www.oregonpublichealth.
org
Quarterly Newsletter of the Oregon Public Health Association
Road to revolution
Kitzhaber stirs citizens to act
BY TERRY HAMMOND
I n these dark days of the Oregon Health
Plan, leader John Kitzhaber is on the
stump. Every few days in past months a
fresh announcement showed Kitzhaber
spreading the word, always
brandishing the same title:
On the Road to Revolution:
Fear and Loathing in the
U.S. Health Care System.
Kitzhaber is eloquent,
backed by over 20 years in
Oregon politics, including
four sessions as senate
president and two terms as
governor. In health care, of
course, he has been the
leader of an expectant vision
of access to all, furnished
originally in the aspirations of the Oregon
Health Plan.
In many particulars, Kitzhaber’s
message today is the same as ever, which
demonstrates our lack of progress in the
15 years since the first public risk pools
inaugurated OHP. On the contrary, now
OPHA Mission
• Protect and promote the health
of all Oregon residents
• Educate and support public
health workers
• Advocate for just and equitable
health policies
Probe
THE
10 years since the official starting date
of OHP in 1994, no one is celebrating
the anniversary.
In his campaign for governor in 1994,
Kitzhaber continued to push his long-
standing complaint against the “cost
shift” in healthcare payments, rep-
resenting the idea that we are paying for
the care of everyone anyway, insured and
uninsured, and we could do it a lot more
effectively by assuring coverage directly
with an explicit, basic package of benefits
for all.
INSIDE: ™ Artist reclaims public space
™ New data on hunger and TANF
™ Failure of medical savings accounts
™ Director speaks on multicultural health
™ Return bout on Healthy Start ™ And more …
Summer 2004
Studies have since shown that a cost
shift from public funds reimburses most
uncompensated hospital care, though
often not in time to assure the viability
of the hospital, and not before debt col-
lectors terrorize patients who cannot pay;
but the implication is that cost
shifting cannot explain the sharp
increases in private insurance
premiums.
Recognizing the cost shift
from federal and state general
funds, and other sources, is
important enough. These hidden
payments underlie what Kitz-
haber sees as the fundamental
problem in the current healthcare
system, namely, no one knows
who is responsible to cover those
who cannot pay.
An obvious first step to clarify this
situation would separate citizen con-
tributions for public-sponsored health
care in a state trust fund for that purpose,
distinct from general taxation. Then the
public would see its stake, and be
continued on page 12
2 The Probe

Center on Community Accessibility You can help us

Offers October 2004 Conferences spread the word
Thursday & Friday Saturday, October 9 Please consider distributing
October 7 & 8 Celebrate Wellness V The Probe to colleagues and
Access the Future A Conference Promoting
friends interested in Oregon
A Pacific Northwest the Health and Wellness
of Oregonians with public health. With office
Conference on the ADA,
Accessible Information Disabilities technology, the best way to
Technology, and Education achieve a magazine format is
Presented by Target audience includes by double-sided copying, with
The Northwest ADA & IT Center Youth and Adults with two automated staples on the
Disabilities, Educators, left side.
All 3 days will be held at the Businesses, Service Providers,
Embassy Suites - Portland Airport ADA Specialists, State and
County Representatives,

