“Healthification”: The Good and Bad of Making Everything a Health Issue
Health professionals, health care institutions and public programs have been expanding their purview, taking on socio-economic problems with targeted programs addressing what those of us in health care call the “social determinants of health.” At the same time, public health has also been broadening its traditional mission to include problems such as gun violence and homelessness, as part of its general mandate to protect and improve the health of communities. Yet while it’s long overdue that medicine look beyond its stethoscopes and “remunerectomies,” and that public health look beyond the traditional mission of public health agencies to the more fundamental drivers of the health of communities, the question is whether and when the “healthification” of everything makes sense and is productive.
Let’s start with how hospitals, health systems and Medicaid programs are expanding their missions to take on the social determinants of health. In an August 2023 JAMA Forum, Sherry Glied and Thomas D’Aunno took on this issue, arguing: “Health systems and hospitals should tread warily into the provision of social services and policymakers should not encourage this approach. It has real risks, such as diverting scarce resources to socially less-desirable uses, and few prospects of success. Social determinants of health should be addressed by the social service organizations and governments that specialize in this work. There are fundamental mismatches between the priorities and capabilities of hospitals and health systems and the task of addressing social determinants of health.”
That’s a pretty strong conclusion. What does seem to make the most sense for the health system are more targeted non-medical interventions aimed at chronically ill or high-risk groups when the payoff in terms of improvements in health outcomes is the most plausible. For example, a children’s hospital reaching out to low-income, chronically ill children and their families in the community. Pediatricians providing lock boxes for guns to their patient base when appropriate. A Medicaid program supporting community organizations to address the broader needs of the homeless, including providing transitional housing so people’s lives can be stabilized and health and mental health issues can be addressed.
When Medicaid takes on social determinants, its dollars generally flow through to community organizations and local agencies that, as Glied and D’Aunno put it, “specialize in this work.” As we explain in a new policy brief, eight states now have Medicaid waivers from CMS to provide up to six months of transitional housing to special needs populations, including the homeless and immigrants. In its evaluations of waiver programs enabling states to use Medicaid to pay for non-medical services to address social determinants, CMS has been laser-focused on program impact on health outcomes. As challenging as that is, it is far more achievable than trying to impact poverty or homelessness or income inequality itself. In a different JAMA piece, Stuart Butler offers a few good examples of hospital systems partnering with social services organizations in similar ways and discusses how government can encourage more partnerships between health systems and community organizations.
Another way health care institutions can make an impact on socio-economic issues is as local employers, housing developers and stewards of the local environment, a role that will also help them rebuild trust in their communities. In many cities, they are the major local institution and have historically poor relationships with low-income communities and communities of color.
Many years ago, when I started the Health Care for the Homeless Program at the Robert Wood Johnson Foundation, a colleague—former Health Care Financing Administration head Bruce Vladeck—and I served on an Institute of Medicine (now NAM) committee looking at health care for homeless populations. We publicly dissented from the final report when it was considered a bridge too far for a health group to conclude that housing was important to the health of the homeless. The field has come a long way since then.
Perhaps the most notable example of this progress: Echoing several state and local foundations, the Robert Wood Johnson Foundation, the nation’s largest health philanthropy, is directly confronting structural racism as it impacts health, making that a core priority working with groups and communities across the country (Confronting Structural Racism to Transform Health | | RWJF).
In the bigger picture, much of the answer to our larger socio-economic problems will ultimately need to come from outside the health system altogether, through income, housing, education, jobs and food policy. One example: the expansion of the Child Tax Credit will almost certainly do more to alleviate child poverty in America (and potentially impact child health along the way), than all the efforts to address social determinants undertaken by all the hospitals in the U.S. combined.
Many of the strategies that matter most when it comes to addressing poverty and related issues are what social scientists call “income strategies” not “service strategies.” One example of an income strategy is the guaranteed minimum or basic income experiments around the country. A small randomized trial of one in Stockton, California documented what these have generally been showing: improved economic and quality of life outcomes along with, notably, improved health and mental health outcomes. When I was in the welfare field there was an old saying, “the best welfare program is a good job.” Leaving aside that we didn’t deliver nearly enough good jobs and people still don’t earn adequate wages often enough, the point is the right one. The answers to poverty and related problems that have impact at scale are not found in the health system.
That said, one thing that is often under-appreciated is that providing health insurance coverage is itself an income strategy, since coverage not only affords access to care but also substantial economic security to a public whose chief health care worry is paying medical bills.
Labeling socio-economic problems as public health issues and expanding the scope of public health is a more nuanced issue. Gun violence is viewed as a public health issue because it has such drastic health consequences, and in the U.S. has taken on epidemic proportions. Housing, poverty, food insecurity, racial inequality, homelessness and more are also often now characterized as public health issues for the same reason.
However, while health outcomes are the problem we health policy people worry about the most, reducing poverty, expanding low-income housing, providing better paying jobs, or addressing racial injustice are huge goals in themselves, regardless of their impact on health. There are no bigger goals than reducing income inequality, or racial injustice, irrespective of the impact doing so has on health outcomes. Each also represents a field of its own, with its own experts and community organizations and government agencies who have worked for generations on these difficult challenges.
Putting a health label on socio-economic problems doesn’t change the politics of the issues or the partisan division we have in the country about addressing them. It hasn’t helped with Covid or with gun violence, as obvious examples. It doesn’t make red states any more eager to spend money on public health or social programs for low-income people and people of color. Quite the contrary; public health has been under attack in the red states.
On the other hand, framing socio-economic problems as public health issues may help public health doctors, who generally have more experience dealing with community health, to wrest territory and status from clinical medicine and possibly gain more resources as well. Defining gun violence as a public health issue may empower public health agencies like the Centers for Disease Control, state health departments and health services researchers to collect data and conduct research on the problem at a time when there has been opposition to doing that. It encourages research and new efforts to address the health-related aspects of gun violence, including suicide-related gun deaths and the mental health dimensions of the problem. And it may help mobilize health professionals of all stripes to get involved in gun violence, especially emergency room doctors who see gun violence firsthand and can speak to the issue with standing and credibility.
Still, while gun violence has public health implications, it surely isn’t only, or even primarily, a public health issue. It is also a social issue, a public safety issue, a legal and constitutional issue, a cultural issue, a big issue in the culture wars and a divisive partisan issue. Moreover, the most important actions to limit the supply and availability of guns in the U.S. are state and federal legislative actions that don’t involve the health or public health system. The law—or the absence of laws aimed at guns and gun use—is almost certainly the most important factor in reducing gun violence. Of course, public health can add its voice to the need for changes in the law.
There is both good and bad about the “healthification” of socio-economic problems, and those of us in health and public health would do well to approach an expanded mission with precision, humility and respect for others who have long worked on these issues. The larger answers to poverty, income inequality, racial injustice, and our deeper socio-economic problems—all of which influence health—are mostly to be found in broader social and economic policies outside of our world.