Monday, June 29, 2015

Working More Earning Less

Health Departments and their employees are responsible for displaying cultural competency: that is, we need to have knowledge about the lives of the people we serve and have command of resources that are appropriate to their needs. We need to understand that health inequities exist--that access to the resources to promote health is unequally distributed; and that in order to combat this we need to work to modify the root causes of health inequity.

I often struggle to articulate these concepts both with my coworkers and to community members. The Mid-Michigan District Health Department (MMDHD) is in the process of renewing the community health assessment and improvement plans (I will just call them Assessments) our communities have created in all three of the counties we serve. In updating the Assessments, I happened upon a new (to me) way of understanding what is happening economically to our communities. It gave me a new way to try to show community members something about inequality and how it is connected to root causes.

Some quick background on our Assessments: The three counties we serve--Clinton, Gratiot and Montcalm--are so different from each other that it does not make sense to do a single Assessment for the entire district. It would be easier, but the results would not really reflect the characters of the counties. The project in Montcalm is called Healthy Montcalm; in Gratiot it is Live Well Gratiot; and the Assessment for Clinton County is a regional project involving Ingham and Eaton counties which do think of themselves as being part of a unified region. It is called Healthy! Capital Counties.

Here are three charts that I have been sharing with residents during our discussion of the root causes of health problems, especially health inequity. These slides happen to be for Gratiot County but the picture is the same in all three.

The first chart, above, is unemployment. Unemployment was so high a few years ago it was difficult to fathom how we would ever get out of it. Happily, unemployment is returning to more normal levels and our counties are catching up with the State as a whole, which is catching up with the nation. Now for the bad news…

This chart, above, is average household income. The chart shows that while we are working, we are not earning more money. You would think if there are more wage-earners in households, because employment is up, that household incomes would be rising, but they are not. Now for worse news…

This chart is of the poverty rate, which continues to increase in spite of increased employment. As we just saw, average household incomes are not changing, but inflation is chugging along at its expected 1-2 percent per year. So slowly more and more households are sinking below the poverty line. One term that people use to describe such households is Asset Limited Income Constrained (ALICE). People are working, but their incomes don’t cover even the basics.

The story this tells is very important in explaining people's behavior--they are working but they are less and less able to access basic care for themselves and their families over time. This is why the expansion of Medicaid is so important. As Michiganders lose ground, Medicaid provides a way for them to access preventive and health services.

Finally, Michigan's legislature, believing that suffering may cause low income Michiganders to work harder and earn more, wants to mandate that after two years on Medicaid, they must go into the health insurance marketplace with its huge deductibles and co-pays. Michiganders just can't afford it. They are working, but their incomes are not going up.

The final thing about all this that bothers me is that these charts also describe MMDHD's workforce. My team worked without any pay raise for a number of years, and the increases they are getting now just keep pace with inflation. Part of what is so crazy about this is that their skill levels keep increasing as they learn new technologies and apply concepts, like quality improvement, to making their work more and more efficient. But their pay does not change to reflect this. In this way they are exactly like the people they serve. Maybe understanding this will help to see--it's not an us/them thing, it's just us.