U.S. Is Many Different Communities When it Comes to Health

The following excerpt comes from the November 1, 2017, article by Sternberg in US News and World Report.

The jigsaw puzzle of U.S. counties fits neatly together into a pleasing whole, displaying America as a land of many parts.

Within those parts, people in adjacent communities may have similar lifestyles and incomes. They may eat similar foods, enjoy the same music, picnic in the same parks and vacation at the same campgrounds or beaches.

But look more closely and you’ll find people living in neighboring communities often live very different lives. Residents in one county may suffer many more days of poor physical or mental health – or both – than those in the county next door. People in many communities even live longer than those in communities nearby, a pattern that extends nationwide.

Which is why community health assessments – including a new U.S. News ranking of the nation’s Healthiest Communities, to debut in March – are so valuable for identifying trouble spots and targeting remedies to where they’ll do the most good.

Think of them as diagnostic scans of what ails America, from soaring rates of obesity, hypertension, and diabetes to pervasive mental health problems and opioid abuse. The overlapping epidemics are having a profound impact nationwide. For the first time in nearly a century, life expectancy has begun to decline in major population groups, and not just in poor underprivileged neighborhoods. Death rates rose for white men, white women, and black men, and remained essentially unchanged for black women and Hispanic men and women.

“This is the first time we’ve really seen fairly marked decreases in life expectancy in key groups and not simply the socially disadvantaged,” says Dr. William Stead, chief strategy officer at Vanderbilt University Medical Center and McKesson Foundation professor of biomedical informatics.

In most measures of population health, the world’s richest country lags behind other developed countries, despite trillions spent each year on medical care.

“Waves of chronic disease are reaching historic rates,” says Tyler Norris, chief executive of the Well Being Trust, a $100-million nonprofit funded by Providence St. Joseph Health to help improve the nation’s mental and physical health. Chronic diseases not only reduce productivity, he says, they have driven health care costs so high that they are “unaffordable no matter who you are.”

Eighty percent of the growth in Medicare spending – now totaling nearly $650 billion a year – is due to chronic disease, says Kenneth Thorpe, of the Rollins School of Public Health at Emory University and chairman of the Partnership for Chronic Disease.

Tragically, this chronic-disease epidemic of diabetes, hypertension, heart disease, stroke, arthritis and other ailments is occurring against the backdrop of a revolution in medical care, one that ushered in countless innovations including antibiotics, blockbuster drugs, high-tech surgery and genetic medicine.

The roots of the problem run deep, anchored in national neglect of festering social problems and each community’s history, culture, economy, schools, hospitals, neighborhoods and sense of place. These so-called social determinants offer a way of assessing community health. They show that poor health and other social problems are more heavily concentrated in some neighborhoods than others, variations that may not be apparent when examined at the national or state levels.
Read the full article.


Useful Resource: FedCommunities.org

Fedcommunities.org offers community development resources from all 12 Federal Reserve Banks and the Federal Reserve Board of Governors.  The information portal provides research, publications, and tools for those working in community development. “Healthy Communities” is one of the key areas of policy explored on the site. The available resources include

Decisive action by communities can reduce health disparities and improve lives

From the article by Risa Lavizzo-Mourey and Victor Dzau on STAT

Our choices for good health depend on our choices for everything else in life: a good education, safe and decent housing, a secure job that allows us to support our families.

What happens when those choices don’t exist? Ask Alpha Whitaker.

Whitaker, a single mom in Indianapolis who put herself through college, had to turn down a dream job because she didn’t have a safe way to get to work. Her bus route ended 10 blocks from the job, and she would have had to walk through a dangerous neighborhood — twice — every day.

In choosing safety, Whitaker gave up a job with full health benefits, a 401(k) plan to help her save for her daughter’s education, and a salary that would have allowed her family to move to a safer neighborhood. These things — financial security, health insurance, education, and neighborhood — influence health.

Fortunately, Indianapolis is one of many US communities working to create better choices for their residents in transportation, public safety, and employment. In doing so, they are creating better choices for health as well.

