Sunday, May 7, 2017

Public Health Policy and Social Class

How does social class prejudice reveal itself in public health? Among conservatives it might be the attitude that low income people deserve to be sicker, and we don’t need to help them, because they are lazy. Liberals have their attitudes, too. For example, “we are experts and know best what you poor folks need,” although that, too, is often not true. I’ve been thinking about this in connection with public health programs that just don’t work the way they should: transportation benefits that people have too much trouble using, mental health coverage that is inadequate for the problems many people face, cuts to programs that have worked well; and yet public health tolerates these situations! Why? Let’s explore one concrete example how social class works in public health: efforts to reduce tobacco smoking. 

Tobacco is the drug of choice for low income Americans. For example in Gratiot County we found that 31 percent of adults who earn $20,000 or less smoke compared to 9 percent of adults who earn $75,000 or more. Twenty-nine percent of mothers smoked while pregnant!  This is a really big deal. In another blogpost I wrote about how heart disease deaths are increasing in rural Michigan. 

Today, public health in Michigan has two favorite ways to try to help people quit. First, you can sign up to get friendly text messages that encourage you to keep trying; second, Michigan like other states has jacked up taxes on cigarettes to high levels (not high enough for some) in hopes of making smoking too expensive. You can find lots of research that says these two approaches are effective in getting people to quit, but they aren’t, at least among low income people. The reason public health says texts and taxes get people to quit smoking is because that’s all we’ve got left. Our general fund budgets are far less likely to support tobacco cessation programs than they once were, and health insurance, including Medicaid, doesn’t reimburse enough for us to support cessation programs by billing insurances—but still, we want to be able to say we’re doing something.

The Campaign for Tobacco Free Kids publication “Tobacco Tax Increases Benefit Lower Income Smokers and Families” reflects the official consensus stating “increasing price is proven to reduce smoking, especially among kids and among those with low incomes.”

But not everyone agrees. In “Poor Smokers, Poor Quitters, and Cigarette Tax Regressivity” appearing in American Journal of Public Health, Dahlia Remler found, “cigarette taxes heavily burden poor smokers who do not quit, no matter how tax burden is assessed.” In another study in the Journal of Policy Analysis and Management, Remler said, “Very high cigarette taxes, however, have a dirty little secret: their regressivity. Overwhelmingly and increasingly, smokers are concentrated among the poor. Moreover, our era of rising cigarette taxes is also an era of dramatically rising income inequality and possibly lower purchasing power for the poor.” 

The public health community has rallied behind the taxes. The Campaign for Tobacco Free Kids says, somewhat snarkily, “it is smoking itself and its health harms that are hurting the lower-income population,” not the taxes. Therefore the Campaign is not responsible for the harms of the taxes. The social class bias in this attitude is somewhat breathtaking. You can almost hear someone huffing “if they are too stupid to quit, screw them.” The Campaign is a left-leaning progressive public health organization, but here, their attitudes are similar, for example, to Republicans in the House of Representatives who think it is OK to get rid of health care benefits for low income people because they “made bad choices.”

But evidence is mounting that tobacco taxes are harmful to the poor. Katherine T. Hirono and Katherine Smith published a review of the literature and concluded that “very large cigarette tax increases unintentionally harm the most vulnerable in society: smokers who are homeless, very low income, and/or suffer from mental illness… Low-income smokers who either can't or won't kick the habit following large tobacco tax increases face increased financial hardship, and so do their families.”

But surely low income people don’t give up food or other necessities just to keep smoking? Remember that tobacco is very addictive. A study by the Research Triangle Institute showed that low-income smokers in New York, which had the nation's highest state cigarette tax, spent nearly a quarter of their household income on cigarettes. Nationally, those with the lowest incomes smoke less, but still spend just over 14 percent. 

In raising these issues, I want to challenge my colleagues to think about how social class influences our response to the unintended consequences of our liberal policies. In 1920, in the face of rampant alcoholism, who could have imagined that prohibition would cause alcohol-related mortality to soar out of control? But it did. But that wasn’t the worst failure of public health at that time. The real failure was refusing to support the repeal of prohibition once it was understood that the law had made things worse. The public health community supported prohibition to help people avoid the harms of excessive alcohol consumption, but couldn’t change course even after it understood prohibition was making things worse. 

