Dr. Rajiv Bhatia, Founder and President of The Civic Engine

(Music)

Mark Masselli: This is conversations on H ealthcare. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well , Margaret believe it or not, it has been 5 years since the passage of
The Affordable Care Act. So much has changed in just a few short years.

Margaret Flinter: And the numbers tell much of the story. Since the passage of The
Affordable Care Act, more than 60 million Americans have gained coverage through the
insurance market places through Medicaid expa nsion and the number of uninsured
Americans is at its lowest in years.

Mark Masselli: Roughly 75 million Americans have since gained access to preventative
care and screens at no cost to them, 30 million Americans under the age of 65 cannot
be denied cov erage due to a pre - existing condition .

Margaret Flinter: And it does not mean that the law doesn’t continue to be controversial
and politically divisive, but it is gaining in popularity among the American people with
70% Americans who prefer some kind of repair versus repeal measure.

Mark Masselli: Things can always be made better but there are some significant
changes that have happened in the year of health reform about 88% of the nation’s
hospitals have switched to electronic heath records as well as about 50% if the nations
practices .

Margaret Flinter: But we want to note while the transition to electronic health records
and expanded, health IT operations has been tough for many practices. No one
disagrees that it paves the way for better data coll ection and better access to health
data for healthcare consumers and researchers as we move forward.

Mark Masselli: And that is something o ur guest today knows quite a bit about, Dr.
Rajeev Bhatia is the former director of Occupational and Environmental Health for the
city of San Francisco and created many innovative health impact assessment tools that
utilizes data to improve the health of the entire community. He has since taken his
model nationally having founded The Civic Engine which helps municipal ities strengthen
the economic foundations of their health of their communities.

Margaret Flinter : And Lori Robertson Managing Editor of FactCheck.org stop s by . She
is always on the hunt for misstatements spoken about health policy in the public domain
a nd no matter what the topic you can hear all of our shows by going to CHCradio .com .

Mark Masselli : And as always if you have comments please email us at CHC radio at
chc 1 .com or find us on Facebook or Twitter. We love hear ing from you.

Margaret Flinter: Now we will get to our interview with Dr. Rajiv Bhatia in just a
moment.

Mark Masselli: But first here is our producer , Marianne O’Hare , with this week’s
headline news.

(Music)

Marianne O’Hare: I am Marianne O’Hare with these healthcare headlines. It is crunch
time for the so called doc fix and in a rare show these days there is a bipartisan effort
underway to repair the outdated and dysfunctional system for reimbursing physici ans
who treat Medicare patients. The house likely to vote on the plan to scrap the old
st
Medicare reimbursement formula before the March 31 deadline which is when they
scheduled 21% drop and reimbursements goes into effect. According to the summary
of $2 00 billion deal, the current system would be scraped and replaced with payment
increases for doctors for the next 5 years as Medicare transitions to a new system
focused more on quality and accountability. The American Medical Association urged
Congress t o and make these changes and seize the moment while it’s here. A total of
16.4 million non - elderly adults have gained health insurance since The Affordable Care
Act became law 5 years ago this month. Those gaining insurance since 2010 include
2.3 million young adults aged 18 to 26 able to remain on their pare nts health insurance
plus another 14.1 million adults who obtained coverage through expansions of
Medicaid, new market place coverage and other sources. Officials says the percentage
of people without coverage has dropped by about a third from 20.3% to 13 .2% in the
first quarter of 2015. And finding a good night’s rest in the hospital seems next to
impossible for many . Well the study in Shiner [PH] showed a few inexpensive
interventions could do the trick in improving sleep greatly. A natural sleep aide
melatonin, an eye mask, and ear plugs greatly improved the time sleeping for most
patients in the study. It turns out all the three help but the melatonin had the most
significant impact . I am Marianne O’Hare with these healthcare headlines.

