As Some Holdout States Revisit Medicaid Expansion, New Data Show It Pays Off

From the article by Shefali Luthra on Kaiser Health News:

Although the GOP-controlled Congress is pledging its continued interest — despite stalls and snags — to dismantle Obamacare, some “red state” legislatures are changing course and showing a newfound interest in embracing the health law’s Medicaid expansion.

And a study out Wednesday in Health Affairs adds to these discussions, percolating in places such as Kansas, Georgia, Virginia, North Carolina and Maine. Thirty-one states plus the District of Columbia already opted to pursue the expansion, which provided federal funding to broaden eligibility to include most low-income adults with incomes up to 138 percent of the federal poverty level (about $16,000 for an individual).

Researchers analyzed data from the National Association of State Budget Officers for fiscal years 2010 to 2015 to assess the fiscal effects of expansion’s first two years.

Their findings address arguments put forth by some GOP lawmakers, who say the expansion will add to the nation’s budget deficit and saddle states with additional coverage costs, forcing them to skimp on other budget priorities like education or transportation.

The researchers concluded that when states expanded eligibility for the low-income health insurance program they did see larger health care expenditures — but those costs were covered with federal funding. In addition, expansion states didn’t have to skimp on other policy priorities — such as environment, housing and other public health initiatives — to make ends meet.

“This is a potential big benefit, not only to people who get coverage, but to state economies,” said Benjamin Sommers, an associate professor of health policy and economics at Harvard University’s public health school, and the study’s first author.

This finding — that states expanding Medicaid didn’t encounter unforeseen budget problems — shouldn’t be surprising.

“Expansion is basically free” to the states, agreed Massachusetts Institute of Technology economist Jonathan Gruber, one of Obamacare’s architects who worked with Sommers to systematically compare the budgets of all 50 states to examine Medicaid expansion’s impact. “That’s the big insight,” he said. “There’s no sort of hidden downside.”

And that may be part of what’s fueling this renewed interest, said Edwin Park, vice president for health policy at the left-leaning Center for Budget and Policy Priorities. These states are seeing the federal windfall their neighbors received while trying to navigate public health concerns like opioid addiction, he said. They “are looking at how their neighbors or expansion states have done, and see the benefits,” Park said. “The primary argument against the expansion on the state level has been it’s going to break the bank. The research demonstrates that’s not the case.”

But a caveat: The data used in this analysis reflected only years during which the federal government picked up 100 percent of the tab for expanding Medicaid eligibility and therefore could overestimate the benefit to state budgets. That’s because in 2017 that federal support begins to taper off, and by 2020 states have to pay 10 percent of the expansion costs themselves.

Read the full article.

Workers Who Give Care To The Homebound Often Can’t Afford To Get Their Own

From the article by Shefali Luthra on Kaiser Health News:

For more than two decades, Celeste Thompson, 57, a home care worker in Missoula, Mont., had not had regular contact with a doctor — no annual physicals and limited sick visits. She also needed new glasses.

Like many others who work in the lower rungs of the health care system, she has worked hard to keep her clients healthy by feeding them, dressing them and helping them navigate chronic conditions.

But because of the low wages and the hourly structure of this industry — which analysts estimate is worth nearly $100 billion annually and projected to grow rapidly — workers like Thompson often don’t have health insurance. Many home health agencies, 80 percent of which are for-profit, don’t offer coverage, or their employees don’t consistently clock enough hours to be eligible. They generally earn too much to qualify for public aid but too little to afford the cost of premiums.

“It’s a social justice issue. We have a workforce that is the backbone of long-term [care] services, and they themselves don’t have coverage,” said Caitlin Connolly, who runs a campaign to increase home care wages at the National Employment Law Project, an advocacy organization.

In 2015, Montana opted in to the 2010 health law’s expansion of Medicaid, the state-federal low-income health insurance program. Thompson, who was making about $10 an hour, immediately signed up.

Her vision care was among the first things she focused on. She had not visited an eye doctor in nine years — a problem because her job includes keeping track of patients’ pill bottles and making sure they take the right medications. “I had to use a magnifying glass to see small print,” said Thompson, who now wears bifocals. Her doctor has since warned her she may need a stronger correction soon.