Yes, it bothers me that Michigan’s Mackinac Center, which opposed the Affordable Care Act, also opposes tobacco taxes. And I worry my musings may be mistaken when I see that my own public health association, the Michigan Association for Local Public Health, strongly supporting increased tobacco taxes. But we need to remember that real human beings are the objects of our policy prescriptions. I remember meeting a low income woman at a community event where Chantix, a drug that helps people quit, was being distributed. She began crying. A tobacco cessation counselor hugged her and said, “You’re afraid you won’t be able to quit” and the woman sobbed, “I’ve tried so many times and nothing works.” I didn’t know people cried about not being able to quit smoking until I saw it. 

Think about this: it is difficult to argue that we raise cigarette taxes because we really want to help low income people quit, given that we do so little else to help them do so. If we wanted to help people quit we would use the tax increases to address the problems in people’s lives that keep them smoking. But we don’t. In Michigan we have used tobacco tax revenue for things like scholarships, school aid and debt service. I agree those things are important, but so little tobacco tax revenue goes for smoking cessation in Michigan that the State gets a grade of F from the American Lung Association for its paltry tobacco prevention efforts. The real reason for the taxes is to plug budget holes, and we don’t lose sleep thinking about the woman who spent her last dollar on cigarettes and doesn’t know what she will eat tomorrow.

Thursday, January 5, 2017

Obamacare and Local Public Health

A lot of times I ask my wife, Debra Bennett, among other people, to read potential blog posts. Her comments help me communicate more clearly.  This time she told me this post is too complicated, and I should concentrate on explaining to people, in clear simple terms, how repeal of the Affordable Care Act would impact them directly. I haven’t taken her advice and the reason for that is I want to use this blog, not for simple advocacy, but to expose the real challenges faced by local public health.  There are probably 6,000 people working in local public health across the State and the purpose of this blog is to show others what we see every day.  The vast majority of local public health departments are located in rural parts of Michigan. These are places where heart disease mortality rates for low income people are rising, where suicide and heroin overdoses are surging. Local public health departments are madly trying to figure out what is happening and what can be done about it.  This is also Trump country. We spend much of our time, whether it is talking about a contaminated well or helping a mother get respite care for her handicapped child, loving on people who decided to use their votes to “shake things up”, and because of the election things are likely to get that much more difficult for everyone. The details of this story are complicated and technical, and what I’m trying to do here is let people see some of these details--details that are ordinarily invisible to most people.


When Donald Trump was elected people became concerned that the next Congress would repeal the Affordable Care Act (ACA or “Obamacare”). However, some pundits reassured people that Congressional action would not be too extreme. For example, well-informed commentators appeared on Politico’s Pulse Check (It’s the episode entitled “Obamacare Endangered”) and said that while Congress may repeal the ACA, it would actually retain important parts of it, because Congress would not want to take away people’s health insurance, and because the ACA is actually good for the health care industry.

But the incoming Congress is not behaving so rationally.  Now journalists are writing that the next Congress is likely to repeal many of the most important and beneficial parts of the law, including the expansion of Medicaid. What does this mean for public health? Sure, people will lose their health insurance, but that won’t impact local public health directly, will it?  Sure it will.  Repeal of the ACA would unravel much of the innovative work to strengthen preventive services that local public health has been engaged in for the past six years.  And understanding this helps show how repeal of the ACA could literally be deadly to those whose lives have been changed by it.

This isn’t just about protecting programs. Any time legislatures attack health care or public health people get sick and even die as a result. A contemporary example is what happened in Texas after their legislature cut funding for family planning services in 2011.  You might be surprised that cutting family planning funding could have a big, negative impact on health.  In fact, family planning is counted among the ten great public health achievements because when women acquired the ability to control their fertility both infant mortality and maternal mortality plunged. MMDHD is the only public provider of family planning services in our three counties (Cherry Health provides services to people for whom they are the primary care provider). These services include comprehensive personal health services--not just birth control—for people who might not be getting care anywhere else. The Texas legislature cut funding for family planning in order to close down Planned Parenthood clinics because some help women get abortions, and did not consider the impact losing access to their other services would have on women’s health. As soon as the funding cuts went through maternal mortality doubled!*  

Yes, I am afraid Michigan could be facing something similar, soon, not necessarily because of cuts to Planned Parenthood—the Michigan legislature made a lot of noise about doing that only to discover Michigan gives no money to Planned Parenthood—but because of the impact that repeal of the ACA could have on public health.

There are three major ways that repeal of the ACA could impact public health. The first would result if repeal leads to the elimination of the Healthy Michigan Plan (expansion of Medicaid) or the Health Insurance Marketplace ( or “Obamacare”). More than 640,000 additional people have gotten health insurance through Healthy Michigan and an additional 313,000 bought health insurance through the exchange.  Nearly one million Michiganders will lose health insurance if these plans are eliminated.

