Throughout our nation’s history, our elected leaders have shaped health through advocacy, education, and their own example. In honor of Presidents Day, the de Beaumont Foundation has released a quiz sharing some fun facts about presidents and health over the years. Take the quiz.
- Who is the only president to win two national college championships?
- Who was the first president to order mass vaccinations?
“Collectively, our elected officials – at the state, local, and federal levels – have as much or more influence on Americans’ health as doctors and hospital CEOs,” said Brian C. Castrucci, CEO of the de Beaumont Foundation. “We created this quiz to make Presidents Day fun while also noting the vital role of policy in shaping and improving health.”
For more information on the presidents and public health, see “Presidential Promotion of Health-Related Behaviors Through Words and Example,” by Marc A. Safran, USPHS, Military Medicine, volume 178, issue 4 (April 2013).
Take the quiz.
By Catherine Patterson
My first job out of college was as a Head Start teacher. I had a classroom full of 20 three-year-olds, and I’m not afraid to admit (now) that I had NO IDEA what I was doing. I was the very definition of “fake it till you make it” that first year. Thankfully, my students put up with me, and I ended up spending five years as an early childhood educator.
Now, 15 years later, I’m working closely with cities and advocates on the CityHealth initiative, a project of the de Beaumont Foundation and Kaiser Permanente that works to improve the health and quality of life for urban residents across the nation. One of the policies on the CityHealth platform is high-quality pre-Kindergarten education. CityHealth just released a report that outlines the characteristics of what makes an early education program “high quality” — things like class size, teacher-to-child ratio, professional development, and teacher qualifications. Read Pre-K in American Cities, by CityHealth and the National Institute for Early Education Research.
If you had told 22-year-old me that the work I was doing at Head Start was actually going to impact the future health of my students, I would have put you in time-out. My goal was to teach children, not treat them. However, research shows that participation in top-notch early education programs has a profound impact on health. When done right, all children can benefit from early childhood education, regardless of family income or zip code. Consider these findings:
- For programs that incorporate certain health targets, such as immunizations and screenings, children show increased visits to pediatricians and dentists.
- Children who attend high quality pre-K programs are less likely to smoke and have lower rates of teen pregnancy.
- They are more likely to obtain more years of schooling and have higher lifetime wages (which is correlated with better health outcomes).
- Participants are less likely to commit crimes, and are less likely to be obese.
Pre-K is also a sound investment. According to Nobel Prize-winning economist James Heckman, for every dollar spent on high quality early education, there’s a return of 7 to 10 dollars.
Anecdotally, I saw the impact the Head Start program made on families every day. We fed children two meals and several snacks every day. We brought in students from Howard University’s College of Dentistry to perform screenings and provide referrals for nearby dentists. My colleagues and I helped children learn the skills necessary for self-control and emotional intelligence, which set them on a path of success in school settings. It was a demanding job, and also extremely rewarding.
But as folks in education know all too well, this is an individual-by-individual approach. The children in these programs benefit, but too many children don’t have access to high-quality programs. That puts many children at a disadvantage — in terms of education and health — before they even begin kindergarten. That’s why I went back to school to get a master’s degree in public policy. I wanted to be a part of changing the environment in which children and their families live, work, and play. We need change at the systems level so that all kids — no matter where they live — have an opportunity to fully develop their talents and abilities.
That’s what makes projects like CityHealth so exciting. By addressing community needs like housing, economic security, transportation, and the environment — and not just individual social needs — we can give every child the chance to live healthier lives.
Read Pre-K in American Cities, and let us know what you think at @deBeaumontFndtn on Twitter.
At the de Beaumont Foundation’s 2018 holiday party, Katie Sellers (right) was the proud winner of the “I Love Rachel” shirt, created by Lizzie Corcoran (left).
By Rachel Locke
My time as the ASPPH Philanthropy Fellow at the de Beaumont Foundation has ended, and as I begin my new role as a program associate, I wanted to look back at some of my favorite moments, projects, and events I got to be a part of as a Fellow. After graduating with my MPH in Environmental Health Sciences from the Columbia University Mailman School of Public Health, I didn’t really know what types of initiatives I would get to work on, but the experience far exceeded my expectations. Here are five highlights:
1. The Foundation’s First-Ever Tweetup
I had participated in Twitter chats but had never attended an in-person Tweetup until the event we held with the American Public Health Association (APHA) at the APHA annual meeting in San Diego in November. There was something about the in-person experience, held outdoors at sunset with food and drinks, that brought out the best in the Tweeters. While it addressed important issues, the chat also brought out the creativity and humor among public health folks, as demonstrated by the memes and GIFs we got In response to questions like “How would you describe public health to a child?” and “How confident are you that health in the U.S. is moving in the right direction?”
