The Commonwealth Fund has recently issued its 2018
Scorecard on State Health System Performance. This scorecard has data for
each state (+ DC, so 51 spots), measuring performance against a variety of
metrics evaluating access to health care, quality of care, efficiency in care
delivery, health outcomes, and income-based health care disparities. Because
the Scorecard has been issued 2013, Commonwealth can compare the current year’s
rankings and performance to previous ones, seeing how states get better (or
worse) on these individual measures as well as on overall performance.
There is not much
change. The Top 5 in performance remain Hawaii, Massachusetts, Minnesota,
Vermont, and Utah, in the same order as last year. The Bottom 5 (47-51) are Arkansas,
Florida, Louisiana, Oklahoma, and Mississippi, and are close to the same, the
only change being Florida dropping 5 spots to join the group and displacing
West Virginia, now at 46. Hawaii at the top and Mississippi at the bottom are
not only unchanged, but remain far ahead or behind of their nearest competitor.
The top regions are still the Northeast and Upper Midwest, with the West
dragged up by Hawaii and Utah but otherwise an average to low average group.
Commonwealth also ranks the states on degree of improvement
of their scores in each of 43 different indicators. More indicators improved
than went down, which in itself is a good thing, but there are a lot of
caveats. For one thing, it doesn’t measure amount of improvement, or how much
less a state might have improved compared to others. For example, Oklahoma
joins the list of the top 5 states with improvement on the most indicators (17,
to rank it #4), and yet dropped two
places in the overall ranking, from a dismal 48 to 50th! This is not
good. More important, however, were the areas in which indicators fell for many
states and for the nation as a whole. This include rising death rates (a really
big one!), including a 50% increase in deaths from suicide, alcohol, and drug
use since 2005, rising obesity, and gaps in care with a rising disparity
between and within states.
Many of the improvements are in areas that have been focal
points of public health policy, like decreasing smoking. This is good, but this
long-time-coming advance over the tobacco industry’s heavily funded effort to
get people to continue to smoke, and young people to take it up, has still not
been entirely won. More important, the lessons from the anti-tobacco campaign have
not yet transferred to the other well-funded high-profit threats to health,
notably sugar and guns, as well as alcohol and pharmaceuticals. Unfortunately,
each of these struggles seems to need to rise up almost as if the others hadn’t
been joined; activists can and do learn from the previous ones, but so do industries
that manufacture unhealthful commodities. These industries replicate the
strategies that tobacco used to delay change for so long. The main one, of
course, is the liberal application of money to politicians. The same lobbyists
who worked for tobacco work for sugar, and guns, and alcohol; the color of
their money is still green, and politicians still enjoy receiving it.
While it is true that many politicians from both major
parties have been recipients of such largesse, the retreat from reality-based
policy that is the hallmark of both the Trump administration and the Republican
Party in Congress has major impact on the causes of illness and will continue
to do so into the future. One good example of the latter is the aggressive
retreat from environmental regulation, personified by EPA administrator Scott
Pruitt, rolling back auto-pollution emissions standards (a decision currently
being challenged by a coalition of states led by California). Another is the
firm resistance to common-sense regulation of guns, which result in over 30,000
US deaths a year, a tiny fraction of which are from foreign terrorists. Limitations
on semi-automatic weapons and high-capacity magazines, waiting periods and
background checks, absolutely would decrease the number of these deaths (the
majority, by the way, are suicides), but are blocked by legislators feeding
from the gun-industry funded NRA trough.
Not only politicians are recipients of graft; a recent New
York Times exposé provides
evidence of pharmaceutical companies using ostensible “speaker’s fees” to
actual provide kickback payments to physicians who are big prescribers of their
drugs. The article emphasizes payments to doctors who practice pain medicine
and are in a position to prescribe large amounts of the opioids manufactured by
these companies. Sadly, this is almost as unsurprising as the graft going to
politicians to compromise our health. What we should be is outraged about it,
and working to combat it. Certainly the politicians do not seem to be. In the
conclusion to her “controversial” speech at the White House Correspondents’
Dinner Michelle Wolf noted that: “Flint still doesn’t have clean drinking
water.” It is harsh, it is true, and it is almost as bad as the news that the
government of Michigan will no
longer be providing free bottled water, even though the tap water is still
unsafe.
Flint, of course, is a majority minority
and overwhelmingly poor city. It has long been clear that its struggles with lead-poisoned
water is not coincidental with the makeup of its population, and it not a
coincidence that it is in Michigan. The Commonwealth Report illustrates a wide
divide between those states that have better and those that have worse health
status. Largely, the map is geographic with northern states better and southern
states worse, but there is a tongue of northern states in the worse group,
heading up from Kentucky and West Virginia into Indiana, Ohio, and on up to
Michigan. What these states have in common with most of those in the south is
control by Republicans who in most cases have not, in most cases, expanded
Medicaid for their citizens. Expansion of Medicaid was a central part of the
Affordable Care Act, but a Supreme Court left the decision on whether to do so
optional for the states; those that have not done so have worse population
health status. This is exacerbated by changes in federal policy that have
increasingly made access to health care worse and more expensive in most
states, with the impact felt most in states that have elected Republican
government and that voted for President Trump.
In another blog post, First
Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse,
the Commonwealth Fund notes that*:
·
About 4 million working-age people have lost
insurance coverage since 2016
·
The uninsured rates among lower-income adults
rose from 20.9 percent in 2016 to 25.7 percent in March 2018
·
The uninsured rate among working-age adults
increased to 15.5 percent
·
The uninsured rate among adults in states that
did not expand Medicaid rose to 21.9 percent
·
The uninsured rate increased among adults age 35
and older
·
The uninsured rate among adults who identify as
Republicans is higher compared to 2016
·
The uninsured rate remains highest in southern
states
·
Five percent of insured adults plan to drop
insurance because of the individual mandate repeal
This is also not good news. Much of the problem is because
employer health insurance costs (much of it passed on to workers) have been
rising as Medicare and Medicaid control costs. A Washington Monthly article (excerpted
by the great Don McCanne in his Quote of the Day) calls for price controls,
noting that much of the cost (in lower wages) that workers bear for higher
health insurance is not obvious to them, and they would thus have sticker shock
from a Medicare for All program. Dr. McCanne notes that a current California
bill, AB 3087, calls for price controls, and is supported by unions but opposed
by industry and the California Medical Association so it has little chance of
passage, suggesting that this solution is not more palatable to the powerful.
He calls for well-thought out Medicare for All program, saying:
Now
would it be that difficult to let people know about the hidden costs of health
care that they are already paying? Do people really prefer being kept in the
dark by an opaque financing system rather than being enlightened by the transparency
of financing through an equitable tax system, especially if the amount being
spent is somewhat less for all but the wealthiest of us?
I do not think so. It is time to do something to change a
status quo that is unacceptable for the health of so many as well as
unaffordable. It is time to do the right thing.
*Also summarized by
Dr. McCanne
No comments:
Post a Comment