PROVIDENCE – At best, only about 20 percent of the money now spent by the health care delivery system is focused on health, wellness and prevention. The question is: what is the best strategy to redress that imbalance in investment and in health equity? And, how does community, place-based health fit into that equation?

The gap that separates health and health care delivery in Rhode Island – and potential bridges across existing policy and financial divides that could be built to connect them – were made tantalizingly visible at two significant events held last week, a day apart.

The first, the 2015 Health Equity Summit, held on May 7 in Warwick at the Crowne Plaza Hotel, sponsored by the R.I. Department of Health, was the first such gathering of its kind. It brought together the 11 new Health Equity Zone collaborations that have been created in Rhode Island, an initiative to support the development of community-based health initiatives. [See link to ConvergenceRI story below.]

Among the more than 500 participants were: Barbara Fields, executive director of Rhode Island Housing; Louis Giancola, president and CEO of South County Hospital, Donna Huntley-Newby, director of the RN to BSN program at Rhode Island College; Gemma Gorham, project director at Brown University’s Institute for Community Health Promotion; and Betsy Stubblefield Loucks, of the R.I. Green and Health Homes Initiative.

The second, “Medicaid on the Move,” the Economic Progress Institute’s 7th annual policy and budget conference, held on May 8 at the Marriott Hotel in Providence, brought together a roomful of health reform advocates, health policy experts, and health care professionals. It featured presentations by Gov. Gina Raimondo, Linda Katz, the policy director and co-founder of the Economic Progress Institute, Cindy Mann, former Medicaid director for the Obama administration, and Elizabeth Roberts, secretary of the R.I. Executive Office of Health and Human Services. They shared their views on the ways that the Medicaid program can be strengthened and re-invented in Rhode Island.

Among the more than 250 participants were: Elizabeth Burke Bryant, director of Rhode Island Kids Count; Neil Steinberg, president and CEO of The Rhode Island Foundation; Rep. Art Handy of Cranston; Tom Boucher of Neighbor Health Plan of Rhode Island, Jennifer Wood, chief of staff for Elizabeth Roberts; Rebecca Kislak, policy director and counsel at the R.I. Health Center Association, and Dr. Pablo Rodriguez, who was broadcasting the event for Latino Public Radio.

The sponsors included: Neighborhood Health Plan of Rhode Island, UnitedHealthcare, AARP, BankRI, the Rhode Island Health Center Association, Gateway Healthcare, RIPIN, Family Service of Rhode Island, Community Provider Network of Rhode Island, and the Office of the Social Ministry at Catholic Charities, and the R.I. AFL-CIO.

The confluence of the two summits, and the potential convergence of the two rivers of conversation, seemingly so important to connect, did not happen. That was a bit frustrating, according to a number of participants who attended both conferences, speaking with ConvergenceRI at the Medicaid conference.

What did happen, however, was that the disconnect between health care delivery reform and community place-based health initiatives became much more visible and tangible, in a way that has never occurred before in Rhode Island.

Health as the greatest common denominator
The 2015 Health Equity Summit proved to be an illuminating series of presentations and discussions focused on topics that are all too often pushed aside by the health care delivery system – from the social determinants of health, the revitalization of neighborhoods to improve health, links between the environment and mental health, and empathy across lines of difference.

It was punctuated by a series of cultural performances that emphasized the diversity of Rhode Island’s communities – African drumming, Bollywood dancing, Project 401 hip hop, story telling as a healthy tool, and a Carribean reggae soul band at a networking reception.

“Rhode Island is a stronger, more vibrant place when all of our residents have the opportunity to attain their full potential,” said Dr. Nicole Alexander-Scott, the director designee of the R.I. Department of Health, in a news release. “Despite the great work being done by our health care providers, educators, community groups, and many more, we still see inequalities in health outcomes in Rhode Island.”

A new periodic table
The presenters at the Health Equity Summit represented a broad spectrum of disciplines and perspectives, sandwiched around breakout sessions in the morning and afternoon.

