Population Health Blog

Population Health Blog

Why It Matters

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

Reflecting on health equity and the ‘Great’ Society

By Dennis Archambault

At this precarious moment in health policy, when the call to make America “great” comes with the goal of dismantling the Patient Protection and Affordable Care Act (ACA), it’s good to reflect on the often cited quote by Dr. Martin Luther King, Jr.: “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.” Dr. King spoke those words in the context of a speech he gave to the Medical Committee for Human Rights in Chicago, 1966. At the time, the Great Society was rising, and there was great hope the civil rights would extend into the realm of access to quality health care for all, and ultimately, health for vulnerable populations.
“Great” in that society was meant to be inclusive. An affluent society could afford to properly care for its elderly, disabled, and low income populations through health and human services. Even those of a more conservative bent adopted a “compassionate” perspective that the needs of the poor should be addressed in some baseline way. That led to thinking about a two-tiered approach to care.

Today, Gov. Rick Snyder and others who realize the social and economic value of expanded Medicaid – for those who fall within 133 percent of the federal poverty level – are calling on president-elect Donald Trump and his administration to preserve this important component of the ACA, which has ensured that more than 600,000 Michigan residents have access to the same quality of health care as everyone else – a major step toward resolving the inequality and injustice that Dr. King spoke about in 1966. As the president and Congress review the ACA, Gov. Snyder says, “I hope they carefully look at the success we’ve had in Michigan, because we didn’t just do Medicaid expansion. We put requirements for health and wellness on the front ends, and personal responsibility.” While that latter requirement is controversial, most community health people would agree that incentives are helpful in getting people to adopt good health behaviors.

Health analysts are noting that expanded Medicaid is likely to go with several other provisions. It’s uncertain what would replace the ACA. There’s talk of block grants to states. There may be a yet-to-be disclosed plan that Congress will reveal. Proponents of universal coverage have felt that the ACA wasn’t the right solution. Opponents of a national health policy of any kind have opposed it. It’s hard not to conclude that it’s a return to the attitudes that prompted Dr. King to conclude that inequality and injustice in health care is the most shocking and inhuman of all forms of inequality. Dr. Brian Smedley, co-founder and executive director of the National Collaborative for Health Equity noted shortly after the 2016 presidential election, put it into perspective “The expressions of bigotry, racism, misogyny, and xenophobia in the aftermath of last week’s election must be stopped. But the ideology behind these attacks – even if never expressed – also poses a tremendous barrier to building a Culture of Health, which priorities equity and values all populations equally.”

It is a precarious moment for health policy. And as health policy has reflected society in so many ways, it’s a precarious moment for society. As the debate to preserve access to health care – and access to health – we would be wise to reflect on Dr. King’s quote. But also consider another often-quoted reference from the civil rights leader: “A genuine leader is not a searcher for consensus, but a molder of consensus.”

The debate that has waxed and waned in American society since Dr. King’s era has been revived, as has the meaning of what makes American society “great.”

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

Here’s the deal: We’re going to keep going

By Rachel Poulain

We are going to continue to be kind and inclusive. We’re going to keep making sure our children know they are loved and valued and that growing up in a safe, secure and nurturing society is their birthright. We’re going to show up, with the strength and courage to believe in the United States as a nation that lifts up freedom, equity and justice for all. We’re going to keep making sure our Muslim, Latino, Black and LGBTQ brothers, sisters and children know they are safe. We’re going to wake up each day and handle business.

Grieve because you must.
But please do not fall into the abyss of fear that has generated such a dark sociopolitical stage. Please.

What we have now is our courage and our faith in all who are traveling this rough road with us.

When the dark seems to subsume everything,
those of us who still can, must exaggerate Light.

Every minute of every day we have to chose between fear and love.
Choose love. Breathe love. Be love.

There are a lot of us in this together.

Find your way toward what feels valuable and good
and take your refuge and your stand there.

We’ve got this.

With love, light and faith in the greater good…

Rachel Poulain, director of Public Engagement, Unnatural Causes. Unnatural Causes is a documentary and public engagement campaign sponsored by California Newsreel. For information visit www.unnaturalcauses.org.



When wealth becomes understood as ‘health’

By Dennis Archambault

The financial management firm, Brown Brothers Harriman, published an advertisement recently with the headline, “Preserve wealth. The best way to grow it.” The ad features a child carrying in a tray of young greens into a room where her mother was sorting through fresh vegetables. The ad copy ran:  “We start every day with one mission in mind: To protect and grow our clients wealth so it lasts for generations…”

If you take the same visual and change one word, you have an idea that we all can attest to: “Preserve health. The best way to grow it.” The child is discovering fresh greens and her mother is harvesting fresh vegetables – a great image of healthy eating. Disease prevention, health promotion and wellness, improved environmental quality, access to nutritious food.

The test would read: “We start every day with one mission in mind: To protect and grow our clients health so it lasts for generations.”

All it takes is for society to equate health with wealth and we’ll be much further ahead.

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

Abundant vacant land in Detroit offers an opportunity to develop healthy environment

By Ashley Edwards

To exercise and connect with nature in a safe place is a luxury for some communities. Urban communities in cities like Detroit with vast vacant tracts of land, much of it unsafe and undeveloped, are especially deprived of this opportunity. On February 17, 2016, Detroit Future City published a report called Achieving an Integrated Open Space Network in Detroit.This report illustrates the importance of transforming Detroit vacant land into open spaces to improve the quality of life for Detroiters.

