Jim Schuyler

Weekly Reader: Vital Conditions for Thriving People and Places

To VACAP Leadership and Friends:

This Week,  the Reader is focusing on new ideas and new opportunities.
   First, a story this morning on NPR In Health Care, "More Money is Being Spent On Patients’ Social Needs. Is It Working?"  By Phil Galewitz. 

    When doctors at University of Pennsylvania Health System clinics noticed that many of its poorest Medicaid patients failed to show up for appointments, they decided to give out free one-time rides. But that did not reduce the patients’ 36 percent no-show rate. In the past decade, dozens of studies by state and federal governments, private hospitals, insurers and philanthropic organizations have studied whether addressing patients’ social needs improves health and lowers medical costs. These strategies focused on social determinants of health and the studies have been unclear on which strategies are most effective or feasible. The reports found that even when such interventions show promising results, they only serve a small number of patients and several studies did not go on long enough to detect an impact or they did not evaluate health outcomes or health costs.

     North Carolina is spending $650 million over five years to test the effect of giving Medicaid enrollees assistance with housing, food and transportation, and California is redesigning its Medicaid program to dramatically increase social services to enrollees. The move to address social needs is occurring because many experts and policymakers agree that simply increasing access to health care is not nearly enough to improve patients’ health.  The Affordable Care Act spurred changes in how insurers pay health providers, moving away from a set fee for each medical service to payments based on value and patient outcomes. This gives hospitals a financial incentive to help patients with nonclinical problems—such as housing and food insecurity—that can affect health.
   Temple University Health System launched a two-year program last year to help 25 homeless Medicaid patients who frequently use its emergency room. The program provides these patients with free housing and caseworkers to help them access other health and social services. The caseworkers can help with furnishing the apartments, setting up healthy delivered meals, and submitting applications for income assistance. To qualify, participants must have visited the emergency room at least four times in the previous year, with medical claims exceeding $10,000. Temple has seen promising results—the participants’ average number of monthly ER visits fell 75% and inpatient hospital admissions dropped 79%. Use of outpatient services jumped by 50%, showing that patients are seeking more appropriate and lower-cost settings for medical care. Apartment assistance is expected to end after two years, but administrators hope to find all of the participants permanent housing and jobs. 

   Steven Carson, senior vice president at Temple said, “Housing is the second-most impactful social determinant of health after food security. Our goal is to help them bring meaningful and lasting health improvement to their lives.”

    Temple is helping to pay for their program along with two Medicaid health plans, state grants and a Pennsylvania foundation, and a nonprofit human services organizations helps to operate the program. The effort is expensive—the “Housing Smart” program cost $700,000 to help 25 people for one year or $28,000 per person. They don’t yet have the data to prove whether the program will save money in the long-term by reducing hospital visits. Elena Marks, CEO of Houston’s Episcopal Health Foundation said that social and economic forces have a greater impact on health than do clinical services like doctor visits. This is a new and emerging field and the evidence is weak for some, mixed for some and strong for a few areas. Despite incomplete evidence, the status quo isn’t working either—so let’s go look for some other solutions.

    The federal Centers for Medicare and Medicaid Services (CMS) is funding a number of efforts and remains committed to helping states meet enrollees’ social challenges including education, employment and housing. A CMS official said, “Evidence indicates that some social interventions targeted at Medicaid and CHIP beneficiaries can result in improved health outcomes and significant savings to the health care sector.”

        For those agencies that have major hospitals in your communities, you may want to think about serving as the local human service organization and discussing a partnership with the hospital to test the impact of meeting social needs of patients and their families (it does not seem that much work has been done in this area using a whole family strategy).

