The Health of Arkansas

Yesterday, Arkansas Governor Asa Hutchinson beamed as he announced a drop in the number of state residents receiving health insurance through Medicaid.

Today there are fewer Arkansans on Medicaid than when I took office in January 2015, while our state’s population continues to increase. In the last year alone, the rolls have decreased by 117,000 (10%). Because of the reduction in Medicaid enrollment, DHS is now projecting that it will spend roughly half a billion dollars LESS (taxpayer money) on Medicaid in SFY’19 than anticipated in the biennial budget.

Perhaps to some, this is great news. We’re saving money! Woopee! All those freeloaders out there sucking on the government teat are now out in the cold where they belong.

But wait. We’re talking about medical care here, people who are sick or disabled or otherwise unable to obtain health care because they can’t afford to buy insurance. By his own numbers, our governor just celebrated the fact that 117,000 people of Arkansas are no longer able to obtain health care.

Now maybe that’s not exactly true. Maybe some of those folks got well from cancer or liver failure or whatever caused them to qualify for Medicaid. Maybe some of them got great jobs and have insurance now through their employers. Maybe some of them became the sudden beneficiary of their Aunt Tilley’s fabulous estate. Or won the lottery.

Or maybe not.

The reduction might have something to do with the federal government’s deep cut in advertising about how to sign up for health care. Or the federal government’s reduction in the sign-up time period. Or the state’s questionable method of deciding who to remove from the program—the electronic data system currently in use automatically deletes anyone who doesn’t respond to a request for income information. As in, one lost piece of mail. One overlooked letter amid a pile of unpaid bills. One person’s inability to comprehend what is being asked of him as he undergoes chemotherapy.

Last year, the governor looked for all the ways he could reduce the amount of money Arkansas pays for health coverage. As reported in the Arkansas Times in the May 2, 2017, edition, the governor’s goal was to lower the income limits.

As part of the Affordable Care Act, Arkansas expanded Medicaid via a unique policy known as the private option, which uses Medicaid funds to purchase private health insurance plans for low-income Arkansans. The concept was later re-branded as “Arkansas Works” by the governor. The expansion covers adults who make less than 138 percent of the federal poverty level — that’s $16,400 for an individual or $33,600 for a family of four.

The governor’s proposed changes to eligibility remove anyone who makes more than the federal poverty line (that’s $11,880 for an individual or $24,300 for a family of four) from the Arkansas Works program. Only people who make less than the poverty line would qualify going forward. That includes not just the beneficiaries who are covered by private option plans but also those who were deemed medically frail under Arkansas Works (the 10 percent of beneficiaries with the greatest medical needs, who are currently routed to the traditional Medicaid program rather than private option plans).[1]

So just to be clear, any single person earning more than $990 per month or head of household with spouse and two children earning more than $506 per person would no longer qualify for government assistance in gaining health insurance. This hasn’t yet been implemented because the federal government has not yet responded to Gov. Hutchinson’s request for the change. But really, governor?

Even the 138% of poverty level leaves lots of people without access to care. In 2013, 21% of Arkansas adults went without health care because of the cost. Do bragging rights automatically come to Gov. Hutchinson because that number dropped to 15% by 2016? What is 15% anyway, besides a seemingly small number?

The state’s estimated population is 3,004,279. Take away 23.6% of that for people below 18 years of age (non-adults). That leaves 2,295,270 adults. Fifteen percent of that equals 344,290 adults in this state without health care. That’s a lot of friends and neighbors.

In a November 2017 report, the Arkansas Times explained another proposed part of Hutchinson’s Medicaid ‘reform.’

Those between the ages of 18-49 would be required to work 80 hours per month; if they were not working, they would have to participate in job training programs or certain approved volunteer activities. Beneficiaries must be in compliance for nine months out of the year or they would be removed from the program for the duration of the year. Beneficiaries 50 or older would not be subject to the work requirement; exemptions would be available for others who met certain criteria, such as caring for dependent children.[2]

Studies have examined the realities of financial need in the United States and have come up with a set of numbers that reveal just exactly how morally bankrupt is the governor’s reasoning (along with the increasingly evident moral bankruptcy of the entire Republican party).

