Is the NFL Dying?

Here is one of the more intriguing headlines of Super Bowl week:  “Is the National Football League dying”?

Probably not, but too many of its former players are dying young, and for reasons that may be preventable.  Many people are concerned about growing evidence of brain injury from the violence of the game. But that’s just part of the story.

Linemen are too heavy. Their excessive weight is a danger to running backs now and to their own health after they hang up the cleats.

Baltimore Ravens safety Bernard Pollard raised the issue when he was quoted as predicting the demise of pro football, in part because of its violence, but mostly because of the way the rule makers are responding to that violence.  “I hope I’m wrong,” he added, “but I just believe one day there’s going to be a death that takes place on the field because of the direction we’re going.” 

President Obama weighed in on football safety, too, but in a less dire way.  “I think that those of us who love the sport, he said in an interview with the New Republic, “are going to have to wrestle with the fact that it will probably change gradually to try to reduce some of the violence.”

Both Pollard and the President were alluding to head trauma – a growing concern for athletes and others exposed to repeated brain injury.

Last month, the New York Times summarized a number of studies related to football and brain injury.  One concluded that 60% of NFL players had a least one concussion during their football playing years, and 26% had 3 or more.  

Another was published in the Journal Brain in December 2012.  Researchers examined the brains of eighty-five deceased individuals who were subjected to repeated minor head trauma during their lives.  They looked for evidence of brain damage called chronic traumatic encephalopathy, or CTE. 

They found that 80 percent of the brains (or 68 of the 85) showed evidence of CTE. 

Thirty-five were from former professional football players, all but one who played in the NFL.  Thirty-four of those showed signs of CTE.  The brains from those who were hit most during the game – linemen and running backs – were most likely to have it.

CTE is clearly a significant health problem for NFL veterans, but it isn’t the only one. 

We learned recently that the brain of former player Junior Seau showed evidence of CTE at the time he took his life in the spring of 2012. 

His death stood out in part because he was the 8^thplayer from the 1994 San Diego Chargers Super Bowl team to die young.  I wrote about this in a column last year.

But among the Chargers who died young, Chris Mims was reported to have weighed 468 pounds (170 pounds over his playing weight) when he died at the age of 38 of heart disease.  Lew Bush, who played at 245 pounds, died of a heart attack when he was 42.  Shaun Lee was reported to be over his 300 pound playing weight and have diabetes when he died at age 44.

So it is not just the hard hits.  Weight-related chronic disease is also a significant health problem for many football players.

And this year’s Super Bowl teams are heavier than ever, putting them at greater risk than ever.

The linemen on Pollard’s Ravens team weigh in at an average of 308 pounds.  Without the tight ends, their average weight is 318.

The San Francisco 49ers linemen average 296 pounds.  Without the tight ends, their average weight grows to 311.

To put this in some context, the 1994 Chargers linemen were thin by comparison, weighing in at 289 pounds.  And the linemen (absent tight ends) from last year’s Super Bowl teams averaged 306 pounds – 12 pounds less than the Ravens this year.

But the CTE and obesity-related disease we see today occurs among players who played at the time of the 1994 Chargers, not the 2012 Ravens and 49ers.

The eleven running backs on the Ravens and 49ers weigh an average of 222 pounds.  And that’s only because 260 pound Ravens fullback Vonta Leach is one of them. 

Without Leach, they average 217 pounds – almost 100 pounds lighter than the linemen who block for, and tackle, them.

So, among rules and equipment changes, why doesn’t the NFL also introduce an upper weight limit for players in the game?

Then maybe we wouldn’t have to read so many obituaries of great athletes who die young. 

Go Ravens!  

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

Will Obama's Bold Vision End the Myth of Entitlement Reform?

As President Obama begins his second term, he does so with an expansive vision for America.

“America's possibilities are limitless,” he said in his inaugural address, “for we possess all the qualities that this world without boundaries demands:  youth and drive; diversity and openness; an endless capacity for risk and a gift for reinvention.   My fellow Americans, we are made for this moment, and we will seize it - so long as we seize it together.”

There are many potential roadblocks toward achieving that bold vision.  One is the myth that entitlement reform must be a part of it.

