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Cartoon of the Day: Trumpcare vs. Obamacare

It has been a while since I have written in this space. Partly this was a result of a personal medical problem (I am OK now and perhaps one day I will regale you with stories of my treatment) and partly because I do not have much new to say. I practice and teach family medicine in the deep south. My state, Alabama, has declined to expand Medicaid. 90% of White Alabamians have the luxury of having health insurance and feeling, well, entitled. 84% of Black Alabamians have health insurance. Only 70% of Hispanic Alabamians report the same. My practice has been colored by these facts ever since the passage of Obamacare. Much of what I have written has been about the passage, implementation, trials and tribulations of Obamacare in Alabama.

My lack of writing in this space recently has been, in part, because health policy wise there has been not much to write about. The last three and a half years have been about the states that have chosen to expand working to correct other gaps in care while those of us in non-expansion states have been watching. In what is likely not a coincidence, many of the people live in the states that have chosen not to expand Medicaid which are also those states which chose to enslave humans (92%). From a policy standpoint, I have to admit that when I am asking for money to study a healthcare problem (hospital closure, unnecessary hospitalization, vaccination gaps) and the reviewers ask “Why not expand Medicaid instead of my giving you money” I don’t have a good answer.

What are we missing out on? Improved health outcomes, for one. This includes patient based outcomes (an improvement in healthy days in the month, reduced overall and disease specific mortality), provider based outcomes (improvement in the physicians’ bottom line), state based outcomes (less money spent on healthcare). In addition, because people are more steps away from bankruptcy, they report in general being better off (reductions in rates of food insecurity, poverty, and home evictions). In short, we in Alabama are much worse off for not having expanded.

In just over a month we will select a president. The incumbent, Donald Trump, ran for office 4 years ago with the promise to “repeal and replace Obamacare.” As part of that he vowed to “block grant” Medicaid. He promised to replace the ACA with something “terrific,” “phenomenal” and “fantastic.” In 2020 alone he has promised an Obamacare replacement plan five times, each time promising to unveil it “within 2 weeks.” The plan has never materialized. Instead, his administration has joined a lawsuit with 18 non-expansion states to gut the law (an unusual stance for the federal government to work towards the nullification of one of the federal laws, but as the kids used to say, WHATEVER). If they prevail they will take health care access away from 25 million people. In addition, for the last six months the lack of federal leadership regarding Covid-19 has also put us in a bind because we are a low tax state, meaning that we rely on the federal government to work on matters such as this. The result of the last three and a half years has been that, in Alabama, we have been in health policy limbo, waiting for President Trump to drop the other shoe.

Joe Biden, on the other hand, had an active role in the passage of the Affordable Care Act. He understands healthcare and healthcare policy. He has a viable plan to effectively get universal coverage in the United States. Although, one can never underestimate the ability of the powers that be to do something dumb, maybe even Alabama can’t screw this up.

Which brings us to last night. I was asked to watch and comment on the health policy aspects of the debate. Here is what we learned: Short answer, nothing new. Long answer, the candidates argued, obfuscated and hurled accusations over a range of health issues, including but not limited to: coronavirus, Obamacare, abortion, drug prices, vaccines, trust in science, stay-at-home orders, private health insurance, the public option, and the Trump administration’s ongoing lack of a health care plan. Specifics were as follows –

The President repeated assertions that he’d done a “great job” managing the public health threat and urged states to reopen, contradicting the head of the CDC whom he appointed.

Joe Biden believes that 200,000 deaths were way too many from Covid-19. The President disagrees.

Joe Biden understands that the future of care access in America is intertwined with the Supreme Court nomination, the President disagrees.

The President believes he has reduced the price of insulin, which, he has not for most people.

The President accused Joe Biden of wanting to take over all of medicine. Joe Biden pointed to the work he had already done and said he would not.

For me, as someone who has watched the poor of Alabama suffer from a failing of the healthcare infrastructure brought on by failed federal policies, needless deaths from preventable illnesses and now from Covid-19, and unnecessary bankruptcies for the past three and a health years, I am ready for a change. Last night did not convince me otherwise.

Fallout over Comic Cowboys continues as Mobile councilman quits ...
Sign in Comic Cowboys parade. Prichard is an African American community north of Mobile

I grew up in Baton Rouge, Louisiana. I graduated from Robert E. Lee High School. I ran track in high school and had many Black teammates. I did not go to their house and they did not come to mine. I was in college prep courses as well. I had Black friends who were relatively well off and whose parents were professionals. I rarely went to their house and they rarely came to mine. I do not pretend to understand what it is like to grow up poor and Black, or just Black, in the South.