2. Launch of the 40 Under 40 Program
The de Beaumont Foundation announced in early November a new initiative – the first-ever list of “40 Under 40 in Public Health.” This initiative provides a platform for young public health professionals to apply to be recognized as a public health leader who is showcasing new ideas, creative problem solving and innovative solutions. There are lists like this for people in healthcare, but our list will specifically showcase leaders who recognize that health is more than healthcare. As we have been working on this new initiative, we have received many nominations for candidates. It’s been uplifting to see how many people want to showcase the work of their supervisors and colleagues, and the Foundation is excited for the announcement of the first cohort of 40 Under 40 winners in the spring.
3. Unleashing the Creativity and Innovation in the Governmental Public Health Workforce
Using data from our PH WINS survey (Public Health Interests and Needs Survey), the Foundation identifies high- and low-scoring metrics that help to characterize and understand the governmental public health workforce. When asked if creativity and innovation are rewarded in their workplace, fewer than half of public health professionals said yes. Without fostering creativity and innovation, the public health workforce will be unable to tackle new and complex health challenges. Public health professionals who say creativity and innovation are rewarded are more likely to be satisfied with their job and are less likely to consider leaving their organization. This new research on creativity and innovation is a call to action for public health leaders to think about how to foster creativity and innovation in their workforce to help improve workplace measures and to drive change in health departments.
4. Attending the BUILD Health Challenge 2018 Annual Convening
In September, I attended the 2018 annual convening for the BUILD Health Challenge. I heard from BUILD sites and grantees about the population health problems they are tackling and how the unique BUILD collaborative model has catalyzed their work. Sharing learnings across BUILD sites, real-time examples of cross-sector collaborations in practice and an in-depth look at systems thinking for community health were just a few of the topics I was able to delve into at the meeting.
5. Seeing Policy Change in Action
One of the most inspiring things about working at the Foundation has been celebrations of local policy successes. For example, working with CityHealth, an initiative of the de Beaumont Foundation and Kaiser Permanente, partners in San Antonio passed a new Tobacco 21 policy and Baltimore signed a Complete Streets policy. Many other cities are working gaining or improving their bronze, silver, or gold medal status with CityHealth. Members of the Big Cities Health Coalition like San Francisco moved policies banning the sale of menthol cigarettes and all flavors of e-cigarettes, and members are taking up gun violence prevention as a key issue to focus on. These movements and concrete policy wins that will protect population health are public health policy successes that can be replicated and scaled across the nation.
In Health Affairs, de Beaumont Foundation CEO Brian Castrucci and John Auerbach, CEO of Trust for America’s Health, weigh in on the growing involvement of health providers in addressing patients’ social needs — saying these interventions are a good step, but not enough. Read “Meeting Individual Social Needs Falls Short of Addressing Social Determinants.”
Castrucci and Auerbach (who’s also a de Beaumont board member) applaud the fact that hospitals and healthcare systems are paying attention to the causes of illness and taking steps to intervene — for example, by buying food, offering temporary housing, or covering transportation costs for high-risk patients. The challenge, though, is that these actions meet the needs only of some patients, and only after they’ve become sick. And more important, they don’t change the social and economic factors that led to their health needs. “While healthcare leaders have come to realize that these programs are less expensive than providing repeat healthcare services for their highest cost patients, such patient-centered assistance does not improve the underlying social and economic factors affecting the health of everyone in a community. These granular social interventions are necessary to help individual patients, but we must also remain focused on the broader, community-level social determinants of health if we are to improve our nation’s collective health.”
The answer, they say, lies in community-level policy change to address hunger, unsafe housing, economic inequities, and other conditions that affect the health of all residents. Working together, healthcare providers, public health professionals, policymakers, and advocates can enact far-reaching social change and actually make our communities and our nation healthier. Read the blog post.