The reason that entitlement reform is at the top of some political agendas has nothing to do with the growth in entitlement programs today.

Some people with these agendas don’t like any government-run programs and won’t listen to the facts about them. 

Those who do look at the facts see the rapid growth in Medicare and Medicaid spending through 2009.  According to the Center for Medicare and Medicaid services, Medicare spending increased by an average of 10.9 percent per year between 1967 and 2009, and Medicaid spending by an average of 10.7 percent per year between 1975 and 2008.

They believe that this rate of growth is not sustainable.  But since the beginning of President Obama’s first term, we haven’t sustained a growth rate even close to this.

A report from last September and two more reports released in the last couple of weeks – one from the Department of Health and Human Services (HHS) and another from the Bureau of Labor Statistics (BLS) – show just how far the myth is from today’s reality.

The new HHS report found that per capita Medicare spending increased by just four-tenths of one percent in 2012, following increases of only 3.6 percent in 2011 and 1.8 percent in 2010.

And according to some new BLS data, the overall medical inflation rate last year – which should tell us something about Medicare and Medicaid growth in the coming year – was 3.2 percent. 

There is a much more immediate health spending problem about which policymakers should be worried – one that entitlement reform could make worse. 

High health costs may burden state and local governments.  But they burden people who rely on Medicare and Medicaid far more.

In an article entitled the High Cost of Out-of-Pocket Expenses published in September by the New York Times, Judith Graham summarized from a third recent study.  The study found that during the last five years of life:

• People on Medicare spend $38,688 on medical costs.
• People with Alzheimer’s spend $66,155. 
• The top quarter of spenders spend a whopping $101,791.

Some policymakers love talking about the unfairness of the “death tax.”  How about the unfairness of this hidden “pre-death tax” that gets bigger every time elected leaders cut entitlement spending? 

Entitlements are not the problem.  The cost of health care is.  Entitlements are – and always have been – the solution to the problem of a middle class forced into poverty by high health care costs near the end of life. 

And while entitlement reform may reduce government expenditures, it will only do so at the expense of those who need Medicare and Medicaid the most.

President Obama said it well in his address. 

“We must make the hard choices to reduce the cost of health care and the size of our deficit.  But we reject the belief that America must choose between caring for the generation that built this country and investing in the generation that will build its future.  For we remember the lessons of our past, when twilight years were spent in poverty, and parents of a child with a disability had nowhere to turn.  We do not believe that in this country, freedom is reserved for the lucky, or happiness for the few.  We recognize that no matter how responsibly we live our lives, any one of us, at any time, may face a job loss, or a sudden illness, or a home swept away in a terrible storm. The commitments we make to each other - through Medicare, and Medicaid, and Social Security - these things do not sap our initiative; they strengthen us.  They do not make us a nation of takers; they free us to take the risks that make this country great.”

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

The Shock of Sudden Violence

The shock of sudden violence is so severe it takes your breath away.

When it happens in a time and place where it is unexpected, it does more than just remind us that no one is immune to it.  It also reminds us how pervasive it is, how much it affects us all, and how important it is that we do something about it. 

In the summer of 1989, I imagined that sudden, random violence was something far removed from my hometown.  But I was about to learn differently.

An article in The Atlantichas just detailed the event, dredging up some quarter century old memories of a day that changed my community’s life.

I was running for Mayor of Middletown, Connecticut, at the time, and had reserved a booth at the city’s annual Sidewalk Sale in late July.  I was handing out yardsticks, asking for a vote “for government that measures up to your expectations.”

Suddenly, there was a commotion about a block north of where I was standing.  I noticed people running in two directions, both toward and away from the Woolworth’s store in the center of downtown. 

A young girl, randomly chosen, had been grabbed outside the store and then repeatedly stabbed by a 38 year old man.  She died on the spot.  Hundreds of people witnessed the event.

Over the next weeks and months, Middletown was in shock, just as other communities – Newtown, Aurora, Tucson, Blacksburg VA, Littleton CO, and others – have been shocked since.

The trauma in Middletown almost killed our downtown.  Its suddenness and randomness made everyone feel unsafe.  It killed much of our sense of community and personal safety.

The healing didn’t happen very quickly.

