Massachusetts Health Council

Common Health
for the
Commonwealth

Massachusetts Trends in the

Preventable Determinants
of Health

2010
 Massachusetts Health Council

Common Health
for the
Commonwealth
Massachusetts Trends in the
Preventable Determinants of Health
2010
Supported by

Massachusetts Health Council

73 Oak Street - 1st floor Newton, MA 02464
617-965-3711
www.mahealthcouncil.org
 Table of Contents
President and Executive Director’s Message .......................1

Acknowledgements and Research Collaborators.......... 2-3

Executive Summary........................................................... 4-5

Access to Care ..................................................................... 6-9

Alcohol ............................................................................10-13

Asthma .............................................................................14-17

Blood-Borne Pathogens; HIV/AIDS, Hepatitis C ........18-21

Education..........................................................................22-25

Obesity and Overweightness ..........................................26-29

Oral Health.......................................................................30-33

Poverty ..............................................................................34-37

Tobacco .............................................................................38-41

Violence ............................................................................42-45

Notes ......................................................................................46
 Message from the Executive Director and President

"C ommon Health for the Commonwealth” is here for 2010. This report is the 6th edition of the
Massachusetts Health Council’s report on critical, costly, and preventable factors affecting the
health of the residents of Massachusetts. We are pleased to bring this important information to the forefront
of Massachusetts health policy and hope it stimulates not only debate but action on the items that negatively
affect health status. The Council is dedicated to promoting prevention as this is the best way to avoid health
care problems and their associated high costs. Since 1999, the Massachusetts Health Council has released this
biennial report tracking costly and preventable public health problems. These include societal issues, such
as poverty and lack of education, that have a real and profound impact on the health of our residents. The
Council reiterates its commitment to prevention and wellness as the way to improve the health status of the
residents of the Commonwealth.
This report again provides evidence based research as a means to measure and propel activities to address
health care trends both as individuals and as a state. The Massachusetts Health Council’s sixth edition
corroborates that our “common health” continues to be affected not only by access to health care, but also
by social, economic and environmental factors.
You will find information on health care trends, a compilation of the progress made in our public health
goals, and a series of focused perspectives provided by experts in each field highlighted in this report. These
determinants of health and their measures should continue to guide the dialogue with policymakers,
academicians, researchers, clinicians, providers and others in creating programs to support improving our
collective health.
One goal of the report is to support the enhancement of the public health infrastructure and to focus on the
disparities that exist between those who have access to care and prevention and those who do not. We must
change our priorities from a predominately “sickness response system” to one that supports an increasing
and effective investment in prevention and wellness that can reduce the utilization and costs of the health
care system, save lives and reduce suffering.
This report continues to measure rates of poverty, access to care, lack of education, air pollution/asthma,
tobacco use, obesity, violence, poor oral health, alcohol use, infectious blood-borne disease; all preventable
indicators that affect the health status of Massachusetts residents. Our report provides a context and series of
benchmarks for policymakers on Beacon Hill when they consider health care matters. Obviously, no single
issue can be considered in a vacuum and the fiscal challenges created by the country’s economic problems
make new state funding or programs extremely difficult in the near future. However, not all preventive
action requires new money as demonstrated in the recommended policy directions.
The Massachusetts Health Council encourages the use of this report and its expanded policy perspectives. It
can be a guide to concretely address those initiatives that reduce and eliminate poor health, especially among
our most disadvantaged communities. A common theme running through our policy recommendations
is prevention. We need to do a better job of getting the prevention message to the public — that lifestyle is
closely linked to health and that individuals can take steps to improve their health and the health of their
loved ones. We need to find creative ways to deliver that message in schools and workplaces — by providing
toolkits to teachers and employers for example. Every indicator we track is preventable; the solutions to
these problems are documented in the report. We just need to get the word out. Prevention today for a
lifetime of health!

Susan H. Servais David Matteodo

Executive Director President

Massachusetts Health Council 1

 Editor-In-Chief
Hollis Burkhart

Editors
Susan Servais
Nanette Vitali

Principal Investigator
David Allan Levine, Ph.D., has written widely on management, health care issues,
and history. We greatly appreciate the numerous hours he spent compiling and ana-
lyzing input from numerous data sources and contributors to produce a report that
is relevant and readable.

Research Advisor
Bruce Cohen, Ph.D., Director of Research and Epidemiology, Massachusetts
Department of Public Health, has given innumerable hours to ensure the accuracy
and timeliness of the data in this sixth edition. He provided invaluable support for
and was instrumental in the implementation of the first five editions as well.

Research Collaborators

Myron Allukian, Jr., DDS, MPH Russet Morrow Breslau

Oral Health Consultant Executive Director
Tobacco Free Mass
Caroline M. Apovian, MD, FACP, FACN
Associate Professor of Medicine Eric Brus
Boston University School of Medicine Director, HIV Health Promotion
Director, Center for Nutrition and Weight Management AIDS Action Committee
Boston Medical Center
Stacey Chacker
Noah Berger Director of Environmental Health and
Executive Director Asthma Regional Council
MA Budget and Policy Center Health Resources in Action

Michael Botticelli
Director, Bureau of Substance Abuse Services Jenny Caldwell Curtin, MPP
MA Department of Public Health Coordinator of Alternative Education and
Rachelle Engler Bennett Trauma Sensitive Schools
Director of Student Support MA Department of Elementary and Secondary Education
MA Department of Elementary and Secondary Education

2 Massachusetts Health Council

 Research Collaborators, continued
Daniel Church, MPH Michael Monopoli, DMD, MPH, MS
Epidemiologist, Viral Hepatitis Coordinator Director, Policy and Planning
MA Department of Public Health DentaQuest Foundation

Suzanne Condon, MS Carlene Pavlos

Associate Commissioner and Director Director, Violence and Injury Prevention
Bureau of Environmental Health MA Department of Public Health
MA Department of Public Health
Patricia Quinn
Kevin Cranston, MDiv Executive Director
Director, HIV/AIDS Bureau MA Alliance on Teen Pregnancy
MA Department of Public Health
Mary Tittmann
Alfred DeMaria, Jr., MD Policy Analyst
Director, Bureau of Communicable Disease Control MA Budget and Policy Center
State Epidemiologist
MA Department of Public Health Elizabeth Umbro, MPP
Public Policy Manager
Carol Goodenow, PhD MA Alliance on Teen Pregnancy
Director, Coordinated School Health
MA Department of Elementary and Secondary Education Kurt Wise
Policy Analyst
Holly Hackman MA Budget and Policy Center
Epidemiologist
MA Department of Public Health

Elaine Kirshenbaum
Vice President of Policy, Planning, and Member Services
Massachusetts Medical Society
Publisher of the New England Journal of Medicine

Special Thanks
The Massachusetts Medical Society deserves special Novartis generously funded the report’s research and
recognition for publishing the report. The Massachusetts compilation. The Massachusetts Health Council is grateful.
Health Council was founded through the efforts of the
Society in 1920 and continues to enjoy its significant
support.

Graphics and Layout

Robb Webb, Creative Manager

Massachusetts Health Council 3

 Executive
Social, Economic, Environmental
ACCESS TO BLOOD-BORNE PATHOGENS
RISK FACTOR ALCOHOL ASTHMA
CARE HIV/AIDS HEP C
Indicator:
������������������������������������������������������� ���� �� ����� ���������� ���������� ��� ��������� ����� �� ����
������������������������������������������������������������������� ������������������
������������ New HIV Cases, 2001—2009
Adult Binge Drinking in MA 2003-2009 18
1200
Orthopedic Surgery 20% ���
2007 16
2008 18% ���
18.3% 14 1000
2009 17.7% 17.5% 17.7% 17.5%

����������������������������
Cardiology 16% 17% ��
15.7% 12
14%
800 ��
Gastroenterology 12% 10
��
10% 8 600
��
Family Medicine/GP 8%
6
��
6% Mass. Overall U.S. Median 400
4 ��
Internal Medicine 4%
2 200 ��
2%
OB/GYN
���� ���� ���� ���� ���� ���� ���� ����
0% 0
0
����
2003 2004 2005 2006 2007 2008 2009 2001 2002 2003 2004 2005 2006 2007 2008 2009
0 10 20 30 40 50 60 2001 2002 2003 2004 2005 2006 2007 2008 2009

Average Wait for a Patient

Lifetime Asthma Rates for Rate of Newly Diagnosed
Appointment, by Medical Adult Binge Drinking New HIV/AIDS Cases
MA Adults Confirmed HCV cases
Specialty, 2007 - 2009

Period: 2007-2009 2003-2009 2001–2009 2001–2009 2002-2009

Trend: Rising Stable Rising Falling Stable

Most Recent Estimate: 17.5% 15.7% 481 4,171

High Risk Groups: Hispanics White teenagers School-age children Black and Hispanic males Adolescents and young
Hispanic children Young adults (ages 18-24) Adults ages 18-24 Gay, bisexual and other adults
Children with disabilities Adult males in higher Multi-racial & Black adults males having sex with male IV drug users
income brackets Adults with lower
Adults with less than a education, lower income population
college education level individuals IV drug users

Key Issues: • Although 97% of MA resi- • Binge drinking more prevalent in • Environmental irritants are • Disparities in mode of trans- • Growing proportion of new
dents have insurance, physician higher income & educational groups risk factors associated with mission: White males through cases are adolescents and
shortages negatively impact onset of asthma male-to-male sex, Black males young adults
• Binge drinking and heavy drinking
patient access to care through male-to-male sex and
above the national average • COPD, cardiovascular dis- injection drug use; Hispanic • Distribution shifted: two
• Only 44% of MA internists ease and depression often males through injection drug cohorts primarily infected: age
• Rates of unmet alcohol treatment
accepting new patients comorbid with asthma use 27 and age 51
need above national average for all
• Primary health services age groups • Current asthma prevalence • Younger, less educated people • Surveillance difficult because
increasingly being provided in rose 27% from 2000-2009 more apt to seek testing than most people with HepC are
• Alcohol abuse linked to cirrho-
emergency departments older age groups unaware they carry it
sis of liver, kidney failure, diabetes, • Multi-racial & black adults
• 23% of Hispanics had no high blood pressure, cardiovascular with highest rates of asthma • Estimated 8,000 MA residents
personal doctor disease
unaware they are infected
• Individuals with disabilities •Adolescents fail to understand the
more than twice as likely as link between alcohol and risks
those without to forego needed
health care
Policy Directions: •Health care stakeholders • Train vendors of alcoholic • Continue the Environmental • State & federal health care • Provide prevention services
must work collaboratively on products to eliminate sales to Public Health Tracking System to reform will increase access to younger injection drug users
key issues to secure a strong minors, rewarding salespeople monitor pediatric asthma to testing, care and treatment as they may be at highest risk of
physician workforce who identify fake IDs services seroconversion
• Reduce exposure to mold and
•Physician workforce policies • Work with law enforcement and other asthma triggers in schools • Increasing access to non- • Multi-component programs
must be fair with an equitable conduct compliance checks with and child care settings medical support services are (prevention, education, coun-
payment system alcohol retailers critical elements of an effec- seling, screening, access to
• Address asthma epidemic tive HIV care system (case drug treatment and methadone)
•Administrative simplifica- • Review policies on the adver- through collaboration between management, housing, peer may be required to control
tion through standardization is tising of alcoholic products and public health and environmental support, and mental health transmission of HCV
essential to ease the burden on limit alcohol advertising to youth regulatory agencies services)
physicians • Expansion of screening and
• Increase sales taxes on • Increase comprehensive asth- • Ensure access to treatment medical management programs
•Professional liability must be alcoholic beverages to support ma education for all HIV+ residents regard- needed
addressed, especially with pay- prevention programs, substance less of income, incarceration,
ment reform abuse treatment and education • Promote reimbursement for • Increase resources to
comprehensive asthma manage- or citizenship status
improve and enhance viral
•The payers and the state must • Create avoidance/prevention ment by health payers • Expand HIV testing, care hepatitis surveillance
work openly and collabora- programs that directly involve and support programs to bet-
tively with physicians to secure young people • Promote the use of Asthma • Develop and transmit infor-
Action Plans for children with ter serve the African-American
success in electronic health and Latino/a population mation to the public and pro-
records, registries, and access • Eliminate exemption on 6.25% asthma at school and childcare viders on HepC prevention and
to timely accurate data. sales tax for off-premise loca- centers • Continue to expand access screening
tions to routine HIV testing in medi-
•Medical student debt must • Increase capacity of statewide
cal settings while preserving
be addressed to encourage • Educate parents on the impact & local partnerships to provide essential civil liberties and
young physicians to remain in of alcohol on adolescent brain education and advocate for patient protections
Massachusetts and long-term negative conse- change
quences from early alcohol con-
sumption

4 Massachusetts Health Council

Summary
& Health Risk Behavior Indicators
EDUCATION OBESITY AND ORAL HEALTH POVERTY TOBACCO VIOLENCE
OVERWEIGHTNESS

Percentage of MA adults Who are Overweight or Obese, Current Adult Smokers in MA and US 2000-2009
2001-2009 ��������������������������������������������������������������������� Percentage of People in Poverty, MA & US 2005-2008
���������
25%
���
14%
24.5
��� 13.3% 13.3% 13.2%
24 12% 12.5% 20% Violent Crime Trends – Boston and Massachusetts – 2009* vs. 2008
���
23.5 All Violent Crime Murder Forceable Rape Robbery Aggravated
��� 10% 10.3% Assault
9.9% 9.9% 10.0%
23 Boston 2008 6,676 62 237 2,398 3,979
��� 15%
8% Boston 2009 6,192 50 269 2,227 3,596
22.5
���
% change (7.2%) (19.4%) +13.5% (7.1%) (9.6%)
(improvement)
22 6%
��� 10%
Mass. 2008 29,888 167 1,744 7,071 20,906
21.5
��� 4% Mass. 2009 30,136 172 1,701 7,427 20,836
MA US % change +0.8% +3.0% (2.5%) +5.0% (0.3%)
���
21 US MA (improvement)
5%
2% *All 2009 data are preliminary and may reflect somewhat different reporting standards among agencies.
��� 20.5
Source: FBI Uniform Crime Report

��� 20 0%
���� ���� ���� ���� ���� ���� ���� ���� ���� 2000 2001 2002 2004 2006 2008 2005 2006 2007 2008 0%
2000 2002 2004 2006 2007 2008 2009

Annual High School Dropout MA Adults Who Are MA Adults Who Did Not Visit
Rate, Massachusetts
Poverty Rate Current Adult Smokers Violent Crime in MA
Overweight or Obese The Dentist In The Past Year

2002–2009 2001-2009 2000–2008 2005–2008 2000–2009 2008–2009

Falling Stable Falling Rising Falling Rising

2.9% (8,585) 57.5% 22.2% 10% 15% 30,136

Hispanic and Black students
Low Income students
Special Education students
Blacks & Hispanics Children, Elderly Children under age 18 Youth 18-24 years old Black women
Lower income Low Income, Disabled Blacks Hispanic & Black youth Adolescents and young adults
Less educated Hispanics, Blacks Hispanics Less educated, lower Individuals with disabilities
income individuals
Persons with HIV

• Adults with least education are • Correlations exist between
apt to have the worst health
• Improved “health literacy” will stroke, osteoarthritis, respiratory
positively impact individuals problems, and certain cancers
health
• High churn rates appear to and racial/ethnic groups
be linked to underachieving aca-
demic performance
• Third grade reading proficiency were either overweight or obese
a key predictor of high school
dropout rates
• Disparities in on-time gradua-
tion rates among racial and ethnic
groups significant.
• Create a positive school
climate in which students can
succeed with positive relation-
ships with school staff and
peers
• Create smaller class sizes
with individual academic sup-
port
• Local, state, and regional
partnerships are needed to
stem dropout rates
• Use early warning dropout
indicators in school districts
including attendance rates,
mobility rates, and MCAS
middle school scores
• Use and promote the
Behavioral Health and Public
Schools Task Force online
assessment tool to provide
guidance and a structure for
improved practices in schools.
• Implement ESE and MA
Alliance on Teen Pregnancy
implemented pregnancy pre-
vention programs.
• 24% of MA residents do not • At the present time (2010) • Tobacco-related deaths • MA is statistically the most
overweight/obesity and hyper- have access to dental benefits there is only 1 job available include cancers of lung, larynx, violent state in the Northeast
tension, diabetes, heart disease, for every 5 people seeking throat, esophagus & mouth region.
• Disparities in rates among employment
racial and ethnic groups in dental • Nonsmokers exposed to sec- • Aggravated assault & forcible
disease • Educational level highly cor- ond hand smoke increase risk rape are the highest of any state
• Disparities present with gender related with poverty status of heart disease & lung cancer in the region
• 48% of surveyed 3rd graders
had dental disease • 50% of Hispanic children • Students who smoke more • Nearly 1 in 5 MA high school
• More than one-third of all chil- live in poor families likely to engage in other risky students reported being bullied
dren screened in public schools • MA ranks 36th in nation in behaviors (i.e., substance in past year.
% of residents with access to • Lower income individuals abuse)
fluoridated water are more likely to die prema- • 15% of MA youth said they
• MA School Nutrition Bill turely due to unhealthy eating • Steady increases in smoke- seriously considered attempting
passed in 2010 • Less than 50% of MA cities and environment less tobacco use and cigar suicide in past 12 months
and towns have a MassHealth smoking offset decrease in
dentist provider cigarette smoking statistics
• MA needs a statewide cam- • Increase public education • Continue to access ARRA • Continue to increase ciga- • Re-establish a coalition of
paign to prevent childhood about the importance of dental funding available for direct rette excise taxes. public and private agencies,
obesity hygiene and prevention pro- benefits to families and indi- community groups, human ser-
moting oral health as an essen- viduals (Making Work Pay • Continue the Massachusetts vices, police, health care, men-
• Improve availability of tial part of overall health credit, Economic Recovery Tobacco Cessation and tal health, schools, and clergy
medications and devices that Payments, extended and Prevention Program (MTCP) around violence prevention
help control obesity and over- • Increase number of commu- to reinstate programming to
expanded Unemployment
weightness nities with water fluoridation Insurance benefits and high risk populations • Improve lighting in commu-
nities with increased walking
• Provide access to fresh, • Increase number of school expanded Food Stamp pro- • Educate parents on latest patrols
healthy, nutritious foods and sealant programs in MA gram) trend of use of other nicotine
physical activity to promote containing products (gum, • Toughen the laws against
• Oral health needs to be an • Creation and preservation
healthy living in schools, of jobs through ARRA support candy) rapidly increasing people caught with an illegal
workplaces, and within the integral component of health among young people firearm
care reform and an essential and increase access to work-
community force training programs
component of any health pro- • Increase funding to the Dept • Increase mentoring programs
• Require safe walkways and gram of Public Health’s Tobacco so at-risk young people have a
• Increase access to adult
better lighting in community basic education and higher Control Program to educate strong relationship with a car-
development including bike • Maintain the adult Mass the public, especially youth, ing adult
Health Dental Program education
paths through a comprehensive anti-
• Advocate for access to smoking campaign • Reduce access to firearms
• Increase opportunities for • Expand community health
center dental programs affordable and quality early
physical activity in schools education and childcare • Better enforcement of laws • Change social norms that
and workplaces • Increase the number of prohibiting the sale of tobacco support violent attitudes and
• Maintain Social Security products to minors behavior
• Provide incentives to MassHealth dental providers
programs to prevent increased
employers for workplace well- • Create an Oral Health Plan senior poverty • Increase the availability of • Address sexism that under-
ness programs for MA, 2010-2015 which free or low cost smoking ces- lies gender-based violence,
should form the basis for oral • Maintain Unemployment sation services and medica- homophobia and hate crimes
• Ban use of trans fat in res- Insurance benefits tion against GLBT communities
taurants health promotion activities

