An Accurate Census – Our Health Depends on It!

When I was a skinny, naïve teenager, I worked the summer of 1980 for the US Census Bureau going door to door, pencil in hand, filling out census forms. Or rather, I went trailer park to trailer park in the outskirts of Odessa, Texas, where I was assigned to work. Do you know how many pit bulls and Doberman pinschers live under the steps of trailer houses in West Texas? I do. Fortunately, that was not one of the census questions.

The US Census counts each resident of the country, where they live on April 1, every ten years ending in zero. The count is mandated by the Constitution to determine how to apportion the House of Representatives among the states.  The US has counted its population every ten years since 1790. Households will be able to respond to the 2020 Census online, over the phone, or through a paper questionnaire. Results are anonymous and confidential; answers cannot be used against you by any government agency or court.

My appreciation for the US Census has grown tremendously since my days walking trailer parks. Far beyond being a simple head count, an incredible $1.5 trillion in federal dollars are distributed according to census counts. Myriad local and state governments, businesses, and community groups rely on US Census data to determine needs, guide investments, provide services, and lobby for state and federal funding.  If the count isn’t accurate, the distribution of funds isn’t fair. We have one shot every ten years to get it right.
Healthcare in particular has much at stake if the US Census does not get accurate information. As I love to mention, the healthcare sector drives our local economy. The State of Texas cannot ignore the healthcare sector either. Elena Marks, president and CEO of the Episcopal Health Foundation, states, “No sector is as dependent within the state budget in drawing down federal funds than the health sector, and those funds are based on population that's determined by the Census. Health clearly stands the most to gain, and the most to lose if there's an undercount.”  In fact, experts estimate that a 1% undercount in the Census could cost Texans about $280 million per year for health programs alone. Current forecasts predict anywhere from a 4%-8% undercount in Texas.

From political representation to federal funding for clinics, Medicaid, the children's health insurance program and much more, a complete and accurate Census count is crucial for community health – especially for low-income and vulnerable populations like many in deep East Texas.  The $1.5 trillion in federal money guided by census data helps fund the Children’s Health Insurance Program (CHIP), Medicaid, Medicare, the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and community health centers funded through the Health Resources and Services Administration Health Center Program. Indivar Dutta-Gupta, co-executive director of the Center on Poverty and Inequality at Georgetown Law, notes that the groups that tend to be undercounted at the highest rate, unsurprisingly, are also the ones that would probably most benefit from greater access to and provision of health care and coverage.

The Census is also fundamental for population health data, including calculation of death rates, birth rates, and fertility rates.  A recent journal article titled Census 2020—A Preventable Public Health Catastrophe  points out that population counts provide denominators used to derive disease prevalence and rates. Inaccurate counts limit our ability to understand and track disease over time. If we cannot accurately stratify our populations by social factors such as education and race/ethnicity, we cannot assess their relationships to health.  Rural populations with spotty Internet connectivity are also likely to be undercounted.  Simply put, if we can’t measure social disparities in health, we are hindered in working to reduce them. Given our history of hurricanes, we need to understand that a flawed Census will compromise efforts to track and effectively manage natural disasters and emergent public health threats (coronavirus?), which require geographically focused provision of food, water, and shelter.

Lately, it seems as if politics gets in the way of everything. We must understand that federal dollars follow people. More people counted equals more funding coming our way. Whether or not we like with the ways those dollars are raised or spent, we should all agree that we deserve our fair share of whatever dollars are distributed. An accurate US Census is something we should all be able to count on and get behind!

A True Community Health Needs Assessment

The IRS requires charitable hospital organizations to conduct a community health needs assessment (CHNA) every three years and to adopt an implementation strategy to meet the community health needs identified through the CHNA. CHI St. Luke’s Health Memorial recently completed their 2019 Community Health Needs Assessment and will now begin the process of developing, adopting, and implementing a strategy to address identified needs. Much of this strategy will depend on working together with community stakeholders, many of which participated in the assessment data collection and interview process. Additional data was obtained from sources such as the Texas Department of State Health Services, the US Census Bureau, the Centers for Disease Control and Prevention, the Episcopal Health Foundation, and the Robert Wood Johnson Foundation’s County Health Rankings.

