NORTHSIDE

HEALTH CARE

NorthSide: Health Care

Summary A recent analysis conducted by St. Louis City rated the two primary zip codes of the NorthSide area, 63106 and 63107, as the zip codes of most concern in the city. This rating is attributable to several health care indicators such as the areas extreme poverty and high unemployment, the prevalence of vacant lots, the rate of avoidable hospitalizations, the number of emergency room visits, and the overall mortality rate of the area. The NorthSide population heavily relies on government programs such as food stamps and Medicaid. An estimated 57% of the NorthSide residents receive food stamp assistance, which is more than twice the proportion of St. Louis City and more than four times the proportion as the St. Louis metropolitan area or Missouri. The NorthSide population also receives substantial assistance from Medicaid. On a per capita basis, the amount of Medicaid spending attributable to the area is an estimated 67% higher than St. Louis City and nearly three times as much as either the St. Louis metropolitan area or Missouri. The NorthSide area has been the victim of a steady de-population, an eroding tax base, and health disparities that mimic those of third world countries (North St. Louis Health Care Access Study Task Force1 & 2, v). The capability of a population to contribute productively to a community depends to a great extent on its overall health. Yet, looking at the health of the population of the NorthSide area of St. Louis, it is clear that the health status of the area ranks as the worst of any area of St. Louis. The City of St. Louis Health Departments 2007 update to its publication, Public Health: Understanding Our Needs gives the NorthSide area3, represented by all of zip code 63106 and the southern portion of zip code 63107, a 3.23 rating, the highest all zip codes in the city and representing two of the three zip codes of most concern4 (City of St. Louis Department of Health, 2). The major factors that contribute to these ratings are derived from several categories of data including demographic, socio-economic, quality and access, epidemic, environmental, injurious and behavioral

www.mowonk.com

NORTHSIDE

HEALTH CARE

Table 1: Demographic Indicators

Indicator10 Overall Population Population Change 0-4 Age Cohort 15-24 Age Cohort 65+ Age Cohort 15 to 44 Female Age Cohort Crude Birth Rate* Fertility Rate* Crude Death Rate** Racial Polarization (% Black) 63106 (15) 10,875 (13) 3.1% (1) 11.8% (9) 15% (13) 10.4% (4) 23.7% (1) 26.5 (2) 113.2 (6) 1386.7 (3) 93.6% 63107 (12) 16,083 (4) -1.4% (5) 8.6% (6) 15.5% (9) 11.8% (13) 21.4% (4) 17.2 (4) 80. (7) 1303.6 (7) 89.5% St. Louis City 353837 1.60% 7.30% 13.70% 12.40% 22.10% 15.1 66.5 1107.9 50.90% Missouri 5,810,759 3.90% 6.40% 15% 13.60% 20.60% 13.7 64.1 970 11.40%

Source: City of St. Louis Department of Health, 6-27 * Per every 1,000 population ** Per every 100,000 population factors, and causes of death. The data from the study primarily came from years 2002-2005 with some additional data coming from 2006 (City of St. Louis Health Department, iii).

Socio-Economics
In terms of socio-economic indicators, both zip codes 63106 and 63107 were ranked in the top 5 zip codes of most concern in every indicator except one, the crimes against property indicator where zip code 63107 was rated of the 9th most concern. The 63106 zip code was rated the zip code of most concern (1st) in `ive of the eight indicators. Four of the `ive areas were all linked to economic indicators: income, poverty, employment, and education attainment; they are correlated with negative public health and health outcomes related to indicators such as lead poisoning, infant mortality, sexually transmitted diseases, mortality and morbidity rates and environmental conditions (City of

Demographics
In terms of demographics factors, zip codes 63106 and 63107 were ranked5 1st & 5th respectively in the 0-4 age cohort indicator6, 1st and 4th respectively in crude birth rate7, 2nd and 4th respectively in fertility rate8, and 3rd and 7th respectively in racial polarization9 (City of St. Louis Department of Health, 6-27). Table 1 shows how zip codes 63106 and 63107 ranked in each of the demographic indicators.

www.mowonk.com

NORTHSIDE

HEALTH CARE

Table 2: Socioeconomic Indicators

Indicator Average Household Income Households Below Poverty Female Head of Household Education Level Unemployment Rates Crimes Against Property* Crimes Against Persons* Vacant Lots 63106 (1) $22,597 (1) 25.8% (1) 29.8% (1) 58.1% (1) 16.3% (5) 151.2 (4) 51.2 (3) 981 63107 (5) $32,373 (3) 22.6% (3) 22.6% (2) 58.3% (2) 15.9% (9) 128.9 (5) 44.9 (2) 1109 St. Louis $44,111 10.90% 12.40% 71.60% 7% 116.7 23.9 296 Missouri $58,555 5.90% 8% 81.50% 4.80% 40 5.4 NAV

Source: City of St. Louis Department of Health, 30-45 * Per every 1,000 population

St. Louis Health Department, 30). These health outcomes start even at lifes earliest beginnings and are inextricably coupled to the socioeconomic status of both the mother and the father. If the parents are living at the lower socioeconomic rung of society- so will the children- and a spectrum of disparities across diseases and injuries will continue into adulthood, resulting in a vicious and repetitive cycle (North St. Louis HCASTF, 4). Additionally, for the other two socioeconomic indicators, crime and vacant lots, crime leads to instability in an areas economy and among its youth while vacant lots cause sanitation and vector problems (City of St. Louis Health Department, 44-48).

