This month, Sanjay Basu, Waymark’s Head of Clinical, took the opportunity to speak with Dr. Atheendar Venkataramani MD PhD, a Waymark advisor, Assistant Professor of Medical Ethics and Health Policy at the University of Pennsylvania, and Director of the Opportunity for Health Lab. Atheen describes his experience as a physician and economist studying how economic opportunities shape health outcomes, well-being, and population health.
Sanjay: We are big fans of your work on improving economic opportunities and the relationship between such opportunities and health outcomes. Can you provide us some examples from your recent work about how economic policies shape opportunities for people to be healthy?
Atheen: For our team, the insight that people's opportunities–which we define as their real or perceived prospects for future upward social mobility–matters for their health came from our discussion with patients. We would hear things from patients like, “I'm not that interested in quitting smoking. I don't see the point of trying that since I'm kind of stuck in the station of life.” Or, “I'm living in an area where people like me don't get very far. And so it's hard to be motivated to stay healthy.” That came up a lot in our interviews about social factors, but especially around health behavior modification.
The first thing we did after hearing these sentiments was to look at the data, and whether there were signals there that people's beliefs about their future economic mobility might be driving their health. We first looked at differences in health outcomes between places in the United States that tended to have high versus those with low mobility. We got very lucky and were able to make headway into this question because there was a group at Harvard University led by Raj Chetty and others who had used very, very large data sets of tax records and looked at, county-by-county, what economic mobility looked like relative to where one started in terms of their household income early in life. Using that data, they were able to create measures at the county level of people's likelihood of upper mobility over time. In a very early paper we showed that economic mobility was independently correlated with measures of health including mortality, prevalence of smoking, and so forth.
Subsequently, we looked at the health impacts of policies and events that credibly shaped people's access to economic opportunities. I'll give three examples. One that is top of mind for a lot of Americans who are thinking about the evolution of health in this country is: what happened to manufacturing industries in the Midwest, a place where we have also seen dramatic increases in mid-life mortality? We looked at the closure of automotive assembly plants, large opportunity-producing plants which employed a lot of people in the heartland across generations. Their closure represented a huge decrease in the opportunities available for workers, especially those without a four-year college degree. We showed that in places where auto plants closed versus where they remain open, there was a huge relative increase in opioid overdose deaths. We found a cause and effect between people's opportunities and their health.
That was a decrement in opportunity, but they are also policies that have expanded opportunity. One was the DACA program, which allows a certain group of undocumented immigrants have access to the US labor market, and the myriad opportunities for advancement therein. In that study, we showed that DACA led to a real reduction in the degree of psychological distress.
A third example involves affirmative action policies. While there's currently a Supreme Court case, which will decide the fate of affirmative action going forward, in the last 20 to 25 years, nine states banned affirmative action in college admission decisions. For us, that was a way of looking at a policy that historically was there to expand economic opportunities to groups that were marginalized, but now was being taken away. We were able to show that in states that banned affirmative action,smoking and alcohol use increased among underrepresented minority teens who would've otherwise benefited from the policy.
Most recently, we've taken our research on the relationship between economic opportunity and health back to our initial clinical insights. We just finished fielding a survey experiment of 500 people across the country online, in which we use techniques from psychology to temporarily shift people's beliefs about the degree of opportunity that's available in the United States. What we're able to show in the survey study is that for those who are randomized to a condition that emphasizes the possibility of upward mobility in the United States, you see increases in reported intentions to exercise, eat a healthy diet, and get a flu shot this season. That's bringing it back to the individual patient. In the future, we hope to leverage these insights to try to design trials where we credibly motivate people around things that they could do in the future to help boost their investments in their health.
Sanjay: One of our efforts at Waymark is to provide meaningful paths to advancement for people in the communities we serve, including paid training to become a community health worker and equity in our company. You’ve written about closing the racial wealth gap and how health systems can improve the accumulation of intergenerational wealth. Can you tell us more about that proposal and its requirements?
Atheen: Starting with the racial wealth gap, there are two facts that are useful to start out any discussion. One is that the wealth gap, after closing from 1860 to about the mid-1950s, has remained pretty stable over the last several decades. Wealth is inherited generationally, and there are a large number of forces that preserve the racial wealth gap.
The second fact comes from a paper coming out next week that looks at life expectancy for people 50 years and older. Our study shows that wealth alone fully explains the Black-White disparity in life expectancy at that age, with measures of income and education collectively only having half the explanatory power of wealth. We show that policies that have been proposed to close the wealth gap, for example through reparations, would fully remediate the racial longevity gap.