On the surface, the link might not be obvious. But as “Communities in Action: Pathways to Health Equity,” a new report from the National Academy of Medicine’s Culture of Health program shows, health equity and equal opportunity are inextricably linked. The report, commissioned by the Robert Wood Johnson Foundation, defines health equity as the state in which everyone has a chance to attain their full health potential.

Americans today live shorter, sicker lives than people in other developed countries. Across America, health varies by income, education, race and ethnicity, geography, sexual identity, and disability status. We pay a high price for these health disparities in lost lives, wasted potential, and squandered resources. They also affect national security: Some 26 million young adults are unqualified to serve in the United States military because of persistent health problems, poor education, or convictions for a felony. The report estimates that racial health disparities are projected to cost health insurers $337 billion between 2009 and 2018.

“Communities in Action” spotlights how communities are working together to create pathways to health equity. By addressing factors well beyond access to health insurance, cities like Indianapolis, Buffalo, Minneapolis, San Antonio, and Los Angeles are seeding the conditions needed to enjoy full, healthy lives.

Take the Indianapolis Congregation Action Network (IndyCAN), a multiracial, multifaith group that took on limited access to bus routes. That transportation issue created barriers to good jobs and opportunity. Working with a variety of stakeholders, including the residents most affected, IndyCAN helped pass a regional transit referendum to triple bus service in Indianapolis, fuel economic development, and increase access to jobs. Because all residents understood that improved bus service would benefit everyone in the community in a range of ways, the referendum passed last November — with the Indianapolis Chamber of Commerce as a leading champion.

This is just one example of what a community can do to promote health equity. “Communities in Action” explores many other efforts to curb violence, boost education, improve social connectedness, and expand access to healthy foods — all of which create the opportunity for healthier lives. Although their approaches differ, these community efforts consistently bring a shared vision for promoting health equity, building and harnessing community capacity, and involving many different sectors to enlist broad buy-in.

Read the full article.

Sentinel Communities: Mobile, Alabama

The Sentinel Communities project — a part of the Robert Wood Johnson Foundation’s Culture of Health Initiative — will track health outcomes in 30 cities to understand

  • Local health care landscape
  • How challenges can be addressed in areas with different geographic and historic landscapes
  • How communities make progress or address barriers in improving population health.

The Sentinel Communities were chosen to reflect the nation’s diversity in terms of demographics, geography, and approaches to health. The following, drawn from the first report about Mobile, AL., provide some context for health issues in city.


  • In addition to an overall 25% poverty rate for Mobile, significant income inequality exists between black and white residents, with black households earning about half the median income as white ones.
  • While educational attainment has increased among white residents, the percentage of black residents with a bachelor’s degree or higher declined between 2010 and 2014.
  • Despite progress, Mobile residents have a lower life expectancy and higher rates of teen pregnancy, obesity, smoking, and uninsurance than the national average.
  • Even with the introduction of a new Regional Care Organization that may improve insurance coverage for residents, Mobile remains a federally designated health care shortage area.


See the full report for charts on indicators such as income, teen pregnancy, mortality, and educational attainment as well as some of the initiatives currently in place to address health issues.


Re-balancing medical and social spending to promote health: Increasing state flexibility to improve health through housing

From the article by Stuart M. Butler, Dayna Bowen Matthey, and Marcela Cabello from Brookings:

Although the United States spends considerably more of our GDP on medical services than other developed nations, our health outcomes are no better, and in many areas, much worse.  Even more significant, perhaps, is that when we look at health spending compared with spending on social services, the U.S. is a noticeable outlier. On average, nations that are members of the Organization for Economic Cooperation and Development (OECD) spend about $1.70 on social services for every $1 on health services; the U.S. spends just 56 cents.

The research on social services, health spending, and health outcomes suggests strongly that it is no coincidence that the U.S. has this unusual combination of spending and mediocre outcomes. We have the wrong balance of social and medical spending if one of our priorities is improving health overall and measures such as infant mortality and life expectancy. This pattern from the international evidence is reflected in data from within our own borders. States with a higher ratio of social to health spending also have significantly better health outcomes for such conditions as adult obesity, asthma, mental health indicators, mortality rates for lung cancer, high blood pressure, and heart attack, and Type 2 diabetes.