(Music)

M ark Masselli: We are speaking today with Dr. Rajiv Bhatia Founder and Director of
The Civic Engine. They are providing civic literature with strategies to strengthen the
economic foundations of health in their communities. An internist, data scientist a nd
social medicine practitioner, Dr. Bhatia was Director of Occupational and Environmental
Health for San Francisco’s Department of Public Health where he created the program
on health equity and sustainability. He co - founded the non - profit organization o f Human
Impact Partners. Dr. Bhatia has received several awards including the Ho mer Calver
Award from the American Public Health Association. He earned his maters in Public
Health at UC Berkeley and his medical degree at Stamford and now he has served on
the Clinical Facility at the University of California, San Francisco. Dr. Bhatia w elcome to
Conversations on Healthcare.

Dr. Rajiv Bhatia: Thank you so much for having me on the program .

Mark Masselli: You have had a great perch during your 10 year a s Director of
Occupational and Environmental Health for San Francisco’s Department of Health.
During that time you saw the need to expand the development of data points to be
gathered to ensure public health creating a system that had not existed before a nd you
learnt what a vital tool open data could be actually improved public health by fostering
more transparency and could you start off by telling our listeners what made you look at
public health issues from this new perspective?

Dr. Rajiv Bhatia: Mai nly the universal consensus but the fact is most important for
protecting health and to managing chronic diseases aren’t the things that healthcare
systems provide. The basic human needs like financial self sufficiency, education, safe
neighborhood. I me an if basic needs aren’t met, people don’t have the resources they
need for healthy living. After my residency, I worked at a clinic where I saw all those
patients with asthma who were living in run down house who did not feel secured
enough to complain a bout their landlord. So we were taking care of problems that could
be prevented and as a doctor I did not have the tools to help my patients. When I joined
the health department, I saw the same thing but at the neighborhood. What I saw was
community residents and organizations doing the work needed for public health but at
that time they had a little meaningful support from the public health department.

Margaret Flinter: Well Dr. Bhatia, I think we often think of areas like San Francisco as
an exception perhaps to the world, there is a level of affluence that perhaps mitigates
against the social determinants of health. Tell us as you began to identify them, what
about that experience that you had focused on new areas of data collection in your
assessment of this public health issues?

Dr. Rajiv Bhatia: Well when I started my public health work in the late 1990, some
neighborhood like Davey Hunters Plain were isolated from job opportunities, had poor
transportation, lack of basic neighborhood services like banks and supermarkets. Other
San Francisco neighborhoods were bit more stable but working class jobs were
evaporating and residents were being sliced out. The gentrification perhaps was real
and stressful. For some families, the only affordable housing options were living in
single room occupancy hotel without a bathroom, kitchen, poor ventilation. The
fundamentally illegal and substand ard occupancies, the city tolerates because they
don’t provide any other option. San Francisco has one of the highest rates of
pedestrian injuries in the county. Many people thought the streets and intersections are
really for the safety and convenience of cars and in San Francisco all the questions of
money and resources that rather a question of priority or political will. Most health
departments don’t have a real power or authority to deal with these problems. So if saw
if we can inform the debate, w e might be able to generate accountability and needs of
that. And that’s what led to the idea of measuring health at the neighborhood level
holistically. The health department and the collaboration of community organizations
decided simply to measure wha t the people wanted and needed to be healthy at every
neighborhood. We wanted to do that in a way that informed policy debate and held city
agencies accountable to health needs.

Mark Masselli: You know I am quite excited about the development of your he alth and
back assessment tool because it really connects the dots at the neighborhood level.
But it also requires a sort of a new change or thinking by the leadership and it needs
sort of talked about the lack of political will that might exist in communi ties and obviously
your initiative created some friction amongst some of these guards. So talk about that
intersection and on the other hand sort of the acceptance that this -- and the residents
this has in the neighborhoods.

