Tag Archives: Health in All Policies

The Greater Health Impacts of the Affordable Care Act

My son had an accident and broke his leg and I found a lump for which a routine biopsy was needed.

When these things happened to my family, I was relieved I had health insurance to help meet our medical needs. But it’s been an expensive and confusing experience – even quality health insurance coverage (procured through my partner’s employer) is proving inadequate at sparing my family the negative health effects of high medical bills. It made me wonder – how has the expansion of health insurance through the Affordable Care Act impacted peoples’ economic security? How much farther do we have to go to ensure that people can access health care without significant financial stress?

While our health issues were serious enough to require treatment, they were not unusual. I had to spend $1,500 (after insurance paid what they would) to discover my lump was, thank goodness, totally fine from a cancer perspective. Not so, from a financial perspective. Then recently, my son was playing with his cousins, fell, and broke his leg. Not sure what the total bill for this is going to be yet, but I’m guessing it also will be around $1,000 after insurance. In the health insurance world, these are probably considered moderate costs for a “consumer” who also pays health insurance premiums every month. But for a household with a tight and perpetually stretched budget like ours, this extra expense causes a great deal of stress.

This financial stress has a number of additional impacts to our family’s health and well-being. My partner and I have to make decisions about the things we will forgo in order to pay these bills. These are not fun conversations and I could see how over time they might end up putting too much stress on a relationship. For couples that separate, there is a cascade of health effects that happen: isolation, depression, anxiety, and negative impacts on children are well documented in the research.

There’s also research that looks at the long-term “economic scarring” that happens (such as during a recession) when families have to make tough choices about spending money on basic needs and medical bills, rather than on things like educational achievement, investments, or starting a small business. When scores of families are forced to make these trade offs (such as during a recession) our whole economy suffers. Our current system of health insurance not only does not protect people’s right to be healthy and productive, but when one of us gets sick or injured in the current system, we all pay.

In HIA, we seldom look at the health impacts of health care policy. We usually focus our policy efforts more upstream, and think of health care as a safety net after upstream efforts have failed. Health care becomes relevant when we aren’t able to change the unhealthy places where we live, work, go to school, and play. Yet through my personal experiences with the financial burdens of health care, I am gaining a different perspective on the greater health impacts of inadequate health insurance. It’s informing my research on the health impacts of financial stress through a new HIA project in our Economic Security Program that I’m leading with our partners, ISAIAH, in Minnesota.

Although the ACA represents a leap forward, we still have a long way to go towards ensuring everyone has health care that doesn’t come with a heavy dose of financial stress. I believe that health care could and should be considered a human right rather than a commodity, as it is now. We should all have the ability to be healthy and lead productive lives, without living in fear of having an accident, or being stricken with an unwanted illness and not being able to afford diagnosis and treatment. We are still far from this ideal.

Climate Action is Health Action: Why Support for California Climate Legislation is Good for Our Health

This week’s blog was originally published by the Public Health Institute (PHI) on August 25, 2015. 

“Amid a historic drought that has been linked to climate change, California’s state legislature is currently considering bills that aim to significantly reduce greenhouse gas emissions in the coming decades. Often considered a bellwether in American politics and a global leader in combating climate change, California’s proposed bills could provide a model for other governing bodies to set similar goals at local, state and international levels. This year, the state’s governor, Jerry Brown, assembled state-level governments from around the world to sign a commitment to match California’s proposed target for reducing emissions. The U.S. government also recently announced a Clean Power Plan that echoes California’s groundbreaking 2006 climate change legislation.” Read more… 

Fair Housing for Better Health

One year after Michael Brown was killed by police officer Darren Wilson in Ferguson, Missouri, galvanizing the Black Lives Matter movement, the role of housing segregation in perpetuating racial injustice is in the news. Residential segregation is one of the major mechanisms that produce racial health disparities in the United States, but there is some reason for optimism that new national policy efforts will challenge ongoing segregation.

Last month, the U.S. Department of Housing and Urban Development (HUD) announced the Affirmatively Furthering Fair Housing (AFFH) rule. This rule comes on the heels of the Supreme Court’s June decision that affirmed the legal rights of plaintiffs to challenge housing policies with racially “disparate impacts” – without being required to show that racial discrimination was intentional. A non-profit called the Inclusive Communities Project brought the suit against the state of Texas Department of Housing and Community Affairs, arguing that Texas was allocating too many of its federally funded tax credits for affordable housing -housing for low-income, predominantly Black residents- to developments in poor, urban neighborhoods. This decision in turn came shortly after the release of a study out of Harvard’s Department of Economics, showing that moving from a high poverty to a low-poverty neighborhood as a young child led to measurable benefits in adulthood. These included better educational outcomes and higher incomes – two of the strongest predictors of health outcomes.

