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

Money, Insurance, and Health: An Unfair Relationship

Money doesn't buy happiness, or so they say. But money can buy better health. Add one more difference between the haves and the have nots.

There are many determinants of health. Some behaviors are more under our individual control than others. The Big Three, as I like to call them – smoking, diet, and exercise – would, at first glance, seem to be entirely personal choices. That would be untrue.

Social and economic factors are a major determinant of health. These factors include education level, employment, income, family and social support, and community safety. Each of these factors is correlated with financial well-being. In fact, these social and economic factors as a whole are more important even than individual health behaviors, such as tobacco use, diet and exercise, alcohol and drug use, and sexual activity, since health behaviors also correlate strongly with educational level, employment, income, etc. In other words, we cannot address health behaviors in isolation; we must simultaneously address education, jobs, social services, and community safety if we are to improve health.

Another significant determinant of health – the one that gets the most national attention – is access to and quality of healthcare. In the United States, that access is governed primarily by insurance coverage. Every country rations healthcare; in the United States, we just happen to ration it by separating the insured from the uninsured, and that is very much along economic lines. A privileged few are wealthy enough to be able to pay out of pocket for whatever care they need, but they rarely need to. They have insurance. Good insurance. They can afford to pay their deductible, however high it may be. The working poor, however, have some income but little or no savings and often no health insurance coverage at all. They are the ones who get hit with the entire, undiscounted bill for their care. Bankruptcy is an all-too-common result.

Our healthcare system does make some patchwork provision for the truly indigent, but no one should kid themselves that charity care is in any way equivalent – either in breadth of coverage or ease of use – to what we want for ourselves. Even those with insurance are burdened with astronomical deductibles and copays that most simply can’t afford. These persistent financial burdens can force patients to choose less expensive procedures or to go without care altogether.

And then there is Obamacare.

Implementation of the Affordable Care Act, aka Obamacare, started in 2010, when 16% of the US population – more than 40 million people – were uninsured. Healthcare provided since the advent of Obamacare is, as promised, both more affordable and more available. The percentage of people without health insurance has been cut in half.

The dirty little secret is that many healthcare providers don’t take Obamacare plans, funneling patients into inadequate primary care networks and forcing them to drive long distances for more specialized care. In other words, even under Obamacare we continue to ration care with money-related barriers. No question, Obamacare is far from perfect, but it is still better than nothing.

Ray Perryman, considered by many to be the Texas economist par excellence, issued a report in April 2019 titled Economic Benefits of Expanding Health Insurance Coverage in Texas. In this report, Dr. Perryman states, "Health care needs do not simply go away because individuals do not have insurance coverage. Instead, medical issues tend to escalate and lead to higher costs and worse outcomes. Texas would gain over $110 billion in new Federal health spending during the first 10 years." For the callous who are only interested in the economic benefit accrued to the state’s coffers, this report delivers that in spades.

Guess what, though? According to the Perryman Group report, expanding health insurance coverage in Texas also would result in enhanced “health and wellbeing of individuals directly affected by receiving coverage” as well as “reductions in the numbers of uninsured, fewer emergency room visits, improved health outcomes, enhanced employment and productivity, and other desirable developments.” That is a win-win, my friends.

There has been little political appetite to expanding coverage in Texas for fear of “socialized medicine” and an ever-more-intrusive Federal Government. I get it. We can have differences of opinion about whether and how much healthcare is a “right”, how much “responsibility” is required along the way, and the role of government in healthcare. But, leveraging $9.00 in federal resources for every $1.00 in state funding that results in improved health and return on investment is a bet I would make any day of the week.

Our individual and community health depends on many things. Money – or lack thereof – is the most insidious factor. Improving the health of an entire county, as measured by the Robert Wood Johnson County Health Rankings, will require a concerted effort on both the public and private sector fronts and with both large and small scale efforts. Expanding health insurance coverage in Texas via the Affordable Care Act would be an impactful place to start.

