Population Health Blog

Population Health Blog

Why It Matters

A definition for health equity: new, improved, and universal…

By Dennis Archambault

This May, after months of research, reflection and consultation among the nation’s leaders in health disparities and health equity research and policy, under the auspices of the Robert Wood Johnson Foundation, a unified definition of health equity was arrived at:

“Health Equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

Paula Braveman, a physician and public health practitioner, the director of the Center on Social Disparities in Health, was one of the framers of this definition. She writes in a recent Health Affairs journal blog post, “The growing interest in health equity – and in getting clearer about a definition – signals readiness for a paradigm shift in the focus of health equity research and action in this country… and a willingness to say: This is about core values – namely, fairness and justice.”

Dr. Braveman adds that while this is a time when health policy experts are willing to have tough conversations about the policies and programs that have led to inequitable gaps in health, “Unfortunately, the current national political context is more hostile to health equity – and to justice in general – than any other during my lifetime. And that makes it all the more crucial for us to be crystal clear and strategic in our words as well as our deeds.”

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

Returning to our point of origin?

 

“History repeats itself; first as a tragedy, second as a farce.”
– Karl Marx

By Dennis Archambault

Authority Health was established in 2004 as the Detroit Wayne County Health Authority due to a crisis involving Detroit hospitals inundated with uninsured patients, primarily through their emergency facilities. The Detroit Medical Center said that Detroit Receiving Hospital and Hutzel Hospital could not continue to sustain the debt of uncompensated care. The Michigan governor, Wayne County executive, and City of Detroit mayor, acting on the recommendation of a local commission, established this organization to strengthen the health care safety net and minimize the pressure on hospital emergency services. Early on, we operated with the slogan, “It’s about access for all.”

The Affordable Care Act did much to relief the access problem by offering a method of insuring most Americans, and in states like Michigan, enabling low income residents an opportunity to qualify for expanded Medicaid benefits. That was then – well, not quite. Depending on how Congress acts regarding its efforts to repeal and replace the law, the ACA may be with us a few months longer – and perhaps longer, with revisions. But what seems certain is the elimination of the Medicaid program – not only expanded Medicaid, but a significant portion of traditional Medicaid.
The specifics have been widely documented in the popular press. What population health advocates are facing is a massive regression in policy to a time when the poor sought health care in hospital emergency departments as a clinic of last resort. Many individuals and organized groups have protested this. Public approval for the Senate legislation is much lower than any reasonable politician would want to risk. Yet, the Senate soldiers on – or at least its leadership. And the president, trying to make a deal, has suggested that the ACA should be discontinued immediately and let the replacement process follow due course. Or not.

Expanded Medicaid has provided access to health care services for over 600,000 people in Michigan. Traditional Medicaid provides important maternal health, care for the disabled, and for the low income elderly. Ron Lieber, a business columnist in The New York Times, offers a cautionary tale regarding the latter category https://www.nytimes.com/2017/06/30/your-money/plan-on-growing-old-then-the-medicaid-debate-affects-you.html?_r=0. Typical business readers would not consider themselves at risk for becoming an impoverished elder. But as Lieber writes, one in three people who turn 65 will find themselves in a nursing home at some point. Citing the Kaiser Family Foundation, 62 percent cannot pay the bill on their own.

The Hill, a policy-oriented news publication in Washington, D.C., has reported that the proposed Senate health care legislation is likely to have deeper cuts in Medicaid than the House bill, which does not bode well http://thehill.com/policy/healthcare/338411-senate-gop-considers-deeper-medicaid-than-house-bill.

Medicaid is meant to be a safety net program. It’s clear that a lot of people are at risk at losing access to essential health services – taking us right back to where we started in 2004.

Dennis Archambault is vice president of Public Affairs for Authority Health

Why would anyone want children to eat ‘crap’?

By Dennis Archambault
Michelle Obama has responded to the Agriculture Department’s position which effectively reverses much of the work that the former first lady did to create progressive school nutrition policy during the Obama administration years. And she didn’t coat her language: “Think about why someone is OK with your kids eating crap.”

Agriculture Secretary Sonny Perdue announced this month that school meals would no longer have to meet some requirements connected with Obama’s initiative to combat childhood obesity by reconstituting the nation’s school meal menus. The nutrition regulations were part of the “Healthy, Hunger-Free Kids Act of 2010 and advocated through the “Let’s Move” campaign, created by Michelle Obama as first lady.
Perdue argues that the regulations add costs to school budgets and waste – students aren’t eating the food. “If kids aren’t eating the food, and it’s ending up in the trash, they aren’t getting any nutrition – thus undermining the intent of the program.