Massachusetts Health Council 5

 Access to Care
T he ultimate goal of Massachusetts’ landmark health
care reform law of 2006—universal coverage—has
nearly been realized. In 2009, several state surveys separately
reported that 97% of Bay State residents had some form of
health insurance. For that reason, we are taking a different
look at this indicator and focusing on access to health care
instead of access to insurance. While having obtained health
insurance may make it more likely that Massachusetts
residents will enter the health care system for needed
services, being insured offers no guarantee of access to care.
A host of market factors, including physician availability
and geographic location and distribution of health care
facilities, impact the capacity of the system to service local
and regional populations. Health care as a community asset
is disproportionately distributed across Massachusetts.
While the Boston region has the highest number of acute
care hospitals, community health centers, and physicians
(including primary and specialty care) per capita, it has
the lowest number of nurses per capita (including RNs and
LPNs) compared to the state as a whole. The North and
South East regions have the lowest number of acute hospital
beds and physicians per capita. The South East region has no
trauma center, and ranks lower than the state average for
the number of community health centers per capita.
Trends
According to the Massachusetts Medical Society’s
Physician Workforce Study, in 2009 seven physician specialties
were operating in labor markets categorized as “critical” or
“severe”—dermatology, family medicine, internal medicine,
neurology, OB/GYN, urology, and vascular surgery.
Physician shortages in community hospitals were reportedly
most acute in three specialties: internal medicine, family
medicine, and general surgery.
The ability of a physician to refer his or her patients
to specialists, and their wait times for appointments, are a
continuing and growing problem, especially for internal
medicine and family practice specialties. Whereas 87% of
cardiologists and 95% of gastroenterologists were found to
be accepting new patients, only 44% of internal medicine
6 Massachusetts Health Council
physicians were accepting new patients, compared to 58% in
2008. Of internists accepting new patients, the average wait
time for an appointment in 2009 was 44 days, compared to
50 days in 2008. Among family practice/general practitioner
physicians, just 60% were accepting new patients, down
from 65% in 2008 and 70% in 2007. Of those accepting new
patients, the average wait time in 2009 also was 44 days, up
from 36 days in 2008 and 34 days in 2007.
The ability to recruit and retain physicians to work in
Massachusetts continues to be of great concern to the state’s
medical practitioners and, by extension, the public. In 2009,
three out of four practicing physicians (74%) believed that
the current pool of physician applicants was inadequate to
fill vacant positions, with two-thirds (68%) of practicing
physicians reporting they had difficulty filling vacancies.
An overwhelming majority (96%) of community hospital
medical staff presidents reported difficulty filling vacant
positions with qualified applicants. Recruitment times for
practicing physicians in thirteen specialties ranged from
a low of 12.5 months (vascular surgery) to 28.6 months
(dermatology).
Meanwhile, many primary health care services
continue to be delivered in hospital emergency departments
(EDs), this despite the intent of the 2006 health care reform
law to shift patient care away from emergency departments
to primary care physicians. ED patient utilization rates have
not only increased over time in Massachusetts relative to
the U.S. on a per-hospital basis, but Massachusetts patients
continue to rely more intensively on EDs for their medical
care on a per capita basis as well. In 2009, the average hospital
ED in Massachusetts reported 40% more patient visits than
the average U.S. ED. The American Hospital Association
found that the number of emergency outpatient visits per
1,000 population in 2008 was approximately 19% higher in
Massachusetts than the U.S., or 480.1 emergency outpatient
visits per 1,000 population in Massachusetts compared to
404.6 in the U.S.
Unsurprisingly given these stressors to the system,
various measures of career satisfaction reveal a continuing,
high level of discontent among practicing physicians in
Massachusetts. Forty-two percent said they were dissatisfied
or very dissatisfied with the current practice environment,
roughly the same percentage that has prevailed since 2002.
Overall, in 2009, 16% of medical practitioners said they
would not choose medicine as a profession again, including
one in four neurosurgeons (29%), orthopedic surgeons
(27%), and general surgeons (24%), and one in five family
medicine physicians (20%).
Groups at Risk
Respondents to the Department of Health’s 2009
BRFSS survey were asked whether they had a person they
thought of as their personal doctor or health care provider.
They were also asked if they were unable to see a doctor
in the past year due to cost, and whether they had visited
a medical provider for a checkup in the past year. Overall,
10% of respondents said they had no personal health care
provider, and 7% said they could not see a doctor due to
cost. Significant disparities were found in race-ethnicity
categories, with 8% of Whites, 17% of Blacks, 23% of Hispanics,
and 15% of Asians indicating they had no personal health
care provider, and 5% of Whites, 11% of Blacks, and 18% of
Hispanics indicating they could not afford to see a doctor.1
Level of education and household income were also strongly
predictive, with less well educated and poorer individuals
more likely to have no provider or be unable to afford a
doctor. However, 76% of all survey respondents said they
had had a checkup in the past year, as did 83% of persons
with self-reported disabilities.
Children (ages 0 to 18) fared as well or better than
adults in access to health care in 2009. According to a
Division of Health Care Finance and Policy survey, nearly
all children, regardless of race-ethnicity or family income
relative to the federal poverty level, had a usual source of
care, a doctor visit, and a preventive care visit in the past
12 months, though the share of Hispanic children with a
doctor visit dropped between 2008 (92%) and 2009 (83%).
Hospital emergency departments continued to be a locus of
care, especially for lower-income children, who were more
likely than those from higher income families to have had
1Insufficient data available for Asians.
Massachusetts Health Council
a non-emergency visit as their most recent ED visit in the
past 12 months. Children in fair or poor health or with a
disability were more likely to have had an ED visit in the
past 12 months than children in better health or without a
disability, and were twice as likely as healthier children to
live in families with difficulties paying medical bills in the
past 12 months.
Massachusetts continued to be a model for the nation
in preventive screenings. The Commonwealth reported one
of the best cancer screening rates in the U.S., with 85% of
women age 40 and older reporting they had a mammogram
in the past two years in 2008 (compared to 76% nationally),
and 64% of people age 50 and older reporting they had
a colonoscopy in the past five years (compared to 52%
nationally). Rates of prostate cancer screening and flu
vaccination were also high in Massachusetts compared to
national averages.
References
Estimates of Health Insurance Coverage in Massachusetts from the 2009
Massachusetts Health Insurance Survey (Executive Office of Health
and Human Services, Division of Health Care Finance and
Policy), October 2009.
Access to Health Care in Massachusetts: Results from the 2008 and 2009
Massachusetts Health Insurance Survey (Executive Office of Health
and Human Services, Division of Health Care Finance and
Policy), November 2009.
A Profile of Health Among Massachusetts Adults, 2009: Results from
the Behavioral Risk Factor Surveillance System (Massachusetts
Department of Public Health, Bureau of Health Information,
Statistics, Research, and Evaluation), June 2010.
Massachusetts Medical Society, Physician Workforce Study,
September 2009.
Massachusetts Medical Society, 2009 Physician Practice
Environment Report, 2010.
Massachusetts Department of Public Health, Health of
Massachusetts, April 2010.
7
 Access to Care continued
Policy Perspective
For the past nine years the Massachusetts Medical Society (MMS) has conducted an annual Physician Workforce Study
to evaluate labor market conditions and document physician supply trends across the Commonwealth. Results from the 2010
study confirms that there are still significant shortages across several specialties in Massachusetts, with a continued focus on
primary care.
Massachusetts is a model for health reform for the nation. While access to care has improved under Chapter 305, universal
health insurance coverage in Massachusetts can only be sustained if there is a strong physician workforce. To accomplish this,
a number of changes to the health environment must take place.
• Health care stakeholders must work collaboratively on key issues in order to secure a strong
physician workforce that will deliver top quality cost effective care.
• Health care stakeholders must advocate for physician workforce policies that secure a fair and
equitable payment system during payment reform. If physicians believe that practice viability is
unsustainable under a new payment system, Massachusetts may experience further recruitment
and retention problems.
• Administrative simplification through standardization is essential to ease the burden on physician
hours and bend the curve on the rising cost of overhead.
• Professional liability will remain a concern and barrier, especially with payment reform, unless it
is addressed before new payment models are introduced.
• Implementation of electronic health records (EHRs), registries and access to timely accurate data
will improve the quality of care physicians deliver and reduce the rise in cost when delivering care.
The payers and the state must work openly and collaboratively with physicians to secure success in
these areas.
• Medical student debt is a growing concern and must be addressed to encourage young physicians
to remain in Massachusetts, especially in primary care and those specialties with shortages,
through a combined state and private effort. This may include requiring physicians to deliver care
in a geographic area with a predominantly underserved population or practicing primary care for
a number of years.
Massachusetts has a history of providing some of the best care in the world. Among other reasons, this is a direct reflection
of its top quality physician community. Stakeholders must work together to ensure a practice environment for physicians that
will both encourage retention and recruitment, but will also enable better coordination of care and the ability to do what
physicians do best – care for their patients.

Elaine Kirshenbaum
Vice President of Policy, Planning, and Member Services
Massachusetts Medical Society
Publisher of the New England Journal of Medicine

8 Massachusetts Health Council

 �����������������������������������������������
Percentage of Adults Who Have a Personal Level of Education and Health Care Access, 2009
Health Care Provider, 2001-2009 ���

92
���
90 MA overall
US median
���
88

86 ���

84
��� ��������������������������������
����������������������������������
82 �����������������������������������
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80

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78

76 ���

74
��
2001 2002 2003 2004 2005 2006 2007 2008 2009
������������ ����������� ��������������� ��������������

Source: Massachusetts Department of Public Health, Behavioral Risk Source: Massachusetts Department of Public Health, Behavioral Risk
Factor Surveillance System Factor Surveillance System

Average Days Wait for a Patient Appointment, by Medical

�������������������������������������������������������������������
Specialty,������������
2007 to 2009

Orthopedic Surgery 2007

2008
2009
Cardiology

Gastroenterology

Family Medicine/GP

Internal Medicine

OB/GYN

0 10 20 30 40 50 60

Source: Massachusetts Medical Society, Physician Workforce Study

2009 Length of Time to Recruit Physicians in MA*
2009 Length of Time to Recruit Physicians in MA
35

30 ������

25

20

15

10

0
ne
gy

y
YN
gy
y

ne

ry
gy
ic

er
og

er

og

ge
i
lo

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lo

lo
ed
ic

rg
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rg

ic
ol

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ro

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ro

ur
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op

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su
at

nc

rd
eu

te
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M

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ro
m

rth

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en

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la
eu
er

ily

er
al
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rn

en
N

s
as

te

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Source: Massachusetts Medical Society, Physician Workforce Study

Massachusetts Health Council 9

 Alcohol
E xcessive alcohol consumption poses numerous adverse
consequences to health status. Cirrhosis of the liver,
kidney failure, and an increased susceptibility to various cancers
are only a few of the costly outcomes of alcohol abuse. Overuse
of alcohol is a complicating factor in diabetes, high blood
pressure, and cardiovascular disease. Children are known to be
at particular risk of alcohol’s deleterious effects. Its use during
pregnancy can severely damage a developing fetus, creating
numerous problems that can last a lifetime. The effects of even
a small amount of alcohol on children under age 18, when
their bodies and brains are still developing, can be profound.
Adolescents typically fail to appreciate the classic risks
associated with alcohol use and abuse, which include decreased
inhibition, poor decision-making, greater likelihood of injury
to self and others (e.g., automobile accidents), and violence
(including sexual violence) to others, as well as an increased
propensity for anxiety disorders, depression, and suicide
ideation.
Trends
The National Center for Chronic Disease Prevention and
Health Promotion’s yearly BRFSS survey of Massachusetts
adults (ages 18 and older) asks respondents about their
consumption of alcohol in the past month. “Binge” drinking
is defined as males having five or more drinks, and females
having four or more drinks, on one occasion. “Heavy”
drinking is defined as males having more than two drinks per
day and females having more than one drink per day.
In 2009, as in previous years, the survey found alcohol
abuse in the Commonwealth to be spread broadly across
gender, racial/ethnic, educational, and economic lines with
overall rates of binge drinking and heavy drinking consistently
above the national average. In 2009, 17.5% of Massachusetts’
adults reported binge drinking in the past month (virtually
unchanged from 17.7% in 2008 and 17.6% in 2007), and 6.2%
reported heavy drinking (compared to 6.7% in 2008 and 6.0%
in 2007). The U.S. median for adult binge drinking was 15.7%
in 2009, for heavy drinking 5.1%.
Among demographic subgroups, 22.6% of adult males
10
in Massachusetts and 13.0% of females in 2009 reported binge
drinking, though females (6.5%) outpaced males (5.7%) in
heavy drinking. White adults (18.9%) were more likely than
Hispanics (13.3%), Blacks (11.4%), Others (11.3%), and Multi-
racial persons (9.1%) to be binge drinkers. Adults living in
households earning less than $15,000 (9.0%) were the least
likely to report binge drinking, with the highest rate of binge
drinking (19.9%) reported among the $50,000+ income group.
However, the highest percentage of heavy drinkers (7.7%) was
found among the $35,000 to $49,999 income group, followed
by the $50,000+ group (6.9%). Adults with a high-school
education or G.E.D. (18.9%) were more likely than college
graduates (16.4%) to be binge drinkers, while those with some
post-high school education (7.1%) were most likely to be
heavy drinkers.
Adolescent surveys report that those who drink alcohol
started drinking before age 13, with some trying alcohol as
early as age 10. Half of MA 6th graders who drink reportedly
get their alcohol at home. Twenty-five percent of MA 8th
graders admit to being drunk at least once.
Among Massachusetts high school students, the number
who reported ever having at least one drink of alcohol in
their lifetime decreased again, from 81% (2001) to 71% (2009),
and current alcohol use also dropped, from 53% (2001) to
44% (2009). In 2009, 25% of high school students statewide
reported binge drinking in the past month (in Boston, 18%);
4% reported having had at least one drink of alcohol on
school property within the last 30 days; and among students
who were currently sexually active, 24% (females 20%, males
28%) said they drank alcohol or used drugs before their last
sexual intercourse.
Groups at Risk
In 2009 as in previous years, the most reliable predictor
of excessive drinking among Massachusetts adults was
younger age. Binge drinking was reported by 34.5% of
individuals in the 18-24 age group, and for each successive
older group the numbers declined in stepwise fashion
— ages 25-34 (26.4%), 35-44 (19.7%), 45-54 (16.1%), 55-64
Massachusetts Health Council
(9.5%), and 65+ (3.9%). For heavy drinking, however, the
reported rates were flatter across the age spectrum, perhaps References
indicating a truer level of alcohol abuse in Massachusetts. Massachusetts Department of Public Health, Health of
The 18-24 age group comprised the heaviest drinkers (7.6%), Massachusetts, April 2010.
with the remainder ranging from 7.0% (ages 45-54) to 5.1%
U.S. Department of Health and Human Services, Substance
(ages 65+).
Abuse and Mental Health Services Administration
Drivers and passengers of motor vehicles were again (SAMHSA), “Massachusetts: Adolescent Behavioral Health
found to be at high risk due to alcohol abuse. In 2008 in in Brief: A Short Report from the Office of Applied Studies,”
Massachusetts, 363 persons were killed in car crashes, 151 September 2009.
(42%) of these being alcohol-related and 124 (34%) involving
“Alcohol Prevalence and Trends Data — 2009,” U.S.
a .08+ blood alcohol concentration (BAC) driver. In 2009,
Department of Health and Human Services, National
27% of Massachusetts’ high school students reported riding
Center for Chronic Disease Prevention & Health Promotion,
with an intoxicated driver one or more times during the
Behavioral Risk Factor Surveillance System.
previous 30 days, and 9% (males 10%, females 8%) said they
U.S. Department of Health and Human Services, Centers
drove after drinking.
for Disease Control and Prevention, “Youth Risk Behavior
Last year, the MA Department of Public Health funded
Surveillance — United States, 2009,” Surveillance
106,000 treatment admissions for approximately 58,000
Summaries, MMWR, vol. 59, no. SS-5, June 4, 2010.
people. Yet according to interviews conducted as part of the
“Persons Killed, by State and Highest Blood Alcohol
National Survey on Drug Use and Health (NSDUH), as well
Concentration (BAC) in Crash,” National Highway Traffic
as in the opinion of many experts in this field, most people
Safety Administration (NHTSA), 2008.
in need of treatment do not seek it. In Massachusetts, the
rates of unmet alcohol and/or drug treatment need have
been above the national averages for all age groups across
all survey years, with the highest levels of those needing but
not receiving treatment occurring, predictably, among young
adults.