Probe
7900 NE 82nd Ave THE
Portland, OR 97220 Health Professionals and other
interested persons.
For more information, contact
The Center on Community Accessibility is
Angela Weaver-Roebuck
a program of the Oregon Institute on
Phone: 800-949-4232 Disability and Development, and Child
Email: weaverro@ohsu.edu Development and Rehabilitation Center TERRY HAMMOND Editor
Website: http://cdrc.ohsu.edu/oodh at Oregon Health Science University. HELENA WOLFE Graphic design
DANA KAYE Communication chair
KATE KARLSON Webmaster
Wisdom & Compassion in Aging
News published in The Probe aims to
Exploring the Tibetan Buddhist Concepts of Wisdom
and Compassion As They Relate to Aging provide information. Views expressed in
A One-Day Seminar for Healthcare and Aging Professionals this newsletter do not necessarily
represent the views of OPHA members
Chökyi Nyima Rinpoche Tuesday, July 13
or its board of directors.
Tibetan Meditation Master 8:30 AM–4:30 PM
and Renowned Teacher
Native American Student
David Shlim, M.D. & Community Center Give us your news!
Physician, Author, and President Portland State University We invite you to send stories, news
of the Chokling Tersar Foundation 710 SW Jackson (downtown) and graphics. Submission dates:
Additional Guest Speakers include $25 Students/Seniors ISSUE STORY DEADLINE
Dr. Sharon Baggett—Slide $50 Nonprofit Professionals Winter Dec 21
presentation on ‘Aging in Exile: $75 Professionals & General Public Spring Mar 21
Stories of Tibetan Elders’ Lunch Available for $10 by Reservation Summer Jun 21
Ann Cason—Author of Circles of Care *CEU’s Available for additional cost Fall Sep 21
on ‘Entering the Elder’s World’ Pre-registration requested for publication on the 10th of
January, April, July, and December
For registration & information contact
Donna Harris at IOA, 503-725-3018 or Karen Shimada, 503-408-4755 Contact Terry at terryh@pdx.edu
Email: info@jfrfoundation.org • Website: www.innerintegrity.com/cnrportland Oregon Public Health Association,
Sponsored by the Jessie F. Richardson Foundation, Institute on Aging at Portland State University, 818 SW 3rd Ave, #1201, Ptd 97204
The Center for Healthy Aging at OHSU, and the Oregon Center for Spirituality and Health
Summer 2004
Missionary or medicine man?
Artist makes public art a vital good
BY TERRY HAMMOND
T he therapeutic value of art and
gardens is recognized in academic lit-
erature in environmental psychology, and
occupies one part of the growing interest
in health and the built environment. Most
public health initiatives, even for personal
behaviors, expect to intersect at some
point through physicians, if only for their
professional endorsement; but the track of
art and gardens bypasses medicine in favor
of artists and gardeners.
Artist Brian Borrello combats public
sterility from his studio in Portland with a
variety of projects. He is not exactly
responding to medical necessity, but close
enough for the scrupulous care he shows
in both diagnosing what the public needs,
and embedding the cure in the symbolism
of art (see www.brianborrello.com).
Standard practice for Borrello includes
his currently well-publicized Silicon
Forest at the new Rose Quarter tram stop.
His CV contains a long list of similar
projects, with intricate ideas of place
represented in the details of monumental
sculptures, park columns, murals, and an
enormous variety of outside art with metal
and glass, neon, and many other materials
and results, including poetry and events.
The ideas perpetually brew and spew from
his fervent imagination like a machine gun
– a simile that suits his favorite recent
project, Guns in the Hands of Artists,
using real guns from the police station.
He expresses himself, too, in a stac-
cato, rat-a-tat-tat that quickly panels the
room with images and ideas, always with
a soft inflection as if asking at each shot,
Don’t you think? For Borrello, the bursts
inevitably target public interaction and
inspiration through art, involving the
central career of art: that alchemical
transformation of ideas into space, which
Borrello says, like many artists, “smacks
of the divine.”
Helping others to create their own art,
conveying not simply art, but Art as an
attainment of the human spirit, is one of
Borrello’s specialties. Looking at the
curative aspects of art, he believes the
“creative impulse is vital in experiencing
our full human potential ... to lead a life
of curiosity, inquiry, and imagination.”
Visualization grounds ideas
Visualizing that potential is an
important aspect of the process. Last
October, Borrello was hired by the U.S.
Army Corps of Engineers to set up a
booth at the national brownfields
conference, held at the Convention
Center, and draw what people envision
as a sustainable community. The caption
under a photo of Borrello sketching at
The creative impulse
is vital in experiencing
our full human
potential … to lead a
life of curiosity, inquiry
and imagination
the event quips “Got art?” The Corps
does. He repeated the performance in
February, and created an 8 ft mural.
The idea to “draw your vision” was
implemented more literally in Borrello’s
Wordsmith Project in 1997. In coop-
eration with Vernon Elementary School,
students wrote poetry that Borrello
copied exactly, in handwriting, spelling,
even ruled paper, onto billboards and
various kinds of wall art, and spread
around the community.
Earlier, in New Orleans, he worked
with cancer patients at the children’s
hospital to create images of the chil-
dren’s experiences, which he then fired
on ceramic tiles and arranged in a 65ft
mural. He felt the permanent installation
required heroic proportions to represent
the heroism of the children, battling like
Little Billy Slaying the Cancer Dragon.
3
The Silicon Forest at the Rose Quarter
tram station in Portland connects
imagery of the original forest at the
spot with the region’s powerhouse
electronics industry.
Art shapes community design
In all cases, art is used as a vehicle to
create elements of positive experience in
a community, and attempt to overcome
negative elements both for individuals
and the public – “using art,” Borrello
says, “in ways that only art can be used.”
Current projects for Borrello include
collaborations with the local office of
Alta Planning+Design on metropolitan
parkways, and with the well-known City
Repair Project on a “pocket park” devel-
oping in North Portland. These kinds of
community-based projects are best
represented in the Sunnyside Plaza,
developing for several years in a South-
east Portland neighborhood.
Epidemiologist Jan Semenza of Port-
land State University has been a leading
light in the Sunnyside project, and placed
continued page 4
4 The Probe

