Policy Thoughts

State Dollars Not The Only Thing In Short Supply

By: Don Sloma, WHF Director of Policy

Talk about “the Public Good” may sound just as naive as hoping for big cash to start flowing magically into the state treasury this year.   But the Governor’s ‘Public Good’ inspired idea for new taxes on tobacco, candy, gum and carbonated beverages is gaining ground as an alternative to --- or as a supplement to a temporary sales tax increase.  State Rep. Eileen Cody, House Health Committee Chair, included it in HB 3204 introduced yesterday.
  
The poor pay more under either a sales tax or a ‘sin’ tax, of course, and that is not good.  But a sales tax hike hits all ‘non-essential’ spending, spreading the financial pain a bit more widely than a big hike on tobacco, candy, gum and pop.  

On the other hand, taxing the heck out of these ‘anti-foods’, just as we tax alcohol and tobacco, may cut consumption, just as it has with those vices.  So a new “tobacco and sugar” tax package might hurt the poor on one hand, but it might also have a big plus a sales tax doesn’t have.  If policy makers also target some of the new money toward promoting healthier food choices among the poor, this ‘tobacco and sugar’ tax idea could start looking pretty ‘public interest sweet’: Better diets, more state revenue and more public health effort against the leading causes of preventable death.    

The political calculus is another matter.  The public may already favor sugar taxes, especially if some of the money helps make healthier dietary and physical activity choices easier.  But the corporate interests who sell sugar laden products --- and who also heavily sweeten both political parties’ campaign coffers ---- are already less than amused.  Have you seen their ads?  A beleaguered mother lugging a veggie laden grocery bag through her front door complains that in these tough times she simply cannot cope with taxes on ‘fruit juices and soda’.  She begs us to tell law makers to give her a break. 

We are left wishing these companies would only give us one.  Sugar sweetened beverages are not food under the law in Washington or in many other states.  They haven’t been for some time, because they have little or no nutritional value.

We understand that all policy makers need to balance public priorities against possibilities, both technical and political.  If the singular public priority in Olympia these days is additional revenue, it probably won’t trump the political realities against taxing candy, gum and pop.  But if public priorities include a healthy dose of concern for public health, we wonder if the balance might tilt differently.

Cuts, Taxes and the Governor's New Revenue Plan

When Governor Gregoire released her ‘balanced, but unjust’ budget last December, we praised her leadership in warning us away from its ‘all cuts’ approach.  We agreed cuts in K-12 levy equalization, public health, safety net programs and medical care subsidies among others would be felt far too sharply by those already hurt most by the recession, and already at the greatest health risk.   We agreed that increasing inequity in these ways would not only jeopardize health in Washington; it would be a step toward transforming us into something other than the state we are proud to live in. 

On Wednesday, the Governor completed her promise to submit a combined ‘cuts and new revenue’ alternative to that unjust budget.  The program restorations already revealed include K-12 levy equalization, some early learning programs, public health services for pregnant women, young mothers and children, detox and drug treatment services, Apple Kids Health Insurance and the Basic Health Plan.  These are not all of the restorations we would have made, but it is a good list, especially since it addresses educational opportunity as well as health and safety net priorities, just as we do in our biennial report card on Washington’s Health.

Even more encouraging, the Governor fulfilled her promise by suggesting a revenue package that takes dead aim at some of our riskiest personal health habits.   Of some $768 million in new revenue, the Governor proposes to collect almost a third by taxing tobacco, candy, gum, and carbonated beverages as follows:

Taxed Item                                                                        Projected Revenue (Millions)

	Carbonated beverages @ 5 cents per 12 ounces at wholesale		$ 93.60
	Cigarette tax from $2.025 to $3.025/pack and OTP at cigarette rate		$ 88.80
	Impose sales tax on candy and gum		$ 28.00

The evidence shows that an additional dollar a pack tax on tobacco will further reduce tobacco consumption.  And her support for using some of the funds to target those groups still disproportionately using tobacco goes a long way toward restoring her reputation as a compassionate, anti-tobacco crusader.

Her suggestion of new taxes on candy, gum and carbonated beverages will open a new set of debates about tax policy and public health that we welcome.  There is evidence that the effects of taxing these products may be similar to that of taxing tobacco, and that the public may already favor such measures, especially if, as we urge, at least a portion of the revenue helps make healthier dietary and physical activity choices easier.

