Monthly Archives: September 2008

Overdrawn

Hardly noticed, and buried deep in the hundred pages of bailout legislation, is a provision that would raise the statutory ceiling on the national debt to an eye-popping $11.315 trillion dollars. In part, it includes the $700 billion bailout money, the $85 billion the U.S. government is lending to save the insurance company AIG, and the $200 billion it put up for mortgage giants Fannie Mae and Freddie Mac.

It will even affect the iconic National Debt Clock in New York that now sits above the entrance of an Internal Revenue Service office in midtown Manhattan. It will need to be reprogrammed to handle the extra digit!

Why do I care? Why should you? Well, I have three children and promised their life would be better than my own. We should not hand my kids or yours a debt payment that is the greatest in the history of the world. With each year, government spending rises and the budget deficit gets bigger. As Steve Chapman, a columnist and editorial writer for the Chicago Tribune writes “As the Baby Boom generation retires, the gap will grow. Given current trends, federal outlays stand to double between now and 2050, while revenues remain roughly stable.”

He continues to write, “By then, two programs — Medicare and Medicaid — will cost as much as the entire federal budget does today. Which means that, essentially, we’ll be financing two federal governments. If you dislike carrying a defensive end on your back, wait till his twin climbs aboard.”

Wikipedia concisely states, “The Government Accountability Office (GAO), Office of Management and Budget (OMB) and the U.S. Treasury Department have warned that debt levels will increase dramatically relative to historical levels, due primarily to mandatory expenditures for programs such as Medicare, Medicaid, Social Security and interest. Mandatory expenditures are projected to exceed federal tax revenues sometime between 2030 and 2040 if reforms are not undertaken. Further, benefits under entitlement programs will exceed government income by more than $40 trillion over the next 75 years. The severity of the measures necessary to address this challenge increases the longer such changes are delayed. These organizations have stated that the government’s current fiscal path is “unsustainable”.”

In Congressional testimony, Peter Orszag, Director of the Congressional Budget Office said that “substantial increases in revenues,” perhaps even in tax increases, will be necessary in the short term to cover the initial infusion of hundreds of billions in borrowed dollars into the private sector, especially given the already record budget deficits and federal debt levels the government is currently running.”

He also said “that the combination of high budget deficits and record expenditures on bailouts — including the proposal now before Congress — has significantly hampered the government’s ability to respond further to any economic crises.”

On his blog site Orszag states, “How Would Rising Budget Deficits Affect the Economy? Sustained and rising budget deficits would affect the economy by absorbing funds from the nation’s pool of savings and reducing investment in the domestic capital stock and in foreign assets. As capital investment dwindled, the growth of workers’ productivity and of real (inflation-adjusted) wages would gradually slow and begin to stagnate. As capital became scarce relative to labor, real interest rates would rise. In the near term, foreign investors would probably increase their financing of investment in the United States, but such borrowing would involve costs over time, as foreign investors would claim larger and larger shares of the nation’s output and fewer resources would be available for domestic consumption.”

He continued to state, ”According to CBO’s simulations using that model, the rising federal budget deficits under this scenario would cause real gross national product (GNP) per person to stop growing and then to begin to contract in the late 2040s. By 2060, real GNP per person would be about 17 percent below its peak in the late 2040s and would be declining at a rapid pace. Beyond 2060, projected deficits would become so large and unsustainable that the model cannot calculate their effects. Despite the substantial economic costs generated by deficits under this model, such estimates greatly understate the potential loss to economic growth because the effects of rapidly growing debt would probably be much more disorderly and could occur well before the time frame indicated in the scenario.”

The growth of the federal debt is the emergency we face. It is unsustainable and unfairly burdens future generations. We’ve seen the enemy; it is our appetite for spending.

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Save a life

Infections – we all get them, and astoundingly, many people will die from them. But, you’d never think that we’d get them in the hospital while being treated for another illness. Or see the needless loss of life of a newborn baby because of an infection in a nursery.

Some individuals will become infected in an ambulatory care facility. These infections are called health-care-associated infections (HAIs), also referred to as hospital acquired infections.