The 2019 CHNA was created by the Center for Community Health Development at Texas A&M University at the request of CHI in collaboration with multiple non-profit community organizations, churches, school districts, and individuals. The entire CHNA is published on the CHI website at www.chistlukeshealthmemorial.org/about/health-needs-assessment/. Because CHI St. Luke’s Health Memorial is a regional health system, the assessment covered not only Lufkin and Angelina County, but a seven-county region that included Polk and San Augustine counties, where CHI facilities also are located.

I have a number of thoughts after reviewing this recent assessment.

1. The health of a community is dependent on far more than just availability of health care. This is well-demonstrated by both the Robert Wood Johnson Foundation’s County Health Rankings (www.countyhealthrankings.org/) and the Episcopal Health Foundation (www.episcopalhealth.org/en/research/county-health-data/). To improve health, we must identify and address everything from education level and health behaviors to racial, ethnic, and socioeconomic factors that affect a community’s health.

2. The 2019 CHNA is community-driven, and solutions to our health needs must include the community as well. So many partners exist, including Burke, the Angelina County & Cities Health District, the Coalition, our many school districts, DETCOG, the Texas Forest Country Partnership, and, of course, our city and county governments. All will need to be engaged in moving the needle to improve the health of our communities.

3. The role of the hospital in the community has changed. In the past, hospitals were primarily a destination to deal with an acute episode, like having surgery or managing a heart attack. Now, hospitals must be part of the chronic care management team for patients with heart disease, diabetes, cancer, mental health issues, and more. Hospitals are being graded – and paid – on how successfully they keep patients out of the hospital, if you can believe it! That requires coordination with community partners to ensure that people get the care they need both before and after they require care in a hospital facility.

4. Risk factors – behaviors – such as smoking, obesity, and exercise must be addressed, as well as substance abuse and mental health needs. We are doing this already, to some extent, across organizations and municipalities. More can be done.

5. Education is widely recognized as one of the primary social determinants of health. The St. Luke’s region has a lower proportion of residents with a college degree (14.2%) than either Texas (28.7%) or the US (30.9%). Within the region, the rate varies from a low of 11.6% in Jasper County to a high of 16.7% in Angelina County, yet both are significantly lower than Texas or the US. Household income and insurance status, which are closely linked to education level, also impact community health. Affecting change in these areas will require a generation of effort.

6. One of the key findings of the CHNA – and one that will require a lot of thought and planning to address – is the inadequacy of local and regional transportation. Lack of transportation impacts access to preventive services and early detection of illness as well as access to treatment and follow up.

As a result of the needs identified in CHI’s 2019 CHNA, with few exceptions, premature death rates in our region are higher than the State in virtually every category. This CHNA must not be an exercise on paper only. Follow up must happen. We have a good idea now of the need. We also have strong communities with excellent resources that can come together to find and implement solutions. Our health depends on it.

Achieving Equitable Cancer Care Access in Texas

Much is known about what influences the health of a community, including individual health behaviors as well as social and economic determinants of health.[1] Health equity has been defined to mean that everyone has a fair and just opportunity to be as healthy as possible.[2] Being un- or under-insured puts people at serious disadvantage when it comes to access to healthcare and potential for positive health outcomes.