  Second, a major story on the US economy in June 20 Washington Post  "The economy isn’t going back to February 20. Fundamental shifts have occurred." by Heather Long. This article does not provide many answers, but I think it is important to think about what are the impacts of fundamental changes on the people and communities that you serve. How do you adjust the your agencies’ programs and service priorities to respond to these changes and uncertainties?
   The pandemic disrupted everything, damaging some parts of the economy much more than others. But a mass vaccination effort and the virus’s steady retreat this year has allowed many businesses and communities to reopen. What Americans are encountering, though, is almost unrecognizable from just 16 months ago. Prices are up. Housing is scarce. It takes months longer than normal to get furniture, appliances and numerous parts delivered. And there is a great dislocation between millions of unemployed workers and millions of vacant jobs... There’s dispute, among other things, about how many of these changes are temporary and how many are true fundamental shifts that will stick around for years and reshape behaviors. But many people agree, at least, the changes are proving very disruptive.  
  • Nearly a quarter of workers are likely to work at least a day or two from home each week, the McKinsey Global Institute predicts.
  • E-commerce, which grew three times faster last year than in prior years, shows few signs of ebbing.
  • The surge in home prices is exacerbating the affordability crisis as first-time buyers are getting priced out. Experts fear a rental crisis could be next. Many of the fasting growing home prices are in smaller cities as Americans are relocating to places with more green space and sense of community.
  • Inflation hit a thirteen-year high in May 2021 and is widely viewed as the biggest risk that could sink-or at least stall-the recovery’s progress.
  • Workers are increasingly demanding more pay and better working conditions. They want more flexibility, more opportunities for workers of color and more understanding from employers of mental health and child care needs. There are an estimated 9.7 million job openings right now, according to job site Indeed. That is a record, and several million more than the nation has seen before.
  • Many first-time homebuyers are being priced out because they can’t afford the high down payments. They will have to stay as renters.
  • Some are predicting the nation is on the verge of a rental housing crisis. At the end of June 2021, the national eviction moratorium expires, and many landlords are eager to bump up rent and force out tenants who lost jobs in the pandemic. Investors have bought cheap single-family homes and hope to rent them out for good profits. Single-family home rents rose 5.3 percent a year as of April 2021. In a worst-case scenario, it could lead to more homelessness, even in such a hot economy. It would certainly reinforce the divides between the haves and have nots.
  • Companies heavily invested in technology which has led to the rise of automation during the pandemic—robots and telework. The gains in the economy are unlikely to be evenly distributed. Automation has its downsides, especially layoffs for workers without college degrees. Are we able to create real opportunities for people who have been in low-wage, low skilled jobs?
  • On the hiring front, there is nearly one unemployed person for every job opening, and it is not easy to fill vacancies. People don’t necessarily live where the jobs are or have the right training and skills. After such a harrowing year, workers are also reluctant to do the same thing they did pre=pandemic for the same pay and conditions.
  • Workers are quitting their jobs at the highest rate ever recorded, and many Americans are launching start-ups they wanted to do for years. New business applications jumped 24 percent in 2020, the biggest surge in history, and they remain at a much higher level than pre-pandemic.

     Heather Long concludes, “About the only certainty is that the economy coming out of the pandemic is going to luck much different than it did before.” 

  So what does that mean for you and your agency? Community needs may have changed significantly since your agency’s last needs assessment. You will know if your community is seeing significant home price increases, if there are many renters who are still behind in rental payments, and if families are being evicted from rental housing. Think about where there are new job opportunities in your communities as well as small businesses that are starting up and hiring, businesses that are hiring and expanding, and businesses that are growing and relocating into your communities. What about continuing food insecurity, lack of child care, and transportation challenges that may keep families from seeking work and may lead to evictions and greater homelessness? Community action should be on the front lines of advocating for and working toward an inclusive and equitable recovery.

That is it for now. There are many other important stories that the Reader would like to cover. So it is possible that there will be another edition this week. Hope this Reader gives you and your team something to think about as you plan for the future.


Thanks for reading!

Jim Schuyler 
VACAP


Articles Referenced in this Blog:

The economy isn’t going back to February 2020. Fundamental shifts have occurred.
In Health Care, More Money Is Being Spent On Patients' Social Needs. Is It Working?