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

Justice, Social Justice, Health, and Health Care, Part III

Health Disparities

Etiologic Agent	# deaths per year
Tobacco use	400,000
Diet/activity	300,000
Alcohol	100,000
Microbial agents	90,000
Toxic Agents	60,000
Firearms	35,000
Sexual behaviors	30,000
Motor vehicles	25,000
Illicit use of drugs*	20,000

What are some of the components of the social determinants of health? They include, certainly, housing, food, warmth, education, the overall treatment of women and especially the education of women. There is evidence that greatest determinant of the quality of a society, and especially its economic standing, is related to the education of women. Let us take the example of “food deserts”. 2.3 million (2.2%) of continental US households are more than a mile from a supermarket and do not have access to a vehicle. There are food deserts not far from me in Kansas City, KS. In a community called “the Argentine”, largely populated by Mexican Americans, it can take more than two hours on 3 buses to reach the supermarket. It could be faster to walk, but hard to carry back groceries. In fact, the inability to carry much on any one trip can lead to fresher food, but this requires availability of stores. In an article in the NY Times (July 31, 2011), Russell Shorto describes “The Dutch way: bicycles and fresh bread”; riding bicycles everywhere not only provides great exercise, but the limited carrying capacity means that the bread – and other food – is fresh daily.

The unequal distribution of the social determinants of health is a major cause of health disparities, as demonstrated in the slides from Dr. Jones, and in a few from Dr. Woolf.  The latter shows us a list of the 9 most common etiologies of death, from tobacco use (400,000 deaths per year) through illicit drugs (20,000, and not including the use of “licit”, legally prescribed, drugs). Seen this way, by root cause (that is “tobacco”, “diet and activity”, “alcohol”) as opposed to medical diagnosis (like “heart disease”, “cancer”, “liver disease”) we get a clearer picture of the true role of social determinants. Only one on the list, (#4, microbial agents) is even considered part of “traditional” medicine. Dr. Woolf also demonstrates the tremendous impact that education has on health with data from the University of California San Francisco (UCSF) Center for Health Disparities that show that 26.7% of those with less than a HS education describe themselves as having “fair” or “poor” health, compared with 5.8% of college graduates, a five-fold difference! The racial and gender difference in age-adjusted mortality rates is also dramatic; the death rate for black males is coming down, but still far exceeds white males and black and white females (and, although the rates for women are lower than for men, they are much higher for black women than for white women).

In a provocative “thought experiment” published in the American Journal of Public Health, “Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”[1], Dr. Woolf and his colleagues demonstrate that even if we attribute all current and recent reduction in mortality to medical advances (nowhere near true; most are due to the types of societal change generally characterized as “public health”, such as clean water, sanitation, and cleaner air), eliminating the disparities that exist on the basis of educational level would dwarf that change, as shown in this graphic.

The County Health Calculator produced by Woolf and colleagues from Virginia Commonwealth University, and available free on line,  allows one to look at the socioeconomic status (measured as percent of people with income s >200% of poverty) and education (measured as percent of people with at least some college) for every state and county, and compare it to the other states or counties within a state. A neat “slider” feature allows you to change these rates (e.g., make the rate the same as the best or worst) and see what the change in deaths would be. For Harris County, Texas (Houston) , if 5% more people attended some college and 5% more had an income higher than twice the federal poverty level we could expect to save 1,200 lives, prevent 12,200 cases of diabetes, and eliminate $97.8 Million in diabetes costs every year.

Bradley and Taylor, in an Op-Ed piece in the NY Times, “To fix health care, help the poor”, NY Times, (12/8/11) cite their research challenging the simplicity of the notion that the US spends far more per capita on health care than other developed countries. While true on its face, the US spends far less on social services that might decrease the need  for health care; when lumped together, the difference decreases, although the US stands out as being one of very few countries where almost all health+social services spending is on medical care. [2]

A major way to address social determinants and health disparities is the implementation of “health in all” policies, for such things as

·         Land use (what is the density? Are there open spaces? How is space used?)

·         Built environment (are distances to schools and shopping walkable? Are there facilities for exercise?)

·         Transportation (can people get to the store or the park?)

·         Agriculture (what about antibiotic and drug use in raising livestock? How about the conditions of farmworkers, including exposure to pesticides?)

·         Environmental Justice (are there toxins in the environment? Lead? Who is exposed to “brownfields” and do their children have higher rates of cancer? )

·         Health policies (smoking in public places)

·         Taxes (do these encourage or discourage the building of a healthful society?)

Although these areas are outside of traditional medicine, physicians can be involved in addressing them; they are (like Dr. Henry A. Withers, for whom this lecture is named) community leaders who have great moral authority.

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[1] Woolf SH, Johnson RE, Phillips RL Jr, Philipsen M.“Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”, Am J Public Health. 2007 Apr;97(4):679-83. Epub 2007 Feb 28.PMID:17329654

[2] Bradley E et al, “Health and social services expenditures: associations with health outcomes”. BMJ Quality and Safety 2011 Oct 20(10):826-31.