Mental illness is both a widespread problem and a complex challenge for health care policy. Gender is an important factor in mental healthcare but gender perspectives are often overlooked when addressing the population’s mental health needs.
Women deserve specific attention from mental health care policy. The new Status of Women and Girls Report shows that the female population constitutes the largest proportion of those who experience mental health issues. “41% of Minnesota’s women college students report a diagnosed mental-health condition at some point in their life,” the report reads.
While biology and genetics influence mental health, psychosocial factors in women’s lives play a main role in contributing to their higher risk for mental illness.
The National Alliance on Mental Illness (NAMI) in Minnesota reports that women are more vulnerable to mental health problems due to common social stressors on the female population, such as “multiple work and family responsibilities, sexual and physical abuse, sexual discrimination, lack of social supports, traumatic life experiences, and poverty.”
Socio-economic gender inequality produces disastrous ramifications on the mental health of girls and women. Discrimination in the workplace, sexual harassment in schools, and gender biases in family life pile on risks for mental illness. Studies by NAMI indicate that greater social equity likely leads to more equal rates of depression in women and men.
Harvard professor Mary-Jo DelVecchio Good promotes mainstreaming gender perspectives in mental health policy. “Healthy policies for women are supported by state gender ideologies that enhance the cultural, political and legal status of women by legitimizing equitable public investment in and protection of females as well as males,” she writes.
As the state moves forward in working to defeat gender inequality, Minnesota can in turn improve overall mental health.
Effective mental health care must consider gender needs. Men and women often cope with different mental health problems, according to The Status of Women and Girls Report. Men are more likely to have externalizing problems that are destructive to others while women are more likely to have internalizing problems that are self-destructive.
Many young girls struggle with these internalized problems, such as feelings of depression or loneliness. Unfortunately, Minnesota lacks resources to help. The state ranks 49th in the nation for school counselor-to-student ratios in a 2009 Minnesota 2020 report.
Minnesota must invest in accessible, quality mental health services and educate communities about available resources. By centralizing gender perspectives in mental health policymaking, Minnesota can empower a healthier and more equal society.
Good news from MNsure: in the first seven months of its operation, Minnesota’s uninsured rate has dropped by 40 percent. That represents over 180,500 more people with health insurance. The majority of these enrollees have signed up for expanded public insurance programs, but many others have purchased private coverage. (Many people who previously had coverage have also switched to more affordable MNsure options.) Minnesota’s uninsured rate is currently just 4.9 percent, which is our state's lowest rate ever and the second-lowest in the nation.
As impressive as this accomplishment is, it’s not the end of our efforts to help people access affordable healthcare. Not only do we still have five percent of Minnesotans left to reach, approximately 260,000 people, but we need to make sure that those who have gained health insurance continue to stay insured. That’s the true test of our success, and it will require ongoing effort on a few fronts.
Many, many people don’t fully understand how their health insurance works (even my own husband needs my help to comprehend his). They avoid seeking medical care because they’re not sure how much it will cost them. They find doctors’ bills confusing (as most of us do). If they make a costly mistake, such as using an expensive out-of-network provider, they might be hesitant to use their insurance in the future for fear of another unexpected expense. If we’re truly going to improve health and lower costs, we need to help people use their insurance wisely and confidently.
We also need to make sure that people keep the health insurance in which they’ve enrolled. I often meet clients who tell me, “I used to have insurance, but the renewal paperwork was confusing and I missed the deadline to send it in,” or, “I couldn’t afford my insurance anymore and I didn’t think there was anything more-affordable out there.” Whether due to a life change, a missed payment, or a paperwork error, it’s not hard to lose coverage. Insurance exchanges and providers need to make it easy for people to understand what is required to maintain coverage and easy to make changes to their insurance when their life circumstances merit it (one major weak point for MNsure at present).
People also need to want to keep their insurance. One year’s worth of big publicity around enrolling in insurance isn’t enough to convince everyone that they should always be covered. We need ongoing education about the value of insurance, the affordability of insurance, and the cost of not having insurance. Consumers will need to believe that their insurance is worth having, or they might not renew it--penalties nonwithstanding.
