1 The Truth About Health Reform: Crisis in U.S. Health Care System: Access, Cost, Quality Ellen R. Shaffer PhD MPH Joe Brenner MA EQUAL Health Network

August, 2010August, 2010 EQUAL Health NetworkEQUAL Health Network 1111

The Truth About Health Reform:The Truth About Health Reform:

Crisis in U.S. Health Care Crisis in U.S. Health Care System: Access, Cost, QualitySystem: Access, Cost, Quality

Ellen R. Shaffer PhD MPHEllen R. Shaffer PhD MPHJoe Brenner MAJoe Brenner MA

EQUAL Health NetworkEQUAL Health Networkwww.equalhealth.infowww.equalhealth.info

415-922-6204 415-922-6204 [email protected]

August, 2010August, 2010

mailto:[email protected]


What Is EQUAL?What Is EQUAL?


About This Series

Many in the EQUAL Health Network are helping to spread the word: The Truth About Health Reform.The Series offers several Power Point slides from which presenters can choose.This presentations provides timely, reliable information on problems with access, cost and quality of the U.S. health care systemIf you use these slides please credit the EQUAL Health Network.Our work depends on your support. Donate online at www.equalhealth.info. Thanks!


EQUAL PartnersEQUAL PartnersEEquitable, quitable, QQuality, uality, UUniversal, niversal, AAffordabffordablle health caree health care

Center for Policy Analysis, anchor organizationCenter for Policy Analysis, anchor organizationRekindling Reform, NYRekindling Reform, NYCalifornia Public Health Association-NorthCalifornia Public Health Association-NorthCalifornia Women’s AgendaCalifornia Women’s AgendaOlder Women’s LeagueOlder Women’s LeagueLinks:Links:– Unitarian Universalist Legislative Ministry of Calif.Unitarian Universalist Legislative Ministry of Calif.– American Medical Women’s AssociationAmerican Medical Women’s Association– National Women’s Health Network/Raising Women’s VoicesNational Women’s Health Network/Raising Women’s Voices

Congressional Progressive Caucus Inside-Outside GroupCongressional Progressive Caucus Inside-Outside Group


The Truth About Health ReformThe Truth About Health ReformCrisis in Access, Cost, QualityCrisis in Access, Cost, Quality


Crisis in Costs, Access, QualityCrisis in Costs, Access, Quality

$2.5 trillion a year$2.5 trillion a year

Health care inflation growing faster than Health care inflation growing faster than economyeconomy

45 million uninsured45 million uninsured

Outcomes in U.S. worse than countries Outcomes in U.S. worse than countries with universal coveragewith universal coverage

U.S. companies and workers: constraint U.S. companies and workers: constraint on competitivenesson competitiveness


Health Care in the U.S.Health Care in the U.S.

Progress Progress – Advances in science and technologyAdvances in science and technology– Social change: inclusion of women, people of Social change: inclusion of women, people of

color, patients’ perspectivescolor, patients’ perspectives

Financing, Delivery system, have not kept Financing, Delivery system, have not kept pacepace

Role of Government - controversial Role of Government - controversial


The Problems:The Problems:Financing, Organization, DeliveryFinancing, Organization, DeliveryFragmented financing Fragmented financing – Maze of public and private payment systemsMaze of public and private payment systems– No guarantee of coverage for most peopleNo guarantee of coverage for most people– Profit motive for a public goodProfit motive for a public good

Drives fragmented delivery systemDrives fragmented delivery system– Complex, hierarchicalComplex, hierarchical– Too much acute care, not enough primary careToo much acute care, not enough primary care– Little coordination among health care providers Little coordination among health care providers – No match between where health care needed and No match between where health care needed and

where available where available


Losing Primary Care:Losing Primary Care:

Shortages in Shortages in pediatrics, internal medicine pediatrics, internal medicine and family medicine.and family medicine.

Decreased access Decreased access to geriatricians and gynecologists.

Shortages in Shortages in pediatrics, internal medicine pediatrics, internal medicine and family medicine.and family medicine.

