Solutions for the Underaffiliated

Is alcohol is causing problems? Here’s a simple, private way to cut back or quit altogether.

Ever thought you should drink less alcohol? Maybe you’re not at the bottom, but one leads to many. Less patient at home? Less sharp at work?
You don’t want to quit, but less would be better.
Alcoholics Anonymous could work, but opening up to strangers is daunting. Maybe you don’t believe in the philosophy or think it takes too much time.
Oar Health — www.oarhealth.com — provides private, online and telehealth services via trained clinicians who listen to your situation and prescribe naltrexone, which is FDA-approved for the treatment of alcohol problems.
I spoke with Jonathan Hunt-Glassman, CEO & co-founder of Oar Health and Dr. Joshua Lee, Oar’s clinical advisor and professor in the departments of population health and medicine at the NYU Grossman School of Medicine in New York City. He is also director of the NYU Fellowship in Addiction Medicine.

Solving the rural hospital dilemma to address an aging population, poverty, and isolation

Solving the rural hospital dilemma to address aging and isolation
How do we take on the facts that health tends to be worse and demand for mental health services and the suicide rate are rising in rural communities?
The core healthcare challenges in rural communities are transportation because people have to travel to get care and many senior citizens can no longer drive, social isolation, the availability of specialized services, and the financial viability of rural hospitals.
I spoke with Tyler Malone, a research Investigator for the North Carolina Rural Health Research Program in the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill about how to address these problems by enhancing rural hospitals.
The risk of living in a rural community
Rural communities can be diverse ethnically and culturally, but they all tend to be older, poorer, and isolated. Therefore, health tends to be worse than in suburban and some urban areas.
Also, demand for mental health services is rising in rural areas along with the suicide rate. It seems like social isolation and limited economic opportunity are to blame.
The core healthcare challenges in rural communities are transportation because people have to travel to get care and many senior citizens can no longer drive, the availability of specialized services, and the financial viability of rural hospitals.
Solutions to revolve around the future of rural hospitals
Many rural hospitals are facing insufficient demand for their services and capabilities to generate enough revenue to cover their fixed costs. Further, many rural residents are poor. Medicaid does not pay hospitals well, and without it people can’t pay for care in the first place.
The risk of hospital closings is that people with complicated situations and/or who must be treated immediately can’t get care. 
Complicating things is that many people “bypass” their rural hospital, believing that going to a suburban or urban facility is better. Bypassing rural hospitals threatens their viability because they miss out on revenue they otherwise might have received.
The research community hypothesizes that people may believe that urban hospitals are better than rural hospitals, because they hear about newer facilities and equipment and nice cafeterias. 
The reality is that rural hospitals are as good or better than suburban and urban hospitals when comparing outcomes of routine procedures. 
However, suburban and urban hospitals typically perform better in specialized services because the volume of cases gives clinicians more experience treating a wider variety of conditions and complications. 
So when there is a greater risk of post-surgical complications, as there often is with lower-income and older people, it makes sense to go to a hospital where the doctors have seen a wider variety of situations.
Still, even if people have to visit a hospital that is far away to take care of an urgent need, they may not return for follow-up visits because they lack transportation, or it is simply too far. Putting off care can lead to complications, which then puts people back in the position of needing urgent care.
To help people make informed decisions before traveling to a distant hospital, an organization called The Leapfrog Group provides the availability of different services and outcomes associated with them at specific hospitals.
Another risk of rural hospitals closing is that they are often the largest employers in small towns. When they close people leave, increasing isolation and lack of access to care for those who remain. Economic conditions get even worse after years of decline brought on by the departure and closure of manufacturing and distribution operations over the last 50 years.
What’s left would be chain retail stores, restaurants, and organizations that cater to old and low-income people.
Combined, figuring out the most appropriate services for rural hospitals to provide to serve the community and remain financially viable is critical.
Solving the rural care dilemma
Where Medicaid covers a broad enough population, it can allow more people to access care. That would drive demand for services, which would increase the viability of local hospitals.
Still, the underlying problems are still age, isolation, low incomes and poverty, and transportation. 
Some Staes are exploring rural emergency hospitals (REH), which would have fewer than 50 beds, only focus on emergency and outpatient services, and not offer inpatient services.
These types of hospitals wold provide services that need to be delivered right away. People would have to go further away for hospital stays. The catch is that hospitalization may also be required immediately.  
The questions become how people will be transported in a reasonable amount of time and what capacity of inpatient services in rural hospitals is required.
Rural communities have a history of applying their own solutions to local problems, so many rural communities want to figure this out by themselves. 
For example, New Growth Transit is an example of addressing the transportation challenges of rural communities. New Growth Transit, a Missouri organization comprised of a volunteer network of local drivers, takes people with mobility challenges to healthcare facilities that are further away and with getting to grocery shopping and local doctors appointments.
A services like Mental Health GPS might also be valuable to rural communities. It connects people who don’t know where to turn for mental and behavioral services to local resources.
And again, people can checkout The Leapfrog Group to help them decide which hospitals to go to based on the availability of services and outcomes of them.
Additional Resources
If you live in a rural community, you can find its rural-urban community area (RUCA) code to see how “rural” it really is. A higher number means less access. RUCA codes are based on population density, levels of urbanization and journey-to-work commuting to characterize all U.S. census tracts with respect to their rural/urban status and commuting relationships to other census tracts.
The Cecil G. Sheps Center for Health Services Research at UNC-CH has a “financial distress” model that evaluates whether or not a hospital could potentially close.
The Rural health information Hub provides a range of information and resources about rural health, including news, reports, and analysis.

