The fourth session of the workshop examined existing research relevant to investment in health for improved and more equitable outcomes, resource allocation across different sectors, and prevention and community health improvement efforts. The panelists also explored implications of this research on policy and practice as well as on areas meriting further study. Dora Hughes, an associate research professor at the George Washington University Milken Institute School of Public Health, moderated the discussion.
AREAS OF CURRENT RESEARCH
Social and Behavioral Interventions
Sherry Glied, the dean and a professor at the Robert F. Wagner School of Public Service at New York University, discussed recent research efforts on the decompositions of drivers of health, such as behavior, social circumstances, environment, genetics, and medical care. She explained that using these decompositions can be helpful in making comparisons within a cross-section or between different locations, but their utility for guiding policy is limited because of the complex interaction of factors that lead to bad health outcomes. For example, if a person died of HIV in the United States in 2020, one could attribute the death to multiple factors: the behavior of sharing needles or having unprotected sex; the social circumstance of limited access to pre-exposure prophylaxis therapy; genetics, in being more susceptible to HIV infection; and medical care that provided an insufficient response or limited the person’s access to antiretroviral therapy. These factors interact, making it impossible to decompose the factors in such a way that identifies any one of them as the sole cause of death. Furthermore, time and location shape these factors. For instance, a decomposition conducted before antiretrovirals were invented would look quite different than one performed today. Glied said that medical care can be identified as the determinant of a particular outcome only once an intervention exists to address the issue; for example, mortality related to HIV was not attributed to medical care before effective treatment was identified. However, behavioral and environmental causes are considered in the absence of interventions to address the issue. For instance, poor diet and lack of exercise contribute to obesity and mortality, and deaths are attributed to these factors regardless of whether effective treatments or interventions to address diet and exercise are available. Glied suggested that the medical care standard should be applied to behavioral and environmental causes. This would involve considering how effective interventions can be implemented in the behavioral and social determinant space. This approach broadens research from identifying associations between health outcomes and the social determinants of health to include studying
the effects of potential social, behavioral, and environmental interventions on health outcomes. Glied said that the evidence base for interventions is limited, especially given that results are often context-specific.
A more robust evidence base and a change in standards for social and behavioral interventions are warranted, Glied said. Oftentimes, these interventions are judged according to a cost-saving standard, such as whether improving housing saves the health care system money. In contrast, new medical interventions tend to be judged according to a cost-effectiveness or cost-benefit standard. For instance, a cost-effectiveness approach may reveal that distributing inhalers more aggressively costs less than rehabilitating housing, but the latter may yield greater benefits. Moreover, the benefits of addressing the social determinants of health extend beyond health outcomes. For example, Glied said, better housing is of benefit even if it does not improve asthma, whereas an inhaler that does not improve asthma is useless. Research indicates that the transfer of income to very low-income families can improve infant birthweight, longevity, nutrition, mental health, and maternal mental health (Aizer et al., 2016; Braga et al., 2020; Costello et al., 2003; Ko et al., 2020; Markowitz et al., 2017).
Clinical and Social Aspects of Patient-Centered Care
Meena Seshamani, the vice president of clinical care transformation at MedStar Health, said that her position at a health system with 10 hospitals and 300 outpatient centers involves creating connections among hospitals, ambulatory sites, the community, post-acute care, and home health in an effort to provide patient-centered care. She and her team identify clinical and social determinants of health and intervention steps that can be taken. Using quality-improvement approaches (e.g., root cause analysis), the team works to identify gaps in services, referrals, and follow-through. The impact of interventions is assessed in terms of both processes and outcomes. Examples of process impacts include whether referrals were followed up, which staff interacted with the patient, and other facets of the patient experience. Outcome impacts involve health outcomes, cost and use of services, and the effects on the overall community. Seshamani pointed out several data collection challenges in assessing the impact of social interventions. For example, the electronic medical record has Z codes to indicate whether a patient is negatively affected by various social determinants of health, but it does not include a method of indicating the degree of that impact. Similarly, when a referral for a social intervention is made, the system is not able to capture whether the referral was followed up on, the degree of impact on the patient, or whether the patient’s family was affected. Seshamani remarked that these data challenges make it difficult to break down siloed care and get a broader picture of a patient’s experience across health and
social interventions. She concluded that assessing the ultimate impact of interventions will require greater investment in data collection.