I went to medical school in New Orleans, caring for the underserved of that city. One of my most vivid memories was when the wealthiest woman in New Orleans drove up to Charity Hospital in her Limousine to visit her servant of 50 years, whom she had paid in cash so was not eligible for Medicare. As I recall, she was dying of breast cancer. In an open bay ward. With no one to help her change out her bed pan. The society lady visited for an hour then went back home. I did not know what it was like to be poor and Black in New Orleans.

I moved to Mobile in the 1990s. I did my residency and stayed on at the University of South Alabama, caring for the underserved. I spoke with people who were thought to have “anxiety” because they “couldn’t sleep” as part of a study. Ever try sleeping in a bathtub so the bullets won’t hit you accidentally? I had a colleague who would hide his pager when he came to events in “white” neighborhoods because, if pulled over for being Black, he feared going to jail for dealing drugs. I have had patients stop seeing me because “you take care of n_____.” I have no clue what it is like to be poor and Black, or just Black, in Mobile Alabama.

I now work, in part, trying to undo systemic problems in our care delivery system in Mobile. My offices are in the “medical complex” area of Mobile. Six miles to the east is Springhill, the neighborhood where the well-heeled (white) Mobilians live. When they are born, evidence suggests that they will have, on average, 83 years until they die. They enroll in private school at the age of 5. They have a car from the time they are 16. They go to expensive colleges and return in time to be the magnate of industry that they were born to be and then another lifetime to enjoy the fruits of their labor. They get to ride in parades with signs that belittle the Black folks in the community for, well, being poor.

Six miles to the south of us is the working class community of Maysville. When they are born they are, on average, predicted to live for 65 years. They are not destined to be captains of industry. They have to drive for miles just to get fresh produce. Because they work multiple, low wage jobs, most do not have health insurance. Because Mobile has systematically underfunded public transportation, they have to beg for rides to the doctor. They are descendants of the enslaved humans that once made Alabama one of the richest states in the union. They are accused of being lazy, crack heads, and drug dealers. They are convicted of the crime of living while Black. They are sentenced to 55 years of hard labor, 10 years of a broken body and no way to pay the doctor’s bills, and a death at 65. They get to come to parades and see signs telling them that they should be ashamed for being Black.

I don’t know what it is like to be poor and Black in Mobile, but what I do know is that there are a lot of folks that do. They find out because they were born in the wrong place. They find out because, despite working hard, they can’t get a job that offers a living wage, much less basic benefits such as health insurance. Mobile has one of the highest rates of disparities between the wealthy and the poor in the country. Last night, the mayor offered “thoughts and prayers” to those Black citizens who live in Maysville and hurting and those white citizens who live in Springhill and are scared. He suggested that:

By creating One Mobile to become a safer, more business and family friendly city, and By uniting America into One Nation under God, indivisible, with liberty and justice for all.”

I hope that his prayer is answered. I hope that the Lord commands him to speak out against white privilege and work to eliminate it in all aspects of city life. I hope that the Lord commands him to lead the charge to remove vestiges of the confederacy from the city, which have traditionally been an instrument of oppression. I hope that the Lord commands him to make it a priority that workers have a living wage if they are willing to work a 40 hour week. I hope that the Lord commands him to make combating food deserts, public transportation deserts, and health care deserts a priority of his administration. Mostly, I pray he will do what it takes to erase the legacy of 300 years of enslavement on half the citizens of Mobile. While I don’t know what it is like to be Black, I sure know what equity looks like.

As states in the deep South and elsewhere are starting to open up from shelter-in-place orders I think we need to get some things straight.

Things that the virus is not:

  1. A deep state conspiracy. It was not created in a lab in Wuhan. It almost certainly is a naturally occuring coronavirus that moved from a bat to humans via an intermediate mammal.
  2. Going to magically go away. Very few people have immunity right now. Summer does not make this virus go away. We are stuck with it until 60% to 80% of Americans get it (culminating in about 1,500,000 dead Americans), we get a vaccine (unlikely in the next year) or we take stopping the spread of the virus seriously as other countries have done.
  3. That thing you had in January. It is almost certain that only 1% to 5% of the population in any place in America except New York City has been exposed to the virus based in antibody testing
  4. Just a bad “flu.” In a really bad flu year in the United States we have 61,000 deaths over the entire season. We have had at least 75,000 deaths from this virus in 2 months.
  5. Not going to hurt me. Randomly people die in car accidents. Randomly people die of this virus. Less randomly older and chronically ill people die of this virus when exposed.
  6. A plot by big pharma to harvest your healthcare dollars. This is a virus that is killing people. It is not activated by masks. It is spread through coughing droplets on others.

