April 10, 2016
Underscoring the Opportunity
“Protecting health, saving lives—millions at a time” is the motto of the Johns Hopkins Bloomberg School of Public Health. Although not the principal motivation for or lesson from the assessment by Chetty and colleagues published in JAMA,1 encouraging prospects for community health strategies are suggested by the findings in this article on income and life expectancy.
In an impressive analysis based on mortality data and deidentified tax records with more than 1.4 billion person-year observations and nearly 7 million deaths among individuals living in the United States during the 15 years between 1999 and 2014, Chetty et al confirm the long-observed association between higher income and longer life expectancy, as well as the recent increase in the gap in life expectancy between the richest and poorest 5% of the US population.1 Looking specifically at the lowest income quartile, Chetty et al also found little association between life expectancy and various measures of access to medical care, physical environments, employment conditions, or levels of income inequality.
On the other hand, the authors found significant geographic variations in life expectancy among those in the lowest income quartile, including significant disadvantages conferred by the prevalence of unhealthy behaviors, such as tobacco use and obesity, and community characteristics, such as government expenditure levels and the proportions of college graduates and immigrants. In this low-income group, life expectancy variation by community ranged from a high of about a 4-year gain to a low of a more than 2-year loss in life expectancy during the 15-year period. Community is powerfully associated with life expectancy.
Given that the study was designed to reflect income distributions throughout the United States, the implications for the potential effect of population health strategies at the community level are important. It has long been known from national-level data that incomes and standards of living are associated with life expectancy,2– 4 that education levels are powerful predictors of health,5 that behavioral factors, such as tobacco use and poor diet and activity patterns, are major contributors to early death,6,7 and that, in the aggregate, medical care is not a strong determinant of the health of populations.8 This study brings those observations to the community level for which the potential effect is substantial.
In the face of established and well-known health disadvantages for those with low incomes, the study nonetheless underscores the possibility for local initiatives to help people blunt the sharp edge of those adverse health consequences. This is especially important not only because of the often remote prospects for tax and income policies required to level job and income profiles, but also because of increasing attention, incentives, and levers to support better coordinated community health initiatives.
The Affordable Care Act of 2010 (ACA) contains a number of provisions that may help in this respect.9Beyond its basic contribution of bringing health insurance coverage to those for whom it was previously out of reach, the law establishes the basis and advances the capacity for greater accountability for health outcomes, use of health financing to strengthen communitywide health improvement efforts, integrating health and social services for better management of behavioral health challenges, and directing the focus of measurement to issues that make the most difference in peoples’ health.
An important conceptual element of the ACA is the establishment of accountable care organizations to facilitate a shift in focus throughout health care from one aimed at merely the provision of services to one aimed at producing intended outcomes—the so-called shift from volume to value. The Secretary of the US Department of Health and Human Services has established goals related to 4 categories for Medicare payments. Category 1 has no link of payment to quality, and category 4 has payment focused on population or community health improvement. These goals aim to steadily increase the proportion of Medicare patients served in care payment and delivery models that target communitywide outcomes.
Although the Secretary’s goals are focused on services provided through the Medicare program, many states have recognized for some time the importance of linking Medicaid-funded health services with related social services, such as housing, transportation, and education. Working through the National Governors Association, several states have been pursuing ways to introduce flexibility into Medicaid expansion that will allow them to develop program linkages aimed at communitywide health improvement.
Reinforcing the community-oriented perspective is the establishment by the US Centers for Medicare & Medicaid Services of an Accountable Health Communities initiative to foster communitywide progress in the health of Medicare and Medicaid beneficiaries. Similarly, another ACA provision establishes requirements for tax-exempt health care delivery organizations to undertake community needs assessments and demonstrate the communitywide benefit from their activities. Along these lines, in the face of the increasing measurement burden, interest and demand are growing for a parsimonious set of standardized measures that might simultaneously reflect systemwide performance in health care, ensure awareness and responsiveness to community and population factors, and ensure the availability of a robust and reliable resource for new knowledge on intervention effectiveness. An Institute of Medicine report10 presents a prototype set of core measures with this orientation.
Such efforts to enhance focus and activity on supportive community environments are consistent with the important findings of the study by Chetty et al that local area characteristics and social support are correlated with better life expectancy among the low-income population group. An interesting dimension of the authors’ analysis relates to its assessment of social cohesion, for which religiosity was used as a proxy, and was not found in the study to correlate with better life expectancies. This suggests that larger cultural issues and community orientations are at play, a factor consistent with the initiative of the Robert Wood Johnson Foundation to advance a culture of health in communities throughout the nation.11
Income matters in health, and the report by Chetty et al confirms this. But it also presents important insights as to the many other ways in which communities shape life prospects, and as such suggests both the promise of learning much more about the dynamics in play, while strengthening communitywide public health approaches to better capture opportunities at hand.