Tag Archives: public health

Time To Rethink Federalism

I used to begin my classes in Law and Public Policy with what I call the “constitutional architecture,” the structures of U.S. government. As I would tell students, the Founders had divided authority both vertically and horizontally–through Separation of Powers and Federalism.

Most graduate students were familiar with those terms. Undergraduates generally knew that we had three branches of government, although the term “Separation of Powers” was less familiar to them, but very few could define federalism–the division of jurisdiction between the federal government and the states. Both mechanisms were intended to provide “checks and balances”–to limit the power of the central government.

The world we inhabit is very different from the world that confronted the nation’s founders. We still need federalism–but it is past time to review and adjust the current divisions of authority among local, state and federal levels of government.

A number of those divisions are still useful and should be retained. State and federal governments have no reason to assume responsibility for handing out zoning permits or policing domestic violence disputes, to choose a couple of examples, but other current assignments of responsibility no longer make much sense. State-level management of elections, for example, was necessary in the age of snail-mail registration and index cards identifying voters; in the computer age, it’s an invitation to misconduct–an invitation that  state-level lawmakers eagerly accept.

In a number of areas, there are awkward pretenses of state “sovereignty” where contemporary realities mean none really exists. (Think of federal highway dollars that are conditioned on state compliance with federally mandated speed limits. Or the similar “strings” attached to federal funding.) 

At the other end of the spectrum, there are an increasing number of issues, including but certainly not limited to the threats posed by climate change and the pandemic, that must be addressed globally.

Then there are the increasing tensions created by legislators in red states who want to be free of the constraints imposed by the Bill of Rights.

The GOP has never gotten over its original resentment over incorporation–the odd word for the doctrine that nationalized the Bill of Rights. That process was premised on the 14th Amendment principle that fundamental liberties protected by the Bill of Rights should be a “floor”–that a citizen in Alabama should enjoy the same basic rights as a citizen of New York. States are able to enlarge on those rights, but–at least until Donald Trump managed to pack the Supreme Court with rightwing ideologues–they have been forbidden to retract them.

There are multiple reasons to revisit the division of authority between the nation’s state and federal governments. I realize that any effort to do so would be met with alarm–much as we’ve seen with calls to eliminate the filibuster that currently prevents the Senate from actually governing. We humans are creatures of habit: we become accustomed to the world we have grown up with, and assume that the structures of whatever society we inhabit are just “the way it is.” (A great example: the people who argued against same-sex marriage by insisting that marriage “has always been between one man and one woman.” That’s demonstrably false. Even if you ignore biblical history, more than half of the world still recognizes plural marriage. But it was true within the confines of their limited experience.)

A recent guest essay in The New York Times pointed to the undeniably negative effect of our current federalism on public health.

Tennessee and North Carolina are both digging out from catastrophic flooding, while parts of Louisiana were flattened by Hurricane Ida, and most of New Orleans remains without electricity. Ida’s remnants also brought even more rain to areas of the South and beyond that were already dangerously waterlogged.

In the Utter Failure to Understand What “Pro-Life” Really Means tournament, normally a very close battle in the red states, Texas is currently uncontested: Its leaders just made it easier to carry a gun and harder to end an unwanted pregnancy in the same week.

Finally, in the Colossally Botched Medical Emergency competition, it’s neck and neck across the region as Republican governors double down on efforts to block mask and vaccine mandates, along with every other pandemic-mitigation attempt made by people who are not allergic to science.

The author points out that every single one of these disasters is a public health emergency that red state governors have worsened “in every way imaginable.” (A recent NBC poll confirmed that politics has played havoc with public health. It found 91 percent of Biden voters vaccinated opposed to 50 percent of Trump voters.)

 Citizens’ health and safety– and the extent of their civil rights–  should not depend upon their state of residence. 

Guns

I don’t post often about America’s insane gun culture, because the lines have been drawn for a very long time, and the combatants’ feet are firmly in cement.

I could share innumerable facts: how many people die by gun each year, the margin by which the thousands domestic gun deaths exceed deaths in war, how guns facilitate suicide…on and on. It wouldn’t matter to the relative minority of gun owners who stockpile weapons and foam at the mouth at any suggestion that we withhold firearms from wife-beaters, crazy people or people on the terrorist watch-list.

Unfortunately, the foaming-mouth folks can rely upon the congressional GOP to ignore any and all facts, and block efforts to fund research into gun violence.

Research does exist, however, and rational people will find it persuasive. The Guardian recently reported on data from an experiment in the Bay Area.

For each new millionaire household the San Francisco Bay Area has produced, there are at least four new people living below the poverty level. San Francisco’s property crime rate has spiked to the highest in the nation. Many people – tech newcomers and longtime residents alike – complain of feeling unsafe.

At the same time, with little fanfare, the Bay Area has seen a dramatic drop in its homicide rate, driven by a considerable decrease in deadly shootings.
Across the region, the overall gun homicide rate has dropped 30% in the past decade, a Guardian investigation of homicide data across more than 100 cities has found.

