It’s been about 30 years since the birth of the Healthy Cities and Healthy Communities movement, which is predicated on the belief that health and well-being are what drive vital communities and strong economies. And to improve community health for all, we need to invest in more than just access to high-quality medical care. “If we’re going to have a significant population-level health impact, it’s not just going to be better health care policy, nor better public health policy, but healthier public policies and private policies,” explains Tyler Norris, Chief Executive Officer for Well Being Trust.
What creates health? Living-wage jobs, education, stable housing, access to affordable, healthy food, and mobility to travel to work, school, and worship. Tied to these are the factors of well-being, as identified by the Greater Good Science Center: meaning and purpose, a sense of belonging, awe and wonder, and generosity. When things go awry, people with these factors turn out better. “Health is a byproduct of lives and communities working, not a medical care intervention, as important as that is.”
“What is novel in all this isn’t this information; it’s that the medical and health care sector has known this for decades and yet we have done incredibly little as a sector despite a $3 trillion spend within our control, the fifth-leading economy by itself in the world, to actually change population-level health outcomes,” says Norris. A growing body of research continues to point at the morbidity and mortality gap of Americans compared to other countries. We know this has to do, in part, with the lack of health equity, but even highly advantaged Americans are worse off than their counterparts in other countries. “We are not delivering a return on our health care dollar.”
Norris describes Step 13, a program for homeless substance abusers in Denver, Colorado, which he helped found 35 years ago and which is still in operation today. “We provided something very simple: stable housing. A home, a place to be, that you could save, get a good night’s rest, park your stuff, and wake up.” The second part of the program is readiness for work, making sure everyone is sober the night before and able to keep a job. “The conversation wasn’t, ‘What’s the matter with you?’ It’s, ‘What matters to you?’ And a recognition that behavior change and environmental change are key.”
Across the country, thousands of initiatives have begun to embrace a whole-person, whole-system approach to health. But these initiatives take time. When Norris joined Kaiser Permanente a few years ago, they thought that applying the right incentives of that integrated care delivery system to billion-dollar 1, 2, and 3-year behavior change initiatives in schools and workplaces would make a big impact. The result? It didn’t.
“We have not delivered sustained behavior change in general because we have had inadequate dose. In other words, [the] reach, intensity, and duration of our interventions, of our efforts to be able to create a population-level health impact, have not been adding up. Not long enough, not strong enough,” says Norris.
“It becomes an ethical matter before us as a health care sector when we know that care and coverage for everyone is essential, and clinical-community integration between high-quality care and the community assets that we know are important to health is essential, and we know that we need to meet people’s social and economic needs — they’re basic human needs — we know that our health care organizations need to behave like anchor institutions and buy local and hire local and use their investment portfolios locally to drive the local economy,” argues Norris.
Well Being Trust released a report in November 2017 called Pain in the Nation, which calculates that last decade, about one million Americans, or 100,000 a year, died of deaths of despair — alcohol abuse, substance abuse, and suicide. At current rates, the Centers for Disease Control and Prevention estimates that the next decade will move us from 1 million a year to 1.6 million deaths of despair. In some communities, particularly rural, Well Being Trust expects those rates to almost double.
We need better integration of mental and behavioral health into primary, emergency, and acute care, but that’s just “table stakes,” according to Norris. We also need to address adverse child and adverse community experiences and create healthier public policies that invest in the social determinants of health.
With the health care sector commanding 20% of the U.S. economy, we need to take on a leadership role, Norris argues, working with communities on organizational practice changes, public policy changes, and private-sector impact investments that will ensure intergenerational well-being.
We have two systems: the system of care, and the system of health. One way to help us think about them differently is to stop talking about people as consumers. Consuming medical services is not the goal. “People are pro-sumers,” says Norris. “People drive their health by what they do themselves and how they show up for each other. Health care needs to be buying health from communities that are the producers of health. It creates a very different notion about what the marketplace needs to be.”
From the NEJM Catalyst event Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, held at Vanderbilt University Medical Center, January 25, 2018.