…Thompson is part of a large population of home-based caregivers who might be affected by such changes. From 2010 to 2014, about half a million of these workers gained new health insurance through Obamacare, estimates PHI, a New York-based nonprofit that researches this slice of the labor force and advocates for improved working conditions, in a March issue brief.

Most home care workers’ gains came from living in states that, like Montana, expanded Medicaid. But even with Obamacare in place, many home health workers — perhaps 1 in 5 — remain uninsured. By contrast, about 8.6 percent of all Americans lack coverage.

Read the full article.

Talking About Equity: Promoting the Curb-Cut Effect

From the Annie E. Casey Foundation Blog:

In a recent Stanford Social Innovation Review article, Angela Glover Blackwell shows how developing policies to create equity can improve everyone’s lives. She does it with a simple example: curb cuts.

Glover Blackwell, CEO and cofonder of PolicyLink, a grantee within Casey’s equity and inclusion portfolio, cites the push by citizens with disabilities and advocates in the late 1970s to make communities more accessible for wheelchairs. When the federal Americans with Disabilities Act required that curb cuts and sidewalk ramps be installed everywhere, the new accessibility didn’t just make a difference for the disability community. The curb cuts and ramps created a new way for mothers with strollers, cyclists, delivery workers, scooter riders, kids on bicycles and just about every pedestrian to travel streets more safely and easily. The Casey Foundation believes the same principles can be applied to improving outcomes for children in the United States.

“Creating policy that is explicit about eliminating an inequity around race or ethnicity is one of the most effective paths to creating better opportunities and outcomes for all children, not just one group,” says Nonet Sykes, director of racial and ethnic equity and inclusion at Casey. “Using tools, such as the Racial Equity Impact Assessment, can help leaders fine-tune pieces of legislation for targeted investment.”

Glover Blackwell cites other policies that have had similar results — such as seat belt laws and the G.I. Bill of the 1940s — as further evidence of the curb-cut effect.

She writes that applying curb-cut thinking to transportation infrastructure or employment policy would significantly boost the GDP of the country’s 150 largest metropolitan regions. Further, she notes, policies to create equitable opportunities for children of color could strengthen our economy for generations, especially since children of color will soon comprise the majority of kids in the United States.

 

Read the full article.

The Insidiousness of Unconscious Bias in Schools

From the article by Seth Gershnson and Thomas S. Dee at Brookings:

Humans frequently make automatic decisions at a subconscious level. The human brain’s capacity for reflexive decisionmaking is what Nobel Laureate Daniel Khaneman calls “System 1” (as opposed to the more analytical, thoughtful, deliberate decision making of “System 2”) in the best-selling “Thinking, Fast and Slow.” This evolutionary adaptation was, and is, sometimes necessary for survival. However, these automatic responses occur via the rapid processing of new information through existing patterns of thought. Thus, because our automatic responses are shaped by our lived experiences and the broader social contexts in which we live and work, a pervasive byproduct of reflexive decisionmaking is unconscious bias (UB), which is also referred to as implicit bias or implicit social cognition.

Specifically, UB is the phenomenon in which stereotypes, positive or negative, influence decisions and behaviors without the individual consciously acting on the stereotype or being aware that he or she is doing so. Moreover, UB can occur even when individuals know or believe the stereotype to be false.

The insidiousness of UB is that it can create self-fulfilling prophecies that create and perpetuate inequities between in- and out-groups, even when the initial stereotype was incorrect (and there was no pre-existing difference between in- and out-group members). This post outlines some promising interventions we identify in a recent report, commissioned by Google’s Computer Science Education Research Division, that can short-circuit the recursive processes and self-fulfilling prophecies triggered by UB.

In this report, we argue that the consequences of UB may be particularly salient in the hierarchical environments of schools. Specifically, UB likely perpetuates socio-economic, gender, and racial gaps in educational outcomes such as academic performance, engagement with school, course and major choice, and persistence in higher education, particularly among historically disadvantaged and underrepresented groups such as low-income and racial-minority students. These gaps in educational outcomes then manifest in corresponding workplace disparities in pay, promotions, and employment.

