President Obama has supported a substantial increase in the federal minimum wage from $7.25 to $10.10.  Based on a report released by the Congressional Budget Office in February 2014, raising the minimum wage would help get 900,000 people out of poverty but it could cost 500,000 jobs. Contrary to popular opinion, the bulk of minimum wage workers are mid- or full-time adult employees, not teenagers or part-timers. According to the Economic Policy Institute, an increase to $10.10 would either directly or indirectly raise the wages of 27.8 million workers and provide a modest boost to U.S. GDP. A report by the Center for Economic and policy Research points to small employment effects with modest increases in the minimum wage.  Other economists and policymakers favor expanding the earned income tax credit over the minimum wage or the combination to support working low-income Americans.  The economics of the living wage is complex and its health benefits could be summarized as followed:

Obesity - Melter and Chen using data from the Behavioral Risk Factor Surveillance System (BRFSS) from 1984– 2006  found that a $1 decrease in the real minimum wage is associated with a 0.06 increase in BM.  The real minimum wage in the US has decreasedReal minimum wage decreases can explain 10 percent of the increase in BMI since 1970. Other researchers have also found that low wages increase obesity prevalence and body mass.

Mortality and health status – analysis of a proposed living wage ordinance in San Francisco by Bhatia and Katz demonstrated that a modest gain in income would be associated with substantial health benefits, improvement in educational attainment of workers’ children and decreased risk of premarital childbirth.

Access to health care -  a study by McCarrier et al. examined associations between state-level minimum wage policies and respondent-level indicators of access to health care and showed that minimum wage policies do not adversely affect health care access. In fact, they found evidence that higher minimum wages are significantly associated with reduced odds of workers reporting cost-related barriers to needed medical care.  Even with expansion of health insurance under ACA, high-deductible health plans could increase out of pocket cost for most Americans.  There is also evidence that the benefit of providing health insurance for low-income workers is more cost effective than living wage increase. 

UPMC currently faces challenges from Highmark, the City of Pittsburgh, and labor organizers.  The following outline is an introduction to what are complex and intertwined legal, political, and economic issues.

UPMC versus Highmark
UPMC and Highmark are engaged in a multifaceted struggle over the health care market in southwestern Pennsylvania. The most contentious issue: will Highmark plan members continue to have access to UPMC services after the current contract ends on December 31, 2014?

• UPMC’s voice: G. Nicholas Beckwith III, the chair of the UPMC Board of Directors, wrote an op-ed (6/17/13) that said Highmark needs 41,000 patients to reach its financial goals.  Virtually all of those must come from UPMC.  As hospital admissions are declining and hospital admissions are a zero-sum game, UPMC estimates that would lead to 11,000 job losses.  He said a new contract with Highmark would allow them to “steer and tier” patients away from UPMC.
• Highmark’s voice: Highmark President and CEO William Winkenwerder Jr. responded with an op-ed (7/7/13) that questions UPMC’s intentions.  According to the CEO, UPMC wants “cartel-like competition without choice” and will act to interrupt the continuity of patient care for millions of people.  
• The state legislature is still trying to pass the “Any Willing Insurer” bill that requires UPMC and Highmark to accept one another’s insurance, regardless of whether they have a contract.  Dan Frankel, one of the authors of this bill, represents Squirrel Hill.
• Governor Corbett negotiated the 2012 contract agreement between UPMC and Highmark and has expressed a willingness to intervene again.
• A recent move: UPMC acquired the Altoona health system and the Attorney General didn’t oppose it on anti-competitive grounds.  However, he warned that Altoona clients, who mostly have Highmark insurance, shouldn’t lose access due to UPMC ownership.  
• A history of lawsuits: West Allegheny sued UPMC and Highmark for stifling competition.  Highmark then bought West Allegheny and UPMC countersued Highmark for stifling the growth of UPMC’s insurance wing.  Clients of both have sued both of them for unwarranted high rates.  In October, UPMC and Highmark agreed to drop their suits, but this does not resolve the core problem.
• A recent news summary.

City of Pittsburgh versus UPMC
During the Ravenstahl administration, the City of Pittsburgh sued UPMC to have its nonprofit status revoked.  The city argues that UPMC is not acting as a charity. The closure of UPMC Braddock Hospital, investment in international services, and executives’ salaries are among the justifications of the allegations.  

