Insight

Welcoming New Hampshire: Weaving Cultures, Building Community

--By Eva Castillo-Turgeon, NH Alliance for Immigrants and Refugees   

    For immigrants, the process of adapting to a new culture, language and community can be very difficult. Such is the case of immigrants that come to New Hampshire. I have heard some describe the process as "like moving to another planet, where everything is different, where you feel like an alien".

    On the other hand, it is also difficult for the receiving community. They find it hard to communicate and to identify with new arrivals. Many people have mixed feelings about the changing faces in their neighborhoods and others are not sure where to start to develop a sense of connection.

   How are newcomers supposed to integrate if they are not feeling welcomed? And how is the receiving community going to welcome all these new faces if they feel anxious and apprehensive about their presence in their towns? Interaction and dialogue between members of the immigrant and the receiving communities is the key to promote mutual respect and acceptance. These in turn will allow for successful integration.

   Welcoming America works to help strangers become neighbors in the communities that receive those immigrants. In their words, "Welcoming America focuses on the communities where new immigrants have made their homes, helping neighbors build relationships built on trust and understanding". The initiative started in Tennessee in 2007, as result of tensions due to the arrival of refugees in the town of Shelbyville and the lack of communication and understanding between the cultures. The model has proven to be successful in breaking down barriers and promoting understanding. It has been replicated in 19 states including New Hampshire.

   The Welcoming New Hampshire initiative was brought to the state in 2011 by NH Alliance for Immigrants and Refugees (NHAIR), with collaboration of a strong group of community leaders and organizations. We have built a local coalition of native-born and immigrant voices to counteract misconceptions and focus on integration.

   The recent incidents in Concord highlight the need for more communication and positive interaction between different segments of the community and immigrants. As the face of the state becomes more diverse, people need to come together and share their feelings and concerns. Welcoming New Hampshire strives to promote dialogue between immigrant and receiving communities.

 The Welcoming initiative creates a safe space where respectful dialogue can take place; where all members are allowed to express their beliefs free of judgment, and where questions are asked from a position of curiosity.

 We recognize that building trust begins by sharing one's ideas. By exploring our common values we build a connection and develop common goals that will result in a stronger, more welcoming community.

   To find more information about Welcoming America visit their website at www.welcomingamerica.org and become a member of friends of welcoming.

   To become involved in the Welcoming New Hampshire initiative or to find more information about it contact: Eva Castillo at Ecastillo@miracoalition.org or call (603) 661-2873.

Visit the Welcoming NH page on Facebook for announcements and events.

 The New Hampshire Alliance of Immigrants and Refugees(NH-AIR), a program-agency of the Massachusetts Immigrant and Refugee Advocacy Coalition (MIRA), is the only organization in New Hampshire  with the mission of promoting the rights and integration of immigrants and refugees-statewide. The organization serves the state’s foreign-born residents with policy analysis and advocacy, institutional organizing, and training and leadership development. NH-AIR educates and civically engages immigrants and refugees to build their social capital -- as voters and leaders advocating for public policy change that ensures the civil and human rights of all NH residents. 

 

 

 

 

Help for Granite Staters with Pre-Existing Conditions: Two Paths to Affordable Coverage

--by Lisa Kaplan Howe, Policy Director, NH Voices for Health

2014 is a big year for those of us closely watching – and eagerly awaiting – full implementation of the new health law.  That’s when many of the major changes under the law go into effect – including additional health insurance consumer protections for adults with pre-existing health conditions and significant health care needs, creation of the health insurance Exchange marketplaces, and increased access to Medicaid coverage, premium tax credits and cost-sharing reductions for working families.  However, it’s important not to lose sight of the many provisions that have already gone into effect and are helping people across New Hampshire.  An example of that is the Pre-Existing Condition Insurance Plan (PCIP) - also known as the federally-qualified high risk pool.  Through this, Granite Staters with pre-existing conditions who can’t get affordable coverage through commercial insurers, can purchase insurance coverage.   

The federal PCIP creates a bridge to 2014, when this program will no longer be necessary.  The new health law will require all insurers to sell coverage to anyone who applies regardless of their health status and history and will prohibit insurers from charging higher premiums for people with pre-existing health conditions.  Recognizing the value of the federal PCIP to New Hampshire residents, providers and the state’s health care system, New Hampshire was the first state in the nation to create and enroll residents in the program. 