An important reason for such patterns is that in advanced countries, improvements at the margin in health tend to come more from additional investments in a good living environment and lifestyle habits than from more investments in medical services. Indeed, public health experts now agree that a variety of factors beyond access to and quality of health care influence population health.  The U.S. Centers for Disease Control, for instance, estimates that health behaviors, medical care, and genes together contribute approximately 50 percent of the influence on population health, while social and environmental characteristics contribute the remaining 50 percent.

This suggests a three-pronged approach to improving health in the U.S.:

  • First, to improve health outcomes while actually curbing health care costs, we need to rebalance federal spending patterns. In particular, the new Administration and Congress need to adjust the current ratio of medical-to-social spending by shifting some current health care expenditures to investments in tackling “upstream” social factors with a bigger impact on health.  The evidence suggests that such a shift could contribute to decreased hospital utilization, and thus reduced spending by Medicaid and Medicare, while improving health outcomes.
  • The federal government should help states take the lead in this rebalancing. The best ways to rebalance and reflect local conditions and opportunities will differ from place to place, and states are the best-placed level of government to facilitate large-scale cross-sector strategies to improve health. Moreover, the research evidence on the best combination of medical and social services to improve health is not as robust as we would like. Therefore, it is important to permit much more state investigation and experimentation with re-balanced funding, combined with solid evaluation of experiments, so that states and federal policymakers can learn from each other.
  • The federal government should review the evidence that social services are often the route to improved health, and agencies should work with health officials on ways to reprogram funding. A particularly promising such area for the new Administration to focus on would be housing.

Read the full article.

When Housing Comes First, Hospitals Benefit

From the article by Lola Butcher on Hospitals & Health Networks:

Supportive housing is a multifaceted model to help homeless individuals and families that face complex challenges such as addiction, mental health conditions and disabilities that can be overwhelming. In addition to permanent housing, the model provides social services that range from substance abuse programs and life skills training to case management and job training.

Many, but not all, supportive housing programs use the “housing first” approach, endorsed by the federal government. Under “housing first,” permanent housing should be made the top priority for homeless individuals and families; addressing behavioral, social and other factors comes second.

The peace of mind that comes from a safe place to live helps individuals as they tackle addiction or other challenges. Plus, service providers know where to contact the individuals to provide the help they need.

“If you provide housing stability first and then provide the wraparound supports, people are much more successful,” says Shannon Nazworth, executive director of Ability Housing, a nonprofit organization that provides supportive housing in parts of Florida.

Ability recently received a grant from the Florida Blue Foundation, a philanthropic foundation affiliated with the state’s Blue Cross and Blue Shield health plan. The grant supports a statewide pilot project to study how permanent supportive housing affects the health and quality of life of high utilizers of crisis services — and how it affects their use of health care and other publicly funded support services.

A growing body of research, in fact, suggests that the benefits of housing programs for the health care system might be substantial. Researchers at Yale University’s Global Health Leadership Institute evaluated and summarized the results of several studies in the area in their report “Leveraging the Social Determinants of Health: What Works?” (Lauren A. Taylor et al., Blue Cross Blue Shield of Massachusetts Foundation, 2015):

  • A “housing first” program in Seattle found that the median per person, per month cost of incarceration, emergency medical services, hospital-based medical services, detoxification and other publicly funded programs fell from $4,066 to $958 after 12 months in housing. This added up to annual net savings — after accounting for housing costs — of $29,388 per person compared with a control group.
  • A Massachusetts initiative that targeted homeless people with serious mental illness reduced the average number of hospital days per client from 102 to seven within two years after housing placement. That reduced hospital costs by about $18 million per year overall.
  • A Los Angeles program that serves homeless patients with the highest public services and hospital costs documented that every $1 invested in housing and support reduced public and hospital costs by $2 the following year and $6 in subsequent years.

Read the full article.


What can Population Health Learn about Financing from Affordable Housing and Community Development?