Access and Quality

While the characteristics of the population of the NorthSide area contributes to poor health outcomes, residents in the area also suffer from a lack of health care access and quality to address these issues. Overall, the North St. Louis area suffers from fewer physicians, dentists and health care professionals when compared to the rest of St. Louis; additionally, the area lacks adequate health facilities to serve the population (North St. Louis HCASTF, 32-35). The Access and Quality indicators in the City of St. Louis Health Departments publication suggest the same. Zip codes 63106 and 63107 rank 4th and 5th respectively in hospital

www.mowonk.com

NORTHSIDE

HEALTH CARE

Table 3: Access and Quality Indicators

Indicator Hospital Admission Rates* Avoidable Hospitalizations* Emergency Room Visits* Medicaid Eligible Prenatal Care Low Birth Weight Teen Pregnancy 10 to 17 Teen Pregnancy 10 to 14 Infant Mortality** Out-of-Wedlock Births Teen Abortions 10 to 17*** Birth- Medicaid Birth- WIC Birth Food Stamps Birth- Smoking Birth- Alcohol Birth-Education 63106 (4) 233.4 (1) 37.9 (3) 719.3 (1) 54.4% (4) 21.2% (12) 12.3% (3) 11.3% (3) 1% (7) 15.2 63107 (5) 208. (4) 31.3 (6) 572.8 (3) 42.1% (8) 20.2% (2) 16.4% (5) 10% (6) 0.6% (8) 13.7 St. Louis City 153.5 19.8 406.2 26.40% 15.50% 12% 6.70% 0.50% 11.9 Missouri 135.5 12.9 361.5 NA 11.90% 8.10% 3.50% 0.20% 7.8 36.40% 205.5 46.30% 41% 21.40% 18.10% 0.60% 18.60%

(1) 90.8% 65.90% Graph 3: 2010 H(3) 8School Dropout Rate igh 8.2% (14) 179.3 (1) 82.4% (1) 73% (1) 62.1% (9) 15.7% (14) 0.5% (4) 39.7% (11) 192.3 (2) 81.4% (2) 72.1% (2) 60.5% (4) 19.6% (16) 0.4% (2) 40.9% 214.9 63.70% 56.90% 42.10% 15.90% 0.80% 31.40%

Source: City of St. Louis Department of Health, 47-85 * Per every 1,000 population ** Deaths per every 1,000 live births *** Per every 1,000 pregnancies

www.mowonk.com

NORTHSIDE

HEALTH CARE

admission rates11, 1st and 4th respectively in avoidable hospitalization rates12, and 3rd and 6th respectively in emergency room visits13 (City of St. Louis Health Department, 52-57). There is a clear void in the area in terms of preventing health problems, educating

residents on health strategies, and speci`ically being able to afford quality health care. In a health care access study of North St. Louis City, focus groups held with area residents commented on the accessibility and quality of health care available to them.14

If you dont have insurance, lucky Ive got some, but if you dont have insurance, when you go to these hospitals, they got two signs on the wall, no cellular phones be used and we will stabilize you but we cant, we dont have to keep you, you go to your primary doctor So thats on the walls of these hospitals (North St. Louis HCASTF, 49). If somebody go in the emergency room or hospital and they go in with high blood pressure, they will not give these peoples the medicine they need- what they do is work on them that night, get their blood pressure down, tell them to go to a clinic the next day knowing that the people wont get into clinics until three months later because everybody is overcrowded. (North St. Louis HCASTF, 49). And a lot of Afro-Americans North St. Louis theyll wind up dying because they cant get medical help when its needed or go to aor one of the hospitals and they have to sit in a waiting room for hours and hours before theyre seen, even after seen theyre referred to a, a neighborhood clinic that really cant do a whole lot for them. (North St. Louis HCASTF, 49). I get Medicaid and I get Red, White, and Blue--. Im disabled. But then still again, when I go to the emergency room, when they see me, they send me back out in the lobby, you have to sit out there four or Kive hours before you get seen. If you aint got no good insurance, youre going to have to sit there all day [while] persons with insurance are seen. (North St. Louis HCASTF, 50). The clinics are understaffed, thats why you have to go back the next day. You know, theyre understaffed. All the workers seem like theyre stressed because they all seem like theyre underpaid and overworked because you have one person doing three peoples jobs and thats not good. (North St. Louis HCASTF, 50). Well healthcare for me basically is either the clinic or the ER because I cant, no insurance, Im not going anywhere else. And for me to go to any one of them places I got to be feeling bad. I mean, because Im going to take it for a couple days Kirst and until I cant move or something then take me to the hospital or something. Thats my healthcare. (North St. Louis HCASTF, 54).

www.mowonk.com

NORTHSIDE

HEALTH CARE

But go to a doctor and have a primary physician and that kind of thing, thats considered a luxury Poor people go to the emergency room when theyre sick. (North St. Louis HCASTF, 53). And thats why the emergency rooms are loaded. Because when they say go to the doctor? I aint got no money for that. (North St. Louis HCASTF, 54). Not surprisingly, the NorthSide area also leads the city in Medicaid eligibility, the percentage of mothers who give birth while participating in Medicaid, the percentage of mothers participating in the Women Infants and Children (WIC) Program at the time they give birth, and the percentage of mothers who participate in the food stamp program at the time they give birth; all are indicators of the poverty in the area (City of St. Louis Health Department, 74-79). Additionally, the area ranks at the top in out-of-wedlock births and near the top in teen pregnancy for ages 10-14 and ages 10-17 as well as the education attainment of the mother at the time they give birth with roughly 40% of the mothers lacking a high school education. While the evidence clearly shows that the NorthSide lacks quality and accessible health care, it does not directly show the factors that contribute to the poor health outcomes of its residents speci`ically in regard to the availability of healthy food. In focus groups, residents of North St. Louis complained about the predominance of liquor stores and shortage of places to access food and expressed frustrations with having to leave North St. Louis to access all types of resources (North St. Louis HCASTF, 52). The excerpts below were taken from the focus group sessions of North St. Louis residents:15

