Looking Back on the Desegregation of U.S. Hospitals in 1966

[Last summer, I wrote the following review of  The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America’s Health Care System by David Barton Smith.  The review just came out in The Common Reader.  I still think the book is required reading in our times.  And I love the cartoon!]

On a Saturday morning in January 1967 Dr. Jean Cowsert, an African-American physician, was found shot to death in front of her home in Mobile, Alabama, after a stone had been thrown through her front window and she went out to investigate. Though police concluded that she had accidentally shot herself, in the months prior to her death she had been a key confidential informant to officials from the U.S. Department of Health, Education and Welfare (HEW) concerning the Mobile Infirmary’s publicized efforts to thwart patient desegregation of its facilities. A HEW official’s carelessness may have inadvertently disclosed her identity to desegregation opponents.

Dr. Cowsert’s is one of many compelling stories in David Barton Smith’s powerful account of U.S. hospital desegregation in 1966, triggered by the convergence of national civil rights mobilization, the 1964 Civil Rights Act and the 1965 enactment of Medicare. In The Power to Heal: Civil Rights, Medicare, and the Struggle to Transform America’s Health Care System Smith tells how federal health officials—with backing from President Lyndon Johnson, HEW Secretary John Gardner, and other federal officials—mobilized to achieve a startlingly rapid transformation of America’s hospitals, erasing the stain of racial segregation that had always prevailed across the nation, North, South, East, and West.

Smith’s account stands in vivid contrast to the equally compelling and failed story of American public school desegregation, best told in the 1976 Pulitzer Prize-winning Simple Justice: The History of Brown vs. Board of Education and Black America’s Struggle for Equality by Richard Kluger. In that case, the 30-year struggle to overturn “separate but equal” racial segregation in public education, culminating in a landmark 1954 U.S. Supreme Court’s 9-0 decision in Brown v. Board of Education, to this day has been mostly unachieved. A bold court decision was fatally undermined by a subsequent enforcement ruling committing the nation to an unsuccessful implementation strategy called “with all deliberate speed.” The contrast between successful desegregation of U.S. hospitals versus failed desegregation in public education is instructive.

Smith writes: “In four months, civil rights activists … transformed the nation’s hospitals from our most racially and economically segregated institutions to our most integrated. In four years, they changed patterns of use of health services that had persisted for half a century. The fundamental moral imperative—that those needing medical care should receive it—began for the first time to reflect actual use of services. A profound transformation, now taken for granted, happened almost overnight.”

A bold court decision was fatally undermined by a subsequent enforcement ruling committing the nation to an unsuccessful implementation strategy called “with all deliberate speed.” The contrast between successful desegregation of U.S. hospitals versus failed desegregation in public education is instructive.

As with so many aspects of American society prior to the 1960s, segregation ruled. A 1952 report by the South Conference Education Fund titled “The Untouchables: The Meaning of Segregation in Hospitals” documented 12 deaths of African Americans denied admission to white-only hospitals governed by white physicians and white dominated medical associations. In most of the nation, black-only hospitals were under-staffed, under-financed, and under-equipped.

Beginning in the 1940s, black health professionals who were systematically excluded from the white medical mainstream, supplied backbone in the struggle for civil rights in hospitals, in schools and across American society. Theodore Roosevelt Mason Howard, MD, Sonnie Wellington Hereford III MD, Reginald Hawkins DDS, W Montague Cobb MD PhD, Charles Watts MD, George Simkins Jr. DDS—these are long-forgotten names of physicians who stood up for justice in their communities and in courts.

Though the 1946 Hill-Burton Act banned racial discrimination in new and expanded hospitals for which it provided ample federal funds, the law explicitly sanctioned “separate but equal” facilities. A 1962 federal lawsuit, Simkins vs. Moses Cone, attacked the constitutionality of that provision, winning crucial support from the Kennedy Administration, and upheld by the U.S. Supreme Court in March 1964 just as Congress was passing that year’s landmark Civil Rights Act. That law’s Title VI, for the first time, prohibited using federal funds for racial segregation.

Passage of the bold 1964 law, though, was insufficient to compel hospital desegregation. The critical catalyst was the passage of Medicare in July 1965 providing many millions of dollars in payment for medical services for senior citizens for the first time. Though Title VI clearly applied, its remedies and enforcement powers were meager. The question became: Would President Lyndon Johnson enforce Title VI compliance in Medicare by blocking payments to racially segregated hospitals? An initial push for voluntary desegregation failed as surveys conducted by civil rights activists had proven in mid-1965.

