Health status in the United States and State Health Performance: The Commonwealth Fund report and potential solutions

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 50^th! 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

Fake news, fake facts, and fake science: making stuff up to justify hurting people and the planet

The flood of “fake news” threatens serious damage to our society as surely as floods have recently destroyed much of the Caribbean and coastal US or fires have burned up much of Northern California. While it is President Trump (whom I call the #Trumpenik, from the Yiddish “trombenik”, a lazy person or ne'er-do-well; a boastful loudmouth) who uses the term most often, in fact it is he and his allies who create most of the falsehoods. A central and terrifying one is the denial by the President and his EPA of global warming, certainly linked to the increase in horrific storms and fires, and the counter-scientific efforts of his administration to make it worse by increasing the burning of fossil fuels and refusing efforts to contain climate change despite the fact that it is “Trump country” that is supplying much of our nation’s alternative energy. 

Key to this fake news is the use of “fake facts” to support reactionary political agendas. While these agendas are mostly about making more money for the richest people and corporations rather than the middle and working-class Americans who support them, they also exploit a bizarre antipathy toward science among a good hunk of our population. (One explanation is that science sometimes reveals facts that are incompatible with pre-existing beliefs, so we reject them. However, the Catholic Church finally got over its opposition to Galileo, so maybe there is, eventually, hope.) Indeed, these people don't oppose all scientific facts, but rather those that make them uncomfortable despite being true. This is suggested by the efforts to manufacture false “scientific” facts to buttress social agendas. A prominent example is the use of “fetal pain syndrome” to justify efforts to limit access to abortion, particularly in the second trimester. The flaw here, of course, is that the evidence for fetal pain is slim to none, certainly before the third trimester, as shown is several reviews of the literature, and discussed at length in this article in Popular Science. LiveScience.com notes that “The American College of Obstetricians and Gynecologists (ACOG) said it considers the case to be closed as to whether a fetus can feel pain at that stage [20 weeks] in development.” Of course, while the number of people who would change their positions on the availability of second-trimester abortion if they believed that the fetus experienced pain during the procedure would be small to minimal, it provides a convenient, if false, cover for efforts to restrict access, including a House bill that passed just this month in Congress.

This use of fake facts and junk science has recently been expanded beyond restricting abortion to efforts to limit access to contraception for women. Let’s get this completely straight: access to contraception has been a terrific thing. It has given women – and men – much greater control of their reproduction, dramatically reduced the incidence of unintentional pregnancy (although this still remains far too high), and, duh!, even reduced the incidence of abortion. While the decision to use contraception should and does remain up to the individuals involved, it needs to be easily available to them. Thus access is critical. For many – including but not limited to teens – access is, instead, very limited, and there are ongoing efforts in Congress and in many states to further restrict it. Particularly onerous and vile is the effort of the Trump administration to roll back the ACA’s mandate for insurers to cover birth control, pandering to the religious right.

A terrific piece by Aaron Carroll on October 10, 2017 in the NY Times, “Doubtful science behind arguments to restrict birth control access”, details and refutes the bogus claims made by those who want, bizarrely, to do so. These include the idea that access to contraception has not reduced unintended pregnancy (it absolutely and most assuredly has, and greater availability would further reduce it). The Trump (and at the time, Tom Price-led) Department of Health and Human Services used cherry-picked and archaic data to support its tortured argument. Carroll notes that “In 2011, the unintended pregnancy rate hit a 30-year low. And the teenage pregnancy rate and teenage birthrate right now are at record lows in the United States. This is largely explained by the use of reliable and highly effective contraception.”

HHS also argues that there are health risks, especially from hormonal contraceptives. There are, of course, but there are health risks and side effects from any drug treatment, and the risk of harm from the treatment has to be weighed against the probability of benefit. Ironically, in the care of hormonal contraception, the most significant side effects (both symptoms and even blood clots) are similar to (if generally less severe than) those from the condition contraception is designed to prevent – pregnancy. That is, not using contraception because of concern about these side effects and then getting pregnant increases the risk of these adverse events!

The bugbear for religious conservatives in this debate is their fear that contraceptive availability will increase people – especially teens -- having sex, but for the rest of us the concern is how this would impact the unintended pregnancy rate. Carroll cites a “2016 study in The New England Journal of Medicine showed that the unintended pregnancy rate among women who earn less than the federal poverty line was two to three times the national average in 2011. An earlier study showed that in the years before, that rate was up to five times higher.” From a cost point of view, the study’s author, Jeffrey Peipert, notes that “Every dollar of public funding invested in family planning saves taxpayers at least $3.74 in pregnancy-related costs.” For women (and their partners), especially those who are low-income or teens, the direct cost for contraception is sometimes prohibitive, especially for the most effect type of contraception, long-acting reversible contraception (LARC), IUDs and hormonal implants, that have a high one-time up-front cost. It is the programs to make these more affordable and available are exactly the ones being targeted for major cuts. And, in the “adding insult to injury” department, the justification for cutting some programs is sometimes the existence of other programs, which are also being targeted for cuts!

The use of junk science, sadly but unsurprisingly, is not limited to contraception, abortion and even climate change. In a Viewpoint piece published in JAMA, October 10, 2017, “Flawed theories to explain child physical abuse”, John Leventhal documents a new trend in legal cases of child abuse. Defense attorneys bring in “medical experts” who testify that something else could have caused the child’s injuries. These include real diseases that could cause the findings but are both uncommon and can be ruled out with proper workup, real diseases that are very uncommon and unlikely to cause the findings, and essentially made-up conditions to explain the findings. Since child abuse is generally not a controversial area (nobody claims to be in favor of it!) the reasons for this seem to be mainly personal gain – such “experts” make big money for this testimony. There are not that many real experts in child trauma willing to offer absurd pseud-explanations for the injury, so there will be fewer of you willing to testify in defense of the perpetrators, so you again stand to make a lot more money.

In any case, the use of fake or fraudulent science and fake facts to support political agendas is one of the many bad things growing in the fertile “don’t try to tell me the facts” environment in Trumpian politics. The administration is now allied with “traditional” Republicans to facilitate rape of the planet in pursuit of gains for the wealthiest, and with “populists” in pursuit of social repression. There is some irony in that these advocates for “freedom” (e.g., from gun control) are so intent on denying it to others (e.g., gays, women, poor people, children), but apparently this is a long-standing US tradition (see: slavery), which inspired Abraham Lincoln’s famous quote “Those who deny freedom to others deserve it not for themselves,” There is also irony in the pursuit of the cloak of (fake) scientific facts to facilitate an anti-scientific agenda.

But the irony is not nearly sufficient satisfaction to mitigate the terror.