What the virus is…The virus is real.  It  came over from China (west coast) and Europe (east coast). It has almost certainly killed almost 100,000 people in this country so far although the death toll will be artificially low due to the way we categorize deaths (I know, I fill out death certificates all the time). It is almost certain that a medication will not help with mortality. If you get the virus, your risk of death depends on your age (very few under 65 die as compared to a lot over 80), your underlying health (those with chronic illness and/or obesity fair much worse than those who are basically healthy), and your exposure history (if you do not come in contact with droplets of spit contaminated with Covid-19, you will not catch it).

The way it came into the United States is a follows. Initially people got off an airplane from either China or Europe with the virus growing in their upper respiratory tract. They may have had a fever, cough and body aches. They may have developed a fever and body aches once off the plane. They may never have done so and cleared the virus. The travelers then went to an activity where there were a lot of other people. A scientific meeting in Boston, A jet setter party in Connecticut. Mardi Gras in New Orleans. They coughed on people at these places and a lot of them got infected. Problem was we were not testing those folks who were coming from infected areas. No tests.

First 100 deaths in the US didn’t happen until the last half of March. How did it happen? The people at  Mardi Gras, at meetings, in New York, the ones who were young and healthy then went and infected a couple of other people and mostly, the virus stopped there. Sometimes, before these people got sick (or even after), they went and did another group activity. They went to a community sing along. They went to a funeral and cried on their sister’s shoulder. They went to church and coughed on someone. At these events, though, there were older and sicker folks. When these folks got sick, they got really sick. Sometimes they went to the hospital, who couldn’t test them. When they got to the hospital there may have been lack of concern because it wasn’t in the community (again, no tests), and/or a lack of protective clothing. Health care workers would get exposed. They would get sick but, because they are troopers, would continue to work through the “flu.” If their job happened to be in a nursing home, many older people who were at risk would get exposed and some would die (either in the nursing home or in the hospital), many other health care workers would get exposed, and then many more people died. The workers in the nursing homes then go back to THEIR families and the cycle continues. Although, as the saying goes, we all have to die sometime, it doesn’t have to all be in the next month. Even now, we do not have enough tests, the ability to administer tests, or protective gear for folks caring for nursing home patients. About 1.5 million people live in nursing homes in this country. That will be a lot of deaths that don’t have to happen

So, the country is opening up and, in the words of the President, “some people will be affected badly.” Assuming you do not want to be the proximate cause (or the 2 degrees of separation cause) of someone’s Papa’s death, there are some things you can do:

  1. Wear a mask. If we get infected we may not know it for 3 or more days. A mask keeps us from infecting someone else who may have an underlying condition or just be older and more susceptible.
  2. Wash your hands or use hand sanitizer. This will keep you and others from getting it.
  3. Stay physically active. Outside is usually safe with social distancing.
  4. Stay away from and don’t hold gatherings of more than 10 people now and 50 people until there is a vaccine. There is clear evidence that social distancing works and when it goes away people die. Stay 6 feet away from folks you are not quarantining with.
  5. Stay home when possible. Remember, you don’t know if you will become sick 2 days from now
  6. Most importantly, stay home if you are sick. If you have a new loss of smell, cough, fever, shills, shaking chills, or shortness of breath but are otherwise healthy, don’t go out for 14 days.

Unlike many countries, we missed the opportunity to control this virus before is became endemic. If we follow the above measures, become much better at testing and protection of healthcare workers and first responders, and learn how to give up some freedom so that those infected can be isolated, then we can get control of our lives back with minimal loss of Meemees and Papas. The alternative is to lose 2,000,000 folks. Guess we each have some choices to make.

 

My first wife died almost 4 years ago, in April. She was 55 years old when she died. Her life story was remarkable in and of itself, one in which I was fortunate to play a part. Her story began, it turns out, with a natural experiment.

First, she was taken from her biological mother and placed in foster care for several months. Second, her adoptive parents were carefully selected. They were screened for resemblance (white but not too white), religion (not Catholic), and temperament.  Third, little Delphine had the full 1960’s data wipe. Her birth certificate was changed to reflect her adoptive parents and new name (Danielle). The date and size (I suppose) remained the same but the hospital, mother’s city of birth, father’s name, and any other detail was transferred over then attested to be the truth by the Orleans Parish registrar. She was a tabula rosa, existing to be filled out with the essence of Bev and Hank. She was one of 100,000 “closed adoptions” in 1961.

How did this experiment turn out? By the 1970’s, adoptees (mostly post WWII babies) were clamoring for personal information. Many were unhappy with their wiped identity. By the 1980s registries popped up and birth parents were allowed to register as were adoptees. By the 1990s most adoptions had some degree of openness. With the advent of 23 and Me, there were no secrets. Most adoptions now include some degree of openness.