“You have to stop and think, why don’t you want our kids to have good food at school?” Obama said recently at a public health summit. “What is wrong with you? And why is that a partisan issue? Why would that be political? What is going on? … Take me out of the equation – like me or don’t like me. But think about why someone is OK with your kids eating crap. Why would you celebrate that? Why would you sit idly and be okay with that? Because here’s the secret: If someone is doing that, they don’t care about your kid.”

A lot of people have worked very hard, against multiple odds, to change policy and change behavior in our troubled educational environment. The MOTION Coalition, which organizes around the issue of childhood obesity, advocates policy that reinforces good nutrition and eating behavior, not the other way around. To have this reversed in a single action hurts – not just the egos of advocates, but the youth of America who have become less fit and more prone to diet-related disease than ever.

Obama, who represents a model for healthy parenting for many women in American, responded to Perdue’s assertion: “How about we stop asking kids how they feel about their food because kids, my kids included, if they could eat pizza and French fries every day with ice cream on top and a soda they would think they were happy, until they get sick. … You know what? Kids don’t like math either. What are we going to do? Stop teaching math?

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

Public Health Commission report may be ‘transformational’

By Dennis Archambault
One of the promising developments to come out of the Flint water crisis has been the Public Health Advisory Commission. As commissions go, it initially appeared to be an action that was as promising as a constructive dialogue could be – short of substantive and systemic change. That doesn’t seem to be the case, at least as far as the report goes.To begin with, the commission was well-represented with health providers, educators, non-profit executives, academicians, and several other stakeholders of the public health system. Eden Wells, M.D., MPH chief medical executive of the Michigan Department of Health and Human Services, served as chair. His comments introducing the commission’s report reflect the potential of its recommendations: “hope that the recommendations will energize a statewide effort towards a more comprehensive, cohesive, accountable and effective public health system.” He also acknowledged that the state “is committed to public health excellence, recognizing the need for change in order to truly achieve a transformational public health system.”

One should key into the word “transformational.” One might also add a word: “disruptive.”

The three top priorities for consideration are significant:
1. Create a permanent Public Health Advisory Council. This would ensure that a vehicle exists to address emerging state and local health issues;
2. Ensure all state departments employ a “health in all policies” approach when implementing policies and programs, “elevating public health”;
3. Recognize disparities in public health funding and unmet needs throughout the state.

These are only three of 39 recommendations. If the governor addresses just these three the state will be much better off. We have been advocating for a health in all policies approach to government decisions, along with others throughout Michigan. Now is the time to advocate for this method of ensuring that actions taken by government are indeed in the interest of the citzenry – certainly in the health interests of the citizenry.

Check out this report for yourself: http://www.michigan.gov/documents/snyder/PHAC_Final_Report_556718_7.pdf

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

State public health advocates offer governor opportunity to strenghten public health integrity in Michigan

By Dennis Archambault
As Gov. Snyder considers the final report of the Michigan Public Health Advisory Commission (http://www.michigan.gov/documents/snyder/PHAC_Final_Report_556718_7.pdf) it’s an opportunity for all population health advocates to consider this moment as a potential breakthrough in struggle to improve public health in Michigan. The report submitted to Gov. Snyder includes three basic recommendations:

1. Continuing and Expanding Collaboration:
Collaboration is often talked about but seldom achieved in a world of intense competition for scarce financial resources. The advisory commission’s report recommends that collaboration be enforced to engineer a broader engagement around efficient use of public and private funds. The recommendation to establish forums for regional collaboration makes sense.

2. Collaboration between State Departments:
The essence of this recommendation is establishing a “Health in All Policies” requirement for state departments in implementing policies. It’s a process used in California and one advocated at the county level throughout Michigan. It is a means of ensuring that the health risk to our communities is properly assessed prior to state policy action. The ethical principle that underscores this recommendation is environmental justice. Too often, vulnerable populations fall victim to injustice due to a lack of voice or influence in public policy decisions.

3. Investing in Michigan’s Public Health:
Anyone working in public health, or related community health initiatives, knows that national public health expenditures has decreased steadily in the past decade. This has had a direct impact on our emergency response capability, as well as our ability to address the health impacts of poverty, racism, food insecurity, and adverse childhood experiences, as the advisory commission report confirms. In an era in which government is intent on reducing taxes and overlooking the human service infrastructure (in lieu of the physical infrastructure and military), advocates need to convince elected officials that this is not an issue limited to vulnerable communities and populations – even though pockets of vulnerability are showing up in seemingly affluent communities. Just as roads deteriorate if they aren’t maintained, so does the social infrastructure.
The governor asked representatives from the public health sector for their advice. They have provided a very thoughtful and comprehensive report. Now it’s up to the governor and legislature to determine if they really want ensure good public health in Michigan.

