More money, less preventable deaths

Public health activities, which are designed to promote health and prevent disease and disability, are a crucial component in reducing health disparities and improving community health. However, despite the increased focus on community-based health interventions (discussed in an earlier Bronx Health REACH post available here), national health spending on public health activities accounts for less than 5 percent of the total. The Affordable Care Act authorized a major expansion of federal public health spending ($15 billion over the next 10 years), but critics of health reform still argue that evidence linking public health activities to positive health outcomes is lacking. Public health professionals and community health advocates can attest that community-based interventions have been successful in changing unhealthy behavior, but a new study provides even greater evidence of the link between public health activities and better health. The study found that increasing public health spending lowers mortality rates from preventable causes of death. Though many of us in the field aren’t surprised by this news, it gives strong support to public health efforts in communities across the country.

The study, published this month in the journal Health Affairs, analyzed changes in spending patterns and mortality rates within the service areas of nearly 3000 local public health agencies over a 13 year period (1993-2005). The authors found that the degree of change in per capita spending varied widely across communities and only 65 percent of agencies experienced positive growth in the study period. However, in areas where public health spending increased, there were statistically significant reductions in mortality in four of the six mortality rates examined. Infant mortality and cardiovascular disease mortality were particularly affected: infant mortality fell by 6.9 percent and cardiovascular disease mortality fell by 3.2 percent for each 10 percent increase in spending. Diabetes mortality and cancer mortality also fell. The study’s authors concluded that public health spending was one of the most consistent determinants of community-level preventable mortality, even after accounting for differences in demographic and socioeconomic conditions.

By finding a clear association between spending and mortality, this study suggests that additional spending, such as that under the Affordable Care Act, would generate improvements in population health over time. It also warns against severe cuts in the health budgets of state and local governments. While health spending continues to be a frequent target for those against “big government”, this study provides the necessary evidence that our nation’s public health is a wise investment. Lowering mortality rates from preventable causes should be a top priority for the legislators and policymakers that are deciding how the federal government spends its money.

Health Care Organizations Issue Call to Action to Eliminate Health Disparity

For over a decade Bronx Health REACH has been working within underserved communities to eliminate health disparity. In that time, government agencies, hospitals, and health systems have become more willing to address health disparities and work toward solutions to achieve health equity. This partly stems from ethical obligation, but it also enhances performance and makes good financial sense. (Chronic diseases account for the largest health gap among ethnic and minority populations and are responsible for 75 cents of every dollar spent on health care in the U.S.) Even so, the Call to Action to Eliminate Health Care Disparities, issued by leading national health care organizations last week, is notable for its commitment in providing a foundation to accelerate efforts to achieve health equity.

Led by the American Hospital Association (AHA), the “Call to Action” brought together five major health care organizations, including the American Association of Medical Colleges (AAMC) and the National Association of Public Hospitals and Health Systems, to focus their efforts on eliminating health disparity. “We’re in a new era of health care,” says Dr. Maulik Joshi, senior vice president of the AHA. “Collaboration is a key part of the process.” The group will focus on three building blocks: increasing the collection and use of race, ethnicity and language data; increasing cultural competency training for all staff; and increasing diversity in leadership and governance. The organizations will pool resources and tools and have created a website (www.equityofcare.org) as a portal for information on how to implement these initiatives within hospitals.

A main impetus for joining this effort, says Dr. Marc Nivet, chief diversity officer at the AAMC, was the recognition that medical schools and teaching hospitals need to do a better job in communicating the importance of health disparity. “We’re creating future physicians and we’ve known for a long time that we’re not providing a workforce that is culturally competent,” says Dr. Nivet. “We need to have the concept and understanding of health disparity woven into the curriculum.” Collecting and sharing data is also a key component so that people understand the issues and better policy can be made. The goal, says Dr. Joshi of the AHA, is not just systematic data collection, but a better understanding of the community and how the right data can be used achieve equity of care.

The importance of integrating the entire hospital structure with the community is also a key part of this effort. “Community organizations have been in the right place for decades in terms of trying to improve health by not just paying attention to health care, but paying attention to other social determinants of health,” says Dr. Nivet. “It’s important that all of that knowledge is transferred through shared learning between major medical institutions and community groups to figure out how we can all work together more closely going forward.” Dr. Joshi agrees, saying that hospitals are often role models in the community and collecting better data allows hospitals to know their communities in a more comprehensive way. “We need to move away from this mentality that we sit in the community to that we are part of this community,” concludes Dr. Nivet.

