The State of the State's Health
A Report From The Oklahoma State Board of Health
creating a state of health

Board of Health

Gordon H. Deckert, M.D., President
Beth Anita Gordon, Vice President
R. Brent Smith, M.D., Secretary-Treasurer
John B. Carmichael, D.D.S.
Glen E. Diacon, Jr., M.D.
Dan H. Fieker, D.O.
Jay A. Gregory, M.D.
Walter Scott Mason, III, Esq.
Frank W. Merrick

Introduction

The State Board of Health presents its first annual report on The State of the State’s Health to the citizens of Oklahoma. Working with the Oklahoma State Department of Health, our purpose is to provide an assessment of the general health status of Oklahomans. Collecting, analyzing, and using health data are essential components for public health. The Institute of Medicine’s 1988 report, The Future of Public Health, thoroughly supports this position. Assessment functions are a particular responsibility of a health department.

This report compares public health indicators for Oklahoma with those of the nation, as a means of selecting issues that have serious implications for maintaining and improving the health status of Oklahomans. We may suggest certain conclusions, but remedies must come from a much broader base than either the State Board of Health or the Oklahoma State Department of Health.

As the nation and Oklahoma approach the year 2000, public health agencies have renewed their efforts to examine the health status of its citizenry. The State Board of Health has adopted 56 representative or sentinel objectives for Healthy Oklahomans 2000. These are intended to be general indicators of progress and are integrated into the Department’s priority setting process. Our aim is to improve the health status of Oklahoma citizens.

Oklahoma Economic and Population Characteristics

Overall, Oklahoma has an older population. In 1995, the median age of Oklahomans was 34.6 compared to 34.3 for the U.S. (Figure 1). The proportion of the population in Oklahoma 85 years and over is greater (1.60%) than the U.S. proportion (1.38%) (Figure 2). Between 1990 and 1995, this group increased from 45,000 to over 52,000. In the future, the proportion of Oklahoma's population will be increasingly older and Oklahoma will see increased demands on services for the elderly as we enter the 21st century.

Other distinctive characteristics of Oklahoma’s population include its racial and ethnic breakdown, the percentage of the population living in rural areas, and the percentage of the population with incomes below the poverty level. Oklahoma’s Native American population is 8.1% of the total, the highest percentage of any other state in the continental United States. African Americans comprise 7.7% of our population; Hispanics, 3.1%; and Asian & Pacific Islanders, 1.3%. Larger numbers of Hispanic people are migrating into the state (Figure 3). We must anticipate these changes and be prepared to meet the health needs of different ethnic and racial groups.

More than 32% of Oklahomans live in rural areas compared to 24.8% for the U.S. (Figure 4). Available health care services tend to be clustered in urban areas. Some rural counties in Oklahoma do not have doctors who deliver babies or hospitals that allow deliveries. We need to assure access to quality health care services for all Oklahomans, including the large percentage of Oklahoma’s population that live in rural areas.

Per capita personal income for Oklahomans is $18,580 versus $23,208 for the U.S. This is about 80% of the U.S. average. For each age group, Oklahoma has a higher percentage of people in poverty compared to the U.S. (Figure 5). In 1990, the percentage of Oklahomans whose 1989 income was less than 100% of the poverty level was 16.2% (Figure 6). By 1995, this percentage had increased to 17.1%, while the U.S. percentage had increased to 13.8%. Also, the percentage of those whose 1989 income was less than 150% of the poverty level is 27.2% compared to 21.1% for the U.S. (Figure 6). Many Oklahoma citizens fall into an income level that is too high to qualify for health care assistance through Medicaid, yet they are unable to afford health insurance or basic health care services. In study after study, poverty is correlated with serious health outcomes.

How should we address this problem? How can Oklahoma afford to provide assistance to those without any type of health care coverage? Our county health departments certainly cannot expand their services enough to meet these increasing needs. These are serious questions. We simply cannot ignore those who do not have access to health care. If we do, all of us will bear a much larger burden in the not-too-distant future.

In summary, the Oklahoma population is older, poorer, and has a larger percentage of its population living in rural areas where health care is more scarce. These factors are often predictors for poor health. For Oklahoma, as we shall see, the health of Oklahomans is becoming poorer and is worse than the U.S. for a number of factors.

Public Health Status Indicators

Americans are living longer. Average life expectancy is now almost 80 years for women and almost 73 years for men. This trend is expected to continue to increase. However, it must be considered that as the average life span increases, the numbers of elderly who need assistance will increase. Additionally, it must be seriously considered that in 15 years (the year 2010) the baby boom generation will begin to retire, and as they age, produce increased demands for assistance.

