San Diego is the 18th healthiest among California’s 58 counties according to the fifth County Health Rankings report, a collaboration between the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation.
Overall, San Diegans are in poorer health than their neighbors to the north in Orange County, which ranked sixth in the state. California’s largest county, Los Angeles, ranked 28th.
The counties with the highest and lowest rankings in the state are in Northern California. Marin County, just north of San Francisco, is the healthiest and Lake County is the least healthy.
Compared with San Diego, Marin has lower rates of adult obesity and smoking. More of its population is educated and affluent — two measures highly correlated with good health, according to Kate Konkle, associate researcher at the UW Population Health Institute.
“Education and income and employment in particular have the greatest impact on health outcomes,” Konkle said.
The difference in income levels between Marin and San Diego counties is significant. The median household income in Marin County is nearly $89,000, compared with roughly $60,000 in San Diego. The statewide median household income is $58,322.
In Lake County, the median household income is $35,437. The unemployment rate is 15%, compared with San Diego’s 8.9%, and 32% of children in Lake County live in poverty as compared with 20% in San Diego and 10% in Marin County. Lake County ranked 57th in the report. One California county, Alpine, was not included in the ranking.
Health Reform and Increased Access to Insurance
Despite San Diego’s relatively good showing in the UW rankings, some health officials are worried California’s southernmost county may experience problems with access to care.
Two of the components of a community’s health rankings are availability of health insurance and access to clinical care in physical and mental health.
The Affordable Care Act’s primary goal of expanding health insurance coverage through increased access to Medicaid and private health plans has resulted in 1.3 million Californians buying private insurance through the new state exchange and 1.5 million being added to Medi-Cal, California’s Medicaid program.
That’s a good thing, experts say, but access to insurance alone won’t address health concerns.
“Moving people from that uninsured category to insured is a really important first step,” Konkle said. Still, she said, “I always remind communities, when you’re talking about access to care, it goes far beyond insurance.”
Issues of access are of great concern to doctors practicing in San Diego.
Jim Schultz, chief medical officer of Neighborhood Healthcare, a federally qualified health center with 10 locations throughout San Diego, said he has not yet seen much change in patient volume as a result of expanded access to insurance under the law. His facilities, he said, already are operating at capacity.
“We have not seen an uptick in patients because we were already seeing the unfunded, but we have seen some of our unfunded patients receive Medi-Cal,” he said. “This is a good thing for the patients as they now have coverage for testing and specialty services, hospitalizations, imaging [and other services] that they previously could not afford.”
But the ability to pay for specialty care doesn’t equal access, said Theodore Mazer, a San Diego otolaryngologist and speaker of the California Medical Association’s House of Delegates.
“You haven’t fixed the system, you’ve just piled onto it,” he said.
A dearth of specialists in San Diego willing to see Medi-Cal beneficiaries is causing many patients to travel long distances to get the care they need, Mazer said.
“Why do I have to have a cancer patient in my office under a Medi-Cal managed care program go all the way to close to the Mexican border to get their oncology care, and go to UC-San Diego [Health System] or someplace else for their radiation therapy? Why can’t they do it within their own community?” he asked.
Increasing access to care and generally improving the health of San Diegans remains very much a work in progress, said Nicholas Yphantides, chief medical officer of San Diego County’s Health & Human Services Agency, but one the county is committed to.
“Increasing access to a sick care system is not going to be the long-term solution, and we are not satisfied with just expanded coverage,” he said.
How Counties Were Ranked
The county rankings compare counties on 29 factors that affect health. Each received two different primary rankings: health outcomes and health factors.
“Health outcomes we think about as a picture of today’s health. So, looking at length of life, and quality of life … how healthy are people living right now? How long are they living?” Konkle said.
Health outcomes provide measures of premature death, poor health days and premature births.
A county’s “health factors” rating results from performance in four categories related to health behaviors that strongly predict the state of a county’s health. They are:
1. Health behaviors: Health behaviors contribute to 30% of a county’s overall health ranking. This category includes the percentage of adults living in the county who smoke, are obese, physically inactive, drink alcohol excessively and other measures.
2. Social and economic factors: Measures that take stock of a population’s levels of education, income, childhood poverty, social support and the percentage of children living in single-parent homes contributes to 40% of the overall health factor ranking.
3. Clinical care: This section of the report measures a county’s rate of uninsured residents and overall access to primary care and preventive medicine. It accounts for 20% of the overall health ranking.
4. Physical environment: A county’s physical environment, which includes items such as air pollution, long commutes and housing problems, accounts for 10% of a county’s health ranking.
Konkle said it’s important to remember that no one measure can stand alone in health rankings.
“What we like to remind people is that while these are all separated out in a nice, linear model that there’s a lot of interaction between all of these areas.”
Overall, the report shows that nationwide, the rates of teen births, smoking and preventable hospital stays have decreased over the past number of years. However, Konkle points to a consistent rise in childhood poverty nationwide. In San Diego, 20% of children live in poverty, according to the report. That number has increased by 5% since 2010.
“Even for counties that have lower rates of children in poverty to begin with, most of them are seeing increases. That’s huge, especially when you’re thinking about the next generation. More and more [kids] are starting off at a deficit,” Konkle said.
San Diego’s Comprehensive Approach to Public Health
San Diego officials years ago recognized the interplay between economic opportunity, education and the health of its population.
Three years ago, the county embarked on a 10-year public health initiative called Live Well, San Diego! The program takes aim at the root causes of illness and rising health care costs, much of which involves addressing the measures identified in the County Health Rankings report.
According San Diego HHS official Yphantides, Live Well, San Diego! “is not just about health, but about safety and thriving. And when I see data like this, they completely validate the integrated perspective” that the county is taking, he said.
One of the program’s early success stories demonstrates the powerful effects of an integrated approach to improving a community’s health.
Several years ago, San Diego’s Chula Vista school district initiated a community-wide effort to reduce childhood obesity. One out of three children in the 6th grade was considered obese.
The district adopted a host of new policies around physical education and activity, and the food available on school campuses. They worked with the community to make more fresh fruits and vegetables available to families and to increase safety in public play spaces for children. In two years, more than 800 children lost enough weight to no longer be considered obese.
“There is a direct correlation that we are growing deeper in our appreciation of, between a child’s health status, and their educational performance. So, healthier kids are better students,” Yphantides said.
Increasing access to care and generally improving the health of San Diegans remains very much a work in progress, said Yphantides, but one the county is committed to.
The goal of Live Well, San Diego! Yphantides said, is to improve the health care delivery system so that is “more responsive, proactive, and considerate of what individual clients’ needs are.”
In recognition of the strong connection between economics and health, Yphantides said, the county is working closely with chambers of commerce and large local employers to expand opportunities for the community.
“This is all about not just physical health, but financial and educational health, as well,” he said.
The County Health Rankings report provides resources and tools for counties interested in undertaking similar community efforts.