From the article by Katherine Wright at Rethink Health:

To help communities thrive, the United States currently invests in affordable housing and community development through centralized financing structures, implemented at the state and local levels. By any measure, it has been a tremendous success.

For example, Housing Choice Voucher Program vouchers (formerly known as

Section 8) have supported 5.3 million people with safe and secure housing between 1974-2014. The Community Development Block Grant, first passed in 1974, has brought forth $144 billion in community development investments. And, as of 2013, an estimated 13.3 million people have resided in homes financed by Low-Income Housing Tax Credits.

At ReThink Health, we have learned that the multi-sector partnerships addressing population health in their communities have been mostly financed through grants. And this made us curious: if affordable housing and community development were financed only through grants, where would our communities be today? We also wonder, how did these structures come to be? And, how might communities approach sustainable financing for population health in much the same way?

We prepared a couple of case studies investigating the development of central financing structures for these two sectors, and found that the stories provide a lot of food for thought. Here are three standout observations.

  • Observation 1: Stakeholders stayed the course across generations.
  • Observation 2: Stakeholders were willing to work collectively.
  • Observation 3: Stakeholders made choices to balance federal-level structures with state- and local-level implementation.

Read the full article.

Repealing Federal Health Reform: Economic and Employment Consequences for States

From the issue brief published by The Commonwealth Fund:

…Recent analyses show canceling the ACA’s tax credits and Medicaid expansion would double the number of uninsured Americans.2,3 As millions lose their insurance, hospitals and other providers would see their uncompensated medical care costs soar by $1.1 trillion from 2019 to 2028, and they would experience major revenue losses as well.

But repeal could also have much broader economic repercussions. Our analysis examines the potential economic and employment effects of repealing the ACA’s tax credits and Medicaid expansion, without a replacement plan, for every state and the District of Columbia. We estimate changes in:

  • employment—the number of jobs lost in health care, construction, and other sectors of the economy
  • economic activity, such as state gross product (the state equivalent of national gross domestic product) and business output
  • state and local tax revenues.

…Health care will comprise almost one-fifth (18.5%) of the nation’s economy by 2019.9 As such, major changes to health care will reverberate across other parts of the economy.  Federal tax credits first flow to health insurers. Most of the money, aside from carriers’ overhead, flows to hospitals, clinics, pharmacies, and other providers. Similarly, federal funding supports state Medicaid programs, which pay health care providers. These are the direct effects of federal funding.

Most of the revenue earned by health care providers is used to hire and pay staff and to purchase goods and services, like clinic space or medical equipment. In turn, those vendors pay their employees and buy additional goods and services. This is the indirect effect of federal funding.

The induced effect is manifested as workers use their incomes to pay for food, mortgages, rent, transportation, and other goods and services, which provides income to other businesses.

Federal funding thus initiates an economic cycle that ripples throughout the economy, both within and across state borders. The gains from this cycle also generate additional state and local tax revenues. When federal funds are cut, the results play out in the other direction, triggering losses in employment, economic activity, and state and local revenues.

The potential effects of the repeal of both premium tax credits and Medicaid expansion include:

  • …repeal results in a $140 billion cut in federal funding for health care in 2019. This in turn leads to about 2.6 million jobs lost that year, rising to nearly 3 million by 2021. A third of these lost jobs are in health care, but the majority is in other industries such as construction, real estate, retail trade, and finance. Nearly all are private-sector jobs.
  • …canceling states’ Medicaid expansions lowers federal funding by $466 billion from 2019 to 2023. This leads to 1.5 million fewer people with jobs in 2019. Moreover, gross state products shrink by nearly $900 billion and state and local tax revenues drop by $29 billion.

Read the full issue brief.

Hospitals Can Be Key to Healthy People, Healthy Economies

From the article by Johnny Magdaleno on Next City:

With the U.S. medical care industry spending more than $340 billion on goods and services every year, health systems and hospitals have the type of money that could revitalize the communities where they save lives.

That is, if they tended to funnel those dollars down to the neighborhood level.

