March 2021 Newsletter

My weeping cherry tree was a gift in March


Welcome to my March 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

March felt different one-year into the pandemic. The increase in vaccinations is starting to bring hope and allowing people to reconnect in-person. This is a critical first step for individuals and families who have been isolated. Unfortunately, the vaccination rollout challenges and distrust, continue to create uncertainty about reaching national vaccination goals.

There continues to be misinformation about the vaccines and efforts to dissuade people from getting the vaccine. The Public Health Collaborative has a misinformation alert tool that keeps people up to date on the misinformation and provides resources to help combat such information. They have also developed a vaccine misinformation management field guide. I think of myself as someone who is keeping up with the field and the misinformation, but there is much more happening than I had realized.  In the age of social media, there are so many more information channels for anyone around the globe seeking to manipulate information.

Drew Altman CEO of the Kaiser Family Foundation (KFF) posted about “Where to Start to Build Vaccine Confidence.” If you want vaccination information coverage from KFF go to their COVID19 vaccine monitoring dashboard.

Vaccine passorts/credentials are also heating up as another area of uncertainty. The Wilson Center hosted a global event “Vaccine Passports: A public health solution or ethical and legal minefield.” It helps identify the many complexities around how vaccination credentials and identity authentication are complicated and raise important concerns about how individuals will or will not be able to travel or engage in a range of activities including attending local events or using certain services. The speakers had global, EU and US perspectives that highlighted many challenges. These included: whether the solution will be government or industry driven; the need to have technology and paper-based solutions; and that not everyone can or will be vaccinated, thus credentialing also needs to reflect the option of a current negative COVID19 test.

NPR article “Stop Blaming Tuskegee” delivers an important message for all COVID19 and public health officials. The notion that the historic horrific mistreatment of Black men in a sustained syphilis clinical trial drives Black Americans distrust of the health system and the vaccine excuses the existing structural racism in healthcare. We don’t need to look any farther than the many non-COVID disparities, including infant mortality and all major types of cancer. These, in combination with all of the disparities revealed by COVID19 underscores that the distrust is based on today’s inequities and racism.

On March 2nd AdhereHealth launched a technology platform to help a broad range of organizations engage and get vaccinations to vulnerable populations. They are repurposing their medication adherence model for this purpose. Their customers are clinicians, plans and governments, arguably anyone who has a stake in increasing engagement of vulnerable populations who are not getting vaccinated for a range of reasons. I imagine the business model is payment by the organizations and it may be risk based. I hope there are Medicaid health plans and programs who are helping support use of this type of technology in community and rural clinics that serve vulnerable populations.

In recognition of the broad challenges presented by mis- and disinformation, the Aspen Institute is hostingan intensive, six-month commission bringing together experts and vital perspectives from government, media, civil society, and the private sector to deliver recommendations for how the country can respond to this modern-day crisis of faith in key institutions.” The Commission on Information Disorder has a commendable set of goals in both understanding and trying to address the threat of disinformation in all public and private forums. It will be extraordinarily difficult to navigate the balancing of free speech, cyber security, hate crimes and protection of vulnerable and underserved groups and individuals. Nevertheless, if we don’t try, we cannot succeed.

Unfortunately, violence and unrest continue to be driven by racism. The Atlanta mass shooting that targeted and murdered Asian women exposes another segment of structural racism that has been in our country since the late 1800s. Asian hate crimes have risen since the pandemic was characterized as originating in China and misinformation implied it was caused by China. Asians have been viewed as the model minority that has achieved economic success. This “success” may have allowed the sustained racism to be masked or minimalized. Our efforts to acknowledge and address all systemic and structural racism cannot wait and must look at all forms of racism and bigotry.

Somewhat a good news bad news story, we will be hearing about and seeing more and more research going into the details of COVID19 disparities. A recent NYT article highlights eviction rates for New York city renters are 4 times greater in the hardest hit COVID communities that are also predominantly Black and Latino communities. Here are two other examples of the growing research: “Pandemic precarity: COVID-19 is exposing and exacerbating inequalities in the American heartland” highlights the many aspect of living conditions in Indiana that have worsened during the pandemic and in turn yielded greater health disparities; and, “Studies spotlight COVID racial health disparities, similarities,” from University of Minnesota’s Center for Infectious Disease Research and Policy, discusses four studies that assess health disparities and the underlying causes.

President Biden’s first official news conference highlighted his commitment to everyday people and recognition that he will have to prioritize the many critical issues facing our country. He is starting with the Pandemic and the economy, but on behalf of the poor and working people verses the wealthy. He doubled the number of vaccines that would be delivered in the first 100 days of the administration and will use $10B of the stimulus dollars on delivering vaccines and building confidence in the hardest hit and highest risk communities.

