Equity, Social Policy, and Social Determinants of Health
Full recovery from COVID-19 pandemic, social unrest will require new policy that promotes equity, streamlines access to social services through small businesses
Unprecedented job loss due to the COVID-19 pandemic has led to an economic crisis for families of all backgrounds and incomes levels and our current health and social services programs are ill equipped to handle this need. Moreover, long-standing racial health disparities and the stigma associated with using social services will persist in the absence of significant systems-level change. It is possible to integrate delivery of means-tested financial support while growing small businesses, reinvigorating local and state economies, and producing a more skilled workforce. The Social Services, Technology, and Administrative Restructuring Initiative (the “SSTAR Initiative”) is a five-point, research-backed policy proposal that would incorporate multiple sectors- employment, food, housing, education and transportation- into a universal, centrally-administered benefits program. The SSTAR Initiative is rooted in the knowledge that healthier populations with lower levels of inequality contribute to a stronger economy.
Understanding the need for social services integration to promote equity and public health
The COVID-19 pandemic has revealed a population suffering from limited opportunities to receive preventive care, inadequate and uneven access to healthcare professionals, and increasingly crippled by the heavy burden of noncommunicable diseases such as obesity, diabetes, and cancer. Individual health outcomes are largely determined by social and economic factors. The conditions in which people are born, grow, live, work, and age have a greater impact on overall health and well-being than healthcare. These conditions- known as the social determinants of health (SDoH)- are shaped by the distribution of money, power, and resources at local, state, national, and global levels and are largely responsible for the unfair and avoidable differences in health status seen between groups on the basis of race and ethnicity.
The pandemic has highlighted long-standing health disparities attributable to unequal access to quality education, food, housing, employment, healthcare, and clean air. We must pursue comprehensive policy transformation informed by SDoH research in order to reverse this trend of failing health and financial decline. Expansion and integration of the benefits available in existing federal social safety net programs into a single entitlement program with greater flexibility, efficiency, and responsiveness to the needs of our population is one such transformation.
Core principles for social safety net policy post-COVID: efficient, flexible, essential, universal
The SSTAR Initiative would accelerate the process of regaining health, financial stability, and promoting equity in several ways. First, the SSTAR Initiative would create a single administrative agency to enhance efficiency in eligibility determinations and distribution of benefits. Currently, means-tested programs require multiple applications and independent verification processes that can significantly limit access. The SSTAR Initiative would aim to minimize or eliminate duplicative paperwork and automate eligibility determination across programs. The central agency would determine eligibility based on means testing, tax status, and through a combination of local, state, and federal program guidelines. In its initial form, the agency would also aggregate funds available from all existing means-tested programs into a single account.
Second, funds distributed through the SSTAR Initiative would be flexible and could be used in a manner that an individual or household feels is most useful. Current means-tested programs are inflexible, forcing recipients to use funds in prespecified ways which do not meet the shifting needs of a household. For example, the SNAP benefit can only be used to purchase food and cannot be repurposed to cover rent- even if that need is greater at a particular time. The SSTAR Initiative would provide tools to help households understand how to best make use of the support they get and plan their budget accordingly; every person could allocate funds according to specific need in a given month using an online platform. For example, a household may prioritize assistance with housing costs via the online portal and receive additional guidance on how to manage their benefit to cover that expense. Moreover, they may elect to use most or all of their monthly allotment to cover that expense. Households that elected to receive additional financial planning support would receive alerts when funds arrive, when funds are running low, and how to adjust for unexpected expenses. They would be able to select the best way to receive this information (i.e., email, SMS, or push notification from SSTAR app).
Third, funds distributed through the SSTAR Initiative could be applied to a much wider range of goods and services that are essential to protect health and prevent illness. Many of these services could be provided through existing small businesses. For example, STTAR funds could be used to pay for car repairs at a local auto shop- this ensures that people can get to work while providing a new source of revenue for the mechanic shop. Table 1 is an illustrative list of the types of purchases that would be covered under the SSTAR Initiative.
Table 1. Essential goods and services covered by the SSTAR Initiative
There is precedent for using government funds to pay for services that implicate the social determinants of health. Level II HCPCS codes, specifically some “T” codes (T1000 – T5999) already provide a framework for reimbursement in the current healthcare system. These codes were introduced originally as temporary national codes for use by state Medicaid agencies in an effort to reimburse providers for work such as alcohol and substance abuse services, home health services, behavioral health services, non-emergency transportation, and family training and counseling for child development. Currently, T codes are used primarily by state Medicaid agencies for services or items that lack a permanent national code.
Finally, the SSTAR Initiative would provide all Americans with a StarCard – a simple and efficient means by which to access and distribute stimulus and unemployment funds, means-tested support like food stamps, and targeted funds to support job training and placement programs. Universal enrollment could help remove the stigma associated with receiving government support. All Americans would receive a StarCard and would be able to make use of it (or not) as each individual or household saw fit. No single group would be identified as needy. At the same time, it would also create the means by which to deliver funds to specific groups as needed in a much more efficient manner. The card itself would operate much like a debit card linked to a central account that could be administered by third parties such as participating banks. Whenever funds are applied to it through policy decisions or means-testing at the state or federal level, the card would be loaded automatically and funds could be spent at will.
