Maternal mortality in the US and UK: Why do we tolerate paying so much more for so much worse outcomes?

Last year, ProPublica, in association with NPR, published Why Giving Birth Is Safer in Britain Than in the U.S. In typical journalistic style, it starts by grabbing your attention with a case report of a woman in England who almost died of post-partum hemorrhage, but did not. The lesson is presumably that she did not because the physicians, midwives, and others attending her followed a rigorous set of established protocols for addressing post-partum hemorrhage that are implemented nationally in the UK.

Of course, there is a possibility that this individual woman could have died, or had to undergo more invasive surgical procedures further down the protocol’s algorithm, but the real point is that, overall, the system is working. The evidence is in that the maternal mortality rate (deaths/100,000 women delivering) is 8.9 in Britain, while in the US the rate in 2015 was 25.1, three times that of the UK! What makes this more dramatic is that the disparity has developed only since 1990; until then the maternal mortality rates in the US and UK had been declining in parallel since the 1950s.

The article cites several reasons for this difference. One, a very important one, is that the UK collects data on maternal mortality nationally and develops guidelines based upon this data which are implemented nationally. In contrast, the US collects data at best by state, or even by hospital, and

There is no federal-level scrutiny of maternal deaths, and only 26 states have an established committee (of varying methodology and rigor) to review them. Nor do all U.S. hospitals routinely examine whether a death could have been avoided. Procedures for treating complications such as preeclampsia, and for responding to emergencies such as hemorrhage, vary from one doctor, hospital and state to the next.

This is true despite the fact that the methods used by the British to collect and analyze this data were developed in the US. While there has been a well-documented 30-year effort to improve quality and to reduce preventable deaths (a category into which most maternal mortality falls) in the US, led by such organizations as the Institute for Healthcare Improvement (IHI) and embraced by such other organizations as the American Hospital Association (AHA), National Center for Quality Assurance (NCQA), the Joint Commission for the Accreditation of Healthcare Organizations (TJC), the National Academy of Medicine, and on and on, no compulsory national approach to this problem has developed. This reflects a common, and often knee-jerk, opposition to centralized approaches to almost everything, even when they have been determined to have an important effect on reducing death. It is actually parallel to efforts within hospitals to standardize care, to require, for example, all surgeries to go through a series of prescribed steps (“timeouts”) before operating, or limiting the number of different devices implanted to those needed by different types of patients rather than by the preference of the individual surgeon (for an interesting discussion, see A. Gawande, “Big Med”, New Yorker, August 13, 2012). That is, it is effective where it has been done, but it is not mandated to be done everywhere and comprehensive national data is not even collected.

Another big part of the successful UK approach to the reduction of maternal mortality has been collecting detail on what happened and why; this goes beyond “there was a death”, or “there was a death from hemorrhage”, or “there was a death from sepsis”, to identifying why it happened, particularly if the reason was something that is relatively easily addressed. Marian Knight, head of MBRRACE-UK, the group that collects the data and makes the guidelines, says

It’s all very well to know a woman died of sepsis, but to know that she died of sepsis because nobody measured her temperature, as they had no thermometers on the postnatal ward, that’s where the instruction Put a thermometer on your postnatal ward might make a difference. It’s not just the what, it’s the why.

Can you believe that there might be post-partum units where there is no thermometer? Apparently it has happened. And having a rule that it must be present is a way of preventing it from happening again.

There are at least three other important dimensions. One is that, as the report states, “These U.S. deaths are not spread equally. Women who are poor, African American or live in a rural area are more likely to die during and after pregnancy.”  This is not a big surprise.  Poor women, minority women, rural women, and uninsured women do much worse, and are much more likely to die from complications of delivery. It is the familiar song in the US, as in so many areas, of health and of every aspect of society. Is it not true in Britain? The article goes on to say

In the U.K., while inequalities persist when it comes to serious complications, according to 2012-2014 data, there is no statistically significant difference in mortality rates between women in the highest and lowest socioeconomic groups. All British women have equal access to public medical services, including free care and prescriptions from pregnancy through the postpartum period.

This also has two components; the greater equity of the quality of healthcare delivered to all segments of the population, a result of having a national health care system, and less disparity in the “social determinants of health”, the actual quality of the lives of people (women, in this case) before they access care. Especially for rural women, some of the problem the lack of an adequate number of health professionals. Over 20 years ago, family medicine residencies in Texas were surveyed and only a small percent of residents were interested in providing rural obstetric care, but no OB/Gyn residents were! This has not improved; while a recent study published by Tong, et al., in Family Medicine (Characteristics of Graduating Family Medicine Residents Who Intend to Practice Maternity Care) found that 22% of FM residents planned to deliver babies, they cite his 2012 study that showed that only 9.1% of FM residency graduates were delivering babies 1-10 years out into practice despite an intention to do so of 24%, comparable to the current study.

Another dimension is that the difference in maternal mortality reflects a greater focus on the health – and life -- of the pregnant woman in Britain, while in the US the focus is more on the health of the fetus and the newborn. This goes far beyond the issue of abortion, although the focus on children rather than women is one that is also characteristic of the anti-choice movement in the US. It is so deeply ingrained in our culture that even many health professionals (including midwives, doctors, and nurses) who see themselves as “pro-choice” and would never want to see a maternal mortality, are still more focused on the fetus and baby. It results in a practice, if not a belief, that considers the woman but a vehicle for producing a child.

Finally, there is cost, ironically but again unsurprisingly much higher in the US. Much higher. The total cost for a normal vaginal delivery in the US is about $30,000, and about $50,000 for a Caesarean section. In Britain, the cost for a normal vaginal delivery or planned Caesarean is about $2500, or less than 1/10^th the cost in the US, perhaps rising to $3400 for complicated cases (such as the one that leads off the article). Thus, the US charges far more, but has much worse outcomes for maternal mortality (as for many other conditions). This is not a side note; it is not just an interesting contradiction that our care costs more but has worse outcomes. And it is not by any means limited to pregnancy care or maternal mortality, but is present in our healthcare system at almost all levels and for most conditions. What ties these two components, cost and quality, tightly and inversely together, is that our “healthcare system” is only secondarily about delivering quality healthcare, and primarily about being a profit-making business.