The Anti-Vaccination Movement is Fake – and Dangerous – News

Most vaccine-preventable diseases of childhood are at or near record lows. Vaccines prevent the deaths of about 2.5 million children worldwide every year. Yet some highly contagious diseases like measles and whooping cough still pop up where enough people are unvaccinated.

In the United States, compliance with childhood vaccinations remains quite high overall. At least 90 percent of children are getting the recommended vaccinations on time for many diseases – but not all, and not in all locales. Maintaining a high percentage of children vaccinated is important. Herd immunity occurs when a certain threshold percent of a community (such as a school) is vaccinated, reducing the probability that those who are not immune will come into contact with an infectious individual. For highly infectious diseases like measles, 90 to 95 percent of a community needs to be vaccinated to provide herd immunity. That is why vaccinations are required for our schoolchildren.

According to the Texas Department of State Health Services, students are required to have seven vaccinations in order to attend a public or private elementary or secondary school in Texas: Diphtheria/Tetanus/Pertussis (DTaP/DTP/DT/Td/Tdap), Polio, Measles, Mumps, and Rubella (MMR), Hepatitis B, Varicella (chicken pox), Meningococcal (MCV4), and Hepatitis A. Texas law allows physicians to write medical exemptions if they feel the vaccine(s) would be “medically harmful or injurious to the health and well-being of the child or household member.” All well and good.  Texas law also allows – ill-advisedly – “parents/guardians to choose an exemption from immunization requirements for reasons of conscience, including a religious belief.” The “belief” of the anti-vaccination movement is based on lies and is only “religious” in its cult-like following of a dangerous (and discredited) Pied Piper, Andrew Wakefield.

A 2017 Washington Post article states, “A leading conspiracy theorist is Andrew Wakefield, author of the 1998 study that needlessly triggered the first fears. (The medical journal BMJ, in a 2011 review of the debacle, described the paper as “fatally flawed both scientifically and ethically.”) Wakefield’s Twitter handle identifies him as a doctor, but his medical license has been revoked. The British native now lives in Austin, where he is active in the state and national anti-vaccine movement.”

The political noise made by these charlatan zealots has been difficult for legislators to ignore. This disturbing movement has been gaining traction especially in certain private schools in Texas. In one such school, the Austin Waldorf School, reportedly more than 40 percent of the school’s 158 students are unvaccinated. This is mindboggling ignorance in a “school” where tuition ranges from $11,450 to $17,147 a year.

Baylor College of Medicine professor Peter J. Hotez, MD, PhD, Founding Dean of the National School of Tropical Medicine and Director of the Texas Children's Hospital Center for Vaccine Development is truly on the front lines of the battle being waged by the anti-vaccination movement. The fact that Dr. Hotez is both a world authority on infectious disease and a parent of an autistic child hasn’t stopped the anti-vaccination movement from attacking him. It does, however, make their attacks even more sad; they have no facts to back up their case, so they just get mean (for example, saying he is in denial that vaccination caused his daughter’s autism).

This insidious – and disproven – idea that vaccines are linked to autism continues to rear its ugly, dangerous head, despite what Dr. Hotez calls “rock-solid proof” to the contrary published in peer-review journals like the New England Journal of Medicine, JAMA (the Journal of the American Medical Association), the British Medical Journal, and by organizations like the Institute of Medicine and the American Academy of Pediatrics. The data that originally was claimed to show a link between vaccines and autism was later found to be falsified. In other words, the anti-vaccine crowd is fueled by conspiracy theories and truly fake news. (Though not known with certainty, it is believed genetics and environmental exposure during early pregnancy may play a role in development of autism.)

The problem with conspiracy theories is that facts don’t matter. Those who try to argue based on facts are automatically considered part of the conspiracy. Unfortunately, President Trump was rumored early in his presidency to favor a proponent of this ‘vaccines cause autism’ theory to chair a new commission on vaccines, lending credence to the lies. Thankfully, those commission efforts appear to have stalled.

Some argue against vaccinations on the basis of parental rights. I’m so sorry, but you do not have the “right” to endanger others’ children. It is a time-honored role of government to provide a safe, healthy environment for its citizens. Just look at the public health disaster in Flint, Michigan, where the government abdicated its responsibility.

