Jordan Wolfe’s Award-Winning Essay

Our second winning essay comes from Jordan Wolfe of The George Washington University Milken Institute School of Public Health:

Just as there are countless forms of cancer plaguing the human population, there are a plethora of different health disparities that we face as well, and just as there is no one cure for cancer, it is unrealistic to expect one straightforward solution for all health disparities either. Instead, the solutions we create must be specific, explicit, and tailored to the population and problem being addressed. One of the most pressing but underacknowledged health disparities that currently exists in America is that of police violence and brutality towards the African American population.

Although not commonly perceived as a public health issue, police violence and brutality has a grave impact on the health of both individuals and communities. Living in a neighborhood where the local police engage in high rates of frisking and use-of-force is significantly correlated with physical health outcomes such as diabetes, blood pressure, asthma, and obesity, as well as mental health outcomes such as depression, suicidal behavior, and severe feelings of hopelessness and worthlessness. Although the African American community makes up only 13% of the American population, they shouldered the burden of 26% of police-related deaths in 2015, 24% in 2016, and 23% in 2017. At an aggregate level, cities with 16% more African American residents experienced 66% more police excessive force complaints. This data points to a public health phenomenon occurring not just at the individual level, but at the community and institutional level, which is referred to as the “minority threat hypothesis”, which proposes that cities with more minority residents employ greater coercive control strategies by the police.

This is not to say that police departments are not making efforts to address the issue and curb rates of police violence. As a matter of fact, many local police departments have instituted new training programs, cultural awareness workshops, and community policing efforts in hopes of forging new and better relationships between police officers and their communities to prevent further violence. What is lacking here is cohesiveness between departments and a national support of their efforts. One solution to this void could be the creation of a mandatory and publicly-accessible community policing portal, instituted nationally through the Department of Justice. This portal could serve as a forum for local police departments to report their innovative strategies and best practices for decreasing police violence, as well as track use-of-force and violence outcomes. In comparison, CMS mandates that hospitals publicly report the rate at which their hospital employees receive the flu vaccine; this is required because workers who don’t receive the vaccine pose a threat to patients, and the hospital should be transparent and accountable for this. Like hospitals, police departments play a major role in their communities and should be held accountable for the impact of their actions on the community’s health. Only once we recognize police violence as a public health issue and treat it as such can we hope to make measurable progress in addressing and eliminating it.

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Posted by on February 7, 2018 in Uncategorized


Susan Grafstrom’s Award-Winning Essay

Our first winning essay comes from Susan Grafstrom from the University of Minnesota:

My current pursuit of a Masters of Public Health degree at the University of Minnesota and future career plans include reducing rural health disparities and improving the health of rural Americans.   I’ve given a lot of thought to this topic so from my perspective, to eradicate health disparities, two things need to change.

First, the inclusion of representatives on local, state, and national policy and work groups who live and work in rural areas or other areas of disparities needs to be a requirement of any policy setting or program development group.  Too often important decisions are made by legislative, academic or career professionals who may study rural health or other health disparities but have never personally experienced, lived or worked within these areas.  While they may be knowledgeable about their field of study, gathering information, drawing conclusions and making decisions are made in the context of their frame of reference which is mostly urban-centric.  Recently on the radio show Rural Health Leadership Radio, Roger Knak the CEO of a hospital in rural Oklahoma remarked, “You’re not going to change the health of a community at an academic center.”

Second, we will never be able to eradicate health disparities until we have a very clear understanding of the health of those experiencing disparities without the availability of strong statistical information.  Lack of data is problematic for most rural areas and I would surmise this is the same for other areas experiencing health disparities as well.

Specifically for rural America, The County Health Rankings are promoted as a snapshot of how healthy a county is and is referenced frequently as a way to measure population health.  Counties are ranked against one another in each state partly to create a competitive environment to increase health and ultimately scores, but also as a measurement for leaders to utilize in program planning and decision-making. While I do not disagree that this tool is valuable, data for rural counties is not as statistically sound as data for urban counties.  According to the article, “The County Health Rankings: rationale and methods” 1The County Health Ranking does not promise accuracy in the reliability of estimates, particularly for counties with smaller populations; we recognize that the reliability of our measures does vary.

Second, when good data sources are available they are measured too infrequently to be utilized for responsive population health.  In Minnesota, The Minnesota Student Risk Survey is given to all school districts in the state.  While it has very detailed community, county and state level data it is only done every 3 years and only on the same three grade levels.

