The Public's Health: Health Systems and Public Health Thinking | Public Health Post

Every health care provider—from pediatrician to geriatrician—has seen how hunger and homelessness affect health. The disordered lives of patients disrupt appointment-keeping and medication adherence but also create problems themselves. For example, they drive depressive symptoms, high blood pressure, and hospitalizations for asthma.
Recognizing this, some health systems are paying attention. Our health system in Boston recently announced plans to subsidize housing to improve housing options for patients for whom it is accountable. 

Part of a health system’s new interest in the fundamental drivers of health is financial. Medicaid, in our state and others, adjusts payments to hospitals based on whether a patient is homeless; homelessness is treated like any other complicating diagnosis, an additional cost of care. So systems can lose money if they do not collect and appropriately bill for housing status. But there are other, more charitable explanations, including the possibility that such information can drive new program development and position the health systems to help fix underlying economic and social conditions where other community services have failed, in order to improve their patients’ health.
Perhaps at core, health systems are dealing with the fundamental challenges to health in no small part because they have to: because societally we have fallen short of a collective understanding of health as a public good. Health systems may move us toward this understanding through the relevant investment in resources that can improve the health of their patients.
In many ways, the embrace by health systems of the fundamental drivers of health is welcome. Health systems are ubiquitous; the machinery of medicine touches all our lives and its administrators are in a position to have real influence if they choose to change how they do what they do. But, should health systems own and run food pantries, or manage apartment buildings? Should medical systems, often central to a community’s economy, take on the provision of social services as part of patient care? Should health systems assess what they cannot reliably address? And if they do, will these new services drag resources from diagnosis and treatment, the centerpieces of medical care? 

Health systems are powerful political entities as well. They can convene stakeholders, influence state and local policymakers, spur government action to address housing and education and hunger with an eye toward health improvement. Can health systems’ new engagement with the foundational drivers of health spur a long-overdue national reckoning and a re-commitment to improving the conditions that can actually make Americans healthier?  

Michael Stein & Sandro Galea