• The tax issue: Non-profit = tax-exempt.  Pittsburgh’s property tax base is unusually weak.  Due to archaic annexation laws, the city hasn’t expanded its boundaries in any meaningful way in over a century.  The density of municipalities in Allegheny County is among the highest in the country.  Thus, Pittsburgh benefits from a disproportionately small portion of the tax base compared to other major cities.  Taxing UPMC’s enormous landholdings (more than $1B in Pittsburgh alone) would help compensate for this issue.
• UPMC’s response: UPMC is suing for civil rights infringements because it says the city singled out UPMC among all tax-exempt organizations in the city.
• The actors: The relationship between the city, SEIU, and Highmark are not completely transparent.  Fair Share Pittsburgh seems to be a nexus for them.  SEIU was a significant part of Mayor Peduto’s political coalition during his campaign.
• The numbers (according to Fair Share Pittsburgh). UPMC as a whole had $10B+ in revenue, $300M profit in 2012, and $500M+ profit in 2011. Jeffrey Romoff, UPMC President and CEO, made more than $6M.  20+ executives made more than $1M. Changing UPMC’s non-profit status would net the city $11M in property tax and public schools would get $14M
• Alternatives to revocation of nonprofit status are under consideration.
• The state legislature passed a bill in 2013 saying the legislature, rather than the courts had the sole authority to determine whether an organization is a pure public charity.

UPMC labor debates
SEIU has been attempting to organize workers at various UPMC sites.  Make It Our UPMC is the coordinating body for this activity, which is not entirely separate from the city’s lawsuit.

• In early March, SEIU organized two days of protest outside the U.S. Steel Tower that had around 1000 participants at its max.  The protest resulted in Mayor Peduto and Romoff agreeing to a closed-door meeting.
• Examples of labor issues

1. Two employees were fired, one was suspended, others affected, possibly for labor organizing activity.  In response to SEIU complaints, NLRB charged UPMC for intimidating and retaliating against employees involved in organizing activity. 
2. UPMC laid off 130 transcriptionists, and the outsourced company offered to hire them all but at around half the pay.  Insurance coverage at UPMC was also lost.  No severance was given because all were offered jobs.  
3. UPMC Altoona nurses, supported by SEIU, recently agreed to a new contract.  They went on a one-day strike in February.

Politicians Involved with Make It Our UPMC

• Rep. Jake Wheatley - 19th District, Allegheny
• Rep. Erin Molchaney - 22nd District, Allegheny
• Pittsburgh City Council: Bruce Kraus, President, Daniel Lavelle, Darlene Harris, Natalia Rudiak, Deb Gross, Dan Gilman, Corey O’Conner
• Allegheny County Council: Amanda Green-Hawkins

UPMC Fair Hiring

• UPMC received a contract to provide care to federal workers.  As a subcontractor, UPMC is required to report on its hiring practices to comply with equal opportunity laws that date to the civil rights era.  UPMC challenged that it was a subcontractor and repeatedly lost in courts.  Now it is challenging the constitutionality of that law.  This is a 9 year long legal challenge.
  
• The City Council also is trying to get UPMC to drop its case.  It is believed that if UPMC wins no federal subcontractor will have to comply with this law.  UPMC says everyone is mischaracterizing the case.
  

Compiled and written by Collin Schenk (MS1 at UPSOM).

A child who grows up in Pittsburgh, PA with parents who earn in the 10th percentile, ends up, on average, in the 40th percentile based on data from Raj Chetty and Nathaniel Hendren, Harvard, and Patrick Kline and Emmanuel Saez, U.C. Berkeley (interactive graphics by the NYTimes).  These researchers are part of the Equality of Opportunity Project which finds (1) upward income mobility varies substantially within the U.S.  Areas with greater mobility tend to have five characteristics: less segregation, less income inequality, better schools, greater social capital, and more stable families, (2) Contrary to popular perception, economic mobility has not changed significantly over time; however, it is consistently lower in the U.S. than in most developed countries.

Pittsburgh has one of the highest mobility rates compared to Atlanta or Memphis.  As a whole, kids have a better chance rising out of poverty in the Northeast, Great Plains and West compared to the Southeast and industrial Midwest. 

What are the policy implications for these findings? Racial discrimination is playing a role but investment in education and community development will result in poverty reduction and higher income mobility.  Details, details, details.

