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The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
November 16, 2020
The Health of Aging Populations Social Determinants of Health
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Funded through the Older Americans Act and Medicaid, New York’s county-organized system of home- and community-based services supports thousands of older adults every year. The recipients of these services are people like Loretta, an 83-year-old low-income woman living alone, with four chronic health conditions. Loretta struggles with cooking, self-care and other activities of daily living, so the home-based services she receives, including meals, transportation, and housekeeper chore services, are critical to her ability to remain in her home and out of the hospital or nursing home.
It should be no surprise then that many public leaders are beginning to recognize the value of these nonmedical services, which address social determinants of health and can impact both health outcomes and expenditures. But with demand exceeding current resources, we are relying on health care providers to offer what are social, not clinical, services and paying for those services out of Medicaid and Medicare budgets.
Why is the health care sector expected to shoulder this increased responsibility? First, the health care system is more mature in measuring effectiveness and using incentives to improve performance than sectors like housing or transportation. Second, in recent years, even with increasing budget deficits, the public health care system, including Medicare and Medicaid, is still perceived as having the most money. Third, our society is slow to incentivize complex multisector collaboration. It’s easier to charge the health care system with fixing social determinants of health — just as we have handed similarly unrealistic responsibilities to our teachers and police officers.
That approach is problematic because strengthening social services, transportation, housing, and other supports for vulnerable older people does not fall within the traditional expertise of the health care system. Additionally, by choosing to rely predominantly on the health care sector, other key players in a true multisector approach are allowed to minimize — and even ignore — their accountability in systemic reform efforts. For example, many health care providers pay for vans to bring people to and from their doctor’s appointments, but this does nothing to address the lack of public transit options in low-income communities.
How can we create a better system of care for older adults like Loretta? For both government and philanthropy, strategies for broadening the responsibility for improving social determinants fall into three categories: leadership, investment and accountability.
Some states are stepping up at the highest levels to create systemwide accountability for the quality of health and life for older people. California’s governor is developing a statewide Master Plan for Aging, engaging representatives from the environmental, economic development, and agricultural sectors along with the “usual suspects.” The Massachusetts Governor’s Council to Address Aging includes representatives of Health and Human Services, Elder Affairs, Labor and Workforce Development, Transportation, and Housing and Economic Development and their respective constituents to address longer-term plans and barriers to successful aging. And in New York, the governor’s executive orders on Health Across All Policies and Age Friendly New York have stimulated similar action in that state.
In all three states, philanthropy plays a leadership role along with the heads of state government, sharing part of the financial burden and also providing connection with local communities and experts in the field.
US health care costs far exceed those in other developed countries. Yet, in many countries, spending on social supports is much greater than here in the United States. Investments need to be made in subsidized housing, food supports and caregiver support, not just medical care, to achieve successful, healthy aging. When the lens is broadened to think about social determinants of LIFE, opportunities and synergies become apparent.
While government remains the largest funder of such services, private funders can make strategic investments to demonstrate proof of concept and scale evidence-based programs and services like SASH and CAPABLE.
None of the efforts described above will achieve their potential if a broader culture of accountability is not created beyond the health care sector. The health care system, through its long-standing institutions like the National Committee for Quality Assurance, the National Quality Forum, and Institute for Health Care Improvement have supported quality measurement for years, and contracts between payers and provider systems are consistently moving to “value-based payment” with both upsides and downsides for performance.
Governments can speed this accountability for social services by revising their service contracts with counties and other local agencies to move beyond counting heads to requiring stronger assessment, evaluation, and data analytics for continued funding. Here, philanthropic funders can add the most value by building the capacity of the non-profit service providers to respond to these new expectations.
The United States has finally acknowledged that health care accounts for a small fraction of what makes people healthy. Thus we must be careful to use our governmental and philanthropic tools to spread the responsibility, capacity, and accountability across all relevant sectors and systems and not only look to health care to manage, fund, and strengthen social and community supports.
Thinking and working through our collective responsibility for social determinants of LIFE, where each sector accepts accountability for equity and quality of life by being the best it can be in its own lane, will help us realize our country’s commitment to all of our people more quickly and effectively.
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