So much of what drives our health are factors that have little or nothing to do with health care. Despite this well-known fact, we still prioritize health care in almost all our policy discussions on health. From insurance to delivery to payment reform, health care gets more than its fair share of time in the spotlight.
We’ve all seen the studies that show how our zip code determines more about our health than any other factor. Consider one study that found that the quality of care as well as outcomes associated with schizophrenia varied significantly across each county in the state of North Carolina. There’s no more simple way to say it other than place matters. Where you live - your community - is a huge factor for your health.
And while we may “know” this, we rarely pursue public policy that puts this into practice. Our programs, policies, and investment strategies tell a different story – one that prioritizes the structures we have always had – the structures that emphasize health care over community – structures that reinforce a notion that care is about coming to a clinic rather than that clinic or those services coming to you. And perhaps it would be a different story if we had the health outcomes to show for it, but sadly, we don’t.
The Commonwealth Fund routinely puts the United States spending and outcomes in perspective. In their 2020 issue brief they found that the “United States spends more on health care as a share of the economy — nearly twice as much as the average OECD country — yet has the lowest life expectancy and highest suicide rates among the 11 nations.”
While how we got here is a longer story, and one that has been told and continues to need to be told, I want to focus on how we can better reprioritize community as a deeper solution for our health.
In 1977, Dr. George Engel, a family physician from Rochester, New York introduced the biopsychosocial model to the medical world. His article in Science, which is a must read, was a direct challenge to the biomedical model that dominated medicine. Dr. Engel acknowledged that simply looking at the biology of health and illness was never going to give us a full picture of the problem and the solution. His model helped set a new paradigm for how we engage in different conversations about health. It helped usher in new opportunities to embrace the power of social as well as the importance of our mental health. It also gave us one of the clearest ways to begin to discuss the role of our communities.
There have been attempts to better address community in the health care sector. Take for example this document from the American Academy of Family Physicians, which lays out how important it is for primary care to begin to identify critical aspects that contribute to a person’s health like their community. How can someone best prioritize their health when they have unstable housing? How can we expect a person to get more exercise when there are no sidewalks in their neighborhood? There are countless examples where community factors carry more weight in their impact but still get less attention.
Herein lies our opportunity. To meaningfully impact our health, we must figure out how to bring more of the community into our solutions. The evidence, if it could speak for itself, would argue that this is one of the most significant ways to change our overall health. Its not just about having community leaders at the table bringing forward their solutions – a vital component of deeper change – but about integrating the community conditions into our policy agenda. To this end, there are three things we could consider to help right size this problem.
1) Invest wisely: A few years ago, I was a part of a bit of work that examined state budgets to see how much they invested in health care vs. how much they invested in social programs. What we found was not surprising: In California, health care spending grew 146 percent over the last 10 years while the spending on community conditions only grew by 39 percent. While this example was limited to one state, it’s probably a theme that plays out in many states. If we don’t begin to shift our investments to be more focused on community factors, we are not going to see the changes we want.
2) Communicate clearly: Sometimes we don’t do a great job of communicating out about how important community factors are to our health. Terms like “social determinants of health” have helped bring more attention to community factors, but even then it feels too little too late. How can we share more in our policy debates about the role of community conditions? Can our messaging be more inclusive of how factors like housing, transportation, employment leads to a more significant improvement in our health?
3) Engage often: Sometimes the tables we sit at have the same faces. We’ve all been there. Those meetings usually don’t lead to a change in our strategy but rather reinforce what we already know (or even worse, maintain the status quo). We need to diversify the tables we sit at – to have all the sectors, public and private, health care and non-health care, sit together in service to advancing health. Engaging those community leaders who are outside of health care can be one simple yet powerful strategy for recentering community back to where it should be within our broader health strategy.
For us to truly be successful at improving our nation’s health, we have to dig deeper into community solutions – we have to acknowledge their role and do something about it.