(Note: Some of the examples in this tutorial are based in Georgia, where this site was created. That said, virtually all of the advice is based on county-level data that is applicable to and available in every U.S. state.)
Why should you cover poverty and health in your county:
- Low-income women are less likely to have adequate prenatal care and more likely to give birth to premature or low birth weight infants, who often require additional, costly medical care as they develop. In Georgia, African-American babies are twice as likely as white infants to die before they are old enough to talk.
- Children from low-income families often miss out on preventive immunizations and check-ups that detect developmental or sensory impairments. Treatable health problems ranging from head lice to advancing deafness undermine individual achievement and the school system as a whole. Unaddressed health problems can contribute to lower test scores, inflate demand for special education services, and boost drop-out and teen pregnancy rates.
- Low-income and minority teens have higher pregnancy rates than higher-income, white teens, and teen pregnancies are increasing among Georgia’s growing Hispanic population. Teen mothers are more likely to drop out of school, less likely to be employed, more likely to require public assistance, and at greater risk for persistent poverty.
- Poor neighborhoods have more fast-food outlets than supermarkets. Not surprisingly, people in these settings are more likely to consume calorie-rich, nutrient-poor foods than they are to follow dietary guidelines promoted by public health authorities. Easy access to a cheap, unhealthful diet sets the stage for obesity, hypertension, diabetes and other chronic problems that reduce productivity, increase dependence and shorten lifespan.
- The working poor are less likely to have employer-provided health insurance than higher-paid workers. Uninsured workers are less likely to undergo periodic physical exams, and as a result risk factors and early signs of cardiovascular disease, cancer, diabetes and other chronic conditions may be overlooked until disease worsens and treatment becomes costlier and cure less likely.
- Even minority patients who are fully insured and can pay for care are harmed by bias-driven disparities in medical care. In Unequal Treatment, the Institute of Medicine reported that insured black people who suffer a heart attack are less likely to receive many treatments that white people receive. This partly explains why, in all age groups, cardiovascular disease death rates for African Americans are nearly one-third higher than for any other group.
- Regular mammograms and Pap smears are standard procedures for insured women, and follow-up is routine when abnormal results are found. Poor women are less likely to be screened for breast or cervical cancer, and when a diagnosis is made they often lack access to tumor genotyping, costly new drugs and other interventions available to women with private health coverage.
- Mental health problems such as depression and substance abuse take an enormous toll on productivity, parenting, and other vital aspects of daily life – yet the availability of free or low-cost services is declining in many communities. Psychiatric units in many hospitals have been shut down, turning emergency rooms and jails into holding pens for people whose mental illnesses could be effectively treated in an appropriate setting.
- Dental benefits are rare for the working poor, even those with some form of employer-based health insurance. Nor is oral health care provided by Medicaid or Medicare. Preventive care, such as tooth cleaning and filling of dental caries, is rarely available to low-income children or adults. For many people in poverty, tooth extraction is the only dental service they have ever received. Being gap-toothed can significantly lower lifetime earnings, because free dentures are rarely available and job options are limited by appearance.
- When communities compete for a new manufacturing plant or government installation, local leaders know that the winner is often the one with the better- educated workforce. Because employers anticipate that they will shoulder many medical costs for a new workforce, having a healthier pool of potential hires can also be a competitive advantage.
- The number of Georgia residents over 65 is increasing at nearly twice the national rate, transforming us from a “younger than average” state to one with a disproportionate share of older folks. This will significantly impact family caregivers, demand for personal care services, need for assisted living and nursing home beds, physician and hospital services, ambulance services and even highway safety.
- Even though Medicare covers many medical and hospital services, being over 65 does not sever the lifelong tie between poverty and poor health. According to a report compiled by the University of Georgia’s Institute of Gerontology, older Georgians are at elevated risk for health problems because 38% of them live below or within 200% of the poverty level and 25% are minorities.
How to measure the opportunity to cover poverty and health in your county:
Answer these 46 questions:
- What percent of school-age children live in poverty?
- What percent of children in your county qualify for Medicaid (in Georgia, this is PeachCare)? Is your county serving all eligible children or is there a waiting list?
- What health problems do school nurses say cause the most absenteeism?
- What do school nurses see as the greatest unmet health needs for school-age children and adolescents?