So, that is the bottom line. The US has three times the maternal mortality rate of the UK despite charging ten times as much for delivery. The reasons are the absence of a national strategy to identify and remedy the causes of maternal mortality and the lack of a national healthcare system to provide the access necessary for women at risk. It causes the suffering and death to disproportionately affect those women who are already at greatest risk: the poor, minority, rural, and uninsured. The root cause is that our healthcare system is composed of poorly interconnected components, most of which are run as businesses to make money.

It is inequitable, and it is irrational from a health perspective if not from a business one. It causes unnecessary death and excessive cost, and seems to not be improving. It is not acceptable. We need to change it.

The Political is Personal: Corporate power, social isolation, and the health of the nation -- Part 1

This talk was delivered on April 16, 2018, at the 29th Conference on Primary Care Access, Monterey California.

                                   

Our society has increasingly become about isolating people and making them feel alone, thus decreasing, and sometimes almost eliminating both social cohesion and any sense of social solidarity. This may seem most obvious when people – not just young people – don’t hear us because they have earbuds in, or walk into us on the street because they are staring at their phones, or worse yet, are looking at their phones while driving – but it is much more serious and profound. In his seminal 2000 book, “Bowling Alone”, Robert D. Putnam re-introduced the term “social capital” (previously used by Alexis deToqueville, John Dewey, Jane Jacobs, and others), to describe a sense of social solidarity and support, the absence of which erodes civil society and decreases political participation. Ways that it is manifested include fewer extended families living with or near each other, greater geographic mobility, and more emphasis by people on their individual, rather than community or even family, lives and achievements. More and more studies point to “loneliness” as a key variable in our health. Evidence has also linked this increased separation to worse health status.

Importantly, this isolation is not simply an organic development in our society. It is also a core manifestation of very late stage monopoly capitalism. What we have today: monopoly (or at least oligopoly) corporations stifling competition, more and more mergers and takeovers with concomitant rises in prices, and stagnant or decreasing standards of living even for most of those living in the richest country on the globe. The stock market may go up, but most people’s lives are not getting better.

Socially, this has resulted in us feeling alone, separated from others and often feeling as if we are nothing but the targets of marketing campaigns that urge us to buy-buy-buy and trade in what we have on something newer – and better! Nothing is exempt, every protest or revolutionary idea is commoditized, from Che Guevara posters to the feminist movement to protest music to environmental concern – all becomes grist for the profit mill. The only challenge for the corporations is how to get us to spend more while paying us less.

More than Adam Smith, or David Ricardo, or Milton Friedman, or any other political philosopher or economist, the world we are living in and moving towards was predicted by George Orwell. 1984 describes massive superpowers in a continual war that provides the justification for suppression of dissent domestically, and the overall thought-control of the state. Does it sound at all familiar? We see some examples of this in the CDC being told it cannot use certain terms, in restrictions on journalists’ reporting, and the refrain of “fake news” every time those in control do not like what the “true news” is.

The only real threat to this status quo would be if people got together and organized, whether against war and nuclear weapons, climate change, the obscene increase in wealth inequality, racism, or health and access to health care. Therefore every effort to do so, from “Occupy” to #Black Lives Matter to the Standing Rock opposition to the Dakota Access Pipeline, to the struggle for universal health care, to, most recently, the struggle to get control of guns and stop or decrease killings both in schools and in the community (#enoughisenough)is challenged and demeaned, and efforts are made to break them up. We are repeatedly told that we are not our brothers’ keepers, that we should not be paying “more taxes” to ensure that our fellow Americans (not to mention people in the rest of the world) are fed, housed, clothed, warm, and educated. Indeed, sometimes even kept alive – see the rising mortality of white Americans (Case and Deaton). White Americans, specifically low-income white Americans, are the only group for which mortality is rising, although it is critical to note that the absolute mortality rate of minorities, especially African-Americans, remains much higher. Even when the things that we feel are in fact shared by many or most others, this is kept secret by the pro-corporate media. When a NY Times poll on taxes shows that most people feel that they pay too much in tax, and that the wealthiest pay too little and should pay more, only the first is reported. So each of us who feels that way thinks we are alone. It prevents us getting together.

 

How does this manifest in health? I have already mentioned rising mortality. While much of this has been tied to the “opioid epidemic”, it goes deeper; opioids, and other substances, including alcohol, tobacco and other drugs, may be the mechanism of death, but the root causes are social. As a society, for many of us, we have lost our jobs, we have lost our sense that our children’s lives can be better, and too often we have lost hope. Our social structures have not just withered, they are actively being destroyed.

The dominant narrative changes to meet these structural needs, and almost always plays on the racism upon which this country was founded. For example, during the “War on Drugs”, the assumption was that users were mostly minority and were called “addicts” and were at fault and were to be punished; now that users are more and more white and have had their drugs prescribed by physicians, they are “victims”. When a white man commits mass murders by gun or bomb (as recently in Austin, Las Vegas), he is the problem – troubled, mentally ill. When a minority or Muslim person does, it is a reflection on their race or religion.

In fact, they are all victims, and we are all perpetrators..

The ACA helped many people gain financial access to medical care, but even if it is not completely dismantled, that care is becoming less accessible, and costs are going up for many patients. Medicaid, and even Medicare, are in the sights of those who are seeking ways to fund the enormous tax cuts that they passed for the wealthiest individuals and corporations. People continue to go without health care, especially without prevention and early diagnosis and treatment, the kind of care that family physicians, provide. The US remains the only industrialized country without a national health system, insurance, or service, and our thought leaders continue to insist that such a program is inaccessible.

In a recent JAMA article, Papinicolas, Woskie, and Jha compared the costs of care in the US to ten other wealthy countries. They observed that the US has “administrative costs” (including profits) almost 3 times that of other countries, that we pay more for procedures and for drugs, and that a big part of the problem is that we have a higher percentage of poor people. Shockingly, the coverage in the NY Times, especially by the headline writer was, in the online edition “Why Is U.S. Health Care So Expensive? Some of the Reasons You’ve Heard Turn Out to Be Myths”, and perhaps even more inaccurately in the print edition, “United States healthcare resembles rest of world”.

What? Anyone who has been to this conference before, anyone who is awake, in fact, knows this is not the case. To extract these headlines requires both careful cherry-picking of the data, as well as including such falsehoods as “40% of US physicians are in primary care”. That would be news to all of us in primary care; it is, in fact, also known as the “Dean’s Lie”, maintaining that everyone entering Internal Medicine is in primary care, when 80+% become subspecialists and more than half the remainder hospitalists.

