Earlier this summer I was interviewed for an article in MetroDoctors, the journal of the Twin Cities Medical Society (TCMS). The focus of the September/October issue was health disparities. I thought you might be interested in how I responded to their questions. My interview is included below. If you would like to see the entire content of the issue, go to:
A Conversation with Edward Ehlinger, MD, MSPH
Minnesota is reported to be one of the healthiest states in the nation - what needs to be done to preserve that title from a population health standpoint?
Almost every study and report ranks Minnesota as one of the healthiest states in the country. Minnesota has the second longest life expectancy at birth and one of the lowest infant mortality rates. The state also has the sixth longest life expectancy after age sixty-five and Minnesota seniors are considered the healthiest in the country. The common belief is that our good health is due to our great medical care system (rated number one in the country) and good insurance coverage (second best in the country). The reality is that medical care is a relatively small contributor to our overall health – around 10% by most calculations.
The biggest contributors to health (40% - 60%) are socio-economic factors like education, income, individual and community-level wealth, mobility, and housing. Overall, Minnesota does well in these categories which is reflected in our health status. However, Minnesota also has some of our country’s greatest disparities in these “social determinants of health,” so it’s not surprising that our state also has some of the greatest health disparities. These disparities are manifested most dramatically in populations of color and American Indians. Given the rapidly increasing number of individuals of color in our state, simple math tells us that unless we reduce these health disparities we will not be able to maintain our ranking as one of the healthiest states. Evolving research on this topic is demonstrating that disparities negatively affect everyone in the community. The health of people at the top of the socio-economic spectrum is diminished by health disparities. Paul Wellstone was correct when he said that “we all do better when we all do better.”
To reduce these disparities, we must first change the narrative about what creates health. We need to recognize that the biggest determinants of health are not medical care and personal choices but the socio-economic factors that affect all of us. We also have to acknowledge that how these factors affect us didn’t occur by accident; they were established by policy decisions at national, state, and local levels and that many of these decisions benefit the white population and disadvantage populations of color and American Indians. This is known as structural racism.
Achieving healthy equity is the central challenge for Minnesota if we are to remain one of the healthiest states in the nation. Modifying our policies, systems, and environments to support the achievement of that goal is crucial to the success of our state.
How does Minnesota compare to the rest of the country in terms of health disparities? Are there any models of healthcare equality from other states/countries being used as guides for Minnesota's plan for the future?
Minnesota has some of the greatest health disparities in the country, including the greatest black/white disparity in infant mortality and the third greatest disparity in unhealthy life after age 65. Some of that is due to the good health of the white population but a great deal is due to the poor socio-economic status of minorities in our state. While national comparisons are useful, we’ve begun to focus our comparisons on the states in which Big 10 universities are located (states more comparable to MN and which also have some of the highest levels of disparities). Even with this focus, Minnesota does not fare well. Minnesota has the greatest black/white disparity in income, poverty, high-school graduation, and home ownership. Given this, our health disparities are not surprising.
Even though Minnesota has some of the greatest health disparities in the country, no state is doing well in achieving health equity. Although there are currently no good state models about how to effectively address disparities, there are some historical examples about what works. During the “War on Poverty” in the 1960s and 1970s, there was a concerted, comprehensive, and community-based effort to address the social determinants of health. Concurrent with that was a more balanced investment of health and human service resources between medical care, public health, and social services. This strategy led to an overall improvement in health along with a narrowing of health disparities. When this approach was abandoned for a more individual-focused, means-tested, and medically-based approach and funding for public health and social services was reduced, the rate of health improvement slowed, disparities increased, and health care costs began to rise.
The experiences in other countries reinforce what was seen in the U.S. War on Poverty. Where there is a community-based effort to address the social determinants of health and a more balanced investment in medical care, public health, and social services, health outcomes improve and disparities are reduced. These experiences are serving as models for the Accountable Communities for Health that are being developed as part of Minnesota’s State Innovation Model (SIM) grant efforts. A new collaborative between Big 10 universities and their state health departments will also be addressing these issues.
Disparities in health outcomes--what do you see as causes, possible solutions and what can individual health providers do to combat health disparities? Is there a role for TCMS?
While health care accounts for only 10% of overall health, medical care can play a significant role in addressing disparities. Increasing the focus on primary care and integrating that care with public health and social service interventions has been shown to help reduce disparities. Including community health centers and community providers in healthcare networks can also help. Other approaches that show promise are integrating behavioral and mental health services into primary care, care coordination, home visiting, and use of community care teams, navigators, community health workers, and trained interpreters. Diversifying the workforce and enhancing cultural competence would also be helpful. Standardized collection of race, ethnicity, and language data would help to better target and evaluate health care services.
More importantly, the World Health Organization has noted that medical care is also a social determinant of health and that “when appropriately designed and managed, health systems can address health equity…when they specifically address the circumstances of socially disadvantaged and marginalized populations…excluded through stigma and discrimination…and they may be influential in building societal and political support for health equity.” This is where TCMS can play a leadership role. As the voice for physicians in the Twin Cities area, TCMS can continually raise health equity as an issue in policy and healthcare discussions and help influence the broader socio-political environment that impacts ’upstream’ factors like poverty, education, and housing.
Are there community/population specific unique health metrics?
