Social service shortfalls hinder health, boost medical spending

BERKELEY SPRINGS, W.Va. — States that spend more money on social services and public health programs relative to medical care have much healthier residents than states that don’t, a study out today by a prominent public health researcher found.

The study comes as the Obama administration prepares to fund its own research to support the idea that higher social service spending can improve health and lower health care costs. Last week, the Department of Health and Human Services proposed a long-awaited rule that will pave the way for more doctors and hospitals to work closely with social services providers to keep people healthier, such as with home visits or help with housing.

Health care and social services experts in West Virginia, where jobs and access to health care can be hard to come by, cite daily reminders of how improved services can save money later. Their challenge is expanding the reach of the programs they do have. "There's always more need than resources," says Audrey Morris. director of the non-profit Starting Points of Morgan County here.

The new study is the first to compare state spending on social services — which are generally less expensive than medical costs — to spending on Medicare and Medicaid and to residents' health. Many state officials, including those here, say Medicaid claims are busting their budgets and federal officials struggle to rein in Medicare spending on drugs and medical treatments, especially for chronic disease.

Politicians from both parties say health care spending increases,  although slowing, are unsustainable, but they disagree often vehemently over how to address the problem. Yale University public health professor Elizabeth Bradley, lead author of the study,  is urging more efficient — not more — government spending.

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Bradley and her co-authors found that for every dollar of Medicare and Medicaid spending for residents of the average state, an additional $3 was spent on social services and public health between 2000 and 2009, the latest available. Washington, D.C., and states including Colorado and Nevada had the highest ratios of social service and public health spending relative to medical costs - about $5 for every dollar of medical treatment — and were much healthier.

New York and Massachusetts joined traditionally poor-health states including West Virginia, Kentucky and Louisiana with the lowest ratios of social services to medical spending, averaging about $2.30 on social services for every medical dollar spent. People in these states also tend to have higher rates of heart attacks, lung cancer, mental illness and obesity, the study showed.

Community groups, businesses, churches and others should join state and local government to better provide residents with services including housing, transportation, nutrition support and job training, says Bradley. Failing to do so can increase what everyone pays in taxes and on health care.

"It's not just that it’s moral or immoral, it’s just smart," says Bradley, co-author of the 2013 book The American Health Care Paradox: How Spending More is Getting Us Less, which helped prompt HHS' new "innovation" project testing Medicare reimbursement for social service referrals.

The changes Bradley is suggesting don't even require wholesale changes in state and local policy or long research projects. It's things like job training programs that "get a little public money but are mostly not well managed."

"There are some people who would say that these problems are so big, so complex that we have to focus on things in the health system," says Baltimore, Md. health commissioner Leana Wen, an emergency physician. "But I see public health as a vehicle to talk about everything else."

Aetna CEO Mark Bertolini says the time is right for this realignment of health care priorities. Before the recession, people thought of social services as being for "those poor people," says Bertolini, and, then, "a majority of people couldn't afford the basic necessities."

Bradley and co-author Lauren Taylor's 2013 book reported the United States lagged nearly every other developed country in social service spending, outspent them in medical spending and had nearly the sickest citizens.

As the Yale researchers found in the new study, a 20% change in the median ratio of social to health spending would result in there being 85,000 fewer obese adults in a state the following year, the study found. Adults with obesity incur about $2,700 more in average annual health care expenses than those who aren't obese.

Shortfalls, successes in services

Chance Miller, 7, grabs a giant green bell pepper off a table at Starting Points and begins eating it like an apple. He just left the Boys and Girls Club of America's after-school program downstairs, where he usually insists on staying until 6:30 p.m. to do his homework, eat dinner and play with friends.

Chance and his mother, Meredith Bradshaw, represent both the benefits and shortfalls of social services in an area that was once home to bustling coal and sand mining industries. Bradshaw is lucky to make $12.35 an hour at a furniture factory that is one of the very few businesses in the area to offer health benefits. Still, she relies on Starting Points for dinner for her family three nights a week, for donated clothing and free fresh vegetables and other grocery staples.

"This is the best program ever," says Bradshaw, 42. "People here are like family."

Bradshaw makes too much money to qualify for educational assistance so she can take college classes to get a higher paying job, but she did learn late last week that she can train to become a furniture sprayer. That would give her a dollar an hour raise and could ultimately lead to $15 an hour.

Soon, Chance will be able to study robotics at his after-school program, one of the many ways a single building in one of the country's poorest states is preparing a child to be a healthy, self-sufficient adult.

"Getting children off to healthier, stronger starts in life is key to making real progress," says Laudan Aron, a senior fellow at the Urban Institute who specializes in social welfare issues.

The Shenandoah Community Health Center and the Starting Points office here work together like a small-scale replica of what the federal government hopes our health system will become.

Finding a minimum wage job — even 30 miles away — is often cause for celebration in Berkeley Springs. Getting to it is another story altogether. There's no public transportation, no taxicabs and no Uber, though there's talk the ride sharing company may enter the area soon.

So one of the things that takes much of Morris' time — two clients in one recent morning — is finding money to pay to get cars that break down diagnosed and fixed if that isn't too pricey.

Without transportation, residents can fall deeper into the cycle of poverty, drugs and depression that can put chronic health conditions in the background.

How social services change lives and health:

• Housing. Before she moved into affordable rental housing in Washington, Josseline Rivas-Valdez, who immigrated from El Salvador, often wound up in the emergency room because of suicide attempts and drug overdoses stemming from childhood sex abuse. Now on Medicaid, she's sober, hasn't been hospitalized, goes to regular therapy and her son, 11, no longer suffers from a stress-related stomach disorder.

Laurel Blatchford, senior vice president of solutions at Enterprise Community Partners, says housing is "bending the health care cost curve." Enterprise recently commissioned a study that found Medicaid expenditures for affordable housing residents declined 12% overall and 16% for seniors and people with disabilities.after they moved in.

• Job training. Khai Nguyen and Daniel Nguyen co-founded of VEGGI Farmers Cooperative in New Orleans to train the Vietnamese fisherman in the Versailles Arms public housing project to be urban farmers after Hurricane Katrina. The pair benefited from support and resources from the non-profit Propeller, which helps social entrepreneurs. The co-op now supplies many of New Orleans' top restaurants and grocery stores with vegetables and tofu, has a weekly farmer's market and offers employment in an area of the city known as a "food desert" with scarce jobs and few who speak English.

After Katrina, "I think we were the only ones in the community providing social services," says Khai Nguyen, who says the farmers report improvements in their physical and mental health related to the jobs.

• Transportation. Bertolini says one of the reasons Aetna was so interested in acquiring Humana was the innovative risk appraisals it does of its Medicare Advantage patients' needs, including forat-home risks and transportation needs. Humana at Home sends Uber drivers to help clients get to places, such as the senior center, which Aetna may expand to a larger audience.

After a Starting Points client needed to get to Martinsburg, W.Va. for a mental health appointment, Morris says the local sheriff brought the man there and back seeing he had a meeting there anyway.

Connecting, changing communities

The federal shift to a health care system that's accountable for how much it spends and how healthy it keeps patients has been painful or painfully slow, depending whom you ask.

Medicare's quality initiatives until now have been limited to a handful of medical conditions, including heart disease, pneumonia and hip and knee replacement. Medicaid programs around the United States are increasingly getting federal permission to reimburse health care providers for paying for things like housing assistance, air conditioners and allergy-reducing vacuums that improve people's health.

More money is not always the solution, says Aron of the Urban Institute.

"In many ways, we are spending plenty. We're just not spending it well," says Aron,. "It's just not reaching the places, the people, and the needs where resources are most needed."