It took at least a decade or two of steady changes to the Main Street area for that to happen.  These changes were so significant that – with the exception of a few businesses, nonprofits, and restaurants that remain from that time – one would barely recognize the Middletown of twenty-five years ago in its vibrant downtown today.

The trauma to which Sandy Hook and other communities have been exposed is even greater. 

To appreciate fully the scale of the Sandy Hook tragedy, we must realize that because of it Newtown’s 27611 residents – who experienced zero murders in 2011 – may well have experienced the highest homicide rate in the nation in 2012.

The healing time will be long.  And, at some level, my limited personal experience in Middletown suggests that a community exposed to that level of violence may never fully recover.

And this suggests something even more frightening about the shock of violence in communities across the nation.

There were 14,612 murders in the United States in 2011.  That’s 4.7 homicides for every 100,000 people.

In Middletown, Newtown, and Blacksburg, the homicide rate was zero.  In Aurora, it was 3.  In Littleton, it was 5.  Even in Tucson, which lived through the shopping center massacre that year, it was under 10.

Murders are uncommon in these communities, contributing to their newsworthiness.

But elsewhere, the everyday shock and trauma of violence is so much more powerful.  And because it is so prevalent, media headlines cannot capture fully its true effect. 

The murder rate per thousand in Miami in 2011 was 17, in Philadelphia 21, in Jackson 30, in St. Louis 35, in Detroit 48, and New Orleans 58.

Here is another way to look at this.  The Aurora massacre this past summer will double Aurora’s homicide rate in 2012, by a factor of 3.6 per hundred thousand residents. 

The people of St. Louis collectively live through the trauma of an Aurora-level massacre an average of once every six weeks, the people of Detroit live through it every month, and the people of New Orleans live through it every three weeks.  No one gets used to this.

If this is hard to absorb, imagine what these war zones must be like for the children and families living in them.  Every year, 3.5% of adults have diagnosable PTSD, and almost 8% will have it at some point in their lives.  Half will have PTSD before they reach the age of 18.

What are we doing about the traumatic effect of all of this violence in all of our neighborhoods – including those where it is commonplace?  And, more importantly, what are we doing to prevent such violence in the first place?

Email Paul Gionfriddo at gionfriddopaul@gmail.com.  Follow Paul Gionfriddo on Twitter: @pgionfriddo.

The Chain of Neglect: The Real Link Between Violence and Mental Illness

More than 11 million American adults with mental illnesses – 4.5 million of them with serious mental illnesses – are not receiving care today.  So it may not be unreasonable to conclude that the history of public mental health services over the last century can be summed up in a single brief sentence. 

We replaced the chains of institutions with a chain of neglect.

I have argued that this chain of neglect typically begins when children with mental health needs are still young, and continues throughout their lives.  And that it often has tragic consequences.

Why is it so important that we talk about breaking it now, the month after Sandy Hook and almost exactly two years since the mass shooting in Tucson?

It is because tragedies like those in Sandy Hook and Tucson remind us that it is wrong to balance budgets on the backs of children and young adults with mental illness and expect that there will be no consequences.

This is a sensitive, and even complicated, issue to discuss, because mental illness doesn’t cause violence.  Violence causes mental illness.

Violence and mental illness also share some of the same risk factors, such as trauma and abuse.

They have something else in common, too.  They often appear together in times of tragedy.  And this may be the result of conscious policy decisions we have made.  

It is hard to exaggerate the enormity of the problem that we have created by chopping away at mental health services. 

In 1970, according to a 2009 articleby Steven Sharfstein and Faith Dickerson in Health Affairs, there were 525,000 psychiatric beds in American hospitals.  Eighty percent were in public institutions.  By 2002, the number had dwindled to 212,000.  Only 27% (or approximately 57,000) were in public institutions. 

In the last ten years, things have gotten much worse.  Between 2002 and 2010, states cut even more beds, reducing the number of public hospital psychiatric beds from 57,000 to just over 43,000.  By 2009, according to SAMHSA Administrator Pamela Hyde, over 10 million people were reporting that they had unmet mental health needs.

What did states do after cutting inpatient beds?  They cut community services, too.  Since 2008, according to the National Association of State Mental Health Budget Directors, states have cut mental health budgets by $4.6 billion.

