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.

Treatment Gaps Persist Between Low- And High-Income Workers, Even With Insurance

From the article by Michelle Andrews on Kaiser Health News:

Low-wage workers with job-based health insurance were significantly more likely than their higher-income colleagues to wind up in the emergency department or be admitted to the hospital, in particular for conditions that with good primary care shouldn’t result in hospitalization, a new study found.

At the same time, low-wage workers were much less likely to get preventive care such as mammograms and colonoscopies, even though many of those services are available without cost-sharing under the 2010 health law.

There’s no single reason for the differences in health care use by workers at different wage levels, said Dr. Bruce Sherman, an assistant clinical professor at Case Western Reserve University in Cleveland and the study’s lead author, which was published in the February issue of Health Affairs.

Finances often play a role. Half of workers with employer-sponsored insurance are enrolled in plans with a deductible of at least $1,000 for single coverage. As deductibles and other out-of-pocket costs continue to rise, low-wage workers may opt to pay the rent and put food on the table rather than keep up-to-date with regular doctor visits and lab work to manage their diabetes, for example.

Likewise, convenient access to care can be problematic for workers at the lower end of the pay scale.

“Individuals are penalized if they leave work to seek care,” Sherman said. “So they go after hours and their access to care is limited to urgent care centers or emergency departments.”

The study examined the 2014 health care claims, wage and other data of nearly 43,000 workers at four self-funded companies that offered coverage through a private health insurance exchange. Workers were stratified into four categories based on annual maximum wages of $30,000, $44,000, $70,000 and more than $70,000.

Workers in the lowest wage category were three times more likely to visit the emergency department than top earners, and more than four times more likely to have avoidable hospital admissions for conditions such as bacterial pneumonia or urinary tract infections. But they used preventive services only half as often, the study found.

Read the full article.


U.S. Cancer Mortality Rates Falling, But Some Regions Left Behind, Study Finds

From the article by NCI Staff on the National Cancer Institute’s Cancer Currents Blog:

Rates of death from cancer in the United States dropped by 20% between 1980 and 2014, according to new research from the Institute for Health Metrics and Evaluation at the University of Washington.

However, these gains were not distributed equally across the country. In 160 of the United States’ approximately 3,000 counties, cancer mortality rose substantially during the same time period.

The disparities in mortality between some counties were stark, the researchers found. In 2014, for example, the county with the highest overall cancer mortality had about 7 times as many cancer deaths per 100,000 residents as the county with the lowest overall cancer mortality.

Although disparities in cancer incidence and mortality have been well documented, Ali Mokdad, Ph.D., who led the study, said that the magnitude of the disparities seen in this study “was a surprise.”

The findings were published January 24 in JAMA.

Read the full Blog Article.

Re-balancing medical and social spending to promote health: Increasing state flexibility to improve health through housing

From the article by Stuart M. Butler, Dayna Bowen Matthey, and Marcela Cabello from Brookings:

Although the United States spends considerably more of our GDP on medical services than other developed nations, our health outcomes are no better, and in many areas, much worse.  Even more significant, perhaps, is that when we look at health spending compared with spending on social services, the U.S. is a noticeable outlier. On average, nations that are members of the Organization for Economic Cooperation and Development (OECD) spend about $1.70 on social services for every $1 on health services; the U.S. spends just 56 cents.

The research on social services, health spending, and health outcomes suggests strongly that it is no coincidence that the U.S. has this unusual combination of spending and mediocre outcomes. We have the wrong balance of social and medical spending if one of our priorities is improving health overall and measures such as infant mortality and life expectancy. This pattern from the international evidence is reflected in data from within our own borders. States with a higher ratio of social to health spending also have significantly better health outcomes for such conditions as adult obesity, asthma, mental health indicators, mortality rates for lung cancer, high blood pressure, and heart attack, and Type 2 diabetes.

An important reason for such patterns is that in advanced countries, improvements at the margin in health tend to come more from additional investments in a good living environment and lifestyle habits than from more investments in medical services. Indeed, public health experts now agree that a variety of factors beyond access to and quality of health care influence population health.  The U.S. Centers for Disease Control, for instance, estimates that health behaviors, medical care, and genes together contribute approximately 50 percent of the influence on population health, while social and environmental characteristics contribute the remaining 50 percent.