"We are so desperate for jobs in West Virginia, we don't want to do anything that pushes industry out," said Maya Nye, president of People Concerned About Chemical Safety (excerpt from the NYTimes).  Last week, MCHM, a chemical used to wash coal leaked from a storage tank into the Elk River in Charleston, W. Va. depriving safe water to about 300,000 residents in the "Chemical Valley."
This latest calamity stirs up the classic clash of jobs-vs-the-environment. Drilling for natural gas by hydraulic fracking, New Jersey Pinelands natural gas pipeline and the Keystone XL are just some examples.  The debate pitches industries, towns, workers against environmental groups but jobs seem to trump everything especially when the economy is just dragging.  Of course, the health consequences to environmental degradation is palpable.  A analysis of China’s Huai River policy, which provided free winter heating via the provision of coal for boilers in cities north of the Huai River but denied heat to the south, results in life expectancies about 5.5 y lower in the north owing to an increased incidence of cardiorespiratory mortality. 

It is sometimes difficult to assess the health risks to a community or even when the risk is statistically real, the priority on everyday survival often takes precedence.  We see this in our patients making choices about prevention practices such as smoking cessation, eating healthier or quitting a job that is stressful, physically painful or killing you slowly with toxins over years.  The inertia is overpowering especially when patients have limited options or coping ability and overwhelming pressing needs.  Furthermore, our society feeds on vulnerable people who have a scarcity mindset. 

We should NOT have to trade personal health or environmental health for livelihood and opportunities.  What we need more than technological innovations is social innovations.  Perhaps the chemical spill in W. Va. could be averted with better regulations or economic development that is less dependent on coal and fossil fuel.  We also need to focus on strengthening the public health emergency response, educating ourselves about risk-reducing strategies and engender a collective responsibility for each other well-being as w communities and global growth.  In health care, we call this single-payer! 

I believe the author Marjorie Holmes said that.  The concept of home is vastly different depending on who you are, what you do and where you come from.  It is indeed an extension of oneself--an abode to uphold or a victim of our neglect, and ideally a source of nourishment.  The neighborhood is an even broader encapsulation of one's existence. 

At this festive holiday season, allow me to transgress to bring the realities of homelessness into our consciousness.  We all agree that it has been a stormy year in health care.  The one aspect of the ACA that is relatively popular is the Medicaid expansion and subsidies that allow low-income Americans to obtain affordable health insurance.  Many states are looking for innovative solutions to cut rising Medicaid costs.   New York State is implementing an ambitious supportive housing program targeting Medicaid patients who have high health care costs under the motto Housing as Health Care.

Providing supportive housing for those who experience homelessness and mental illness has been shown to reduce hospital use, decrease health care costs and improved health parameters especially for high utilizers.  Tenants in supportive housing programs have affordable apartments and easy access to a network of professionals to help them stay housed and healthy.  Numerous studies have quantified the disproportionately high service utilization of homeless people with disabilities including hospital-based acute care such as emergency rooms, psychiatric hospitals as well as shelters, jails and prisons.  As mentioned above, a significant and growing burden of this cost is borne by Medicaid funding. 

Studies have shown that supportive housing helped save taxpayers millions of dollars but upfront investment costs lead state and federal governments to embrace these programs less enthusiastically. Evidence of cost effectiveness is not yet available from the NYS program.

We know that housing quality and neighborhood sociodemographic characteristics are associated with mental health. A study by McKenzie in Europe suggests that neighborhood physical quality could counteract the adverse impact of substandard housing.  Lower income individuals and families rely on strong social networks and support in the neighborhood to maintain psychological well-being.  Put it bluntly, even if you place is a dump, having access to positive social interactions (safe green space, gardens, shops, fitness facilities and other community amenities) provides respite and stress relief. 

For 2014, if wishing for everyone to have a cozy home comforted by loved ones is too starry-eyed then we should work to build neighborhoods, develop social ties and safe play areas for our children.  Then the world will be a better place and wishes for good health will come true.  Of course, we need to first end and prevent homelessness. 

Joy and peace to all. 

The socioeconomic impact of immigration is substantial. Between 2001-2011, immigration accounted for 40% of total population growth in the OECD.  According to the International Migration Outlook 2013, high-income countries continue to attract immigrants and students from around the world since the global financial crisis of 2008.  India, China, Poland and Romania are top countries of origin into OECD countries.  In the face of rising unemployment, migrants’ labor market situation has worsened compared to natives over the past years particularly for Latin Americans in the US and migrants from North Africa in Europe.  In a country such as the US, where immigrants are often young and the social safety net is not large, the effect of immigration is often more positive—increasing the GDP by 0.03 percentage points.