It doesn’t take a policy expert to conclude that when 4.5 million people with serious mental illness are receiving no mental health services, this is neglect.

And this neglect is the real link between mental illness and violence.  Because while mental illnesses may not lead to violence, neglecting them assuredly will.

We can fix this. 

After the Sandy Hook tragedy, the Hartford Courant invited me to make some suggestions about how. 

I offered three.  Because mental illnesses typically begin in childhood, the first is intervening early, by making mental health screening a part of regular well-child and, later, well-care exams.  The second is intervening in the schools, by adding new special education services – paid for by states, not local education authorities – as symptoms of mental illness begin to affect school performance.  The third is intervening when young adults need services, by re-directing dollars from jails and prisons to community mental health programs.

The resulting Op Edit, Breaking the Chain of Neglect, was published by the Courant on December 28^thand appeared in print on December 30^th.  I hoped that it would add to a Connecticut dialogue about improving mental health services – one that has been ongoing for at least thirty-five years, when I first served in the State Legislature.

But perhaps we can all hope for something more in the aftermath of so many potentially avoidable tragedies – thoughtful new policies, instead of neglect.

In the past week, the column has been reprinted by a dozen others, including the Arizona Daily Star, the Dallas Morning News, the Tulsa World, the Las Vegas Sun, the Milwaukee Journal Sentinel, the Lawrence Journal World, the Chattanooga Times Free Press, the Kansas City Star, and the Youngstown Vindicator.

If policymakers in just those areas were to decide to work together to improve mental health services for children and young adults, then the prevention, early intervention, and treatment improvements we need so badly might finally come.

And those policymakers could leave a lasting legacy for their own children – who, I can attest, may someday need the services themselves.  

Follow Paul Gionfriddo on Twitter @pgionfriddo.  Find Paul Gionfriddo on Facebook at http://www.facebook.com/paul.gionfriddo.  Email Paul Gionfriddo at gionfriddopaul@gmail.com.

In the Fiscal Cliff Deal, A New Push for Long Term Care in 2013

When the House of Representatives voted by a comfortable margin a few hours ago to approve the American Taxpayer Relief Act (ATRA) and step away from the "fiscal cliff" for another two months, it agreed to two Senate provisions affecting elders and others with long term care needs.

The first was the "doc fix," which prevented a nearly 30% cut in Medicare payments to physicians.  This was important.  If it hadn't happened, doctors would have fled the Medicare program.

The second was tucked away into Section 643 of the Act.  It establishes a new 15-member Commission on Long Term Care, replacing the CLASS Act provisions of the Affordable Care Act that are now finally, formally repealed by ATRA.

The Commission could turn out to be a very big deal if it does it job well, because it could lead the way in changing our system of providing and financing long-term care in America.

The Commission is charged with writing a bill over the next six months "to establish a plan for the establishment, implementation, and financing of a comprehensive, coordinated, and high-quality" long term care system for elders, people with cognitive impairments, people needing help performing activities of daily living, and all "individuals desiring to plan for future long term care needs."

The Commission will focus on three things:

• the interaction and coordination of new services with Medicare, Medicaid, and private long term care insurance;
• improvements to Medicare, Medicaid, and private long term care insurance needed to ensure availability of long term supports and services; and
• long term care service workforce needs.

If the Commission completes its work on time, it could mean the introduction of new long term care legislation as early as the fall of 2013.

What could this legislation mean for us?

It could be the first step on our nation's long and necessary path to bring long term care costs under control, and make long term care services available to individuals without first impoverishing and exhausting them or their families.

It could also help states bring Medicaid costs under control, and the federal government better manage Medicare costs, too.  Long term care costs are the real culprits in rising Medicaid costs for state budgets and state taxpayers.

Let's keep our eyes open, and hope for two things.  First, that this new Commission does a better job fixing our nation's long term care problem than our broken Congress has done with the Fiscal Cliff.  And second, that if it does bring some recommendations forward, Congress listens.

This column is an Our Health Policy Matters extra.  Read on below for this week's regular column.  Follow Paul Gionfriddo on Twitter @pgionfriddo.  

