Introduction
Welcome to my April 2021 Living Conditions and Health newsletter. You can find past newsletters with additional background materials, and different stories and initiatives on my website and in my LinkedIn articles or posts. Join me in identifying and coordinating initiatives that advance health, health equity and community and healthcare redesign.
Shannah’s Insights and Reflections
April was Minority Health Month and there were many programs and announcements highlighting what public and private organizations are doing to address health equity. Many discussions were grounded in the health inequities of COVID19. These are important and valuable initiatives, but the inequities are not unique to health and healthcare. One article describes the many ways, the health system collects the disparities of structural racism. Structural racism is rooted in: lacking access to critical resources and supports that provide needed basic living conditions; and, historic social injustices and inequities in all aspects of life. An article in the Hill on the need for an increased minimum wage that offers a living wage is another example of ongoing policies that disproportionately impact minorities. These negative social determinants have been present for decades, if not centuries and will require sustained and increased efforts to fix.
The current minimum wage is inadequate for individuals and families to live on. MIT’s Living Wage Calculator shows that “A single-mother with two children earning the federal minimum wage of $7.25 per hour needs to work 138 hours per week, nearly the equivalent of working 24 hours per day for six days, to earn a living wage.” This was based on 2019 data and is likely worse due to increase prices resulting from the pandemic.
Lyft and Uber continue to try to help with transportation access, but COVID19 has made it harder to find drivers and increased prices. Lyft has Pass for Healthcare that allows sponsoring healthcare or social service organizations to cover the rides and set parameters around the cost, distance, frequency etc. Transportation is not only a barrier to keeping medical appointments. Addressing rides primarily for medical appointments versus an affordable transportation infrastructure that serves local residents equitably are too very different solutions. Imagine if healthcare and social service organizations partnered with local businesses and government to provide free and reduce fee rides regardless of the trips’ purposes.
A RACmonitor article, highlights the status of evictions in the US. The CDC extended the order to prevent evictions through June 30, 2021 for people suffering economic hardship and doing their best to pay what they can. Nevertheless, landlords and lenders are using loopholes to get around the order. The fundamental problem will still persist regardless of when the moratorium is lifted. We need better and sustainable housing options. As long as the pandemic persists, we need to avoid creating circumstances that force low-income individuals and families into shared living settings that are more susceptible to spreading COVID19.
CDC Director Rochelle Walensky declared racism a serious public health threat, stopping just short of what many states, cities and localities have done when declaring racism a public health emergency. It is still an important step in recognizing the severe toll racism has on all races and ethnicities experiencing hatred, violence and systemic marginalization and oppression. Ideally it will bring much needed investment as is envisioned in the Executive Order on Advancing Racial Equity and Supporting Underserved Populations (first discussed in January’s newsletter).
The Chauvin conviction for the murder of George Floyd demonstrates police can be held accountable, but there are too many examples, even after the conviction, that show more fundamental and systemic changes are long overdue. Our country is divided about what, if any, constraints police should have on when/if force, and deadly force, can be used. Racist and inequitable actions by the police are evident across the county. As president Biden has said, it is terrorism and the time for fundamental change is now!
Health Affairs blog discussed building on lessons from six state Medicaid experiments in OR, WA, MA, MN, RI and NC. All states have explicit requirements regarding social determinants of health and advancing health equity. Most are providing incentives, and all are measuring health outcomes by race, ethnicity and language, but are somewhat challenged with data limitations. They are seeking to better connect and enable regional structures across stakeholders that include the social services sector. My favorite model is in the state of Washington. It is operating accountable communities of health (ACHs) “intended to create a community-based governance structure that includes but is not run by Medicaid and oversees managed care contracting and coordinating healthcare and human services to address SDOH.” My ongoing concern is how tightly tethered it is to health outcomes, when these are basic living condition needs that have quality of life impacts and should support all people in need whether eligible for Medicaid or not.
I watched Coded Bias, in April and it should be on everyone’s much watch list. It is available free on Netflix. As the title implies, the way information is used today in both the public and private sector is biased, often purposefully and almost as often unintentionally because the data being used is historic and often fundamentally bias by exclusion. We know this from medical research that was historically always done with white males. What most of us likely don’t realize is how much data analysis techniques — machine learning, data algorithms and artificial intelligence, bake in historic trends and biases. Even when we have better data, how it is used can, and often does, incorporate biases. The movie is riveting, especially if you are a bit geeky, but important for everyone to know.