Symbols and spirit join community action

continued from page 3
it in the literature recently with published
data on health connections in the
American Journal of Public Health (Sep
2003). Working with many other artist
contributors and neighbors, Borrello
created the template for the sunflower
mural at the intersection that defines the
plaza. He shaped iron bars into the exact

The golden mean

may be an essential
feature underlying
a universal
human conception
A favorite piece from the Wordsmith Project, “I love my brain” says it all, in of beauty
illuminated neon.
dimensions of the golden mean, rep-
resenting the exquisite geometry of real
sunflowers and many other living things
in nature. The golden mean may be an
essential feature underlying a universal
human conception of beauty, offering one
answer to the ancient question posed by
Socrates.

Details glisten with intent

Enraptured by details, Borrello ends
our interview describing the symbolic
elements in the Silicon Forest installation,
drawing attention to the glass disks on
the canopy creating dappled forest light,
the stumps cast in cement, an LED
campfire, the elaborate mime of photo-
synthesis through solar panels in the
“trees,” and onward through a wide-
ranging resume of ideas hither and yon
that have been or might be cast into
material to reflectively engage people in
their environment.
At last, possibly out of breath, he
Borrello’s monolithic art at the Peninsula Crossing Trail in North Portland gives concludes with a characteristic matter-of-
definition to a parkway that traverses the industrial district.
fact tone and sharp glance: “This is about
wellness, not illness.”
Don’t you think?
Summer 2004
The Sunnyside Plaza is the target for an experimental study of health outcomes relative to neighborhood social capital and
public space.
Call for papers on health needs Call for conference papers on
of native groups planning public health
In collaboration with Kaiser Family Foundation, the
American Journal of Public Health announces an upcoming
theme on meeting the healthcare needs of American Indians
and Alaska Natives. Guest editors are soliciting contributions
in “Health Policy and Ethics” and “Research and Practice.”
Articles and analytic essays are encouraged that address the
challenges or approaches to eliminating healthcare disparities
in access, quality, or financing.
Submission deadline is Sept.1, 2004. The online
submission system (http://submit.ajph.org) provides
instructions, including guidelines for various types of papers.
Select “AIAN series” under the Theme Issue menu.
5
Co-sponsored by the the Journal of the American
Planning Association and the Robert Wood Johnson
Foundation, the American Planning Association 2005
national conference will feature a special track on planning
and public health. Abstracts are due by July 28, 2004. The
conference will be held in San Francisco, March 19-23.
Selected papers from the public health sessions will be
included in a special issue of JAPA, planned for 2006.
Send abstracts of 500-750 words to Prof. Marlon Boarnet
(mgboarne@uci.edu) by July 28. Papers examining any
aspect of the link between planning and public health are
invited.
6 The Probe
‘Multicultural’ targets persistent disparities
BY TERRY HAMMOND
A lexis, the executive secretary for the
new director at the state Office of
Multicultural Health, calls me back
apologetically, saying the only hour
available this week for an interview is
Monday at 8 a.m. I comply, and then jot
down the answer to the first question.
One hundred days into his job, James
Mason is keeping busy.
Mason is a familiar figure to OPHA
members, and a confident choice for his
new state role. The definition of that role
has changed with each new director,
Mason says. Unlike state agencies
serving those with disabilities, the aged,
or low income, the name “multicultural”
offers much room for interpretation.
Partly, Mason’s national network of
academic contacts in multicultural affairs
helps shape his capacity to act. He admits
he is presently doing whatever he finds
appropriate, and waiting to see what
boundaries come with the job. His list of
activities includes a cycle of people in
various dimensions in and out of gov-
ernment or on and off the street, and a
familiar litany of workshops, panels,
affirmative action, community events,
interagency cooperation, and safety net
clinics.
These are the components from which
health is supposed to emerge, and the
evaluation-minded will want to connect
the dots to health outcomes relative to
state expense, but this is not how Mason
views his mission. With only a slight
prompt, he turns the conversation to a
different topic entirely.
Take the issue of protective sex. Now,
if you don’t care about living, why should
you worry very much about it? Mason
argues with a barrage of stories, illus-
trating his point that finding positive
meaning in life is essential to all kinds of
healthy behaviors.
The idea encompasses a common
concern for low self-esteem, but draws a
wider circle. One story paints a picture
of indignation in a Latino man facing
personal questions from a physician.
James Mason, new director at the
state Office of Multicultural Health,
embellishes dialogue with a wealth of
stories.
Others portray distrust, language con-
fusion, privation, fear; or a detail, like
cultural differences in the perception of
time. Gradually, it becomes clear that this
is not a personal matter of attitude adjust-
ment. Meaning is a shared experience.
Rather than stepping up to a series of
clinics or campaigns, Mason’s job, as he
sees it, is a continuous process of
“sensitizing” relations between indi-
viduals and groups, finding a “credible
voice” and a “credible venue,” and acting
as a “cultural broker.” The office, in other
words, is a center for civic capacity.
The first targets for this kind of
attention are persistent disparities in
APHA alerts grassroots to contraceptive obstruction
In May, the American Public Health
Association issued an action alert, calling
on members and grassroots organizers to
urge the Food and Drug Administration
to stop delaying a decision to allow over-
the-counter emergency contraceptives.
Emergency contraception significantly
reduces the risk of pregnancy.
On Feb. 17, the FDA announced it
has postponed a decision on whether to
permit the sale of emergency contra-
ceptive Plan B without a prescription,
health, usually most acute in groups of
color. Lead exposure, infectious diseases,
and heart disease are examples Mason
chooses off the top of his list. He steers
away from the idea, though, that ad-
dressing health disparities is a matter of
access to health care. This is not just
health care or even health, he emphasizes,
but “systems of care” that involve
employment, housing, food, whatever it
reasonably takes to “help people’s lives
become more meaningful and worth-
while.” Then they are more likely to take
care of themselves.
Diverse needs often fall within the
purview of fellow state agencies, and
Mason sees cooperation as a top priority,
stating: “My vision is to see this office
become more of a resource internally.”
One of the principle problems, he says,
is most people don’t know what public
health means. An internal advocate for
health, addressing specific instances,
could sensitize a whole range of public
officials to their roles in public health.
Other states, Mason points out, also
have offices of multicultural health, but
some give the title to “minorities,” and
others prefer to say “disparities” or
“inequalities.” Multicultural appears to
give Mason a nice horizon, expansive,
like the stunning view from his office
across the riverfront to downtown
Portland.
“Number one,” he says, “everyone
has a culture.” Largely, it’s the fit, not
the color or the cure, that seems to interest
the new director most.
citing a need for more information on the
drug and its use among teenagers. The
announcement came after a joint meeting
of two FDA advisory panels in December
2003, which voted 23-4 to recommend
Plan B be sold without a prescription.
APHA supports the FDA advisory
committee recommendations, and advises
contacting the acting commissioner of the
Food and Drug Administration to urge him
to move forward with the recommenda-
tions of the two FDA advisory committees.
Summer 2004 7
TANF welfare boundary

