Health Equity Your Zip Code Matters

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1 Health Equity Your Zip Code Matters Pediatric Nurse Conference November 1, 2018 Nathan Fleming MD MPH Pediatrician - Physician Lead for Quality and Health Equity Children s Hospital of Wisconsin Children s Urgent Care

2 What is health equity? Key Terms Social Determinants of Health (SDoH) Area Deprivation Index (ADI) Life Expectancy Health Inequity Health Equity means that everyone has a fair and just opportunity to be as healthy as possible. Health Equity requires addressing obstacles to health such as poverty and discrimination, then taking action to remove obstacles like lack of access to good jobs with fair pay, quality education, safe housing, healthy neighborhoods, and Source: County Health Rankings and

3 Equality versus Equity: Wheels for All

4 Life Expectancy in Wisconsin Improvements over the last 30 years

5 Health Outcomes are generally improving over the last 30 years Cause of Death Infant Mortality Rate per 1,000 Births Mortality Risk Under 5 years Percent (%) Wisconsi n United States % 0.62% Mortality Risk Ages 5 to 24 years Percent (%) 0.65% 0.77% Data Source: (1) Infant Mortality. CDC WONDER query by state and for counties in Wisconsin for Linked Birth/Infant Death Records, (United States Department of Health and Human Services et al., 2018). (2) Mortality Risk. Institute for Health Metrics and Evaluation (2017). Risk calculated at the county-level using mortality data from 2014.

6 Springfield USA Average Springfield Population = 100,000 Average Family 5 people Goal: Find the Springfield, the healthiest Springfield, in the United States to raise 3 children

7 Springfield Can be Anywhere Springfield was one of the most common names for a city in the U.S. I thought, This will be cool; everyone will think it s their Springfield. Matt Groening creator of The Simpsons and Futurama /#bJw7beMgLHrROAJY.99

8 Health Outcomes Life Expectancy

9 Health Outcomes Children Mortality or YPLL

10 Givens, M.J., Bergum, A., Willems Van Dijk, J. Et alt. University of Wisconsin Population Health Institute. What Works? Social and Economic Opportunities to Improve Health for All. September,

11 Educational Outcomes

12 Givens, M.J., Jovaag, A., Willems Van Dijk, J. Et alt. University of Wisconsin Population Health Institute. County Health Rankings 2018.

13 Givens, M.J., Jovaag, A., Willems Van Dijk, J. Et alt. University of Wisconsin Population Health Institute. County Health Rankings 2018.

14 Givens, M.J., Bergum, A., Willems Van Dijk, J. Et alt. University of Wisconsin Population Health Institute. What Works? Social and Economic Opportunities to Improve Health for All. September, 2018.

15 Economic Opportunities

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17 Wisconsin has a decent life expectancy and low degree of income inequality

18 Where would you like to live? Comparing Springfield Across Wisconsin A. Dane County B. Jackson County C. Marquette County D. St Croix County E. Walworth County

19 Which Springfield is Healthiest? Health Outcomes, Healthcare Costs, and SDOH

20 Springfield, Dane County Population = 531,273 Life Expectancy = 81.1 Area Deprivation Index = 90 Total Cost of Preventable Healthcare Events = $301,132,138 Cost per Person ~ $566

21 Springfield, Walworth County Population = 102,959 Life Expectancy = 79.6 years Area Deprivation Index = 97 Total Cost of Preventable Healthcare Events = $108,469,732 Cost per Person ~ $1,053

22 Springfield, Jackson County Population = 20,562 Life Expectancy = 78.6 years Area Deprivation Index = 103 Total Cost of Preventable Healthcare Events = $20,910,934 Cost per Person ~ $1,017

23 Springfield, Marquette County Population = 15,067 Life Expectancy = 79.0 years Area Deprivation Index = 101 Total Cost of Preventable Healthcare Events = $41,497,398 Cost per Person ~ $2,754

24 Springfield, St. Croix County Population = 88,029 Life Expectancy = 80.7 years Area Deprivation Index = 87 Total Cost of Preventable Healthcare Events = $27,279,679 Cost per Person ~ $310

25 How does Milwaukee Measure Up? Population = 967,903 Life Expectancy = 77.7 Area Deprivation Index = 106 Total Cost of Preventable Healthcare Events = $989,931,000