Well, we really don’t know how the “taking away of babies and wiping them clean” experiment worked out because it wasn’t treated as an experiment. The societal belief  was that being taken out of a house where one is unwanted and being placed in a loving, nurturing environment would always be a good thing. Perhaps we should have looked more closely.

But a research brief published in October by the Institute for Family Studies threw a bit of cold water on this fantasy. The report, written by psychologist Nicholas Zill, was sobering: At the start of kindergarten, about one in four adopted children has a diagnosed disability, twice the rate of children being raised by both biological parents. Adopted children were significantly likelier than birth children to have behavior and learning problems; teachers reported they were worse at paying attention in class, and less able to persevere on difficult tasks.

In Danielle’s case, she found her birth mother (Pat) when we were in our 30s and had just moved back to Mobile. Or, rather, her birth family found her. At the reunion (on Royal Street during Mardi Gras), I knew that the slate was never wiped clean, despite the efforts of the state of Louisiana. Where Bev was shrewd, Pat was open (like Danielle). Where Bev was practical, Pat was creative (like Danielle). Where Bev was closed, Pat was open. Where Bev used soaps whose smells I found irritating, Pat used THE SAME SOAP AS DANIELLE. Oddly enough, Pat was 55 years old when she died.

The tabula rosa thing was not studied as an experiment. Why study something we knew “felt right?”  The closest science came to looking at this was the Minnesota Study of Twins Reared Apart. These investigators look at closed adoptions where twins were taken from families and raised as singletons. They have found that genetic factors appear to influence personality, mental, and activity-level changes as adults become older, to the tune of half. Yup, turns out you can only wipe the slate 50% clean.

One example of the amazing similarity of twins reared apart is the so-called “Jim twins”. These twins were adopted at the age of four weeks. Both of the adopting couples, unknown to each other, named their son James. Upon reunion of the twins when they were 39 years old, Jim and Jim have learned that:

  • Both twins are married to women named Betty and divorced from women named Linda.
  • One has named his first son James Alan while the other named his first son James Allan.
  • Both twins have an adopted brother whose name is Larry.
  • Both named their pet dog “Toy.”
  • Both had some law-enforcement training and had been a part-time deputy sheriff in Ohio.
  • Each did poorly in spelling and well in math.
  • Each did carpentry, mechanical drawing, and block lettering.
  • Each vacation in Florida in the same three-block-long beach area.
  • Both twins began suffering from tension headaches at eighteen, gained ten pounds at the same time, and are six feet tall and 180 pounds.

Closed adoption have not stopped. This is because when people look at a newborn they don’t see a thing half full of mom and dad but believe they are viewing a tabula rosa, despite evidence to the contrary.

Why think about natural studies? Because we are about to embark on one in this country around Covid-19 spread. What we know is that, left unchecked, every person with Covid-19 infects about 3 other folks and they infect 3 other folks, and so on until the whole world is infected and about 2% of the world is dead. That is, unless, the person who is infected stays home AND the person who is not infected doesn’t come into contact with an infected person. This breakage in the chain of infection has occurred because of shelter in place severe social distancing. Currently, this is a nationwide effort. As we reach the end of this phase, we are about to see 50 states going in different directions. The East Coast and West Coast states, for the most part, seem poised to maintain distancing for a bit longer, test a lot of folks, and chase down those that are infected to keep them from restarting the chain of infection. We on the Gulf Coast seem poised to demand an end to social distancing, eschew testing, hit the beaches and the baseball stadiums, and blame Barack Obama for the destruction of the economy.

Many are looking at this Covid-19 crisis through a different lens than I. What I see is a broken the chain of infection. What I see is a virus that is deadly and lurking, waiting for the chain of infection to be re-activated. We are about to embark on a natural experiment. Those of us whose neighbors look around and see conspiracy may bring Covid-19 deaths back into our nursing homes. I only hope we are measuring what happens.

 

“Nobody knew that health care could be so complicated”  @realDonaldJTrump

We are 341 days and some change away from the presidential election which will determine the fate of healthcare in this country. The current president, Donald J Trump, campaigned in 2016 on the “repeal and replace Obamacare” platform. Although there was a flurry of activity which threatened to bring back the fear of preexisting conditions and the creation of an Obamacarelite product (perfect for those not planning on being sick) for the most part Obamacare remains intact. In fact one of the key components, Medicaid expansion, actually seems stronger than it did under president Obama.