For a family with two adults and two children, the average cost of living in the United States hovered around $65,000 per year in 2015. The figure excludes discretionary spending on nonessential goods and services, such as leisure, entertainment and luxury items.[3]

To be fair, another source gathering economic data specific to locations gives credit to a lower-than-average cost of living in Arkansas. For a family of four in Little Rock, the average monthly cost is $2876.46. For an individual not paying rent, the monthly cost is estimated at $819.24.[4] However, in the governor’s proposed lower income limit, in neither case is there any ‘leftover’ income adequate to buy health insurance. In case you didn’t notice, the estimated average cost of living for Little Rock is $400 MORE than the cutoff income level for those seeking Medicaid coverage under the governor’s preferred income guidelines.

It’s no secret that Arkansas is one of the unhealthiest states in the nation. We rank 48th. We have higher rates of diabetes, cardiovascular disease, cancer, and general poor health both physically and mentally. In particular, according to a January 1, 2018, report published in the Arkansas Democrat Gazette, from 2013 to 2016, “the percentage [of Arkansans] who reported that their mental health had not been good in 14 of the past 30 days rose from 14.7 to 16.4 [percent.]”

The report I’d like to hear from Gov. Hutchinson would show data about the number of marginally-employed people who have gained better-paying jobs. It would show how many of those suffering mental or physical illness have gained any improvement in their health. I’d like to hear that Arkansas is spending more, not less, on health care not only in direct services but in education—I’m talking about nutrition education, cooking lessons, and everything else humanly possible to teach people how to eat healthy—which, tragically, probably doesn’t include toaster pastries for breakfast.

I’d like to hear the governor talk about how vouchers and private schools won’t be allowed to siphon money away from public schools. I’d like to hear his analysis of how inadequate education leads to poor self-esteem and how a positive self-image is key to a person’s ability to pay attention to diet and exercise. I’d like to hear him talk about how a person who doesn’t feel good either mentally or physically is a prime candidate for substance abuse.

I’d like to hear the governor discuss the abysmal status of substance abuse treatment options in the state, a crushing health care issue that gets short shrift in public discussion. More on that in another blog.

The governor needs to say that fundamentals like good health and proper education make all the difference in how a person participates as a vital member of society or how he/she gains and maintains sufficient employment. He needs to say, again and again, that a person who is well, who has learned how to reason, and who recognizes the responsibility of self-care and citizenship is the kind of person we absolutely must gain a lot more of in this state.

