Population Health Blog

Population Health Blog

Why It Matters

Research confirms that expanding Medicaid is good for the economic of low income people

By Dennis Archambault

The proponents of Healthy Michigan have not had much share of voice in the debate over work rules for the expanded Medicaid program. However, a recent University of Michigan Ross School of Business study has confirmed the economic benefit of the health insurance benefit for low income individuals and suggests that the proposed work rules would put thousands of unemployed enrollees at risk.

It’s interesting to read, in specific detail, what proponents of expanded Medicaid have felt for some time. On one hand, the target population is struggling and in debt. They also are likely to have a chronic disease, which requires regular medical care, if not urgent episodes of hospitalization. On the other hand, however, having their health insurance covered reduces the economic burden and makes it more likely that their health will be better managed.

Note some of the findings:

  • Reduced the amount of medical bills in collections that the average enrollee had by 57 percent, or about $515.
  • Reduced the amount of debt past due but not yet sent to a collection agency by 28 percent, or about $233.
  • Led to a 16 percent drop in public records for financial events such as evictions, bankruptcies and wage garnishments; bankruptcies alone fell by 10 percent.
  • Resulted in enrollees’ being 16 percent less likely to overdraw their credit cards.
  • Led to improvement in individual credit scores, including the number with a “deep subprime” rating falling by 18 percent and the number listed as “subprime” falling by 3 percent.
  • Allowed enrollees to engage in more borrowing to buy cars or other goods and services, which is consistent with better credit scores. Enrollees experienced a 21 percent increase in automotive loans. Other studies have found that Medicaid expansion reduced use of payday loans and reduced interest rates for low-income people.
  • Helped people with chronic illnesses and those who had a hospitalization or emergency department visit during the study period with bigger reductions in their bills sent to collection and bigger increases in their credit scores.

Miller and colleagues published an academic report on the research in the Journal of Public Economics. Check that out for more details: https://www.sciencedirect.com/science/article/abs/pii/S0047272718300707.

Dennis Archambault is vice president, Public Affairs, at Authority Health.

 

What does urban agriculture have to do with the Farm Bill?

By Kathy Beard

The growing movement towards urban farming has a champion in Senator Stabenow but her efforts may be jeopardized soon. In 2016 she introduced the Urban Agriculture Act of 2016 . The act provides assistance to urban farmers with the goal of providing fresh, healthy options to the underserved. This Act became part of the revisions by the Senate to the Agricultural Act of 2014, frequently referred to as the Farm Bill. Section 7212 of the revised Senate Farm Bill amends the 1990 version to include grants for research, education and training to enhance urban and indoor agricultural production and for evaluation of these methods. It provides $4 million dollars per year (2019-2023) and an additional $10 million each year to carry out the process. It also authorizes $14 million for a two-year census data-gathering project to collect information on urban agricultural production including community gardens and farms, rooftop farms, greenhouses and vertical farming . The House Bill does not address urban agriculture . Excluding urban farming puts the Senate’s bi-partisan proposal addressing this issue at risk for a number of reasons.

As in the general legislature, the conference committee is dominated by Republicans (18 to 14) putting any chance of a democratic initiative in jeopardy of being cut from the final proposal. Second, according to the USDA, the top 10 states for agriculture production, in order, are California, Iowa, Texas, Nebraska, Minnesota, Illinois, Kansas, North Carolina, Wisconsin, and Indiana . Of those states, Nebraska, Illinois, Wisconsin and Indiana are not represented however. Texas, whose primary products are ranching, dairy and crop commodity goods , has three members. California, the largest vegetable and fruit producer with over 200 different crops, has only one representative. Commodity cash crops, dairy and farm animals are the primary sources of income for the remaining states represented on the committee. In most urban areas, it is still against the law to raise farm animals. The focus then, of the committee will not be on urban agriculture but on those cash producing items that bring money to the state.

