Thursday, December 26, 2013

A Prosperous New Year?

Because of declining federal support and flat tax revenues, the State of Michigan is under intense pressure to operate more efficiently. Consider this: for every function it performs - public health, mental health, human services, emergency preparedness, etc. - the State is divided in a different set of regions. There are many dozen such regions with different numbers of units, different boundaries and different principles of governance. Many people agree this situation is inefficient and wasteful. No matter who the governor is, he or she would almost certainly want to align the various regions. This is exactly why our innovative Governor Snyder has proposed to divide the state into ten Prosperity Regions with which he wants State agencies to align their services. Here is a map of Michigan's 43 local health departments (LHDs). Notice that 30 are single county and 13 are district health departments with multiple counties.

And here is a map of the 10 envisioned Prosperity Regions. Notice that the Mid-Michigan District Health Department (MMDHD) is in 3 different Regions.

Will Michigan one day have only 10 LHDs contiguous with the Prosperity Regions? Recently the Executive Committee of the Michigan Association for Local Public Health (MALPH) met with the leadership of the Michigan Department of Community Health (MDCH) to discuss funding for LHDs for the coming year. We talked about many things, including the likelihood the Governor's grants for community-based prevention programs called 4x4 ("Four-by-Four"), will not be restored, as well as a proposal to involve LHDs in outreach and enrollment when Medicaid expands in April. But what I want to write about in this post are some thoughts I have had about the Prosperity Regions. In the meeting, MDCH leadership told MALPH that Prosperity Regions are likely to become a reality and that we need to start thinking about how to adapt to them. The question I want to discuss here is, "How will implementing Prosperity Regions impact public health?"

One way of looking at it is that aligning LHDs with Prosperity Regions could save public health. If State funding available to LHDs must continue to fall, then one way to maintain an adequate level of services is to consolidate or regionalize them to save on administrative costs. Actually, local public health has been doing this for years. MMDHD includes three counties (Clinton, Gratiot and Montcalm) that have been served by a single district administration for over 40 years. By consolidating Michigan's 43 LHDs into 10 we could, in principle, save money. When I explained the concept of Prosperity Regions to front-line staff recently, I told them, "Don't worry, this won't affect your jobs. There will still be the same number of wells and WIC clients in each county after Prosperity Regions." But then I pointed to administrative staff in the room, including myself, and said, "The idea is to get rid of our jobs." And so it is.

Others are not so certain administrative savings will be realized. They point out that the span of control of supervisors and directors will remain about the same. For example, every 7 to 10 nurses or sanitarians will still need a supervisor regardless of consolidation. Every 4 or 5 supervisors will need a Director. They argue that historically, savings have usually been realised in one of two ways: leveraging technology or cutting services.

I do think Prosperity Regions could improve local public health in some places. In some small single-county LHDs, Boards of Commissioners may be unable to fund adequate levels of services. If these counties joined better-endowed districts, the quality of the services provided could improve.

So how do we get to Prosperity Regions? This is the big question. In the Public Health Code the authority and responsibility to form LHDs - including district health departments - lies with counties - specifically Boards of Commissioners - not the State. The State cannot tell a county, "For the purposes of public health you are now part of district 'X'". Only County Boards can do this by creating Intergovernmental Agreements (IGAs). So if the Governor wants counties to rearrange themselves to conform to the Prosperity Regions, he either has to have a big carrot or a big stick. I question whether the carrot can be very big. The reason we are contemplating all of this is because of the money we don't have. As for a stick, the Code requires the State to support the health of the public. There will probably be no threats to defund services.

Think about this: current district health departments were created after long and difficult negotiations between counties. To craft their IGAs the Commissioners had to deal with:

  1. Governance. Counties had different ideas about delegating their authority and had to craft mutually acceptable new forms of governance. 
  2. Politics. Some counties favored a more forward-leaning regulatory environment, and some did not. A high degree of trust was required for Boards to join a single regulatory regime. 
  3. Finances. Counties' fortunes vary widely. To form districts they had to create funding formulas that seemed fair to all. 

To say the least, it will take a lot to get counties to abrogate existing IGAs and align with Prosperity Regions. MMDHD has experience with this. On three different occasions MMDHD and the Ionia County Health Department have tried to merge and we failed each time. The reason was always that our finances - how appropriations are determined, pay scales, etc - were so different that we realized it would actually cost all four counties money to merge. We couldn't propose a sure money loser to the Boards. But I think politics may be the biggest hurdle. For example, the Governor's plan envisions Clinton County in a single district with Ingham. Clinton has a majority Republican Commission with a light-touch local ordinance. Ingham is almost all Democratic with an aggressive regulatory regime. Will Red or Blue Boards really be willing to dilute their authority by merging?

Another approach would be to change the Public Health Code to strip counties of the power to create district health departments, and make public health more like Human Services where all employees work for the State. But such an approach would have to go through the legislature, where most representatives started as County Commissioners, and count on local votes to get re-elected. It isn't clear to me that the legislature would agree to usurp local control.

To move things forward, the State is asking LHDs to experiment with the idea of Prosperity Regions. So far I'd say what we've learned is that, when it comes to Prosperity Regions, we should either go all the way or not bother. In-between is a bad idea. For example, the State recently released small grants for training on household lead awareness. The grants were released to the core counties in each Prosperity Region. So MMDHD got contacted three different times by health departments in our adjoining Regions and asked to participate in their three grants. As the grant suggested, the first LHD to contact us offered to train our staff in exchange for our support. We agreed, but had to tell the second and third that our staff only need to be trained once. Instead they agreed to train staff of local community-based organizations. But arranging that will make a lot more work for us for which we won't be paid. This is not more efficient than just getting one grant. But my real beef with this approach is that it is not addressing the main hurdles that have to be crossed to get to Prosperity Regions, which, as I mentioned, have to do with cost of government at the county level. To solve Prosperity Regions you've got to solve county finances.

So this is my worry about how the move toward Prosperity Regions won't help public health. While we experiment with it, we could spend a lot of time doing things in ways that aren't rational, before we finally confront the fact that the existing structure isn't going to change. Look back over my earlier posts and think about all the things we need to be doing in this era of rapid transformation. Public health cannot afford to take it's eye off the ball.

