Issue 8 | Fall 2011

Summary

Innovation districts have sprung up all over the world, creating ecosystems for tech innovation in urban centers, and spurring economic activity and entrepreneurial creativity. This article proposes a modification on that concept to introduce the notion of an impact district, capitalizing on the same energy but with social impact as a primary objective. An area such as Germantown in Philadelphia would be a prime target for situating an impact district, where the benefit of the impact district would have the compounding effect of contributing to an area with need.

Innovation districts¹ have sprung up all over the world, creating ecosystems for tech innovation in urban centers. Innovation districts have spurred economic activity and entrepreneurial creativity from Barcelona to Boston, from Paris to right here in Philadelphia. These geographies have taken tech innovation out of the office parks and into the urban center. What if we took all of the wonderful social innovations found in this Journal and concentrated them in a Philadelphia neighborhood? What if we took all of the talent, investors, and ideas gathered at a conference like SOCAP² over a span of four days in Fort Mason, and concentrated them in a Philadelphia neighborhood over a span of four years? Finally, what if local residents could not only participate, but play a central role in developing social innovations and enterprises? 

The innovation district model is transferable to the field of social impact. Innovation districts consist of clusters of entrepreneurs, research universities, venture capital firms, and tech startups. We imagine building a new type of local ecosystem centered on residents, social entrepreneurs, impact investors, B Corporations, schools, social service organizations, and research universities; an impact district.

Impact investing and social entrepreneurship have the potential to revolutionize the way we build businesses, unlock the capital markets, and incentivize social sector collaboration. We propose to root that revolution in a Philadelphia neighborhood, one with a long-standing history of social innovation and revolution itself: Germantown. 

Collective impact³ and impact investing⁴ have taken the social sector by storm. Even though they have already yielded promising returns, these concepts still feel a bit sterile (not unlike some office parks). What if we gave them a living, breathing physicality? No place has done this better than the Downtown Project in Las Vegas.⁵ The Downtown Project transformed an overlooked area in Las Vegas into a thriving tech hub, while creating over 165 companies, 1,000 jobs, and $135 million in economic output. 

What would a Downtown Project for social impact look like? Could it generate similar impact and investment? Could we root this in a neighborhood like Germantown, with talent, institutions, and history, but also a place that could benefit from improved social outcomes? Stay tuned.

Author bio

Mike Clark is the Executive Director of Impact Germantown. He is a systems entrepreneur based in Philadelphia, Pennsylvania. He has researched, published, and worked in the areas of collective impact, financial innovation, impact investing and social entrepreneurship. Mike also served as a Peace Corps volunteer in Bulgaria. He holds a Bachelors degree from the University of Scranton, and a Master of Public Administration from the University of Pennsylvania’s Fels Institute of Government.

References

1. “Innovation Districts,” Brookings Institute, accessed November 12, 2016, https://www.brookings.edu/innovation-districts/.

2. SOCAP16, accessed November 12, 2016, http://socap16.socialcapitalmarkets.net/.

 3. John Kania and Mark Kramer, “Collective Impact,” Stanford Social Innovation Review (2011), accessed November 12, 2016, https://ssir.org/articles/entry/collective_impact.

4. “A Short Guide to Impact Investing: A Primer on How Business Can Drive Social Change,” Case Foundation, accessed November 12, 2016, http://casefoundation.org/resource/short-guide-impact-investing/.

5. Downtown Project, accessed November 12, 2016, http://downtownproject.com/.

As a community pediatrician, I have had the privilege to provide high-quality care to low-income and vulnerable populations. Despite the administration of vaccines, medical treatments and screenings, many of my patients continued to suffer high levels of chronic disease and often could not comply with prescribed treatments. Inadequate housing, failing schools, lack of access to affordable and healthy foods in addition to inaccessibility to transportation collectively created a milieu that challenged their ability to be healthy.  

Maslow’s Hierarchy of Needs illuminates the idea that the most basic levels of need (safety, shelter and food) must be met before an individual can reach his or her full potential. A prescription alone does not have the breadth of power to supply these needs nor deter the impact of lack of access and resources. In order to truly improve health outcomes and tackle health inequity, upstream interventions and cross-sector engagement are critical. 

Growing income inequality and poverty is plaguing many communities across the country, with a person’s zip code having a greater impact on health and overall success than any other demographic factor. We know that place matters. A recent Harvard University study by economist Raj Chetty showed that where a child grows up has significant effects on his or her prospects of upward mobility.  

Growing up in communities that limit a child’s physical, economic and educational potential contributes to and perpetuates poor health and incidence of chronic disease, among other public health metrics. Out of the many neighborhood characteristics examined by Chetty, the relationship between commute time and social mobility proved to be stronger than the relationship to crime, elementary-school test scores or the percentage of two-parent families and social mobility.   