Economic Evaluation of Policy
Simon Walker, a senior research fellow at the University of York’s Centre for Health Economics, described how his research focuses on using economic evaluation to inform multiple heterogeneous decision makers, all of whom have different goals. An economic evaluation can provide evidence on the benefits, costs, and opportunity costs of alternative policies, making it possible to assess whether the benefits exceed the opportunity cost. The economic evaluation is based on two sets of questions: (1) questions about values or normative principles and (2) questions about factual assessments (Walker et al., 2019). In terms of health spending, the first set of questions may involve the outcomes of interest, the relative values of those different outcomes, and any variation in outcome value for certain individuals over others related to equity concerns. Factual assessments identify the impact of a policy on those outcomes of interest, in terms of both benefits and opportunity costs.
A lack of societal consensus on values makes it difficult to develop a universally accepted definition of the social welfare function, Walker said. Such a function could be used in determining outcomes of interest and their relative values, which would ultimately inform decision making. He explained that societies typically structure themselves into different areas of responsibility, each with its own decision makers, goals, and resource allocation. For example, countries may have a Ministry of Health responsible for improving population health, a Ministry of Criminal Justice responsible for maintaining law and order, and a Ministry of Social Welfare responsible for ensuring that no one is living within poverty. Walker said that analysts should consider policies from these various perspectives and inform decision makers with evidence relevant to their particular responsibilities. He described an evaluation he conducted on an alcohol misuse intervention with criminal offenders in the United Kingdom (Ramponi et al., 2021). Funded by the health care system, the intervention had impacts on the health of participants, but it also had criminal justice impacts, including a potential reduction in recidivism and a subsequent reduction in crime-related health impacts for would-be crime victims. Evidence on the direct impact of the intervention on health and health-associated opportunity costs could be provided to decision makers in health, while evidence on the intervention’s impact on reoffending and associated opportunity costs could be provided to decision makers in criminal justice. Walker noted that a case such as this—in which the intervention yields benefit for both health and criminal justice—is more straightforward than situations
in which one area may see benefits and another may see losses. However, even when an intervention has mixed results for different sectors, an analysis that identifies costs and benefits can facilitate discussion between decision makers. Walker said that a potential policy response would be co-financing arrangements or transfer payments that spread the cost and benefit across sectors.
Walker emphasized the importance of recognizing the potential impact of a policy on multiple sectors and of estimating the opportunity costs of outcomes that could be generated with alternative uses of resources. For example, it is important to understand the value of spending on health care by the private and public sectors as well as the value of spending on social care because such an understanding is helpful in evaluating the opportunity cost related to budgets1 and also the value placed by society on each of these areas. This, in turn, can inform decision making. Walker suggested that the values and perspectives of the decision makers involved be considered in conducting wide evaluations that capture a variety of spending effects. These evaluations should take a symmetrical approach in capturing both the value realized and the opportunity costs resulting from the policy, he said.
Population Health Interventions
Rachel L. J. Thornton, an associate professor in the Division of General Pediatrics and Adolescent Medicine at Johns Hopkins University, described three sentinel research contributions relevant to health spending and also her own research trajectory. The first contribution was the 19th century work of W. E. B. Du Bois that articulated the connections between social conditions and health among African Americans in Philadelphia (Du Bois, 1899). A century later, the National Academies’ Institute of Medicine (IOM) published two reports that explored equity issues in health: Crossing the Quality Chasm identified equitable care as a central component of quality, and Unequal Treatment suggested that the drivers of inequity transcended presumptions about how the mission and delivery of health care should be designed (IOM, 2001, 2003). Thornton said that her early research focused on differences in patient–provider communication quality for African American patients compared with White peers. This involved considering disparities as the product of human interactions rather than presuming impartiality among physicians. This view of disparities is relevant in exploring the motivation for population health improvement programs and the implicit assumptions made about who the service recipients will be, Thornton said. She subsequently examined urban planning policy
in Baltimore City and its potential role in addressing community conditions that influence health and health trajectories.
