WHAT WOULD IT TAKE TO MAKE MINNESOTA THE HEALTHIEST STATE IN THE NATION - AGAIN?

WHAT WOULD IT TAKE TO MAKE MINNESOTA THE HEALTHIEST STATE IN THE NATION - AGAIN? Ed Ehlinger, MD, MSPH Commissioner Minnesota Department of Health August 6, 2015

Alfred, Lord Tennyson born August 6, 1809 Poet Laureate, wrote Charge of the Light Brigade Knowledge comes, but wisdom lingers.

Minnesota is a healthy state State Health Rankings 2014

Life Expectancy at Birth #2 Male life expectancy - #1 Female life expectancy - #2

MN Infant Mortality Rate Among the Best in the US

MN #1 in Health Care System Performance Access, Quality, Cost, Outcomes

Garrison Keillor, born on August 7, 1942 Minnesota! Where the women are strong, The men are good looking, And all our health statistics are above average.

How did we get to be a healthy state? We invested in the public good. We cooperated. We made wise investments in our healthcare system. We made some wise policy decisions

Trend in Minnesota s Health Ranking We we State Health Ranking - Minnesota

Trends in MN Outcomes and Determinants Deviations from the US Mean

Factors Affecting MN State Health Ranking

What is affecting our state s health ranking? Positives (in top 5) Cardiovascular deaths (1) Premature death (2) Poor physical health days (2) Poor mental health days (4) Insurance coverage (4) Diabetes (4) Negatives (in bottom 10) Public health funding (44) Binge drinking (46) Pertussis (48) Disparities

Minnesota s Health Care Spending Includes public health, correctional facility health, & Indian Health Service Source: Minnesota Health Care Spending and Projections, 2012, Feb. 2014 Minnesota 44 th nationally in per capita public health spending

Decreasing Investment in Public Health

Wet Attitudes toward alcohol Percentage of adults drinking 5 or more drinks on an occasion one of more times in last month Binge Drinking Rate of Metropolitan Areas Duluth, MN / Superior, WI 20.3% Minneapolis / St. Paul, MN 16.2% Median Metropolitan Estimate 14.5% CDC: BRFSS, 2004

Our booze is too cheap and it s literally killing us. Washington Post, 4/2/15

Disparities in Outcomes and Risk Factors White Black Hispanic Smoking (Percent of adult population) 18.0 22.2 16.9 Binge Drinking (Percent of adult population) 21.8 19.4 15.9 Drug Deaths (Deaths per 100,000 population) 9.5 17.7 6.8 Obesity (Percent of adult population) 25.2 32.0 29.5 Physical Inactivity (Percent of adult population) 20.6 26.9 33.9 High School Graduation (Percent of incoming ninth graders) 92 66 70 Chlamydia (Cases per 100,000 population) 150 1450 364 Diabetes (Percent of adult population) 7.2 8.8 9.6 Poor Mental Health Days (in last 30 days) 2.8 3.8 4.0 Poor Physical Health Days (in last 30 days) 2.9 3.3 3.6 Infant Mortality (deaths/1000 live births) 4.4 9.0 5.3 Cardiovascular Deaths (deaths/100,000 population) 183.4 189.2 112.6 Cancer Deaths (deaths/100,000 population) 180.5 194.8 111.3

USA White and Black IMR: 1980-2011 Health Equity is the Central Challenge in MN and US 25 20 15 White: 10.9 Black: 11.42 10 5 0 NCHS

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 35.0 Infant Mortality Rate in Minnesota, 1980-2011 White and U.S. Born African American 30.0 25.0 * 28.8 20.0 15.0 10.0 White: 9.3 * * Black:10.2 5.0 0.0 4.1 * Rates not calculated for less than 20 events White U.S. Born African American

The role of public health The landmarks of political, economic and social history are the moments when some condition passed from the category of the given into the category of the intolerable. I believe that the history of public health might well be written as a record of successive re-definings of the unacceptable. Geoffrey Vickers

Disparities in Birth Outcomes are the tip of the health disparities iceberg Disparities in Birth Outcomes Heart disease Hypertension Obesity Renal failure Cancer Asthma Alcoholism Cirrhosis Unwanted pregnancies Diabetes Stroke Drug abuse Homicide Nephritis HIV STDs Dementia Substance Use COPD Injuries Suicide Influenza Depression Anxiety Tuberculosis Malnutrition

Garrison Keillor, born on August 7, 1942 Minnesota! Where the women are strong, The men are good looking, And all our health statistics are above average Unless you are a person of color or an American Indian.

