I wrote last week about the Prevention and Public Health Fund, which the Affordable Care Act (ACA) created to invest in improving overall population health – with the hope that improved health will help slow the growth of healthcare costs. Another provision of the ACA that aims to reduce future healthcare costs is “Maternal, Infant, and Early Childhood Home Visiting Programs” (Section 2951). Three studies published in the latest supplemental issue of the American Journal of Public Health address this type of program.
Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programs send trained professionals to the homes of parents of infants and young children to promote child health and development and reduce child abuse, neglect, and injuries. The Nurse-Family Partnership is probably the most widely known and extensively researched home-visit model; it enrolls vulnerable (generally, low-income and teenaged) first-time mothers while they’re pregnant and links them with public-health nurses who visit them during their pregnancies and the first two years of their children’s lives. The nurses provide “guidance for the emotional, social, and physical challenges these first-time moms face.” In the stories on the Nurse-Family Partnership website, that guidance ranges from teaching 17-year-old Shanice relaxation techniques and how to interpret her baby’s cries to equipping 19-year-old Amanda with self-confidence and an action plan to leave an abusive boyfriend. (For an even more in-depth story, read Katherine Boo’s fascinating 2006 New Yorker piece “Swamp Nurse.”)
Professor David Olds and his colleagues developed the nurse-family partnership model and conducted the first randomized trial of it in Elmira, New York. Followup studies conducted after the children reached age 15 found that the children whose mothers received visits had 48% fewer verified incidents of child abuse or neglect and were 58% less likely to have been convicted of a crime, while visited women had spent 20% less time on welfare.
Reductions in child abuse, criminal convictions, and time on welfare translate into public savings, as well as harder-to-quantify improvements in quality of life. A Washington State Institute for Public Policy analysis of a nurse-family partnership program for low-income families calculated that a program investment of $10,291 per participant yielded $22,781 in savings due to reduced crime, child abuse, disruptive behavior, substance abuse, and need for public assistance, as well as children’s greater likelihood of graduating high school and securing employment. That’s a net savings of $13,181 per participant, as well as a big reduction in suffering.
Birth spacing and enrollment factors
In a study just published in the American Journal of Public Health (AJPH), Katherine Yun and colleagues examined the impact of the Pennsylvania Nurse-Family Partnership on birth spacing for first-time Latina mothers. Short intervals between pregnancies are associated with higher risks for preterm births and low-birthweight babies, and the national 2020 Healthy People goals include reducing the number of pregnancies that occur within 18 months of a previous birth.
In this study, Yun et al used client data from 23 Pennsylvania NFP programs, welfare eligibility files, and birth certificate files to compare birth spacing in two groups: Latina women who were enrolled in an NFP program for their first child’s birth and who had received some form of welfare assistance in the previous year (the enrollee group) and demographically similar Latina women who had received some form of welfare but were not enrolled in an NFP program (the non-enrollee group). The study sample included women who delivered first-born babies in Pennsylvania between 2003 and 2007, with followup through the end of 2009 to identify subsequent births to the same mothers.
The researchers found a decrease in the risk of short interpregnancy intervals (18 months or fewer) for Latinas enrolled in the program compared to the nonenrollees. When considering all age groups in the sample, 22.9% of enrollees and 25.8% of non-enrollees had conceived second children within 18 months. When considering only those age 18 and under at first birth, the difference was greater: 24.3% compared to 28.9%. (Findings for both analyses were statistically significant.) The authors note that these effects “were smaller than those seen in an NFP randomized controlled trial that included a large cohort of Latina women,” but that the difference “might reflect expected changes in program effects after wide-scale implementation outside of the experimental setting … [or] secular trends, such as declines in the US adolescent birth rate over the past 2 decades.”
In discussing the study limitations, the authors note that although they used propensity score models to create a matched sample of non-enrollees, there might be unmeasured differences between the women who enrolled in the program and those who didn’t, which could bias the results. Factors influencing at-risk first-time mothers’ enrollment in a home visitation program are the subject of another study appearing in the same issue of the AJPH.
Neera K. Goyal and colleagues studied enrollment in the Hamilton County, Ohio Every Child Succeeds program, which sends visitors to at-risk mothers’ homes during pregnancy and the first year of the child’s life. The model emphasizes “early prevention during pregnancy, education in child development and health, parenting skills, and maternal economic self-sufficiency.” Women are eligible if they are unmarried, younger than 18, or low-income. Using vital statistics records and census data as well as referral and enrollment information, the researchers identified factors associated with referral and enrollment in the home-visitation program. They found:
Results demonstrated that referral was more likely among those with lower education and in women living in communities with higher levels of social deprivation. However, once women were referred to home visiting, enrollment was paradoxically less likely for those with lower education and higher community levels of social deprivation. This suggested that despite appropriate referrals among the target, eligible population, there was lack of engagement among women at highest risk who were perhaps most in need of home visiting.
