Upfront: Live long and prosper

February 7, 2013
by Peter Seidman
Pacific Sun (Marin, California)

Statistics consistently show that Marin is one of the healthiest counties in the state and the country. But those statistics mask an uncomfortable truth: Marin also has some of the most severe health disparities in the state. Simply put: Where you live in Marin plays a role in how long you live.

On the other hand, residents of Mill Valley, Belvedere, Tiburon and Larkspur have a life expectancy of 85; Kentfield residents, 87 years.

Healthy Marin Partnership formed in 1995 in response to SB 697, the 1994 bill that requires nonprofit hospitals to compile community needs assessments every three years. The idea behind the legislation is that if hospitals receive a tax break, they should pay back their communities by contributing to studies that look at needs and how they can be filled.

County public health officer Dr. Matt Willis says the needs assessment process in Marin has taken on a new dynamic, one whose goals and processes can mesh with the coming of the Affordable Care Act. In November, Willis participated in an intensive workshop—which included Marin's three nonprofit hospitals along with other health-care stakeholders—that focused on community needs, current conditions and future challenges.

"In Marin we had a unique confluence of important voices from around the county who had a perspective on health disparities," says Willis. The county Office of Education, community-based organizations, the hospitals and clinics all participated. "About 40 people gathered in one room for four hours." The topic of discussion: What does the county most need, what are the biggest problems? "It was I think a unique sign of a cultural change that's occurring." Willis notes that at the meeting service providers who offer critical services, such as the hospitals, "represented one end of the spectrum of health-care" in the same room as people who represented the other end, "which represents the social determinism of health-care," including education, parks and recreation, "those other kinds of services" that play a part in quality of life and life expectancy.

The participants, representing a broad spectrum of health-care providers, "engaged in a single dialogue," says Willis, with the objective of "combining efforts in a unified framework, operating under the assumption that health begins in families, begins in neighborhoods, begins in schools." That paradigm is a key to the Affordable Care Act.

Part of the needs assessment included compiling data for the county showing a 17-year disparity in life expectancy for Marin residents, depending on where they live. "There's an atmospheric change in the way we're understanding health and health disparities," says Willis. "It's being seen now through a lens of social justice. We are now able to begin the discussion of the reality that health disparities really begin in policies that determine life experience in neighborhoods, schools and families way upstream of when a patient lands in a clinical setting with a medical condition."

Integrating health concerns with policy considerations regarding housing, recreation and transportation is becoming clearer as the Affordable Care Act comes closer to reality. Marin has a jump on the process. Still, Willis says, there's much work needed to fully integrate health concerns with policy decisions. "Health and Human Services needs to be an effective partner with local policymakers at the city council level and the Board of Supervisors to really work toward a health policy framework." As an example, Willis notes that if a transportation policy is on the table, the health of the population the system serves also should be on the table. Whether seniors need a bus stop, for example. "Public health should have a presence when these kinds of policy decisions are being made."

Willis says that while Marin is "famous nationally for being a hub" of healthy eating and organic farms, the county still has two census tracts that "are actually food deserts," a contributor to lower life expectancy. According to "Portrait of Marin," a report released last year sponsored by the Marin Community Foundation, "Paradoxically, in a county as committed to protecting and preserving agricultural lands and supporting local farmers as Marin," the Canal neighborhood in San Rafael and the Lynwood section of Novato are food deserts. Those neighborhoods have life expectancies that fall below the average for Marin.

The county has a multitude of programs to reach out into communities to promote healthy living and healthy eating. The question remains: Why has more progress not been made in the areas with stubborn life expectancy disparities? "That's the million-dollar question," says Willis. "It's because of a lot things. It's tied to geopolitical realities of immigration and the fact that we have a significant portion of our population who come from the developing world." That kind of connection between immigration issues and health disparities hasn't been on the front burner during the most recent immigration debate—yet. But the connection between immigration and health-care costs should be part of the discussion.

"Immigrants in Marin may arrive here with not a lot of resources," says Willis, "and they're coming to an affluent county where property values are high and rents are high, and they're trying to make do. They may be challenged by language. They may be challenged by not having insurance, not being documented." Each issue requires its own intervention. And it must be done within the parameter of tight public health budgets.