One of the challenges in developing and evaluating programs to address and eliminate health disparities is the relative lack of data for many communities on many of the contributing factors/social determinants, and even on health status itself. Improving the infrastructure for health data collection is a necessary and important step for the development and evaluation of programs to eliminate disparities. Work is being done on standardizing the collection and reporting of race, ethnicity, and language data within the healthcare, public health, and social service systems. Efforts are also underway to incorporate data into the analysis of community health metrics that impact the social determinants of health from non-health agencies, like education, transportation, housing, and economic development.
Federally Qualified Health Centers--how do they play into the mix of serving the underserved, especially in this new reality of expanded health care coverage? Do we need more centers or clinics willing to see people who still may be underinsured or confronting the higher than expected deductibles that they now have through their new health insurance plans?
Community Clinics will play an increasingly important role in advancing health equity. Not only will they be sensitive and responsive to the financial issues that will continue to influence health care decisions by both the patient and provider but, more importantly, they are better suited to address the language, cultural, and community issues that attend many health concerns in immigrant and minority communities. Their community-oriented approach to primary care will be increasingly important as our community becomes more diverse. They can also play a role in organizing communities to advocate for policy changes at the state and local levels that address the disparities affecting their health and prosperity.
Does the psychological stress associated with poverty contribute to poor health? If so, how is this manifested? Are there specific approaches planned or in place to treat and support those afflicted?
The stresses of poverty, racism, historical trauma, and adverse childhood experiences are well documented as significant factors contributing to poor health. On an individual level, the development and implementation of “trauma-informed care” is showing promise in reducing the harms caused by these stressors. On a broader level, a “health in all policies” approach is being initiated to change the policies and systems that disproportionately affect populations of color and American Indians. This approach has the potential to reduce the level of toxic stress experienced by some communities. Reducing community-level poverty, improving educational outcomes, and stabilizing housing will help prevent the adverse childhood experiences that are negatively affecting the health of numerous children.
Does the acknowledged shrinkage of the middle class contribute to poor health in our population? If so, is the eventual solution a political/socioeconomic one or a clinical one?
Where disparities in wealth are the widest, the disparities in health are the greatest. As these disparities increase, the health of everyone suffers, even those at the top of the socio-economic strata. Despite having the best medical care system in the country, our disparities have increased which puts our overall health at risk. The long-term solution is socio-political, not clinical. Investing more in our clinical care system is not the answer. The most effective approach is to invest in a community development strategy that provides everyone an equal opportunity to be healthy.
What are some of the specific mechanisms in place for dealing with the health of children in poverty circumstances?
Family and community health and stability are at the core of addressing the issues of children in poverty. The increase in the minimum wage will play a huge role in improving the health status of children and their families. Minnesota data show that moving from the lowest quintile of income to the second lowest, increases life expectancy by over three years and reduces days of poor health by almost 50%. The investments being made in safe and secure housing will also be significant. Paid parental leave and paid sick leave would particularly help improve the economic and health security of low-income families. Ten weeks of paid maternity leave has been shown to reduce infant mortality rates by 10%. Other income enhancements and a focus on the prenatal to three period in a child’s life show promise of improving the health of low-income children.
Who will be able/eligible to use the services and resources of the Center for Health Equity? How will the Center’s performance be judged?
Advancing health equity is the central focus of all of the activities of the Minnesota Department of Health. Every division, office, program, and center will approach their work with the question of how does their efforts advance health equity. The Center for Health Equity will be a resource for data and health equity expertise for all parts of the agency, help facilitate and coordinate health equity efforts across the agency, and identify new opportunities. The Center for Health Equity contains the Center for Health Statistics, the Office of Minority and Multicultural Health, and the Eliminating Health Disparities Initiatives grants. These resources will be available to anyone in the community. In particular, racial and cultural liaisons and data related to health equity will be available to communities of color and American Indians and to organizations working with those communities. Targeted grants addressing specific high priority needs will also be available.
Where do you hope to see the most significant change in Minnesota's healthcare delivery in the next five years?
Health is not solely the responsibility of the healthcare sector. Overall health is a community responsibility. To optimize the health of all Minnesotans, healthcare must be embedded in the community and be responsive to the needs of the community as determined by the community. Health is a public good and how resources are invested to create health should be determined by and accountable to the public. The community-based models being implemented through the Statewide Health Improvement Program (SHIP), county-based purchasing, and Hennepin Health show promise in improving health, advancing health equity, and reducing healthcare costs. Using what is being learned from these efforts to better integrate clinical care, public health, and social services and in Accountable Communities for Health will play a major role in designing a more effective approach to creating a healthy Minnesota.
What has been your biggest "aha" moment since becoming Commissioner?
I’ve been (and continue to be) an advocate of a single-payer system for health care. However, what I’ve learned since becoming health commissioner is that the mechanism of financing healthcare is far from the most important factor in creating a healthy society. What’s most important are the conditions and circumstances in which people are born, grow, live, work, learn, play, pray, and age; and that these circumstances are often determined by forces beyond the control of the individual including: economics, social policies, politics, and the distribution of money and power. Yet, most people have been indoctrinated into the narrative that health is created by their personal choices about diet and exercise and the quality of the health care system.
The biggest “aha” moment for me was when I saw the energy unleased by articulating a different narrative about what creates health. The narrative that health is really created by economic, environmental, and social conditions resonates with what most people intuitively know about health. It also helps them realize that these conditions are not immutable and can be changed by an organized community effort; that creating a healthy society is their responsibility not just that of health professionals. Seeing communities throughout the state becoming engaged in and empowered to create the conditions in which people can thrive and be healthy has been astounding and makes this an exciting time to be health commissioner.
Reprinted with permission, MetroDoctors,September/October 2014.