Improving Population Health

How Much Can Expanded Community Health Centers Do?

By David A. Kindig, MD, PhD

Many readers of this blog will not know that I “came of age” professionally as a Social Pediatric resident at the Martin Luther King Jr. Office of Economic Opportunity (OEO) Health Center in the South Bronx in the early 1970s. With vision and funding these health centers provided innovative primary care using interdisciplinary health care teams. 

What some may not know (or may have forgotten) is that such centers also provided an array of broader services such as job training, legal advocacy, and school health. We didn’t speak of epidemiology and disparities back then, but we understood that community health depended on more than the availability of healthcare services (and on the health of those who did not access them). I also learned an important policy lesson: grants go away—and when they do, many of the innovative services go with them.

The new Patient Protection and Affordable Care Act (PPACA) calls for a significant expansion of federal community health centers and the National Health Service Corps. In his important June 3 New England Journal of Medicine commentary, Dr. Eli Adashi and colleagues describe the current role and reach of such centers, including the PPACA’s plan to increase the number of patients served (to 40 million annually) while adding 15,000 new primary care providers by 2015.

While applauding this initiative, the authors cite numerous challenges to such an expansion, including state Medicaid cutbacks, lack of capital and information technology infrastructure, governmental administrative issues, and the limited production pipeline of primary care providers.

Last week I reported on a recent meeting at the Federal Reserve which highlighted potential partnerships between Community Health Centers (CHCs) and Community Development Financial Institutions (which address low-income housing, economic development, and other social services such as early childhood education).

Adashi and colleagues briefly mention the CHC role in “a broad swath of needs for coordinated disease prevention and health maintenance.” However, the authors fall short of calling for the broad interventions that the OEO provided and paid for 40 years ago. It is worth noting that one of the authors, Dr. Jack Geiger, successfully ordered groceries from the OEO central pharmacy for his malnourished patients in the Mississippi Delta!

In the end, this tremendous push for expanded healthcare access may require a focused, concerted, all-hands-on-deck approach. But we should keep in mind what the OEO knew in the 1960s--that healthcare is only one determinant of health with no clear accountability for the rest.

Some CHCs continue to offer a broad spectrum of services. With the White House and the Office of Management and Budget championing “place-based” initiatives, perhaps some funds can be set aside for pilot programs. For these pilots, CHCs (defined not only as federally qualified health centers but also community-funded safety net clinics, faith-based clinics, family practice residency programs, rural health centers and free clinics) could lead the integration all health promoting investments. However, without a permanent funding stream, even successful pilots (such as OEO) can regress. If successful, perhaps long-term funding streams from Community Benefit or Accountable Care Organization (ACO) savings could be attempted.

It worked once, but was not sustained. Isn’t it worth another try?

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Population Health and the Federal Reserve...Are You Kidding?

By David A. Kindig, MD, PhD

I’ve mentioned before that a “convergence of scholarship, policy, and practice initiatives seems poised to bring an overdue population health perspective to thinking about and acting on health and health improvement.” One of the purposes of this blog is to keep track of all that is bubbling up in likely—and often unlikely—places.

This convergence was exemplified by a meeting I attended last week at the Federal Reserve in Washington, DC. The event was co-sponsored by the Federal Reserve Bank of San Francisco and the Robert Wood Johnson Foundation and was titled “Healthy Communities: Exploring the Intersection of Community Development and Health.”

The meeting brought together public and private sector experts in policy, community development, and finance to explore what the fields of health and community development can learn from each other (for background reading, check out this issue of Community Development and Investment Review).

