Why One Pediatrician is Tackling the Health-Wealth Connection
Editor’s Note: For the second post in our blog series, we wanted to highlight someone who was working directly across sectors to address the health and wealth connection. We turned to the brilliant Adam Schickedanz, MD with a series of questions to help us understand not only the connection between these determinants of health, but how it manifest in his work, where the medical field connects and advances this work, and how he got connected to this work.
As a pediatrician, how do you see financial well-being show up in your work?
I see the health impact of finances every day. Often, financial hardships lead directly to medical emergencies, like an infant having seizures after the parents diluted bottles of formula too much in the hope they could make their last can of formula powder stretch to the end of the month. Other times the health harms accumulate over years, such as worse asthma in poor neighborhoods with greater air pollution or earlier development of diabetes due to a combination of the toxic stress of poverty and unhealthy food. Nearly every aspect of a child's health—from cardiovascular fitness to mental health to growth and development—can be deeply impacted by the financial circumstances of their family and community. It is also important to point out that one major threat to family financial well-being today is the sky-high costs of health care. So, not only do I think constantly about how finances might be contributing to health outcomes, I also consider whether the costs of medical care itself might undermine the financial well-being of my patients' families.
- So, in your practice you see how health impacts financial wellbeing, and vice versa ?
Yes, definitely! One of the clearest examples of how this connection showed up in my practice was the first time a parent of one of my patients asked me if I could help her find a job. I was in my primary care clinic seeing a newborn infant who had recently been discharged from the hospital. The baby had been treated for a life-threatening infection and his mother had been with him every minute, hanging on every development in treatment and going through the roller coaster of emotions. Meanwhile she could not work and was losing earnings, and, unbeknownst to me, during his hospital stay she was replaced at her job without legal recourse. So when I sat down in the clinic room a few days after her son went home from the hospital and asked her the same question I ask to open every visit, "How can I help you today?", she asked me if I could help her find work and handed me her business card. Despite everything her child was going through health-wise, her top priority in that clinical visit was the fact that she needed to make money to keep a roof over her family's head and food on the table. The biggest threat to her son's health in that moment was poverty. I realized I could do more as a pediatrician to treat poverty and improve financial well-being directly as part of clinical practice.
The notion that finances strongly influence health is far from new. Physicians have recognized financial hardship as a root cause of illness for centuries. The first American pediatrician, Abraham Jacobi, operated a nursery for orphans of economically destitute parents. For him, childhood disease and poverty were inseparably linked. Modern pediatrics has expanded notions of how poverty influences the health of children and the adults they become. In the last few decades, medicine as a whole, and pediatrics especially, has seen a paradigm shift toward greater emphasis on the "social determinants of health" which the World Health Organization defines as the conditions in which people are born, grow, live, work and age, all shaped by the distribution of power, resources and money. Physicians now, nearly universally, recognize that financial health and other related social determinants are the primary drivers of disparities in health outcomes of people.
- Knowing there is a shift to think more holistically about financial health and overall physical health, what opportunities do you see for the medical field to address the issues that emerge around health and wealth?
Since the implementation of the Affordable Care Act, health care systems have been more and more economically incentivized to deliver preventive services that address the health consequences of poverty and other social determinants. It used to be that health care outcomes relied on a higher volume of prescriptions or procedures, but now health care systems are increasingly being paid more to deliver better health outcomes. Because health outcomes are so dependent upon the social determinants of health, hospitals and clinics are naturally looking for ways to prevent disease by tackling "upstream" health risks like poverty rather than of waiting for their "downstream" health consequences to materialize.