And one other thing about our community is that you can walk a half a block from your home and you right in a liquor store. We have liquor stores all around in our residential areas. You do not see that in Ladue, ChesterKield, its in a certain spot they are all around us, even near the churches (North St. Louis HCASTF, 52). One of the biggest problems and my issue is that we dont have a big community grocery store in our neighborhood. It really doesnt make sense, it really hurts a lot of, it really hurt a lot of people in the neighborhood and mainly seniors (North St. Louis HCASTF, 52). There are not a lot of resources available in our community. We have to go out into the suburbs and to the outskirts of the, we have to out to the suburbs to shop and put our money in their communities. They [whites] have communities and we have neighborhoods, which makes it where they [whites] have resources and we dont have resources (North St. Louis HCASTF, 52).

www.mowonk.com

NORTHSIDE

HEALTH CARE

A 2009 United States Department of Agriculture report on food deserts con`irms these residents statements. The 2008 federal legislation that called for the report, H.R. 6124, de`ined a food desert as an area in the United States with limited access to affordable and nutritious food, particularly such an area composed of predominantly lower-income neighborhoods and communities (H.R. 6124, Section 7527). The report discusses food accessibility in urban areas and speci`ically comments that the situation looks more severe in the St. Louis area in comparison to the Washington D.C. area. The study goes on to state that there are several low-income

grids with moderate to high densities that are more than a mile from a supermarket, especially in the central and northern parts of St. Louis, Missouri (USDA, 25). The following map of the St. Louis area is contained in the report as Map 2.3; the City of St. Louis is located immediately left of the light blue line running from top to bottom (the Mississippi River) while the western border of the city is outlined by the dashed line. Food deserts are located in the bubble-shaped areas on the map; the low-income areas are within the thick black-lined borders. Nearly all of the north part of St. Louis City is contained in a bubble.

Source: USDA and Economic Research Service, Access to Affordable and Nutritious

www.mowonk.com

NORTHSIDE

HEALTH CARE

Table 4: Epidemics Indicators

Indicator* HIV Infection AIDS Cases AIDS Mortality Syphilis Gonorrhea Chlamydia TB Cases Hepatitis A Hepatitis B Zip Code 63106 (9) 30.2 (14) 10.1 (3) 17.4 (14) 5.0 (2) 1453.2 (1) 2401.1 (4) 10.1 (11) 0 (5) 7.5 Zip Code 63107 (12) 26.9 (13) 10.1 (10) 9.4 (5) 10.1 (3) 1412.2 (2) 1978.3 (2) 16.8 (12) 0 (7) 6.7 St. Louis City 34.9 13.8 9.3 8.2 755.1 1130.8 6.4 0.7 5.7 Missouri 6.1 1.9 2.2 1.5 161.3 347.8 2.2 0.8 3.1

Source: City of St. Louis Department of Health, 87-105 *Incidences per 100,000 population

Epidemics
The City of St. Louis Department of Health 2007 publication de`ines an epidemic as the occurrence in a community or region of cases of an illness, speci`ic health-related behavior, or other health-related events clearly in excess of normal expectancy (City of St. Louis Department of Health, 146). Based on the

report, the NorthSide area ranks at the top of the city in incidences of Chlamydia with a rank of 1st and 2nd respectively for zip codes 63106 and 63107, and near the top for incidences of Gonorrhea, cases of tuberculosis, AIDS mortality, and cases of Hepatitis B (City of St. Louis Department of Health, 87-105). Table 4 shows the epidemics indicators.

Table 5: Environmental Indicators

Indicator* Lead Poisoning* Asthma** Foodborne Illness*** Zip Code 63106 (14) 4.1 (1) 8.3 (1) 17.6 Zip Code 63107 (2) 14.4 (2) 6.3 (10) 11.8 St. Louis City 7 3 10 Missouri 2.8 1.4 35.1

Source: City of St. Louis Department of Health, 107-113 *% poisoned for every 100 tested **Incidences per 1,000 population ***Per every 100,000 population

www.mowonk.com

NORTHSIDE

HEALTH CARE

Environmental
In some cases, the external environment can cause problems with its populations health. This is especially true for the NorthSide area as zip codes 63106 and 63107 rank at the top, 1st and 2nd respectively, in hospitalization cases of asthma between 2002 and 2005. Zip code 63106 also ranks 1st in foodborne illnesses while the 63107 zip code ranks 2nd in cases of lead poisoning (City of St. Louis Department of Health, 107-113). Table 5 shows the environmental indicators.

related, non-motor vehicle related, and overall, as well as deaths caused by behavior such as suicide and homicide. Table 6 shows how zip codes 63106 and 63107 rank for these indicators.

Causes of Death
The NorthSide area ranks near the top in almost every indicator relating to causes of death. Table 7 shows how the area ranks in terms of overall mortality, heart disease mortality16, cancer mortality, CVA mortality17, in`luenza and pneumonia, COPD mortality18, diabetes mortality, and life expectancy in years.