Decreased access Decreased access to geriatricians and gynecologists.


Focus on Health Care vs. HealthFocus on Health Care vs. Health

Money is concentrated on health care vs. public Money is concentrated on health care vs. public healthhealth

Improvements in health, increased life span in Improvements in health, increased life span in 2020thth Century, related to Century, related to – Environment – clean air, water, housingEnvironment – clean air, water, housing– Social and economic equalitySocial and economic equality– EducationEducation– Economic wellbeingEconomic wellbeing– Democratic participation, control over life Democratic participation, control over life

circumstancescircumstances


Structural Obstacles to HealthStructural Obstacles to HealthSocial and economic inequalities undermine Social and economic inequalities undermine individual/community healthindividual/community health Economic policiesEconomic policies– Low income, unstable economy, multiple Low income, unstable economy, multiple

jobs/unemploymentjobs/unemployment– Suburban sprawl and design discourage exerciseSuburban sprawl and design discourage exercise– Food & agriculture policies encourage poor dietsFood & agriculture policies encourage poor diets– Reduced social spending, educationReduced social spending, education– Reduced democratic participation, communityReduced democratic participation, community

Health ConsequencesHealth Consequences– Stress, incidence and poor management of chronic Stress, incidence and poor management of chronic

diseases, tobacco use, violencediseases, tobacco use, violence


Private Vs. Social InsurancePrivate Vs. Social Insurance

We have to cover everyone to save We have to cover everyone to save money.money.

Private insurance has failed as a Private insurance has failed as a mechanism to assure coverage for health mechanism to assure coverage for health care or to control costs.care or to control costs.

Social insurance programs through the Social insurance programs through the government are much more successful.government are much more successful.


Politics of ReformPolitics of Reform

Entrenched interests and appeals to Entrenched interests and appeals to ideology have successfully blocked reform ideology have successfully blocked reform for decades.for decades.

The incremental proposals on the table The incremental proposals on the table are a step forward but not a final solution.are a step forward but not a final solution.


Health Care Costs Too MuchHealth Care Costs Too Much


Health Care is Big BusinessHealth Care is Big Business$2.5 Trillion A Year$2.5 Trillion A Year

August, 2010 EQUAL Health Network 1616

Distribution of National Health Expenditures, by Type of Service, 2008

Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc.

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2008; file nhe2008.zip).

Physician/ Clinical Services 21.2%

Hospital Care 30.7%

Other Personal Health Care

12.9%

Nursing Home Care, 5.9%

Prescription Drugs10.0%

Home Health Care, 2.8%

Other Health Spending 16.5%

http://www.cms.hhs.gov/NationalHealthExpendData/




Relative Contributions of Different Types of Health Services to Total

Growth in National Health Expenditures, 1998-2008

Nursing Home Care4.3%

Home Health Care2.7%

Other Personal Health Care

11.7%

Hospital Care29.8%

Prescription Drugs12.7%

Physician and Clinical Services

20.9%

Other Health Spending18.0%

Notes: Percentages may not total 100% due to rounding. Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc.







Total Health Expenditures Per Capita, U.S. and Selected Countries, 2003


* 2008 and 2009 NHE projections. .Source: K. Davis, Why Health Reform Must Counter the Rising Costs of Health Insurance Premiums, (New York: The Commonwealth Fund, Aug. 2009).

0

25

50

75

100

125

2000 2001 2002 2003 2004 2005 2006 2007 2008* 2009*

Insurance premiums

Workers' earnings

Consumer Price Index

Insurance Premiums Rising Faster Than Workers’ Earnings 2000–2009

Percent

108%

32%

24%


Premium as % of Median Family Income, 2008–2020

1112

1314

1617

18 18 18 1819 19 19

20 2021 21

22 2223

24

18

0

5

10

15

20

2519

99

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

Percent

Projected



Health and Welfare Expenditures, General Fund, All K-12 Districts and County Offices of Education, California

