By Dr. Paul Ehrlich
A couple of weeks ago I traveled to Memphis to give a talk to a number of pediatricians about the relationship between infant nutrition and the likelihood of subsequent allergies. I have given a series of these lectures (full disclosure—they are sponsored by Nestlé®, which makes the partially hydrogenated, casein-free formula Good Start®), and they are always well received. Short as it was, I enjoyed my stay in Memphis and the lively give and take with the audience.
Since then a couple of Tennessee stories have caught my eye that I believe worth mentioning on this website. One is that an access-to-epinephrine bill for schools is now being debated before the state legislature. As someone who decades ago took part in founding both the Food Allergy and Anaphylaxis Network (FAAN)–now merged with Food Allergy Initiative (FAI) to form Food Allergy Research and Education (FARE)—and Allergy & Asthma Network/Mothers of Asthmatics (AANMA), I am very pleased to see that bills like these are on the legislative agenda nationally and in many states.
However, the other story creates a larger public health context that throws some cold water on the satisfaction we can all take in the progress we have made in raising visibility for food allergies. Namely, that Tennessee Governor Bill Haslam has now joined with other Southern governors in rejecting the extension of Medicaid to low-income adults under terms of the Affordable Care Act. The Governor wants the Medicaid money to subsidize purchase of private insurance instead. (For a discussion of this approach, see this New York Times editorial.) As a doctor who takes both private insurance and Medicaid (not all my colleagues do) I believe that treating the poorest will not only provide the biggest payoff in the long run, financially and socially, but it’s the right thing to do. In the short term, the State of Tennessee will continue to rely on a lottery to ration health insurance. As reported in the Times, the lottery shuts down after 2,500 phone calls to the hotline, usually in the first hour, when there are almost 200,000 eligible.
Tennessee has an interesting history with “universal” health care. A previous governor took a stab at it, but found, as elsewhere, that providing health insurance to all citizens is hard for a state to do on its own.
I am not going to question the motives of the current governor for not participating except to point out that Tennessee currently ranks #39 on the list of healthiest states (Vermont, which has a strong health insurance program is #1; Hawaii is #2, New Hampshire 3 and Massachusetts, home of Romneycare is number 4) and almost all of those lower on the ladder than the Volunteer State have also rejected the Medicaid expansion. (Click on maps for county-by-county breakdown–the darker the shading, the worse the life expectancy.)
I would like to say is that important though emergency access to epinephrine is, it serves only a fraction of the health care picture even for food-allergic children, or allergic and asthmatic children, let alone the totality of the school population. Personally, I think keeping food out of classrooms, especially birthday cupcakes, would help not only the food allergic but their classmates as well. The State of Tennessee had an estimated shortage of almost 20,000 nurses in 2010, a figure that was projected to double by 2020. How many schools are doing without a nurse? While teachers are frequently trained to administer epinephrine, are we prepared to burden them with a wider set of responsibilities for student health? At a time when teachers are being held accountable for the performance of their students as never before, can we continue to saddle them with greater responsibility for their health as well? Another Tennessee legislator is proposing that parents of needy students whose children don’t meet performance standards have their family benefits cut by 30% from a maximum of $185 a month.
I don’t want parents of anaphylaxis-prone children to focus with less laser intensity on their own kids. First things first. But I worry that a single triumph in school health policy may detract from the larger picture. Will the epinephrine budget come at the expense of some other facet of student health? Will it be paid for with less art, music, or gym?
Three Tennessee cities made the top five for worst asthma cities in the 2012 Asthma and Allergy Foundation of America® (AAFA) rankings, with Memphis at number one, Knoxville number three, and Chattanooga number five. If the environmental and social factors that contribute to this dismal record could be alleviated, it might pay for a lot of preventive routine health care.
{Graphics: Geographic and Racial Variation in Premature Mortality in the US, by Cullen, Cummins, and Fuchs; Working paper 17901, National Bureau of Economic Research. Additional research by Henry Ehrlich.}