More employers are offering high-deductible health plans and more workers are willing to choose lower-priced plans that require them to pay more out of pockets for health care. This strategy is embraced by public and private exchanges to keep the rising costs of healthcare down (will it?). Supporters of high-deductible plans claim that people will become smarter health care consumers more aware of health care costs and willing to discuss choices and options with providers. It may be a good deal for people who are generally healthy, rarely see doctors and could afford ($1000-7000 range deductibles) thousand dollars for medical care when needed. So what are the down sides?
A study by Galbraith in JGIM showed that the odds of reporting delayed or forgone care due to cost were 3-4 times greater for adults and children with high deductible health plan compared to traditional plan families. Lower-income families in HDHPs have increased rates of cost-related delayed and forgone care. According to a recent article by Reed in Health Affairs, 19% of plan members surveyed reported delaying or avoiding a preventive office visit, test, or screening because of cost even though it was exempted from their deductible. Most health plan members surveyed have low awareness of preventive cost-sharing exemptions.
Health insurance is supposed to protect members from financial worries, debts, promote healthy lifestyle and prevention practice. A study published in AJM suggested that about 62% of all bankrupcies in 2007 were medical before the major impact of the housing collapse and recent economic downturn. We are indeed full of contradictions when it comes to health care policies and practices. We believe in safety net and we have supported many on Social Security disability programs, but we don't believe in health insurance that is straightforward and well-designed--protect all of us from medical expenses we could not easily afford on our own. Perhaps our health system is getting too complex (understatement), too many band-aids and too many self-interest groups wanting status quo. There is an alternative proposal. To find out more...
Why we die young compared to other high-income countries--homicide, car accidents, drug overdoses, mental health...
According to a recent study by Ho published in Health Affairs this month, a significant gap (2/3 of the difference for males and 2/5 for females) between the US and the mean of the comparison countries in life expectancy at birth is explained by mortality differences below age 50. The major drivers of differences in life expectancy at birth for males in 2007 were homicide, unintentional injuries, perinatal conditions and NCDs; for females, unintentional injuries, NCDs and perinatal conditions are the main contributors to excess mortality under 50. The author (and my own bias included) alluded to policy implications focusing on younger ages such as: income inequality, urban poverty, residential segregation, gun ownership and availability, public transportation, traffic safety (annual number of km driven in the US exceeds that in the comparison countries), prescription drug monitoring programs (Americans consume more prescription medications than any other populations as well). Along the same theme...
In the Global Burden of Disease 2010 Study, violence as a cause of YLLs (years of life lost due to premature mortality) is 7 per 100,000 in the US (seven times higher than high-income Asia-Pacific, western Europe or Australasia); but in tropical and central Latin America, the rates are substantially higher 30+/100,000. The huge variation in violence mortality reflects (again) socioeconomic inequalities, political contexts and public health strategies. There are lessons, policy implications for governments, leaders if they care about these outcomes.
A study by Kindig and Cheng in the same issue in Health Affairs added to the body of literature on the regional variation in health outcomes in the US. The authors examined trends in male and female mortality rates from 1992-96 to 2002-06 using county-level data from the County Health Rankings, BRFSS, CDC database and US census with a number of covariates including geographic regions, household income, educational levels, single-parent households, children below federal poverty level, smoking, obesity, PCPs, insurance coverage, preventable hospitalizations, etc.
Sure mortality rates are falling in most US counties but a large number of counties (43%) had no reduction in female mortality rates during the study period. The authors identified a number of factors most strongly asociated with mortality change including education levels, the region the county was located in (south vs. northeast), and smoking rates. Higher proportions of Hispanics and adults with a college degree (see my previously blog and our journal club) were associated with reductions in mortality rates. And remember mortality rates (male or female) were NOT predicted by any of the medical care factors such as rates of primary care providers, preventable hospitalizations or precentage of uninsured.
So where should we put most of our money and resources--education, housing, neighborhoods.
President Obama recently announced his support for preschool education, citing programs in Georgia and Oklahoma. It makes me question my own support of programs such as Head Start. I have not looked into its evaluation and the long term impacts until now. Here is a synopsis of my finding:
- The Abecedarian and Perry demonstration projects provided high-quality child care/preschool for children from disadvantaged backgrounds and showed positive educational and life outcomes at a cost of about $12-19,000 a year per student (Head Start costs a lot less up front but also a lot less effective). Return on investment was about 6.9% according to University of Chicago Economics Professor Charles Heckman. There were 111 participants in the Abecedarian and 128 in the Perry RCT design evaluations with follow up to age 40 in the latter project.
