By Josh Arnold ('17), Founder and Director of G.A.L.A
Our goals for the day were . . .
- To understand the relationship between health and healthcare
- To examine the underlying factors that contribute to health and wellbeing.
- To discuss the role of public policy on our health and healthcare systems
We began with small group conversations to reflect on the film, UnNatural Causes: In Sickness and in Wealth. The documentary takes place in Louisville, KY juxtaposing the lives of five different individuals living in five different districts defined by starkly different education and income opportunities. The main takeaway was that there is a direct correlation between income and education on expected health outcomes- the greater the income and education, the more positive the expected health outcomes.
Although this evidence was not surprising for most of our class, it was alarming nonetheless. Furthermore, when income and education variables are removed from the equation, or controlled, race alone will also have a direct relationship with expected health outcomes - a person of color in the United States experiences greater health risks than a white person in the United States. The film dissected this race correlation by researching how sustained levels of cortisol can compromise your immune system. In other words, chronic stress leads to failing health. I believe the film was suggesting that with all other variables aside, a person of color in the US is more susceptible to chronic stress because of how frequently they are subject to individual prejudices, on top of the daily struggles of navigating a society where institutionalized racism is still so deeply embedded in our economic, political, and criminal justice systems.
To summarize, the film drove home the point that economic and education policy is health policy, and therefore trying to address health policy outside this broader context is ignoring the overwhelming impact social determinants have upon our health and wellbeing.
Following the film discussion our class was joined by the honorable John T. Broderick, Jr., Co-Chair, Change Direction Initiative and Peter Evers, Co-Chair, Change Direction Initiative, CEO Riverbend Community Mental Health. John shared a very moving story about the ways in which mental illness has impacted his life and those of his loved ones, an experience which ultimately inspired him to lead, with Peter, NH’s “Campaign to Change Direction” campaign, a national effort to change the culture of mental health in America so that all of those in need receive the care and support they deserve. John and Peter brought with them a stack of “Know the Five Signs” rack cards that are designed to help people identify when someone is in emotional pain and may need help.
John asked the group, “Imagine you are explaining to your boss that you will not be at work the next day because you have an important physical therapy appointment to recover from a recent knee injury.” John then asked, “Now imagine that same conversation only this time your reason for not coming into work the next day is because you have a meeting with your psychiatrist to help work through a recent episode of depression.” Not a single person suggested these two conversations would feel or be received the same, but John insisted that we must aim for that if we are to change the culture surrounding mental illness in our society. The onus is on each of us, for collectively we contribute to the stigma faced by the 1 in 5 adults who in their lifetime have a mental illness problem and yet sometimes feel ashamed to talk about their experience.
Peter delved more into the history of mental illness and how far our treatment has come, largely due to the way we now approach it as a public health issue, instead of how it was historically treated as a public safety issue. Today, intervention and evidence-based treatment can heal people who only 30 years ago would have been considered “incurable”.
Without dismissing our accomplishments, Peter also emphasized that there is a large gap between where we are now and were we need to be. To get there we must start measuring success by actual health outcomes, not simply what medications are administered. Why is the discharge criteria for mental illness simply that the person won’t die after they leave the hospital or clinic? Why do we say someone has diabetes, but say someone is mentally ill? Peter concluded by naming quality, satisfaction, and cost-effectiveness as the three primary benchmarks by which we must judge our treatment going forward.
Next up was Trinidad Tellez, (’11), MD Director, Office of Health Equity NH Department of Health and Human Services, leading a segment on Broadening the frame from Healthcare to Well-being: Social Determinants of Health, Disparities, and Health Equity. Trinidad introduced the Triple Aim approach to measuring the value of treatment based on 1) population health, 2) per capita cost, and 3) experience of care, which encompasses access and reliability.
We circled back to the film during Trinidad’s presentation to elaborate on the social determinants of health, including autonomy, quality education, housing and ownership status, role models, the built environment and environmental hazards, access to healthy foods, parent’s education, and so on. Once again, the greater the education and income, the greater the life expectancy. Regardless of income and education, however, health disparities directly correlate with race as well. When considering our demographic trajectory of a more diversified state, not to mention there are parts of NH that are already 40% minority, these disparities demand our attention.
In order to better understand these disparities we need to be asking the right questions so that we collect the necessary data, and more importantly are able to disaggregate that data. The resource NH Health Wisdom is one of the ways we are moving in this direction. Trinidad also encouraged us to look into the Health Equity Guide published by the CDC to help us understand these complex issues.
Our goal is not simply to have no disparities, but to actually realize health equity, where everyone has the opportunity to achieve optimal health regardless of their color, education, sexual orientation, gender, job, zip code, etc. Eighty percent of health is not healthcare but rather these conditions or situations that we do not all have the same opportunity to change or achieve, thus influencing our ability to have optimal health (social determinants of health). Similarly, many “lifestyles” we associate with poor health are imposed on some people more than others based on access to certain choices. For example, the ability to recreate safely outside in the fresh air, the ease of buying or growing fresh produce and fruits, or whether or not clean water pours freely from the tap, are lifestyle choices for some, but socio-economic circumstances for many others.
