FROM THE DIRECTOR
OCTOBER 2019
Systemic Inequity in Health and Wealth

The social determinants of health are an important framework for asset building. The evidence is strong and consistent that the conditions one lives in as a result of their income, the quality of their housing, the community assets, the security of having savings to weather economic bumps, and the reduced stress and anxiety resulting from a future orientation supported by savings or wealth is fundamental to health and economic stability and mobility. What that list does not adequately emphasize is that the systems and the institutions we interact with can support positive outcomes from choices made by individuals and provide hidden supports to avert crisis that result in wealth stripping and poor health. It helps explain why a growing number of funders see asset building as the key to equity and improved health in our communities, and recognize how fees and fines and spiraling debt and instability are widening the ever-growing wealth gap.

We cover a lot of ground in this newsletter and in our newly released report, Pioneering Health and Wealth Integration for Children. The field is  advancing in its research, active investments, advocacy, and resultant systemic change.

I was struck by the efforts to start to restore or build responsive versions of the hidden systemic protections that helped build the middle class for some in the three postwar decades as one way to advance equity. Revisiting hiring practices for persons who served their time and are returning to community, reimagining the cost of post-secondary education, revisiting the debt and wealth stripping behaviors of public and private entities as well as rethinking tax system incentives are key.

Like many of you, my awareness of medical debt is setting off alarms. I have a colleague who had medical insurance provided by her employer. She was taken to the hospital in an emergency due to a burst cyst requiring emergency surgery because her body was filling with blood. The economic risks of spiraling debt were many (it could be the ambulance fees, or out of Network doctors) and not the result of her choice. While the insurance thankfully covered most of the hospital costs, the $3,000 insurance deductible from the emergency surgery will be economically debilitating and that, too, is not the consumer choice but instead is a product of the employer trying to control costs when the insurer provides a lower cost plan if the deductible increases. Nor was my colleague making a choice to incur the debt when the hospital did  not apply its charity care for which she qualified to admissions (emergency or otherwise) or conceals its charity care program (as is the case for the majority of medical debt). If the social determinants were to be applied to this area of health care economics as well as the health care is delivered, there would need to be systemic reform on multiple levels to relieve the consumer of wealth stripping  and its adverse effects on health.

In other words, wealth building and health are, in part, a function of individual choices. But in far greater part, these desired outcomes are a function of the choices offered by private and public systems.

At the front end, consumers make and will continue to make choices from what is offered or made known to them by our systems and institutions.

  • When insurance is unaffordable,it has the embedded risk of high deductibles that visit unmanageable debt on the ill, thus the system fails.
  • When hospitals hide charity care availability in order to allow them to pursue collections of skyrocketing medical debt, the system fails.
  • When medical debt is written off to justify nonprofit status or to reduce taxes, and is sold to collection agencies creating zombie debt, the system fails. When the courts allow collection agencies to use the system to strip wealth and to ignore statute of limitations on debt, the system fails.

All of these are systemic levers in just ONE area that can be corrected to restore balance. By applying the real world social determinants, we can help correct and reverse the ongoing economic precariousness that is expanding wealth gaps.

There is lots of work to do but increasingly funders and financial institutions are acting. Let’s keep building on this momentum. Join AFN and help spread the word peer to peer and community to community.