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THE CONTEXT
Boston is at the forefront of public health innovation. It birthed the nation’s first Department of Public Health, launched the national conversation about incorporating public safety into the health arena, and is home to world-class medical institutions, neighborhood-based health centers and exemplary health prevention initiatives. Boston has 22 inpatient hospitals — 16 of which are teaching hospitals — 3 medical schools, 25 community health centers, dental schools, schools of public health, and community-based health initiatives. One of the nation’s largest centers of medical research, Greater Boston has ranked first in National Institutes of Health (NIH) grant awards over the past 8 years. The health services sector is also a significant contributor to the city’s economy, employing 106,989 people in 2003 — or 1 out of 6 city jobs. Boston and the region are widely considered healthy places to live: Boston was ranked as the healthiest city for men by Men’s Health in 2001, and Massachusetts has been among the top ten states for 14 of the 15 editions of United Health Foundation’s annual State Health Rankings. However, high rankings and a multitude of resources tend to mask disparities in access to health services and health outcomes.
KEY TRENDS AND FINDINGS
Boston’s comprehensive public health network and initiatives achieved major progress over the past decade.
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Boston’s teen birth rate declined by 46.3% for adolescents ages 15-17 years between 1992 and 2002.
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Self-reported maternal smoking during pregnancy decreased by 70% to 4.5% of all births between 1992 and 2002.
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HIV/AIDS incidence rates (new cases per 100,000 population) dropped by 71% between 1992-2002, from the decade high in 1992.
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Asthma hospitalization rates for children under age 5 dropped by 23% between 1994 and 2002.
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Elevated blood lead levels among Boston children declined by roughly 90% since the early 90s, falling from 42% in 1991 to 3% in 2003.
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Infant mortality rates declined by 32% from 1992 to 2002, from 10.3 deaths per 100,000 births in 7.0.
Sources: Data cited by Boston Public Commission, 2004 Natality Report and the Health of Boston 2004 Chartbook.
In response to constrained state budgets, public health funding in Massachusetts was reduced by 24% in real terms from $551 million in fiscal 2001 to $417 million in fiscal year 2005, according to the Massachusetts Budget and Policy Center. These state budget cuts led to budget reductions in Boston’s public health programs and services. As a result, rates of preventable disease are rising. Hepatitis A infections in Boston doubled after elimination of state funding for the vaccine in July 2003, marking the worst rate in a decade, according to a report by the Boston Foundation and Massachusetts Health Policy Forum. Whooping cough among Boston public school students in first quarter 2004 increased six times over each of two previous years, and active TB appeared in the classroom following cuts in school health clinics and services. Asthma hospitalization rates rose almost 5% in 2002, according to the BPHC, and The Boston Globe reports that Boston now has the sixth highest syphilis rate in the nation.
While public health funding declined, state spending on medical care increased dramatically. According to the Massachusetts Taxpayer’s Foundation, not adjusted for inflation, public state spending on Medicaid & other non-DPH health care increased from about $4.9 billion in 2001 to about $6.4 billion in 2004 to an estimated $7 billion in fiscal year 2005. (Half of these expenditures are reimbursed by the federal government). The Massachusetts Budget and Policy Center explains that while MassHealth appropriations grew faster than the rest of the state budget after 2001, various MassHealth programs, eligibility and benefits were actually scaled back, and the increase reflects higher health care costs.
Health insurance premiums are rising, and fewer employers offer benefits in Massachusetts. The amount paid by the average Massachusetts worker for health insurance premiums has risen nearly 50% between 2000 and 2004, while average earnings only rose by 14% according to Families USA. The number of non-elderly individuals with employer-sponsored health insurance fell by 27,872, and those with individual insurance rose by 52,506 in Massachusetts between 2000-2003, according to the Kaiser Family Foundation, based on Current Population Survey estimates. A consensus is emerging that health care coverage for all residents is a critical and shared objective, and state legislators, business leaders and health care advocates are working together toward this possibility.
Racial/ethnic health disparities persist. Disparities by race vary, but are prevalent across most health measures in Boston, the Commonwealth and the nation, reflecting complex social and economic factors. Infant mortality is used worldwide as the premier indicator of community well-being, and in Boston in 2002, black infants under the age of one were more than two and a half times more likely to die than white infants, reflecting a higher rate of low birth-weight and prematurity, according to the Boston Public Health Commission. Low birth-weight by maternal birthplace in Boston in 2002 was 15% for US-born blacks, 11% for US-born Latinos, 7% for US-born whites, and 7% for US-born Asians, but 13% for Haitian-born, 7% for Dominican Republic-born, 5% for El Salvadoran-born, and 8% for Chinese and Vietnamese-born Boston mothers, according to the Boston Public Health Commission referencing state data. (see indicator 7.4)
Hunger and homelessness are increasing in Boston. More than 81% percent of food pantries and 54% of soup kitchens sponsored by Project Bread in Boston reported increased need in past years, according to data cited in 2004 by the United States Conference of Mayors-Sodexho USA. Homelessness in the city has risen steadily since the mid-1990s, reaching 6,241 in 2003, up from 4,774 in 1995 according to the Boston Public Health Commission and the Boston Shelter Commission’s annual homeless census, with an increase in homelessness among families and youth.