The Governor’s proposal is more likely the beginning and not the end of the debate about the propriety, effectiveness and public acceptability of taxing items like these that are arguably linked with obesity.  But these debates should begin.    

Finish Health Reform and Move On

By: Don Sloma, WHF Director of Policy

It isn't pretty.  We do not love it.  It doesn't do enough to reform medical care or contain costs.  It will take too long to implement.  And there is real political risk in it, both for those who have dirtied their hands trying to build  it and for those trying to dismantle it.

BUT  at this point, any final health bill Congress may enact, seems pretty likely to contain the first real government boost for health we have had in a long time.  It is likely to contain:

·       expanded public health funding for state and local health departments, now near collapse in Washington,

·       chronic disease prevention, with a focus on obesity,

·       better medicare and medicaid support for proven clinical preventive care like mammograms, immunizations, and

·       a bit of help for primary care.

Additionally, any reform passed this year will likely add millions more poor and near poor kids and adults to the rolls of the insured, will curb a few of the worst abuses of insurance companies and will get a start on some promising ideas for a fairer medical insurance market place and better quality medical care.
 
There is no denying that a year's shouting and hollering has stolen the luster from the prize.  The final bill is unlikely to be the change many of us believe in.  But it is improvement.  Congress should do as the President asked in his State of the Union Address. It should not walk away.  It should pass it, and move on to create jobs and to finish fixing the economy.
 
There will be plenty of time to improve on health reform next year and the year after that.  Small steps on an embarrassingly large problem may not be the change we want, but doing something now may be the only way of beginning the change we need.

Education Bill Doesn't Make The Grade

By: Don Sloma, WHF Director of Policy

Last year and again this year, an unholy alliance of school system bureaucrats is trying to draw legislators into a reckless game of chicken.   They want them to risk our kids' safety and health to underscore their frustration with the state's failure to fund schools adequately.  "If you won't fund needed class size reductions, teacher pay raises and a host of other items to lift up our schools", they say, "then repeal a host of well intended, but unfunded or underfunded state mandates." 

Nice move, except their list of repealers includes direction that our kids be offered nutritious food, adequate exercise, certain emergency medical planning and response, and frequently updated information about coping with very real threats from violence, gangs and bullying, to drugs, infectious diseases and more.  One of the offending bills is Senate Bill 6604. 

Please call, text, email or otherwise raise your voices to Senator Hobbs, the bill's sponsor, and perhaps more importantly, to the members of Senator McAuliffe's Education Committee where this bill needs to die.  Tell them two wrongs (lack of school funding, and walking away from school safety and health) don't make a right.  Tell them YOUR Priorities of Government include safe and healthy kids at school. Ask that they get busy thinking of solutions for adequate school health programs instead of wasting their time with this nonsense.  One option may be something like Senator Kohl-Welles bill (SB 6755) to create a public/private Coordinated School Health partnership.  Even doing nothing on school health, the legislature's strong suit in these tough economic times, is way better than sacrificing our kids in this reckless game.

Tobacco, Taxes and the State Budget

By: Don Sloma, WHF Director of Policy

Should differences over health reform, taxes and the role of government distract us from the places where public officials and health leaders get together and get it right?  Consider tobacco, taxes and the state budget. 

For the last decade, public health officials have competently led a War on Tobacco.  The result: Far fewer of our kids are taking up the habit, and adult smoking is down by a third.

Our Healthiest State Campaign celebrated Washington’s leading rank in smoking rates (fifth lowest among states in 2008) by recognizing the chief enabler of all this good government, Governor Christine Gregoire, as our Hero in Health Care.  As lead architect of the landmark national tobacco settlement that provided the early financing for Washington’s War on Tobacco, and as state public health chief and master Tobacco War General Mary Selecky’s boss, few politicians deserve more credit for this success than she.

But our Governor’s reputation as a rabid anti-tobacco crusader risks serious damage this year amidst the carnage around Olympia’s budget.   The no new taxes, balanced budget she was bound by law to deliver last month (and which to her credit, she made no bones about opposing) included another $2.4 million cut in tobacco prevention. 

After last year’s cuts and after the state’s plan to end its earmarking of any tobacco related settlement dollars or tobacco tax revenue for prevention,  we are worried that Olympia’s inevitable partisan battles over taxes and spending might stub out the still unfinished War on Tobacco. 