With these findings in mind, the AFFH rule is designed to reduce racial and economic residential segregation, and work towards achieving the unfulfilled promises of the 1968 Housing Act, so that more children gain the benefits of living in high opportunity, low poverty neighborhoods. AFFH asks cities to generate plans for reducing segregation, and connects municipalities to HUD data and support to design and implement these plans. This Supreme Court case, and HUD’s policy response, will be equity wins if they can open up some of America’s wealthy, exclusionary and generally White neighborhoods to affordable housing development. Policy conversations about racially concentrated poverty have too often veered towards pathologizing poor Black communities – created through decades of explicitly racist housing policies – without examination of the processes of exclusion that create concentrated affluence. Sociologist Patrick Sharkey writes forcefully that,

“Living in predominantly black neighborhoods affects the life chances of black Americans not because of any character deficiencies of black people, not because of the absence of contact with whites, but because black neighborhoods have been the object of sustained disinvestment and punitive social policy since the emergence of racially segregated urban communities in the early part of the 20th Century. Residential segregation has been used consistently over time as a means of distributing and hoarding resources and opportunities among white Americans and restricting resources and opportunities from black Americans.”

This “hoarding” creates racially concentrated areas of affluence, dominated by White residents. And these communities receive plenty of government housing subsidies, in the form of mortgage interest tax deductions. One of the ways that rich White neighborhoods maintain their boundaries is through zoning restrictions that make it difficult if not impossible to construct affordable multifamily housing (whether subsidized or not.) Hopefully the AFFH can work towards ensuring that some of these neighborhoods become more racially and economically inclusive.

But some have responded to AFFH as if it’s an indication that building affordable housing in high poverty neighborhoods is necessarily wrong. It’s true that housing alone will not reverse “sustained social disinvestment” in poor Black communities, nor will it transform a punitive criminal justice system into one designed to support health. But good housing combined with sustained and comprehensive investment in public services – services that focus on community well being rather than punishment and incarceration – could work to ensure that people who do live in these neighborhoods also have the opportunity to live healthy lives. Furthermore, as previously high poverty urban neighborhoods across the United States gentrify, permanent affordable housing means that low-income families can stay in these neighborhoods and actually gain some of the benefits of new investments. Building racial and economic health equity will require both approaches – dismantling the policies that allow resource-rich places to exclude poor people, but also directing resources to communities that need them the most.

College Education in Prison: Why it’s a Smart Choice for Everyone

Today’s guest blog post is written by by Marsha Weissman, Executive Director of Center for Community Alternatives and Sandy Lane, Professor of Public Health and Anthropology, Syracuse University

“In 1994, college education programs flourished in New York State – there were 23 colleges awarding degrees to people in 45 state prisons, funded partially through the national Pell grant program and its New York State equivalent, the Tuition Assistance Program (TAP).” Read more


Good Jobs For All Would Boost Health, Reduce Inequities

Last week several national organizations launched the Putting Families First: Good Jobs For All campaign to bring the issues of jobs, poverty, and inequality to the center of the national debate. “Today, our country is more aware than ever before that our entire economic system is out of balance. We have reached a time in history where the need, the opportunity, and the energy are all here to create an economy that works for our families—now we need the will and the dedication of the American public to make it happen,” wrote Deepak Bhargava, Executive Director of the Center for Community Change.

The campaign will mobilize people around the country – especially poor people and people of color – to advocate for a national agenda focused on:

  1. Guaranteeing good wages and benefits, including a $15 minimum wage, access to paid sick days and paid family leave, and protections from wage theft;
  2. Valuing families by making high quality, affordable early education and child care available to all working parents and their children;
  3. Building a clean energy economy through large-scale investment to substantially reduce our reliance on carbon-based energy and to repair and rebuild our infrastructure;
  4. Unlocking opportunity in the poorest communities by channeling federal investments to communities with high unemployment and low wages to help rebuild their local economies and provide access to jobs and wealth-building opportunities; and
  5. Taxing concentrated wealth, including eliminating differences in taxation of capital gains and income, strengthening the estate tax, increasing taxes on the highest incomes, ending the ability of corporations to defer US tax payments on offshore income, and taxing corporations for wage inequality.

This is a bold and ambitious agenda that would create over five million new jobs a year by directing government to take an active role in guiding our economy through investing and shaping new and emerging sectors. These investments would be targeted to help those who need it most, closing racial and gender inequities, and be paid for by changes in our tax system that reward those who create wealth in this country – hard working people.