As we gear up for the next election it seems that healthcare is once again getting the politician’s attention. The Republicans are still of the mind that “Obamacare doesn’t work” although they are unable to come up with anything better. The Democrats have pushed out seemingly hundreds of ideas. Though somewhat of a moving target, it seems that the ideas can be coalesced into “Medicare for All” (Sanders and Warren), “Medicare for some more” (most folks), and “Better Obamacare for some” (Harris and Buttigeig). What piqued my interest today was what I thought was an arcane mental health discussion. Senator Harris called to:

Repeal the Institutions of Mental Disease (IMD) exclusionThe IMD exclusion precludes Medicaid funding for adults receiving care in psychiatric facilities with more than 16 beds, and has also exacerbated a severe shortage of acute psychiatric care beds nationwide. Repealing the IMD exclusion will reduce the number of Medicaid patients who end up in already strained general hospital emergency rooms when they need acute psychiatric care.

I thought “This makes sense” until I saw this Vox article:

But on Monday, when Harris’s campaign rolled out its mental health policy plan, it had not been nearly so thoughtful. Harris seems to have gone all-in on attacking the freedom, dignity, and privacy of people with mental health conditions. People like me.

I have to admit, although I know little about the Senator, she does not strike me as THAT evil.

As it turns out, back in 1965 when Medicare and Medicaid were being designed, there were a lot of people in mental institutions that were being imprisoned for their mental illness. Congress, fearful of states using the new Medicaid money to build bigger insane asylums, created a mental illness exception for inpatient treatment. Any facility with more than 16 beds that exclusively treated mental illness was ineligible for Medicaid funding. Although there have been some attempts to repeal it, this exception has stuck over the years. In part because of fears of mental health advocates such as those expressed in Vox. In part because of fears of increased cost. From a demonstration project which included Alabama where the exception was waived:

“Overall, we found little to no evidence of MEPD effects on inpatient admissions to IMDs or general hospital scatter beds; IMD or scatter bed lengths of stays; ER visits and ED boarding; discharge planning by participating IMDs; or the Medicaid share of IMD admissions of adults with psychiatric EMCs.

Available data suggest, however, that increased access of adult Medicaid beneficiaries to IMD inpatient care would likely come at a cost to the federal government.

In short, we are likely to find ourselves where we have always been. Folks suffering from serious mental illness (including substance abuse) only able to use their Medicaid for treatment if they are not too sick. This is in part due to a fear that those who are functional have that they will be locked away rather than treated in the least restrictive environment. This is also reflects the reality that the feds fund “healthcare,” not the prisons and underpass encampments where folks with intractable mental illness are now found.

Nobody knew mental health care was THIS complicated…

Resident: The patient is a 45 year old black male…

Me (interrupting): I really don’t like identifying people by the color of their skin. What else do you know about him?

Resident: The patient is a 45 year old automobile mechanic who is here for a recheck of his diabetes…

Me (interrupting): Who lives where?

Resident: I don’t know, Mobile. Can I please just finish?

Me: Not until you tell me where he lives and why it’s important

Resident (whispering to another resident): is there another attending I can talk to?

Our current mayor, when he was elected, established an outcome for his “mayorship.” He stated, unequivocally, that he wanted Mobile Alabama to be the safest, most business and family friendly city in America by 2020. Well, OK, in my objective writing classes we were taught to focus on SMART objectives. That is, they had to be specific, measurable, achievable, relevant, and time oriented. For example: We want to to be the most family friendly city based on the “family friendly poll” that is administered by the governor’s office twice a year and includes a scientific sample families in Mobile, Huntsville. Montgomery, and Birmingham. Yeah, forgot that step, I’m afraid.

What should it mean to be the most “family friendly” city in Alabama? Mobile is a geographically large city. Bordered by a river on one side, the city stretches 12 miles in one direction and almost 10 miles in another. Does “family friendly” mean parks? We got some, but not a lot. Does it mean churches? We got a lot of those. I bet it is neither one of those. I would bet, if you ask people, they want it to mean a good life for their children. I bet people would say “I want my kids to be happy, healthy, and successful.” How are we doing with that?

Turns out, the federal government keeps statistics on the “healthy” part at the neighborhood level. You can use a tool (such as this) to find out if you live in a healthy neighborhood or an unhealthy one. If you live in an unhealthy one not only are you doomed to a likely premature death but so are your children, In Alabama the healthiest neighborhood provided it’s denizens with a life expectancy of 88 years (an affluent suburb of Birmingham) to 63 years (an area of Montgomery that Martin Luther King marched through 50 years ago). Mobile’s neighborhoods range from a high of 81 to a low of 63.

The neighborhood with the lowest life expectancy in Mobile is not that far from my house. I treat several patients who live there. What sets the neighborhood apart? The people are poor. They work, just not at affluent jobs. One in four are uninsured. One in five report poor mental health and/or poor physical health. A baby born in this neighborhood can only expect to live to 65. A baby born in the mayor’s neighborhood? 82.