Thornton has conducted recent research with Pamela Matson of the Johns Hopkins School of Medicine to explore specific reforms informed by public health evidence, such as rezoning to reduce the density of and proximity to alcohol outlets in residential neighborhoods in Baltimore City with the goal of improving neighborhoods and communities. Thornton said that this work considers the multitude of responses that may occur when a targeted intervention addresses one component of a complex system and the extent to which these responses propel change or reinforce the status quo. She noted a propensity within systems to maintain the “status quo” through a set of responses that undermine progress. These “reproducing phenomenona” in population health, in which interventions fail to produce transformative results, may be a result of the tendency within a system towards maintaining the status quo. In other words, in the face of interventions healthcare systems can reproduce longstanding patterns, and Matson suggested that the wisdom of people experiencing the conditions of the system should be used to disrupt this phenomenon. Researchers’ perceptions and even empirical, quantitative data may suggest a set of targeted solutions that, when implemented or evaluated, fail to produce the results anticipated when the solutions did not take into account other conditions or contingencies within the system. Thornton acknowledged the challenge in distilling a complex research approach into actionable components. She added that the complexity of the elements involved in entrenched patterns requires a new level of creativity in science and in implementation.
Impacts of Historic Segregation Practices on Current Health Status
Jacob Faber, an associate professor at the Robert F. Wagner School of Public Service, New York University, said that his research focuses on the causes and consequences of racial residential segregation and the explicitly segregationist federal housing policy adopted during the New Deal in the 1930s that featured redlining, racially restricted covenants, and underwriting rules that explicitly discriminated against people of color (University of Richmond, n.d.). He reported that his research indicates that people living in locations redlined by the federal government nearly a century ago tend to experience increased segregation, wider racial wealth gaps, lower levels of upward economic mobility, and more difficulty in obtaining mortgage credit today. The intransigence of inequality over time is demonstrated not only as relates to housing policy, but also in the health crises faced by communities of color. For instance, recent research indicates that more segregated locations in the United States experienced higher rates of COVID-19 infection and mortality and that historically redlined neighborhoods saw a higher
prevalence of COVID-19 risk factors (National Community Reinvestment Coalition, 2020; Torrats-Espinosa, 2021). Faber said that historical medical industry practices of exclusion and exploitation of people of color have engendered justified skepticism which has translated into COVID-19 vaccine reluctance. He added that his research indicates that housing foreclosures are linked with negative health consequences.
Faber emphasized that this research suggests that policy solutions should be structural and long-term in scope. Because current inequalities were intentionally constructed, society thus has a moral obligation to address them, he said. Narrow, nonstructural solutions often use deficit models that blame communities of color for issues related to the social determinants of health. However, the needed structural solutions may require 10–20 years to demonstrate the full impact on the multigenerational issues they address, as was the case in the U.S. Department of Housing and Urban Development (HUD) Moving to Opportunity program (Ludwig et al., 2013).
Health Policy Effects on the Federal Budget
Chapin White, the deputy director of the Health Analysis Division at the Congressional Budget Office (CBO), described how CBO projects the federal budget and the impact of proposed federal legislation on revenues, outlays, and deficits. The role of the CBO is to outline financial tradeoffs; the agency does not make policy recommendations. The federal budget is deeply shaped by health care policy, and, among its many other tasks, the CBO examines the financial ramifications of preventive health care, opioid use disorder, prescription drug pricing, and health insurance expansions. However, the agency’s analysis is limited to the impact of a policy on the federal deficit and does not consider projected health outcomes or health equity. For example, the 2012 CBO report on raising the excise tax on cigarettes explored (1) the revenues that would be generated by increased taxes; (2) the projected decrease in the number of people who smoke; (3) the increase in the number of individuals in better health and thus able to participate in the labor force, thereby generating tax revenues; (4) how much longer people might live; and (5) the effect of greater longevity in increasing Social Security and Medicare claims (CBO, 2012). White explained that health effects are relevant to CBO research, but they are not the goal of the work.