And here is my final worry: that Prosperity Regions may deepen, not reduce, regional inequality. Although Gratiot and Montcalm counties have an extensive history of collaboration on health issues, efforts to collaborate with the core counties of the envisioned Regions have not been so successful. Do they really want to solve our rural transportation problems, for example; do they really think rural poverty is as serious a social justice issue as urban poverty? For Prosperity Regions to truly address the health needs of these communities, the Regions will need to have strong guarantees built into their IGAs to protect the less well-endowed counties. These guarantees are built into many of the current IGAs and would need to be re-built from the ground up.

Tuesday, October 8, 2013

Public Health Getting Small: The Case of Social Media

Yesterday I made the point that steep budget cuts in public health have caused us to embrace more limited goals over time, and have forced us to use strategies for achieving those goals that have limited impact. Today I am going to explore this in the context of social media.  Social media—Facebook, Twitter, texting, etc.—has been touted as a way for public health to reach more deeply into the community to educate and mobilize in ways we could not in the past.  This article from The Nation’s Health is typical.  But is this really happening because social media is a great way to do public health, or is it because, well, you can have a Facebook page or twitter account for free. According to the National Association of County and City Health Officials, more than half of local health departments have Facebook pages.  But is anyone healthier as a result? To dive into these questions I'll start by talking about what local health departments should be doing, and then contrast it with what we are doing.

In public health we have a clear idea of what we should be doing.  We say that we should be implementing evidence-based practices. The National Association of Local Boards of Health has an excellent guide to the topic .  What this means is that we should be doing things that are scientifically proven to work.  We should not spend a lot of the tax payers’ dollars on things whose effectiveness is questionable.

In looking at the evidence base, most public health researchers conclude that the most effective and lowest cost way to improve community health is through public policy, for example regulations against smoking in public places like bars and restaurants, regulations requiring food handlers to be trained, and regulations requiring inspection of septic systems. While the technology underlying many public health interventions is very effective: vaccines, sewers, seat belts, etc., public policies always accompany the successful implementation of such technology:  kids must be vaccinated to go to school; if you build a house you have to hook up to the sewer or get a septic system; cars must have seat belts and drivers must wear them. Some people are bugged by regulations, but regulations work to protect the health of the public.

Another thing the evidence shows is that broad-based multi-media campaigns to educate and inform the public can be effective in improving public health also. The City of New York’s anti-smoking campaigns are a good example. These campaigns involve many community organizations, multiple media channels and the use of messages shown by research to be effective. Furthermore these campaigns are sustained for long periods of time and are regularly evaluated so course corrections can be made. All of this means they cost money. 

 There aren’t many good examples of such campaigns from Michigan recently.  The Governor’s 4x4 campaign encouraging people to get health screenings was intended to be such an effort, but the financial support was never there in the legislature.  Furthermore, at the end of the day there was no enduring policy change.  When the campaign dollars were gone it was back to business as usual.  MMDHD had a tiny bit of funding for one year under that plan. Our employee who was trying to support the plan by working 10 hours a week on it is now busy helping people get insurance on the Marketplace instead.

We start out trying to convince policy makers to embrace policies that protect the health of the public. If that doesn’t work we switch to broad-based community campaigns to convince the public to alter their behavior voluntarily.  When we can no longer afford effective campaigns, we switch to, well, Facebook pages. 

John’s Hopkins student and experienced social marketer Erica Holt is researching public health and social media.  She recently shared her literature review on the topic. She asked and answered the question…
“Does social media work [for public health] in certain situations, with certain audiences, for certain health outcomes? There’s not one study that I’ve found that shows this is the case, just yet.”

Before I go on, I should say I agree that health departments should have Facebook pages and Twitter accounts.  They should have them for the same reason they have a sign in front of their building, or a phone number.  The thing is, you cannot show that the sign improves health. The existence of the sign is not a sufficient condition for health improvement; it tells you a health department is here, but not whether that health department is doing its job.

In fact MMDHD is listed in a recent issue of the American Journal of Public Health as an innovator because we got into Facebook early.  However, the same article concludes that most local health departments with Facebook pages have fewer than 200 followers! 

There are some evidence-based practices related to social media that Erica Holt missed. But these practices do not support the effectiveness of broad-based campaigns based on free social media alone.  Instead they all involve interventions using social media with people who have already made up their mind they want to make a change—for example text message reminders to diabetics who are already involved in a nutrition and exercise program.  MMDHD’s Facebook page for breastfeeding moms in the WIC program is popular because these moms are engaged with their health and want to learn more.  But texting an over-eater who is not worried about their over-eating has shown no promise so far.  And Facebooking about immunizations on a site with 200 followers isn’t going viral.

One of the most widely cited examples of the effective use of social media by public health is the Zombie Apocalypse campaign the CDC has run for several years.  The campaign was enormously fun for us in public health, and it probably is effective as a curriculum aid. But I wonder what we got at the end of the day.  I still want to know if Americans understand the principles of communicable disease control better, or if they are more supportive of governmental public health, as a result?

Monday, October 7, 2013

The Shutdown: How Cuts Weaken Public Health

We are into the sixth day of the government shutdown of October 2013. Is it affecting the Mid-Michigan District Health Department?  Yes, it is.  We’ll begin the day on Monday morning by working on contingency plans (Instead of doing the work our clients and staff want us to be doing!). If this goes on a couple of more weeks, the State may have to stop reimbursing us for some services. Without that reimbursement we will not be able to pay staff to deliver those services, so the Federal layoffs will start turning into state and local layoffs.  Furthermore, our employees eat and shop locally, and our clients spend their benefits in local stores, so local businesses will soon feel it, too. 

But today I am not going to blog about how bad the consequences of this way of making policy are for the public interest.  Plenty of other writers have got that covered. In this post I do want to make two points:  First, the shutdown is just another in a long series of blows to the ability of American communities to protect the health of the public. Second, these blows have had a cumulative affect that is profound in certain ways. One of the more profound effects of the long decline is that, over time, it causes us to set goals that are more and more limited, and to use strategies for achieving those goals that are less and less effective. Oddly, we are doing this without really acknowledging that it is happening.

To the first point: here is a great slide, first used by my predecessor, Kim Singh. We have continued to update it. It shows funding for what is called Essential Local Public Health Services (ELPHS) in Michigan.