How can the mayor improve the health of this neighborhood? There are some simple fixes that could happen tomorrow. An effective bus route through the neighborhood, for example. A find a way to subsidize a source of fresh vegetables and fruits that is less than two miles away. Offer community support services at the neighborhood elementary school.

I believe that family friendly means that our children, who have not yet made any choices, have an equal chance at success. By that metric we have a ways to go by 2020/

 

Today, Mobile has set its sights beyond historic racial inequality, social inequity, and environmental disasters. Residents, local government, and community-based organizations are forging a consensus on what Mobile’s future should look like, from building an economically strong downtown to providing more easily accessible options for physical activity. Increasingly, community engagement and cross-sectoral partnerships are having a visible impact.

RWJF Culture of Health Sentinel Community Snapshot Mobile Al November 2016

I have to admit when I saw this I was a little taken aback. Tied up with the implementation of a new Electronic Health Record and planning a move to a new space, I figured I must have missed an e-mail or something. Mobile was one of 30 cities chosen by the Robert Woods Johnson Foundation from around the country. They were going to watch us as we developed “a culture of health.” I thought to myself “this is great” and “wow, what a big job.” I only hope that someone has been put in charge that is up to the task.

Because, as it turns out, a “culture of health” doesn’t just mean that we have good doctors and hospitals:

Think of social determinants as the root-causes of health and disease.

Imagine a bucket full of health. This bucket has a hole in the bottom and the health is dripping out (disease). We can mop up the floor below every hour, maybe even squeeze some of the health back into the bucket from the mop. But eventually, the health will be lost because we are not addressing the root of the problem. Instead, we can look for ways to prevent the hole and stop the leak from occurring.

And per the report we have a ways to go:

  • The median household income in Mobile is $38,644 per year, compared with $43,511 for Alabama and $53,482 for the United States (Figure 1).3 Inequality between the city’s black and white residents is striking, with black residents earning about half the median income of white ones. If you are poor you cannot afford good food, educational activities, or safe housing. These all are associated with poor health outcomes.
  • While more likely to have some college education or an associate’s degree in 2014 than they were in 2010 (Figure 2), the percentage of black residents who had a bachelor’s degree or higher in 2014 declined from 2010, despite increases in higher education among white residents. Educational attainment is always associated with better health outcomes. 
  • Teen pregnancy rates in Mobile County are 57 per 1,000 for women aged 13 to 19, compared with 47 per 1,000 in Alabama and 20 per 1,000 in the United States. Teen pregnancy is associated with a lack of knowledge regarding contraception and a lack of access to effective long acting contraceptive methods.
  • The county’s mortality outcomes are higher than the national average for preventable noncommunicable diseases, such as heart diseases, cancer, and diabetes. This reflects limited physical activity, limited opportunities for physical activity, and a very high level of obesity.
  • The city has an uninsured rate of 17%, which is more than 2% higher than the national average.

The report is very complementary of the Mayor’s “One Mobile” initiative and the Three Mile Creek park development.

Unfortunately, the community piece that was cited as most important in transforming our community was “Live Better Mobile.” From the press conference in 2012:

A “Live Better Mobile” program was unveiled today during a news conference. It’s aimed at creating public awareness focusing on three efforts – achieve healthy weights, prevent teen pregnancy, and quit tobacco.

The focus for the 37 community partners participating in the program is on prevention, nutrition and exercise.

“If we’re going to have a significant impact on health and well-being of our citizens, it’s going to take a community effort,” Dr. Bert Eichold of the Mobile County Health Department, said.

The group’s website is now dead. Their FaceBook page hasn’t been updated in a year.

So, Mobile, RWJF and the country are watching us. For the next five years they will be following the health of Mobilians. Are we up to the scrutiny? From the comments:

Talk from the fat cats is cheap. Want to encourage people in Mobile to Exercise? Give them a place to get out and exercise. Spend $70,000 on a weekly Ciclovia event. Pave that Rails-2-Trails from Prichard to Citronelle. Spend a money to construct Exercise Trails instead of spending money constructing Airbus Roads which don’t even have bicycle lanes.