New data tracks hunger and health

BY KIM HOFFMAN finding is less surprising given the differences were not observed for general
relative youth of the sample (those in state of health, depression, or overweight,

F rom May to December 2002, a

sample of 637 recent recipients of
Temporary Assistance for Needy
child-bearing years).
Differences in the five areas of health
were than tested between Portland and
but Portland residents were significantly
more likely to have high blood pressure/
hypertension and diabetes (both,
Families (TANF) participated in a non-Portland residents. Significant p=<0.0001).
computer-assisted telephone interview This pattern was repeated when
concerning a wide range of questions comparing regional differences in the
about demographics, insurance coverage, Heightened food health of only the food insecure pop-
health, dependents, and children’s health. ulation. Although we discovered no
This was the first of two waves of data insecurity correlates evidence that food insecurity influences
collection separated by 12 months in the health differently for those living in
Access to Healthcare and Welfare Portland compared to the rest of the state,
Reform Study conducted by the Center with a lower the regional differences discovered in
for Public Health Studies at Portland high blood pressure/hypertension and
State University. state of health diabetes for the whole sample warrants
Demographic characteristics of parti- closer scrutiny.
cipants in the study closely match the
characteristics of total TANF recipients
for the same period. Food insecure Table 1 Selected characteristics of TANF sample
households are particularly likely to lack Age Food security status
a working telephone, however, so the 18-24 30% Food secure 48%
data could significantly underestimate the
25-34 40% Food insecure 30%
actual number of food-insecure house-
35-44 23% Food insecure with hunger 22%
holds. Table 1 shows the Selected
characteristics of the TANF sample. 45 and over 7% Body-mass index
The survey instrument utilized the Sex Underweight 1%
USDA 6-item food security module, with Female 90% Normal weight 33%
one minor modification. Recommended Male 9.8% Overweight 26%
procedures were followed for coding the Race Obese 35%
questions, and assigning food security White 72% Health status
scale values to households. Black 5% Clinically depressed 29%
Analysis began by examining the Hispanic 15% Fair/poor health 30%
entire data set for relationships between Asian 1% Region
food security and health outcomes. Table Native 2% Portland 18%
2 shows the results of a two-tailed
Other 5% Non-Portland 82%
Pearson correlation.
As expected, general state of health
had a strong significant relationship to Table 2 Correlation of food Table 3 Test of difference in
food insecurity. Heightened food inse- security with selected variables mean values between Portland
curity correlates with a lower state of Variable Pearson correlation and non-Portland TANF
health. Also as expected, mental health
General state of health –.229** Variable p-value
scores were strongly related to food
insecurity. Higher levels of depression CESD mental health score .319** General state of health 0.661
are correlated with higher levels of food (higher scores more depressed) CESD mental health score 0.184
insecurity. BMI –.019 BMI 0.821
Surprisingly, the relationship between
High blood pressure/ .059 High blood pressure/ <0.0001
BMI and food insecurity was not statis-
tically significant. Also, high blood hypertension hypertension
pressure/hypertension and diabetes were Diabetes –.40 Diabetes <0.0001
not related to food insecurity though this **Correlation significant at 0.01 (2-tailed)
8 The Probe
More questions cloud Healthy Start impact
BY JOYCE EDMONDS
T he spring 2003 issue of The Probe
featured an article by Tom Engle
questioning the State Commission on
Children and Families claim that the
Healthy Start Program reduces the
incidence of child abuse and neglect.
Engle compared rates of child abuse and
neglect in counties with a Healthy Start
program to counties without a Healthy
Start program. He concluded that child
abuse and a neglect trend between the
counties were identical, and suggested
the Healthy Start program may have
“overstated” its outcomes.
In the following issue, The Probe ran
a rebuttal by NPC Research. The eval-
uators compared child abuse and neglect
rates among the population of children
receiving Healthy Start services in 19
counties, to children in the same counties
who had not received Healthy Start. They
found the child abuse and neglect rate
was lower among those children receiv-
ing Healthy Start services.
These differing conclusions raise
interesting policy questions, especially as
the state grapples with huge budget
shortfalls and decisions regarding
additional state program cuts. The
purpose of this article is to further explore
Healthy Start’s evaluation claims as they
relate to child abuse and neglect.
In an ideal world, program planners
would follow the steps outlined in good
program planning, and integrate scien-
tific research methods into the program
evaluation. In the world we live in, most
programs try to squeeze their services to
fit available funding, which is generally
limited and inadequate. Due to cost,
rarely is program evaluation based on
scientific research methods.
Without randomization, control
groups, controls for confounding varia-
bles, or the use of other statistical
methods, there is little to prove that a
program, service, or intervention really
impacts a population in a positive way.
Herein lies the problem for Healthy Start.
The state of Oregon has invested over
$60 million from the state general fund
into Healthy Start. The program has
expanded annually since July 1994,
receiving strong legislative support
during a time when most programs
experienced major funding cuts. Yet, the
program relies on a simple program
evaluation using raw numbers, per-
centages and frequencies. Despite
plentiful resources, a sophisticated
evaluation using more advanced stat-
istical principles has never been con-
ducted. The program deserves a better
The program
deserves a better
evaluation using
stronger statistical
methods
evaluation using stronger statistical
methods. Without a stronger evaluation,
the program has been left vulnerable to
the type of question that was presented
by Tom Engle.
Reopen the debate
Reducing child abuse and neglect is
one of Healthy Start’s major goals. Below
are a few points of discussion regarding
the program’s design, evaluation, and
reporting flaws that cause discerning
