November Newsletter

On Thanksgiving we should pay tribute to all of the unsung Native Americans


Welcome to my November 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

Do you know someone with Long COVID? It is bad enough to have these challenges and symptoms, but to then be stigmatized and isolated will only make it worse. This BMJ opinion piece highlights the challenges and offers ways to support people with Long COVID.

Lancet Public Health article on the tremendous impact of Adverse Childhood Events (ACEs) is disheartening, yet vital for increased awareness. The article leads off by stating “it is estimated (globally) that one out of two children ages 2-17 suffer some form of violence each year.” The article cross referenced a meta-analysis estimating 89.9% of adults who are homeless have at least 1 ACE and 53.9% had 4 or more. Preventing childhood violence should be a top priority in all countries and communities.

This is the first article I’ve seen highlighting workers comp as an area that could substantially benefit from addressing socio-economic factors. I’m sure there have been activities, but perhaps not covered in the press. This aligns with more employers recognizing the role of social determinants of health on workers generally and potentially underlying risks of workplace injuries.

David Nash’s article about the Chicago Rush University Medical Center’s (RUMC’s) Health Equity advances by addressing social determinants reviews the important roles academic medical centers can play to make fundamental and lasting changes. The initiative focuses on a community where the disparity in life expectancy was documented as 14 years. The article refers to a paper by the RUMC team that identifies 5 pillars of change:

  1. Name and eliminate racism
  2. Adopt an anchor mission
  3. Create wealth-building opportunities for employees
  4. Eliminate health care inequities
  5. Address the socials and structural determinants of health

The article goes into detail on how RUMC is addressing each pillar.  The creation of West Side United a community engaged racial health equity collaborative that brought together six large health systems, held listening sessions with the community, established a community run organization and began their critical work. It made the community highly responsive to the COVID-19 challenges and addressing equitable treatment during the pandemic. This model, and their successes thus far, look like a great model to adopt!

Tina Kauh’s Health Affairs blog “ Racial Equity Will Not Be Achieved without Investing in Data Disaggregation” emphasizes how much the high-level race and ethnicity categories mask disparities and inequities by lumping people in large categories in which internal variation is dramatic. She cites a study on Asian Americans that revealed they are one of the most economically divided groups. The existing OMB standard categories have not changed since 1997 and even these are not consistently captured. She highlights the work Robert Wood Johnson Foundation is supporting and says more philanthropic investment is needed in addition to what research institutions have been investing. I agree whole heartedly with the blog. Philanthropy can help, but I believe the majority of investments should come from Federal and State governments to support the additional work and help establish models and methods for disaggregation.

The Bipartisan Policy Center provides a comparison of two legislative proposals to prevent evictions: the Eviction Crisis Act of 2021 and the eviction Prevention Act of 2021. The former has bipartisan support the latter only democratic. The article concludes that addressing the crisis should be a bipartisan effort given the devastating effects of evictions.

Two State Scorecards and a National Analysis

The following three entries show how far our country and states must go on critical equity issues. Too often the same states appear as the worst performers. Ideally there would be standards and incentives being set by the Federal government, but the lack of bipartisan leadership suggests as these problems will persist.

Commonwealth Fund releases State Scorecard on health equity showing every state has substantial inequities relating to outcomes, access, and quality of healthcare. The white population in every state is markedly better off. In some states the Asian American, Native Hawaiian, and Pacific Islander population is comparable or slightly better off than the white population in the state.  Tragically, in most states Black, Latinx/Hispanics and Americans Indians/Alaskan Natives populations are substantially worse off, in some states varying by as much as 80% across the combined measures in Minnesota and Michigan. More upsetting is that more specific measures such as death from illnesses that are treatable with early access to treatment, the difference in the percent of deaths per 100,000 population can be 3 or 4 times higher for blacks vs. whites. This is the cases in TN, LA, and TX. All of these inequities need immediate and sustained attention if we hope to make headway on structural racism.

Altarum released a Healthcare Affordability Policy Scorecard that ranks all US states and the District of Columbia, although HI, NJ and SC are not ranked because they had insufficient data in all categories. Even though these three states did not have complete data they have some and SC look to be very closes to the bottom ranking. The scorecard gives a policy and outcome score in 4 categories: curb excess prices, reduce low value care, extend coverage to all residents, and make out-of-pocket costs more affordable.  All states have room for improvement with MA coming in first but given the equivalent of a B-. VT and RI came in 2nd  and 3rd raising the question of whether small states have an advantage, the next 2 states are OR and CO. At the bottom TX, followed by GA, and AL & OK tied for 3rd from the bottom. It would be interesting to put a diversity and equity filter on the state characteristics.

Route Fifty writes about more analysis showing discriminatory police violence has been systematically under reported, based on a Lancet article written by Global Burden of Disease 2019 Police Violence US Subnational Collaborators. The under reporting and misclassification in the traditional resource of the National Vital Statistics System is estimated at 55% during the time frame from 1980 to 2018. The states with the highest underreporting were: OK, WY, AL, LA and NE. The incidence of violent deaths of Black men killed by the police in the USA over the course of their lifetime is 1 in 1,000 and is 2.5 times more likely than for white men. When compared to other disease burden/causes of death this incidence would and should be a priority for change, particularly as our country declares racism as a public health emergency.

SIREN picks

My picks for SIREN’s November’s newsletter are:

“For profit, but socially determined: the rise of the SDOH industry” The research focuses on the fast-growing private industry that increasingly sells to payers, providers and government to help address gaps in Social Determinants of Health (SDOH). The paper does a good job of characterizing the market and highlights it is heavily concentrated in 12% of the identified market.  The paper goes on to note the impact on outcomes and on community-based organizations is mixed and the makeup of the market is not focused on the most well documented components of SDOH shown to make a difference in health. I might call this early analysis evidence of a market failure because the investments do not meet the needs and have the potential to undermine the service delivery. I would love to see a comparison of upstream investments not tied to healthcare versus those that are tightly tied to healthcare.

“Distinguishing neighborhood and individual social risk factors in health care” I’m flagging this research because it relates to the Health Affairs blog about the need for disaggregation discussed above. It concludes that relying solely on neighborhood-level social risk factors that don’t include similar person level risk factors over attribute inequities to neighborhood characteristics. This misattribution is likely worse when there is insufficient differentiation on individual characteristics.

My interests often align with the starred entries of the monthly newsletter so I encourage everyone to sign up for their newsletter on SIREN’s home page.


Roundtable on CMS Innovation Center Health Equity Strategy registration December 8, 2021, 1:30-3:00

Modern Healthcare’s Social Determinants of Health Symposium, December 9, 2021 Virtual price tag $99.00

RISE Summit on Social Determinants, March 20-22, 2022, Nashville TN

AHA Community Health Improvement: Accelerating Health Equity Conference 2022– May 10-12, 2022 | Cleveland, OH 

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