Less risky behavior by youth overall in Boston is being undercut by subsector trends in substance abuse, unsafe sex, and violence. The Youth Risk Behavior Surveillance System (YRBSS), a national survey conducted in public high schools, reports a decrease in youth suicide attempts in Boston, from roughly 14% of high school youth in 1993 to 9% in 2003; a decline in participation in binge drinking from roughly 20% in 1993 to 16% in 2003; and a decline in students who had been sexually active in the previous three months from 42% in 1993 to about 36% in 2003. However, social pressures faced by subgroups such as gay, lesbian or bisexual-identified youth have led to comparatively high rates of substance abuse and risky behavior in past years. (see indicator 7.5.4) There is also an uptick in the abuse of heroin: students who had used heroin one or more times rose from 1% in 1999 to 2% in 2003, with an increase in substance abuse mortality overall from 17.6 deaths per 100,000 population in 1999 to 21.5 in 2002, according to the Boston Public Health Commission. Whites have the highest rates. A resurgence of youth homicide has taken place, particularly in Mattapan, Roxbury and Dorchester. (see Public Safety)
The link between environmental toxins and health is driving Boston’s strategies. Environmental exposure to toxins found in or near residential areas are linked to certain cancers, respiratory irritation, inflammation, and hindered brain development. Boston’s focus on environmental hazards has produced significant results, including a 90% decline in childhood lead poisoning, with the work of organizations such as Alternatives for Community and Environment (ACE) and Lead Safe Boston, a collaborative strategy between the BPHC and the City of Boston Department of Neighborhood Development (DND). The Boston Public Health Commission Taking Action: Understanding Health Inequities report shows that the number of dumpster storage lots, junkyards and transfer stations are highest in Roxbury (30) and North Dorchester (21) among selected Boston neighborhoods. While no direct link has been made between these hazards and health, data show that the highest asthma hospitalizations for children under 5, averaging annual rates between 1998 and 2002, were in Roxbury, at 14.6 per 1,000, and in North Dorchester, at 13.0. (see indicator 7.7.1)
Boston mirrors a dramatic increase in obesity nationwide over the past 20 years despite lower rates than the national average. In Boston, about 47% of Boston residents were considered overweight or obese in 2001, compared with 57% in the US in 2000, according to the Boston Public Health Commission. These figures vary across neighborhood — from a high of 66% of adults in Mattapan to 32% in the Fenway. The percentage of overweight students in Boston increased from about 12% in 1999 to about 14% in 2003, according to the YRBSS, with almost 20% of Latino students overweight or obese, 14.6% of black students, 6.1% Asian students, and 7.6% of white students.
MAJOR ACCOMPLISHMENTS AND INNOVATIONS 2002 - 2004
Mayor Thomas M. Menino appointed the Mayor’s Task Force to Eliminate Health Disparities in April 2004. The task force gathers 23 industry and community leaders from hospitals, higher education institutions, community health centers and other health coalitions such as REACH 2010 and Cherishing Our Hearts and Soul Coalition. Co-Chaired by Red Cross of Greater Boston Executive Director Deborah Jackson and Dr. Gary Gottlieb, President, Brigham & Women’s Hospital, it reported back to the Mayor with recommendations.
A new Asthma Center on Community Environment and Social Stress (ACCESS) was established in 2003, as one of five national centers focused on reduction of racial, ethnic and socioeconomic disparities in this measure. The center is a partnership between the Center for Community Health Education Research and Service, Inc. (CCHERS), the Channing Laboratory at Brigham and Women's Hospital, and the Harvard School of Public Health.
Massachusetts implemented the Smoke-Free Workplace Law on July 5, 2004, making it the sixth state to implement legislation to address the health risk of second-hand smoke. Smoking is now prohibited in workplaces, bars and restaurants. Between May 2003 and April 2004, Boston Tobacco Control conducted 1903 inspections and issued 47 violations.
The City of Boston was awarded more than $1 million in federal funding by the Centers for Disease Control for community-based initiatives to reduce diabetes, obesity and asthma as part of a $6 million program through 2008. Boston also announced $180,000 in new funding for substance abuse prevention and treatment, through the Neighborhoods Organizing Against Drugs (NO Drugs) Initiative.