Texas needs to stop allowing nonmedical “conscientious” exemptions in our schools. Your “right” to ignorantly and dangerously keep your child from receiving vaccinations stops at the schoolhouse door. California made it tougher for parents to opt out of vaccination compliance and vaccination rates increased. Texas should do the same.

In this New Year and upcoming legislative session, may the Texas Legislature resolve to pass legislation limiting nonmedical exemptions. Here’s hoping they can ignore the cacophony of lies and claims of “rights” of those who try to stop them. Those liars endanger all our children, and that is not a right they should have.

Support Raising the Smoking Age to 21

The 85th Texas Legislative Session is in full swing. On Wednesday, February 15, a bill was filed in the House by Representative (and physician) John Zerwas (R) to raise the smoking age in Texas to 21 (so-called Tobacco 21, or T21 for short). A companion bill has been filed in the Senate. This is truly a bipartisan effort and is a great idea. For decades now, the legal drinking age has been 21. Tobacco kills far more people than alcohol, and almost all long-term smokers start smoking before they reach the age of 21.

Deep East Texas contains the lowest ranked counties in Texas for health outcomes, and part of that is due to our higher smoking rates. Nearly 90 percent of adults who smoke started smoking before the age of 18 and nearly 100 percent started by age 26. 18- and 19-year-old smokers are a major supplier of cigarettes for younger kids, who rely on friends and classmates to buy them. Raising the smoking age to 21 can help decrease our smoking rates as well as save tax dollars on future healthcare spending related to tobacco use.

Speaking of tax dollars, annual Texas health care expenditures directly caused by tobacco use amount to a whopping $8.85 billion, and we taxpayers bear part of that cost. The State Medicaid program’s total health spend as a result of tobacco use is $1.96 billion. No, we can’t save all of that, unfortunately, unless no one smokes. However, Jeffrey Fellows, PhD, in a Center for Health research report wrote, “Increasing the smoking age to 21 [in Texas] would result in 30,500 fewer smokers after three years, and lead to $185 million in reduced healthcare expenditures and productivity costs over five years. Lower cigarette excise tax revenue of $3.4 million would reduce the 5-year net savings; however the state would still generate a net financial savings of just under $182 million.”

It isn’t just about dollars; it’s about lives, too.

The Institute of Medicine predicts that smoking prevalence would decline by 12 percent if the national minimum age of sale was raised to 21. One of their models also predicted that raising the national minimum age of sale to 21 would result in approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those individuals born between 2000 and 2019. Smoking kills.

In case you wonder if the tobacco companies think this will work, here’s a quote from a 1986 Philip Morris report (one of the largest suppliers of tobacco products worldwide): “Raising the legal minimum age for cigarette purchaser to 21 could gut our key young adult market (17-20) where we sell about 25 billion cigarettes and enjoy a 70 percent market share.” To the tobacco industry, it is always and only about market share and profit.

Raising the smoking age to 21 isn’t the only answer to our smoking and poor health epidemic. Many cities and even entire states have gone smoke-free. Texas needs to. Dietary and exercise components of good health also need to be emphasized. But if we can lessen the number of the next generation who start to smoke simply by increasing the smoking age of to 21, why wouldn’t we? That’s right… there is no good answer. For a healthier Texas and Angelina County, support Tobacco 21.

Resolve to Improve the Health of our Region

January is a time of resolution, and often our New Year resolutions focus on diet and exercise. My friends, we need a city, county, and region resolution to lose weight!

In July, 2016, Sabrina Perry wrote an article for HealthGrove.com – a health data analysis and visualization site – titled, The County with the Highest Obesity Rate in Every State. She repeated the American Medical Association’s contention that obesity is a disease and noted that the World Health Organization considers obesity a global epidemic. I perused the article with interest, looking for the county in Texas that got the dubious honor of being the fattest. Unfortunately, it was our very own Angelina County.