The Affordable Care Act (ACA, or Obamacare) provides an opportunity for states to expand health coverage to low-income families through the Medicaid program. Multiple recent analyses demonstrate that Medicaid expansion is having an especially positive impact in rural areas in expansion states.[3] Many expansion studies point to improvements across a wide range of measures of access to care.[4] Finally, research shows that Medicaid expansions result in reductions in uninsured hospital or other provider visits and uncompensated care costs, whereas providers in non-expansion states have experienced little or no decline in uninsured visits and uncompensated care.[5]

Texas is one of thirteen states that has chosen not to expand Medicaid. The majority of states not participating in Obamacare expansion are in the Deep South,[6] and these states are also the states in the lowest quintile in overall health as ranked by United Health Foundation.[7] (The State of Texas ranks 37th in overall health in the United States.[8])

That’s not to say the State of Texas doesn’t spend a lot of money on healthcare. According to the Comptroller’s office,[9] healthcare spending represents nearly half the state budget - $42.9 billion in fiscal 2015 – spread across various agencies. Seventy percent, or $30.3 billion, went to spending for Medicaid and CHIP. That spending also includes direct support of various institutions.

For example, the University of Texas MD Anderson Cancer Center, which markets itself heavily as “the nation’s top hospital for cancer care for 14 of the past 17 years”[10] and “one of the nation’s top two hospitals for cancer care every year since the [US News & World Report America’s Best Hospitals] survey began in 1990,”[11] has an operating budget of $5.2 billion and over 20,000 employees.[12] Of that $5.2 billion, 4% - $210.1 million – is general revenue appropriated by the State of Texas.[13]

As a radiation oncologist, I practice in the shadow of MD Anderson, even though I live 120 miles north of the Texas Medical Center. It is a long shadow. That shadow is often comforting, like an old friend. But it is a shadow that discriminates with strict financial barriers and selective insurance contracts. There is a joke in the medical community that the first and most important biopsy you get at MD Anderson is a wallet biopsy – no pay, no play.

MD Anderson does participate in the Texas Medicaid Program and has a financial assistance program for cancer patients who meet residency and certain financial eligibility requirements.[14] Uncompensated care in fiscal year 2018 at MD Anderson totaled only $170.4 million,[15] certainly less than the $210.1 million appropriated by the State of Texas and less than 3.3% of their operating budget. Modern Healthcare looked at the proportion of charity care provided by the country's 20 biggest not-for-profit hospitals and hospital systems by revenue in 2015 and 2016 and found that the average proportion of operating expenses devoted to charity care was 5.21%.[16]

In fiscal year 2017, MD Anderson provided care to a mere 420 people who primarily had no insurance and who met their financial assistance program requirements.[17] That is barely one unique patient a day at an institution that sees 141,600 patients a year.[18] MD Anderson’s first core value[19] is: “Caring: By our words and actions, we create a caring environment for everyone.” But not everyone gets in.

MD Anderson has a huge and wealthy donor base as well. As just one example, their Moon Shots Program,[20] launched in September 2012, has received $464 million in private philanthropic commitments so far.[21] In 2018 alone, 9.5% of their budget – $498 million – came from restricted grants and contracts and philanthropy.[22]

Let me say, I am in awe of the research that comes out of MD Anderson. They have every right to be proud of their #1 ranking and of having a Nobel Prize-winning scientist on staff.[23] The knowledge that comes out of an institution that sees 141,600 patients a year is staggering. The training of health care providers, including at Harris Health System facilities, is excellent. But I grieve when Texas residents who need the care MD Anderson can provide are prevented from going there.

Ultimately, quality health care is not just about rankings; it must be about access to care as well. As a state-supported institution, MD Anderson needs to loosen its requirements for providing uncompensated care and be willing to negotiate and accept reasonable contracts with insurance providers, especially Medicare Advantage and Obamacare plans. After all, a hospital cannot be “best” if it isn’t best for all. (That is not to let insurance providers off the hook. I have no doubt they shy away from contracting with MD Anderson, knowing less expensive care can be had elsewhere.)

The State of Texas should require minimum levels of charity care and insurance plan participation when hundreds of millions of state dollars are being allocated. State legislators, in view of the substantial economic[24] and health[25] benefits associated with the expansion of Medicaid, should invest in increased health insurance coverage in Texas via the Affordable Care Act. And finally, health care ranking organizations like US News & World Report should include access to care and charity care metrics when ranking hospitals.[26] These are the right – and equitable – things to do.