Massachusetts Health Council 11

 Alcohol continued
Policy Perspective
The United States Surgeon General indicated, in his 2007 Surgeon General’s Call to Action to Prevent and Reduce
Underage Drinking, that “Alcohol is the most widely used substance among America’s youth … a higher percentage of young
people between the ages of 12 and 20 use alcohol than use tobacco or illicit drugs.” The report goes on to discuss how adults
underestimate the number of adolescents who drink; how early they begin drinking; how new research describes the possible
impact that drinking has on the adolescent brain; and the long term negative consequences that can occur from early alcohol
consumption.

While the report clearly outlines the seriousness and enduring nature of the issue, it also makes a very clear and optimistic
statement: “Underage alcohol use is not inevitable, and schools, parents, and other adults are not powerless to stop it.” In
Massachusetts, we have made progress over the past several years by increasing the age of first use and reducing use at both the
middle and high school level.

We can continue to achieve success and prevent underage drinking only if all of the facets of our society; the federal
government, the state, cities and towns, local communities, schools, adults, parents, and youth work collaboratively,
consistently and relentlessly together to change attitudes and remove or limit access to alcohol. Multiple strategies that reduce
or eliminate access to alcohol and foster attitudes to prevent early use are necessary.

Prevention providers can train servers/vendors of alcoholic products to eliminate sales to minors, but, if we fail to look
at where many underage youth get their alcohol, from older siblings, friends, or from home, and we do not target strategies
that will address this access point, we limit our chances of success. If we work with law enforcement and conduct compliance
checks with alcohol retailers and implement appropriate sanctions against those unwilling to abide by the law, we can achieve
success. If we widely publicize, via the local and regional press, these compliance checks and outcomes, both negative and
positive, we can achieve greater and more far reaching success.

At the federal, state, and community levels, we need to take a look at our policies on the advertising and taxation of
alcoholic products. Research shows that even modest price increases on alcohol products decrease underage drinking. These
policy changes are the most powerful and effective tools we can use to combat alcohol access.

Continued success against underage drinking is not only possible but likely if we implement strategies that change the
environment and the norms regarding underage alcohol use. Policy changes limiting advertising, raising prices, requiring
server training and retailer compliance checks will mean that adolescents will have greater opportunities to reach higher
educational achievement, lower future rates of substance abuse problems, and attain healthier futures.

Michael Botticelli
Director, Bureau of Substance Abuse Services
Massachusetts Department of Public Health

12 Massachusetts Health Council

 AdultBinge
Adult Binge Drinking
Drinking in
in MA
MA2003-2009
2003–2009
20%

18%
18.3%
17.7% 17.5% 17.7% 17.5%
16% 17%
15.7%
14%

12%

10%

8%

6%

4%

2%

0%
2003 2004 2005 2006 2007 2008 2009

Source: Behavioral Risk Factor Surveillance System. Trends Data

Alcohol-Related Traffic Fatalities, Massachusetts and U.S., 2008

Alcohol-Related Traffic Fatalities, MA and US, 2008

45% 42%
40% 37% MA US

35% 34%
32%
30%

25%

20%

15%

10%

5%

0%
% Alcohol Related % .08+ BAC driver
Source:
Source: National National
Highway Highway
Traffic Traffic Safety Administration
Safety Administration

Alcohol
Alcohol UseUse
andand Abuse,
Abuse, 2009:
2009: MA MA andUS
and USAdults,
Adults,ages
ages 18-24
18-24

70%

60%

50%
MA
US median
40%

30%

20%

10%

0%
Alcohol Use* Binge Alcohol Use Heavy Drinking

Source: National Center for Chronic Disease Prevention & Health

Promotion, Behavioral Risk Factor Surveillance System
*At least one drink of alcohol within the past 30 days

Massachusetts Health Council 13

 Asthma
A sthma is a common and growing public health
problem in Massachusetts and the US that impacts
the lives of many individuals, children as well as adults.
Historically, the six-state New England region, comprising
the U.S. Department of Health and Human Services (DHHS)
Region I, has the highest current asthma rate of any of the
ten DHHS regions nationally. An estimated 1 million New
England adults are currently affected by asthma. In 2009,
Massachusetts ranked first (tied with Maine) in the New
England region for the highest rate of current asthma, at
10.8%.
According to the Massachusetts Department of Public
Health asthma attacks can be triggered by a variety of causes,
such as second-hand smoke, outdoor air pollution, allergens,
and respiratory viral infections, in addition to known factors
such as obesity and smoking. Environmental irritants — i.e.,
“something in the air” outdoors or inside a home, office, or
other building — are also potential risk factors. The dollar
costs to the health care system associated with asthma are
substantial, with total hospital charges in Massachusetts
exceeding $136 million in 2007, according to DPH estimates.
Co-morbidities are frequently encountered in
conjunction with a current asthma diagnosis. These may
include conditions such as Chronic Obstructive Pulmonary
Disease (COPD) (emphysema and bronchitis), cardiovascular
disease (heart disease and stroke) and depression. New England
adults with current asthma and co-morbid conditions
generally experience increased symptom severity. Co-morbid
conditions were more likely to be reported by adults ages
55+, those with incomes of less than $25,000, those with less
than a high school education, those who were overweight or
obese, and smokers. Depression (i.e., having been told by a
doctor they were depressed) was more likely to be reported
by women, the obese, and smokers, in addition to those with
incomes of less than $25,000 and with less than a high school
education.
Trends
When asthma is well controlled, people can sleep
through the night, go to work and school, and live normal
active lives. However, in Massachusetts a startlingly small
portion of people with asthma report having good control
14
of their condition — approximately one in four adults and
one in three children. Prevalence of asthma is reported in
two ways. “Lifetime” prevalence is the proportion of survey
respondents that answered “yes” to the question: Have you
ever been told by a doctor, nurse, or health professional that
you had asthma? “Current” prevalence is the proportion of
survey respondents that answered “yes” to the question: Do
you still have asthma?
In 2009, according to data from the National Center
for Chronic Disease Prevention and Health Promotion,
15.7% of all Massachusetts adults had been told in their
lifetime that they had a diagnosis of asthma, up from
15.4% in 2007. In 2009, lifetime asthma prevalence among
Massachusetts adults ranked third highest among the New
England states (New Hampshire, 16.4%; Rhode Island, 15.8%;
Connecticut, 15.3%; Maine, 15.2%; Vermont, 14.7%), and was
17% higher than the US median (13.4%). In 2009, more than
1 in 10 Massachusetts adults (10.8%) said they currently had
asthma, compared to 8.8% of all US adults for the same year.
From 2000 through 2009, current asthma prevalence in the
Bay State increased 27% (statistically significant), from 8.5%
to 10.8%.
National survey data distilled and analyzed by
the Asthma Regional Council (ARC) of New England
provide additional details. According to these data, 3.9% of
Massachusetts adults with current asthma reported having
been hospitalized for asthma in the past year; 11.9% reported
a cost barrier to seeing a doctor; and 17.1% reported a
cost barrier to purchasing medications. Other findings
from the ARC analysis: 21.7% of Massachusetts adults with
current asthma reported their activities were limited to a
moderate degree or more due to asthma; 38.2% reported co-
morbidities such as bronchitis, emphysema, COPD, diabetes,
heartdisease, or stroke; and 27.6% reported a diagnosis of
depression.
Groups at Risk
Lifetime and current asthma affects all demographic
segments of the Massachusetts adult population, though
disparities exist between sexes, age groups, race/ethnicities,
educational attainment, and household income. In 2009, Bay
State women (18.0%) were more likely than men (13.3%) to
Massachusetts Health Council
have been told in their lifetime that they had asthma. Adults
in the 18-24 age group (23.1%) were most likely to have ever
been told they had asthma, while those in the 65+ age group
(12.0%) were least likely. Multi-racial adults (22.4%), Blacks
(18.5%), and Hispanics (16.0%) were more likely than Whites
(15.7%) to have been told in their lifetime they had asthma.
The prevalence of lifetime asthma among Massachusetts
adults was significantly higher for those with less than a
high school education (20.4%) than for college graduates
(14.5%). Also, the prevalence of lifetime asthma decreased
step-wise with increasing household income: Adults living
in households with an income of less than $15,000 (22.2%)
were more likely than adults living in households with an
income of $50,000 or higher (13.9%) to report ever having
received an asthma diagnosis.
Similar socio-demographic disparities were found to
exist among Massachusetts adults who currently have
asthma. In 2009, women (13.0%) were more likely than men
(8.3%) to report current asthma. Multi-racial adults (16.1%)
and Blacks (14.4%) were more likely than Whites (10.9%) and
Hispanics (8.5%) to report current asthma. Adults with less
than a high school education (14.4%) were more likely than
college graduates (9.6%) to report current asthma. Adults
living in households with an income of less than $15,000
(18.4%) were more than twice as likely as those living in
households with incomes of $50,000 or more (8.6%) to report
current asthma.
Asthma is a common chronic condition reported among
school-aged children in Massachusetts. According to the
Department of Public Health, during the 2007-2008 school
year the reported prevalence of asthma among 709,479
students enrolled in 2,085 Massachusetts schools (grades
K through 8th) was 10.85%, unchanged from 2006-2007
(10.8%). Reported asthma prevalence for all children by
grade level showed that prevalence generally increased by
grade through grade 5 (Kindergarten, 9.3%; grade 5, 11.6%).
After grade 5, prevalence leveled off at approximately 11%.
Asthma prevalence for males was 12.5% (up from 10.9%
in 2003-2004), and for females 9.1% (up from 8.0% in 2003-
2004). In 1,577 schools reporting, statewide pediatric asthma
prevalence was highest for Black and Hispanic students
at 13.9% for both racial classes. Prevalence among White
students was 9.5%, with the lowest rate reported among
Asian students at 7.9%.
One potential environmental factor associated with
Massachusetts Health Council
the development and exacerbation of asthma is persistently
high ozone levels in the air we breathe. In 2008, the U.S.
Environmental Protection Agency (EPA) revised its 8-hour
ozone exceedance standard from 0.084 parts per million
(ppm) to a more stringent 0.075 ppm. In 2008, Massachusetts
exceeded EPA’s new 8-hour average ground-level ozone
standard with 18 ozone exceedance days, which under the
old standard would have been only 8 days.
References
Asthma Regional Council of New England, Living with Asthma
in New England, February 2010.
“Scourge of asthma is acute in N.E.,” Boston Globe, April 26,
2010.
Massachusetts Department of Public Health, Health of
Massachusetts, April 2010.
“Asthma Prevalence and Trends Data — 2009,” U.S.
Department of Health and Human Services, National
Center for Chronic Disease Prevention & Health Promotion,
Behavioral Risk Factor Surveillance System.
Massachusetts Department of Public Health, Bureau of
Environmental Health, Pediatric Asthma in Massachusetts, 2006-
2007, April 2009.
“Historical Exceedance Days in New England of EPA’s 8-
hour Average Ground-Level Ozone Standard,” United States
Environmental Protection Agency, Region 1.
Gilliland FD. 2009. Outdoor air pollution, genetic
susceptibility, and asthma management: opportunities
for intervention to reduce the burden of asthma. Pediatrics.
Mar;123 Suppl 3:S168-73.
Patel MM, Miller RL. 2009. Air pollution and childhood
asthma: recent advances and future directions. Curr Opin
Pediatr. Apr;21(2):235-42.
Cetta F, Sala M, Camatine, M, Bolzacchini, E. 2010. Traffic-
Related Air Pollution and Childhood AsthmaEnviron Health
Perspect. 2010 July; 118(7): A283–A284.
Pediatric Asthma Surveillance in Massachusetts 2007-2008.
(Massachusetts Department of Public Health, Bureau of
Environmental Health). July 2010.
15
 Asthma
Policy Perspectives
Evidence linking ambient and indoor air pollution
to adverse health effects — particularly acute respiratory
and cardiovascular mortality and morbidity — continues
to be strengthened by a growing body of literature that
demonstrates health impacts at current ambient air
pollutant concentrations. A recent report (Damp Indoor Spaces
and Health) on mold and moisture in indoor environments
highlights the likelihood that exacerbations of asthma
and allergic response are associated with such indoor air
pollution exposures.
As part of the Massachusetts Department of Public
Health’s (MDPH) Environmental Public Health Tracking
Program (EPHT) — a new health and environmental
surveillance system described in the 2008 issue of “Common
Health for the Commonwealth” — MDPH has conducted
systematic indoor air quality testing and pediatric asthma
surveillance in a statistically representative sample of schools
across Massachusetts. To access the EPHT portal, log onto
<www.matracking.ehs.state.ma.us/>. The most current
(2007/2008) statewide surveillance data demonstrates
a prevalence of pediatric asthma in Massachusetts of
approximately 10.85%, with 99.3% of public and private
schools reporting.
In 2006, MDPH tested 106 Massachusetts schools for
environmental health exposures such as carbon dioxide
and mold. Seventy-one schools had visible mold or moisture
problems in at least one classroom or library. MDPH
analysis found a statistically significant association between
the presence of mold or moisture and the prevalence of
childhood asthma in the schools tested. These findings
underscore the need for policy changes that reduce exposure
to mold and other asthma triggers in schools and child care
settings.
Outdoor air pollution in general is recognized as a factor
in both the development of childhood asthma1, asthma
attacks, and other respiratory and cardiovascular conditions.
The US Environmental Protection Agency’s proposal to
strengthen the national ambient air quality standards for
fine particles, ozone, nitrogen oxides and sulfur dioxide is
intended to enhance public health protection, including
the health of sensitive populations — people with asthma,
children and the elderly.
Studies continue to emerge evaluating the role of traffic-
related sources of air pollution and individual susceptibility
in air pollution–mediated asthma.2 These studies support
DPH’s Merrimack Valley study, which links the prevalence
of pediatric asthma among children with residential
proximity to high-traffic roadways, as described in the 2008
issue of “Common Health for the Commonwealth.”
These study results continue to demonstrate the
1Clark et al. 2010
2Patel et al 2009; Cetta et al, 2010
16
continued
importance of collaboration between public health
and environmental regulatory agencies at all levels of
government to address the asthma epidemic, particularly
among children.
Suzanne Condon, MS
Associate Commissioner and Director
Bureau of Environmental Health
Massachusetts Department of Public Health
Asthma is a complicated disease that compromises
health and quality of life, and places a heavy financial weight
on those with the disease, as well as our health care system.
Currently, there is no known cure for asthma. However,
with comprehensive asthma management, a person with
asthma can lead a full and healthy life.
The Strategic Plan for Asthma in Massachusetts: 2009
– 2014 (developed by MA Department of Public Health,
Massachusetts Asthma Action Plan and 60 lead partners)
calls for a coordinated approach to address asthma, targeting
both clinical and environmental aspects of the disease. It
recognizes that many factors affect a person’s asthma: the
quality of healthcare they receive, environmental exposures,
and their own individual behaviors. In order to reduce
disparities in asthma outcomes and improve the quality
of life, there is a need to take collective action on multiple
levels (individual, family, government, healthcare payers and
providers, employers, etc) and in multiple settings (health
care clinics, homes, schools, child care settings, work, and
outdoors). Below are examples from the plan that provide
opportunities for effective prevention:
• Improve asthma management — improve standards of
asthma care; increase the number of healthcare providers
that address environmental factors related to asthma;
increase comprehensive asthma education; promote
reimbursement for comprehensive asthma management by
health payers; and promote the use of Asthma Action Plans
for children with asthma at school and childcare centers.
• Reduce exposure to environmental factors that cause and/
or exacerbate asthma.
• Better understand the causes of asthma and the role of
primary prevention; and
• Increase capacity of the statewide and local partnerships to
provide education, and advocate for change.
Stacey Chacker
Director of Environmental Health
Health Resources in Action
Asthma Regional Council of New England (Director)
Massachusetts Health Council
 �������������������������������������������������������
������������������

18

16

14

12

Percentage of Adults Who Have 10

Ever Had Asthma in Their 8
Lifetime, MA and US 2001–2009
6
Mass. Overall U.S. Median
4

0
2001 2002 2003 2004 2005 2006 2007 2008 2009

Source: Massachusetts Department of Public Health; U.S. Centers for Disease Control
and Prevention

14%

12%
11.4% 11.7%
11.0% 11.3% 11.1% 11.1%
10% 10.8%
10.2%
9.3%
8%

Reported Asthma Prevalence 6%

by Grade in School (K–8) 4%

2007-2008 School Year
2%

0%
n:

1:

2:

3:

4:

5:

6:

7:

8:
rte

de

de

de

de

de

de

de

de
ga

ra

ra

ra

ra

ra

ra

ra

ra
G

G
er
nd
Ki

Source: Massachusetts Department of Public Health, Pediatric Asthma Surveillance

Ozone Levels: EPA Exceedance Days:

Massachusetts, 2001-2008 (recalculated per 2008
standard, 0.075 ppm)
50

45

40

Ozone Levels: EPA Exceedance Days 35

Massachusetts, 2001–2008
�������������

30

(recalculated per 2008 25

standard, 0.075 ppm) 20

15

10

0
2001 2002 2003 2004 2005 2006 2007 2008

Source: U.S. Environmental Protection Agency, Region 1

Massachusetts Health Council 17

 Blood-Borne Pathogens — HIV/AIDS, Hepatitis C
A cquired Immunodeficiency Syndrome (AIDS) results
from infection by the human immunodeficiency
virus (HIV). The virus damages the immune system, leaving
the infected person susceptible to a host of opportunistic
infections and associated malignancies such as Kaposi’s
sarcoma, invasive cervical cancer, and certain lymphomas.
HIV is transmitted through unprotected sex and the type
of blood contact that comes from sharing contaminated
injection equipment.
Hepatitis C, the most common chronic blood-borne
infection in the U.S., is caused by the hepatitis C virus
(HCV). Similar to HIV infection, it is spread by direct contact
with the blood or bodily fluids containing the blood of an
infected person. Blood transfusions were a major source
of hepatitis C infection until July 1992, when widespread
screening of the blood supply was instituted. Today, the
dominant mode of HCV transmission is injection drug
use. Sharing drug injection equipment (including needles,
syringes, cookers, cottons, and rinse water) with an infected
person can spread the virus. Infected mothers can pass it to
their newborns, although this is uncommon. Unprotected
sex with an infected person is a relatively inefficient mode of
transmission, although it may occur. In health care settings,
injuries due to handling of needles or other sharp objects
contaminated with blood may also pose a risk.
Trends
In 2009, 8,130 confirmed and probable cases of hepatitis
C infections were reported to the MA Department of Public
Health. Most of these are likely to be chronic infections.
From 2002 to 2008, there was an upswing in cases from
7,200 to 9,700 but then a slight drop in 2009 to 8,130. More
than 100,000 persons in Massachusetts are estimated to have
chronic hepatitis C, some of whom are at risk of cirrhosis
(fibrotic scarring), liver failure, and liver cancer.
A significant demographic shift among newly diagnosed
HCV cases between 2002 to 2009 has been noted. In 2002
there were relatively few cases of HCV infection reported
in younger people. Most cases were among older adults,
the majority of whom were infected many years ago. This
was consistent with national data that suggested that acute
HCV infection was decreasing. Since 2007, however, there
has been a growing number of new cases in Massachusetts
among adolescents and young adults who were almost
18
certainly infected recently. In 2002 the age distribution of
HCV cases reported to MDPH was in the shape of a classic
bell curve, with a single peak between the ages of 44 and
50 years, with the predominant age of infected individuals
at around 47 years old. By 2009, the distribution of cases
changed to a bi-modal (two peak) curve, with one peak
rising at 27 years old and a second at 51 years. While older
individuals continue to be the largest group among reported
cases, since 2007 there have been over one thousand cases
of confirmed and probable infection reported annually
among people between the ages of 15 and 25 years. Available
evidence suggests that trend is largely due to sharing
injection equipment for heroin use among people in this
age group.
Each year, a greater number of Massachusetts residents
are living with HIV/AIDS than in the year before. In 2006,
there were 737 new cases and now, in 2009, there were
481 newly confirmed HIV/AIDS cases reported to the MA
Department of Public Health. People known to be living
with HIV/AIDS in 2009 included 4,884 Black, non-Hispanics,
4,016 Hispanics, 7,182 White non-Hispanics, 331 Other/
Unknowns for a total of 16,413 people known to be living
with HIV/AIDS in Massachusetts. As of December 31, 2009,
non-U.S.-born individuals accounted for about 20% (3,567)
of all people living with HIV/AIDS, and their proportional
representation has been increasing over time. Non-U.S.-
born individuals comprised 19% of HIV infection diagnoses
in 1999, but 30% in 2007. People born outside the U.S. and its
territories are estimated to comprise 12% of the population
of Massachusetts.
Since January 1, 1999, 30,537 persons have been
reported to have HIV/AIDS in Massachusetts. Of these,
16,413 (59%) were alive as of December 31, 2009. In addition,
the Department of Public Health estimates that as many as
8,000 others may be infected and not know they are infected,
bringing the number of persons living with HIV/AIDS in the
Commonwealth to between 25,000 and 27,000.
Groups at Risk
In 2009, more confirmed cases of chronic HCV infection
were identified in men than in women in almost all age
groups. However, the male to female ratio was closer to one
in the 15 to 25 year age group than in older cohorts, as they
have been for the last several years. Cases were distributed
Massachusetts Health Council
widely across Massachusetts, though with larger numbers
in urban Boston, Worcester and Springfield. MDPH HCV
surveillance data are limited in regards to race/ethnicity and
risk history due to the high volume of reported cases and
limited resources to support investigations of viral hepatitis
cases.
Of the 16,413 individuals (71% male, 29% female) known
to be living with HIV/AIDS in Massachusetts at the end of
2009, 79% were age 40 or older. Forty-four percent were
White, 29% were Black, and 25% were Hispanic. Black and
Hispanic people each comprise 6% of the total Massachusetts
population.
Male-to-male sex (35%) and injection drug use (24%)
were the leading reported exposure risks for HIV infection
in Massachusetts in 2009. Among males, male-to-male sex
was the predominant exposure mode (49%), followed by
injection drug use (23%). Among females, heterosexual sex
with partners of known risk and/or HIV status (34%) and
presumed heterosexual sex with partners of unknown risk
and HIV status (29%) were the most frequently reported
exposure modes.
The 2009 data also reveal significant racial/ethnic
disparities in reported mode of HIV transmission. White
males were most apt to contract HIV infection through
male-to-male sex (69%). Among Black males, however, the
exposure mode was more evenly distributed between male-
to-male sex (26%), injection drug use (24%), and presumed
heterosexual sex with partners of unknown risk and HIV
status (23%). Among Hispanic males, injection drug use
(42%) was the leading reported risk for HIV infection. While
the predominant exposure mode among White females
living with HIV/AIDS was injection drug use (46%), the
predominant exposure mode among Black females was
presumed heterosexual sex with partners of unknown risk
and HIV status (44%), and among Hispanic females it was
heterosexual sex with partners of known risk and HIV status
(43%).
In 2009, 11% of Massachusetts adults said they had been
tested for HIV in the past year. Among racial-ethnic groups,
8% of Whites, 21% of Hispanics, and 28% of Blacks reported
past-year testing. Younger people (20% in the 18-24 age group,
18% in the 25-34 group) were more apt to seek testing in the
past year than older age groups (11% and 5% in the 35-44 and
45-54 age groups, respectively). Those with less than a high
school education (23%) were much more likely than high
school graduates (10%), college 1-3 years (13%), and college
4-plus years (9%) to be tested within the past year.
Massachusetts Health Council
References
Massachusetts Department of Public Health, Health of
Massachusetts, April 2010.
Massachusetts Department of Public Health, “Public Health
Fact Sheet — Hepatitis C,” October 2006.
U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, “Surveillance for Acute Viral
Hepatitis — United States, 2007,” Surveillance Summaries,
MMWR, vol. 58, no. SS-3, May 22, 2009.
“Jury awards $500m in hepatitis C case,” Boston Globe, May 8,
2010.
Massachusetts Department of Public Health, Bureau of
Infectious Disease Prevention, Response and Services,
Massachusetts STD, HIV/AIDS and Viral Hepatitis Surveillance Report:
2008 (2010).
Massachusetts Department of Public Health, Bureau of
Infectious Disease Prevention, Response and Services, “Viral
Hepatitis Slides: STD 2008 Annual Report,” 2010. Also: MDPH,
“Viral Hepatitis Slides,” data current as of July 27, 2010.
“The Massachusetts HIV/AIDS Epidemic at a Glance,”
Massachusetts HIV/AIDS Data Fact Sheet, Massachusetts
Department of Public Health, January 2010.
Massachusetts Department of Public Health, “The
Massachusetts HIV/AIDS Epidemic at a Glance — Detailed
Data Tables and Technical Notes,” HIV/AIDS Surveillance
Program, January 2010.
“Who is experiencing differential impact from HIV/AIDS?”
Massachusetts HIV/AIDS Data Fact Sheet, Massachusetts
Department of Public Health, January 2009.
“People Born Outside the U.S.,” Massachusetts HIV/AIDS
Data Fact Sheet, Massachusetts Department of Public Health,
January 2009.
“Who is currently living with HIV/AIDS?” Massachusetts HIV/
AIDS Data Fact Sheet, Massachusetts Department of Public
Health, January 2010.
A Profile of Health Among Massachusetts Adults, 2009: Results from
the Behavioral Risk Factor Surveillance System (Massachusetts
Department of Public Health, Bureau of Health Information,
Statistics, Research, and Evaluation), June 2010.
U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, “Youth Risk Behavior
Surveillance — United States, 2009,” Surveillance Summaries,
MMWR, vol. 59, no. SS-5, June 4, 2010.
IOM (Institute of Medicine). 2010. Hepatitis and Liver Cancer:
A National Strategy for Prevention and Control of Hepatitis B and C.
Washington, DC: The National Academies Press.
19
 Blood-Borne Pathogens — HIV/AIDS, Hepatitis C
continued
Policy Perspectives
HIV/AIDS remains a significant public health
challenge, both in terms of sustaining effective prevention
interventions and providing care services for state residents
who are HIV+. Due to HIV treatment advances over the last
decade, many people living with HIV can expect to achieve
a normal life expectancy. The long-standing commitment
in the Commonwealth to ensure access to treatment for all
HIV+ state residents irrespective of income, incarceration, or
citizenship status is core to this successful outcome.
The recent accomplishment of state health care reform
and pending implementation of federal health care reform
will further enhance access to testing, care, and treatment
services. However, there is a belief that health care reform
will make dedicated state and federal funding for HIV/AIDS
redundant and unnecessary. This is a dangerous hypothesis.
The success we have accomplished in reducing new infections
and improving health outcomes for persons living with HIV/
AIDS is explicitly rooted in the network of prevention and
care services that has been built and sustained over the past
twenty years with dedicated funding.
People living with HIV/AIDS are disproportionately
impacted by poverty, homelessness, substance use, and
1As of September, 2010
2The National HIV/AIDS Strategy: Federal Implementation Plan, July 2010, pg.21
The IOM report on viral hepatitis and liver cancer that
was published in January, 2010 makes clear that despite the
extremely high morbidity and mortality related to viral
hepatitis infections, federal and state funding for viral hepatitis
services is extremely limited and there is no coherent federal
strategy. As a result, all states, including Massachusetts,
struggle to address the range of service needs of affected
populations.
Given the recent trend of increasing HCV infections
among adolescents and young adults in Massachusetts and
the long-term consequences of undiagnosed and untreated
illness, prioritization to identify the scope of the problem
and implement prevention and screening programs for
those populations is urgently needed. As noted in the IOM
report on viral hepatitis, it is of particular importance to
provide prevention services to younger injection drug
users (IDU) as they may be at highest risk of seroconversion
20
mental illness. Today there are over 3,500 HIV+ persons in
the country on medication waiting lists .1 These challenges
are further compounded by stigma and discrimination that
persists thirty years into the domestic epidemic. The full
range of support services that help HIV+ individuals to stay
engaged and retained in medical care are unlikely to be third
party reimbursable, even in a system of universal coverage
We risk losing ground if we fail to preserve critical health
promotion programs, such as case management, housing,
peer support, and mental health services. The recently
released National HIV/AIDS Strategy calls for “increasing access
to nonmedical support services as critical elements of an effective HIV care
system.” 2 In fact, these are the very components that will
maximize the benefits of health care reform for all persons
impacted by chronic medical conditions. It remains the role
of public health to ensure care services are relevant and
responsive, and to protect the rights and health of our most
vulnerable residents.
H. Dawn Fukuda, Sc.M.
Director, Office of HIV/AIDS
Massachusetts Department of Public Health
in the years following initiation of injection practices.
Furthermore, prevention of HCV infection in these
populations is complex due to the high infectivity of the
virus, the already high prevalence of HCV among IDU, and
the lower health care utilization of IDU. The IOM report
states that multi-component programs (those that include
prevention education, counseling, screening, access to drug
treatment and methadone, etc.) may be required in order
to effectively control transmission of HCV among IDU.
However, prevention education and services to young, at-
risk people in Massachusetts have been limited since this
trend has been noted, largely due to limited resources and
difficulties reaching this population. Transmission appears to
be continuing at a high rate.
The issue of limited to no resources for viral hepatitis
services is not a problem limited to Massachusetts. In
the previously cited IOM report on viral hepatitis (2010),
Massachusetts Health Council
recommendations are made to increase resources to improve New HIV Cases, 2001 - 2009
New HIV Cases, 2001—2009

and enhance viral hepatitis surveillance, as the current 1200

structure for these activities is highly fragmented and under-

1000
resourced. While Massachusetts has been able to establish
a reasonable level of basic surveillance for HCV infection 800

by utilizing other disease surveillance infrastructure, the

600
data collected are still inadequate for comprehensive
program planning and resource allocation purposes. This 400

has complicated the ability to fully define the scope of the

epidemic in Massachusetts and nationally, and to fund the 200

range of indicated services for people at-risk for, or living 0

with, these infections, including education (for providers 2001 2002 2003 2004 2005 2006 2007 2008 2009

and communities), screening and medical management. 2009 Data are preliminary
These services are all specified in the IOM report as being Source: MA Department of Public Health, HIV/AIDS Surveillance
Program
critical to reducing transmission, morbidity and mortality
among affected populations. Given that there are new
treatments for HCV infection on the near horizon that may Percentages of 16,413 People Known
improve treatment outcomes and reduce the duration of to be Living with HIV/AIDS on
treatment, expansion of screening and medical management PeopleDecember 31,with
known to be living 2009 by on
HIV/AIDS Gender
July 31, 2010 by
programs will be increasingly indicated. While innovative Gender and Race/Ethnicity
and Race/Ethnicity
programs have been implemented in Massachusetts towards 60%

those goals, it is clear that these need to be expanded widely

50%
throughout the state.
40%
Male
Daniel Church Female
30%
Epidemiologist/Viral Hepatitis Coordinator
Massachusetts Department of Public Health
20%

10%

0%

Rate
���� of Newly
�� ����� Diagnosed,
���������� ���������� ���Confirmed, HCV
��������� ����� �� ����
White non-Hispanic Black non-Hispanic Hispanic Other

Infection Cases by Year Source: MA Department of Public Health, HIV/AIDS Surveillance

Program
���

��� People Living With HIV/AIDS on December 31,

People Living With HIV/AIDS on December 31, 2009
����������������������������

��
2009byby Massachusetts
Massachusetts Health
Health Services Services Region
Region
��

��

��

��
BOSTON
��
N.EAST
�� METRO W.
���� ���� ���� ���� ���� ���� ���� ���� S.EAST
���� WESTERN
CENTRAL
Prison
Source: Bureau of Communicable Disease Control, MA OTHER
Department of Public Health

