Healthy (2004)

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Healthcare is a particularly difficult issue to analyze on a regional basis. The system of care that is in place is highly fragmented and involves government, employers and third party intermediaries as well as healthcare providers and patients. For better or worse, the federal government has assumed the lead in this policy area; local, county and regional governments play only a limited role. Further, like some other issues (e.g., housing and childcare), healthcare involves access, cost and quality concerns that are deeply intertwined. Still further, the healthcare industry is in the midst of a profound transition. Indeed, there is some evidence that access and cost issues pertaining to healthcare are once again achieving salience on the nation’s public policy agenda. Finally, at a conceptual level, various models can be applied to healthcare. For instance, the disease model focuses on the prevalence and treatment of illness and injury. The ecological model addresses environmental causes of morbidity and mortality, while the behavioral model recognizes that individual behaviors play a significant role in health outcomes. 

We believe that all of these and other models, including the public health model, have merit. Nevertheless, the particular set of indicators included in this section was selected largely on the criteria of the behavioral health model, more specifically, on the basis on the Healthy People 2010 initiative that the federal government is using to promote positive health behaviors. This model was selected for two reasons: first, because it lends itself to the development of local and regional action plans; and second, because targeted efforts of this kind can have a dramatic impact on health outcomes. The Healthy People 2010 program consists of 20 focus areas and a large number of goals and objectives. Ten leading indicators, however, have been adopted as part of this national healthcare strategy. We believe that they deserve special attention. Some data that is more reflective of the disease and ecological models of health are featured here as well, particularly as they pertain to minority populations. 

Table 82: Leading Health Indicators, Healthy People 2010

Physical Activity	Mental Health
Overweight and Obesity	Injury and Violence
Tobacco Use	Environmental Quality
Substance Abuse	Immunization
Responsible Sexual Behavior	Access to Healthcare
Source: Department of Health and Human Services

One caveat must be noted. In fact, we have very little local, county or regional data pertaining to health behaviors. This domain is data poor. For this reason, the dearth of sub-state data is featured prominently in the policy recommendations included at the conclusion of this section. The data that follow are drawn from national and statewide databases, including a database underwritten by the Kaiser Family Foundation and the 2001 administration of the Behavior Risk Factor Surveillance System, which includes data obtained from 3,993 individuals statewide. Additionally, the six hospital systems located in Lake County sponsored a survey of 1,000 Lake County residents in 1996. Where appropriate, these data are cited as well. The report to the community that its sponsors published in 1996 needs to be updated and extended to LaPorte and Porter Counties. Nevertheless, it was very well received at the time it was published. Indeed, this report testified to the need for local, county and regional analyses of these kind.

7.1 Mortality

Heart disease and cancer continue to be the leading causes of death in Lake, LaPorte and Porter Counties. The percentage of deaths due to heart disease is somewhat higher in LaPorte and Porter Counties than it is in the state as a whole. In contrast, the percentage of deaths attributable to cancer is somewhat higher in Lake and LaPorte Counties than it is statewide. The difference is not great, however, in either case. 

Table 83:  Leading Causes of Death in Percent (2001)

Lake		LaPorte	Porter	Indiana
Heart Disease	37.8	40.9	42.4	37.9
Cancer	24.4	23.8	24.5	23.2
Other	37.8	35.3	33.1	38.9
Source: Indiana Business Research Center

Infant deaths continue to be a problem, particularly in Lake County, despite a decrease of 6% since 2000. Teen deaths due to accident, homicide and suicide in Lake County decreased 47% since 2000, while LaPorte and Porter Counties experienced slight increases over the two-year period. Although the number of deaths are decreasing in both areas, these figures are particularly troublesome and should be viewed as a public health concern. Statewide, 56% of all deaths in 2002 in the 15 to 19 age cohort were attributable to automobile accidents, homicide and suicide. This rate is above the national average of 50%.