Further, House Republican Chairman, Mike Conaway is a strong proponent of improving the rural, not urban, environments. He was the driving force behind the recent review of SNAP benefits which ultimately led to the proposal to restrict SNAP benefits by “offering SNAP beneficiaries a springboard out of poverty to a good paying job, and opportunity for a better way of life for themselves and their families – code for tightening the work restrictions for Able Bodied Adults Without Dependents (ABAWD) . It is this portion of the bill that will be the most heavily debated.

There is a sense of urgency to speed the process of completing a bill by September 30 when the bill is set to expire. In cases like this, what many would consider a small matter may be sacrificed for expediency. Proponents of urban agriculture should be vigilant during this time and prepare to react to any threats to this portion of the bill. Click here to learn more about the committee hearings.

Recommended sites:
House Committee on Urban Agriculture
USDA Data on Cash Crops by State

Kathy Beard is program manager, MOTION Coalition, an initiative of Authority Health

Fix the (social) potholes!

By Dennis Archambault

Throughout the primary election the overstated campaign issue was “fix the potholes.”  It’s not too much of a stretch to suggest that this is a metaphor for fixing or strengthening the state’s physical infrastructure. What about the social infrastructure?

The Citizens Research Council has released a report  (https://crcmich.org/an-ounce-of-prevention-what-public-health-means-for-michigan/)  that documents the drop in spending on public health in Michigan, pushing the state to the bottom in per-capita public health expenditures. You’d think that the Flint disaster would have prompted greater debate about the need for a stronger public health system, and specifically “health in all policies,” which could have prevented, or certainly minimized the damaged caused by poor government oversight.

According to the CRC report, Michigan has seen a worst-in-the-nation outbreak of Hepatitis A, numerous outbreaks of vaccine-preventable diseases, an infant mortality rate well above the national average, and above average prevalence of chronic disease.

The report notes that the state has spent just enough to match federal public health funding, leaving local health department scrambling for funds to do little more than their required duties.

Why wouldn’t this be a campaign issue? Why is it that public health is seldom even mentioned in policy debates?

Eric Lupher, president of the CRC, concludes, “While the state has been engaged in a very successful Pure Michigan campaign to promote the state as a place to live, work, and play, its neglect of public health services creates negative press that often washes out the benefits of the promotional campaign. It detracts from the state’s investments in workforce development and job training. And it inflates healthcare costs that are high to begin with.”

Dennis Archambault is vice president, Public Affairs, at Authority Health.

The next generation of lower income seniors face a perilous future, which is bound to impact population health.

By Dennis Archambault

Advocates of low income housing are anticipating a “tsunami” as gentrification pushes existing low income tenants out of rental properties, more people losing their homes due to the collapse of their household income, and fiscally unprepared people retiring – some earlier than expected. The latter is a particularly acute problem as the Boomer generation retires with inadequate retirement savings. The homeless population in this segment is expected to climb, if not soar.

The New York Times did a good job reporting on the economic issue (https://www.nytimes.com/2018/08/05/business/bankruptcy-older-americans.html?nl=top-stories&nlid=67835882ries&ref=cta). This will be a critical concern for population health in the coming years.

Dennis Archambault is vice president for Public Affairs at Authority Health

 

 

The link between demolitions and childhood blood levels in Detroit

By Laura Wilson

In the last several years, Detroit’s demolition program has received media attention for its potential association with increased blood lead levels in Detroit children. The demolition program, which began in 2014, has resulted in over 14,300 demolitions. The percentage of elevated blood lead levels (EBLL) in children has steadily decreased in Detroit and statewide. However, 2015 marked the first increase in this percentage in Detroit in decades, from6.5 percent to 7.9 percent. In 2016, the percentage increased again to 8.8 percent.

The topic resurfaced recently with a public feud between Dr. Abdul El-Sayed, the former director of the Health Department now running for governor, and Mayor Mike Duggan revolving around whether the city appropriately heeded Dr. El-Sayed’s warnings about demolitions and childhood lead exposure a few years ago. There is little evidence to know what occurred between Dr. El-Sayed and Mayor Duggan, but the conflictraises important questions around the prioritization and complexity of public health efforts.