Getting public-health services to those who can benefit from them most is often a challenge. In another study published in the same AJPH issue, researchers look at a program that takes a different approach: It seeks broad enrollment, and then targets more-intensive interventions to those most in need, rather than seeking to enroll only high-need participants.
Casting a wide net in Durham
Kenneth A. Dodge and colleagues examined emergency care episodes in a child’s first six months of life, comparing families randomly assigned to the Durham Connects program to those who were not. Unlike the more narrowly targeted home-visit programs, Durham Connects is available to families regardless of income (or other maternal characteristics) and whether or not the birth is a first birth. During the 18-month study period (July 1, 2009 – December 31, 2010), the families of babies born on even-numbered days were assigned to the program, and those with odd-numbered birth dates were not.
Durham Connects begins in the hospital when the mother gives birth and a staff member explains the program and asks for enrollment consent. Parents who agree to participate receive one to three home visits during the baby’s first 3-12 weeks and a staff member followup (by phone or in person) one month later. During their visits, nurses evaluate health and psychosocial risks in four areas known to affect child wellbeing: “(1) parenting and child care (child care plans, parent–infant relationship, and management of infant crying); (2) family violence and safety (material supports, family violence, and past maltreatment); (3) parent mental health and well-being (depression and anxiety, substance abuse, and emotional support); and (4) health care (parent health, infant health, and health care plan).” The nurses also provide up to 20 brief “teaching moments,” offer extended education on specific topics (crying, breastfeeding, etc.) as needed, and help connect families to relevant community resources.
Subsequent interventions vary depending on risk scores, with low-risk families receiving little further contact and those with higher scores receiving referrals to community services and followup communications. Those whose scores show imminent risk receive emergency interventions; only 1% of the families completing the program fell into this category.
The researchers obtained records from the two hospitals at which the participant births occurred and tallied the number of emergency department visits and overnight hospital stays the infants had in the six months following their initial release from the hospital. Their analysis found that Durham Connects infants had 59% fewer emergency medical care episodes in their first six months of life than did infants in the control group. Based on the costs of those episodes, they calculated that every dollar spent on the program saved $3.02 per infant in emergency-care costs in the first six months of life. “For a community the size of Durham with an average of 3187 resident births per year and a Durham Connects intervention cost of $700 per birth, a community annual investment of $2 230 900 in the Durham Connects program would yield a community-wide emergency health care cost savings of $6 737 318 in the first 6 months of life,” Dodge et al conclude.
The Durham Connects program, the authors note, was designed to be implemented at the population level, not just offered to a group of high-risk families. This universal delivery can reduce the stigma that can otherwise reduce enrollment in programs for low-income or otherwise at-risk mothers. Dodge et al also report that while home-visiting programs are promising, none has yet scaled up successfully. As scale-up occurs, penetration and retention can decline, while quality and fidelity can degrade. And, they point out, scaled-up programs rely on communities having sufficient resources to provide the services to which home visitors might connect eligible families. In contrast, they write, Durham Connects “was delivered universally in a mid-sized community with a high rate of poverty.”
Durham Connects is a nonprofit founded with support from Duke University, the Durham County Health Department, hospitals, the Department of Social Services, and the nonprofit Center for Child and Family Health; The Duke Endowment funded its multi-year pilot. In addition to Durham Connects, which is available to all local families, the county offers other programs for higher-need families, and Durham Connects nurses often help assure that eligible families obtain these additional services.
Uncertain outlook for federal funding
The Department of Health and Human Services (HHS) has been distributing the ACA-appropriated MIECHV money to state entities “that have implemented high-quality, evidence based home visiting programs.” Most recently, 13 states received a total of $69.7 million. Because the ACA requires that entities serving high-risk populations get priority when grants are awarded, programs like Durham Connects are unlikely to receive money from this funding stream. As research on the impacts of different home-visit models accumulates, communities may decide to seek other sources of funding for programs like Durham Connects that serve larger populations with lower per-participant costs.
The Affordable Care Act only appropriated funding for MIECHV programs through fiscal year 2014. Grantees are required to report to HHS by the end of 2015 on their improvements in benchmark areas, including improvements in maternal and newborn health; prevention of child injuries, abuse, and neglect; improvement in school readiness and achievement; and reduction in crime or domestic violence.