Building the support system we take for granted to help Medicaid members

Disrupting the cycle of poverty with social supports.
Imagine not having food, no way to get to the grocery store, and not having a friend with a working car to get you there or to take your kids to school. That could happen every day to a family on Medicaid.
Imagine having an asthmatic child and not being able replace your carpet with solid flooring, so he misses school and you miss work to take care of him. 
Imagine being a doctor, feeling futile because you know that the treatments you are recommending likely won't work because your patient's basic health needs are not being met.
A unique pilot program disrupts the cycle of poverty by helping children and adults become more productive, so they can perform better at school and work. When people aren’t hungry or worried about where their next meal is coming from, paying bills, getting to the doctor, or cleaning their home for their asthmatic child, for example, they can focus on being their best.
Of course it works! The program coordinates the provision of the basic necessities we take for granted, so we can lead productive, healthy lives.
People who qualify for the program are assigned a care manager who assesses their health plan and need for services, then connects the patients with community organizations that can help them. 
The program includes 29 service categories, from transportation vouchers and weekly produce boxes to parenting classes and help finding housing.

Does helping people to be healthier, more productive, and less expensive make things worse?

Why do we need any more proof that having basic necessities, access to care, and social support leads to better health in order to help poor people live healthier, less expensive and more productive lives?
We all know that poor people can’t afford deductibles and copays, lack food, gas for a car, struggle with rent, and don’t have a social network with the means to help them. Instead of seeing a doctor to get better, they go to the emergency department or straight to the hospital when they can’t go on. 
Private payers, the Centers for Medicare and Medicaid Services (CMS), and state and local governments want evidence that providing things like transportation, food, rent, and household health accessories like air filters reduce costs and improve health before they will fund them.
We spoke with Laurie Stradley, Executive Director of Impact Health about the Healthy Opportunities Pilot, which aims to provide that evidence. 
Still, are we just adding more administration and complexity to the healthcare system? People with money have already proven that being able to pay for the basic necessities to establish health, plus the healthcare to maintain it, experience lower costs and better health.

Using cars, trucks and trains in new ways to save the planet.