1999 – 2008

$4,141,480,778

$4,453,877,356

$4,726,123,269

$5,078,581,838

$5,342,054,525

$3,809,476,978

$3,416,287,095

$3,050,988,422

$2,713,748,321

$2,494,403,395

$2,000,000,000

$2,500,000,000

$3,000,000,000

$3,500,000,000

$4,000,000,000

$4,500,000,000

$5,000,000,000

$5,500,000,000

$6,000,000,000

1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008

Year


31.1%27.7%

26.0% 25.6%

48.8% 49.3% 50.0% 49.4%47.9% 47.7% 48.0%

44.3% 43.1% 42.1%

21.5% 22.2% 23.0% 23.9% 25.0% 25.3% 24.5%

21.6%24.4%

20.7%21.6%

29.1%

47.4%

26.8% 27.8%

34.1%

27.6%

37.2%35.3%

0%

10%

20%

30%

40%

50%

60%

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Notes: Percentages may not total 100% due to rounding.


Distribution of National Prescription Drug Expenditures by Source of Payment, 1998-2008

Private Insurance

Consumer Out-of-Pocket Payments

Public Funds





Private Health Insurance Administrative Costs per Person

Covered, 1986-2008

$90 $101

$156 $169$208 $217 $211

$264

$439$474 $471

$482$351

$466$425

$289

$235$210$208$206

$159$137

$76$0

$100

$200

$300

$400

$500

$600

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Notes: These data show the net cost of private health insurance per private enrollee (including Blue Cross/Blue Shield, commercial insurance, HMOs, and self-insured plans), as calculated by the Centers for Medicare and Medicaid Services. Net cost of insurance is the difference between premiums earned and benefits incurred, and includes insurers’ costs of paying bills, advertising, sales commissions, and other administrative costs; net additions/subtractions from reserves; rate credits and dividends; premium taxes; and profits or losses. Private enrollment is estimated by CMS using the National Health Insurance Survey and the Current Population Survey.

Source: Kaiser Family Foundation calculations NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Expenditures by type of service and source of funds, CY1960-2008, file nhe2008.zip, Admin.& Net Cost of Priv. Hlth Insurance, Pvt Health Insurance); and private health insurance enrollment data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, Table 4 at http://www.cms.hhs.gov/NationalHealthExpendData/downloads/bhg08.pdf.




http://www.cms.hhs.gov/NationalHealthExpendData/downloads/bhg08.pdf


Number of Uninsured GrowingNumber of Uninsured Growing



New York Times



Health Care in CaliforniaHealth Care in California

6.6 million uninsured in 2006 = 20 % of non-6.6 million uninsured in 2006 = 20 % of non-elderly population elderly population 763,000 children uninsured763,000 children uninsured300,000 significantly at risk for losing their 300,000 significantly at risk for losing their coveragecoverageHealth care spending grows two to three times Health care spending grows two to three times faster than California's economyfaster than California's economyHealth insurance premiums grow significantly Health insurance premiums grow significantly faster than overall health care spendingfaster than overall health care spending

- source: SB 810 - source: SB 810


Quality of Care:Quality of Care:People Suffer and Die Because of People Suffer and Die Because of

Our Cruel and Unfair SystemOur Cruel and Unfair System


A man in his early 20s with a worsening dental infection was unable to afford a dentist. He finally saw a physician who prescribed an antibiotic, but the patient was unable to pay for the prescription. He came to our clinic when the infection had spread to his chest. He died soon after admission. The egregious is commonplace in our non-system. JAMAVol. 286 No. 20, November 28, 2001"Within the System of No-System," Robert L. Ferrer, MD, MPH

Uninsured: Dying from a Toothache Uninsured: Dying from a Toothache in the U.S. in the U.S.