Dr. Eduardo Sanchez, the chief medical officer for Prevention with the American Heart Association, stressed the importance of measurement in defining health equity in his morning keynote. “If we don’t measure, we don’t know where we are,” he said.

Sanchez also spoke about the need to focus on the social determinants of health that can reduce high blood pressure as a preventive approach.

Dr. Mindy Thompson Fullilove, a professor of Clinical Psychiatry at Columbia University, in her keynote luncheon address, “Links between the Environment and Mental Health, sketched out what she called the “Periodic Table of Urban Restoration,” as a community-based health equity strategy.

Her new periodic table of elements included symbols and concise messages: Cm, keep the whole city in mind; Ff, find what you’re for; Up, unpuzzle the fractured space; Us, unslum all neighborhoods; Mm, make a mark; Sr, strengthen the region; Mp, create meaningful places; Cb, celebrate your accomplishments; and Ss, show solidarity with all life.

Thompson did not mince words as she retold the tale of urban renewal in America in the 20th century: Health equity was “swept away by racism and greed.” Thompson dissected what happened in cities such as Pittsburgh and Cleveland through redlining of the cities by banks, driving diversity out of the urban centers, pushing black families into increasing crowded neighborhoods that were outside the zone of new investment.

Social determinants of health
In the breakout sessions, there was a broad smorgasbord of conversations.

Eric Loucks, an assistant professor of Epidemiology at Brown University, gave a concise, detailed presentation that represented a full semester’s course that he teaches on the social determinants of health. Loucks also talked about potential solutions that can change the equation, such as the focus on green and healthy homes and nurse family partnerships.

Viviane Saleh-Hanna, chair and associate professor of Crime and Justice Studies at the University of Massachusetts Dartmouth, gave a provocative talk on “Criminal Justice and Anti-Blackness: Life and Death within the Shadows of Slavery,” tracing the ways that control of slaves became part of the criminal justice system.

There were also two breakout sessions focused on neighborhoods: “Revitalizing Neighborhoods To Improve Health”; and “People in Your Neighborhood: How Health Teams and Community Network Resources Can Reduce Health Disparities.”

A measure of hope
Dr. Peter Simon, a retired epidemiologist at the R.I. Department of Health, described context of what it felt like to attend the Health Equity Summit. “I felt like I was present at the beginning of a social movement more than the typical conference organized by a state agency,” he said.

“We had a much-needed conversation about the social and environmental determinants of health – those factors such as quality of housing, education, jobs and economic development,” Simon continued. “Perhaps, more importantly, we heard presentations about the more complex social dynamics of racism, discrimination, oppression and violence in our urban communities.”

Simon was buoyed by the experience, saying he was reminded of Rhode Island’s state motto when leaving the conference: Hope.

Simon also praised the way that the R.I. Department of Health has structured its investments in health equity, assuring that everyone will have the opportunity to fully realize their potential, regardless of color, culture, gender, disability status, sexual identity, the conditions of birth, and zip code.

Redefining health policy
Katz, in her presentation at the Medicaid on the Move conference, set the stage by going through the basic facts: one in four Rhode Islanders, some 266,000, receive affordable health insurance and/or long-term services and supports through Medicaid.

That number includes 147,000 children and parents who are enrolled, mostly through RIteCare, with most parents having income just above the poverty line: less than 138 percent of the federal poverty level, or $27,000 for a family of three.

In addition, there are some 22,00 Rhode Islanders who are 65 years or older that are enrolled, along with another 31,000 adults with disabilities and 75,000 low-income adults without children.

The financing of Medicaid is federal state partnership, with federal government providing about 50 percent of the current cost. In FY 2012, the feds share of the $1.974 billion total was $1.032 billion.

Katz stressed two financial points: while state Medicaid enrollment has gone up, the actual per member per month costs have gone down; and, state Medicaid trends compare favorably with national and commercial trends. Between 2009 and 2013, the costs per member per month shrank by 1. 5 percent for the state Medicaid program, while the costs per member per month for the commercial insurance plans grew by 2.9 percent over the same time period, a 4.4 percent difference.