Understanding the role that transportation infrastructure plays in creating economic mobility and access to opportunity is directly tied to ensuring healthy and livable communities. Under the leadership of Secretary Anthony Foxx, the United States Department of Transportation (USDOT) has embraced this unsettling statistic and is changing the way it approaches transportation policy, moving the conversation from building infrastructure to building pathways to opportunity.

In a recent interview with the American Public Health Association’s publication Nation’s Health, Secretary Foxx commented that “…transportation is place-making.” Transportation does not just take you to a place, it can create a place. Depending on how transportation infrastructure is developed and implemented, it can close off communities and create divide, or it can revitalize and mobilize. This is captured in Secretary Foxx’s Ladders of Opportunity initiative, a body of work and policy interventions that provide access to opportunity and economic mobility for all Americans.  

Centered on three principles, Ladders of Opportunity is more than just a program or project, it is a new way of thinking:   

• Work – infrastructure investment creates jobs and paves the way for businesses, particularly small and disadvantage enterprises.
• Connect – a multimodal transportation system provides Americans with safe, reliable, and affordable connections to employment, education, healthcare and other essential services.
• Revitalize – transportation infrastructure can lift up neighborhoods and regions by attracting new opportunities, jobs and housing.

These three simple concepts underscore the ubiquitous influence transportation infrastructure has on daily life. Instilling these principles into the U.S. Department of Transportation’s DNA is the key to using transportation policy to create economic opportunity.  

Changing the way a governing body, agency or department thinks is no easy task. Culture shifts in industries often come as a result of a tipping point, when a hand is forced to do things differently as a result of external forces. Being proactive about culture change so that it allows an organization to actualize its true potential requires a savvy strategy and strong leadership that not only spurs top-down change, but also invigorates an upward momentum. This is the approach that Secretary Foxx has implemented to ensure that well beyond his tenure as Secretary of Transportation, decision-makers within the Department as well as across the country are held accountable for ensuring pathways to opportunity are seamlessly integrated into transportation policies and programming.  

Utilizing the bully pulpit, Secretary Foxx has created a Ted Talk-style presentation that he will conduct to stakeholders and decision-makers across the country. Orated through his personal story of how a highway entrapped the Charlotte, North Carolina, neighborhood he grew up in, while illustrating the impact of poor urban planning through vignettes, Secretary Foxx eloquently sheds light on the transgressions of historic policies that shaped communities for generations and perpetuated economic divide, inequity and poor outcomes. In doing so, he amplifies the notion that place matters, and that it is the responsibility of current policy- and decision-makers to be mindful of all implications of building a new road or highway, including its impact on health. 

It is not only in the presence of action behind transportation policy that communities and neighborhoods are impacted, but it is also the absence of consideration of vulnerable populations that builds walls to opportunity instead of roads. Walls to opportunity can present themselves through a variety of mechanisms, one of which can be demonstrated through the story of Raquel Nelson.    

Raquel Nelson is like many other Americans across the country. A single mother of three, 30- year-old Raquel attended Kennesaw State University in Georgia while providing for her children. Unable to afford a car, she utilized public transportation to connect her from her suburban home to school, work and the grocery store. On the night of April 10, 2010, Raquel disembarked the bus with her children at a stop across the street from her apartment complex in Marietta. Eager to get home, she walked her family across the busy four-lane state road, as most of her neighbors did daily.  

But as they crossed the street on this day, Raquel and her family were struck by a van, wounding her and her two daughters while fatally injuring her 4-year-old son. While grieving the loss of her child, Raquel was charged with second-degree vehicular homicide, failure to cross at a cross-walk and reckless conduct.  The jury’s heavy-handed verdict reflected the lack of insight into what truly caused this horrific event. This was not a failure of Raquel’s judgement, but a failure of urban planning – the closest crosswalk was three-tenths of a mile away from the bus stop. 

Raquel’s case sparked outrage in both the civil rights community as well as among urban planning and public transportation organizations, bringing to light how lack of pedestrian considerations in urban planning can negatively impact vulnerable populations. As the income inequality gap widens, many Americans with lower incomes are forced to move out of gentrified urban neighborhoods to more affordable, inner-suburban areas where the infrastructure is more suitable for driving than utilizing public transportation.  

The inability to afford a vehicle puts you at a disadvantage, and coupled with the lack of pedestrian-friendly infrastructure creates an environment that many Americans like Raquel have to endure in order to have access to education, jobs and healthcare. Public health advocates understand the detrimental impact of poverty and income inequality on health, however situations such as Raquel’s highlight how transportation infrastructure serves a critical role in bridging the gap to access and directly impacts outcomes. 