Injury and Behavior

The 2007 City of St. Louis Department of Health publication also provides statistics on the prevalence of injuries, motor vehicle

Table 6: Injury and Behavior Indicators

Indicator* Motor Vehicle Accident Mortality Non-motor Vehicle Accident Overall Accident Mortality Homicide Suicide Zip Code 63106 (15) 8.6 (8) 41.4 (10) 50.1 (5) 47.9 (13) 8.6 Zip Code 63107 (7) 18.4 (4) 56.3 (4) 74.7 (4) 54.8 (7) 13 St. Louis City 14.1 37.7 51.8 24.8 12 Missouri 20.2 25.4 45.4 6.7 12.1

Source: City of St. Louis Department of Health, 115-127 *Per every 100,000 population

www.mowonk.com

NORTHSIDE

HEALTH CARE

Table 7: Causes of Death

Indicator* Overall Mortality* Heart Disease Mortality* Cancer Mortality* CVA Mortality* In`luenza and Pneumonia* COPD Mortality* Diabetes Mortality* Life Expectancy in Years Zip Code 63106 (3) 1564.1 (3) 418.2 (3) 336.4 (2) 89.3 (8) 34.5 (3) 57.5 (2) 71.9 (2) 65.1 Zip Code 63107 (4) 1346.4 (5) 369.2 (5) 268.2 (6) 71.9 (2) 48.4 (8) 41.8 (4) 55.6 (4) 68.1 St. Louis City 1097.2 321.3 232.2 64.5 34.5 39.7 37.4 73 Missouri 894 256.3 200.2 57.8 48.4 47 25.5 76.8

Source: City of St. Louis Department of Health, 130-145 *Age-adjusted per every 100,000 population

2000-2010 Trend for Health Indicators

A recent report by the St. Louis Regional Health Commission, Decade Review of Health Status for St. Louis City and County 2000-2010 provided a mixed bag for whether health was improving in the two zip codes of the analysis, 63106 and 63107. The heart disease hospitalization rate improved for zip code 63106 over the decade but worsened when compared to the regional norm for zip code 63107. The same trend held for both zip codes in terms of hospitalization rates for diabetes.

The hospitalization rate for strokes in the 63107 zip code worsened over the course of the decade when compared to the norm for the region. The analysis also reported that both zip codeschronic obstructive pulmonary disease (emphysema, bronchitis, and other respiratory diseases) rates worsened over the course of the decade. The prevalence of childhood asthma signi`icantly worsened in zip code 63107 when compared to the region. Additionally, the rate of sexually transmitted disease infections improved for both zip codes over the course of the decade when compared to the region (St. Louis Regional Health Commission).

www.mowonk.com

10

NORTHSIDE

HEALTH CARE

Federal, State, and Other Spending on Health Care

State and federal governments have several programs to pay for the health care of its residents. The food stamps program19 and Medicaid assists low-income individuals while Medicare primarily serves the sixty-`ive or older population. The following analysis aims to estimate of the amount spent by federal and state governments for such programs in the NorthSide area of St. Louis. estimate, the data includes several years for which this expansion is not included.21 As a result, Missouri Wonk will adjust the `igure to account for this change by applying the difference between the `ive-year and one- year estimates of St. Louis City; the difference is a 20.9%22 increase in the population receiving food stamps. Using this `igure, Missouri Wonk estimates that 3,091, or 57.4%, of NorthSide households received food stamp bene`its in 2010.23 In 2010, Missouri households received a total of $1,332,800,000 in food stamps (Missouri Department of Social Services, 7). According to the census bureau, there were 313,472 households in Missouri that received food stamps in the past twelve months (United States Bureau of the Census 2011, 4). This results in an average of $4,252 in food stamps annually per household. Using these `igures, Missouri Wonk estimates that NorthSide area

Food Stamps/SNAP
Of the 5,385 households in the NorthSide area20, the 2010 American Community Surveys 5-year estimates indicate that about 47.5%, or 2,557 households received food stamps; the food stamp program is funded by the federal government and administered by the state. However, this number is likely lower than the actual number because the U.S. Congress expanded the SNAP program in 2008; since the ACS estimate is a `ive-year

Table 8: Estimates of Food Stamp Assistance

Households Receiving Food Stamps 3,091 37,319 100,313 313,472 Number of Households 5,385 142,152 797,660 2,350,268 % of Households Estimated Receiving Food Amount of Food Stamps Stamps 57.4% 26.3% 12.6% 13.3% $13,142,932 $158,680,388 $426,530,876 $1,332,800,000

Area NorthSide STL City STL Metro Missouri

Sources: American Community Survey, 1-year and 5-year estimates Missouri Department of Social Services, 2010 Annual Report

www.mowonk.com

11

NORTHSIDE

HEALTH CARE

Graph 1: Percentage of Households Receiving Food Stamps

70.00%$ 60.00%$ 50.00%$ 40.00%$ 30.00%$ 20.00%$ 10.00%$ 0.00%$ NorthSide$ STL$City$ STL$Metro$ Missouri$

households received a total of $13,142,932 in food stamps in 2010. Missouri Wonk can also use the one-year American Community Survey estimates to determine the number of households and projected amount of food stamp funding for the City of St. Louis, the St. Louis Metropolitan Area, and Missouri. These estimates are provided in Table 8. According to estimates from the Congressional Budget Of`ice, participation and spending on food stamps is expected to grow in the short term, through 2013 or 2014, but start to decline in the long term, from 2014 through 2022.