Table 84:  Number of Infant Deaths (2002)
	Lake	LaPorte	Porter	Indiana
2002	72	12	16	649
1990	77	12	15	827
Source: Indiana Youth Institute

Table 84:  Number of Child Deaths Age 1-14 (2002)

Lake		LaPorte	Porter	Indiana
2002	32	5	6	279
1990	36	8	10	340
Source: Indiana Youth Institute

Table 86: Number of Teen Deaths from Accident, Homicide

and Suicide (2002)
Lake		LaPorte	Porter	Indiana
2002	21	10	5	237
1990	26	3	14	265
Source: Indiana Youth Institute

Table 87: Leading Causes of Death Among Hoosiers Age

10-24 in Percent (2001)
Cause of Death	Indiana
Motor Vehicle Crashes	30
Homicides	16
Suicides	13
Other injuries	13
HIV Infections	0
Other Causes	28
Source: Indiana Business Research Center

Death rates also vary by race. In 2000, the death rate for White Hoosiers per 100,000 population was 915. At 1,152 deaths per 100,000 population, the death rate for African-Americans was 26% higher. Nationwide, however, some progress has been reported toward the Healthy People 2010 goal to substantially reduce health disparities based on race and ethnicity. During the 1990s, differentials were reduced for all ethnic groups among 10 of the 17 key indicators tracked in this regard, including: access to prenatal care; infant mortality; the incidence of teen births; death rates from heart disease, homicides, motor vehicle crashes, and work-related injuries; the tuberculosis cure rate; the syphilis case rate; and poor air quality. Improvement was also demonstrated in five measurement categories among all racial and ethnic groups except American Indians and Alaskan Natives: total death rate; and death rates for stroke, lung cancer, breast cancer and suicide. 

At the same time, significant differentials along racial and ethnic lines still exist. This is undoubtedly due to a number of variables, including access to care, the environment and differences in lifestyle. We also know that higher death rates are associated with higher levels of racial segregation, and that this is true both for Whites and for African-Americans. In a study published in the 1999 edition of the Sociological Forum, researchers at the University of Michigan and the University of California at Berkeley examined the link between residential segregation and mortality in 107 cities with populations in excess of 100,000 and African-American populations of at least 10%. The City of Gary was listed among the most highly-segregated cities in the study. The analysis established a strong correlation between two different measures of African-American residential isolation and higher mortality rates both for African-Americans and Whites. According to one of the authors: “This finding is important because it suggests that the poor living conditions associated with very high levels of segregation are costly for the entire society.” 

7.2 Cost and Insurance Coverage

In the assessment of Lake County health issues that was conducted in 1996, only 8.5% of Lake County residents reported that they lack either private or public health insurance. This figure has undoubtedly risen given the dramatic increase in the number of the uninsured nationwide over the course of the last 10 years. Although the statewide figure continues to fall below the national mean, there are substantial differences related to race and ethnicity. In Indiana, 12% of Whites are uninsured, 19% of African-Americans are uninsured, and 24% of Hispanics are uninsured. 

Table 88:  Percent of Primary Health Insurance Status

(2001-2002)
Type of Coverage	Indiana	United States
Employer	63	57
Self-Covered	4	5
Medicaid	7	12
Medicare	14	12
Uninsured	12	15
Source: Kaiser Family Foundation

Table 89: Percent of Primary Health Insurance Status for

Children 18 and Under (2001-2002)
Type of Coverage	Indiana	United States
Employer	69	60
Self-Covered	5	4
Medicaid	15	23
Medicare	0	0
Uninsured	10	12
Source: Kaiser Family Foundation, 2004

Over 10% of all Hoosier children are now uninsured as well. Indiana has achieved recognition, however, for its aggressive enrollment of children, pregnant women and low-income working families into its Hoosier Healthwise program. In all, 85,320 citizens of Lake, Porter, and LaPorte Counties are now enrolled in this program. This represents 19.9% of the statewide total. There is some evidence that the state may be backing away from its proactive approach to enrollment in this important program. 

Table 90: Number of Children Enrolled in Hoosier

Healthwise (2002)
Lake		LaPorte	Porter	Indiana
2002	41,053	6,476	5,059	354,687
1998	31,859	4,358	2,694	217,451
Source: Indiana Youth Institute

7.3 Risk Factors

Nine of the ten leading indicators noted in the introduction will be addressed in this section of the report. The tenth indicator focuses on environmental factors, which are addressed in more detail in section 6.0. Unfortunately, we have very little regional, county or local data pertaining to most of these indicators. 

The Healthy People 2010 goal for physical activity is no more than 20% of the population engaging in no physical leisure time activity. 

Table 91: Percent of Adults with No Physical Activity

(2001)
Indiana		United States
2001	26	26
Source: Kaiser Family Foundation

Our second risk factor is excess weight and obesity. The Healthy People 2010 goal aspires to reduce the percentage of individuals who are overweight to less than 40% of the population. This will be a difficult tasks to achieve given the fact that almost 60% of all Hoosiers were overweight or obese in 2001, the eighth highest percentage in the country. This included 68% of African-Americans and 61% of Hispanics. 

