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When the Office of Economic Opportunity, which was funding Geiger’s clinic (the first community health center in Moundville, Mississippi funded by Lyndon Johnson’s Great Society) , found out, they were furious — and sent an official down to Mississippi to inform Geiger that they expected their dollars to be used for medical care. To which Geiger famously replied: “The last time I checked my textbooks, the specific therapy for malnutrition was food.” [Excerpt from “Wellness is More than Not Being Sick” by Rebecca Onie, Chapter 18 in Creating Good Work: The World’s Leading Social Entrepreneurs Show How to Build A Healthy Economy edited by Ron Schultz]

When Dr Jack Geiger got to Moundville in 1964, he found conditions to be reminiscent of those he had seen in South Africa, and not in a good way. The staff of the community health center, who supposed they were going to be dealing with TB, cancer, and other medical problems instead found themselves overwhelmed by the social problems that undermined health in the region, such as hunger and unemployment. In a way that was prescient,  members of the community were included for the first time in decisions about their health and the future of the area through inclusion on the board and the clinic staff.

These medical folks soon found themselves engaged in food security, developing safe drinking water, and economic development, The clinic developed a farm cooperative to allow community members to grow food for themselves and earn additional money from selling produce to others. They not only saw patients in their offices but went into people’s homes to focus efforts on how to prevent illness. In the days of Jim Crow, they were considered a significant threat to the status quo.

Today, the Delta Health Center has a Facebook presence. The community health movement has spread to almost every part of the country. It is not unusual for the local Center to provide services to all, regardless of ability to pay. However, it isn’t enough. Just as Dr. Geiger saw that food was the treatment for malnutrition, we now know that chronic illness, cancer, and premature death are caused as much by poverty and genetic predisposition as by bad luck. The zip code you are born in predicts whether you will live an additional decade and what that experience will be like. The next Dr. Geiger will need to get into the weeds a bit more.

The Center for Health Innovation at CMS has put together a blueprint to get to the next step. Called Accountable Communities, it envisions health professionals hooking folks up with food, pest control, legal services, and other resources needed to help them overcome the tyranny of the zip code. Health Affairs has outlined what resources we as care providers need to overcome that tyranny:

1) Health Systems Need To Commit To Real Clinical Integration Of Social Needs – If we are going to anticipate the “rising risk” patient, we as care providers need to know something not only about the “really sick” but about all folks in the community and their anticipated needs. Some insurance plans are capturing this on all of their covered folks but doing a terrible job of sharing with other members of the health care team. We need to all know who is suffering so we can match people with resources.

2. Commit To Developing A Workforce That Is Truly Focused On Addressing Social Needs – It will take more and different types of care providers to help folks to not get sick in the first place. What should our outreach strategy be? Do we develop community health workers? Do we recruit volunteers? While it takes a village, more importantly it takes way more than just doctors. Once a need is identified, we need case workers engaged in hooking folks up with services such as food pantries, financial planners, pest control specialists, and legal aid.

3. Commit To Giving That Workforce The Information They Need To Do Their Jobs Well– Community resource availability is an ever-changing picture. Static information sources (books, pamphlets, etc) are rapidly out of date. Medical personnel often are unaware of what the community has to offer. Whose job is it to hook up community agencies with sick people?
4. Commit To Follow Up – For folks at risk of getting sick, repeated contact to help them become motivated to change is the key, even when they don’t want to think about their health. Who makes this contact? Do we aggressively pursue those who feel they don’t need services but clearly do?
5. Commit To Collecting And Analyzing Data – This is a lot of data on people. Target knows when a person is pregnant, often before the baby-daddy does. Do we use this data for the forces of good? If so, who does and how do they use it?
The Great Society didn’t make us great but it sure helped this county. Although still poor, the health markers in Bolivar county are better than 11 other Mississippi counties. For rural Mississippi, that is saying something. Maybe through Accountable Communities we can all take that a step to disassociating illness and poverty.

 

 

For those of us old enough to remember, the largest expansion of government FUNDED healthcare was the introduction of Medicare Part D. Enacted in 2003, it took effect in January 2006. As of today, only about 75% of eligible folks have signed up. This is in part because folks have other coverage (such as the VA) make a decision and, for the number of people no chronic conditions, the $1100 the spend on prescriptions is less than the $4800 they pay into Part D. Helping people make the decision, as I recall, whether or not to sign up were an army of sales people from the 33 different plans, the government, and the managed care organizations.

If you look at the sales effort for the Affordable Care Act, it has been much more low key. This is in part because, at least in Alabama, there are a number of people who consider selling ObamaCare the equivalent of selling tickets to Hell. Also, because of the long lead time, those with a vested interest (the insurance companies) have not been as aggressive as the pharmaceutical companies were.

The universal coverage piece of the Affordable Care Act is dependent on those who are poor (below 139 of poverty) obtaining Medicaid. Many of the “Red” states have balked at this provision and are not likely to “try and sell” it to the people. Someone is going to have to do it. A poll by the Joint Center for Political and Economic Studies asked citizens of several Red States (including Alabama) about the sales pitches and here is what they found:

The good news? They found:

strong support for the Medicaid expansion  provision of the Affordable Care Act as well as  for other provisions of the health care law. On  the survey’s general question about Medicaid  expansion, 62.3 percent of respondents, including  majorities in all five states and a majority of  non-Hispanic whites, supported expansion.  The survey’s detailed question on Medicaid  expansion received 53.8 percent support from  all respondents and majority support in all five  states. A majority of non-Hispanic whites did not support Medicaid expansion on the detailed  question, but a plurality did.

The bad news?

For those not wanting the expansion, the following arguments were not helpful in moving them to yes:

  • What if you heard that this would mean many low income people in your state would be left without health insurance, and your state would be giving up additional federal dollars for covering its uninsured residents?
  • If your state rejects Medicaid expansion, taxpayers in your state would be subsidizing health care in states that do  expand Medicaid coverage. Knowing this, would you still prefer to keep Medicaid as it is today, or would you prefer to expand Medicaid to cover more low income uninsured people in your state?
  • After the first three years when the federal government pays for all of the costs of Medicaid expansion, [STATE] can withdraw from the program any time it wants. Knowing this, would you still prefer to keep Medicaid as it is today, or would you prefer to expand Medicaid to cover more low income uninsured people in your state?
  • The nonpartisan Kaiser Family Foundation and the Urban League calculated that states will get $9 from Washington for Medicaid expansion for every $1 they spend on the expansion. Would knowing this make you more or less likely to support Medicaid expansion?
  • A side benefit of the Medicaid expansion is that it would create thousands of new jobs and large amounts of economic activity and new tax revenue in your state. For example, the state of Alabama estimated that the Medicaid coverage expansion would reduce the state’s uninsured population by 232,000 individuals while generating $20 billion in new economic activity and a $935 million increase in net state tax revenue. Would knowing this make you more or less likely to support Medicaid expansion?

Not asked was if those opposed would prefer all poor people to sicken and die or just those that don’t look like them.

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