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

Mental health coverage may be lost in new health law

By Dennis Archambault

As legislators sift through the details of the revision of the Affordable Care Act currently proposed by Republican members of Congress, expanded Medicaid is a critical concern for advocates of the health care safety net. Reductions in the expanded Medicaid program over the next decade will not only limit access to health care for millions of low income people, they would eliminate the requirement to provide essential health services
Beginning in 2020, the plan would eliminate an ACA requirement that Medicaid cover basic mental-health and addiction services in states that expanded it, allowing them to decide whether to include those benefits in Medicaid plans.

Thirty-one states, including the District of Columbia, have expanded Medicaid programs, including Michigan. Authority Health has supported Gov. Snyder’s effort to preserve expanded Medicaid. It’s unclear how the governor views the proposed elimination of essential health services.
The Affordable Care Act specifies 10 “essential” health services that expanded Medicaid plans must cover. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services, among others. Republicans say that the new reimbursement mode will allow states to determine what they want to offer their beneficiaries. However, experience suggests that mental health care probably won’t factor into the priority-setting.

People who work with low income populations are acutely aware of the toll that chronic stress plays. Often multiple social determinants are constant pressure points: meeting the mortgage payment, or the car payment, or utilities; the stress of getting to a job site or getting children to a good, safe school; and the stress of living without hope.
Mental health conditions contribute to physical health maladies, or may be “phantom” undiagnosed contributing causes of pain and physical symptoms. It’s bad enough that community mental health agencies are understaffed and underpaid for their services to this population, much less removing the capacity to serve.

Society is steadily drifting away from a universal consciousness around health to defining a two-tiered system. There is legislative and community outcry; but that seems to have had little impact on the direction of the new law.

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

Creating resilient communities

By Dennis Archambault

At a time when society is undergoing a difficult transition, one in which the future of the Afforable Care Act — specifically expanded Medicaid, as well as the support of community health centers and graduate medical education teaching health centers is in doubt, it is helpful to consider the value of resilience.

Richard Heinburg, in his essay, “A Hard-Nosed Optimism,” refers to the “optimism of the will” in discussing the notion of community resilience.

Referring to the 20th century writer, Antonio Gramsci’s concept, “pessimism of the spirit; optimism of the will,” during challenging times, people need to be aware of the realty retain sufficient optimism to endure.

“Persistence of the best of what we humans are and have achieved will require us to build resilient, enduring communities—ones with high internal levels of mutual trust, and that are capable of adapting quickly to changing conditions and responding effectively to a range of threats. Such communities arise and sustain themselves only by nurturing and prizing certain qualities of character on the part of their members.
“The people who are most likely to be of use in such communities are those who exhibit old-fashioned virtues, including honesty, bravery, self-control, cheerfulness, humility, and generosity. The ability to amuse and entertain oneself and others will be a welcome bonus; likewise the ability to speak convincingly, and the willingness both to endure discomfort and to find satisfaction in small things. I think qualities like these may start to get at what Gramsci meant by ‘optimism of the will.’”

The Community Health Resilience Initiative http://oha.inl.gov:7777/pls/apex/f?p=101:HOME states, “Regardless of the event, a community’s ability to successfully return to a “new normal” is based on its resilience, or its capacity to withstand, respond positively to, adapt, and recover expeditiously from a crisis or adversity.” There is no signal definition accepted for community resilience. Variations include:

• “The ability to prepare for and adapt to changing conditions and withstand and recover rapidly from disruptions, including deliberate attacks, accidents, or natural occurring threats and incidents.”

• “The ongoing and developing capacity of the community to account for its vulnerabilities and develop capabilities that aid that community in (1) preventing, withstanding, and mitigating the stress of a health incident; (2) recovering in a way that restores the community to a state of self-sufficiency and at least the same level of health and social functioning after a health incident; and (3) using knowledge from a past response to strengthen the community’s ability to withstand the next health incident.”

• “Community resilience is the ability of a community to use its assets to strengthen public health and healthcare systems and to improve the community’s physical, behavioral, and social health to withstand, adapt to, and recover from adversity.”