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[1] https://www.angelinaradiation.com/blog/county-health-where-do-we-begin

[2] https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html accessed 7/5/19

[3] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[4] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[5] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[6] https://familiesusa.org/product/50-state-look-medicaid-expansion accessed 7/4/19

[7] https://www.americashealthrankings.org/learn/reports/2018-annual-report accessed 7/5/19

[8] https://www.americashealthrankings.org/learn/reports/2018-annual-report/findings-state-rankings accessed 7/5/19

[9] https://comptroller.texas.gov/about/media-center/news/2017/170131-health-care-spending.php accessed 7/3/19

[10] https://www.mdanderson.org/newsroom/md-anderson-ranked-no-1-for-cancer-care-in-national-survey.h00-159226512.html accessed 7/1/19

[11] https://www.mdanderson.org/patients-family/becoming-our-patient/why-md-anderson.html accessed 7/1/19

[12] 2019 Quick Facts report of fiscal year 2018 data https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/1/19

[13] 2019 Quick Facts report of fiscal year 2018 data https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/1/19

[14] https://www.mdanderson.org/about-md-anderson/business-legal/office-of-health-policy/uncompensated-care-program.html accessed 7/5/19

[15] 2019 Quick Facts report of fiscal year 2018 data https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/1/19

[16] https://www.modernhealthcare.com/article/20170424/BLOG/170429935/how-much-charity-care-do-not-for-profit-hospitals-provide accessed 7/7/19

[17] https://www.mdanderson.org/about-md-anderson/business-legal/office-of-health-policy/uncompensated-care-program.html accessed 7/4/19 How does MD Anderson serve the low-income population?

MD Anderson has a long tradition of providing quality cancer care for many low-income residents of Texas.

In FY17, MD Anderson provided care to 420 people who primarily had no third-party insurance and who qualified for partial or full financial assistance under MD Anderson’s patient financial assistance program. The estimated unreimbursed cost associated with these patients was $17.5 million.

In addition, MD Anderson provided care to 3,717 people whose primary source of insurance coverage was a state or locally sponsored governmental program such as Medicaid, CHIP, Harris County Hospital District or other Texas county-specific indigent program. The estimated unreimbursed cost associated with these patients was $12.5 million.

MD Anderson’s combined estimated unreimbursed costs for these two categories of patients in FY17 was $30 million.

For the past 23 years, MD Anderson also has provided cancer services at Lyndon B. Johnson General Hospital for low-income Harris County residents. This program is staffed by MD Anderson faculty physicians, nurses and others at an annual cost to MD Anderson of $4 million. The MD Anderson program at LBJ General Hospital more than 1,000 new patients and had more than 12,000 follow-up patient visits in FY13.

[18] https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf At MD Anderson, everything we do revolves around our patients. In Fiscal Year 2018, more than 141,600 people sought the superior care that has made MD Anderson so widely respected — 45,000 of whom were new patients.

[19] https://www.mdanderson.org/about-md-anderson.html accessed 7/4/19

[20] https://www.mdanderson.org/cancermoonshots.html accessed 7/5/19

[21] https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/5/19

[22] https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/5/19

[23] https://www.mdanderson.org/newsroom/nobel-prize.html Jim Allison, PhD

[24] https://www.perrymangroup.com/media/uploads/reports/perryman-economic-benefits-of-expanding-health-insurance-coverage-in-texas-03-2019.pdf accessed 7/7/19

[25] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[26] Why did U.S. News adjust for socioeconomic status? In 2014, the National Quality Forum, an influential standard-setting body, recommended considering socioeconomic status in certain evaluations of hospital performance. Since our objective is to enable a patient who is consulting our ratings to make apples-to-apples comparisons among hospitals, it follows that we should adjust for patient attributes such as age, sex and socioeconomic status. https://health.usnews.com/health-care/best-hospitals/articles/faq-how-and-why-we-rank-and-rate-hospitals accessed 7/4/19

County Health: Where Do We Begin?

