I’m thrilled to be contributing to Plunderbund in 2018. For my first post I would like to share a few thoughts about approaching the public health crises that face Ohio. My hope is that such thoughts might help sharpen our political strategizing just a bit. I hope that this perspective is not only helpful in this important mid-term and gubernatorial election year, but the beginning of an ongoing conversation among Ohio’s progressives interested in health care activism.

Bluntly put, progressives tend to reduce health care to a set of policy positions that, while important, do not get to the heart of the matter. Please don’t get me wrong: I have spent the better part of the last 8 years defending, advocating for, and teaching about the Affordable Care Act (ACA). I consider the bill to be a landmark achievement on par with the passage of Medicaid and Medicare in 1965. We have demonstrable, tangible evidence that the ACA has made a real difference in Ohioans’ lives. The ACA has undoubtedly saved lives.

2017 understandably put progressive Ohioans on their heels. We did a lot of organizing, built powerful organizations, and – I truly believe – played a formidable role in avoiding a full scale repeal of the ACA. While this fight continues, I believe that we now need a sharper lens to help us look past the daily defense of the ACA and the daily threat of repeal, even while we run interference in that arena.

The first order of business is becoming clear on what drives health.

To state the obvious, Ohio is home to some of the nation’s premier health care institutions. This is especially true in the area of children’s health, with Cincinnati Children’s hospital consistently ranking first among the nation’s children’s hospitals, and Nationwide Children’s in Columbus, Rainbow Babies in Cleveland, and Akron Children’s always appearing at the top of the list. Other great facilities are peppered throughout the state. These institutions are led by some of the state’s strongest advocates for public health and staffed by thousands of dedicated professionals. Many of these professionals have been vocal during the ACA repeal efforts. They fully understand the lifeline that Medicaid is for kids, their parents, the disabled, and many others in our state.

Infant mortality data from the Ohio Department of Health

Yet, despite this impressive showing, Ohio ranks in the bottom quartile in infant mortality, and – though it is coming down slowly – remains 24% worse than national averages. The state’s total infant mortality rate does not tell us the whole story, however. Shamefully, the infant mortality rate for black children far exceeds (15.2/1,000 live births) that of white children (5.8/1,000 live births). The Cuyahoga County infant mortality rate for black babies is double the national average and three times that of white babies in the same area.  Racial disparity explains the lion’s share of Ohio’s terrible overall ranking in these categories.

I’ll offer just one more example. How is it that Ohio could be home to one of the world’s premier institutions in the area of cardiology and cardiac surgery – the Cleveland Clinic – while heart disease continues to be the state’s number one killer? Also, in light of this health care expertise, how should we understand Ohio’s stubborn smoking rates – ranking 46/50 in the nation, with 25% of Ohioans self-declaring as smokers?

The answer is that what we often focus on in health are not the core drivers of better health outcomes.

Don’t get me wrong. We have lots of talented and dedicated professionals – including some state and federal politicians – working hard to turn around the state’s health profile. Maternal and child health and smoking are priorities of the Ohio Department of Health.

Of course, as well, especially as a medical educator, I do not assert that medical care, access to health care services, or expertise do not matter. They are critical pieces of the puzzle. But it is important to recognize that what we generally think of when we think of health care are largely secondary to the first-order causes of ill health.

My point is to make sure we keep focus on what really drives health and not get lost in the political ping-pong and posturing taking place in DC and Columbus. Amidst advocacy for saving the ACA and someday establishing a single payer, universal health care system in the state (as SPAN Ohio and others are doing, with some support from state representatives, we need to remember that core progressive values – equality and justice, above all – are our central concern. After all, while single-payer universal health care would be a great step for our state (and country), it will not be able to undo the systems of oppression and discrimination, in our cities as well as rural towns, that create durable conditions for poor health. We will not take on the opioid crisis until we establish better – and better and more reliably funded – supports for mental health and addiction prevention.

Public health scholars widely recognize that the “social determinants of health” are the major drivers of health outcomes. It is my hope that in 2018 progressives in Ohio can absorb just a bit more of this thinking to ensure that when we are engaging in advocacy and activism, we remember that homelessness, substandard and environmentally unsound housing, segregated schools and neighborhoods (with Ohio’s deep history of redlining and real estate discrimination), police brutality, access to foods, and transportation (to name just a few) are all drivers of health.

While we continue to fight the fight in 2018 of saving (and building on) the ACA, we should keep in mind that if we can move the needle on these determinants, the upstream effects will be dramatic. Only when we pull Ohio out of the national rankings gutter on key health indicators can we start to see what our health care systems can do. Progressives should focus on prevention, since it is there that social justice is most powerful.


Daniel Skinner, Ph.D., is Assistant Professor of Health Policy in the Department of Social Medicine at Ohio University’s Heritage College of Osteopathic Medicine, in Dublin, Ohio. Follow him on Twitter at @danielrskinner