This is just one of the stories Secretary Foxx uses to illustrate the impact of transportation policies on everyday Americans. Raquel’s ability to provide for her children while pursuing her education to create a better life for her family was greatly dependent on transportation and urban planning decisions. This is what Secretary Foxx wants to ingrain into decision-makers – it is more than just a road, bridge or highway, it is a conduit to opportunity.  

Through discretionary grant programs, technical assistance efforts and innovation, USDOT is translating Secretary Foxx’s Ladders of Opportunity presentation into real work, leveraging its regulatory power to spur revitalization in distressed communities and encourage local and state decision-makers to think differently about transportation policy and projects. From Richmond to Phoenix, neighborhoods across the country are using transportation as a way to connect Americans to opportunity. Initiatives such as the LadderSTEP program help cities advance transportation projects that revitalize and support access to opportunity, while the Transportation Investment Generating Economic Recovery (TIGER) competitive grant program invests in projects that more reliably, safely and affordably connect communities to centers of employment, education and other services. 

Acknowledging the role that health plays in access to opportunity and equity, initiatives are not restricted to just roads and bridges. USDOT’s Rides to Wellness program is a strategic initiative to build partnerships, stimulate investment and drive change in the health and transportation sectors by supporting innovative solutions to healthcare access for vulnerable populations. Over 3 million Americans miss a doctor’s appointment due to transportation barriers.  USDOT is working to address this issue head-on, understanding its potential in helping to reduce the burden of chronic disease by improving access to healthcare services. 

Bringing together public health stakeholders with transportation practitioners is also crucial in improving the built environment. In 2012 USDOT’s Federal Highway Administration released the Metropolitan Area Transportation Planning for Healthy Communities report, which documented leadership among local transportation planning entities that successfully integrated health and transportation. Local communities are highlighted, showing how decision-makers took a comprehensive and holistic approach to health that went well beyond the well-established assessments of health impacts related to safety and air quality.  

In addition, interagency collaborations have yielded significant impacts. Last year, the Centers for Disease Control and Prevention and USDOT came together to launch the Transportation and Health Tool. Intended for transportation practitioners, this interactive database helps decision-makers understand many of the issues at the intersection of transportation design and public health with the intent to strengthen collaboration between these two sectors. In 2009, the Environmental Protection Agency (EPA), the Department of Housing and Urban Development and USDOT came together to form the Partnership for Sustainable Communities to improve access to affordable housing, increase transportation options and lower transportation costs while protecting the environment. Creating livable and affordable communities is critical in the public health space, as the built environment is one of the many structural elements that have a direct impact on health outcomes. Breaking down the silos between these stakeholders and implementing a “health in all polices” approach allows for alignment of action that places the health and well-being of a community at its center, improving outcomes and promoting equity.

Secretary Foxx’s Ladders of Opportunity Ted Talk-style presentation and agenda is a call to action for decision-makers, practitioners and community leaders to be invigorated around the potential for transportation policy and infrastructure to be beacons for social change, economic mobility and improved health. Every American should have the ability to create his or her own destiny, instead of that destiny being dictated by zip code. As Secretary Foxx has said, “Through transportation, we can ensure that the rungs on the ladder of opportunity aren’t so far apart – and that the American dream is still within reach for those who are willing to work for it.”  

Dr. Kamillah Wood currently serves as special advisor on health and transportation to Secretary Anthony Foxx at the United States Department of Transportation as a White House Fellow. Previously, she served as associate medical director of Mobile Health Programs at Children’s National Health System in Washington, D.C. Contact information: This email address is being protected from spambots. You need JavaScript enabled to view it.. 

References:

1. Raj Chetty and Nathaniel Hendren. “The Impacts of Neighborhoods on Intergenerational Mobility: Childhood Exposure Effects and County-Level Estimates.” May 2015.
2. Bluestein, G. “Raquel Nelson Fights Murder Charges in Son’s Jaywalking Death in Georgia.” Huffington Post. April, 17, 2012.
3. Hughes-Cromwick, et al. “Cost Benefit Analysis of Providing Non-Emergency Medical Transportation.” Prepared for the Transit Cooperation Research Program, Transportation Research Board of the National Academies. October 2005.
4. Metropolitan Area Transportation Planning for Healthy Communities. Prepared by U.S. Department of Transportation Research and Innovation Technology Administration, John A. Volpe National Transportation Systems Center, Federal Highway Administration. December 2012. 

Access to oral healthcare is critical to overall health and remains a challenge, especially for low-income and vulnerable populations. In fact, there is a silent epidemic of oral diseases that is plaguing undeserved communities and without an innovative systems framework for improving oral health, the challenges will continue to be a barrier to a healthier population. 