Here are some initial impressions:

• I learned that the “other” CDC is the Community Development Financial Institutions or Corporations, which promote affordable housing and business development to keep individuals and families out of poverty. (See articles by Richter and Andrews in Community Development and Investment Review issue linked to above.)
• I was pleased that the multiple and social determinants of health took center stage, with significant discussion on the damaging biological stress pathways associated with lower socioeconomic status.
• The fields of health and community development share many priorities, including early childhood investments, fresh food infrastructure, and efficient and innovative healthcare delivery.
• We must aggressively advocate for health in all policies, from nonprofit hospital Community Benefit regulations to the Community Reinvestment Act.
• Both the White House and the OMB seem fully supportive of multisectoral and place-based strategies as well as redirecting financial streams in innovative and more cost-effective directions.
• There may be a major opportunity for collaboration between federal Community Health Centers (CHCs) and community development organizations as CHCs are set to greatly expand to cover 40 Million low income persons under health care reform.

As we continue to call for broad and inclusive approaches for improving population health, we need to continue to identify common ground and build alliances with partners in unlikely places.

Have any to add to the list?

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

A Dream Budget for America's Health

By David R. Riemer

I had a dream last night that I got a phone call from Barack Obama. It's the kind of dream that only a former city and state budget director could cook up.

B-r-r-i-n-n-g-g-g-g (Did telephones ever really go "b-r-r-i-n-g-g-g-g? Do they still?)

Me: "Hello? This is David Riemer. May I ask who's calling?"

Voice: "This is Barack Obama."

Me: "Is this a joke?"

Obama: "No, it's the President...of the United States."

Me (remember: it's a dream): "Good evening, Mr President. I think you're doing a great job. Especially with national health insurance, given the weak Congress you've got. How can I help?

Obama: "David, I'd like you to think about becoming the nation's budget director. The current director of OMB, Peter Orszag, is resigning. As I’m sure you know, he has been advocating a cross-sectoral Place Based Strategy for many of our federal investments. I just nominated Jacob Lew to replace him, but who knows what Congress will do. So I wanted a back-up. I hear you were successful budget directors for both Milwaukee Mayor John Norquist back in the late '80s and for Wisconsin Governor Doyle in Wisconsin in 2003. The nation' budget is a mess. If need be, I'd like you to come to Washington to fix it."

Me (please remember...a dream): "Mr. President, if called upon, I'd be happy to accept the challenge."

Obama: "Thanks. One more thing. The people of the United States are far less healthy than they we ought to be. You know a lot about health policy. I understand you helped design Wisconsin's wonderful BadgerCare program. And I just learned that in your current job at Community Advocates, you're helping to lead the Milwaukee Tobacco Prevention and Control Coalition. Good stuff! If you end up in DC, I'd want you to use the federal budget to make Americans healthier."

Me: "No problem."

Obama: "A lot healthier."

Me: "It can be done."

Obama: "I'd like a brief report from you on exactly how you'd make Americans healthier. OK?

Me: "You'll have it tomorrow...tomorrow...tomorrow..."

And the dream (or was it a nightmare) ends.

But if it were true--if I really did end up as new Director of OMB, and had the job of using the federal budget to make Americans healthier--what would I recommend to the President of the United States?

Why Should People Who Care About Our Country's Health Contact the IRS Before July 22nd?

By David A. Kindig, MD, PhD

There is a looming deadline that those of us who care about health should know about.

For more than 55 years, nonprofit hospitals have had to justify their tax exempt status by providing benefits to the communities they serve. This is a big deal, since having this status amounts to a collective tax savings for the nonprofit hospitals of about $20 billion annually.

Until recently, nonprofit hospitals have mostly contributed this “community benefit” by providing care to people who can’t afford it and by offering screenings, health education, and other outreach activities. Hospitals were neither required to engage in certain activities nor document or evaluate their efforts.

Over the past couple of years, however, reporting requirements have increased.

One of the newer reporting requirements is IRS Form 990 Schedule H, where nonprofit hospitals report their community benefit activities. Unfortunately, Schedule H doesn’t give credit where credit is due.

The form does give credit for contributions made in the areas of charity care, health professions education, research, health education, and some types of community outreach. But it gives no credit for contributions beyond health care in areas such as housing, the environment, economic development, community coalition building, advocacy, and community workforce development. Of course, these are exactly the kind of investments we need more of to improve health outcomes and reduce disparities.