Therefore, to eradicate health disparities include the leadership and membership of individuals part of the disparity and eliminate data deserts which will provide city, county and regional decision makers with accurate information from which to measure health or to set health programming and policy.


  1. Remington PL, Catlin BB, Gennuso KP. The County Health Rankings: rationale and methods. Population Health Metr. 2015;13:11. doi:10.1186/s12963-015-0044-2.
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Posted by on February 5, 2018 in Uncategorized


AcademyHealth Disparities Interest Group Student Essay Contest Winners

In December 2017, the AcademyHealth Disparities Interest Group sponsored a student essay contest prompting entrants to respond to the question “What do you think must happen over the next decade to eradicate health disparities?” Numerous entries poured in and 9 winners were selected to receive a free student membership to AcademyHealth. Over the rest of the month, the winning entries will appear on this site in no particular order. So stay tuned and check back often.

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Posted by on February 3, 2018 in Uncategorized


AcademyHealth Disparities Interest Group Sponsoring Student Essay Contest

The AcademyHealth Disparities Interest Group is sponsoring a student essay contest. Winners receive a 1-year student membership in AcademyHealth, and their essays will be posted to this blog. The full details are available by clicking this link: AH Disparities IG Student Essay Contest

Please share broadly with students who might be interested as the deadline for submissions is rapidly approaching.

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Posted by on December 5, 2017 in Uncategorized


Health Wonk Review: Repeal Fatigue Edition

For health policy wonks, 2017 has been exhausting. First, Paul Ryan pulled a bill from the floor of the House because he didn’t have the votes. Obamacare supporters–or at least those opposed to the notion of taking insurance coverage away from tens of millions of Americans–breathed a sigh of relief only to watch a revised version of the bill pass the House a short while later. Then, the Senate took up repeal legislation, only to vote it down at the hands of Senators Collins, McCain, and Murkowski. The zombie seemed dead once more, but zombies rarely stay dead. Soon, we learned of Graham-Cassidy. Then, just this week, after Senators Collins, McCain, Paul—and potentially Murkowski—announced their opposition to the bill, the GOP leadership announced that the Senate would not vote on Graham-Cassidy. Given budget reconciliation rules, the Senate only has until September 30th to pass a repeal bill with just 50 votes (Vice President Pence then casting the tie-breaking vote). Thus, it would appear that repeal efforts will be delayed until the spring of 2018 when fiscal year 2019 begins, and new budget reconciliation rules are established. All of that said, I am sick and tired of sitting on pins and needles as this process has unfolded. Based on the submissions I received this week, many of my colleagues seem to share my sentiments, as very few posts focused on Graham-Cassidy. In recognition of that, I present you with the “Repeal Fatigue” edition of the Health Wonk Review.

First up, though, I’m going to get the Graham-Cassidy post out of the way. Charles Gaba at ACA Signups who submits “Revenge of the Three-Legged Stool: Graham-Cassidy Edition” to explain how the proposed bill would disrupt the individual insurance market using everybody’s favorite health care metaphor. Meanwhile, the HELP Committee hearings in pursuit of bipartisan legislation to stabilize the individual insurance market hinged in large part on loosening up the ACA’s Section 1332 “innovation waivers,” through which states can propose to alter — and potentially redesign — their ACA marketplaces. The flashpoint concerns the so-called “guardrails,” which stipulate that a waiver proposal must demonstrate that the alternative scheme will cover at least as many people, with coverage at least as comprehensive and affordable as in the state’s existing marketplace, without increasing the deficit. Can those standards — or the way in which HHS applies them — be eased in any way acceptable to Democrats? In How could Patty Murray ‘thread the needle’ with Lamar Alexander? Andrew Sprung of xpostfactoid sketches a boundary line that Democrats may have to decide whether to cross. Finally, InsureBlog’s Henry Stern discusses the lie that was “bending the cost curve down.”

Jay Norris of Colorado Health Insurance Insider, writes “In Colorado, (like most states) we don’t have a reliable measure for the network size for each insurance carrier. I’m trying to get the ball rolling with a python program I wrote to parse SERFF data and create the bar chart shown in the submitted post. So far, the results are somewhat surprising and very interesting. I’m almost finished with a script that will automatically parse all 64 Colorado counties and create bar charts for each county. I’m trying to finish that script tomorrow and will hopefully have some county level data included in that same post.” Read the full post here.

Jason Shafrin, the Healthcare Economist, revisits a classic article describing why the way doctors die is different compared to the rest of us.