In 1995, the age adjusted death rate per 100,000 for the U.S. was 502.9 and life expectancy was 75.8 years, the highest ever. But in Oklahoma, the age adjusted death rate was 541.2, considerably higher than the national rate.

When looking at the well-being of our state, there are specific key health status indicators, four major categories, that can be considered: chronic diseases, injuries, childhood health concerns, and infectious diseases. We begin by looking at the leading causes of death for Oklahoma and the nation (Figure 7 and Figure 8). After adjusting for the effects of age-related illnesses, the top four leading causes of death for both Oklahoma and the U.S. are heart disease, cancer, cerebrovascular disease, and chronic obstructive pulmonary diseases (COPD). Unfortunately, Oklahoma has some of the highest rates in the nation for these disease categories.

Why is Oklahoma overburdened with these chronic conditions? One cause is Oklahoma’s use of tobacco products. We have one of the highest rates of smoking in the nation (Figure 9), particularly among our women. Excessive deaths due to heart disease, cancer, stroke, and COPD can be linked directly to smoking. Other factors include poverty, as already mentioned, limited access to health care, obesity, nutrition, and sedentary life style.

The fifth leading cause of death in Oklahoma and the U.S. is unintentional injuries. Of particular concern are deaths due to motor vehicle accidents (Figure 10). Again, we do not compare favorably with other states. We also have higher rates than the national average for deaths due to suicide (Figure 11). Among our white population, rates of homicide are also higher (Figure 12).

Because of these high rates of deaths due to heart disease, cancer, stroke, COPD, and traumatic injuries, Oklahoma has excessive rates for years of potential life lost (YPLL) (Figures 13 and 14). YPLL is a measure of premature death. It is defined as the number of years lost between the age of birth and age 65. Oklahoma is losing its most precious resource, our citizens, at an alarmingly higher rate than the nation at large.

Our hope for the future is our children. That is why the Board of Health and the Oklahoma State Department of Health take childhood health concerns so seriously. Currently, one in two children born to Oklahoma residents is the result of mistimed or unintended pregnancy. Studies convincingly demonstrate that such children are at greater risk than those born to women who intended their pregnancies. Another measure of the potential for good health starting in infancy is the level of prenatal care received during the first trimester of pregnancy (Figure 15). Unfortunately, Oklahoma lags behind the rest of the nation in this regard. If we are serious about taking care of our children — our future — we must insure that pregnant women have access to and receive quality prenatal care, especially in the first trimester. In Oklahoma, between 1991 and 1993, a greater proportion of women, across all races except for Native Americans, did not receive prenatal care in the first trimester, as compared to the U.S.

Another important measure that helps us define our hope for the future is births to teenagers (Figure 16). Often, pregnancies among young females ages 15-19 are unintended. Births resulting from unintended pregnancies can have detrimental and long-lasting effects for both the teenage female and the newly born infant. Oklahoma has significantly higher birth rates than the U.S. average for 15- to 19-year-old females. In 1995 in the United States, 13.2% of all babies born were born to women under 20. In Oklahoma, the figure was 17.0%.

In Oklahoma, 26% of 2-year-old children are not adequately immunized. This is unacceptable. Increased attention is needed to improve immunization rates of Oklahoma’s children, thereby protecting them against serious and deadly diseases that are preventable with vaccines. Also in Oklahoma, only an estimated 58% of community water systems are fluoridated compared to the Healthy People 2000 target of 75%. Efforts to increase the number of communities that have fluoridated water systems need to be aggressively pursued since fluoridation has been proven safe and effective in reducing dental disease, especially in children.

Rates of infectious diseases also help us understand the health status of our state. Currently, our rate of infectious hepatitis A is the highest in the nation, over seven times higher than the national rate. Rates of tuberculosis in our Native Ameri-can population in 1995 were 40% higher than the national rate, and the rate of drug resistant tuberculosis has risen to unacceptable levels (Figure 17). We must remain vigilant in our prevention, education, and immunization efforts in order to protect our citizens from the spread of infectious diseases. We all need to learn once again that hand washing prevents the spread of such diseases; for example, hepatitis A.

One of the biggest public health concerns nationally is the potential for new and emerging infectious diseases. Oklahoma is no exception. Ensuring a strong state public health infrastructure with state-of-the-art public health laboratories and disease investigation systems is critical to prevent the spread of all types of infectious diseases, common or newly emerging.

Clearly, based on this review of public health status indicators, Oklahoma’s overall health has room for improvement.