Don’t worry alone
Cindy Mann, who began her career as an attorney at Rhode Island Legal Services and then moved the Massachusetts Law Reform Institute, had the responsibility of overseeing the expansion and transformation of Medicaid during the last five years. She has since left the government and is now a partner at Manatt Health in Washington, D.C.

Mann stressed that it was important to put Medicaid spending in an economic perspective: that the largest single source of federal dollars coming into Rhode Island was through Medicaid. 

Mann delivered the most memorable line of the session, urging the audience, in the words of her former boss, Don Berwick, at the Centers for Medicare and Medicaid Services: “Don’t worry alone.”

Instead, Mann said people should share their worries together, and to recognize that it was “OK if you trip sometimes.”

Mann also suggested that there were potential ways to leverage federal funds that Rhode Island had secured through a federal waiver in 2009, but had not yet utilized. She also suggested that Rhode Island should study the work being done in Oregon, in Tennessee, and in Alabama for potential ideas of how to develop a better model.

The next phase of reinvention
Roberts, sounding as if a great weight had been lifted from her shoulders, announced that the budget amendment item, an 85-page document with 34 proposals, based on the deliberations of the reinventing Medicaid working group, had been submitted that morning to the R.I. General Assembly, detailing the $91 million in proposed cuts in state Medicaid spending. Committee hearings on the new budget amendment are scheduled to begin on Wednesday, May 13.

“There was not universal agreement,” Roberts said. She also acknowledged that there was more work to do ahead of the group, looking at longer-term reform and reinvention. And, she thanked all those participants, including Linda Katz, for participating in the working group.

Moving forward, as part of the next part of the assignment to reinvent Medicaid, Roberts hoped that the new positive revenue reports would enable Medicaid to raise the payment levels for CNAs involved in long-term care.

And, acknowledging a dialogue with Dr. Pablo Rodriguez, Roberts said there was also a need to look at equity issues involved in more wealthy citizens putting their assets in trusts to gain access to the Medicaid system for long-term care.

Roberts had also been a speaker at the Health Equity Summit the day before, but until prompted by a question by ConvergenceRI about how the conversations between health equity and Medicaid policy could be brought together, she had not mentioned the earlier conference.

“There is real recognition,” Roberts said, responding to ConvergenceRI’s question, “certainly when we’re looking at the budget side, no one could accuse us over investing in some of the things you’re talking about.”

Roberts continued: “We acknowledged that in the proposal we submitted yesterday,” citing the home stabilization efforts as a way to improve services and save money. The goal is to focus on innovations in long-term care that are community-based, she said.

Roberts also pointed to the work being done as part of the $20 million SIM, or State Innovation Model award. “There has been a lot of discussion about how to connect what impacts our health to health care reform and primary care,” Roberts said, exploring new ways to establish linking these together.

Roberts added that the community health team structure, a pilot program underway now in Pawtucket and Central Falls and South County, as part of the Care Transformation Collaborative, could serve as a place of common ground, built around community resources, “to make sure that people’s health improves." 

Awareness
Rep. Art Handy, from Cranston, who was sitting next to ConvergenceRI at the Medicaid conference, leaned over and asked about the Health Equity Summit, which he said he was unfamiliar with. Handy also wanted to know more about Health Equity Zones. [ConvergenceRI sent him a link to previous articles.]

Handy also wondered out loud how the concept of Health Equity Zones was related to the concept of Neighborhood Health Stations proposed by Dr. Michael Fine, the former director of the R.I. Department of Health. [See the link below to view a new video about Neighborhood Health Stations.]

After the conference, a community advocate for health care, who attended both conferences, came up to ConvergenceRI and said: “I’m so glad that you asked that question. That’s exactly what I was wondering to myself: how do the two conversations connect?” She added: “I’m not sure that your question got answered.”