In January 1964, President Lyndon B. Johnson declared an "unconditional war on poverty in America," unleashing a flurry of policies and programs to improve Americans’ health and prosperity. LBJ well understood how poverty, among other social problems such as racism, hunger, and homelessness, makes people sick. Today, over five decades later, health experts agree: what happens outside America's health system also matters to Americans' health. A healthy community is a resilient community, and a resilient community is a healthy community.
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Social and economic factors affect people's physical and mental health and resiliency. Some of these factors include their ability to pay for medicines and healthy food, their transportation options, their access to high-quality education and child care, their jobs and financial resources, and their housing and environmental conditions. Hence, under-resourced populations generally are less healthy than more-advantaged ones. Strong evidence shows they have higher rates of chronic diseases, such as diabetes, hypertension, and heart disease, as well as other disparities in health outcomes, such as lower life expectancies. Disparities occur in many groups, including, but not limited to, the following: people with low incomes, people of color, people that live in the outskirts of urban areas and rural communities, people with disabilities, people in jail and prison, and people in the LGBTQIA community. We must find ways to bring people to services, and services to people.
Today, over five decades later, health experts agree: what happens outside America's health system also matters to Americans' health.
Unemployment, small business closures, and an economic recession amid the COVID-19 pandemic have been especially hard on under-resourced populations. Central Texas, and the entire nation, have seen startling statistics regarding health disparities during COVID-19. For instance, Austin Public Health reports that between mid-March and mid-October of 2020, fully 48 percent of the people hospitalized for COVID-19 in the five-county Austin metropolitan statistical area (Travis, Williamson, Hays, Bastrop, and Caldwell Counties) were Lantinx and 10 percent were Black.
But the crisis has yielded some positive changes, too. COVID-19 highlighted and exacerbated the long-standing need for remote and mobile services delivery in the Austin area, and it accelerated innovations in health care, social services, transportation, and other industries. Consider these five local examples:
- Telemedicine and telephonic medicine. During COVID-19, Central Health-affiliated CommUnityCare clinics in Travis County saw a tremendous increase in telemedicine and telephonic medicine; up to 70 percent of its health care appointments transitioned from in-person to remote.
- Mobile COVID-19 testing. Central Health/CommUnityCare and Austin Public Health implemented mobile COVID-19 testing in Travis County, as did many other communities nationwide. Under-resourced populations received special consideration. For example, CommUnityCare's Mobile Team conducted COVID-19 testing for people living in shelters.
- Online connection to community resources. The City of Austin COVID-19 website offers resources for individuals, health care providers, and businesses, ranging from a call center for high-risk workers to testing and recovery assistance. Likewise, the United Way for Greater Austin assembled robust resources on its ConnectATX website, including emergency food, housing, transportation, physical and mental health, benefits, child care, and parenting.
- Grocery delivery. Grocery delivery services, once a luxury for people with higher incomes, became available to people with lower incomes and helped high-risk individuals avoid grocery stores, food pantries, and public transportation, and, therefore, infection and hospitalization. For example, Good Apple, an Austin-based grocery delivery company, launched from The Impact Factory at UT Austin, leveraged partnerships with local farms, food banks and pantries, private transportation companies, city government and philanthropies to deliver 650,000-plus pounds of healthy food directly to the doors of more than 21,000 older adults with low incomes and others at high-risk from COVID-19. This has saved untold lives and health care dollars since mid-March 2020.
- Video calls for mental health. Video conferencing platforms, once a novelty, became commonplace, and for some, a tool to combat mental health issues exacerbated by shelter-in-place ordinances. For example, Big & Mini, another organization in the portfolio of The Impact Factory at UT Austin, is an online platform and smart phone application aimed at bridging generations and reducing social isolation and loneliness. Big & Mini has matched 600-plus pairs of seniors and teens in 50 states and 22 countries since early April 2020.
COVID-19 also increased health systems' focus on population health, accelerating cross-sector partnerships to slow the spread of disease. Consider these examples from the Austin area:
- Rapid distribution of PPE. Travis County health care providers, nonprofits, faith-based entities, companies, and community groups partnered to enable drive-through distribution of Personal Protective Equipment (PPE) such as masks and hand sanitizer for under-resourced populations, as well as delivery of PPE to small businesses and apartment complexes.