The national agenda for creating a healthier people has been set for decades. The Healthy People 2020 document and its stated goals for specific disease areas was set in motion by former U. S. Surgeon General, Dr. Julius Richmond, and his colleagues to set measures for increasing the human capital of the United States through the well-being of its citizens. With credit for the earliest public health innovation in the United States given to Paul Revere, we continue to strive toward the value proposition of health for all people. The nation is currently focused on a specific set of goals as stated in Healthy People 2020.

On the pathway to overall health and wellness, practices of healing and medicine have tracked human history with various and tremendous levels of advancement. Throughout this evolution, there has remained a difference between care focused on the individual and approaches that are required when poor health or illness affects a population. Innovative solutions in medicine become more relevant and necessary when diseases such as cholera, whooping cough, and more recently, HIV/AIDS, stymie the experts and  ”downstream” medical interventions are the focus, treating symptoms to alleviate immediate suffering.  

Urgency to save entire communities has forced innovation and dissemination (i.e., ”spread” not only for curative solutions and, more importantly, for generalizable preventive techniques). Prevention theories have led to the appreciation that community-wide solutions can mitigate the resource problems of a healthcare system focused on symptoms by better understanding the factors that contribute to better health. A 2003 National Call to Action to Promote Oral Health by the U.S. Surgeon General indicated that the nation could address the silent epidemic of oral diseases by applying similar theories.

One can look back to the health insurance experiments of the 1960s where innovations in reimbursement of healthcare providers for well-being rather than health impairment emphasized the value on prevention. A new resource distribution method was introduced with the hope of driving healthcare providers and patients toward a more effective and efficient system to maintain health. Those systems continue to be complex and misunderstood by patient and doctor alike. Similar thinking was applied to the maintenance of oral health, however a different financing system was created alongside employer-based medical coverage. A major difference of the dental financing system design is that it would not and, in many instances, still does not cover catastrophic events, but instead provides benefits in a prepayment model that can be applied to care expenses based on a set of standardized protocols.  

The drivers for oral health and overall health are similar, the advances in science and opportunities for prevention align, however, the systems of care delivery and financing remain separate. Little change in the standardized protocols of oral care by dental professionals has been seen. Downstream treatments, identified in oral healthcare as restorations, are delivered mainly by surgeons who are situated in expensive suites where they repair broken enamel, root out damaging and painful nerve damage, and if needed, perform surgeries to diminish further pain and suffering. Advances in the field include new knowledge about the diseases of the mouth, their connections to systemic health, the complexity of the causal agents and conditions that promote disease progression, and more recently, how to assess individual disease risk. Still, prevention techniques to reduce oral diseases are mainly remanded to the interaction between the clinician and the patient at a time when the patient is more than likely facing consequences of oral diseases and in the context of how to stop them from getting worse. For the average person, the connection to and advice on prevention of oral diseases has come from manufacturers and distributors of chemicals that when applied by the user, can stop cavities, will refresh breath and create whiter teeth. Whether by clinician direction or marketed self-care methods, the mouth has been isolated from the rest of the body.

While the core principles of how to create better oral health are all in place, many people continue to face obstacles toward attaining oral health in the first place. Add to that the confusion about how the payment system is supposed to work, and the system-based obstacles increase. The working systems support an individual in need of repair, who can afford the help, and with a clinician who is well paid for their services.  However, when measured against what is known through scientific, evidence-based and community-based research, the current systems fail to achieve to reach and/or provide quality care to millions of people. The field of oral health presents tremendous opportunities for systems transformation through innovative redesign of the way care is delivered, what it is designed to do, where it takes place, how it is paid for, who pays for it and what outcomes it produces. In order to address the burden of oral diseases carried by millions of marginalized people, existing systems call for disruption.

Disruptive innovation, introduced by Clay Christensen, is beginning to gain interest among oral healthcare providers. Primary care has embraced the innovation momentum for decades. The Quality Movement has been testing healthcare professionals and organizations for their effectiveness and efficiencies to reduce pain and suffering and to save lives. Public policy is driving Triple Aim expectations for appropriate reimbursement models not only for medicine, but with some degree of innovation, for oral healthcare services. Amidst these demands, the same primary actors are responsible for creating a nation of healthy people. The polarities of those humanitarian intentions are stark, when one considers that the systems within which these expectations are to be met are not designed to achieve those desired outcomes or to benefit all people. A systems view, with opportunities for innovation, is promising for redesign in consideration of the demand for new ideas, swift application, lower per capita costs and broader community engagement. 

A systems approach becomes more useful in appreciation of what actually creates health and well-being. For decades, it has been understood that the major factors which impact health are those of environment, lifestyle, biological and genetic factors. This accepted view provides a broader framework within which resource allocation for healthcare can be more responsible and responsive. The health sector can then be effectively understood as part of a vast ecosystem of economic, social and cultural components that are unavoidably connected and interdependent as factors in creating its intended results.  

