Making Health Services Our Priority

Are essential health and behavioral health services a priority for our elected officials?  We got a clear picture when House leaders offered their 2011 continuing resolution and President Obama proposed his 2012 budget this past week.   

Both the continuing resolution to fund federal agencies for the current fiscal year and the President’s budget proposal for next year cut billions of dollars from the federal budget.  Some essential health services are surprising targets.

Cost Per Person to Restore Proposed Health Cuts

For a total savings of $2 billion, or just over six dollars a person, would we choose to slice what they chose to slice, or would we make health services a bigger priority?

The continuing resolution proposed to cut $1.3 billion from community health centers.  These centers are located in every state.  They provide comprehensive primary care to everyone, regardless of their ability to pay.  They employ doctors, dentists, nurses, counselors, and other health professionals. 

They treat a lot of elders, people with disabilities, and lower income working families because they accept Medicare and Medicaid in addition to private insurance.  They provide high quality services, and meet a significant consumer demand.  According to the National Association of Community Health Centers (NACHC), they served 20 million Americans in all income ranges last year. 

NACHC responded that the proposed cut would cost 3.3 million Americans their care during the next few months, worsening the health care crisis in our country and driving up costs for everyone.

The continuing resolution also proposed a $500 million cut to mental health and substance abuse services, reducing the federal Substance Abuse and Mental Health Services Administration (SAMHSA) budget from $3.7 billion to $3.2 billion.  This is a 10% reduction from actual FY2010 funding.  It affects hundreds of thousands of children and adults with serious behavioral health problems. 

Elected leaders are betting that reducing services won’t backfire and leave more people with behavioral health problems without any treatment.  However, in providing the justification for her budget request, SAMHSA Administrator Pamela Hyde noted that over 10 million Americans already have unmet mental health needs and mental illnesses cost our economy over $100 billion per year, making this at best a risky, pound-foolish bet. 

Essential health services weren’t spared by President Obama in his proposed 2012 budget either.   

The President proposed taking $133 million from prevention by eliminating funding for the Preventive Health and Health Services Block Grant and halving funding for the Healthy Environment program aimed at preventing asthma and other chronic conditions. 

Though asthma has become one of the most common chronic conditions in our country, the President’s budget seems to be throwing in the towel on asthma prevention.  In justifying the cut in his proposed budget, his budget office writes “there are currently limited proven means of asthma prevention. In asthma care, the key intervention is to increase use of inhaled corticosteroids...” This is an uncharacteristic and remarkably one-sided rationale for emphasizing treatment at the expense of – instead of in concert with – prevention.

Each state decides how to allocate the prevention dollars it receives through the Preventive Health Block Grant, choosing 265 programs of local importance to support. 

In Florida, for example, the block grant has been used for chronic disease prevention programs, water fluoridation activities, and services for victims of sexual violence.  In Connecticut, it has funded childhood lead poisoning prevention, youth violence prevention programs, older adult fall-related injury prevention, and cardiovascular disease prevention.  In Texas, it has been used for sanitation services in rural border counties, support for a trauma registry, and support for local public health services.

While the President argues that there are other prevention services available, the long-standing problem in this country is not that we fund too many prevention services, but too few.    

Funding for this block grant is already $50 million less than it was in 1994, and it should come as no surprise that our health status as a nation has declined across a number of indicators since that time. 

What if we said no to cuts to these community health centers, behavioral health services, and prevention programs?  The $2 billion this would cost would add up to approximately $6.19 per person for the year.  Spending this $6.19 would result in the retention of hundreds of prevention programs across the country, up to 11 million physician visits, and services to over 200,000 adults and children with behavioral health problems. 

Have our nation’s resources really become so scarce that we can’t afford $6.19 a person to buy all this?

Maybe so, but I suspect the real answer lies in our priorities.  They spend this much every week on the war in Afghanistan, and both the President and Congressional leaders have made Afghanistan their continuing priority.  It’s past time for some new ones.