Source: MA Dept of Health

Massachusetts Health Council 21

 Education
“S tay in school” and “go to college” is more than
just feel-good advice. It speaks directly to a proven,
powerful connection between education and the health and
wellbeing of a populace over a lifetime.
In every state, including Massachusetts, adults with
the least education are most apt to have the worst health
— this according to a 2009 report issued by the Robert Wood
Johnson Foundation, Commission to Build a Healthier
America. In the survey, Massachusetts ranked 5th. among
the 50 states with the lowest overall self-reported rate of
“less than very good health.” Seventy percent of adults who
had not finished high school reported they were in less
than very good health, compared to 26% of college gradu-
ates. The wide gap existing between those with less than a
high school education and college graduates regarding their
health status confirms what numerous other studies have
consistently shown — that the health among adults and, by
extension, their dependent children is inextricably linked to
educational attainment, and that lack of a college education
especially influences a multitude of health-related factors
and choices, including likelihood of smoking cigarettes,
drinking alcohol to excess, and gaining excessive weight, as
well as experiencing greater difficulty securing meaning-
ful employment and expanding household income over a
lifetime.
The ability to understand the determinants of health,
wellness, and disease prevention as they impact one’s self
and family is “health literacy.” Yet growing disparities
among our socio-economic groups mean that while some
Massachusetts residents are getting healthier by taking
advantage of new information as it becomes available, oth-
ers due to lack of education are failing to improve or are
becoming less healthy. As the gap between education and
health widens, the challenge is to translate the knowledge
gained into practice in a way that is comprehensible and
meaningful to people, so that it will improve lives.
Trends
In 2008-2009, 2.9% (8,585) of 292,372 students enrolled in
Massachusetts public schools, grades 9 through 12, dropped
out of school — a 0.5 percentage point improvement
in the dropout rate compared to 2007-2008 (3.4%). The
Commonwealth of Massachusetts operates a vast, complex,
and highly diverse educational system consisting of 392
22
operating school districts, 62 charter schools, and 31
educational collaboratives. During the 2009-2010 school
year 1,831 public schools were in session across the Bay
State—1,146 Elementary, 314 Middle/Junior High, and
371 Secondary. Nearly a million students were enrolled
statewide in 2009-2010, almost .5% fewer than in 2007-2008.
Enrollment breakdowns by race/ethnicity, Kindergarten
through Grade 12, were: African-Americans 8%, Asians 5%,
Hispanics 15%, Multi-Race Non-Hispanics 2%, and Whites
69%. White enrollments dropped by 2 percentage points and
Hispanic enrollments increased by one percentage point as
compared to 2007-2008.
The likelihood of any student, regardless of gender, race,
ethnicity, or selected population graduating with his or her
class in four years from a Massachusetts public high school
in 2009 was slightly better than 8 in 10 (81.5%). Yet within
this group, significant disparities existed. Females (85%) were
more likely to graduate on time than males (79%). Blacks
had a 69% on-time graduation rate, Hispanics 60%, Multi-
race Non-Hispanics 81%, Asians 86%, and Whites 87%. Sixty-
seven percent of all low income students graduated in four
years, as did 65% of Special Education students and 58% of
Limited English Proficient students.
Groups at Risk
As the data consistently show, high school dropouts are,
disproportionately, low income students, students of color,
and students with limited proficiency in English. In 2008-
2009 as in previous years, males (3.4%) were more likely than
females (2.5%) to drop out of school. Among race/ethnicity
groups, African-Americans had a 5.6% dropout rate,
Hispanics 7.5%, Multi-race Non-Hispanics 3.4%, Asians 1.7%,
and Whites 1.8%. Among special populations, low income
students had a 5.0% dropout rate, Special Education students
5.0%, and Limited English Proficient students 8.5%.
In Boston, according to MA Department of Elementary
and Secondary Education, the dropout rate in 2008-2009 was
7.3%, compared to 2.9% statewide. Sizeable disparities existed
across the district, depending on the particular school,
neighborhood, and programs offered. In the city’s highly
competitive examination schools (Boston Latin School and
Boston Latin Academy), the dropout rate was minuscule to
non-existent (0.1% and 0.0%, respectively). For most other
schools in the district, dropout rates in the 3% to 10% range
Massachusetts Health Council
predominated, with a few schools registering rates in the
20 – 30+% range. Among race/ethnicity groups, Hispanics
(9.4%) continued to have the highest dropout rate, compared
to Blacks (7.8%), Multi-Race Non-Hispanics (4.8%), Whites
(3.8%), and Asians (2.2%). Male students (8.5%) were, as
usual, more likely than females (6.0%) to drop out.
According to many educators, one often overlooked
factor negatively impacting a school’s overall academic
performance is its “churn rate” — the frequency with which
students transfer into or out of school during the year. High
churn rates are said to create unstable learning environments.
MA Department of Education findings for 2008-2009 appear
to support this connection. Certain student populations
recorded high churn rates in 2008-2009: Limited English
proficiency, 25.5%; low income, 17%; and Special Education,
14%. Among race/ethnicity groups, churn rates were highest
for Hispanics (21%), followed by African-Americans (19%),
Multiple race/non Hispanics (13%), Asians (11%), and Whites
(7%). These higher churn rate populations are the same
populations with higher drop-out rates. Churning may be a
factor in the difficulty in serving those drop-outs.
Reading is fundamental to success in school, and
children who do not attain literacy skills by third grade
struggle to catch up in future years. According to a study
of MCAS test data conducted by Boston-based Strategies for
Children, 74% of children who read poorly in third grade
continue to read poorly in high school, making third grade
reading proficiency a key predictor of high school dropout
rates. The study found that 43% of Massachusetts third
graders, and almost two-thirds (65%) of low income third
graders, fail to become proficient readers by the time they
finish third grade. For non-low income third graders, the
percentages were almost exactly reversed: 69% proficient or
above, 31% below proficient.
Massachusetts Health Council
References
Robert Wood Johnson Foundation, Commission to Build a
Healthier America, Reaching America’s Health Potential: A State-
by-State Look at Adult Health, May 2009.
Massachusetts Department of Elementary and Secondary
Education, Massachusetts School and District Profiles.
Massachusetts Department of Higher Education, “Highlights:
First-Time Student Enrollment, 2002-2008,” Board of Higher
Education Meeting, October 6, 2009.
Massachusetts Department of Higher Education, “2009-2010
Performance Measurement Report,” Report to the Board of
Higher Education, March 16, 2010.
Massachusetts Department of Higher Education, “Degrees
Confirmed at Massachusetts Institutions of Higher
Education: Enhancing and Expanding the Commonwealth’s
Workforce,” June 2009.
“Boston Public Schools, Cohort 2009: 4-Year Graduation
Rate by School,” Boston Public Schools, Office of Research,
Assessment, and Evaluation, 2010.
Massachusetts Department of Elementary and Secondary
Education, “Dropout Rates in Massachusetts Public Schools,
2008-2009,” March 2, 2010.
“Q and A: Boston Public Schools 2008-2009: Student Dropout,”
Boston Public Schools, Office of Research, Assessment, and
Evaluation, February 2010.
Massachusetts Department of Elementary and Secondary
Education, “Student Mobility Rates in Massachusetts Public
Schools, 2007-08 and 2008-09,” April 23, 2010.
“Concern over students switching schools,” Boston Globe,
August 2, 2010.
Strategies for Children, “The Importance of Reading
Proficiency,” June 2010.
“Grade 3 students lagging on reading,” Boston Globe, June 10,
2010.
Massachusetts Department of Elementary and Secondary
Education, “Cohort 2009 Four-Year Graduation Rates – State
Results," March 16, 2010.
23
 Education
Policy Perspectives
Education, particularly earning a high school diploma,
is important for a number of life outcomes, including
health outcomes. While years of efforts have brought the
Massachusetts annual dropout rate to 2.9 percent, its lowest
in more than a decade, that still amounts to nearly 8,600
students leaving high school in one year. In light of this,
the Massachusetts Graduation and Dropout Prevention and
Recovery Commission set an ambitious goal for the state to
reduce the rate to 1.7 percent by 2014.
Significantly reducing the number of students who
drop out of school takes a combination of systemic efforts at
the community, district, school, classroom, and individual
student levels. With this in mind, schools can make strides
by attending to the health and mental health issues
that interfere with student learning. The Massachusetts
Department of Elementary and Secondary Education (ESE)
is helping support these efforts in a number of ways. For
example, the ESE-chaired Behavioral Health and Public
Schools Task Force developed an online assessment tool
and framework (http://bhps321.org) for schools, providing
guidance and a structure for improved practices. The ESE and
the Department of Public Health also developed guidelines
addressing the nutritional quality of school foods and the
establishment of school wellness committees. Additionally,
ESE and the Massachusetts Alliance on Teen Pregnancy
have helped districts implement evidence-based pregnancy
prevention programs.
Beyond these initiatives, the ESE is involved with
many grants and workgroups in collaboration with other
state agencies, districts, and organizations to increase the
educational attainment and associated health and well
being of youth and their families. Current efforts include
Race to the Top, the National Governors Association’s State
Strategies to Achieve Graduation for All, the Early Warning
Indicator Index pilot, the Dropout Prevention and Recovery
Work Group, Green in the Middle Service-Learning, Online
Learning for At-Risk Students, and Alternative Education.
More details can be found on the Dropout Reduction website,
http://www.doe.mass.edu/dropout.
As noted in the Dropout Commission report, while the
decision to drop out is an individual one, it is often reflective
of the levels of family, school, and community support an
individual student receives. Furthermore, the decision to
drop out creates grave consequences for the Commonwealth,
and we have a collective responsibility to meet the challenge
head on.
Carol Goodenow, PhD
Jenny Caldwell Curtin, MPP
Rachelle Engler Bennett
MA Department of Elementary and Secondary Education
24
continued
The educational impacts of teen pregnancy warrant
particular attention.
Teen parenting is the leading reason girls give for leaving
school, and a significant factor for 19% of boys who drop out.i
National data indicate that teen pregnancy is a factor for 26% of
students who leave school each year. In 2009, this amounted to
more than 2,200 students in Massachusetts. Additionally, teen
pregnancy has generational effects. The children of teen parents
are more likely to repeat a grade, and more likely to drop out of
school themselves.
Efforts to address the achievement gap and to increase
high school graduation rates should include a comprehensive
plan to address teen pregnancy When teens earn good grades,
have plans for higher education beyond high school and/or
avoid problems in school, they initiate sex later and are less
likely to become pregnant or get their partners pregnant.ii
The teen birth rate for Massachusetts Hispanic teen
girls is more than 5 times that of white teens, and triple the
statewide rate. Correspondingly, the percentage of female
Hispanic students in Massachusetts who indicate that they
received mostly poor grades is double the rate for black
females, and triple that of whites. School achievement and
dropout may help explain some of the disparity in teen birth
rates.
Patricia Quinn
Executive Director
MA Alliance on Teen Pregnancy
Births (Vital Records). Massachusetts Community Health Information Profile
(MassCHIP). Version 3.0r324. Massachusetts Department of Public Health. Data
downloaded September 1, 2010.
iThe Massachusetts Alliance on Teen Pregnancy (2010). Expecting Success: How
Policymakers and Educators Can Help Teen Parents Stay in School. Retrieved Sep-
tember 2, 2010, from http://www.massteenpregnancy.org/sites/
default/files/expecting%20Success_1.pdf
iiKirby, D., Lepore, G., & Ryan, J. (2005). Sexual Risk and Protective Factors: Fac-
tors Affecting Teen Sexual Behavior, Pregnancy, Childbearing. Washington D.C.:
The National Campaign to Prevent Teen Pregnancy.
Massachusetts Health Council
 Annual High School Dropout Rate
Massachusetts, 2002–2009
4.0%

3.5%

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%
2002–03 2003–04 2004–05 2005–06 2006–07 2007-08 2008-09

Source: Massachusetts Department of Elementary and Secondary Education

Annual High School Dropout Rate by Race/Ethnicity

Massachusetts,
Annual High School 2008–2009
Drop-out Rate by Race/Ethnicity – Massachusetts 2008-2009

8%
7.5%

7%

6% 5.6%

5%

4%
3.4%

3%

2% 1.8% 1.7%

1%

0%
White African- Hispanic Asian Multi-Race
American Non-Hispanic

Source: Massachusetts Department of Elementary and Secondary Education

Annual High School Dropout Rate by Income Status

Massachusetts, 2008–2009
6.00%

5.00%

4.00%

3.00%

2.00%

1.00%

0.00%
Low Income (82,718 enrollment) Non-Low Income (209,654 enrollment)

Source: Massachusetts Department of Elementary and Secondary Education

Massachusetts Health Council 25

 Obesity and Overweightness
T he obesity trend in Massachusetts has been moving
steadily upward for most of the past decade to almost
double. The MA Department of Public Health (MDPH)
estimates that $1.82 billion per year in medical expenses
in the Bay State are directly attributable to adult obesity.
Nationally, 25% to 30% of the rise in health care spending
is due to the rise in obesity. Moreover, high rates of
obesity among children, in Massachusetts as elsewhere,
are producing many of the same deleterious health
consequences that were once thought to affect adults
only, such as hypertension and “adult-onset” (type 2)
diabetes. For adults, hypertension, dyslipidemia, non-insulin
dependent (type 2) diabetes, coronary heart disease, stroke,
osteoarthritis, respiratory problems, and certain cancers,
including endometrial, breast, and colon cancer, are among
the known correlates to overweight/obesity.
Trends
Over the past decade obesity prevalence has increased
significantly in the Commonwealth. In 2009, 21.8% of MA
adults were found by the MA Department of Public Health’s
Behavioral Risk Factor Surveillance System (BRSSF) survey
to be obese, whereas in the year 2000, the Massachusetts’
obesity rate was less than 17% and in 1995, it was less than
12%. It is important to note, however, that as reported in
the 2008 edition of the MHC health status indicator report,
the obesity rate in Massachusetts in 2007 was 22%. The 2009
obesity rate shows a very slight decrease of .2%.
As for the classification that includes both
overweightness and obesity, in 2009, 57.5% of MA adults, ages
18 and older, were classified as either overweight or obese, a
slight improvement over 2008 (58.1%) and 2007 (58.9%) but
still a troublesome increase over the past decade.
Although this data shows that the obesity rates in
Massachusetts have stabilized over the last 3 years, 57.5%
is a dangerously high percentage of overweight and obese
residents.
Among MA high school students, in 2007, the
overweight rate was 11% and has increased to 14.3% in 2009.
The obesity rate for this high school group has stabilized
at 10.9% over the past 2 years. Among MA middle school
students in 2009, 10% were obese and 17% were overweight,
26
each one percentage point lower than in 2007. Among MA
low-income children ages 2-5 in 2008, the obesity rate was
16.7%, virtually identical to 2007. The disparities in rates of
youth overweightness and obesity among our cities and
towns is staggering, measuring as low as 10% in Arlington
and as high as 47% in Lawrence. It is important to note;
however, that the city and town data are “preliminary” and
should be interpreted with caution since in smaller towns
a relatively small sample of students was measured and
students in Essential School Health Service Program (ESHS)
districts are not necessarily representative of all public
school students in the Commonwealth.
The DPH’s 2009 BRFSS data revealed that obesity affects
all age groups, educational attainments, and household
income levels, ignoring none. Disparities were noticeable,
however, in gender — adult males (25%) were more likely
to be obese than adult females (19%), and among racial/
ethnic groups — Blacks (32%) and Hispanics (28%) had
higher rates of obesity than Whites (21%). The youngest age
group, 18 to 24 (12%), and the oldest group, ages 75+ (18%),
were less likely to be obese than all ages in between (22%
to 26%). Those with 4-plus years of college (17%) were less
likely to be obese than less well educated groups (25% to
26%). The wealthiest households, those earning $75,000+,
were the only income group to report an obesity rate below
20% (18.9%), as compared to households earning less than
$25,000 up to $74,999, which reported obesity rates in the
22% to 27% range.
Obesity is a major risk factor for type 2 diabetes, a
chronic disease that, by MDPH estimates, is responsible
for 9.9% of medical care costs in the Commonwealth. The
percentage of Massachusetts adults diagnosed with diabetes
increased by an average of 4.1% a year between 2000 and
2009, a rate that was consistent with the national increase.
In 2009, 11% of Blacks, 9% of Hispanics, and 12% of Asians in
Massachusetts, compared to 7% of Whites, reported they had
diabetes. Another known correlate of obesity, hypertension,
was reported by 1 in 4 Massachusetts adults (26%) on average
over the 3-year period, 2007-2009.
Massachusetts Health Council
Groups at Risk
One-third of low-income 2- to 5-year-olds participating
in the Massachusetts Women, Infants and Children (WIC)
Nutrition Program were either overweight (17%) or at risk
of being overweight (17%). Among older children similar
patterns were observed. According to a MDPH report,
109,674 Massachusetts public school children in grades 1, 4,
7, and 10 were given BMI screenings by school nurses in 2008-
2009. In each of the 4 grade levels, at least 28% of children
screened were overweight or obese, with males in all 4
grades more likely to be overweight or obese than females.
Highest rates of overweight (18.1%) and obesity (21.6%) were
found among males in grade 4, closely followed by males
in grade 7 (17.2% overweight, 20.4% obesity). Lowest rates of
overweight (16.7%) and obesity (11.9%) were found among
females in grade 10.
Among the Massachusetts high school population in
2009, a sizeable proportion ignored basic concepts of good
nutrition as well as the need to engage in regular physical
activity. In 2010, with the passage of the MA School Nutrition
Bill, school aged children will begin to have access to better
nutritional food and hopefully develop better eating habits
while at school.
References
A Profile of Health Among Massachusetts Adults, 2009: Results from
the Behavioral Risk Factor Surveillance System (Massachusetts
Department of Public Health, Bureau of Health Information,
Statistics, Research, and Evaluation), June 2010.
“Alarms on youth obesity in Mass.,” Boston Globe, September
9, 2010.
“Overweight and Obesity (BMI) Prevalence and Trends Data
— 2009,” U.S. Department of Health and Human Services,
National Center for Chronic Disease Prevention & Health
Promotion, Behavioral Risk Factor Surveillance System.
U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, “Youth Risk Behavior
Surveillance — United States, 2009,” Surveillance Summaries,
MMWR, vol. 59, no. SS-5, June 4, 2010.
Pediatric Nutrition Surveillance: 2008 Report, U.S. Department of
Health and Human Services, Centers for Disease Control and
Prevention, 2009.
F as in Fat: 2010 — How Obesity Threatens America’s Future, Robert
Wood Johnson Foundation, Trust for America’s Health,
2010.

Classic gender differences involving actual versus Massachusetts Department of Public Health, Health of
Massachusetts, April 2010.
perceived overweight status were revealed by the YRBS
survey. Though adolescent males (14%) were twice as likely Massachusetts Youth Health Survey: 2009 (Massachusetts
as adolescent females (7%) to be obese, they were less likely Department of Public Health, 2010), pre-publication data.
than females to describe themselves as “overweight” (25%
Kenneth E. Thorpe, “The Preventable Causes of Rising
vs. 33%) and considerably less likely to be trying to lose
Healthcare Costs,” Emory University, Rollins School of
weight (31% vs. 60%). Perception of being overweight drove
Public Health, December 16, 2008.
a number of risky behaviors: 10% of females and 6% of males
said they did not eat for 24 or more hours to lose weight The Status of Childhood Weight in Massachusetts, 2009 (Massachusetts
or to keep from gaining weight during the 30 days before Department of Public Health, Essential School Health
the survey. Five percent of both female and males said they Services Program), September 2010.
took diet pills, powders, or liquids to lose weight; and 5% of
females and 4.5% of males said they vomited or took laxatives
in order to lose weight or keep from gaining weight.

According to the Massachusetts Department of Mental

Health, 73% of DMH patients are overweight or obese.
Various studies have shown that the rate of obesity among
patients with schizophrenia ranges from 42%-81%.

Massachusetts Health Council 27

 Obesity and Overweightness continued

Policy Perspective
Massachusetts ranks third lowest among the 50 states in rate of BMI-defined obesity, although obesity prevalence still
continues to increase in Massachusetts and elsewhere. However, since our state is a leader among states in halting the epidemic,
we should be thinking of the next frontier, which includes prevention, and specifically prevention of childhood obesity.
Michelle Obama has spearheaded the Lets Move Campaign to prevent childhood obesity, and she and her staff are hoping that
this campaign leads to change during the Obama administration and as well as longer term. The Obama Lets Move Team is
asking each community to bring the messages to their families so that a grassroots efforts will build and tie to the larger Lets
Move backdrop. For prevention, a message that combines healthy foods such as fresh fruits and vegetables, low fat dairy, lean
protein and whole grains with daily physical activity is necessary to support children’s healthy weight focus. We know that
the best time to educate parents is the perinatal period, when women seem most interested and empowered to make lifestyle
changes for the benefit of themselves and their families. Breastfeeding is associated with lower body weight for both mother
and child, and this should be a starting point. Teaching good nutrition in the school system and in the home can partner with
increased physical activity to help reverse the unhealthy practices that have governed the past 20 years and led to increases in
childhood obesity. The industry must change and is changing. More and more, healthier options are aligning themselves next
to less healthy options — i.e., in fast food restaurants. Now let’s make the right choice —not always easily done.

A study of Massachusetts students evaluated during the 2008-2009 school year showed that more than one-third of the
students were overweight or obese. Even more striking, the poorest cities in the state had the highest rates of students with
overweight or obesity. The differences between the poorest and the wealthiest are dramatic, at 47% versus 10% respectively of
students who were overweight or obese. This underscores the focus of Michelle Obama’s campaign, which is to provide fresh
fruits and vegetables to children and to educate children and their parents about good nutrition. Unfortunately our state
reflects the rest of the country in creating an economic milieu which deprives poorer families from access to the healthiest
foods. A change as big as what “Lets Move” implies is necessary to counteract this stark reality.