AHIP published an issue brief on Medicaid Managed Care Organizations addressing Health Equity. This issue brief highlights how Medicaid and particularly Medicaid managed care are designed, and best positioned to address health equity. I whole heartedly support the positioning and intent. We also need to recognize the constraints and opportunities faced by Medicaid. Here are a few:

  • Medicaid and Medicare were created as social and economic support programs back in 1965! Medicaid specifically for medically needy Americans.
  • Medicaid is uniquely a State and federally funded health insurance program run by the states. Apart from minimum federally set standards, each state program is designed by the state. We see the disparities among Medicaid programs in payment rates and coverage every day to the detriment of underserved populations.
  • WalletHub offers a comparison of Medicaid coverage that highlights how variable coverage is across states. This variability offers natural laboratories that can yield insights into what does and doesn’t work.
  • The Affordable Care Act option for Medicaid Expansion was a political hot button. 23 states embraced the option from the beginning, January 1, 2014. 15 states have adopted since then, 6 soon after the effective date, 5 in the last 2 years. 12 states have not embraced the option.  (State adoption information comes from KFF State health facts)

I’m seeing a growing number of medical, nursing and public health school programs focused on health equity and social determinants of health. I even came across a randomized control trial for Strategies for Health – an interprofessional game-based approach for teaching about SDOH. The trend I see as perhaps most promising is having students engage in communities where living conditions are the drivers of health disparities.

The announcement of Walden University’s and the National League of Nursing’s creation of the Institute for Social Determinants of health and Social Change also looks promising. The first program will be a Interprofessional Leadership Academy for Social Change. The Institute is located in Minneapolis where George Floyd’s murder launched national racial reckoning that has accelerated needed change. Recognizing the important role nurses play in healthcare access and really seeing the patients as individuals and appreciating the context of their living conditions is needed and overdue.

Diversity in EMS, a new bimonthly column in EMSWORLD, will concentrate on questions of bias and diversity in Emergency Medical Services. The first article discusses unconscious bias and a free tool from Impact4Health’s that helps “healthcare organizations identify and mitigate bias that may influence care.” The tool uses 70 plus best practices to improve diversity and bias issues. The article highlights the ways unconscious bias at the initial contact with an individual needing healthcare can affect the entire series of healthcare services that follow. The tool has not yet been applied to EMS, but the article recommends the value of the assessment steps. EMS services can be the critical gateway for better care. For example, a model called community paramedicine includes social workers as part of EMS staffing to help assess and address SDOH.

The focus on nursing and EMS above, suggests a dual focus on living conditions that could be the model for investment and differentiation of services to address health equity and discrimination. Health systems and services need to understand SDOH, know how to help people connect to needed services and arguably be one of the streams of investments in needed social and community infrastructure. Meanwhile the Social and community infrastructure and services need to be built out, strengthened to address upstream drivers of health and partnered with the health services and systems to facilitate referrals and avoid gaps in care and support.

A quote from an opinion piece in the NYT caught my eye because it can apply to too many of the questionable COVID investments in large companies “Once again, we have socialized an industry’s losses and privatized its profits.” This was referencing the airline industry, that may have saved 75K jobs, but at the tune of $300,00 per job. We’ve seen it in the past with banking and we have seen it across a number of industries during COVID, including those applying for the PPP, Paycheck Protect Program, loans that were meant for small businesses.  There should be a community investment obligation that comes with the funds along with a restriction on passing it on to shareholders verses employees and communities.

I want to revisit my coverage of the CVS housing investment. A recent article about a $12.4 million investment in affordable housing in South Phoenix, partnering with a local nonprofit, is a large investment in one locality. The investment includes a mobile RV offering screenings for chronic conditions. This combination will make a difference particularly to those lucky enough to get one of the 60 housing units.

Health and Social determinants technologies are here to stay, but what will it mean. I often say technology is a double-edged sword and the same is true for the data increasingly amassed and used by technology. Below are just some of the recent activities. The same way redlining occurs when lenders refuse loans in certain geographies or census data is used in gerrymandering, the growth of detailed SDOH data and the availability of vaccine and test credentials can be misused. The government, industry and communities all need to work to be transparent, ethical and both limit and call out abuses to ensure that we can leverage the technology and data for improved health and equity.

  • Unite US “is an outcome-focused technology company that builds coordinated care networks to connect health and social service providers together” recently closed a $150M series C funding round.
  • ONC’s “health equity by design” focus (see below)
  • Gravity project’s standardization of how SDOH data is collected
  • Vaccine credentials/passports
  • Health Information Exchanges’ being the broker or utility for linking health and community-based organizations and sharing needed information

Tech and data are tools that can be used for good or bad. Let’s try to establish incentives and guard rails to head them in the right direction.

Please share the newsletter and connect via LinkedIn or email with your reactions and input.


The Office of the National Coordinator of Health Information Technology (ONC) 2021 Annual Meeting (3/29-30) had three breakout sessions and one plenary session on Social Determinants of Health. Registration was required, but likely the recordings and slides will be available after the fact. The Biden Administration’s New National Coordinator of ONC, Micky Tripathi provided this equity perspective at a virtual Health IT leadership Roundtable.

I think what we need to work on, and at ONC we’re doing this, is health equity by design, where, from the beginning, we look at what are health equity considerations and how do we take that in as a fundamental design criterion so that we have fewer surprises down the road.

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