The epidemic of overweight and obese children is of particular concern. About 13% of children and adolescents are now overweight or obese, more than double the number from 20 years ago. Risk factors for heart disease, such as high cholesterol and high blood pressure, occur with increased frequency in overweight children and adolescents. Additionally, type II diabetes, previously considered an adult disease, has increased dramatically in children and adolescents. Excess weight and obesity are closely linked to type II diabetes. Finally, overweight adolescents have a 70% chance of becoming overweight or obese adults. This increases to 80% if a parent is overweight or obese. Overweight or obese adults are at risk for a number of health problems including heart disease, type II diabetes, high blood pressure and some forms of cancer. In short, this epidemic in childhood obesity should be treated as a public health priority. 

Table 92: Percent Overweight or Obese (2001)

Indiana		United States
2001	58	56
Source: Kaiser Family Foundation

Our third risk factor is tobacco use. In 2001, more than one-fourth of all Hoosiers continued to smoke, the fifth highest rate in the county. There are no significant differentials in this statistics pertaining to race and ethnicity. Tobacco is an equal opportunity killer. The number of pregnant mothers who smoke has fallen in recent years. LaPorte County is still experiencing alarmingly high numbers in this performance category, however. More than one quarter of all expectant mothers in LaPorte County smoked during 2002. This is significantly higher than the comparable percentages for Lake and Porter Counties. 

Table 93: Percent of Adults Cigarette Smoking (2002)

Indiana		United States
2001	27.7	23.1
Source: Kaiser Family Foundation

Table 94: Percent of Mothers Who Smoked During

Pregnancy (2002)
Lake		LaPorte	Porter	Indiana
2002	15.4	24.2	17.0	19.1
1990	25.4	32.6	27.7	26.6
Source: Indiana Youth Institute

Our fourth risk factor is substance abuse. Northwest Indiana has been identified by the Justice Department as a “high intensity drug trafficking area.” There is no question but that substance abuse continues to be a problem in Northwest Indiana. In 2001, 27% of Hoosiers in the 10 to 24 age cohort reported having used marijuana during the preceding 30 days; 8% reported that they had used cocaine at least once. In 1998, Indiana recorded 3.7 drug-induced deaths per 100,000 population. For African-Americans, the death rate due to substance abuse was 8.2 per 100,000 population. The Healthy People 2010 goal is less than one death per 100,000 population. 

Alcohol abuse continues to be a problem as well. In the assessment of Lake County health issues that was conducted in 1996, 4.5% of adults identified themselves as chronic drinkers, meaning that they consume two or more alcoholic beverages per day. Statewide, only 2.6% of adults identify themselves as chronic drinkers. In 2001, 30% of all Hoosiers in the 10 to 24 age cohort reported episodes of heavy drinking in the month preceding the survey. 

Our fifth risk factor is irresponsible sexual behavior. Data pertaining to teen pregnancy and sexually transmitted diseases are presented. Nationwide, the teen birth rate (age 15 to 19) was 43% in 2002, while for Indiana, the rate was slightly higher at 45%. The ratio of teen births to total births in Lake and LaPorte Counties remains quite high, however, in comparison to Porter County and the state as a whole. Data pertaining to income, poverty and education presented in several of the preceding sections of this report point to the many challenges that accompany teen births, both for the mother and the child. 

Table 95: Percent of Teen Births as Percentage of Total

Births (2002)
Lake		LaPorte	Porter	Indiana
2002	25.9	35.5	10.5	22.5
1990	40.1	41.3	11.2	35.6
Source: Indiana Youth Institute

With the exception of syphilis, the incidence of sexually-transmitted diseases in Indiana trails the nation as a whole. 

Table 96: Sexually-Transmitted Diseases per 100,000

Population (2002)
Type of Coverage	Indiana	United States
Chlamydia	281	297
Gonorrhea	122	125
Syphilis	5	12
Source: Kaiser Family Foundation

The AIDS epidemic has not escaped Northwest Indiana, however. Lake, LaPorte and Porter Counties have reported 13% of the cases reported statewide to date. In all, 542 residents of Northwest Indiana have died from the disease. 1,008 citizens of Lake, LaPorte and Porter Counties now have AIDS or carry the HIV infection.