Fires, floods, storms. Even if you’re not sure about whether carbon emissions are behind them, why not try something new for our kids just in case?
Let’s start with transportation since about 30 percent of United States greenhouse gas emissions come from the transportation sector. That’s driven by Americans’ everyday use of cars, trucks, trains and planes. 
I spoke with Ned Ryan Doyle, a self-taught expert in what people can do to reduce our carbon footprint. His DIY approach shows it’s easier to do than you might think.
Nearly 60 percent of transportation-related greenhouse gas emissions come from cars and light-duty trucks and 23 percent from medium-to-heavy-duty trucks. 
There are at least two natural drivers of transportation-related carbon emissions.
First, cities and suburbs were built when gas was cheap, seemingly in infinite supply, and we were not feeling the effects of climate change. Today, gas is expensive and the impact of carbon emissions is clear.
Suburbia makes driving inevitable. How do we optimize our driving in it?
Second, the wealthier a family is, the larger its carbon emissions. According to Oxfam and the Stockholm Environmental Institute, the world's wealthiest 10% were responsible for around half of global emissions in 2015. 
This is because of the natural tendency to buy a larger home, more cars, and boats. All that requires energy, which for the most part, comes from boring fossil fuels.
Chances are, if you are reading this, you fit into both of these situations and can do something to reduce your transportation-related footprint. 
First,  the Covid-19 pandemic proved we can work from home, which reduces the use of cars and, therefore, carbon emissions. We should advocate for our employers to continue to allow a significant amount of time to work from home.
Second, buy new and used electric cars and trucks. In addition to reducing carbon emissions, the total cost of owning an electric vehicle can save thousands of dollars over three years. 
Car and Driver compared total costs of electric and gas-fueled Hyundais and Ford F-150s, including maintenance, energy use, gas, charging, depreciation and tax credits: https://www.caranddriver.com/shopping-advice/a32494027/ev-vs-gas-cheaper-to-own/
The EPA also has a calculator to customize your analysis:  https://afdc.energy.gov/calc/
Third, plan your local trips and vacations. Pretend you get ONLY two trips out of the house a week. What are the places and things you need, like groceries and prescriptions? What are the best times of day and routes to travel?
Chances are you don’t need at least one of your cars for hauling things and people around town. Buy an electric vehicle and rent a larger car, like an SUV, for vacations. 
Fourth, reduce the use of long-haul trucks by expanding the rail system and use of it. On average, rail is four times more fuel efficient than trucks, and emits 75% fewer greenhouse gases. Imagine highway driving with fewer trucks!
Fifth, deploy electric-powered long-haul trucks to fill in the routes trains can’t cover and expand the use of electric delivery trucks, e.g. postal vehicles and those with the Amazon, FedEx and UPS logos.
All of this will drive up the availability of long-haul and car charging stations,  which is currently a bottleneck in the uptake of electric vehicles, especially in rural areas.
Imagine having electric charging stations just like we have gas stations along the highway.
Changing our driving and habits and transportation usage is possible. The technology is available for us to reduce carbon emissions. Why not give it a shot?

Yes to modernization; No to more congestion

Let’s use new federal infrastructure funds to improve life and protect cities from climate change, not just to create construction traffic from fixing roads, pipes and bridges.
How can we do better?
Solutions for the Underaffiliated spoke with Joe Kane, a Fellow at the Brookings Institution and economist, planner, and researcher. He works at the intersection of transportation, water, broadband, and energy.
Let’s switch to a more proactive approach by: 
Aligning infrastructure projects with what’s necessary to deliver a more equitable, safe, productive, and sustainable society, 
Leveraging new technologies to deliver it,
Expecting more transparency and accountability from those implementing infrastructure projects, and
NOT accepting Band-Aids on an outdated systems.
Read More
 

Can Doctors Regain Authority in Corporate Medicine?