Together, these two facts suggest interventions to close the racial wealth gap need to incorporate new ways of thinking about the problem and the need to bring in new actors to try to address them and that there's potentially very high returns in making a dent in this gap.
For physicians like us and healthcare organizations like ours, how do we meaningfully take on this huge social determinant of health that otherwise would go unaddressed or has been so recalcitrant to intervention for so long? I really appreciate what Waymark is doing, and I think that's absolutely the way to go. First, I think health systems should take a look at things that they are doing right now that perhaps could perpetuate the gap. Some potential examples are practices like sending bill collectors after patients who may not be able to afford episodes of care. These types of policies can greatly increase financial insecurity, which itself has negative effects on health, but over time can also hollow out or expand the wealth gap or perpetuate this wealth cap in ways that are bad for health.
The second thing to consider is the economics of healthcare in the US, which is such that many health systems feel that to survive in this marketplace requires growing in size. They are trying to tap into some economies of scale, ostensibly as a means to providing better care. But as health systems become large, their bargaining power relative to payers increases. And so health systems are able to command higher prices, which can, in a labor market, increase prices for everybody. Anne Case and Angus Deaton have made the argument that through such actions, health systems may inadvertently lead to disemployment in other sectors by virtue of making fringe benefits harder to pay. So health systems and healthcare organizations should ask how our business practices, especially as non-profits, might be contributing to this broader set of dynamics that leads to this wealth cap in the first place.
There are many places health systems can be proactive in addressing wealth gaps. One example is that health systems have a workforce that ranges greatly and in terms of the types of jobs that are done and the wages that are paid for those jobs. The low wage workforce in healthcare tends to be drawn from Black and Brown communities. We have a study from a few years ago that shows that at least 50% of the low wage workforce that makes below the minimum wage are drawn from these communities. A vast majority of these workers are women, many have children, and too large a share of these individuals live below the poverty line.
We've suggested that healthcare systems that have reasonable profit margins can pay low wage workers more for their labor to maintain a living wage. Additionally, important things that health systems can do include providing pathways to advancement within the workforce, whether it's through job training or advanced courses to get to the next level of skill. Those are important things that health systems can do too.
Health systems can provide financial counseling, or access to tax accounts like HSA retirement accounts that make it easier for lower wage workers to save. There's a lot on the finance side that we could do to improve the stream of income that comes into these households, and also allows households to save and invest and gain wealth. The fact that as a new company you're starting with these principles in mind is, I think very unique and I think really great to hear.
Sanjay: Thank you for that. To help us understand what programs work best for Medicaid beneficiaries, we’ve also relied a lot on randomized, controlled trials. Can you talk a bit about why you believe randomized controlled trials need to be adopted more in Medicaid to support innovations and particularly in the context of churn as we end Medicaid continuous coverage requirements?
Atheen: The Medicaid program has a rich history of allowing for demonstration and innovation within its program. Hence, you have 51 different Medicaid programs in the United States, one for each state and territory. Year to year, you see new types of policies being adopted in an effort to meet the needs of specific populations or subpopulations.
Medicaid, at its core, is a grand experiment. One of the things that is fascinating is that, despite the experimental ethos of Medicaid, we haven't actually leveraged the statistical tools of experimentation to get more credible answers to what interventions work and what don't. Oftentimes, Medicaid demonstration projects tend to just be evaluated in a pre-post kind of way. You might be able to get a cause-and-effect relationship, but oftentimes many things are changing and make it hard for us to interpret a before-and-after result as a true cause and effect.
That's why I think I feel very strongly that randomized control trials can help nail down whether a program worked or not. We're putting a lot of money into the program. These changes that we do with demonstration projects can be expensive and are often based on technologies for which we have good, theoretical reasons that they'll work. But we haven't had the experimental approach or time to gather if there's any unintended consequences or ways we can do things better. So the whole program is ripe for experimentation.
Alongside all of this, there's this really interesting literature on administrative burdens on public programs. The benefits of these programs depend a lot on the experience and the types of things people have to do to remain eligible and to access benefits. The harder we make it for people to participate, the less potential benefit they're going to get. And so we've seen this explosion of studies showing that there are simple things that tend to make user experiences easier versus harder.
I think this is such a critical moment in health policy. There's real interest in trying to understand how we make health better in populations that we've historically underserved. There's real interest in how we pay for value and there's real interest in how we deliver care in ways that are impactful without creating waste.
All three of those streams of thought can intersect and create opportunities for innovation. I will say it's very exciting to be working in these areas, and it's exciting to see a company like Waymark at the head of all three of those streams.