The Health Law's Focus on Prevention and Clinical Care

--by William J. Kassler, MD, MPH

It seems far easier to respond to the needs of a sick individual rather than address the underlying causes of our major health problems. In spite of the fact that, in the last 100 years, every major contribution to the improvement of health status in this country has come from prevention, we have been reticent in our commitment to a robust prevention agenda.  We spend massive amounts of money on caring for the sick ($2.5 trillion in 2009, which is over 17% of our GDP or $8,086 per person); yet we invest less than 1% of our total health expenditures on prevention.  The Affordable Care Act (ACA), a far reaching and potentially transformative piece of legislation, gives us the opportunity to change that. 

The public debate over health care reform has centered on provisions to bring more people into the system through expanded insurance coverage; what has gone largely unnoticed is that the legislation also has a strong focus on prevention.  The most direct way in which the ACA addresses prevention is creation of a new Prevention and Public Health Fund with $12.9 billion allocated over 10 years for prevention and public health programs.  Components of the fund include direct support of community and clinical prevention services, tobacco control and obesity prevention initiatives, and resources to strengthen state and local health departments.   Of particular note is $20 million set aside for integration of primary care services into community-based mental health settings.   However, the fund’s ongoing survival is far from certain.  This past April, the House of Representatives passed a bill to repeal the Public Health Fund.  While the Senate is unlikely to follow suit, things could change in 2013. 

As important as the fund is to support needed public health programs and infrastructure, it also serves to reinforce the split between public health and clinical care.   Public health is seen as something apart from healthcare, something that government and community organizations do.  The more ambitious and potentially transformative provisions of the health care reform law seek to better align public health and medical care by bringing prevention and population-based strategies into clinical care. 

Got Diploma? Got Health Insurance?

--by Jeanne Ryer, EH Program Director

June is a transition time for many of us:  graduations, the end of school, and the beginning of summer and new opportunities.  For young adults and their parents, though, the transitions can bring some worry – and about more than where hang the new diploma!

The transition from school to work doesn’t come with automatic health insurance.  New grads are finding it takes longer to land a good job, and a job with health insurance may not be in the cards for a few years. While many feel invincible, their parents worry that an illness or an accident could set them back financially for years to come.

The new health law builds on one that New Hampshire has had for several years.  Young adults under age 26 can now stay on their parents’ insurance even if they are not in school. They don’t need to be living at home or financially dependent on their parents to qualify.  If they  don’t have access to health insurance through their own job, they can stay on the parents’ family plan.

Two simple quizzes can help parents and kids figure out their options and next steps. 

Make it a family priority to keep everybody covered!

Making Sense of Medicare

--by Martha Bauman, EH Advisory Council member and Keene Sentinel columnist

Is Medicare the cause of present and predicted budget deficits?  Does it provide boutique care for seniors while the rest of the population struggles to pay for essentials?  Or is Medicare an essential component of health care in an advanced nation, enabling older people to be contributing members of society for more years?  Does Medicare reduce the burden of care on local facilities?  Or does Medicare enable people to live “too long?” 

Proposals for changing Medicare will continue to be controversial as the budget process moves forward, but no one is proposing to eliminate this popular program.  That would be political suicide.  A voucher program proposed by U.S. Representative Paul Ryan (R, Wisconsin) is included in the budget recently passed by the House.  Implementation of this change would not take affect for citizens now age 55 and older. 

A capped, annual voucher would be allocated for each Medicare recipient, who would use the voucher to buy health insurance in the private market.   This is not a new concept.  In some ways it is similar to the current Medicare Advantage program, where the private insurer gets a monthly payment to cover the Medicare recipient.  As readers may know, the government had to increase the amount it paid to private insurance companies (the voucher) over the cost of traditional Medicare.  Otherwise, the private market wasn’t interested. 

Vouchers would not be sufficient to buy coverage equal to that of Medicare, according to a Congressional Budget Office analysis.   What services would be covered, and what not covered, is not yet known.  But a voucher plan would likely increase out-of-pocket costs.   Nor does the voucher proposal include consumer protection, to prevent higher premiums based on age.  It is not likely to survive the Senate budget negotiations just ahead. 

The Ryan proposal is not the only proposal for reining in Medicare costs, which are indeed rising.  Note, however, that Medicare costs are increasing at less than the rate of health care costs overall.  Per enrollee spending in private health insurance grew at an average annual rate of 9.3 percent per year between 1970 and 2008.  Medicare spending grew at an average annual rate of 8.3 percent.  The industry-wide increase in health care costs is a major factor in the increased cost of Medicare. 