These are funds the State pays local health departments to provide mandated services.  It shows that ELPHS today is 3 million dollars less that it was a decade ago.  But it also shows that funding is 13 million dollars less than would be needed to provide the same level of service, adjusted for inflation!  In other words we only have two-thirds of the inflation-adjusted ELPHS dollars we did a decade ago.  Of course the services are still mandated.

Other cuts, like the sequester, the shutdown, reductions in local funding and the loss of grant funds have had their impact, too. Since 2008, 44,000 local public health jobs have been lost according to our professional organization, the National Association of County and City Health Officials. A dozen of those positions were at MMDHD.

As a local health department loses resources, its ability to carry out its mission is compromised. By this I mean it is forced to set more limited goals, and to use strategies that are less and less effective.  I am going to write about this tomorrow. I’ll be taking as my example the use of social media to educate and inform the community about health issues, in which health departments are settling for what may be fairly ineffective communications strategies that happen to be free. 

Monday, September 2, 2013

Fixing Public Health? (Accreditation!)

This will probably seem like a very wonky post, unless you worry about the fact, as I do, that the public health system in the United States is broken, and ponder ways to fix it. People who worry about public health have converged on the concept of national public health accreditation as one way to address this challenge. 

Over the past ten years public health folks have participated in an intensive effort to create a system of national public health accreditation, which would align the work of local, state and federal public health agencies while ensuring that every one of them is really doing what it ought to be. With tremendous support from the CDC and the Robert Wood Johnson Foundation, among many other national caliber players, they have launched the Public Health Accreditation Board (PHAB) which has just accredited its first batch of public health agencies, including our sister Central Michigan District Health Department.  This effort is very important and well overdue, but it faces several vexing challenges, the most important being Washington DC weirdness. This post is about how we are trying to embrace national accreditation, while fixing its flaws, here in Michigan.

The story begins 25 years ago, long before anyone was thinking of national accreditation, when Michigan created its own state system for accrediting local health departments, known as the Michigan Local Public Health Accreditation Program (MLPHP). This system was needed because, in the United States, local public health is funded through myriad idiosyncratic grants and contracts from various federal agencies, which are disbursed by states. In the past, ensuring compliance with this rococo array of funding streams was a bureaucratic car wreck. MLPHP folded these compliance activities, along with compliance with the state's public health code, into a single streamlined process, saving time and money. MLPHP is governed by a Commission representing most organizations concerned with public health in Michigan, and it has had an ongoing quality improvement process, which has vastly improved communication between the state and local public health. MLPHP has been very effective. Since the inception of the program the performance of local health departments has steadily improved. Today, on average, most local health departments miss four or fewer of the approximately 190 indicators used in MLPHP during the review process.

How would a system of national accreditation compare to MLPHAP? There are 57 states and territories. A national system of public health accreditation could never take all the vagaries of state and local laws and regulations into account.  Instead, when PHAB created its national standards and measures it used a theoretical framework called The Ten Essential Services which describes the cycle of research-policy development-enforcement-evaluation that all public health agencies engage in, in one form or another. The application of this framework can be bracing for health departments. Governmental public health can slip into bureaucratic complacency--giving shot after shot, performing inspection after inspection--without asking if the effort is worthwhile. Undergoing national accreditation, staff at a local health department may feel for the first time that they really understand the mission of public health while gaining renewed respect for our special skill sets. So while local accreditation teaches the jot and tittle of the law, national accreditation imparts the heart and soul of public health: the science, methodologies and social and political context. An important distinction before proceeding: compliance with federal contracts is mandatory, but accreditation by PHAB, which is a free-standing non-profit corporation, is voluntary.

So there is the first "vexing challenge" to national accreditation: many state systems of accreditation are so effective at ensuring compliance with the law--increasing efficiency and saving money--that locals may be unwilling to adopt the voluntary national system, in spite of its virtues. You see, the national system does not eliminate the need for compliance with federal grants and contracts. All the contract grunt work continues, with national standards slathered on top as an extra layer. In this age of the Sequester, it can be too much to bear.

And there is your second "vexing challenge": it’s that the darn CDC itself, along with its brother agencies Environmental Quality and Agriculture, on the one hand splatter public health with a fire hose of contractual reporting requirements, and at the same time cooked up the Ten Essential Services and created PHAB and want us to do that dance, too, without funding any of it.

Why, oh why, didn't CDC and PHAB fold contract compliance into national accreditation, so we could do it once and be done? The requirements of the various siloed federal public health programs reflect the structure of the federal budget, and thus congressional priorities, not best practices in public health. Congressionally mandated reporting requirements are only going to increase, not decrease, at the same time that federal ardor for national accreditation grows hotter. It is what it is.

The third "vexing challenge" is funding. PHAB was created by people who care about public health, to help us rediscover our mission and basic public health science. But it is not an official federal program, and so it is not funded.  Thus PHAB has to charge fees for participation, which can run into tens of thousands of dollars, depending on the size of the health department. That’s right: we aren’t funded to comply with national accreditation, we have to take money from services to pay for it!

Amazingly, several local health departments in Michigan are doing both local and national accreditation--eating the costs and working their staff hard--in an effort to make their departments the best they can be.  MMDHD itself just completed local accreditation (missing only one indicator which has been corrected) and intends to apply for national accreditation by the end of 2013.

What about it? Can we fix what the Feds broke? Once again Michigan is at the forefront. Michigan has convened an ad-hoc Committee on Accreditation Efficiencies (I am a Co-Chair) to explore ways to merge the two systems (And we know for sure that PHAB is hopeful this experiment will bear fruit).  The Committee wants to see if it is possible to make the two accreditation systems feel like one system.  It is asking the following questions: 1) If a health department meets certain PHAB measures, can they be deemed to be in compliance with indicators in MLPHAP? 2) Are there MLPHAP indicators which, if met, PHAB would consistently accept as meeting PHAB measures? 3) How can we pay for a merged system? Would there be any savings in contract compliance costs from cross-walking the two systems that would enable the state to, at least partly, help defray locals’ PHAB fees?

Again, sorry about the wonk factor in this post.  But I feel like it is important for folks to know that people in public health aren’t just accepting the dysfunction in government that is out there, but are trying to find ways to make things work for our communities. I also feel like it is important for people to know how incredibly weird and difficult it gets when you try to do that. It is what it is.

