What Wealth [Inequality] Means for Health

President Obama's recent budget proposal has been declared unanimously "ambitious." The health component of Obama's plan includes $634 billion dollars in spending over 10 years as a "down payment on health care reform." According to an article in the San Francisco Gate, approximately half of this amount would be generated by limiting charitable and mortgage interest deductions on taxpayers above the 28% income tax bracket and more would come from reducing Medicare payments to private insurers.

Given that I have little expertise in economic growth and government fiscal planning, I cannot comment to any great extent on the details of the budget plan nor its impact of the growing deficit and national debt, etc. However, I am excited to reflect on what it could mean for public health. 

An October 2008 report ranked the US just behind Mexico and Turkey for having highest income inequality of all OECD (Organization of Economic Cooperation and Development) countries.  In fact, many studies have found that countries with more equal distribution of wealth have -- at ALL levels of income -- better health outcomes. That means that not only does living in a more equal society confer health advantages to the poor and disadvantaged, but it also benefits the health of the wealthy. Notably, the health of the poor is improved to a much greater degree than the health of the wealthy (think of what $5000 could mean for someone making $20,000/year compared to someone making $200,000) through such redistribution. 

So how might this work?

1. Increased income may improve a person's ability to access needed resources (e.g. health insurance, transportation to health care, living in a toxin-free environment, buy healthier foods)
2. Increased income may improve a person's mental health and reduce stress (resulting in lower rates of chronic disease, such as hypertension and cardiovascular disease)
3. Redistribution of income may promote programs and services for the poor

In areas of great income inequality, housing segregation, stereotypes, and blame hamper the rich from investing greater resources towards disadvantaged populations. For example, why support a new 'free clinic' when you can build a state-of-the-art hospital with the latest health technologies? All too often highways, rivers, and walls separate the haves from the have nots -- and do not allow us to come together and learn from each other. 

How this might affect the middle class is something that I haven't been able to fully flesh out. I think that it is likely that they would benefit from these measures; though proposals that hurt entrepreneurial activities and small businesses could certainly serve as a disincentive for some who are trying to bridge that gap between the middle and upper class. Furthermore, it may need to be reassessed whether those making $250k should be labeled as "wealthy" to the same extent as those making much more. As an interesting Fox News (yes, Fox) article pointed out "HENRYs [high earners, not rich yet] carry significant mortgages, pay heavy property taxes, make charitable donations and sock money away for their children's college education." The slight increase in income tax coupled with the lack of deductions for mortgage payments and charitable giving may decrease the spending of people earning this much -- further deteriorating the economic situation. I just don't know.

My final assessment: this economic plan could be one of the single-most important factors that improve population health in the United States in the 21st century. While individuals may not see an overwhelming effect on their health, society as a whole could benefit greatly.

What the Stimulus Means for Public Health

President Obama passed the Stimulus Bill (a.k.a. the American Recovery and Reinvestment Act) on Monday. Immediately, I got an email from APHA announcing how pleased they were "with the $1 billion investment in disease prevention and wellness activities...[and]with the inclusion of $2 billion to improve community health centers and expand services and $500 million for the training of primary care providers." Additionally, I received an email sent from the Director of Nutrition Policy at the Center for Science in the Public Interest who praised the inclusion of funding for community-based prevention and wellness programs, equipment for the National School Lunch Program to help schools prepare healthier meals, and increased support for WIC recipients. 

You make ask, "why is public health part of this stimulus plan?" or even argue that it has no place in it. I disagree.  Maintaining the health of our nation during this economic crisis must be a priority. Healthy workers are productive workers, just as healthy mothers have healthy babies. Healthy babies grow into healthy adults.

Just as the education system will suffer greatly as a result of budget cuts and spending freezes, so will those serving in public health see their budgets shrink and their resources dwindle. Thankfully, the education system will receive $100 billion in investment through the Stimulus Bill (see Nicholas Kristof's Sunday column for his take on this). The $3 billion for public health pales in comparison to that amount. Nonetheless, I think that the public health priorities included in this bill will speak volumes for the types of activities that the administration will pursue in the coming months and years.

It is worth noting that what is good for education is also good for public health. Higher educational attainment is associated with lower risk of disease and death for most health problems. Reducing disparities in education may serve to improve the public's health more than any technological innovation in medicine (e.g., electronic medical records) could hope to. I hope we do not lose focus of the fundamental causes of poor health, to do so would be a tragic misstep.

Take Our Beef, Or Else!

The week before leaving office, former President Bush approved a 300% tariff hike on Roquefort cheese. The news caught my attention while riding the T. Dramatically, the Metro article suggested that in retaliation the EU may raise the tariff for US imports of Coca-Cola. While this seems a bit far-feteched, I had to wonder 'Why? Why did our government decide to place such an enormous tax on Roquefort, the infamous moldy, sheep's milk, inimitable creation?'  

Well, according to reports in Time, Huffington Post, and the UK's Guardian this political decision was made to punish the European Union (EU) for their refusal to import meat raised with artificial hormones and antibiotics, a restriction that dates back to 1989. Take that EU or more specifically, the French district of Lozeyron! No longer will Americans enjoy your delectable cheese because you refuse to import our potentially toxic meats! I mean really?! What may be the effect of such tariffs -- recipes left unfulfilled? Wisconsin (i.e., domestic) alternatives embraced? Roquefort-lover riots in protest?