While those leading the campaign – the Center for Community Change (whose board I am chair of), the Center for Popular Democracy, Jobs with Justice, The Leadership Conference for Civil and Human Rights, and the Working Families Organization – are thinking about this as a jobs campaign, it is also a campaign to improve health and reduce health inequities. Several speakers at the launch event, including Senator Sherrod Brown of Ohio and SCOPE Executive Director Gloria Walton, noted the impacts of income on health and lifespan, but health is still an underutilized frame when talking about social and economic policy.

The Putting Families First campaign aligns with HIP’s new Economic Security Program, which will bring public health data, framing, and voices to social movements advancing a range of economic security policy campaigns.

As we’ve said before, no single factor is more important for healthy living than an adequate income, and none is more harmful to health than persistent poverty. Economic security is necessary for people to thrive, successfully manage stress, and prevent disease. Overwork, poor quality food, housing insecurity, and other consequences of low wages and unemployment contribute to physical and mental health problems including high blood pressure, diabetes, heart disease, and depression.

Economic security requires guaranteeing that work is available, safe, and pays a decent wage. Ensuring that families have a decent standard of living is one of the most powerful tools we have to protect and promote health.

An Uncomfortable Truth – Our Failure to Address Racism

This blog article is a re-post of an open letter to the public from Dr. Muntu Davis, who is the Health Officer and Director for Alameda County Public Health Department in California. Dr. Davis offers the kind of public health leadership we love, linking common health issues with their social determinants like racism. 

Dear Alameda County residents, partners, colleagues, and friends,

Everyone should live in conditions that support and foster living a healthy, fulfilling and productive life. These conditions include clean and safe environments, good education, good quality housing, stable employment, an income to pay for basic daily goods and services, such as food, shelter, clothes, and healthcare, among others – all of which should be free from discrimination, whether explicit or not. Read more…

Health – and Health Professionals – Must be Front and Center in Policy Debates

This blog post was first published by the Detroit Wayne County Health Authority on Feb 9, 2015. 

Too many babies are dying in Detroit – just as in my town, Oakland, California. Too many people are dying earlier than they should be. Heart disease rates are soaring. None of these facts are in dispute. But when we ask why or what can we do, we get some different answers.

Some say we need to improve the health care system. But while health care is important, it does not address the reasons people are getting sick. Most of us go to the doctor’s office when we are already sick.

Others attribute it to personal behaviors, saying that if people ate better and exercised more, their health would be better. That’s true, but if we examine why people don’t have healthy behaviors, we quickly find that healthy options are limited – particularly for those living in low-income communities. Healthy food is scarce. Parks aren’t safe. Streets aren’t walk-able. Good jobs are scarce, so stable housing in neighborhoods with high performing schools remains only a dream.

At the root of all of these, however, is a tragic reality: The most important reason health outcomes in Detroit are so bad is that we have created public policies that mean parents can’t get good jobs, our kids go to inadequate schools, and many members of our communities are isolated from opportunity. We have created policies that mean kids don’t have the healthy food, stable housing, and good education they need to thrive. They live under constant stress because these policies have resulted in difficult family conditions and community violence. The way they live each day is simply not conducive to good health.

The good news is that change is possible. There are many things those of us working in health can do. We can use our individual and collective voices to advocate for policies that get at these core issues – policies that promote full employment and higher wages, integrated communities with affordable housing, and a strong educational system. And we can use the resources our organizations have to address these underlying determinants of health.And we should do all this recognizing that the communities suffering from poor health outcomes bring their own expertise that should be respected.

Because we are all in this to improve people’s health, we must use the power and resources we have to work for that change. For example:

  • Public health professionals and organizations can contribute data and research that connect the dots between public policy and health outcomes.
  • Non-profit hospitals can include an analysis of the determinants of health in their community health needs assessments and use their charitable community benefits dollars to address the root causes of disease instead of,or at least in addition to, treating the symptoms of public policy.
  • Medical professionals can support community organizers and policy advocates fighting for policy change by using their individual and collective voices in support of those community-led efforts.
  • Public health nurses can help build social cohesion and strengthen social networks when they are out in the community providing services.
  • All of us in health professions can help build the capacity of low income people and people of color to advocate on their own behalf for policies that improve living conditions.
    And all of us can use the power of our positions to build relationships between those facing the greatest inequities and those who can change policy.
  • These are all components of a Healthy Public Policy or a Health in All Policies approach that is based on advancing health equity. Health in All Policies is the concept of incorporating health considerations into the policies and programs of sectors that are the root causes of health – education, housing, land use, transportation, jobs, and incarceration.

