What Happens If The Government Shuts Down Tonight?

The Consequences

    Unfortunately, no one can be sure what will happen if the government shuts down tonight.  However, there are a few possible consequences that are particularly troubling.

1.) It will (and possibly already has) hurt the economy - we still haven’t fully recovered from the recent recession though we have been improving somewhat.  The uncertainty that has come from this most recent battle between democrats and republicans in congress has already caused the stock market to go down in the last few days.  If there is a shut down, especially if it lasts for more than a few days, it could disrupt the economy by causing cuts in government salaries and contracts and harming the trust of investors among other things. (Economists Warn of Dire Consequences of Government Shutdown, Debt Default)

2.) Two-thirds of government employees will be put on unpaid furlough - those government workers who are designated as essential (Congress, the President, Defense Department Officials, Air Traffic Controller, uniformed Military personnel, etc) will continue to work and be paid.  Those who are designated as unessential, will not work, will not be paid, and will not be guaranteed retroactive pay when the government shutdown ends (How Will A Government ShutDown Affect You?).

3.) The CDC could close its doors right as flu season begins - Although influenza is not as deadly as it used to be (thanks to flu shots), the CDC still estimates that from the 1976/77 flu season to the 2006/7 flu season there was a range of influenza based deaths between 3,000 and 49,000 people per year (Estimating Seasonal Influenza-Associated Deaths in the United States: CDC Study Confirms Variability of Flu) .  Whether a flu season is on the low or high side of the range depends on the predominant strain.  If the government is shut down for more than a few days, government funded flu shot programs would be shut down as well (Federal government shutdown would imperil key Acadia tourism season, flu shots and fuel aid).

The Equity and Fairness Issue

    If the government shuts down tonight, the people who will be most hurt are not those who are responsible for the harm.  This year, rank and file members of congress’s income is $174,000 which is increased if a congress member is in a leadership position.  The median household income in the US is $50,502 which means that congress is paid 3.45 times more than the median.  The median government worker earns $74,714 (congress gets 2.33 times more) and the average enlisted soldier earns $33,141 (congress gets 5.25 times more).  Average Americans, government workers and enlisted soldiers all get paid much less than congress and will have a harder time dealing with not being paid if the government shuts down - they also have done nothing to cause the government shut down.  So why does congress continue to get paid while they don’t?

What Can We Do?

    So what can we do about the shutdown now?  What can we do to prevent shutdowns in the future?  And what can we do about the equity and fairness issue?  One thing we can all do in the short term is call our congress members to urge them to do their jobs and focus on passing a budget, not politically grandstanding.  Beyond that, I have a few suggestions.

1.) Congress members should be the first people to stop being paid if a shutdown happens and they should still have to work to stop the problem.  They were getting paid and not doing their jobs before the shut down, so they owe the American people some work.

2.) Congress members pay should be tied to the American people’s.  If politicians want a raise, they have to make life better for the rest of us.

3.) We should have publicly funded elections.  Currently, elections incentive people who are good at getting people to give them money to run for office.  This isn’t the most important quality for congress member.

Health Disparities and The Social Determinants of Health by Glenna Martin

Will Universal Health Care Reduce Health Disparities in the US

In the biomedical model of health, access to health care leads to improved health. The “logical” assumption then follows that universal health insurance would lead to equal access to these services and thus improved overall health. As we get closer to October 1^st, when the state health exchanges will open, we must ask ourselves if this assumption is true. When we get to universal or near universal health care coverage, will health disparities decrease?

 We can look to countries that have universal health currently to see if this is true. In the United Kingdom, which has had universal health care for 60 years, population health has improved, but class differences in health and mortality have actually increased.[1] In Sweden, with universal health care since 1955, there are also still socioeconomic status related health inequities.[2] Taiwan implemented national/universal health insurance in 1995, and makes for a contemporary case study of health inequities. After implementing national health insurance, Taiwanese patients increased their use of the health care system, averaging 14 visits to physicians in 2004. These visits were predominantly made by elderly and poor patients.  However, results of a 10-year study concluded that although population health improved countrywide, particularly in the “lower ranked health classes”, the change was small.  Although they found a decrease in health disparities, the magnitude of the reduction was small compared with the size of the remaining gaps (~6%). Thus, the authors concluded, “Relying on universal insurance alone to eliminate health disparity does not seem realistic.”[3] The general examples of Sweden, England, and Taiwan illustrate that universal health care coverage in the US would tend to improve population health to some degree, but would not significantly reduce health disparities.