Three Magical Numbers for 2013

Will health and mental health spending be part of the next Grand Bargain, Mini-bargain, or No Bargain at all?2013 could be the ultimate transition year for health policy – a wait-and-see time before the big changes ACA brings in 2014.  Or it could be much more.

Forget this week's latest budget drama.  Three often little-noticed numbers over the next few months will tell us much more about how this health policy year will eventually unfold.

The first is the Medicare “cost rate” projection for the next 75 years.  It will arrive in April in the Annual Report of the Medicare Trust Fund trustees.  This projection will tell us how much we need to worry about the present and future cost of our favorite entitlement program.

The second – especially in the aftermath of Sandy Hook – is the number of cuts or additions states make to their mental health budgets.  We’ll know this by the late spring or early summer.  It will tell us just how much our legislators have been moved by recent news to improve mental health services around the country.

The third will come in July.  It is the health care inflation rate for the past year, which is typically published in July in Health Affairs.  This will tell us all we need to know about the cost of health care in general, and the Affordable Care Act in particular.

The overall health care inflation rate matters to everything and everyone. 

In both of the past two years, the health care inflation rate was below 4% - the first time this has happened in a generation. 

This went largely unnoticed, because insurance costs are just beginning to catch up. 

But in a $2.7 trillion health economy, every 1% reduction in inflation is worth about $27 billion. And with health inflation currently projected at 5.7% annually over the next decade, more low numbers could eventually mean a difference of about $50 billion in health care spending per year. 

Over ten years, that’s around $500 billion of avoided spending – half of the total cost of the Affordable Care Act.

The Medicare “cost rate” projection could have just as big an effect on the way we address the long-term cost of Medicare. 

The Medicare Trust Fund trustees quantified the Medicare crisis this way on page 32 of their 2012 report.  They wrote that the average “income rate” for Medicare would be 3.86% over the next 75 years, and the average “cost rate” would be 5.12%.  That leaves an average deficit of 1.35% annually – the amount by which we would have to raise Medicare taxes or reduce Medicare services to keep the program solvent.

But there are two factors that influence the cost rate – the increasing Medicare population and the increased cost of health care services.  We already have a pretty good idea about the projected Medicare population over the next 75 years.  What is less certain is how much health care will cost.

That’s where health care inflation comes in again.  If it goes down, then so will the projected Medicare cost rate.

Then the life of the trust fund will be extended beyond 2024, Medicare’s projected share of GDP will go down, and the feeling of crisis around the Medicare program may dissipate in the coming year.

Mental health spending levels will tell us even more than lagging public health expenditures about how serious we are about prevention.

This is because states have been cutting both public health and mental health budgets for the last few years.  States will have to revisit both of these decisions in the wake of Sandy Hook.  Public health cuts are predictors of crises to come.  But mental health cuts are predictors of crises of the day.

Mental health cuts have so squeezed providers that they can no longer meet the service needs of our population.  Court systems and prisons are absorbing the pressure, increasing costs to states.  And when state mental health cuts are aimed at children’s services, we all eventually pay the price. 

There will be plenty of opportunities for states to improve mental health services.  Periodic mental health screening for children and adults, improving special education services, and re-directing adult mental health spending from jails to community mental health centers are just a few examples. 

Even before Sandy Hook put a spotlight on the lack of mental health services, the tens of thousands veterans returning from the Middle East were becoming a growing constituency for increased mental health funding.

We often say that there can be no disagreement about supporting our troops or our children.  And - despite the recent compelling evidence that our elected officials are incapable of rational, timely compromise - we’ll have our chance to prove it yet again this year.

Let us hope we don’t come up short.

Questions?  Email gionfriddopaul@gmail.com.  Follow Paul Gionfriddo on Twitter @pgionfriddo.

The Top Health Policy Stories of 2012

Health and mental health policy stories dominated 2012.  From how the Affordable Care Act framed the health policy debate at the start of the year to how the Sandy Hook tragedy framed the mental health and public health debate at year’s end, 2012 will go down in history as the most significant year in health policy since the 1960s.

Here are summaries of a few of the biggest news stories.

