Introduction
Welcome to my June 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
I’m leading off with this thought provoking quote from the Toronto Star that applies equally to the US and should be a priority for all state and Federal legislatures.
“The worst thing we risk facing would be to reflect at the end of the next decade — or perhaps after the next pandemic — and realize we failed to seize this pivotal moment. That we failed to deliver a new vision for a fairer, greener and more innovative Canada, after our pandemic war. That after winning, we had no equivalent to housing for veterans, the NHS, the G.I. Bill, or great new universities — those enduring legacies of post-WWII rethinking and rebuilding. That we simply threw money at the same agencies and programs, expecting a different outcome.”
Life expectancies have dropped globally and in the US. Disparities are significant in life expectancy for US Blacks and Hispanics verses US Whites. Specifically, -1.36, -3.25 and -3.88 years respectively. For Blacks in the US this makes the existing disparity even worse dropping to an average life expectancy of 72 years in comparison to the US average of 77 years and close to 6 years when compared to US Whites. Although perhaps this is not a surprise given the disparities caused by COVID19, it is one more reason we need to build back better! The study results with a great visual abstract can be found here.
A study about the impact of hospital investments in social determinants of health (SDOH) yields mixed results at best. One of the main problems is the sample sizes are small. In my opinion this is largely due to the narrow investment targets focused on high utilizers rather than on investing in upstream community needs that support the community and the broader at-risk population.
A study of Oregon’s Medicaid investments in SDOH shows early promise with a very different approach, even during the pandemic. It makes a point of requiring Coordinate Care Organizations (the Medicaid managed care contractors) to reinvest a growing portion of their revenues into community services support and to establish a community advisory council made up of more than 50% Medicaid members that informs community health priorities and how funding is invested. This feels like a promising model.
A Health Affairs funding SDOH article on “aggregate precision investment” discusses an aggregate ROI methodology for bringing in multiple investors to support community interventions that would benefit individuals and families for which different types of organizations have a role or responsibility. It envisions an aggregator as a data or financial organizations that could “harness” data to facilitate participation by multiple investors that would help solve the underfunding of SDOH. Perhaps the aggregator should be a community development financial investor (CDFI) partnered with a health data analytics company, since CDFI’s already focus on underserved communities.
My main concern is the precision nature of the investment. If it is too narrowly defined, it will not help address sustained and systemic problems in a community. The authors believe that with enough stakeholders supporting enough community members it could reach critical mass; yet also state the investing stakeholders are unlikely to fund support for individuals for whom they do not gain ROI. I’m hoping the pandemic has helped all stakeholders recognize they have a greater stake than just their members/constituents/patients/employees. Time will tell.
There is growing evidence that people are leaving their jobs because of inadequate pay. Such pay is also the main underlying cause of industries struggling to find workers particularly in the hospitality and service industries. I believe a similar dynamic is at play when states create health programs to cover the underserved that provide inadequate payment. This opinion piece from Dr. Reginald Washington explains why a Colorado bill designed to address racial disparities likely will have the opposite effect.
States are struggling to distribute COVID19 rental assistance funding for a number of reasons including many, if not all, states did not have rental assistance programs and were building from scratch. This challenge is not unique to this program and suggests there should be technical/program assistance for these new urgent and large funding initiatives to facilitate success.
The National Academies of Science Engineering and Medicine (NASEM) Response and Resilient Recovery Strategic Science Initiative – Issued a report and held a webinar on COVID-19 and Rental Evictions. They have extensive near-, short- and medium-term recommendations to avoid the looming housing crisis. It is a very comprehensive set of steps that hopefully the Administration and states will embrace. Unfortunately, the timing appears to be gated by establishing a task force. I recognize the need to facilitate collaboration and build a broad coalition, but the prior article and the many states announcing plans to end the eviction moratorium as soon as the National moratorium ends indicates timing is critical.
The Biden-Harris Administration’s equity in education approach is designed to address disparities in school resources for schools that have been historically underserved and majority non-white. All of the details are not yet determined, and the initiative will have to get sufficient support in Congress. Nevertheless, it targets much greater investments in schools that have insufficient funding and resources and are a known component of structural racism. The initiative also creates incentives for states to change policies that sustain or increase inequities across schools. I’m hoping with some help from Congress, this could be a reform model for advancing racial equity in other Federal/state programs.
Stanford Law Review article about school policing and using the public health lens for assessing and reforming such programs makes the case for insuring we are looking at the intersection of education and civil rights.
“A public health approach to school policing offers a number of benefits. It focuses on socio-ecological drivers of disparities, supports interventions at preventative and structural levels, expands invested stakeholders, unsettles disciplinary conventions, and offers diverse methodologies to advance a contemporary justice agenda in which research, policy, and practice intertwine to expose and address racism as the root cause of health inequities. (Article footnotes have been removed but can be found in the original article.)
Ubiquity sponsored an article on the value of data in a social determinants of health strategy. This article highlighted how purposefully defining program goals and data regarding the membership needs in addition to the community-based resources are critical to advancing cost savings and improved quality. I anticipate that it may be dependent on coverage penetration in communities. Improved tech service navigation platforms may help with access, but I worry that it is potentially limiting the service assessment, and connection to services, to members driving the highest costs verses all of the members who could benefit.
As a panelist for a NATOA event, I presented trends and emerging solutions on technology and seniors in relationship to social isolation. Access to and affordability of technology, comfort/confidence with technology and physical and mental challenges when using technology are all drivers of seniors using or not using technology. Many, if not all of these, are social determinants. This concept is confirmed by a set of studies about patient portal access disparities referenced in this recent article from Sara Heath.
RECENT & UPCOMING EVENTS AND RESOURCES
I was recently made aware of Aligning for Health’s biweekly Social Determinants Newsletter. It has a lot of health system and policy content. Much of which is developed from a health system perspective, but still helpful. It also contains a lot of event and funding opportunity information for the next 6 months. The link will also take you to where you can subscribe to the newsletter for free.
Bringing Light and Heat: A health Equity Guide for Healthcare Transformation and Accountability 5 “key steps of a process to drive radical transformation to achieve equity” webinar July 29 10AM PT/1pm ET.
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