To stretch its public health dollar, the county continues to partner with community organizations, schools and neighborhood groups. One of the most interesting for the immigrant community is the Marin Promotores Initiative, created to reduce racial, ethnic and other social inequalities affecting the health of residents. Promotores essentially is Spanish for health promoter. The concept calls for community members, who speak the same language, understand the culture and are familiar with neighborhoods, to act as educators and connections between the community and health policy issues.

"We are working with them, and having them carry the message is one of the ways we are working in the Novato area, [along with the health coalition there] and in the Canal neighborhood and Marin City," says Larry Meredith, director of the county Health and Human Services Department. Because promotores live in the community, they hold the confidence of their neighbors when it comes to disseminating health information. "With training and guidance, they become a rich source in the system."

The county also has a program dubbed "The Sisters," crafted during the last three years or so, says Meredith. It's an attempt to bring county services to people rather than remain aloof in county offices. "We hire people in organizations like Ritter because that's where all the clients are who may be eligible for some form of public assistance. Rather than requiring them to come to [county offices], we have people there, at Marin Community Clinics, at Canal Alliance. We go to where the people are and educate them and do the preliminary work, so they can determine their eligibility where they are." If they turn out to be candidates for services, Meredith adds, they "can go and have all their paperwork done. It's a new model of engaging the public."

Ensuring access is a cornerstone of the new health-care paradigm. Willis says the ultimate goal is based on the premise that "every human being has a right to the highest attainable standard of health," no matter the ZIP code.

The most egregious level of disparity, he says, is exhibited when people are sick and cannot receive care. Marin, he says, is fortunate because it has three nonprofit hospitals that will treat people regardless of their insurance status. "That piece of the safety net is intact, but that obviously is a failure of upstream measures that would prevent those kinds of things from happening." The emphasis on "upstream measures" to prevent emergency room visits or trips to the doctor's office are key to the Affordable Care Act and the push for public health initiatives in Marin.

"What's emerging as a center of the Affordable Care Act is a [concept] for a medical home [for patients]." The home concept offers health services such as cancer screening, blood pressure checks, routine health maintenance and preventive care, "all things that go into keeping health rather than regaining health once it's lost," says Meredith. The concept improves health in the upstream environment while it also trims the cost of health-care.

In addition to increasing the availability and ease of access to health-care, say both Willis and Meredith, thinking about health-care in new ways will become increasingly paramount as the Affordable Care Act becomes reality. "Stop thinking of health as health-care per se," says Willis. "Start thinking of health as not something we get at the doctor's office but something we get that starts in families, schools, workplaces, places where we play, the air we breathe, the water we drink, the conditions in which we live." Those are the "most important determining factors of our health status." And that's why Health and Human Services should have a seat at the policymaking table.

A report compiled by the Trust for America's Health, titled "A Healthier America 2013, Strategies to Move from Sick Care to Health Care in Four Years," notes the contributions pubic health departments play in keeping the nation healthy—and the financial challenges that impinge on that effort.

"Where you live shouldn't determine how healthy you are," the report states, "and public health departments serve as the unique and essential component of an integrated health system that looks out for the population as a whole, rather than focusing on the health outcomes of individuals alone."

According to the report, "Among the challenges in the next four years are the coming changes in the overall health system that emphasize cost containment and improved health, and the expansion of the number of individuals with insurance coverage for direct preventive services." Willis estimates that about 18,000 Marin residents will receive insurance coverage under the Affordable Care Act. "That will offer them an opportunity to receive urgent care when needed. The Affordable Care Act also will offer an opportunity to engage those clients an upstream preventive care."

Despite all the advances and all the budget jiggering to make funds go as far as possible, a sizable number of Marin residents in this pre-Affordable Care Act period live in a health-care shadow. The number of patients seeking care from public health services in the county has increased.

According to Willis, who previously was an internal medicine doctor at Marin Community Clinics and began his duties as public health officer in December 2011, about 20 percent of the Marin population "is hidden from the majority" who enjoy a high standard of health. While Marin is the healthiest county in the state and much of the data used to paint an overall picture show results "we feel appropriately proud of," says Willis, the picture is the result of countywide data. The overall data points obscure the reality that pockets in Marin are underserved.

A 17-year lifespan disparity attests to that conclusion.

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