While we’re on vacation, we’re re-posting content from last year. This post was originally published on January 30, 2013. Since then, the Senate has passed an immigration-reform bill, but the House has not voted on it.
By Liz Borkowski
In Wonkblog yesterday, Sarah Kliff highlighted an important aspect of immigration reform: Undocumented immigrants who gain legal status will also gain access to the Affordable Care Act’s options for getting health insurance. The Congressional Budget Office estimated that the ACA would reduce our nonelderly uninsured by 32 million, but 23 million people would remain without health insurance – and one-third of those people would be undocumented immigrants.
The ACA has two main mechanisms for offering affordable coverage to the uninsured: 1) expansion of Medicaid eligibility to all legal residents with income up to 133% of the federal poverty level, which the Supreme Court has since made optional for states, and 2) creation of state-based health insurance exchanges through which individuals and small businesses can purchase affordable, good-quality insurance and through which individuals can receive premium subsidies if their incomes are between 133% and 400% of the poverty level. Undocumented immigrants have long been ineligible for Medicaid, and the ACA prohibits them from purchasing insurance through the exchanges. So, these two routes to insurance coverage are closed to undocumented immigrants.
Uninsured patients have long gotten care from community health centers, which provide primary care to all who seek it regardless of insurance status or ability to pay, and hospitals, which must screen and stabilize anyone who shows up in an emergency department requesting care. (Emergency rooms and community health centers are key parts of the “healthcare safety net,” which delivers health services to vulnerable populations.) Due to Congressional decisions, though, many health centers and hospitals will find it hard to continue serving the uninsured who’ll still visit them as the ACA is implemented.
Under the ACA, hospitals that have relied on “disproportionate share” funding meant to offset costs of caring for uninsured patients will see that funding slashed. Medicare and Medicaid’s “Disproportionate Share Hospital” programs are designed to send funds to hospitals that deliver lots of uncompensated care to low-income patients. Under the ACA, those payments will fall to half their former levels. These cuts were made on the assumption that hospitals would provide far less uncompensated care as uninsurance rates fell. However, hospitals that treat large numbers of undocumented immigrants and those in states that decline to expand Medicaid eligibility will still be delivering lots of uncompensated care. The New York Times’ Nina Bernstein explored the impacts on some of the hospitals that are seeing their DSH funds decline as their burdens of uncompensated care remain high.
Denying insurance opportunities to undocumented immigrants also has implications for the community health centers that provide care to much of the uninsured population. Federally qualified health centers do get federal grants to assist them in serving the uninsured, but they also rely heavily on Medicaid. Right now, a lot of uninsured undocumented immigrants with incomes below 133% of the federal poverty level are paying very little for care from community health centers; if a portion of these patients were to get Medicaid coverage and continue getting their primary care from CHCs, the health centers’ finances would be better off.
Health centers face another ACA-related challenge, too: Many of those who gain Medicaid coverage will seek care from CHCs, which have long been a major provider of high-quality, cost-effective care to Medicaid beneficiaries (and to immigrants who appreciate health centers’ commitment to providing care to non-native English speakers). In anticipation of a surge in demand for health center services, the ACA included an $11 billion Health Center Trust Fund to enable health center expansion. But, as I wrote back in August, Congress raided that pot:
Under the ACA, Health Center Trust Fund money should have totaled $1 billion in FY 2011, with most of that money going to health-center capacity expansions. But the April 2011 budget deal that averted a government shutdown slashed that to $600 million, and most of that was shifted from expansions to ongoing operations because the budget for funding existing centers’ operations was also cut. The FY 2012 federal appropriations level is also far below the amount specified in the ACA, and will also have to be largely devoted to sustaining existing capacity rather than adding new capacity. (If you want all the gory details, they start on page 12 of this brief from the Kaiser Commission on Medicaid and the Uninsured.)
Congress should fully invest in community health center expansion and figure out a way to ensure (through DSH payments or another mechanism) that hospitals delivering high levels of uncompensated care are able to survive financially. They should also consider the healthcare safety net when drafting immigration-reform legislation. Allowing immigrants who’ve applied for, but not yet received, green cards or citizenship to purchase subsidized coverage through the exchange would be one way to ease the burden on the providers that care for undocumented immigrants.
Carcinogen use and release declines dramatically in Massachusetts: An important step in cancer prevention
While we’re on vacation, we’re re-posting content from earlier in the year. This post was originally published on June 26, 2013.
By Elizabeth Grossman
In 1989, Massachusetts enacted a remarkable and landmark law known as the Toxics Use Reduction Act (TURA). Supported by both environmentalists and industry, and passed unanimously by the state legislature, TURA established toxics use reduction as Massachusetts’ preferred strategy for pollution prevention, and for reducing public, occupational and environmental exposure to hazardous chemicals. The law requires in-state businesses to report on their use of toxic chemicals. It also established programs to support state industries’ toxics use reduction efforts. In the two decades since the bill’s passage, use and release of toxic chemicals by Massachusetts businesses has declined remarkably. Between 1990 and 2010, companies reporting hazardous chemicals use and emissions under TURA have documented a 40% reduction in toxic chemical use, a 71% reduction in toxic byproducts and a 91% reduction in on-site releases of toxic chemicals.