With only six months until the July 1, 1966, inauguration of Medicare, “Gardner was launching perhaps the riskiest domestic policy initiative in the nation’s history. It tied together the fate of Johnson’s two signature pieces of legislation—the Civil Rights Act and Medicare,” Smith writes.

In December 1965, HEW Secretary Gardner distributed a memo declaring that Medicare compliance with Title VI “is too important to be treated as anything less than the highest of priorities in our total program,” committing staff and resources to the task. With only six months until the July 1, 1966, inauguration of Medicare, “Gardner was launching perhaps the riskiest domestic policy initiative in the nation’s history. It tied together the fate of Johnson’s two signature pieces of legislation—the Civil Rights Act and Medicare,” Smith writes.

The challenges were daunting. A January 1966 review concluded that at least two-thirds of Southern and border state hospitals were out of compliance, while many Northern hospitals operated as de facto segregated facilities.

Gardner’s team quickly concluded that success would require “no ‘all deliberate speed’ pass for hospitals wishing Medicare funds. No money should go to any facility where race played any role in the treatment of patients, employees, or medical staffs.” Compliance was handed to HEW’s Public Health Service managed by U.S. Surgeon General William H. Stewart and the new HEW Office of Equal Health Opportunity. But with months before Medicare’s rollout and more than 4,000 noncompliant hospitals, how could they achieve this seemingly impossible task?

When HEW leaders put out a call for volunteer temporary federal employee transfers to perform compliance, more than 1,000 employees, mostly from the Social Security Administration and the Public Health Service, answered yes. They included “bench scientists from NIH, veterinarians, pharmacists, managers of Social Security field offices, venereal disease investigators, even a ‘medical officer from the Indian Health Service complete with an Eskimo secretary.’”

The challenges were daunting. A January 1966 review concluded that at least two-thirds of Southern and border state hospitals were out of compliance, while many Northern hospitals operated as de facto segregated facilities. On March 4, 1966, Surgeon General Stewart sent a letter to all U.S. hospitals with this message: “To be eligible to receive Federal assistance or participate in any federally-assisted program a hospital must be in compliance with Title VI … Representatives from the Department of Health Education and Welfare Regional office will be visiting hospitals on a routing periodic basis …”  Three weeks later, Dr. Martin Luther King offered his historic judgment: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Smith provides many anecdotes of intransigent hospital officials who tried to hoodwink inspectors, concluding that “the vast majority of the hospitals chose to comply in order to get the Medicare payments, and it was remarkable how fast and dramatic the changes were.”

Smith provides many anecdotes of intransigent hospital officials who tried to hoodwink inspectors, concluding that “the vast majority of the hospitals chose to comply in order to get the Medicare payments, and it was remarkable how fast and dramatic the changes were.” Literally overnight, the blood supply from the Louisiana Red Cross Blood Bank, previously labeled “white” and “colored,” was integrated. At a June 15 White House meeting with hospital officials, President Johnson declared: “The federal government is not going to retreat from its clear responsibility … and I hope that you will not retreat either.” By June 15, more than 80 percent of hospitals were complying, and by June 30, the number had risen to 94 percent. “By January 1967,” Smith reports, “the mopping up, with only a few exceptions, had been completed.”

Not all changes were welcome. According to Smith, “within two decades of the implementation of Medicare, all but four of the more than 400 20th century historically black hospitals had closed or converted to other purposes.” The Office of Equal Health Opportunity was disbanded by President Richard Nixon. And the problems of racial and ethnic inequities and disparities in health and health care are enduring national concerns.

Still, the rapid and effective desegregation of U.S. hospitals is one of our nation’s—and our health care system’s—shining moments. Smith’s book is the authoritative source to understand the political, social, economic, and cultural context of this transformation. Perhaps as monuments to Confederate generals are demolished, we might find space for a monument to Dr. Jean Cowsert.

Is “Dental Care for All” on the Horizon?

[This commentary, “Might Oral Health Be the Next Big Thing?” was published in the December 2016 edition of the Milbank Quarterly.  It was written back in September — pre-November 8th.  Just sayin’…]

Has the time come for a national movement in the United States to expand access to affordable and quality oral health services? A growing network is betting that the answer is yes. Let’s consider this nascent movement using the three ways that public health knowledge gets translated into public policy: the knowledge base, the social strategy, and political will.1

The Knowledge Base—What Do We Know?

