Happy Holidays from "Health on the Horizon"!

I will be taking the next 2 weeks off for the holidays, but will return Friday January 6, 2012 where I will continue on my journey around the state of Pennsylvania to see how the Patient Protection and Affordable Care Act applies to groups, individuals and institutions. 2012 should be an interesting year. You will meet a nurse from Lancaster General, explore the health/wealth gap in Philadelphia, meet recent college graduates and see a series on medicare. Above all however, we'll be paying close attention as the Supreme Court begins reviewing the PPACA.

In the meantime, join "Health on the Horizon" on Facebook and Twitter

Peace of the season and best wishes for a happy and healthy New Year! Holly

Happy Holidays from "Health on the Horizon"! 

I will be taking the next 2 weeks off for the holidays, but will return Friday January 6, 2012 where I will continue on my journey around the state of Pennsylvania to see how the Patient Protection and Affordable Care Act applies to groups, individuals and institutions.  2012 should be an interesting year.  You will meet a nurse from Lancaster General, explore the health/wealth gap in Philadelphia, meet recent college graduates and see a series on medicare.  Above all however, we'll be paying close attention as the Supreme Court begins reviewing the PPACA. 

In the meantime, join "Health on the Horizon" on Facebook and Twitter

Peace of the season and best wishes for a happy and healthy New Year!  Holly

Lebanon Family Health Services: Contraceptive Services

This is the fourth of a 5 part series on "Women's Health". Thank you to Lebanon Family Health Services for their assistance with this series.

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Lebanon Family Health Services
Ann Biser, Donna Williams, Kim Kreider Umble, Vicki DeLoatch

According to the National Campaign for the Prevention of Teen Pregnancy, the United States has the highest teen pregnancy rate in the industrialized world.  The United States teenage pregnancy rate is nearly 2X higher than the United Kingdom (the highest in Europe) and 10X higher than Switzerland (the lowest in Europe)[1].  Sadly, this is not shocking news to those that have worked in the field of adolescent reproductive health for the majority of the past half century.  It has been this way for quite some time.  It is a reality that advocates have been screaming about, but has either fallen on deaf ears or become a pandering tool for political debate.

The debate has been wide and has a tendency to tug at the social nerve that lies beneath the American Psyche.  While the issue is complexly intertwined with the dynamics of poverty, the debate concerning its solutions have ranged from attitudes towards sexuality education, access to contraception and cultural attitudes concerning sexuality in general.  The one thing all sides of the debate can agree upon is this:  unplanned teen pregnancy is a problem. 

Teen mothers are 60% more likely to drop out of school which further perpetuates the cycle of poverty and resulting in higher rates of babies being born into poverty[2].  These babies are also more likely to have poor school attendance, drop out of school, have lower cognitive scores, end up in prison and ultimately become teen parents themselves.  A cycle that weighs heavy on our society.  It is estimated that teen pregnancy costs tax payers $10.9 billion annually ($463 million in PA for 2008), but when rates are decreased huge savings can be found.  For example, between 1991 and 2004 we saw a 1/3 decrease in teen pregnancy that resulted in a $6.7 billion savings.[3]

This leads us back to the question posed above.  What are the other industrialized countries doing better than the US that leaves them with much more positive teen pregnancy statistics?  The answer is simple.  They have more open access to healthcare, including reproductive healthcare.

Since 1973 Lebanon Family Health Services has been meeting this reproductive health need for underserved women in Lebanon County.  According to Donna Williams, Chief Operating Officer at LFHS, “We often hear that women receiving medical assistance are treated differently at other offices.  It is important that in order to reach this population with the ultimate goal of improving health outcomes, that these clients are treated fairly and with respect.  In the end, these women will become active partners in their healthcare and society benefits.”

Now with the passage of the Patient Protection and Affordable Care Act, access to contraception will be considered an essential benefit under the preventive health component of the law.  In other words, insurance companies now have to cover birth control.

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[1] United States: Martin, J.A., Hamilton, B.E., Sutton, P.D., Ventura, S.J., Matthews, T.J.,  Kirmeyer, S. & Osterman, M.J.K.. (2010).Births: Final data for 2007. National Vital Statistics Reports,58 (24). Other Countries: United Nations Statistical Division. Demographic Yearbook  2007. New York: United Nations

[2] The National Campaign for the Prevention of Teen Pregnancy.  Counting it Up:  The Public Costs of Teen Childbearing, 2008.