- Head Start is a federal program under DHHS with a budget of about 8 billion in 2012 and serves close to a million children nationwide. The program provides comprehensive services that include preschool education, medical, dental, and mental health care, nutrition services, and parental support. There have been 2 recent reports on the long-term impacts/outcomes of Head Start:
- The Head Start Impact Study released Jan 2010 showed that the advantages children gained in cognitive development and health during their Head Start and age 4 yielded only few statistically significant differences in outcomes at the end of 1st grade for the sample as a whole (disappointing).
- A follow-up report tracking the progress of these same children through third grade was published late in 2012. You guess it, by third grade, the Head Start program had little to no impact on cognitive, social-emotional, health, or parenting practices of participants.
- Apparently, we have 1600 Head Start programs of various qualities. Craig T. Ramey and Sharon Landesman Ramey concluded in their paper: "exemplary Head Start programs should serve as mentors, while failing programs must be transformed or terminated promptly to prevent harm."
- So what's the verdict? "re-invent" Head Start? faciliate competition, expand model programs, support State's initiatives, etc. (just don't increase the deficits hah). Early childhood education and care has become a core issue for the OECD. Its focus is on improving quality of ECEC with data on country policy experiences, toolkits and international comparison. I say they have a head start on us and it's time to get cracking!
One of my previous blogs asked what is the evidence on gun control? The tragedy in Newtown, CT is probably as much about mental illness as about gun violence. The package of 23 executive orders issued by Present Obama includes an important directive aimed at the CDC to research gun violence and its impact on public health and safety lifting a 16 year moratorium on federal funding as a result of aggressive lobbying by the NRA. A Gun Policy Summit took place on Jan 14-15, 2013 and provided a series of policy recommendation. They include (among many others):
- Establishing a universal background check system, which would require a background check for all persons purchasing a firearm
- Persons convicted of 2 or more crimes involving drugs or alcohol within a
three-year period would be prohibited from firearm purchase for a period of 10 years
- Federal restrictions of gun purchase for persons with serious mental illness
should be focused on the dangerousness of the individual (hum?)
- Fully fund federal incentives for states to provide information about disqualifying mental health conditions to the National Instant Check System for gun buyers (huh?)
- Congress should provide financial incentives to states to mandate childproof or personalized guns
- Ban the future sale of assault weapons, incorporating a more carefully crafted definition to reduce the risk—compared with the 1994 ban—that the law can be easily evaded
- Ban the future sale and possession of large capacity (greater than 10 rounds) ammunition magazines
The Johns Hopkins University Press released Reducing Gun
Violence in America: Informing Policy with Evidence and Analysis (cover shown above). This volume provides empirical research and legal
analysis to inform the policy debate by helping lawmakers and opinion leaders identify the policy changes that are most likely to reduce gun violence in the U.S.
As someone who is interested in public health policy and primary determinants of health, this question has perked my curiosity since college years. A recent NYTimes' Commentary by Thomas Edsall "The Hidden Prosperity of the Poor" highlighted the debate over the rising inequality in this country. I would like to summarize my own take of this complex topic.
- a number of studies (Kondo, Elgar, Zheng to name a few recent ones, see bib) have examined the association between income inequality and population health; results are mixed/inconsistent but there seems to be a negative impact of income inequality (as measured by gini coeff) on premature mortality, healthy life expectancy and self-rated health
- it is thought that income inequality results in poor health through loss of social capital, social cohesion, interpersonal trust, psychosocial stress.
- The effects of income inequality are more "apparent" in multilevel, cross-sectional datasets, over time and gender-specific (seen in men), and there is a threshold effect of income inequality on health.
- it is unclear whether public health expenditure could mediate the harmful effect of income inequality on health.
- the question is not laissez faire and the belief in the hidden prosperity of the poor and middle class but which policies in social security, welfare, labour market, immigration, tax reform are necessary to address poverty and income inequality!
According to a recent report from the US National Research Council and Insitute of Medicine, U.S. Health in International Perspective: Shorter Lives, Poorer Health, when compared with 16 high-income "peer" countries, we fare worse in 9 health domains:
- higher infant mortality rate, low birth weight and other adverse birth outcomes
- higher deaths from motor vehicle crashes, non-transportation-related injuries and violence
- highest rate of adolescent pregnancy and STIs
- second highest prevalence of HIV infection and highest incidence of AIDS
- more deaths from alcohol and drug-related mortality compared to others
- highest obesity rate
- second highest death rate from ischemic heart disease
- lung disease is more prevalent and associated with higher mortality
- higher prevalence of arthritis and activity limitations
What are in our favor:
- The US has higher survival after age 75 than peer countries, higher rates of cancer screening and survival, better control of BP, cholesterol levels, lower stroke mortality, lower rates of current smoking, and higher average household income.
What could be possible explanations for the US health disadvantage?