The United States has problems with oral health. While most Americans’ oral health has improved markedly over 60 years, many millions are left behind and hurting. Societal improvements in science, technology, education, hygiene, community water fluoridation, and school-based services have not been broadly shared.2 Today, 130 million Americans, primarily adults, have no dental coverage. Many Americans with coverage find today’s health insurance cost-sharing requirements a prohibitive barrier to care. Medicare provides no dental coverage for 70% of its enrollees; 40% of them did not visit a dentist in 2014 and 60% have severe or moderate gum disease. Medicaid does cover dental services for low-income children but 17 million of them got no dental care in 2009. In most states, Medicaid covers no or little dental care for poor adults, while 47 million Americans live in areas where finding a dentist can be impossible.dental-diseases

Because of these access issues, 25% of adults over age 65 have lost all their teeth (edentulism). In 2009, US hospital emergency departments saw 850,000 visits for preventable dental pain. The avoidable disease called dental caries (or cavities) is 5 times more prevalent than asthma and affects 60% of children age 5 to 17. For those left behind, it’s a crisis. Oral health is an important part of US racial and ethnic health disparities.

Bad oral health results in pain, substandard nutrition, sleep loss, lost school time, work absence, worse jobs, and lowered self-esteem. Chronic oral infection is a proven risk factor for diabetes, osteoporosis, heart and lung disease, low birth weight, and if a dental abscess grows out of control, sepsis. Good oral health care improves overall health and decreases hospitalizations for conditions such as cerebral vascular disease and rheumatoid arthritis. The link between tobacco use and oral disease has been recognized since the US surgeon general’s 1964 report on smoking and health.3
Continue reading “Is “Dental Care for All” on the Horizon?”

Assessing President Obama’s Health Legacy

I was asked last August to write an assessment of President Barack Obama’s public health legacy for the January issue of the American Journal of Public Health.  My drop-dead deadline was mid-October when the overwhelming consensus indicated a likely electoral victory for Hillary Clinton who would have continued President Obama’s directions.

Funny how things can turn so suddenly, as they have with the electoral college victory of Donald Trump and the emergence of a new and conservative federal Administration.  Some of my commentary — just released — still seems appropriate, even if a big chunk of Obama’s legacy is repealed.

So here’s my official appreciation of what Barack Obama has done for Americans’ health and America’s health care system.  (If you look at the AJPH, you will see two companion editorials, one by Drs. Steffie Woolhandler and David Himmelstein critiquing the Obama legacy from the left, and one by Dr. David Sundwall with a critique from the moderate right.


A CONSEQUENTIAL EIGHT YEARS FOR HEALTH CARE AND PUBLIC HEALTH

Every modern US president since Harry Truman has impacted the nation’s health through his successes and failures.1 Arguably, Lyndon Baines Johnson created the most important legacy through the establishment of Medicare and Medicaid in 1965. Whether Barack Obama’s health achievements equal or exceed those of LBJ is a judgment best left for historians. At this point, it is reasonable to conclude that the Obama public health legacy will be deep, broad, and wide.barack-signature

Obama’s landmark achievement, the Affordable Care Act (ACA; Pub L No. 111–148), along with related enactments, assumes outsized significance in the real world and in this commentary. In addition, many other laws, regulations, executive orders, and other actions contribute to a compelling Obama public health record. In this brief overview, I consider the ACA and the President’s other public health accomplishments.

From the ACA to Obamacare

Although the ACA, to date, has fallen far short of the public health community’s expectations on many fronts, it is close to the most ambitious health reform law that could have been achieved in the 2009–2010 US Congress, or in any other modern Congress for that matter. Also, the ACA is still only six years old. The 1935 Social Security and 1965 Medicare–Medicaid laws initially fell well short of their respective visions, and only later matured into their current recognizable forms after decades of subsequent improvements. So it is and will be with the ACA, born in a contentious and madly partisan legislative environment, with many improvements still needed to fully realize its ambitious goals. That realization should not denigrate the law’s accomplishments.

On access, more than 20 million formerly uninsured Americans have obtained health coverage, and the US rate of uninsurance has dropped to the unprecedented low rate of 8.6%.2 Coverage gains have disproportionately benefitted those most in need, especially lower income, non-White, and younger adult households. The shameful health insurance practices of medical underwriting and preexisting condition exclusions, as well as annual and lifetime benefit limits, have been abolished. Medicaid now makes quality and affordable coverage available to nearly all low-income Americans in the 31 states that have adopted the ACA expansion; over time, the 19 other states will follow. Although the work is far from done, this is extraordinary progress after so many decades of trying and failing.

The content of health insurance in all markets has been improved markedly. The ACA’s Title I guarantees that nearly all health insurance policies include 10 essential health benefits including, for example, mental health and addiction services, as well as prescription drugs. Another section requires that all health insurance policies must offer all clinically effective preventive services such as vaccines and cancer screenings that are recommended by the US Preventive Services Task Force, and with no cost sharing. Many millions more than the formerly 20 million uninsured have benefited from the ACA’s access and coverage provisions.