And what about the fact that we have so many people in poverty? Does this somehow excuse our high cost – and frequent inaccessibility – of care? Or should it, rather, be a wakeup call, an assertion that things are NOT OK, that we need less inequality and, like the other countries studied, a better safety net to ensure that not only medical care but the major social determinants of health – housing, food, warmth, education, safety – are in place for all Americans. Pundits persist in their “unaffordable” argument although it strains credulity in the time of trillion dollar tax cuts, and continue to use un-Americanism as a justification for avoiding “socialized medicine”. Apparently, to them, Americanism includes the right to do without health care, be sicker, and die younger.

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To be continued...

Life expectancy, socialism, and the determinants of health

“Socialism,”writes Washington Post columnist Kathleen Parker on February 9, “has always appealed to the young, the cure for which isn’t age but responsibility. This usually comes in the form of taxes and children, both of which involve working and sacrificing for the benefit of others, the extent of which forms the axis upon which all politics turns.” Parker is discussing the brouhaha around comments about the need for women to support Hillary Clinton’s presidential bid, particularly those by Gloria Steinem that young women are supporting Bernie Sanders because, essentially, that’s where the boys are. Her logic seems a little contradictory to me, because socialism is all about being part of a society that we are all in together, where we work and sometimes sacrifice for the benefit of others.

Parker really means that we become more selfish, that the “others” narrows from our whole society to that small group, presumably our nuclear family, for whom we work and sacrifice. Of course, she is only talking about some people. Some people never have children. Others of us realize that there are benefits that we all want as a society – transportation and police and schools and even a social safety net – that makes us more than willing to pay our taxes. And a few people, very wealthy, accumulate much more money than they or their children could ever use and pay very little in taxes. They, to be sure, are big fans of the popular narrative endorsed by Parker: that the rest of us need to buckle down and take care of our kids and not make a fuss and be socialist and threaten their gravy train. And for sure keep paying taxes, so that when they need to be bailed out the government has the funds.

It is a deeply flawed narrative, but it holds a lot of sway, and is used to justify policies that have facilitated the greatest transfer of wealth, from most of us to a few of them, in a century. More and more Americans are on a treadmill, working harder and harder to discharge their responsibilities to their families and pay their taxes, because their real wages are stagnant or decreasing. Our economy increasingly is one where little is manufactured but we all tithe to the kitty (or is it a lion?) of the financial services sector; its “players” compete for that money taken from the rest of us (anyone seen “The Big Short”?) and it bothers them not one bit. That it bothers a lot of young people enough to support Senator Sanders (who Parker says “never outgrew his own socialist-rebellious tendencies”) should make all of us happy and optimistic, since what is happening now is not good for most individuals, their families, America, or the world.

It’s also not good for a lot of people’s health. The New York Times’ Sabrina Tavernise reports on February 12, 2016 that the “Disparity in Life Spans of the Rich and the Poor Is Growing”. “Experts have long known that rich people generally live longer than poor people,” she begins, but how much longer is increasing. This was most recently demonstrated by a study conducted for the Brookings Institute by Barry Bosworth, Gary Burtless, and Kan Zhang (“What growing life expectancy gaps mean for the promise of Social Security”). Men in the bottom 10% of income born in 1920 lived 6 years less than those in the top 10%; for those born in 1950 it will be 14 years. For women the increase is as great, from 4.7 to 13 years, and for women in the bottom 30%, life expectancy has actually decreased. This is not a good trend, and it is not limited to the outliers in the top and bottom deciles. As illustrated by the accompanying graph, the more you make the longer you can expect to live. Tavernise makes clear that this is despite the advances that have occurred in medicine and technology; indeed those have relatively little impact upon longevity or health, despite the amount that we as a society spend upon them; most estimates of the contribution of all medical care to health status are in the 10-15% range. This is, nonetheless, where most of our health expenditures (now over 17% of GDP) are, and of course to the extent that they are of benefit to individuals they are far more available to those who have more money. Per Tavernise: “The Social Security Administration found, for example, that life expectancy for the wealthiest American men at age 60 was just below the rates in Iceland and Japan, two countries where people live the longest. Americans in the bottom quarter of the wage scale, however, ranked much further down — one notch above Poland and the Czech Republic.”

The Times article quotes the usual sources to tell us that lower income people are likely to have more negative health behaviors, like smoking and prescription opioid use (but, somewhat surprisingly, not that much more obesity – 37% in the lowest and 31% in the highest income group). Health behaviors are important; they may be as significant as medical care in determining our health. So is biology, our individual genetics. But even smoking only accounted for a fifth to a third of the difference.

The real causes of the difference in life expectancy are the “social determinants of health” (SDH). These include having a place to live, having enough to eat, having warmth in the winter, living in a neighborhood with lower rates of both interpersonal (muggings, homicide) and institutional (environmental pollution, lack of access to basic resources like stores, transportation, sidewalks) violence. They also include the occupational risks accompanying many lower-income jobs that involve physical labor and the toll it takes on the body (and increase the probability of living with chronic pain and using opioids). The SDH are tied to other risk behaviors, such as smoking. And, since socioeconomic status is highly correlated with that of one’s family of origin, people with higher incomes were likely to be born and raised in families with higher incomes, which confers a lifelong health benefit. Of course, this negative impact of SDH would be expected to be greatest in the lowest socioeconomic groups, which it is, but above them surely people have those basic needs met? Why are they living less long than the really rich?

A big part of the reason is misperception by the well-off, which includes most policymakers, politicians, pundits, and even journalists of how much money people make, and thus how many people are well-off. The median household income in 2014 (US Census Bureau report) was about $53,000. Half the households made less, and half more. The bottom 80% of income earners account for about 50% of all income, with the top 20% having the other 50% and the top 5% over 20%.  An individual with an income of $100,000 is in the top decile on that table, and so it is less surprising that folks making less have some deficit in their health and life expectancy.

From the Timesarticle: “At the heart of the disparity, said Elizabeth H. Bradley, a professor of public health at Yale, are economic and social inequities, ‘and those are things that high-tech medicine cannot fix.’”. I have cited Bradley before (To improve health the US must spend more on social services, December 18, 2011), and her point, that in the US we spend far more on medical care than other social services, is still right on. We spend huge amounts on high-tech and variably effective care that benefits a relatively small number of people (and, disproportionately, those with higher income) and much less than other OECD nations on other social services that actually improve health and life expectancy. Oh, but those countries spending that money are those “social democracies” that Bernie Sanders goes on about. You know, socialist. The ones where people are healthier and live longer.