Indeed, there is ample evidence of UB in educational settings, both in experimental labs and “in the field” with real individuals who were unaware of their participation in an experiment. For example, Moss-Racusin and colleagues conducted a lab experiment in which science faculty at research universities reviewed fictitious applications for a hypothetical lab assistant position and systematically rated male “applicants” higher than otherwise-identical female “applicants.” In a similar field experiment, Milkman and colleagues emailed meeting requests from fictitious prospective doctoral students to professors and found that white male “students” received more, and faster, responses than female and non-white students, particularly in higher-paying STEM careers like computer science and engineering. A recent field experiment conducted by one of us and colleagues found that the instructors of online courses were nearly twice as likely to respond to discussion-forum comments placed by students who were randomly assigned white-male names. Consistent with a UB interpretation, the pro-male bias was observed among both male and female faculty in these studies. The K-12 context is also ripe with suggestive, quasi-experimental evidence of pervasive UB in the form of systematic grading biases and student-teacher racial match effects.

Additionally, individuals from stereotyped out-groups themselves react negatively to seemingly innocuous environmental factors, such as the demographic composition of a classroom, the race or sex of an instructor or proctor, and even the design and decoration of the classroom. One example of this is the phenomenon of stereotype threat, whereby the mere threat of being stereotyped by a white (male) instructor, even when no outright bias is expressed, may distract black (female) students, ultimately leading to poor performance on exams and even disengagement from school.

Read the full article.

 

National Minority Health Month 2017: Bridging Health Equity Across Communities

Did you know that your zip code can be a predictor of your health? Along with your income and education level, where you are born, grow, live, work, play, learn, and age determines your quality of health. The choices you make each day about what to eat, when to work out and whether or not to see a doctor are important. The condition of your surroundings, or the social determinants of health, is the other part of the foundation upon which better health is built. However, many Americans, particularly racial and ethnic minority populations, are significantly impacted by the social determinants of health and the resulting disparities, or inequities, in health and health care.

Each April during National Minority Health Month, the U.S. Department of Health and Human Services (HHS) Office of Minority Health (OMH) raises awareness about health disparities, their causes and the impact they have on minority communities and on the nation as whole. This year, the HHS OMH is proud to join its partners in communities throughout the country as we build bridges to help end disparities in health and health care. Bridging health equity across communities extends beyond public health—it focuses attention on the indirect social and economic conditions in which we live. By addressing the social determinants of health and working together across sectors, we can help eliminate health disparities and advance health equity for everyone.

National Minority Health Month 2017 is focused on access to transportation that makes it possible to get to a well visit; neighborhoods where it is possible to exercise or play outdoors; and accessible grocery stores that make it possible to eat a well-balanced diet. Through collaboration with those who lead efforts to improve education, the safety of our neighborhoods, and other aspects of our communities, we can improve living conditions and help individuals live longer and healthier lives.

See the resource website developed by the Office of Minority Health for ideas and activities you can do around National Minority Health Month.

Raising Awareness about Health Disparities and Health Equity

The 2017 theme for National Minority Health Month — Bridging Health Equity Across Communitieshighlights the importance of collaborating across sectors and communities to address health disparities and the social determinants of health in the efforts to achieve health equity. As a part of National Minority Health Month, the Office of Minority Health developed a website — in English and Spanish —  with various tools and resources:

  • Example social media posts
  • Graphics for use on websites, in newsletters, and on social media
  • Listing of related blog articles
  • Suggested Action Steps

The website also lists upcoming events:

Decisive action by communities can reduce health disparities and improve lives

From the article by Risa Lavizzo-Mourey and Victor Dzau on STAT

Our choices for good health depend on our choices for everything else in life: a good education, safe and decent housing, a secure job that allows us to support our families.

What happens when those choices don’t exist? Ask Alpha Whitaker.

Whitaker, a single mom in Indianapolis who put herself through college, had to turn down a dream job because she didn’t have a safe way to get to work. Her bus route ended 10 blocks from the job, and she would have had to walk through a dangerous neighborhood — twice — every day.

In choosing safety, Whitaker gave up a job with full health benefits, a 401(k) plan to help her save for her daughter’s education, and a salary that would have allowed her family to move to a safer neighborhood. These things — financial security, health insurance, education, and neighborhood — influence health.

Fortunately, Indianapolis is one of many US communities working to create better choices for their residents in transportation, public safety, and employment. In doing so, they are creating better choices for health as well.