MULTIFACTORIAL!!! the logical answer (ended up to be my conclusion for a number of clinical challenging cases over the years). Remember that even highly advantaged Americans may be in worse health than their counterparts in other countries! here are 4 groups of factors:
- US health care and public health system: costliest health care system (you heard repeatedly); fragmented, quality, safety issues
- social factors: poverty, income inequality, education/employment, racism
- individual behaviors: we consume calorie-dense, low-nutrient food, are less physically active, love prescription drugs and illicit drugs, less likely to wear seatbelts and helmets and own more firearms...One could argue that individual behaviors/lifestyle are heavily influenced by social factors and the built environment.
- built environment: (physical and social environments) car culture, neighborhood factors, work stress, pollution, etc.
Where do we go from here? (and not just alert the public and more research studies) We have underinvested in public health, education and community environments in this country and have not achieved many critical national health objectives. Local and national conversations on important social and health topics are often shadowed by political divisions, claims of American exceptionalism, individualism and belief in limited government. It is also time that our claim as a big heterogeneous country with a vibrant immigrant population (and in generally better health according to the report) should NOT hamper us from achieving consesus and policy and implementation. We should be able to come up with diverse solutions for various communities--there may be a few things we could learn from the localist movement?
Childhood obesity is getting national attention as a public health crisis. Native American children have the highest prevalence of obesity. Blacks and Mexican-Americans had rates higher than whites. Low-SES adolescent girls have much higher prevalence than higher-SES counterparts especially white adolescent girls. The disparities in the prevalence of obesity may be the result of the interaction between genetic and environmental factors with the latter playing a key role in fueling the obesity epidemic.
The upward trends in obesity and extreme obesity may turn downward slightly from 2003 to 2010 among preschool-aged children living in low-income families according to a research letter published in this week's JAMA by Pan et al. (CDC) using data from the Pediatric Nutrition Surveillance System which includes almost 50% of children eligible for federally funded maternal and child health and nutrition programs. In the accompanying viewpoint, Dr. Ludwig and others called for the restructuring of the Supplemental Nutrition Assistance Program (SNAP), previously known as the Food Stamp Program to focus on nutritional quality of food purchased/consumed by SNAP recipients. It has to start with a more systematic approach to data collection by the USDA and collaboration with DHHS.
We need national to grassroot level strategies to cut back on sugary drink consumption. Find out more about the unprecedented marketing of sugary drinks to youth from the Rudd Center for Food Policy & Obesity at Yale. Past proposals included penny-per-oz taxes on sugar-sweetened drinks and NYC's soda ban (prohibits sugary soft drinks larger than 16 ounces (473 ml) from being sold in restaurants, movie theaters and food carts). School, home, public education and social marketing do not seem to work?
When I first embarked on this question years ago--could physicians address social determinants of health in the clinical context? YES! This was my conviction. I believe in the physician as public health professional and as the community-responsive physician. Some physicians choose to wear different hats in a day even--caring to patients in clinic, hospital, volunteering with community organizations, advocating for policy change and researching on public health issues BUT most physicians in the US just practice medicine--what WE are best trained for. SO could we care for patients, group of patients, community, vulnerable populations, treat acute problems, manage heart failure, diabetes, stroke, mental illness as well as address issues such as poverty (very grandiose I know), racism, income inequality, physical inactivity, illiteracy, access to healthy food, transportation, crime, etc.? Could we refine our clinical skills, improve systems-based practice, coordination of care, team work, collaborate with public health department/researchers, explore further the interaction among various health determinants, divert some (MUCH MORE) resources from heatlh care delivery into addressing social determinants. I became interested in pay for performance in population health promoted by Dr. Asch and others, a lofty concept but complex in implementation. People say Obamacare, ACO are the baby steps in that direction. This website is perhaps an attempt to answer this question...
Our nation just experienced a tragic event at Sandy Hook. Dr. Suzanne Koven in her blog asked "Did any doctor ask Nancy Lanza about guns?" Would it help? Did Ms. Lanza have a PCP? Did Mr. Lanza ever seek help or disclose to anyone any trouble? answers we may never know. What is the role of doctors when it comes to gun violence? (stick to the A1C, LDL, BP and other quality measures in the 15 min visits right?). What is the evidence on gun violence? (stay tuned...)
It's the debut of the SDHPitt blog. Time to share and reflect. Peace and Joy to the world!
These are some of my favorite quotes:
“Charity depends on the vicissitudes of whim and personal wealth; justice depends on commitment instead of circumstance. Faith-based charity provides crumbs from the table; faith-based justice offers a place at the table.”
-- Bill Moyers
“It is very expensive to give bad medical care to poor people in a rich country.”
― Paul Farmer
Equality of opportunity is absolutely necessary but not sufficient in building a genuinely fair and efficient society.”
― Ha-Joon Chang, 23 Things They Don't Tell You About Capitalism
“It is more difficult to fight poverty in a rich country than in a poor one.”
-- Mother Teresa
"I wish to do something Great and Wonderful, but I must start by doing the little things like they were Great and Wonderful"