Now, why would we expect, or want, our young people to “grow out” of the idea that this is a good thing?

Medicaid expansion: Is there something the matter with Kansas?

One of the key parts of the Affordable Care Act’s (ACA) effort to cover most Americans was the expansion of Medicaid to cover everyone under 138% of the federal poverty level (FPL). The Supreme Court decision in 2012 (National Federation of Independent Business v. Sebelius) found in favor of the “individual mandate”, allowing the law to go forward, but found against the ability of the federal government to withhold all Medicaid funding from states that did not expand Medicaid. This decision did not prevent the federal government from creating an incentivefor states to expand Medicaid, which it did; for the first 4 years the federal share of cost of expansion would be 100%, dropping to 90% thereafter. This is quite a financial incentive, and as of December 15, 2015, 31 states have expanded Medicaid, 4 are considering it, and 16 are not, depicted on this map from the Kaiser Family Foundation (KFF).

Neither of the Kansas City area states, Kansas and Missouri, are in the expansion group, and thus a significant portion of their population remains uncovered. Like the other 14, control of their legislatures (and in Kansas, of the governor’s office) is in the hands of very conservative Republicans ideologically hostile to ACA. However, this is a problem not only for the poor people left without insurance and their advocates (like many of the healthcare foundations), but also the states’ hospitals, who continue to have to provide care for these people without reimbursement. To some degree it is also a problem for the state’s business community because more than half of the this group of people are employed, mainly in small businesses that cannot afford to buy private health insurance. It also decreases, in the opinion of many Chambers of Commerce, the state’s ability to attract new business and jobs.

On January 5, 2016, I attended a forum on expanding KanCare (Kansas’ privatized Medicaid program) sponsored by many of these business organizations (6 Chambers of Commerce), hospitals, physician provider organizations, and healthcare foundations (see list of sponsors on KC COC site). The event, held in Overland Park in the Kansas City area, followed a similar one held in Wichita in November, 2015.  It began with a presentation by Dave Kerr, a Republican former president of the Kansas State Senate, detailing how Medicaid expansion would bring in at least 10 times what the state would have to spend. After this were two panels, one consisting of 5 KS legislators (3 Republican, 2 Democratic; 3 senators, 2 representatives), and the other of 5 healthcare experts.

Prominently included in the second group was the president of the Indiana Hospital Association, Doug Leonard, who presented how his state had effectively expanded Medicaid. The presumption of the sponsors of the event was that this would resonate in Kansas, because Indiana is also a conservative state with a very conservative governor (Mike Pence) who had mandated the expansion based on certain principles of individual responsibility and fiscal neutrality. Indiana’s plan is one of 4 (those with asterisks on the map) that were developed with federal waivers. In its first year, it has enrolled 220,000 people into its Medicaid program, and, largely because it is paying providers at Medicare rates, increased by 1,000 those who accept Medicaid. It is paid for by a combination of increased cigarette taxes and levies on hospitals.

Unsurprisingly, this resonated well with most of the attendees and speakers, although support was not universal. Sen. Jim Denning (R., Overland Park), who is considered a health policy leader in the state senate (apparently he works for a group of private ophthalmologists), indicated that Indiana’s program would not pay for itself after the first year and would have to tap into the state general fund. The moderator asked Mr. Leonard, who drily indicated that perhaps Sen. Denning had information that Indiana did not have. When the moderator asked Sen. Denning the source of his information, he indicated “the Forbes article”. Mr. Leonard responded that, first of all, it was not an article but a blog post in Forbes, and second that the state had responded point-by-point to its incorrect assertions.  

Sen. Denning’s credibility as a source of facts was already questionable, as he had previously asserted that Medicaid expansion would affect only those between 100% and 138% of the FPL as those below 100% were already eligible for KanCare (not true; in Kansas, adults actually must be actual below about 33% of FPL, in addition to being a a special group like mothers of dependent children or disabled, to be eligible for KanCare) and that those between 100% and 138% of FPL could buy subsidized “silver” plan coverage on the exchanges for about $2.50 a month (not true; those below 138% of FPL are not eligible to buy coverage on the exchanges at all). I do not know if he misspoke or whether he believes those assertions to be true. If the latter, it is not clear whether whether those misconceptions in part inform his opposition to KanCare expansion (and thus could be changed by the facts) or if his ideological opposition informs his willingness to believe such incorrect information. However, he is a leader in the state senate, and so he is probably accurate when he asserts that the KS legislature will not expand KanCare. Other legislators on the panel, including the Republicans, indicated that such expansion would require leadership from KS Governor Sam Brownback, which the governor has not indicated will be forthcoming. One, Sen. Jeff King (R., Independence) is from the town whose hospital recently closed, at least in part because it could not count on KanCare expansion; he indicated that his father, who had had 2 heart attacks, was now 25 miles, not ¾ of a mile, from the closest hospital.

Beyond Sen. Denning, there were other concerns about the forum. Every panel member was white, and other than one state senator, Laura Kelly (D., Topeka), every one was man. Women gave the opening and closing remarks, but there were no people of color who spoke. This was obvious, but not the only important way in which the speakers (at least) and probably audience differed from the average person. One reason was that there were a lot of business leaders, because they have clout. They do, however, have a limited – and not always accurate – view of the rest of the people in this country. They seem to think that support for expansion of KanCare (and other social programs) is important until people get good jobs and get these benefits from their work (they referred a lot, disparagingly, to the “able bodied unemployed”). But where are the jobs? Job creation is supposed to be a high priority of the governor and legislature, and is the stated reason for the dramatic tax cuts of 2012 (indeed, rich people are now renamed “job creators”) but not only has job growth been slow, but it is mostly in lousy jobs – poorly paid and without benefits (eg., health insurance!). There was a great deal of talk about “retraining”, but there simply are not enough “good” jobs to employ everyone no matter how retrained they are. Their myopia may be because many well-to-do people have contact with others who are like them; in their neighborhoods, work, and country clubs. They have little insight into the real issues confronting those in the bottom 80%, not to mention 50% or 10%. I doubt they even know what the numbers are, but this article from CNN Money, with its neat interactive graph, should help; the median household (not individual) income in the US is $52,000.

