POSTED ON JANUARY 11, 2012:
OK Is Not Ok
We're sick. We're facing a physician shortage. And many can't afford care. So what's our next move?
We are sick, and we're getting sicker. The 2011 State of the State's Health Report paints a picture of an unhealthy Oklahoma, and one sharply divided along racial and socioeconomic lines. While wealthier, better-educated and insured Okies are as healthy as people anywhere, the rest of the Sooner State is falling far behind the rest of the nation.
For example, while in your neighborhood and along Riverside, the sveltes and wanna-be sveltes have quality time to run and bike and work out, taken as a whole, Oklahoma's obesity rate is among the highest in the nation. It's a big ravine between rich and poor; or at least the middle class and the have nots. People making less than $15,000 a year are more physically inactive than those next up on the ladder, those pulling in $30,000 and more who have some additional education and more stable jobs.
Oklahoma's infant mortality rate is about 30 percent higher than the national average, according to the annual report. But break that statistic down along ethnic lines, and there are still some cultural divides.
Cancer incidences, diabetes prevalence and mortality all soar above the national average here in Oklahoma.
And it's not just our health that's failing us. We're facing a physician shortage, especially in rural areas. Insurance premiums have skyrocketed in recent years, and our healthcare system is a tangled web of red tape and regulations, all wrapped up in a distorted system of payment.
Chances are, if you can afford insurance, your premiums are footing the bill for those who can't. The system is broken. Our state is sick. So what's our next move?
If we're going to fix the problem we've got to see it clearly -- and admit it -- first. Let's take a closer look at some of Oklahoma's grimmer statistics.
The 2011 State of the State's Health Report provides a carefully focused magnifying glass onto the health of Oklahomans; offering county-by-county rankings and report cards.
When it comes to morbidity, Oklahoma ranks pretty high. Our mortality rates and infant mortality rates are higher than the national average, though as the report stated, infant mortality is nearly twice as high among African American infants as white infants.
The Sooner State leads most others in deaths due to heart disease and strokes (cerebrovascular disease). The health report's summary noted "particular concern" over the "disproportionate burden of heart disease and cerebrovascular disease deaths among African Americans, with higher rates than any other ethnic group in Oklahoma."
Oklahoma also ranks among the 10 worst states in cases of diabetes and lower respiratory disease, again "with significant disparities seen among Native American and African Americans," the report stated.
We're a sickly state, but also one that's sharply divided along racial lines.
Our Highs Are Lows
Prevalence of diabetes in Oklahoma is 7th highest among the states. Okies who are older with less income and less education are most prone. The Oklahoma State Department of Health estimated $3.28 billion was spent on health expenditures due to diabetes in 2008.
Additionally, diabetes diagnoses vary from race to race. About 15.1 percent of Native Americans have diabetes compared to 9.4 percent of non-Hispanic whites.
This summer Oklahoma's waistline made news when the United Health Foundation released its annual obesity rankings. The state rose to among the top two in the nation. Two-thirds of Oklahoma adults had a Body Mass Index (BMI) of 25 or above (overweight or obese). Parceled out among groups, this figure shows obesity is more prevalent among Native Americans (40 percent) and African Americans (41.3 percent). Their non-Hispanic white counterparts have an obesity rate of 29.7 percent, while Hispanics have a rate of 30.3 percent.
Overall, the state's adult obesity rate has nearly quadrupled since 1988.
In the State of the State report card, Oklahoma earned an "F" for obesity rates in people aged 35-64, including the age group with the highest obesity rates (those aged 45-54, 39 percent). Tulsa County is doing better than other parts of the state and earned a "C" for its obesity rate of 27.4 percent.
But where a waistline grows, so do other health problems. As our obesity rates rise, we're also seeing higher rates of diabetes and certain types of cancer. One in five hospital admissions now includes a diagnosis of diabetes, according to the state health report.
Okies have had a hard time ditching bad habits. Though smoking is on the decrease in Oklahoma, our state is still ranked among the top two in the nation for smoking. Smoking is the leading cause of preventable death.