CBO projections rely on data generated by researchers outside the agency to quantify the benefits gained from improved health or longevity, White noted. Additionally, agency focus tends to be on the distribution of tax credits, not on the distribution of health status or equity. The structure of congressional committees—each with limited jurisdiction—leads to a fragmentation in policies which extends to policy analysis, with budget
accounts and federal programs analyzed individually, White said. He added that the United States has a pluralistic society in which the federal government’s influence is limited, albeit substantial. State governments and the private sector also have jurisdiction over complicated issues such as housing, food, and health care. Decisions regarding these broad areas are made at multiple levels by a variety of decision makers.
Policy Health Impacts and Financial Ramifications
Hughes, noting the policy tension between focusing on the health impacts of federal programs and on their financial impacts, asked Walker how this issue has manifested in the United Kingdom. Walker said the U.K. approach varies by sector. The National Health Service emphasizes investments in terms of the impact on health relative to opportunity costs by considering whether investments yield improvements in population health and the distribution of health. Strong guidance informs policy by structuring policy evaluations and placing the focus on health improvement, Walker added. The finance ministry, Her Majesty’s Treasury, sets clear guidelines on evaluating policy in terms of benefits and costs. Walker said that decision making in the United Kingdom is at times heavily influenced by cost saving and balancing budgets. This has particularly been the case during the past 10 years of austerity measures, in which local-level decision makers have been required to prioritize cost containment over maximizing objectives via investment. Walker noted the tension between cost containment and the long-term nature of public health goals. Hughes asked White how the CBO accounts for the long-term processes of addressing multigenerational issues. White replied that the agency typically uses a 10-year budget window for analysis. In addition, some analyses make 30-year projections, but these are limited to federal revenues, outlay, the deficit, and the ratio of debt to gross domestic product. He stated that this lens does not assess the trajectory of the health status of the population.
Data Collection Challenges
Hughes asked how Maryland has approached data collection, given the challenges in collecting data on a policy that relies on multiple decision makers with differing objectives. Seshamani responded that much of her work at MedStar Health involves community health, palliative care, primary care, geriatric care, and chronic disease management—areas of medicine that do not fit neatly into a specific office visit or billing code—and that siloes can make it difficult to develop a clear picture of value and
impact. For instance, 17 hospitals in the Baltimore region are implementing a grant-funded behavioral health crisis intervention that provides a mobile crisis unit for rapid response. Because it is a health system intervention, metrics include reductions in emergency department use and hospitalizations. Seshamani remarked that while these metrics are important, they do not capture the multiple impacts that effective behavioral health services can have, such as effects on involvement in the justice system, workplace productivity, family dynamics, divorce rates, and abuse rates, nor do they reflect the historical, structural, and intergenerational nature of factors such as those described by Faber (e.g., effects of redlining in the housing market being experienced by the subsequent generation). She added that bringing together multiple stakeholders can provide more comprehensive metrics of impact. Additionally, qualitative research can capture an improved sense of community and well-being in addition to intergenerational dimensions.
Federal Policy Investment Assessment
Hughes asked Glied to speak to how the increased child tax credit included in the American Rescue Plan Act (ARP) may influence health risk.2 Glied replied that the child tax credit is expected to bring a significant number of children out of poverty. She cited a working paper that found that a similar program in Canada had significant effects on childhood poverty but found no evidence of a change in the labor supply (Baker et al., 2021). Although American society is more comfortable providing people with in-kind resources such as food and housing, the most robust evidence on the effect of social determinants on health is in regard to income, Glied said. Providing families with income is associated with improved mental health and housing stability. She added that many intervention benefits extend beyond short-term health impacts. For example, the benefits that Medicare can have for individuals and communities may require many years to become evident. Glied added that the decision to make long-term investments involves trade-offs and ethical and moral considerations; researchers should provide the information legislators need to make these determinations.