This suggests a three-pronged approach to improving health in the U.S.:

  • First, to improve health outcomes while actually curbing health care costs, we need to rebalance federal spending patterns. In particular, the new Administration and Congress need to adjust the current ratio of medical-to-social spending by shifting some current health care expenditures to investments in tackling “upstream” social factors with a bigger impact on health.  The evidence suggests that such a shift could contribute to decreased hospital utilization, and thus reduced spending by Medicaid and Medicare, while improving health outcomes.
  • The federal government should help states take the lead in this rebalancing. The best ways to rebalance and reflect local conditions and opportunities will differ from place to place, and states are the best-placed level of government to facilitate large-scale cross-sector strategies to improve health. Moreover, the research evidence on the best combination of medical and social services to improve health is not as robust as we would like. Therefore, it is important to permit much more state investigation and experimentation with re-balanced funding, combined with solid evaluation of experiments, so that states and federal policymakers can learn from each other.
  • The federal government should review the evidence that social services are often the route to improved health, and agencies should work with health officials on ways to reprogram funding. A particularly promising such area for the new Administration to focus on would be housing.

Read the full article.

Measuring Social Determinants of Health among Medicaid Beneficiaries: Early State Lessons

From the policy brief  by Anna Spencer, Bianca Freda, Tricia McGinnis, and Laura Gottlieb of the Center for Health Care Strategies, Inc.:

Social determinants of health (SDOH) are conditions in the environment in which people are born, live, learn, work, play, worship, and age that affect health outcomes and risks, functioning, and quality-of-life. These social, economic and environmental conditions, in addition to health behaviors, relate to an estimated 80 percent of health outcomes in the United States. Moreover, behavioral patterns/health-risk behaviors (40%), social circumstances (15%), and environmental exposures (5%) play a significant role in premature death in this country (Exhibit 1). These determinants of health disproportionately affect those in low-income brackets.

Given Medicaid’s role in serving people with complex clinical, behavioral health, and social needs, state Medicaid agencies are uniquely positioned to identify and help address these diverse social challenges. In recent years, many of these agencies have developed strategies to support providers in addressing patients’ SDOH that complement more traditional medical care delivery programs. Some state Medicaid agencies have started to integrate coverage for interventions focused on SDOH into new value-based payment models. Many Medicaid managed care organizations (MCOs) are also developing interventions that address SDOH by linking clinical and non-clinical service delivery to improve health outcomes and cost efficiencies. At the federal level, the Center for Medicare and Medicaid Innovation (CMMI) is planning to test whether Accountable Health Communities (AHC) are a cost effective approach to identifying and addressing select unmet social needs of Medicare and Medicaid beneficiaries across the country.

Collecting information on social risks — including access to food and housing and employment status — is a key component of developing and implementing interventions to address these risks. Select providers and health care organizations are pioneering strategies to collect and use patient-level SDOH information to better direct interventions. These efforts, however, are not universal. Medicaid can play a key role in driving consistent measurement, collection, and use of SDOH data among health plans and providers. Little is known, however, about Medicaid and public health efforts to assess SDOH among Medicaid beneficiaries, including the degree to which standardized SDOH measures are used.

Building on previous CHCS work on health-related supportive services in Medicaid, CHCS sought to learn more about SDOH data collection by Medicaid and other state agencies, including whether there was any standardization across programs and how the data was being used. CHCS conducted interviews with more than 30 key informants representing eight states, as well as the Center for Medicare and Medicaid Innovation, the Association for Community Affiliated Plans, and a Medicaid MCO to better understand how states collect and apply beneficiary SDOH data. These interviewees represented diverse perspectives, including Medicaid and public health department officials, metrics managers, and experts in data analysis, health information policy, and informatics. Drawing from the interviews, this brief explores: (1) how states define and collect patient-level SDOH information; (2) processes for measures selection; (3) the multi-pronged ways Medicaid and other state agencies are using SDOH data at the patient and population level; (4) challenges to capturing and using SDOH data; and (5) key considerations for Medicaid in advancing SDOH measurement approaches. The information gleaned from the interviews offer valuable early lessons to help policymakers and researchers drive greater and more consistent collection of patient level SDOH information.