Maybe some things are worse.
"Smoking kills more Oklahomans than alcohol, auto accidents, AIDS, suicides, murders and illegal drugs combined," the health report noted.
Oklahoma is one of only two states that do not allow communities to adopt any policy on tobacco that's stronger than state law.
Okies also earned an "F" in physical activity. Our state ranked 49th in the nation for lack of physical activity. Thirty percent of Oklahoma adults reported not being physically active, the health report showed.
A large socioeconomic gap separates those with lower income from their wealthier counterparts. In 2009, Oklahomans earning $15,000 per year or less reported physical inactivity at a rate of 47.9 percent, while only 16.8 percent of those who earn more than $75,000 a year are physically inactive.
Education appears to play a role in physical inactivity as well. College grads were more than twice as likely to be physically active as Okies who only graduated high school. Only 19.1 percent of those with a college degree are inactive versus 45.1 percent of those with just a high school diploma.
Oklahoma is the worst in the nation when it comes to packing our plates with healthy fruits and vegetables. According to Centers for Disease Control and Prevention (CDC) behavioral risk factor data, only one in seven Okies reported eating fruits and veggies five times a day or more.
This trend may stem in part from the lack of availability of fresh, cheap and healthy foods. Only 0.3 percent of Oklahoma's cropland acreage is harvested for fruits and veggies. Less availability translates into fewer farmers markets and higher prices at grocery stores that pay extra to ship in fresh foods from farther away.
To wash down our unhealthy foods, Okies love their "pop." This vice has become an American staple over the years. According to federal government health data, the calories in soda now make up about 10 percent of our total caloric intake. Pepsi, Coke, Dr. Pepper, whatever your drink of choice may be, these sweet and bubbly drinks are the only specific dietary item directly linked to weight gain.
Diet soda, on the other hand, cuts the calories but is still a topic of controversy among soda lovers and nutritionists. A few animal studies have shown a possible link between the caramel coloring in dark sodas (like Coke and Pepsi) and vascular problems.
A 2009 Nurses' Health Study found that women who drank two or more diet sodas per day had a 30 percent drop in kidney function. All the carbonation, acid (phosphoric or citric) and sugar in sodas can cause damage to tooth enamel, too.
Insurance Companies Rule!
Our state report card is dripping in bright red "F"s; it's the type of report we'd have hidden from our mothers. Oklahoma received failing grades in everything from heart disease deaths to our mortality rate to our risk factors for illness.
These failing grades don't necessarily apply to all Okies equally. Those who are well-to-do are doing great, while those without the resources are getting sicker, less healthy year after year.
About one in six Okies lives in poverty, which ranks Oklahoma 41st in the nation, or in the Top Ten, if you are so inclined to think, in the percentage of residents living below the poverty line.
Poverty is a complicated term. The U.S. Census Bureau defines the word by establishing a threshold below which Americans can't live a healthy life with basic resources. Oklahoma's women, young adults and minorities are poorest, and are also more likely to engage in unhealthy behaviors, be exposed to environmental hazards and have limited access to health care services.
The southeastern part of Oklahoma has the highest levels of poverty, according to 2008 Census Bureau numbers. Tulsa County's poverty rates are around the national average (13.2 percent), with 13.6 percent of Tulsa's population living in poverty.
Oklahoma has the 48th highest rate (again, in the Top Two--you're do'in fine, Oklahoma!) of uninsured adults in the U.S. without health care coverage; many Okies don't receive the relatively inexpensive preventive care they need. About 19 percent of Tulsa County residents are uninsured, which is higher than the national average of 14.3 percent.
Without money or resources or access, impoverished Oklahomans simply do without ... until they get really sick. Then the state must dole out expensive pounds of cure -- where ounces of prevention, exercise or medication may have worked before -- that no one can afford.
But someone must foot the bill. Minority groups and those with less income, education or resources are plagued by the lion's share of health problems, though few can afford the cost of expensive care.