Is corporate medicine leading to an over-priced, hollowed out healthcare system characterized by dissatisfied patients and fewer healthcare providers, fed up with poor working conditions?
We spoke with Dr. Mitch Li, an emergency physician and founder of Take Medicine Back, which advocates for taking back medicine from corporate interests.
Here are some highlights:
Corporate ownership of a health care organization implies that profit is more important to it than patient care when making strategic and operating decisions.
The conflict between clinicians’ mission to deliver quality care and corporations’ profit motive is not as simple as good vs. evil, so understanding the nuances is important to determining how to resolve it.
Corporate medicine creates the risk of lower-quality care and a poor patient experience, resulting in less trust of the organization, healthcare system and clinicians.
Doctors and nurses increasingly worry about negative repercussions from their employer based on either the care decisions they make or their comments about the role of corporate interests in care. 
There are existing ways to align the mission of healthcare practitioners and business interests the can be applied.

Want affordable housing? Flee suburban living.

Suburban sprawl came with a price. Urban living can reduce housing costs, political divisiveness, and carbon emissions.
We spoke with Andy Paul, a founding member Affordable Asheville, a chapter YIMBY Action, a national organization dedicated to affordable housing.
Less affordable housing, needing a car, and policies that promote wealth-based segregation have led to homelessness, increased carbon emissions, and produced mono-cultures of like-minded people, which fuels political division.
Increasing the availability of affordable housing diversifies neighborhoods, which leads to innovation and education. That creates a vibrant culture people want to visit, which drives tourism and retail revenues as a result.
Adding public transportation makes it easier for people to visit these areas and enables middle class people to live in them, both of which increase revenues for both businesses and government. It can also reduce traffic, which reduces carbon emissions.
Society can’t afford sprawl
Almost one-third of American households spend more than 30 percent of their income on rent or mortgage.
31%of all households are spending 30% or more of their income on housing. 
50% of renting households are spending 30% or more of their income on housing.
21% of owning households are spending 30% or more of their income on housing.
The typical cost of having ONE car is $1,000 a month, including the payment, gas, insurance, maintenance, and required government fees.
Flight from the city, whether forced or by choice, separated people into islands of “people like us” — tribes devoid of the sometimes uncomfortable mix of cultures, that leads to innovation, tolerance, empathy, and learning.
At least part of the total volume of carbon emissions is caused by all the driving sprawl created.
Population Density, Rezoning, Public Transportation
To increase the availability of affordable housing and address the aforementioned challenges, we need to change zoning rules to allow more multi-family housing like duplexes and quadplexes.
At the same time, our communities need to build out more robust public transportation to reduce the need for cars.
To be a just society, provide subsidies so the poorest have homes.  Housing is foundational to help people get on their feet to become as productive a possible. The root cause of homelessness is unaffordable housing, not substance abuse.
Productivity, Vibrancy, and a Positive Impact on Climate Change
One way to fund this is through tourism revenues. 
Adding affordable housing diversifies neighborhoods, which leads to innovation and education. That creates a vibrant culture people want to visit, which drives tourism and retail revenues as a result.
If people can afford their homes and don’t need cars, they can spend more in the local  businesses. That leads to more opportunities to reinvest in infrastructure and business, which increases tax revenues for parks and infrastructure.
That attracts more tourists, which drives up revenue at hotels, tourist attractions, bars, and restaurants. It becomes a productive cycle.
With greater density, worker productivity could improve. People could spend less time driving to and from work and have peace of mind that they could leave work as needed to take kids to and from childcare, school, and doctors’ appointments.
More subsidized housing means fewer homeless camps on the roadside or under expressways.
Fewer cars on highways means lower carbon emissions.
If this sounds good to you, find an affordable housing advocacy organization in your area and volunteer. If you own a business, advocate for more affordable housing near your business.

