Welcome to my Summer 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
This newsletter is a bit jam packed because I chose to combine July and August. Apologies for the longer than usual read.
COVID19 Continues to Govern Our Lives
Back to school debates and policies reveal how many different factors affect where individual, families, teachers, school districts and policy makers stand on: in-person and hybrid attendance, masks, and vaccinations. In some respects, it highlights the complexity of the sustained pandemic and how different risk considerations, and life circumstances, shape our individual and system approaches.
The two months of summer witnessed an enormous swing in the waning and resurgence of the pandemic. US vaccination rates grew with the approval of the vaccine for 12- to 18-year-olds. Unfortunately, politics, misinformation and distrust continued to fan the anti-vaccination fires.
Will full approval of the Pfizer vaccine remove a critical barrier to higher vaccination rates? It seems too soon to tell, but the consistent data showing 99% of COVID deaths are unvaccinated people should help more individuals and families to decide it is worth the down-side risks that to-date have been limited. Someone recently asked in a health literacy forum if there are better terms than ‘post-pandemic’; particularly since the end of this pandemic is nowhere in sight, and it is more likely it will evolve to something like the flu if we are lucky. It is a tough question with no great catchy terms. A recent National Geographic article shed light on how past pandemics evolved.
Mental Health, Health disparities, Medicaid and the US Safety Net
Many articles throughout the pandemic discuss disparities in mental health and mental health services. This recent article about mental health challenges faced by the underserved in Ohio highlights how difficult it is and has been for people in poverty and marginalized in society to manage through the added stress of the pandemic. These challenges were largely impossible to navigate when added to the inequities and uncertainties that children and young adults were already facing. Medicaid is again the place to turn for low-income families and children; however, state Medicaid programs often have very limited coverage and access for mental health. This Healthline article discusses the Medicaid mental health limitations and why we aren’t doing enough.
The article “Medical Debt is a Significant Social Determinant of Health” should not really be news, but a quick read underscores how much Medicaid expansion can make a difference and how tightly intertwined personal debt is with rapid decline in health and mental health.
A late June issue brief from Milbank Memorial Fund provides a good basic road map on how to address health disparities through Medicaid. It talks about COVID19 health disparities and short-term changes made to address these disparities. It also acknowledges that long-term changes are needed to address historic health and racial disparities that got worse during COVID and are rooted in systemic biases. Many articles and forums are focusing on the role of Medicaid and the importance of our beleaguered safety net health system.
I find myself wondering about Medicaid sadly being our “separate but equal” health coverage that, in too many states, does the bare minimum versus fostering a more fully integrated health system. The US health system is unfortunately more of a patch work of health businesses, some quite large and robust; however, many of these businesses are not accessible to a significant portion of our country’s population.
The U.S. hasn’t changed how it measures who’s poor since 1964, This article from Route Fifty highlights that we still essentially use three times the cost of purchasing food for a minimally adequate diet and the calculation doesn’t take in to account the other costs of basic living necessities. How can we really address food insecurity when the metrics do not reflect true costs? Sadly, poverty is not just about food and most safety net programs use this outdated measure of poverty for eligibility. Hopefully the efforts of the Administration and Congress to address poverty and social determinants of health (SDOH) will develop an alternative approach.
Sara Heath reports on a recent study showing that older adults living in areas with high deprivation scores have 2 years less mobility than older adults living in more affluent areas. Deprivation in a neighborhood encompasses many poor conditions including poor infrastructure, limited food access and limited healthcare access. The study also points out that it is likely tied to structural racism that limited where people could rent or buy housing. Unfortunately, we’re seeing this continue to play out today in housing intended to help low-income individuals and families, as highlighted in this recent article on poorly constructed homes in a DC Low-income housing program. New low-income homeowners had to leave due to poor construction. The construction should NOT have past inspection, would likely not happen in more affluent neighborhoods, or would have been shut down and forced to compensate anyone who had been harmed. Meanwhile two years after the problems emerged, the city plans to shut down the buildings and only now is creating a task force to help the residents being forced to move.
Federal Government Activities
The Social Determinants Accelerator Act of 2021 is a step in the right direction for creating an interagency council focused on SDOH and for hopefully creating and implementing accelerated plans to address SDOH for vulnerable populations in up to 25 communities. It is funded to the tune of $25 million, $5M of which can be used to support the Council activities. Hopefully 2022 will see a sizable increase in funding.
In July, House members launched a Congressional Social Determinants of Health Caucus that has bipartisan cochairs. They are seeking public input on challenges and opportunities to address SDOH, particularly in light of the stark realities evident during the pandemic. Submissions are due September 21st. There is an online form requesting specific responses in four areas: Experience with SDOH, Improving Alignment, Best practices and opportunities, transformative actions, and an open forum to state any remining input. This is potentially a companion effort to the executive order on advancing racial equity and supporting underserved communities that will help advance needed legislative changes.
In early August, the Office of Management and Budget submitted a report to the president on its “study of methods for assessing how government practices create or exacerbate barriers to full and equal participation by all eligible individuals.” The report highlights that the effort is nascent and represents both a sprint and a marathon. It recommends agencies establish cross-functional agency equity teams and assess their high-impact services – highest spending programs, largest transactions or most customers, highest impact on lives or traditionally focused on underserved communities. There are 5 core areas of findings:
- A broad range of assessment frameworks and data and measurement tools have been developed to assess equity, but equity assessment remains a nascent and evolving science and practice. This section includes listings of assessment tools and discussion of data challenges and potential solutions.
- Administrative burden exacerbates inequity. This section discusses the many ways Federal program requirements create barriers and hardship. It then flags known burden drivers and an extensive list of potential solutions.