At any cost.

~~~

[1] https://www.arktimes.com/ArkansasBlog/archives/2017/05/02/governors-proposed-cuts-to-medicaid-eligibility-will-increase-costs-for-working-poor-likely-to-increase-uninsured-rate

[2] https://www.arktimes.com/arkansas/state-still-awaiting-federal-approval-on-medicaid-expansion-changes/Content?oid=11322951

[3] Cost of Living https://www.investopedia.com/terms/c/cost-of-living.asp#ixzz53JNGsNLI

[4] https://www.numbeo.com/cost-of-living/in/Little-Rock

Advertisements

The Critical Need for Dental Care

A friend of mine I’ll call Tom is a Vietnam vet. His back is so wrecked he has to take a pain pill before he gets out of bed. He lies there in pain waiting for the drug to kick in. Then he stands in a hot shower until the muscles relax enough for him to walk. For years, he did this each morning before packing up his tools and heading out to work. Now he can’t work.

Jumping out of helicopters into the jungle with a heavy pack did this to Tom’s back. He was a skinny little kid to start with. But his back is not why Tom is in crisis now.

For years, Tom had bad teeth. He finally managed to save up enough to get them pulled but it took more months to save sufficient money to buy dentures. Tom’s down to skin and bones because he couldn’t bear the pain of chewing.

Two years ago, the Veterans Administration Hospital discovered Tom has COPD. Since then, he’s been on oxygen plus inhalers and struggles for each breath. The damage from a lifetime of work as a painting contractor can’t be undone, all those jobs of clearing away old asbestos insulation and sheetrock dust without wearing proper respiration masks. It wasn’t just a matter of not having money for a mask or not wanting the hindrance of something that restricts vision and mobility, although both those things applied. It was even more a matter of not realizing what atomized paint and volatile chemicals could do inside his body.

Now the VA has found that he has a faulty heart valve. Fixing it will be tricky because the vessel adjacent to the faulty valve has an ominous bulge, otherwise known as an aneurysm.

Inhaled particulate aside, how much of Tom’s predicament can be attributed to years of living with bad teeth? Plenty. As it turns out, respiratory disease can be a direct result of poor dental health:

Bacteria from periodontal disease can travel through the bloodstream to the lungs where it can aggravate respiratory systems, especially in patients who already have respiratory problems. A study published in the Journal of Periodontology uncovered a link between gum disease and an increased risk of pneumonia and acute bronchitis.

Or how about dementia, a condition increasingly suspect in Tom’s case?

Tooth loss due to poor dental health is also a risk factor for memory loss and early stage Alzheimer’s disease. One study, published in Behavioral and Brain Functions, found that infections in the gums release inflammatory substances which in turn increase brain inflammation that can cause neuronal (brain cell) death.

The U. S. Surgeon General in 2000 stated: “…oral health is intimately connected to general health and can be implicated in or exacerbate diabetes, heart disease and stroke, and complications during pregnancy.” And that’s the tip of an iceberg of ailments including erectile dysfunction and even cancer.

… a study published in Immunity earlier this year also hinted that a bacterium implicated in gum disease, Fusobacterium nucleatum, can reduce the ability of the immune system to recognize and destroy cancer cells.

Veterans theoretically get all their health care needs met. But there’s no veterans’ coverage for dental. Medicare and Medicaid also don’t cover oral health. It’s as if our mouths don’t matter.

In the seventeen years since the surgeon general issued his report clearly outlining the devastating systemic harm caused by poor dental health, nothing has been done to expand dental care to those who need it. Awful images jokingly posted on social media about “Walmartians” invariably include people with horribly decayed teeth. Or no teeth at all.

A 2016 Alternet article, “Why in Heaven’s Name Aren’t Teeth Considered Part of our Health?,” reveals that over 106 million Americans have no dental coverage and that one in four has untreated dental decay.

The social cost is as high or higher than the medical cost. We are immediately disgusted by those with visibly bad teeth. People with rotted teeth have a hard time finding employment and are shunned in social circles. Bad teeth are a marker of the lower classes. As noted by Susan Sered, author of the Alternet article,

The reality is that tooth decay signifies poverty in pernicious ways. Without expanding insurance to cover oral health, millions of Americans will continue to live with pain, stigma and the risks of systemic diseases that could be averted through an accessible and integrated system of dental care.

Even before the surgeon general issued his report, common sense told us that decaying teeth sent infection into our bloodstream and compromised our immune system. A steady drip of pus into the body’s blood and lymph systems overwhelms not only the body’s ability to resist infection but also damages otherwise healthy tissue in vital organs.

No wonder Tom has a diseased heart, diseased lungs, and a poor prognosis. He lived with rotten teeth for years. Nobody in the VA stepped up and advised him about this problem. It’s not in their job description.

Likewise, as noted in the Alternet article, the lack of dental coverage in Medicare and Medicaid leaves out large segments of the population most in need of care. It’s estimated that 70% of seniors lack dental care precisely at a time in life when dental problems are most likely to appear.

Except for the random ‘free’ clinic for those qualified (and those lucky enough to live near one and who find their way through the tedious process of discovering where and how such clinics function), those without expensive dental insurance are on their own in addressing this vital and overlooked medical need. Many, like Tom, go without attention to their dental health until they can literally pluck teeth out of their inflamed gums like so many ripe plums.

There’s no excuse for this country to continue to ignore dental health. As one of the fundamental causes underlying so many severe medical conditions, dental disease should rank near the top of conditions covered fully by all insurance programs. In addressing oral health, insurance companies could help prevent or reduce many long-term ailments that cost untold millions and generate incalculable pain and suffering.

There’s no help for Tom. Even after saving enough of his meager pension to purchase dentures, he has continued to decline. It takes all his effort to simply walk across the room. While the VA gropes with surgical options for his heart and keeps him supplied with pain meds and oxygen, Tom lives at home alone without access to Meals on Wheels or other resources that could bring him at least one hot meal a day. He lies in bed watching television, dependent on liquid nutrition drinks and microwaved meals for food. His family chips in when they can, but that’s not a daily meal.

Tom insists he’s not interested in assisted living in the veterans’ home because he’s heard bad things about how people there are treated. He’s also not close enough to death to qualify for hospice. He’s stubborn and proud and thinks he might be able to work again.

This travesty stems largely from the failure of our nation to recognize the insidious creeping harm of poor dental health or the true preventative nature of proper dental care. It’s hardly news that there’s little to no respect for prevention—the lack of understanding about nutrition and poor food preparation skills are a big part of the nation’s mushrooming health care costs, driven in part by the rise of fast food and the barrage of advertisements for unhealthy foods.

“We are what we eat” has never been a more important thought. Especially when we consume bacteria from rotting teeth.