Medicare
Medicare primarily serves ages sixty-`ive and older. However, there are certain cases where those younger than sixty-`ive can receive coverage under the program.24 Medicare enrollment `igures are not readily available for the NorthSide area but Missouri Wonk can estimate the number of enrollees by applying the Medicare enrollment `igures of age groups from the 2010 American Community Survey for St. Louis City to the population of the NorthSide. The 2010 American Community Survey reports that 1.1% of St. Louis City residents under the age of

www.mowonk.com

12

NORTHSIDE

HEALTH CARE

Table 9: Estimate of NorthSide Population with Medicare Coverage

Age Group Under 18 Years Ages 18 to 64 65 Years and Over Total

NorthSide Area Population 4,541 8,272 2,008 14,821

Population with Medicare Coverage 50 414 1,950 2,414

Source: American Community Survey 2010, 5-Year Estimates

Table 10: Medicare Spending

Area NorthSide STL City STL Metro Missouri Estimated Total Estimated Estimated Total % of Population Population with Medicare Population with Medicare Medicare Spending 2,414 44,052 288,031 939,617 14,821 313,158 1,966,839 5,843,454 16.3% 14.6% 14.6% 16.1% $24,859,372 $453,647,496 $2,966,143,238 $9,676,175,866

Source: American Community Survey 2010, 5-Year Estimates

eighteen, 5% of residents between the ages of eighteen and sixty-four, and 97.1% of residents sixty-`ive or older had Medicare coverage (ACS 2010, 5-year estimates). Estimates of the population with Medicare coverage by age group are provided in Table 9 and the amount of Medicare spending attributable to this population is provided in Table 10. Medicare spending will likely exceed in`lation over the course of the next nine

years. According to the National Health Expenditure projections, Medicare spending will have an average annual growth rate of more than 7% between 2011 and 2021 (Centers for Medicare and Medicaid Services, 22). This forecast incorporates the impacts from the Affordable Care Act, the health care legislation approved by Congress and President Obama in 2010.

www.mowonk.com

13

NORTHSIDE

HEALTH CARE

Graph 2: Estimated Per Capita Medicare Spending by Region

$1,700&& $1,650&& $1,600&& $1,550&& $1,500&& $1,450&& $1,400&& $1,350&& $1,300&& NorthSide& STL&City& STL&Metro& Missouri&

Medicaid
The census does not provide estimates for the number of residents enrolled in Medicaid by census tract level. The agency started asking health insurance questions in 2008; as a result, health insurance data is only available for de`ined areas with larger populations until they release the 2008-2012 5year estimates. However, there is information for St. Louis City regarding Medicaid enrollment. Since Medicaid eligibility is based on income, Missouri Wonk will use the poverty by ratio of income responses to extrapolate the number of residents who were covered by

Medicaid in 2010 in the NorthSide area. First Missouri Wonk gathered information for St. Louis City regarding health insurance coverage by age group by poverty status and determined the percentage of population by ratio of poverty level that had Medicaid coverage. Next, Missouri Wonk collected information regarding poverty status by ratio of income for the NorthSide area. Then, the St. Louis percentages of the populations with Medicaid coverage by ratio of income to poverty level were applied to the ratio of income to poverty levels of the NorthSide area to estimate the number of residents in each age category (under 18, 18-64, and 65 and older) with Medicaid coverage. After conducting this analysis, Missouri Wonk

www.mowonk.com

14

NORTHSIDE

HEALTH CARE

Medicaid Coverage
Medicaid covers four different populations: children, aged, blind and disabled, pregnant women, and adults. Children Medicaid covers costs for children in households with incomes below 150% of the federal poverty level; the state and federal government split this cost. SCHIP, a program almost entirely `inanced by the federal government, provides Medicaid coverage to children in households with incomes greater than 150% but less than 300% of the federal poverty level; there is a premium associated with this coverage. Aged Medicaid provides coverage for those 65 or older with incomes at or below 85% of the federal poverty level. Blind & Disabled Medicaid provides coverage for blind individuals with incomes at or below 100% of the federal poverty level and disabled individuals at or below 85% of the federal poverty level. Adults Medicaid provides coverage for pregnant women with incomes at or below 185% of the federal poverty level and for individuals below approximately 19% of the federal poverty level. estimates that 38% of the NorthSide residents have Medicaid coverage; broken down by age group, this results in 68.8% of the population under age18, 20.8% of the population between the ages of 18 and 64, and 35.2% of ages 65 or older that have Medicaid coverage. Of the 68.8% of the population under the age of 18 with Medicaid coverage, an estimated 88% receives traditional Medicaid coverage, with the remaining 12% receiving coverage through SCHIP. Determining the number of individuals in each Medicaid category requires further analysis. While the aforementioned estimates provide counts for children and the aged in the NorthSide area receiving

www.mowonk.com

15

NORTHSIDE

HEALTH CARE

Table 11: NorthSide Area Estimated Medicaid Enrollees by Category

Children 2,749 Aged 707 Blind & Disabled 1,150 Adults 571

Medicaid coverage, Missouri Wonk needs to determine the number of individuals in the 18-64 age group who fall in the blind and disabled and adult categories. While the percentage of the NorthSide area population with a disability and with Medicaid coverage is likely larger than St. Louis City or Missouri because of the extreme poverty in the area, there is no readily available information to suggest how much larger. To obtain an estimate, Missouri Wonk used linear regression analysis to project the percentage of the disabled population with Medicaid coverage. To make this projection, Missouri Wonk took median income and disabilities census data for 55 counties in Missouri (the census

requires certain population requirements for the disabilities data which is why there is 55 counties instead of 115). Using statistical analysis software, STATA, Missouri Wonk ran a regression analysis of the county median income against the percentage of the population ages 18-64 with a disability and covered by public health coverage. With a median income of $18,025 in the NorthSide area, the model estimates that 13.9% of the population is both disabled and with public health coverage.25 The remaining 6.9% of the 18-64 age group is expected to fall in the adult Medicaid category. These percentages by categories result in the estimates for the number of NorthSide residents enrolled in Medicaid by category contained in Table 11.