Maternal and child health advocates will be advocating for Congressional reauthorization of MIECHV program funding. Brent Ewig of the Association of Maternal and Child Health Programs notes that funding the program at existing levels for another five years would cost $2 billion, and still only reach a small portion of the eligible population.
As studies continue to demonstrate the long-term benefits of home-visit programs, local and state officials probably recognize that supporting these programs makes financial sense. However, with all states except Vermont having legal requirements for balanced budgets, it can be hard for states to make expenditures now for savings that will show up in future budget years. Although politics can make it hard for Congress to increase spending on public programs like MIECHV, there are no legal constraints on its ability to invest in children’s health today in order to reduce future unemployment and Medicaid spending. For lawmakers seeking to improve children’s lives, supporting home-visit programs is one evidence-based way to do so.
The day I spoke with Idaho minimum wage activist Anne Nesse, it was quite cold in her hometown of Coeur d’Alene — 29 degrees, to be exact. The harsh winters came up more than once during our conversation about low wages in the northwestern state.
“We’re at the bottom,” Nesse said. “We have the lowest wages in the whole nation and we’re cold up here.”
Staying warm should hardly be a luxury in a state notorious for its cold winters, but keeping up with basic necessities can be a challenge for Idaho’s working families. According to the Bureau of Labor Statistics, Idaho leads the nation in the percentage of workers — 7.7 percent — who work at or below minimum wage. In fact, Idaho residents earned less in 2012 than just about everyone else in the country, ranking 49 out of 50 in per capita income. (Mississippi holds the bottom spot on the list.)
But Nesse is hoping that will change this year. As the founder of Raise Idaho, she’s busy collecting signatures to get a minimum wage raise on the ballot in November. The goal is to raise Idaho’s minimum wage from $7.25 (the federal minimum wage) to $9.80 by 2017 and link the state’s minimum wage with the cost of living index to keep up with inflation. The ballot initiative would also raise the minimum wage for tipped workers from $3.35 an hour to $5.90.
The signature collecting is a bit of a fallback plan. Nesse also authored a bill (based on the proposed federal Fair Minimum Wage Act) that she hopes the state legislature will act on this session. But she doesn’t sound overly confident on that front — “you’d like to think that our governing bodies would take this on, but it’s very, very rare,” she told me.
So Nesse is turning to the people of Idaho to stand up for working families instead. The campaign’s goal is to collect 84,000 signatures, of which it has about one-ninth so far. The campaign has supporters out collecting signatures in just about every town in Idaho, Nesse said.
Nesse, who ran unsuccessfully for her state’s legislature in 2012 and has worked as a teacher and nurse, is not afraid of losing at the ballot box. Someone, she said, has to stand up for Idaho residents working two or even three jobs just make ends meet.
“It’s a human rights issue, not a partisan issue, and you never lose a human rights issue — you just get closer,” Nesse said. “There are too many people running around saying don’t put it on the ballot, what if it loses? But we can’t be afraid to fail.”
New year, new wages
If Nesse and her fellow advocates are successful, Idaho will join a number of states in raising the minimum wage.
This new year brought with it higher minimum wages in 13 states. In nine states — Arizona, Colorado, Florida, Missouri, Montana, Ohio, Oregon, Vermont and Washington — wages went up thanks to existing laws that adjust wages in accordance with inflation. In Connecticut, New York and Rhode Island, the raises are due to legislative action, and in New Jersey, a voter-approved ballot measure raised the minimum wage to $8.25. In July, California’s minimum wage hike goes into effect and will eventually rise to $10 an hour by 2016. In the District of Columbia, the minimum wage will rise to $9.50 per hour this year, $10.50 in 2015, and $11.50 in 2016, with automatic increases based on inflation thereafter.
And similar minimum wage movements — either by legislative action or ballot initiative — are gaining ground in Maryland, Minnesota, Massachusetts, Hawaii, Illinois, Alaska, South Dakota, Arkansas and, of course, Idaho.
Unfortunately, raising the minimum wage — which the feds have done only three times in the past three decades — usually meets loud opposition and arguments that better wages equal fewer jobs. However, research has “thoroughly debunked that argument,” said Tsedeye Gebreselassie, staff attorney at the National Employment Law Project.
“People’s real-world experience with today’s economy is quickly debunking these myths,” Gebreselassie told me.