- Repurposing space. Many under-resourced populations are at high-risk for both acquiring and spreading infections. For example, people experiencing homelessness often have no place to shelter-in-place after testing positive. The City of Austin provided space in motels free of charge so people who needed to could isolate.
- Data visualization. Many communities have developed COVID-19 tracking dashboards. The Austin Public Health Department collaborated with researchers at The University of Texas at Austin to provide data and visualizations on the City of Austin and Travis County websites that track COVID-19's spread by ZIP code and demography. Specific dashboards for long-term care facilities and community testing rates also are available. Likewise, Central Health and CommUnityCare developed modeling and dashboards on their websites to identify COVID-19 hot spots and map testing and positivity rates by ZIP code, race, and ethnicity for the populations they serve.
Moving forward, policies aimed at reducing health disparities must prioritize cross-sector collaborations, improve insurance reimbursements for social services impacting health, work to achieve digital inclusion, and enable data sharing and evaluation to improve equity.
Increasing cross-sector collaborations. Tackling the social determinants of health and resolving health inequities and disparities requires partnerships and pooling of resources across governments, businesses, nonprofits, academia, and others. The Central Health/CommUnityCare Southeast Health and Wellness Center in Austin offers free cooking and exercise classes on-site and provides space where needed social services can co-locate, such as the Supplemental Nutrition Assistance Program (SNAP) and the Women, Infants and Children (WIC) program. Foundation Communities, an Austin-based, nonprofit developer of affordable housing, provides wraparound support services to residents of its developments, such as digital literacy, tax preparation, and on-site education for children.
Policymakers must build on successful existing collaborations while also forging new partnerships, and pursuing opportunities across sectors, from housing, transportation, and financial and economic counseling to healthcare, nutritious food, job training and education. Outreach and engagement must include stakeholders and neighborhoods from the outset via surveys, social media, texting platforms, phone calls, emails, informal community events, and formal advisory boards so appropriate services can be co-created.
- Improved reimbursement for social services. The pandemic has drawn attention to the positive effects social services can have on health. Policies enabling more generous payments from insurance companies to social service providers align incentives between healthcare and other industries affecting the social determinants of health. More reimbursement would reward nonmedical providers for alleviating social problems affecting health and encourage further collaboration between health systems and nonmedical evidence-based programs.
- Digital inclusion. As evidenced by increases in telehealth services, online job training, and virtual learning in K-12 and higher education, the pandemic shed light on both the need for and the power of online services to improve health and well-being. Policymakers must prioritize funding to provide universal access to high-speed broadband as an essential utility comparable to water, electricity, and sewers. In 1936, the United States Congress passed the Rural Electrification Act; the time has come for Congress to pass the Universal Broadband Act.
- More data sharing and evaluation. COVID-19 has illuminated the need for better platforms and policies to improve data sharing among local government entities and various community healthcare providers and hospitals. At the local, state, and national levels, the lack of consistent, coordinated data has hampered disease identification, tracking, and treatment. Additionally, good data must be accompanied by specific criteria and outcome measures to evaluate the effectiveness of health care, social services, and wraparound service programs. We cannot close the equity gap and eliminate disparities unless we have evidence-based, data-driven policies with standards and key performance indicators.
As America endures multiple crises, President Johnson's call to action is as urgent today as it's ever been. The COVID-19 virus has killed over 200,000 people, while a vaccine remains months away. Small businesses are shutting their doors permanently while more and more Americans lose jobs amid an economic recession. Under-resourced communities have been hit hardest.
As America endures multiple crises, President Johnson's call to action is as urgent today as it's ever been.
May LBJ's example guide us as we push for long-overdue policies that can improve health and prosperity for all. Only then will we have the healthy and resilient communities we need.
Sherri R. Greenberg, MS, is a Professor of Practice and Fellow of the Max Sherman Chair in State and Local Government at the Lyndon B. Johnson School of Public Affairs at The University of Texas at Austin. Michael K. Hole, M.D., M.B.A., F.A.A.P. is Founder and Executive Director of The Impact Factory and an Assistant Professor of Pediatrics, Population Health and Public Policy at Dell Medical School and the Lyndon B. Johnson School of Public Affairs.