Oklahoma's Medically Uninsured

Oklahoma’s medically uninsured may be one of the most important barriers to improving our people’s health. The numbers of uninsured are testing the limits of the ability of providers of last resort to supply needed services, whether rural or urban hospitals, public health clinics, or health practitioners in the private sector.

The estimated medically uninsured population under age 65 in Oklahoma is 600,000, or 21.0% of our population (Figure 18). This estimate is the seventh highest among the 50 states and the District of Columbia. In 1994, it was estimated that 21.6% of Oklahoma’s children were uninsured, 3rd highest in the nation and an increase from the 17.6% figure in 1993. The dentally uninsured population is even higher.

Some believe that Medicaid will take care of the uninsured. This is not the case. In Oklahoma, Medicaid serves approximately 13% of the state’s population while 21% of the population still has no health insurance coverage at all. Many of the uninsured do not qualify for Medicaid either because they are not eligible to receive state assistance or because they do not meet other financial or categorical standards. Based on data published by the Urban Institute, only 44% of the families with incomes below the federal poverty level in Oklahoma were covered by Medicaid during the period 1990-1992.

The average profile of a patient who comes to a local free clinic operated by one of Oklahoma’s largest hospitals, is a single mother with three or four children and two to three jobs, none of which provide health insurance. Such a person earns about $15,000 a year, which means she cannot qualify for Medicaid.

Has the number of uninsured in Oklahoma reached a plateau? Some experts predict the numbers will be with us for some time — either because we do not recognize the problem or do not solve it. In fact, the number of medically uninsured are likely to increase in the next few years, as will the difficulty of their obtaining needed care. Several factors support these predictions.

1. In this era of a market-driven health care delivery system, physicians and hospitals are less financially capable of providing charity care. Cost shifting has been the primary technique for hospitals to provide medical care to the uninsured. Market pressures from managed care organizations, insurance companies and employers are forcing health care providers to cut costs. Hence, cost shifting is a less viable option.

2. The rapidly changing health care delivery system, driven by competition, may also reduce the system’s capacity to provide charity care. Hospital mergers, the development of multi-hospital systems and joint ventures between hospitals and physicians frequently create systems that do not serve the medically uninsured in substantial numbers.

3. Poverty and low incomes are almost synonymous with Oklahoma’s uninsured population. The Census Bureau reports that in 1995, Oklahomans on average saw their income decline and the number of families living in poverty increased. Median household income was down 5.2% from 1994. Meanwhile, the percentage of Oklahoma households living in poverty in 1995 rose to 17.1%, up from 16.1% the previous year.

4. Traditionally in Oklahoma, most of the uninsured population are employed. In 1992, the most recent data available, 74% of the uninsured were full-time employees, 15% were employed part-time and 11% were unemployed. Nationally, the percentage of the population having health insurance through an employer is decreasing.

5. Finally, the traditional providers of last resort: public hospitals, community health centers, neighborhood clinics, public health departments, and primary care physicians (especially those in rural areas), are being threatened by eroding revenue streams from Medicaid services and other efforts at the state and federal level to contain costs.

Conclusions

Unnecessary Disability and Loss of Life

Oklahoma has the unfortunate distinction of being above national rates for most of the key public health status indicators. This means that our citizens are overburdened with disability and unnecessary death. Oklahoma cannot afford the many years of productive lives that are being lost.

Uninsured

Augmenting the problems of our excessive disease and death rates is the continuing high number of uninsured people in the state. For those without health insurance, public or private, and with no other means to pay, basic health care is neglected. Often, the uninsured will not seek health care until an emergency occurs or a simple disease becomes serious. When this happens, everyone loses.

Neglect of Health Care for Children

Our most vulnerable citizens are also our youngest. Children are at risk for numerous infectious diseases and unintentional injuries. Poor health care among the young predicts a higher rate of chronic disease among the working adult population.

When considering plans for improving Oklahoma's health status, the continued rise of health care costs above the rate of inflation must be considered. This report does not address this issue specifically.

Recommendation OCIHO-Oklahoma Consortium for Improving the Health of Oklahoma This first annual report on The State of the State's Health makes one recommendation. As we approach the new millennium, we recommend th formation of a consortium that would look seriously at the issues raised in this report and from a broad base develop solutions for imporving Oklahoma's health status. The Oklahoma Consortium for Improving the Health of Oklahoma (OCIHO), would include representation from health professionals, state policy makers, representatives from chambers of commerce, and concerned citizens. The State Board of Health looks forward to working with you toward Creating a State of Health.