Even if strides are made in prevention, we still have 66% of Americans who are already overweight or obese. Treatment
options for the practitioner are few and far between. However, the field of obesity medicine is gaining ground as a subspecialty
and within it lies the cornerstone of treatment, diet, exercise, and lifestyle change. Medications and surgery are more aggressive
treatment options, and we are finally seeing several drugs and devices going before the FDA for approvals this year and in
the next few years. Perhaps one or two drugs will be approved along with one or two devices so that the obesity specialist
will have a few more tools to help individuals with weight loss and more importantly, weight maintenance. There are still
treatment gaps for those currently suffering from obesity, and the main gap lies in insurance coverage for office visits and
medications for obesity. The Obesity Society (TOS), the society for the prevention and treatment of obesity, is made up of
scientists and practitioners interested in a solution for our nation’s number one epidemic. TOS has proclaimed that obesity is a
disease. Let’s act like we believe this and fight for coverage not only for bariatric surgery, but for diet and exercise therapy and
pharmacotherapy.

Caroline M. Apovian, MD, FACP, FACN

Associate Professor of Medicine
Boston University School of Medicine
Director, Center for Nutrition and Weight Management
Boston Medical Center

28 Massachusetts Health Council

 Percentage Percentage
of MA AdultsofWho Are Overweight*
MA adults Who are Percentage
PercentageofofMA Adults
MA Adults Who
Who Are Overweight*
are Overweight (BMI > 25.0)
by Level of Education, 2004-2009
(BMI > 25.0) by Race/Ethnicity
Overweight (BMI > 25.0), by 2004–2009
Race/Ethnicity, (BMI > 25.0) by Level of Education, 2004–2009
80%

41%
2004 70%
Asian 31% 2006
38% 2009 60%

65%
50%
Hispanic 61%
63%
40%

71% 2009
30%
Black 71% 2006
2004
67%
20%

54%
10%
White 55%
57%
0%
< High School High School College (1-3 yrs) College (4+ yrs)
0% 20% 40% 60% 80%

Source: Massachusetts Department of Public Health, Source: Massachusetts Department of Public Health,
Behavioral Risk Factor Surveillance System – Trends Data Behavioral Risk Factor Surveillance System – Trends Data

Percentage of MA Adults Who are Overweight* Percentages of 109,674 MA Public School Students
or Obese, 2001–2009 Who Are Overweight* or Obese,
Percentage of MA adults Who are Overweight or Obese, Percentages of 109,674 MA Public School Students Who Are
2001-2009 Overweight orLevel
by Grade Obese,and Gender,
by Grade 2008-2009
Level and Gender, 2008-2009
���

40% Males
���
Females
��� 35%

��� 30%

���
25%
���
20%
���

15%
���

��� 10%

���
5%
���
���� ���� ���� ���� ���� ���� ���� ���� ���� 0%
Grade 1 Grade 4 Grade 7 Grade 10
Source: Massachusetts Department of Public Health
Source: Massachusetts Department of Public Health,
Behavioral Risk Factor Surveillance System – Trends Data
Essential School Health Services Program

*Based on Healthy People 2010 Standards

Massachusetts Health Council 29

 Oral Health
O ral Health has been treated separately from the rest
of the body and often not included in programs and
policies that seek to improve health. Current research shows
that oral infection is associated with serious systemic disease
such as cardiovascular disease, diabetes, pulmonary disease
and perinatal complications. Oral conditions can often give
important clues about one’s state of physical health. Access
to oral health care and prevention can have a significant
impact on overall health and well-being but there are barriers
to receiving oral health care in Massachusetts. Disparities for
vulnerable populations or groups at-risk have been extensive
and continue to exist due to the lack of access to prevention
programs, dental treatment, and dental providers.
Trends
Unlike medical insurance where Massachusetts health
reform has led to coverage for approximately 97% of resi-
dents, only about 76% of the residents of the Commonwealth
have access to dental benefits, 17% with MassHealth and 59%
with commercial insurance. 1.3 million residents live in
53 cities and towns federally designated as Dental Health
Professional Shortage Areas (DHPSAs). The percent of adults
who did not visit the dentist over the past year has improved
slightly from 23.4% in 2006 to 22.2% in 2008. Disparities con-
tinue with 42% of White adult residents having tooth loss
compared to 52% of Blacks and 49% of Hispanics. Blacks and
Hispanics experienced a significant increase in reports of
access to dental care in 2009 from 61% to 72% for Blacks and
from 65% to 72% for Hispanics.
In a 2008 survey among third graders in Massachusetts,
48% had experienced dental disease in the past which,
although unacceptable, is lower than the national aver-
age of 50% and one of the lowest rates in the nation. 17%
were noted to have untreated dental decay, lower than the
national average of 26% and lower than the Healthy People
2010 goal of 21%. Disparities among children continue to
exist, however (Graph 3).
Seniors continue to face difficulty in accessing dental
care. For MassHealth seniors (over 60 yrs.) 73% did not have
a dental visit over the last year vs 28% of all seniors over
65 years. In a 2010 survey of Massachusetts seniors it was
found:
• 74% of seniors in long term care facilities had gingivitis and
59% had untreated decay with 34% having major to urgent
30
dental needs.
• 35% of seniors at meal sites had untreated decay with 17%
having major to urgent dental needs.
• Nearly 20% of seniors at meal sites had not had a dental visit
in more than 5 years.
Cost of dental care, lack of insurance and shortage of
dental providers were the three major barriers to seniors
receiving care in long term care facilities.
Although community water fluoridation has been
shown to be the most effective way to prevent dental disease,
the Commonwealth has made little progress in increas-
ing the number of communities that provide fluoridation.
Massachusetts continues to rank 36th among states in per-
cent of residents with access to fluoridated water.
Between 1995 and 2005, more than 8,000 new cases
of oral and pharyngeal cancer were diagnosed in the
Commonwealth with approximately 2,000 cases result-
ing in death. Although oral and pharyngeal cancer can be
diagnosed in early stages by relatively non-invasive visual
exams by dental and medical providers, many continue to
be diagnosed at later stages with spread to other tissues and
a poor prognosis.
Groups at Risk
Disparities in receiving oral health care for vulnerable
populations have always been extensive and continue to
exist. These groups at-risk include children, the elderly, low
income, developmentally disabled, medically compromised,
homebound or homeless, persons with HIV, MassHealth
members, the uninsured and institutionalized, as well as
racial, cultural, and linguistic minorities.
After having been eliminated in 2002 and reinstated in
2006, the MassHealth Adult Dental Program was dramati-
cally reduced in July 2010, eliminating restorative care effect-
ing over 680,000 MassHealth adults.
The primary dental safety net in our state has increased
since 2008 to consist of 48 community health center dental
programs and satellites, which have over 377,000 patient
visits per year. The Massachusetts Dental Society continues
to encourage more of its members to become MassHealth
providers. There has been an increase in dental providers
for MassHealth patients. In 2008, 20% of dentists accept-
ed MassHealth but in fiscal year 2010, 27% of dentists in
Massachusetts Health Council
Massachusetts were MassHealth providers. However, this
improvement is lagging behind the number of family prac-
titioners (75%) who accept MassHealth. Only 11% of these
dentists were active providers (billing more than $10,000 a
year for treatment) in 2008 but that number has increased
to 18% in 2009. As in 2008, more than 50% of Massachusetts
cities and towns still did not have a MassHealth dentist pro-
vider.
A 2008 statewide survey of public school nurses showed
only 8% of schools had a school dental sealant prevention
program. In 2010, a change in the dental practice acts and
provider regulations will allow dental public health hygien-
ists to provide oral preventive services in schools and other
community settings with a collaborative agreement with a
dentist.
In addition to dental public health hygienists, a pro-
gram to increase oral health services by MassHealth medical
and nursing providers became effective October 2008. The
new program provides families with oral health education,
anticipatory guidance, and fluoride varnish application to
children’s teeth, an effective preventive measure for their
child patients. This improves access to high risk children in
non-dental settings.
References
M. Allukian, “The Neglected Epidemic and the Surgeon
General’s Report: A Call to Action for Better Oral Health,”
American Journal of Public Health Sept. (2008): S82-85.
M. Allukian Jr., “Oral Diseases: The Neglected Epidemic,”
Scutchfield, F.D. and Keck C.W. ed. Chapter 28 in Principles
of Public Health Practice, Third ed., Albany, N.Y., Delmar
Publishers, 2009.
Department of Health and Human Services. Oral Health
in America: A Report of the Surgeon General, Rockville, MD: US
Department of Health and Human Services, National
Institute of Dental and Craniofacial Research, and National
Institutes of Health, 2000.
Special Legislative Commission on Oral Health, The Oral
Health Crisis in Massachusetts, Massachusetts Department of
Public Health, Boston, February, 2000.
Massachusetts Department of Public Health, Office of Oral
Health. The Status of Oral Disease in Massachusetts: The Great Unmet
Need 2009. Boston, Massachusetts Department of Public
Health, 2009.
Massachusetts Health Council
Massachusetts Department of Public Health, Health Survey
Program, Bureau of Health Information, Statistics and
Evaluation, A Profile of Health Among Massachusetts Adults, 2008:
Results from the Behavioral Risk Factor Surveillance System, October
2009.
Catalyst Institute, The Oral Health of Massachusetts’ Children,
January 2008.
Centers for Disease Control and Prevention, Populations
Receiving Optimally Fluoridated Public Drinking Water ---
United States, 1992-2006. Morbidity and Mortality Weekly Report.
2008; 57(27): 737-741.
M. Allukian, “Massachusetts Fluoridation Update 2006.”
Journal of the Massachusetts Dental Society. 55.1 (2006): 16-22.
V. Bhatt and M. Allukian Jr., “A survey of the knowledge and
interests in dental prevention programs of Massachusetts
local boards of health in non-fluoridated communities,”
(Unpublished study), Boston, MA, 2010.
Massachusetts School Nurse Survey, Massachusetts
Department of Public Health Office of Oral Health, conducted
December, 2008 (unpublished).
Oral Health Collaborative of Massachusetts, The Massachusetts
Oral Health Report, May 2004.
M. Allukian Jr., “Who is Helping Seniors Improve Their Oral
Health? What is Our Responsibility?,” Journal of the Massachusetts
Dental Society, 37 (Fall 2008):68-69.
Massachusetts Department of Public Health, Office of Oral
Health. The Commonwealth’s High Risk Senior Population:
Results and Recommendations from a 2009 Statewide Oral Health
Assessment, July 2010.
Massachusetts Medical Society, Physician Workforce Study,
Waltham, MA, June 2007.
United States District Court of Massachusetts Civil Action No.
00-CV-10833-RWZ, Health Care for All, Inc. et all Plaintiffs v.
Governor Deval Patrick, et al Defendants, Eighth Report of
Remediation Monitor Filed 7/30/2010.
Mapping Access to Oral Health Care in Massachusetts, Massachusetts
Oral Health Collaborative Report. October 2006.
Better Oral Health for Massachusetts Coalition, Oral Health
Plan for Massachusetts: 2010-2015, 2010.
31
 Oral Health
Policy Perspectives
Despite being almost entirely preventable, oral dis-
eases (tooth decay, periodontal disease, oral trauma, and oral
cancer) continue to present a serious disease burden to the
residents of Massachusetts and the US. In order to address
that disease burden, it is important that oral health is con-
sidered an essential component of health by policy makers.
The national health reform Affordable Care Act and CHIP
reauthorization show promise that oral health, at least for
children, is beginning to be considered an essential compo-
nent of health, since each includes mandated dental benefits
for children. Policies that support access to effective dental
benefits across the life span and other socioeconomic demo-
graphics is an important way that the residents and families
of Massachusetts can be helped to maintain good oral health.
Additionally, non traditional settings and providers of oral
health care, such as physicians, school based programs, nurs-
ing home programs, and other components of the safety net
must receive continued funding and priority.
Community based prevention is as important as indi-
vidual care to improve oral health. Massachusetts should
continue to provide resources to insure that every resident
of Massachusetts, with access to a community water sup-
ply, receives the benefits of community water fluorida-
tion. Community based prevention, such as school sealant
programs and fluoride rinse programs must continue to be
supported by informed policy makers. Information about
the importance of oral health and ways that individuals can
maintain good oral health should be readily available in
the community and regular surveillance of the oral health
status of Massachusetts’ residents must be developed and
maintained.
The Better Oral Health for Massachusetts Coalition
has recently released an Oral Health Plan for Massachusetts,
2010-2015. That plan should form the basis for oral health
promotion activities in the Commonwealth.
Michael Monopoli, DMD, MPH, MS
Director, Policy and Planning
DentaQuest Foundation
32
continued
Oral health must be an integral component of total
health and a much higher priority in the development and
implementation of all health policies and programs, espe-
cially for vulnerable population groups. Community water
fluoridation must be the foundation for improving the oral
health of every community in our state. In non-fluoridated
high-risk communities, school fluoride rinse/tablet/varnish
programs are recommended. Currently there are more than
52,000 children participating in these programs. School-
based sealant prevention programs for high-risk children
ages 6–8 and 12–14 years old also need to be promoted for
preventing tooth decay.
The Better Oral Health for Massachusetts Coalition
released the oral health plan for Massachusetts in April 2010.
The State Oral Health Plan must be financed and implement-
ed to (1) increase the number of effective population-based
prevention measures like fluoridation and school prevention
programs such as sealants, and fluoride rinses/tablets/var-
nishes in high-risk and/or non-fluoridated communities and
(2) Improve access for vulnerable populations. Oral health
should be an integral component of health care reform,
especially for all those living at 300% or below the poverty
level. The Adult MassHealth Dental Program needs to be
restored with a reasonable fee schedule. Community health
center dental programs need to be expanded, increased and
better funded. The new Public Health Dental Hygienists for
public health settings must be promoted and supported. The
number of dentists actively treating MassHealth patients
needs to be dramatically increased from 18% to at least 70%.
Community and professional organizations, leaders,
decision-makers, local boards of health, and the public must
be informed and educated about this plan and work together
to improve oral health in Massachusetts.
Myron Allukian, Jr., DDS, MPH
Oral Health Consultant
Massachusetts Health Council
 ���������������������������������������������������������������������
Percentage Of Ma Adults Who Did Not Visit A Dentist In The Past Year 2000-2008
���������

24.5

24

23.5

23

22.5

22

21.5

21

20.5

20
2000 2001 2002 2004 2006 2008
Source: “A Profile of Health Among Adults 2008”. BFFSS. February 2009

������������������������

���������
Source: MDPH BRFSS, 2008
������������������������

Disparities in the Prevalence of Untreated Tooth Decay Among Massachusetts' Third Grade Children

���������

Source: Catalyst Institute "The Oral Health of Massachusetts' Children" January 2008