Just earlier this month, the Center on Budget and Policy Priorities released a report on the impact of the federal Fair Minimum Wage Act of 2013, which was introduced in the House by Rep. George Miller, D-Calif., and in the Senate by Sen. Tom Harkin, D-Iowa. The bill would raise the federal minimum wage to $10.10 in three annual increments and index it to inflation. According to the report’s authors, Jared Bernstein and Sharon Parrott, the argument that such an increase would reduce employment among low-wage workers is not backed with evidence. In addition, the argument that raising the minimum wage would mostly benefit teenagers is also a myth. The authors write:
To the contrary, the vast majority of those who would benefit are adults, most are women, and their families depend on their paychecks; the average worker who would benefit from the (federal proposal) brings home half of the family earnings. This reflects the fact that the low-wage workforce has gotten older and more highly educated in recent decades: between 1979 and 2011, the share of low-wage workers (those earning less than $10 per hour in 2011 dollars) aged 25 to 64 grew from 48 percent to 60 percent, while the share with at least some college education grew from 25 percent to 43 percent.
In terms of job loss, the report cites an overview of more than 60 studies by economist John Schmitt that found the “weight of the evidence points to little or no employment response to modest increases in the minimum wage.” Still, Bernstein and Parrott note that other studies have shown that a minimum wage raise can be tied to some job losses or reduced work hours. But the “impacts are small enough so that the net result for the vast majority of low-wage workers is a net gain in earnings,” the report states.
Overall, the proposed federal wage changes would offer a “net benefit” to low-wage workers and would act as a “policy tool that pushes back against rising inequality,” Bernstein and Parrott write.
Gebreselassie told me that today’s economic climate coupled with the growing low-wage job sector and a groundswell of states passing their own minimum wage hikes may push Congress to take action on the Harkin-Miller bill, “but it’s a hard lift.”
“We’re in a situation now where one in four private-sector workers makes less than $10 an hour, which is an amazingly high figure,” she told me. “The Harkin-Miller bill would benefit 32 million American workers — it’s important literally for millions of people, but it’s also really critical to our economy, which relies primarily on consumer spending.”
Luckily, Gebreselassie noted, the American public is on the side of fairer wages. In a recent Gallup poll, 76 percent of Americans said they’d vote to raise the minimum wage to $9 an hour. And even in traditionally conservative states, residents side with workers — for example, more than three-quarters of Missouri voters backed a minimum wage increase in 2006.
“I think part of the battle to win a higher minimum wage is just to get it in the national conversation as a key component to a healthy economic recovery,” Gebreselassie said. “And I think that’s starting to happen.”
To learn more about the nation’s minimum wage campaigns, visit www.raisetheminimumwage.com.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
That’s a common phrase offered by government officials after workers are killed on-the-job. It’s the sentiment shared yesterday by Labor Secretary Tom Perez in response to the January 20 incident that claimed the lives of Keith Everett, 53 and David Ball, 47. The worksite, International Nutrition, manufactures additives for livestock and poultry feed.
Perez’s exact remark was:
“There are many questions yet to be answered about what caused this disaster, but I am confident that the answers provided by federal, state and local officials can offer lessons that will help avoid tragedies like this one in the future.”
News accounts report that OSHA and other investigators suspect that an explosion of combustible dust played some role in the disaster. A dozen or so workers were transported to hospitals, including four listed in critical condition. Workers inside the plant told reporters some of the following:
“I heard the explosion and stuff started falling, so I ducked for cover. It was pitch black in there. All I could see was fire.”
“I just heard a crack pop and big ball of fire, and I just took off running when I heard the first crack.”
I predict it won’t be long before state or local officials confirm or exclude whether combustible dust is a factor or cause of the incident. OSHA, in contrast, is not likely to comment on a cause until its inspection of the scene is completed. The agency has a six-month window to issue citations, if warranted, to the employer. The worker health and safety community will be paying close attention for information about the incident, especially if a dust explosion is the culprit.
As Liz and I have written many times, and the Charleston Gazette’s Ken Ward has reported, too, it’s a workplace hazard that calls out for regulatory action. In mid-December 2013, the Gazette’s editors bemoaned the Obama Administration’s lack of progress to protect workers from this deadly hazard.
A Center for Public Integrity (CPI) investigation identified more than 450 incidents since 1980 which involved combustible dust. CPI’s Chris Hamby reported that nearly 130 workers were killed and more than 800 injured in these preventable blasts.
Even before the Obama Administration took office, then Senator Obama chastised the G.W. Bush Administration for failing to issue a standard on combustible dust. A press statement he issued in 2008 said:
“We must do everything we can to protect America’s workers and prevent terrible accidents, like the deadly explosion at Imperial Sugar earlier this year, that occur as a result of combustible dust. It’s long past time that OSHA issue a standard to prevent these kinds of accidents, and if the agency will not do so, then Congress must legislate one as soon as possible.”