[3] Ibid.

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Breastfeeding provisions in the PPACA



This is the third of a 5 part series on "Women's Health". Thank you to Lebanon Family Health Services for their assistance with this series.

Family Health Services
Ann Biser, Donna Williams, Kim Kreider Umble, Vicki DeLoatch

In 2010, Lebanon County reported that 56.9% of all infants were breast fed at birth; this rate lags far behind the national average of 75% according to the Centers for Disease Control’s 2010 Breastfeeding Report Card.  Furthermore, the CDC’s 2010 Breast Feeding targets were also to see 50% of babies still breast feeding at 6 months, the national average is 43% with Lebanon County’s breastfeeding average duration at 14.6 weeks.    

While much research has shown the immediate as well as long term benefits to breastfeeding such as the development of a healthy immune system and a reduced risk many chronic diseases, there still remains many cultural barriers to women’s ability to breastfeed.  Many of the cited barriers involve cultural acceptance of the practice.

Over the years, Lebanon Family Health Services has been working diligently with its clients to encourage, initiate and support their clients in breastfeeding as part of their WIC program, a challenge that is felt both locally and nationally.  “One of our biggest challenges the staff faces is overcoming the myths surrounding breastfeeding,“ states Sara Wingert, a WIC staff member at LFHS.  “They often express concerns that range from physical discomfort to issues of practicality, such as returning to work.  We spend individual time with clients educating about the benefits and advantages of breastfeeding,” she concluded. 

One of the essential benefits provisions under the Patient Protection and Affordable Care Acts (PPACA) is now to support breastfeeding as part of the preventive care component of women’s health.  All insurance plans must now cover breast feeding supports such as counseling, consultation with a trained provider and equipment rental for breast pumps.  The bill also requires employers to provide reasonable breaktime for mothers who are nursing.

Like many of the provisions included in the preventive health component of the PPACA, the breastfeeding provision falls in line with current research in the area of public health.  By increasing the number of infants that receive breast milk there is a risk reduction in acquiring many acute and chronic diseases such as GI infections, lower respiratory infections, asthma, obesity and diabetes[1].  Therefore, in the long-term, reducing the healthcare costs associated with treating such conditions.  It is estimated that 75% of national healthcare expenditures are spent on treating chronic diseases[2], many of which could be prevented or reduced by utilizing prevention practices such as breastfeeding. 

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[1] S ip et al., “A Summary of the Agency for Healthcare Research and Quality’s Evidence Report on Breastfeeding in Developed Countries,” Breastfeeding Medicine 4, no. s1 (2009):  s17-s30.

[2] “Chronic Disease and Health Promotion,” Centers for Disease Control and Prevention, 2009.

Lebanon Family Health Services: Tobacco Cessation in the PPACA

This is the second of a 5 part series on "Women's Health". Thank you to Lebanon Family Health Services for their assistance with this series.

Lebanon Family Health Services
Ann Biser, Donna Williams, Kim Kreider Umble, Vicki DeLoatch

In 2010 The Lebanon Family Health Services provided 1587 clients with tobacco cessation education and counseling sessions.  Through the years, funding for such programs has been a challenge.  However, buried deep within the 2010 Patient Protection and Affordable Care Act we can find that this will become a mainstream program provided for women’s health.

Under the essentialbenefits component of the PPACA, services that insurance companies are now required to cover, there are provisions for preventive health.    The preventive health element is further broken down into four categories: (1) Evidence-Based Screenings and Counseling, (2) Routine Immunizations, (3) Preventive Services for Children and Youth and (4) Preventive Services for women.    These services are based on the recommendations for the Institute of Medicine and will have no cost sharing on the part of the patient.

According to the Centers for Disease Control, women who smoke during pregnancy are 2x more likely to experience premature rupture of membranes, placental abruption and placenta previa.  Additionally, it leads to their babies having a 30% chance of being born prematurely and with a low birth weight.  These babies are also up to 3x more likely to die of SIDS (Sudden Infant Death Syndrome).  All together, this not only impacts quality of life for infants and children, but racks up costly medical bills.