White remarked that it is relatively straightforward to determine the financial impacts of expanded access to medical care or child care tax credits, but it is complex to consider the effects on improved well-being. For example, an evidence base is emerging on the long-term effects that
2 The American Rescue Plan Act of 2021 increased the child tax credit from $2,000 to $3,600 for children under age 6 and $3,000 for children 6–17 years of age, and these credits will be made available through advance periodic payments, https://www.congress.gov/117/plaws/publ2/PLAW-117publ2.pdf (accessed November 8, 2021).
Medicaid eligibility for children has on their earnings as adults. White added that decision makers need a broader set of information than the CBO provides. Because the role of the CBO is limited to quantifying financial trade-offs, the office relies on the outside research community to fill in the gaps left by CBO research. He clarified that the components of large legislative packages, such as ARP, are scored individually and that although the interactions between these components are assessed, such assessments are limited to the impact of the legislation on the federal deficit. In some instances, legislation includes both “costs” and “savers” in an effort to avoid increasing the overall deficit. In these cases the CBO assesses whether the intended balance has been achieved. White noted that the CBO tracks state expenditures in an effort to anticipate how states will respond to federal actions, but the CBO does not project state outlays.
Policies and Practices to Address Inequality
Hughes asked Faber how insights from his research could be translated into federal policies or programs. Faber replied that the growing body of research on housing inequality indicates that the structures implemented to intentionally segregate people for generations can inform models for integration. The Biden Administration has demonstrated a willingness to study reparations, is reinstating the 2015 Affirmatively Furthering Fair Housing rule, and passed the ARP to make a more robust social safety net.3 Faber acknowledged that these steps fall short of the transformative power of the New Deal. He noted that, in 1968, George Romney served as HUD secretary and instituted the Open Communities Plan without President Nixon’s approval. Although the plan was ceased once Nixon learned of it, it serves as an antiracist housing policy model. It included investment in previously redlined neighborhoods and the creation of affordable housing and opportunities for home ownership for African Americans in affluent white neighborhoods, and it would have granted the federal government the power to undo local zoning provisions. Faber emphasized that structural determinants of inequality are more powerful drivers of disparities in health, housing, and job access than individual bias, but steps can be taken to address discrimination. For example, the burden of proof in housing discrimination cases currently lies with the victim, who must prove that an individual discriminated against him or her due to belonging to a protected class. The burden of proof could be shifted to potential discriminators by creating reporting requirements for real estate agents and landlords akin to
3https://www.federalregister.gov/documents/2015/07/16/2015-17032/affirmatively-furthering-fair-housing (accessed November 8, 2021).
the Home Mortgage Disclosure Act, which requires the reporting of home mortgage applications.4
Thornton commented that research indicating that criminal justice decisions are influenced by implicit bias and that the cognitive processes of health providers can lead to racial disparities in care points to the need for mechanisms to guide interpersonal decision making (IOM, 2003). For instance, technology built by a diverse team of researchers and testers could provide steps that slow down providers’ cognitive processes to help them make more considered decisions regarding patients’ treatment trajectories. Additionally, methods could be developed to help providers rethink the language used to characterize the social conditions affecting people’s health and to attribute these social conditions to society rather than to individual patients. Thornton emphasized that the social determinants of health are sometimes used to characterize individuals rather than to describe a set of conditions. Moreover, research is needed on the heuristics that health care providers use to rapidly categorize a problem and respond accordingly. This could improve the ability of providers to recognize the threat to health and well-being that a patient is facing and to respond in a just and appropriate way. Because decisions are made within a structural context that reinforces the appropriateness and validity of certain behaviors, a structural response that requires providers to behave differently may be needed to disrupt the perpetuation of that context. Thornton remarked that current approaches to problem identification in health care can focus disproportionately on intra- or interpersonal causes of poor health and that a greater focus on structural contributors to poor health is needed.