And because OSHA was not taking action on this matter, one chamber of Congress did act. Under the leadership of Cong. George Miller, a bill requiring OSHA to issue a combustible dust regulation passed the House of Representatives.
A few months later, and shortly after the Obama Administration took office, then Secretary of Labor Hilda Solis said:
“It’s time for workers to stop dying in preventable combustible dust explosions. Workplace safety is not a slogan. It’s a priority clearly embodied in our laws.”
But month after month, year after year, the Labor Department has failed to act. Last fall, OSHA indicated it plans to take comments in April 2014 from a select group of small business on a draft version of a regulation. That’s a step the agency previously suggested would take place in April 2011, then December 2011, then October 2013, and November 2013.
If the deaths of David Ball, 47, and Keith Everett, 53, and the injuries to their co-workers, were caused by combustible dust, Labor Secretary Tom Perez will have the information he needs to “avoid tragedies like this one in the future.” If he’s serious, he’ll see to it that OSHA convenes its meeting of small businesses. That would finally get the ball rolling on a regulation to address combustible dust and save workers’ lives. Otherwise, the Secretary’s remarks are just the same shallow words uttered by politicians after every other disaster.
Earlier this month, county officials in Hammond, Indiana declared a state of emergency due to extreme weather — but, reports Salon’s Josh Eidelson, Linc Logistics employees doing warehouse work for Walmart were told to stay on the job, despite working in temperatures that organizers say reached negative 15 degrees. After reportedly having multiple requests for early departure denied, workers stopped working and started looking up weather information on their phones. Their boss eventually sent them home, and shut the warehouse the next day, but a worker reportedly suffered frostbite after being ordered to work in sub-zero temperatures on the following day, Eidelson reports. Later, workers presented management with a petition for heaters — they say only the break room and bathrooms are heated — and a request that the company release its OSHA logs.
Walmart workers and the subcontracted workers in Walmart-supplying warehouses have mounted a series of strikes in recent years, and some have filed lawsuits. Marketplace’s Mitchell Hartman reported last week on two legal victories for these workers and their advocates:
On Tuesday, U.S. District Court Judge Christina Snyder, of California’s Central District, reaffirmed an earlier decision that a class-action lawsuit (Carrillo v. Schneider Logistics) filed on behalf of warehouse workers who loaded goods for Walmart outside Los Angeles, can go forward. The judge rejected the claim by Walmart and Schneider (a national logistics company that operates warehouses for Walmart), that she should dismiss the lawsuit because the warehouse workers were directly employed and paid by subcontractors (in this case, temporary staffing agencies), and not Walmart or Schneider.
And on Wednesday, the National Labor Relations Board’s general counsel issued a formal complaint against Walmart for allegedly taking illegal retaliation against dozens of Walmart workers in 14 states. Those workers (many affiliated with the group OUR Walmart, backed by the United Food and Commercial Workers union) had engaged in protests and strikes over wages and working conditions. More than sixty Walmart supervisors and one company executive are named in the complaint, for allegedly threatening workers who participated in strikes at Walmart stores in May and June of 2013, in California, Kentucky, Texas, Washington and other states. The NLRB complaint says the workers were given written and verbal warnings and reprimands for striking. The complaint also says Walmart has miscategorized time spent on strike as an ‘unexcused absence’ from work.
In other news:
New York Times: As nonprofit worker centers and other advocacy groups have successfully pressured employers to improve working conditions, business groups and lobbyists are mounting campaigns against the organizations.
Charlotte Observer: A proposed change to federal poultry inspection rules would replace USDA poultry inspectors with poultry company employees and allow processing lines to speed up. But, as a 2008 Observer investigation found, many poultry workers are already suffering serious injuries at the line speed currently allowed. (Also see the Observer’s editorial weighing in against the poultry rule.)
Omaha World-Herald: An explosion at the International Nutrition plant in Omaha killed two workers – Keith Everett, 53, and another worker whose name has not yet been released — and injured 10 more.
San Francisco Chronicle: Saru Jayaraman, author of Behind the Kitchen Door and co-founder of the Restaurant Opportunities Center of New York, is one of the nation’s top activists for restaurant workers.
Occupational Safety and Health Administration: A new educational web resource, http://www.osha.gov/hospitals, offers a wide range of materials to help hospitals take steps that protect hospital workers and enhance patient safety. Many of the materials address safe patient handling programs and policies, to prevent musculoskeletal disorders among hospital workers.