Look around and it is evident. Angelina County has the highest obesity rate in Texas, coming in at 37.5%. That means nearly 4 out of 10 of us aren’t just overweight; we are downright fat. To achieve the dubious distinction of being fat, you have to get to a body mass index (BMI) of over 30. To give you an idea what it takes to qualify as obese, consider a 5’11” male such as myself. My appropriate weight is less than 180 pounds (and probably more like 160 pounds). Any more than that and I am considered overweight. But to be considered obese – which is what 37.5% of Angelina County residents are – I would need to weigh 215 pounds or more. For me, that would be at least 35 pounds overweight, if not more. I routinely see patients with a BMI of 40 or more, which is considered extreme (or morbid) obesity. That would be a whopping 100 pounds overweight for me.

What can we do?

Dan Buettner, author and founder of bluezones.com, has been writing for years about particular geographic pockets around the world where people live longer. According to the website, “Residents of the Blue Zones live in very different parts of the world. Yet they have nine commonalities that lead to longer, healthier, happier lives.” So much of this is what has been preached to us for decades: don’t smoke, eat your vegetables and legumes, exercise, don’t overeat, and drink wine in moderation. On top of this are stress-related factors, having strong family and friend relationships, and spirituality.

It’s not just that we are obese. Our overall health is terrible. The Robert Wood Johnson Foundation ranks population health by county. In Texas, many of the lowest ranked counties are in deep East Texas. Wouldn’t it be great if Lufkin could be known not just for pump jacks and forests, but also for the health of our citizens? This can only work for communities if each of us individually works at it. We have family, friends, and lots of churches. Strengthen those relationships. And, let’s stop smoking, exercise, and eat right!

I recently participated in a set of strategic planning sessions hosted by the Texas Forest Country Partnership called Stronger Economies Together, or SET. The purpose was to set goals for growth across a broad spectrum of our regional economy, from forestry and tourism to manufacturing and healthcare. Our SET healthcare workgroup noted that we have significant work to do if we are going to impact the poor healthcare factors and outcomes the Robert Wood Johnson Foundation identified in the deep East Texas region. We set an ambitious goal simply to raise our overall health ranking from the lowest 20% to the next lowest; in other words, from poor to still below average. But we have to start somewhere.

This will require a multi-year effort working with all aspects of the healthcare and social service community to start to move the dial toward a healthier region. We can do it, but we all need to make – and keep – that that resolution for better health!

Colorectal Cancer Screening: 80% by 2018

Katie Couric has raised awareness of colorectal cancer ever since her husband died of the disease in 1998. Yet colorectal cancer remains the second leading cause of cancer death in the United States, only surpassed by lung cancer. Both are preventable: lung cancer by not smoking, and colorectal cancer by screening for and removing precancerous polyps.

The American Cancer Society has teamed up with the CDC (the Centers for Disease Control and Prevention) and other organizations to set an ambitious goal of screening 80% of eligible people for colorectal cancer by the year 2018. Screening for colorectal cancer is incredibly important because removing precancerous polyps actually prevents colorectal cancer. Across the nation, if 80% of the eligible population gets screened, it would prevent 277,000 new cases of colorectal cancer and 203,000 deaths (270 of those in Angelina County!) within 20 years. Those are staggering numbers.

Why so high? Because one in three adults in the United States between ages 50 and 75 – about 23 million people – are not getting tested as recommended. In Texas in 2016, there will be 9,680 new cases of colorectal cancer and 3,520 deaths. This translates in Angelina County to about 36 new cases and 14 deaths this year alone. Remember, these are preventable deaths.

How are we going to achieve this screening goal locally?

The Angelina County & Cities Health District, CHI St. Luke’s Health Memorial, the Temple Cancer Center and our local gastroenterologists have teamed up with the American Cancer Society and CPRIT – the state-funded Cancer Prevention Research Institute of Texas – to educate our area population and screen eligible patients for colorectal cancer through a cooperative grant headed by UT Tyler. Most insurances cover routine screening, but this group stands ready to make sure that any eligible patient, whether insured or not, has access to life-saving screening and, if a cancer is found, treatment as well.