HAIs are a serious and pervasive issue afflicting our health care system. According to the Centers for Disease Control and Prevention (CDC), HAIs are estimated to be one of the top 10 causes of death in the US, totaling 100,000 per year. That means more patients die of HAIs than from HIV/AIDS (60,000 per year) and automobile accidents (40,000 per year). Specifically, central-line infections occur in 250,000 people a year in the US, and are fatal between 5% and 28% percent of the time.

HAIs are very costly, should be mostly preventable, and everyone – patients, employers, hospitals and even state and federal government (Medicare) – bears the burden of these costs. It is reported that HAIs add as much as $20 billion in additional costs to the health care industry. In 2005, the average payment for a hospitalization in Pennsylvania was over six times higher for patients who contracted a hospital-acquired infection than for patients who did not acquire infections, according to a report by the Pennsylvania Health Care Cost Containment Council. Moreover, a 2007 study of 1.69 million patients who were discharged from 77 hospitals found that the additional cost of treating a patient with an HAI averaged $8,832. This is alarming when data show that Medicare, alone, the federal health insurance program for persons over 65, paid for over one-third of all hospital costs in 2005, according to the American Hospital Association.

Ironically, the Federal Office for Human Research Protections shut down a Michigan HAI project, even as it proved itself to be effective. I think it is time for Congressional action.

Can we reduce HAIs? The leading hospitals in the nation successfully tackling them are Allegheny General Hospital in Pittsburgh, Johns Hopkins in Baltimore, and a consortium of hospitals in Michigan. Allegheny, under Dr. Jerome Granato’s leadership the past five years, and with support from Dr. Peter Perreiah of the Pittsburgh Regional Health Initiative, reduced central-line HAIs by 90% in two years, and sustained a 15 month period in their ICU with no infections.

In this state, the Puget Sound Health Alliance (Alliance), a regional consortium of employers, providers, health plans, unions, and patients aimed at improving the quality of health care in Puget Sound, has made HAIs a priority (www.pugetsoundhealthalliance.org). An Alliance workgroup recommends “highlighting the incidence of hospital acquired infections to lower their occurrence and resulting costs to the system.” The Alliance is currently working with the State Department of Health to make the data more transparent and more consumer-friendly, and will include HAI outcomes data in future reports of its own Community Checkup Report (www.wacommunitycheckup.org). The Alliance is also researching how it can help accelerate current HAI efforts in the Puget Sound region using the proven interventions from Pittsburgh and Johns Hopkins.

Mirroring national efforts, the Washington State Hospital Association (WSHA) and Washington State have been engaged in patient safety efforts. Washington was the first state to get all its hospitals participating in Institute for Healthcare Improvement’s 100,000 Lives Campaign. WSHA is actively engaged in national efforts in addition to its own effort, which includes providing technical assistance to hospitals and disseminating posters and brochures to promote hand washing and staff training. Washington State, in 2007, passed SB1106 to mandate public reporting of certain HAIs beginning in January 2009. A phased-in approach, in July 2008, all hospitals were required to start collecting and reporting all central line-associated infections in ICUs. (When this data will be available to the public has not yet been determined.)

We know what works, as evidenced by efforts in Pittsburgh, Baltimore, and Michigan, and now it’s our turn to implement these best practices here and work with the federal government to break down barriers to efforts that will save patients’ lives. It is imperative that we publicly report the incidence of health care associated infections by facility in King County and the State of Washington, in order to shed light on the problem and save lives.

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Fragile, handle with care

Renata Alder, a New York Times film critic and award-winning novelist, made a concise observation of society’s need to respond to the needs of the mentally ill. She said, “Nothing defines the quality of life in a community more clearly than people who regard themselves, or whom the consensus chooses to regard, as mentally unwell.”

The tragic shootings in Skagit County that claimed six lives once again reminds us of the fragility of our state’s Mental Health system. It’s not the first time we’ve received this kind of reminder. Eleven years ago, the stabbing death of a retired Seattle firefighter by a mentally ill man who had been released from jail prompted changes in the law. But all too often it takes a tragic crime before we discuss the needs of the mentally ill.

