To Be Healthy, Live Among the Wealthy?

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

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

Source: US Census and County Health Rankings, 2012

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

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

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

She’s right.

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

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

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

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

Then we discover something more.

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

Consider these examples from three different states.

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

What do they share besides poverty and poor health?

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

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

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

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

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

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

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

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

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

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

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

Jim Hurley's Forgotten AIDS Message

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

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

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

I first met Jim when we were high school debaters. 

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

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

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

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

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

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

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

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

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

Last year, CDC also reported that in 2009:

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

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

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

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

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

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

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

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

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

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

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

April is STD Awareness Month.  To increase awareness about AIDS, please consider sharing this column with friends and colleagues.  If you have questions about this column or would like to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.

Mitt's Plan

Imagine what a nightmare healthcare scenario might look like.

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

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

Then you get another chronic disease.

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

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

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

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

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

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

You’re out of luck.

You might call this nightmare far-fetched.

Or you could call it Mitt’s Plan.

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

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

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

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

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

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

She describes herself as “financially drained.”

I imagine she sometimes feels physically drained as well.

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

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

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

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

Anna Brown's Death

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

She left two small children. 

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

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

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

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

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

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

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

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

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

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

What a tragedy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How We Really Hope the Supreme Court Will Rule on the Affordable Care Act

The Affordable Care Act has finally had its days in court this week.

And commentators who were certain on Monday that the Supreme Court would uphold the individual mandate were just as certain on Tuesday that it would not.  Perhaps they have some special insight into the thinking of the Justices. I don’t.  I’ll just wait for the decision. 

In the meantime, I’m wondering not how each of us thinks the Court will rule, but how we hope it will rule.

The answer isn’t so simple, because we divide into – and often move among – three competing minority camps about health reform in general:

• The Affordable Care Act represents the best compromise for insuring more people while preserving most of our current public/private payer system.
• Expanding reform to a single payer system like those favored by other developed nations would be better. 
• Replacing ACA with a private market-based system is at least worth a try.

If we’re as uncertain as polls cited by the Kaiser Family Foundation suggest, I suppose we all could just close our eyes, vote for Mitt Romney, and assume from his record and rhetoric that we’ll get all three.

But the Court will decide first, so let’s consider the rooting interests of several interested and sometimes overlapping groups.    

If you favor a single payer, “Medicare-for-all” program:

You want the Court to find the individual mandate unconstitutional, but severable from the rest of the bill. 

Why?  The individual mandate was originally the alternative to “single payer,” so you would like to get the individual mandate out of the way.  Then single payer becomes an option again, but only if the rest of the law, including the Medicaid expansion and the consumer protections, remain in effect.  This is because our private insurance market will become too expensive if people use those consumer protections to wait to buy insurance until they are sick.

If you want to reduce the size and scope of the state Medicaid programs:

You want the Court to rule the Medicaid expansion unconstitutional, but the individual mandate constitutional. 

Why?  This combination will most constrain Medicaid growth because lower income people will have to purchase health insurance in the private market.  They’ll qualify for a subsidy, but not for Medicaid.

If you want more universal coverage, but don’t care whether it’s private or public:

You want the Court to uphold the entire law.

Why?  Although philosophically impure, the combination of Medicaid expansions, Medicare cost containment strategies, Medicare tax increases for the wealthy, and subsidized private insurance for the middle class will lead to more coverage, and fewer uninsured.

If you or a child of yours has a chronic condition, such as diabetes, mental illness, or cancer:

You may not care whether the individual mandate is constitutional or not, but if it isn’t, you want it to be severable from the pre-existing condition coverage and community rating portions of the law.

Why?  If the PCIP experience is any indication, you may not want to be forced to buy insurance.  But when you do try to buy it, you don’t want to be denied affordable coverage because of your pre-existing condition.

If you are an early retiree on your former employer’s health insurance:

You want any provisions found to be (1) unconstitutional and (2) not severable from the pre-existing condition and community rating portions of the law to be severable from the rest of the law.

Why?  This could gut much of the law, but not the provisions that subsidize your coverage.  You won’t have to worry that you could either lose your health insurance or be forced to pay a lot more for it.

If you are a Medicare recipient:

You want any provisions found to be unconstitutional to be severable from Medicare expansions.

Why? If they aren’t, you’ll need an immediate bipartisan agreement in Congress to keep your donut hole prescription drug coverage and your free annual check-up in place.

If you want insurance that will cover long term care needs:

You’re already out of luck. 

Why? That provision was axed from the law before it was ever implemented – and you don’t hear anyone talking about restoring it.

And, if you’re okay with denying or capping coverage for pre-existing conditions, allowing insurers to make as much profit on insurance as they can, having gaps in prescription drug coverage for elders, and paying for the sick and uninsured through increased premiums on people who have insurance:

You want the Court to find the whole law unconstitutional.