The study analyzed homicide data across California’s Bay Area from 2007 to 2017. During that time, gun homicide rates fell across all racial groups, but the decrease was largest for black residents.

What was particularly striking about these findings was that the dramatic drop came at the same time as criminal justice reforms in California reduced the number of people in the state’s jails and prisons.

The reduction came as cities like Oakland and Richmond did what a number of scholars have recommended: they changed their approach to the problem, investing tens of millions of dollars in public health approaches to gun violence.

The study considered–and dismissed–the possibility that gentrification was the reason violence subsided.

Three cities that are undergoing intense gentrification saw the biggest drops in gun homicides. But outlying suburbs – the towns where many residents forced out by gentrification have moved – did not see a corresponding increase in violence…

The Bay Area still sees nearly 300 gun homicides each year. But these changes are profound. The majority of America’s gun homicide victims are black, killed in everyday shootings in segregated, economically struggling neighborhoods in cities such as Oakland and Richmond. It’s this everyday toll of violence, not mass shooting casualties, that drives America’s gun homicide rate 25 times higher than those of other wealthy countries.

The article noted that cities that once ranked among the nation’s deadliest have seen enormous decreases, and emphasized that these decreases spanned a decade– they weren’t single-year drops. The declines persisted over the years.

California has the strongest gun laws in the country, and it has enacted more than 30 new gun control laws since 2009 alone. The Guardian credited those constraints, together with the change in approach to violence prevention, for the reduction in gun homicides.

There’s early evidence that local violence prevention strategies – including a refocused, more community-driven “Ceasefire” policing strategy, and intensive support programs that do not involve law enforcement at all – were a “key change” contributing to these huge decreases.

As the article concedes, there are still plenty of problems in the Bay Area. (Police shootings haven’t declined, for example.) But there is a lesson here.

Of course, lessons are lost on people determined not to learn them.

Health and That Chinese “Hoax”

One of the unfortunate aspects of this bizarre Presidential campaign has been the lack of attention to the truly important issues America faces. Not that sexual assault, bigotry and massive ignorance are unimportant, but between disclosures about Trump’s “groping,” his “scorched earth” attacks on pretty much everyone, and his increasingly obvious mental health issues, the Orange One has sucked up all the oxygen in the room, with the result that issues of enormous consequence have received little attention, and even less thoughtful discussion.

Earlier this month, I posted about Trump’s selection of “environmental experts” for his transition team–a group of denialists about the reality of climate change.

We are already experiencing the severe weather that we’ve been warned will accompany our new climate reality; hurricanes that pick up power from warming oceans, flooding in some regions, droughts in others. But it isn’t only weather and agriculture that should concern us.

I often quote my cousin, an eminent cardiologist whose own blog is devoted to providing accurate medical information and debunking what he aptly calls “snake oil.” He recently reminded me that there is a health dimension to climate change that is too often overlooked:

At this time, most thoughtful people acknowledge the reality of humanly generated climate change on our environment, but they often fail to understand the real threat this poses to human health in general.

Now, the American College of Physicians (ACP), one of our most respected medical institutions, has issued a sobering position paper on climate change and it effects on human health, including higher rates of respiratory and heat-related illness, increased prevalence of vector-borne and waterborne diseases, food and water insecurity, and malnutrition. Persons who are elderly, sick, or poor are especially vulnerable to these potential consequences, according to this group. The ACP also states its belief that it’s incumbent on all those in the health industry to play an active role in protecting human health and averting dire environmental outcomes.

This ACP publication emphasizes that climate change presents a “catastrophic risk” to human health over the next hundred years that may wipe out all of the health advances made over the previous 100 years. The average temperature on Earth has increased by almost 1 degree since 1889, and greenhouse gas emissions have increased by almost 50% from 2005 to 2011. It is predicted that by the end of the century, the Earth’s temperature may increase by 5 to 9 degrees Fahrenheit. Ice in the Arctic and Antarctic seas has melted at unprecedented rates and the water levels worldwide have risen by almost 7 inches over the last 100 years. The World Health Organization has predicted that climate change will cause an additional 250,000 deaths per year from 2030 to 2050 due to malnutrition, increased malaria, increased respiratory illness, heat-related illness, food issues due to crop losses, and increases in waterborne infectious diseases and vector-borne illness:

Their current recommendations include the following:

The entire health care community throughout the world must engage in environmentally sustainable practices that reduce carbon emissions.
Support efforts to mitigate and adapt to the effects of climate change.
Educate the public, their colleagues, their community, and lawmakers about the health risks posed by climate change

As guardians of human health, we must assume a more active role in avoiding these disastrous consequences—if not for our own well-being, but for that for our children and all future generations! These efforts could well begin with how we all vote in the coming election!

My concern is not simply with the efforts of fossil fuel companies to stave off changes so that they can continue to profit, or with the fundamentalists (too many of whom are in Congress) who piously insist that God will take care of us.