Regardless of the definition used, the concept deserves consideration in population health, especially within impoverished communities.

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

‘Corner stores’: Oases in the food desert?

By Dennis Archambault
At a recent meeting of the Detroit Food Policy Council’s Grocery Store Engagement Committee, it occurred that many of the small markets that comprise the network of 1,200 – not known for offering fresh, nutritious food – may be areas of opportunity. The committee is undergoing a strategic planning process which will likely include some form of persuading them to augment their product line to better serve the health needs of our community. Organizations in other cities, such as the Philadelphia Food Trust (http://thefoodtrust.org/), are working on similar strategies.

In Detroit, Authority Health is in the second year of a State of Michigan grant to promote fresh fruits and vegetables in Southwest Detroit markets – “Mi Plato, Mi Vida”. An announcement of a new initiative is coming later this spring. It makes sense to take an assets view of the challenge rather than a deficit view. If the buildings are there, and people are using them to buy their food, it makes sense to try to persuade the owners that improving their store environment and product offerings will lead to sales and everyone wins.

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

Primary care physicians and providers play an essential role in health equity

By Dennis Archambault
The recent report by the National Academies of Sciences, Engineering, and Medicine, “Communities in Action: Pathways to Health Equity,” offers promise in efforts to promote health equity. Authority Health has long held that one of those pathways is through the primary care relationship between physician or provider and patient. Medical residents in our teaching health center program are oriented to population health through a University of Michigan certification program, with the expectation that they will incorporate this knowledge into their primary care practice.
The Canadian Medical Association has been a progressive voice in this area. Four years ago, it adopted a policy statement that has direct implications for practitioners: “Health equity is created when individuals have the opportunity to achieve their full health potential. Health equity is undermined when social and economic conditions, the social determinants of health, prevent or constrain people from taking actions or making decisions that would promote health. While the majority of these determinants fall outside of the traditional health sector, the implications for health services in Canada are enormous. Most major diseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic groups having the greatest burden of illness.”
In a 2008 report, the World Health Organization has challenged all providers: “Those in the health sector bear witness to, and must deal with, the effect ts of the social determinants of health on people… The health care system and those working within it have an important and often under-utilized role in reducing health inequalities through action on the social determinants of health.
Finally, recently Cecil Wilson, M.D., president of the World Medical Association, said in a blog post, “The primary responsibility for addressing the social determinants of health is that of government and society. But physicians, by virtue of their role in the health care system – taking care of patients and possessing an intimate understanding of health care – must play a role in addressing this problem.”
We hope that social determinants become included in standard health histories, and ongoing counseling with routine wellness visits. That, coupled with navigation assistance can help physicians direct their patients to resources that will mitigate the social barriers to achieving optimum health.

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

EPA advises MDEQ to improve public participation in permit process

By Dennis Archambault

If you attend public hearings on industrial permit requests, you’d think that minority communities are actively engaged in the process. However, Michigan Department of Environmental Quality (MDEQ) administrators staffing these hearings remind the audience that only comments of scientific merit will be considered as appropriate testimony. That rules out nearly all of those who attend such hearings, except for a few academic and scientific professionals.

The Environmental Protection Agency (EPA) issued an opinion in January that challenged the degree to which MDEQ engages its minority population (Detroit News, Jan. 23, 2007). The EPA’s letter to MDEQ referenced a 1992 complaint by African Americans residents in the vicinity of a new Genesee power plant who felt they would be exposed to toxic chemicals. Specifically, the EPA told MDEQ to “ensure its public involvement process is available to all persons regardless of race, color, national origin…”

That sounds a lot like distinguishing between universal access to health insurance and universal access to health care. Undoubtedly, MDEQ can defend its performance, and does: “MDEQ public participation processes, over the past 20 years, have been expanded to address the concerns raised in the (EPA) letter.” EPA may be following formal communication channels to inform minority citizens, but it’s probably not using creative engagement strategies necessary to elicit proactive comments, and providing credible assurances as to their concerns.

It’s a typical challenge for institutional communicators attempting to reach minority audiences. In the case of environmental health, informing the community of a public hearing isn’t enough. There needs to be engagement to deal with fears and substantive concerns that may not have scientific merit but can be responded to appropriately. In its response, MDEQ says that “there has been no harm to public health from this facility.”

The positive outcome of this opinion has caused the MDEQ to review its minority engagement. “Although the historic complaint is closed, the EPA includes some recommendations to bolster our public participation processes,” according to a MDEQ spokesperson.

Dennis Archambault is vice president of Public Affairs for Authority Health