Dr. Rajiv Bhatia: So you ar e exactly right. I mean health impacts assessment with how
reform is kind of carried forward. You just need to have a really simple common sense
to frame it . The decision maker should be informed about the health consequences of
decisions. It resonated with community members because we are no w talking about the
real need and we were talking about the (inaudible 9:10) we weren’t chopping them up
and dealing with them in a siloed way that governments normally dealt with them. But
adding health decision o utside the healthcare sector upset the calculus. Decision
makers now have to consider a new issue. The existing stakeholders who have power
share the decision making table, so it’s disruptive. You know tons of data was
embarrassing to agencies in the ci ty. Like when we showed that having economically
segregated lunch times created stigma and reduced school lunch participation. The
ideas with data when they were challenged, it was just embarrassing. And at other

times it forced greater responsibility l ike when we demonstrated that 5% of the city
streets accounted for 55% of the serious and fatal injuries. That caused a change in the
way the cities operate. The planning and transportation agencies eventually adopted
the matrix and used them to target investment in traffic segment. The land developers
even accepted and welcomed the new data driven health regulation protect buildings on
health.

Margaret Flinter: One area that was particular interes t to you was the issue of wage
and income security and I understand that you developed an innovative strategy and
your role in Environmental Health which includes of course the purview of conducting
restaurant inspections to help ensure the workers were no t only safe but they were also
safe economically in terms of earning their fair wage. Tell us more about that, what
were you able to accomplish with that approach?

Dr. Rajiv Bhatia: I cared about income and financial self sufficiency probably more than
any other single issue . I mean it is just to fundamental that like a diabetic who cannot
afford fresh fruit and vegetables, who does not have kind of cook because she is
working multiple minimum wage job, did not have a really hard time managing diabetes
and so I felt (inaudible 11:03) assessments to support a number of wage campaigns
over the years for minimum wage increases and (inaudible 11:12) law in the county,
bringing a health frame to these policy debates was really powerful in changing the
politic al conversation. I can’t say we were the sole cause of these laws happened but I
think we may have helped. With the labor rules need somebody to credible enforcers
too. In 2008, work organizations in San Francisco China Town came to us the problem
of wage staff. Immigrant workers were the most vulnerable to this kind of abuse. The
(inaudible 11:42) since we inspected and permitted the restaurant could we do
something that take action against the bad actors. So we did a few things. We had
inspectors monitor the employee notification and we enforced the city’s new rules. We
also threatened to revoke the permits of the restaurants that were involved in wage stuff
by sanctioning restaurant to violators who were able to get the restaurant to pay back
wa ges and penalties more quickly and we send a strong message that our inspectors
are watching and willing to act on any violation.

Mark Masselli: We are speaking today with Dr. Rajiv Bhatia founder and director of The
Civic Engine dedicated to providing civic leaders with strategies to strengthen the
foundations of health in their communities. Dr. Bhatia was director of Occupational and
Environmental Health for the San Franc isco Department of Public Health where he
created the program Health Equity and Sustainability. Dr. Bhatia as you have noted
open data is the key to generating public health improvements. You know that so much
reminds me on the national level of the work of Todd Park who has really been on the

show talking about liberation and data but it is also essentially determining the best
practices moving forward. Tell us about more compelling data you have collected
during your 10 year in San Francisco and data a round land use. You have talked a little
bit about that, population displacement , improved income, how effective were these
programs in truly protecting the public’s health and how replicable ? Is this approaching
other parts of the country?

Dr. Rajiv Bh atia: It is definitely more replicable and it is becoming easier and easier to
sort of generate and share a data . So only thing we have the specific examples of in
San Francisco like no city, we monitor air pollution really once late in the city and we left
that point speak to the air quality exposures of the entire city. So using some computer
tools, we were able to show that there were particular locations where we are actually
violating the air quality standards and in 2008, this data led to a new city log requiring
buildings in these hot spots to have better ventilation system between the portion. I
mentioned t hat pedestrian hot spot data that shows 55% of the serious and fatal injuries
happen on 5% of the street. So what this shifted was the way that city managed traffic
and police enforcements. Before that data, the police were targeting enforcement
efforts to the high injury location. But then that changed the focus of the police
department and city’s traffic common program agreed to dedicate more on this and
most of their resources to these hot spots of pedestrian injuries. Data does not change
the world by itself. It takes people using the data and science can support good
arguments to make healthy change in things. So neighborhood advocates were the
ones really able to use the data on disparities in parks , in schools and other
infrastructure to win con fessions from developers for community directed investment
fund and for a more affordable housing. I think we were very successful in using data to
change the rules in the game and now we are seeing some of the changes in the
environment in San Francisco. But to be honest, it is going to take some time to see the
results in terms of better health. You know that takes generations and it is very hard to
attribute health improvement to any single factor.