At the Health Business Blog, David Williams writes “Clinical registries produce real world evidence that can be used to improve quality and change clinical guidelines. However, data collection and submission is manual and time-consuming, and hospitals are increasingly turning to external vendors to help. A new study shows that this market will reach nearly $2 billion in the next five years.” Check it out here.

Two posts focused on vulnerable populations. Holly Stockdale and Susan Haber, writing for the Medical Care Blog, share the post “Despite ACA mandates for states to streamline renewal, many beneficiaries still need assistance to retain Medicaid coverage.” According to Stockdale and Haber, “Enrollment in Medicaid has been shown to enhance access to health care for our nation’s most vulnerable citizens. Yet despite these benefits, a substantial number of beneficiaries lose coverage at the time of renewal. An article by Xu Ji and colleagues, published in this month’s issue of Medical Care, demonstrates how critical maintaining continuous Medicaid coverage is for beneficiaries with mental health conditions.” In this month’s episode of #CareTalk, David Williams (Health Business Group) and John Driscoll (CareCentrix), chat about the recent hurricanes that have impacted the USA and what can be done to protect vulnerable populations.

In “More Dumb Things Leaders Say About Health Policy,” Health Care Renewal’s Roy Poses writes “We have discussed many instances of ill-informed leadership of health care organizations. But there has been nothing quite like the recent ignorance of political leaders, often as brought out by the debate over whether to ‘repeal and replace Obamacare.’ Here are three examples from the top of the US executive branch, but also – just for old times sake – from the CEO of one of the biggest US for-profit health insurance companies. Once again I speculated on how much of this is due to “managerialism,” the idea that all organizations, including health care, should be run by people with management backgrounds, but not necessarily with any expertise in what the organizations actually do, again including health care. Or is it part of a growing anti-intellectual trend? In any case, the increasing tendency of top leaders who control health care to ignore facts (and often logic) is extremely dangerous. True health care reform would enable leadership that is well-informed, upholds the values of health care professionals, is honest, open and transparent, is willing to be accountable, and is thoroughly ethical.”

Joe Paduda of Managed Care Matters shares a fascinating post about the opioid crisis. According to him, “Opioids may be a key reason many males are no longer in the workforce – with major implications for Medicaid, workers’ comp, the economy, and health care providers.” Read the full post here.

Lastly, at the Workers Comp Insider, Iowa’s legislature recently enacted a series of measures designed to effect workers’ compensation reform. After a recently announced reduction in the state’s workers’ comp rates, Tom Lynch of Workers’ Comp Insider thinks that someone may need a lesson in the principle of correlation does not equal causation.

That’s it folks. Sorry for the lack of pictures–my turn in the hosting rotation coincided with a busy week. Now go and enjoy a few months without any impending repeal and replace votes!


Posted by on September 27, 2017 in Uncategorized


A Simple Explanation of High Risk Pools

Yesterday, the House of Representatives voted by a margin of 217-213 to pass the American Health Care Act (AHCA). Not surprisingly, their was jubilation from conservatives–who threw a celebration in the White House Rose Garden–and outrage from liberals–who immediately began making donations to support Democratic candidates in the 2018 midterm elections. As a supporter of Obamacare (albeit one who readily acknowledges its limitations and the need to make fixes to the law), I was not thrilled to see the AHCA passed, given both the content of the bill and the manner in which it was passed. However, this post is not about all of that. Instead, I just want to focus on one aspect in particular–high-risk pools.

In an attempt to lower the costs of insurance, the AHCA creates high-risk pools for individuals with health conditions that are costly to treat. Of course, this is not a new concept. States have operated their own high-risk pools for years, with little to no success. Leaving aside for a moment the fact that the AHCA does not provide enough federal subsidies for the high-risk pools to be functional, I’d like to explain the concept of risk pools altogether. That is, I am going to explain to you how insurance works. Because that’s all the insurance function does–it pools risk.