Quality/OutcomesQuality/Outcomes

Infant Mortality: 29th in worldInfant Mortality: 29th in worldLife Expectancy: 78 yrs. (Below other Life Expectancy: 78 yrs. (Below other developed nations )developed nations )Cancer/Cardiovascular disease rates: Cancer/Cardiovascular disease rates: Canada, England, most European Canada, England, most European countries are bettercountries are betterPreventable Hospital Deaths: 100,000/yr.Preventable Hospital Deaths: 100,000/yr.



http://www.pnhp.org/



Potential Years of Life Lost Due to Diabetes per 100,000 Population, 2006

242529

35363739

56

65

99

0

20

40

60

80

100

US* NZ** CAN** NETH OECD

Median

SWED** GER FRA* UK* SWITZ*

*2005**2004

Data: OECD Health Data 2008 (June 2008).


Mortality Amenable to Health Care: Mortality Amenable to Health Care: U.S. Failing to Keep Pace with Other CountriesU.S. Failing to Keep Pace with Other Countries

7681

88 84 89 8999 97

8897

109 106116 115 113

130 134128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150

Fran

ceJa

pan

Austra

liaSpa

inIta

lyCan

ada

Norw

ayNet

herla

nds

Swed

enG

reec

eAus

tria

Ger

man

yFi

nlan

dNew

Zea

land

Denm

ark

Unite

d Kin

gdom

Irela

ndPor

tuga

l

Unite

d Sta

tes

1997/98 2002/03

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee, Health Affairs 2008).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.

Exhibit 2


Lack of Insurance and MortalityLack of Insurance and Mortality

18,000 excess deaths a year are 18,000 excess deaths a year are associated with lack of insuranceassociated with lack of insurance


66% of personal bankruptcies are 66% of personal bankruptcies are due to medical debtdue to medical debt


Copyright ©2008 American Cancer Society

From Ward, E. et al. CA Cancer J Clin 2008;58:9-31.

FIGURE 10 Cancer Survival by Insurance Status*

August, 2010August, 2010 EQUAL Health NetworkEQUAL Health Network 42424242Copyright ©2008 American Cancer Society


Uninsured Rates Among Adults Aged 19 to 64 Years by Income Level, 2001 to 2005

LOW INCOME MORE LIKELY UNINSURED


Race, Class, Insurance and HealthRace, Class, Insurance and Health




Breast Cancer: Blacks and Hispanics Diagnosed Later, More Likely Uninsured




Colorectal Cancer Stage Distribution by Race and Insurance Status

August, 2010 EQUAL Health Network 4646Copyright restrictions may apply.

Haider, A. H. et al. Arch Surg 2008;143:945-949.

Adjusted odds of mortality by race and insurance status (n = 311 503)



We Pay More But Don’t Get MoreWe Pay More But Don’t Get More

Higher costs are related to intensity of Higher costs are related to intensity of carecare

Higher costs are Higher costs are notnot related to better related to better outcomesoutcomes


Variations in Cost/QualityVariations in Cost/Quality

Regions experience different per capita costsRegions experience different per capita costs

High-cost areas pay 30% more than low-cost High-cost areas pay 30% more than low-cost areasareas

Costs are unrelated to health, wealth, outcomeCosts are unrelated to health, wealth, outcome

Two determinants of costs: Two determinants of costs: – Supply of providersSupply of providers– Medical decisions/cultureMedical decisions/culture


We Have To Cover Everyone To We Have To Cover Everyone To Control CostsControl Costs


The Costs of Fragmented CoverageThe Costs of Fragmented Coverage

Illnesses and accidents are predictable for Illnesses and accidents are predictable for large groups over time large groups over time

But unpredictable for small groups in any But unpredictable for small groups in any yearyear

Problems for small groups Problems for small groups – A single catastrophic illness can wipe out A single catastrophic illness can wipe out

fundsfunds


Insurance, Access, CostsInsurance, Access, Costs

Private for-profit insurance companies Private for-profit insurance companies face incentives to avoid spending face incentives to avoid spending premiumspremiums– Identify and avoid “risky” patientsIdentify and avoid “risky” patients– Exclude pre-existing conditionsExclude pre-existing conditions

Insurance companies run up Insurance companies run up administrative costs to avoid “expensive” administrative costs to avoid “expensive” enrollees (sick people)enrollees (sick people)


