Ellen Andrews, Ph.D.

To solve hard problems we need upstream solutions, not downstream fixes. There’s a lot of news about the Supreme Court’s decision on abortion and the latest mass shootings. Efforts to preserve women’s choices and bring sanity to our gun laws are critically important. But we don’t spend as much time finding upstream solutions to prevent problems, so we won’t need a fix. This blindness is very costly in healthcare. 

The reasons women seek abortions are complex but financial challenges are the most common. Half of women who seek an abortion are living below the poverty level. Unwanted pregnancies could be prevented with better access to contraception, meaningful parenting supports, and economic security. 

Sharply reducing the number of guns is key to reducing violence, but so is creating a world where people don’t feel so disaffected that they consider violence their best option. Suicide is up, but we struggle to find mental health resources for people in need. 

Most of the answers to these problems come back to building healthy, supportive communities. Healthcare has a central role in this train wreck. 

Healthcare is a big part of our economy, taking twenty cents of every dollar spent in the US in 2020. Other countries don’t have this burden and they are getting better health value for their spending. It’s not a new idea, but our incentives are all wrong. There’s far more money in treating problems than by preventing them. Heart disease brings in $219 billion each year to the US healthcare system, while helping patients to stop smoking, eat healthy food, and exercise brings is far less profitable. Asking the US healthcare system to prevent problems is like asking Big Oil to divert their profits to solar power.

There is a growing recognition that social factors, health risks, and the communities where people live are more important to our overall health than medical care. Studies estimate that social determinants of health, such as housing, healthy food, and safety, are responsible for 80 to 90% of our health outcomes.

Recognizing this, newer payment models driven by government payers are designed to reward health systems for preventing disease and managing chronic conditions. In the new models, health systems profit by lowering total healthcare costs.  This should give them an incentive to invest in healthier communities to keep their patients healthy, and lower total costs. But it isn’t working. 

In these new models, most health systems hire care managers who screen patients for social needs and make referrals to community organizations. That’s good but the savings from patients not visiting the ER every day don’t go back to housing or other supports that helped them get healthy, it stays in the medical system. A recent study of 626 US health systems found that only 9.1% made investments in social determinants of health and the investments are relatively modest. Their profits are devoted to healthcare system priorities, not community needs.

Many community resources are funded by government through public health. COVID demonstrated the tragic consequences of our historically inadequate public health investments. Health systems make a profit from government’s public investments, but don’t return those dollars back to the community organizations that generated them.

It’s a long trip between tweaking payment models and supporting healthy communities and it’s not working. Payers and government must recover the savings from the medical system and reinvest them in communities. If we want to prevent problems, we need to stop funding very expensive band aids, and get serious about prevention.

More from Ellen Andrews

Ellen Andrews, Ph.D., is the executive director of the CT Health Policy Project. Follow her on Twitter@CTHealthNotes.

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