While a recent study found that only 24% of insurance plans among insured people cover smoking cessation and counseling,[1] research has shown that smoking cessation programs for pregnant women can save as much as $6 for every $1 spent[2].  Given the fact that high risk populations, such as the one served by the Lebanon Family Health Services, are more likely to smoke during pregnancy, this provision would be an asset to their institution.

According to Vickie DeLoatch, “When a prenatal patient comes into our program and shares the challenge that she faces with tobacco addiction, we always view it as an opportunity to effect a positive change. The true appreciation that is expressed when they receive assistance is gratifying.  Help and support is sought to become tobacco free and we can provide this support through the tobacco cessation programs offered at Lebanon Family Health Services”.   

The recently passed Patient Protection and Affordable care act will comply with recommended strategies and policies put forth by the Centers for Disease Control by offering pregnant smokers counseling and cessation interventions from the first prenatal visit and throughout pregnancy.

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[1] Partnership for Prevention, Insurance Coverage of Clinical Preventive Services in Employer-sponsored Health Plans:  Preliminary Results of a Partnership for Prevention/William M. Mercer National Survey, 2001.  Washington, DC.  Partnership for Prevention.

[2] Marks JS, Koplan JP, Hogue CJR, Dalmat ME. A cost-benefit/cost-effectiveness analysis of smoking cessation for pregnant women. American Journal of Preventive Medicine 1990;6(5): 282-9.

Lebanon Family Health Services: Maternal and Newborn Health

This is the first of a 5 part series on "Women's Health".  Thank you to Lebanon Family Health Services for their assistance with this series.

Lebanon Family Health Services
Ann Biser, Donna Williams, Kim Kreider Umble, Vicki DeLoatch

A young couple with a newborn infant fastened to a car seat carrier was exiting Lebanon Family Health Services on a late September day.  In the brightly lit waiting area with neatly arranged children’s toys, a new mother nurses her infant.  Next to her, a pregnant woman waits.  Nutrition information is displayed about the room that is also the home for the WIC program (Women, Infants and Children-special supplemental nutrition program).  As you enter the upstairs hallway, one will find displayed the remnants of a “clothesline project”, an exhibit where colorful t-shirts depict the tragedy endured by those who are survivors of domestic abuse and rape put together by the Sexual Assault and Resource Center.  Each shirt tells its own story of pain, sorrow and agony.  However, like a mother’s embrace, the warmth that permeates the walls of this central Pennsylvania facility encircle the display and all the empowered souls it represents.  They have endured and they are safe in this place.

 It hasn’t always been this way.  In 1973, when Lebanon Family Health Services began, these women had nowhere to go for women’s health services.  Through the years, as the ranks of the uninsured grew, so did the number of women showing up to the emergency room in the Lebanon County community ready to deliver a baby that had never received any prenatal care.  In 1990, their services expanded to include prenatal care.  For over 35 years, The Lebanon Family Health Services has been serving uninsured and underinsured woman with reproductive health and nutrition services. 

 The benefits of prenatal care are conclusive.  Women who receive prenatal care while pregnant experience a dramatic reduction in maternal deaths, low birth-weight babies, miscarriages, birth defects and many other preventable infant problems.  However, with roughly 13% of woman being uninsured and many others considered underinsured because their health insurance policies either do not cover prenatal care or consider it a pre-existing condition, many woman, particularly minority woman are not able to access this vital and research proven medical care.[1]  The sad reality, as the numbers of uninsured has grown over the past few decades, so has the grim statistic of infant mortality.   According to the Centers for Disease Control, in 1960, the United States ranked 12^th in infant mortality, 23^rd in 1990 and 29^th in 2004.

 In 2014, because of the Patient Protection and Affordable Care Act (PPACA), these women that have utilized Lebanon Family Health Services will now be insured.  Above all however, the PPACA also states that as part of the essential benefits, healthcare items that insurance plans are now mandated to cover, prenatal and infant care are included.   It has become a question to many that have worked for decades helping the uninsured acquire access to healthcare what will happen to places like The Lebanon Family Health Services.  For Kim Kreider-Umble, CEO of Lebanon Family Health Services, she welcomes this change.  “Bring them on,” she responds in response to the new inflow of patients.  After all, this is what she and advocates like her have been fighting to achieve for decades.  “Now, this can be a place of choice instead of a place of need for our clients,” she explains.  They plan on marketing directly to this population with their quality services and meet the increased demand with smart utilization of resources such as schedule adjusting and doubling duties.  “After all,” Kim concludes, “Healthcare is a right, not a privilege!”