The hazards of urban blight are well-known. Unfortunately, the renovation and demolition of older buildings brings its own environmental health hazards, as dust is kicked up into the air from homes that may contain lead or other harmful chemicals. This can be problematic in cities like Detroit, where 93 percent of homes were built before the banning of lead paint in 1978. As a result, such an expensive large-scale demolition program becomes a challenging balance act of efficiently removing blight while also trying to ensure hazardous exposures are minimized through appropriate protocol, contractor compliance, and educational programs.

Since the beginning of the program, the city has taken steps to mitigate the hazards of demolitions. In 2016, though, the Detroit Health Department, led by Dr. El-Sayed, conducted a study to evaluate the association between demolitions and children blood lead levels. They found that the odds of blood lead level elevation in children increased by 20 percent if they lived within 400 feet of a single demolition and 38 percent if there were two or more demolitions. This relationship was specific to summer months when kids are out of school and spending more time in their homes and neighborhoods. The researchers concluded that demolitions may have contributed to about 2.4 percent of cases of EBLL in Detroit, which would account for the recent uptick in EBLL percentages.

In light of these findings, Dr. El-Sayed convened aDemolitions and Health Task Force. In early 2017, the taskforce met four times to develop recommendations for the city,prior to Dr. El-Sayed’s gubernatorial run. In the last year, the city has incorporated a few of the taskforce’s recommendations, including protocol improvements and a texting service program launched in November 2017 that residents can enroll in to be notified of nearby demolitions.

This year, the city is taking a more proactive, preventive approach to lead paint exposure. A new Interagency Lead Poisoning Prevention Task Force was announced in March that is focused on exposure resulting from lead paint in the homes of children. As part of its $1.25 million pilot program, the city is halting summer demolitions in the fivezip codes with the greatest percentage of EBLL (48202, 48204, 48206, 48213, and 48214) where they will conductdoor-to-door outreach and educational programs, specifically targeting the homes of children and pregnant women.

Despite this promising new program, large demolition projects include a lot of players and a lot of moving parts. Detroit, like other cities, has a complicated history with management of demolition and ensuring compliance among contractors. For this reason, it is important for both residents and population health researchers to be watchful of what is being prioritized and what is being compromised in even the most well-intentioned efforts.

Laura Wilson is a Masters of Public Health Candidate at the University of Michigan School of Public Health. She is serving a Health and Housing internship at Authority Health.

https://www.freep.com/story/news/local/michigan/detroit/2018/06/15/detroits-demolition-program-diversity-concerns/493305002/

Percentage of children under age 6 with elevated blood lead levels
Year Detroit Michigan
2011 10.2% 5.0%
2012 8.5% 4.5%
2013 8.0% 3.9%
2014 6.5% 3.5%
2015 7.9% 3.4%
2016 8.8% 3.6%
Data from Michigan DHHS Childhood Lead Poisoning Prevention Program Annual Reports

Elevated blood lead levels:  > 5 µg/dL as defined by the CDC.

 

Figure 1: Blood Lead Levels by ZIP Code

http://content-static.detroitnews.com/projects/lead-levels-detroit-2016/interactive-map.html

Figure 2: Demolitions by City Council Zone

https://data.detroitmi.gov/Government/Demolitions-Data-Lens/xhif-khyv

Figure 3: Demolitions by Location

https://data.detroitmi.gov/Government/Demolitions-Data-Lens/xhif-khyv

Michigan court case on the ‘right’ to literacy offers insight into the right to health care

By Dennis Archambault
People who believe health care is a right, might want to pay attention to a recent court case that concluded that education isn’t a right (https://www.freep.com/story/news/local/michigan/detroit/2018/06/29/judge-dismisses-lawsuit-against-snyder-over-detroit-kids-literacy/747732002/). There certainly is legal reasoning behind the pros and cons of this argument, but with the conservative bent of the judicial system these days, it’s safe to assume that the definition of “rights” guaranteed by the constitution is fairly narrow and not really open for debate.
What’s interesting in Judge Stephen Murphy’s response is that he acknowledged the deplorable condition of education for students in low income communities like Detroit. “The conditions and outcomes of plaintiffs’ schools, as alleged, are nothing short of devastating. When a child who could be taught to read goes untaught, the child suffers a lasting injury – and so does society.” But that’s not a matter for the courts. “In other words, access to literacy is not a fundamental right,” Judge Murphy wrote. It’s a matter for elected officials, judged in the court of public opinion and eventually in elections.