This has led to a host of clinical programs designed to identify actionable consequences of poverty and financial insecurity, like not being able to afford healthy food or a safe place to stay, and then connect patients to resources that can address these so called "social needs". Of course, these issues would be better treated if they were prevented in the first place by helping patients thrive financially. So, some clinics and hospitals are beginning to explore better ways to foster the financial well-being of their patients and communities. As some of the largest employers in the cities around the country, health systems have increasingly recognized and leveraged their positions to advance community economic development. Additionally, nonprofit hospitals, which have a legal obligation to invest in community services and programs that promote health, have in some cases made large investments in creating affordable housing units. Other clinicians and health care systems have implemented programs that integrate financial capability services into routine clinical practice, known as "medical-financial partnerships,” they provide accessible services to patients while also demonstrating how financial well-being and health care can intersect and overlap. Health systems have a huge opportunity to influence and impact financial well-being at the individual and community levels through these approaches.
- What programs or policies do you think show promising solutions for improving health and financial outcomes together?
The answer depends to a large extent on the local health and financial needs of each community. Just as certain communities face higher rates of obesity or lung disease, the unique challenges to financial security communities face and how those financial issues relate to health services and outcomes should drive solutions, ideally with input from community members themselves. That being said, there are some especially promising strategies with a strong track record of success in many different communities.
As a pediatrician, I gravitate toward interventions that focus on the earliest years of life because they have the biggest impact on our lifelong health trajectories. It turns out this is true of not just health interventions but financial interventions too. Policies and programs that support family financial stability early in a child's life like the Earned Income Tax Credit (EITC), Medicaid, Supplemental Nutrition Assistance Programs (SNAP) and affordable high quality childcare and preschool have been shown to improve various measures of children's health, development, achievement and, as adults, their ability to sustain themselves financially and create an economic return on investment to their communities. That is why the American Academy of Pediatrics recommends that children should be screened for financial hardship at all child clinic visits and, when appropriate, referred to programs like these to reduce financial strain. The benefits of these public programs and policies are just a fraction of the kinds of lifelong financial and health benefits that early childhood health-wealth interventions might deliver.
Comprehensive financial empowerment and coaching programs that address multiple aspects of financial well-being in families with young children leverage many of these public programs at once in the context of wraparound financial services (i.e. asset building, debt reduction, credit counseling and so on). A study conducted with LIFT-Los Angeles found that these comprehensive programs improve low-income parents' mental health which is a key determinant of their children's health and development. Taking that approach one step further we and other financial capability organizations and health systems have begun partnering to integrate financial capability services into pediatric clinics and incorporate health care delivery more broadly through medical-financial partnerships.
Other areas that show substantial promise for deploying financial services to address health and financial well-being focus on relieving the economic burden of costly health care services, such as programs to help cancer patients navigate their health care costs and avoid bankruptcy. Oncologists have coined the phrase "financial toxicity" to describe the financial harms of cancer treatment using language mirroring that used to describe the side effects of chemotherapy or other medications. “Cost-conscious care” has become a buzzword in forward-thinking health systems and has the potential to redefine the scope of health care's obligation to "do no harm" to patient financial status. These efforts are all-the-more effective when deployed in partnership with experts in financial services.
Ultimately, we will need to address the inter-related risks to financial well-being and health through individual and structural interventions, which will require both new models of patient/client services and policies that can level the health-wealth playing field for marginalized communities.
- What would you tell individuals who are interested in exploring the health-wealth connection but don’t know where to start?
The first step is getting involved in conversations about health-wealth and communities that exist to foster them. The Prosperity Now Health and Wealth Network is one great example. Others include the Building Healthy Places Network or the Social Interventions Research and Evaluation Network.
If you want to get involved in health-wealth interventions, finding the right partner is key. Many of the communities where health-wealth conversations are happening already have tools to foster collaboration across sectors. You may also want to reach out to medical centers or financial capability service organizations in your community to explore partnerships. Given the tight link between financial, physical, and mental health, chances are you can find a collaborator on the other end who understands the importance of health-wealth partnerships and programs.
Want to join our conversation and work to advance equity at the intersections of health and wealth? Please follow our Health and Wealth Network page for updates on the Network, including upcoming (and past) webinars, blog posts by experts and resources such as our social media toolkit to help spread the word!