Although the IRS has not yet specified community benefit financial requirements (such as a fixed dollar amount or a revenue percentage), some are advocating that this happen sooner rather than later. Experts believe that charity care currently makes up a large part of community benefit spending, but the need for that should change with fewer uninsured as health care reform gets underway. Dollars currently used to provide healthcare for the uninsured could and should become available for other activities.

In addition, the new Patient Protection and Affordable Care Act (PPACA, PL 111-148) requires hospitals to conduct community health assessments every three years. What has not yet been decided is whether hospitals will be required to conduct these assessments independently or whether they will be allowed to collaborate with other community agencies.

The IRS is currently seeking public comment on how to best align Schedule H with the PPACA.

I urge you to submit your opinions by the July 22 deadline. Here are the points I’ll be including in my own message:

• Hospitals should carry out the required community health assessments in partnership with local public agencies and other community organizations and not be forced to conduct a separate, independent needs assessment.
  
• The new rules should explicitly allow public health and community health improvement activities to count as community benefit
  
• The IRS should call for more research to recommend whether an overall dollar or revenue percentage should be required--and if so, how funds should be allocated among charity care, public health programs, and other activities.
  

Let’s help create a permanent mechanism for making community health expenditures count—and keep coming—for population health improvement.

...............................................................................................................

I appreciate the assistance of Connie Evashwick, ScD at St Louis University and Pamela Russo, MD, MPH at the Robert Wood Johnson Foundation in providing background on this issue.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

In the Literature: Comparing States' School Health Policies

About once a month, MATCH Project staff review a wide variety of academic journals to identify recent articles having particular relevance to population health policy, research, and practice. University of Wisconsin Robert Wood Johnson Health and Society scholars and faculty recommend an article or two to feature on the blog.

We recently connected with Professor Marilyn Nanney at the University of Minnesota to learn more about her recent research that examines the relationship between state school nutrition and physical activity environments and youth obesity.

What prompted you to do this research?

Our research team set out to explore the effectiveness of school nutrition and activity policies. This study just scratches the surface of this complex question. The daunting scale of the current childhood obesity epidemic has put tremendous pressure on policy makers to take action based on limited--but best available—evidence. Policy decisions are being made on evidence that is less than we would accept for other health interventions like drug therapy, for example. Since the problem requires that we take action now (rather than waiting until we have all the answers), I agree with this approach. However, evaluating the effectiveness, including negative consequences, of policies is important to do, especially with limited resources. This study is one tiny step towards building that evidence.

What do you think is particularly interesting and/or novel about your approach?

First, we were economical. Instead of collecting new data, we found data that already existed (from the Centers for Disease Control and Prevention) that could help us answer our research questions. Second, we took a comprehensive approach to evaluating the school obesity prevention policy environment. We looked at school vending and physical education policies, infrastructure and system supports, and expert certification and training to create as broad a picture as possible of the policy environment. We went beyond many other studies, which have tended to focus on one or two components of the school environment, such as vending or fundraising policies.  

Briefly describe your findings. Did you encounter any unexpected obstacles?

Our main finding is that the “fattest” states have more state driven school nutrition policies. It seems that as the number of school policies mandated by the state increases, youth weight increases! Since it’s highly unlikely that nutrition policies make kids fatter, our interpretation is that the “fattest” states (like Tennessee, Arkansas, Mississippi) are responding to the problem by instituting more state-level nutrition policies. But we need a different kind of study to test this assumption. 

What are the implications of this work either for further research or for practice?

This study offers many opportunities to move forward with this line of research. First, we need a better understanding of the relationship between school policies and weight –especially over time.  Second, we need to bring the focus down from the 30,000 foot view (i.e., state policies and state youth obesity prevalence) to the more proximal view (i.e., the effect of school policies upon students attending those schools). Answering these two questions will bring us closer to evaluating policy effectiveness. However, since kids’ spend much of their time in out-of-school environments, a significant challenge still remains in teasing out the contribution of school policies upon weight. Do school food policies promote better food choices when kids are away from school--or not?