A new report from the Toxics Use Reduction Institute (TURI) at the University of Massachusetts, Lowell based on this data shows a similarly dramatic decrease in state businesses’ release and use of 74 different known and suspected industrial carcinogens. According to the TURI analysis, which is based on data from businesses reporting chemical use under TURA, environmental releases of potentially carcinogenic chemicals declined 93% between 1991 and 2010 while reported use declined 32% between 1990 and 2010. If the single most-used potentially carcinogenic chemical used during this period, styrene monomer (which accounts for 76% of carcinogenic chemical use) is excluded, the decline in overall use of known and suspected carcinogens is even greater: 53 %.
The report leaves some questions unanswered – for instance, it doesn’t address the health impacts of the documented declines in chemicals use – but this is the first such analysis of TURA data and is essential for any further investigations into cause and effect. “We were interested in declines irrespective of why,” explained report co-author Molly Jacobs, project manager with the Environmental Health Program of U Mass Lowell’s Center for Sustainable Production.
In addition to looking at release and use of 74 potentially carcinogenic chemicals, the report also examines trends in use of chemicals associated with eleven types of cancer: among them breast, bladder, brain and lung cancer, leukemia and non-Hodgkin’s lymphoma. Here as in the report as a whole, researchers found that declines in releases exceeded those in use of these chemicals. Between 1990 and 2010, releases in chemicals associated with breast and mammary gland cancer, liver, pancreatic, prostate and testicular cancer all declined by more than 90%, while releases of chemicals associated with lung cancer decreased by 77 %. Use of chemicals associated with specific cancers declined more modestly – 26% for chemicals associated with breast cancer, 28% associated with leukemia and 29% for those associated with lung cancer – but 65% for chemicals associated with prostate cancer and 88% for chemicals associated with testicular cancer.
Big reductions for some chemicals
The reduction in release and use of some individual chemicals is especially striking. Release of ten of the 74 reportable known or suspected carcinogens declined by 90% or more. These chemicals include trichloroethylene (TCE), tetrachloroethylene (PERC), formaldehyde, methylene chloride, cadmium and chromium and their related compounds. During the same time – 1990 to 2010 – use of TCE declined by 92%, PERC by 85%, and cadmium and cadmium compounds by 69%.
TCE and PERC, noted TURI when releasing the report, are the compounds associated with the Woburn, Mass. childhood leukemia cluster identified in the 1980s and made famous by A Civil Action – the book and movie about the community whose water was contaminated by these chemicals. This contamination was eventually traced to W.R. Grace & Company, which was indicted in 1987 for lying to the US Environmental Protection Agency about its use and disposal of hazardous chemicals. The case against the company brought by the children’s families was settled out of court in 1986. Both would have been fresh in mind when TURA was enacted.
While releases of potential carcinogens have declined dramatically, these chemicals continue to be used in large quantities. In 2010, Massachusetts businesses reporting under TURA used more than 300 million pounds of these chemicals and released more than 500,000 pounds to the environment. Known and suspected carcinogens topping the use list were styrene monomer, sulfuric acid, toluene diisocyanate, lead and lead compounds, along with generated dioxin and dioxin-like byproducts.
That releases have declined so much more than use suggests that reductions may be taking place primarily at the end-of-the-pipe, explained Jacobs and report co-author Rachel Massey, TURI senior associate director and policy program manager. This appears to indicate that Massachusetts industries have gotten far better at controlling where toxic chemicals go at the end of the manufacturing process than they yet are at eliminating these compounds further upstream. This information also suggests that while environmental exposures to potential carcinogens may be declining as releases drop, occupational exposures may be continuing.
Chemical exposures and cancer
Do the dramatic declines in carcinogen releases mean fewer people in Massachusetts are getting sick? The report’s data can’t tell us that, explained Jacobs. According to Massachusetts Department of Public Health data, the state’s cancer rates have increased since the 1980s, by about 14% for men and 19% for women. Incidence of certain types of cancer has increased markedly, while others have declined. Currently, about 100 Massachusetts residents are diagnosed with cancer every day, resulting in more than 38,000 new cancer cases in 2012. However, given cancers’ typically long latency periods, unless a cancer is very specifically associated with a certain chemical exposure – which is relatively rare – associating environmental exposure to individual chemicals with specific cancer diagnoses is very difficult, explained Jacobs.
But what the report can tell us something about, explained Jacobs and Massey, is trends in contribution to cancer risk. “Cancer is a multi-factorial disease,” explained Jacobs. It typically doesn’t have one cause but many possible contributing factors – including environmental chemical exposures. Because these exposures may occur prenatally as well as later in life, they are difficult to document precisely. Yet if we eliminate environmental exposures that constitute cancer risk factors, overall risk declines.
“Think of it as slices of a pie,” said Jacobs, in which each slice present represents a cancer risk factor. While it may never be possible to remove all the slices, reducing and eliminating exposure to carcinogens improves the prospects. Although the dramatic decline in Massachusetts’ environmental releases of a significant number of known carcinogens is no guarantee of health outcomes it is, however, very good news in terms of beginning to eliminate those exposures as potential risk factors.