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[1] “Health Insurance for Pregnant Women,” American Pregnancy Association, http://www.americanpregnancy.org/planningandpreparing/affordablehealthcare.html

To mandate or not to mandate: Is there a question?

The old cliché, “politics makes strange bedfellows” seems to come to mind a lot lately.  This week marked an important week for the PPACA.  In light of 11^th Circuit Court of Appeals rulings regarding the constitutionality of the PPACA, the Supreme Court has decided to take on the case.    While all 5 of the lower Appellate Courts have upheld the law in its entirety, it is the individual mandate that seems to be the pesky element that has rattled the political dialogue.  The individual mandate was deemed unconstitutional in the 11^th Circuit Court.  This ruling has sparked a debate from all angles of the political spectrum. 

 Since its passage in 2010, there are those that sit in the “anti-mandate” camp based on the grounds that the law represents government and congressional over-reach.  This argument insinuates that the mandate is unconstitutional on the grounds that the government can’t force individuals to purchase a product.  This sentiment has resonated with many of those that have supported the Tea Party movement in the past 2 years and expressed by the voters in Ohio last week.

On the other hand, another “anti-mandate” camp argues that the mandate is a reflection of the billion dollar corporate lobbying power of the health insurance industry in the writing of legislation that ultimately becomes public policy.  After all, the mandate will allow the health insurance industry to gain 32 million new unsolicited customers.  This camp argues that if the mandate is eliminated, we can ultimately get big insurance out of the game and open up the doors for “Medicare for all”.  Recently, the public hasn’t had the stomach for corporate power.  This distaste for the lobbying power of corporations is reflective in the wave of national Occupy protests. 

If only American political discourse was that simple.  In that fuzzy gray area, there are those that sit with one foot in each of the camps.  Regardless of which side of the “anti-mandate” camp you may (or may not) sit on, the reality is that large numbers of uninsured people aren’t good for anyone and it is in the national interest to improve access to healthcare.  According to the Kaiser Family Foundation, in 2009 32% of the uninsured postponed seeking treatment due to cost, 26% simply went without care due to inability to pay for it and 27% could not afford prescription drugs.  As a result, the uninsured become sicker and more costly.  In the end we all end up paying for them when they are admitted to emergency rooms and hospitals.  They go bankrupt and the insured pay the bills with our rising premiums, deductibles and copayments. 

So this brings us back to our original question. As the ranks of the uninsured have escalated in recent decades, does the existing free-market approach to accessing healthcare still remain a viable option?  Since the 1980’s, we have watched the lobbying industry balloon from a small cottage industry to a draconian giant, can we really afford to wait for our political system to change before we conquer our challenges with accessing healthcare?

The answer lies within the power of the Supreme Court.  In the end, maybe the only thing that all the camps will agree on is that this decision will go down in history as a defining moment for public health.

The Shop Owner

This project formally began in the summer of 2011.  However, thinking back on it, it actually began much earlier.  I just didn’t realize it.  Hind-sight is always 20/20.  This journey informally began in a small clothing shop in my home county in March of 2010. 

Artwork by:  Jennifer Tracy

It was shortly after the passage of the PPACA when I wandered into a small business that I had driven by many times before.  For months I had wanted to check out this small clothing shop and this day I stopped.  It was a quiet Saturday afternoon and I was the sole customer in the store.  As I was sifting through the racks, the owner, who was sitting leisurely behind the counter, struck up an informal conversation.  I could tell he was somewhat bored and that the day had been a slow one. 

He told me all about how he began his business and the challenges of being a small business owner when Wal-Mart, Target, Kohl’s and the like are within a short drive.  I listened with a sympathetic ear.  He continued to talk about his daily challenge to make a livable wage in this establishment that was clearly struggling.  It was then that the infamous lines I was so accustomed to hearing in our media rang out of his mouth, “My taxes are killing me!” he stated.    He continued with, “Now with this health care law they are going to go up even more!”