individuals to question the claim that
Healthy Start reduces child abuse and
neglect rates in Oregon.
1. The Healthy Start Status Report 2001-
2002 uses an inflated denominator
(N=14,072) for its maltreatment stat-
istic, including the number of children
that receive basic services. Basic
services are often a phone call to the
parents, a newsletter, a packet of
material, or one welcome baby visit.
It is improbable that this degree of
intervention will have any impact on
child abuse and neglect prevention,
and is certainly not an evidence-based
practice. The logical group to identify
as an intervention group would be the
intensive service clients (N=3,027).
2. The report compares the maltreatment
rate among Healthy Start clients, most
of whom are first births, to the mal-
treatment rate among all children
regardless of birth order, despite
stating elsewhere that maltreatment
is lower among first-born than sub-
sequent children.
3. Despite the program’s emphasis on
universal services, only select first-
birth families receive intensive ser-
vices. In Oregon, an estimated 18,000
first births occur each year. Of the
3,037 clients receiving intensive
Healthy Start services during the
2001-02 reporting period, only 1,579
(52%) were born in that year. The
remaining children were born as early
as 1995. This means only 9% of first-
birth families received service. Fur-
thermore, a reported 51% of these
intensive service families received 12
months or less of service. How is it
possible that such a small cohort of
individuals in a short-term inter-
vention manage to show the dramatic
results reported? Determining a path-
way might help convince us.
Reports lack rigor
Healthy Start reports that the rate of
child abuse and neglect is lower among
children served in the program than
children not served in the program. The
data used to support this statement is no
doubt true. However, the interpretation
of the data should be questioned as it is
used to consistently tout a cause-and-
effect result in the program. The same
skepticism must be applied to reported
Healthy Start results in prenatal care and
immunization rates.
If we are to sincerely explore the
impact of prevention efforts on the rates
of child abuse and neglect, we need
rigorous, well-designed evaluations
overseen by disinterested parties. At a
continued on page 9
Summer 2004
NEWS BITES
New professional certificate targets infant
mental health
In fall 2004, Portland State University will launch a new
25-credit graduate certificate-of-completion program for
professionals who provide services to families with children,
prenatal to 36 months of age. The certificate program in infant/
toddler mental health trains participants in current research and
interventions.
The first cohort in the 2-year program starts fall 2004. To
accommodate working professionals, courses are web-based,
with some weekend sessions.
The application for fall term expired June 30. For future
opportunities, more information and application materials are
available online (www.ceed.pdx.edu/imh), or contact Janet
McIntosh at 503-725-4815 or 1-800-547-8887, x4815, or
mcintoshj@pdx.edu
Oregon hikes against hunger
A new event, Oregon Hikes Against Hunger, scheduled Jul
15-Aug 15, provides an opportunity for individuals or teams
to help fight hunger in their own communities. The hikes aim
to raise awareness of our state’s hunger problem, and promote
donations to Oregon Food Bank.
Brochures, posters and pledge sheets are available. You can
also request a speaker to come to your organization. More
information is available online (www.oregonfoodbank.org), or
contact Briana Winterborn at 503-282-0555 ext. 226
(bwinterborn@oregonfoodbank.org).
New reports on Healthy Start
suggest no positive effects
continued from page 8
minimum, we need existing evaluation reports to be clearer
about the numbers reported and the conclusions drawn. Without
this, the public is misled and progress deferred.
We need to implement stronger evaluation methods and
interpret our findings accurately in order to inform and strengthen
early childhood program design and to better support program
claims. The stakes are too high to demand anything less.
In the most recent issue of Child Abuse and Neglect, several
articles present well-researched findings on Healthy Start that
show no evidence of a positive effect. I encourage those who are
interested to request a copy of the Healthy Start status reports
from the State Commission on Children and Families, and
examine the data for yourself.
9
What is Food Security?
Definitions from the Life Sciences Research Office (Anderson 1990)
Food security—Access by all people at all times to enough
food for an active, healthy life. Food security includes at a
minimum: (1) the ready availability of nutritionally adequate
and safe foods, and (2) an assured ability to acquire
acceptable foods in socially acceptable ways.
Food insecurity—Limited or uncertain availability of
nutritionally adequate and safe foods or limited or uncertain
ability to acquire acceptable foods in socially acceptable
ways.
Hunger—Uneasy or painful sensation caused by lack of
food. The recurrent and involuntary lack of access to food.
Measuring food insecurity
The most common method used is the USDA’s Food Security
Core Module (FSCM) of 18 items which assesses food
insecurity, and hunger, respondents’ anxiety about food
insufficiency, and the impact on their budget or consumption
decisions about how to alter food consumption. An
abbreviated 6-item scale has been developed by the National
Center for Health Statistics using a subset of the 18-item
version, which was used by the AHWR survey instrument.
USDA 6-item food insecurity module
(modified)
In the last twelve months, did you or others in your household
ever cut the size of your meals or skip meals because there
wasn’t enough money for food?
(IF YES) How often did this happen?
01 In only 1 or 2 of the past 12 months
02 Some months but not every month
03 Almost every month
In the last twelve months, did you ever eat less than you felt
you should because there wasn’t enough money to buy food?
In the last twelve months, were you ever hungry but didn’t
eat because you couldn’t afford enough food?
Consider this statement: “The food that I bought didn’t last,
I didn’t have money to get more.” Was this true for you in
the last twelve months? Would you say:
00 Never
01 Sometimes
02 Often
How often do you worry about where your next meal is
coming from? Would you say:
00 Never 03 Often
01 Rarely 04 Always
02 Sometimes
10 The Probe
30%