The questions for Washingtonians are these:  What priority of government, what ideological victory and what tax policy argument justifies a retreat from our government’s successful war against the leading cause of preventable death?  Should cynicism about government end its successful expressions of our outrage at an industry that profits by selling a product that, when used as directed, kills? 

While you are thinking about these things, just know that tobacco companies are strategically upping their advertising in states and targeting groups that have been abandoned by publicly funded tobacco prevention.  They know the research:  When tobacco prevention dollars go down, a marketing opportunity opens for them and smoking rates go up.

If we let that happen, each of us should wonder about our own commitment not just to health, but to fairness. 

Why fairness?  All of this comes just as our successful state tobacco program is redirecting its efforts toward those groups not helped much yet by the raft of incentives, supports and other inducements to quit: the mentally ill, the drug addicted, the poor and a few racial and ethnic minorities who now shoulder the health (and the tax) burden of tobacco far more heavily than the rest of us. 

If getting folks to stop is the goal, there’s plenty of evidence that higher tobacco taxes gets the job done.  In fact, it has proved the single most effective thing we can do.   That is why it has been encouraging to hear talk around Olympia in recent weeks of adding another buck to the two dollar a pack cigarette tax, and finally taxing chew and snuff at the same rate as cigarettes.

But if some of the money isn’t earmarked to help these remaining smokers quit, especially given that many of them already have so much else stacked against them, is it really fair to make them pay more?    Should we exploit their addiction without offering them any special help, just so the rest of us don’t have to pony up to keep the government afloat in a recession? 

We don’t think so.  If Olympia needs to find new revenue, tobacco taxes are a good place to look.  But if there is a tobacco tax bump, let’s all be sure at least some of it is set aside to help those still addicted and at risk of becoming addicted.  We owe it to them and we owe it to our own consciences.

And Now For Something Completely Different

By: Don Sloma, WHF Director of Policy

Food Journalist Michael Pollan is making the talk show rounds this week promoting his new pamphlet “Food Rules” as one common sense and common science based answer to health reform. His short prescription: Prevent obesity and chronic illness by “eating food, only less, mostly plants.”

http://www.huffingtonpost.com/michael-pollan/food-rules-a-completely-d_b_410173.html

“Food Rules” is a pithy collection of 64 rules, each with its own mercifully short, truthy sounding explanation or justification.  
 
We like the style and the approach.  We see lots of wisdom here, and we agree improving diets along many of these lines would reform our health system in some ways more sustainable than many of the elements currently under discussion in Congress.
 
But Pollan’s book won’t make following his 64 rules any easier amidst what he describes as “the treacherous landscape of modern food and the often-confusing science of nutrition”.  As he well knows and often says, that will take national agricultural and food industry reform.  
 
Nor will it stop the poorest and least educated among us from using tobacco, still beating out obesity as the leading preventable cause of premature death. That will take public policies and programs to make smoking too hard, too expensive and too socially lame a choice for anyone to make, especially the poor, the undereducated, the addicted and the minority group members who now disproportionately engage that behavior.
 
Nor will it buy health insurance for the tens of millions who can’t afford a doctor.  Nor will it find cancer early, or prevent childhood diseases, nor bend the curve on medical cost inflation that threatens now to eat our school budgets, our government and our businesses’ bottom lines.
 
Michael Pollan is a real leader in the fight to improve nutrition and to prevent obesity in our country, and we love him for it.  His new pamphlet is a real contribution to all that and folks should check it out. But this ad blitz overpromises health reform through a pamphlet just when our nation may finally be getting serious about fixing a much more complex set of health problems.  
 
Buy the pamphlet.  Follow the rules that make sense to you. Then go ahead and support national health reform, and the raft of food, public health and social environmental reforms we will still need in the years to come if following Pollan’s “Food Rules” is ever to become the easy choice.

The Courage to Lead

By: Don Sloma, WHF Director of Policy

Governor Gregoire fulfilled her legal requirement to submit a balanced budget with no new taxes. She dubbed it, “balanced, but unjust”.  She then vowed to produce her recommended budget next month, with new revenue.  She outlined her general intention to save some of the programs we believe are most critical to making ours not the healthiest state, but simply a state where health, education and some degree of equity are not endangered species.
 
Our Governor is facing a state revenue shortfall worse than the one in the early 1980s that led the “no new taxes” Governor John Spellman to break his campaign promise, and to dash his own hopes of a second term by leading a recalcitrant legislature in the largest single tax increase the state had ever seen.  
 
