Defund Health Care
Defund the police can be understood as a call to reallocate dollars to address the consequences of the tragic inequities we see in our communities. Similarly, in health care, we find striking disparities that are best addressed through investments in team-based approaches and coordinating care with the wide array of community-based organizations (CBOs) and governmental agencies that include social determinants of health in their mission. Health disparities will not be solved by throwing more money at individual health care services. Just as we should consider a range of options including defunding police departments to better manage the crises that are stoked by the inequitable conditions in our neighborhoods, we should evaluate defunding individual medical services to refund the human, and social services needed to create a healthier and more just society.
There are many parallels between the re-evaluation of the roles of police in our society, and the attempts to address social determinants of health. The World Health Organization defines social determinants as the conditions in which you are born and live that are shaped by money, power, and resources. For example, the Federal Reserve looked at 2019 data and found that the typical White family has eight times the wealth of the typical Black family and five times the wealth of the typical Hispanic family. We can all imagine how our lives would be different if our family had eight times more wealth. We can recognize the impact of social determinants on health when we identify disparities in care. The Center for Disease Control defines health disparities as preventable differences in the burden of disease experienced by socially disadvantaged populations.
Police are often called upon to handle individuals with underlying behavioral health and substance use issues. These are not core competencies of our police. Similarly, health care providers have no special expertise in addressing social determinants, which include challenges such as housing insecurity and food insecurity. However, health care providers can and should screen for social determinants, and use team-based approaches to connect patients with the CBOs and government agencies that can help address their patient’s needs.
When social determinants are addressed, health disparities are reduced, and managed care companies, which are incentivized to decrease costs as well as improve quality, stand to benefit. States such as California are also pushing managed care plans to assume responsibility for addressing social determinants. Because programs that tackle social determinants can lead to health care savings by reducing emergency room visits and hospitalizations, it is reasonable to expect managed care companies to help foot the bill for addressing social determinants. But managed care companies have little experience in working with social determinants, and have shied away from providing the case management and navigation services that is required to coordinate care between patients, clinicians, and the CBOs and governmental agencies with missions that encompass social determinants.
Before giving the keys to our social service system to managed care companies, lets consider an alternative model that creates a sustainable infrastructure embedded in public health departments. This makes sense for several reasons. First, there is one public health department in each jurisdiction that is responsible for improving the health of their communities and populations regardless of health insurance coverage. We don’t need every managed care company to create its own social determinant network when there are multiple managed care companies in each market.
The other issue is that social determinants overlap the wide array of social service programs that are outside the scope of traditional health care systems. Why pour more money into managed care when we already spend close to 97% of all health care dollars on individual health care services and only 2–3% on public health? We should be investing our tax dollars in our communities, including public health approaches to keeping people healthy that can more efficiently and effectively impact entire populations, rather than relying on individual visits to doctor offices. It also means building the infrastructure within public health departments for an information exchange that preserves patient confidentiality, as well as a network of navigators in health care provider offices, CBOs, and governmental agencies, to connect residents to the services they need.
The health of individuals and the safety of our communities are both impacted when poverty and racism erode our neighborhoods. The response is not to funnel all our resources into managing the consequences that are manifested through calls to the police or visits to a doctor. We should deal with the causes not just the effects. This means supporting educational opportunities and creating jobs with a living wage to end poverty. And it means investing in neighborhoods with green spaces and access to physical activity and nutritious foods that improves the health of our communities.
Our response must also include funding to better coordinate services, be it access to mental health or substance use, or to the range of social services that are available through CBOs and governmental agencies. This does not mean that police are not needed in a world that can be hostile, threatening, and violent. Or that we don’t need a health care provider when we are sick. But it does mean both the police and medical professionals should have access to providers that have the tools and skills to best assist with the range of human and social service challenges they encounter.
Team-based approaches can make the job of both our police and medical professionals easier and more rewarding by allowing them to focus on what they are trained to do, and what they do best. In health care, we can accomplish this by refunding our public health infrastructure to facilitate information exchange between providers and CBOs and governmental agencies along with a system of navigators or community health workers to work directly with patients.
A strong argument can be made that managed care systems can and should fund increased investment in programs that address social determinants because of the downstream reductions in expensive outcomes such as emergency room visits and hospital stays. This doesn’t mean that programs that address social determinants should be embedded in managed care companies. The bottom line: defund individual health services by redirecting dollars from managed care companies while refunding team-based approaches and care coordination built around public health departments to improve the delivery of human and social services in our highest risk communities.
Dr John Zweifler is a family physician with years of patient care, medical education, and medical administration experience. He currently works as a physician consultant with the Fresno County Dept of Public Health, and consultant with he Terry Group with a focus on population health. He is the author of the e-books, “Tipping Health Care in the Right Direction”, and “Pop Health.” He can be reached at john.zweifler@terrygroup.com