Table 97: HIV/AIDS (2002)
Cases	Lake	LaPorte	Porter	Indiana
AIDS reported since 1982 HIV reported since 1985 Source: Indiana State Department of Health	747 489	107 94	826 593	927 958

Table 98:  Living with HIV/AIDS (2002)
	Lake	LaPorte	Porter
1990	763	148	97
Source: Indiana State Department of Health

Table 99:  Deaths from AIDS (2002)

Lake		LaPorte	Porter
Since 1985	446	47	49
Source: Indiana State Department of Health

Our sixth risk factor addresses mental health needs. In 2001, over one-third of all Hoosiers reported that they had experienced poor mental health over the preceding 30 days. The percentages were comparable for Whites, African-Americans and Hispanics. In the assessment of Lake County health issues that was conducted in 1996, 22.8% of respondents reported that they have faced or are facing serious bouts of depression. Perhaps not surprisingly, among those who indicated that they have household income below the poverty level, the rate was 44.4%. 

State mental health expenditures per capita tend to be lower in Indiana than in the nation as a whole. In 1997, only $40 per capita was expended for this purpose. Only nine states spent less per capita. 

Table 100: Percent Reporting Poor Mental Health During

Preceding 30 Days, (2001)
Type of Coverage	Indiana	United States
2001	36	34
Source: Kaiser Family Foundation, 2004

Our seventh risk factor pertains to injury and violence. Nationwide, 10.6 deaths per 100,000 population were attributable to firearms in 1999. The comparable number for Indiana was 11.3 deaths per 100,000 population. Again, however, there are significant disparities based on race and ethnicity. In Indiana, 38.0 African-American deaths were recorded per 100,000 population in 1999. Only the District of Columbia reported a higher death rate due to firearms among African-Americans.

By any measure, however, 1,232 instances of abuse reported and 2,532 instance of neglect reported in 2001 in the region must be viewed as a serious concern. 

Table 101: Children Reported and Substantiated as Victims of Abuse and Neglect (2002)

Reported Reported Substantiated Substantiated Lake County Abuse Neglect Abuse Neglect

2002 936 1,616, 230 577 2001 827 1,364 220 641 2000 638 1,072 244 754 1999 625 1,186 191 740 1998 614 876 150 376

LaPorte County 2002 513 763 80 196 2001 686 1,033 112 312 2000 368 615 115 306 1999 367 569 66 184 1998 694 789 122 193

Porter County 2002 200 692 39 392 2001 291 1,105 79 634 2000 273 857 98 650 1999 327 1,017 87 592 1998 386 975 105 521

Source: Indiana Youth Institute

Our eighth risk factor involves the immunization of at-risk populations – both children and the elderly – against disease. Nationwide, 73% of children age 19 to 35 months were immunized in 2000. At 72%, Indiana ranked 28th among the 50 states in this regard.

For seniors, two types of vaccination are recommended: annual flu shots and one-time only vaccinations against pneumonia. The Healthy People 2010 goal for flu vaccinations is 90% of all seniors on an annual basis. For the pneumococcal vaccine, the goal is 90% vaccinated at some point in time. At least with respect to the influenza vaccine, progress has slowed in recent years. Nationwide, the number of seniors who received flu shots declined by 2% between 1999 and 2001. In Indiana, the number who received the influenza vaccine fell by 0.4%. There are significant differences among the races with respect to this performance category as well. Statewide, only 41.9% of African-American seniors received flu shots in 2001, and only 29.5% have received the pneumonia vaccine. 

Table 102: Percent of Seniors Who Received Vaccines in

Last 12 Months (2002)
Indiana		United States
Influenza	66.3	66.4
Pneunmococcal	110	132
Source: Kaiser Family Foundation

To a significant extent, our ninth risk factor, access to healthcare, is intertwined with issues pertaining to insurance coverage and cost, which are addressed above. To supplement this discussion, however, we now focus on prenatal care, a vexing manifestation of the access issue. We will then proceed to the capacity of our healthcare system to meet our needs as a community.

Low birthweight is closely associated with, but not entirely attributable, to access to prenatal care. Unfortunately, the percentage of prospective mothers in LaPorte County who have access to or avail themselves of prenatal care in the first trimester lags significantly behind the state’s performance as a whole. Lake County’s performance lags as well. 