Download the full document.

When Housing Comes First, Hospitals Benefit

From the article by Lola Butcher on Hospitals & Health Networks:

Supportive housing is a multifaceted model to help homeless individuals and families that face complex challenges such as addiction, mental health conditions and disabilities that can be overwhelming. In addition to permanent housing, the model provides social services that range from substance abuse programs and life skills training to case management and job training.

Many, but not all, supportive housing programs use the “housing first” approach, endorsed by the federal government. Under “housing first,” permanent housing should be made the top priority for homeless individuals and families; addressing behavioral, social and other factors comes second.

The peace of mind that comes from a safe place to live helps individuals as they tackle addiction or other challenges. Plus, service providers know where to contact the individuals to provide the help they need.

“If you provide housing stability first and then provide the wraparound supports, people are much more successful,” says Shannon Nazworth, executive director of Ability Housing, a nonprofit organization that provides supportive housing in parts of Florida.

Ability recently received a grant from the Florida Blue Foundation, a philanthropic foundation affiliated with the state’s Blue Cross and Blue Shield health plan. The grant supports a statewide pilot project to study how permanent supportive housing affects the health and quality of life of high utilizers of crisis services — and how it affects their use of health care and other publicly funded support services.

A growing body of research, in fact, suggests that the benefits of housing programs for the health care system might be substantial. Researchers at Yale University’s Global Health Leadership Institute evaluated and summarized the results of several studies in the area in their report “Leveraging the Social Determinants of Health: What Works?” (Lauren A. Taylor et al., Blue Cross Blue Shield of Massachusetts Foundation, 2015):

  • A “housing first” program in Seattle found that the median per person, per month cost of incarceration, emergency medical services, hospital-based medical services, detoxification and other publicly funded programs fell from $4,066 to $958 after 12 months in housing. This added up to annual net savings — after accounting for housing costs — of $29,388 per person compared with a control group.
  • A Massachusetts initiative that targeted homeless people with serious mental illness reduced the average number of hospital days per client from 102 to seven within two years after housing placement. That reduced hospital costs by about $18 million per year overall.
  • A Los Angeles program that serves homeless patients with the highest public services and hospital costs documented that every $1 invested in housing and support reduced public and hospital costs by $2 the following year and $6 in subsequent years.

Read the full article.


Economic Effects of Medicaid Expansion in Michigan

From the post by The Commonwealth Fund:


The debate over whether and how to repeal the Affordable Care Act often focuses on the cost of the Medicaid expansion—an area of concern for some states, which starting this year must assume a portion of the coverage costs for newly eligible enrollees. Less attention is paid to the economic benefit expansion states receive from the influx of federal money, including increased employment and tax revenue. The authors of this Commonwealth Fund–supported study assessed the economic impact of Michigan’s Medicaid expansion. The Healthy Michigan Plan has enrolled roughly 600,000 low-income residents.

What the Study Found

Michigan’s Medicaid expansion will create at least 30,000 jobs in the state each year from 2017 to 2021 and raise personal income by more than $2 billion each year. The added economic activity is projected to yield $145 million to $153 million annually in state tax revenue.

Read the full post from The Commonwealth Fund.

Communities in Action: Pathways to Health Equity

From the blog article by the Robert Wood Johnson Foundation:

Americans today live shorter, sicker lives than people in other developed countries, and, across the nation, health varies by income, education, race and ethnicity, and geography. Warning that the United States will pay the high price in lost lives, wasted potential and squandered potential resources until these gaps are closed, a comprehensive report from the National Academies of Sciences, Engineering, and Medicine (NASEM) calls for leaders across sectors to make health equity a priority for the nation.

Why Does Health Equity Matter?

When health equity is achieved, “everyone has the opportunity to attain full health potential, and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance,” the report says. And ensuring that opportunity is crucial not just for individuals, but also for the nation’s economic and growth prospects, for its national security and for its communities’ well-being and vibrancy.

Data show the costs of current health inequities: The report estimates that racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018. The impact on national security is also high, with some 26 million young adults unqualified to serve in the U.S. military because of persistent health problems, or because they are poorly educated or have been convicted of a felony.