 I just hope someone is in charge…

 

The website 538.com has posted an essay (found here) about the great state of Alabama. Unlike most click bait-y articles that Alabamians seem to be attracted to on Al.com (i.e. What are the 11 greatest barbecue places within 30 miles of Bryant-Denny stadium?) but instead an in-depth look at healthcare in Greene County, Alabama. Greene county is currently the least populated Alabama county (9,045 people, 81.5% black or African American). In 1860, the county had about 30,000 people. Well, kinda depends on your definition. 23,598 of those “people” were actually enslaved human beings. Although the math works out to approximately 4 enslaved humans for every 1 “person,” in fact it was almost 7000 enslaved humans were owned by about 50 folks. As described in the Encyclopedia of Alabama, this was not a bad thing

In the decades leading up to the Civil War, Eutaw experienced a golden era as the mercantile and legal center of the Black Belt. The first courthouse, built in 1838, burned in 1868. The current courthouse was built in 1993.

The county is in a region of the state known as the “black belt”, named not for the color of the population but for the color of the soil. The slow slide to economic despair over the last 150 years has taken a toll on the region. Immediately after the civil war, the region was home to 40% of the “citizens” of Alabama. The systematic oppression of former slaves and the descendants of former slaves has lead to the growth and development of many civil rights leaders, blues musicians, and story tellers. It has also lead to a bunch of people moving away. The region, once the economic engine for the region, is now home to 12% of Alabama’s population. In the words of one Percy County resident

“The only reason people come to town now is for funerals, and they leave as soon as they’re over ’cause there’s nothing to do and nowhere to stay,” said Walker, 64, the son of sharecroppers

For those who have stayed, economic prosperity has been an uneven proposition. The racial makeup of the Black Belt region was 52.2% African American, 45.8% White, 0.2% Native American.

The poverty rate among [Wilcox] county’s white population is just 8.8 percent, which is lower than all but five counties. The poverty rate among the county’s much larger black population is 50.2 percent. The 41.4 percentage point gap is the largest in the state.

Other Black Belt counties have a similar dynamic. Lowndes County has a 4.1 percent white poverty rate – the lowest in the state – but a 34.5 percent black poverty rate. In Perry County, the white poverty rate is 8.1 percent, while the black poverty rate is 32.7 percent. In Marengo County, it is 5.6 percent and 40.8 percent respectively.

So why worry about these folks? Can’t they continue to vote with their feet?

“The Black Belt is a road map,” said Patrick Sullivan, a professor at the Rollins School of Public Health at Emory University who previously worked on HIV surveillance at the Centers for Disease Control and Prevention. “That’s what’s so tragic and so compelling. It’s an endgame depiction of what happens when you have social and structural inequalities. It’s the vestiges of slavery and inequality, and in the long run those things do play out as health inequalities.” Sullivan and colleagues have studied why HIV rates are so much higher among African-Americans and Latinos than other racial groups3 and found that health insurance is the most important mediating factor. People in both racial/ethnic groups are more likely to be poor and have less education, which are related barriers, but insurance coverage is where the local and federal government could improve access to treatment, Sullivan said.

Alabama is not a Medicaid expansion state. Our Doctor-Felon-Former-Governor decided it was a political chance he did not want to take, even after his re-election into a term limited position. Remember, adults who are employed but make less that 138% of poverty uninsured are not eligible for Obamacare. In counties like Greene, where 40% of the population is below the poverty level, that is a lot of folks, almost all of them black. When the median household income is $20,000, people are going to choose food when having to decide regarding food vs insurance, every time. So what is the right thing to do? In the words of my friend and colleague John Waits, quoted in the article:

“Nothing happens without Medicaid,” Waits said. “It is the No. 1, the No. 2, it is the top 10 solutions.”

I’m beginning to think this is about something other than partisan politics.

I had to quit my job because of the stress I had to endure was putting me at high risk for a stroke or heart attack and I couldn’t physically keep up anymore
I’m 56 years of age
My job was 32 hours a week
But because of Obama care my insurance was costing me $600 dollars a month for just major medical!
No dental no eye care no life insurance
So by the time I paid my rent, electric, water, sewer, garbage, car insurance, house insurance etc, I had enough money to put gas in the car to get to work and buy ramen noodles and some cheap hot dogs for food!
Over 60% of my net pay went to insurance that covered nothing!
Now I am unemployed with ZERO insurance
Its pretty damn sad when all the damn medicaide and dissabilty cheats are eating steak with perfect teeth and new glasses and are in perfect health while I have to bust my damn ass just to eat ramen noodles wityh bad teeth , basbasd eyes, and life threatening health problems!!

So here I am, no job, no insurance, no hope

Patient’s story as posted on Obamacare stories

The average household income in the United States is $51,000. From that you pay for our food, shelter, children’s education, and movie tickets. Oh, yeah, and $5000 for a health insurance policy. One of the things that Obamacare did was begin to put a cost on our insatiable healthcare consumption. Turns out, that cost is VERY high.