As a function within the health sector, philanthropy is prone to directing funds to address immediate community needs, rather than investing at a larger systems level. In oral health, funding initiatives like Mission of Mercy provide necessary interventions as expressions of charity that, without their existence, would leave many people without any option for care. As a marginalized health problem for marginalized populations, oral diseases perpetuate health disparities and thus require social and systemic disruptive innovations to avoid conditions where the needs are dire and intervention measures are drastic. Oral health philanthropy has embraced opportunities to address these systems and promote the ideal states in the realms of policy, financing, care and community. The DentaQuest Foundation and its supporting enterprise have put forth a systems change framework that identifies the characteristics of the ideal states of these four systems. The theory of change to attain these ideal states requires the engagement of a broad and diverse network of stakeholders. 

Figure 1: Systems Framework for Oral Health: The Ideal States of Policy, Financing, Care and Community.

Across the nation, a network of such stakeholders is moving the system components in consideration of their own place(s) and role(s) in the previously referenced ecosystem. Innovative champions from among the health professions are proving to be the primary change agents toward the attainment of the Care System component identified in the Figure 1 as: “Oral Health is integrated into all aspects of healthcare .”   

To attain this population-oriented and person-centered improvement, a funding collaborative is supporting a systems solution that incorporates the mouth with the rest of the body. The National Interprofessional Initiative on Oral Health (NIIOH) is a co-funded network comprised of practitioners and experts from a range of health disciplines, including physicians, nurses and nurse practitioners, physician assistants, health professions educators and others who believe that oral disease can be eradicated, and are aligned in their efforts to integrate oral health into person-centered care as a solution. Previous to the development of NIIOH, primary care clinicians were more likely to omit mention or examination of the gums and teeth in the patient encounter, providing limited opportunity to identify abnormalities or to address early signs of disease.  

This collaborative has revolutionized models for person-centered care that include oral health by developing Smiles for Life, a nationally-adopted oral health integration curriculum (Society of Teachers of Family Medicine 2016), influencing approaches to health professions education (Dolce, Holloman, and Fauteux 2016) and reforming clinical practices (Haber et al. 2015), (Hummel et al. 2015).

The integration of oral health into primary care is a systems-focused approach whose success, as it continues to spread, will improve patient health outcomes and has the vast potential to positively impact the populations of underserved and vulnerable communities. Multiyear evaluation of NIIOH strategies have revealed changes in practice, expanded and revised medical education curricula and professional collaborations on many levels.   

These innovative solutions will continue to emerge through collaborative investments by funders and the network mindset of interdisciplinary champions. As we witness the early successes in interprofessional education, practice and financing innovations, it is likely that through the shift toward the priority of prevention, a fidelity to attaining the highest quality measures of individual and community life, and more equitable application of human and financial resources, will create a much healthier nation.

Beginnings

Since the dawn of our republic, equality has served as a foundational value within American culture. It earns first mention in Jefferson’s famous line in the Declaration of Independence as a “self-evident” truth: that all men are created equal. In his Gettysburg Address, Lincoln famously reframes this “truth” as a “proposition” to which the nation is dedicated, in other words, as a guide star for the American project. Equality is also enshrined in the 14th Amendment of our Constitution as a commitment to “equal protection” of the laws. And of course, the ideal of equality animates the most famous speech of the civil rights era, Martin Luther King’s “I Have a Dream.” In King’s poetic image of little black boys and girls joining hands with little white boys and girls “as sisters and brothers,” we can see the compelling vision of equality, and the liberation it implies. 

And yet throughout our history the “self-evident” truth of equality has not really been a truth at all, if by “truth” we mean an accurate description of reality. Indeed, American society has always exhibited profound inequality: for people of color, for women, for those without land or wealth. Today, equality remains an unachieved ideal, a work in progress. It is a creed that some feel we have been called to live out, to give meaning, yet one that we have failed to practice. The deep chasm between the vision of universal equality and the stark reality of unfairness and oppression in everyday life reminds us of Rousseau's famous opening line of The Social Contract: “Man is born free, and everywhere he is in chains.”

The Current Situation: Ongoing Narratives of Inequality and Injustice

Thanks to an army of psychologists and behavioral economists, we understand that the human imagination and heart are driven not so much by facts and figures as by compelling stories. Over the past several years, the nation’s attention has been riveted upon graphic stories about profound inequalities in our justice system. We have seen story after story in which police officers have used excessive, lethal force upon black civilians. 2014 witnessed the stories of Eric Garner, Michael Brown, Laquan McDonald, Tamir Rice and Antonio Martin, among others. In 2015 and 2016, the narratives continued, including tragic incidents involving Eric Harris, Walter Scott, Freddie Gray, Sandra Bland, Philando Castile, and Keith Lamont Scott, among many others. 