The top-spending 1% of the population

uses 27% of all healthcare resources
Percent of Total Expenditures

20%
The top-spending 5% of the population
uses 45% of all healthcare resources

The top-spending 30% of the population

uses 90% of all healthcare resources
10%

The lowest-spending 90% percent of the

The lowest-spending 50% of the population
population uses less than or equal to
uses 3% of all healthcare resources
their share of all healthcare resources

0%
Source: Marc L. Berk & Alan C. Monheit, 2001, %

%
%
50

70

90

95
98
"The Concentration of Health Care Expenditures
Revisited," Health Affairs , 20(2), 9-18.
Population by Degree of Spending

Distribution of Personal Healthcare Expenditures, 1996

Medical savings accounts

Zombie policy proposal is a dead end

T he idea of individual savings
accounts for health insurance has
been thoroughly debunked, yet persists
inadequate as a system of universal
insurance, partly because those in most
need would suffer repeated shocks of
everyone and tracking utilization to apply
appropriate subsidies. This proposes a very
complex and intrusive machinery.
with a new name – now "health" instead high deductible payments, and depend Strong evidence shows MSAs are a
of "medical" savings accounts – and a upon catastrophic coverage that defeats dead end. Current popularity of the idea
neverending enthusiasm. A conference of the stated purpose of prudent consumer may be resisted by the following points.
Canadian experts on healthcare policy, choice. Also, those in good health build 1. Systemwide, the idea is technically
facing the same free-enterprise ideas that up balances that remove funds from the impossible.
continue to morph and reappear in spite insurance pool. The young and healthy 2. The real costs in health care are
of rejection, dubbed the phenomenon are attracted to MSAs and expose other concentrated among a small segment
“zombie policy.” Science can't kill it. insurers to adverse selection. of the population. MSAs do nothing
MSAs are designed with a large The reality of these problems was to control choice where it really
deductible, capped by catastrophic very succinctly stated recently by matters.
coverage, and a basic premium subsidized Halvorson and Isham in Epidemic of 3. Individual accounts remove payers
by an employer or the government. It’s a Care (2003), referring to the distribution from the system of insurance, leaving
good idea for corporate employees wanting of personal healthcare expenditures as in 90% of all expenses uncovered.
to personally manage their considerable the graph above. If 90% of the population 4. Deductibles discourage both ap-
resources, but a bad idea for everyone applies for an MSA with an average propriate and inappropriate care,
else. This conclusion is supported by a premium deposit, where will the money making the system a poor reflection
simulation of a similar proposal for come from to pay for the 10% where all of a normal market. (Newhouse
individual Social Security accounts. the costs are really occurring? admitted as much in the RAND
Analysis there showed, in any case, that For those who are ill, MSAs or any experiment, and suggested a public
establishing an individual account for deductible system of insurance is in- budget could be more efficient.)
everyone is technically impossible. equitable. This problem was recognized by 5. Deductibles are unfair to those
An early analysis of MSAs by first Joseph Newhouse in the RAND Health with chronic illness and disability,
Oregon Health Plan Administrator Vickie Insurance Experiment. He suggested a requiring complex administration to
Gates showed the proposal would be solution by instituting a means test for restore equity.
Summer 2004
Medical Reserve Corps
Medical volunteers serve communities
W hen a disaster or other public
health crisis strikes close to home,
local response efforts are always joined
by an outpouring of volunteer support.
That willingness to “pitch in” is a strong
and natural impulse for many people
during times of community need. But for
public health and medical professionals
wanting to lend their skills during such
times, the situation has not been simple.
Utilizing public health and medical
volunteers requires a more organized
approach. Their skills and knowledge are