I see lots of both poor and “regular” people as a doctor in the clinic and in the hospital. I live in a neighborhood that is mostly, well, working class. I see my neighbors, adults and children, on the streets when I walk my dogs. They’re trying, but it is not easy for them. Jobs are scarce, and many of those  that  they can get involve the sort of physical labor that takes its toll on their bodies and leaves them prematurely disabled. Lack of health insurance exacerbates their problems. A major recent NY Times/Kaiser Family Foundation study, reported by the NY Times, finds “Even Insured can face crushing medical debt”. Those business leaders who may think that $200K a year (for a household, most with two earners) is “middle class” should know it puts that household in the top 5% (and, for goodness sakes, in many parts of the country households making $200K are still struggling!). It would be good for them to meet with some regular folks and find out about their lives. I applaud the work that the various healthcare foundations in Kansas, many of whom co-sponsored this event, are doing. But our leaders, political, business, and otherwise, need a little reality check to leaven the ideology.

There are a lot of things that impact on whether a person is healthy besides access to health care (the social determinants of health: housing, warmth, food, education, safety, etc.). But access to health care helps. 

Precision medicine, trade policy and the cost of drugs: benefiting people or profit for business?

In a recent (January 29, 2015) New York Times Op-Ed, Mayo Clinic anesthesiologist Michael Joyner writes that “’Moonshot’ medicine will let us down”. What Dr. Joyner is referring to is what is now most commonly called, particularly in the large academic medical centers that have bought into it in a big way, “precision medicine” or occasionally “personalized medicine”. This is the concept that, by knowing your individual genetics, medicine can devise targeted treatments for diseases (most of the emphasis is on cancer) that will work for you, but maybe not for other people. Maybe the treatment most commonly used for the disease isn’t right for you; this would find it out.

It is a very attractive concept, and one that has clearly gained traction since the first complete sequencing of the human genome in 2003, moving from a science fiction idea to a mainstream investment by many institutions. As Dr. Joyner notes, “President Obama’s new budget is expected to include hundreds of millions of dollars for so-called precision medicine. The initiative, which he introduced last week in his State of the Union address, has bipartisan support and is a bright spot in the otherwise tight funding environment for medical research.” That is the “moonshot” part – hundreds of millions of dollars. When other funding for research is stagnant or being cut. Because it sounds cool, exciting, really like something cutting edge, a step toward the day when disease will no longer bedevil the human race. However, Dr. Joyner adds: “Unfortunately, precision medicine is unlikely to make most of us healthier.” Bummer.

Maybe he is wrong. Maybe the medical centers investing heavily in precision medicine, and the federal government which will fund it (of course, the “investing heavily” is not unrelated to the “hundreds of millions in federal funding) are right. “Star Trek” here we come! But let us look at the evidence that Dr. Joyner presents. He notes that most common diseases that affect people, even those with clear association with families and thus likely genetics, such as Type II diabetes, are not the result of a single or even a few genes that could be targeted if they could be fixed. There are multiple genetic characteristics that impact whether someone has a tendency to get DM2. Moreover, whether it actually occurs is a result of a complex interplay between those genetic risks and actual behaviors such as diet and exercise. He argues that it is obesity, caused by behaviors but certainly abetted by social changes in our lives, jobs, and easily availability of cheap high-calorie food leading to obesity, that has been the major culprit, given that DM2 (and obesity) is an epidemic of the last half-century, therefore not a result of any genetic change. In addition, even when there are genetic factors for differences between people in their response to treatment, it turns out that these do not explain most of the difference (“missing heritability”), such as in response to the anticoagulant warfarin (a so-far failed effort to use precision medicine to choose treatment). Treatment of chronic diseases like cystic fibrosis by genetic intervention has been unsuccessful, and cancer (like microbes) mutates a lot faster than genetically normal cells.

Joyner also raises the very real concern that people’s behaviors will change in ways that work against their health when they learn their genetic risk. Some people will use the information that they are at lower genetic risk to adopt risky behaviors. This has been described in many areas, everything from people with negative cardiac tests continuing to smoke and overeat to men who have had negative HIV tests and circumcision to decrease their risk of spreading HIV increasing their unsafe sex practices. He also notes that the opposite test result, finding yourself to be at greater genetic risk, can also lead to unsafe practices because you figure you’re doomed anyway. In addition, he notes that there are some people (“worriers”), “…who might embark on a course of excessive tests and biopsies ‘just in case.’ In a medical system already marked by the overuse of diagnostic tests and procedures, this could lead to even more wasteful spending.”

The main message here is only in part that “precision medicine” is something whose time has not yet come and may or may not ever come. More important thing is that, despite this, the government is planning to invest hundreds of millions of dollars in it. Most important is that money is not being spent on implementing treatments for conditions that we do know how to treat. People who are poor or uninsured cannot access many already available – and often incredibly expensive – treatments for diseases like cancer (see my piece “Squeezing the needy: a truly flawed financing system for healthcare”, March 2, 2013) or hepatitis C or many neurologic diseases. “Precision medicine” treatments are certainly going to be even more costly. In addition, we do not spend the necessary money to address the social determinants of health--housing and food and warmth and education--that make more of a difference in health than all of health care.

Indeed, we invest large amounts of money, public as well as private, in programs that effectively make our health worse. Sometimes this is in subsidies to major environmental polluters (BP, anyone? How about fracking and the Keystone XL pipeline?), and sometimes it is more direct, when we actually invest government funds in making treatments more expensive and less accessible to people, albeit to the benefit of the drug companies? Noted economist Joseph Stiglitz takes this on in another recent Times Op-Ed, “Don’t trade away our health” (January 30, 2015). He describes how the US Trade Representative, who negotiates trade agreements “supposedly on behalf of the American people”, is in fact consistently working on behalf of big corporations. In the case of the Trans-Pacific Partnership, this will mean increased obstacles to lower-cost generic drugs by making competition more difficult. “Just the availability of generics drives prices down: In generics-friendly India, for example, Gilead Sciences, which makes an effective hepatitis-C drug, recently announced that it would sell the drug for a little more than 1 percent of the $84,000 it charges here.”  This competition should be encouraged; it is the essence of capitalism. But our trade representative is representing big business, not people.

Of course, high drug costs are already a reality. On January 28, 2015, the Times’ Business Section previewed a study coming out in the New England Journal of Medicine from Harvard. “Study finds HIV drugs priced out of reach”. Much of the great advance made against HIV in the last few decades come from effective and more tolerable drug regimens. Atripla, for example, is a once-daily combination of 3 drugs (2 made by Gilead, one by Merck), that is extremely effective. But this study shows that the “flexibility” available to insurers under ACA will mean that folks with worse insurance (usually poorer people) will have to pay $3,000 a year more for Atripla than those with better policies. Again, the poor pay more.