I had to step back, take a deep breath and gather my thoughts.  I knew from this shop owner’s description of economic struggle, this wasn’t true.  However, to him and the perception of many other citizens, it felt very real.  I understood that.   This fear had to be taken seriously.  Like many people in March of 2010, I had grown tired of controversy and debate.  I was mostly tired of lack of information, misinformation and media sensationalizing.  This encounter was evidence it was taking a real and damaging toll. 

Ironically, according to a public opinion quiz conducted by the Kaiser Family Foundation in February of 2011, 75% of Americans did not know basic pieces of information about the PPACA.  Meanwhile, 84% of these people believed they would be harmed by the law.[i]  These were also individuals that got their information primarily from cable news outlets, a testament that the main objective of these “news” outlets is to merely entertain for profit motive and not inform and educate us. 

It was time to turn down the noise.  In a quiet and subdued tone I began to explain all that I knew about the PPACA.  I informed him about the Small Business TaxCredits, SHOP (Small Business Exchanges), Basic Patient Protections, MedicalLoss Ratio and Rate Review.  Above all however, I could tell I needed to address his real fear, taxes.

It was evident from our dialogue that this gentleman did not make more than $200,000 a year and he would therefore not see any tax increases.  In fact, he would see tax credits and subsidies.  I explained how it would be paid for with a tax on wealthier Americans who make over $200,000 and not the working and middle class.  As I explained how the funding of this bill would work, I could tell from looking at him that he also didn’t appear to be someone who went “tanning”!  With that said, I explained how the bill would be funded with a 10%tax on tanning salons.    He also didn’t appear to be someone that would be impacted by the excise tax on high-end healthplans, a plan that is often enjoyed by individuals in much higher paying professions.  The other revenue sources come from stricter requirements on Health SavingsAccounts and fees on the medical device and drugindustries.  Finally, there would be a shared responsibility between employer and employee.  Individuals will pay a fine if they violate the individual mandate and employers will pay a $2000 fine if they do not provide health insurance and their employees receive premium tax credits to purchase on the exchanges.

As he packed the last item into my bag, the shop owner held a blank and confused stare on his face.  His world had been shaken.  As I thanked him for his time and neighborly conversation, his muddled look sank into the pit of my stomach.    I had not convinced him.  I carried an odd emotion that falls somewhere between anger and sadness.  I looked around at the surrounding store fronts and was quickly reminded the time of year.  It was lent.  Outside the clothing shop I gave up cable news and I have never gone back.

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[i] Kaiser Family Foundation.  Public Opinion:  Assessing Americans’ Familiarity with the Health Care Law.  February 2011.


Next Week:  The Supreme Court takes on the PPACA

Theresa BrownGold

In the tradition of The Hopi people, oral storytelling from generation to generation is used to educate about their history, traditions and morals.   A tradition that has withstood the test of time.  When I began the "Summer at the County Fair" series, my mission was similar, to educate about the bigger social issue of the uninsured through the use of storytelling.  See their faces, hear their stories and link them to the public health research.  In my journeys around the state of Pennsylvania, I met Theresa BrownGold from Bucks county.  Theresa tells the story of the uninsured through portrait art in her Art As Social Inquiry project.  Like The Hopi, Theresa inspired me to pursue the art of storytelling.  Whether it be the stroke of the paintbrush or the keyboard, our hope is that these stories too will impact future generations to make change.  Theresa is this week's guest blogger.

An Artist’s Call to Action: ART AS SOCIALINQUIRY
By Theresa BrownGold (guest blogger)

Anyone who is indifferent to the well-beingof other people and the causes of their future happiness, can only be layingthe ground for their own misfortune. Dalai Lama

In 2008 I started an art project I call Art As SocialInquiry.  The idea for this project surfacedafter decades of observing the hundreds of thousands of people (and I mean thatliterally) I encountered in 30 years of working in the restaurantbusiness.  You can imagine that, after somany conversations, I had heard many thousands of stories of people helpingpeople.  One day it struck me, “Why do somany people who support so many charitable causes with their time and money getabsolutely livid and resolute in opposing real reform for creating a system inwhich all people can access healthcare in the United States?” 

Surely, if these good people really knew what washappening to the “others,” the ones who had no or not enough health insurance,the ones not like them, they might feel differently.  I wanted to create an honest dialog byconnecting the issue of access to healthcare to real lives affected by ouropinions.