Enter the hope and change. To make health care affordable and easily accessible to every American, President Obama's health care plan was born. But to say "Obamacare" has caused controversy is an understatement.
The plan has drummed up millions of detractors, who think the plan is unconstitutional. Tulsa attorney David Hyman, who specializes in healthcare regulations, licensure and the quality control of medicines, said, "I think there's a lot of good sense in [the health care plan]."
Hyman laid out the two sides: "Those who oppose it say the government is constitutionally prevented from compelling people from buying anything, including health insurance.
"The other side is everybody needs health care. Why should some people walk into an ER and not pay for it? If we're going to have health care, if we're going to decide that health care is something that citizens want, how are we going to provide it if we can't find a way to pay for it?"
Critics of Obama's plan also say it will impose billions of dollars of additional cost onto Oklahoma's already strained budget. However, a recent report by Oklahoma Policy Institute, a public policy think tank that advocates for the poor and disadvantaged, released a statement in October that said these criticisms "are way out of line with other studies and based on mistaken assumptions and methodologies."
The institute's director, David Blatt, said, "We think that anyone who looks carefully at the assumptions and calculations of the various studies will agree that the federal government is on the hook for the lion's share of the cost of health care reform."
Additionally, Blatt said, "The fact that the federal government will take over funding responsibility for functions now borne by the state, such as health care for adults with mental illness, will help the state budget and offset some of the expense of a larger Medicaid population."
Blatt echoed Hyman's thoughts: "There is no doubt that paying for health care at a time of scarce resources will remain an ongoing challenge for the state. However, by significantly reducing the number of Oklahomans without health insurance, the Affordable Care Act will reduce the strains that uncompensated care places on our health care providers and will provide better health care and greater financial security to Oklahoma families," Blatt concluded.
We're all struggling with a health care system that's broken. Those who don't have insurance are showing up on hospital doorsteps when they're very ill. Providers must treat them even if they can't pay. So, who picks up the tab? Those with insurance. "If 25 percent of the people, say, are not paying for their care, or paying too little, somebody has to eat that shortfall," Hyman said.
"Some of that shortfall is covered in cutting back services that are provided, but very much of that care is covered in cost shifting. The people who do pay, pay a bit more to cover the loss that the provider experienced as a result of the people who don't pay," he said.
"Why not require everybody to pay? It would be a more fair distribution," Hyman said.
We are a sickly state, badly in need of health care for everyone. Do we continue to allow Oklahoma's impoverished, uneducated and some minority groups to get sicker?
Red Tape Labyrinth
For 26 years, Hyman has handled the complex transactions in what he calls "an enormous web of interactions" that constitutes the medical industry.
He's worked on the legal side of these interactions not only between doctors and hospitals, but also between "different types of hospitals, different types of healthcare service providers, drug manufacturers, drug distributors and retailers and mail orders," Hyman explained.
Oklahoma's medical industry, he said, "really is in the nature of a spider web, which makes it very difficult to provide health care services to the community."
And picking your way through the health care labyrinth is an expensive venture. "How does health care get paid for? That's a determinant that everybody's struggling with right now," Hyman said.
Right now, Medicare finances an enormous chunk of health care in Oklahoma and the U.S. in general. The federal government is already financing the bulk of our health care costs, so Medicare in turn "has a huge influence on the entire health care system," Hyman said.
Though Medicare dictates how much they will pay for medical services (talk about the tail wagging the dog) through a fee schedule that depends "upon the growth of the American gross domestic product," he explained.
Theoretically, it makes sense to look at your budget and determine how much you'll shell out (for medical expenses or anything else) according to how much money you make. The sustainable growth rate system sounded practical and sturdy ... until 2008, when the economy started to teeter.
"The problem comes when the economy starts to dip and demand for physician services goes up," Hyman said.
With an economic downturn, a drop in the U.S. credit rating and drooping GDR, "doctors are supposed to be paid less," he said.
"Under Medicare's sustainable growth plan, [doctors] will get less money" to see patients. To prevent a drop in physician fees, Congress has stepped in a few times to defer the drop in pay.