After reciting the ugly economic history of the past year, summarizing her most recent efforts to streamline, consolidate and reduce unnecessary spending and reminding us of the many cuts already made but only now being implemented that threat our health, education and collective welfare, Governor Gregoire offered these words:
 
“What can we cut? Education, public safety, and the safety net for our most vulnerable.

In short, we can only cut what I believe makes us Washington.

We can increase class sizes. We can deny the treatments that keep sick people from getting sicker. We can close the doors to higher education for low-income students. …
 
“Those are the decisions we face, and they have everything to do with our values as a state. I realize the future this budget will create. It does not reflect my values nor do I believe it reflects the values of my fellow citizens. Let me be very clear: I do not support this budget.

As required by law, it is balanced. For me, it is unjust.”
 
Unconvinced? Please read the details of the cuts yourself here and at www.ofm.wa.gov.
 
When you are finished, if you are the Washingtonians we believe you are, you will be looking at your Christmas list, your vacation plans, and maybe even some of the boats, the cars and the homes around the Sound with some different eyes.  
 
Thanks Governor.  We needed this.

Will the “Melting Pot” or Horatio Alger Be the End of Health Reform?

By: Don Sloma, WHF Director of Policy and Fisher Qua, WHF Public Affairs Intern

Among the darkest fears about health reform and the American character is that the US may be simply too diverse to extend coverage to all.   Americans are proud to say Lady Liberty lifts her lamp beside the golden door.  Most Americans believe our open borders and opportunities have attracted the most diverse population on the planet.  But some despair that our diversity itself makes a national guarantee of health care unattainable. 

At least some evidence challenges both our concept of the US as the world’s most extreme “melting pot” and the idea that cultural diversity rules out universal health care.  

That’s the good news we will share here. 

The bad news is that the All-American “sacred cow” of economic determinism and its current result --- economic inequity --- may be the greater obstacle.   If that is so, universal health care may not be impossible, but if it happens, it will beat both the odds in the experience of other nations, and it will alter a fundamental tenant of the American myth. 

Equal opportunity is as American as apple pie; but opportunity is not universally held to include entitlement.  To many, social entitlements from any source, including from our own government, are un-American.  To these folks, entitlements undermine their very idea of freedom’s final measure: individual initiative properly rewarded by different social results; in other words an economically measured meritocracy.  

We are among the most freely charitable people on the planet, and among the most pragmatic.  So, using government to mitigate the costs of health care to help the poor and the disabled and at the same time improve the economic prospects of our businesses has been accepted conditionally.  However, as with most other social guarantees, it remains under constant threat from hard bitten keepers of “American Ideals”.  Our only relatively stable universal social entitlement is education, and that we believe is more to protect freedom itself than to promote social equity, according to Jefferson’s belief that only the educated person can preserve his or her own freedom. 

All around the world, differences in race and ethnicity result in real distances between peoples’ mores and manners.  But how does one gauge the degree of difference among the planet’s thousands of racial and ethnic groups?  Are Northwest Natives more or less like Inuits than Mayans and Frenchmen?

James Fearon, a Stanford economist, constructed a measure of cultural and ethnic difference based on the concept of “fractionalization” --- a term common in development economics and political science.  Fractionalization recognizes cultural “distance” regardless of the nation in which it exists, and so creates a composite measure that works across nations.   Fearon holds that primary language and communication barriers are proxies for differences between groups.  The basic tenets of Fearon’s work have been accepted by health services researchers in the US as one important way of thinking about health disparities. 

So according to Fearon, is the United States as diverse a country as we believe? Not quite.  Among 21 Western democracies, the U.S. ranks 5th in terms of both ethnic and cultural fractionalization. Canada and Switzerland outrank the U.S. with significantly higher degrees of ethnic fractionalization and nearly twice the level of cultural difference. Spain and Belgium exceed the ethnic fractionalization index of the U.S. while both Belgium and New Zealand have higher levels of cultural fractionalization than the U.S.

If the U.S. is not unique in its ethnic, racial, or cultural diversity, is there another social condition preventing us from universal health care?
  