- Are all Medicaid-eligible women in your county currently receiving care, or is there a waiting list for essential services such as contraception or prenatal care?
- What do public health nurses identify as the major health concerns for low-income women in your county? Could preventive care stave off some of these problems?
- Is your local WIC Program (which serves low-income pregnant women, infants and small children) fully enrolled? If there is a waiting list, how long is it?
- How do WIC nurses describe the health status of women, infants and children enrolled in this program? What preventive or treatment interventions are most needed?
- What percent of people over 65 live in poverty?
- Are there waiting lists for Medicare beneficiaries who need adult day health programs, home health aide services, transportation to medical appointments, or Meals on Wheels?
- What percent of Medicare beneficiaries have signed up for Part D (drug) benefits?
- What patterns do local pharmacists observe among older patients? Is there an increase in the number of people over 65 who cannot afford to fill their prescriptions? How common is this?
- What percent of primary care physicians (internists, family practitioners, pediatricians, D.O.s) in your community treat publicly insured patients, i.e. those covered by Medicare, Medicaid, TriCare or the Veterans Administration?
- How many of these physicians accept new patients with these forms of insurance?
- How many of these physicians will treat uninsured patients?
- What percent of specialists (orthopedists, endocrinologists, cardiologists, etc.) in your county accept Medicare, Medicaid, VA or Tricare patients?
- What percent of specialists care for uninsured patients?
- What percent of adults in your county are uninsured?
- How many jobs have been lost in your county over the past year? How many of these jobs provided health insurance?
- What is the dollar value of uncompensated care is provided each year by hospitals in your community? Is this loss rising or falling?
- How are local hospitals seeking to cover this revenue shortfall?
- How does the quality of care provided by your local hospitals compare with similar-sized institutions elsewhere? Is performance improving or declining?
- What medical problems account for the largest number of visits to hospital emergency departments?
- What are the demographic characteristics of uninsured emergency room patients?
- How have these demographics shifted over the past year, looking at factors such as age, race, employment status and having a fixed address?
- What percent of ED visits are for non-urgent health problems? What is the trend?
- What percent of ED visits are for mental health problems?
- How has demand for ambulance/EMT services changed over the past year?
- Are EMTs refusing to transport people more often? If so, what explains this trend?
- Does your county have privately-supported clinics providing free or low-cost health care to uninsured and medically indigent patients?
- What services do they provide? What services do they exclude?
- How long do patients wait for diagnosis and/or treatment at these private, charitable clinics?
- What clinical services are provided by your county health department? How has demand for services changed in the past year, and how long do patients wait for appointments?
- Is specialized medical care provided by the public health department, either by staff physicians or on site or by private specialists who accept referrals?
- Have individual, low-income patients been adversely affected by limited access to specialized care?
- Is there a federally qualified health clinic in your county? Have clinics sought this status and been turned down? Are any clinics applying now?
- Has the Health Resources and Services Administration designated your county as health professional shortage area (HPSA), a dental health professional shortage area (HPSA-Dental), or a mental health professional shortage area (HPSA-Mental Health)?
- What oral health services are available to children in poverty?
- Is any oral health care available to adults in your community via the health department, free or low-cost clinics, or dentists donating services?
- What are immunization rates for school-aged children?
- What is the influenza immunization rate for at-risk adults and children in your community? Are free flu shots available?
- Is free, confidential HIV screening available to any resident who wants to be tested?
- If a person tests positive for HIV, is free or low-cost HIV/AIDS care available in your community?
- Can an uninsured HIV/AIDS patient receive state-of-the-art antiretroviral therapy locally, or will travel to another city be required?
- What is the pattern of HIV transmission in your community? Are minorities and women over-represented among newly diagnosed patients?
- Although many Georgia communities have become more racially and ethnically diverse in recent years, hospital and clinic staffing rarely mirror these changes. Recent immigrants are often slow to seek medical care because they can’t talk to doctors or nurses and because they lack insurance or proper documentation. Can local providers communicate with patients who speak limited English?
A step-by-step approach to finding and reporting important and engaging stories.
Although American women are far more likely to die from cardiovascular disease than breast cancer, cancer is the more disturbing nightmare for most women. Women living in poverty are no exception.
But what happens when an uninsured, low-income woman is diagnosed with breast cancer today? Now that budgets are shrinking for public health and every other government service, will a low-income breast cancer patient have access to the same care as the fully insured, middle-class woman who lives across town?