While there is still a long way to go to reduce environmental cancer risks – especially those in the workplace – and to understanding how Massachusetts’ remarkable achievement in reducing environmental releases of carcinogenic chemicals will affect public health, that this data exists at all is in itself remarkable. A number of states have begun to establish hazardous chemical use reporting programs – mostly focused on children’s products – but Massachusetts’ program remains unique among state pollution prevention programs. No other states require comparable chemical use reporting and no others have comparable programs aimed at reducing toxics use while supporting local business development. And the dramatic reductions in toxics release and use the TURI report documents have all been achieved without a single in-state chemical ban or restriction.
As other states move ahead with industrial chemical-focused pollution prevention policies and federal policy-makers debate reform of the Toxic Substances Control Act, they might do well to see what they can learn from Massachusetts.
Elizabeth Grossman is the author of Chasing Molecules: Poisonous Products, Human Health, and the Promise of Green Chemistry, High Tech Trash: Digital Devices, Hidden Toxics, and Human Health, and other books. Her work has appeared in a variety of publications including Scientific American, Yale e360, Environmental Health Perspectives, TheAtlantic.com, Salon, The Washington Post, The Nation, and Mother Jones. Chasing Molecules was chosen by Booklist as one of the Top 10 Science & Technology Books of 2009 and won a 2010 Gold Nautilus Award for investigative journalism.
While we’re on vacation, we’re re-posting content from earlier in the year. This post was originally published on March 12, 2013.
By Liz Borkowski
On March 12, 2003, the World Health Organization issued a global health alert for an atypical pneumonia that was soon dubbed SARS, severe acute respiratory syndrome. The coronavirus had a high fatality rate; it emerged in China’s Guangdong province and within a month affected 8,000 patients, killing 774 of them in 26 countries. Toronto was one of the cities hit hard by the disease, and ace health reporter Helen Branswell of the Canadian Press has written several pieces on ten-year anniversary of the outbreak.
In “A decade ago, SARS raced round the world; Where is it now? Will it return?” Branswell writes for the Canadian Press:
Measures taken in 2003 to contain the outbreak — isolating SARS patients and quarantining people who had been exposed to a SARS case to prevent them from exposing others — succeeded at putting out that particular fire.
“That human adapted virus, that spread all the way to Singapore, Canada and … all that, that is not circulating currently in animals or in humans,” says Malik Peiris, a microbiologist from Hong Kong whose lab was one of two to first identify the virus responsible for the explosive outbreak that killed 916 people worldwide, 44 in Canada.
“(But) you can’t be sure that SARS won’t come back.”
That’s because close relatives of the virus exist in nature. And the cascade of events that led a bat virus to spark a human disease outbreak could repeat themselves, experts warn.
In “Ten years later, SARS still haunts survivors and health-care workers,” Branswell writes that 20% of the global SARS cases and 43% of the Toronto SARS cases were healthcare workers, and some of the survivors suffer from PTSD. The report Ethics and SARS: Learning Lessons from the Toronto Experience by the working group of the University of Tonronto Joint Centre for Bioethics describes some of the strains on healthcare workers:
“Mary,” a nurse in the Intensive Care Unit, is afraid that when she goes to work she will have to care for SARS patients and may become infected. Her husband asks her to call in sick, pleading that it is her duty as the mother of three small children not to risk giving them SARS. “Mary” feels torn. She feels her primary responsibility is to do everything in her power to protect her children. At the same time, “Mary” has a strong commitment to her profession, and the family needs her income. She has studied hard to become a staff nurse, and is aware of the importance the hospital places on good attendance. Her salary is affected by calling in sick. She also wants to support her colleagues on the front lines by going to work.
For the first time in more than a generation, Toronto health care practitioners were forced to weigh serious and imminent health risks to themselves and their families against their obligation to care for the sick. This generation of clinicians had entered their profession in an era when there was little expectation of facing deadly infectious diseases that had no ready cure. Suddenly, a large number of health care workers, particularly nurses and doctors, faced tough choices about how much risk to take. They had to put their lives at risk to help others. Dozens of medical workers, most of them nurses, caught SARS during their work. The most public example of the sacrifice by a health care worker was the untimely and tragic death of Dr. Carlo Urbani, who was infected in Vietnam.
SARS imposed great stresses on health care workers. They feared contagion for themselves and their families, and being shunned by others in case they were infectious. They suffered from disrupted routines, and loss of work for those who were quarantined or were unable to work because their hospitals had cut back on admitting non-SARS cases. Many health professionals had to wear cumbersome and very uncomfortable equipment to protect themselves, causing discomfort and hampering their ability to work. This also reduced the human contact with sick and dying patients.
Hospital patients suffered, too, the report explains, as hospitals canceled surgeries and barred patients’ family members from visiting them.
In several Asian countries, travel restrictions hammered the tourism industry, disrupting families’ livelihoods and harming countries’ economic growth. Economists Jong-Wha Lee and Warwick J. McKibbin calculated that SARS cost Hong Kong 2.63 percent of GDP and China one percent.
In 2007, SARS-inspired revisions to the International Health Regulations entered into force. The IHR require all 194 WHO member states to report certain disease outbreaks to WHO (including novel influenzas) and to strengthen their surveillance and response capabilities. In an interview with Helen Branswell, WHO Director General Margaret Chan – who was Hong Kong’s director of health during the SARS outbreak — explained how global preparedness has improved since SARS:
“SARS was a very important event…. And many countries have learned from SARS…. The SARS event sort of gave them additional impetus and the sense of urgency for them to really revise the International Health Regulations.”
