November 26, 2019

Addressing Symptoms and Root Causes

The following is an interview with Kathy Ko Chin, MS, President and CEO of the Asian & Pacific Islander American Health Forum, a national health justice organization which influences policy, mobilizes communities, and strengthens programs and organizations to improve the health of Asian Americans, Native Hawaiians, and Pacific Islanders. She’ll be speaking as a panelist at our Cambridge meeting on December 2.

Austin Frakt: Among health care systems, plans, and programs, there has been increasing discussion of, if not investment in, approaches to addressing social needs. What is driving this phenomenon? Why is it happening now (as opposed to, say, 10 years ago)?

Kathy Ko Chin: For most of the past decade, life expectancy has been higher in the US than at any point in our history. We die less due to acute disease and infection. The causes of morbidity and mortality have shifted to (a) chronic disease and (b) conditions of despair (opioid overdose and suicide), which are diseases tied less to medical care and more to lifestyle and living condition factors, which are more greatly impacted by social determinants of health.

Despite this overall rising life expectancy, for people of color, even adjusted for factors such as income and education, life expectancy has not risen as significantly. The impact of racism, particularly structural racism embedded in social policies, continues to show itself through inequities in health outcomes, access to health care, and quality of care. With the wide availability of social media, there is an awakening across the country to the realities of racism and discrimination, which is supporting a wider range of actors to address racism and the social determinants of health.

There is growing research and data showing the correlations between long-term health and living conditions, or conversely, like with Adverse Childhood Experiences (ACEs), the association of the number of traumatic ACEs with chronic disease in later life. Therefore, social determinants of health become all the more important to prevent, manage, and eliminate the diseases which are most prevalent in our country.

Social determinants of health have become more widely understood as something that must be addressed when trying to advance health. We have seen data which shows that medical care actually only address 25% or less of keeping someone healthy. Where a person lives, their educational attainment, and their cultural history are all perhaps more important to addressing disparities in health, as compared to the medicine or treatments they are prescribed. Although many of us may have suspected this before, we now have more data and research showing the linkages between social factors and health then we did 10 years ago.

This is far from a new concept for those organizations who have been working on health equity for decades, but it is encouraging to see it now coming from a wide variety of actors inside and outside of the health space. At the same time, we have to make sure that patients’ needs and the true drivers of health outcomes are addressed and not lost in the high profile attention that “health equity” and “social determinants of health” are now getting.

To what extent should the health system be involved in addressing social needs? After all, these are not traditionally in the purview of health care. Are the boundaries of health care shifting? Should they?

Our country currently spends nearly $3.4 trillion on health care, representing 18% of the GDP. Although one in five dollars in the economy are spent on health costs, health outcomes are still worse than countries who spend a fraction of that amount or less per capita than the U.S.

The rise of the concept of the health care system addressing social needs and social determinants is based on these unimaginable numbers. If there were ways to re-align the allocation of resources, to take a portion of these funds spent and spend them in ways that better addressed both social needs and improved health, that would be a much better use of our collective resources.

There are numerous examples of how using a relatively small fraction of health care expenditures on social determinants has resulted in lower overall expenditures and improved outcomes. That’s what drives this line of inquiry. But it has not been embraced at a massive enough scale as to truly transform how care is delivered, how social needs are addressed, or how dollars are spent.

At a very granular level, in immigrant communities across the country, there are scores of low-income families for whom their health status and access to care is compromised. But the one consistent solution is for them is accessing services at local community based organizations (CBOs) which meet a wide range of their social and human needs. Particularly in the current climate of anti-immigrant sentiment, CBOs are trusted sources of information, support, and services for the communities they serve.

If some of the $3.4 trillion spent on health care could be re-directed to support such deeply trusted CBOs, they could significantly expand their patient navigation services, their enrollment services for health insurance and other benefits, and be advisors and partners to the health care system. For each investment of $100,000, a modest amount compared to $3.4 trillion, thousands of clients could be better served.

There are opportunities for health care systems to work with CBOs who are the trusted providers for the community and are already providing many of these social needs services. One example is the community health center model. Many of our CBOs focus on “whole person” or integrated care, which includes not just their immediate health needs, but providing assistance with job placement, housing, food , mental health, and other social needs.

Are we making progress in addressing social needs and/or social determinants of health? How would we know if we are? What would constitute “success”? How should we measure it?

Success is achieved when a person’s identity (including immigration status), where they live, and their cultural and family history are no longer the primary determinants of their health outcomes. It means that people who are limited English proficient can readily access health services in their primary language and immigrants do not face policy barriers to eligibility for public health insurance programs. Success is when cultural competency and anti-discrimination practices are fully integrated into both health care and the interrelated systems, such as housing and nutrition aid, that impact health.

These will be difficult to achieve, for certain, as well as measure, yet we cannot expect overcoming decades of systematic discrimination and harm to be easily overcome. We have made the first steps on this path by acknowledging that a person’s social circumstances determine their health. We must address both the symptoms and root causes of those circumstances, working to achieve true health equity.