The extremely graphic media accounts of these events, often including shocking videos, have been interpreted by many as compelling illustrations of widespread societal injustice, sparking public protests calling for change. The Black Lives Matter movement has swept the nation, beginning in Ferguson, MO, and spreading through Los Angeles, New York, Bloomington, Cleveland, Milwaukee, Chicago, Baltimore and many other major cities and communities. The movement has protested evident discrimination not only within the justice system, but also across many other sectors of American society in which racism has produce a full spectrum of inequality. We measure this inequality through documented racial and ethnic disparities in educational achievement, employment, income, housing, asset development, health, longevity, access to capital, civic engagement, political participation, political power and other features of social equality. 

Equal Outcomes: Opportunity for What?

There are three standard ways to measure inequality: income, consumption and wealth.¹ Using income alone, a simple rank ordering of lowest to highest income of the population depicts inequality. Taken one step further, one performs a ratio of a higher income to a lower income.² We’ve become familiar with the outcome of this ratio: those at the top of the income bracket have between five and 70 times the income of those at the lowest point of the income bracket. Income measures are also used at the national level, calculating the percentage of national income that a population group (e.g., the lowest 5% of households by income) receives. 

Many economists consider the use of income data to measure inequality erroneous, however, as it does not take into account taxes or government transfers (such as social security, food stamps, unemployment benefits, etc.). Capital gains, a significant source of non-cash income largely realized by the wealthy, are also not included in income data until they are accrued.3 While distribution measures get us a bit closer to an accurate picture of inequality, they also are dependent only on income data, which provides an incomplete picture of household income. 

To avoid some of the problems with employing income alone as an outcome measure of equality, some economists look instead to patterns of resource consumption. Consumer Expenditure Survey data is used to estimate the total value of goods and services consumed over an individual’s (or group’s) lifespan. As you may imagine, there is a substantial lifetime spending difference between the rich and the poor. This lifetime spending inequality turns out to be less than standardly reported pre-tax income inequality.³ It is less because the consumption measure may mask significant differences in actual economic well-being between rich and poor as all households, regardless of size or income, consume a standard package of goods and services in the course of daily life. What percentage of household income this consumption package costs may provide a more accurate picture of inequality. For example, when your paycheck equals your expenses for basic needs, 100% of household income is consumed. Conversely, a person of significant wealth with a large amount of discretionary income might spend as little as 10% of household income on basic needs.

A third measure of inequality attempts to correct for the incomplete nature of income data and the skewed nature of consumption data—wealth or net worth. Calculating a household’s net worth takes into account cash and non-cash income (capital gains), savings, investments, real estate and the value of expensive consumer goods (such jewelry, cars or art collections). These standard categories of a wealthy household’s portfolio are mostly absent within low-income households, yet such elements of wealth are routinely excluded from standard inequality measures based on income data.

In contrast to economists, sociologists are more holistic in approaching the measurement of inequality in outcomes, looking at inequality of conditions (unequal distribution of income, wealth and material goods) and inequality of opportunity (unequal distribution of life chances as represented by factors such as education level, health status, and contact with the criminal justice system).⁴

The Tension with Freedom

The scope and depth of our comprehension of unequal outcomes in America tells us something important. Understanding the facts about a situation, even understanding fundamental causes and trajectories, does not necessarily lead to change. This is especially true when, as in American culture, there are contradictory values in the social system. Of course we know that American culture contains substantial elements of individual, systemic and structural racism and classism. But beyond these original sins that reflect cultural values diametrically opposed to equality lies the cherished, inalienable right to liberty, or freedom. In considering the tension between the values of freedom and equality, it is important to note that a focus on freedom is what inspires the call for equality. Inequality limits freedom: That is the reason that inequality is a problem. 

Nevertheless, within American culture, the value of freedom often is expressed in tension with equality. This is because many feel that freedom only has real meaning when it manifests as individual power: the power to own property, to create wealth, to act, to express oneself, to influence others, even to aid others. Here is the rub. The expression of power by any person or group always has the potential to limit the power of another person or group. Power afforded to one can easily manifest as oppression to another. The right to bear arms promotes equality with others who bear arms, but it creates the possibility for domination over those lacking arms. In this way, the exercise of any freedom entails the possibility for oppression, and thus threatens equality. Unchecked freedom leads inexorably to inequality. In its most extreme version, the value placed on freedom may even call into question the very legitimacy of the societal interest in equality, as we see in some ideological expressions on the extreme right.⁵

The focus on freedom in American culture, combined with our nation’s ample, if regrettable, historical legacy of racism, sexism and classism (including, for example, slavery and oppression of women), leads to a politics that is not fully committed to equality of outcomes in American society. This is starkly visible in the current ideological divide between the right and left on issues of racial, gender and ethnic equality. Many on the left believe that the long history of injustice in American society requires the redistribution of economic and political power to achieve equity, even if that means limiting the freedom of individuals and groups who have inherited historical advantages from inequality. In contrast, many on the right insist on limiting power redistribution according to a concept of Pareto efficiency or optimality, meaning that no individual’s welfare should be diminished in the cause of promoting equality for another.⁶ According to this view, it will be fine to promote little black girls and boys holding hands with little white girls and boys “as brothers and sisters,” as long as the little white girls and boys lose no advantage in the process. 