26 Where would you like to live? County Population Life Expectancy (years) Area Deprivation Index Cost per Person of Preventabl e Health Care Events Cost of Preventable Health Care Events Dane 531, $566 $301,132,13 8 Walworth 102, $1,053 $108,469,73 2 Jackson 20, $1,017 $20,910, th Marquette 15, $2,754 $41,497, st St. Croix 88, $310 $27,279,679 5 th Milwaukee Rural? Springfield, 967,903 St. Croix 77.7County 106 Urban? $1,023 Springfield, $989,931,00 Dane County 0 County Health Ranking 3 rd 45 th 71 st

27 Why is Milwaukee so unhealthy? Le Counte, E.S., Swain, G.R. Life Expectancy at Birth in Milwaukee County: A Zip Code-Level Analysis. Journal of Patient-Centered Research and Reviews, :

28 Life Expectancy in Milwaukee Zip Codes Within Milwaukee County, Life Expectancy at birth varies by 12 years between Zip Codes Le Counte, E.S., Swain, G.R. Life Expectancy at Birth in Milwaukee County: A Zip Code-Level Analysis. Journal of Patient-Centered Research and Reviews,

29 Where you live matters whether you are rich or poor Le Counte, E.S., Swain, G.R. Life Expectancy at Birth in Milwaukee County: A Zip Code-Level Analysis. Journal of Patient-Centered Research and Reviews, : Pathways to Population Health, 2017

30 Legacy of Redlining Vila, P.M.. et alt. Health Disparities in Milwaukee by Socioeconomic Status. Wisconsin Medical Journal, Vol 106, No. 7.

31 Children s Urgent Care Six Clinics serving Families on Nights and Weekends in Milwaukee, WI Salm Ward, T.C.. et alt. Influence of Socioeconomic Factors and Race on Birth Outcomes in Urban Milwaukee. Wisconsin Medical Journal, Vol 109, No. 5.

32 Cooper, R.A. et alt. Poverty, Wealth, and Health Care Utilization: A Geographic Assessment. Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol 89,

33 Salm Ward, T.C.. et alt. Influence of Socioeconomic Factors and Race on Birth Outcomes in Urban Milwaukee. Wisconsin Medical Journal, 2010.

34 Why is Healthcare so Expensive in Milwaukee? Cooper, R.A. et alt. Poverty, Wealth, and Health Care Utilization: A Geographic Assessment. Journal of Urban Health: Bulletin of the New York Academy of

35 Cooper, R.A. et alt. Poverty, Wealth, and Health Care Utilization: A Geographic Assessment. Journal of Urban Health: Bulletin of the New York Academy of Medicine,

36 What are the health outcomes in the communities where I work as a Pediatrician? Life Expectancy for Boys At Birth Infant Mortality Rate per 1,000 births Mortality Risk Under 5 years Percent (%) Mortality Risk Ages 5 to 25 years Percent (%) Delafield % 0.61% Mayfair % 0.74% Mequon % 0.53% New Berlin % 0.56% Oak Creek % 0.74% 16 th Street % 0.74% Wisconsin % 0.65%

37 Policy Decisions made in 1938 impact Health Outcomes in 2018 Givens, M.J., Jovaag, A., Willems Van Dijk, J. Et alt. University of Wisconsin Population Health Institute. County Health Rankings

38 How can we improve health for families in Wisconsin? #1) Free-for-All (No Investment), #2) Equal Investments, or #3) Equitable Investments in Health Givens, M.J., Jovaag, A., Willems Van Dijk, J. Et alt. University of Wisconsin Population Health Institute. County Health Rankings

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40 Everybody tries to survive Some people will help each other

41 How are we spending money on Health? Because we under-invest in prevention, we over-pay for health care emergencies

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43 Equality = Everyone gets the same resources regardless of needs or risks

44 Expenditure Spending Priorities for Local Health Departments Budgeted Expenditures by Program Area 2018 Example: LHD spending for a population of 100,000 Program Area Operating Cost % Budget Administration $175, % Chronic Disease $101, % Infectious Disease $197, % Injury Prevention $30, % WIC $200, % Environmental Protection $16, % Consumer Health $250, % Emergency Preparedness $501, % Quality $8, % Health Data $20, % Health Laboratory $38, % Vital Statistics $33, % Other Programs $83, % Total $1,670, states including Wisconsin - made cuts to their public health budgets from FY to FY State funds allocated to public health is shrinking State funding for public health is: always first to be cut. public health is not well understood by legislators public health does not compete well against other priority areas such as education and law enforcement. Total CDC Funding for Wisconsin $12,824,029 State Budget for Public Health $83,930,400 Total $96,754,429 Wisconsin ranks 48 th in per person public health spending $ in 2018 $$$ $10-40 Wisconsin, Mississippi $50-80 Oregon, Georgia, California $ Alabama, Arkansas, Massachusetts Lang and Warren. A Funding Crisis for Public Health and Safety: State-by-State Public Health Funding Facts 2018 Trust for America s Health: TFAH

45 Health Equity = Every unicorn gets the basic support they need to create a better outcome

46 Which situation is just and fair? Options: Free-for-all, Equal, or Equitable? Which situation is the most efficient use of resources? Options: Free-for-all, Equal, or Equitable?