The opportunity to be healthy is not equally available everywhere or for everyone in Minnesota. Advancing Health Equity Report to the Legislature February, 2014

Why should we be concerned about disparities

Each 1 percent rise in income inequality is associated with a 4 percent increase in deaths among persons on the low end.

Why addressing disparities is important 50 years of growing diversity 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Percent Of Color 1960-2010 U.S. MN Twin Cities 1960 1970 1980 1990 2000 2010 36% 24% 17% Source: mncompass.org

Alfred, Lord Tennyson born August 6, 1809 Poet Laureate, wrote Charge of the Light Brigade Tis not too late to seek a newer world. To create a newer and better world, we need to make health equity our central focus.

What Would It Take To Move Disparities from Given to Intolerable and Assure the Good Life for All Minnesotans?

If equity was the starting point for our decisionmaking, our work would be different. WE NEED TO START ALL CONVERSATIONS ABOUT POLICIES AND PROGRAMS WITH THE QUESTION HOW WILL THIS AFFECT HEALTH AND EQUITY?

Our Work Would be to Advance Health Equity and Optimal Health for All by: Expanding our understanding about what creates health Implementing a Health in All Policies approach with health equity as the goal Strengthening the capacity of communities to create their own healthy future

Clinical Care 10% What Creates Health? Genes and Biology 10% Physical Environment 10% Determinants of Health Health Behaviors 30% Social and Economic Factors 40% Determinants of Health Model based on frameworks developed by: Tarlov AR. Ann N Y Acad Sci 1999; 896: 281-93; and Kindig D, Asada Y, Booske B. JAMA 2008; 299(17): 2081-2083.

Attributable Causes of Death Firearms Tobacco 42% Diet/Physical Activity 35% Tobacco Alcohol 9% Microbial Agents 7% Diet/Physical Activity Toxic Agents 5% Firearms 2% Each year in the United States: $15.3 Billion is spent marketing tobacco $6 Billion is spent marketing alcohol $2.9 Billion is spent marketing soda (by just 1 company)

Communities of Opportunity Low-Opportunity Communities Parks & trails Grocery stores Thriving small businesses and entrepreneurs Financial institutions Better performing schools Good transportation options and infrastructure Sufficient healthy housing Home ownership Social inclusion IT connectivity Strong local governance Good Health Status Poor Health Status Contributes to health disparities: Obesity Diabetes Cancer Asthma Injury Unsafe/limited parks Fast food restaurants Payday lenders Few small businesses Poor performing schools Increased pollution and contaminated drinking water Few transportation options Poor and limited housing stock Rental housing/foreclosure Social exclusion Limited IT connections Weak local governance

Life Expectancy in Twin Cities

Disparities in Minnesota Disparities are not just because of lack of access to health care or to poor individual choices. Disparities are mostly the result of policy decisions that systematically disadvantage some populations over others. Especially, populations of color and American Indians, GLBT, and low income Structural Racism

Disparities in health are the tip of the societal disparities iceberg Disparities in Health Unemployment Poor housing Social exclusion Poverty Racism Violent neighborhoods School suspensions Liquor stores Drug abuse Bad schools Homicide Food deserts Crime Red lining Incarceration Substance Use Lack of wealth Environmental Injuries Contamination Suicide Immobility Disrupted families Segregation Blight Lack of hope Necessary conditions for health (WHO) Peace Shelter Education Food Income Stable eco-system Sustainable resources Mobility Health Care Social justice and equity World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at <http://www.who.int/hpr/archive/docs/ottawa.html>.

Triple Aim of Healthcare Better care for individuals Lower per capita costs Better health for populations Institute of Medicine

Triple Aim of Healthcare could be detrimental to health particularly health equity Individual health model not a community health model Population health Assumes healthcare is responsible for population health Healthcare is made the benevolent dictator of health All of health is viewed through the lens of healthcare Healthcare determines and reinforces the narrative about what creates health Healthcare dictates where health investments are made Under-resourced communities and health equity are particularly sensitive to the rule of healthcare What s good for healthcare may not be what s best for communities or advancing health equity.