Table 12: Missouri Medicaid Spending by Category

Category Number of Enrollees Spending for Category Average Annual Spending per Enrollee Children 530,529 $1,640,500,000 $3,092 Aged 77,296 $1,262,400,000 $16,332 Blind and Disabled 160,740 $2,969,200,000 $18,472 Adults 109,795 $584,400,000 $5,323

Source: Missouri Department of Social Services 2010 Annual Report

www.mowonk.com

16

NORTHSIDE

HEALTH CARE

Table 13: NorthSide Medicaid Population Spending by Category

Category Number of Enrollees Average Annual Spending per Enrollee Total Children 3,125 $3,092 $9,662,500 Aged 707 $16,332 $11,546,724 Blind & Disabled 1,150 $18,472 $21,242,800 Adults 571 $5,323 $3,039,433

The Missouri Department of Social Services 2010 Annual Report stated that there was a total of $6.457 billion spent in `iscal year 2010 on MoHealthNet, Missouris Medicaid program. Using the `igures provided in the report, there was a per enrollee spending average by category of the amounts contained in Table 12. Applying these same per enrollee annual spending amounts to the estimated number of NorthSide Medicaid

enrollees by category results in the `igures contained in Table 13. Using census information, Missouri Wonk can also estimate the amount of spending for St. Louis City and the St. Louis metropolitan area. Table 14 summarizes the number of enrollees by each Medicaid category for the NorthSide area, the City of St. Louis, the St. Louis metropolitan area, and Missouri.

Table 14: Estimate of the Number of Medicaid Enrollees by Category

Area NorthSide STL City STL Metro Missouri Children 3,125 31,164 117,954 530,529 Aged 707 7,263 26,460 77,296 Blind & Disabled 1,150 15,692 57,371 160,740 Adults 571 13,043 27,386 109,795

Note: The number of children for the NorthSide, St. Louis City, and St. Louis metropolitan areas may be underrepresented because the number of children with Medicaid coverage reported for Missouri by the census, 446,381, was signi`icantly lower than the number reported by the Missouri Department of Social Services, 530,529. Sources: American Community Survey, 5-year Estimates Missouri Department of Social Services 2010 Annual Report

www.mowonk.com

17

NORTHSIDE

HEALTH CARE

Table 15: Total and Per Capita Medicaid Spending Estimates

Area NorthSide STL City STL Metro Missouri

Medicaid Spending (in millions) $45.49 $574.27 $2,002.39 $6,456.42

Population 14,821 313,158 1,966,839 5,988,927

Medicaid Spending per Capita $3,069 $1,833 $1,018 $1,078

The amount of per capita Medicaid spending for each area is contained in Table 15. Of the $6.456 billion 26 in Medicaid spending in `iscal year 2010 in Missouri, the Missouri Foundation for Health estimates that 52.55% came from federal sources, 18.01% came from state general revenue, and 29.44% came from other sources, primarily Federal

Reimbursement Allowance taxes levied on hospitals, pharmaceuticals, managed care companies, and nursing facilities (Missouri Foundation for Health, 9). The estimated amounts spent in each area by source are shown in Table 16. The amount of spending for each area by source is also presented in Graph 3.

Table 16: Estimated Per Capita Medicaid Spending by Source

State General Revenue $553 $330 $183 $194 Total Medicaid Spending per Capita $3,070 $1,833 $1,018 $1,078

Area NorthSide STL City STL Metro Missouri

Federal Sources $1,613 $963 $535 $566

Other Sources $904 $540 $300 $318

www.mowonk.com

18

NORTHSIDE

HEALTH CARE

Graph 3: Estimated Per Capita Medicaid Spending

Missouri#

STL#Metro#

Federal# State# Other#

STL#City#

NorthSide# $0# $1,000# $2,000# $3,000# $4,000#

According to National Health Expenditure forecasts, the amount of federal Medicaid expenditures is expected to grow at an annual average rate of more than 9% between 2011 and 2021; the amount of state Medicaid expenditures is expected to grow at an average annual rate of 10.8% over the same time period (Centers for Medicare and Medicaid Services, 22). These projections account for the expansion of Medicaid that was part of the 2010 federal health care law.

charity care and bad debt of these health care providers. Charity care is free or reduced cost services provided to low income persons. Bad debt is the amount owed by patients to health care providers, which the providers are unable to collect. A report by the Missouri Hospital Association pegged the amount of uncompensated care provided by Missouri hospitals at more than $967 million in 2010 (Missouri Hospital Association, 3). While some of this cost is covered by federal and state governments, a large portion of uncompensated care is not. To offset this cost, providers charge more for services purchased by the private market, a practice often referred to as cost shifting. The practice results in a hidden tax on private