An affluent society that believes in social equity should provide a basic standard of living that guarantees opportunity for the vulnerable, but it is not bound to do so. Education, health care and disease prevention services, housing, food security, safety, mobility – these are social values that need to advocated for, and once won, defended as public opinion and elected leadership changes. These are social determinants of health and wellness, which judges like Stephen Murphy would say are important to society, but not guaranteed by the constitution.

The takeaway from this decision? The political process matters. As crazy as it seems at times, it is the process through which a democracy thrives, and how society advances, or not.

Dennis Archambault is vice president for Public Affairs, at Authority Health.

Well-financed advocacy groups resist upstream change, frustrating health equity efforts

By Dennis Archambault

Special interests have always financed advocacy efforts. But the recent article, “How the Koch Brothers Are Killing Public Transit Projects around the County” (https://www.nytimes.com/2018/06/19/climate/koch-brothers-public-transit.html) offers a perspective on how difficult it is to make “upstream” systemic change to influence the social determinants of health.

Publicity about workers spending hours on bus rides to work – or walking in all kinds of weather — have raised awareness as to how difficult it is to get to (and hold) a job in this region. But the sobering reality is that there are oppressive financial forces, such as Americans for Prosperity, that provide financing to oppose progressive, social programs like regional transportation. Americans for Prosperity is the advocacy group funded by the Koch brothers, known for financing countless Republican campaigns. Paid activists, using a sophisticated data service, identify voters inclined to be of a more conservative orientation, then appeal to their interests.

Recently, civic leadership in Nashville supported a $5.4 billion transit plan. Americans for Prosperity made 42,000 phone calls and knocked on 6,000 doors to engineer defeat of the measure. “This is why grassroots works,” said the Tennessee state director for the organization. Their mantra: Public transit goes against what some Americans define as “liberties.” If someone has the freedom to go where they want, do what they want, they’re not going to choose public transit. They’re probably not going to be inclined to support other measures that remove social determinants of health – because the fear of governmental encroachment.

Reportedly, Americans for Prosperity have set up shop in Southeast Michigan to combat this year’s regional transportation campaign.
It’s difficult enough to convince people to spend money for the common good, much less when well-financed opposition is at work. Someone is going to have to come forth to defend these initiatives, and it’s unlikely that the government will, unfortunately.

Dennis Archambault is vice president for Public Affairs at Authority Health.

Governor, Legisalature must face consequences of Medicaid ‘work’ law

By Dennis Archambault

Michigan Senate Bill 897, which at this point is awaiting Gov. Snyder’s signature, will require able-bodied adults to maintain at least a part-time job in order to qualify for Healthy Michigan, the expanded Medicaid program. It actualizes a long-held desire by many legislators to force recipients to “have skin in the game,” or “earn” their social benefit. This is despite the assertion by several people working with safety net populations that most recipients of social programs work – some more than one job. And those who don’t work aren’t likely to work for a variety of reasons, most of which we would characterize as “social determinants of health.”

Recently, the Detroit Free Press published an interesting statistic: 53.4 percent of able-bodied Detroit residents don’t work. (https://www.freep.com/story/money/business/john-gallagher/2018/06/08/workforce-participation-detroit/674401002/) That’s largely due to lack of transportation, education, and skills. A large percentage of the population has re-entered society from a prison term. The Free Press didn’t provide a number that 53.4 percent represents, but in a city of 700,000 people, that represents a lot of people – a lot of people who will allow their health condition to worsen until they need emergency care. That, of course, means a lot of discomfort for people and a cost burden that some emergency health providers may not be able or willing to endure.

It’s unlikely that the unemployed will find work to maintain their health benefit. In a robust employment market like we have today, this population would be working.