But it isn’t the loss of the ability to go to the doctor that is the issue. The reality is that primary care doctors don’t necessarily do a very good job of serving low income, vulnerable people who tend to have complicated problems that extend beyond their specialty. Health insurance enables these people to access other preventive services such as mental health and substance abuse treatment, smoking cessation and rehabilitation. Losing health insurance means people will lose all this other stuff, too, and these services are the ones they really need the most, that help them recover their health.

The second way that repeal of the ACA would impact public health has to do with new, innovative public health programs that have been stood up over the past six years leveraging opportunities in the ACA which could be swept away. The ACA has changed the environment in which providers of preventive services are operating so that they are encouraged to create and experiment with new ways of finding at-risk people and meeting their needs. Elsewhere I have written about activities like the diabetes prevention program, co-location of mental health and physical health services and community health workers (CHWs) which are directly aimed at enabling the sickest and most vulnerable people to receive services they need to recover their health. To provide just one concrete example of how this has worked in Michigan, Medicaid health plans are now required to support community health worker (CHW) programs. This requirement was enacted as part of the Michigan’s State Innovation Model, its implementation of the ACA. CHWs meet peoples’ non-medical needs (housing, food, transportation, etc.) to get them to the point where they can begin to focus on health. For example, MMDHD has created a CHW program that focuses on adults with chronic diseases.  In Saginaw there is a CHW program that focuses on people with mental health problems and Muskegon has a program for women with risky pregnancies. Michigan’s CHW programs were evaluated and shown to improve health outcomes and reduce costs, but our elected leaders may decide that’s no reason to keep them around.

For an employer, writing on-line about the challenges your operation is facing can be fraught. Yes it is good to try to attract attention to potential threats. Maybe advocacy can change the outcome. But your employees may read what you write and think “Oh my god! That’s my job he’s writing about!” So to any MMDHD employees who read this, I want you to know we are working on a Plan B (and C in fact) to sustain our programs in case the ACA is repealed in a way that affects us.

The third way repeal of the ACA would affect public health could result from the elimination of the Prevention and Public Health Fund (PPHF). The PPHF is one of the best parts of the federal budget you never heard about. It was established under the ACA to ensure that the ACA focused as strongly on public health as on health care. Michigan has received nearly 100 million dollars from the fund which has been used for obesity reduction, tobacco programs, heart disease prevention, cancer prevention and other activities.  Funds have gone to health care systems, tribal governments, universities, community groups like YMCAs, and yes, local public health. Unfortunately the fund has been embattled since it was created and much less has been appropriated by Congress than was hoped for. Nearly a billion dollars have been shifted from the PPHF to support existing, inadequately funded CDC programs, too.  This detail is important because it means the fund is also supporting our existing, routine local public health programs (for example family planning) through the CDC. If the PPHF was eliminated due to a repeal of the ACA it would mean more than simply losing the special programs mentioned above, but it could mean a reduction in local public health’s regular operating budget.

So for example, suppose a million Michiganders lose their health insurance and lose access to family planning services through their primary care doctor.  They might turn to local public health for family planning as they did before the ACA.  But just at that moment support for local public health could be reduced because of elimination of the PPHF.  This could be a real train wreck.  

And don’t think Planned Parenthood will be there to fill the gap.  Legislatures that don’t fund that organization and trying to shut them down by saddling them with bogus regulations that make it too expensive for them to operate. Since Michigan doesn’t fund Planned Parenthood there is no stream of dollars that could be shifted to other providers, like local public health, if Planned Parenthood leaves the State.

And we are only talking about the impact in one area:  family planning!  Now think about the impact across the suite of programs local public health offers: communicable disease, outbreak investigation, immunizations, WIC and home visiting programs, children’s programs, hearing and vision programs, oral health, community health workers and care coordination programs with mental health.
Could Michigan experience as spike in maternal mortality in the near future?  It’s something we need to take very seriously, but it’s likely next time the damage will be spread even further.

* The story of what happened in Texas is complicated. Maternal mortality rates have been rising in many places in the United States, not just Texas. One reason is that vital statistics agencies are getting better at identifying cases of maternal mortality. Increases may also be linked to the general increase in mortality among low-income people that has been evident lately. You should also know that Michigan is also, like Texas, a state with high maternal mortality. Still the sudden, enormous jump in Texas is hard to explain without understanding that many women lost access to family planning services there.