often highly technical, which requires
coordinating with complex public health
and medical emergency response sys-
tems. Medically trained volunteers can
sometimes undertake work that carries
risks of harm and legal liability for all
involved. As a result, without adequate
preparation in advance, a valuable
community resource often goes unused
when it is most needed.
Corps units dot region
Fortunately, this situation has begun
to change, due to the organizing efforts
of the Medical Reserve Corps. In the
State of Washington, for example, MRC
units are being formed in Kitsap,
Snohomish, Spokane, and Thurston
counties. One is sponsored by a depart-
ment of health, one by a medical society,
and two by departments of emergency
management. Other MRCs in the region
include the Lane County Medical Society
and Multnomah County Department of
Health in Oregon; the Panhandle and
Southeastern district health departments
in Idaho; and the Department of Health
and Human Services in Alaska.
Team draws on many skills
MRC volunteers are mostly public
health and medical professionals includ-
ing physicians, pharmacists, emergency
medical technicians, nurses, infectious
disease specialists and many others.
However, volunteer interpreters, chap-
lains, amateur radio operators, legal
advisors, and others can fill key support
positions. These volunteers sometimes
work with existing local emergency
response programs. Assitionally, they
supplement existing local public health
initiatives such as outreach and pre-
vention efforts, immunization programs
and blood drives. Every community
organizes its MRC somewhat differently
to meet its local needs.
To date, over 175 MRC units have been
formed in 46 states. The Medical Reserve
Corps program was launched in July 2002
as a specialized component of Citizen
U.S. health administration demands
politics first on WHO science panels
A World Health Organization
official is presently negotiating with the
Bush administration over its policy
requiring that a “senior political
appointee” approve scientists invited to
participate in scientific review panels.
The story was reported in the June 26
LA Times, and passed on by Kaiser
Family Foundation.
In April, an official from the Depart-
ment of Health and Human Services
called for WHO to send its requests for
scientists to participate on panels to HHS
Secretary Tommy Thompson for review,
instead of contacting researchers directly.
In a letter to WHO officials, William
Steiger, special assistant to Thompson,
wrote, “Except under very limited
circumstances, U.S. government
experts do not and cannot participate
in WHO consultations in their indivi-
dual capacity,” adding that regulations
11
Corps, a national network of volunteers
dedicated to making sure their families,
homes and communities are safe from
terrorism, crime and disasters of all kinds.
The Medical Reserve Corps program
office is headquartered in the Office of
the U.S. Surgeon General and functions
as a clearinghouse for community
information and best practices. Its role is
to help communities achieve their local
visions for public health and emergency
preparedness and response. Guidelines
for starting a MRC unit in your commu-
nity can be found on the MRC website
(www.medicalreservecorps.gov).
For more information, contact the
MRC program office at 301-443-4951,
or at MRCcontact@osophs.dhhs.gov
A longer version of this article
originally appeared in the spring 2004
newsletter of the Washington State Public
Health Association.
“require HHS experts to serve as
representatives of the U.S. government
at all times and advocate U.S. govern-
ment policies.”
WHO officials have “refused to
implement” the agency’s request
because it could “compromise the
independence of scientific delibera-
tions,” the Times reports.
The U.S. demand is the most recent
action by the administration allowing
politics to intrude on scientific
deliberations and reporting of facts.
Denis Aitken, WHO assistant director
general, said, “It’s an important issue
for us. We do need independent
science. If we want government
positions, we have government meet-
ings. We have many, many of these
government assemblies, but they
address a separate set of concerns” than
the scientific review panels.
12 The Probe