Precision medicine may sound good, and certainly cool, and sexy. It may even benefit some people, if at very high cost, in the future. But right now, today, there are lots of conditions we know how to treat and lots of people who are not getting that treatment because they don’t have the money, are not desirable, have diseases not in the most preferred “product lines”. And we are spending federal money on making some of the drugs that we have that we know are effective less available.

Despite publicity about or funding for precision medicine or any other “new idea”, the fatal flaw is that our health system is not about improving our health, it is about profit. This is intolerable.

Our health is going downhill: poor public health and poor attention to the social determinants

“Our health is going downhill” shouts a headline in the Kansas City Star, January 4, 2009. The local take of this article, by Alan Bavley, was the poor performance of Kansas and Missouri, the two states served by the Star, on the 2014 report on America’s Health Rankings, published by the United Health Foundation, the longest-running ranking of public health status in the nation, since 1990. Bavley emphasizes that both states have dropped significantly in those rankings; Kansas was 12^th in 1990 and is now 27^th; Missouri was 24^th in 1990 and is now 36^th.

This leads to a lengthy discussion of why both states have dropped, mainly attributed to a lack of investment in public health, and how there is a geographic disparity, with states on the coasts doing overall better than those in the Midwest: “What explains this dramatic difference between the coasts and the Midwest is broad investments on the coasts in things that make communities healthy,” Bavley quotes Patrick Remington of the University of Wisconsin. What this misses, however, is the even worse news that is hidden by “rankings” data. While in rankings of states there will always be a #1 (in this case, Hawaii) and a #50 (you guessed it, Mississippi) this hides the fact that, overall, states have gotten worse over this 25-year period. The graphs in the print edition of the Star (not included in the on-line edition) show the decrease in rankings noted above for the two states over time. However, on the “America’s Health Rankings” website one can not only look at the map showing relative state rankings but also click on each state and see how its absolute health ratings have changed over time.

Hawaii, ranked #1 in 2014 (Vermont is ranked #1 for the whole 25-year period), has nonetheless had its health status drop quite dramatically since 1990, while Mississippi, #50, has actually slightly improved. Locally, Kansas’ health status has dropped significantly consistent with its slippage in the rankings, but Missouri’s, after a big dip in the intervening years, is about the same as it was in the mid-1990s, despite its lower ranking. How can this happen? How can Missouri drop 12 places in the rankings despite having about the same health status if the top-ranked states are getting worse? The only explanation is that the gap was even greater in the past, and that some states in the middle, such as Illinois (#30) and Pennsylvania (#28) have gotten better while Missouri has stayed the same. Hawaii has dropped from a rating of +0.7 to +0.3, while Mississippi has gone from -0.4 to -0.3. Dr. Remington’s comments may be accurate, but they were more accurate in 1990, and since then states have seen a race to the middle, if not the bottom, in terms of public health.

The rankings above are the “all outcomes” rankings from the United Health Foundation studies. They are composed of several subcategories. One component lowering these overall outcomes is the obesity rates, which have risen nationally from 11.6% in 1990 to 29.4% in 2014 (!) as well as in every individual state. Diabetes has risen nationally from 4.4% to 9.6%. Physical inactivity has stayed relatively constant, but distressingly high, at nearly 75%. On the other hand, the last measure, smoking, has gone down nationally from 29.5% to 17.6%, but has tended to stay the same over many years more in lower-ranked states, such as Mississippi, Missouri, and even Kansas.  The study ranks senior health separately, but this tracks pretty well with overall health; Hawaii is the best, Kansas is 25, Missouri is 42, and Kentucky replaces Mississippi (#47) as the worst. The study also examines rankings for a variety of other characteristics, some of which are different for the overall population and for seniors. They include chronic drinking (seniors), binge drink (all adults), depression (seniors), etc., as well as societal measures which might impact or “confound” health status including education level, percent of “able bodied” (no disability) adults and percent of children in poverty.

The study also provides us with information on health disparities, obesity levels by different sub-populations, based on education, race/ethnicity, age, gender, urbanicity, and income. Two non-surprises: the South and South Central regions do the worst, and the problem is greater for those with lower education, non-white race/ethnicity, and lower income; urban status and age have less impact. In terms of educational impact on health disparity (the difference between the highest and lowest educated in terms of health status), things change: Hawaii is still #1 but Mississippi is #2, while California is #50! Unfortunately, for many of the states with both low overall health status and low disparity, it means that even the better-educated have poor health status.

So what do we learn? Yes, as Dr. Remington points out, some parts of the country generally do better than others (although identifying these as the Northeast , West, and North Central  regions is more accurate than saying “the coasts”), and the South and South Central regions tend to be worse. Yes, as Mr. Bavley highlights, both Kansas and Missouri have significantly slipped in the relative rankings. But we also see the whole country getting worse, particularly with regard to conditions such as obesity and diabetes. And we see the most dramatic drops in certain states, not only Kansas but Wisconsin (down from +.38 to barely positive at all, +.07). The people interviewed for the Bavley article in Kansas and Missouri, as noted above, cite inadequate, and decreasing, spending on public health as the reason.

It is certainly one of the big reasons, along with a consumer society that encourages consumption of high-calorie, low nutrition foods. And a car-based society that makes exercise a specialty activity, more available to some than others, rather than part of life. And a terrible economy where a shocking number of people don’t have jobs and others have to hold down two or more to make ends meet so have little time for exercise. The other huge reason are those “social determinants of health”; the impact of poverty, racism, poor education, inadequate housing and food. The social structure and social support for the most needy in the US has never been adequate, and is eroding, more in some states than in others, sometimes on purpose (because of political beliefs) and sometimes by a (possibly) more benign neglect.

Some of it is the chronic problem of public health, that its successes are the absence of disease and thus less obvious. It is easier to feel grateful for treatment of a disease we have contracted than, say (as I have often said before) to be grateful each morning that we don’t have cholera because we have clean water. It is, perhaps for some, easier to think we don’t need to vaccinate our children when diseases that the vaccines prevent are no longer in evidence. But it is a fatally flawed analysis. When a good has resulted from doing effective preventive efforts, the solution is to keep up our efforts, whether vaccination or public health.