The Supreme Court Decision on the Affordable Care Act.  Nothing quite compares to the drama of the day in June when the Supreme Court ruled the Affordable Care Act to be constitutional.  Few people guessed right in advance that the decision would come down to finding the “individual mandate” to be constitutional because it is a tax, but mandatory Medicaid expansion unconstitutional because it tied future federal funding for the existing state Medicaid programs to the Medicaid expansion.

People on both sides of the debate came away wanting more, and states reluctant to accept the decision waited months to see if the fall election would change the policy environment.  It didn’t.  So as the year drew to a close was whether they, or the federal government, would implement the insurance exchanges.

The Debate over the Future of Medicare.  In the campaign, we all learned more about the two major parties’ competing visions about the future of Medicare.  The Democrats want the current structure of the program preserved; the Republicans would like to make the current Medicare program just one option available to seniors among a variety of private health insurance plan choices.

When the dust settled, the Democratic vision had carried the day.  Nevertheless, Mitt Romney’s supporters argued afterwards that he actually “won” the Medicare debate when he took a majority of the vote of senior citizens.  But even that “victory” may have resulted from the fact that he opposed the $716 billion cut.

Meanwhile, a little compromise is all we really need to preserve Medicare – but not the increase in the age of eligibility policymakers have recently pushed. 

The Medicaid Expansion.  The governors of seven southern states declared in the summer that with Medicaid expansion now an option, they weren’t planning to implement it.  They cited the significant cost of doing so.  Florida, for example, said it would cost $351 million a year, and Texas trumped that with a $4.4 billion price tag. 

But by the end of the year those states were faced with the fact that it will be at least 9 times more expensive not to expand the program.  Not embracing the expansion would cost Florida at least $3.2 billion and Texas $39.6 billion in annual lost federal revenue. 

That’s a lot of money to turn down – especially when the alternative is asking state taxpayers to foot the bill.

The Cuts to State Mental Health Services.  As of 2012, the tally of state budget cuts to mental health services grew to $4.6 billion over the past four years, with no end of cutting in sight.  I wrote about the real-time effects of these cuts in Anna Brown’s Death, California Screaming, the Mental Health Policy Mistakes We Make and the Sons and Daughters Who Pay for Them, and, focusing on veterans, in Iraq and Back and Answering the Call. 

There’s a depressing bottom line to all these stories: people with mental illness got lip service or worse. 

Athletes – and Others – Dying Young.  When Pro Football all-star Junior Seau died in the spring, it revived talk of the Curse of the 1994 San Diego Chargers. He was the 8^th member of that team to die before turning 45.  Were these deaths the cumulative effect of concussions? Or related to long-term side effects of performance-enhancing drugs that ruined the legacy of Lance Armstrong and a host of steroid-era baseball superstars, like Mark McGuire, Barry Bonds, Sammy Sosa, and Roger Clemens?

Not exactly.  At least in the case of the ’94 Chargers, former professional athletes weren’t dying young from concussions or performance-enhancing drugs, but for many of the same reasons – accidents, obesity, heart conditions, and complications from diabetes – non-athletes die young, too.  It’s avoidable, but not when we cut $5 billion from public health as we did this year.

Sandy Hook.  We need to say it again. Violence is a public health problem, not a mental health problem.  If we learn nothing else from tragedy, I hope it will be these three things: anyone of us could be a victim of violence; we can prevent much of it by treating it as a public health problem; and blaming people with mental illness for the increase in violence in America will only lead us down a dark path.

I wish you all a safe, peaceful, and Happy New Year. 

The Tragedy of Sandy Hook

The entire world is in mourning over the senseless and horrifying massacre of innocent children and adults in Sandy Hook, Connecticut. 

This hit so close to home for me, about forty miles from where I grew up.  So many of my former legislative colleagues are among those trying to help the state through it. 

I can’t even pretend to imagine what this must be like for the families of Sandy Hook. 

On the first day of the tragedy, too many politicians trotted out their tired old line that “today is not the day to have the debate” about gun control.  Thank God their tone-deaf voices were silenced by the outcry of reasonable people.

Connecticut Congressman John Larson (D-1) said that “Congress should be prepared to vote on requiring background checks for all gun sales, closing the terrorist watch list loopholes, and banning assault weapons and high capacity clips. Those measures don’t solve all our problems, but they’re a start.”

