Gina S. Lovasi, MPH, PhD, is associate dean for Education and Dornsife associate professor of Urban Health at Drexel University’s Dornsife School of Public Health, authored a guest post for the News Blog on how to view tax season through a health equity lens this year.
We’ve passed the annual tax-filing deadline, and households across the country have gathered financial papers documenting tax payments — with the ostensible goal of paying our share so the government can provide for the public good. But as the pandemic continues into its third year, it’s reasonable to wonder how those tax dollars are being used to build healthier, more equitable communities — and how we are to know if those programs are working.
One often overlooked barrier to financial stability is medical debt. An analysis this month from Peterson Kaiser Family Foundation found that 16 million adult Americans owe more than $1,000 and 3 million owe more than $10,000 in medical debt, with a disproportionate burden held by those with disabilities, and low income Americans, among other groups.
In some states, including Oregon, Alabama, Kansas, South Carolina and Wisconsin, part of tax refunds can be garnished due to medical debt.
The implications of poverty for health have been underscored by the COVID-19 pandemic. Wealth can be used to protect health, and poor health and past health expenses can also undermine earning ability.
Hospitals and government agencies launch well-intentioned programs aimed at closing the gap and improving health in economically marginalized settings. Too often, these efforts are not sustained, and are little more than a distraction from glaring, persistent structural inequities in our society. The problem with these efforts is that they rarely include funding for evaluation. And when they are evaluated, at times they are compared to doing nothing — rather than doing something else that might also help.
By contrast, when testing new medical treatments, there is a standard of evidence that requires comparison. When a new medical treatment is proposed, it undergoes rigorous scrutiny before it is approved for the public. While comparisons may also be made to a placebo — the equivalent of “doing nothing” — during this process, once a usual approach to care has emerge — even if imperfect — new options must be tested to show that they improve on the status quo.
We need to infuse this high standard into our place-based work to benefit health.
What should we start with as a standard care option for supporting health and health equity in communities? I mention one option above, which is an equivalent amount of medical debt forgiveness. Another would be to allocate the equivalent amount to community-led grants, looking to models such as the University of Alabama at Birmingham’s Community Health Innovation Awards.
Yet, there will be challenges ahead. The first is differences across settings. There cannot be a singular way forward. The second is what to measure in order to show whether or not we are on track to achieve results. There are multiple health outcomes that matter, but not all will be responsive to recent change. Valued outcomes used to compare countries, such as life expectancy or years of healthy life, are unlikely to give us the timely information we seek at a local level. Third, layered approaches with multiple complementary components provide the greatest potential for detectable health benefits, but these can leave doubt as to the roles of various components. We need to distinguish the essential “active ingredients” from those which could be dropped to reduce costs — while still achieving the same benefits. Addressing these challenges will require additional dedicated funding.
We should not resign ourselves to stop learning what works. Ideas continue to come forward and there are strategies to transform scattered efforts into evidence. Comparative evidence is dynamic and growing. Growing this evidence is well aligned with the mission of a new unit within the National Institutes of Health, Advanced Research Projects Agency for Health. In the spirit of solving practical problems, we should identify what we can all do to support community health, identify variations in how to proceed and compare options based on valued health outcomes.
While taxes are a certainty year after year, health inequity doesn’t have to be. Our money could do a lot to make a more healthy and equitable nation – but only if the initiatives it supports are built and tested on evidence.
Gina S. Lovasi, MPH, PhD, is associate dean for Education and Dornsife associate professor of Urban Health at Drexel University’s Dornsife School of Public Health. She co-directs the Global Alliance for Training in Health Equity Research, recently co-edited Urban Public Health: A Research Toolkit for Practice and Impact, and is a member of the Scholars Strategy Network.