Feb. 14, 2017

Q & A with Director of Center for Health Policy

What impact would repealing the Affordable Care Act (“Obamacare”) have on the health of U.S. cities, particularly those with a high low-income population? 

Like most things in life, it depends. In this case, it depends on what comes in its wake, and how quickly. Without a replacement that achieves the same level of access to insurance, which, it has to be said, is not the same as access to care or wellness, it’s fairly clear that individual and population health indicators are very unlikely to improve. Many of the protections that came into being through the ACA, i.e., the “Pre-existing conditions” clause, the elimination of lifetime coverage limits, not to mention the marketplace are all things that have added immediate value for US citizens. The ability to purchase health insurance through a subsidy provided by your neighbors is a powerful example of how we help each other, which is critical in our cities, counties, towns and farms. Particularly for the low-income among us, elimination of those subsidies without a like-for-like replacement that is seamless, puts people at risk of losing access to care and once again resorting to emergency departments for basic care. 

Such a scenario would take us right back to the path we had been, on which saw uninsured citizens foregoing needed care, seeking care out in less than ideal settings (see emergency department comment above), and arriving at a health care provider’s door further down the path of an illness than they could/should be. Proposals being discussed include shifting control (aka, risk) to states with a much smaller Federal presence, (re) creation of “High-Risk Pools” with or without Federal support given to states to offset the costs and other solutions that are often framed as market-based. 

The greatest concern I have is that low-income individuals and families historically couldn’t and likely won’t be able to afford said markets in a future without significant monetary assistance from their neighbors. Health Insurance Lotto (“You Gotta Play to Win,” is an ad slogan that I grew up seeing on billboards and in commercials that seems pertinent here) will, like all lotteries, disadvantage the already disadvantaged. There will likely be many, many more “losers” in this version of a lottery, than “winners”. 

What effect might repealing the Medicaid expansion under Obamacare have on state and municipal budgets? 

Late last year, I had the privilege to address the Health Committee of the Council of Governments at their Annual Meeting in Williamsburg, VA. The same question was on the minds of several of the legislators on the committee and in attendance. In short, states that have relied on the subsidies offered though the ACA will have to eliminate programs and likely trim their Medicaid rolls. These two actions will largely offset one another as Medicaid spending declines in sync (or nearly so) with the decline in Federal subsidy. However, it would be shortsighted to think that the states’ challenges end there, and are limited to states that expanded Medicaid eligibility through the ACA. 

The vast majority of adult Medicaid recipients work, if not necessarily continuously. Many work more than one job, neither/none of which offers fringe benefits like usable health insurance and paid time off. From lost productivity due to chronic illnesses that prevent or impair work, to emergency department visits (ED’s are not allowed by law to turn patients away without assessing and stabilizing them) for non-emergencies (which can increase wait times for more ED-appropriate care), to the shifting of costs from commercial payers and Medicare to cover the expenses of those 10’s of millions who would no longer qualify, not only for Medicaid, but also secondarily by those who can’t afford insurance because the Exchanges will also be eliminated, states are facing potentially drastic fiscal challenges. 

For better or worse, the health services sector is a major employer in nearly every state, which in many cases, kept local and state economies afloat during the Great Recession. Loss of the provisions that allowed expansion of coverage/services to the Medicaid population in most states will likely result in moderate to large-scale job loss. The Legislators I spoke with in Williamsburg were none-to-eager to see the ACA repealed without something at least equally effective in its place. 

What are the most important factors to consider in choosing a city that is good for your health? 

There are several, and to some degree, they depend on your age and life circumstances. If you are young and healthy, you want a city that is demonstrably concerned with the factors that support healthy lifestyles: ready access to healthy food, exercise and a healthy environment. If you are not quite so young or healthy, you want to be sure that your city of choice boasts adequate health services, including public health resources. The Social Determinants of health are likely as important (if not more so) as other factors in maintaining health and wellness. Things like living in a safe environment, including low rates of interpersonal assault, access to clean water, public spaces for walking, strong education and employment infrastructures. 

Since health and wealth are both long term investments, what are some effective strategies for convincing people to invest more in their health today? 

Individuals are famously hard to motivate. In my view, the challenge is to help people make the connection between their health tomorrow and the choices they make today and link that to a better, more transparent understanding of true costs of care decisions. One size does not fit all. What motivates one person will likely have little effect on another. Much like people have variable appetite for risk in investing, so do they have variable appetite for making healthy food choices, choosing to exercise and quitting smoking. I think our future will necessarily shift away from “satisfaction” and toward “goals,” once we collectively begin discussions about health and healthcare with clear definitions of individual health goals for patients. 

In terms of investment, a strategy that strives for health goal attainment and not satisfaction offers the best hope to convince individuals and populations to make the necessary investment. When “patient satisfaction” is derived through the attainment of health goals that a person sets for himself or herself, the payoff is much greater for patient, providers and payers. 

What tips do you have for a person looking to embrace a more healthy lifestyle while on a budget? 

Walk, don’t ride. Take the stairs, not the elevator. Smoke 10% fewer cigarettes a week. Eat half of the nightly slice of cake each night. Start simply and don’t try to win the war in a day. Everything I mention above is free; in fact, the smoking strategy saves money. I don’t believe that gym memberships necessarily translate to health. The little things that everyone can do to the best of their ability will go a long way to effecting the lifestyle change that is necessary to achieve wellness. Behavior change is what we need as a population. Decisions are relatively easy but changing one’s actions? That’s the personal hard work to invest in. 

I think this particular challenge is greatest for people living in areas of concentrated poverty and scarce-shared resources. They often go hand in hand. For example, it’s very hard to eat healthy food, which paradoxically is generally more expensive than empty-calorie foods, if you live dozens of miles from an affordable source of healthy foods or a dozen feet away from a grocer that you can’t afford to shop. Again, things that aren’t necessarily directly tied to one’s blood pressure or smoking status can have an outsized impact on one’s health; for better or worse. 

What measures can local authorities undertake in order to improve local health care systems? 

Collaborate. Partner with and create conditions that encourage collaboration among public health officials, physicians, hospitals, housing authorities, educators, environmental protection offices, the criminal justice system and the pertinent federal authorities. Mitigating the societal factors that underlie the great majority of a population’s health status is a team sport. Youth who have safe, clean schools and aren’t constantly hungry have a much better chance of avoiding behavioral problems that lead to unfavorable encounters with the justice system. 

Missteps along the way, including being born to unsupportive or abusive parents (who were themselves abused in many cases) can lead to an Operating Room in my Trauma Center via an expensive helicopter ride. The chips that are so prominently displayed (and tastier than the hard-to-find low-quality fruits and vegetables) in many local bodegas can lead to Type II Diabetes, blindness, heart disease, amputations and bypass surgery. I don’t believe it’s government’s role to dictate behavior. 

I do believe that the people who, in this great nation of ours are the government, have a much greater role to play in the health of our neighbors than we currently demonstrate. Employers that provide healthy work environments and support employees who seek to improve their health help all of us and their bottom line simultaneously. The schools that provide education about wellness and fitness, and partner with local grocers and nutritionists to not only understand, but also enable (i.e., financially) sound dietary choices by our children, will improve the well-being of their communities for generations to come. Perhaps the most important aspect of what local governments can do through partnership is to recognize that we didn’t become unhealthy as a nation overnight. Reversing that trend requires long-term commitment and courage.

Original Article can be accessed here.

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Associate Professor of Surgery and Director of the UVA Center for Health Policy
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