Why?  That’s where we were when all this began.

Note: Click here for simple explanations about some of the Supreme Court issues that are discussed in this week's column.

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.

The Disintegration of Health and Mental Health Care

How will the Supreme Court respond to an argument next week that might lead to the disintegration of health care in America?

In recent years, we have been making slow policy progress in better coordinating and integrating primary and specialty care, and health and mental health care.  Two milestones were the passage of the federal Mental Health Parity Act in 2008 and the Affordable Care Act provisions in 2010 that prohibit insurance discrimination against people with pre-existing conditions, both in coverage and in cost.

These are opening more primary care doors to people with mental illnesses. 

80% of all mental health problems are first seen in a primary care office.  And it now pays for a primary care clinician to screen for mental health problems.  According to one recent projection completed by the Mental Health Association of Palm Beach County (available on request from that organization), a primary care practitioner can generate in excess of $100,000 in insurance payments for every 2,500 behavioral health screenings he or she completes.

Integration also appears to pay off for patients in earlier and more effective care.  Between 2006 and 2009, the number of primary diagnoses of mental illness in general hospitals dropped from 2.4 million to 1.6 million, as more clinicians recognized the need to treat health and mental health symptoms – which are often indistinguishable – together.

Now the Supreme Court is being asked to weigh in on the question of integration.

Next Wednesday, on its third day of oral arguments about ACA, the Court will hear arguments about whether the individual mandate is “severable” from the rest of the Act.  How it responds may well determine whether the recent progress we’ve made to integrate care will stall.

Here’s why. 

The Obama Administration is arguing that the individual mandate is intertwined with two other provisions – the mandate to provide coverage without regard to pre-existing conditions and the mandate to provide coverage at no additional cost to those with chronic conditions.

These are important consumer protections, but the Administration’s view is that without the individual 

mandate healthy people will choose not to purchase insurance that covers expensive chronic conditions.  Instead, they will just wait until they get sick and then buy the coverage that will still be guaranteed to them if the other mandates remain.  This will in turn force up the price of insurance for everyone. 

The Administration supports ACA, but most ACA opponents also agree with the Administration on this point, as have some judges who have already ruled on the law.

If the Supreme Court finds the individual mandate unconstitutional, and then also agrees that it is not severable from the other provisions, it would overturn these two additional mandates.  This would result in a worst-case scenario for people with mental illnesses – a return to the private insurance market we’re just now leaving behind, where premiums are too high for them to afford, and coverage is too low for them to obtain effective treatment.

It won’t help people with other chronic conditions, either, as they head back out of primary care settings and into hospitals for treatment.  We’ll all lose out, because properly diagnosing and treating chronic conditions early means less cost down the road, more effective care, and better patient outcomes.

The historical pressure against integration in the health care delivery system isn’t philosophical or constitutional, but is often the product of increasing specialization among health care providers.  In 1960, there were approximately 7.5 primary care physicians and 7.5 specialty care physicians in the United States for every 10,000 citizens.  Fifty years later, in 2010, there were just under 7 primary care physicians per 10,000 citizens, but over 13 specialists. 

Specialists by training know a narrow area of medicine well.  As a result, we have grown to think about chronic diseases one at a time, and we often treat them this way, too. 

But this isn’t very efficient or effective, because patients usually bring more than one problem at a time to their primary care clinicians.  And by the time they are in care, almost two-thirds of patients with at least one chronic condition have at least one more.

That’s why we need integrated health and mental health services, and fair coverage for chronic diseases.  And that’s also why – if policymakers aren’t ready with an alternative – the disintegration of health and mental health care could result from the Supreme Court’s decision about severability.

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.

The Biggest Environmental Disaster of the Decade

Here is a cautionary tale about the risk of downplaying the importance of environmental health.

A year ago, Fukushima City was a bustling city with a population of 290,000.  Its people were going about their business the day the earthquake and tsunami hit northern Japan, triggering the biggest environmental disaster most will ever experience.

At first, the trains stopped running because of damage to the railways, and most of the city’s water stopped running because of ruptures in water mains.

Over the next several days, a silent toxin began to spread along with word of the natural disaster.  The Fukushima nuclear power plants, 39 miles southeast of the city, began melting down, releasing radioactive particles into the air and water. 

Although Fukushima remained outside the quarantined evacuation zone stretching twelve miles out from the nuclear facility, waves of radioactive cesium dust escaped the zone, flying on the winds toward the city.  As it rained and snowed, the cesium dust fell to the ground, infiltrating homes and businesses, hospitals and markets, roadways and parks. 

A year later, the Fukushima government is still trying to save people’s homes by cleaning up a deadly environmental mess.

