Rising health care costs are straining the budgets of Greater Boston’s families, businesses and city and state government. 

• Individuals and families are hard pressed to meet rising out-of-pocket costs for health care, whether or not they have insurance. 
• Employers are responding to rising costs by eliminating or limiting workplace health insurance benefits. 
• According to the Municipal Research Bureau, the rising costs of health insurance premiums are eating away at any new spending by the City of Boston--the fiscal year 2007 health insurance increase of $22.9 million represents almost 30% of the total increase in the City’s operating budget. 

Both the public health and health care delivery systems are experiencing shortages of qualified workers, particularly in primary care.

• A statewide workforce assessment conducted by the Coalition for Local Public Health in 2006 found that more than 70% of local health officials in Massachusetts report that they do not have enough staff to consistently fulfill their responsibilities.  Health inspectors and public health nurses are in short supply.  The assessment also found that nearly one-fifth of Massachusetts’ public health workforce will be eligible to retire in the next two years.
• Massachusetts Medical Society's 2006 Physician Workforce Survey found that the state faces a severe lack of primary care physicians, with 54% of community hospitals reporting shortages of primary care physicians and family practitioners, up sharply from 21% three years earlier.
• Boston increasingly lacks access to cost-effective primary care doctors and nurses, with many doctors moving away from primary care to pursue more lucrative specialty care.  The Massachusetts Medical Society reports that only 20% of medical students are selecting primary care, down from 50% in the recent past.  Nationally, the Bureau of Labor Statistics anticipates a shortage of some 1 million nurses by 2012.

With insufficient adult and childhood mental health services, hospitals have become the only point of access to services for many people suffering from mental illness in Massachusetts.

• The National Alliance for Mental Illness’2006 report Grading the States gave Massachusetts a grade of C- based on a review of nearly 40 aspects of mental health care.  The report found that the system has been grossly under-funded for over a decade, leaving roughly 10,000 mentally ill people on a waiting list for a case manager to help them get treatment.
• The cost of such poor performance, the report found, is a rising number of people with mental illness in jails and prisons or showing up in emergency rooms when their illnesses reach the crisis point. 

The Commonwealth faces many challenges as it implements key provisions of the Universal Health Care legislation and works to eliminate the problem of the uninsured in Massachusetts.

• The new Connector will need to ensure that residents have access to affordable yet comprehensive health insurance plans.
• One concern is that, unless health care inflation is brought under control, state subsidies needed to implement the law will cost more than available revenues.  A legislative staff analysis of the law predicted that the plan would fall short of money within two or three years.

Individuals who want to lead a healthier lifestyle often lack information, realistic options and public support for more physical activity and healthier choices.

• Well maintained and programmed parks and public spaces and expanded youth recreation programs coupled with public safety improvements are needed to create safe environments for children, youth and adults to engage in regular outdoor activity.
• Improved sidewalk conditions and better trash removal can encourage more walking and jogging.
• In 1996 Massachusetts ceased to require physical education as a regular part of the school weekday, and to-date an estimated 50% of Massachusetts schools have eliminated phys-ed.  Many schools also allow access to vending machines containing junk food—most of which contains harmful trans-fats. 

A diverse, culturally competent workforce is lacking at all levels of the health care system. 

• While people of color comprise half of Boston’s population, no teaching hospital reports more than 10% of physicians from underrepresented minorities, according to Health Care for All. 
• A recent study released by the University of Massachusetts-Boston’s Center for Women and Politics, titled A Seat at the Table?, found a significant lack of diversity among the state’s 125 hospitals’ boards of directors and trustees.  Among board members, 93% are white, and 75% are male; 3.7% are African American, 1% Hispanic, 0.9% Asian and 25% are women.  Fear of cultural misunderstanding, language barriers, lack of knowledge of the US system and the specific concerns of gay, lesbian, bisexual and transgender individuals hinder access for many individuals who benefit from staff and resources trained to be attuned to their concerns and needs.

Boston’s youth are facing a variety of physical and mental health challenges.  

• Youth violence and fear of violence is a growing problem.  The greatest challenge may be the draining of hope for the future stemming from experiences of violence and poverty. In the 2005 Youth Risk Behavior Surveillance System (YRBSS) survey, 30% of Boston public high school students reported feeling sad or hopeless for more than two weeks in the prior year—and suicide attempts increased between 2003 and 2005.
• Tobacco, alcohol and drug use continue to attract many high school students, with 47% having tried cigarettes, 68% having tried alcohol and 39% having used marijuana, according to the 2005 YRBSS.
• Many youth are at risk from lack of physical activity, with 44% reporting watching three or more hours of TV per day, and 32% reporting that they do not engage in even moderate physical activity.  At the same time, 14% of students considered themselves overweight and another 19% felt that they were at risk of becoming overweight.

State budget cuts have affected Boston’s unique network of community health centers, reducing their capacity to offer preventive programs and health promotion activities. 

• Community health centers are an integral part of the health “safety net,” serving 1 in 9 Commonwealth residents, with over 3 million visits statewide through 184 sites, according to the Massachusetts League of Community Health Centers.
• State funding for community health centers was reduced by 40% between fiscal years 2001 and 2007, leading to reductions in staff and services, despite increased demand for services.

In light of the misalignment health determinants and health spending, public health experts point to the need for a broad, active and well informed constituency for public health to advocate for sustained public funding and a cost-effective focus on prevention, public education, unbiased health information and media coverage that promotes healthy lifestyles.

Boston’s public health infrastructure faces many challenges with respect to emergency preparedness.

• The Federal government is withdrawing funding and responsibility for disaster preparedness, leaving cities like Boston to address the issue with far fewer resources. 
• With shrinking numbers of available hospital beds, public health officials and emergency department physicians have raised concerns about capacity in the event of a natural disaster or widespread epidemic of a contagious disease such as avian influenza.
• In the aftermath of Hurricane Katrina, concerns have been expressed that Boston’s most vulnerable populations would be those most affected in a disaster.