The Heritage Foundation reports, “An estimated 5.6 million Americans suffer from severe mental illness. It strikes without regard to age, gender, race, education, socioeconomic status, culture, or ideology. In many cases it brings suffering not only to the individual but also to family and friends. Depression, which causes many of the 30,000 suicides in America each year, especially targets the elderly…” They also conclude that the “economic costs of mental illness are staggering. America spends over $69 billion yearly on direct treatment costs.”

So what are the major challenges facing the State of Washington’s Mental Health system? A state-commissioned study of residential and hospital bed capacity and need that was completed several years ago found an additional 680 residential and inpatient beds are needed statewide. But no action was taken on that study. Instead, state and local hospital beds have continued to be closed, and even more closures are planned next year.

The 1999 Legislature initiated the “Community Integration Assistance Program” to improve the process of identifying mentally ill offenders released from the Department of Corrections. These individuals, who pose a threat to public safety, were to be provided with treatment and services for up to five years. The funding provided by the state for each person served is $700 per month for Medicaid-eligible participants and $900 per month for those not on Medicaid. The reimbursement rate has not increased since the program began in 2000 despite an enormous increase in housing and other costs. In many cases, especially in King County, the cost of housing alone exceeds the reimbursement received from the state that is meant to cover all costs

Housing is absolutely critical for people with mental illness if the mentally ill are to benefit from treatment and move toward independence, employment, and recovery. It is integral for them to have the best opportunity, yet housing is hard to find for anyone with low income, and even harder for those who have a serious mental illness. The homeless, mentally ill, are much more likely to commit crimes and end up in jail. It is imperative that the housing dollars authorized by the recently adopted sales tax for mentally ill services should not be diverted for other uses.

We need training for our police about how to work with people with mental illness, and more resources for police to refer people to programs that help avert crises and violent acts; to divert people from jail and into treatment.

Legislation on gun ownership for people who have been involuntarily committed needs to better align between the state and county – currently there are different standards – with state legislation allowing ownership if you have been committed for 14 days or less and federal legislation not allowing ownership if you have been committed for any length of time.

There is insufficient state funding to provide services for people who are mentally ill, but not covered by Medicaid, either because they are too disorganized to get through the process, or because their illness is new (such as the first break psychosis of young people), or because of their immigration status. When people can’t get the treatment they so desperately need, they are much more of a risk to themselves and others.

Involuntary commitment is an extremely controversial issue. Most people with mental illness are not dangerous and their civil rights must be protected. Yet many people believe that it should be easier to commit people who have mental illness. As a result, commitment laws have been amended numerous times since 1998, all with the intent of making it easier to commit people who might be a danger.

Last year, the state Mental Health Division brought in national consultants to lead a task force of mental health professionals, law enforcement, consumers, advocates, prosecuting and defense attorneys, and state officials to review the involuntary commitment law. The conclusion of the task force is that changing laws is not the answer; what is needed are more accessible, consumer-focused, comprehensive services.

Even if the state were to respond to all of the issues listed above, there is no way to ensure that nothing like what happened 11 years ago in King County, or last week in Skagit County, will ever happen again. What we can and should do is provide services and safe housing for persons with mental illness that will minimize the risks for them and for society, while also giving them the resources needed to help them in the recovery process.

The Heritage Foundation report concludes, “Current mental health policy tends to support the status quo system regardless of the effectiveness of services.” This must not continue. America has the compassion, resources, and available treatments to care effectively for its citizens who suffer from severe mental illness.”

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Do you have any skin in the game?

In King County our budget process has always been placed above political ambition and the parochial self-interest of different branches. It is my fervent hope that that tradition will continue as we grapple with the most difficult budget the County has ever faced. Unfortunately, that isn’t the tempo of recent public discussions.

Who stands to lose if we continue down the battle path, you the taxpayer, voter, and resident of King County? So the question for you: do you have any skin in this budgetary game?