Strong sentiments against immigrants particularly unauthorized immigrants in the US and a dysfunctional Congress have delayed immigration reform legislation (S.744) which calls for an eventual pathway to citizenship for undocumented immigrants while ramping up border security measures. Certainly there is enthusiastic support for the recruitment, hiring and retention of highly-skilled foreign workers (H-1B visas) with economic implications.  (How this policy is affecting the global health care workforce crisis is the subject of discussion another time). 

Research and practice have highlighted the increased risk for disease, trauma and social stressors among this population (low-wage immigrants and refugees) from discrimination, substandard living and exploitative labor conditions.  There is a growing public health literature that favors access to health care for immigrants but also one that is concerned with disease transmission (TB, HIV, STI) and national security threats (Viladrich, 2012).  The public discourse on immigration comprises a full spectrum of model to undeserving immigrants, welfare-dependents to drivers of economic growth. 

I would argue for a more “simplistic” view of immigrants.  Migration is an undeniable fact of life.  Of course there are differences in how our society regards undocumented immigrants and the native poor but our policy should aligned with the concern for social inequality and how we treat and provide for those less fortunate—all racial ethnic groups and no matter how they come to live in America.  In hard times (economic or political upheavals), feelings and beliefs about self-sufficiency and individual responsibility trump justice and humanitarian consideration and create ethnic tensions pitching one group against another.  Even the argument to provide immigrants with health care and social benefits for the sake of self-interest and return on investment seems like a weak cover for avoiding the discussion of poverty and social justice.  If we use this same lens to approach vulnerable immigrants and low-income Americans then we are all better off on the road to policy and legislative reform that will benefits all Americans.

The current problem with the health care market place enrollment under ACA and the driver behind Obamacare beg the question of the role of government in our daily lives but particularly when it comes to improving health. Obamacare is essentially a conservative program, market-driven private insurance exchanges, built on means-testing, state decentralization and promise of billions of dollars in future subsidies to expand coverage for those in the lower income brackets.  The ultimate beneficiaries might be insurance companies, corporate medicine and a relatively small number of Americans with new insurance coverage and fewer out of pocket spending.

Opponents to ACA cite cost, government bureaucracy, economic impacts but probably the core value and beliefs at stake are the role of government, charities and what we should do about inequalities in our society, if at all?  I would like to tackle our love-hate relationship with charity.

Americans are known to be very charitable people globally as individuals, corporations, nonprofits and government.  Republicans (speaking in generality) like charities but favor market-approach or they just don’t like governments to be the facilitator.  Ricardo Salinas, founder and CEO of Grupo Salinas said in a recent interview by Charlie Rose: “Charity is limited….not self-sustaining.”  He himself has supported a Mexican non-profit organization that promotes microfinancing and social responsibility.  This issue has been and is currently studied and explored globally.

GiveDirectly is an organization that allows governments and foundations to provide direct cash transfer to the extreme poor.  It collaborates with Innovations for Poverty Action (IPA) to conduct a RCT in western Kenya where recipients received an average of $500 over 9-12 months.  Recipients were free to spend the transfer as they wished.  The study (May 2011-Jan 2013) found that GiveDirectly’s transfers allow poor households to do home improvements, increase livestock holdings, spend on food, health care, education and social and family events  which led to reduction in hunger and food insecurity and increase in psychological well-being.  Transfers do not increase spending on alcohol and tobacco and have little impact on health or education over this short evaluation period. 

A November 2013 publication in AJPH by Guanais examined the combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil from 1998-2010.  There are 13 million families enrolled in the federal program as of 2010 which provides cash to poor families if they comply with regular school attendance and use of preventive care services.  His analysis confirms earlier evidence that the primary health care expansion contributed to the reduction of the postneonatal infant mortality rate in Brazil and adds new evidence that conditional cash transfers from the Bolsa Familia Program may have helped to overcome important barriers to some forms of primary health care because of low family income. 

So what’s the connection to Americans and Obamacare?  We are not the same as Africans and Brazilians you say.  By the way, we call cash transfers by government/tax payers to poor people welfare and entitlement programs; cash transfers by foundations/corporations charity, gifts, donations; by business groups and non-profits: social enterprise.  We disdain the first category and glorify the latters.  Contrary to the views of many, Obamacare is NOT really an entitlement program.  What do you call cash transfers from government to corporations?  As a whole, we don’t have the patience to wait and reap the impacts of cash transfers to the poor.  We accept the fact that as our economy is recovering, US income inequality is still on the rise.  We accept random acts of kindness over large-scale programs in the name of libertarian ideals and personal responsibility.  We (speaking as a country) did not endorse health care as a human right and so single payer system.  In health care, we need to innovate beyond neoliberal ideology because confined within that framework, we got Obamacare and all its mess (and it’s just the beginning). 

