These are uncertain times for health-policy watchers, not to mention for people who depend on affordable health insurance and healthcare services. The future of the Medicaid program for low-income people and private health insurance markets are at stake in the current public-policy debate.
On May 4 the House of Representatives passed the American Health Care Act, which the non-partisan Congressional Budget Office (CBO) predicts would lead to 23 million people becoming uninsured over the coming decade (starting with 14 million in 2018). If enacted, the AHCA would lower average health-insurance premiums relative to what they would be under current law, but it would achieve this mainly by permitting insurers to reduce the scope of benefits covered by health plans and potentially charge some with pre-existing conditions much higher premiums. Significantly, according to the CBO, the AHCA would increase premiums for many older and sicker people buying coverage in the individual (not employer-sponsored) market, for some by as much as eightfold. This, according to the CBO, would put coverage out of reach for many vulnerable people who need it most.
The increase in the uninsured would come largely from the ranks of Medicaid. The AHCA rolls back federal funding not just for those who gained coverage under the Affordable Care Act (ACA), but also for the entire program, which currently covers nearly 1.8 million Garden State residents. This could have major downstream financial impacts on healthcare providers and even school districts, which depend on Medicaid to cover services for special-needs children.
The AHCA is now in the hands of the U.S. Senate, which is expected to make major changes. If the Senate passes a bill, the ability for Congressional leaders to reconcile the two versions of “repeal and replace” is by no means assured. In the meantime, the future of health coverage under the ACA is deeply uncertain, which could lead more insurers to exit the individual market or raise premiums.
As important as it is, the debate on the future of the ACA should not distract us from other opportunities to improve health and wellbeing. In fact, estimates are, that in the U.S., health-related behaviors and social circumstances account for a much larger share of premature deaths than do healthcare system factors.
Just as Tip O’Neill famously wrote that all politics is local, to a large extent health is local too. A new report by the Rutgers Center for State Health Policy demonstrates that the communities in which we live are inextricably linked to our health and wellbeing.
The Center’s report is the first in a series based on the New Jersey Health and Well-Being poll. In the poll, we asked 1,202 randomly selected New Jersey adults to rate their neighborhoods as a place to live overall and for specific community attributes important to achieving and maintaining good health.
Poll results are strikingly consistent across a range of measures of neighborhood quality and healthfulness. The chart below captures the story. On average, 80 percent of Garden State residents rate their neighborhood as a good or excellent place to live. While a smaller majority of low-income residents also give excellent or good rating, these respondents are more than twice as likely to give a rating of fair or poor compared to the state average.
As the chart shows, it is not just the poor who give low ratings: black, Hispanic, and noncitizen poll respondents do as well. Likewise, low neighborhood ratings were given by people who say their health is not good and those without health insurance.
When asked about aspects of their communities that are related to the opportunity to get and stay healthy — access to healthy foods, places to walk and exercise, even public libraries — we see the same pattern of responses. Jersey residents who are poor, black, Hispanic, noncitizens, sick, or uninsured are much more likely to express negative ratings. It is deeply troubling that those who need the most help achieving good health seem to have the least local opportunities to do so.
These patterns are likely to be exacerbated if legislation like the current version of the AHCA becomes the law of the land. Many more people will be uninsured, which means that many will forego needed preventive and treatment services. That has public health implications for everyone. Other proposals emanating from Washington to reduce spending on programs like Meals on Wheels and Community Development Block Grants would further undermine health in New Jersey communities.
Undeniably, federal health and budget policy changes are strong forces that will determine the health of our neighbors, but actions taken by the state Legislature and governor as well as private philanthropies are also vitally important.
The Health and Well-Being poll was funded by the Robert Wood Johnson Foundation and designed with input from eight New Jersey grantmakers with the aim of informing public policy and their own grant investments. The foundations understand that while their resources are limited, they can play important roles in seeding local innovation and advancing opportunities to make communities healthier. Here are a few examples.
+ The Nicholson Foundation has long invested in community-based healthcare coalitions and just announced a new in-home asthma intervention pilot program.
+ The Horizon Foundation for New Jersey invests in health literacy and improvements of community spaces.
New Jersey is most fortunate to be home to these charitable enterprises and, as the Health and Well-Being poll demonstrates, their attention to communities is well placed with important opportunities to invest further. But foundation resources are tiny in comparison to the needs at hand. They can seed innovation, bring communities together, and pilot high-potential ideas, but they cannot achieve the level of sustained investment that is needed to turn our polling results around.
Whether the coming year will be one of great retrenchment in investment in community health is unclear. Debates in Washington will be important, for sure. Beyond that, this year New Jersey will elect a new governor and Legislature; the ways in which they invest in our communities will also be highly consequential. Private foundations’ efforts can inform fruitful policy directions.