Research that identifies the key social conditions that potentiate and perpetuate positive health trajectories is also needed, Thornton said, commenting on in-progress and recently completed research on ancillary benefits for Supplemental Nutrition Assistance Program (SNAP) recipients (see, for example, You et al., 2021). Thornton remarked that the 2019 NASEM report Shaping Summertime Experiences: Opportunities to Promote Healthy Development and Well-Being for Children and Youth specifically identified the potential positive effects on child health and well-being associated with expanding SNAP benefits during the summertime for children (NASEM, 2019).
This became particularly relevant during the precipitous school closures in response to the COVID-19 pandemic, which highlighted the connection the school has with health and well-being. Thornton encouraged health care professionals to consider the ways in which dollars directed to other sectors may influence patients’ health and lived experiences. She suggested that as
4https://www.govinfo.gov/content/pkg/STATUTE-89/pdf/STATUTE-89-Pg1124.pdf (accessed November 8, 2021).
investment determinations are made, decision makers should consider the context and assumptions that support the rationale for the investment.
Thornton suggested that decision makers should also examine whether limiting access to specific categories of goods will optimize people’s ability to use benefits to meet their needs. Glied said that she is beginning to research how SNAP benefits affect families’ overall budgets and how this influences health outcomes. She added that the increased child tax credit is encouraging, but societal concern persists that cash benefits will affect the labor supply. This concern could be addressed by creating a job guarantee rather than supplying income, she said. Glied commented that non-cash benefits have two sets of beneficiaries: (1) the families who receive the food stamps or housing, and (2) the suppliers—such as farmers and housing developers—who obtain new markets. Medicaid is a robust program because it benefits both low-income families and the health care providers and health systems that have a vested interest in seeing it well supported.
Walker said that the United Kingdom makes capitation payments to primary care physicians based on neighborhood deprivation indices. This structure pushes public funding to areas that stand to see the greatest health gains. He noted that this method focuses on providing medical care to individuals rather than improving the health of individuals before care is required.
A participant asked how wasteful health care spending can be reallocated to evidence-based social interventions. Glied replied that health care spending increases each year without any analysis indicating the expenditures lead to better outcomes. The racial wealth gap was created over generations, so addressing it should not be dependent on generating health care savings: moral imperatives should not be tied to decreasing health care spending, Glied said.
Hughes asked how various sectors such as social science, medicine, and economics are collaborating on initiatives. Seshamani replied that in creating the Health Care Payment Learning and Action Network, the Centers for Medicare & Medicaid Services (CMS) brought together a variety of stakeholders and perspectives, including patients, providers, payers, and employers. She pointed to the value of considering economic, sociological, and clinical factors in creating metrics for quality and program outcomes. Glied remarked on the tension between efficiently running a program and collaborating with sectors that have different goals and missions. She emphasized that while collaboration is important, this tension should not be ignored. Citing the example of the Fort Bragg demonstration study—in which a comprehensive continuum of care for children’s mental health did
not result in better clinical outcomes—she said that collaboration alone will not lead to better services (Bickman, 1996).