The Environmental Protection Agency (EPA)defines open space/green spaces as “any open piece of land that is undeveloped (has no buildings or other built structures) and is accessible to the public. Open space can include: Green space (land that is partly or completely covered with grass, trees, shrubs, or other vegetation). Green space includes parks, community gardens, and cemeteries, schoolyards, playgrounds, public seating areas, public plazas, vacant lots.”

Access to an integrated open space network offers numerous benefits from a population health perspective, including mental restoration, active recreation and active transportation.One study found that people living in areas with few outdoor recreation facilities were more likely to be overweight (Catlin, 2003). Moreover, the Detroit Future City report noted that the “age, income and minority status place some residents at a disproportionately greater risk of adverse health impacts caused by environmental hazards.

According to the Detroit Alliance for Asthma Awareness, “14.8 percent of the children in Detroit suffer from asthma, 69.1 percent of Detroiters are obese or overweight and on average deaths resulting from heart disease in Detroit are 50 percent higher than the national average (Detroit Future City Implementation Office, 2016).” Detroit is a clear example of the health outcomes that can result from the lack of access to open spaces. The health of populations ranging from children to adults are negatively impacted from the lack of access to open spaces.

Additionally, open space and health is a concern for many urban communities around the United States. Ironically, while some areas of Detroit need green space integrated in redevelopment strategies, many areas have a lot of vacant space – brown and green – that offer opportunities for creative reuse.

Los Angeles shares the challenge of redeveloping vacant land.In 2014, LA OpenAcres,a project of the Los Angeles Community Health Council, launched a database of open and accessible lands in the city. “The council proposed a vision of neighbors working together throughout Los Angeles to create hundreds of community forest networks, mini-parks, urban farms, green markets, plazas, playgrounds, and other public spaces by 2050. LA Open Acres is now serving as a catalyst and a way-finding tool to unlock the potential of acres of underutilized land.”

Developing open spaces is an equitable solution to address adverse health issues caused by environmental hazards and the lack of walkability.  “By incorporating trees and vegetation into vacant land transformation activities, pollution can be reduced by absorbing airborne pollutants as well as helping filter pollutants from soil and water (Detroit Future City Implementation Office, 2016).”Environmental and policy interventions that promote healthier lifestyles by encouraging physical activity through integrated open space networks are especially important to urban communities. Moving forward we need to create open spaces in community development; but with extensive vacant land in Detroit, we also need to apply thoughtful development strategies to promote population health.

Ashley Edwards is the 2016-17 W.K. Kellogg Population Health Fellow.

Access to water service in Detroit continues to be a population health issue


By Esperanza Cantu

Access to water service by vulnerable populations remains an issue for the Population Health Council. Recently, Professor john powell, director of the Haas Institute for a Fair and Inclusive Society, co-chair of the Population Health Council, advised its Community Engagement and Advocacy Advisory Committee, to work within the purview of the Council’s expertise and focus on the public health effects of lack of access to processed water. The committee issued a statement approved in June that advocated for public health-based exceptions to the water shutoffs. Building upon a memorandum from Raquel Castañeda-López, City Council Member of District 6, the statement advocates for a moratorium on water shutoffs for the following:

• Infants and children under the age of 18
• Seniors age 62 and above
• Persons with mental illness
• Persons with disabilities
• Expectant and/or breastfeeding mothers
• Persons dealing with chronic diseases or otherwise in need of critical and/or medical care

The Population Health Council continues to support the adoption of a water affordability plan, as opposed to the current assistance plan administered by the Great Lakes Water Authority. Philadelphia City Council passed water affordability legislation unanimously in November 2015, and Mayor Michael Nutter signed the ordinance on December 1, 2015. “The law marked the beginning of a fundamental shift in how the City of Philadelphia would assist low-income families in maintaining life-essential water service,” according to Community Legal Services of Philadelphia.According to the legislation, Philadelphia’s water affordability plan must be implemented by September 2017. Importantly, current available research suggests that water affordability plans result in higher utility revenues because customers are better equipped to pay bills that are based on household income.

Back in Detroit, however, community members opposed to the current water assistance plan released a report entitled “Mapping the Water Crisis, The Dismantling of African-American Neighborhoods in Detroit, Volume I.” The group, called “We the People of Detroit Community Research Collective,” presented research that shows a correlation between water shutoffs and home foreclosures. In 2006, the Detroit Water and Sewage Department decided that unpaid water bills could be included in property taxes. The majority of foreclosed homes with unpaid taxes in Wayne County have been in Detroit. It is estimated that between 12 and 27 percent of tax-foreclosed homes had water debt included in unpaid property taxes. Despite the poor data available to the community research collective, the picture that emerges reveals structural racism that unfortunately continues to disparage Detroit’s Black community.

Recently, mixed reports have emerged suggesting funding for Detroit’s water bill assistance program may not last through the month. The Detroit Water and Sewage Department and Great Lakes Water Authority released a statement that indicated the program is adequately funded and is not running out of money, despite recent reports indicating that it was in fact out of funds.

As officials continue to grapple with how to receive payments from water customers, the Population Health Council continues to advocate for a water affordability plan as a long-term solution, and a moratorium to the populations listed above as exceptions based on public health.

Esperanza Cantu is manager of Health Equity and Collaboration for Authority Health