"As of this year, the deferrals are up to a 27 percent reduction in physician compensation," he said. But each time that reduction would go into effect, Congress has stepped in with what's colloquially called a "doc fix," to prevent the decrease in pay.
The latest fix will expire Feb. 29. President of the American Medical Association, Peter Carmel, released a statement Dec. 23: "Congress now has to enact a real and fiscally responsible solution to this sorry cycle of scheduled cuts and short-term patches that compromises access to care for patients and drives up costs for taxpayers."
Deferral or no deferral, the inherent problem remains: not even the federal government can afford the ballooning health care costs in this nation.
Even if a permanent "doc fix" solution is found, "if you pay doctors more, the threat is that the hospital will then get paid less. The imaging centers might get paid less. Nursing homes might get paid less. If you only have a certain amount to go around ..." and Hyman trailed off.
Is There a Doctor in the State?
The cost crisis is only part of Oklahoma's problem. "We really don't have enough doctors," says Hyman, an attorney with Doerner, Saunders, Daniel & Anderson/ "Pretty poor health conditions, outside of the more affluent parts of the cities" is a serious concern . . . "it's nothing that money can't solve," though coaxing a bright young doctor to move to a tiny Oklahoma town may prove difficult.
Tulsa Attorney, David Hyman
The real question Hyman posed is, "How do you get a shortage of physicians spread far enough around the state to take care of all of the people, while at the same time developing some type of system to get people to take better care of themselves?
"So what do we do about it?" he asked.
He's convinced Oklahoma has a few ready-to-go solutions to keep medical costs reasonable while also stretching a strained system of care. The answer, Hyman said, is in ancillary providers -- those nurse practitioners (NP), physician's assistants (PA) and midwives who are far cheaper than a full-on doc. "They can provide absolutely adequate and necessary care because that's what they're trained to do," Hyman said.
"A physician is trained to handle a certain complexity," he said. "A nurse practitioner can handle everything a patient needs maybe 90 percent of the time. The other 10 percent of the time, they'll know to refer that patient on to appropriate care."
Hyman thinks a small, rural Okie town unable to provide enough work for a full-time physician may be able to employ a part-time nurse practitioner instead. An NP is a registered nurse (RN) who has done graduate school training and has completed a certification process through state boards.
"Some are midwives, nurse anesthetists, general medicine practitioners, and all of them operate within the scope of their training, experience and certification," Hyman explained.
The point is, Hyman said, that Oklahoma has "a whole community of health care providers other than medical doctors and doctors of osteopathy who are all trained and closely regulated."
Mid-level health care providers like NPs and PAs "get paid a percentage of what physicians get paid," Hyman said. "They are probably one of the more cost effective ways of delivering health care particularly in a state like Oklahoma ... at least until we get more physicians, if that ever happens."
Most of a doctor's medical training is subsidized by the federal government, too. Economic uncertainty puts the future of medical education funding in jeopardy, just like everything else in the government's budget, Hyman said.
Much of our medical common sense comes from the misconception that if a little care is good, then a surgically trained physician, a lineup of expensive medical machines and an arsenal of pharmaceuticals is better.
We've made incredible advances in the sciences and technology in the past decade, but there's no need to fight a cold with a nuclear warhead. Sometimes just seeing a nurse before a problem advances, changing up your diet, or taking walks in the afternoon would do the same good in the long run.
And Now the Good News
Take a deep breath; the worst is over. Now, we definitely think you've earned a lollipop, Elmo Band-Aid or happy face sticker for reading this far.
See, that wasn't so bad, now was it?
Oklahoma is making some strides to reduce its tobacco dependency, especially through programs funded by the Oklahoma Tobacco Settlement Endowment Trust (TSET). Fewer youth are using tobacco, more Oklahomans are quitting tobacco and Okie schools, universities and businesses are implementing 24/7 tobacco-free policies.
The American Lung Association ranked Oklahoma as one of the most "quit-friendly" states in the union. SoonerCare, Oklahoma's Medicaid system, offers seven FDA approved treatments -- from nicotine gum to medicines like Zyban and Chantix -- plus programs like SoonerQuit for Women and SoonerQuit Prenatal.