Why Won’t Universal Health Coverage Significantly Reduce Disparities?

The reasons for health inequities are complex.  They include determinants of health such as income, education, socioeconomic status, discrimination, housing, environment, food security, social support, transportation, and working conditions.[4]^,[5],[6],[7] Moreover, sources of disparities exist even within the healthcare system, as evidenced by the Institute of Medicine (IOM) report, “Unequal Treatment.” This report found approximately 175 studies documenting racial/ethnic disparities in the diagnosis and treatment of various conditions that persisted even after controlling for possible confounders.[8] Thus, even universal access to health care does not guarantee universal equal treatment. 

Access to medical services should not be considered the primary driver of disparities in health status. Income and other social determinants are the fundamental causes of health as they contribute to social gradients, influence many diseases, are reproduced over time, and function through various pathways of risk. Perhaps most significantly, income represents access to resources that, when ample, can be used to avoid health risks or when absent can lead to increased risk.[9]

Would Universal Health Care Help At All?

Evidence indicates that with universal medical care coverage health disparities would likely improve for certain sub-populations (such as individuals with HIV and children) who are particularly vulnerable and responsive to changes in availability of medical care. Additionally, health insurance can positively affect control of high blood pressure for adults, especially those in low-income groups.[10]^,[11] Still, questions remain about how effective health insurance can be for other groups and which aspects of medical care deserve more investment versus social infrastructure programs.[12]

Although an abundance of literature exists to demonstrate the existence of health disparities and to describe causation, there is a lack of evidence discussing effective policy interventions.[13] It seems most plausible that although universal health care coverage in the US would likely improve some aspects of population health, until the fundamental causes of health are effectively addressed there will still be inequities and consequently disparities in health. This is not to say that we shouldn't provide universal health care as it is, and should be, a fundamental right.  However, historically, access to good medical care occurs after progress on public education, higher wages, increased employment, and housing provisions are achieved.[14] If we are serious about reducing health disparities, we have to think outside of the biomedical model and start thinking more holistically.

---

[1] Cockerham, W.C. (2013) Social Causes of Health & Disease 2nd edition. p. 120. Cambridge: Polity Press.

[2] Bleich, S. N., Jarlenski, M. P., Bell, C. N., & LaVeist, T. a. (2012). Health inequalities: trends, progress, and policy. Annual review of public health, 33, 7–40.

[3] Wen, C., Tsai, S., & Chung, W. (2008). A 10-Year Experience with Universal Health Insurance in Taiwan : Meauring Changes in Health and Health Disparity. Annals of Internal Medicine, 148(4), 258–267. Retrieved from http://annals.org/article.aspx?articleid=739496

[4] Braveman, P. a, Egerter, S. a, & Mockenhaupt, R. E. (2011). Broadening the focus: the need to address the social determinants of health. American journal of preventive medicine, 40(1 Suppl 1), S4–18.

[5] Braveman, P. (2006) Health disparities and health equity: concepts and measurement. Annual Review of Public Health 27 pp 167-194.

[6] Solar O, Irwin A. (2010) A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). WHO, Geneva

[7] Williams, D.R. Sternthal, M. (2010) Understanding Racial-Ethnic Disparities in Health: Sociological Contributions. Journal of Health and Social behavior 51: S15-S27.

[8] Institute of Medicine. (2002) Unequal treatment: confronting racial and ethnic disparities in health care. Washington: National Academies Press.

[9] Link, B., & Phelan, J. (1995). Social Conditions as Fundamental Causes of Disease. Journal of health and social behavior, 35, 80–94.

[10] Andrulis, D. (1998). Access to Care Is the Centerpiece in the Elimination of Socioeconomic Disparities in Health. Annals of Internal Medicine, 419–420.

[11] Levy, H., & Meltzer, D. (2008). The impact of health insurance on health. Annual review of public health, 29, 399–409.

[12] Frankel, S. (2001). Commentary: Medical care and the wider influences upon population health: a false dichotomy. International journal of epidemiology, 30(6), 1267–1268.

[13] Ibid. See citation 2.

[14] Hart, J.T. (2001). Commentary: Can health outputs of routine practice approach those of clinical trials? International journal of epidemiology, 30(6), 1263–1267. 