Click link to download the infographic “Social Determinants and Social Needs: Moving Beyond Midstream.”
by Brian Castrucci and John Auerbach
Until recently, efforts to improve the health of Americans have focused on expanding access to quality medical care. Yet there is a growing recognition that medical care alone cannot address what actually makes us sick. Increasing health care costs and worsening life expectancy are the results of a frayed social safety net, economic and housing instability, racism and other forms of discrimination, educational disparities, inadequate nutrition, and risks within the physical environment. These factors affect our health long before the health care system ever gets involved.
Hospitals and health care systems have started to address these social determinants of health through initiatives that buy food, offer temporary housing, or cover transportation costs for high-risk patients. The prevalence and initial success of these efforts are clear in headlines such as: “What Montefiore’s 300% ROI from Social Determinants Investments Means for the Future of Other Hospitals,” “Social Determinants of Health Gain Traction as UnitedHealthcare and Intermountain Build New Programs,” and “How Addressing Social Determinants of Health Cuts Healthcare Costs.” But when you take a closer look, these articles aren’t about improving the underlying social and economic conditions in communities to foster improved health for all – they’re about mediating patients’ individual social needs. If this is what addressing the social determinants of health has come to mean, not only has the definition changed, but it has changed in ways that may impede efforts to address those conditions that impact the overall health of our country.
In 2008, the World Health Organization’s Commission on the Social Determinants of Health defined those determinants as the “conditions in which people are born, grow, live, work, and age” and “the fundamental drivers of these conditions.” This term prioritizes a broad, community-wide focus on the underlying social and economic conditions in which people live, rather than the immediate needs of any one individual. While health care leaders have realized that programs to buy food, offer temporary housing, or cover ridesharing programs are less expensive than providing repeat health care services for their highest cost patients, such patient-centered assistance does not improve the underlying social and economic factors that affect the health of everyone in a community. While targeted, small-scale social interventions provide invaluable assistance for individual patients, we must also remain focused on the social determinants that perpetuate poor health at the community level.
A recent speech by Health and Human Services (HHS) Secretary Alex Azar highlighted the dichotomy between individual-level “social needs” and community-level “social determinants.” Secretary Azar emphasized that factors like housing and transportation have an important effect on Americans’ health. He asked rhetorically, “How can someone manage diabetes if they are constantly worrying about how they’re going to afford their meals each week? How can a mother with an asthmatic son really improve his health if it’s their living environment that’s driving his condition?” And he appropriately noted that we “can’t simply write a prescription for healthy meals, a new home, or clean air.”
Exhibit 1. Click on image to download full-size graphic.
In his discussion of how to address health-related community conditions, Secretary Azar, like a growing number in health care, focused on the social needs of individual patients. In his speech, he recounted the success of the Accountable Health Communities model, noting that “participating providers screen high utilizers of healthcare services for food insecurity, domestic violence risk, and transportation, housing, and utility needs. If needed, patients are set up with navigators, who can help determine what resources are available in the community to meet the patient’s needs.” He even went so far as to suggest that Medicaid may allow hospitals to pay for housing, healthy food, and other services. But in order to improve our nation’s health, we must look beyond “superutilizers,” Medicaid recipients, and those who are already sick. Secretary Azar appropriately noted that health care navigators “can help determine what resources are available in [a] community.” However, while growing in popularity, health care navigators and similar enhancements to health care can’t actually change the availability of resources in the community. They can’t raise the minimum wage, increase the availability of paid sick leave, or improve the quality of our educational system. These are the systemic changes that are necessary to truly address the root causes of poor health.
Efforts To Address Social Needs Are Necessary, But Not Sufficient
Even if they don’t address broader social conditions within patients’ communities, health providers’ efforts to meet individuals’ non-medical needs are praiseworthy and potentially life-saving. In Chicago, Advocate Health Care saved nearly $5 million by screening for malnutrition risk factors and establishing an enhanced nutrition care program. In Boston, a six-months-or-longer, home-delivered meals benefit for dual Medicare-Medicaid eligible patients was associated with significant reductions in emergency room visits and overall health care cost savings. An initiative to link WellCare Medicaid and Medicare Advantage plan members to social service organizations resulted in an annual savings of $2,400 per person. In Hennepin County, Minnesota, millions of dollars were saved by offering unconventional services to patients with complex health, housing, and social service needs. The University of Illinois at Chicago reduced costs by 18 percent by identifying homeless patients who could benefit from housing support. These are just a few of the studies and reports documenting the health care system’s efforts to go beyond its own walls to improve health outcomes, decrease consumption of medical services, and reduce costs.