On transforming medical care, the ACA has reset the US health system irreversibly on a course away from wasteful and inefficient fee-for-service payment toward value-based models that reward quality, effectiveness, patient centeredness, and population health management. Accountable care organizations, patient centered medical homes, bundled payments, readmission, and hospital-acquired condition penalties—all these and more have become part of the nation’s emerging accountable care and “triple aim” landscape. Implementation of electronic health records has advanced with impressive speed and reach, as more than 80% of nonfederal acute care hospitals have adopted basic electronic health records with clinician notes. Although partisan bickering slows the continuous policy improvement of most ACA provisions, the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), approved by the Republican-controlled House and Senate and signed by President Obama, only expands and deepens the ACA’s direction toward alternative payment models.

Yet another ACA landmark is the major expansion of federally qualified community health centers that now serve more than 24 million Americans at 1375 centers in 9200 communities, as well as the National Health Service Corps that provides medical student debt relief in exchange for service in underserved communities. As of 2015, 9600 Corps clinicians were providing primary care services, more that twice the number of 3600 doing so in 2008.

Beyond the ACA

Any list of the Obama Administration’s key health gains must include groundbreaking achievements in environmental health protection. The successful negotiation of the Paris Agreement on climate change, formally ratified in October 2016, for the first time has set the global community on a low-carbon course. Additionally, the Obama Administration’s numerous initiatives to limit carbon and other forms of pollution from power plants, cars, trucks, homes, and businesses are changing fundamentally how Americans consume energy, enabling the nation to meet its environmental goals in ways that will save countless lives. For example, the Environmental Protection Agency’s 2013 regulation on “National Ambient Air Quality Standards for Particulate Matter” will prevent thousands of premature deaths of elderly and young children from cardiovascular and respiratory illnesses caused by soot pollution.

Smoking is still the nation’s leading cause of preventable death. The 2009 signing of the Family Smoking Prevention and Tobacco Control Act, giving the US Food and Drug Administration authority to regulate nicotine as a controlled substance, was only the most public evidence of progress. The 2009 federal tobacco tax increase of 62 cents per pack, included in the reauthorization of the Children’s Health Insurance Program, combined with the “Tips from Former Smokers” campaign launched by the US Centers for Disease Control and Prevention, were among many initiatives that have contributed to major declines in both adult and adolescent smoking rates, including a drop among adults from 20.6% in 2009 to 15.3% in 2015.3

Regarding nutrition and food policy, the Obama Administration has reformed essential federal nutrition programs that provide a critical safety net for millions of American children and families. Lead by the US Department of Agriculture, for the first time in decades, the most current dietary science is being applied to nutrition programs. More than 50 million children now have healthier food environments at school. Because of new food standards, nearly four million schoolchildren have access to nutritious meals each day in summers, and eight million low-income women, infants, and young children receive improved WIC food packages.

Unknown to the public has been massive upgrading and professionalization of emergency response systems in the United States and globally. Two National Health Security Strategy Plans (NHSS), 2010 to 2014 and 2015 to 2018, have galvanized national efforts to minimize the health consequences of large-scale emergencies in response to the deficiencies evidenced by the tragedies of the 9/11 terrorist attacks in 2001 and Hurricane Katrina in 2005, to achieve a “health-secure and resilient nation.”4 The work’s impact can be seen in the US government’s response to national and global health security threats over the past eight years such as the 2009 influenza pandemic (H1N1), Middle East respiratory syndrome (MERS), the West African Ebola epidemic, and the current Zika virus threat. This new infrastructure helped to address health security threats from recent international crises such as the 2010 Haitian earthquake, the 2011 Japanese tsunami and nuclear power plan incident, and the 2013 Philippines typhoon.

Space constraints do not permit a thorough presentation of the public health achievements and progress by the Obama Administration. Such a full list would also describe: national and global progress in addressing the HIV-AIDS epidemic; fundamental changes in behavioral health financing and access including progress in addressing the advance of the opioid epidemic; adoption by numerous federal agencies of social determinants of health approaches in housing by the US Department of Housing & Urban Development and in transportation by the US Department of Transportation; major declines in adolescent pregnancy rates; unprecedented attention to the health needs of lesbian, gay, bisexual, transgender, and questioning communities; and much more.

