PUBPOL 3280 Prelim 1

US Health expenditure vs outcomes

more than any other OECD nation, 5.3T, 8% of GDP

but… worse outcomes

• leading rates of obesity

• lower life expectancy

health outcome stats (Day 2)

• 5% of pop accounts for 50% of health spending

• 6 in 10 adults have chronic disease

• 7 of 10 leading COD are preventable

drivers of health

• health behaviors (30%)

• cllnical care (20%, but 90% of spending)

• social and economic factors (40%)

• physical environment (10%)

the system doesn’t pay for anything preventative, just for the treatment once the problem happens

unisured trends

went from 16.7% uninsured to only 8% in the past couple decades, but coverage does not equal access

health gaps based on race

• 14 year life expectancy gap between Asians and native peoples

• African American and native american die of pregnancy related causes at a rate of 3x higher than white women

age+disease trends

• older adults are projected to outnumber children by 2035

• increasing chronic disease burden

epidemiological transition

main COD in 1900s was infectious disease, now, it is lifestyle-related chronic diseases (ie. heart disease, cancer, etc)

• suicide has also climbed to #11 in this decade

real vs artifactual trends in data

real: changes in age structure, changes in surivival, changes in incidence (how many patients get the disease)

artifactual: changes in disease recognition (ie. doctors are better at diagnosing ADHD, alzheimers, now then before), classification, changes in reporting accuracy

Shifting health landscape (medical model to pop health model)

medical model:

• treating sickness, symptom reduction

• in patient

• specialty driven physicians

• FFS and payment for volume (the more tests MD runs, the more money they get)

pop health model:

• manage populations, focus on prevention

• ambulatory care (in the community, homes, virtual)

• primary care driven

• integrated, full person care

• payment for value

IHI triple aim

increase the health of the population and quality of care while reducing per capita cost simultaneously

defining “populations”

• communities

  • all people in a given region at a given time

  • defined geographically or by a shared set of characteristics

  • “total population health”

• empaneled patients

  • individuals attributed to a specific provider or health system

  • “accountable care” or “population medicine”

defining “health”

not merely the absence of disease or sickness, but complete physical, mental, and social well-being

definition of pop health

measuring health outcomes and their upstream determinants and using these measures to coordinate public health agenices, and healthcare delivery systems in the community to improve health

key ACA policy drivers- access

1. individual mandate

   • goal: extend health insurance coverage

     • individual insurance mandate with penalty (lasted 5 years)

     • eliminate denial for pre-existing conditions

     • children covered on parents’ insurance until age 26

     • compels the healthy to buy insurance to balance risk pool

2. Medicaid expansion

   • goal: extend coverage to low-income individuals

     • implement income-based eligibility for Medicaid (below 138%FPL)

     • not all states expanded coverage

3. state insurance exchanges

   • goal: ensure quality affordable insurance

     • state marketplaces with premium subsidies

     • min essential coverage (MEC) for 10 essential benefits (ie. prescription drugs, maternity care, etc)

     • 60% min actuarial value: minimum % of expected healthcare costs a health plan must pay

4. support for community health centers (FQHC)

   • Fed doubles FQHC funding

   • Fed increases training opportunities and tuition reimbursement to encourage providers to practice there

key ACA policy drivers- Community and population based activities

1. national prevention strategy

2. prevention and public health fund

   1. prevent chronic diseases+eliminate disparities

   2. nation’s first mandatory funding stream dedicated to primary prevention (risk factor reduction)

3. incentives for workplace wellness

   1. wellness grants and discounts for small businesses

4. community health

   1. strengthens community benefit requirements for hospitals, community health needs assessments (CHNA) enforced by IRS

key ACA policy drivers- prevention and health promotion

1. expand primary healthcare training

   1. goal: increase number of PCPs, especially in rural areas

      1. fund residency programs

      2. train NPs and PAs

      3. grants to states to expand the PC workforce

2. no cost-sharing for annual USPSTF recommended screenings

   1. all on insurance not on the individual

3. Medicare annual wellness visit

   1. 
      

4. Medicaid expand children’s free preventative services to adults

5. ACOs accountable for pop health outcomes

key ACA policy drivers-quality

1. Triple aim

2. creates center for Medicare+Medicaid Innovation to test new payment and delivery models

3. authorizes value based payment programs

key ACA policy drivers

1. access

2. community and population based activities

3. prevention and health promotion

4. quality

What can mortality data tell us?