Hard Thinking and Action on the Public Health Front

--by Linda Rae Murray, MD, MPH, President, American Public Health Association

April 4^th was the forty-third anniversary of the day that the Martin Luther King Jr. was assassinated in Memphis.  As we consider the challenges facing public health it is useful to remember the great contributions to social justice made by Dr. King who said;

“Rarely  do we find men who willingly engage in hard, solid thinking. There is an almost universal quest for easy answers and half-baked solutions . Nothing pains people more than having to think.”

Health is a basic human right and means that the underlying social determinants of health must be organized based on social justice principles. Where this is not the case , as in the United States, it  means that some people will be less healthy than others because of what zipcode they live in , the size of their paycheck, or the color of their skin. Health inequities result in tens of thousands of premature deaths each year in America.  This is the fundamental problem facing public health in America.  How can we end health inequities and create the conditions which will allow everyone to optimize their health ?

This requires hard thinking and actions on the part of public health. We must be willing to speak out and advocate for the conditions that create healthy people, healthy families, and healthy communities. State and local health departments continue to be buffeted by cuts, layoffs and furlough days.  Optimizing health requires that our public health infrastructure be strengthened. It means we must fight for investments in social policies and conditions that promote healthy people and communities. This requires real universal medical insurance regardless of immigration status.  It means advocating for adequate funding of our schools, for jobs with dignity, for supports for people facing hard times. During this Public Health Week, we would do well to remember Dr. King’s words, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

One Year and Counting

--by Jeanne Ryer, Endowment for Health Program Director

This week will have plenty of prognostication about whether the health law will succeed or fail.  But I like to test my health policy assumptions against the real life experiences of people around me.

So far, it seems to be working out pretty well.  At least a couple of times each week I hear from people that have their young adult kids on the family health policy, providing peace of mind for the parents and some security for the “kids” in a pretty daunting economy. A bit less often, but more poignantly, are the families with children with serious illnesses who now can’t be denied health insurance.  Their relief is palpable, especially for those that were approaching the lifetime limits on care.

And there is NOBODY who regrets the end of what was called “rescission” where health insurance companies could deny your coverage, even after years of paying the premiums, because of some inconsequential error on your application. For our own family and others, preventive visits are now fully covered, and there is better protection from the dreaded Medicare donut hole.

So all in all, after a year, things are shaping up pretty well.  But we have a long way to go to get to the really essential changes that come in 2014.  I live in Carroll County, where the number of people who can’t afford or get health coverage is north of 17%, the highest in the state.  That makes us more like Missouri than the New Hampshire average and a lot closer to Texas than I am comfortable with. So I know, and know well, people who have never had any health insurance.  I know people who have died because they didn’t get the care they needed for lack of insurance. I know people right now trying to deal with serious illnesses and no health insurance.   These are hard-working people, proud, and contributors to their community.  It is a shame, really a shame, that those contributions will be diminished because they couldn’t’ get the health care they needed.

So while we have made a great start, it is just the beginning. And we must keep going.

 

Facts Are Stubborn Things

--by James W. Squires, M.D.

In 1770, John Adams observed: “Facts are stubborn things; and whatever may be our wishes, our inclination, or the dictates of our passion, they cannot alter the states of facts and evidence.”

One year after the enactment of health reform, public discussion of health reform is dominated by words and phrases that include “Government takeover of health care” and assertions that the law is unconstitutional. In my opinion these assertions do not rest on a body of facts. Rather, it reflects wishes, inclinations and political dictates.

Here, also in my view, are some facts:  (1) The rapid and sustained rise in the cost of health care in a significant contributor to the national debt. (2) Health care costs in New Hampshire are among the highest in the country. (3) The cost of health care plays a major role in business decisions in New Hampshire and the nation. (4) We spend far more on treating disease that preventing it. (5) Among the 1.3 million residents of New Hampshire, somewhere between 110,000 and 130,000 lack health insurance.

The Affordable Care Act attempts to address each of these five stubborn facts and much more.  Unfortunately, opinions are not facts.  Take, for example, the view that the law is unconstitutional.  No, the law is not unconstitutional and the matter will not be settled for years to come.  The facts are that a number of lower courts have expressed a variety of opinions on the subject.  Not until the Supreme Court makes a decision will the matter be settled.  Until then, the Affordable Care Act is the law of the land.

How the health reform debate plays out will be largely determined by whether or not our nation and our state can separate facts from wishes, inclinations, and political passions.  As for me, I fall in line with Mr. Adams and fervently hope we can stick to stubborn facts.