Senator Joseph Lieberman (I-CT) and Senator Richard Blumenthal (D-CT) also called for an assault weapons ban.  

But does our nation have the will to do this and more?

I hope so, because if the images of six and seven year olds staring down the barrel of an assault weapon in their last split seconds of life do not motivate us, then nothing will.

And there are two big things that it is past time to do. 

This first is to get lethal firearms out of the hands of people who are not defending us.  The second is to reverse the damage we’ve caused by neglecting and discriminating against people with mental illness because we mistakenly think that they are the cause of all the violence.

According to data reported in July by the Manchester Guardian, we are by far the most gun-toting of all of the most civilized nations in the world.  If the population of Newtown, Connecticut, is just average, then among them they already own 24,513 firearms. 

Adam Lanza’s mother owned the three of them used in the Sandy Hook massacre.  A self-described gun enthusiast, she was reported to feel she needed all this weaponry for safety and self-defense.  In the moment before her life was taken, did she feel safer, or better defended?

A member of Congress from Texas, Rep. Louie Gohmert (R-1), thinks we need even more. Does he really believe that the other 24,510 Newtown firearms made the children of Sandy Hook any safer that day?

Perhaps the horror of this massacre might open our eyes to something else – every day, an equal number of our sons and daughters die in our towns and cities because someone shoots them to death.

In 2007 alone, over 9,000 people in our country died because of gun violence, far more than the 6,656 Americans who have died in both the Iraq and Afghanistan wars since their beginning. 

We can do much better than this.  And, as President Obama declared in Newtown, “we will have to change.”

But making real change is not just finding someone to blame.

After tragedies, we often find at least hints of mental illness in the people using the guns.  But when we do, we miss the point. Violence is not a mental health problem, it is a public health problem.

Today, we are too quick to equate violence with mental illness, too quick to send people with serious mental illnesses to jail, and too quick to balance our state budgets by neglecting the people with the greatest service needs.

Connecticut’s Governor, Dannel Malloy, has shown leadership in his response to the massacre.  But another test of that leadership will come soon.  He recently ordered the rescission of up to $9.5 million in mental health services funding in Connecticut.  This funding is desperately needed to prevent and mitigate mental illnesses.  Governor Malloy is not alone in this regard – in all fifty states $4.6 billion has been cut from state mental health services during the last four years. 

Will Governor Malloy rescind that rescission now, and call on his colleagues around the country to do the same, so we can re-build our nation’s mental health services infrastructure, and better detect and treat mental illnesses early?  Will he help de-stigmatize those with mental illness, who are more often the victims of violence than its perpetrators?

Will the nation have the will to raise the money we need for prevention?

Because only if we do will we be able to say that protecting all of our children from harm is our highest priority.

Addendum:  There are news reports that Adam Lanza’s mother may have, for behavioral reasons, removed him from school at some point for home schooling.  I believe that voluntary or involuntary removal from school is often one step in a years-long chain of events that leads to bad outcomes. 

This time might therefore become a critical intervention point to change a bad trajectory and prevent future tragedies of all sorts – if we were to change our special education policy as follows:

Whenever a parent or a school believes that a special education student needs to be removed from his school for behavioral reasons, either via suspension, expulsion, or voluntary removal, for at least five consecutive days or for at least ten days in the course of a school year, there must be a mediation scheduled within 10 days with the school district, the parents, and the state education department as a mandatory third party.  The purpose would be to develop a new IEP with additional services.  The new IEP must have the input of a child’s regular health and mental health providers, if there are any.  If not, health and behavioral evaluations should be done to inform the mediation, with the state picking up the cost.  If any two parties agree to the additional services, then the services must become an immediate part of the IEP, with the state picking up the additional cost.  If the parents are not one of the parties in agreement, they still reserve their right to go to due process.  If the student is not yet admitted to special education, then the same event should trigger an immediate outside evaluation for eligibility for special education services.

Let’s assume that all parties would act in good faith.  But just in case one were concerned that a local district would low-ball a set of services from the start to shift more costs to the state, then a district could be made responsible for the costs of either its existing plan or the average cost of plans for comparable students in other districts, whichever is greater.

We’re all searching for answers.  This is just one suggestion.