On the surface, the link might not be obvious. But as “Communities in Action: Pathways to Health Equity,” a new report from the National Academy of Medicine’s Culture of Health program shows, health equity and equal opportunity are inextricably linked. The report, commissioned by the Robert Wood Johnson Foundation, defines health equity as the state in which everyone has a chance to attain their full health potential.

Americans today live shorter, sicker lives than people in other developed countries. Across America, health varies by income, education, race and ethnicity, geography, sexual identity, and disability status. We pay a high price for these health disparities in lost lives, wasted potential, and squandered resources. They also affect national security: Some 26 million young adults are unqualified to serve in the United States military because of persistent health problems, poor education, or convictions for a felony. The report estimates that racial health disparities are projected to cost health insurers $337 billion between 2009 and 2018.

“Communities in Action” spotlights how communities are working together to create pathways to health equity. By addressing factors well beyond access to health insurance, cities like Indianapolis, Buffalo, Minneapolis, San Antonio, and Los Angeles are seeding the conditions needed to enjoy full, healthy lives.

Take the Indianapolis Congregation Action Network (IndyCAN), a multiracial, multifaith group that took on limited access to bus routes. That transportation issue created barriers to good jobs and opportunity. Working with a variety of stakeholders, including the residents most affected, IndyCAN helped pass a regional transit referendum to triple bus service in Indianapolis, fuel economic development, and increase access to jobs. Because all residents understood that improved bus service would benefit everyone in the community in a range of ways, the referendum passed last November — with the Indianapolis Chamber of Commerce as a leading champion.

This is just one example of what a community can do to promote health equity. “Communities in Action” explores many other efforts to curb violence, boost education, improve social connectedness, and expand access to healthy foods — all of which create the opportunity for healthier lives. Although their approaches differ, these community efforts consistently bring a shared vision for promoting health equity, building and harnessing community capacity, and involving many different sectors to enlist broad buy-in.

Read the full article.

Black History Month Sheds a Light on Racism as a Public Health Threat

From the article posted by Atif Kukaswadia on the PLOS Blogs: Public Health Perspectives:

Black History Month came and went all too quickly — while it gave our nation a spotlight for the accomplishments and contributions of the black community, it also reminded us to reflect and focus on the threats facing African-Americans all year around. Beyond the month of February, civil rights advocacy continues to address racial disparities in voting rights, education and criminal justice, but discrimination also impacts the black community in ways that aren’t typically seen as social issues. This is particularly true in public health and should be addressed by doctors and nurse practitioners.

Discrimination affects mental and physical health

Racism is detrimental to mental and physical health because repeated exposure causes a heightened sense of fear and anxiety regardless of whether victims experience physical violence or merely anticipate discriminatory behavior. The Southern Poverty Law Center reported more than 1,000 hate crimes in the month following the 2016 presidential election — 221 of which were logged as anti-black incidents. The past several years of media coverage on tragic cases of police brutality and alarming stop-and-frisk regulations shows us that many more cases often go unreported, and have profound negative impact on the health of African-Americans.

Long-term physical manifestations of discrimination include depression, high blood pressure, cardiovascular disease, breast cancer and premature death. One of America’s leading social epidemiologists, Nancy Krieger, points out that constant stress from racial profiling can give way to unhealthy coping mechanisms, like over- or undereating, retreating from personal relationships, unstable anger management, violence, and other lifestyle choices. These coping mechanisms exacerbate poorer health outcomes overtime, creating a cycle based in what Krieger terms “embodied inequality” — the idea that human bodies do not partition social and biological experiences.

Discrimination shapes health care

Indirect effects of racism in health care are often harder to see on the surface, but can create barriers to accessing quality care. These barriers can be identified through social determinants of health, which are “conditions in one’s environment — where people are born, live, work, learn, play, and worship — that have a huge impact on how healthy certain individuals and communities are or are not,” according to Healthy People 2020. Victims of racism are more vulnerable to the risks of living through social determinants that make it harder to seek medical care, like inadequate transportation, low income, poor health literacy, fewer educational opportunities, underemployment, and other systemic barriers.

Black communities have historically experienced more structural barriers to health care than white communities, which not only make it harder to seek treatment, but can also lead to poor outcomes even if treatment is accessed. A 2012 study from Johns Hopkins University found that many primary care doctors hold a subconscious bias toward their black patients, which undermines any positive outcomes of a medical visit. During visits with black patients, the study revealed that doctors tended to speak slower, use less positive tones, dominate conversations and spent less time addressing social aspects of the patients’ lives. Inadequate patient-doctor consultations can result in poor health literacy, which can lead patients to wait longer before seeking care for a health issue, and ultimately creates more urgent and expensive treatments long term.