We know this approach works. In the early 20thcentury, child mortality rates plummeted as a result of new child labor, sanitation, worker safety, and zoning laws passed by our government and implemented in the face of opposition from those who were profiting from the lack of regulation. This all happened before penicillin was invented or immunizations were available.

So, why not get involved in policy decisions that are being debated right now? Both Governor Snyder’s proposed sales and gas tax increase and Detroit Future City will affect the health of huge numbers of people. Health must be part of the debate.

There are many excuses we can give for not doing this work, including that it makes us uncomfortable and it feels alien. But if we are serious about improving health in Detroit, these are the kinds of actions that are required of us.

Jonathan Heller is, Co-Director of Human Impact Partners, and will be the keynote speaker at the 2015 Population Health Forum on March 2.

A New Public Health Approach to Criminal Justice Reform in New York City

New York City just announced a bold but smart step forward: it will allocate $130 million over the next four years to a public health approach to criminal justice. The goal, according to The New York Times, is “to break the revolving door of arrest, incarceration and release that has trapped many troubled individuals in the system for relatively minor, quality-of-life offenses.”

Recognizing that almost 40% of those in New York City’s jails are mentally ill, and that people were cycling in and out of jail repeatedly as a result of substance abuse and mental health problems, the City will implement public health programs throughout the criminal justice system, from “tripling the size of . . . pretrial diversion programs” to increasing “the amount of resources devoted to easing the transition from jail back into society.”

“I think this is what criminal justice looks like in the 21st century,” said Elizabeth Glazer, Mayor Bill DeBlasio’s criminal justice coordinator, who was co-chair of a task force that developed the new policy.

We couldn’t agree more. New York’s shift reflects findings and recommendations of two recent HIAs we conducted – one on treatment alternatives to incarceration in Wisconsin and one on Proposition 47 in California, which reduced the penalties for drug possession and petty theft crimes. Both studies found that so-called tough-on-crime strategies have not succeeded in increasing public safety but have led to recidivism rates around the country greater than 50%. People in prison or jail are six times more likely to have a mental health disorder and 20 times more likely to have a substance abuse problem. Most importantly, we found that programs to address mental health and substance abuse issues reduce recidivism and are cost-effective.

The Vera Institute of Justice recently released an expansive report – On Life Support: Public Health in the Age of Mass Incarceration – that backs up the City’s approach by describing the myriad intersections between the justice system and public health. David Cloud, author of the report, writes:

Mass incarceration is one of a series of interrelated factors that has stretched the social and economic fabric of communities, contributing to diminished educational opportunities, fractured family structures, stagnated economic mo¬bility, limited housing options, restricted access to essential social entitlements, and reduced neighborhood cohesiveness. In turn, these collateral consequences have widened the gap in health outcomes along racial and socioeconomic gra¬dients in significant ways.

These findings parallel our own. The Vera Institute also sees an opportunity in the Affordable Care Act to address these issues. The report is part of a new initiative called Justice Reform for Healthy Communities, which fundamentally recognizes that “mass incarceration is one of the major public health challenges facing the United States.”

An amazing New York Times editorial on the day before Thanksgiving, Mass Imprisonment and Public Health, also reflects this public health approach. Citing the Vera report, the editors point out the obvious: people in prison are not healthy. People in prison also often come from impoverished communities that have serious health issues and less access to health care. The Times said: “The experience of being locked up — which often involves dangerous overcrowding and inconsistent or inadequate health care — exacerbates these problems, or creates new ones.” Solitary confinement and other prison “management” practices do additional harm. As the Times noted, this also affects future generations, with 2.7 million children nationwide having a parent in prison. The editors conclude:

If this epidemic is going to be stopped . . . public health and criminal justice systems must communicate effectively with one another. . . . Public health professionals should seize a unique opportunity to help guide criminal justice reform while they have the chance.

Again, we couldn’t agree more. It’s time for public health leaders across the nation to step up and seize this moment. Human Impact Partners is happy to support those in public health that want to move in this direction. This new direction only further affirms what we are focused on: Transforming the policies and places people need to live healthy lives by increasing the consideration of health and equity in decision-making.

Am I a Scientist or an Activist?

For a recent graduate of a master’s in public health program, Human Impact Partners’ Health and Equity Fellowship was a golden opportunity to put those three little letters at the end of my name to good use. Health Impact Assessment combines both analytic rigor and a participatory, community-driven approach to promote health, equity and justice. So on my first day at the HIP office, I had to ask myself: Am I a scientist or an activist?

As a biology undergrad researching the genetics of virulence in human-parasite interactions, I was squarely in the scientist camp. As a public health graduate student, participating in city council meetings to support changes to Oakland’s rent ordinance to protect low-income tenants, I was treading into activist territory. At various points I’ve identified more strongly as one or the other as these split personalities played a constant tug-of-war.