47 Location and Health Disparities Health Inequity Across WI

48 What if women ran the world? How would our towns be different?

49 What if my grandmother was mayor? Barbara built a park to benefit everyone!

50 Health Behaviors Wisconsin Milwaukee (ME), WI Waukesha (WU), WI Ozaukee (OZ), WI Health Behaviors Adult smoking 17% 18% 13% 12% Adult obesity 31% 33% 25% 26% Food environment index Physical inactivity 21% 23% 18% 19% Access to exercise opportunities 86% 99% 96% 90% Excessive drinking 26% 25% 25% 27% Alcohol-impaired driving deaths 36% 34% 38% 41% Sexually transmitted infections , Teen births Health Equity in Wisconsin means 188,000 fewer adult smokers 139,000 fewer adults who drink excessively 96,000 fewer adults who are obese County Health Rankings and Roadmaps. Wisconsin Health Gaps Report. (2015)

51 Health Outcomes Wisconsin Milwaukee (ME), WI Waukesha (WU), WI Ozaukee (OZ), WI Health Outcomes Length of Life Premature death 6,000 8,100 4,600 4,200 Quality of Life Poor or fair health 15% 19% 11% 11% Poor physical health days Poor mental health days Low birthweight 7% 10% 6% 6% Every year, nearly 3,200 deaths in Wisconsin could be avoided if all residents in the state had a fair chance to be healthy. County Health Rankings and Roadmaps. Wisconsin Health Gaps Report. (2015)

52 Social and Economic Factors Wisconsin Milwaukee (ME), WI Waukesha (WU), WI Ozaukee (OZ), WI Social & Economic Factors High school graduation 88% 74% 94% 96% Some college 68% 65% 80% 82% Unemployment 4.10% 5.10% 3.60% 3.50% Children in poverty 16% 28% 5% 5% Income inequality Children in single-parent households 32% 50% 18% 18% Social associations Violent crime Injury deaths Health Equity means 41,000 fewer people who are unemployed 94,000 fewer children in poverty County Health Rankings and Roadmaps. Wisconsin Health Gaps Report. (2015)

53 Physical Environment Wisconsin Milwaukee (ME), WI Waukesha (WU), WI Ozaukee (OZ), WI Physical Environment Air pollution - particulate matter Drinking water violations No Yes No Severe housing problems 15% 22% 13% 11% Driving alone to work 81% 76% 87% 85% Long commute - driving alone 27% 25% 33% 35% Health Equity means 88,000 fewer households with severe housing problems County Health Rankings and Roadmaps. Wisconsin Healt Gaps Report. (2015)

54 How to connect community conditions to health outcomes? Pathways to Population Health (2017)

55 London Underground Milwaukee Public Transit

56 How can we connect needs and resources? Pathways to Population Health (2017)

57 Pathways to Population Health (2017) Givens, M.J., Bergum, A., Willems Van Dijk, J. Et alt. University of Wisconsin Population Health Institute. What Works? Social and Economic Opportunities to Improve Health for All. September, 2018.

58 Pathways to Population Health (2017)

59 Sources Trust for America s Health Stephen Bezruchka. Health Equity in the USA. Social Alternatives. Vol 29, No. 2 (2010) County Health Rankings and Roadmaps. Wisconsin Health Gaps Report. (2015) Healthy Wisconsin 2020 Strategic Plan Institute for Research on Poverty. Wisconsin Poverty Report. ( Pathways to Population Health was the result of 2 year of intensive research, interviews and community capacity building work. I am very grateful to the friends, experts, mentors and frontline workers who contributed to the book. This presentation pulled from information from County Health Rankings and Roadmaps with supportive data from IRP and Trust for America s State-by-State Public Health Funding Annual Report. BroadStreet (2018). Area Deprivation Index. BroadStreet Methods Wiki. Access available at upon request Le Counte, E.S., Swain, G.R. Life Expectancy at Birth in Milwaukee County: A Zip Code-Level Analysis. Journal of Patient-Centered Research and Reviews, : )