And cutting back on our social safety net is a good prescription for worse health.

Delmar Boulevard, Geo-mapping, and the Social Determinants of Health

The social determinants of health are those factors that affect people’s health status that are the result of the social situation in which they find themselves. Thus, in the well-known graphic from Healthy People 2010 (dropped, for some reason, from Healthy People 2020), which I have reproduced several times, they complement the other determinants such as the biological (genetics), but are represented in most of the other areas. Physical environment and socioeconomic environment, certainly, but even “behaviors” are affected by the circumstances into which one is born and lives. So is biology, actually, as we learn more about genetic coding predisposing some people to addictive behaviors. Certainly it is not all volitional or evidence of weak character.

The social determinants of health can be partially enumerated, and include adequate housing (including sufficient heat in the winter), adequate food, education, and also a reasonable amount of nurturing

and support from your family. In short, they are “the rest of life”, outside and often ignored by the healthcare system. Camara Phyllis Jones, in her wonderful “cliff analogy” (which I have also reproduced before) creates a metaphor in which medical care services are provided for those who need them (or “fall into them”) along a cliff face, while the social determinants of health are represented by how far a person, or a group of people, lives from that cliff face. As such, it illustrates the degree of protection that we all have from falling off that cliff, more for some and less for others.[1]

One of the clearest ways to show the impact of these determinants is by a technique called “geo-mapping” in which certain characteristics (income, educational level, gang violence, drug use, number of grocery stores or liquor stores, public transportation routes, whatever you can think of) are laid over maps of a city, town, or region. We have seen these portrayed on TV or in the newspapers as national and state maps for political events (such as what areas voted for who), but they can also be very useful for understanding the different challenges faces by people living in different areas. The work of Steven Woolf and his colleagues at Virginia Commonwealth University has greatly contributed to this work; in addition to their incredibly useful County Health Calculator, has produced graphs that can be found on the Robert Wood Johnson Commission for a Healthier America site that show how life expectancy can vary dramatically in different neighborhoods, as in the map displayed of the Washington, DC area, mapped along Metro lines for greater effect, or the one of my area, Kansas City, Missouri (which doesn’t have a Metro!)

A recent contribution to this field has been made by Melody S. Goodman and Keon L. Gilbert, of Washington University in St. Louis, who mapped the dramatic differences across Delmar Boulevard in that city, in “Divided cities lead to differences in health”. Their graphic shows the disparities in education, income, and housing value, and, unsurprising, racial composition, on either side of Delmar. This work was covered in a BBC documentary. Dr. Goodman, speaking to a symposium from her alma mater, the Harvard School of Public Health, is quoted as saying “Your zip code is a better predictor of your health than your genetic code.”

This is a pretty sad commentary, given not only the incredible amount of money that has been spent on unraveling the genetic code but the amount of faith and expectation that we have been convinced to have in how this new genetic knowledge will facilitate our health. By knowing what we are at risk for, genetically, the argument goes, science can work on “cures” that target the specific genes. This is a topic for a different discussion, but in brief one problem is that the most common diseases we suffer from are not the result of a single gene abnormality. It is probable that, at least in the short-to-medium term, knowledge of our genetics will be more likely to lead to higher life insurance rates than cures of our diseases. The more profound issue, however, is that there is evidence from the social determinants of health, from the work of Woolf and Goodman and many others, that we do not address the causes of ill health even when we know what they are.

Why is this so? Why is there such great resistance to understanding, believing, that investment in housing, education, jobs, and opportunities will have a much greater impact on people’s health than more and more money spent on high-tech medical care (and, of course, profit for not only the providers, but the drug and device companies and middleman insurance companies)? It is in part because we hope (and, when we are more privileged, expect) that we will be the beneficiaries. And it is also because we choose to believe that those who do not have the benefits we have (of money, education, family) somehow “deserve” it because of character flaws.

The issue of “fault” is articulately addressed by Nicholas Kristof in a New York Times Op-Ed on August 10, 2014, “Is a hard life inherited?” Kristof argues that it is, not genetically but because the circumstances to which one is born and in which one grows up, the presence of caring parents who read to you rather than beat you, who take care of you instead of abusing drugs, as well as adequate food and housing make a tremendous difference in how you turn out.

Indeed, another major study by Johns Hopkins sociologist Karl Alexander, to be published in his “life’s work”, “The Long Shadow: Family Background, Disadvantaged Urban Youth, and Transition to Adulthood”, and covered on NPR, confirms this. Alexander and his colleagues tracked nearly 800 children for more than 20 years, and found that those from less privileged backgrounds with lower incomes and less supportive families did worse. Only 33 of the children moved from the low income to the high income bracket. Problems with drugs and alcohol were moreprevalent among white males than other groups, but they did better financially anyway. Some people, rarely, overcome the deck being stacked against them, but most of those who do well after being born with relative privilege would likely not be among them had they been in the same situation.  Kristof writes:

ONE delusion common among America’s successful people is that they triumphed just because of hard work and intelligence. In fact, their big break came when they were conceived in middle-class American families who loved them, read them stories, and nurtured them with Little League sports, library cards and music lessons. They were programmed for success by the time they were zygotes. Yet many are oblivious of their own advantages, and of other people’s disadvantages. The result is a meanspiritedness in the political world or, at best, a lack of empathy toward those struggling…

That lack of empathy leads to a lack of action; we are willing to accept people living in conditions that we would never accept for our family and neighbors, not only across the globe but across town, or even across a street. From the point of view of health, our priorities and investments are misplaced when we do not address the social determinants of health as well as cures for disease. When we do not try to change the known factors of zip code that impact our health as we investigate those of the genetic code.

If there are to be “cures” that come from our understanding of genetics, there is every reason to expect that they will be one more thing that is available to the people on the south side of Delmar Boulevard in St. Louis long before they are to those on the north side of the street.

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[1] Jones CP, Jones CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved, 2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228

Quality health outcomes depend upon the Social Determinants of Health

On the heels of the publication by the Center for Medicare and Medicaid Services (CMS) of how much money Medicare paid to individual physicians (discussed on this blog in Medicare payments to doctors: the big issue is the underpayment for primary care, April 9, 2014), we have revelations of inequity in Federal payments to health providers. A panel of the National Quality Forum (NQF), convened by the Administration to look at this issue, has determined  that payments for “quality of care” to hospitals under the Affordable Care Act (ACA) tend to reward those hospitals caring for higher-income patients and penalize those who care for the poor (Robert Pear, “Health law’s pay policy is skewed, panel finds”, New York Times, April 27, 2014). This cannot be the way we want to go, and thankfully that is the conclusion reached by the panel. It is, however, the NQF that developed these 600 or so quality indicators, and has not recommended adjusting them for the socioeconomic status of the patients that a hospital cares for (although it does adjust for severity of illness).