My concern is that far too many of us arguably normal folks will react just like patients whose doctors tell them to quit smoking or start exercising– patients who know the doctor is right, but who lack the will to follow through.

Unhealthy Indiana

Yesterday, the IBJ reported the latest data on public health indicators, under a headline that telegraphed the results: “Indiana public health continues to slide.”

When the most recent data is compared to previous studies, it becomes quite clear that Hoosiers are moving in the wrong direction. We are fatter, more sedentary, more diabetic. Hoosiers smoke more than citizens elsewhere, and more of our babies die in infancy.

Not exactly a distinction we would choose.

Furthermore, since our policymakers seem to care a lot more about money than about Hoosier health and well-being, it may be useful to point out that poor health drives up costs. As the IBJ pointed out, Indiana employers spend more per worker on healthcare than employers elsewhere in the country. And that doesn’t include the costs of sick days or reduced productivity as a consequence of health issues. (Forgive me for an indelicate observation: Indiana legislators determined to keep business taxes low don’t seem to understand that the added costs incurred by reason of an unhealthy workforce are just as much a part of business overhead as state income or property taxes.)

No–true to our Hoosier Heritage, which is nothing if not shortsighted–State government is perfectly content to shift health costs to employers, and keep Indiana’s public health spending low. And it is low. In 2012, Indiana ranked 49th out of 50 states in per person spending on public health, despite the fact that preventative public health measures like immunization and screenings demonstrably and dramatically lower overall health costs.

To add insult to injury, Governor Pence has signaled that he will not expand Medicaid in order to participate in the Affordable Care Act, aka “Obamacare.” As I have previously noted, there is no rational basis for that decision; it rests entirely upon a perceived political need to pander to a rabid GOP base motivated solely by an unreasoning hatred of President Obama and anything he supports.

If Indiana opts to participate, an estimated 450,000 Hoosiers would benefit. And here’s the kicker: if Indiana does participate, the federal government will pay all the costs for the first three years. The state’s portion would then phase in gradually, topping out  at 10% in 2020.

And if we don’t participate? Well, poor people have this pesky habit of getting sick anyway. And we already pay to treat them–frequently, in the least cost-effective way, when they appear at hospital emergency rooms. When uninsured folks are treated there, the costs of their un-reimbursed care drives up the premiums of those with insurance. If the hospital is public, our taxes go up. If the hospitals still can’t recover their costs, they cut healthcare workers or reduce services. The 10% Indiana would eventually have to pay to cover far more people is unlikely to be more than we are actually paying now in a variety of ways–it would just be more visible and much more cost-effective.

Indiana certainly wouldn’t want to do something that was actually cost-effective.

To Your Health…..

Federalism has many virtues, but it also makes some problems more difficult to solve. I don’t care how much your local city council cares about air pollution, there isn’t a whole lot they–or even your state legislature, assuming you have a more enlightened one than we do here in Indiana–can do about it. Health policies likewise tend to require state or national action; there isn’t a lot that local communities can do.

But there are some things we can do locally, and there really isn’t any excuse for failing to do them. Cities and states can encourage healthy lifestyles and physical fitness by providing well-tended parks, by increasing bike lanes, and by banning smoking in public places. These measures not only promote public health, they ultimately save money by reducing Medicaid and similar costs.

The Ballard Administration has at least responded to calls for additional bike lanes (although those downtown, where I live, are considerably less than optimal–the ones on New York Street were evidently painted by someone who was drunk or otherwise seriously incapacitated). Otherwise, not so much. Far from expanding opportunities for recreation, our parks have been shamefully neglected. And worst of all, Ballard has consistently blocked efforts to ban smoking in public places.

The Mayor’s refusal to honor his campaign promise to sign a smoking-ban ordinance is particularly galling, not just because he did a 180-degree turn on the issue once he was elected, but because smoking bans are a low-cost, highly effective way to improve public health.

There are essentially two arguments against smoking bans. Bar owners worry that business will suffer if customers cannot smoke in their establishments. Other opponents of the bans argue that no one has to patronize a bar or restaurant–that if smoke bothers you, you can just go somewhere else.  The evidence from other cities that have passed these bans should comfort the bar owners–far from diminishing, in many places business actually improved when nonsmoking customers weren’t assaulted by the smell of  “eau de stale cigarette.” And the argument about choice ignores the very real health hazard smoking poses for employees. (When asked about the impact on workers, Mayor Ballard dismissed employees as “transients” whose health clearly was not a concern.)

Hint: Telling hard-working waiters and bartenders that they should just get another job if smoke bothers them ignores the realities of the current job market, among other things.

Cities are in a world of fiscal hurt right now. At a time when there isn’t money to do many of the things that would improve our neighborhoods, a smoking ban is a virtually cost-free way to improve public health and make our public spaces more pleasant at the same time. Polls show an overwhelming majority of residents favoring such a ban, and in fact, when he ran for Mayor, Ballard supported the policy.

All of this makes the Mayor’s current, stubborn opposition hard to understand. If he has reasons for his abrupt about-face, he has yet to articulate them.