Corporate sponsorship and improving health

Corporate giving

Although regular consumption of junk food like soda, candy, and fast food is known to be bad for health, many companies associated with selling ‘junk food’ donate to non-profits and sponsor initiatives to improve communities. For example, earlier this week, Michelle Obama announced the ‘Drink Up’ campaign to encourage Americans to drink more water. Many of the companies that are sponsoring this effort are companies that produce bottled water. It turns out that many bottled water companies are owned by the same companies that produce soda, suggesting a conflict of interest. However, major health improvement campaigns are few and far between. Are public health campaigns like ‘Drink Up’ helpful or harmful? 

Examples of corporate giving to improve health

Michelle Obama’s Drink Up effort is just one example of this phenomenon. Earlier this year, Coca-Cola unleashed an anti-obesity campaign (You can Watch the commercial here).  Coca-Cola a main soda producer is now committed to “create awareness around choice and movement, to help people make the most informed decisions for themselves and their families.”  As found on the website, Coca-Cola supports over 280 physical activity or nutrition education programs. Coca-Cola sponsored 10 boot camps around the United States.

Another example is McDonald’s hosting nutrition events. In May 2012, McDonald’s hosted an event at Union Terrace Elementary School in Pennsylvania called ‘What We’re Made Of’ and made a $1,000 donation to benefit fitness and nutrition education. From the press release “The objective is to empower families with information they can use to make healthy food choices and to arm parents with information about McDonald’s commitment to the well-being of kids. A ‘farm table’ display will serve as the centerpiece of discussion and showcase some of the fresh ingredients found in McDonald’s food.” However, it is well documented that a diet high in fast food is harmful.  Studies have found that a child that eats fast-food consumed more fats, sugars, calories and carbohydrates and fewer fruits and non-starchy vegetables compared to kids who didn't eat fast food. Studies have also been done that link obesity to familiarity with fast-food advertising. Is nutrition education with Ronald McDonald or the McDonald’s logo like one big advertisement?

Why ‘junk food’ companies should sponsor health initiatives

1.     To improve health  -  Americans, as a whole, have poor health. We eat too much and don’t move enough. Free events and education to the public opens a discussion on how to improve overall well-being. People from low-income neighborhoods have less access to opportunities to improve health and tend to have worse overall health outcomes. Opportunities to improve health are necessary to achieve health equity.

2.     To supplement funding from cash strapped entities  -  Governments, schools, and non-profits have tight budgets. In some cases mandates from policies are largely unfunded and in order to meet the law, entities have to create partnerships. For example, a school district that must, by law, provide physical education but does not have money in the budget for curriculum development or staffing needs donations from somewhere.

Why ‘junk food’ companies should NOT sponsor health initiatives

1.     Advertising opportunities disguised as good  -  Logos are powerful tools. Most Americans cannot possibly look at a 5K-race bib with the Dairy Queen logo and not think of blizzards. Recently researchers have found just a 30-second exposure to a product changes a person’s preferences for a brand. In the time it takes to run a 5 K there are a lot of 30-second exposures.   

2.     Inconsistent messaging  -  Seventy McDonald’s restaurants throughout Arizona hosted back-to-school health and safety fairs to provide health screenings and information on health insurance. Many of these events actually took place at McDonalds. Based on the USDA’s My Plate nutrition guidelines fast food is considered a food to be consumed in moderation. It is confusing for children to bring them to a fast food restaurant to learn about health. Not to mention the free advertising McDonalds gains by putting a backpack on thousands of children.

In the end, is it okay for ‘junk food’ companies to sponsor health related events?

There are important health policy and equity concerns to consider when answering that question. First, we know that people in low-income neighborhoods lack health opportunities and discretionary income to seek these opportunities. There is a need for physical activity activities. Free, community based fitness events warm my heart and I like that families are educated about food choices. Second, the health disparities between richer and poorer neighborhoods are real. Third, companies have the extra money that governments, schools, and non-profits lack. A $1,000 donation is beneficial for students. But there is a major ‘yuck’ factor. My gut reaction is that companies know that there is an opportunity for free advertising through sponsorship and the power of that advertising on their bottom line. So what if companies do only sponsor health related initiatives to bring in the money. Would it be fair to deprive people of the opportunities if such sponsorship wasn’t allowed? Do public health campaigns, like Michelle Obama’s, need corporate sponsors? Personally, I am torn. I am curious what others think about this issue. Please comment below.

The US vs. the Top Countries for Healthcare Quality and Cost

Health Care in the US

Health reform has been a hot political topic for a long time.  From Franklin Roosevelt trying to include publicly funded healthcare programs in Social Security to Barack Obama signing into law the Affordable Care Act, health reform has been a major player in the politics of the United States.  So, after 80 years of constant debate and reform, how is the US doing?  There’s a little bit of good news and a lot of bad news.