Friday, August 9, 2013


On October 1st, 2013 open enrolment begins in the Marketplace, the on-line mall where eligible people (those with incomes between 133% and 400% of the Federal poverty level) will be able to buy health insurance under the Affordable Care Act. In many states, October 1st is also the day when open enrolment begins for people newly eligible for Medicaid. What we are hearing is that Michigan is likely to be one of those states, as it is increasingly likely that in late August the legislature will accept Federal funding to make Medicaid available to all citizens with incomes below 133% of the Federal poverty level.

This is a really great thing, because as many as a million Michiganders (maybe 15,000 in Mid-Michigan) who have been suffering without health insurance could finally be covered. More benefit will result from the expansion of health care coverage than many of us understand. First, the newly insured people will have access to preventive health services which will reduce premature death and disability. This will improve the overall health of our communities. Second, covering these people will reduce the cost of health care for people who already have insurance.  Why? Because the emergency room and other uncompensated health care costs of the uninsured show up in the medical bills of those with insurance and these will start to go away. Third, falling health care costs will benefit employers by reducing the costs of their employees’ benefit packages. This will help the whole economy.  Are you skeptical of these claims?  Keep reading because down below I’ll look at the experiences of the states that have already implemented the Marketplace.

Before I go there I have to acknowledge that many, many people are confused about the whole Obamacare thing. In reality, there are only two things you need to know about October 1st: 1) If you want Medicaid you can go to the MiBridges website and find out if you are eligible and sign up if you are. 2) If you want to shop on the Marketplace you can go to the Marketplace website (it’s not up yet) and find out if you are eligible and get health insurance there. And if you use the Marketplace you may qualify for a generous subsidy to help you make that purchase depending on your income. That’s it! You are now fully informed! All the rest of what you have been hearing is overheated political hype.

The graphic above helped me understand how simple it is. The Medicaid expansion will cover low income adults with incomes up to 133% of the Federal poverty level, or kids up to 200%. The rest of us with incomes up to 400% of the poverty level will be eligible to get a subsidy to get insurance on the Marketplace (when this chart was made it was called the Exchange).

But what about the whole “mandate” thing? Yes, it’s true that if you are eligible for the Marketplace, but choose not to buy health insurance, and if you owe taxes, then you will have to pay a little bit more in taxes ($90). They’ll use those tax dollars to pay hospitals to take care of the uninsured. That’s the big, bad mandate.

The challenge for local public health—indeed for the entire health and health care community—is that research indicates that as many as three-quarters of those who will be eligible for health insurance don’t know it!  Somehow we need to get the word out. And if we are successful, and folks want to sign up, we have to be ready to help them do it.  Making this much more difficult is the fact that the Michigan Legislature refused Federal assistance with the Marketplace. The State could have received $30 million to plan for open enrolment, but it declined. Because of this public agencies and non-profits across the State are being asked to do the work of preparing for open enrolment without funding.
Nonetheless, community agencies are trying to figure out how to respond. Michigan Consumers for Healthcare has helped pull together regional meetings to orient people to the Affordable Care Act.  You should visit their website if you’ve got questions about it.  And in each of our counties we are convening the community collaboratives to plan as best we can for open enrolment.  The Building Stronger Communities Council in Clinton, The Gratiot Collaborative Council and the Montcalm Human Services Coalition have all come together to create plans to publicize open enrolment and to tell community members where they can go to get help signing up for health care coverage.

OK, I promised to share some of the evidence about the benefits of the implementation of the Marketplace.  I’ll skip recent articles crowing about 30-50% reductions in premiums for individual plans in Oregon and New York.  It’s likely other plans and other states won’t see results that good.  Instead let me refer you to a more balanced article that gives a good overall analysis. In the article, Economist David M. Cutler concludes that growth in health care costs is slowing down as a result of the Affordable Care Act and that the economy will certainly benefit.  Indeed he says…

“Neither the sequester nor the Medicare tax increase in the Affordable Care Act would have been necessary if Washington had dealt with health spending some time back.”

As a final treat here is a link to a cute six minute video that shows how the whole plan is supposed to work.  Enjoy.   

Thursday, July 4, 2013

Health Disparities Should Be Taken to Heart

We were saddened by the death of actor James Gandolfini who died of a heart attack on June 19th, 2013. Interestingly, as is sometimes the case when a celebrity dies, his passing has been used as an opportunity to teach people about health and disease--in Gandolfini's case heart disease (think of Rock Hudson and HIV, Bette Davis and breast cancer). In my opinion, however, a big opportunity to teach about how disease and death really happen was missed by the coverage, and in one way the coverage was actually harmful. I'll write about that and what it has to do with public health in Mid-Michigan below, but first, how has the press covered Gandolfini's heart attack?

Writers like Ken Sepkowitz who wrote about Gandolfini in the Daily Beast on June 20th, and Maggie Fox writing for NBC on the 21st, appropriately used his death at the relatively young age of 51 to warn that heart disease remains the leading cause of death in the United States. As Sepkowitz wrote:

"The CDC tracks the impact of cardiac disease closely, and the numbers are staggering. According to their statistics, about 600,000 people in the U.S. die from heart disease each year, meaning heart attacks, heart failure, rhythm disturbances, and other problems. It’s the nation’s No. 1 killer. Of these deaths, coronary heart disease—the narrowing of the arteries that feed the heart—accounts for more than half the deaths."

The writers of these articles call for individuals to lead healthier lifestyles, for more awareness of heart disease, and laud improvements in medical technology. So, what's wrong with that?

One thing that is wrong is the perpetuation of the myth that a big killer like heart disease is not really a public health problem, but is more related to individual choices. It’s the idea that heart disease is happening because individuals are making "bad choices" and if they'd just stop it we'd be fine. The reality is that widespread heart disease is the result of public policies that harm people's health, and the solutions to it also lie in the public sphere.

Consider this: heart disease mortality rates have been cut in half in the past 35 years. In the jurisdiction of the Mid-Michigan District Health Department, heart disease deaths have declined from over 400 per 100,000 people in 1980 to 206 today.* This amazing drop is mostly due to the sharp decline in smoking--the rate of smoking was also halved during the same period. Significant reductions in smoking were only achieved after policies were enacted that prevent people from smoking in public places, workplaces, restaurants and bars. The other important contributing factor is advances in medicine--if you do get heart disease you are a lot less likely to die of it today--and these advances are largely the result of public, not private, investments. Thank goodness for these positive trends since as we know, other risk factors like obesity and hypertension have been moving in the wrong direction.