If you have ever experienced a home construction or renovation project, you have an idea of what environmental health officials are facing.  When you tear down a wall, sheetrock dust collects everywhere and sticks to everything – furniture and floors, wall hangings, clothes, and even inside cupboards and cabinets.  To clean it, you have to wipe down everything individually.  And what you don’t catch goes back into the air, eventually needing to be cleaned up again.

Now imagine that this dust were completely invisible and radioactive, and both indoors and outdoors.  That’s what the people of Fukushima have to clean.  Building by building and property by property, they go about their task.  They can’t just wash the cesium down the drain.  They have to dig out the top two inches of their landscapes, and cart away the vegetation and dirt as radioactive waste, or create mini nuclear waste dumps by burying everything contaminated in deep holes in their own backyards.    

If just one property owner refuses, then as it rains again, the entire neighborhood can be re-contaminated.

We should all know by now that Fukushima’s story today could be Hartford’s, Miami’s, or West Palm Beach’s tomorrow.  Hartford is just 40 miles from the Millstone nuclear plants, Miami is 25 miles from the Turkey Point nuclear plants, and West Palm Beach is 40 miles from the Jensen Beach nuclear plants.

If a Fukushima-level event hit near me or my family, I’d want a strong Health Department with a clear environmental health mandate ready to respond. 

But that’s not what people in Florida are getting.

Last week, Florida’s State Legislature passed a law eliminating the Division of Environmental Health from the State Health Department.  It also eliminated the Community Environmental Health and Healthy Communities, Healthy People programs.  The Florida Public Health Association and others fought valiantly against these changes.

Not only did the legislature eliminate the Division of Environmental Health, it removed from the Health Department’s duties in section 381.0011 of the Florida statutes the power to quarantine “premises as the circumstances indicate for… providing protection from unsafe conditions that pose a threat to public health.”

Faced with a Fukushima-level event, radioactive or otherwise, the Florida Health Department will no longer have the independent power to create an evacuation zone to protect the public health.

The legislature did give some quarantine responsibility back to the Department as an amendment to section 381.00315 of the Florida Statutes.  But in that section, the Department’s authority is severely restricted.  It must consult with any agency that might be affected, its quarantine order is limited to sixty days, and violations of the order are punishable by as little as a $500 fine.

In other words, if the Fukushima meltdown had happened in South Florida, any general quarantine orders related to Miami would have expired ten months ago, and the only penalty for repeated re-contamination of a neighbor’s property might be a $500 fine.

Political leaders often embrace nuclear energy and many other industrial contaminants, in spite of the risks and costs.  These risks may not bother them, but at the very least they could give the rest of us a modicum of protection.

Otherwise, the biggest environment disaster of the decade may not be the one we witnessed in Japan.  It could be the one that just played out in the Florida legislature.

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.

To Improve Health, Spend More on Social Services

Does a stronger safety net mean a healthier community?  Apparently so, according to recent research.

It’s a well-known fact that the United States spends 16% of its GDP on health, far more than any other country in the developed world.

It’s also a well-known fact that all of our health spending doesn’t give us an edge in life expectancy or a number of other indicators of the overall health of the population.  One of the reasons for this is that we spend so little on public health, compared to health care.

But there may be another reason, too. 

We spend too little on welfare and social services. 

To put this into context, it is important to remember – with a nod to the late George Carlin – that “welfare” wasn’t always one of the “seven dirty words” no politician could utter in public.  (The others today are “liberal,” “tax” and “increase” used in the same sentence, and “bigger,” “government,” and “spending,” also used in the same sentence.)

When I was a member of the Connecticut Legislature in the 1980s, the most common argument about welfare was whether we should increase welfare benefits by the same percentage as the increase in the cost of living (liberals held to this position), or whether we should cap them at something akin to the percentage increase in the overall state budget (conservatives held to this one).

President Clinton and Speaker Gingrich changed all that in the 1990s when they struck a bipartisan agreement never to promote welfare again unless it was coupled with the word “reform.”

However, if we care about health, it may be time to think about reforming welfare reform.

In an article entitled Health and Social Services Expenditures: Associations with Health Outcomes (the abstract is available using the link; the full article is available for purchase), Dr. Elizabeth Bradley of the Yale School of Public Health and three colleagues showed that more spending on social services may lead to even greater improvements in life expectancy, infant mortality, and potential years of life lost than more spending on health services.

They did this by comparing overall health and social services spending for thirty countries, including the United States, and linking this to five indicators of health.

Most of the other countries in the analysis spent about twice as much on social services, as a percentage of GDP, than they did on health.  The United States spent a little less (13%) on social services than we did on health (16%). 

Our combined 29% may seem high, but it is pretty close to the average for developed countries.  This is because we spend less on social services as a percentage of GDP than do others. 

But it looks like spending just a few percentage points more on social welfare could lead to lower death rates from infancy on.