The StarCard would require a unique identifier for each citizen and a secure method for access. This presents a significant technological challenge but states have been able to meet this demand in the context of programs like SNAP; the central administrative agency would work closely with states at the outset to develop state-specific strategies to identify all eligible individuals. Moreover, the SSTAR Initiative would leverage new technology to create a secure and accountable system that limits the risk of fraud. A block-chain system would be established so all transactions could be recorded and multiply verified on the chain. There would be several points at which to verify that accounts are secure and to restrict access to funds in the event that fraudulent use was detected. StarCard funds lost to unauthorized use would be replaced in a timely fashion. Ultimately, the StarCard would minimize the risk of fraud as all spending is tracked electronically.
Structural elements that promote small businesses
The SSTAR Initiative would promote national recovery post COVID-19 through systems-level changes that embrace small and potentially local businesses as conduits for financial stability and health-promoting behaviors. The flexibility and universal availability of the StarCard over the lifecourse means that every American would choose how and where to spend StarCard dollars in their community. For example, individuals with small children may use the majority of their StarCard benefit to cover the cost of childcare in early years and then the cost of education or summer programs as the child ages. At every stage of development businesses rooted in the community could provide goods or services that are covered by the StarCard. StarCard dollars could be used at any retail location that accepts debit or credit cards but businesses that choose to be designated as community-based organizations would be rewarded through supplemented discounts to consumers. Eligible businesses would have to fall under one or more of the five points (sectors) of the SSTAR Initiative.
In this way the SSTAR Initiative creates a new model for supporting the small business community while providing a far wider range of services for families in need. Vocational programs, transportation programs, childcare providers, even small landlords could be partially supported by SSTAR Initiative funds. This model eliminates inefficiencies associated with current government-funded programs by introducing competition between providers, all of which are existing businesses (and not purely government-funded entities). Through this program all funds distributed by the government- either as benefits, stimulus money or through tax rebates- could reach families immediately and then be applied as needed to meet household needs through preferred vendors.
As a country we will continue to suffer the same grim fate in the face of every new economic or public health challenge unless we adopt a truly innovative approach to promote greater financial stability and population health over the long-term. We must create a new system that ensures access to essential resources for more Americans. Effectively, the SSTAR Initiative would repair gaping holes in the current social safety net – restructuring our fragmented and inefficient system into a modern, efficient, and cost-effective system that supports all of us.
To be sure, the SSTAR Initiative- even with its potentially tremendous reach in terms of financial and health recovery- is not a panacea for all that families in our country will face on the post-pandemic landscape. However, creating a program uniquely tailored to the social and economic realities we are facing is a significant step forward. In this moment we cannot let the perfect become the enemy of the good- we must begin the difficult and messy process of re-building immediately. What we are proposing is radical – and just what is needed right now.
Assistant Professor of Health Policy & Management, Columbia University
Co-Director, Better Health Systems Lab
Lecturer, Department of Health Policy and Management, Columbia University
The Program for Translational Research on Adversity and Neurodevelopment
P-TRAN is housed in the Bennett Pierce Prevention Research Center (PRC) at Pennsylvania State University (PSU) and is responsible for oversight and coordination of the NPSC. This innovative program employs a transdisciplinary and translational neuroscience approach as the foundation for meaningful research, practice and policy. P-TRAN integrates theoretical perspectives and empirical methods to: (a) elucidate the etiological underpinnings of mental, emotional and behavioral (MEB) problems; (b) identify mechanisms underlying intervention responsivity; (c) inform more precision-based approaches to prevent and treat MEB problems; and (d) transfer scientific knowledge into an actionable format to inform public and private sector investments. P-TRAN provides a supportive translational research infra-structure for a “community” of cross-cutting scientists at PSU and beyond. The ultimate goal is for our research to exert a significant and lasting beneficial impact on child development, family functioning, and community scaffolding.
P-TRAN applies a 6-phase translational framework to guide our etiological research in a way that informs the design of precision-based interventions, comparative effectiveness trials, and imbedding of resultant programs and practices to achieve broad population level effects (Fishbein et al., 2016). Type 0 translation (T0) refers to how discoveries in genomics, epigenetics, molecular biology, neurophysiology, and the behavioral and social sciences may shed light on etiological heterogeneity and reveal malleable mechanisms in the emergence of at-risk subgroups. Type 1 translation (T1) applies this mechanistic information as a blueprint for developing both screening tools and adaptive intervention strategies. Type 2 (T2) allows for the validation and refinement of the various adaptive intervention strategies via creative designs. Type 3 (T3) refers to comparative effectiveness (confirmatory) trials where personalized intervention models are pitted against “one-size-fits-all” models in real-world settings. Type 4 (T4) recognizes that while precision-based prevention can also target entire communities by modifying service delivery systems (e.g., systems change, interagency collaboration), environmental changes through social networks, or instituting targeted policies that are different from one community to the next. And Type 5 (T5) refers to globalizing the application of this knowledge and change in public opinion.
For more information, visit www.p-tran.com