The other thing that is wrong is that the coverage continues to foster the belief that everyone needs to be equally concerned about heart disease. The reality is that heart disease, like most health threats, tends to prey on vulnerable, low-income people. Generally speaking, people of Mr. Gandolfini's stature, and others who are well-off (if not rich), are comparatively less likely to get heart disease than working class, unemployed, uninsured people and minorities.

For example, lower income people are twice as likely as those with higher incomes to be living with heart disease.  In Michigan, nearly 7 percent of those with incomes under $35,000 have been told by a doctor they have heart disease, while only 3.6 percent of those with incomes over $75,000 have heart disease.

Lower income people tend to have more risk factors for heart disease. Nearly 40 percent of adults with incomes under $35,000 have been told they have high blood pressure and 45 percent have high cholesterol. But among those with incomes over $75,000 only 26 percent have high blood pressure and 36 percent have high cholesterol.

Do low-income people really die at a higher rate from heart disease? Of course they do, and we see this at the Mid-Michigan District Health Department.  Consider one of our counties, Clinton County, which is one the state's wealthiest, with an average household income of over $58,000 dollars per year. Clinton has a very low heart disease mortality rate, only 181 per 100,000 people. In contrast Gratiot and Montcalm are lower income counties with household incomes right around $40,000. The heart disease mortality rate in Gratiot is 244 and it is 204 in Montcalm.

The failure to acknowledge these health disparities makes it very difficult for people to identify the kinds of actions that are truly necessary to improve health—actions that would reduce the economic and social inequality that cause so much poor health in the first place. For example, groups that are still called “minorities” (although they are majorities in some other parts of the country), like African Americans, Hispanics and Asians are still in the low single digits as a percentage of the population in Mid-Michigan. This leads some to say, “We don’t have diversity here”, or “We don’t have disparity here.” And if we don’t have diversity or disparity then health problems here must not be due to inequality, they must be due to “bad choices”.  How can Mid-Michigan elected leaders vote against the expansion of Medicaid to bring relief to their constituents who are suffering without affordable health care (Courageous Senator Roger Kahn is a notable exception)? Because, they think, around here we don’t have disparity, we have people who made bad choices who have to live with the consequences.

But the reality is we DO have disparity in Mid-Michigan: severe, lingering economic and social inequality that is all the more pernicious because it is invisible to some of us—invisible even though it is obvious in the unemployment statistics, the poverty rates and on the faces of our clients at the Health Department.

The best way writers like Sepkowitz and Fox can help Americans fight disease and death is to emphasize at every opportunity its economic and social causes. When we can see the inequality around us, then we’ll be able to embrace policies, like Medicaid expansion, that can change it.  

A happy, healthy Fourth, everyone! 

*The data used in this post come from the Michigan Department of Community Health and can be found at In particular look at the Behavioral Risk Factor Survey which has data broken out by income.

Friday, May 10, 2013

MMDHD and the Velsicol PBB Contamination

I think most people who live in this part of Michigan know the story of the Michigan Chemical Corporation (later Velsicol Chemical Company) that operated in St. Louis from the 1930s-1970s.  The factory manufactured DDT and PBB, as well as salt and other chemicals.  In terms of jobs, those were good times for Gratiot County, but some products were toxic, and the factory—now defunct—skirted environmental stewardship and regulations.  Tons of DDT was dumped into the Pine River (now an EPA Superfund Cleanup Site).  In 1973 PBB was accidentally shipped to a Farm Bureau plant in Battle Creek and mixed with livestock feed.  It was fed to animals which our citizens ultimately consumed.  It was the largest chemical contamination in the history of our country.  The story is well told in the book “The Poisoning of Michigan” by Joyce Egginton. (Norm Keon donated a copy to our library in 2010 and encourages all of us to read it.)

This incident is personal for the Mid-Michigan District Health Department. Some Department employees or relatives worked at the factory or lived in the immediate neighborhood, including our Medical Director Dr. Graham, who had a summer job there while he was in college.  Like other residents of the area, these people live with uncertainty as to how their health or the health of their loved ones has been affected.
One of the first things I asked when I came to the Department was what our role was in the mitigation and monitoring of the after-effects of the PBB contamination. I was saddened to learn that—although our Environmental Health unit wanted to be actively involved—there was little we could do. We had no funding for testing or counseling or any of the things a more-well-endowed Department might have done.  All we could do was continue to be a witness to this tragedy.  Our epidemiologist, Norm Keon continued to attend the Pine River Citizen Superfund Task Force.    

It was through the Task Force that Norm met people from Emory University’s Rollins School of Public Health, including Dr. Michele Marcus. She and her colleagues want to study the long-term health effects of PBBs.  And so they are collaborating with MMDHD’s Epi team to start a small project and go after a bigger grant from the National Institute of Environmental Health (NIEH).  MMDHD is going to do blood draws from 20 exposed people, including MMDHD employees who were exposed. Emory will use the analysis of those samples as data for a proposal to the NIEH for a major study, which they say has a good chance of being funded. At last, we have something we can do to try to help our community recover.
This all makes me think two things: First, even if all you can do is hang in there with your community and be a witness to its big health challenges, do it. Norm’s patience and vigilance has borne fruit after years of waiting. Second, the best possible outcome of all this would be to get a big NIEH grant, help Emory do a definitive study, and find: absolutely nothing; to have conclusive proof that the nightmare is over. 

Sunday, April 7, 2013

Searching for a Business Model for Public Health

Have you read the recently released report by the Trust for America’s Health, “Healthier America 2013”? It is an excellent attempt to summarize the opportunities for public health to transform itself during the roll-out of the Affordable Care Act. Over and over again the urgent need for public health to work hand-in-hand with health care systems is highlighted in the report. 

Public health departments must adapt to work with new entities and financing mechanisms in the reformed health system, such as by working with Accountable Care Organizations (ACOs) or within newly capitalized care structures and global health budgets, to help improve health beyond the doctor’s office.
A key component of this, obviously, will be the ability to exchange health information with other parts of the health care systems electronically. Let’s consider my health department’s Maternal and Infant Health Program (MIHP) as an example. This program coordinates care for pregnant women and their children, many of whom are facing serious risks in their pregnancies. Our health department has an electronic health record (EHR) system. We manage our MIHP cases using the EHR which works quite well. We are completely paperless—well, almost.