Employment-Based InsuranceEmployment-Based Insurance

The U.S. is the only country where most people The U.S. is the only country where most people get health care coverage through workget health care coverage through workBut there is no requirement for employers to But there is no requirement for employers to offer or pay for coverage!!!offer or pay for coverage!!!Large employers: 96% offerLarge employers: 96% offerSmall employers: 43% offerSmall employers: 43% offer– (fewer than 50 employees)(fewer than 50 employees)

Principles of insurancePrinciples of insurance– Cover everyone at risk = AffordabilityCover everyone at risk = Affordability– If not, assume only those at risk will buy = Not If not, assume only those at risk will buy = Not

affordableaffordable


(How Did We Get Here?(How Did We Get Here?U.S. Path to Private Insurance)U.S. Path to Private Insurance)

Began in 1930s/DepressionBegan in 1930s/Depression– Communities pooled funds in nonprofits to Communities pooled funds in nonprofits to

help pay for health carehelp pay for health care

Continued as tax-free benefit during WWIIContinued as tax-free benefit during WWIIOther countries turned to government-Other countries turned to government-financed social insurance, or combined financed social insurance, or combined with heavily regulated nonprofit insurancewith heavily regulated nonprofit insuranceU.S. medical societies, businesses, and U.S. medical societies, businesses, and insurance companies opposed these insurance companies opposed these trendstrends


Private Insurance Has FailedPrivate Insurance Has Failed

Government Plans are More Government Plans are More SuccessfulSuccessful


Free Market Cannot Control CostsFree Market Cannot Control Costs

Doctors, hospitals, drug companies try to Doctors, hospitals, drug companies try to get highest price for best careget highest price for best care

Payers try to pay lowest price for best carePayers try to pay lowest price for best care– Individual patientsIndividual patients– EmployersEmployers– Insurance companiesInsurance companies– GovernmentGovernment


Why Doesn’t It Work?Why Doesn’t It Work?

Individual patientsIndividual patients– Don’t know what care we need, rely on providersDon’t know what care we need, rely on providers– Vulnerable when sick, can’t negotiateVulnerable when sick, can’t negotiate– Prices not transparentPrices not transparent

EmployersEmployers– Only cover a small percent of “covered lives”Only cover a small percent of “covered lives”– Part of fragmentation problemPart of fragmentation problem

Insurance companiesInsurance companies– Generally not big enough to negotiate lower prices Generally not big enough to negotiate lower prices

with hospital chains, drug companieswith hospital chains, drug companies– If successful, keep savings for profits, other costsIf successful, keep savings for profits, other costs– Not sufficiently regulated Not sufficiently regulated


Administrative BarriersAdministrative BarriersMultiplicity of protocols, formularies Multiplicity of protocols, formularies complicate medical decision-makingcomplicate medical decision-making

Insufficient regulationInsufficient regulation– Unclear fine print -- not standardized, Unclear fine print -- not standardized,

unknown coverageunknown coverage– State rules can set benefit levels, some State rules can set benefit levels, some

standardsstandards– Need federal agency with staff and clout to Need federal agency with staff and clout to

assure accountabilityassure accountability


PreventionPrevention

Incentives for prevention are Incentives for prevention are underminedundermined Employer who pays for prevention Employer who pays for prevention may not still be the employer in 5 may not still be the employer in 5 yearsyears


Government Can Do ItGovernment Can Do It

Big enough to negotiate with drug Big enough to negotiate with drug companies and hospital chainscompanies and hospital chains

No profit motiveNo profit motive

But now covers less than half the But now covers less than half the population population


Government SuccessesGovernment Successes

MedicareMedicare

Veterans AdministrationVeterans Administration

Community Health CentersCommunity Health Centers

HawaiiHawaii


MedicareMedicare

Popular federal government program covers population over age 65From 1997 to 2007, Medicare’s cost per beneficiary rose on average 4.4% per yearPrivate insurance premiums increased by 7.4% per year—a 30% difference over the full 10 years.

