My professional coming of age took place the late 1960s, in one of the original Office of Economic Opportunity (OEO) neighborhood health centers in the South Bronx. Because the health centers were a part of the larger federal antipoverty strategy, they were founded on a broad view of health (we would call it a population health framework even though that terminology didn’t exist then). Health care innovation was the core, with community health workers, health care teams, and the understanding that the residents who didn’t use the clinic contributed to overall neighborhood heath as much as those who did.
But the OEO funding paid for much more than health care, including job training, legal advocacy, school health programs, neighborhood built environments – what we now see as the multiple determinants of health. But one of the main lessons of my entire career was the following: when the grant goes away, the programs or innovations which it supported dwindle too. Don’t get me wrong: federal and foundation grants are essential for innovation to occur, and I have served productively on both the giving and receiving ends of this equation. But initial funding almost always ends at some point (through change of political priorities or foundation leadership and priorities), and additional funds must be sought for sustainability or going to scale.
I also ran a large urban hospital for four years. Among many other major lessons, I came to appreciate the beauty of funding formulas and streams that just keep on delivering resources every day or week or month. A good example are the Medicare payments supporting medical resident education; these “extra” payments are built into Medicare funding formulas and provide ongoing, regular support for this important activity. Of course, they certainly come under political scrutiny occasionally and have to be justified and defended, but by and large they are embedded as well-established fiscal supports like mortgage interest deductions or agricultural subsidies.
Despite more than a decade of helpful and creative public and private grants, I remain extremely concerned about our slow progress in addressing health inequities by geography, by race and by economic status. These injustices are sapping our national productivity and quality of life. We need to go beyond grants to identify sustainable resource flows that are up to the magnitude of the challenge.
I have been suggesting using some of the savings realized from eliminating ineffective and wasteful health care dollars, such as a share of ACO shared savings or IRS Community Benefit reform – but these may not be entirely workable or sufficient. We need to take a close and creative look at how to maximize efficiencies and possibly consolidate multi-sector revenue streams from education, business, and community development agencies toward achieving common health goals.
Voluntary efforts are not adequate if we are serious about this task. Let’s commit ourselves over the next decade to finding these more robust, dependable mechanisms and documenting real progress in the areas that will have the greatest impact on population health.
David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.