Both houses of Congress have now passed, and President Obama has signed, the omnibus spending bill, and it’s a welcome relief from budget battles through the end of this fiscal year (September 30, 2014). I was especially curious to see what the bill contained for the Prevention and Public Health Fund, an important part of the Affordable Care Act that has suffered under previous budget manuevering.
Section 4002 of the Affordable Care Act established the Prevention and Public Health Fund “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs.” It authorized and appropriated $500 million for the Fund in its first year (FY 2010), with the amount rising gradually up to $2 billion in FY 2015 and each year thereafter. The money is to be used for “prevention, wellness, and public health activities.”
Under the original legislation, the Fund in FY 2014 should have contained $1.5 billion. Due largely to past cuts, the total Fund amount in the just-passed spending bill is nearly $1 billion (it comes in at $928 billion, after the mandatory $72 million sequestration cut). Congress also did something it hasn’t done in previous years, and specified how that money should be doled out among different public-health programs. That’s a welcome step, given that the money could otherwise get shifted toward less-prevention-focused priorities.
Some news outlets have apparently been reporting erroneously that the fund has been cut. The American Public Health Association’s Public Health Newswire blog features a video clip of Senator Tom Harkin (D-Iowa) clarifying that 100% of the Fund resources have been allocated to prevention and wellness activities.
An important investment, competing with other worthwhile priorities
The Fund’s creation was a welcome step toward redressing US under-investment in public health. In a fact sheet about the Fund, the American Public Health Association notes that in the US, “only 3 percent of our health care spending is focused on prevention and public health, when 75 percent of our health care costs are related to preventable conditions.” The Department of Health and Human Services website gives examples of the kinds of programs the Fund supports in each state, including anti-tobacco and anti-obesity campaigns, vaccine modernization efforts, and prevention-focused data collection and research. As Kim Krisberg wrote in post for the 2013 National Public Health Week, such programs can pay off in later healthcare savings, and that knowledge informed the Fund’s creation:
In 2008, the nonprofit [Trust for America's Health] released an oft-cited report on the cost savings related to investments in disease prevention. The report found that an investment of $10 per person per year in proven community-based efforts that increase physical activity, improve nutrition and prevent tobacco use could save the nation more than $16 billion annually within five years — that’s an ROI [return on investment] of $5.60 for $1 invested. In fact, [TFAH President Jeff] Levi said that one of the reasons for passage of the Prevention and Public Health Fund, the landmark funding stream included in the Affordable Care Act, was that advocates were able to show the potential for ROI.
Savings from prevention investments don’t materialize immediately, though, and current budget holes tend to command more immediate attention. Back in early 2012, Congress voted to take a total of $5 billion from the Fund as part of a “doc fix” deal to avert scheduled cuts to Medicare providers’ reimbursement rates. In 2013, the Obama administration announced that it would use nearly half of the year’s remaining Fund dollars on building the federal health-insurance exchange. Medicare payments and the federal exchange are both worthwhile things to spend money on. Under-investing in prevention, though, means that we’re likely to keep facing unsustainable healthcare-cost growth — and that means we’ll keep facing tough decisions about how to pay Medicare bills.
Spending prevention money on prevention
Congress’s decision to allocate FY 2014 Fund dollars to specific programs means the money isn’t available to plug holes in the healthcare budget — instead, it will actually be used for prevention. CDC will get most of the Fund dollars for various programs; in addition, the Administration for Community Living will get $27.7 million for Alzheimer’s Disease prevention, chronic disease self management, and falls prevention; the US Preventive Services Task Force will get $7 million; and the Substance Abuse and Mental Health Services Administration will get $62 million for Access to Recovery and suicide prevention.
The CDC activities supported by the Fund in 2014 include programs to prevent cancer, diabetes, heart disease, and stroke, as well as efforts to tackle healthcare associated infections, smoking, and lead poisoning. The agency will also make grants for immunizations, workplace wellness, and building epidemiology and laboratory capacity.
The spending bill also specifies that of the Fund’s nearly $1 billion “$5,000,000 shall be available to conduct an extension and outreach program to combat obesity in counties with the highest levels of obesity” — defined as counties in which 40% or more of the population is obese, as determined by the Behavioral Risk Factor Surveillance System (BRFSS). CDC’s analysis of 2007 BRFSS data found that “counties with the highest obesity prevalence largely were in the South, western Appalachians, and coastal Carolinas.”