While individual-level interventions are beneficial, characterizing them as efforts to address social determinants of health conveys a false sense of progress. These strategies mitigate the acute social and economic challenges of individual patients, but they do so without implementing long-term fixes. They are often limited to a small segment of the population – those who are in the worst health and have the greatest health care costs. Meanwhile, those patients who do not rank among the “sickest and most expensive” are ignored.
We Need Policy Changes That Target Social Determinants Of Health
Policy makers have the power to address the social and economic conditions that affect community health. For example, in Kansas City, Missouri, voters recently approved a ballot initiative empowering health inspectors to respond to tenant complaints about a broad range of housing conditions, funded by an annual fee of $20 per unit for landlords. Earlier this year, the City Council of Alexandria, Virginia voted to raise the city’s meal tax to fund affordable housing. These communities and others like them have embraced the need for policy intervention to improve the social determinants of health for their citizens.
National initiatives offer states and local communities a roadmap for identifying and implementing gold-standard strategies to improve public health. In an initiative known as Health Impact in 5 Years (or HI-5), the Centers for Disease Control and Prevention (CDC) developed a list of 14 evidence-based policies to improve population health. CityHealth, an initiative of the de Beaumont Foundation and Kaiser Permanente, provides city leaders with a package of nine policy solutions that can help millions of people live longer and better lives.
Hospitals and health systems may be stepping up by referring a patient with mold in his or her apartment to a tenant’s right advocate, feeding a patient who needs food, or providing an on-site exercise program. But these interventions do not address the mold in that patient’s next-door neighbor’s apartment, community access to healthy food, or the availability of low-cost exercise options. These community-level changes can only be made through policy action. While they work to address their patients’ immediate needs, hospitals and health systems would do well to recognize and support community-level policy actions.
Not An Either/Or – Social Needs And Social Determinants Must Both Be Addressed
This isn’t about picking one approach over another – we need social and economic interventions at both the community and individual levels. We often discuss health using the metaphor of a stream, with upstream factors bringing downstream effects. Social needs interventions create a middle stream (Exhibit 1). They are further upstream than medical interventions, but not yet far enough. Social needs are the downstream manifestations of the impact of the social determinants of health on the community. Improvements in our nation’s health can be achieved only when we have the commitment to move even further upstream to change the community conditions that make people sick. The demand for social needs interventions won’t stop until the true root causes are addressed. This should ring especially true as the movement to Accountable Health Communities and value-based care gains momentum. Any success these new payment structures enjoy will be short-lived if the underlying social conditions in the communities where they work remain unchanged. While the allure of short-term economic gains from mediating patients’ social needs nearly ensures media and stakeholder attention, the incentives to advance policy, legislation, and regulation to improve health more broadly are often less clear. Redefining the meaning of “social determinants” to be mostly or only about the immediate social needs of expensive patients makes it harder to focus on the systemic changes necessary to address root causes of poor health.
Words Matter: For Understanding. For Clarity. For Change.
In 2003, David Kindig and Greg Stoddart offered a comprehensive definition of population health. Twelve years later, Kindig expressed concern that the use of the term had grown too broad, writing that it’s “growing use, most notable in the Triple Aim and in clinical settings, has resulted in a conflicting understanding of the term today.” Is the term “social determinants” heading for a similar fate? If we, even inadvertently, imply that the social determinants of health can be solved by offering Uber rides to individual patients or by deploying community health navigators, it will be challenging, if not impossible, for public health advocates to make the case for proven policies like alcohol sales control, complete streets, and healthy food procurement.
Words matter. Common definitions ensure that we understand each other. When health care leaders and public health officials use “social determinants of health” to mean different things, it becomes more difficult for us to engage meaningfully with community partners, who will struggle to differentiate between these complementary but different approaches. This may seem like semantics, but when we use this term too broadly, we risk losing the specificity needed when calling on partners to make far-reaching social change, and we weaken our ability to implement the community-level efforts necessary to improve community health. And, ultimately, that doesn’t help any of us get healthier.
Published by Project HOPE/Health Affairs as Brian Castrucci and John Auerbach. “Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Health.” Health Affairs Blog (Millwood), January 16, 2019. The published post is archived and available online at https://www.healthaffairs.org/do/10.1377/hblog20190115.234942/full/.