Society’s moral evaluation of Pareto efficiency involves an ongoing assessment of what one group of people owes to another. Imagine a family in which the mother and father grow fat while their children starve to death. No one would defend such an allocation of food because of strong moral and legal norms about the obligations of parents to feed their own children, in view of (and despite) their obvious lack of productive powers in securing food. We expect children to depend on their parents. On the other hand, imagine how you might feel if the police showed up at your door each night to remove excess food from your refrigerator so that it could be used to feed refugees living at a local charity.  

The difficult balance between the values of freedom and equality is worked out every day through the myriad processes of our local, state and national governments, combined with the philanthropic efforts of third sector organizations. We pay taxes to fund programs and policies that benefit others. Every day, in countless ways, individuals limit their freedom to protect the welfare of others. We give from our surplus to support those who have less. At different points in our lives we may be on the opposite ends of the giving and receiving spectrum. How are we to understand this effort to achieve an optimal balance between liberty and equality? We could call this desired balance the pursuit of justice. The most difficult policy issues that we face at home and abroad arise because we are not clear about how to strike this just balance across the vast domain of human affairs. The institutions of government that work to strike this balance on a daily basis in our communities—from our police departments, to our judiciary, to our legislatures, to our executive powers—do not all seek the same equilibrium points. They also do not share the same understandings about the truth of the current situation, nor the same beliefs about effective strategic action in the pursuit of justice. 

This incoherence results in an inconsistent and often chaotic approach to balancing liberty and equality, different in method and results for different people in different communities engaged in different systems. Aristotle observed incisively that, in the pursuit of justice, treating different things similarly is no better than treating the same things differently.⁷ Coherent thinking about social justice requires a shared vision of the outcomes to which we aspire and the recognition that strategic action in pursuit of justice depends upon an awareness of meaningful differences and a willingness to act upon them or discount them, depending on the context. Unfortunately, a shared vision of justice, and about which differences matter and which do not, and toward what ends, is precisely what we lack in our system as a whole. To point out one simple example, some believe that our societal systems must be highly conscious of race to achieve justice (as in a white police officer being aware of unconscious racial bias in dealing with a black citizen), while others believe that the system should be intentionally blind to racial differences (as in a college admissions office avoiding affirmative action programs for students of color). 

The Justice Opportunity Zone: Equality of Opportunity

In this ongoing tension between competing ideologies, with the right more focused on freedom and the left more focused on equality, there is one arena of significant agreement: the importance of equality of opportunity. The concept of opportunity is celebrated in the idea that people are “created” equal, with the implicit recognition that true freedom will cause inevitable inequalities to arise as serendipity combines with natural talents and hard work. The idea of equal opportunity is also celebrated in the commitment to equal protection of the law enshrined in the Constitution. The inspiration here is that the fundamental rules of engagement in the marketplace and the public sphere should be the same for all. There is an expectation of fair play and that our judicial system will create an equal playing field for actors across the private and public spheres. 

While there has been a large volume of thought and research applied to understanding inequality of outcomes, the concept of equality of opportunity has received comparatively less attention in the historical conversation about measuring equality, even though it provides an arena of striking consensus across the American political landscape. 

How might we measure equality of opportunity as distinct from outcome measures of inequality? Four observations are important here. 

First, we must recognize that the concept of opportunity implies a developmental approach to equality and human outcomes. The idea in a nutshell is that each person in society is presented with a starting position and then moves through a process of development and engagement in society that will lead to a set of outcomes over the course of a person’s life. This idea has important consequences in thinking about outcome measures. For example, it would not make sense to compare the income of a person near the starting line with that of a person near the finish line of their social engagement and trajectory. It may be challenging to unscramble “starting position” data from available data sets.

Second, a focus upon opportunities in a developmental process necessarily implies the definition of a series of opportunity baselines, a set of thresholds that we take to define the minimum conditions of meaningful opportunity.⁸ To illustrate the concept, consider the example of a meaningful educational opportunity. One might persuasively argue that today an educational system which fails to expose students to information technology tools will negatively affect opportunity, even though it is possible to receive a base-level education, in terms of literacy, math, and knowledge, without the use of computers or advanced information technology. 