I hope this is the beginning of a trend toward spending Prevention and Public Health Fund money on prevention activities rather than on healthcare. The more funding we direct to prevention efforts now, the more we’ll learn about how best to prevent diabetes, heart disease, and other conditions that sap years of healthy life from the US population. With continued investments in prevention and public health, we can not only save money on healthcare costs, but help people live longer, healthier lives.
It was one of those weeks when two seemingly unrelated topics crossed my desk. Only later did it strike me that they were connected. Both involved toxic substances and what we know about their adverse health effects. One concerned the contaminated water supply in West Virginia. The other involved a commentary by attorney Steve Wodka about a newish revision to OSHA’s chemical right-to-know regulation.
The drinking water emergency in West Virginia—thousands of gallons of MCHM (methylcyclohexanemethanol) which flowed into the water supply— has focused attention on the inadequacy of the key law for US chemicals policy, the Toxic Substances Control Act (TSCA). Many residents want to know, and journalists have been asking: “how is MCHM going to affect people’s health?”
Quickly they learned the manufacturer of MCHM doesn’t have a clue about its long-term health effects. Nothing about how it might affect their kids. Nothing about effects on the offspring of those who drank it. Nothing about whether it may cause neurological problems, or cancer. There’s no law–not TSCA or any other—that even expects them to know, and there’s no law requiring them to find out. For now, we are resigned to live in a giant black hole, with far too little health information about the 80,000 chemicals that are manufactured or processed in the U.S.
As Richard Denison with the Environmental Defense Fund wrote:
“How, you might well ask, is this possible? How can a chemical in active production and use – and now being released into the environment and exposing people – be on the market without any publicly available hazard data or evidence of its safety?”
There are however, a few chemicals about which there is ample information on some of their long-term health effects, specifically whether the cause cancer. (Largely because people served as guinea pigs in their workplaces, were exposed to toxic agents, and developed cancer as a result.) Both the International Agency for Research on Cancer (IARC) and the US National Toxicology Program (NTP) have sophisticated review procedures, involving panels of scientific expert, to evaluate the epidemiological data and identify compounds for their carcinogenicity. To-date, the groups have independently classified about 60 substances as known human carcinogens. They’ve also designated some substances as likely to be or possible human carcinogens; IARC lists about 400 and NTP about 200 of these suspect compounds. At least for these toxic substances, individuals who are exposed or potentially exposed are not quite as stuck in that information void.
For nearly 30 years, workers who used or came into contact with these designated or suspect carcinogens had the benefit of a cancer warning label on containers of these compounds. If IARC or NTP classified them as carcinogens, OSHA required labels on containers of them to include the cancer warning. I say had because of what I read in Steve Wodka’s commentary.
In “Explaining the Inexplicable: OSHA’s Gift to the Chemical Industry,” Wodka writes:
“Until 2012, OSHA had a rule which required that a cancer warning label be placed on a chemical if it appeared on a national or international list of cancer causing chemicals. The rule was clear, simple and easy to enforce. It was not even controversial. But it is no longer in effect.”
Wodka is referring to OSHA’s 1983 Hazard Communication standard, which was amended in March 2012 to align with the “Globally Harmonized System of Classification and Labeling of Chemicals.” He points to a change between the old and the new HazCom standard that I’m embarrass to admit never made it on my radar screen. He explains:
“OSHA decided to toss this entire system overboard and return to the olden days when these disputes were settled not by the quality of the evidence, but by the number of gunslingers one could hire. Under OSHA’s new “globally harmonized system” of hazard communication, a chemical manufacturer can dispute the science on which a cancer designation had been based. When these disputes arise, OSHA, not the manufacturer, bears the burden of proof. The agency will always be outgunned by the global chemical industry and worker protection will suffer. Inexplicably, this wound was completely self-inflicted. No one demanded or petitioned OSHA to make this change.”
The whole idea for the original 1983 HazCom standard was giving workers the “right-to-know” about the chemical hazards in their workplaces, especially how the compound could affect their health. The rule’s requirements for labeling of containers—including language about any IARC or NTP cancer designation—gave workers easy access to critical hazard information. That requirement was deleted by OSHA in 2012 when it revised its HazCom regulation. I’m glad (I guess) for Steve Wodka’s commentary bringing it to my attention.
Anxiety and frustration linger among WV residents on how little is known about the chemical that contaminated their drinking water. TSCA does nothing to help them know. OSHA’s HazCom standard used to require chemical manufacturers to label carcinogenic compounds based on IARC’s and NTP’s evaluations. Now those cancer warnings are no longer required by OSHA to be on the labels.