Think of it like this: As you may or may not know, I developed Guillain-Barré Syndrome in January. That’s an extremely rare condition, but it is also very expensive to treat. Six months ago, I had no idea that this would happen to me. However, I can tell you that this year there will be between 3,000 and 6,000 Americans who develop the condition. I can also tell you that there will probably be 30 to 60 cases in the state of Iowa (where I live) this year. Insurance works by pooling risk. No insurance company would want to cover just me in the event that I developed Guillain-Barré (or any other illness). However, if they were to enroll the entire state of Iowa, they would be very comfortable assuming that 30 to 60 individuals would develop the condition, and they would build this into the pricing of their product. The science behind crunching these numbers is what actuaries do for a living. As you can probably see, the law of large numbers is at work here: Namely, it is difficult to know with much certainty whether or not a given person will contract a particular illness, but it is relatively easy to know with certainty how many people in a given population will contract a particular illness–and the certainty increases as the population gets larger. The idea of insurance, then, is to spread this risk around evenly such that the people who do get sick are not bankrupted by their illness, and the people who don’t get sick are happy to have paid for the peace of mind that they would have been protected financially had they happened to have gotten sick. Make sense? Now go out and start an insurance company. Just kidding.

Historically, insurers have sought to offer coverage to low-risk individuals while avoiding high-risk individuals. Doing so meant that insurers could maximize their profits by collecting premiums while minimizing their medical losses (which is what they call it when they have to pay for someone’s health care claim). When Obamacare forced insurers to cover everyone (called “guaranteed issue”), it meant that insurers could no longer avoid the high-risk individuals. And, if you’re tracking with me, that meant that the high health care costs of these individuals got added into everybody’s premiums, which made them go up in some cases.

The rationale invoked by the AHCA is that we want to remove these high-risk individuals from the general risk pool and place them in their own high-risk pool. It follows that the general risk pool would then have generally healthier people in it, with lower costs to spread around, and the price of the insurance would come down for these people. Meanwhile, in the high-risk pool, there would be nothing but extremely sick people with high health care costs. Insuring them would be very expensive, because after all, it’s not a question of whether you might get sick, the insurers know that you are sick to begin with. Coverage in these high-risk pools would be so expensive in fact that people couldn’t afford it unless the federal government propped it up with enormous subsidies. And that’s where the AHCA falls woefully short.

But the point I want to leave you with is that, even if the AHCA provided adequate subsidies, high-risk pools would remain an awful idea in principle, because insurance is all about pooling risk, and it works best when you get everyone in the pool. To help that notion sink in, I want to use an actual pool as a metaphor. Well, two pools, actually. An olympic-sized swimming pool and a kiddie pool. We’ll use chlorine to represent high-risk individuals, and water to represent healthy individuals. As you know, chlorine is used to sanitize pool water, but direct contact with chlorine can cause chemical burns. So, in the swimming pool, we want to have lots of water, with just the unavoidably necessary amount of chlorine. Everything works out great for the most part. Still, some individuals may complain about the chlorine. They may suggest that all the chlorine from the olympic-sized pool should be isolated and placed in the kiddie pool, which has much less water in it. That creates all sorts of problems, because the concentration of chlorine is far too high in the kiddie pool. Granted, this is not a perfect analogy, but I’m sure you understand my point. And hopefully you now have a better understanding of why a high-risk pool is not the solution to dealing with sick individuals. The solution is to get everyone–the healthy and the sick–into the same pool. The healthy might not like paying a little bit more, but if they were being honest with themselves, they never know when they might become ill. Trust me, I’ve learned firsthand that expensive illness can be a sudden and unexpected guest in anyone’s home. It’s time we acknowledged that we’re all in this together, and share the burden, rather than ostracizing the sick so we can save a buck while they suffer.

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Posted by on May 5, 2017 in Uncategorized


My Thoughts on the AHCA

Ladies and gentlemen, may I have your attention please: Do you hate Obamacare? Do you remember how people made fun of Pelosi saying “we have to pass it to find out what’s in it?” Well guess what? None of that was true. But this, speaking of the AHCA, the Republicans’ bill to repeal Obamacare absolutely is:
“The final bill text has not yet been released to the public, and there has been no independent analysis of the cost of the bill or its impact on health coverage. Yet the House plans to forge ahead with a markup in the Rules Committee late Wednesday night and a floor vote on Thursday.”
I really hope it doesn’t pass. Really and truly. But if it does, I don’t ever want to hear another word from anyone when their premiums go up, or they lose their coverage, or their insurance doesn’t cover this or that procedure. They won’t be able to blame Obama anymore. They will have swallowed every single lie that they were spoonfed for the last 8 years or so. And they will get to experience the results.
Aw, who am I kidding? I care about people. I got into this field to make a difference for the better. I will never stop fighting, never stop listening, and never stop caring about people and their access to high quality health care. I just hope the GOP doesn’t make my job any harder than it already is.

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Posted by on May 3, 2017 in Uncategorized

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