With all of the recent posturing, press releases, press conferences and rumor mongering, one of the most critical services the County provides has received very little discussion. In this day and age of confrontational politics and news, it could become the unfortunate victim.

So, let me digress a bit. Remember these points. The human body is an ecosystem, flourishing and nurturing hundreds of millions upon billions of bacteria and microbes; the history of disease should worry us; human beings are not a stationary species; and, when we kiss, hold or shake hands, share our food, or engage in sex, we are simply mixing up a new batch of microbial material!

History is replete with the impacts of infectious diseases. Insects, birds, rats, plants, and humans have transmitted these diseases. They have reshaped history and retired entire cultures. Germs reshaped the history of the lands we now call the United States. Disease nearly eradicated the Native American population of North America. It is estimated that two thirds of the Native American population died of illnesses introduced by Europeans. Do we face these same threats today? According to all of the experts, the threat is growing at an ever-increasing rate. These organisms are mutating and evolving with remarkable speed with increasing resistance to medical treatment: they are genetically shrewd and wish to survive. SARS, avian influenza, hantavirus and extensively drug resistant tuberculosis are just a few recent examples of newly identified infectious agents that have caused serious human illness. Our food production and distribution system makes it easier than ever for contaminated products to reach large numbers of persons spread over wide geographic areas. So far this year the US has seen more measles cases than any time since 1996, primarily do to infected persons from other countries traveling to the US and setting off a series of outbreaks. How does all of this happen?

Wikipedia provided this description of the skin: ”The skin supports its own ecosystems of microorganisms, including yeasts and bacteria, which cannot be removed by any amount of cleaning. Estimates place the number of individual bacteria on the surface of one square inch (6.5 square cm) of human skin at 50 million though this figure varies greatly over the average 20 feet2 (1.9 m²) of human skin. Oily surfaces, such as the face, may contain over 500 million bacteria per square inch (6.5 cm²).” That is just the skin!

But, it isn’t just our skin that houses bacteria and microbes. Dr. Trudy M. Wassenaar, in “Bacteria more than Pathogens” says, “We house millions of bacteria on our skin and in our nose, mouth, and gut:

  • Up to 500 species can be found as normal oral flora
  • There can easily be 25 species living in a single mouth
  • A milliliter of saliva can contain as many as 40 million (4 x 107) bacterial cells
  • 108 bacterial cells present in the cecum (the initial part of the colon) per milliliter of content is normal and many of these species are different from those found in the mouth
  • We are born sterile (free of bacteria) but within hours we are colonized by our little friends, not to be left alone again.”

NPR reports, “The human body contains 20 times more microbes than it does cells. In fact, a visitor from outer space might think the human race is just one big chain of microbe hotels.” Inside and out, we are just one big carrier of other life forms!

But, why should King County government care about your body or mine?

Typically, we live in a natural, harmonious balance with the multitude of organism we naturally carry within our bodies and even more potential pathogens living in innumerable natural reservoirs in the environment, including animals, water and soil (I.e., influenza and avian influenza viruses, Legionnaire’s disease, leptospirosis, E. coli, salmonella and other food-borne diseases). We’re literally surrounded by infectious agents.

But, all too often, that natural balance is upset, leaving us vulnerable to disease. Germs constantly learn new tricks – development of drug resistance and new virulence traits allow them to cause disease more effectively in human populations. In addition, new infectious agents emerge when we upset the balance between man and nature, encroaching on new habitats (SARS).

As Mary Wilson from the Harvard School of Public Health and the Harvard Medical School in her seminal paper “ Travel and the Emergence of Infectious Diseases” states, “Today’s massive movement of humans and materials sets the stage for mixing diverse genetic pools at rates and in combinations previously unknown. Concomitant changes in the climate, technology, land uses, human behavior, and demographics converge to favor the emergence of infectious diseases caused by a broad range of organisms in humans, as well as in plants and animals.” Simply put, the introduction of an infectious disease can happen any day, and at anytime. It is not a matter of if, but when. They will arrive with someone, likely a visitor, relative, friend, or a neighbor.