“…All in all, and because of the impetus coming from the SARS outbreak in 2003, countries of this organization reviewed and also renewed and also updated the IHR and all these requirements actually paved the way for countries to build their capacity and also understand the need for transparency.”
“And we have noticed that the time from event diagnosis to reporting to WHO has decreased tremendously. And the country capacity is much better than pre-SARS. It’s a long way to tell you: Yes. Because of SARS, I think the world is in a much better position to detect events.”
Global communication about disease outbreaks can only happen once a new outbreak has been identified, and that relies on local surveillance capacity. Both surveillance and response capacity can easily fall prey to budget cuts, though, as memories of past epidemics fade. The US saw a big investment in preparedness after 9/11 and the anthrax attacks, but funding has since declined. SARS’ 10-year anniversary should serve as a reminder that we won’t get a warning before the next outbreak hits, and we need to be ready.
While we’re on vacation, we’re re-posting content from earlier in the year. This post was originally published on April 16, 2013.
By Celeste Monforton
An analysis by Mine Safety and Health News (MSHN) finds that nearly $70 million in delinquent penalties are owed to the U.S. Treasury by mining companies for violations of federal mine safety and health regulations. One of the top offenders is James C. Justice II, the owner of the Greenbriar Resort in White Sulphur Springs, WV. He owes more than $1.33 million in delinquent penalties.
MSHN notes that his net worth is estimated by Forbes magazine to be $1.7 billion. MSHN’s analysis shows 60 mine operators have racked up more than $100,000 in delinquent penalties, and there are seven who each owe the public coffers more than $1 million in delinquent penalties. The 60 mining companies alone account for more than half of the $70 million in delinquent penalties.
Monetary penalties are initially proposed by the Labor Department’s Mine Safety and Health Administration (MSHA) for violations observed by federal inspectors during mine inspections. If a mine operator or contractor objects to the inspector’s findings or the penalty amount, he has the right to contest it before an independent body of judges. The penalty might be upheld, reduced or deleted altogether, but once the case has been heard and decided, the mine operator is expected to pay the penalty amount determined by the judge. It is these kind of cases—ones in which the violations and/or penalties are deemed “final orders”—for which the $70 million is owed. The unpaid penalties are considered delinquent when six months pass without a payment.
The same day I read MSHN’s report about the $70 million in delinquent penalties owed by mine operators, I learned that MSHA plans to defund a program that provides about $8 million in grants to State-based organizations—nearly one in every State—-to conduct safety training.
In these austere times, it seems more important than ever for the federal government to get serious about collecting the money it’s owed from lawbreakers. Local governments do it—-I think of the wheel clamp or “parking boot” affixed to a vehicle to prevent it from being moved until parking tickets are paid. Traffic control officers use parking boots for habitual parking violators. In Los Angeles, a vehicle will get the “parking boot” if it has five or more unpaid citations. In Houston, a vehicle can get booted for having three or more outstanding citations. In Washington, DC, a vehicle can get booted for having two parking tickets that are more than 60 days old, and now the City is looking to garnish income tax refunds of repeat parking violators. Surely if cities can get tough with individuals who break parking regulations, we can get more creative in forcing labor law violators to pay the penalties they owe.
Currently, MSHA will attempt to collect unpaid penalties from mine operators with letters and phone calls. If 180 days pass and the agency is unsuccessful, they can refer the debt to the U.S. Treasury for further debt collection efforts. But with $70 million in delinquent penalties owed by mine operators, these current collection efforts obviously aren’t cutting it. (An analysis by the Center for Public Integrity found the same under performance collecting unpaid penalties assessed by OSHA to employers who violate worker safety regulations. The Center reported that over the most recent seven fiscal years, “OSHA referred about $131 million in debts to the Treasury Department, but only about $16 million was collected.”)
Earlier this year, Congressman George Miller (D-CA) introduced the Robert C. Byrd Mine Safety Protection Act (H.R. 1373) which would strengthen certain provisions of the federal Mine Safety and Health Act. Section 305 of Miller’s bill specifically addresses mine operators with delinquent penalties.
It says, if a mine operator has not paid a penalty within 180 days after it has become of final order and the operator has not entered into a formal plan to pay off the penalty, the Secretary of Labor shall issue an order to withdraw all persons from the mine. Without workers in the mine, production will cease. The withdrawal order will remain in place until the delinquent penalty is paid or the operator enters a formal plan to pay off the penalty. Furthermore, if the operator fails to keep up with the payment plan, another withdrawal order will be imposed.
A practical, common sense approach, like a “boot” device for mine operators.
In tight fiscal times, National Public Health Week highlights the return on public health investments
While we’re on vacation, we’re re-posting content from earlier in the year. This post was originally published on March 8, 2013.
by Kim Krisberg
In a little less than a month, public health workers and their community partners in Macomb County, Mich., will set up at the local Babies”R”Us store to offer parents a free child car seat check. The Macomb County Health Department has been organizing such car seat checks for years now, knowing that proper child vehicle restraints can truly mean the difference between mild and severe injuries, or between survival and death.