And this is an important population to target for reducing tobacco dependency. SoonerCare subscribers use tobacco at a much higher rate (58 percent of subscribers) than the state average (23.7 percent), according to CDC estimates.
The number of uninsured Oklahomans (ages 18-64) is on the decrease, too, thanks in part to the Oklahoma Health Care Authority's "Insure Oklahoma" program.
The Sooner State is battling the bulge with a new statewide plan, Get Fit, Eat Smart, to reduce the obesity rate through nutrition and physical fitness.
In 2004, the CDC awarded the state health department a cooperative agreement to address obesity issues in Oklahoma. Through this agreement, the Oklahoma Physical Activity & Nutrition Program (OKPAN) coalesced to organize and funnel funding into programs targeted at fighting the fat.
A task force between OKPAN and the Oklahoma Fit Kids Coalition (Fit Kids) yielded specific strategies for five focus areas: physical activity, breastfeeding, screen time, healthy eating and surveillance and evaluation.
Since the CDC awarded funding to Oklahoma, 164 bills were enacted and implemented 304 local policies. In total, the CDC gave 28 states about $1.6 million per year in funding. Oklahoma leveraged the CDC funding, and pulled in $32.6 million -- about $2 for every one dollar in CDC money -- for statewide obesity programs.
Complex Problem, Simple Solutions
State programs aside, there are cheap, easy and simple things we can all do to improve our health and well-being. Cancer Treatment Centers of America (CTCA) helps people focus on getting healthy once they're already diagnosed with a serious disease.
But what if we could start before we get really sick?
CTCA Oncology Dietitian Jasmyn Walker gave UTW some great tips on how to get well and stay well.
"The key is getting a variety of healthy foods into your diet," Walker said.
She recommended a diet of fruits, veggies and plant-based proteins like nuts, seeds and whole grains. Try to balance out your plate a little more. Less meat, more greens.
"We have a tendency to fill (a plate) with maybe two-thirds protein and the other third with carbohydrates," Walker said. Our meals are not only very large but also "very skewed," she said.
Pack your fridge with your favorite fruits and veggies to load your diet with vitamins, fiber and disease-fighting phytochemicals. Walker recommended staying away from canned veggies, which contain "extra preservatives that aren't natural."
And when you're shopping at the grocery store, stick to the perimeter. That's where you'll find all the basics for great eating.
The culinary staff of CTCA works with oncology dietitians like Walker to make what she calls "deceptively delicious" meals for their patients. "We have a lot of various desserts we make using natural sweeteners, beet juice ... and the patients really enjoy that."
They serve a "famous black bean brownie" that combines plant-based fiber and protein with tasty elements for a perfectly balanced and tasty alternative.
"It's never too late or too early to reduce the risk of cancer," Walker said. "Even if you've already been diagnosed with cancer, it's important to reduce the risk of recurrence."
Walker also said it's important to maintain tight control of diabetes. "About eight to 18 percent of all cancer patients also have diabetes," she said. "And uncontrolled diabetes can weaken the immune system, increase risk of infection and increase risk of mortality."
Studies from the CTCA show that about a third of the most common cancers could be reduced by physical activity, healthy diet, maintaining a healthy body weight.
Walker recommends cruciferous veggies like broccoli, bok choy, cabbage and Brussels sprouts for vitamin-packed goodness. Instead of grabbing a package of Oreos, head over and grab some blueberries or blackberries instead. Top your favorite fruits with non-fat whipped cream for a delicious dessert without the guilt, trans fats or extra calories.
For many of us, it's a matter of ingrained bad habits built on top of cultural, social and economic problems. We may not be able to fix our broken health care system, but we can all try to make small, painless changes. Add some green leafies to your plate, park in the back of the grocery store lot. Walk the dog. Go for a swim. If you can't quit smoking altogether, try reducing your habit by a few sticks a day.
Live life. Be well.
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