Health Is Community the community in the fullest sense is the smallest unit of health to speak of the health of an isolated individual is a contradiction in terms. Wendell Berry in Health is Membership Healthcare should be community-centered not patient-centered.

CENTRAL CHALLENGE FOR MINNESOTA: ELIMINATING DISPARITIES AND ADVANCING HEALTH EQUITY Health Equity cannot be achieved solely by the health care system and the public health system. Other sectors need to be engaged

Health in All Policies Approach Helps Strengthen Community Capacity Information technology Recreation & Open Spaces Healthy Food Public transit & Active transportation Quality & Affordable Housing Green & Sustainable Development Community oriented media Healthcare Economic Opportunity Fair Justice System Complete Neighborhoods Quality Environment Safe Public Spaces

Policy and System Changes Related to Social Determinants of Health (selected) Marriage Equity Minimum Wage Paid Leave Family and Sick Federal Transportation Policy REL data Broadband connectivity E-Health Policies Ban the Box Buffer strips Contracting policies Target Corporation Contracting Policy Cabinet HiAP Approach State Agency Policy Changes CIC (Big 10)/SHD Initiative Carbon emissions Others depending on the opportunities Data Community energy Partnerships Tools Health Impact Assessments White papers Commentaries

Themes Indicators Outcomes Social Determinants Vision

% Obese Policy, System, and Environmental Change Strategies Improve Health and Reduce Costs 32.0 Obesity Climbed in U.S. and States Without *PSE; Held Constant in Minnesota 30.0 Iowa 28.0 Minnesota 26.0 North Dakota 24.0 22.0 South Dakota Wisconsin 20.0 2003 2007 2010 2013 Data source: CDC Behavioral Risk Factor Surveillance System * Refers to Policy, Systems and Environmental change supporting healthy behaviors U.S. Median Rate

World Health Organization Commission on Social Determinants of Health Framework for Addressing Social Determinants of Health IMPACT ON EQUITY IN HEALTH AND WELL- BEING Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization.

World Health Organization Commission on Social Determinants of Health IMPACT ON EQUITY IN HEALTH AND WELL- BEING Health System INTERMEDIARY DETERMINANTS Social Determinants of Health Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization.

Health care levers to influence disparities Stability of coverage Networks to include Community health centers Community providers Behavioral and mental health services Services to include: Care coordination Preventive services Home visiting Healthcare Homes Community Care Teams Workforce Interpreters Navigators Community Health Workers Other kinds of providers Emphasis on primary care Transportation Individual and community education Data collection on race, ethnicity, and language Tracking of progress Cultural Competence Integration with public health and social services

World Health Organization Commission on Social Determinants of Health IMPACT ON EQUITY IN HEALTH AND WELL- BEING Health System STRUCTURAL DETERMINANTS Social Determinants of Health Inequities INTERMEDIARY DETERMINANTS Social Determinants of Health Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization.

Social Determinants of Health Have the Largest Impact on Equity in Health and Well-Being Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization.

Triple Aim of Healthcare Better care for individuals Lower per capita costs Better health for populations Institute of Medicine

Triple Aim of Health and Health Equity Implement a Health in All Policies Approach with Health Equity as the Goal Expand Our Understanding About What Creates Health Social Connectedness Strengthen the Capacity of Communities to Create Their Own Healthy Future

Medical Care Community/Public Health Public Policies Essential in Advancing Health Equity and Optimal Health for All Expand Our Understanding About What Creates Health Implement a Health in All Policies Approach with Health Equity as the Goal Social Connectedness Strengthen the Capacity of Communities to Create Their Own Healthy Future Medical Care Public Health 0 10 20 30 40 50 60 70 80 90 100

WHAT WOULD IT TAKE TO MAKE MINNESOTA THE HEALTHIEST STATE POSSIBLE? It would take all of us working together because:

Public health is what we, as a society, do collectively to assure the conditions in which (all) people can be healthy. -Institute of Medicine (1988), Future of Public Health Edward P. Ehlinger, MD, MSPH Commissioner, MDH P.O. Box 64975 St. Paul, MN 55164-0975 Ed.ehlinger@state.mn.us