Note: This column was published early this week because of the timeliness of the issue.  My prayers are with the people of Newtown.  Our Health Policy Matters will be return to its regular publication on December 26 and January 2.

Secession Fever

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

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

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

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

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

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

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

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

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

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

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

Infant mortality would go up, too. 

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

Disease prevention would also take a hit. 

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

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

Mental health services would not be spared, either. 

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

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

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

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

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

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

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

The Rule of 9 and the ACA Medicaid Expansion

There’s a simple way to calculate just how much a state will save in the long term by expanding the Medicaid program under the Affordable Care Act.  Just multiply whatever it says it will cost by 9.

That’s because the federal government will contribute at least $9 worth of match for every dollar a state spends on Medicaid expansion.

By now, we’ve all heard just how big some of the match numbers will be.  Based just on the estimates provided by the state itself in its January 2012 Supreme Court brief, Florida, for example, would gain at least $3.2 billion annually.

But Florida’s Governor has openly fought the expansion until recent weeks, and has yet to say whether or not he will support it in any form. 

He’s not the only one.  A weekend article in the Washington Post reported that as many as thirteen states may be leaning against the expansion, versus 17 plus the District of Columbia that are pursuing it.

According to the analysis on which the article was apparently based, the governors of 8 of the 13 anti-expansion states have recently reiterated their opposition to the expansion.  These include six – Georgia, Louisiana, Mississippi, Texas, South Carolina, and Oklahoma – that have been in the “rejection” category since the summer, and two –Maine and Alabama – whose governors added their states to the rejecting list in mid-November.

These governors typically cite the cost of the expansion as the reason to reject it.

However, a report released last week by the Kaiser Family Foundation took a close look at these costs over the next ten years and came to a different conclusion.  During a decade when the federal match will range from 90% to 100% for newly covered populations, the first column in the table below represents the incremental cost of the expansion over ten years for each of the eight current rejecting states.  And the second column represents the increased federal revenues each state will receive if it changes its mind:

Alabama             $1.1 billion          $14.3 billion

Georgia               $2.5 billion          $33.7 billion

Louisiana             $1.2 billion          $15.8 billion

Mississippi          $1.0 billion          $14.5 billion

Texas                  $5.7 billion          $55.6 billion

South Carolina   $1.2 billion           $15.8 billion

Oklahoma           $689 million        $8.6 billion

Maine                 ($570 million)      $3.1 billion

That comes to over $160 billion in lost revenue to these eight states alone.

Those lost billions represent money that will reimburse hospitals, nursing homes, community health centers, doctors, nurses, and behavioral health providers for care they will have to provide anyway.   

It’s especially hard to imagine what the Governor of Maine could be thinking.  Its $3.1 billion in new federal Medicaid revenue would actually be accompanied by a reductionin state Medicaid spending over the next ten years. 

The same is true in Connecticut, Delaware, Massachusetts, New York, Hawaii, Maryland, Iowa, Vermont, and Wisconsin.  With the exception of Iowa and Wisconsin, the others are all – logically – working toward expansion.

By the rule of 9 alone, it would seem that Medicaid expansion would be as close to a policy no-brainer as a state could get.

But just as there is a reason beyond the headlines why some states are reluctant to embrace setting up state health insurance exchanges under ACA, there is a reason why they don’t want to expand Medicaid, too.

It is because – just as in the case of rejecting ACA health insurance exchanges – states that are thinking of rejecting the Medicaid expansion just don’t do a very good job of protecting the health and mental health of their population.

On average, the thirteen states embracing the Medicaid expansion rank just under 17^th in the Best States for Your Health ranking, while the eight current rejecting states rank 39^th– a huge difference despite the presence of Maine, ranked 8^thoverall, on the rejecting list.

And on average, the thirteen states embracing the Medicaid expansion currently average 20^th overall in spending on mental health services, while the rejecting states together average 36^th. 

Some state governors saying no to expansion claim that the reason is because they are worried that the federal government will someday cease to fulfill its end of the bargain to pay 90% of the costs. 

But what I think they are really communicating is something else.  They personally reflect the view that health and mental health are not priorities in their state.  And they still hope to elect more people like them to Congress in the coming years to kill the expansion.

It’s cynical to hope for this, and it won’t happen.