A guest newsletter by Leonard Egede
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Thursday, July 14, 2022 | The Latest Research, Commentary, And News From
Health Affairs

Dear John,

Today's newsletter is written by Leonard E. Egede, a professor of
medicine, chief of the division of General Internal Medicine, director
for the Center for Advancing Population Science and the inaugural
Milwaukee community chair in health equity research at the Medical
College of Wisconsin.

From The Desk Of Leonard Egede

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More than 20 years of health disparities research has brought me to an
important conclusion: the gulf placed between rigorous science and
political advocacy must be bridged by health care researchers.

This bridge must be based on rigorous trials and evidence that survive
the scrutiny of peer review.

However, to be useful in the hands of those making policy, the bridge
needs to be built with more intention than is often appreciated. As an
example, I'll walk through how I came to this conclusion using an
article my team and I published

in the most recent issue of Health Affairs.

Our nation continues to grapple with how to respond to the death of
George Floyd, widespread and systematic racial inequalities
, and increasing evidence
that already disparate health outcomes

continue to diverge following the COVID-19 pandemic.

Though some action has been taken, the primary difference is increased
awareness of the importance of social risk factors on health.

Recently, attention has been given to structural racism as being
associated with these social risk factors. However, this does not fully
capture what is happening in the lives of those experiencing racism
every day.

Structural racism is
antecedent to the social determinants of health and therefore a key
driver of these social risk factors.

Therefore, to change systematic inequalities we see around us, we must
incorporate factors influencing the health of individuals at multiple
levels. This includes the macro level of societal policy.

A decade ago, my research team and I shifted our emphasis to conducting
work rooted in the social ecological framework
. This
framework captures the concept of multiple levels of influence affecting
health, including interpersonal, community, and societal influences.

We find great utility in considering the National Institutes of Health
(NIH) National Institute on Minority Health and Health Disparities
(NIMHD) research framework
. This
framework highlights multiple domains of influences across the life
course that impact individual, community, and population health.

Importantly, it directly calls out policies and laws, societal
structures, and societal norms as influences on population health.

By conducting analyses to understand the impact of social risk factors,
we identified different leverage points on which to test interventions.

We also conducted focus groups and interviews with key stakeholders and
community members to give context to interventions we developed
. Finally, we worked to
obtain funding to test the impact of these interventions on the health
of adults with diabetes.

It was in this context that we were invited to look at the evidence base
for nonmedical interventions to reduce risk for and improve clinical
outcomes for type 2 diabetes.

We conducted an extensive review but found few clinical trials that
integrated medical and social interventions within the context of adults
with diabetes.

Positive impacts were found when combining food supplementation with
referral and diabetes support, financial incentives with education and
skills training, housing relocation with counseling support, and medical
care and social supports through the EMR.

However, much more work is needed developing and testing multicomponent
interventions at a large scale and addressing a broader range of social
risk factors.

Having completed the review, something else stood out to us.

There were no interventions directly addressing structural racism within
the context of type 2 diabetes.

Though evidence from observational research existed, the lack of
clinical trials or natural experiments left a hole where normally we
would have offered evidence-based policy recommendations.

We saw an opportunity to consider how one could act on upstream social
determinants of health given the evidence that did exist.

What resulted was a set of policy levers that may serve as a road map
for future interventions given the racialized context of social risk in
the United States. We see this work as one way to address the impact of
structural racism on the health of the nation.

Some policy opportunities we identified that could improve the health of
adults with diabetes include:

* Medicaid expansion

* Policies that help ameliorate vulnerabilities of our health system in
times of systemic shock such as the COVID-19 pandemic

* Policies that establish new billing practices for uninsured patients

* Policy levers within the labor market targeting social mobility

* Expansion of existing Department of Housing and Urban Development
programs

While our work is primarily in diabetes, the process we followed is
relevant across conditions. A thorough search of the evidence is
necessary, followed by actionable strategies.

But we cannot stop at that point.

While individual level interventions need to be conducted, we cannot
ignore connecting evidence to policies that change upstream factors
outside the control of individuals.

For example, we can provide healthy food vouchers for individuals who
experience food insecurity. However, until we address the location of
grocery stores and how investments in communities are decided, community
health will not change.

Policy matters and health care researchers cannot ignore the hard work
that comes after conducting high quality research.

Health care researchers need to go beyond publishing their work. They
need to actively put good science in the hands of those making policies
with the end goal of changing lives.

We propose that research should be done with the intent of changing
inequitable policies. In Milwaukee, we have a team of eight MD and PhD
researchers we have named the Health Equity Research Group.

We come from diverse disciplines and have over fifty program staff who
work across seven NIH-funded studies focused on addressing inequalities
in health.

The sole purpose of our team is to generate evidence that changes policy
at the local, regional, and national level.

In addition to interventional work, our team is creating nationally
representative databases to build a framework for studying the impact of
structural racism and historical redlining on present-day health
outcomes.

We believe that multiple teams of this size and scope are needed across
the United States.

Poverty is the driver of so many social risk factors impacting health.
As a result, teams focused on conducting high quality research that
targets structural inequalities in health is relevant across diverse
communities.

We hope the work completed in the Health Affairs review spurs on the
great work ahead of us. Ultimately, if we are brave enough to create
evidence and then use it to change policy, we will bring meaningful
change to pass.

Want to read more newsletters like this? Become a Health Affairs Insider

to receive curated newsletters on topics like health reform and social
determinants of health.

Read Egede's Study

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Elsewhere At Health Affairs

Today in Health Affairs Forefront, Christopher Palmieri and coauthors
argue that integrated Medicare-Medicaid programs

offer an effective solution to address the challenges facing dually
eligible individuals living with behavioral health conditions.

Barbara Lyons and Diane Rowland identify opportunities to improve
Medicare's Home Health Benefit

program so that it could better serve beneficiaries who need support at
home.

Are you enjoying articles from Forefront? Consider joining Health
Affairs Insider

to show your support for high value health policy news, commentary, and
analysis.

Daily Digest

Nonmedical Interventions For Type 2 Diabetes: Evidence, Actionable
Strategies, And Policy Opportunities

Leonard E. Egede et al.

Integration Of Medicare And Medicaid Services Is Essential For Dually
Eligible Individuals With Behavioral Health Needs

Christopher Palmieri et al.

Reset Medicare's Home Health Benefit

Barbara Lyons and Diane Rowland

 

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mailto:[email protected]

About Health Affairs

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, and Health Affairs Sunday
Update .  

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health care workers to save lives across the globe. Project HOPE has
published Health Affairs since 1981.

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