The car seat check is taking place April 4 in observance of the fourth day of this year’s National Public Health Week (NPHW) celebration, which officially runs April 1–7 and is organized by the American Public Health Association (APHA). Bill Ridella, director and health officer for the Macomb County Health Department, said the April 4 event was chosen to coincide with that day’s NPHW focus, “Protecting You While You’re on the Move”; however, he noted that it also fits in perfectly with this year’s overall NPHW theme, “Public Health ROI: Save Lives, Save Money.”
That’s because according to the Centers for Disease Control and Prevention, proper child safety seats reduce the risk of death in car crashes by 71 percent for infants and 54 percent for children ages 1 to 4. In fact, according to researchers, child safety seats save an average $2,200 in medical spending for an average $52 investment — that’s a return on investment (ROI) of $42 for every $1 invested. In Macomb County, after years of collecting data and offering hundreds of individual car seat checks annually, Ridella reports that more than 80 percent of child safety and booster seats inspected were installed improperly — “and we know that correctly installing them does save lives and prevent injury,” he told me.
“(This year’s NPHW) theme is universal and it’s something that public health should be very proud of,” Ridella said. “It’s so important to stress that whether it’s at home, school, work or in the community, public health reaches people everywhere.”
Macomb County is planning to hold a number of events during the 2013 NPHW celebration and is one of hundreds of communities nationwide that will be rallying around this year’s theme of public health ROI. Kimberly Moore, director of Affiliate Affairs at APHA and lead organizer for NPHW, said this year’s theme was chosen because it “underscores the role of public health in our economy and the fact that a strong public health system has implications that go far beyond just the health of a community.”
“Public health has such a broad reach and when we invest in strong systems, we can see returns for years to come,” Moore told me. “There are challenges. In public health, you may not see the return today or tomorrow, it doesn’t come overnight…but if we have a long-term plan to invest in (public health and prevention) and if we’re consistent about investing, then we’ll see more successful health outcomes at less cost.”
Moore noted that measuring ROI in public health can be tricky — “it’s different than in the business world where you invest ‘X’ amount of dollars and get ‘X’ amount back. That not always the case in public health…we also need to account for improvements in quality of life, the number of lives saved and improvements in the health status of our communities.” Indeed, quantifying public health ROI is a challenging endeavor, and related research isn’t nearly as prolific as research into the effectiveness of public health interventions on people’s health. But it’s also a research field that’s quickly emerging and one that advocates and researchers say is crucial in an era in which public health must fiercely compete for every penny it gets.
What’s the value of public health?
At the University of Kentucky, professor and researcher Glen Mays said he’s particularly excited about this year’s NPHW theme of public health ROI. Mays is at the forefront of a growing field known as public health services and systems research, which studies the organization, delivery and financing of public health services. The research field is especially relevant to public health ROI as it often zeroes in on how improving efficiencies and effectiveness within public health can help the discipline thrive in a time of dwindling resources.
“I think it’s a very important and very timely theme,” said Mays, a co-principal investigator at the National Coordinating Center for Public Health Services and Systems Research. “We need to focus attention on the value of public health because historically, the field has struggled with a lack of public and policy recognition of the value that public health provides for society.”
The old adage that the work of public health is often invisible, he noted, does public health no favors in the competition for resources.
Unfortunately, Mays told me there isn’t “nearly the amount of evidence that is needed and really demanded by policymakers on this issue of (public health) ROI.” He said one of the reasons the research is challenging is simply the inherent nature of public health work. For example, we may not see returns on public health investments until far in the future, especially in work targeting chronic disease rates. Mays also noted that because public health activities can have such far-reaching impacts, the health and economic effects are often dispersed among many different populations — “one nutrition program can affect cancer, heart disease, even injury rates…so how you account for all that becomes very challenging.” Still, public health ROI can certainly be calculated, Mays said.
For instance, Mays co-authored a study published in 2011 in Health Affairs that examined the relationship between local public health spending and preventable death over a 13-year period. He and co-author Sharla Smith found that mortality rates fell between 1.1 percent and 6.9 percent for each 10 percent increase in local public health spending. In Washington state, researcher Jeffrey Harris and colleagues recently published a similar study on the ROI of public health-led tobacco prevention efforts. Harris, a health services professor within the University of Washington School of Public Health and director of the school’s Health Promotion Research Center, said he and co-authors “really wanted to see whether the program was working the way we thought it was,” noting that the tobacco program’s funding was under extreme threat from the state legislature.
And the study, published in February in APHA’s American Journal of Public Health, found that public health was indeed making a difference. Of the tobacco interventions studied, researchers found that the state health department-led program had the most consistent and biggest effects on heart disease, cerebrovascular disease, respiratory disease and cancer. Over a 10-year period, the state program, which included media and school-based campaigns, a quitline and policy enforcement, was associated with the prevention of nearly 36,000 hospitalizations, saving about $1.5 billion. It also means the program saved more than $5 for each $1 invested.
Despite the findings, which were shared with state lawmakers, the legislature zeroed out funding for the tobacco program in 2011, Harris told me. However, it did restore some of the funding in 2012 after the study was published — “it’s one thing to write a paper and another to have it published,” Harris noted.
“It shows that policy is an interesting process and cost effectiveness is important but it’s just one part of the story,” he said.
