By Jayne O’Donnell
February 3, 2015

BALTIMORE — The Obama administration is working to build evidence supporting increased federal and state spending on anti-violence, social service and other programs to improve life in poor neighborhoods and limit the growth in health care costs.

The move comes despite more limited reports done by outside groups and is designed to create a paper trail that makes the need for and efficacy of the programs for Medicare and Medicaid recipients indisputable by showing the cost savings.

In the next step in the Affordable Care Act, the Centers for Medicare and Medicaid Services will spend nearly $160 million in grants to community groups, health care providers or other public or private entities that will screen patients for unmet social needs and link them with services that help with housing, hunger, interpersonal violence and other social ills.

The agency will then study whether this access improves health and lowers costs. International data show the United States spends far more on health care and far less on social services than other developed countries that have far healthier citizens. And numerous studies have shown how stable housing and other social supports keep people out of the hospital, while efforts to combat inner city violence have sharply reduced gun-related homicides.

The research was inspired in part by Yale public health professor Elizabeth Bradleyand her 2013 book, The American Health Care Paradox, which analyzed global health care and determined that higher social service spending led to better overall health.  Her new report compares states' social service spending with health status and will appear in an upcoming issue of Health Affairs.

CMS' challenge, she says, "comes down to politics."

"It does require a shift in a very large industry in the U.S. — the health care industry," which is a powerful lobbying force in Washington, Bradley says.

The public's attention on health care lately has been on insurance enrollment and political battles over costs,

"It's not that people don’t agree that (social services are) important and it's not that they don’t care, but we haven’t adequately made the case that it saves money and has value," says Darshak Sanghavi, a physician who heads population and preventive health at CMS' innovation center. "Many, many people of various political persuasions can agree that saving money would be beneficial, especially if we are helping people with their underlying social problems."

Despite the ACA's push to reward hospitals and doctors for improving people’s overall health — or penalize them if they don't — there’s still no clear way for the government to pay them for improving people’s often-traumatic lives. Nearly 18 million people have gained health coverage under the ACA, but many are still left without a way to pay for their drugs, transportation to their appointments or nutritious food that can help keep them healthy.

Unlike in other countries, health care and social services are handled by separate agencies and, often, branches of the government. Social services were thought of as charity for the poor, while health coverage was for the middle class. It's "part of our American values," Bradley says.

A report out Wednesday by the Prevention Institute calls for far more focus on the "trauma-plagued communities" that result when these social ills including violence, hunger and homelessness are ignored. Exposure to violence alone gives the United States one of the highest rates of trauma-related mental illness in the world, says the report, funded by Kaiser Permanente of Northern California.

Rachel Davis, managing director at the Prevention Institute, says that while it's "really important that there’s a grant of this size on unmet social needs," she says it's particularly heartening — and unusual — that violence was included.

Multiple studies have shown that social services improve health, including:

• Mediation efforts by the national anti-violence program, Cure Violence, in four crime-ridden Baltimore neighborhoods reduced killings by nearly 60% and shootings by more than 40%, according to an evaluation by the Centers for Disease Controland Johns Hopkins University.

• The Ocean Park Community Center in Santa Monica, Calif., found housing and connected 28 homeless people with other social services. That reduced the number and cost of in-patient visits at nearby Providence St. John's Hospital by about 90% and the number of outpatient visits by about 60%, the hospital said.

• Chronically ill patients in Philadelphia who received healthy meals, nutrition education and other services had health care costs that were an average of 28% lower after six months, according to a 2013 article in the Journal of Primary Care and Community Health. 

Americans living in troubled neighborhoods racked by poverty, inequality and inequities aren't able to meet their basic needs, said Howard Pinderhughes, co-author of the Prevention Institute report and a professor at the University of California, San Francisco.

Surgeon Thomas Scalea, the "physician in chief" at University of Maryland's Shock Trauma Center here, sees that first hand in the inability of many patients to get transportation to rehabilitation appointments, their struggles over whether to pay for food or prescriptions and the gun violence, which he says  "is daily business now."

Jenelda Artis is a soft-spoken, model-beautiful 18-year-old who says that "if you aren't from Baltimore it might be hard to get used to" the regular rat-a-tat-tat of gunfire. She's learned to tune it out, but occasionally pauses to wonder if the target might be someone she knows. More pressing matters, however, include that the house she shares with her six siblings, grandmother and mother burned down in the fall, destroying all of their possessions except for some pictures.The fire likely started in an abandoned rowhouse next door, she says.

Artis plans to go to college to study culinary arts, but her grades have suffered a bit since the fire. Making matters worse, one of the students at her high school,Renaissance Academy in the Druid Heights neighborhood, stabbed another in November. The victim later died. The school had been relatively calm until the stabbing so it had an profound effect on the students, says Rachel Donegan, assistant director of Promise Heights, which the neighborhood is called after the "Promise Neighborhood" grant it got for social services from the Department of Education.

On Monday, Promise Heights social workers coordinated a team of 10 psychologists and counselors to help students grapple with the death of another student who was shot in the community Friday night.

The Promise Heights project targets Upton/Druid Heights in part because a 2011 Baltimore health department report showed that compared to the other 54 neighborhoods in Baltimore, it had the lowest life expectancy and the highest death rate from diseases including diabetes, HIV/AIDs and prostate cancer. The homicide rate was nearly twice that of the city as a whole.

Scalea, who has trained military medics in Iraq and Afghanistan, notes that Baltimore's per capita gun violence dwarfs the headline-grabbing statistics in far more populous cities. Baltimore, with about 600,000 residents, had 345 gun-related deaths last year compared with the 400 deaths in New York City with its population of nearly 8.5 million. Non-fatal shooting injuries were up nearly 80% last year over 2014.

Scalea describes a young gunshot victim he had just performed a major operation on as the "quietest, most respectable kid who said, 'Thank so much for saving my life, sir.'"

And as Scalea laments, "We’re going to send this kid right back to the same environment where he got shot," and it could easily happen again.

The high levels of violence can make the lack of affordable fruit and vegetables seem insignificant, but obesity, chronic diseases, mental health problems and violent crime combine to make parts of Baltimore the exact type of communities the Prevention Institute report singles out and its residents the type CMS hopes to reach.

There are four fried chicken carry-outs in Upton/Druid, but if you want a salad, Burger King is about your only option, says Tavon Benson, a 24-year-old resident who now works at the Druid Heights Community Development Corporation, which says it provides "crib to grave" services. Druid shares a border with a far more notorious Baltimore neighborhood, Sandtown, where residents rioted last spring after young black man, Freddie Gray, died while in police custody.

He hopes that in 30 years, there will be "more economic opportunity, less killings, less young people taking each other out, less fried chicken places, more food diversity, more healthy food."

Bradley remains hopeful that even with the polarized health care debate in the United States, politicians and community leaders can come together in a bi-partisan manner to address rising health care costs in ways that actually make people better. The CMS pilot project, she says, is at least a start.

"American health care is really expensive and not enough to keep us healthy," says Bradley. "We’re not really dealing with the social and economic problems that make us sick."