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Supporting Our Health System Means Supporting the Work of Community-Based Organizations

Health care officials, advocates, providers, and industry experts increasingly recognize the importance of addressing social determinants of health – such as education, housing, food security, and immigration status – to improve population health. This recognition has led to increased interest in the role that community-based organizations (CBOs) play in improving health by addressing core social services needs. Many NYIC member organizations address these needs for the immigrant and refugee communities they serve. Despite the new attention to social determinants and CBOs, recent events suggest that in New York State we still have a long way to go.

The New York Academy of Medicine’s “2017 Albany Update” on April 24 featured Deputy Secretary for Health and Human Services Paul Francis as its keynote speaker. Among the slides in Francis’ presentation was a widely published but underappreciated graph showing spending on health care and social services among high-income countries. While the U.S. spends a vastly greater proportion of its gross domestic product (GDP) on health care than other high-income countries, it lags behind its peers in spending on the social services that facilitate access to affordable housing and nutritious food, clean environments, quality education, and a steady income. When health and social service spending are combined, the U.S. lands in the middle of the pack with a distribution that skews heavily toward inefficient health care spending and away from a more effective whole-person approach to health and wellness. Not incidentally, the U.S. also has worse health outcomes relative to other high-income countries. This phenomenon holds when comparing social services spending and health outcomes across states within the U.S., too. An article published last year in Health Affairs compared social services spending relative to health services spending and found that states with higher social-to-health spending ratios had better health outcomes.

Francis’ comments point to the role of spending on social services in generating positive health outcomes. The fact that Francis raised this in the context of a discussion of the state’s Delivery System Reform Incentive Payment (DSRIP) program and Governor Cuomo’s focus on a health in all policies approach, embodied by the recently announced Vital Brooklyn initiative, suggests that New York State officials understand that health improvements won’t simply be achieved by improving health care services.

Following Francis’ presentation was a panel discussion with Jeffrey Kraut, executive vice president for strategy and analytics at Northwell Health, and Lisa David, president and CEO of Public Health Solutions. In one exchange, Kraut wondered whether a problem with the current structure of service provision was the sheer number of CBOs doing too much of the same work and fighting over a very small pool of resources. Kraut appeared to suggest that the number of organizations addressing social determinants of health makes it too difficult for academic medical centers and major hospital systems to effectively interact with so many community partners. Francis and David each observed that there are no easy solutions to this conundrum. But surprisingly, none of the panelists noted the connection between Kraut’s question and Francis’ comments on spending for social needs from 10 minutes before.

Is the problem really that there are too many CBOs? Or that CBOs are disproportionately tasked with meeting the needs of communities battling a host of challenges that emerge from structural inequities in education, housing, gun violence, and immigration law? If public policies directed resources sufficient to meaningfully address the needs of all New York State communities, the work of both health care providers and CBOs would be easier. In the meantime, it is critical that health care leaders recognize the importance of CBOs as core partners for health care delivery and improvement.

Dramatically increasing public investment in social service spending is by no means an easy solution, but it is surprising for a high-level conversation about the structure of the relatively decentralized nonprofit world and its relationship to the rapidly consolidating health care industry to miss enhanced social service spending as an avenue for improving population health. It is particularly unfortunate to hear this arise in a conversation that involves DSRIP. While New York’s DSRIP program was theoretically designed to better incorporate CBOs into health care work, it has in practice disproportionately empowered large hospital systems and struggled to make CBOs central partners receiving a fair share of the program’s $8 billion. DSRIP suffers from the same problem as U.S. public spending overall, and the problem isn’t an overabundance of CBOs – it’s the starvation-level funds invested in the critical work of CBOs to make our communities healthier.

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