Luallen makes case for staying on health-reform course, at forum that focused on relationship between health and communities

By Melissa Patrick
Kentucky Health News

Health is not just determined by access to health care, it is also determined by the communities we live in.

This was the main focus of the annual Howard L. Bost Memorial Health Policy Forum in Bowling Green Sept. 28, with the theme “Building Healthy Places.”

Lt. Gov. Crit Luallen, one of the keynote speakers, ventured off this topic and used her time to “preach a bit” about how important it is for the next administration to continue health reform in Kentucky.

“Kentucky, right now, is at a defining moment in its goal to improve the health of our citizens,” she said. “Today for the first time we have the tools to provide access to quality, affordable health care to all Kentuckians and to move that needle from some of our most persistent low health rankings.”

Luallen noted that because Kentucky embraced health reform and Medicaid expansion, which provides health insurance to those who make up to 138 percent of the federal poverty line, its uninsured rate is now the lowest in the country, dropping to 8.5 percent from 20.4 percent in 2013, just before the Patient Protection and Affordable Care Act took full effect.

She also listed in great detail many of the positive impacts that health reform has brought to the state, including: dramatic increases in preventive screenings; $2.2 billion added to the state’s economy from Medicaid expansion; 12,000 new health-related jobs; and a decrease in uncompensated care to less than $60 million at the end of 2014 from $300 million in 2013.

The last two points are of special interest to Kentucky hospitals, which have cut about 7,000 jobs in the last two years but complain more about managed-care Medicaid than the reform law.

Luallen said, “Even if you don’t agree philosophically with the core fundamental principle of health reform, which is that everyone deserves access to health care, you can’t argue with the numbers about positive economic impacts for local hospitals, local communities, (and) all medical service providers both in terms of direct payments and also in the slashing in the cost of uncompensated care.”

Having worked for seven governors, Luallen noted that as administrations change there is often a lack of “sustained commitment over time to successfully tackle our toughest challenges,” but said it is important to stay committed to the bipartisan “overarching goal” of a healthier Kentucky and remember that “lasting health improvement will take years” and that it is important to “keep this momentum moving forward.”

She also noted that it is important for public policy leaders to “connect the dots” and recognize “the critical linkages between health, economic development, education, crime, drug abuse, businesses needs, and environmental needs.”

“But too often in my experience we let political posturing derail our efforts or we take the easy course when we are faced with difficult decisions,” she said. “But right now, right now in Kentucky, we have the opportunity to truly change the future of this state if we can cement these reforms in a way that has lasting and stable impact, and that will take everyone in this room working toward that goal.”

To the critics who say we can’t afford health care reform, Luallen said, “The truth is, we can’t afford not to move forward with this,” saying that the state-funded, independent studies by both PriceWaterhouse Coopers before the reform was implemented and by the Deloitte Consulting analyzing the first year of the reform clearly say that we can afford it.

Building Healthy Places

The forum then explored through a series of TED-style talks and breakout sessions the link between health and communities, offering insights on how transportation and housing, education, food systems and policy, and employers and workplaces affect our health.

Transportation and Housing: This session focused on how community design and land-use choices affect health, noting that because most of these decisions are made at a local level, community input is often welcomed.

Andrew Dannenburg, affiliate professor at the University of Washington Department of Urban Design and Planning and Environmental and Occupational Health Sciences, recommended communities determine what their “community treasures” are when making plans to improve their community design and then create active living spaces around these areas such as walkable town centers or activating public spaces with farmers markets and free concerts.

“You can educate and tell people to walk, but if you haven’t built the physical infrastructure for a place for people to walk that education has not much value,” Dannenburg said.

He said community design is important because it affects many people at one time and determines physical activity opportunities, water quantity and quality. food access, air quality, transportation safety, and opportunities to engage in social interactions.

Dannenburg suggested ways to create a healthier community, including streets that allow all walkers and cyclers; neighborhoods that provide walking paths to desired destinations like schools and shopping; walkable access to parks; shared-use agreements between schools and their communities; and rail-to-trail conversions like the Dawkins Line Trail that runs from Johnson County to Magoffin County.

He also noted that communities need to ensure safe housing for everyone because substandard housing creates many health problems like asthma, respiratory infections, poisonings, neurological disorders, depression, injury, heart disease and cancer.

Food Systems and Policy: Margo Wootan, director of nutrition policy at the Center for Science and Public Interest, said eating in America is like playing Candy Crush, an online multi-level game played by over 90 million people.

“As the game draws us into spending more time and money, the food environment draws us in to eating more calories,” she said. “More calories than often we plan to eat, and oftentimes more calories than we really want to eat.”

Wootan blamed much of the obesity epidemic on how companies market food and said that it matters because “This whole huge epidemic that is facing this state and the country is explained by an extra 100 calories per person per day.”

” Marketers study human nature and hijack our biology to get us to buy more and more,” she said. “Companies should use their marketing genius to support health rather than undermine it.”

Wootan said it is possible for policy to create change, citing how a major shift in food manufacturing has reduced the amount of trans-fats in the foods we eat by 80 percent. She said that will result in “fewer deaths from heart disease, in less disability from heart disease and stroke and a lower health care cost.”

She also noted that stronger national nutrition standards have led to children eating more fruits and vegetables and whole grains, and calorie labeling on menus of chain restaurants have resulted in companies reformulating what is on the menu and reducing calories for all people who eat in those restaurants.

Education: There are many social determinants to health and education is connected to most of them, Mary Gwen Wheeler, who was health secretary under then-Louisville Mayor Jerry Abramson.

“Education and health are inextricably intertwined,” she said. “College-educated people smoke less, they eat more fruits and vegetables, they exercise more, and they are less obese.”

Also, better-educated people have better social determinants of health, including higher incomes, higher levels of employment, better access to health insurance, living in safer neighborhoods, having better access to green space, living near groceries that offers healthy foods, and living in a communities with cleaner air, Wheeler said, adding, “Education tracks very closely with income.”

Health also affects education, Wheeler said, noting that children with asthma often have poor school attendance and thus poor school performance; and that kids who come to school hungry and sleepy often have poor attendance and aren’t able to pay attention even when they do come to school.

Wheeler noted that while correlation is not causality, she suggested that because so many poor health outcomes and chronic diseases are rooted in poverty, “poverty is a great place to start” looking for a way to improve these social determinants correlated to a lack of education.

She then circled around to say that education is one of the best ways to reduce poverty.

The Kentucky Center for Education and Workforce Statistics recently released a report that says the median wage for high-school graduates in Kentucky three years after graduation is $11,500, below the federal poverty line, she said.

Employers and Workplaces: Employers need to extend corporate health programs into their communities to create a healthier workforce, said Vera Oziransky, author of the report “Beyond the Four Walls: Why Community is Critical to Workforce Health.”

“Workforce health promotion is insufficient without community health promotion,” she said


As an example, she described a worker who has access to healthy food at work, breaks during the day and incentives to engage in activity, but at home lacks access to healthy housing or healthy and affordable food, and lacks the green space to engage in physical activity. These community factors undermine any initiatives that are taken in the workplace.

The Bost forum is sponsored by the Foundation for a Healthy Kentucky in memory of Dr. Howard L. Bost, who created the national Medicare program, developed the Appalachian Regional Hospital system, developed Kentucky’s Medicaid program, improved mental-health services in Kentucky and created the vision for the foundation.

Co-sponsoring partners of the forum were the Friedell Committee, Health Enterprises Network, Kentucky Health Information Exchange, Kentucky Medical Association, Kentucky Public Health Association, Kentucky Educational Television, Leadership Kentucky and the Prichard Committee for Academic Excellence.

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