Advancing Health in New York City: Channeling the Tides to Lift All - PowerPoint PPT Presentation

Advancing Health in New York City: Channeling the Tides to Lift All Boats Marc N. Gourevitch, MD, MPH Department of Population Health, NYU School of Medicine Intersectoral Forum on Advancing Health and Equity in NYC March 26, 2014 Presentation Title Goes Here 1

Overview • Net gains in NYC health over last 10-15 yrs are substantial and must be preserved and extended • Unacceptable inequalities persist, some worsening • Further gains require specific efforts to ↓ inequalities, by: o Sharpening focus on most disadvantaged communities o Engaging other sectors that also produce health o Optimizing impact of healthcare sector on health 2

Current smoking, ≥ 18 years old, NYC 1993–2010 Dowell & Farley, Lancet 2012

4

Change in life expectancy, Females, 1985-2010 IHME, 2013

Life expectancy, by Borough, 1985-2009 Alcorn, Lancet 2012

7 NYC DOHMH, Bureau of Vital Statistics, March 2013

NYC DOHMH, Bureau of Vital Statistics, March 2013 8

9 NYC DOHMH, 2014

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What produces health? 11

Median household income & life expectancy, US counties 12 NY Times, March 16, 2014

Spending on social programs vs. healthcare: impact on health ↑ ratio of social : health expenditures in OECD countries → ↓ infant mortality ↑ life expectancy ↓ potential life years lost (after adjusting for level of health expenditures, GDP) 13 Bradley, Elkins, Herrin, Elbel. BMHJ Qual Saf, 2011

Mortality, USA – Yr 2000: Dx’d vs underlying causes Underlying Behavioral Causes Diagnosed Causes N = 1.2 million N = 2.4 million Heart Smoking Cancer Obes/inact Stroke Alcohol Resp MVA Injury Guns Diabetes Unprot'd sex Flu/Pneu Drugs Other Mokdad JAMA 2004

Mortality, USA – Yr 2000: Social factor attribution 15 Galea, Tracy, Hoggatt, DiMaggio, Karpati, AJPH 2011

Education: Bachelor’s Degree & Higher, NYC, 2000 - 2012 60 50 % NYC adults 40 White Black 30 Hispanic 20 Asian 10 0 2000 2012 Furman Center Annual Report 2012 16

Poverty rate, NYC, 2000 - 2012 35 % households < poverty 30 25 White 20 Black 15 Hispanic Asian 10 5 0 2000 2012 Furman Center Annual Reports, 2006 and 2012 17

Severe crowding: % of rental households, NYC, 2006 - 2012 (>1.5 household members/room) 9 8 7 6 White 5 Black 4 Hispanic 3 Asian 2 1 0 2006 2012 18 Furman Center Annual Reports, 2006 and 2012

19 NYC DOHMH, 2010

Inequalities in income: Gini coefficients* by borough * measure of income dispersion in geographic area

Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and 2012 21

Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and 2012 22

Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and 2012 23

Inequalties in health: which way forward? Furman Center Annual Reports, 2006 and 2012 24

House lights and spotlights • City-wide approaches o Public health and healthcare sectors Ø Regulatory initiatives, prevention: continued promise o Other sectors Ø Downstream impact could be even greater • Community/neighborhood/population – grounded approaches o Fundamental to eliminating health inequalities 25

Complementary approaches: policy and community 2014 2024 2034 ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ A B C D E 26

Complementary approaches: policy and community 2014 2024 2034 ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ A B C D E 27

Complementary approaches: policy and community ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ 2014 2024 2034 A B C D E 28

Complementary approaches: policy and community 2014 2024 2034 A B C D E 29

Complementary approaches: policy and community ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ 2014 2024 2034 ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ A B C D E 30

Smoking rates – NYC, 2002 - 2012 30 25 White, M Black, M 20 Hispanic, M Asian, M 15 White, F 10 Black, F Hispanic, F 5 Asian, F 0 2002 2012 NYC DOHMH, EpiQuery 31

Strategies forward 1. City-wide health policy approaches • Legislation • Regulation • Procurement 2. Bridge other sectors to tackle upstream determinants • Health in All Policies 3. Deepen focus on / partnership with highest need communities 4. Extend the population impact of healthcare 32

City-wide health policy approaches • Legislation • Regulation • Procurement • Examples: o Sugar-sweetened beverage portion size o ↑ age of cigarette purchasing to 21 33

Bridging other sectors to tackle upstream determinants Health in all Policies (HIAP) • Transportation • Education • Housing • Built environment 34

L Brotman, 2014

Moving to Opportunity demonstration • 4248 families in Boston, Baltimore, Chicago, LA, NYC • Randomly assigned (1994-97) to: 1. housing voucher that could be used to move to a low poverty (<10%) neighborhood 2. housing voucher with no geographic restrictions 3. control group • In 2002, one adult (98% female) from each family was followed up by interview Kling JR, Liebman JB, Katz LF. (http://www.ksg.harvard.edu/jeffreyliebman/ MTOcomprehensivejune2005.pdf)

Obesity Outcomes in MTO P = .04 P = .09 50 45 40 35 % Obesity 30 25 20 15 10 5 0 Low poverty Traditional Control Kling JR, Liebman JB, Katz LF. (http://www.ksg.harvard.edu/jeffreyliebman/ MTOcomprehensivejune2005.pdf)

Deepening partnerships w/ communities at highest risk: Hypertension inequalities in NYC Percentage of residents reporting high blood pressure ever and currently taking HTN medications by race (age-adjusted) NYC Community Health Survey 2012 70 60.2 60 51.2 50 40 36.7 Black 30 22.2 White 20 10 0 HBP Ever Currently taking BP Meds

Deepening partnerships w/ communities at highest risk: Health Ministry-based BP Dashboard

Extending the population impact of healthcare delivery • Healthcare system: a minor actor? But: » Resource-rich » Concentrated focus on health » Strong evidence behind preventive interventions • New opportunities » Payment mechanisms favoring population-oriented approach » Primary care » CHWs » Community benefit 40

Total ¡area ¡ Pop’n ¡for ¡ popula+on ¡ which ¡delivery ¡ system ¡at ¡risk ¡ popula+on Total ¡area ¡ Pop’n ¡for ¡ system ¡at ¡risk which ¡delivery ¡

42 Jacobson & Teutsch, 2012

Delivery system? 43 Jacobson & Teutsch, 2012

2020 look-back? Community-grounded, sector-bridging Premature Mortality Univ pre-K Minimum ↑ Affordable Narcan wage housing Accountable Green carts partnership ubiquitous; organizations Safe, well-lit (APOs) stairwells 2013 2014 2015 2016 2017 2018 2019 2020

Moving forward • Don’t dim the house lights • Intensify focus on and deepen partnerships with communities at greatest disadvantage • Broaden interface of healthcare and community health • Actively adopt health strategies in key health-producing sectors • Address income inequality – Tax policy; affordable housing policy; new entry level jobs 45