- The Federal Government needs to expand opportunities for meaningful stakeholder engagement and adopt more accessible mechanisms for co-designing programs and services with underserved communities and customers. This section gives examples of successful stakeholder engagement and acknowledges that there is no one size fits all.
- Advancing equity requires long-term change management and a dedicated strategy for sustainability. This section highlights that current staffing and skill sets do not map to needed capabilities for long-term change. Agencies will need to support and invest in key workforce functions.
- The scale of Federal Government activities creates an opportunity to advance equity through core management functions including financial management and procurement. This section emphasizes transparency in equity of funding mechanism, improved program design and improved equity in procurement.
The report discusses pilots undertaken by certain agencies thus far and ways to expand on the initial findings of the report. This is a thorough report that recognizes the challenges of the advancing racial equity and supporting underserved communities executive order (EO) timing and the current staffing and competing priorities of agencies. My main concern is that it predominantly keeps the agency efforts siloed rather than looking at how interagency efforts would benefit the overall goals of the EO. I’m hoping this will change over time.
“Health Affairs Policy Spotlight with CMS Administrator Chiquita Brooks-LaSure, ” Health Affairs Event, August 12, 2021. The background article on the review of the Centers for Medicare and Medicaid Services Innovation’s past 10 years highlights the new directions discussed in the event with a link to the recording. The six key takeaways are:
- Make equity a centerpiece of every model
- Offering too many models is overly complex, particularly when models overlap
- Re-evaluate how the center designs financial incentives to ensure meaningful provider participation
- Risk taking models need tools to enable and empower changes in care delivery
- Challenges with setting financial benchmarks has undermined model’s effectiveness
- Models can define success as encouraging lasting transformation and a broader array of quality investments, rather than focusing solely on each individual model’s cost and quality improvements
The CMMI vision for the next decade is “a health system that achieves equitable outcomes through high quality, affordable, person-centered care” using 5 strategic objectives: drive accountability; advance health equity, support innovation, address affordability; and partner to achieve system transformation. I’ve added the emphasis on affordability because affordability has been a fundamental barrier to health equity. Cost savings have often had the stronger emphasis and unfortunately models are not necessarily run for long enough time periods to necessarily know the tradeoffs and sustained outcomes. SDOH are called out as part of supporting innovation. I hope they use the concept of a broader array of quality investments on who receives funding and how the SDOH needs are addressed. I’m rooting for CMS and a broader set of stakeholders to explore new models!
The Office of the National Coordinator for Health Information (ONC) updates interoperability standards regarding sexual orientation, gender identity and SDOH data. The information is voluntary, but if provided can help tailor treatment and service referrals.This data is also considered sensitive and can be misused. Privacy protections will need to be applied.
Businesses and the health Industry’s roles in SDOH and COVID
March McLellan ‘s Brink – Global business insights article discusses the role of businesses in supporting resilient communities in recognition of their role during COVID19 and in anticipation of future public health emergencies. The business roles include supporting their employees, influencing their customers and suppliers and bolstering the resources for underserved individuals and communities in the geographies in which they operate.
Online survey spearheaded by Illinois Health and hospital association to help health providers and community-based organizations address health disparities. Is designed to look broadly at racial equity in their businesses and programs in addition to the services provided. The tool was launched the day before Juneteenth. It has 31 questions “designed to measure the degree to which they track and try to reduce racial and ethnic disparities in patient health outcomes.” The questions include how much diversity is reflected in their leadership and whether they are supporting minority owned suppliers all with the goal of dismantling racism through awareness and self-improvement.
PA’s Rehabilitation and Community Providers Association developed an SDOH training module for service coordinators and direct service providers. I’m sure there are other training initiatives, but I have not seen a lot of reporting about this type of training, particularly for people already in the workforce verses healthcare academic programs.
The July and August SIREN newsletters have many informative entries across their topic areas including ‘in case you missed it’ with events of interest. The articles and coverage listed below are the ones I found revealing and compelling and encourage you to do the same, selecting those that are most relevant to your needs and focus. I will be transparent on my bias, the growing initiatives designed to advance individual and community well-being need to focus on the collective community needs not the constrained perspective of provider systems, organizations and health plans that only look at a portion of the population with a narrow clinical outcome lens.
I see support for this perspective in all 4 resources and suggest that we need different models from those that have been developed by individual health systems and plans. In fact, this reminds me of how health IT grew organically and without the needed investment in interoperability or focus on the individual and communities that are all impacted by multiple providers and plans. We will likely save significant investment dollars if we quickly pursue community driven collaborative SDOH interventions, sustainable investments that spread the costs across government, providers and plans — all of which will benefit from the health and economic improvements and engage with the same communities and individuals. This concept also aligns with the 6th key takeaway from the CMMI innovation review discussed above.
My favorite entries:
The last resource has some provocative findings that include: redefining success by prioritizing communities over contracts; advancing health equity requires more investment in organization that are community led by and serving people of color; and invest in community-led solutions that lead with what is best for the community – not just what the healthcare institutions are willing to pay for (emphasis added).
RECENT & UPCOMING EVENTS AND RESOURCES
The guide that was the focus of the July webinar is now available. 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. The guide lays out a 5-step process: Commit; Build capacity; Assess & strategize; Change practice & policy; and Learn. It looks at “light and heat” in each step, i.e., transparency and accountability. The target audience for the guide are leaders at medium to large non-profit hospitals and integrated delivery systems.
2021 Health Equity Training Opportunities Showcase virtual Johns Hopkins annual event for people and organizations across Baltimore interested in training and research opportunities related to Health Equity. September 22,2021 3-4:30PM
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