And as if the moral ground was not reason enough, the economic burden of health inequities amounted to a 1.24 trillion dollar loss nationwide between 2003-2006. Read, monumental mismanagement of human capital.
If we want to be effective we must stop thinking about healthcare as sick care, and begin looking further upstream to think about how health is produced in community. From there we can get on track to attaining good health, defined by The Endowment for Health as, " . . . more than the absence of disease or injury. Good health means overall wellbeing, enabling the realization of one's full potential."
After lunch, we heard from Sanders Burstein MD (’07), Medical Director, Dartmouth-Hitchcock Nashua for a segment titled, Starting the Conversation – Honoring Care Decisions. Much of this conversation revolved around the importance of advance care planning. Most people do not have an advance directive. However, when advance care planning is done well it results in greater confidence that our health care wishes will be followed even when we are unable to speak for ourselves as well as reduced measure of distress and depression by loves ones after death.
Like John was asking us to change the culture surrounding mental illness, I felt as though Sanders was asking us to change the culture around death and dying. Contrary to popular belief, advance care planning is not meant to help someone die, but rather to help that person achieve the things that matter most to them while alive. We were each given a packet with Advance Care Planning materials to work on at home with our loved ones.
Our day concluded with a presentation by Lucy Hodder, Professor of Law, UNH Director of Health Law and Policy Programs with a segment titled, The Role of Public Policy vis-à-vis Health and Healthcare. Lucy’s premise was to help us understand what we need to know in order to be informed leaders in the healthcare conversation. As leaders, Lucy suggests we must a) Talk about the facts b) Talk about the future, and c) Remember it’s about ALL of us.
Each of these points was further elaborated upon with various charts and graphs illustrating the complex “anatomy” of our healthcare systems. Lucy eloquently oscillated between sharing factual data to help us draw our own informed conclusions, and asking us the tough questions that force us to reconcile this data with our own moral compass. Questions like, “Do we owe each other a certain level of care as individuals or society?” or, “If you saw someone that was hurt would you stop to help,” or lastly, “Is our responsibility to help someone who is sick irrespective of why they are sick?” And for all of these questions, how do they translate to our healthcare policy?
For the most part there a society-wide sense that we have a foundational responsibility to help take care of one another, but the sticking points are when we get into the logistics of who is going to pay for it. When having this conversation it is important to note that the US spends a greater percent of our GNP on healthcare than any other industrialized nation, without seeing the equivalent health outcomes, i.e. return on investment.
Consider this – we spend 88% of our healthcare resources on access to care, 4% on social determinant issues and healthy behavior, and 10% on others issues like environmental factors and genetics. Meanwhile the hierarchies of factors that influence health are 50% social determinants and healthy behavior, 20% genetics, 20% environmental, and 10% access to care.
With the anticipation of the Affordable Care Act entering the forefront of our political discourse in the months and years ahead, Lucy took time to help us understand what the impetus was in the first place for this legislative change back in 2010. The list of experiences which led to a general sense that their needed to be drastic change in the healthcare policy included –
1. Coverage was dropped for no reason 2. Pre-existing conditions prevented people from accessing adequate plans 3. People’s plans were dropped from one employer to the next 4. Healthcare was too expensive 5. The “donut hole” effect 6. There was a double digit increase in premiums 7. People could not figure out what their care was going to cost 8. Out of pocket expenses were going up. 9. The sentiment that my tax dollars are going to fund everyone else’s expensive ER visits for those who are uninsured 10. Cannot get access mental health or addiction services.
These were a few of the grievances that led to the healthcare reform conversation in the first place. The Affordable Care Act was based on a premise that the way to pay for a plan to begin addressing some of these challenges was to mandate comprehensive coverage, in other words make everyone buy a healthcare plan. Did this fix all the problems? Certainly not. Did it improve healthcare access for many? Absolutely. Did it lead to unintended negative consequences for others? Absolutely.
My biggest takeaway from this final segment was that a) NH healthcare is not just expensive, but comparatively expensive in the country and even in New England, b) how much care we use is not the main driver of increased cost trends, but rather Pharmacy trends c) employer sponsored coverage remains a real challenge, and d) 80-90% of health is not determined by healthcare, but rather the social determinants discussed previously, and more importantly how misaligned our current spending patterns are to this reality.
It was a long and informative day that, as I mentioned at the beginning, I believe marked a tipping point for the group. For me, of the topics covered so far, this has proven to be the area in which I still have the most to learn. I particularly like how the program days are starting to intersect. For example, I have a heighted awareness of how our education and environmental policies influenced the way I was interpreting and integrating information about our health policies and trends. Next month we are focusing on the Criminal Justice system and I’m sure the dots will continue to connect, and I can only imagine what “I don’t know I don’t know” about that topic!
Oh, and did I mention we are slated to be the best LNH class ever?
To learn more about the 5 signs of emotional suffering, please visit http://www.changedirection.org/nh/