Conclusion

Every Presidency leaves a unique record and legacy of accomplishments and shortcomings, of wins and losses.  Noteworthy during the Obama years has been the extraordinary number of initiatives, programs, experiments, and demonstrations that move moved the needle toward greater access, quality, equity, effectiveness, and efficiency in important matters relating to health care and public health.  Wherever Barack Obama lands in the historic hierarchy of significant and positive contributors to health, the extraordinary efforts made by him personally and by his talented, dedicated, and principled Administration have set a high bar and model for all who follow.  The Obama era has been a consequential eight years, and the Administration’s impact has been overwhelmingly for the better for the American people and for the people of the world.

References

1. D Blumenthal, J Morone. The Heart of Power: Health and Politics in the Oval Office. Berkeley, CA: University of California Press; 2010.
2. K Avery, K Finegold, A Whitman. Affordable Care Act has led to historic, widespread increase in health insurance coverage. ASPE Issue Brief. US Dept of Health and Human Services. September 29, 2016. Available at: https://aspe.hhs.gov/sites/default/files/pdf/207946/ACAHistoricIncreaseCoverage.pdf. Accessed October 11, 2016.
3. Early release of selected estimates from the National Health Interview Survey, 2015. National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201605_08.pdf. Accessed October 11, 2016.
4. Assistant Secretary for Preparedness and Response. National Health Security Strategy and Implementation Plan 2015–2018. US Dept of Health & Human Services. Pg. v. 2014. Available at: http://www.phe.gov/Preparedness/planning/authority/nhss/Documents/nhss-ip.pdf. Accessed October 11, 2016.

Reframing Prevention in the ACA Era

This article, “Reframing Prevention in the Era of Health Reform,” was co-authored by Dr. Howard Koh, Dr. Rahul Rajkumar, and me in the September 13 2016 issue of the Journal of the American Medical Association:

The 2010 passage of the Affordable Care Act (ACA) raised numerous opportunities for disease prevention. Of the 10 legislative titles comprising the ACA legal framework, Title 4 (“Prevention of Chronic Disease and Improving Public Health”) initially held the most promise for delivering new financial resources as well as effective policy for prevention.1 Six years later, Title 4 outcomes show mixed results. In the meantime, however, other ACA innovations are redesigning health systems by incorporating prevention into a range of new care models. Doing so connects the clinic and the community in ways not necessarily envisioned in the statute, thereby broadening possibilities for the future of population health.

Continue reading “Reframing Prevention in the ACA Era”

Shorter Lives and Poorer Health on the Campaign Trail — An Idea

This article was published in the March 2016 issue of the American Journal of Public Health.  A related commentary from Stuart Butler of the Brookings Institute (formerly of the Heritage Foundation) follows: 

For those desiring serious and compelling conversation on the presidential campaign trail about the future of our nation’s health, this is a dispiriting time for two reasons. First, candidates have precious little to say about our most compelling challenges relating to the nation’s health as opposed to our medical care. They follow familiar and politically reliable prescriptions on both sides of the partisan divide. Second, the raw material for a rich and potent debate concerning the public’s health has never been more abundant. I have hope that this conversation can occur, though not in the context of the 2016 political circus.

Here is one example of what I would love to hear presidential candidates discuss in at least one debate: the 2013 report from the National Academy of Medicine (NAM) called “Shorter Lives, Poorer Health.”1 It is a 394-page indictment of our nation’s health and health care systems. Here is the opening:

The United States spends more money on health care than any other country. Yet Americans die sooner and experience more illness than residents in many other countries. While the length of life has improved in the United States, other countries have gained life years even faster, and our relative standing in the world has fallen over the past half century.1(p.ix)

Extensive research confirms “a large and rising international ‘mortality gap’ among adults age 50 and older,”1(p.1) according to the NAM panel.

The U.S. health disadvantage cannot be attributed solely to the adverse health status of racial or ethnic minorities or poor people, because recent studies suggest that even highly advantaged Americans may be in worse health than their counterparts in other countries.1(p.1)

The report’s comparison group includes Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Switzerland, the Netherlands, and the United Kingdom using data between the 1990s and 2008. The health disadvantage was sharpest in nine health domains:

  • Adverse birth outcomes—the highest infant mortality rate among high income countries;

  • Injuries and homicides—a leading cause of death in children, adolescents, and young adults;

  • Adolescent pregnancy and sexually transmitted infections—the highest rate of pregnancies among high income countries;

  • HIV and AIDS—the highest incidence of AIDS and the second highest prevalence of HIV infection;

  • Drug-related mortality—more lives lost to alcohol and drugs than in any other nation, even when excluding drunk driving deaths;

  • Obesity and diabetes—the highest rates of obesity and diabetes among high income nations;

  • Heart disease—the second highest rate among 17 peer nations;

  • Chronic lung disease—higher mortality than in the United Kingdom and other European countries; and

  • Disability—one of the highest prevalence rates of activity limitations among older adults.