Harris also said that it isn’t fair to expect all public health work to save money. For example, he said, if someone breaks a leg and is taken to the hospital, no one asks if setting the bone saves money. However, fixing that leg does provide significant value to society and to the individual. We have to apply that same framework to public health and prevention, he said. Still, Harris notes that while some might think all prevention saves money, that’s not always the case and “we need to be honest about what works and what doesn’t.”
“Oftentimes, we in public health think ‘we do good things so just trust us’…but I don’t think policymakers are swayed by that,” he said. “Even within the realm of prevention and public health, not all goods are created equal.”
But even in a time when cost efficiency seems to reign, public health needn’t abandon its foundations, said Peter Jacobson, professor of health law and policy at the University of Michigan School of Public Health. Social justice and efficiency are not mutually exclusive, Jacobson told me, and it’s critical that public health practitioners and advocates speak within that framework.
“Let’s create a new model where we think about providing better services more efficiently as entirely compatible with the social justice values inherent to public health,” he said. “I share the (social justice) goal and it’s an important voice to have, but it can’t be the voice of mainstream public health, otherwise we won’t have any influence. If social justice is a prong detached from economic efficiency, cost effectiveness and cost benefit, I just don’t think anyone is going to listen.”
In 2008, Jacobson co-authored a study in the American Journal of Public Health that studied the disconnect between health economists and public health workers. In interviewing public health workers, researchers found that they did want to provide decision-makers with better measures of value, but there were many barriers. Among them was a lack of training in conducting such research, plus declining workforce numbers that make it increasingly difficult to squeeze in new analytic tasks. The 2008 study noted: “Aside from the attribution problem, our respondents suggested that understanding public health’s intangible values was the most difficult conceptual and measurement challenge they faced. Virtually every respondent maintained that a unique trait of public health was the intangible value that it has.”
In response, Jacobson and study colleague Peter Neumann developed a “Framework to Measure the Value of Public Health Services” that was published in 2009 in the Health Services Research journal. The framework covers four main components: external factors, internal health department actions, using appropriate measures and communicating value to policymakers. Jacobson told me that if public health doesn’t adapt to a public dialogue that prioritizes value and efficiency, “then we simply cede control to people who have no interest in social justice.”
“What we’re trying to do is to show public health officials ways of navigating in a new environment,” he said.
’This is the gold standard now, whether we like it or not’
Jeff Levi, executive director of Trust for America’s Health (TFAH), was fairly blunt about the need to better communicate the value of public health work.
“We like to believe that we do God’s work and calculating dollars can make people uncomfortable,” Levi told me. “There’s definitely a fear and I get it — that if something turns out not to have a positive return on investment, then it becomes harder to justify. …But I think we need to be willing to say that even though (a public health activity) might not have a cash return, it has value for other reasons. Policymakers are not stupid and they know when we’re fudging.”
Of course, collecting data on public health ROI is quite challenging, Levi said, noting a dearth in funding for such research as well as inconsistent definitions of what exactly public health value is and how to measure it. TFAH itself is no stranger to such research. In 2008, the nonprofit 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 of $5.60 for $1 invested. In fact, 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.
“I think the biggest challenge (public health) faces is operating in a world in which any program is expected to show some kind of ROI and the challenge is how we frame that definition and how we define value,” he said. “This is the gold standard now, whether we like it or not.”
In North Carolina, Greg Randolph and his colleagues at the Center for Public Health Quality are helping public health agencies nationwide improve the quality of their services, which he said can have a direct impact on outcomes and ROI. In fact, every time the center engages in a project with a health department, it also conducts an ROI analysis to capture the benefits of the project to both internal efficiencies and community health. For example, Randolph told me the center had worked on a project to increase hospital referrals to a state tobacco quitline. The project was indeed able to increase referrals and so by using previous research on quitlines and related cessation rates, center staff was able to calculate a beneficial ROI.
Randolph, who serves as the center’s director and is also an associate professor of pediatrics and public health at the University of North Carolina-Chapel Hill, said the ROI analysis not only helps public health workers in justifying current funds, but in leveraging new funding and creating new partnerships. For instance, he said that if public health can prove that its work has financial and health benefits for patients, hospitals may be more willing to collaborate on, or even fund, public health activities.
Randolph also told me that if you’d asked him just a few years ago if public health ROI research was that important, he probably would have said “no.” Now, he hopes it’s research the public health field truly begins to embrace.
“When you start doing these analyses, they may seem foreign and people may be leery about it…but we’ve found that it really does resonate,” he said. “I think it’s really very important to the future of public health.”
In today’s funding climate, “policymakers are looking wherever they can for efficiencies and trying to divert from what’s not working to what works…we need to prove that (public health) can deliver and that we are worthy and good stewards of the taxpayer dollars we’re receiving,” said Emily Holubowich, executive director of the Coalition for Health Funding. Of course, proving public health’s impact doesn’t always come down to dollars and cents, she said, it’s also about saving lives and improving health. Holubowich did note that public health is caught in a bit of a catch-22 situation: In other words, who is going to fund public health ROI research if not the government and yet it’s the government that wants such ROI research to justify spending levels.