Table 103: Percent of Mothers who Received 1st Trimester

Prenatal Care (2002)
Lake		LaPorte	Porter	Indiana
2002	78.2	75.5	81.1	80.5
1990	75.1	75.8	81.4	78.8
Source: Indiana Youth Institute

Nevertheless, the percentage of low birthweight births in LaPorte County mirrors the statewide percentage. Lake County’s deteriorating performance in this regard should be of considerable concern. It is certainly attributable to differences based on race and ethnicity. Statewide, 7.0% of White infants were born with low birthweights in 2001. For African-American and Hispanic infants, the comparable rates were 13.0% and 6.6% respectively. 

Table 104:  Percent of Low Birthweight Births (2002)

Lake		LaPorte	Porter	Indiana
2002	8.3	8.1	5.4	7.6
1990	7.9	6.2	5.1	6.6
Source: Indiana Youth Institute

The U.S. Public Health Service Act requires that geographic areas, usually counties or collections of townships or census tracts, that are in need of additional healthcare resources be identified as such. High need designations can also apply to certain demographic sub-groups. This designation is usually based on the availability of resources within a rational service area based on a 30minute travel time. Other factors include the availability of primary care resources in contiguous areas and high need, for instance, high infant mortality rates or high poverty levels. 

In 2003, the Indiana Department of Health identified five medically underserved communities in Northwest 

66

Indiana: the City of Gary; central Hammond; the City of East Chicago; the City of Lake Station and the low-income population of Porter County.

Three communities were identified as being in need of additional primary care providers: the City of Gary; the City of East Chicago; and the low income population of LaPorte County. Further, three communities were identified as being in need of additional dental care providers: the City of East Chicago; the low income population of LaPorte County and the low-income population of Porter County.

No communities in the region were identified as being underserved by mental health providers or providers of long-term residential care.

Grade: I Trend: Unknown

The grade of “I” is assigned to this policy domain to call attention to the fact that we have very little local data pertaining to Northwest Indiana. Nevertheless, data that are now out of date together with some statewide data are disconcerting.

Goal: As is noted above, the federal government retains the lead responsibility on healthcare policy. Fortunately, this issue may again be achieving salience on the public policy agenda. This does not mean, however, that local and regional strategies cannot play a role. In fact, the behavioral health model that is embodied in the Healthy People 2010 initiative lends itself to local and regional strategies of various kinds.

The Quality of Life Council recommends that institutions in Northwest Indiana adopt the goals of the Healthy People 2010 program in their entirety. Particular attention should be paid to the leading indicators that have been established by the federal government. Additionally, explicit efforts should be undertaken to overcome the significant health disparities that exist between White citizens of Northwest Indiana and African-American citizens.

The achievement of the above goals will be complicated by the fact that so little local data pertaining to health is readily available. Indeed, with three exceptions, we believe that the first priority should be the gathering and analysis of local data. Having noted this, three health concerns – our three exceptions – stand out and should be addressed immediately. They include childhood obesity, the clear need for a comprehensive strategy pertaining to substance abuse treatment and the need for a community-wide commitment to the challenge of child abuse and neglect.

Actions: The above goals are consistent with the Quality of Life Council’s focus on social equity. Four action steps are appropriate with respect to this policy domain.

A formal, sustained effort is needed to document the health and wellness needs of the region. Hospitals, the various healthcare components of the region’s universities and our county and city public health departments should assume the lead in this effort. We call on them collectively to undertake an epidemiological study of the region. The development of an action plan to address the prevention and treatment of identified needs should then follow. Using a grant from the Lilly Foundation, the three United Way organizations of Northwest Indiana have recently undertaken an effort of this kind. Results are anticipated in early 2005

Working together with the above consortium, school districts in Northwest Indiana should assume the lead in addressing the epidemic of childhood obesity that is now well-established. In many cases, this will require a reassessment of decisions made over the course of the last 10 years pertaining to cafeteria services and physical education programs.

We recommend that the Quality of Life Council and other organizations in Northwest Indiana resist ongoing efforts to divert funds from the national tobacco lawsuit settlement to purposes that do not pertain to public health. More specifically, these funds should be dedicated to substance abuse prevention and treatment (i.e., tobacco, alcohol, and drug use).

We recommend that efforts be undertaken by the courts to address the full range of needs that families involved in child abuse and child neglect present. We believe that an innovative program now being developed in Lake County’s Family Court shows promise in this regard. Similar programs have proven successful elsewhere in the country. Typically, they include comprehensive assessments of the family’s circumstances, the development of broad-based intervention strategies and close monitoring. 

Finally, we encourage all large employers in the region to establish formal wellness programs.