Being a reporter, you hypothesize that being diagnosed with breast cancer during a recession is extremely bad timing. You figure that uninsured women have always had a harder time accessing care than wealthier women with health coverage – but now it’s even harder.
This is the hypothesis your reporting will test.
Do a local reality check.
- Find out what care is officially available to uninsured women with suspected or confirmed breast cancer. In Georgia, information about the Women’s Health Medicaid Program, designed to provide diagnosis and treatment for medically indigent women, is available at http://health.state.ga.us/programs/cancer/whmp.asp
- Interview the women’s health nurse(s) at your local public health clinic to find out what’s really going on. Is there a waiting list for newly diagnosed women or those with disease recurrence? Is the wait for an appointment longer than it was one year ago? Learn what you can about the characteristics of the women on this list: age, race, extent of disease, concurrent medical conditions that complicate care, whether they’ve recently lost private health insurance.
- Ask the nurses about their own working conditions: are they being asked to see more patients with fewer resources? Have nursing positions and/or clinic hours been cut? Have budget constraints prevented nurses from ordering additional mammography views, consults with specialists, or other services? Do nurses have more or less help with recordkeeping and case management than they used to?
- Put out feelers for patients who can be interviewed on the record.
Put what you’ve learned in a larger context.
Once you have some idea whether your hypothesis was correct, you can begin adding depth and context to your story.
Talk to the district health director and a representative from the Regional Cancer Coalition to find out whether increased waiting times or service cutbacks are typical of a larger area. Verify their assertions with data.
In Georgia, an overview of Georgia’s Comprehensive Cancer program is available – along with contact information – at http://www.georgiacancer.org/
Answer the “so what?” question.
Use a combination of human stories and statistics and to help your audience empathize with the breast cancer patients, their families and the professionals caring for them.
If your area has higher rates of breast cancer and worse outcomes, that’s a story; and if women in your town are doing better than average, that’s a story, too.
National, state and local breast cancer statistics – incidence, prevalence, outcomes and other measures – are available on numerous websites. These include the National Cancer Institute (www.cancer.gov) and the American Cancer Society (www.cancer.org)
Data for Georgia are available from http://oasis.state.ga.us/
Breast cancer kills women from many different communities, so make sure your story reflects that. For help addressing breast cancer issues in Spanish, check out the website for the National Latino Cancer Research Network, http://www.redesenaccion.org/ Information about peer-support tailored for black women is available at www.sistersnetworkinc.org
Overcoming adversity in hard times.
Who has stepped up to the plate to help low-income women with breast cancer? Look hard enough and you will find local heroes: the sparkplug of the peer support group, the volunteer doctor at the faith-based clinic who manages the respiratory infection not covered by Women’s Health Medicaid, the clinic staffer who delivers medicine to patients isolated on back roads, the shop owner who donates wigs or bra inserts.
Are there any legislative proposals that would expand breast cancer care for women in poverty? What should concerned citizens advocate? Major organizations and agencies, including the Susan G. Komen Breast Cancer Foundation (www.komen.org) and the American Cancer Society, will know what’s in the hopper.
Here are essential resources that should help you cover poverty and health in your county.
Online resources for covering poverty and health in Georgia:
Although the Georgia Health Equity Initiative Health Disparities Report 2008 is billed as “a county-level look at health outcomes for minorities in Georgia,” it includes data about poverty and health for people of all ages and races. The Georgia Department of Community Health team that compiled this report created a “health report card” for each county, with excellent sourcing and explanations for what health indicators mean and how they were calculated.
Public Health and Older Georgians: A road map for research, training, and outreach is a 2005 monograph that provides a county-by-county look at Georgians over age 65, making it a superb complement to the Georgia Health Equity Initiative report cited above. UGA Institute of Gerontology researchers detail the leading causes of disability and death and identify counties where factors such as poverty, rural isolation, race and health level portend greater problems for the future. Reporters who need experts to interview will find them here, as well as an excellent list of research and clinical services in Georgia.
The Online Analytical Statistical Information System (OASIS) is an interactive tool you can use to access and manipulate the Georgia Department of Human Resources’ enormous repository of data including vital statistics (births, deaths), patterns of disease, risky behavior, emergency room visits, hospital admissions, infectious outbreaks. You can obtain neighborhood-level information about the socio-economic status of communities you cover. OASIS enables you to create maps and tables that can be reproduced (with proper citation) for publication or broadcast.