One last note. We also need to keep expanding affordable coverage. There are still people left out of the new marketplace, such as people with certain immigration statuses who are not eligible for insurance. There are also people whose coverage still strains their budget (as I’ve written about here and here). Lowering our uninsured rate is going to require some serious conversations about serving these populations.
This year has been the start of something very promising for Minnesota. But, it’s only the start. We can’t stop working together to keep our state healthy and vibrant.
Pop (or, grudgingly, Soda) is in the news again, with soft drink policy battles in New York City, Massachusetts and Florida. California’s Senate recently passed a bill mandating a warning label for all sugary drinks containing 75+ calories per 12 fluid ounces. And a new American Journal of Agricultural Economics study concludes that a .04 cent per calorie tax on sugary beverages is the way to effect positive public health change.
Minnesota has had a tax on soft drinks and candy products since 1992. It puts soft drinks and candy on the same level as other “non-essential” foods. While it's not been shown to impact health habits in any measurable way, it has the benefit of generating revenue to treat sugar-related health issues.
As this battle expands, states will be looking for the best suite (pardon the pun) of policies to curb over consumption, including taxation, education, and incentives.
Use the tobacco approach
Similar to tobacco package warning labels, California's proposed warning label on sugary drinks acts as an informative and “hands-off” encouragement for positive health decisions. Another tobacco lesson includes ramping up "sin" taxes, a moderate deterrent that also helps generate the revenue to defray obesity, diabetes, and cardiovascular disease's costs. Taxes are complicated to implement and fall most heavily on the poor, so a deep discussion needs to occur pre-taxation.
As we learned through tobacco, taxes and labels usually aren't enough. Changing behavior involves some component of restriction and social unacceptability; reverse the perception that soda is harmless, especially when consumed in mass quantities.
Where Does Minnesota Go From Here?
Public policy lessons teach us that cultivating organic choices rather than forcing choices on consumers is the way to go. This, however, doesn't exclude a stick and carrot approach.
By continuing Minnesota’s 6.5% sales tax on soft drinks, Minnesota is staying on the right course. But the state also needs to ramp up education on this issue and put the sugary option out of easy reach in schools, hospitals and other places where the public gathers.
With the state's obesity rate rising from 10% to 25% since 1990, according to United Health Foundation's most recent numbers, our current policy approach isn't working. It's time we join other progressive policy leaders to take on this problem.
The Minnesota Department of Health and the Minnesota Department of Education just instituted a new program, Moving Matters!, to assist schools in helping students increase their daily activity levels. The program hopes not only to affect children's clothing size and heart health but also to improve their academic performance, which has been linked to regular physical activity.
The fact that Minnesota's obesity rate has jumped from 10% in 1990 to 25% by 2012 shows that we're missing some component of educating people about the importance of healthy eating and active life styles. Hopefully, this program and others like help reverse that tend.
Ultimately yielding a healthier generation involves instilling in our kids, and ourselves, the knowledge to make healthy choices daily--make it habitual. The Moving Matters! program is certainly an excellent step forward for Minnesota kids, but isn’t there more we can do, especially considering that we are well aware of obesity's toll on the health care system?
Through a combination of keeping health care costs low, creating new markets for their products, and altruism (you decide to which degree) major companies are stepping up their anti-obesity efforts. Nike allots its employees time for fitness during the workday. Google’s cafeteria is equipped to battle behavioral economics by placing healthy, well-proportioned food options at the front of the cafeteria. Accenture offers incentives and rewards to employees who exceed 10,000 steps a day. Accenture also offers club sports for their employees to participate in.
Minnesota organizations such as General Mills and the Mayo Clinic have also jumped on the bandwagon with General Mills subsidizing healthy foods with “Fitness Friday’s” and Mayo offering a LiveWell program and a Healthy Living Center for their employees.
These corporate advancements, as well as government programs such as Moving Matters! need to be recognized for their attempts to combat this problem. But if we’re going to kick this public health concern for good, we need to do more. Employers need to continue to work toward aiding employees in achieving and maintaining healthy lifestyles. Schools and parents need to continue to encourage kids to eat well, play often, and stay active. In teaching our youth how to be healthy (and in modeling that behavior ourselves) we will likely decrease our obesity rate. More importantly, we will also increase our productivity, decrease our health care costs, and increase our energy levels to help us truly live to our fullest.