Margaret Flinter: Dr. Bhatia you have made an eloqu ent case in the past that true
democracy is a pre - requisite for good health and we certainly see that reality played out
in the world of community health centers where boards are comprised of community
representatives where no one has turned away for lack of ability to pay and there are
rules and policies in place to ensure access, and also certainly we have seen
community health centers increasing the centers of advocacy and innovation in public
health. Can you speak to that reality and how it applies to the work you are doing now?

Dr. Rajiv Bhatia: I think there is a tremendous opportunity to community health center
to bring political extension to non - medical problems . They are on front line. They are

seeing these problems show up as symptoms and dise ase in their patients. They are
trying their best to help with limited resources, but the health centers aren’t the problem
and the healthcare system isn’t the problem, we need to sort of change the policies and
structures that are leading to the lack of good housing and low wage jobs. It is
important for quality makers to hear what failures are happening, you know, in the other
sectors in the housing sector includes that and how they are profiting healthcare.
Doctors and health professionals can be very credible communicators of that
perspective. The community health centers are not trained and skilled in that political
translation and that is something that I would really like to help and work on the next
phase of my career.

Mark Masselli: Dr. Bhatia it’s a two part question, first I want our listeners to know more
about The Civic Engine which is your effort to extend and scale up the practices you
have applied in San Francisco during national level through partnerships with public and
priva te organizations and the second part is really about how have the recent advances
in technology allowed you to scale up the goals behind health impact assessment and
other tools and where are they being deployed across the county?

Dr. Rajiv Bhatia: Yes w hen we created the San Francisco indicator system, we have to
get data from individual offices and individual city agencies and it was slow and painful .
The open data movement championed making public data sharable. Now this is in the
public to make all of the data findable, accessible, and legible. And what all this means
I think that very soon all of those measures that we use to measure health in San
Francisco and more are going to to be easily accessed and computed through every
neighborhood in the c ountry. Main studies are sort of applying neighborhood indicators
and every city has its own way of doing things and there could be real power in a
common language in a measurement system. The next step I think is deve loping the
consensus and what are th e top neighborhood measures (inaudible 17:48) country wide
to assess community health. There is a project being funded by the department of
housing and urban development right now which I have been supporting to develop and
test the course that a neighbor hood health indicators. It is called the healthy community
index and it has built the national open data resources, EPA resources, central
resources, and local open data resources that we think are fairly uniform across the
country. Minneapolis, San Dieg o, Albuquerque are planning to trying this and having
these measures are going to support the lining of public investment to health that I think
if we can get to a uniform number of these priority measures that it would really make a
difference. So an exa mple of the work I am doing, trying to take this to the next level
with the national center for healthy housing (inaudible 18:34), we have proposed a
national dashboard to measure how well it is enforcing on housing you know a lot of
people live in sub - sta ndard housing and that is affecting their health . We have written

an open data standard to make each city’s inspection data interpretable in the same
way, and we are asking cities to report their inspection data following this format. Once
that is there we can have a dashboard that measures the frequency of common housing
problems, the timeliness of the response. It enforce greater responsibility not only on
the landlord but also on government agencies to attend to it fast. It is going to show
housing safety might vary from neighborhood to neighborhood and what some of these
environmental factors behind poor quality housing are. What I would like to see most is
the data on health claims cause an outcome connect ed to economic and social factors
at the individual level. How much what we have spent on healthcare today is due to
factors like food and security, overwork and exposure to violence. We actually know
these factors affect health. We don’t have an answer to the question of how much we
are spending in the healthcare system to treat these correctable problems . So
whatever it takes to get there is that healthcare systems would have to routinely access
these non - medical risk factors just like they do smoking and blood pressure and then
we need to make the identified data on both outcome and risk available to research .
Then the policies and programs to increase financial security and increase affordable
housing, had added value to cost saving health and some legislators might decide to
shift some of the resources that they are using to treat the symptoms to the upstream
solution.