What organizations are there to protect us? The United Nation’s World Health Organization, the US Center for Disease Control, and most importantly, our King County Department of Public Health are responsible for our health safety. The Department of Public Health is our key local first responder, our community’s immune system. It is that department that has the primary responsibility to prevent, detect, treat, and control the widespread introduction of diseases.

Our local Public Health Agency quietly protects us from infectious diseases every single day. They insure that our food and water are safe to consume. If the local and national health and economic security of the general population were our highest priority, public health would also be our highest priority. It is there that the greatest number of lives can be saved and protected. It is that department who we will all turn to when the infection eventually lands as SeaTac; or arrives at our ports; or drives here on I-90 or I-5. If the Department of Public Health fails, we all lose.

Balancing a budget is a challenge. Public Health must be a priority. One can make a compelling case for the preservation of social safety nets, public safety, and justice. We will need a balanced approach. This is not a time for the cynical and expected game of political one-upmanship. Nor should we tolerate the voices that play to our fears, suspicions, distrust, and our base interest. We are a better community when the voices we hear speak to our optimism, even in the most trying times. Maybe we’ll be pleasantly surprised. Maybe, there is a glimmer of a chance that the common good will be united with common sense. Maybe.

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Down the road

We may be entering an era where our major infrastructure will be owned by private entities with public partner. Matt Rosenberg, a senior fellow at the transportation think tank Cascadia Center for Regional Development, eloquently spoke to this in his article, “A state agency eyes public-private transportation” which appeared in the on-line publication Crosscut. The article suggests that the Washington State Investment Board may be interested in financing various highway improvements in the State of Washington through a public private partnership. The Investment Board, like other large organizations with significant pension and other cash accounts, has found that government’s transportation infrastructure provides a good return on investment.

For many reasons, it is quite likely that there is more than a little interest in this outcome. Washington, like other states across this country face multi-billion dollar investments in highway maintenance and expansion projects. In addition, Congress is not interested in another gas tax increase (last time it was raised was 1983). At this year’s Democratic National Convention, I participated in a Rockefeller Foundation funded session entitled “The 2008 Rocky Mountain Roundtable Transportation & Infrastructure Roundtable.” There was an interesting exchange between Pennsylvania Governor Ed Rendell and Rep. Rosa DeLauro (D) Connecticut. Despite the insistence of both Gov. Rendell and former Speaker of the House Richard Gephardt that a gas tax might be necessary, Rep. DeLauro made it clear that the House of Representatives had little appetite for a gas tax increase. Where does that leave us? Clearly, it is unlikely that we’ll see the Federal government pouring billions into any s tate’s roadway system.

What does this mean? Quite frankly, the Central Puget Sound, like every major metropolitan area of the country, will begin to see system wide variable tolling – not taxes – to finance congestion relief and unclog our roadways. This was suggested in a 2007 study of the region by Jack Oplia from Booz Allen Hamilton on behalf of King County. It is also the position of the United States Department of Transportation. In addition, the Puget Sound Regional Council (PSRC) is also looking at system tolling alternatives in their Transportation 2040 update. One alternative involves just limited access roadways; the other: limited access roadways and arterials. Both alternatives show huge congestion relief and revenue generating potential.

Why will we see private/public partnerships? In order to build you must sell bonds against tolling revenue. To get a good rate from the bond market and a lower toll, government usually pledges its full faith and credit. As states and municipalities reach their capacity to bond, they may seek a large private partner to help cover risk. This is where the private market has aggressively stepped into the transportation arena. Investment banking giants, Morgan Stanley, Goldman Sachs and JP Morgan were all represented by senior partners at the Rocky Mountain Roundtable in Denver touting the capacity of the private sector to invest in our public infrastructure assets. It is has done successfully in the United States and abroad

The future will unquestionably bring system-wide variable tolling. It will ease congestion, reduce harmful emissions, and finance and rebuild our transportation infrastructure. Before these tolled facilities will be owned and operated by the private sector is something we will need to watch closely. We owe the public as much.

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