One of my organization’s clients recently passed away unexpectedly due to a sudden illness. “Kelly” will be missed for many reasons: she was kind, hardworking, and a consummate caregiver. Her sunny presence could lift any room. I even had the privilege of being warmly welcomed into her home and meeting her lovely children, who are all young adults.
Kelly only got health insurance a few months ago, when I helped her enroll in MinnesotaCare through MNsure.
I don’t know enough about the circumstances of Kelly’s illness to speculate about what would have happened differently had she not had health insurance. I do, however, know what generally happens to people who fall ill and can’t afford their medical care.
Having health insurance meant that Kelly had the choice to go to the doctor at the first signs of illness without worrying about how she would afford it. She didn’t have painfully to wait it out, hoping things would either get better on their own or get bad enough that she could go to the ER.
Having health insurance meant that Kelly could seek routine preventative care. Whether or not it would have made a difference in her particular situation, I have no idea. But it can and does make a difference for many people.
Having health insurance also means that Kelly’s family doesn’t have to worry about paying off her medical bills (and didn’t have to worry about whether or not they could afford to make certain medical decisions along the way). The loss of her leadership and income in a multigenerational household will be difficult enough on many levels. Her family probably can’t afford to pay their rent and other expenses without Kelly; they could find themselves evicted. At least their burden doesn’t also include stacks of medical bills, incurred at the worst of times and impossible to pay off.
This is why Minnesota is a leader in ensuring that all people have access to affordable medical care: because it matters. It matters when a pregnant mother can ensure that her baby’s life begins as well as possible. It matters at the end of life when a grieving family has to make hard decisions about a loved one’s care. It matters at so many times in between, when we rely on healthcare to help us live productive, high-quality lives.
I am grateful to be a Minnesotan and I am grateful that Kelly was, too. She made our community a better place, and our community returned a tiny bit of the favor at the end of her life.
The recent state takeover of a Minneapolis nursing home is an extreme example of mismanagement and neglect, and hopefully an outlier in the type of care our seniors are receiving.
In case you missed the news, last Friday, the Minnesota Department of Health assumed control of the Camden Care Center in response to what it called the facility’s extreme safety and security violations. For more on the story, read the department's press release.
Putting this case aside, it's important to broaden the discussion about nursing care. Even well-managed long-term care centers face a number of challenges that will only grow as Minnesota's population ages, especially in rural communities.
The MDH predicts that by 2030, about one in every four Minnesotans will be 65 and older. Most of the senior community resides in rural Minnesota. With a growing elderly population, the quality of Minnesota’s senior care greatly affects the state’s overall wellness and success.
These facts present Minnesota with challenges and opportunity. We must expand ways to keep people living in their homes or communities longer, since nursing homes face constantly rising expenses, limited federal reimbursements and a state budget that is under growing pressure to meet a wide variety Minnesota needs.
One example of better managing resources to keep people out of nursing homes is providing better access to food. The United Health Foundation reports that Minnesota senior citizens' food insecurity increased slightly to 8.6% in the past year. This grim reality is made worse by recent cuts to the Older American Act, which funds senior programming and caregiver support. Minnesota lost $500,000 in OAA funds, causing many senior food programs, including both community meals and home delivery, to shut down throughout the state.
Rural areas encounter added costs to meet senior needs including transportation challenges, lack of density and inconsistent access to care facilities.
Yet, finding the proper combination of increased public funding, health care reform, resource management, and fair labor standards could provide a major employment opportunity in rural areas, as communities health care facility tend to be solid job creators.
The future of Minnesota depends on properly sustaining its aging population, especially in rural areas. Progress is only possible with a cultural shift toward a more supportive perspective of the older population’s place in society. With persistent advocacy for Minnesota's elderly, future policy changes could prioritize senior care by increasing government funding and promoting supportive communities to keep up with changing demographics.
Sometimes public policy leaders are slow in responding to changing technology or an emerging health crisis. But that's not the case in Minnesota when it comes to e-cigarettes (short for electronic cigarettes). Nationally, their regulation has fallen into gray areas. This past legislative session, the Legislature and Governor Dayton took important steps toward ensuring youth and the general public are protected from the harms of e-cigarettes.