Steps Needed to Move Forward
Hughes asked the panelists for suggestions on persuading policy makers, shifting the narrative, or new areas of research or investment that could affect health spending. Seshamani remarked that equity can be a goal in and of itself. For example, a program that does not reduce overall 30-day readmissions but decreases differences in readmission rates among various socioeconomic or demographic groups has successfully addressed some disparities. Walker commented that researchers can provide decision makers with evaluations that extend beyond evidence to include the values and trade-offs involved in the issue. Institutional arrangements impose value structures, and these can be presented for consideration in determining policy. White said that the COVID-19 pandemic began over a year ago and led to shutdowns, major federal legislation, and dramatic changes in how people work and how the health system works; the research community has an important role to play in coming years in understanding what took place, where society is at present, and the direction society needs to take moving forward. Faber said that this has been a challenging time for science broadly and for social science in particular; building resilience and fostering belief in the scientific community is a long-term goal that all researchers should work toward. He added that due to both historical and contemporary practices in the United States, society has a moral imperative to pursue equity. Glied stated that solid economics and evaluation research can contribute to policy decisions. Research can be conducted to determine the most effective policies and the policy areas to focus on—for instance, whether investments in housing or in food stamps lead to better outcomes. The results of this research can then be provided to policy makers who are interested in taking action but are unsure of the best approach. Thornton added that researchers can consider how to translate findings to be of value to policy makers. Given that science can be marginalized in one context or another, she suggested that researchers examine the implicit assumptions inherent in how they conduct and communicate research. She emphasized the opportunity to put a different lens on science and thinking, with this new lens translating to action moving forward.
CLOSING REMARKS AND REFLECTIONS
Kirsten Bibbins-Domingo, professor and chair in the Department of Epidemiology and Biostatistics; the Lee Goldman, M.D., Endowed Professor of Medicine; and the vice dean for Population Health and Health Equity
at the University of California, San Francisco, brought the workshop to a close. She began by emphasizing the gap between health care spending and health outcomes in the United States, which is due in part to underspending on areas that contribute to health and to spending on health care that does not result in health. Panelists reported that approximately 30 percent of health care spending does not improve health and thus involves a loss of potential gain. Tensions emerge when linking overspending in the health care sector with underspending in other areas that ultimately affect health. She said that in some instances it may be more valuable to link these ideas, while in other cases it may be more effective to separate them. Efforts to address health care spending include the per capita spending target set in Massachusetts, the quality benchmarks and priorities for specific populations established in Delaware, and the Milbank Memorial Fund’s initiative to expand these approaches to other states. The Center for Medicare & Medicaid Innovation and the United Way of Greater Cleveland are developing mechanisms for co-investment from multiple sectors in interventions that have demonstrated efficacy.
Data challenges include, Bibbins-Domingo said, data streams that cannot be integrated, the use of a variety of metrics related to health across different sectors, and the difficulty in establishing appropriate metrics to collect data that accurately reflect the impact of an intervention. Another challenge is an individualistic perception of cost that can influence how the general public views policy solutions. Framing the health spending problem in terms of overspending on health and underspending in other areas may create a winner/loser narrative that the public may perceive differently than researchers intend it to be perceived. In spite of substantial inequities in the health care system, both the insured and un(der)insured report concerns about loss in discussions about reducing health care spending. Bibbins-Domingo remarked that in this case, framing the “winners” and “losers” of reduced health spending may generate support for interventions.
The COVID-19 pandemic has highlighted human interconnectedness, raised the stature of health care, and heightened awareness of racial inequities, Bibbins-Domingo said. As a result of the pandemic, the public may be resistant to the idea of reduced investment in health care, but it may be more open to equity efforts. She noted that public goods such as housing, transportation, or early childhood education have value outside of long-term health care consequences. The research standards appropriate for social interventions may be different than those for health care systems; thus, holding interventions to narrowly focused health care standards may not accurately reflect the overall impact of these interventions. Research indicates that a failure to make long-term investments in the social drivers of health results in poor health, but the long-term nature of these investments can be at odds with shorter-term frameworks for shifting costs.
Bibbins-Domingo emphasized the urgency of the current moment to address large social issues such as child poverty, fair wages, the housing crisis, and racial and social inequities. It is also urgent, she said, to address the high cost of health care and low-value health care. These problems are related in terms of budgets, but linking these concepts in messaging and in implementation may not be effective. Bibbins-Domingo added that addressing high health care cost and investment in social sectors that drive health will require a variety of communication strategies.
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