• how frequently people die (rate of mortality)

• ages and CODs

• how much life is lost prematurely

• life expectancy

county health rankings (CHR)

first standardized dataset of validated community health data at the county level

• measures are organized from upstream health factors to downstream health outcomes

• does not measure healthy life expectancy (HLE)

• provides state and US benchmarks, helping to identify areas of concern

years of potential life lost (YPLL75)

a measure of premature mortality

• gives greater weight to deaths occurring at younger ages

• higher for African American and latino pops than white

health related quality of life (HRQOL)

measured with CDCs “healthy days”

4 questions

1. general health

2. physical health

3. mental health

4. has this kept you from usual activities

HRQOL Q1: self-rated health

indicator: percent of population reporting fair or poor health

HRQOL Q2: physically unhealthy days

indicator: mean count of unhealthy days (UHD)

frequent physical distress (FPD)=prevalence of 14+ UHDs in the last 30 days

HRQOL Q3: mentally UHDs

indicator: mean count of UHDs

frequent mental distress (FMD)= prevalence of 14+ mentally UHDs in last 30 days

HRQOL Q4: activity limitations

indicator: mean count of activity limiting days (ALD)

frequent=14+ ALDs in the last 30 days

percentage difference vs percentage point difference

from 10% to 15%

pp differnece is 5 pp

percentage difference is 50% increase using new-old over old

health inequities

pop health is the health outcomes of a group including the distribution of outcomes within the group

social gradient of health (aka wealth health gradient)

the lower a person’s socioeconomic position, the worse their health is

hypotheses explaining correlation between SES and health

1. socal causation hypothesis

   1. education and SES affects health

      1. income/resources, social/psychological benefits, healthy behaviors, healthier neighborhoods

2. health selection bias hypothesis

   1. health affects edcuation: unwell children may be unable to attain higher levels of SES

   2. attendance, concentration

3. confounding

   1. conditions that affect both education and health

   2. social policies, individual/familial characteristics

N Krieger twin study findings

health outcomes among twins who lived together during childhood varied by adult occupational class, working class twin fared worse

effects of stress on social gradient

typically stress response is activated, but when the threat passes the body returns to baseline

but… in some cases its chronic (worrying about rent, job security, etc)

continually activated stress response=physical wear and tear+increased disease risk

macaque monkey social study

examined health outcomes based on social status

subordinates were more likely to exhibit depressive behaviors and had higher stress-related biomarkers

allostatic load

cumulative burden of chronic stress+life events which increases chances of having poor health outcomes

social drivers of health (SDOH) def

economic conditions, social factors and pphysical condition sin the environment in which people are born, live, work, and age, which are shaped by the global distribution of money, power, and resources (WHO)

structuralist vs behaviorist approach

structuralist looks at the whole stream

1. structural determinants (policies, political climate, economic structure)

2. SDOH (employment status, housing, income, education, food access)

3. Behaviors (smoking, excessive drinking, nutrition)

4. health outcomes (morbidity, wellbeing, mental health, mortality)

behaviorist only looks at the last two

social risk factors vs protective factors

risk: health harming SDOH

protecting: health producing SDOH

why does place matter?

• shapes what we’re exposed to (direct impacts)

• shapes which resources and opportunities are available

  • are healthy choices easy, difficult, or impossible?

• place is shaped by policy and investment

built environment def

design, construction, and placement of buildings within a community (zoning, sidewalks, parks, hazards)

social environment

refers to behaviors, connections, norms, social capital and socio-demographic characteristics of community members

cycle of disinvestment

systemic withdrawal of economic, social, and healthcare resources from a community directly drives poor health outcomes, these poor outcomes then suppress economic growth

food desert def

neighborhood with poor access to healthy foods

iceberg analogy

below the waterline: policy, laws, institutional practices

near the waterline: social and economic conditions people live within (SDOH)

above the waterline: behaviors + observable health inequities

racial health inequities examples

• black men and women face 40% to 57% higher hypertension prevalence

• black women face a 50% higher death rate from breast cancer

redlining

banks and financial institutions deny mortgages, loans, and insurance to residents of specific neighborhoods based on race

origin: Home Owners Loan Corporation mapping in the 1930s sorting American neighborhoods by “investment risk”

redlining effects visible today

• covid risk is higher in neighborhoods graded red/yellow

• extreme heat: due to less investment in trees and green space

• higher preterm birth rates

• still visible in clear racial divides in neighborhoods today

structural racism

structures, policies, practices, and norms resulting in differential access to goods, services, and opportunities of society by race

structural drivers of health ex

• school funding based on property tax

• opioid addiction treatment and policy

• water rights and river diversion

• unequal sentencing guidelines

• voter restriction