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Business executive at party: “What do you and your friends do?”

Me: “We work at the medical school”

Business executive: “No, I know that. I mean what is it that you guys DO”

Me: “We all work in different areas. For example I train doctors in Family Medicine”

Business executive: “Well, tell me, why do we need Obamacare”

Me: Very long, detailed soliloquy about pre-existing conditions, the contributors to the cost of health care, etc, fueled by lots of wine and ending in the need for Medicare for All if we don’t let Obamacare do what it was designed to do.

Business executive: “So why does it need to be so complicated? Why can’t folks just pay for insurance?”

Me: Sigh. “Excuse me, I’m going inside for a bit. Can I bring you anything?”

It is difficult to discuss health system reform with people not closely engaged in care delivery. Most people have interfaced with the care delivery system and so believe they know how best to fix it. Most people consume under $300 worth of healthcare annually but don’t question the opportunity cost of having access (over $17,000 annually for a private insurance plan). Most people are thrilled when told of a negative test (“Congratulations, it’s not cancer”) but don’t question whether the test should have been done in the first place. Airplane crashes put the focus on the safety of the aviation industry because 300 people dying at a time is newsworthy. Losing 4000 people annually in Alabama to premature heart disease because of a poorly performing health system is a yawner.

In any given year, only 5% or fewer of the US population use the healthcare system for something serious like cancer Most folks who interface the care delivery system (make a doctors appointment) do so for a self-limited illness. They come in either because a) they want assurances they are not going to die and want to feel better or b) they need a note for work. From a survey done in 2014, when a person seeks care here is what they want:

  1. Be seen without an appointment within 30 minutes any time of the day or night for $0 to include labs and x-rays done on site.
  2. Have the same person see them every time and have them spend unlimited time explaining symptoms
  3. Have this magic 24/365 office close to home (next door is preferable).

Business executives, I suspect, pretty much get this type of care. Michael Jackson, for example, had his own cardiologist. Access costs money. In corporations the CEO tends to have the same insurance as the lowest wage earner. What happens when a large corporation pays for care that includes this type of access? The executive may not be worried by the high premium (average is over $12,000 annually for a family plan) and additional company cost ($5000). The low wage worker, on the other hand, might be willing to trade immediate access for better food or housing choices but isn’t often given the choice. Obamacare was designed, in part, to put the brakes on healthcare inflation.

In states where the Affordable Care Act has been fully implemented more employers are paying for health care and more people are covered by other types of coverage. As more people have ended up on public plans (Medicare and Medicaid) health care inflation has reduced. The number of bankruptcies due to medical conditions have fallen precipitously.

Despite all of the rhetoric, it appears that the system reforms put in place by the Obama administration are working. In an essay in Vox, Mae Rice points out that spending some money on a small luxury like Starbucks every day can lead to enhanced responsibility. We, as a society, have a responsibility to people like her. Not to ask her for her Starbucks money. Not to blame her for failing to save for a catastrophic illness that is unanticipatable. Not to ask her to be a prisoner at a minimum wage job so her CEO can get 24/7/365 access to any specialist she wants. We have a responsibility to provide access to quality healthcare at a reasonable cost. Although not perfect, Obamacare is moving us in that direction. As a society, this is a responsibility all of us, including business executives, should take very seriously.


The Robert Wood Johnson Foundation and the University of Wisconsin have put together a web site which compares the health status of counties within states. Originally done by the University of Wisconsin for Wisconsinites, last year they expanded it to all (well, all but 115) counties in the United States. The local paper dutifully published an article, identifying Mobile County as a low performing county (#46, down from #43 last year) and the neighboring county of Baldwin as a high performing county (#3). The next day, the paper decided to get serious, publishing an editorial identifying what was measured

Social factors and health habits are taken into account in the health rankings, including obesity, smoking, high school graduation rates, air pollution, access to health care, access to exercise and life expectancy.

and pointed out that perhaps building a walking trail would solve all of our problems

From a health standpoint, trails offer cheap and easy opportunities for exercise. Families can walk together; those beginning an exercise program can try a one- or two-mile stretch of trail and improve.

In reality, being third in the 45th ranked state is nothing to brag about. Anyone who knows anything about who lives in cities as opposed to who lives in suburbs likely can make an educated guess as to why Baldwin (suburbs) has better health statistics than Mobile (city) and it has little to do with a 2 mile walking trail.

A more interesting comparison tool, found here, compares counties against others of similar demographics and economics. In this comparison Mobile County still doesn’t fare very well (average life expectancy 73.6 years, peers 73.5-77.8 years, every marker worse than peers except immunization rates and prenatal care access) but Baldwin is no great shakes either (average life expectancy 76.6 years, peers 75.5-78.2 years, worse than peers except in breast cancer survival, infant mortality, and suicide rates).

The purpose of the rankings is not, or so says the University of Wisconsin, to facilitate boosterism but in the hopes that communities will use this information to work towards improving the health of the citizens. I hope that the local paper (as well as the media outlet of any communities whose “rankings” were not what they would like) will look at this page where action steps are discussed. These action steps include working together as a community, finding programs and policies that work, implementing strategies, assessing needs and resources, evaluating efforts, and picking priorities. Additionally, they have targeted advice for community leaders, educators, health professionals, and government officials, and public health officials.

Here is the advice for the community leaders, in case anyone from the local paper is paying attention

  • Get the word out. Reach out to people you know and see every day about the County Health Rankings report, e.g., at a local Chamber of Commerce breakfast or at an urban planning meeting. Post information about the report on a listserv, website, or e-newsletter.
  • Organize. Meet with local leaders and community residents to discuss barriers to health and ways to overcome them. Host a town hall meeting or invite people to one.
  • Get policymakers to pay attention. Tell them about how their county or counties ranked and open a dialogue about ways to improve health in your community.
  • Be an advocate. Step out as a spokesperson about the rankings and the health issues you care about and rally other community leaders to take action.
  • Contact your local public health department about participating in a local task force or, if none exists, organize one to tackle these pressing issues in your community.
  • Ask your local or state health department about what they’re doing in response to the report to make sure you aren’t duplicating efforts.
  • Share your resources. Offer your time, staff, and/or funding with community partners. These are resources that can go toward community plans and programs aimed at tackling factors that affect health.
  • Communicate your message. Write an op-ed or talk to local media about the rankings and what needs to be done to improve the health of your community.
  • Start a conversation. Talk to your friends, colleagues, neighbors, and family members about the health of your community and what everyone collectively can do to make it healthier.

Now that the word is out in Mobile, I hope we’re able to make the rest happen here.