If you are an average American, boy are you ticked off. Half of all Americans spend under $400 a year on healthcare. Pretty much a round of antibiotics for a sinus infection and, for women, a year’s worth of contraception. Not only that but because of high deductibles (to keep the cost down by discouraging consumption) you are paying $5,000 to the insurance company AND paying cash for your sinus infection visit and medicine. Then there are the drug companies and insurance companies that are colluding to raise the prices of formerly cheap antibiotics to get even more of your household income.

About 1% of the people in this country account for about a quarter (27%) of the health care spending. In 2014, this  was about $100,000 per sick person. Those in the top 5% of sick people were responsible for  almost $50,000 in health care costs. These numbers are unchanged since Obama was elected. So what has changed? Before, the costs of these people were hidden. They would get the care for “free” at a safety net hospital who would get money in other ways to pay for it. Or a sick person would use an insurance card then the payment would be denied as a pre-existing condition and the hospital would eat the cost. More likely, the sick person would get on disability, suffer for 2 years, and become Medicare eligible so we the taxpayer would pay. The care still cost money but was hidden in taxes. Insurance companies kept costs low, in other words, by shifting them to the federal government. Now folks under 65 who are sick can pick up an Obamacare policy and get exceptional care. Also on Obamacare stories are ones like this:

Thank you President Obama thanks to your healthcare plan I was able to continue to see specialists, this resulted in a diagnosis of a rare intestinal infection and even more concerning, two stage three colon cancer tumors, one on each side on each side of the colon. This required almost total colon removal from a top notch physician that was able to do my surgery without having to have a bag.

Only problem is, this type of care costs A LOT more than $5,000. .

So, if you bought an Obamacare policy and feel ripped off, let me tell you what your $5000 paid for. It wasn’t eye glasses and dental work for poor people that jacked up your bill. You spent your $5000 on people under 65 with heart disease and lung disease. You purchased them a lot of expensive tests, some time in the hospital, and some expensive drugs. You paid for the person with breast cancer’s $300,000 tab whose $5000 premiums were paid by the cancer treatment facility.  You paid for the person helicoptered in after rolling their car on Interstate 65 while trying to avoid a deer.  You paid for some very expensive medication for people with mental illness to keep them out of a mental hospital.

Did you pay too much? Yes. Other countries can do the same thing better for half as much or less. Perhaps the new adminstration will look at this as an opportunity to further retool our expensive, not very effective care delivery system and reign in some of the profiteering. Or maybe we’ll just continue to blame the poor…

 

Are you going to provide free clinics for sick underprivileged children? Will you do in Alabama what you do on mission trips to other states and countries?

Senator Jim McClendon, explaining why he is sponsoring not one but TWO lottery bills

The legislature in Alabama is meeting in special session starting today to see if they can find more money for the General Fund budget. The budget passed in the regular session was about $100 million short for what was needed to maintain the Medicaid program at its current bare bones level. Medicaid and corrections are the major programs funded by this complicated and convoluted budget process and, as you can imagine, the constituency tends to be silent. The legislature comes back into special session today to determine whether Alabama will become the first state to reduce Medicaid funding below the threshold required for the match.The funding possibilities are as follows:

  1. Governor Bentley’s proposal- a $225 million lottery, with proceeds going to the General Fund. Would require constitutional amendment. Money not available for about a year.
  2. Jim McClendon’s bill, which would include electronic lottery machines in four counties – Greene, Jefferson, Macon and Mobile – with a bond issue to pay for Medicaid in the coming year. Would require constitutional amendment.
  3. House Minority Leader Craig Ford, D-Gadsden, said he’ll bring a lottery-only bill that would set aside lottery proceeds for education. Another Ford bill would include casino gambling as well.  Would require constitutional amendment. Money not available for about a year.
  4. The legislature may create a compact with the Poarch Creeks, allowing them to offer more types of gambling in exchange for an annual fee or a cut of the proceeds. Critics worry that under federal gaming regulations, a lottery could open the door to Creek expansion without a compact. Unclear how this would work. Likely would draw a lot of attention form the feds.
  5. They may opt to use the BP money to fill the gap this year, leaving the hard work for next year.
  6. They may, and possibly will, do nothing and allow Medicaid to become a non-compliant program

If they fail to act. the feds will do one of two things. Because the program’s recipients are disproportionately poor and of color, the feds may sue under the Fourteenth Amendment and require us to find $100 million to maintain a $6 billion program, maintain access to healthcare for ALL Alabamians, and not force the layoffs of tens of thousands of individuals who work in healthcare. Conversely, the Supreme Court has ruled that Medicaid is an optional program. The feds may just allow us to opt out and allow our natural experiment to continue. Let’s see how many folks will come to Alabama instead of Ecuador for mission work.

 

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