There are many ways to be screened, but I want to focus on the two most available. These two  - colonoscopy and FIT testing – are also funded under the CPRIT grant and by almost all insurances. Having a colonoscopy is the best test, in my opinion, because if any polyps are found they can be removed right then and there. If the colonoscopy is negative, nothing else needs to be done for 10 years! My wife and I had ours done the year we turned 50, and it really is not a big deal. Yes, you have to do a bowel prep to clean out your colon, but that is a small price to pay for peace of mind for 10 years.

The second test covered under the CPRIT grant – and the one that will be done most often at the Health District – is the FIT (fecal immunochemical) test. It is a test for hidden blood in the stool, which can be an early sign of colon cancer. This test is done at home by using a small brush to collect some stool and place it on a test card. The test kit is then mailed back to the clinic for processing. The FIT test must be done every year, as opposed to the colonoscopy every 10 years, but it is cheaper and doesn’t require a bowel prep. If the FIT test is positive, a colonoscopy is then necessary.

If you are between the ages of 50 and 75 and have not had a colonoscopy in the last 10 years or had an annual FIT test, ask your doctor to schedule you for one. If you do not have insurance, call Angelina County Connects at (936) 633-1442 and ask the eligibility specialists if you qualify to be screened under the CPRIT grant. Let’s work together to prevent cancer and get to 80% by 2018!

A Texan, West or East?

I am a 4th generation Texan, born in Abilene and raised in Midland. Moving away from West Texas wasn't easy for many reasons, but mainly because I didn't want to take my kids too far from their grandparents. East Texans understand this well, because everyone is related! I was warned early on that you don't talk bad about anyone in East Texas because they are probably related to the person you are talking to. Can I get an Amen?

Tired of feeling left out of the "related-to" crowd, I told Rosemary Blackstock one time many years ago that I was related to a native Lufkinite. She got all excited and asked, "Who?" When I confessed it was my youngest daughter, Phoebe, she deflated a bit and quipped that it wouldn't really count to some old Lufkinites unless she had gone to Kurth Elementary. Of course, Rosemary is actually from San Augustine, which makes the whole "Who's from Lufkin?" joke even funnier. But that was another time, and no one really cares any more.

Anyway, when Catherine and I were considering moving to Lufkin, my mother - who wasn't too keen on us taking the grandkids so far away - engaged in just a tad bit of guilt tripping and manipulation. The conversation went something like this:

Mom: You know there are fire ants in East Texas.

Me: Yes, mother, I know.

Mom: You know there are roaches, too.

Me: Yes, mother.

Mom: It's so hot and humid. And, it rains all the time, and you can't see anything for all the trees.

Me: (Sigh.)

When none of that seemed to work to convince me not to move, she pulled out the trump card (or, in 42-playing West Texas, a domino): "You know, your kids are going to grow up speaking like East Texans..."

Well, that nearly did it, because the only East Texan I knew through my college years was a Baylor friend of Catherine's from Tyler, who had a syrupy, southern-in-the-excess whiney drawl that, luckily, I have rarely heard since.

Undaunted and unintimidated, we made the move. That was more than 20 years ago, and we never looked back.

Don't get me wrong. I appreciate the West Texas desert and its austere beauty. I love driving out to Midland into the expansive, color-swathed West Texas sunset. The pioneer, can-do spirit in West Texas is a big part of what fuels our economy. The bittersweet smell of an oil refinery is the smell of money. (Somehow, the odor from paper mill never had the same connotation to me.)

But I am an East Texan now. I love the trees. I think I appreciate the pine trees even more than many East Texans, who simply want to cut them down. The variety of hardwoods is astounding. And when spring comes around with its procession of pear blossoms, dogwood, redbud, and wisteria, there is no place I'd rather be. I told my mom I can kill fire ants and roaches. (She didn't know about copperheads, water moccasins, and love bugs, thank goodness!) Yes, the heat and humidity is awful. No way around that. But the people in East Texas are friendly, hospitable, incredibly generous, grateful, and loyal folk. I'm a Texan and Lufkin is my home. Oh, and my kids don't have TOO much of an accent... at least, not as thick as my mother's!