Eponymous chair gives K time to think

continued from page 1
compelled to discuss whether the ar-
rangement is satisfactory.
Kitzhaber’s revolution, however,
rejects any reliance on government.
Partisan politicking for power, in his
view, has corrupted not only the federal
government, but state government, too.
Thus we see the view from the top,
wrought from the bitter contract on
America, staged in Congress and in our
legislature since 1993. As governor in
this environment, Kitzhaber grew
strangely silent on healthcare policy.
Now, the call goes out again. Kitz-
haber wants the people to rise up – as
communities, districts, counties – to solve
universal access locally and tell the
government how it can help. After
Kitzhaber outlines the problems of
misallocated resources in the current
healthcare system, and the need for a
social contract in health insurance
analogous to pubic education, he towers
up to engage the communities of
Oregon, all of us in our respective
positions, “to break the governance
structure and …”
and …
and …“plant the seeds of the future.”
This climax is a little deflating. For
all his eloquence, Kitzhaber’s message
in the end looks much the same as a
convocation of health policy experts at a
breakfast forum in April, where clearly
no one had a clue what to do to fix our
fragmented system, manifestly failing to
cope with avoidable illness, disability,
misery, and death. The bill sponsored by
Sen. Wyden, circulating the past few
years, aiming to bring the topic of
healthcare reform to the people, shows a
similar absence of leadership.
The land of promise beckons, and no
one knows how to part the Red Sea.
Let the people decide then. As a com-
munication expert observed of accepted
scientific method, the expectation ap-
pears to be that new ideas will spring from
the ether between a morning shower and
the bus ride to work. Then we check it
out to see if it’s viable. A brigade of such
ideas appears unlikely to carry us very
far, but what else is there to do? Science,
art, governments, markets, are all proving
too slow and incapable of enacting a
sensible healthcare system suitable for
the leading country of the civilized world.
At least, by ignoring current pro-
posals for reform, Kitzhaber indicates the
options we know, like an employer
mandate, a single-payer system, or a
medical savings account, are all inad-
equate. What is adequate, we might wait
to see.
In March, Kitzhaber became the first
recipient of the Kitzhaber Chair on
Health Care Policy, created by the
Foundation for Medical Excellence in
late 2003. The foundation has received
about $450,000 in contributions and
pledges for the chair. We may observe
how Kitzhaber opens dialogue there, in
his own community, with the plan for
medical savings accounts sponsored by
FME, which promises more than any-
thing else the demise of equitable health
insurance in Oregon (see story on p. 10).
At least we know he is going to have time
to think about it.
Send your own ideas, if you can find
a moment before work to help run the
government, subject line KITZHABER,
to info@tfme.org

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