This short announcement caught my eye because it sheds light on the huge influence that the meat industry has on US policy -- both domestic and international. The EU ban on beef imports was due to the untraditional methods used to raise the cattle (i.e., use of antibiotics and hormones to help the cows grow fatter, faster on a  corn, rather than grass-based,  diet). In fact, the International Trade Commission published a 2008 report on the current state of US beef exports, which details which countries and regions are not importing US beef and why.  

Anyway, it was an interesting story I had to share. For more on US Food Policy and developments in "BigAg" check out this US Food Policy blog out of Tufts University. It is a great blog!

The Looming Health Care Crisis

An Op-Ed submission by three Harvard School of Public Health students: Alana Wooley, Katelyn Mack and Jamie Zwiebel. For your reading pleasure. Comments welcome!

As our government leaders grapple with the current economic crisis, another crisis is gaining momentum. We can no longer ignore its symptoms: rising rates of preventable, chronic illnesses; Americans facing trade-offs between doctor visits, prescription drugs, mortgage payments, gas or food; financial concerns determining patient treatment for catastrophic illnesses; and an inability to obtain insurance with a pre-existing illness, among others.  In 2007, 45 million Americans were uninsured.  These numbers will no doubt continue to climb as families and employers alike increasingly feel the direct impact of rising unemployment and inflation.  If we do not address the looming health care crisis, we will undeniably face yet another bailout, this time for health insurance companies and the health care community.

In the most recent presidential debate, Senator Barack Obama (D) told the nation he believed health care is a right and Senator John McCain (R) believed health care is a responsibility.  Whether it is a right or a responsibility, both candidates believe that access to and affordability of health care are important.  While we may disagree about solutions to and responsibility for the health care crisis, 51% of Republicans and 79% of Democrats believe that our nation’s broken health care system is in need of repair (Blendon et al. 2008). While the Presidential candidates agree that something needs to be done, their health care proposals are in vast opposition to one another. 

Senator McCain offers a short-term solution to this imminent crisis.  His health care plan proposes a $2500 and $5000 tax-credit for individuals and families, respectively, to help absorb the rising costs of health insurance.  However, not only is this credit, which is payable only to the insurance companies, considered taxable income, it does not address rising premium costs and treatment expenses.  While this tax credit may be beneficial for young, healthy adults, it would exacerbate the financial burden of health insurance for families and adults living with chronic or catastrophic illnesses. Simply offering a tax-credit to help deflect expenses for an already expensive health care system is not a sustainable solution and one that will be ineffective in reducing the rising numbers of uninsured Americans. 

Senator Obama offers a more comprehensive, long-term solution to the health care crisis. He proposes allowing individuals and families to keep their current employer-offered health care, or opt into a public insurance or obtain private insurance coverage through an insurance clearinghouse. The public insurance would offer coverage similar to that which Senator Obama and Senator McCain have as government officials. Contrary to rumors of socialized health care and fines for not obtaining insurance, this proposal only mandates health insurance coverage for children.  Senator Obama offers a more comprehensive plan that would extend insurance access to those whom the current system does not capture.  While this plan would reduce the number of uninsured Americans and improve coverage for children and families, Senator Obama’s plan would not cover everyone.

The health of our nation is central to the health of our workforce, the strength of our families and communities, and our national security. This election is an opportunity to ensure that the housing and credit woes we now face do not similarly beset the fragile US health care system.  As voters, we must elect someone with sound judgment and visionary thinking.  We can no longer afford short-term solutions.  Our next President must offer long-term, sustainable solutions to the long-standing dysfunction and discord of the US health care system. Let us enter the polls with the economy, health care, and education on our minds, all of which are inextricably linked together. Now is the time.  It is our responsibility to avoid another bailout blunder by electing the candidate with the best solution to improving the health and well being of all Americans.

Bailout: the $810 billion bombshell

There was a great op-ed written by Joel Berg in last week's Washington Post. He wrote from a social services advocate's perspective on the looming government bailout of failing financial institutions. While I acknowledge that some remedy is needed for the mess that lenders have gotten themselves into by thinking the housing bubble would never burst. I am nonetheless baffled by the shear magnitude of the cost. Now, we are learning that the $700billion initially proposed has grown to $810billion (...because of pork?!) -- I am forced to reflect on what this money actually means. Our politicians can talk about the need for social protections, serving "the people", providing for families, communities, and the country. But talk is cheap. True values are revealed by where we spend our money (and our time). Thus, this bailout may (I hope) mean more than rescuing troubled Wall Street investors; rather, it represents a greater value of protection of our livelihoods and lifestyles -- being able to own and keep one's home, start a new business, invest in our children's future education. The details and implementation of this bailout bill will further reveal the underlying values and priorities of those whom we entrust the future of our nation. 

Back to reflection upon this $810billion. What would I do with $810 billion? Would I provide food for the hungry? Legal counsel for the oppressed? Food for the malnourished? Mobile technology for the isolated? Job training for low-wage workers? Bed nets in malaria territory? Funds for non-profit organizations? 

What would you do with $810 billion dollars?