The NAM results are not totally bad and include higher survival after age 75 years, as well as better rates regarding cancer, blood pressure and cholesterol levels, smoking, and stroke mortality. Of note, given recent public preoccupations in the political campaign, the health status of recent immigrants is better than that of native-born Americans.

Yet,

Americans under age 75 fare poorly among peer countries on most measures of health. This health disadvantage is particularly striking given the wealth and assets of the United States and the country’s enormous level of per capita spending on health care, which far exceeds that of any other country.1(p.4)

The Report is a staggering indictment of our American society in this new century. Back in 1980s, President Ronald Reagan taught the nation the power of positive thinking in shaping attitudes. This report is downer, which may help to explain why it is so hard to break into the national conversation.

Yet it is also true is that in recent years, we have seen other reports that paint a bleak picture of our nation’s health.

In November, a new study by Case and Deaton documented rising morbidity and mortality rates among US Whites aged 45 to 54 years.2 A reexamination of the data by Aron et al. at the Urban Institute revealed a shocking increase in the rate of mortality among middle-aged women three times faster than the rate of increase among similarly aged White males: 26.8 deaths per 100 000 population among White women aged 45 to 54 years versus a 7.7% increase among men between 1999 and 2013.3 Figure 1 supports Aron et al.’s conclusion:

There is simply no mistaking the reality that American women are currently dying much earlier than their counterparts in other advanced nations … [including] women of reproductive and childrearing ages, a finding that has huge implications for children, families and communities.3

ajph1

And not to let US health care off the hook, the performance of our medical care system continues to underwhelm. A recently released study by the World Health Organization and The Economist Intelligence Unit, “Healthcare Outcomes Index 2014,” examining the health care systems of 166 nations, ranked the United States number one in spending and number 33 in quality outcomes, placing it among the least efficient systems on the planet, and ranking behind nations such as Lebanon and Costa Rica.4 Figure 2 shows the broad ranges of nations that achieve better results for their societal investments in health care.

ajph2
I recall in the 1980s reading health economists speculate about “flat of the curve medicine,” the hypothetical point at which further expenditures on medical care could actually produce worse health. Figure 2 illustrates that US spending now is beyond the flat of the curve and that the hypothesized adverse outcomes from outsized medical care spending are now real.

Research over the past five years by Bradley at Yale offers a compelling hypothesis to explain at least part of our nation’s dismal performance—among all advanced nations, the United States spends by far the most on a per person basis on medical care while spending nearly the least on a per person basis on nonmedical social service spending such as education, day care, job training, housing support, nutritional assistance, and more.5 Focusing less on medical care and more on needs relating to the social determinants of health seems to help produce more beneficial population health outcomes than our nation’s prioritization on the reverse. Figure 3 illustrates Bradley’s key findings.

ajph3
So here we are with an accumulating knowledge base of a deep and profound societal problem. Our approach—or perhaps non-approach—to health is killing us and weakening our nation. Is there a presidential candidate talking about any of this? Yes, Senator Bernie Sanders proposes a Medicare-for-all single payer system that might provide the best opportunity for systemic reorientation. Yet the real-world chances for such a radical redesign do not offer great confidence.

One of the most surprising developments in American politics in recent years has been the emerging common ground from the nation’s political right and left regarding US criminal justice and prison policies that leave us with the world’s highest incarceration rates. From widely diverging ideological perspectives, deeply divided political adversaries are engaging in serious and substantive collaboration to change these policies.

I see the basis for a new conversation between the political left and right regarding our nation’s over-reliance on medical care to address human needs that could far more effectively and efficiently be addressed in preventive and nonmedical ways by tackling the social determinants of health. Surely, citizens who identify as conservatives have no reason to cheer our outsized and debilitating level of spending on medical care. Might we see in the new incarceration dialogues inspiration for a new and path-breaking conversation on how to get our nation’s health care needs and spending in better order?

Although it is already late to get these issues planted in the 2016 national political agenda and campaign, it is not too late to spur conversation and education. While the process for major political change takes time, the work has to begin somewhere. The nation’s public health community has a lot to say and much to contribute to this process.

Let’s begin.