In managing these cases we collaborate with  the families' primary care providers. The providers refer patients to us, and we coordinate their care with the providers. Information going back and forth between us and them still goes by old-fashioned, messy faxes. Just this morning, I found two “lost” MIHP faxes floating around in our copy room.  We would love to join a Health Information Exchange (HIE) so we would be able to exchange this information directly out of our EHR and ditch the faxes.

In fact, last week we met with one of the two big HIEs in our state to talk about doing just that. This HIE offers a sweet product for managing referrals which is exactly what the MIHP program is looking for. Physicians’ offices in our area are starting to jump aboard the HIE.  We would love to go forward, but there is a snag: the cost.

Participating in the HIE would only cost a few thousand dollars. The problem is that our health department is looking at possible budget cuts next year of tens of thousands of dollars. Our state pays for part of public health out of a health fund that is going to take a big hit this year; there is sequestration; and some of the counties in our district are warning that their general funds are still underwater.
Another complicating factor is that our health department is between two large medical trading areas, each with its own HIE. In order to provide MIHP services electronically across our district, we would need to join two HIEs, at twice the cost. Most frustrating of all, the two HIEs only exchange information between themselves using a protocol called Direct, which is very limited.  It’s kind of like secure email. It would not permit the kind of exchange we really need to make MIHP referrals efficiently.

Yet not joining the HIE at this point poses a risk, too. As more and more physicians join the HIE more of them will be making referrals electronically using the HIE’s product. If the health department does not appear in their system because we haven’t joined, referrals for things like MIHP, family planning and the various testing and screening services we offer will start going elsewhere. Now, I don’t think government should be competing with the private sector to deliver these services. My concern is that medically complicated or vulnerable people who should be seen at a health department may miss that opportunity. Our services need to be sustainable so that we can be here for those who need us.
That’s the challenge we are wrestling with: We need to come up with a business model through which programs like MIHP can generate the revenue we need to be part of our local HIEs. If we are part of the HIEs we'll be part of the future. If not... Will we be able to do it? Our team is working like crazy on that problem now.

Tuesday, March 12, 2013

Bending the Cost Curve--The Role for Public Health

As I think about the Mid-Michigan District Health Department, one question I ask myself is, “What is the single most important thing the Health Department should be doing?” The answer I give to that question is not one I often hear in public health circles: Helping to reduce the cost of health care.

Before I explain why I answer in that way, let me tell you why I didn’t name two other answers I could have given.  I didn’t name “provide basic public health services” like WIC, Family Planning, Children’s Special Health Care Services, etc. The reason is that we are not the only source of these services. If we disappeared, people would still be cared for, although it would be more cumbersome and fewer people would be served. But the truth is, if WIC disappeared, moms would get food from food pantries; if our Vision program were not available, kids would get glasses from the Lions Club. So those services, while important, aren’t the MOST important.  Another program I didn’t name was the On-Site Sewage program in Environmental Health. There is a great argument for naming it the most important, and that is how poor surface water quality was before modern septic regulations. Before our sanitarians could enforce modern regulations many of the beautiful lakes and rivers of Mid-Michigan were essentially open sewers. The only reason I didn’t pick On-Site is because I think what I did pick—reducing the cost of health care—is where we will find the money to continue to work on improving environmental quality.
I think everyone knows the cost of health care in the United States is out of control. It costs nearly twice what it costs in most other countries to deliver comparable health care services. But because so many Americans are uninsured (which is not true is other, similar counties), lack of access to care means we actually have worse health outcomes than other places with similar economies (Click here for more information  The cost of health care hurts us in other ways, too.  For example, employers have to spend more on health insurance for their employees, or else they drop it altogether.  It is well known that workers without health insurance are less productive.  Either way, it makes their businesses less competitive than similar businesses abroad.  Poor competitiveness cuts employment and reduces profits. The cost of health care also makes government expensive. Medicare and Medicaid cost too much, bloating the national budget. The cost of providing health insurance to government workers means we are faced with a choice between cutting programs or raising taxes.
I think there is a crazy feedback loop in there, too. It’s pretty easy to show that one of the strongest drivers of health is the economy. The most affluent communities are the healthiest, and vice-versa. By dragging down the economy, the cost of health care is probably making us sicker.

That’s huge: if we could control the cost of health care, we’d be healthier and wealthier. But is there a role for public health in controlling healthcare costs? Is there are role for a local health department?
Obviously there is.  For example, because WIC supplemental nutrition programs are available for moms, more babies are born full term and neonatal intensive care costs are avoided. Food and water programs prevent the spread of gastrointestinal illness and prevent emergency room costs. It’s easy to show that wherever bans on smoking in public places, bars or restaurants went into effect, emergency room utilization dropped the next day (
However, the cost of healthcare is still going up! So however great public health’s contributions have been, we haven’t done enough to get the outcome we want.
Many people in public health think that we are going to reduce the cost of health care by explaining this situation to our neighbors and elected officials. When they get the bad news people will clamor for tax increases to fund an expansion of public health services. Look, if we did that, it would work; and it would cost a lot less than what we are going to do, but the public won’t there. Sadly, our polity seems content to inadequately fund law enforcement, schools, mental health, other critical services and public health, too.
The place in the system where there are still resources for innovation is healthcare. Public health needs to accept this state of affairs, and to figure out how to partner with the healthcare system to improve outcomes and reduce costs. The tools we need to reduce costs are being developed in the healthcare system and that’s where we need to go.
In fact, thoughtful people have already anticipated this and have laid out a road map for us. The Affordable Care Act, for example, contains specific incentives to connect the provision of health care services to community-based preventive services. Under the ACA the Centers for Medicaid and Medicare Services are encouraging states to stimulate collaboration between prevention providers and care systems through State Innovation grants.

In the State of Michigan, Governor Snyder and the Director of the Michigan Department of Community Health, Jim Haveman, have landed a State Innovation planning grant and have funding to support three pilot sites in Ingham County, Saginaw and Muskegon. They are interested in promoting a model of collaboration developed by Mark and Sarah Redding of Ohio called Community HUBs. The HUB model is local, connecting human service providers, mental health and public health to local physicians and hospitals. Under the model, prevention providers demonstrate the return on investment of the services they provide and market these services to health plans, health care providers and hospitals. It is said that the HUB model is already working in two dozen sites across the country.