Uncompensated Care
In some cases, health care providers furnish health services to low income and uninsured populations in the form of uncompensated care. Uncompensated care is the sum of

www.mowonk.com

19

NORTHSIDE

HEALTH CARE

entities that purchase services from hospitals, chie`ly insurance companies and private health plans. These costs are most likely passed on to individual households. The amount of uncompensated care attributable to an area is largely dependent upon the number of residents that lack health insurance. While the U.S. Census Bureau does inquire about the health insurance status of its respondents, the agency began asking the questions in 2008, which means that the number of residents in the NorthSide that lacks health insurance is unavailable at this time. However, because a lack of health insurance coverage is linked with lower incomes

(DeNavas-Walt, 27) and the NorthSide area has a lower average and median income than St. Louis City, the St. Louis metropolitan area, or Missouri, it is very likely that a larger share of uncompensated care is attributable to the NorthSide population than the three areas of comparison. The size and scope of this disparity, however, will likely change in the next several years as Missouri grapples with whether or not to expand Medicaid coverage to uninsured individuals under the Affordable Care Act.

Summary
A recent analysis conducted by St. Louis City rated the two primary zip codes of the NorthSide area, 63106 and 63107, as the zip codes of most concern in the city. This rating is attributable to several health care indicators such as the areas extreme poverty and high unemployment, the prevalence of vacant lots, the rate of avoidable hospitalizations, the number of emergency room visits, and the overall mortality rate of the area. The NorthSide population heavily relies on government programs such as food stamps and Medicaid. An estimated 57% of NorthSide area residents receive food stamp assistance, which is more than twice the proportion of St. Louis City and more than four times the proportion as the St. Louis metropolitan area or Missouri. The NorthSide population also receives substantial assistance from Medicaid. On a per capita basis, the amount of Medicaid spending attributable to the area is an estimated 67% higher than St. Louis City and nearly three times as much as either the St. Louis metropolitan area or Missouri.

www.mowonk.com

20

NORTHSIDE

HEALTH CARE

Data, Sources, and Area

Relying on census data from 1970-2010, Missouri Wonk can show how the demographics of the population have changed for the NorthSide area. The area of focus in this analysis is the geographic region encompassed by census tracts census tracts 1115, 1202, 1212, 1257, 1266, 1271, and 1275 of the 2010 census. The area is shown below.

Figure 1: NorthSide Area 2010 Census Tracts

1202

1115

1271 1266

1212

1275

1257

Source: Map produced with Geolytics software, ACS 2006-2010 Interface. Note: Numbers above denote census tract numbers used by United States Bureau of the Census.

www.mowonk.com

21

NORTHSIDE

HEALTH CARE

Figure 2: NorthSide Area in Context of St. Louis City

Source: Map produced with Geolytics software, ACS 2006-2010 Interface. Note: The area shown highlighted in red stripes designates the NorthSide Area.

www.mowonk.com

22

NORTHSIDE

HEALTH CARE

Notes
1 This task forces purpose, according to their study, was to investigate the health care access

issues and needs in North St. Louis City (vii). The task force comprised of health care and community leaders in the region; they submitted the study to the St. Louis City Board of Alderman in December of 2008. The study counted zip codes 63106, 63107, 63112, 63113, 63115, 63120, and 63147 as North St. Louis. 2 For purposes of brevity, this study will be cited as North St. Louis HCASTF for the remainder of this analysis. 3 The NorthSide area, comprised of census tracts 1115, 1202, 1212, 1257, 1266, 1271, and 1275 of the 2010 decennial census, also encompasses small portions of the 63113 and 63102 zip codes; however, because these zip codes represent such a small portion of the NorthSide area, they have been excluded from this analysis. 4 The document ranks zip code 63113 the third highest in the city with a 3.20 rating and the 63102 zip code `ifteenth in the city with a rating of 1.86. 5 For purposes of this analysis, those zip codes that appeared at the top of the page, therefore representing the zip codes of most concern for that indicator, were ranked 1; those zip codes appearing at the bottom of the page were ranked 18, representing the zip code of least concern for the indicator. 6 De`ined as the percentage of the population aged 0-4 (City of St. Louis Department of Health, 10) 7 De`ined as live births divided by the estimated population multiplied by 1,000 (City of St. Louis Department of Health, 18) 8 De`ined as the number of live births divided by the estimated number of females aged 15 to 44, multiplied by 1,000 (City of St. Louis Health Department, 20) 9 In the study, zip codes with greater than 75% African American population are considered racially isolated (City of St. Louis Health Department, 26) 10 Again, for purposes of this analysis, the number in parentheses represents the ranking of the zip codes in the City of St. Louis where a lower number is the least desirable and a higher number is the most desirable. 11 These rates give an indication of the amount and types of morbidity in a community (City of St. Louis Health Department, 52-53). 12 These rates are related to poverty, insurance status and availability of primary care. Avoidable hospital condition admission rates can serve as an indicator of the need for primary care access (City of St. Louis Health Department, 54) 13 This may be indicative of poor health outcomes either due to delay in diagnosis and treatment or not receiving and practicing prevention activities (City of St. Louis Health Department, 56).