Massachusetts Health Council 33

 Poverty
I n 2008, the poverty rate in Massachusetts was exactly 10%.
Families and children are considered to be “in poverty”
by U.S. Census Bureau definition if family income is at or
below the federal poverty threshold. For a family of four
with two related children under age 18, the 2008 threshold
was $21,834, while adding a third child only increases the
threshold to $21,910. Research suggests that, on average,
families need an income of about twice the federal poverty
threshold to meet their most basic needs. Thus, families and
children may be classified as “low income” if family income
is at less than twice the federal poverty level.
People who live in poverty are subject to many
influences that contribute to poor health — sedentary
lifestyle, unhealthy eating habits, difficulty accessing
health care, unsafe neighborhoods, and greater exposure
to environmental hazards. For these reasons, lower income
individuals are more likely to die prematurely than
individuals of higher socioeconomic standing.
Trends
Massachusetts is an affluent state with rising income
levels. Over the nine-year period 2000 to 2008, the Bay State
ranked 3rd among the 50 states in personal income per
capita, increasing from $$37,753 (2000) to $43,315 (2005) to
$50,735 (2008) — or 28% above the U.S. average, which was
$39,751 in 2008. Similarly, Massachusetts ranked 6th among
the states in median household income ($65,401) in 2008
— 26% more than the U.S. in entirety ($52,029).
Yet notwithstanding its overall affluence, sizable
pockets of poverty exist within Massachusetts. According
to the 2008 American Community Survey, conducted by
the U.S. Census Bureau, an estimated 622,537 people in
the Commonwealth lived below the federal poverty level
— 1 in 10 (10.0%) of the Bay State’s population of 6,242,524.
Disproportionately represented within these poverty totals
were: Children under age 18 (13%); Blacks or African-
Americans (20%); Hispanics or Latinos of any race (29%);
Asians (14%); those self-identified as some other race (30%);
and those identified as two or more races (19%). Females
(11%) of all races were more likely to live in poverty than
males (9%). Eight percent (401,225) of Whites were poor by
Census definition.
34
As in previous years, educational attainment was
highly correlated with poverty status, in predictable, step-
wise fashion. Among all MA adults, ages 25 and older, 22%
of those with less than a high school degree or certificate
lived in poverty, compared to high school graduates (10%),
some college or associate’s degree (7%), or a bachelor’s
degree or higher (3.5%). Many of these less educated indi-
viduals filled the ranks of the “working poor” (an unofficial
term), generally in part-time jobs, or they did not work at
all. Of 2,157,199 Massachusetts residents, ages 16 and older,
who reported they worked full-time, year-round in 2008,
just over 1% (23,215) lived below the federal poverty level.
But of the 1,488,999 Bay Staters who worked part-time or
part-year in 2008, 11% (165,509) lived in poverty; and of the
1,351,928 individuals listed as “did not work” for any reason,
20.5% (276,643) lived below poverty level.
Groups at Risk
As ever, children are affected most. They must hurdle
huge barriers across generations — including family
structure, parents’ education, and parents’ employment
history, as well as persistent societal prejudices regarding
race, ethnicity, and nativity — if they are to make an
eventual successful move up and out of poverty.
According to data compiled by Columbia University’s
National Center for Children in Poverty (NCCP): In
Massachusetts in 2008, there were 841,172 families with
1,442,005 children under age 18. Sixteen percent (228,265)
of children lived in “poor” families, defined as income
below 100% of the federal poverty level. Nationally, 19%
of children lived in poor families. Of Massachusetts’
population of poor children, 1 in 3 (76,839) were under age
6. Seventy-five percent (170,101) of children in poor families
lived with a single parent, compared to 21% of children in
not-poor families. Forty-five percent (102,122) of children
in poor families did not have an employed parent. Sixty-
nine percent (53,029) of children whose parents had no
high school degree lived in poor families, compared to
36% (99,064) whose parents had a high school degree but
no college education and 7% (76,172) whose parents had at
least some college education. Nine percent (90,034) of White
children, 50% (84,736) of Hispanic children, and 26% (52,795)
of children of immigrant parents lived in poor families, as
did 14% (165,898) of children of native-born parents.1
Massachusetts Health Council
 For many, the odds of escaping poverty are
daunting, especially for those in dysfunctional family
situations. In 2009, the MA Department of Children and
Families (DCF) had 40,095 children in caseload. Of these,
8,024 involved children in placement. Seventeen percent
were 0-2 years old; 13% were 3-5 years old; 21% were 6-
11years old; and 49% were 12-17 years old. Service plan
goals for these 8,024 children included family reunification,
adoption, permanent care with kin, guardianship, and
stabilization of intact family. Nearly half of the placement
caseload involved White children, with the remainder
unevenly distributed among Blacks (17%), Hispanics (27%),
Asians (2%), and other racial/ethnic groups.
Children living in poverty, in Massachusetts and
elsewhere, are impacted in ways that are anything but
subtle. One is hunger. Every year, the U.S. Department of
Agriculture (USDA) surveys householders regarding their
“food security,” asking, for example, whether in the past
12 months they were often, sometimes, or never worried
their food would run out before they got money to buy
more. Households are classified as having “low” food
security when respondents give multiple indications of
food access problems but few, if any, indications of reduced
food intake. They are classified as having “very low” food
security when respondents give multiple indications of
household members being hungry but not eating because
there was not enough money to buy food. Over the period
2006-2008, the prevalence of low and very low food security
households combined in Massachusetts was 8.3%, second
lowest among the 50 states and significantly below the
U.S. average of 12.2%. Prevalence of very low food security
households alone was 3.8%, which was nearer to the U.S.
average of 4.6%. According to the USDA, children in most
food-insecure households, even in those with very low
food security, were “usually shielded” from reduced food
intake, though in 1.3% of households with children, one or
more of the children were subject to reduced food intake
and disrupted eating patterns at some time during the
year.
The long-term implications of food insecurity on
children are disturbing, for they include the real possibility
of malnourishment. Focusing on a cohort of 7,141 low-
income, very young children, ages 4 to 36 months, who
1Comparable data on African-American, Asian, and multi-race children
living in poor families in MA in 2008 were unavailable from NCCP.
Massachusetts Health Council
were seeking treatment in the emergency departments of
five urban medical centers, a team of pediatric researchers
led by Dr. Deborah Frank of Boston Medical Center
conducted interviews with caretakers, reviewed medical
records, and constructed an index that would quantify
the risks to health being imposed on these children as a
consequence of poverty. They found that three prevalent
economic hardships — food insecurity, housing insecurity,
and energy insecurity — combined to be a “robust
predictor” of health and development. The Boston-based
sample totaled 1,671 children, 651 (39%) of whom were
scored as no hardship, 911 (55%) moderate hardship, and
109 (7%) severe hardship. The moderate hardship group was
found by the researchers to be less healthy overall and at
greater developmental risk than the no hardship children,
while those under severe economic hardship were the least
well and at greatest developmental risk.
References
U.S. Census Bureau, “Poverty Thresholds 2008,” June 22,
2010.
“Massachusetts: Poverty Status in the Past 12 Months,”
“Massachusetts: Poverty Status in the Past 12 Months of
Families,” and “United States: Poverty Status in the Past
12 Months,” 2008 American Community Survey (U.S. Census
Bureau), 2009.
“Income, Expenditures, Poverty, and Wealth,” Section 13,
Statistical Abstract of the United States: 2010.
U.S. Census Bureau, “Median Household Income for the
States: 2007 and 2008 American Community Surveys,”
September 2009.
“Massachusetts: Demographics of Poor Children, 2008,”
National Center for Children in Poverty, Mailman School
of Public Health, Columbia University.
Massachusetts Department of Children and Families,
Annual Data and Placement Profiles, December 31, 2009.
Household Food Security in the United States, 2008, Economic
Research Report No. 83 (U.S. Department of Agriculture,
Economic Research Service), November 2009.
Deborah A. Frank et al., “Cumulative Hardship and Wellness
of Low-Income, Young Children: Multisite Surveillance
Study,” Pediatrics, vol. 125 (May 2010), e1115-e1123.
35
 Poverty continued
Policy Perspective
During periods of high unemployment, it is essential that the federal government act to combat increased poverty.
Initiatives by the federal government over the past eighteen months have played a critically important role both in reducing
the number of people falling into poverty and in helping those who are in poverty. While the recession is technically over, the
economic crisis remains very real for millions of families in poverty or close to it. To protect these families, and to keep the
economy from falling back into recession,1 it is critical that the federal government continue efforts to provide low-income
families with the supports they need to weather this storm.
In response to the historic economic downturn (which began in late 2007), in early 2009, Congress approved and the
President signed the American Recovery and Reinvestment Act (ARRA). According to the 2009 Current Population Survey
data, the impact of existing safety net supports - augmented by ARRA dollars - is clear: Social Security payments prevented 14
million seniors from dropping below the poverty line during 2009; Unemployment Insurance benefits prevented 2.3 million
working age adults from dropping into poverty in 2009.2
In Massachusetts, ARRA funding has provided several billion dollars in these type of direct benefits to families and
individuals since the spring of 2009 (totals below run through August, 2010) including:
• Making Work Pay credit = $1.65 billion
• $250/individual Economic Recovery Payment = $289 million
• extended and expanded Unemployment Insurance benefits = $1.70 billion
• expanded Food Stamp program = $252 million

Total = $3.89 billion

In addition to ARRA provisions offering direct assistance to individuals and families (see bullet-pointed items,
above), other ARRA programs have provided more general support to the states, delivering billions in federal aid to state
and local governments. These ARRA dollars have helped protect our nation’s schools, healthcare systems, transportation
infrastructure and other public services from undergoing deeper budget cuts, which in turn has helped protect jobs and
the overall economy. As analysis by the Economic Policy Institute has highlighted, it is the creation and preservation of jobs
through ARRA support of state and local governments that has made the largest contribution to holding down the national
poverty rate.3 The Congressional Budget Office estimates that ARRA dollars created or saved between 1.3 million and 2.7
million jobs in 2009.4
Many of the ARRA programs that have helped to prevent the U.S. poverty rate from increasing even further during
this Great Recession are due to expire in the coming months. Yet the country is still not in a strong recovery; at present there
is only one job available for every five people looking for work.5 If programs such as extended Unemployment Insurance
benefits are terminated before the unemployment rate falls considerably, we could see a much higher number of people in
poverty next year.
Kurt Wise, Policy Analyst
Massachusetts Budget and Policy Center

1Economists have found that direct assistance to low income families is among the most effective means of stimulating the economy and creating jobs. This is the case
because such families spend the assistance immediately to meet their needs and the resulting increase in demand for goods and services stimulates economic activity,
including hiring. See, e.g. http://www.cbpp.org/files/12-19-02ui.pdf, page 7.
2 See Census website, PRESENTATIONS>DAVID JOHNSTON>REMARKS>PG 7: http://www.census.gov/newsroom/releases/archives/news_conferences/20-09-16_

news_conference.html
The Center on Budget and Policy Priorities estimates that a total of 3.3 million non-seniors were moved out of poverty in 2009 as a result of UI benefits, including 1 million
children residing in families that received UI benefits: http://www.offthechartsblog.org/looking-at-today%E2%80%99s-poverty-numbers/
3Economic Policy Institute, A Lost Decade, September 16, 2010: http://www.epi.org/publications/entry/a_lost_decade_poverty_and_income_trends
4Congressional Budget Office, Estimated Impact of ARRA, August 2010 (Table 1, pg 3) : http://www.cbo.gov/ftpdocs/117xx/doc11706/08-24-ARRA.pdf
5 Economic Policy Institute, Reasons for Skepticism About Structural Unemployment (Page 9) available at: http://www.epi.org/publications/entry/bp279/

36 Massachusetts Health Council

 Percentage of People in Poverty MA and US
2005–2008
Percentage of People in Poverty, MA & US 2005-2008

14%

13.3% 13.3% 13.2%

12% 12.5%

10% 10.3%
9.9% 9.9% 10.0%

8%

6%

4%

US MA
2%

0%
2005 2006 2007 2008

Source: U.S. Census Bureau, American Community Survey

Educational Attainment of People in Poverty

Massachusetts,
Educational Attainment 2008
of People in Poverty, Massachusetts – 2008

Bachelor’s Degree or Higher 3.5%

Some College, Associates

Degree
6.9%

High-School Graduatee
(includes equivalency)
10.0%

Less than High-School

Graduate
22.0%

Population, Ages 25 and

Older
8.2%

0% 5% 10% 15% 20% 25%

Source: U.S. Census Bureau, 2008 American Community Survey

Poverty Rates in Massachusetts, 2008

Poverty Rates In Massachusetts – 2008

25%

23.5%

20%

15%

10%

7.1%
5%
4.2%
2.8%
0%
Female householder All families People ages 65 and Married-couple families
families older

Source: U.S. Census Bureau, 2008 American Community Survey

Massachusetts Health Council 37

 Tobacco
T obacco is still the leading cause of death and preventable
disease in Massachusetts. More than 8,000 Massachusetts
residents die each year from tobacco-related causes, which
include cancers of the lung, larynx, throat, esophagus and
mouth, heart disease and stroke, and emphysema and
other respiratory diseases. Tobacco also imposes a huge
economic burden on the Commonwealth, estimated by
the MA Department of Public Health at more than $4.5
billion per year in smoking-attributable health care costs
(e.g., hospital, nursing home, ambulatory care, prescription
drugs, etc.) and $1.98 billion in lost productivity. Eighty-
two percent of current adult smokers in Massachusetts had
their first cigarette before age 19, and 69% were smoking
regularly before age 19. Research indicates that the earlier
young people begin to smoke, the more likely they are to
become addicted to cigarettes. Recent studies sponsored by
the National Institute on Drug Abuse on brain functioning
suggest not only that smoking may be more addictive when
initiated during adolescence, but also that it may heighten
response to other addictive drugs.
Tobacco’s deleterious effects are not limited to smokers
only. Environmental tobacco smoke (ETS), i.e., “secondhand
smoke,” contains known carcinogens as well as hundreds of
other compounds identified by the U.S. Centers for Disease
Control and Prevention (CDC) as toxic. According to the
CDC, nonsmokers exposed to secondhand smoke at home
or work increase their risk of developing heart disease by 25-
30% and lung cancer by 20-30%, compared to those who are
not exposed.
Massachusetts’ leaders have strived to protect the
residents of the Commonwealth from the devastating
toll of tobacco use. In addition to the statewide smoke-
free workplace law, more recent actions have included:
community outreach efforts and interventions; nicotine
patch promotions targeted at specific population groups and
geographic areas with smoking rates higher than the state’s
average; and availability arranged for all FDA-approved
smoking cessation medications and counseling at affordable
co-pays through MassHealth. A $1.00 per pack increase in
the state’s cigarette tax took effect July 2, 2008. Consequently,
cigarette excise tax revenue jumped to $569.1 million in FY
2009, an increase of about $150 million, according to the MA
38
Department of Revenue (DOR). Meanwhile, the number of
packs of cigarettes sold in the Commonwealth fell from 278
million in FY 2007 and 277.6 million in FY 2008 to 243.5 million
in FY 2009, a decline in sales of roughly 12%. “Cigarette tax
revenue up, sales down,” the DOR said, summarizing the
impact of the statewide cigarette excise tax increase.
Trends
In its annual survey of MA adults, the Massachusetts
Department of Public Health asks respondents about their
tobacco use. In 2009, 15% said they were current smokers,
defined as someone who has smoked at least 100 cigarettes
in his or her lifetime and currently smokes either some days
or every day. The percentage of current smokers decreased
by an average of 1.9% a year, 2000 through 2006, and then
decreased more sharply by an average of 5.4% a year, 2007
through 2009. As always, educational attainment and level
of household income were strongly predictive of current
smoking status. In 2009, adults with 4-plus years of college
(7.4%) were less likely than adults with less than a high
school education (27.4%) to report current smoking, and
those with household incomes greater than $75,000 (9.5%)
less likely than all lower income groups to report current
smoking.
The trends with regard to secondhand smoke exposure
likewise were favorable. According to 2009 BRFSS findings,
80.6% of Massachusetts adults said they lived in a household
where smoking was not permitted, a rate that has stayed
relatively stable since 2006 and is nearly 12 percentage points
higher than the level of non-smoking households reported
in 2001 (68.9%). 38.1% of MA adults in 2009 reported
exposure to environmental tobacco smoke in the past 7
days, compared to 73.1% in 2002. Adults ages 18-24 (64.6%)
and 25-34 (50.5%) were more likely than older age groups to
report recent ETS exposure.
Groups at Risk
Since the beginning of the present decade, cigarette
smoking among Massachusetts high school students has
declined significantly, according to all statistical indicators.
Frequent cigarette smoking (more than 20 of the last 30 days)
continued its steady decline in 2009, to 6.9%, down from
Massachusetts Health Council
13.2% (2001). Overall, the percentage of current cigarette
smokers among high school students has decreased by more
References
than 50% from its high (35.7%) in 1995.
Massachusetts Department of Public Health, Health of
Among Massachusetts middle school students (6th,
Massachusetts, April 2010.
7th, and 8th graders), lifetime and current cigarette smoking
similarly have decreased over the past seven years. The A Profile of Health Among Massachusetts Adults, 2009: Results
percentage who had ever tried cigarette smoking (lifetime from the Behavioral Risk Factor Surveillance System (Massachusetts
use) was 14.6% in 2009, down from 27.0% (2002). Current Department of Public Health, Bureau of Health Information,
cigarette use (past 30 day use) was 4.2% in 2009, down from Statistics, Research, and Evaluation), June 2010.
7.1% (2002). Lifetime use was higher among Hispanic (22%) Centers for Disease Control and Prevention, Office on
and Black middle school students (19%) than White, non- Smoking and Health, Fact Sheet on “Secondhand Smoke
Hispanic students (13%). (SHS),” January 15, 2010.
Certain social factors continued to be highly predictive Annual Report of the Massachusetts Tobacco Cessation and Prevention
of current smoking among Massachusetts high school Program (Massachusetts Department of Public Health), Fiscal
students. In 2009, these adverse associations included: live Year 2009.
with a smoker (26%); believe that most people their age Robert Bliss, Director of Communication, Department
smoke (21%); felt sad or hopeless (25%), or considered of Revenue, “Cigarette tax revenue up, sales down,”
suicide (34%); received academic grades of mostly C’s, D’s, or Commonwealth Conversations: Revenue, May 14, 2010,
F’s (28%); have a long-term emotional problem or learning Mass.gov blog (http://revenue.blog.state.ma.us/blog/2010/05/
disability (33%); self-identify as gay, lesbian, or bisexual cigarette-tax-revenue-up-sales-down.html).
(45%); and used alcohol in the past 30 days (34%). Moreover,
high school students who smoke were more likely to U.S. Department of Health and Human Services, Centers
engage in other risky behaviors, such as substance abuse. for Disease Control and Prevention, “Youth Risk Behavior
Compared to those who did not smoke cigarettes, current Surveillance — United States, 2009,” Surveillance Summaries,
cigarette smokers were: about 5 times more likely to report MMWR, vol. 59, no. SS-5, June 4, 2010.
current marijuana use; about 13 times more likely to report “Trends in Youth Tobacco Use in Massachusetts, 1993-2009,”
ever using cocaine; 26 times more likely to report current Data Brief (Massachusetts Department of Education and
cocaine use; 17 times more likely to report ever using Massachusetts Department of Public Health), March 2010.
crack cocaine; 24 times more likely to report current crack
cocaine use; 9 times more likely to have ever tried the opiate
(narcotic) painkiller Oxycontin without a prescription; and
17 times more likely to report current Oxycontin use.
The rate of current use of any type of tobacco (cigarettes,
cigars, or smokeless tobacco) among Massachusetts high
school students has not changed significantly from 2003
to 2009 because declines in cigarette smoking were offset
by steady increases in smokeless tobacco use and cigar
smoking. Current use of “other” tobacco products was
17.6% in 2009, the highest level on record. Also, a number
of other tobacco products, such as Black & Milds, Snus, and
dissolvable nicotine, do not fit neatly into existing categories,
which may result in an underestimation of their use by the
adolescent populations to whom they are targeted.

Massachusetts Health Council 39

 Tobacco continued
Policy Perspective
Tobacco use remains the leading cause of preventable death in Massachusetts, although recent public policy gains
are helping drive down smoking rates in the Commonwealth. At a time when the national smoking rate has hit a plateau,
Massachusetts’ rate continues to decrease at an average of 2% each year, to 15% in 2009. The Massachusetts Legislature can claim
partial credit for this trend, as it passed a 2009 tobacco tax increase and required MassHealth to cover smoking cessation for all
subscribers.
There is still work to be done and there are many challenges that still exist. The tobacco industry has renewed its efforts
to hook youth by flooding the market with new, cheap, cleverly packaged products that appeal to young people. The majority
of smokers in the Commonwealth do not have access to medications and counseling to help them quit. And the state program
charged with reducing smoking rates has faced massive budget cuts.
The Massachusetts Tobacco Cessation and Prevention Program (MTCP) has monitored and reported a troubling new
trend: While youth smoking rates continued to decline, young people’s use of other tobacco products grew at such a rate that
young people’s use of other tobacco products surpassed cigarette use for the first time. To address this troubling issue, MTCP
has begun educating parents and stakeholders across the Commonwealth. A comprehensive tobacco tax would provide solid
policy support to MTCP’s programmatic efforts to reduce youth’s use of tobacco products.
When MassHealth added a smoking cessation benefit for all its members in FY 2007, it saw a 26% reduction in member
smoking rates in 2.5 years. MTCP, which helped design and promote the benefit, has begun the intensive process of analyzing
claims data. Initial findings linked immediate health improvements and a reduction in tobacco-related health care claims to
members’ use of the benefit. Enough evidence now exists to make the case for all public insurance to include a comprehensive,
low-barrier smoking cessation benefit.
Despite its solid performance, the Massachusetts Tobacco Cessation and Prevention Program has had its funding slashed
more than 68% since FY 2009, from $12.75 million to a current level of $4.486 million, less than half a percent of the $900
million annually in tobacco revenue the state receives. The program has adapted its strategies to the current fiscal crisis, but
funding must be restored soon to allow the program to address emerging challenges and reinstate programming to high-risk
populations.

