Population Health Blog

Population Health Blog

Why It Matters

‘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.

Kaiser Releases More Extensive Backgrounder on Social Determinants

By Dennis Archambault
Providers and community health organizations have increasingly come to understand social determinants of health, and how they become “determinants.” In a less fatalistic way, we might call them “influences” that individuals and collectives can alter, thereby giving folks a fighting chance.

In any case, it’s important to understand these social factors and monitor the many policy changes that are impacting them and the ability of individuals to overcome then. The Kaiser Family Foundation just came out with a new, more detailed backgrounder on social determinants, which is worth studying. What’s most interesting was a sidebar on states that integrated social determinants into Medicaid managed care contracts. In a way, it seems amazing that more aren’t, given the how removing social determinants can have a positive effect on health, and thereby save money for the managed care provider.

No matter, check out the latest KFF report on social determinants: https://www.google.com/search?q=Beyond+Health+Care%3B+The+Role+of+Social+Determinants+in+Promoting+Health+and+Health+Equity&rlz=1C1JPGB_enUS596US596&oq=Beyond+Health+Care%3B+The+Role+of+Social+Determinants+in+Promoting+Health+and+Health+Equity&aqs=chrome..69i57j0.28459j0j4&sourceid=chrome&ie=UTF-8

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

Why threaten unemployed people with loss of Medicaid health coverage?

By Dennis Archambault

The reasoning behind the current Michigan Senate legislation instituting work rules on Healthy Michigan doesn’t seem to make sense (https://detne.ws/2rr1mIP). People may be unmotivated to sign up for (and renew) health insurance for a variety of reasons. The threat of losing it or not qualifying for it because of their employment status is unlikely to motivate many of them to try harder.

Most people who receive Healthy Michigan and are able to work have some form of employment. Some even work two jobs and still need the program. Those who don’t work may have psychological challenges, or may simply not want to work. Taking away their coverage won’t change that. In fact, it’s likely to further hinder their productivity given that their health will deteriorate. And, the cost of their use of emergency facilities for otherwise manageable primary care or management of chronic disease will inevitably cost society more. Has there been a cost equation done to estimate how much it will cost if Healthy Michigan is taken from those who aren’t working?

Also, you’d think that the proponents would try to soften the blow by confirming that this unemployed population needs work-readiness help. Where’s the offer to provide job training and placement services? Maybe it’s there but under publicized.

Proponent s of universal health care argue that citizens of this affluent country deserve a certain standard of living – which is largely determined by their health. Whether they work or not is a different question.

The Senate certainly is serious about this. To hold the pay of public officials as ransom for instituting this program is quite a threat.

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

WATER Act of 2018: Is this a solution whose time has come?

By Khawla Rahman

Watching Flint crisis news spew out through media nearly every other day has naturally brought heightened caution to the average homeowner, whether or not they live in Flint itself. Representatives Keith Ellison of Minnesota and Ro Khanna of the San Francisco Bay Area have introduced the Water Affordability, Transparency, Equity and Reliability (WATER) Act of 2018. The WATER Act calls for the creation of a trust fund that would provide $35 billion a year to community drinking and wastewater needs. It will also create approximately 1 million new jobs across the entire economy. The plan would push back a certain amount of the Trump Administration’s corporate tax cuts, while simultaneously increasing corporate income tax by 3.5 percentage points. The Act would do the following:

  • Fully fund the Drinking Water and Clean Water State Revolving Funds
  • Provide additional technical assistance to rural and small municipalities and Native American governments
  • Increase funding to construct, repair, and service household drinking water wells
  • Create a new grant program for the repair, replacement, or upgrading of household septic tanks and drainage fields
  • Increase funding to Native American governments for water infrastructure
  • Require EPA to coordinate a study about water affordability, discrimination by water and sewer providers, public participation in water regionalization efforts, and water shutoffs
  • Restrict drinking Water SRF funding to publicly or locally owned systems
  • Provide funding for public schools to test and replace drinking water infrastructure
  • Provide grants to replace lead service lines serving households

In addition to all of the above, the EPA will conduct a nationwide survey on water affordability. The study will examine rates for water and sewer services: increases over the 10-year period preceding the study and effectiveness of funding. The study, in collaboration with the Civil Rights Division of the Department of Justice, will also explore discriminatory practices of water service providers. Plans that factor in many variables to increase effectiveness and reliability of water are important. This one is worth considering.

 

Khawla Rahman is a Communications student at Wayne State University. She is completing a public relations internship at Authority Health.

Is risk aversion safe for child development?