I’m very excited by the HUB model, because it promises to reduce the cost of health care locally, and use part of the savings to sustain existing public health services and even expand them, not just in health departments, but in other community agencies. I know the HUB concept is not self-explanatory and I’ll write more about it in a subsequent post.

Monday, February 11, 2013

There's Good News, and There's Bad News

One of the most important functions of public health is to monitor the health of the communities we serve and share what we learn—we call this activity community health assessment.  We argue that when people have objective information about health, they will make better public policy decisions.  All other things being equal, I do think that is true. Of course all other things are not usually equal: in our politicized, market-driven world information is manipulated, and people don’t easily let go of strongly held beliefs even when presented with objective information that challenges those beliefs.  So we also have to spend time working to establish the conditions under which people can appreciate objective information.
I recently prepared an orientation for three new members of the Mid-Michigan District Health Department’s Board of Health.  I thought a fun way to introduce the concept of community health assessment would be to challenge the Board members to guess which way health trends are moving:  homicide deaths—up or down? Drug deaths—up or down? And let them have a freewheeling discussion about what the trends mean. I thought the exercise was a lot of fun and the trends we looked at were surprising to me, so I thought I’d share some of them on the blog.
I wanted to get easy-to-understand data which I could graph myself. So I went to the Michgan Department of Community Health’s website, and clicked on “statistics”.  I found a ton of good stuff.  For those who are interested I put some technical notes at the end of this post.
The first thing I want to share is the homicide rate in Michigan shown in the chart below. I was surprised at the clear long-term downward trend, surprised no doubt, because the recent mass shootings are on my mind.  
The chart gives the rate of homicides per 100,000 people. In 2010, 6.4 out of every 100,000 residents were intentionally killed, which is just a little over half the rate in 1988 when 11.8 residents were killed for every 100,000 (Click here for more information). 
One chart by itself can’t answer all our questions.  For example, you might suspect that homicides are down because the population is aging—a smaller proportion of the population is at the age where people are likely to commit homicide.  The MDCH website has data that address this question, showing that Michiganders of all ages are truly less homicidal than we used to be.  You might also wonder if attempted killing is rampant, but our phenomenal emergency rooms are simply saving more of the victims. That’s not it—while it’s true emergency medicine has improved, assaults are down, too. 
If we are mostly interested in gun violence, we might want to know whether the proportion of homicides accounted for by guns has changed over time.  Indeed it has and the increase in homicides you can see in the chart that goes from about 1983 to 1992 was caused by an increase in handgun violence. But on average, over time, guns have steadily accounted for a little over two-thirds of all homicides. People who worry about guns also care about suicides and accidents. Guns are used in most suicides.  In fact the rate of suicides has been fairly flat over time.  In 2010 there were 12.5 suicides per 100,000 residents, exceeding the rate of homicides.  In addition, if you believe that some places have higher homicide rates than others you’d be absolutely right. Low-income urban neighborhoods often (but not always) have high homicide rates, but so do some low-income rural areas. African-Americans are more than four times as likely as Whites to be a victim of homicide. This graph obscures the tragic disparity in homicide deaths between communities. 
And finally, even though homicides are down so much, it doesn’t mean guns are not a problem. When you combine all the forms of mortality from guns: homicides, suicides and accidents, deaths from guns are about double deaths from all forms of homicide combined. Still, given what’s on the news right now, I was really surprised to learn that, over all, we are a lot safer from homicide than we were in the recent past.
Here is another trend that surprised me: drug-related deaths. Again the data are displayed as the rate of drug related deaths per 100,000 residents. The chart below shows that between 1999 and 2010 drug-related deaths in Michigan increased over 240 percent from 7.1 to 17.3 per 100,000.
What accounts for the explosion in drug-related deaths? Chrystal meth? “Bath salts”? In fact, deaths from legal, prescription drugs outnumber deaths from illicit drugs.  Deaths from legal, prescription opioids and hypnotics increased by a factor of four during the time period covered by the chart (Click here for more information).
The data in the chart include many related ways of dying from drug use: taking drugs to get high and overdosing, mixing drugs or drugs and other substances, accidents and injuries (such as car crashes) related to drug use, and it includes prescription errors by the health care system.  One of the most commonly abused substances—sometimes called a drug—is alcohol, and this chart does not include alcohol related deaths (unless another drug was involved). Alcohol related mortality in Michigan has been fairly constant over time. In 2010, 8.1 persons per 100,000 died from a cause related to alcohol use. Deaths from legal, prescription drugs have surged past alcohol alone as a cause of death.
Many things are being done in the counties we serve to try to combat drug related deaths. Clinton, Gratiot and Montcalm counties all have programs to permit people to safely dispose of prescription drugs. The area hospitals are implementing policies to curtail drug-seeking in EDs. And many pharmacies will take back unused medications. Still, I was really surprised that drug-related deaths are 2.7 times more common than homicide deaths. 
Rattled by the scary news about guns? Well, think twice before asking your doctor for a prescription to calm yourself down!
The data in both charts are the rate per 100,000 Michigan residents. Graphing it that way protects against the mistake of thinking, for example, that homicides are trending down when really all that is happening is people are leaving the State resulting in fewer homicides.  
The reason that the most recent year in both charts is 2010 instead of a more recent year is that it takes a long time to accurately finalize the details of death certificates, especially those involving crimes, and then it takes more time to analyze the data and put it on line, especially with staffing levels at MDCH being so low.
The data have been age adjusted. Homicides are more common among younger people so in an aging population the trend could appear to be going down, even if younger people were actually experiencing more homicides per capita. Age adjusting is a simple procedure that fixes this.

Friday, February 8, 2013

You Never Know What Will Catch On: Do 1 Thing

A few years ago Mid-Michigan first responders and public health workers gathered in Lansing to wrestle with the problem of how to encourage people to take preparedness more seriously.  The idea they came up with was a marketing campaign they dubbed “Do 1 Thing”.  Do 1 thing encourages people to take a moment once each month to do one thing to be more prepared for emergencies.  It breaks preparedness down into simple steps that any family or person can take: designating a place to meet if you have to leave your home, making a plan for how you would assist an elderly relative, storing some clean water, etc.  Do 1 thing is promoted through public service announcements, a website, printed calendars, etc. At their website you can sign in and over the course of a year it will walk you through 12 simple steps to be more prepared. And you can follow it on Twitter at @Do1ThingUS.

