Disparities

(Lisa Guernsey, our colleague in the New America Foundation Early Education program, has been tracking the home visitation program in the new Affordable Care Act. The program sends nurses to do home visits to the homes of low-income women who are pregnant or caring for babies. We're crossposting most of the piece she did for the Early Ed Watch blog this week. Her focus, for her blog's readers, is quite specific about the grant application process and timetables. If you want more background on what the program does-- and the evidence that it works -- read her earlier posts here and here and a recent podcast with a short written summary here.)

For the early education field the home visitation program is a bright spot in the new health legislation.

Over the summer, states will be preparing applications to receive federal funding for the program, which is considered a critical piece of the broader vision for a birth-to-age-8 system of early care and education. The first application is due July 9.

The home visitation program (officially titled the Affordable Care Act Maternal, Infant, and Early Childhood Home Visiting Program) is designed to disburse $1.5 billion in grants to states over the next five years. (See this helpful summary from the Center for Law and Social Policy.)

Maggie Mahar at Health Beat did a nice job on the recent New England Journal of Medicine article pointing out that it's not only treatment that varies greatly from place to place, it's diagnosis. As she notes, dinner party conversation in New York might be all-illness all-the-time (when I lived there, it was real estate, but never mind), but those same dinner guests in a different city might not have such a lengthy list of diagnoses -- and may not be any worse off for it. There's a fine, and not always easy to see, line between helpful early detection of diseases that can then be well-managed and unhelpful early detection of conditions that may then be overtreated. Here's her summary:

A startling study published in the New England Journal of Medicine reveals that just as doctors in some towns are more aggressive in treating their patients, physicians in some places are more likely to send patients for tests, and to subspecialists. As a result, their patients are diagnosed with more diseases. Thus, if a Medicare patient who was living in Phoenix (and feeling perfectly healthy) moves to Miami, he may suddenly discover that he suffers from two or three chronic conditions.

(I posted this earlier this week as part of my bimionthly "What Works" series for the Altarum Institute's Health Policy Forum.)

Eight months pregnant, Elvira, 28, was poised, articulate and confident through a two-hour prenatal class. Then she formed a circle with 10 other mothers-to-be, caught a skein of bright pink yarn a nurse tossed to her, and burst into tears of gratitude.

“Thank you, thank you, you have taught me so much,” Elvira said, clasping one strand of the yarn and tossing the skein on to another young woman, who gripped her strand, and tossed it on. The yarn crisscrossed their circle, binding them together in a flash of hot pink.

Here's something that makes no sense to me.

Last summer, in one of my favorite posts on this blog, I wrote about an ambitious, creative attempt to reinvent and improve health care for low-income people with chronic disease in Washington DC -- which describes a lot of the residents of our nation’s unhealthy capital. The Chronic Care Initiative included rival hospitals and community clinics -- people who don’t often sit down in one room together -- in a collaborative quality initiative that included projects ranging from cell-phone apps for diabetes self-care to strategies for getting hospitals to let clinics know when their patients are admitted (which turns out to be way way way harder than it sounds). I have had the privilege of sitting in on a few of the group’s sessions, and had planned to write more about the individual projects as they come on line in the next few months.

Just a quick thought related to Allie's post on child obesity. (And see posts here and here.) We hear a lot about social determinants of health, and the need for sidewalks, walking paths, playgrounds and other places for kids to move around and exercise. Some people tend to dismiss this as do-gooder daydreaming, not health policy. But the March Health Affairs includes a study by Gopal Singh and associates that demonstrates how the environment affects childhood weight. Look at this chart: 

We have written before about an interesting and ambitious initiative to improve care of low-income people with chronic diseases here in D.C., and some of the people involved allowed me to sit in on a brain-storming session earlier this week. The topic was self-care. How to get patients invested in, and capable of, managing their own chronic diseases. 

One of the public health steps within health reform legislation that hasn't gotten much attention is covering smoking cessation in Medicaid. The Senate will cover it for pregnant women under Medicaid, which itself will be expanded. The House goes further, covering smoking cessation for all Medicaid beneficiaries. 

The Campaign for Tobacco Free Kids is pushing for the House approach. The group's president Matt Myers said in a statement this week:

The final health care reform legislation should require comprehensive coverage of smoking cessation treatment, including medication and counseling with no cost-sharing requirements, for all Medicaid recipients, as the House-passed legislation would

Though more people must rely on it in this time of economic hardship, the safety net in California is about to get a whole lot more holes. 

To deal with a $19.9 billion budget deficit, Gov. Schwarzenegger proposes to slash $2.4 billion from health and human services. This is on top of the roughly $2 billion in cuts to health care that were part of last year’s budget deal.  Attempting to explain the austerity of his budget proposals,  the governor declared, “In this budget I refuse to raise taxes, because there are so many other areas where Sacramento can be smarter, more efficient, and save precious taxpayer dollars.”

In her post earlier this week about the debate about the future of the State Children's Health Insurance Program under health reform, Allison Levy mentioned the challenge of low Medicaid payment rates to doctors -- so low that many doctors won't take Medicaid payments. So while Medicaid on paper has a better benefit package than SCHIP, it's hard for low-income people to get those benefits if they don't have a doctor willing to take Medicaid patients.

We get really tired of hearing foes of health reform go on and on about waiting lists in Canada and how it's rationing... And how nobody in the United States lacks care because they can always go to the emergency room. We know that yes, people in other wealthy industrialized countries sometimes wait for elective procedures, but here in the United States people -- particularly the poor and the underserved or the uninsured -- do plenty of waiting and postponing even when lives are at stake.