By Khawla Rahman
Growing up when a fellow child got hurt by an object, one of two things tended to happen often. Either the parent would tell them to get back at whatever it was that hurt their little one, or they would advise him or her that he or she is strong and much tougher than the pain. The parent would then go on to purchase multiple corner guards or place extra carpet over any inch of hard wood in sight.

This begs the question, do we as a society shelter our children too much? Meghan Talarowski, an American landscape designer who has compared British and American playgrounds https://www.nytimes.com/2018/03/10/world/europe/britain-playgrounds-risk.html thinks so. She says that the appearance of a marketplace for high safety play equipment has lead to a gradual sterilization of child play. Characteristics like rubber floors on drop zones or “boulders” made of fiberglass create a “play jail.”

Her observations support this stance as well. They show that British playgrounds, which are known to intentionally place controlled risks like spiky bushes or big trees for climbing, had 55 percent more visitors overall and teenagers were 16 to 18 percent more active. Features like grass, sand, and high swings were what held the most attention. This is in stark contrast to American playgrounds where these ingredients are used minimally.
Britain isn’t the only country who believes in bringing in more risks to build resilience in children. Germany and Switzerland have more than 1,000 forest kindergartens where students, as the name may suggest, learn in the forest using sticks, sharp knives, and fire.

Nature engrossed learning is not nonexistent here but is definitely confined to the borders of extracurricular activities or summer camps. As Talarowski’s article suggests, does sense stimulation need to be incorporated more into the American lifestyle? Is it possible that we could be preventing children from being resilient by cocooning them?

The numbers give a firm “yes”.

Khawla Rahman is a Communication Studies student at Wayne State University. She is completing a public relations internship at Authority Health this spring.

Counseling, a critical component of housing security, is at risk in Detroit

By Dennis Archambault
Coming off a population health forum dealing with the broad impact of toxic stress among people existing in the health and social safety net, it’s not very comforting to realize that a major ally in the housing area is at risk of a significant funding hit. In August, United Community Housing Coalition will lose two HUD grants totally $1.1 million – about 90 percent of its housing placement funds. Housing placement (which includes tenant organizing in the senior high rise buildings in Midtown and Downtown) is a very important service that helps people navigate the process of saving a house from tax or mortgage foreclosure, or even finding a place to live. Ted Phillips, executive director of UCHC, says HUD doesn’t think counseling has merit. We’ve seen how counseling directly applies to moving people who are evicted from a gentrified building, or helping building managers do the right thing.

Housing is a critical social determinant – so much so that Housing First advocates believe that it’s at the top of the social determinant scale. (Although it’s hard to say that food security, transportation, public safety, built environment, and other determinants are that far down the list.) As the movie, “Ghostbusters” popularized, “Who you gonna call?” UCHC and other agencies are in business to take the call and help people made vulnerable by social circumstance meet their basic needs, and ultimately, live healthier lives.
Check out this Detroit Free Press article for details on the UCHC situation: https://www.freep.com/story/news/local/michigan/detroit/2018/04/09/united-community-housing-coalition-hud-funding/482323002/

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

Gun violence as a public health issue lacks scientific evidence, but needs to be addressed now

By Victor J. Dzau, M.D.

Gun violence in America is a public health crisis, and one that scientists have not been able to effectively study for too long. Our nation has been reluctant to address gun violence with lasting evidence-based policies, but it has never been more critical to address this epidemic head-on. Scientific research will not be able to support every policy that needs to change, but we as researchers can lead the way toward enacting common-sense gun control measures.

The National Research Council and the Institute of Medicine, in 2013, authored a report titled Priorities for Research to Reduce the Threat of Firearm-Related Violence that outlined a research agenda focused on illuminating the causes of, possible interventions, and strategies to minimize the burden of firearm-related violence. This research agenda includes areas that warrant further research and highlights current gaps in our understanding that are critical to making informed decisions in the future.

The increasing prevalence of gun violence is a complex and daunting crisis, but it is one that we can see abate in our lifetime. I authored three editorials recently on this topic — two with NAM member Dr. Alan Leshner, CEO emeritus of the American Association for the Advancement of Science and Committee Chair of Priorities for Research to Reduce the Threat of Firearm-Related Violence (Science and Annals of Internal Medicine), and one with NAM Member Dr. Mark Rosenberg, founding director of the National Center for Injury Prevention and Control at the CDC (The Washington Post). All three editorials highlighted the critical need for research to investigate the causes of gun violence, as well as allocated funding to support that research. Evidence-based policies will lead to safer schools, safer communities, and less unnecessary deaths, and do not have to infringe on the rights of law-abiding citizens. These policies are long overdue.

Victor J. Dzau, M.D., is president of the National Academy of Medicine. This commentary was originally published in the March 2018 edition of the National Academy of Medicine newsletter

Is loneliness among the elderly a population health problem for our time?