The Michigan League for Public Policy has argued that “Having healthcare has helped people get and keep jobs, not the opposite… Aside from the complex bureaucratic red tape Medicaid enrollees will have to face and the increased administrative burden on our state caseworkers, this bill does absolutely nothing to address the barriers an individual faces in getting or keeping a job. In fact, it simply directs people to existing resources—resources in many ways that are significantly lacking. We have seen a recent uptick in conversations regarding transit, for example, with stories about trips in and around the Detroit Metro area taking two plus hours. And those stories don’t even account for bus delays, busses not showing up, or riders needing to get off a route to drop their kids at day care. Of course, many of the enrollees live in areas where transit just doesn’t exist.”

The legislators who remain in office long enough to monitor the effects of this legislation will eventually will face the unintended consequences of their action: increased demand on hospital emergency services for primary care and complications of diseases best managed in a medical home.

Dennis Archambault is vice president for Public Affairs at Authority Health.

 

‘Avoiding’ hospital emergency facilities will be a difficult lesson for many to learn

By Dennis Archambault
When the Patient Protection and Affordable Care Act became law, its detractors presented a litany of reasons it would fail. Among them: “You’ll never educate the expanded Medicaid population to stop using emergency services for primary care, chronic disease management, and minor injuries.” It was difficult to argue the point – in the short term. This area of behavior modification, coupled with health literacy, would require several years and a lot of support.

Until recently, hospitals had little incentive to prevent or redirect “avoidable” emergency visits. They were reimbursable and the volume was good for medical residency training programs. Emergency physicians and hospital administrators have long known that a large portion of emergency visits could and should be treated elsewhere. Despite assurances of being seen by a physician in many emergency departments, reasonably educated, insured people have increasingly selected urgent care as an alternative to the emergency visit and their busy primary care provider. But many people still think “E.R.” when they become sick or injured after hours.

Health insurers are being to scrutinize the “avoidable” treatment. As noted in a recent New York Times article (https://www.nytimes.com/2018/05/19/upshot/anthem-insurer-resists-paying-emergency-room-visits-if-avoidable.html) at least one has floated a trial balloon to get people talking about what is bound to occur in time. Some health systems, like the Detroit Medical Center, have tested the efficiency of primary care practices adjacent to emergency departments, for referral and ongoing care of patients with “avoidable” conditions. There is also a public health track within the Emergency Medicine Department of the Wayne State University School of Medicine to address chronically ill people whose care could be better managed in ambulatory setting.

The best way to avoid an emergency visit is to prevent injuries, manage chronic disease, and use an urgent care center if the primary care provider isn’t available. But when you’ve been using emergency services for much of your life, you’re not likely to change your behavior quickly – especially without support and incentives.

Dennis Archambault is vice president, Public Affairs, at Authority Health.

Fewer new low income housing units: an unintended consequence of the tax law?

By Dennis Archambault
Few are likely to complain about a tax cut, even if it so obviously favors wealthy populations over the rest of society. But aside from increasing the wealth disparity in the country, there are consequences of the new tax law, unintended as they may be: low income housing.

It’s bad enough that many cities like Detroit with large numbers of low income and homes people are living in cars or under cardboard shelters – waiting for their names to rise on the waiting list for vacancies in public housing. Now, prospects for new low income housing have dimmed due to the loss of incentive for affordable housing developers to cover the fiscal gap in these projects, usually compensated for through low income tax credits. According to an article in the New York Times (https://www.nytimes.com/2018/05/12/upshot/these-95-apartments-promised-affordable-rent-in-san-francisco-then-6580-people-applied.html) thousands of low income housing projects will not be built due to the loss of tax credit options,  leaving many to wait on a list until an opening arises.

Municipalities have responded by creating funding pools to replace the loss of federal commitment to financing housing. For example, the City of Detroit earlier this year announced plans to raise $250 million to help underwrite the construction of 2,000 new low income housing units. (https://www.freep.com/story/news/local/michigan/detroit/2018/03/12/detroit-affordable-housing-fund/415749002/). Low income housing developers, housing advocates, and others are challenged to create new social enterprise models to get people off the street and into a stable habit. The new tax law isn’t helping.

Dennis Archambault is vice president for Public Affairs at Authority Health.