A Grown-up Health Policy Agenda for 2011

House Speaker John Boehner said recently that Congressional Republicans will have to face raising the debt ceiling as “adults,” echoing his March, 2010 comment that they needed to behave like “grown-ups” when health reform passed. 

The passage of health insurance reform in 2010 did not solve all of our health policy problems, but passing a meaningless repeal measure in the House in January isn’t the best way for members of Congress to start putting their grown-up pants on. 

What might an actual adult health policy agenda look like in 2011?

First, federal and state officials would put more resources into public health.  Like computer anti-virus programs, public health programs work in the background, taking care of us even when we fail to take care of ourselves.  They make sure our water is pure, our neighborhoods clean, our hazardous wastes are disposed of properly, and our children are immunized.  People can argue over whether various prevention initiatives cost more or less than treatment but no grown-up can deny their effectiveness. 

Except, perhaps, some public officials.  Florida’s new governor is proposing to reduce the state’s commitment to public health by folding the State Health Department into the agency that manages the health care system.  “Potato salad,” is what an AFSCME representative called this approach.  More like mystery meat, I think.    

Second, everyone should get a $100 tax credit for athletic equipment.  If we’re going to stimulate the economy with tax cuts, why not stimulate a culture of wellness?  Taking $30 billion of the trillion dollars we’ll spend on health care reform in the coming decade and giving $100 to every citizen for a new pair of athletic shoes, a down payment on a bike or treadmill, a first baseball glove, or other athletic equipment adapted to their needs, would make a meaningful, adult policy statement about the importance of fitness in all our lives.

Third, legislators should require periodic mental health screening as part of the well-care exams of children and young adults.  Serious mental illnesses hit young people disproportionately, and hit them as aggressively as cancers, taking 25 years or more off their lives.  (See the accompanying chart and the bottom of my Health Facts and Sources page for explanations about the comparison.)

We can treat most mental illnesses effectively if we treat them early and aggressively, but we often wait until it’s too late.  One 20 minute mental health screening every five years from age five through age 30 is all it would take to get started, and we’d be on the road to a healthier nation.     

Fourth, mental illnesses should be treated like other chronic diseases, not hidden away in jails.  Would anyone support sending people with uncontrolled diabetes to jail when they go into a diabetic coma because they are being a danger to themselves?  It sounds absurd, but that’s how we treat a significant percentage of the over 25% of us diagnosed with a mental illness every year.  In 2007, Time magazine reported that the country’s largest psychiatric institution was a prison.  Others have estimated that the majority of the people in our jails have mental illnesses.  While almost any alternative would be preferable, the simplest solution is to de-criminalize mental illness, adding more community mental health services and centers and funding them adequately.

Fifth, state and federal policymakers should pass laws de-criminalizing casual drug use and drug addiction.  Pat Robertson suggested this on his show on December 16, 2010, joining a growing chorus of others, including the Justice Policy Institute, who argue that drug treatment is far better and less expensive than incarceration.  We’re still fighting and losing Richard Nixon’s War on Drugs, yet those who were born the year he declared it are turning 40 this year.   It’s time for a change.  Controlling the use of other drugs, like marijuana, the way we control prescription drugs, alcohol, or nicotine is not the same as being “for drugs,” and it’s a far more mature response to the situation we're in than hiding our heads and wishing the drug monsters away.

Sixth, Federal officials should expand the Medicare program to give everyone a medical home and pay for their free annual physical.  Wouldn’t this be a great birthday present for policymakers to give to every citizen – a partnership for health?  Congress went part way there in 2010 by including a free annual physical in the Medicare program, but this should be available to everyone, whether or not they’re privately insured.  If it’s too scary and “big brothery” for some public officials to take this one on, then at least they should provide a tax credit for people to use to pay for it themselves.       

They’re now reading the Constitution in Congress.  I hope they don’t skip over the part of Article One Section 8 that reminds Congress of its duty to provide for the general welfare – meaning the health, happiness, prosperity, and well-being of our people.