References:

1. SH Woolf, L Aron, eds. US Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: National Academies Press; 2013. Available at: http://www.nap.edu/catalog/13497/us-health-in-international-perspective-shorter-lives-poorer-health. Accessed January 15, 2016.
2. A Case, A Deaton. Rising Morbidity and Mortality in Midlife among White non-Hispanic Americans in the 21st Century. Proc Natl Acad Sci U S A. 2015;112(49):1507815083. [CrossRef] [Medline]
3. L Aron, L Dubay, E Waxman, S Martin. To understand climbing death rates among Whites, look to women of childbearing age. Health Affairs Blog. November 10, 2015. Available at: http://healthaffairs.org/blog/2015/11/10/to-understand-climbing-death-rates-among-whites-look-to-women-of-childbearing-age. Accessed January 15, 2016.
4. The Economist Intelligence Unit Healthcare. Health outcomes and cost: a 166-country comparison. Available at: http://stateofreform.com/wp-content/uploads/2015/11/Healthcare-outcomes-index-2014.pdf. Accessed January 15, 2016.
5. EH Bradley, BR Elkins, J Herrin, B Elbel. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf. 2011;20(10):826831. [CrossRef] [Medline]
6. EH Bradley, LA Taylor. The American Health Care Paradox. New York, NY: Public Affairs; 2013.

7. L Neff. Actually, the US is NOT spending more than any other country on health. Sojourners. August 1, 2013. Available at: https://sojo.net/articles/actually-us-not-spending-more-any-other-country-health. Accessed January 15, 2016.

Stuart Butler Responds

McDonough is right about two very important things. First, that in America we have quite dismal outcomes for the enormous amount we spend on health care. And second, that there is a real opportunity for a new political dialog between left and right to take root—though perhaps one that is more of a quiet agreement than a high-profile grand bargain.

McDonough wisely draws attention in Figure 3 of his editorial to the sharp distinction between the United States and other Organisation for Economic Cooperation and Development countries in the relative proportions of gross domestic product spent on health services and social services. The United States is a lonely outlier because we overmedicalize our approach to health conditions and community health. Generally a blend of social, housing, public health, and other preventive strategies would yield better health results than calling an ambulance—and at a fraction of the cost. Even our higher survival rates after age 75 years is a mixed blessing, as Gawande points out, because expensive and frequent medical interventions may extend age but often not the quality of life.1

The good news, both substantively and politically in this election year, is the growing recognition that addressing the social determinants of health is a key—perhaps the key—to improving health outcomes while slowing the growth in health spending as a proportion of gross domestic product and public spending. McDonough and I agree on that, despite his affection for Bernie Sanders’ utopian Medicare-for-all, which likely would do little to address the underlying cost and outcomes problem.

So how could a new conversation develop, of the kind both we both would like to see? I think on several fronts.

First, building on existing collaboration, serious analysts and policymakers on both sides of the political spectrum should explain more extensively how resources currently restricted to either health care or social services and housing should and could be more routinely braided together. Despite some interesting experiments and demonstrations that allow certain health and housing money to be mixed and used creatively, budget restrictions and payment systems generally make this difficult. We could seek to agree on a mixture of legislative action on payments and budgets, and using Medicaid (Section 1115) waivers, to permit money currently available only for medical services to be used instead for housing and social services where that could be shown to improve the health of individuals in a community.

Second, we could agree on bipartisan steps to allow states to experiment with more creative approaches to alter the blend of strategies they have available to achieve improved health outcomes. Section 1332 of the Affordable Care Act (Pub L No. 111–148) is a start, since it will allow states to propose alternatives to some Affordable Care Act provisions to improve coverage and outcomes without increasing federal costs. McDonough and I agree on using 1332 waivers in this way. But a further step would be legislation to allow states to seek even broader waivers to shift money between health and social service programs. For that to happen, conservatives would have to accept increases in total spending on some social service programs. Progressives would have to accept reductions in health programs and reduce their reluctance to granting states more flexibility. Both would have to accept rigorous evaluation to determine what works and what does not.

And third, there is an opportunity for agreement on empowering intermediary institutions2 in neighborhoods, including charter and community schools, as well as health systems,3 to serve as hubs for integrated approaches to achieving health communities. That approach combines the conservative emphasis on the importance of nongovernmental institutions with the progressive emphasis on community action. Again, systematic evaluation is needed.

Hopefully there can be cross-party congressional support agreement on these themes, as McDonough notes has occurred in alternative sentencing. But it is unlikely in the election season that such themes will be seized upon by presidential candidates. In my view, that is probably good, because presidential elections are about differences, not path-breaking agreements. Better, during this election cycle, to foster positive conversations that cause such themes to be taken out of the election debates, so that they will have broad support for enactment after the Election Day dust has settled

References:

1.  Gawande. Being Mortal. New York, NY: Metropolitan Books; 2015.
2. P Singh, SM Butler. Intermediaries in Integrated Approaches to Health and Economic Mobility. Washington, DC: The Brookings Institution; 2015.
3. SM Butler, J Grabinsky, D Masi. Hospitals as Hubs to Create Healthy Communities: Lessons From Washington Adventist Hospital. Washington, DC: The Brookings Institution; 2015.