The Importance of Basic Community Health in the Productivity of America

America’s health crisis is about more than mental and physical conditions, and it costs even more than you think.
It will require  the seemingly impossible task of working together to make the United States healthy.
We spoke with Ted Smith, Associate Professor of Medicine and Pharmacology and The Director, Center for Healthy Air, Water and Soil at the University of Louisville.
Today interconnected forces, like poor food quality, insufficient transportation, limited access to healthcare, weak public education, and other social factors have created entire communities characterized by poor physical and mental health, violent crime, incarceration, unemployment and drug and alcohol abuse.
The more unhealthy people and communities there are in the United States, the more we all pay. Whether it is violence in our cities or insurrections at our nation’s Capitol or higher healthcare costs, or homelessness, or incarceration rates. Americans pay in money, safety, and freedom as more places become undesirable places to live and visit.
The idea of helping people establish a baseline of health to restore these communities is stuck in a debate over whether and how to fund the array of supports people need to live healthy lives.
Some say that’s socialism and people should pull themselves up by their bootstraps. Others say, these people and communities don’t have boot straps. They say that capitalism no longer exists because competition has been allowed to die at the hands of monopolies.  
Further, any notion of sharing wealth seems to be gone, as we seem to feel threatened that someone is going to take we we have or deserve.
The solution is not as simple as solving for one issue. They are all integrated. We can look to history, work together, and change how we live to build healthier communities, and therefore, a healthier nation.
Working together can be done. Americans rallied together to defeat Nazi Germany, Japan, and Italy in World War II.
Capitalism and socialism have always co-existed in the United States. After World War II, The Federal Government helped people buy houses and pay for their education. It started Social Security in 1935, and started Medicare in 1965.
Like a world war, improving the health of all these unhealthy communities requires sacrifice and sharing. Are we up to the task?

Affordable housing is the key to stable, vibrant communities. Let’s build it back

We are all better off when people can afford their homes. Community Land Trusts (CLTs) are one way to expand affordable housing, but we need more homeowners to get on board.
Anna Zuevskaya, Executive Director, and Crystal Sheriff, Community Relations Manager, of the Asheville Buncombe County Land Trust explained the societal benefits of using community land trusts to provide affordable housing.
Community Land Trusts help provide permanent affordability to housing, so low-and-middle income families can buy homes. Homeowners get equity, so they can earn money on the sale of their homes and invest that in a nicer home.
Meanwhile, the original home only increase in value a small amount, so a new family in need of affordable housing can buy it. 
Here’s why it’s needed.
Owning land defines people’s value today. It gives us identity.
Where there is affordable housing, neighborhoods are stable. Where housing is run down, neighborhoods are not stable.
There is a direct correlation between the housing that was built by the Housing Authority starting in the 1960s, during urban renewal efforts, and the housing that was taken away from Black people.
Black people were told the move would be temporary and that they could return or buy a home somewhere else. 
They stayed in Housing Authority housing, and vibrant black neighborhoods disappeared.
The displacement is slow and silent — just like gentrification movements today — as upscale condominiums replace walk-up apartments and high-end retail replaces stores that cater to local tastes.
By taking away the chance to own a home, urban renewal made it difficult for Black people to establish an identity as anything other than a reflection of their poor neighborhood.
CLT’s need help because houses are expensive, and it takes time to build a community, 
The Asheville CLT received $1 million from the city to buy homes and land, but needed more because house prices went up.
It would be helpful if more home owners shared CLT’s mission to provide affordable housing and were willing to sell their land and write off the difference between the appraised value and the sales value.
AirBnB owners can donate a portion of their monthly proceeds to a CLT.
People can volunteer and donate to help CLT’s operate.
Background on Asheville Buncombe Community Land Trust
One of over 160 of community land trust organizations across America. There is probably one where you live.
Its goal is to establish permanently affordable residential, commercial, and community spaces that empower Black, Indigenous, People of Color, and low- to moderate-income residents to build social, economic, and cultural capital.
Community land trusts are nonprofit, community-based organizations which provide affordable housing in perpetuity by owning land and leasing it to those who live in houses built on that land.  
CLTs can be used for commercial space, multifamily rental housing, housing cooperatives, urban farms, community centers, playgrounds, or any other use the board sees fit.