Language included in the Health and Human Services Omnibus Bill restricts indoor e-cigarette use, also called “vaping,” in a variety of settings, including hospitals, clinics, state-owned buildings, city and county-owned buildings, correctional facilities, facilities owned by Minnesota State Colleges and Universities, licensed daycare facilities during hours of operation, and schools. The bill also prohibits the sale of e-cigarettes to minors, requires e-cigarettes and e-cigarette liquid to be sold in child-resistant packaging, and prohibits the sale of e-cigarettes at kiosks in malls.
These measures are good first steps. The Freedom to Breathe Coalition, which is comprised of a large number of health-minded organizations fully support these new restrictions and applaud the bill authors and allies for their work on this issue. Member organizations include, but are not limited to:
Allina Health, American Cancer Society Cancer Action Network, American Heart Association, American Lung Association in Minnesota, Association for Nonsmokers-Minnesota, Blue Cross and Blue Shield of Minnesota, ClearWay Minnesota, Local Public Health Association of Minnesota, and Minnesota Medical Association.
E-cigarettes are the most recent “harm reduction” products promoted by the tobacco industry, which now controls the majority of e-cigarette market share. For decades, filtered, “light,” and low tar cigarettes were marketed as safer ways to smoke. In reality, none of these products were any better for consumers. They were simply a marketing tactic. Tobacco companies are master marketers who use deceitful advertising schemes to gain power and profit while producing and selling the single leading cause of preventable death and disease.
Are we to believe that e-cigarettes are any different?
The science is still out on the health harms of e-cigarettes. However, given the track record of the tobacco industry, it makes sense to err on the side of caution. The e-cigarette debate at the capitol was heated. Health and medical organizations advocated for more regulation and the tobacco industry advocated for little or no regulation of these products. On an issue of public health and well-being, it makes good sense to trust groups who have health and medicine as their primary mission rather than companies who stand to profit from an unrestricted marketplace.
The 2007 Freedom to Breathe Act prohibited smoking indoors and set the standard of clean indoor air that we enjoy today. The Freedom to Breathe Act protects workers and the general public from secondhand smoke. This policy was hard won and is much loved. Policymakers should work to ensure that we don’t go backwards and that our standard of clean indoor air is upheld.
While the legislature took a step forward this session, the new law left work undone. Next session, legislators should continue to push for including e-cigarettes in the Freedom to Breathe Act. In doing so, workers and the general public will not be asked to unwillingly take the risk of exposure to secondhand vapor in public spaces. In the meantime, cities across the state should follow the lead of cities like Duluth, Mankato, and Hermantown and pass strong local policies to protect the health of their citizens.
Betsy Brock is director of research that the Association for Nonsmokers-MN.
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When we think about air pollution -- which isn't often around here, where smog you can see is rare -- we tend to focus on tailpipes and smokestacks. New research suggests we should be looking up higher, to the jets buzzing in and out of Minneapolis-St. Paul International Airport, the 11th busiest in North America.
A university study found that concentrations of harmful particles as far as 5 miles downwind from Los Angeles International Airport exceeded the average measured along L.A.'s famously smoggy freeways. In some places, the measured concentrations were 4 to 11 times greater than normal.
"These results suggest that airport emissions are a major source of [particulates] in Los Angeles that are of the same general magnitude as the entire freeway network," wrote the researchers from the Universities of Southern California and Washington. "They also indicate that the air quality impact areas of major airports may have been seriously underestimated."
Thanks to MINNPOST health writer Susan Perry for highlighting this study and raising questions about its implications in the Twin Cities. She previously reported on earlier studies, including one at MSP, on links between cardiovascular disease and airport noise.
Those studies, she wrote, considered "confounding factors, such as air pollution." The LAX research, however, indicates that bad air may be more concomitant with airport noise than confounding. If you can hear the planes, you're probably breathing their emissions. These include "sulfur dioxide, nitrogen oxide and other toxic particles that are created from the condensation of the jet's hot exhaust vapors," Perry notes, and they are "suspected of worsening many lung conditions, such as asthma and chronic obstructive pulmonary disease (COPD), and of contributing to the development of heart disease."
Indeed, she added, another new study found four times the incidence of breathing problems among children living near Boston's Logan International Airport compared with those farther away, and nearly twice the percentage of adults suffering from COPD. No correlation was discovered, however, with heart disease.