These are the types of social services spending that are associated with longer, healthier lives:

• Public and private spending on old-age pensions
• Spending on support services for older adults
• Survivors’ benefits
• Disability benefits
• Family support
• Employment training and programs
• Unemployment benefits
• Housing support

This list of life-promoting programs reads like a “what’s what” on the state and Congressional chopping blocks these days.

What this excellent article suggests is that we’re not thinking through the relationship of welfare to health.   When we started cutting our social services programs many years ago, we didn’t realize that we were going to be paying the price in higher health care costs and lower life expectancy.

The authors drew the following measured conclusion:

“Although most health-reform efforts to improve health status focus on health expenditures, it may be that additional attention on social services is also needed. This approach is consistent with public-health frameworks, which have frequently highlighted the social over the biological and medical determinants of health.”

After reading the article, I’d say it’s hard to argue with that conclusion.

And I would like to suggest a second one.  In our Declaration of Independence, our nation’s founders asserted that we have an unalienable right to life.  When we knowingly make policy decisions that abridge this right, it is the essence of anti-Americanism.

So, channeling George Carlin once again, maybe it’s time to take a more liberal view of welfare, by supporting whatever taxincrease is needed to support the government spending required for it to play a bigger part in protecting the lives of our people.

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.

Mental Health Cuts Will Lead to Increased Health Costs

On December 8, 2010, Jack Dalrymple, a Republican Governor in the safely Republican state of North Dakota, sent a budget to the state Legislative Assembly calling for an $8 million increase in funding for mental health services.

His transmittal message accompanying his FY2011-2013 proposed budget was simple. “We… need to make investments that help take care of people.  We have all been alarmed recently about teen suicide rates, especially on our Native American reservations.  These highlight the need to make more resources available for critical mental health services for our citizens.”

So, in a $3.3 billion general fund budget, he proposed over $6 million for new inpatient services, community crisis stabilization, and drug dependency treatment.  He also proposed $1 million for suicide prevention, another million dollars for mental health services on college and high school campuses, and a rate increase for mental health providers. 

He summed up these requests by saying that “the physical and mental health of our citizens is always a top priority.”

The North Dakota Legislature apparently agrees.  According to a recent report of the National Alliance on Mental Illness, the state has made up for historically low spending on mental health services over the past three years by topping the nation in increasing spending for mental health. 

As overall state mental health spending in the nation declined by $1.6 billion, North Dakota increased spending for mental health by 48.1%.

In the same time frame, South Carolina, Alabama, Alaska, and Illinois all cut mental health spending by over 30%, and Nevada, the District of Columbia, and California all cut it by over 20%.  In fact, most of the rest of the country is clearly out of step with North Dakota.

A Bloomberg News article headline this past week made clear what cuts to mental health mean: “Mental Health Cuts by U.S. States Risk Boosting Health Costs.”  The reason, as one Illinois emergency room physician pointed out, is that sick patients don’t just disappear when they are denied one set of services.  They seek out another, often more costly, alternative.

In the case of people denied mental health care, it is usually the hospital.

According to the Centers for Disease Control and Prevention (CDC), there were 2.4 million primary diagnoses of mental illness in general hospitals in 2006. In the same year, state mental health spending totaled $104 per capita, according to Kaiser Family Foundation State Health Facts data. 

CDC recently released new data for 2009.  In that year, the number of primary mental illness diagnoses decreased to under 1.6 million.  But the State Health facts data reported that state mental health spending had increased by then to $123 per capita.

In other words, during a time frame when state mental health agency funding increased by 18%, mental health diagnoses in general hospitals decreasedby 35%.

These are the facts, and there is an association here, at least for the most recent three-year period for which we have data. When states spend more on mental health as they did in 2009, fewer people with mental illness need hospitals for care.  And when states spend less on mental health, as they did in 2006, hospital use goes up.

Now that they have the facts, what are states proposing this year?

• The Florida Senate has proposed to reduce adult mental health services funding by 34%.  The House saved Florida from such a spending disaster last year; it will have to do so again this year.
• Connecticut’s Governor has proposed a $12 million cut to the Department of Mental Health and Addiction Services from the state’s already-approved FY2013 budget.
• Alabama last week announced plans to close 4 psychiatric hospitals.
• Illinois has proposed cuttingtwo psychiatric hospitals and a host of community health centers throughout Chicago.
• Mississippi is proposing a 5% cut to mental health that could result in the closing of six mental health facilities throughout the state.
• The Pennsylvania Governor’s newly proposed budget will cut Philadelphia by $42 million in mostly mental health and addiction services funding, according to information provided by the Mental Health Association in Pennsylvania.

Do you detect a pattern here?

Proponents argue that these cuts are being made in the name of fiscal responsibility, but they don't have the vision to see the forest beyond the trees.  Every one of them will make people sicker, state costs higher, and an already bad situation worse.

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.

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.