Also at this time I was phasing myself out of the restaurantbusiness and returning to art-making, something I had studied for a brief timein my twenties.  I had the idea that I couldpaint portraits and tell every kind of healthcare story I could find.  If I created an overview by lining up theseportrait-stories side-by-side, and then invited people to look at was happeningin real lives across the spectrum of healthcare access, would our opinions abouthow we get healthcare change? 

Any doubts I might have had about this new venture werequickly scuttled when I felt a bit of a spiritual push.  I recognized that I, in my small way, wasresponsible for creating this class of “others” who could not get healthinsurance.  As a small business, our healthinsurance group was comprised of my husband, me and one other full timeemployee. When our one full time employee decided to leave after 3 years, Isaid to my co-owner/husband, “If we hire only part time employees, we won’thave to provide health benefits.”  I feltnauseous.  I had to either lie to myselfabout how I was planning to control costs in our system of employer-basedcoverage.  Or, I had to admit that Iwould be contributing to this national epidemic of the uninsured like thehundreds of thousands of other small businesses looking to hire only part-timeworkers.  I thought, “Is this any way torun a country?”

Fast forward to the present. I am 45 portraits into my social inquiry of how we access healthcare inthe US. My goal is to paint at least 100 portraits and have an art show travelthe country for many people to see the portraits and hear the stories.

The portraits I paint are large, expressionistic canvases,40 x 30 inches.  I have no interest inpainting literal images of my subjects. First I listen listen listen thenintuitively express in the painted faces what I’ve heard.  The subjects of my paintings retell what isoften the most harrowing emotional, financial and health nightmares of theirlives.  To paint their faces, I must feelas they do in the recounting of their stories. When the image I paint on the canvas stares back at me as the real liveperson did from across the table during the interview, I know I have succeeded.

These portraits stories and the people behind them havetaught me a few things.  For 2 ½ years Ihave listened to real people tell me how they accessed or tried to accesshealthcare. My conclusions reflect the lessons I have taken away from listeningto the stories of my subjects, and so many others I have not painted.  I encourage you to read the stories online(ArtAsSocialInquiry.org) and draw your own conclusions.

But the one glaring finding from all my interviews:  It isin all our best interests for all to access healthcare in the US. 

For more detailed insights into what Theresa has learned from her work documenting the portraits of the uninsured, visit the extended version of this blog at the Art As Social Inquiry website.

Ghosts of Midnight: Tom, Karen and the rest of them

This is the last of a 6 week series entitled, "Summer at the County Fair". It is a synopsis of 6 hours I spent meeting and speaking with people who were visiting a county fair in western PA. Over the next few weeks you will see the human faces that mirror our national statistics regarding the uninsured and underinsured. Thanks to the Pennsylvania Health Access Network (PHAN) for their assistance in this series.

Photo by "Mule" Symons

It was approaching midnight in late summer as I made my way home.  I’ve always found the interstate to be a lonely place, but on this particular night it was especially forlorn.  The blackness of the night hung over me like a blindfold, unable to distinguish the landscape of the passing miles.  Was it mountain, valley or field?  I didn’t know.  The night left me abandoned.  My dawn departure from home seemed like light-years away and I still had a long way to go.  I felt lost.  Within the horizon of the black night all I could see were the faces of the people I had met in the summer of 2011.  I was haunted by their images.  I never believed in ghosts.  I did now.    What did they want from me?

I was grounded back to reality by the sour convenience store coffee I purchased at my previous stop off Pennsylvania I-80.  As home became closer, the ghosts began to emerge from the darkness and their picture became clearer.  They were beckoning me to tell their story.  Each of them was a brush stroke in a painting that blended together to create the perfect portrait of the uninsured.  I knew the data and the human images of the data appeared before me so willingly this summer.  The puzzle came together on a remote interstate that night.

The Department of Health and Human Services overview of the uninsured states that they primarily live in a family with at least one full time worker, often work in small establishments (such as Brianna), are often young adults between 19-24(like Bill and Tyler), self-employed (like Susan), low wage workers (such as Braianna and Tyler), non-unionized and part-time workers (like Shontell).[i]  This data also highlights another unexpected group, retirees.  Workers that leave their careers but are not quite old enough to qualify for medicare are another cohort that has fallen into the trap of the uninsured.