The chasm between public health and medicine is a frequent roadblock in collaboration between community groups and hospitals, but the “Call to Action” may be the crucial opportunity needed to bridge the gap. We applaud these health care organizations for taking a decisive step forward in outlining steps to achieve health equity and providing resources so that hospitals can implement better practices. As a community-based initiative, Bronx Health REACH looks forward to increased collaboration with hospitals and hopes that this effort galvanizes hospitals across the country to heed this Call to Action and become active in the national effort to eliminate racial and ethnic health disparities.

Building an oasis in the desert

According to the Partnership for a Healthier America, 23.5 million Americans live in areas where finding affordable, healthy food is difficult. These so-called food deserts make healthy eating a true challenge, even if the population is willing to make lifestyle changes. To combat this issue and the rising tide of childhood obesity (of the 23.5 million Americans living in food deserts, 6.5 million are children), the Partnership for a Healthier America has announced an initiative to bring healthy, affordable food to 10 million people over the next five years.

The Partnership for a Healthier America, a key partner in First Lady Michelle Obama’s Let’s Move Initiative, received commitments from six leading grocery retailers, including Walgreens and Walmart, to open or expand over 1,500 locations in low-income areas. Walgreens alone has committed to expand a minimum of 1000 stores by 2016 to serve 4.8 million people in low-access areas. The New York Times reported that Walgreens will turn these locations into “food oasis stores” that will sell fruits, vegetables, and other items they do not normally stock.

This effort comes at a crucial time. One in three children is overweight or obese and the White House has said that, according to some research, today’s youth may be the first generation to have shorter lives than their parents. The lack of access to healthy food is a key contributor to the ever increasing weight of America’s children, as is the concentration of fast food outlets in low-income areas. The Bronx, to take one example, has 43 McDonald’s alone – if you were to add the Taco Bell, Burger King, Wendy, and KFCs that number would be significantly higher.

Some cities have taken their own steps to ban unhealthy foods. In 2008, South Los Angeles issued a moratorium on building new fast food outlets in the area. The ban, advocated for by Community Health Councils, a REACH grantee, allowed existing restaurants to stay, but no new outlets have opened since it was passed. A few years ago, New York City issued a ban on trans fats and Bronx Health REACH led a successful effort to eliminate whole milk in NYC public schools.  

These are all important steps, but an overhaul of how food is distributed in this country is necessary. Though nutrition education is a big part of the effort, people cannot practice what they learn if there is not an affordable and convenient place to buy healthy food. Now is the time to turn our deserts into oases.

Does having health insurance make you happier and healthier?

Does providing health insurance to the poor actually make them healthier? While a critical question in the long-running health care debate, the impact of health insurance on the poor has been difficult to determine as studies comparing the insured versus the uninsured typically have too many variables (income, education, health habits, etc.) to be completely successful. However, a recent study on the impact of Medicaid in Oregon provides the first rigorously controlled look at the costs and benefits of having health insurance.

This study, published by the National Bureau of Economic Research, took advantage of an unusual situation in Oregon, which decided to expand its Medicaid program by selecting 10,000 uninsured people by lottery. This allowed economists to compare those selected by lottery to receive Medicaid with those who had not been picked. Because it is considered unethical for researchers to deny coverage to some people for the benefit of a study, nothing like this had ever been done before.

In short, the findings from the first year are encouraging. The researchers found that when the previously uninsured were given Medicaid they saw doctors more often, felt more financially stable, reported better physical and mental health, and undertook more preventative health measures. For example, Medicaid coverage increased the likelihood of using outpatient care by 35% and of having a regular doctor by 55%. Women on Medicaid were 60% more likely to receive a mammogram than the uninsured group and the likelihood of people having to borrow money or skip other bills to pay for health care decreased by 40%. However, having Medicaid coverage did not reduce the number of emergency room visits and increased utilization of health care services by the insured added up to an extra 25% in annual medical expenditures, making cost still a significant factor.

With the debate on the expansion of public insurance raging, this study is expected to be a strong argument for insuring the poor. However, feeling healthier doesn’t necessarily mean that people are healthier. The study also didn’t assess the quality of care for those on Medicaid, which is a frequent criticism of public insurance. The second phase of the study will attempt to answer at least one of these questions by measuring the health effects of having Medicaid versus being uninsured. The researchers interviewed 12,000 people (6,000 from each category) and measured variables like blood pressure, cholesterol, and weight. Those results will be released once they have been analyzed.

Insuring the poor is a critical component to reducing the chronic disease burden and eliminating health disparity. Relying on “safety net” hospitals, free clinics, and charity care is not a sustainable option, nor a preferable one. However, expanding public insurance on its own is not enough. Without improving the quality of care of those on Medicaid or raising reimbursement rates so that more doctors accept it, the cycle of poor health outcomes for underserved populations will continue. As this study shows, if people are offered the option to live a healthier life they take it. This should be proof enough.

To read the entire study, click here.