The work of Andrea Brandolini, an economics researcher at Banca d’Italia, and Timothy Smeeding, the Maxwell Professor of Public Policy at Syracuse University might shed some light. Brandolini and Smeeding compared income inequality across industrialized nations from the 1940’s to the early 21st century.  Their method resulted in the U.S. ranking lowest among 24 nations, with our income inequality exceeding all but two of the eight “middle income” nations.  Of these, only Mexico and Russia ranked lower.  Canada, Switzerland, Taiwan, and Japan (all nations with health care systems considered models by US reformers) fall somewhere in the middle.

Brandolini and Smeeding’s work supports the conventional wisdom that increases in income inequality predict lower public expenditures on common goods and benefits.  Their data shows that nations with strong social welfare systems, like the Nordic countries, show low levels of income inequality while those with greater degrees of economic inequality had less “socialist” policies.

But does income distribution always predict a nation’s establishment of universal health care? The experience of Canada says “no”.  In 1966, Canada passed the Medical Care Act, which consolidated provincial efforts to provide basic services into a national system of universal coverage. While Canada has shown remarkable stability over the long-term in the distribution of income, the Medical Care Act was adopted at a time when incomes were actually becoming more un-equal.  Canada’s experience offers hope to American reformers that we too might “beat the odds” regarding the usual relationships between economic inequity and public benefits.

We will not speculate here as to whether major public benefit programs like universal health care redress income inequality or whether they exacerbate it by not limiting the consequences for failing to “pick ones self up by one’s boot-straps”. 

And we should remember, of course, that race and ethnicity are well documented as ubiquitous barriers to virtually every social opportunity our supposedly “free and fair” society offers.  So it is no surprise that US income differences also bare too close a relationship to racial and cultural differences to be ignored. 

But careful observers of health reform should probably watch the debate over “affordability” at least as closely for signs of real universal health care as the debate about health disparities.  It is more likely to contain greater clues to any changes afoot in the American character this year.

Here’s hoping we all take a page from our neighbors to the north and around the developed world on this score at least.

Reuters Study: $800 Billion Wasted

A new report by Thompson Reuters, parent company of the respected Reuters News Service, finds the US health care system wastes some $800 billion per year.  Citing widely excessive administrative costs, defensive medicine, duplicated tests, unneeded procedures and outright fraud, the report says much of the current health reform proposals now under consideration in the Congress could be financed by simply redirecting these wasted dollars.
 
The Healthiest State Campaign has combined similar studies with citizens' views on health reform to call for exactly this sort of reinvestment of current health care dollars to finance reform, instead of increasing the already staggering share of our nation's wealth our medical system now consumes.
 
This study could not come at a more opportune time to remind us all that our health systems are broken.  Congress has the makings of real progress, if not perfection in reform before it in the form of several bills it will merge into one in the coming weeks.  We urge them to act transparently, clearly, but boldly to promote prevention, assure universal participation and redesign our health system for far greater efficiency at improving health.  We simply cannot afford the extravagance of our medical system's waste any longer.  It taxes our schools, our environment, our competitive position in the world economy to say nothing of its unfairness's tax on our collective sense of simply right and wrong.  Come on Congress.  Step up and fix health care before the snow flies.

Baucus & Prevention: What About Health, Dude?

The long awaited Baucus Mark on health reform was just released. It contains one giant step for prevention and health improvement, especially for health care provider organizations and for all of those who visit their health provider on a regular basis and who eat, sleep, exercise and otherwise live their lives according to doctor's advice no matter how hard that may be to do. 

That is to say, today's Baucus Mark misses the mark on prevention by a wide margin.  Despite expanded coverage for clinical preventive services in Medicare and incentives for states to expand such coverage in Medicaid, the Baucus Mark contains only the smallest of steps to make healthy choices easy.  There is only a few hundred million over the coming half decade or so for "pilot programs" and "demonstration projects" to work with Medicare and Medicaid recipients on health and wellness issues outside the doctor's office. 

This is a far cry from high hopes we had for community preventive services to make healthy choices easy in communities where people live.  It is a far cry even from the Waxman bill that cut the House's $100 billion investment in such programs to $50 billion a few weeks ago.  It doesn't hold a candle to the Senate HELP Committee bill that would establish a disparities, prevention and public health investment fund providing grants to states, local governments and private organizations as well as expand insurance discounts for healthy lifestyle program participation, incentivize employers, and create a temporary Right Choices health promotion program until other reforms take hold.

We know fiscal times are tight, and that prevention costs money.  Perhaps the coming legislative dance will end with the robust prevention elements Senator Baucus first supported last November in his Blueprint for Reform and that is reflected in other leading proposals.