Sentinel Outcomes Initiative, supported by the Impact Genome Project, is a multiyear effort that will track, study and report on unmet critical human needs of all Americans. They will use “precision science for social impact”. They are looking at six major social determinants and plan to report on a new outcome every two months starting with financial health. The remaining outcomes are social capital, food security, housing, workforce and education.
Pandemic aid doesn’t reach America’s poorest families, a recent Washington Post article highlights many poor families and individuals are off the grid, don’t have tax returns, are paid in cash under the table, have constraints on when they can receive funding, e.g., ineligibility for benefits because you are behind in child support. The populations throughout our country that live under the radar highlight a known problem with many of the standard metrics used to track and assess the ‘health’ of our country and economy. It is not necessarily a true picture of how we are doing and suffers from some of the problems identified in Coded Bias.
Blue Cross NC has created community partnerships to address food insecurity and other social support for its members. They are working with a group of food banks to promote enrollment in food and nutrition services and Supplemental Nutrition Assistance Program (SNAP/Food stamps). The goals are to reduce enrollment barriers, support individuals through the process and destigmatize participation. Different BC NC plans offer different food programs designed to improve healthy eating. These plans build on the payers existing Health equity initiatives.
The SIREN (Social interventions Research & evaluation Network” monthly newsletter highlighted “historic request for applications on structural racism by every single institute at the NIH”. This effort was discussed during the CMS forum on addressing structural racism discussed below under recent events. This is a new and welcome change for all of the disease focused institutes at NIH.
NEJM Catalyst commentary on health equity discusses how incentives can be drivers of increased inequities, because they do not account for high percentages of disadvantaged patients. Clinical outcomes do not recognize the social and economic conditions that drive health status and outcomes such as diabetes control, when patients live in food deserts, don’t have transportation and have limited time due to work schedules. The discussion suggests a 4-tiered incentive approach that looks at: 1) levels of access to care in proportion to representation in the community; 2) transitions in which disadvantaged patients are offered comparable/equitable services, e.g., admissions, referrals to specialist, rehab or recommended home care; 3) quality of care should be redefined with greater focus on prevention of more costly services and less important than access and transitions measures; and, 4) Socioeconomic and environmental impact is a measure of how the health institution practices and presence influence upstream drivers of health outcomes. The commentary suggests the institutions have the least leverage over the 4th set of measures/outcomes. I understand the prioritization on access and transitions. Nevertheless, I think the framework lets healthcare institutions off the hook. The investments in all four levels need to grow and funding needs to shift from clinical care delivery based on improved health to an earlier stage in advance of those outcomes or we are still just living in an acute care, band-aid system.
Employers can and should do more to address SDOH for low wage workers according to an Aetna Executive speaking at a managed care physician’s form. The AJMC article discussed a pilot showing these workers experiencing the same disparities due to inadequate living conditions as the local low-income population and identified many ways employers can improve these conditions. A new survey by Willis Towers Watson indicates a jump in the percent of employers planning to promote diversity, equity and inclusion in their benefits programs and work places over the next three years. Half have already acted on improved maternity benefits. Perhaps this is the start of a trend toward improved social and economic support.
RECENT & UPCOMING EVENTS AND RESOURCES
CMS’ Office of Minority Health hosted a two day virtual forum “The Road to Equity: Examining Structural Racism in Health Care”. The event was chaired by the Office of Minority Health in the Centers for Medicare & Medicaid Services. Panels with government and industry representatives focused on a broad range of health equity topics and issues including data, solutions, access to care and coverage, COVID-19 impacts on disparities and promoting equity. Recordings from the forum should be available here when CMS pulls together the recording from the event. It could take a month or two. Currently, they are only showing events from February. Kudos to CMS on the very diverse and predominantly female speakers. The event structure was an example of how to model diversity and inclusion and show participants/viewers that their views and people are represented/reflected in the discussion and goals.
The RISE Summit on Social Determinants of Health June 13-15 live and virtual.
Health Disparities Research Institute (HDRI) virtually August 9-13, 202,
The Root Cause Coalition National Summit on Social Determinants of Health is being held virtually October 4-6.
Background and Definition
I have chosen the phrase “Living Conditions” rather than social determinants of health (SDOH) to make the concept more accessible. This focus tracks with the Centers for Disease Control and Prevention’s SDOH definition “as conditions in the environments in which people live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
Go here for more information from CDC on its organizing SDOH framework in Healthy People 2020