Significant Changes and a Big Leap

--by Scott Westover, Vice President for Strategic Management, Southern New Hampshire Health System

Several months ago I invited groups of patients to Southern New Hampshire Medical Center to have a conversation about health care.  I have long believed the best decisions in health care are made with the patient in the room, and this was a chance to listen to determine how our health system can best meet patient needs.  This particular evening opened my eyes to the responsibility each of us shares when it comes to keeping the conversation about health care reform productive and solution oriented.

Patients are nervous and uncertain about where to turn for answers where to find a fact-based discussion about the relationship between a patient and his or her physician.  While listening to patients share stories that evening, it occurred to me that that it is the polarizing national debate about the cost of health care and the shortcomings of the American health care system can also erode the confidence patients have in local health care providers. In some ways (I do not believe it was intentional) health policymakers have transferred the problems of the system from the industry to the patients.  We can do better.

Patients who receive insurance through an employer are experiencing dramatic, non-sustainable changes in benefits and personal “out-of-pocket” cost.  Patients who lack access to insurance are concerned about being treated as second-class citizens and some fear they may not have access to care if they become ill.  Patients enrolled in Medicaid and Medicare programs are suddenly aware the discounted payments doctors receive for services rendered to them are a major driver in the skyrocketing cost of health insurance. Everyone seems braced for new restrictions, decreased choice and more direct cost for the care they receive.

When we indulge in conversations that demonize either political party or trivialize the issues with clever sound bites, we are disrespecting our patients and undermining essential reforms. Sustainable solutions will require health care providers, politicians, insurance companies, patients and entire communities to work together.  Every conversation that discourages collaboration or gives an excuse for any party to stay away from the table is short sighted.  It may feel good to identify various boogiemen, but our patients expect more from the health care community.  They expect everyone to do the work that needs to get done in order to improve the overall value of American health care.

First Do No Harm

--by James W. Squires, M.D.

Cut, Cut, Cut.  Wherever I go this word dominates websites, newspapers, talk shows, local meetings and letters to the editors.  Cut what?  Budgets – be they federal, state, municipal, town, or county. All this “cutting” talk takes me back to my surgical days where, to no one’s surprise, “cutting” is an important part of what surgeons do.  But from day one of surgical training, one learns the opposite of cutting and that is: what not to cut.

All physicians learn early in their careers the timeless doctrine of, “first do no harm,” that comes from the Latin expression premium no nocere, and is especially significant in the practice of surgery.  I remember a professor gently moving my hand a few millimeters because where I was going to go would result in some major-league damage.

I could probably teach a college biology major to cut away almost anything; cutting is easy.  Put the tissue under a bit of tension, take scissors or scalpel in hand and slice away.  Removing the thyroid is a good example:  A little dissection here, a bit of cutting there, control the bleeding and presto, the entire thyroid is on the way to the pathology lab. As for harm? The patient may no longer be able to speak, will require hormone replacement for the rest of their life while their calcium metabolism is permanently damaged.

I don’t hear much about the likelihood of doing harm with budget cutting.  And even worse, those likely to be harmed are characterized, by some, as “lazy system abusers” who don’t deserve support and, if on the odd chance someone may be really in trouble, well that is someone else’s problem.  Perhaps some elected officials would benefit from a few days in surgery school and then again, I wonder if the doctrine of do no harm would ever sink in.

During the twenty five years I practiced surgery there were a number of patients whose clinical outcome was far from expected and in certain instances, a slow and painful death was the result. Care was needed during these periods of suffering and I became involved in supporting these patients and comforting their families.  These patients remain forever in my mind’s eye.  During my four years in the New Hampshire Senate, I seldom, if ever, had occasion to spend time with New Hampshire residents who may have suffered as a result of my vote. So to me, the stress and pain of surgical misadventures was significantly higher than the stress of voting, causing me to wonder just what is meant by a “painful” vote.

I conclude by wondering if a better awareness of the consequences of one’s voting decisions might be achieved by a visit to a community mental health center, a food kitchen, a homeless shelter, a foster home and countless other organizations along with boards of selectmen, school boards, and elected municipal officials who will soon, I believe, be directly confronted by their neighbors and friends who knock on the door of public assistance and discover it locked.  The state’s budget crisis is real.  Cuts are inevitable.  But, like any good surgeon, legislators should do some outreach and gain a better understanding of what will constitute one cut too many.