The Good News

We lead the world in healthcare research and cancer treatment.  The five year survival rate for breast cancer is higher in the US than in all other OECD countries.  The US is also among the best for colorectal cancer survival.  We are also more likely to survive a stroke.

The Bad News

Americans spend $8,233 per person per year on average on health care.  The next highest in the OECD is Norway at $5,388 and the average per person for the OECD is $3,268.  As a country, 17.6% of our GDP is spent on healthcare.  The next highest is the Netherlands which spends 12% while the average in the OECD is 9.5%.  

Spending more than other countries might be worth it if we were getting better health from it - unfortunately, we aren’t.  On average there are 2.4 physicians for every 1,000 people in the US compared to 3.1 for every 1,000 on average for the OECD.  There is a similar disparity in hospital beds (2.6 per 1,000 for the US and 3.4 for the OECD).  Life expectancy at birth in the US is 78.7 years, more than a year shorter than the OECD average of 79.8. (Health Costs: How the US Compares with Other Countries)

The National Research Council and the Institute of Medicine compared the US to 16 other developed countries like Japan, France and the United Kingdom.  They found that the US has the highest rates of death by violence and car accident by wide margins.  Among developed countries, we also have the highest chance that a child will die before the age of five. We are 2nd in death by coronary heart disease and lung disease and have the highest teen pregnancy rates as well as the highest rate of women dying due to complications from pregnancy.

Top Countries for Healthcare Quality and Cost

In 2000, the World Health Organization ranked the world’s healthcare systems on five categories: health, health equality, responsiveness, responsiveness equality and fair financial contribution (These are the 36 Countries that Have Better Healthcare Systems than the US).  Thirty-six countries were ranked higher than the United States.  Also, Bloomberg recently ranked the most efficient healthcare systems in the world - those countries who get the most for their dollar, not necessarily those with the best health. (Most Efficient Health Care Countries - Bloomberg).  Below are the countries who ranked higher than the US on WHO’s list, and their ranking on Bloomberg’s list in parenthesis.

		Colun1	Con	WHO 2		WHO 3	4
1	France (19)	11	Norway	21	Belgium (34)	31	Finland (23)
2	Italy (6)	12	Portugal (27)	22	Colombia (42)	32	Australia (7)
3	San Marino	13	Monaco	23	Sweden (10)	33	Chile (13)
4	Andorra	14	Greece (30)	24	Cyprus	34	Denmark (38)
5	Malta	15	Iceland	25	Germany (30)	35	Dominica
6	Singapore (2)	16	Luxembourg	26	Saudi Arabia (29)	36	Costa Rica
7	Spain (5)	17	Netherlands (25)	27	United Arab Emirates (12)
8	Oman	18	UK (14)	28	Israel (4)
9	Austria (16)	19	Ireland	29	Morocco
10	Japan (3)	20	Switzerland (9)	30	Canada (17)

What do the Countries that have the best and most efficient healthcare systems have in common?

France, Italy, Singapore, Spain, Austria and Japan are all in the top 10 for WHO’s health care quality and are ranked highly on Bloomberg’s efficiency scale.  Therefore, it makes sense to learn from them.  As you can imagine, their health care systems vary widely; however, they have a few things in common.

1.) Universal, or near universal, Health Care Coverage - France, Italy, Spain, Austria and Japan all have universal health.  Singapore seems to break the mold, but doesn't really - it just does the same thing in a different way.  Instead of requiring all it’s citizens to have health insurance, Singapore requires all its citizens to contribute a percent of their monthly salary to a personal health care fund.

2.) Government Price Control - All six of the example countries control healthcare costs somehow.  Usually, governments do this by setting rates for procedures and medications, and some require that rates be published in hospitals and doctor’s offices.

What can the US Learn from the Top Countries?

The Affordable Care Act will ideally get us to near universal health care coverage, but that is not enough.  As noted in an earlier post, Massachusetts has had near universal health care coverage since 2006 and healthcare costs have not decreased.  The next step for the United States is for the Government to set prices for procedures and medications.  The system we use now, which has health insurance companies and providers negotiating prices until no one knows what a CAT scan or vaccination actually costs, doesn’t work.  The United States doesn’t have to, and shouldn’t, copy another country’s healthcare system, but it is hubris to think that we can’t learn from others.