Russet Morrow Breslau

Executive Director
Tobacco Free Mass

40 Massachusetts Health Council

 Current Adult Smokers
Current in inMA
Adult Smokers and
MA and US 2000-2009
US 2000-2009 Smoking Prevalence
Smoking for Selected
Prevalence for Selected Population Population
Subgroups: Massachusetts 2009
25% Subgroups: Massachusetts, 2009
30%

27.4%
20% 25%
24.7%

20% 21.1%
15% 19.5%

15%
15.0%

10%
10% 10.7%
MA US 9.5%
7.4%
5% 5%

0%
Statewide 18-24 Years Less than Under $25K Disability College 4+ $75K+ MetroWest
0% Old High School Household Years Household
2000 2002 2004 2006 2007 2008 2009
More Likely to Smoke
Education Income
Less LikelyIncome
to Smoke
Source: Behavioral Risk Factor Surveillance System – Trends Data; CDC
Source: Massachusetts Behavioral Risk Factor Surveillance System, 2009

Current andFrequent
Current and Frequent Cigarette
Cigarette Use Among Use Among
High School High
Students in Current* Cigarette Use by Grade Level
School Students in Massachusetts, 1993-2009
Massachusetts, 1993 - 2009 Massachusetts, 2009
40.00%
12th 21%
35.00% 35.7%
34.4%
11th 18%
30.00% 30.3%
30.2%
Current*
Frequent*
10th 15%
25.00% 26.0%

9th 11%
20.00% 20.9% 20.5%

18.2% 18.4%
17.7% 8th 7%
15.00% 15.5% 15.9% 16.0%

13.2%
7th 4%
10.00%
9.5%
8.9%
8.1%
6.9%
6th 2%
5.00%

0% 5% 10% 15% 20% 25%

0.00%
1993 1995 1997 1999 2001 2003 2005 2007 2009

Source: Massachusetts Youth Risk Behavior Survey Source: MA Department of Education, MA Department of Public Health.
• Current cigarette smoking = past 30 day use * Current cigarette use is reported use in the last 30 days.
• Frequent cigarette smoking = more than 20 of last 30 day use

Estimated Annual Smoking Cessation Return

Massachusetts on Investment
Commonwealth (March
Care Health Plans
2010 Data)
Estimated Annual Smoking Cessation Return on Investment (March 2010 Data)
$18,000,000.00

$16,000,000.00
Estimated Cost
$14,000,000.00 Medical Savings*

$12,000,000.00 Total 5-year ROI

$10,000,000.00
* Based on cost-benefit model at the Business Case ROI
$8,000,000.00 website. Incremental ROI is per participant. Calculations
run by the Massachusetts Department of Public Health,
$6,000,000.00 Tobacco Cessation and Prevention Program (MTCP) on
4/5/2010. Accessed at www.businesscaseroi.org
$4,000,000.00

$2,000,000.00

$-
Year 1 Year 2 Year 3 Year 4 Year 5 Total
$(2,000,000.00)

$(4,000,000.00)

Massachusetts Health Council 41

 Violence
V iolence is wholly destructive of the social fabric of a
community. The recorded statistics are startling in and
of themselves — e.g., 781 gunshot wounds, an average of 15
a week, and 1332 sharp instrument wounds of an assaultive
nature were reported by hospital emergency departments
to the MA Weapon Related Injury Surveillance System in
2009 — yet the statistics do not fully reflect the extent of the
violence problem. Certain crimes, such as sexual assaults,
intimate partner violence and child and elder abuse, may
be reported only sporadically. Injuries from assaults may be
treated as non-crimes in a physician’s office or health center,
and many assaults go unreported to medical personnel and
police, even when a physical injury has occurred.
Whatever the difficulties inherent in its reporting,
violence — the intentional use of physical force or
power against another person or persons — can have a
devastating, long-lasting effect on its victims. Quality of life,
physical health, and ability to carry on the daily business
of existence may all be compromised, especially if multiple
adverse experiences occurred during childhood. Violence
also negatively impacts society through high financial
and property damage costs, reduced productivity, and a
prevailing dread that can contribute to sedentary lifestyles
and social isolation.
For many types of violence, there is evidence of
overlap. According to MA Department of Public Health and
MA Department of Elementary and Secondary Education
survey findings, adults who had experienced intimate
partner violence were more likely to report also having
been the victims of unwanted sexual contact. A similar
pattern was found for dating violence victims. Children
who reported witnessing family violence were more likely
to report experiencing direct peer violence themselves
in the forms of bullying and dating violence. As a social
phenomenon, bullying has profound health and well-being
consequences for young people. Youth who are bullied are
five times more likely to become depressed. Bullied girls are
eight times more likely, and bullied boys four times more
likely, to be suicidal.
Trends
According to the FBI’s annual Uniform Crime
Report (UCR), a total of 30,136 violent crimes (murder
and non-negligent manslaughter, forcible rape, robbery,
and aggravated assault) were committed in Massachusetts
in 2009, a slight (0.8%) increase over 2008. At a rate of 457
violent crimes per 100,000 population, the Commonwealth
was once again, as in multiple previous years, statistically
the most violent state in the Northeast region (comprised of
42
the six New England states plus NY, NJ, and PA). Aggravated
assault (20,836) in the Bay State occurred at a rate of 316 per
100,000 in 2009, the highest of any state in the region and 20%
higher than the U.S. in total. Forcible rape (1,701), at a rate
of 26 per 100,000, a 3.2% decrease from 2008, was higher than
the region overall. However, in murder and non-negligent
manslaughter (172), Massachusetts’ rate of 2.6 per 100,000, a
2.2% increase over 2008, was lower than the region and the
U.S. in total. Robbery (7,427), at a rate of 113 per 100,000, a
4.2% increase over 2008, was also below the regional rate.
Many experts say that violence is preventable and that
the more we learn about the factors that increase or reduce
the likelihood of violence — known as risk and protective
factors — the greater the probability of putting effective
prevention strategies into place. The city of Boston may serve
as an example. In recent years, law enforcement officials have
worked particularly closely with neighborhood groups and
community activists on initiatives to reduce violent crime in
the city’s most troubled neighborhoods, mainly by targeting
gangs and known gang members who are likely to use guns.
As a result of their collaborative efforts, which include
community watch groups and the sharing of intelligence
about gang activity and crime patterns, Boston finished
2009 with its lowest number of homicides and shootings
since 2003. Violent crime in total declined 7%, 2009 vs. 2008.
Over the same one-year period, homicides committed with
a gun declined 27%, nonfatal shootings declined 29%, and
aggravated assaults declined 10%. Rape and attempted rape,
however, saw a 27% increase in 2009 as compared to 2008.
Groups at Risk
In 2009, nearly 15% of Massachusetts adult women
and 5% of adult men responded “Yes” to one or more of
the Department of Health’s BRFSS three survey questions
on whether they had experienced sexual violence at any
time in their lifetime. Sexual violence was defined as having
the sexual parts of the body touched without consent
or attempted or completed sex without consent. The
demographic breakdowns show that no age group, race-
ethnicity, educational level, or household income level
was unaffected by the problem of sexual violence. Within
age groups, women ages 45-54 (20%) most often responded
Yes to the survey’s sexual violence questions, followed by
25-34 year olds (18%). Black women (25%) were more likely
than Whites (14.5%) or Hispanics (7%) to say they had ever
experienced sexual violence, as were college-educated
women (16.5%) compared to high school graduates (7%).
Males with household incomes of less than $25,000 (10%)
were more likely to respond affirmatively than those in all
Massachusetts Health Council
higher income groups (3.5% to 5%). Disability status was a
major predictor of a Yes response: 30% percent of women
and 13% of men with a self-reported disability said they had
experienced sexual violence in their lifetime, compared to
11% of women and 3% of men with no disability.
Statistics regarding gay, lesbian, bisexual, and
transgender adults tell a comparable story. According to a
July 2009 MA Department of Public Health report on the
health of these populations in the Commonwealth, 14% of
gay men and lesbians reported a history of being threatened
by an intimate partner with violence in their lifetime, as did
18% of bisexuals and 35% of transgender persons. Four percent
of gay men and lesbians and 7% of bisexuals, compared to 2%
of heterosexuals, reported having had thoughts of suicide.
In 2009 as in past years, Bay State adolescents and young
adults were at particular risk due to acts of violence or threats
committed by others, or committed by them in response to
others, often at or near school. According to data from the
CDC’s 2009 Youth Risk Behavior Surveillance (YRBS) survey,
nearly one in five Massachusetts high school students (19%)
reported being bullied in school one or more times during
the past year. Thirteen percent of Massachusetts high school
students (females 5%, males 20%) said they carried a weapon
(e.g., a gun, knife, or club) on at least one day during the 30
days before the survey, and nearly 4% (females 1%, males 6%)
reported carrying a gun. Seven percent (females 4%, males
10%) said they had been threatened or injured with a weapon
on school property, and 9% (females 6%, males 12%) said
they had been in a physical fight on school property. Four
percent of high school students (split almost evenly between
the genders) said they did not go to school because they felt
unsafe at school or on their way to or from school. In their
responses to these and other violence-related questions, MA
students consistently placed below the U.S. median, meaning
that overall they were less likely than students nationally
to report fighting or injury, feeling unsafe, or engaging in
dangerous behaviors such as weapon-carrying that could
escalate into violence. Comparable percentages for the city
of Boston were, generally, not appreciably higher than for
Massachusetts as a whole, indicating that the youth violence
problem in the Bay State is not limited to large urban areas
but impacts suburban and rural populations as well.
As a measure of desperation, suicidal thoughts and
other destructive behaviors are a persistent problem for a
sizable number of Massachusetts youth. According to 2009
YRBS findings, nearly 14% (females 16%, males 11%) said
they had seriously considered attempting suicide during
the 12 months before the survey; 11% (females 12%, males
10%) said they made a suicide plan; 7% (split evenly between
the genders) said they had attempted suicide one or more
times; and 3% said their suicide attempt had been treated by
a doctor or nurse.
Massachusetts Health Council
Hate crimes are a particularly vile manifestation of
violence against select groups, crimes motivated in whole or
in part by a bias against the victim’s perceived race, religion,
ethnicity, sexual orientation, or disability. By Congressional
mandate dating to 1990, they are tracked and reported
yearly by the Federal Bureau of Investigation based on
reporting from local and state law enforcement agencies. In
Massachusetts, 351 agencies are charged with investigating
possible hate crime incidents. In 2008, the Commonwealth
reported 333 hate crimes, compared to 353 in 2007 and 379
in 2006. The distribution of cases by type has been consistent
over the three-year period. In 2008 they were: race 168 (50%);
religion 60 (18%); sexual orientation 66 (20%); ethnicity 34
(10%); and disability 5 (1.5%). These cases are clearly a matter
of degree. How many more, seemingly mundane instances
of violence against the vulnerable, occurring in school,
workplace, and home and neighborhood settings, are never
brought to the attention of law enforcement personnel and
thus never become part of the official statistics, remains an
open question.
References
Massachusetts Department of Public Health, Health of
Massachusetts, April 2010.
“Gunshot & Sharp Instrument Cases, MA Residents, 1994-
2009,” (Massachusetts Department of Public Health, Weapon
Related Injury Surveillance System), June 2010.
“Assault-related Gunshot & Sharp Instrument Cases,”
(Massachusetts Department of Public Health, Weapon
Related Injury Surveillance System), April 2009.
Crime in the United States, 2009 (U.S. Department of Justice,
Federal Bureau of Investigation), September 2010.
Preliminary Annual Uniform Crime Report, January-December 2009
(U.S. Department of Justice, Federal Bureau of Investigation),
May 2010.
“Violent crime down in Boston,” Boston Globe, November 25,
2009.
“Homicide rate falls to lowest level since ’03,” Boston Globe,
January 1, 2010.
A Profile of Health Among Massachusetts Adults, 2009: Results from
the Behavioral Risk Factor Surveillance System (Massachusetts
Department of Public Health, Bureau of Health Information,
Statistics, Research, and Evaluation), June 2010.
The Health of Lesbian, Gay, Bisexual and Transgender (LGBT) Persons
in Massachusetts (Massachusetts Department of Public Health),
July 2009.
U.S. Department of Health and Human Services, Centers
for Disease Control and Prevention, “Youth Risk Behavior
Surveillance — United States, 2009,” Surveillance Summaries,
MMWR, vol. 59, no. SS-5, June 4, 2010.
Hate Crime Statistics, 2008 (U.S. Department of Justice, Federal
Bureau of Investigation), November 2009.
43
 Violence continued
Policy Perspective
Massachusetts, like the rest of the U.S. and the world, experiences the impact of violence on its residents, particularly its
young people, every day. Violence is one of the ten leading causes of death for Massachusetts residents age 1-44, and ranks 2nd
for young people age 15-24. More shocking still are the dramatic disparities that we see within those numbers. For example,
young black men have a 36 times higher rate of death by homicide than do young white men.
Deaths and injuries are only the tip of the iceberg in terms of the impact of violence. Research repeatedly demonstrates
that experiences of violence can result in life-long health effects, including impacts to mental health and increased rates
of drug, alcohol and tobacco use, along with increased rates of chronic diseases such as diabetes, heart disease, obesity, and
asthma. These impacts also result in enormous financial costs to our health care system, which must be addressed if health
care reform is to succeed. The pernicious effects of violence reach deeply into communities through high property damage
costs, reduced worker productivity, and a sense of fear and dread that can contribute to social isolation for individuals,
families and communities.
The good news is that violence is preventable. The more we learn about the factors that contribute to violence and
the factors that support peace and safety, the more effective our policies and programs can be at reducing violence and its
devastating impacts. Each day, evidence mounts for the role that social determinants play in the prevalence of violence and
in the severity of its health consequences. While work that addresses individual perpetrators or victims is vitally important
for accountability and for healing, we must adopt programs and policies that prevent violence before it starts.
Violence is complex and no single prevention strategy is a cure-all. However, there are demonstrated strategies that
work and should be implemented and adapted to individual communities and settings.
• Research shows that for young people, a relationship to a caring adult is a key to their healthy development.
• Reducing access to firearms has been shown to reduce violence and the severity of injuries from violence.
• A third challenging strategy involves changing social norms that support violent attitudes and behavior. Such social justice
work must include addressing sexism which underlies gender-based violence, homophobia and its connection to hate crimes
against GLBT communities, or youth development activities that promote healthy alternatives to violence.
Ultimately, our commitment and support of healthy relationships, healthy communities and peace-seeking social
policy will reduce violence in our homes, schools and neighborhoods.

Carlene Pavlos
Director, Violence and Injury Prevention
MA Department of Public Health

44 Massachusetts Health Council

 Assault-Related Gunshot & Sharp Injury Cases Gunshot & Sharp Injury Cases Reported, MA Residents,
Rate per 100,000 residents, by Size of City or Town Gunshot & Sharp Injury 2004-2009
Cases Reported, MA Residents, 2004-2009
Assault Related Gunshot & sharp Injury Cases, Rate per
– 2009
100,000 Residents, by Size of City or Town - 2009
32.5
34.1
Rate per 100,000 34.2
Total Statewide Residents 35.1
34.9
31.3
2113
Under 25,000 2199
2202
Total Case Count 2245
2245
25,000-50,000
2009
1332
1397
2009
50,000-75,000 Sharp Instrument 1363
2008
Wounds 1346
1356 2007
1219
2006
75,000-150,000 781
2005
802
839 2004
Over 150,000 (Boston,
Gunshot Wounds 899
Worcester, Springfield) 889
790

0 10 20 30 40 50 60 70 80 0 500 1000 1500 2000 2500

Source: Massachusetts Department of Public Health, Injury Surveillance

Source: Massachusetts Department of Public Health, Weapon-Re-
System
lated Injury Surveillance System

Hate Crimes and Number of Incidents and Sexual Violence Experienced by Age Group — MA
Bias Motivation, 2006-2008 Sexual Violence Experienced
Adults, by Age Group — MA Adults, 2009
2009
Hate Crimes and Number of Incidents and Bias Motivation,
2006-2008
0.2

TOTAL 0.18

0.16
Disability
Women
0.14
Men
Ethnicity 0.12
2006 2007 2008
0.1
Sexual Orientation
0.08

Religion 0.06

0.04
Race
0.02

0 50 100 150 200 250 300 350 400 0

18-24 25-34 35-44 45-54 55-64 65-74

Source: U.S. Department of Justice, Federal Bureau of Investigation * Insufficient Data

Source: Massachusetts Department of Public Health, Behavioral Risk
Factor Surveillance System

Violent Crime Trends – Boston and Massachusetts – 2009* vs. 2008

All Violent Crime Murder Forceable Rape Robbery Aggravated

Assault
Boston 2008 6,676 62 237 2,398 3,979
Boston 2009 6,192 50 269 2,227 3,596
% change (7.2%) (19.4%) +13.5% (7.1%) (9.6%)
(improvement)

Mass. 2008 29,888 167 1,744 7,071 20,906

Mass. 2009 30,136 172 1,701 7,427 20,836
% change +0.8% +3.0% (2.5%) +5.0% (0.3%)
(improvement)
*All 2009 data are preliminary and may reflect somewhat different reporting standards among agencies.
Source: FBI Uniform Crime Report

Massachusetts Health Council 45

NOTES
NOTES
NOTES
NOTES
 -Dedicated to improving health for all in Massachusetts by promoting
affordable, safe and coordinated healthcare-

2010

2010