Now Do 1 Thing is starting to get national attention. CDC is recommending its use to other communities around the country. Victoria Harp of CDC’s Office of Public Health Preparedness and Response said, “Our Learning Office has highlighted the work of the Do 1 Thing project as a great example of a Whole Community approach to emergency management.  This year our Communications Office is committing to the program.”  CDC and FEMA will be promoting Do 1 Thing to communities throughout the year.

People from the Mid-Michigan District Health Department’s service area who worked on the project included Lynda Farquharson our Emergency Preparedness Coordinator, Jennifer Churchill who was our Public Information Officer and Larry St. George and Steve Lehman from Clinton County Emergency Services. Thanks to them and everyone who worked on the project and congratulations for starting a national trend!

Tuesday, January 8, 2013

Public Health Poetry

The flu vaccine cannot give you the flu, I tell him.
It's dead virus, there's nothing alive about it.
It can't make you sick.  That's a myth.

But if we bury it in the grassy knoll of your shoulder,
an inch under the stratum corneum, as sanctioned by your signature
in a white-coated ceremony presided over by my medical assistant
and then mark the grave with a temporary non-stick headstone,

the trivalent spirit of that vaccine
has a 70 to 90 percent chance of warding off the Evil One,
and that's the God's honest truth.

"Myth Dispelled" by Adam Possner, from JAMA, December 5, 2012.
© American Medical Association, 2012.

Friday, January 4, 2013

Why Flu Spread So Fast In Those Schools

On December 10, 2012 the Health Department got a report from Shelly Millis, Superintendent of the Montebella Schools, that 180 children and teens were out sick with flu-like symptoms.  Some had tested positive for influenza types A and B. Our Medical Director, Dr. Robert Graham recommended that the schools close to halt the further spread of the illness. (This was a recommendation to the Superintendent who made the decision herself.  It was not a case of the Health Department ordering the school to close.)

Ten days later, on December 20th the same thing happened at Central Montcalm schools. With 259 students  out, Superintendent Kristi Teall made the decision to send everyone home. Coincidentally this was the same week some schools were dealing with gun rumors in the wake of Sandy Hook shootings.

Why did the flu spread so fast in these schools?  We used data from the Michigan Immunization Registry to examine the influenza immunization status of the students in the Montebella Schools.  Only 22 percent of the elementary age students had up-to-date flu shots, and only 4 percent of the middle and high school age students did. Four percent!

With so few students protected against the flu, it’s no wonder things got out of hand so fast.  Very few students had any level of immunity so the virus spread easily.  We are used to thinking of the decision to get a flu shot as an individual choice.  But getting a shot is a much about protecting others as it is about protecting ourselves. Everyone’s lives in those two schools were disrupted because they didn’t have “herd immunity”.

This is discouraging. The Health Department used to give thousands of flu shots every year, but now it is down to around 1,000 per year and falling fast. Now that so many pharmacies give flu shots, we hope people are going there to get their shots, but maybe that is not working as well as we hope it will.

By the way, the flu is here in earnest. In the graph below from the CDC, the red line is the percentage of people showing up at emergency rooms with flu-like symptoms. It is headed up fast meaning an early, and probably pretty intense flu season.

It’s not too late to get a flu shot. If you get one tomorrow it will kick in in about two weeks. But the flu season should last at least 10 more weeks so it should be worth it.

Thursday, January 3, 2013

We Don't Do That Anymore: Disappearing Public Health Programs

The federal government funds many programs intended to support local public health services including testing and treatment for diseases like HIV, other STIs, tuberculosis and lead poisoning; disease outbreak investigation; family planning and many more. It may come as a surprise, but the truth is that many local health departments do not offer many of these programs, leaving residents of those communities without access to needed health services.

At the Mid-Michigan District Health Department a good example of this comes from the Breast and Cervical Cancer Control Program (BCCCP).  Breast cancer remains one of the most common cancers diagnosed in women. Most forms of breast and cervical cancer are highly treatable if detected early enough.  But low-income, uninsured women are not able to afford to be screened, resulting in cancers progressing to late stages before being detected and thus higher death rates.  In 1990 Congress created the Breast and Cervical Cancer Control Program (BCCCP) providing money to States to help low-income, uninsured women gain access to breast and cervical cancer screening and diagnostic services. These services include—
  • Clinical breast examinations.
  • Mammograms.
  • Pap tests.
  • Pelvic examinations.
  • Diagnostic testing if results are abnormal.
  • Referrals to treatment.
And yet MMDHD is only able to offer these services in two of the counties we serve, Clinton and Gratiot, because of the intervention of local hospitals. We do not offer these services at all in Montcalm County (Although the Montcalm Area Health Center does).

The dilemma the State faces is that the funding for the program only enables it to offer BCCCP in full form to coordinating agencies in a couple of dozen communities across the state.  The coordinating agencies’ budgets include staffing to manage the program and arrange for follow up care if it is required.  If you are not one of the coordinating agencies you can participate in BCCCP but the only funding you get is a per-client payment that does not cover your costs.

In 2010, running an unsustainable deficit, we had to eliminate our BCCCP program. Before I go any further I need to say that it is a well-established fact in health research that distance to care is inversely related to outcomes. We see this both in rural areas, and in urban neighborhoods that have few providers.  So the fact that Mid-Michigan women would have to get to Grand Rapids, Lansing or Saginaw for screening meant that some would not be able to do so, with the inevitable result that more would have untreatable cancers.

Amazingly, when they heard the program was being eliminated, Sparrow Clinton Hospital and MidMichigan Medical Center-Gratiot stepped in and provided funding to the tune of several thousand dollars each.  Each year nearly a hundred and fifty women get screened and get follow up care if required, because of these generous partners.  Unfortunately, not all low-income rural and urban communities have a provider in a position to be their benefactor.

My last word is about true prevention. Remember, most cervical cancers can be prevented by the HPV vaccine. It is important for boys and men, as well as girls and women to get the vaccine so they do not spread HPV to their partners.  That’s a much better idea than an expensive screening program.