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!