www.mowonk.com

23

NORTHSIDE

HEALTH CARE

14 According to the study, the focus group maintained the anonymity of the participants. As a

result, these quotes cannot be attributed to a speci`ic person. 15 According to the study, the focus group sessions maintained the anonymity of the residents interviewed. As a result, the quotes cannot be attributed to any particular resident of North St. Louis. 16 Heart disease includes rheumatic heart disease, hypertensive disease, ischemic heart disease, and diseases of pulmonary circulation (City of St. Louis Department of Health, 132). 17 Also known as a stroke 18 Deaths from chronic obstructive pulmonary disease include deaths due to bronchitis, emphysema, asthma, and chronic airway obstruction (City of St. Louis Department of Health, 140). 19 This program is also referred to as the Supplemental Nutrition Assistance Program or SNAP. 20 Census tracts 1115, 1202, 1212, 1257, 1266, 1271, and 1275 of the 2010 census; more information is available in the Data, Sources, and Area section. 21 One or three-year ACS estimates are unavailable at the census tract level. 22 The `ive-year estimate indicates 21.7% of the population received food stamps bene`its while the one-year estimate indicates that 26.3% of the population received food stamp bene`its in 2010. (26.3/21.7) -1 = 20.9% increase. 23 2,557 X 1.209 = 3,091 24 For instance if one is disabled and receives Social Security Disability Insurance, has End-Stage Renal Disease, or has Lou Gehrigs Disease. 25 Linear regression analysis is a statistical tool used to measure correlations between variables. The type used in this analysis is called simple regression, which involves only one explanatory variable. In this case, the explanatory variable is median income. There may be other variables that affect the number of disabled individuals in an area that are covered by Medicaid. According to the model, median income explains 50.86% of the variation in the percentage of the population that is both disabled and with public health coverage. The model also supplies a con`idence interval, a projected range in which the true percentage of the NorthSide population who are disabled and have Medicaid coverage likely lies; in this case, the con`idence interval is 12.1% and 15.7%. 26 These total dollars do not include expenditures for Medicaid administration or Medicaid dollars attributable to the Departments of Health and Senior Services or Mental Health.

www.mowonk.com

24

NORTHSIDE

HEALTH CARE

References
Centers for Medicare and Medicaid Services. National Health Expenditures Projections 2011-2021. Retrieved from the world wide web on December 13, 2012 from http:// www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ NationalHealthExpendData/Downloads/Proj2011PDF.pdf. City of St. Louis Department of Health. Public Health: Understanding Our Needs. Volume 3. Update 2007. Obtained from http://stlouis-mo.gov/government/ departments/health/documents/public-health-understanding-our-needs-report.cfm on October 23, 2012. Congressional Budget Of`ice. The Supplemental Nutrition Assistance Program. April 2012. Retrieved from the world wide web on December 14, 2012 from http://www.cbo.gov/ sites/default/`iles/cbo`iles/attachments/04-19-SNAP.pdf. DeNavas-Walt, Carmen, Bernadette D. Proctor and Jessica C. Smith. Income, Poverty, and Health Insurance Coverage in the United States: 2009. U.S. Census Bureau. September 2010. H.R. 6124. An Act to provide for the continuation of agricultural and other programs of the Department of Agriculture through `iscal year 2012, and for other purposes. Section 7527. 110TH Congress, 2ND Session. 2008. Kaiser Family Foundation. Medicare Spending Per Enrollee by State of Residence, 2006-2009. Retrieved from the world wide web on October 28, 2012 at http:// www.statehealthfacts.org/comparemaptable.jsp? yr=92&typ=4&ind=624&cat=6&sub=72. Missouri Department of Social Services. 2010 Annual Report. 2010. Obtained from http://dss.mo.gov/re/pdf/dss-annualreport.pdf on October 28, 2012. Missouri Foundation for Health. Missouri Medicaid Basics: Spring 2010. 2010. Retrieved from the world wide web on December 9, 2012 from http://www.mf`h.org/mm/`iles/ MedicaidBasics2010.pdf.

www.mowonk.com

25

NORTHSIDE

HEALTH CARE

Missouri Hospital Association. 2011 Community Investment Report. Retrieved from the world wide web on December 14, 2012 from http://www.missourihealthmatters.com/ wp-content/uploads/2011/11/2011-Community-Investment-Report.pdf. North St. Louis Health Care Access Study Task Force. North St. Louis Health Care Access Study. Prepared by Research and Evaluation Solutions, Inc. Alexandria, VA: December 2008. St. Louis Regional Health Commission. Decade Review of Health Status for St. Louis City and County 2000-2010. Retrieved from the world wide web on December 10, 2012 at http:// www.stlrhc.org/LinkClick.aspx?`ileticket=u%2fn5OUP%2fx70%3d&tabid=38 United States Bureau of the Census. American Community Survey. Data analyzed through the use of Geolytics, Inc. software: ACS 2006-2010 Interface. Decennial Census 2010. United States Bureau of the Census. Food Stamp/Supplemental Nutrition Assistance Program (SNAP) Receipt in the Past 12 Months for Households by State: 2009 and 2010. American Community Survey Briefs. November 2011. United States Department of Agriculture (USDA) and Economic Research Service. Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences. June 2009.

ABOUT MISSOURI WONK

Missouri Wonk is a rm founded by Brian Schmidt that performs policy analysis services for businesses, trade associations non-prots, campaigns, and government entities.
ABOUT BRIAN SCHMIDT

Brian Schmidt served as the Executive Director of the Missouri General Assemblys Joint Committee on Tax Policy from 2005 through 2011. He received a Bachelor of Political Science degree at Truman State University and a Master of Public Affairs- Public Policy degree at the University of MissouriColumbia.

www.mowonk.com

26