As dusk began to settle on the day just before my lonely drive down I-80, this statistic carried a human face.  Within a few hours of each other I met Tom and Karen.  Tom is a 63 year old retired guidance counselor from Mercer County.  When he retired at the age of 58 he was left to utilize COBRA at the monthly cost of $1600 a month or $19,200 a year.  While Tom was paying for this policy and isn’t considered uninsured, for many low income individuals, this is an impossibility.  Similarly, Karen is a 64 year old retired notary from Butler County who explained that she was now working part-time solely to pay for her health insurance until she reached the infamous “milestone age” of 65, the age to qualify for medicare.  After a lifetime of being a contributing members of society, are these the “golden years” we promised our retirees? 

It was approaching 1am and home was getting closer.  As I thought about Tom and Karen, I knew that retirees like them would benefit from the Patient Protection and Affordable Care Act because of their eligibility for the individual exchanges.  However, Tom, Karen and the other ghosts were still sitting on the passenger seat beside me.  We were traveling on an unfamiliar road.  We were on our way to experience and see the implementation of the PPACA.  The haunting of these ghosts will not end until we achieve access to health care that is not stratified.

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[i] Department of Health and Human Services, Research in Action, Issue #17, September 2004

Thank you for joining the "Summer at the County Fair" series.  Please follow me next week into the fall of 2011 as I explore other aspects of the Patient Protection and Affordable Care Act and how it will impact groups and institution in Pennsylvania.  On 11/4 meet Theresa BrownGold:



Bill's Story

This is the fifth of a 6 week series entitled, "Summer at the County Fair". It is a synopsis of 6 hours I spent meeting and speaking with people who were visiting a county fair in western PA. Over the next few weeks you will see the human faces that mirror our national statistics regarding the uninsured and underinsured. Thanks to the Pennsylvania Health Access Network (PHAN) for their assistance in this series.

The mist of the late July morning stubbornly hung over the mountains of western Pennsylvania when I arrived in Punxsutawney, a town that proudly proclaims itself as being the “capital of weather”. Punxsutawney is home to the infamous character and Pennsylvania icon, Punxsutawney Phil, the immortal groundhog.  Known to the world every February 2, but revered by Pennsylvanians as the state mascot.  I’ve often wondered why this seemingly annoying “pest” has become so cherished and preserved.  As I explored the streets of Punxsutawney, I found a town enshrined in the legend.  The groundhog museum, dozens of groundhog statues scattered about the town and “Phil’s Burrow”, the place the groundhog calls home 364 days of the year.  Every February 2 however, Phil will emerge from his burrow in order to execute the 18^th century Pennsylvania German tradition of predicting the end of winter.  So guaranteed is this event that an entire town proclaims it, our state honors its actor and the nation tunes in each year to hear the results of an oversized rodent as he pursues his own shadow.  Predictable, Guaranteed, Expected, Certain and Secure-all adjectives that could describe Phil’s annual ritual.

As I left Punxsutawney and crossed the counties that lie in the northwest of Pittsburg, I thought about these values.  I thought about the guarantees of our culture.  Hours later I met Bill.  Bill is the full-time manager of the park where the day’s county fair was being held.  He is a 22 year old college graduate with a degree in recreation management.  He is uninsured.  At $23,000 a year, Bill explained to me that he had a choice to make each month between health insurance or food and student loan payments.  As he explained his situation my mind dizzied with confusion.  The quintessential guarantee that many of us have been promised for generations was being torn apart.  Wasn’t a college degree supposed to be our ticket to lifetime security? 

1.2 million College graduates can proclaim this reality.  The uninsured with a college degree now represents 9% of our youth population between the ages of 19-29[i].  So much for guarantees.  Unfortunately this number is only going to get worse as we embark on an economy that has fewer jobs and a job market that relies even more on part-time workers, subcontractors and temporary employees.  Additionally, if a young college graduate is lucky enough to get a full time job, they are less likely to be offered health benefits.  The rate of employer sponsored health care has been declining for the past decades[ii] .