Amazing Accomplishments in Global Health in 2015

We get so caught up in the Donald and Hillary and Ted and Bernie shows.  Yet there is so much else going on in the world about which most Americans never hear — such as global health.

Permit me to draw attention to This Week in Global Health (TWiGH) which has been producing weekly live online programming on global health topics since mid-2014.  Hosted by Dr. Greg Martin, editor of Globalization and Health, (an open access journal) it’s compelling and accessible.  Recently, the group asked its experts to identify big accomplishments in global health in 2015.  The list grabbed my attention, so here it is – see the YouTube video as well: https://www.youtube.com/watch?v=vHxIYdQyejc

  1. Malaria: After 30 years and $565M, 2015 saw the development of the first-ever malaria vaccine; 50% of world population is at risk at risk and this development just might transform millions of lives for the better.
  1. HIV: The World Health Organization updated its guidelines for HIV treatment recommending that it be universal, and that everyone should be treated as soon as positive test result is made; those on treatment are far less likely to transmit the virus to another person.
  1. Climate change: The Paris Agreement on climate change puts in place the first international brakes on global warming, with 196 participating nations, and legally binding when signed by at least 35 countries.
  1. Bariatric Surgery: Though the spread of this treatment is controversial, it is considered the most important breakthrough in diabetes care since the discovery of insulin, with unrivaled health benefits.
  1. Ebola: We are seeing the beginning of the end of the West African Ebola Crisis – though the ordeal is far from over for 17,000 survivors.
  1. Polio: Last year we saw the elimination of polio from the African continent – the last cases were in Nigeria and in September the WHO said that polio is no longer endemic in Nigeria. Only Afghanistan and Pakistan remain as countries with polio.  Eradication is possible!

sdg5

  1. Approval of the Sustainable Development Goals: 2015 saw the final approval of new international health and social development goals; compared with the earlier Millennium Development Goals, the SDGs are more comprehensive, more inclusive, and financed to encourage sustainable development.
  1. Research: A Nobel Prize was awarded to researchers for novel therapies for parasitic diseases and malaria, demonstrating the vital role and positive impact of research on global health.
  1. Ending Extreme Poverty: The number of people living in extreme poverty (defined as less than $1.90 per day) is down 10%, down from over 900m in 2012 to under 700 million now; a big MDG goal to end extreme poverty by 2030.
  1. Maternal & Child Health: Infant mortality is down to an all time low, down 54% since 1990 down by to 5.9 million, from 63 deaths per 1000 live births in 1990 to 32 in 2015; maternal mortality is down 44%.
  1. Water – In 2015, 91% of the world’s population had access to an improved drinking-water source, compared with 76% in 1990.

Well, wow!  I didn’t know that! Let’s notice and celebrate real progress for citizens of the world.  Let’s hope that 2016 brings other good news for the world.

CVS Quits US Chamber of Commerce over Tobacco

The reaction against the U.S. Chamber of Commerce’s advocacy for the global tobacco industry is growing, first reported last week in the New York Times.

Today, the Times reported that CVS Health Corporation announced that it is quitting the U.S. Chamber because of their work around the world in fighting restrictions on tobacco and smoking.  This follows CVS’s major step last year discontinuing tobacco product sales in all its stores.  Double hurray for CVS!smoking

We are still waiting to see whether Boston’s Steward Health Care System and its CEO Ralph de la Torre, will turn their words into action.  Last week, a Steward spokesperson said: “If the chamber is in fact advocating for increased smoking, we do not agree with them on this public health issue.”  Now that the Chamber’s advocacy is clear, it’s time to go beyond words — as Paul Levy makes clear.

The flak against the Chamber is going global, as Margaret Chan, Director General of the World Health Organization, made clear this week:

“By lobbying against well-established, widely accepted and evidence-based tobacco control public health policies, the U.S. Chamber of Commerce undermines its own credibility on other issues … So long as tobacco companies continue to be influential members of the chamber, legitimate businesses will be tarred with the same brush.”

The Chamber is feeling the heat and beginning to lash out against those taking them to task for the deathly advocacy.  Here’s part of their recent statement: “It’s unfortunate that a concerted misinformation campaign about the U.S. Chamber’s position on smoking has resulted in a company leaving our organization.”

If the Chamber wants any legitimacy on this issue, step number one — come clean on how much money you have taken from tobacco companies over the past 20 years. Put it all on the table without delay.  Otherwise — you have no credibility.