By Dennis Archambault

It’s not customary to read philosophy. Or, at least, few people I know tell me about the latest philosophy book or article they read.  Philosophers are thinkers and often have some pretty interesting things to say.

Kwame Anthony Appiah, a  philosopher in Ghana, wrote about a cautionary tale, “What will future generations condemn us for?”  Climate change is perhaps the best example of how various groups speak of our responsibility to the future and how we may be judged for our environmental stewardship. Appliah examines that, our prison system, and “the institutionalized and isolated elderly.”

The philosopher raises the ethical dilemma: “When we see old people who , despite many living relatives, suffer growing isolation, we know something is wrong. We scarcely try to defend the situation; when we can, we put it out of our minds. Self-interest, if nothing else, should make us hope that our descendants have worked out a better way.

Former Surgeon General Vivek H. Murthy, M.D., wrote about the epidemic of loneliness in the Harvard Business Review recently: “During my years caring for patients, the most common pathology I saw was not heart disease or diabetes; it was loneliness.”

Drs. Sachin H. Hain and Craig Sammitt, in their article, “The growing imperative to address senior loneliness,” https://catalyst.nejm.org/growing-imperative-address-senior-loneliness/add, “The problem of loneliness and social isolation is increasingly well-recognized as a societal ill, but maddeningly difficult to address. What can we do to address a problem that has roots that are not just economic, but cultural in nature, and that has downstream implications that include an undeniable effect on health?”

Here we have a population health issue as articulated from various perspectives. We are observing it close up in the population of elderly residents in HUD-contracted senior apartments in Midtown and Downtown. What is the level of their food security? How are they accessing health and social services? How is loneliness affecting their health and well-being?

As we strive preserve low income senior housing, we need to take the next step to preserving health and well-being and addressing the “imperative” of senior loneliness.

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

What about a new Model T as a solution to Detroit’s inability to achieve consensus on mass transit?

By Dennis Archambault

It’s difficult coming from the privilege of employment and automotive transportation to understand what it is like to walk and bus five hours a day for work, much less two part-time jobs paying minimum wage and probably not very rewarding. Yet Detroiters like Ashley Williams need to do that every day (see article in Crain’s Detroit Business http://www.crainsdetroit.com/print/653251).

A few years ago, James Robertson (a.k.a. “Walking Man”) enjoyed his moment of fame after the Detroit Free Press documented his ordeal of walking and busing 21 miles daily from his home in Detroit to a factor job in the suburbs.

It’s a coincidence that both destinations are in Oakland County, a county that stubbornly refuses to help create a regional transportation system that help establish a more equitable system of mobility for lower income populations. These two cases help illustrate, in dramatic detail, the way that access to transportation impacts health.

The Free Press, in a recent update https://www.freep.com/story/news/local/michigan/detroit/2018/02/24/walking-james-robertson-transit-driving/357047002/ added an element to the transportation issue that, ironically, factors into Robertson’s story. While Oakland County won’t help him get to work through a transit system, a crowd-funding campaign raised money to buy him a new car. This raises another dilemma between the prerogatives of philanthropic solutions to social problems and societal solutions for the “greater good.” But that’s another issue.

Robertson’s story was repeated at a presentation in Dallas, Texas, titled, “The Road to Economic Mobility.” A solution raised at that presentation may not follow the narrative of those who have fought the good fight to bring regional transition to the Motor City: an affordable car for the masses.
The spirit of Henry Ford I must have been present for that discussion. Ford, of course, designed the Model T and produced it as an affordable vehicle that would given transit independence to average people; not those in deep poverty, but those who were suddenly part of the employment explosion fueled by mass production of automobiles. “The nation’s urban poor people need affordable passenger vehicles, in addition to mass transit, if they’re to share in the American dream,” noted a Free Press reporter summarizing the Dallas presentation by Rolf Pendalla, senior fellow of the Urban Institute.

“It’s easy to picture a rail line or a bus route. What’s harder is to analyze just how people get to their destinations on chains of transportation methods,” Pendalla said. In fact, even if a form of mass transit were to be approved in Southeast Michigan region, its sprawling, decentralized development will still require connections and lost time, not to mention inconvenience in foul weather. This sprawl was encouraged by automotive transportation and will likely require an automotive solution, unless traveling five hours by bus or some form of light rail/bus connector is created.

What about creating an affordable car, subsidized in some way through grants to auto companies, tax credits for consumers, low cost insurance rates, and low interest loans? Despite an era of reduced commitment to funding social programs, surely sufficient wealth and innovative thinking exists among urban planners and automotive industry executives.

Henry Ford did it, and he wasn’t a socialist.

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