The Boston Public Schools prohibited sale of soft drinks on school grounds for the start of school in September 2004 as part of efforts to combat obesity.
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REMAINING CHALLENGES
Lack of health insurance affects 7.8% of Metro Boston’s population under the age of 64. (see indicator 7.2.1) The highest percentage of uninsured in Massachusetts overall is the Latino population, at 15.1% in 2004, compared to 6.3% for whites (non-Hispanic), 7.5% for blacks (non-Hispanic), and 4% for Asians, according to the Massachusetts Division of Health Care Finance and Policy. The MassHealth publicly-funded health insurance program provided access to 550,600 females and 394,007 males in 2004. Yet experts cite the challenge of accessing MassHealth for working poor who exceed set income levels, immigrants and refugees who are ineligible, and individuals affected by recent program eliminations. Health Care for All reports that since 2002, comprehensive dental care was eliminated from MassHealth coverage, and a recent study shows that 70% of enrolled children statewide did not receive any dental care in the year prior.
Recent state budget cuts are affecting Boston’s unique network of community health centers (CHCs), reducing their capacity to offer preventive programs and health promotion activities. State support for community health centers reduced funds by 30% between fiscal years 2001 and 2004, leading to reductions in staff and services, despite increased demand for services. CHCs are an integral part of the health “safety net,” with over 3 million visits statewide in 2003 through 181 sites, according to a Boston Foundation and Massachusetts Health Policy Forum report.
Public health experts point to the need for a broad, active and well informed constituency for public health to advocate for sustained public funding and a cost-effective focus on prevention, public education, unbiased health information and media coverage that promotes healthy lifestyles.
Higher medical care expenditures do not guarantee better outcomes. A nationwide study by Dartmouth College economists, based on an analysis of actual health outcomes, showed that states with higher Medicare spending often provide lower quality, less effective care to beneficiaries — with more excess, intensive, and expensive care.
Unequal access to health insurance, health care, drugs, testing and medical procedures contribute to racial/ethnic disparities in health. According to the Boston Public Health Commission, 91% of white women obtained adequate prenatal care for births in 2002, compared to 85% for Asian women, 84% for Latinas and 75% for black women. Looking at outcomes, black infants represented about 30% of all Boston births in 2002 but almost 54% of all infant deaths. (see indicator 7.5.1)
With insufficient adult and childhood mental health services, hospitals have become the only point of access to services for many people suffering from mental illness in Massachusetts. The Nation’s Voice on Mental Illness (NAMI) reported an increase of almost 50% in April 2004 in the number of individuals with a serious mental illness in Massachusetts General Hospital’s emergency room and 20% at the Boston Medical Center over the past year. Fewer than 5% of children and adolescents with serious emotional disturbance in Massachusetts receive necessary services, according to the NAMI report. (see indicator 7.2.2)
A diverse, culturally competent workforce is lacking at all levels of the health care system. While people of color comprise half of Boston’s population, no teaching hospital reports more than 10% of physicians from underrepresented minorities, according to Health Care for All. Fear of cultural misunderstanding, language barriers, lack of knowledge of the US system and the specific concerns of gay, lesbian, bisexual and transgender individuals hinder access for many individuals who could benefit from staff and resources more attuned to their concerns.
In Boston, youth behaviors exacerbate the obesity epidemic. Almost 30% of Boston students watch four or more hours of television on an average school day, 21% of Boston high school students do not engage in any vigorous exercise, and 88% of students did not eat at least five servings of fruits and vegetables per day in 2001, according to the Boston Public Health Commission. The Youth Risk Behavior Surveillance System (YRBSS) reports that in 2003, 18% of Boston students were at risk of becoming overweight or obese.
Some Boston neighborhoods have been hard hit by substance abuse, reflecting the need for adequate prevention and services. Drug related hospital admissions — particularly among youth — are at double or triple their average rate in South Boston and Charlestown. The Boston Public Health Commission reports that the number of people who called the state’s substance abuse helpline seeking assistance with abuse of the prescription drug OxyContin more than tripled between 2001 and 2003, increasing from 194 to 519 calls.
COMPETITION
Vermont, Maine, and New Hampshire rank first, second and third respectively in achieving the highest national ranking in the relationship between quality of care and health spending. Using Medicare as a proxy, these states spend between $5000-$5500 annually per patient, compared to Massachusetts, which spends roughly $7000 per patient and ranks only 15th in terms of care, despite world-class medical facilities. Texas and Florida spend roughly $8000 per person but rank last in quality of care.
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