First, let me say that the title implies that we are not doing anything for community health, which is certainly not true. The Angelina County & Cities Health District does amazing work, day in and day out, to provide primary care, immunizations, preventive services, and much more. Our two hospitals – and the physicians, nurses, and other personnel who staff them – are monumental institutions of care, providing both emergency and specialty services (like heart surgery, neurosurgery, neonatal care, and cancer treatment) that many towns our size could only dream of. Our city and county governments help in their own way, with everything from parks, sidewalks and public transportation to smoking ordinances that, together, form a net of support for any broad public health initiative.

But now what? Last month, I wrote of our poor county health ranking (as determined by the Robert Wood Johnson Foundation) and the fact that Angelina County is dead last in Health Behaviors, which includes adult smoking, adult obesity, physical inactivity and access to exercise opportunities, excessive drinking and alcohol-impaired driving deaths, sexually transmitted infections, teen births, and food environment index. Collectively, we’ve got to do more to improve the health of the residents of Angelina County.

As President and CEO of the Episcopal Health Foundation Elena Marks loves to say, health is not healthcare. We cannot spend our way to health by doing more medical procedures writing more prescriptions for illnesses. Once people reach the healthcare system (emergency room or hospital, for example), so much of what determines true health has already been ignored.

What are the determinants of health? Dr. Paul McGaha, formerly with the Texas Department of State Health Services and now Chair of the Department of Community Health in the School of Community and Rural Health at UT Health Science Center in Tyler, describes four broad categories that determine a community’s health. First are social and economic factors, which are 40% of health determinants. These factors include education level, employment, income, family and social support, and community safety. Health behaviors, such as tobacco use, diet and exercise, alcohol and drug use, and sexual activity, accounts for 30% of a community’s health. Our physical environment, such as air and water quality and housing and transit availability, are responsible for 10% of our health. That leaves only 20% for what most people think is actually responsible for a community’s health, and that is actual access to and quality of healthcare. Unfortunately, healthcare expenditures nationwide are so unbalanced that 97.5% of spending – a staggering $3.3 trillion – is for that clinical care which only accounts for 20% of health. In other words, only 2.5% of healthcare spending goes to 80% of what determines our health as a community.

The facts are that US healthcare spending – dollars spent on actual care – far exceed other countries, and US spending on “social services” – including education, parks, public safety, transit, public health, etc. – is significantly less than other countries. What do we get for all that healthcare spending? Worse outcomes and lower life expectancy. Yet spending on healthcare continues to rise.

If we are to improve our county health rankings, we must attack determinants of health on all fronts. Much of that attack must come from outside the healthcare community, though those of us in healthcare need to both inform and encourage that discussion. We must consider the community health needs and ramifications in everything we do. How do we affect overall community health by curriculum choices in the schools, choice of grocery store displays (not to mention availability of fresh, healthy groceries), availability of parks and sidewalks, public safety, welfare, public health spending?

To that end, DETCOG has an opportunity to work with the Episcopal Health Foundation to access county by county data on healthcare and social services spending (analyzed by health economist J. Mac McCullough, PhD, MPH) so that we can learn how spending decisions impact the health and well-being of our residents. From that, we can explore opportunities to impact the health of our entire community by allocating our precious city and county funds for the biggest bang for the buck. Along with possible school-based initiatives mentioned last month, we must continue to look outside the box of traditional healthcare spending for ways to actually improve community health. As they say, it isn’t brain surgery. And that’s the point.

We can’t afford to pay for all the healthcare we are currently providing and projected to need in the future. The beautiful thing is, by wisely directing our resources now, we will be healthier and less of a burden to care for in the long run. That, my friends, is a win-win!