What is happening is that the measures of quality of care are largely not measures of what is done for patients in the hospital, but how they do after – are they readmitted shortly after discharge, are the diseases for which they are being cared for under better control or not, do they get follow-up care. The fact is that for a variety of reasons including money, education, transportation, and competing demands, poor people do not do as well as better-off people, even controlling for the quality of care that they receive when they are hospitalized. A number of panel members comment on this in the Times article, including NQF president Christine Cassel, who says “Factors far outside the control of a doctor or hospital — patients’ income, housing, education, even race — can significantly affect patient health, health care and providers’ performance scores,” and panel member Steven H. Lipstein, CEO of BJC HealthCare in St. Louis who adds “The administration’s current policy on adjustments for socioeconomic status are quite inadvertently exacerbating disparities in access to medical care for poor people who live in isolated neighborhoods. I’m sure that’s not what President Obama intended with the Affordable Care Act.”

These comments are true, but the thrust of the NQF’s comments was the unfairness to the hospitals. This is important as far as it goes – it is outrageous to pay extra money for “quality of care” to hospitals that care for the privileged and penalize those that care for the underserved. Many of the members of the panel and other commenters quoted by Mr. Pear focus on academic teaching hospitals, which indeed care for a disproportionate share of poor people; however, public hospitals (in those areas where they exist) are even more affected. But what is more important is how this issue illustrates the power of what are called the “social determinants of health”, the situation that people live in before they access medical care, and after they are discharged, have on health outcomes.

Health advocate and policy expert Kip Sullivan is more pointed in his comments on Don McCanne’s “Quote of the Day” for April 28, 2014. “The notion that doctors and hospitals are screwing up and will behave if they are subjected to punishment and reward by third parties is not new. The Code of Hammurabi (1750 BC) subjected Mesopotamian doctors to a combination of reward (more shekels) and punishment (cutting off of doctors' hands)…But even Hammurabi didn’t recommend punishing the patients.”  If hospitals that care for poor people are effectively financially penalized for doing so, they will (at best) be further financially challenged in providing that care, and at worst will do their best to not care for the poor to the extent that they can.

Why would the NQF and the Department of Health and Human Services (HHS) take such a position, one that seems both unfair and even mean? One might be tempted to suggest that rewarding the “haves” and punishing the “have nots” is what is usually done by government policy, but we would hope that, given its rhetoric on health care – and the creation of the ACA in the first place – the Obama administration would not be guilty of such intent. We get some better idea from Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services, who is quoted in Mr. Pear’s article as saying “We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients. Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

Now, this sounds almost noble, like a values-based response to critics such as those on the NQF’s panel. However, the clear and obvious flaw in such logic is that hospitals have the power to change the lives of these patients in such a way as to decrease their risk for poor outcomes to be equal to, or better, than, those of higher socioeconomic status. They don’t, and to the extent that they could do more work in the community to help this situation, it would cost more money, so it is absurd that they be financially penalized. Dollars spent by government on health care should first and foremost be required to be spent on health, not on making money for providers (doctors or hospitals) who can by virtue of their location (and possibly other strategies) avoid taking care of the neediest. Hospitals should be judged and reimbursed on the quality of care that they deliver, equitably and without prejudice with regard to socioeconomic status, but cannot reasonably be judged on outcomes which depend on factors far outside the control of those hospitals.

The real issue is that people who are poor have a lot more to contend with than the services delivered as health care. It is not uncommon for our hospital to be treating a person with a bone infection made worse by their diabetes who needs 6 weeks of IV antibiotics. This can be delivered by a home health care agency, and most insurance will pay for it. But it becomes a problem if the person does not have insurance. And is even more complicated when they do not have a home. These people stay in the hospital, at exorbitant cost, for the whole duration of treatment. But would our quality measures be better if we only cared for those with homes and insurance? Would the hospital make more? Of course, as Mr. Sullivan points out, while the hospitals lose financially, ultimately it is the patients who suffer.

The social determinants of health are well-portrayed in the “cliff analogy” developed by Dr. Camara Jones and her colleagues,[1]and discussed in my blog of September 12, 2010, “Social Determinants, Personal Responsibility, and Health System Outcomes”. The care given by hospitals occurs at the bottom of the cliff, after people have fallen, but their risk, both before arriving at the hospital and in returning home, is that they are living so close to the cliff face; their housing is poor, their neighborhoods are dangerous and polluted, their schools do not educate, and food is often scarce and not nutritious.  In their study comparing health costs in the US and Europe, Elizabeth Bradley and colleagues discovered that while the US spends far more on “health care”, if you add in basic social service spending, the difference decreases, but that the US spends most of its combined health-and-social-service spending on medical care.[2](Discussed in a New York Timesop-ed, “To fix health care, help the poor” by Bradley and Lauren Taylor, and in my blog “To improve health the US must spend more on social services”, November 18, 2011.)

It is understandable that, given the political climate in Washington and state capitals and the flak that they took for ACA, the Obama administration does not want to put major effort into addressing the social determinants of health by developing programs to meet the core needs of poor people in our country, to prevent them from getting sick, to give them access to meaningful post-hospital care, to have health workers in communities, punish polluters, decrease crime, and limit health risks. Understandable, but not OK. And in the meantime, on this narrower issue, it obviously requires adjusting for socioeconomic risks for hospitals caring for the poor when their quality incentive payments are calculated.

But sometime soon we are going to have to address the core problems.

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[1] Jones CP, Jones CY, Perry GS, “Addressing the social determinants of children’s health: a cliff analogy”, Journal of Health Care for the Poor and Underserved, 2009Nov;20(4):supplement pp 1-12. DOI: 10.1353/hpu.0.0228. Slides available on line at http://www.csg.org/knowledgecenter/docs/health/CamaraJones.pdf.

[2] Bradley EH, Elkins BR, Herrin J, Elbel B.,Health and social services expenditures: associations with health outcomes, BMJ Qual Saf. 2011 Oct;20(10):826-31. Epub 2011 Mar 29