When a hospital needs food for its cafeteria or off-site laundry services, for example, chances are it’s already signed up for what’s called a group purchasing organization. Nearly 98 percent of U.S. hospitals use this system, and have contracts that see big, often national vendors providing bulk orders and service at discounted rates.

But a new online toolkit designed by the Democracy Collaborative, a community wealth research center based in Ohio and Washington, D.C., is hoping to shatter that norm and help institutions look at the main street businesses and local vendors surrounding them to fill their needs. It’s part of a series, rich with guide points as well as examples of the growing number of hospitals that are already looking to rein their purchasing power to within city borders, called Hospitals Aligned for Healthy Communities.

“[M]any of those dollars leak out of their local communities and do not reach the populations facing the greatest health disparities,” notes an intro page for the toolkit. “Only a tiny portion of health system purchasing — less than 2 percent — flows to businesses owned by minorities and/or women.”

Lead author David Zuckerman estimates that fewer than 1 percent of the average national health system’s investment portfolios are devoted to giving local residents economic development opportunities, like job training and wealth building.

“So there’s a lot of opportunity,” he says. “Even small shifts can have huge impacts.”

A group of hospitals in the University Circle area in Cleveland were some of the first to spearhead this model back in 2005. That program led to collaborations between local hospitals, community foundations, colleges and the local government to link resources together and build job pipelines for disadvantaged workers to get into good-paying health jobs. It also created auxiliary services that have since been a boon to the community, like a local laundry cooperative that’s worker-owned and contracts directly with the participating hospitals.

Hospitals in Albuquerque, New Mexico, just rolled out a similar initiative.

In Richmond, Virginia, nearly 500 entry-level medical jobs stay empty while medical colleges see hundreds of students drop out year after year. So local partners — the city and state workforce development organizations, local nonprofits and two major hospital systems — decided to come together to reverse that history.

Read the full article.


Health is about communities, not just individual care, researchers say

From the article by Megan Scudellari in the Boston Globe:

National health expenditures are expected to hit $3.35 trillion this year, most of it spent on care for one person at a time: doctors’ visits, hospital stays, prescription drugs. But to really improve the health of Americans, two new studies suggest, we also need to aim for a culture of health in communities as a whole.

In one of two studies …in the journal Health Affairs, researchers found that deaths from preventable diseases, such as cardiovascular disease and diabetes, declined significantly over time in communities with tight-knit health networks, such as hospitals and community centers working together to promote exercise or track a flu outbreak. In the second, a team found that cohesive neighborhoods foster good mental health during adolescence, with life-long benefits for children who grow up there.

“Building a culture of health is about how we can get our communities to place greater value on health and well-being,” says Glen Mays at the University of Kentucky, author of the first paper on preventable deaths. “Communities and members of the public absolutely have a clear role in shaping the environment for health.”

Mays and colleagues analyzed survey data from local health officials in 360 communities around the country, collected by the National Longitudinal Survey of Public Health Systems in 1998, 2006, 2012, and 2014. Each official was interviewed about the roles and interactions of various health organizations in his or her community, including government public health agencies, hospitals, community health centers, nonprofit organizations, and more.

The researchers compared those community profiles to causes of death in each area. They found that in locations where many health organizations work together closely and actively to assess and engage a community’s health needs, there was a significant decline in deaths due to cardiovascular disease, diabetes, and influenza — all preventable illnesses. And while more affluent areas were more likely to have large health networks, the effect applies across all communities, says Mays. “There are a large number of communities that have attained these networks, even in low-resource areas.”

Still, the team concluded that less than half of the US population resides in communities with strong, interlinked health networks, so there is much work to be done.

In the second paper…, Louis Donnelly of Princeton University and coauthors used data from a long-term health study on 2,264 children born in US cities between 1998 and 2000. Based on interviews with parents and children, from birth to age 15, the team found that teenagers who grew up in neighborhoods with strong social bonds and neighbors that take action — say, by intervening when children fight in the street — experienced fewer depressive and anxiety symptoms than those from neighborhoods with less social cohesion. Again, the association was independent of neighborhood income. The results align with previous single-city studies in Chicago and Baltimore.

Read the full article.