One way around that conundrum may be shifting part of the dialogue, she said. Plus, she said that everyone is coming into congressional offices these days talking about ROI — “there’s so much noise in the ROI space right now, we’re starting to get drowned out.” Holubowich called on public health workers to talk about immediate ROI impact, such as the effect that a public health program has on individuals and families, the everyday effect on people’s lives.
“Tell the story of real people in your community, focus on personal stories,” she said. “In terms of ROI, we need to think more immediately because that’s the psyche of members of Congress.”
Back at APHA, NPHW organizer Moore hopes this year’s NPHW participants will share local, real-world examples of how public health is changing people’s lives. Just one successful story can make a difference, she said.
“Connect the numbers and data to real-life situations,” Moore said. “A story gives meaning.”
To learn more about the upcoming National Public Health Week celebration, its five daily themes, how to take part or to download a free toolkit with tips on how to get started in your community, visit www.nphw.org.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
While we’re on vacation, we’re re-posting content from earlier in the year. This post was originally published on April 24, 2013.
By Liz Borkowski
For this Workers’ Memorial Week, the National Coalition for Occupational Safety and Health (National COSH) has released “Preventable Deaths: The Tragedy of Workplace Fatalities,” a report that tells the stories of six workers killed on the job and promotes solutions to prevent other workers from sharing similar fates. The report notes that in 2011, 4,609 workers were killed, and construction was the deadliest industry sector, with 721 worker fatalities. The report tells the story of one construction worker killed on the job:
One day in April 2009, Orestes Martinez (29) and two co-workers were working at a construction site for the M.D. Anderson Cancer Center in Houston, Texas, helping to install a two-ton, lead-lined door in the radiation department of the hospital. They were moving the door by hand since no lift device was available. During the installation, the door fell on Martinez, crushing him to death.
The report includes thoughts from Adriana Martinez, Orestes Martinez’s wife. She also told her story for the six-minute video “Our loved ones died at unsafe workplaces,” which features the stories of four families who lost a loved one to a fatal work-related injury.
National COSH’s report includes several important recommendations for federal OSHA, the US Congress, and states to strengthen worker protections. In addition to those recommendations, there are steps that people in charge of building design and construction can take to protect workers at every stage of a building’s life cycle.
At last week’s Good Jobs, Green Jobs conference, Christine Branche and Matt Gillen of the National Institute for Occupational Safety and Health (NIOSH) Office of Construction Safety and Health delivered a fascinating presentation on using a “Life Cycle Safety” approach to ensure that green buildings are safe buildings. We’ve seen a lot of interest in green buildings in recent years, as companies seek to reduce their energy use and earn environmental seals of approval like the US Green Building Council’s LEED certification. So far, however, such green certifications haven’t lived up to their potential to protect the workers who build, maintain, and eventually demolish or refurbish the buildings.
Matt Gillen’s photo of a worker fixing an HVAC system (below) captures several ways that a poorly designed building can be hazardous for workers. This worker didn’t have easy access to the machine – he had to climb a ladder to get to it, and then didn’t have enough space between the equipment and the edge of the building. Without an easily accessible power supply, he had to run an extension cord up to the roof, which presents a potential electrical hazard as well as something additional to trip over. The thing that makes me cringe the most, though, is that he’s sitting on a low parapet and looks like he could very easily fall over the edge.
NIOSH takes the perspective that “a sustainable product, process or technology should not only protect the environment and the consumer but also the worker. Green jobs must be safe jobs.” To ensure that green buildings offer safe jobs, it’s important to consider worker health and safety at the design stage. Architects and engineers should collaborate with occupational health professionals to consider how a building will be constructed, maintained, and repaired or demolished. They should consider all the hazards workers might face at each stage and modify their designs to eliminate or reduce those hazards.
Features common in green buildings can present occupational hazards if those involved in design and construction planning don’t consider workers sufficiently. Installing and maintaining solar panels, for instance, can be hazardous; workers can fall off roofs or through skylights and can be electrocuted. At the design stage, architects can reduce these hazards by ensuring workers installing, repairing, and cleaning solar panels have enough room to maneuver around the solar panels; specifying guardrails or parapets high enough to prevent workers from toppling off the roof; and including anchor, or tie-off, points for workers using safety harnesses. Ensuring easy access to the roof – e.g., by a stairway rather than a ladder – is important, too, especially because solar panels need regular cleaning to operate efficiently.
Ideally, these “upstream” modifications will reduce risks, and additional “downstream” practices can address the remaining risk. The California Fatality Assessment and Control Evaluation (FACE) program responded to a rash of deaths among construction workers installing solar panels by producing a video and fact sheets about risks and preventive measures. These include using fall protection systems and ensuring that lifts are available to hoist solar panels to the roof, so that workers aren’t trying to manually carry panels up ladders. Construction planning is important for ensuring that lift equipment is available, and it can also allow for some assembly to be done on the ground rather than on the roof. At the NIOSH presentation, I also learned that workers can use solar blankets to keep light from getting to solar panels while they’re being worked on – in essence, shutting off the electricity by blocking sunlight.
OSHA’s Fall Prevention Campaign, developed in partnership with NIOSH, lays out a three-step “Plan, Provide, Train” process for preventing falls throughout the construction industry. Their resources include educational resources for employers and workers, many of them geared to workers with limited English proficiency.