Perry warns that all this research is observational, meaning that it can prove associations between airport effects and diminished health, but no causal links. "Other factors, not controlled for in the studies, many also explain the results," she stipulated.
Maybe so, but if you combine findings of heightened, localized air pollution and more ill health you've got a pretty decent case building. Someday, perhaps, we'll be able to "see" invisible threats of air travel to people on the ground and find ways to counter them.
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As Minnesota continues to dig itself out of the funding hole Pawlenty dug, we need to help schools make sure all students are safe and healthy. This means, in part, giving them the resources to hire enough nurses.
Increasing the number of school nurses (along with other important roles like counselors, social workers, and librarians) was one of the major issues in the recent contract negotiations in the Saint Paul district, and the subject has been gaining increased attention in other districts as well. Nurses will be among the 42 additional staff hired in Saint Paul after the Saint Paul Federation of Teachers advocated for them, reflecting community input and the sad fact that many schools did not have a full-time nurse. (Full disclosure: I worked for SPFT for part of the bargaining process.)
The importance of school nurses has been illustrated recently in Philadelphia, where two children have died of potentially preventable medical emergencies in the last school year. The more recent case, involving a 7-year-old boy with a congenital heart defect who passed out at school and later died in the hospital, is somewhat ambiguous. While there was no nurse on duty at the elementary school at the time, it’s unclear if the presence of one would have made the critical difference. However, the 12-year-old girl who died of an asthma attack at a different Philadelphia school earlier in the year, again with no nurse on duty, is less fuzzy.
Nurses are among the many positions cut when school funding suffers. Districts tend to make the (understandable) political calculation to preserve positions that have the most face-time with students and families. I doubt anyone feels good about cutting nurse positions, but it’s one route to reducing spending when funding slows.
This is why a well-funded education system is so important. Schools will keep putting kids into classrooms and putting teachers in front of them for as long as they can, but there’s so much more to a good school than that. Not only should every school have a full-time nurse, but it’s also time to start scaling up the presence of community clinics in schools. Minnesota’s children deserve robust schools that keep them safe and healthy while they learn.
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There's no easy way to talk about this, so I'm just going to come out and say it: we need do everything possible to reach out to people involved in the sex trade and ensure they have access to affordable or free basic health services. Our public health and social justice organizations must get a better sense of the scope and threats facing people in this situation so that we have a better guide for public policy solutions, including viable avenues out of the trade.
Instead of exploring this issue with the same vigor Minnesota brings to most complex policy challenges, we tend to marginalize or even attempt to ostracize people involved with criminal activity, especially in the sex trade because we treat it as a morality issue. Some progress has been made under Safe Harbor protections, but that is only with people under the age of eighteen. What if we reframed the discussion so that public health was at the center of the debate? What if we tried to explore public health solutions to this issue?
Let's work through some of the commonly held beliefs about those who work in the sex trade -- either by choice, force or some complicated mix of both.
Women who engage in prostitution do frequently have HIV or AIDs -- but not always due to their work, according to a Berkley Journal report. HIV/AIDs acquired through drug habits is preventable. The same report described a Project AWARE study in San Francisco which found that sex workers who don't use intravenous drugs have slightly lower rates of HIV/AIDs than other sexually active women who don't inject drugs.
Alexandra Pierce Ph.D., a researcher and program evaluation consultant at Othayonih Research and Evaluation noted that sex workers also face greater health risks than the population at large ranging from mental health issues to domestic violence. One of these serious issues is an increased risk for common communicable diseases: the flu, strep throat, a cold. Due to certain social stigmas and systemic biases it can be difficult for women (or men) in this trade to receive treatment quickly and regularly. We have an obligation to help people for their own sake and the sake of public health at large.
There may soon be more data available on the public health impact. According to Amy Kenzie the Sexual Violence Program Coordinator for the state's Department of Health, the agency does intend to collect data regarding prostitution and health. This is an important step forward.
This under-discussed issue needs to be brought to light. Solutions can vary, but should follow the line of reasoning implemented in needle exchange programs for intravenous drug users. In marginalizing our sex workers, not only do we undermine our longstanding Minnesota tradition of helping those who need it, we undermine public health.