Health Literacy Can Mitigate Racial Disparities

Mitigating the detrimental effects of racism — subconscious or not — is easier said than done, but begins with providers acknowledging that biases exist and are creating health disparities. While medical providers can work to eliminate attitudes that lead to discrimination, they can also participate in public policy and on-the-ground interactions with patients. On an administrative level, providers can employ more diverse staff members, and promote medical research for racial disparities in public health, and work to expand access to quality health care to African-American patients. One potential avenue for intervention is through increased health literacy but in order to promote health literacy among African Americans, nurses, social workers, and educators must collaborate to meet patients where they are, listen to their concerns, advocate for creative solutions, and train others in professional communities to do the same.

Read the full article.

Health Care Outcomes in States Influenced by Coverage, Disparities

From the article by Kimberly Leonard in US News:

Enjoying longer, healthier lives than the average American, and with strong medical coverage and access to care, Hawaiians rank No. 1 in the country for health care, according to the U.S. News analysis of federal data supporting the Best States rankings. But Hawaii has more than a mild climate and residents who share a proclivity for outdoor activities to contribute to its success. The state had a significant head start: a four-decade jump on health care reform.

“It was a really wonderful exciting time and one that’s kind of forgotten by the rest of America,” says Dr. Jack Lewin, who oversaw the state’s implementation of the Prepaid Health Care Act as health agency director.

As a result of the law’s passage, Hawaii became the first state in the country to implement a nearly universal health care system for its residents, enforcing a mandate for all employers whose employees work a minimum of 20 hours a week. The model, originally proposed by President Richard Nixon, would later become the inspiration for Hillary Clinton’s unsuccessful attempts at national health care reforms in her role as first lady in the 1990s.

Though never implemented nationally, the law in Hawaii, as well as measures in other states that have been particularly proactive, provides strong evidence that increasing access to health care coverage has contributed to wellness, according to the data compiled for Best States.

In Hawaii, residents have steady access to preventive care such as screenings and doctor visits, and are among the least likely to report that they skipped needed medical care because of cost. Mortality rates are the lowest in the country, giving Hawaiians the longest life expectancy in the U.S. Their obesity and infant mortality rates also are among the lowest in the country.

Experts say the Hawaiian experience helps give credence to those who say health care coverage is fundamental to reforming the American health care system, noting that people who are uninsured often skip needed testing, care or medicines because of concerns about cost.

“There is a large body of research showing that people who have health insurance are likely to access care and to get appropriate care like cancer screenings, and that leads to ultimately better health outcomes,” says Rachel Garfield, associate director for the program on Medicaid and the Uninsured at the Kaiser Family Foundation, which studies health care.

The U.S. News rankings examine not only how well residents are, but whether they can access medical care and how good that care is. Each of these three components is given equal weight for a final score. The results appear to suggest some parallels across states that tend to be more engaged.

“Higher performing states have huge efforts over time to reform or improve their health care system, and government plays a very important leadership in that,” says Douglas McCarthy, senior research director of the Commonwealth Fund, a foundation that releases studies on health care issues. “The stakeholders are very engaged and created a culture of collaboration. It’s really about bringing everyone to the table.”

Read the full article.

Understanding Poverty

 

In late 2016, Busted: America’s Poverty Myths is a five part series from On the Media exploring the way poverty is portrayed in the United States and the realities that people face. The episodes include (descriptions come from On the Media):

  • The Poverty TourWelfare advocate Jack Frech has taken reporters on “poverty tours” of Athens County, Ohio, for years. But has media attention made any difference in the lives of the Appalachian poor?
  • Who Deserves to be Poor? — The notion that poverty stems from a lack of will power and a poor work ethic is as old as America. Why that needs to be dispelled.
  • When the Safety Net Doesn’t Catch You — Government assistance in the United States helps millions out of poverty, but often the most needy fall through the cracks.
  • Breaking News Consumer’s Handbook: Poverty in America Edition — When reporting on poverty, the media fall into familiar traps. How to steer clear of stereotypes and seek insight.