Now, almost two months into the fellowship, it seems that these two sides of me are pulling in the same direction. Health Impact Assessment – the HIP way – is both science and activism.

Public health has always been a complex field, but in the last decade our definition of public health has expanded so rapidly that it seems to burst at the seams every few years, challenging us to adopt ever more expansive and rigorous frameworks to address the full scope of the issues it encompasses. Public health’s scope has expanded from contagion control to prevention to behavior change and more recently to social justice. Given these changes, it seems that the reach of science is simply no longer expansive enough to encompass that scope on its own. Nor are traditional scientific approaches rigorous enough. Public health needs to look more like advocacy and community organizing to remain relevant to the populations it seeks to benefit.

In graduate school at UC Berkeley, I found myself working to promote the health of undocumented immigrant Latino day laborers. I did this in part through ethnographic research, direct services to help meet day laborers’ basic needs and educational sessions on occupational health — all part and parcel of traditional public health practice. But that alone was not enough. It was only a start.

How do you take control of your own well-being when your health is hugely influenced by a city ordinance that prevents you from seeking work and wages to support your basic needs and those of your family? How do you ensure on-the-job safety when your labor is simultaneously a highly sought-after commodity and a political lightning rod for anti-immigrant sentiment?

These issues, and many others like them, are complex and yield no easy answers. HIP’s combination of public health and social justice frameworks help us ask better questions and use the evidence to tip decisions in the direction of health and social equity, and to empower communities to make change happen.

I’m humbled at the challenge of working with the talented team of smart, motivated professionals at HIP — already, I have learned so much, and hope I can contribute as much as I receive. And I’m privileged to work in solidarity with communities and be a part of movements to make good on the promise of health for all.

HIP is pleased to welcome Darío Maciel as HIP’s 2014-2015 Health and Equity Fellow. As one of our strategies to advance health and equity in decision-making, HIP offers a yearlong, fulltime Fellowship for an emerging public health professional, with a goal of increasing the racial and ethnic diversity among practitioners of Health Impact Assessment and Health in All Policies approaches.

The California Department of Healthy and Equitable Transportation

Driving makes me sick.

It makes everyone sick. I’m not just talking about the frustration of a lengthy commute on crowded freeways, or the road rage when a driver cuts in front of you without signalling.

Driving means dirty, unhealthy air, leading to a host of ills for drivers and the communities they traverse: asthma, respiratory disease, cardiovascular disease, premature mortality, pre-term birth and premature death. Driving creates noise pollution, which can lead to sleep loss, annoyance and stress. It results in collisions with other cars, bicyclists and pedestrians.

So why is the California transportation agency, Caltrans, so strongly focused on building new freeways, on moving too many cars from one place to another, and on short-term solutions to congestion that are quickly overwhelmed by ever-increasing numbers of cars?

Imagine if Caltrans became the California Department of Healthy and Equitable Transportation – if its mission were transformed to responsibility not only for getting people from place to place, but doing so in a way that promoted the health and well being of individuals, communities, society, and the planet.

Those questions came to mind after I read a scathing report released recently by the State Smart Transportation Initiative at the University of Wisconsin that will be further examined by the state Senate Transportation Committee in a hearing Tuesday.

The report says Caltrans has “a mission, vision, and goals not well-aligned with current conditions or demands,” “a portfolio of skills and practices that do not match modern demands,” and “managerial systems and practices that are inadequate to motivate staff and to hold them accountable, and to foster innovation.”

Joel Rogers, one of the authors of the report, told The Sacramento Bee: Caltrans “is still acting too much as your highway department, not your mobility department.”

What if Caltrans changed its focus to people and to the long term? What if it focused on helping people in all our communities get access to the opportunities they need to live healthy lives? On getting people from place to place in ways that improve their health and well-being? On finding solutions that reduce greenhouse gas emissions so that we can curb climate change? On promoting walking, biking and public transit – long-term solutions that are cheaper, cleaner and healthier?

Caltrans also needs to change its planning practices. Instead of developing so-called solutions at their desks and then trying to sell them to the community, Caltrans staff could see themselves as facilitators. They could work more closely with the community, incorporate community knowledge, expertise, and desires along with subject matter expert opinion, and facilitate a consensus based on innovative and targeted solutions. That’s the way we at HIP approach Health Impact Assessments – not as an exercise in top-down expertise, but bottom-up community participation. It works.

Caltrans is the agency California has charged with building, maintaining and running our transportation systems. It’s time that mission was expanded to include providing people with what they need to live healthy lives.