The evolutionary changes in the dynamics of our workforce have left us with outdated guarantees, indicating the societal need for the Patient Protection and Affordable Care Act.  Under the PPACA, Bill can stay on his parent’s health insurance until age 26.  Those over 26 will be eligible for the individual exchanges that will provide them access to health care with guarantees of essential benefit.   Since most youth starting out in their careers fall in a low income bracket, many of them will also qualify for the premium tax credits.  Another reason this cohort has such a high rate of being uninsured is the perception that they are “invincible” and not subject to ill health.  While their rates of illness are lower than their older counterparts, access to preventive care that is now guaranteed by the PPACA will ensure that they enter later adulthood in a healthier and therefore less costly state of health.  Bill and his generation can also expect the other standard benefits guaranteed by the Patient Protection and Affordable Care Act such as medicalloss ratio, basic patient protections and rate review.

Like Punxsutawney Phil, our country has emerged from its burrow to realize that the season of old guarantees has changed. 

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[i] Schwartz, Karyn; Schwartz, Tanya,  The Kaiser Commission and Medicaid and the Uninsured.  Uninsured Young Adults:  A profile and Overview of Coverage Options.  June 2008

[ii] Cohen RA, Makuc DM, Bernstein AB, Bilheimer LT, Powell-Griner E. Health insurance coverage trends, 1959–2007: Estimates from the National Health Interview Survey. National health statistics reports; no 17. Hyattsville, MD: National Center for Health Statistics. 2009.

Shontell's Story

This is the fourth of a 6 week series entitled, "Summer at the County Fair". It is a synopsis of 6 hours I spent meeting and speaking with people who were visiting a county fair in western PA. Over the next few weeks you will see the human faces that mirror our national statistics regarding the uninsured and underinsured. Thanks to the Pennsylvania Health Access Network (PHAN) for their assistance in this series.

Artwork by:  San Suzie

Upon her chest Doris proudly wore a button that was 5 inches in circumference and bore the picture of her daughter, Shontell.  Under typical circumstances this would seem an odd accessory, but today was different.  In the photo button that this prideful mother showed off to the world, Shontell was wearing her nurse’s whites for a photo taken in preparation for her upcoming graduation from nursing school in October. 

Shontell, a 34 year old married mother of 2 from Clarion County had finally made it.  Standing dignified on her own honor she assertively told me how she had done it all on her own.  When she was turned down for scholarships because she was making too much money at her pharmacy technician’s job, she paid her own way through nursing school at the area community college.

As Shontell takes the final sprint towards the finish line to reach the goal she has been intensely striving for she has one final hurdle.  Just as she is about to grab the golden ring and position herself in a place of financial security, she lost her health insurance.  Just days before I met her, Shontell was informed by her employer that they would be cutting her hours back and she would therefore no longer be eligible for health insurance benefits.  Is this the reward for working hard and doing the right thing by society?  Shontell is merely another example of the force the crack in our system has which has increasing grown wider, hungrier and swallows up its victims indiscriminately. 

Shontell’s story is a rather typical one that has evolved quickly over the past half century.  According to the National Center for Health Statistics, in 1980 the number of Americans who were being insured by their employers peaked at 71.4%.  However, 1980-2007 the rates rapidly declined, leaving the number of Americans with employer provided health insurance at 62% in 2007.[1]  As healthcare expenditures ballooned 8 times in this time period and more employers stopped providing it, the crack that sucked up Shontell grew.[2]

The Patient Protection and Affordable Care Act will allow someone who has lost their coverage because an employer is no longer offering it to go on the individual exchange.  The exchange will guarantee Shontell essential benefits and because of her income she will qualify for a premium tax credit that will ensure that she does not pay more than 4% of her income on premiums.   The Kaiser Family Foundation also states that the PPACA’s implementation of the Medical LossRatio and the expansion of Preventive Care will also help alleviate the rapid increase in healthcare costs that have partly contributed to employers no longer offing insurance to their employees.

Shontell is commencing into one of the few, yet rapidly growing industries in our aging country.  What incentive will there be if our nation’s caregivers lose their own health security in their pursuit to help others?

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[1]  Cohen RA, Makuc DM, Bernstein AB, Bilheimer LT, Powell-Griner E. Health insurance coverage trends, 1959–2007: Estimates from the National Health Interview Survey. National health statistics reports; no

17. Hyattsville, MD: National Center for Health Statistics. 2009.

[2] Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, National Health Care Expenditures Data, January 2010