Putnam warned over 10 years ago that we had become more disconnected from family, friends and neighbors, and he thought we could revitalize our civic and religious engagement and rebuild our social capital. 
Pantell and colleagues reported in the September issue of the AJPH that social isolation is a predictor of mortality comparable to traditional clinical risk factors such as hypertension and smoking!  They imply that clinicians and their staff, health plans should screen for social isolation asking 4 questions such as:
1. Marital status
2. In a typical weeks, how many times do you talk on the phone with family, friends or neighbors?
3. Do you attend church or religious services 4 or more times per year?
4. Do you participate or belong to a club or organization such as a church group, union, fraternal or athletic group, or school group?
 It is questionable whether these are easily modifiable risk factors and whether interventions will result in reduction in mortality.  There was a study (and probably more since) which showed impaired transcription of glucocorticoid response genes and increased activity of pro-inflammatory transcription control pathways providing a functional genomic explanation for elevated risk of inflammatory disease in individuals who experience chronically high levels of subjective social isolation.  Would health plans reward members for activities that decrease their social isolation?

On a separate topic and totally my venting regarding the government shutdown: under the rules of the federal government shutdown, members of Congress will continue to receive their salaries--even as hundreds of thousands of government workers are furloughed without pay!  talking about fairness and inequality!!!

Many  economists and researchers have written about the growing inequality in the US.  Tyler Cowen's latest book: Average Is Over like many others supports  the theme of widening gap between rich and poor.  How does inequality manifest in medicine or health care? Most physicians cite lack of access!  Health services researchers tend to focus on behaviors (e.g. adherence) and health systems factors such as quality indicators and cultural competency.  More and more, our society (“regular folks,” politicians, even public health advocates and health care providers recognize the importance of providing equal opportunities for all Americans, support growth of the middle class and on issues such has housing, jobs, education (social determinants of health) BUT increasingly accept that we
as a country thrive on a compassionate survival of the fittest mentality.  

Let me give you an example, abeit a more extreme one.  I just came off a 2-week inpatient service and my team worked with a patient who has a substance use as well as a chronic pain problem.  He has to remain in the hospital for 6 weeks of IV antibiotics because home health would not accept him due to past behavioral issues.  All hospital staff and consultants have advised against giving him opioids because of repeated positive urine drug screen for cocaine and as a high risk candidate.  In my opinion, he
has pain due to current vertebral osteomyelitis and multiple back
surgeries.  He does not see himself as an addict (self-denial possible) but use crack/cocaine to alleviate the pain.  I have treated, crossed
paths with several patients struggling with addiction and certainly some have benefited from second chances—government initiatives, private and faith-based programs BUT more and more, our society has made it tougher for people to have additional second chances.  When someone does not make it in life, it is attributed to their moral and behavioral failings and not social and environmental factors modifiable through policy and
structural changes.  Sometimes, it does not even require such momentous efforts, just a few individuals getting together agreeing on doing the right thing.  

I have dabbled in social support interventions over the years through the Pittsburgh Caregiver Support Network, involvement with patient navigator/advocacy activities and peer support groups but a phone call with a patient earlier today brought reality to a complex issue in American society.  I called my patient whom I've known for over 10 years to inform her that the blood culture obtained the day before from urgent care has turned positive and that she needed to be directly admitted.  Her partner completely broke down on the phone.  Through the anger and despondent sobbing, I could make out: who is going to watch our daughter...you know you can't trust leaving L. in the hospital without someone watching over her.  They'll give her the wrong medications...and it's July, all those new interns...and my mother, I have to take care of my mother.  Can you arrange for the antibiotics at home...will the ID doc see her on a holiday?  Dozens of questions hurled at me, most of which I do not have answers although I do know that I could get more blood culture drawn, IV line and empiric antibiotics started in the hospital.  Could I say for certain that she would be safer in the hospital than at home?  guilt and embarrassment choked up inside me...

What my patient and her partner need is what is labeled an informal social support--family, friends and trustworthy sources.  A formal social support, in contrast, is usually more bureaucratized, stigmatizing, costly, less personalized and accessible.  How do you engender trust and perception of support in formal social support network?  How do we promote public policy that build family social support?  These are some of the programs compiled by the RWJF and County Health Rankings & Roadmaps.