NIOSH has made progress in working with the US Green Building Council and others to integrate worker health and safety into green building design; check out their Prevention Through Design site for more. With better planning, fewer families will join Orestes Martinez’s family in grieving for a loved one killed on the job.
While we’re on vacation, we’re re-posting content from earlier in the year. This post was originally published on July 23, 2013.
By Celeste Monforton
My mailbox today contained an example that Obamacare is working for healthcare consumers. In an envelope from my health insurance provider was a check for $124.08. The cover letter from Humana explained it was a rebate of a portion of my premium, as required by the Affordable Care Act’s (ACA) Medical Loss Ratio standard.
Under the law, health insurers are required to report to HHS’s Center for Medicare and Medicaid Services (CMS) how income from premium dollars are spent. (The first year of reporting was 2011 with the previous year’s spending data.) For individual and small group plans, no more than about 20 percent of premiums can be spent on administrative costs, such as sales and advertising. (The exact percent depends on whether a State makes the case to HHS that a higher percentage is needed in order to keep the insurance market stable. Eighteen states made such requests.) If an insurer’s administrative costs exceed the Medical Loss Ratio for the year, they must refund the difference to the plan’s enrollees by August 1.
My insurer wrote:
“In Texas, Humana Insurance Company did not meet the Medical Loss Ratio standard. In 2012, Humana spent only 76.7 percent of a total of $149,433,285 in premium dollars on health care and activities to improve health care quality. Since it missed the target in your state (Texas) by 3.3 percent of premiums it received, Humana must rebate 3.3 percent of your health insurance premium.”
8.5 million U.S. health insurance consumers will be receiving $504 million this year in premium refunds. A table prepared by CMS provides a breakdown of these refunds by States, stratified by individual, small group and large group markets. The average rebate for all insurance consumers is about $100, but in some States the mean is quite a bit higher. In Idaho, the average refund for a person with an individual insurance plan is $490. For an Oregon resident who is part of a large group plan, the average refund is $1,256.
With all the moaning and groaning by Republicans on Capitol Hill about Obamacare, the refund check from my insurer is one example that the ACA is working. Sixty seven of the law’s 90 key provisions are already in effect. These include requiring insurers to permit young adults to stay on their parent’s insurance plan until age 26, and to cover the full cost of preventative health services, such as mammograms. There have also been funds provided for scholarships and loan repayment to expand the number of physicians, nurses and physician’s assistants in under-served parts of the country, for construction and expansion of community health centers, and tax credits for small businesses and small non-profits to help them purchase insurance for their employees.
No doubt it is a complex law—-the U.S. healthcare systems is a tangled beast—-but Americans are better off with Obamacare, than without it.
People who hold down more than one job not only experience an increased risk of injury at work, but while they’re not at work as well, according to a new study.
Published in the January issue of the American Journal of Public Health, the study found that multiple job holders had a “significantly” higher injury rate per 100 workers for work- and nonwork-related injuries when compared to single job holders. The study, which was based on 1997-2011 data from the National Health Interview Survey, examined nearly 7,500 injury episodes reported during the 15-year study period, of which 802 were reported by multiple job holders and about 2,250 were work-related. When weighted, it comes to about 4.5 million work-related injuries each year, of which about half a million are among multiple job holders. Researchers concluded that even after adjusting for the additional hours worked, multiple job holders still face a higher risk of injury.
The study noted that the effects of working multiple jobs has attracted little attention from researchers and is often overlooked within public health and injury surveillance systems. Much occupational injury research focuses on a person’s primary employment. But in 2011, about 5 percent of U.S. workers reported working more than one job within the same week, while some estimates put the number of men working multiple jobs as high as 20 percent. Authors Helen Marucci-Wellman, Joanna Willetts, Tin-Chi Lin, Melanye Brennan and Santosh Verma write:
Injury research and standard surveillance systems have disregarded multiple job holding, instead describing injury morbidity in terms of exposures at the primary job or the job in which the worker was working when injured. Furthermore, most of the current injury surveillance systems and standard employment surveys in the United States do not account for the dynamic fluctuations in work forms present today.
Researchers found that multiple job holders wore more likely to be college educated, younger, white, nonmarried, working 50 or more hours each week, employed in the service sector, and with less tenure at their primary job. The higher rate of work injuries among multiple job holders was statistically significant among women, those with some college education, workers ages 25 to 44, and whites.
Female multiple job holders, who are more likely than men to have multiple part-time jobs, experienced more work injuries than single job holders. The authors noted that “female part-time workers are usually paid hourly, receive lower wages, and have unstable and unpredictable hours, potentially increasing risk.” The study also found elevated work injury rates among young and blue-collar multiple job holders (though injuries among blue-collar occupations are already the highest of any category).
An obvious explanation for the higher risk among multiple job holders is fatigue, but the researchers said that doesn’t fully explain the numbers. Other factors could be trying to fit full-time workloads into part-time hours, worker inexperience with the job at hand, or less employer investment in part-time workers. In regard to multiple job holders’ increased risk of injury while not at work, study authors said it may be associated with fatigue or the “potentially hectic structure” of working two jobs.
The authors described their findings as a “conservative” estimate of the injury risk to multiple job holders, and noted that the study is limited by low reporting of work injuries among blacks and Hispanics.
To request a full copy of the 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.