Http://www.cms.hhs.gov/nationalhealthexpenddata/downloads/tables.pdf (see table 13)


Hawaiian Health Care SystemHawaiian Health Care System

The Daily Show, Feb. 11, 2010The Daily Show, Feb. 11, 2010““Hawaiians have government-mandated Hawaiians have government-mandated health care and they love it.”health care and they love it.”““We’ve been doing it this way for 40 We’ve been doing it this way for 40 years.”years.”Dog the Bounty-Hunter supports Hawaiian Dog the Bounty-Hunter supports Hawaiian health care.health care.http://www.thedailyshow.com/watch/thu-http://www.thedailyshow.com/watch/thu-february-11-2010/the-apparent-trap/february-11-2010/the-apparent-trap/


Health Reform Is A Political Health Reform Is A Political Challenge Challenge


Tough Road

http://images.google.com/imgres?imgurl=http://washingtonindependent.com/wp-content/uploads/2008/10/fdr1.jpg&imgrefurl=http://washingtonindependent.com/15955/republicans-are-wrong-about-united-government&usg=__clIa4c8nFNARsfX8Pf26QC3qU_I=&h=2928&w=2488&sz=1737&hl=en&start=32&sig2=MKWUfqEw74ONHnSdD6hiZw&um=1&tbnid=ZMoh1nBFU8NnmM:&tbnh=150&tbnw=127&prev=/images%3Fq%3Dfdr%2Bpictures%26ndsp%3D20%26hl%3Den%26sa%3DN%26start%3D20%26um%3D1&ei=aetAS4foG6bktAO0tt2JBA


Some VictoriesSome Victories

1965 – Johnson: Medicare, Medicaid1965 – Johnson: Medicare, Medicaid

1994 – Clinton: State Children’s Health 1994 – Clinton: State Children’s Health Insurance Program (SCHIP)Insurance Program (SCHIP)


$2.5 Trillion: $2.5 Trillion: SpendingSpending or or IncomeIncome??Industry Opposes Income ConstraintsIndustry Opposes Income Constraints

SpendingSpending IncomeIncome

IndividualsIndividuals Insurance IndustryInsurance Industry

EmployersEmployers Pharmaceutical Co.sPharmaceutical Co.s

GovernmentsGovernments Hospitals, PhysiciansHospitals, Physicians


Controlling Costs Means Controlling Costs Means Reducing IncomeReducing Income

Effective cost control would improve Effective cost control would improve access and qualityaccess and quality

But it involves reducing payments to the But it involves reducing payments to the health care industryhealth care industry

Provokes political oppositionProvokes political opposition

Political leadership needed to galvanize Political leadership needed to galvanize reformreform


Politics in 2008: Auspicious Politics in 2008: Auspicious



Politics in 2010: ChallengingPolitics in 2010: Challenging


Economic Collapse –Economic Collapse –But Corporations Still In ChargeBut Corporations Still In Charge


Social institutions weakened: Social institutions weakened: labor, women, civil society - labor, women, civil society -

++Faith Community, online networks growing ++++Faith Community, online networks growing ++


Corporate mediaCorporate media


$2.5 Trillion: $2.5 Trillion: SpendingSpending or or IncomeIncome??

SpendingSpending IncomeIncome

IndividualsIndividuals Insurance IndustryInsurance Industry

EmployersEmployers Pharmaceutical Co.sPharmaceutical Co.s

GovernmentsGovernments Hospitals, PhysiciansHospitals, Physicians


Acknowledgements

Thanks to EQUAL Health Partners: Deborah LeVeen, Elinor Blake, Lee Lawrence, Roma Guy, Karl Keener, Kathie Piccagli

Jeoff Gordon, MD

Some slides from Health Access, PNHP

Documents

1 The Truth About Health Reform: Crisis in U.S. Health Care System: Access, Cost, Quality Ellen R. Shaffer PhD MPH Joe Brenner MA EQUAL Health Network