…The Cost of Inequality

  • In 2015, the percentage of low-birthweight infants in the U.S. rose for the first time in seven years.
  • Racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018.
  • Health care spending accounted for 17.5 percent of GDP in 2014.
  • In 2014, VA-enrolled veterans accounted for 17.9 percent of suicide deaths among U.S. adults.
  • People with disabilities are more than twice as likely not to receive medical care because of cost.

Read the full article.

Alabama infant mortality almost three times higher for African-Americans

From the article by Amy Yurkanin in

Almost 500 babies born in Alabama in 2015 did not live to celebrate their first birthdays, and the tragedy of those deaths fell most heavily on African-American families.

The overall infant mortality rate in Alabama fell to 8.3 deaths per 1,000 births last year from 8.7 in 2014. The rate for white infants fell to a 10-year low of 5.2 as the rate for black infants rose to its highest rate in a decade, 15.3. The most recent infant mortality rate for the nation is 5.8 deaths in the first year for every 1,000 births.

About a third of the 59,651 babies born in Alabama last year were born to African-American mothers.

“The racial disparity between black and white infant birth outcomes continues to be of great concern,” said State Health Officer Dr. Tom Miller in a statement. “The black rate is almost three times the white rate in the state. There is much work to be done to address this ongoing challenge. We need to explore and transform social determinants of infant mortality in our population by addressing modifiable risk factors that contribute to unfavorable birth outcomes.”

“I think we’re heading in the wrong direction,” Thomas said. “We’re seeing the racial disparity widen and that is not the direction we want to be going. To be quite frank, it’s depressing.”

National researchers who study racial differences in infant mortality said much of the disparity can be tied to education, unemployment and other social determinants of health, Thomas said. Reversing those trends could take several years.

The top three causes of infant mortality in Alabama are congenital abnormalities, premature birth and sleep-related causes. The number of babies born before 37 weeks gestation has been dropping in Alabama for years.

Risk factors for infant mortality include poor maternal health, unhealthy lifestyles and short intervals between births. The health department said it will increase education about safe sleeping and contraception to decrease risk factors that can contribute to infant deaths.

Thomas said increasing education around sleeping could hopefully help reduce some infant deaths fairly quickly.

Babies with low birth weight, below 5 pounds 8 ounces, accounted for almost 70 percent of those who died during infancy, according to the Alabama Department of Public Health. Those babies are 20 times more likely to die during their first year than normal-weight newborns and account for about 10 percent of all births in the state.

Read the full article.

What makes a patient more likely to end up back in the hospital? Study finds surprising role for social factors

From the article on Science Daily:

No patient who just got out of the hospital wants to end up there again soon. Whoever’s paying their hospital bills doesn’t want that either.

That’s why the Medicare system has started penalizing hospitals with the highest readmission rates for certain conditions. But a new study suggests that unlike hospital gowns, such penalties should not be one-size-fits-all.

In fact, the study shows, certain social, economic, disability and personal-care factors can make a major difference in the readmission risk of people who were recently hospitalized for heart failure, pneumonia or a heart attack.

And the factors that make the most difference vary greatly from condition to condition, and are largely not something a hospital can change through treatment.

For instance, pneumonia patients who already had trouble with multiple tasks like getting dressed or cooking food, or who needed paid help at home, before their hospital stay were the most likely of all pneumonia patients to be readmitted in the first 30 days after a hospitalization, the study shows.

But for patients with heart failure, that kind of functional difficulty didn’t matter as much as money, family and race. Those who had a higher wealth level or adult children had a much lower chance of readmission — while simply being African American increased the risk of another hospital stay.

And for heart attack survivors, the most important factors boosting their chance of readmission were whether they had been in a nursing home before their hospital stay, and whether their hospital cared for a high percentage of minority patients.

The results, published in the Journal of General Internal Medicine, come from a team from the University of Michigan Medical School and Institute for Healthcare Policy and Innovation, and the VA Ann Arbor Healthcare System. They used data from the Health and Retirement Study, based at the U-M Institute for Social Research, and from Medicare, and looked at 10 measures of disability and what are called “social determinants of health.”

Read the full article.