Margaret Flinter: We had been speaking today with Dr. Rajiv Bhatia founder and
director of The Civic Engine dedicated to providing civic leaders with strategies to
strengthen the economic foundations of health in th eir communities . You can learn
more about his work by going to civicengine.org . Dr. Bhatia , thank you so much for
joining us today on Conversations on Healthcare.

Dr. R ajiv Bhatia: T hank you very much for having me .

Mark Masselli: At c onversations on h ealthcare , w e want our audience to be truly in the
know when it comes to the facts about healthcare reforms and policy. Lori Robertson is
an award winning journalist an d managing editor of FactCheck.org a non partisan,
nonprofit consumer advocate for voters that aim to reduce the level of deception in US
politics. Lori , what have you got for us this week?

Lori Robertson: In early March, US Supreme Court heard arguments in King versus
Burwell , a case that could lead to loss of Affordable Care Act insurance subsidies in
many states. We have seen several numbers being used for how many would lose
subsidies and how many could become uninsured. What ’ s the best estimate? To an
independent analysis put the number who could become uninsured at 8 million. In the
case, the plaintiff argued that the language in the ACA stipulates that insurance subsidy

should be available in the s tates that set up their own exchanges not states that rely on
the f edera l l y run healthcare.gov. The government argues that the law as a whole
makes clear subsidy should be available whether there is a state or federal exchange.
Most states, 34 of them st ill use the federal ly run exchange. In those states, 7.5 million
people qualified for subsidies in the latest open enrollment period. But the number who
could lose subsidies isn’t the same as the number who could become uninsured. Some
would still keep insurance without a subsidy particularly those who most need coverage
for health condition. But as the risk for those insurance markets change considerably
others who did not get subsidies would see their premiums go up making them
unaffordable. So how m any could become uninsured, the urban institute estimates that
8.2 million would become uninsured in 2016, if the court rules in favor of the plaintiff .
These are of course only estimates and they are based on the 34 states of federally run
market places not taking action to set up their own exchanges. And that’s my fact
check for this week. I am Lori Robertson managing editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players a nd is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you would like checked, email us at
chcradio.com, we will have FactCheck.org's Lori Robertson check it out for you here on
Conversations on He althcare.

(Music)

Margaret Flinter: Each week conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Primary care providers have
their work seeing patient after patient all day long. In brief visits, it can be difficult to
cover all of the important bases and often signs of drug and alcohol dependence can
get overlooked and many patients are put off by l engthy questionnaires that are aimed
at determining whether you have a problem with drinking or using drug. Researchers at
the Boston University School of Public Health have determined that asking one simple
question could actually determine the level of the patient’s possible drug or alcohol
dependency. For alcohol use, participants were asked how many times in the past year
they have consumed 5 or more drinks in a day. For other substance use they were
asked, how many times in the past year they have u sed an illegal drug or used a
prescription medication for non - medical reasons. The researchers compare alcohol
screening responses with alcohol dependence reference standards and drug screening
questions with drug dependence standards. The single alcohol screening questions
detected 88% of those with alcohol dependence. The drug question detected 97% of
those with drug dependence. Lead researcher Dr. Richard Sate says this could provide
a valuable rapid assessment for primary care providers to help pati ents and get them to

treatment options they need. A single simple question aimed at revealing drug or
alcohol dependency that could help primary care providers diagnose the problem more
readily, getting patients sooner to the help they need. Now that’s a bright idea.

This is Conversations on Healthcare. I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli. Peace and health.

Conversations on Healthcare, broadcast from the campus of WESU at Wesleyan
University, streaming live at Wesufm.org and brought to you by the Community Health
Center.