Population Health Blog

Population Health Blog

Why It Matters

When health becomes a factor in paying bills

By Dennis Archambault

“I can’t pay my taxes!…”
– Marvin Gaye

Marvin Gaye’s exasperation in “Inner City Blues,” a generation ago, is sadly relevant today as households need to come to terms with which bill to pay and when. Or which not to pay and what are the consequences? Is it the heat bill? The cell phone bill? The rent or mortgage? The car note? Water bill? Assuming the best money management, many working class households face this stress every day. Decisions may be made rationally or irrationally, and with those decisions come consequences.

Utilities like water and heat are essential to life. But they are considered services for which consumers are responsible to pay. There a population – likely served through the Healthy Michigan expanded Medicaid program, but also including some of the lower income levels in the commercial insurance market – that is making choices about which bills to pay. Those choosing to not pay their water bill find ways to get by – borrowing water from friends and family, buying bottled water, and likely not having enough for proper hygiene or hydration.

Prolonged absence of regular access to clean water results several public health concerns, according to
Dr. Wendy Johnson, a public health professional who directs La Familia Medical Center in New Mexico, weighed in on the Detroit issue at a news conference recently:
• Dehydration, which causes a litany of problems, specifically for elderly and young people and those with chronic diseases.
• Poor hygiene, which can help spread and create water-related problems like the skin disease MRSA, as well as various GI issues.
• Unhealthy choices that can cause other health problems. If someone is without water, he or she cannot cook, which means he or she is eating cheap fast-food and drinking sugary beverages, which are less expensive than bottled water.
• Mental health issues. For example, she said, the inability to bathe negatively affects one’s sense of self-worth, as well as the ability to concentrate at school or work.
• Ripple effects; many of the water-borne diseases are contagious.

The Population Health Council has taken a clear position on this issue as being consistent with the federal commitment to providing a level of health care for a level of society struggling with the effects of poverty. Access to water should be provided for populations served through the Medicaid program, not as a consumer service.

Payment assistance, funded through philanthropic funds, may seem compassionate and appropriate, but philanthropic priorities change and demand will increase during economic downturns. Beyond the practicality of charity, it comes down to a systemic argument: Can a society afford to underwrite the cost of water service in a managed access system like Medicaid? And if so, should it?

Dennis Archambault is vice president, Public Affairs, Authority Health

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