Policy and Practice April 2019

Efforts to Address Social Needs Are Necessary, but Not Sufficient Even if they don’t address broader social conditions within patients’ com- munities, health providers’ efforts to meet individuals’ non-medical needs are praiseworthy and potentially life- saving. In Chicago, Advocate Health Care saved nearly $5 million 8 by screening for malnutrition risk factors and establishing an enhanced nutrition care program. In Boston, a six-months- or-longer, home-delivered meals 9 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 10 members to social service orga- nizations resulted in an annual savings of $2,400 per person. In Hennepin County, Minnesota, 11 millions of dollars were saved by offering uncon- ventional services to patients with complex health, housing, and social service needs. The University of Illinois at Chicago 12 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 indi- vidual 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 thatTarget Social Determinants of Health Policy makers have the power to address the social and economic condi- tions that affect community health. For

example, in Kansas City, Missouri, 13 voters recently approved a ballot initia- tive 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 14 voted to raise the city’s meal tax to fund affordable housing. These com- munities and others like them have embraced the need for policy interven- tion to improve the social determinants of health for their citizens. National initiatives offer states and local communities a roadmap for identi- fying 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) devel- oped a list of 14 evidence-based policies to improve population health, 15 an ini- tiative of the de Beaumont Foundation 16 and Kaiser Permanente, 17 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 com- munity-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

assistance for individual patients, we must also remain focused on the social determinants that perpetuate poor health at the community level. A recent speech 5 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 amother with an asthmatic son really improve his health if it’s their living environment that’s driving his con- dition?” And he appropriately noted that we “can’t simply write a prescription for healthymeals, a new home, or clean air.” 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, 6 noting that “participating providers screen high utilizers of healthcare services for food insecurity, domestic violence risk, and transpor- tation, housing, and utility needs. If needed, patients are set up with navi- gators, who can help determine what resources are available in the com- munity 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. 7 But in order to improve our nation’s health, we must look beyond “superutilizers,” Medicaid recipi- ents, and those who are already sick. Secretary Azar appropriately noted that health care navigators “can help deter- mine 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 avail- ability of resources in the community. They can’t raise the minimumwage, increase the availability of paid sick leave, or improve the quality of our edu- cational system. These are the systemic changes that are necessary to truly address the root causes of poor health.

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