Websites for covering poverty and health anywhere, or for adding context to Georgia-focused stories:
The federal Health Resource and Services Administration’s Geospacial Data Warehouse tool makes it easy to create maps showing hospitals, ambulatory surgery centers, nursing homes and other medical facilities. You can overlay data about shortages of dental, mental health or primary care providers, and can see what types of federal grants are in place.
The federal Centers for Medicare and Medicaid Services and the Hospital Quality Alliance maintain this database, which anyone can search to compare quality of care at various hospitals. One limitation is that meaningful data may not be available for very low volume hospitals, many of which are in rural areas.
The Kaiser Family Foundation maintains this essential database, which makes it easy to see how states differ in terms of health status, access, and workforce. From infant mortality to the number of minority medical school graduates, it’s all here.
The National Association of County and City Health Officials brings a state-level perspective to national developments, and “Notes from Washington” keeps tabs on what’s happening on the legislative front.
This interactive database provided by the Annie E. Casey Foundation, which generates high-profile annual reports on the wellbeing of America’s children, tallies health and poverty indicators at the state level and for metro-Atlanta. For example, 34% of Georgia children live in homes where no parent has a full-time, year-round job. You can use this database to discover what percent of mothers smoke while pregnant, where Georgia stands on the list of states where teens die violent deaths, and how fat our children are compared with those in other locales.
The National Association for Rural Mental Health is an education and advocacy group focused on mental health and substance abuse services and research in underserved areas. The web site aggregates news from various public and private sources.
The RUPRI Center for Rural Health Policy Analysis is based at the University of Iowa’s College of Public Health. Research reports on a range of clinical and financial issues are an excellent source for story ideas; experts are on staff. For example, one report documents closures of independent pharmacies in small communities.
The non-profit National Rural Health Association keeps a close watch on government policy and legislative action. Its website is a good source for story ideas and up-to-the-minute news about what’s happening in Washington – with an advocacy viewpoint that is more passionate and less measured than opinions expressed on NACCHO’s site.
The federal Office of Rural Health Policy maintains a site rich in links useful for reporters, and supports eight rural health policy research centers where experts can be found.
This non-profit, national news organization provides daily, in-depth coverage of health policy, finances and trends in health care delivery at the national and state levels. One emphasis of ongoing coverage is health disparities.
Adding new voices to your stories:
Reporters excel at interviewing all sorts of people, extracting the telling anecdote and the quote that sings. When it comes to a beat like health and medicine, good explainers aren’t easy to come by and once we find a hospital administrator or physician who gives good quote, we keep going back.
Using different sources, people who know a great deal but are often overlooked, can freshen stories that we’ve written again and again. Nurses, nurse practitioners, physician’s assistants, dentists, pharmacists, health department outreach workers, emergency medical technicians and other health professionals can enrich your copy and turn you on to new story ideas.
Police and fire officers are also see plenty of unhealthy or risky behaviors – such as dangerous home heating practices, substance abuse, or social isolation of seniors in dangerous neighborhoods.
People who run day programs for elderly folks or deliver Meals on Wheels see the harm that poverty inflicts on elders, and witness some remarkable coping strategies. School nurses are more likely to detect child abuse or neglect than a doctor who sees the child once or twice a year – and more likely to see remarkable examples of resilience.
In addition to tapping the expertise of service providers in the immediate community, you can find scientific and clinical experts and first-person stories by contacting disease-specific organizations and advocacy groups. Well-known national organizations such as the American Heart Association, American Cancer Society, and March of Dimes generally have local affiliates as well as state and national offices. There are thousands more advocacy groups out there, most with a web presence, some focused on common problems and others on rare disorders.
One caveat: When you deal with a support or advocacy group about a story involving new diagnostic tests, therapeutic drugs or medical devices, take a skeptical look at the organization’s funding. Major pharmaceutical companies and device makers sometimes create so-called “Astroturf” groups that masquerade as consumers advocating for their rights, but are actually corporate-financed campaigns to win regulatory approval or insurance coverage for specific products. Corporate “partnerships” can also co-opt the agendas of established grassroots organizations.