As the public dialogue revolves around the need for more testing and more disclosure of the potential health effects of toxic chemicals, I’ll use Wodka’s term “inexplicable” to describe OSHA’s backsliding.
“There’s a lot we don’t know about preterm birth and we know even less about the disparities in those births.”
Those are words from Ondine von Ehrenstein, an assistant professor in the Department of Community Health Sciences at the UCLA Fielding School of Public Health, who recently examined the links between occupational exposures and preterm birth rates among Hispanic women. Perhaps not surprisingly to those in the public health world, von Ehrenstein and her research colleagues did find that Hispanic women are at particular risk for preterm birth associated with certain occupational conditions. However, what may be more surprising — and what could be critical to an effective intervention — was that the effect of occupational exposure on preterm birth risk varied by nativity, or whether a woman was U.S.-born or foreign-born.
“We found higher risks related to physically demanding and shift work, especially among U.S.-born Latina women,” von Ehrenstein told me. “Why is there such a difference? We’ll need further research to really understand.”
However, Ehrenstein and fellow researchers have begun to lay the groundwork. To conduct the study, which was published in the February issue of the American Journal of Public Health, researchers examined a case-control study nested within a cohort of more than 58,300 births in Los Angeles County in 2003 and used the U.S. Census Occupation Codes and Classification System to characterize the mothers’ occupations during pregnancy. The study noted that while previous U.S.-based studies have been conducted on preterm birth and occupational exposures (which is defined as both working conditions, such as daily working hours, and environmental exposures, such as indoor air quality), they have not teased out the relationship of the mother’s place of birth.
Authors also note that rates of preterm birth are higher in the U.S. than in many peer nations. (A recent March of Dimes report found that the U.S. preterm birth rate dropped to 11.5 percent in 2012 — a 15-year low — but it’s still the highest rate among industrialized nations.) Study authors von Ehrenstein, Michelle Wilhelm, Anthony Wang and Beate Ritz write:
The prevalence of preterm birth in the United States increased over the past decades with persistent racial/ethnic disparities, and it remains the main cause of infant mortality. Hispanic women have on average a higher prevalence of preterm birth than non-Hispanic White women, and risks tend to vary by nativity (US-born vs. foreign-born). These disparities remain poorly understood and have not to date been explained by social or demographic factors. …Occupational exposure may increase risks for preterm birth by interrupting the prenatal neuroendocrine balance, thereby promoting premature parturition (birth), and these adverse occupational influences may possibly affect Hispanic populations in the United States disproportionally and may possibly also be modified by nativity.
The study found that among all women who worked during pregnancy, there was a suggestion of increased risk of preterm birth among health care practitioners and technical occupations, building and grounds cleaning and maintenance, and food preparation and serving jobs. Risks were also associated with physically demanding work as well as shift work. When zeroing in on Hispanic women who worked while pregnant, the risk was higher among health care practitioners and technical occupations.
The risk of preterm birth also increased among Hispanic women doing shift work and physically demanding jobs — however, that risk only increased among Hispanic women who were born in the U.S. and not among foreign-born Hispanic women. The elevated odds ratio for preterm birth was statistically significant for foreign-born Hispanic women working in building and grounds cleaning and maintenance (though von Ehrenstein said it’s important to note that this group of Hispanic women also represented the vast majority of such workers). Still, foreign-born Hispanic women working in such maintenance jobs faced a preterm birth risk two-and-a-half times larger than women working in the office and administrative support sector.
“These ethnic disparities indicate that there is room for prevention,” von Ehrenstein said.
Researchers hypothesized a number of reasons for the differences. For example, the pronounced risk among Hispanic health care workers might indicate that such workers are “doing especially heavy physical work, although we currently have no evidence for this,” the study stated. Authors also noted that “lower acculturation has been reported for foreign-born compared with US-born Hispanics, and it has been associated with better support networks, healthier nutrition, and lower rates of smoking and alcohol consumption, reflecting healthier practices among women in the country of origin.” However, Ehrenstein pointed out that some of the biggest factors influencing pregnancy outcomes may be exposures that occur early in life — what she called the life course perspective — which could help explain the differences by nativity.
von Ehrenstein said the findings on nativity could be especially helpful when developing interventions. She also said that working to improve birth outcomes and infant health today — whether through policy or program — can reverberate throughout the lifespan.
“Early health risks may have lifelong implications,” von Ehrenstein said. “So if we want to reduce health costs and the implications for public health, a prime venue for prevention is really in promoting healthy pregnancies.”
To access the full study, click here.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.