Equity baselines always ignore or discount some potential sources of inequality when defining minimum conditions for developmental equity. Sports competitions, for example, do not control for inequities in coaching acumen or player recruiting although professional leagues have used tools like salary caps and draft selection to equalize opportunity. Any systemic approach to equal opportunity must recognize the practical impossibility of eliminating all sources of inequality in establishing starting or threshold capacities. 

Real equality of opportunity must also account for the evolution of advantages that skew unfairly to the top of the societal pyramid. Thirty years ago, a minimum baseline of educational opportunity need not have included access to information technology. Today students from upper-income families who have access to the best educational technologies enjoy significant advantages. To provide meaningful equality of opportunity, baselines must evolve as society develops new tools that create opportunity advantages for those who have privileged access through wealth or social status.

The third critical observation is that the measurement of equality of opportunity, of advantages and disadvantages, necessarily makes assumptions (relying on implied shared values) about what outcomes are important in providing base levels of equal opportunity. We recognize, for example, that we cannot account for certain uncontrollable genetic differences across human beings. We also cannot control for evolving cultural norms and tastes that nevertheless may deeply impact an individual’s outcomes. Obvious examples would involve personal attributes associated with social and cultural norms involving athleticism, beauty or natural ability.

Fourth, the concept of opportunity is clearly bound up with a free market approach to individual engagement and development within society. We assume that productive capacity through individual ownership is a critical determinant of personal outcomes when measuring equality of opportunity. This is an important background assumption because one could easily adopt other approaches to thinking about outcomes that would result in different assessments of the meaning and measurement of equal opportunity. For example, equality of opportunity would have a starkly different meaning within the social culture of a Christian or Buddhist monastery intent on the daily practice of asceticism, spiritual contemplation and communal productivity. 

With these considerations in mind, we can posit that a coherent theory of equal opportunity would need to address at least four evolving and interdependent baseline dimensions of personal development and social engagement: (1) health, (2) education, (3) employment and (4) access to the dominant forms of capital: information, social, and economic. 

An evolving baseline does not define an abstract ideal or stagnant minimum threshold of capacity, but rather dynamically links a minimum baseline to an upwardly mobile average standard achieved by those who enjoy the most success in productivity and engagement in the free market and its related community and public sector spheres. Consider as an example the case with college education. We know that people in society who achieve college education double their earning capacity on average over their lifetimes.9 Nevertheless, because only 34% of citizens in the United States earn bachelor’s degrees, four-year college degree attainment remains a significant source of inequality of opportunity. On average, those with a bachelor’s degree spend 17 years on education when post-graduate work is taken into account. So the achievement of equality of opportunity in the educational arena would require a baseline that actually exceeds support for bachelor degree attainment. In 1970, four-year college degree attainment was less than half of what it is today. Because indicia of inequality evolve over time, so must the minimum baselines that define equality of opportunity. 

Toward an Opportunity Census

We advocate for the development of an annual opportunity census benchmarking the average starting positions enjoyed by the top one-third of the population, and then creating social policies to elevate the remainder of the population to that target level of opportunity. While development of a comprehensive standard pursuant to this general theory remains beyond the scope of this essay, we can outline some concrete examples of opportunity indicia that might be employed. Defining meaningful opportunity would involve measuring key indicators enjoyed at the top of the pyramid, and then ensuring availability across diverse populations.

In the arena of health, equality of opportunity centers on having sufficient health to participate fully in intellectual, physical and social developmental activities. These would include indicia such as:

• Nutrition (e.g., food security, access to affordable fresh foods, average daily intake of sugar, sodium, refined grains, saturated fat) 
• Exercise and group play (e.g., minutes of activity per day, minutes of group play per week) 
• Development of psychosocial health including robust reality testing, imagination and persistence (grit) (e.g., Grit Scale, behavioral task performance) 
• Environmental safety including toxin-free and violence-free living and educational spaces (e.g., EPA air quality index of residential areas, felony crimes per capita, life expectancy)
• Immunization and other disease prevention activities (e.g., availability of clean drinking water, ratio of immunization to birth records, ratio of affordable primary care services to population)
• Access to high-quality medical care (e.g., ratio of public and privately insured persons to population, affordable qualified health centers per capita)

In the arena of education, equality of opportunity centers on being able to participate in high-quality educational activities, both formal and informal, leading through and beyond baccalaureate secondary education attainment. These would include indicia such as:

• Affordable early childhood development of literacy, math and creativity skills (e.g., number of high-quality, licensed early learning centers affordable at 10% of average family income per number of children under 5, percentage of parents with young children having knowledge about impact of early child development)
• Access to affordable safe schools that provide high-quality college-preparatory curricula (e.g., cohort graduation rate, school safety ratings, school district rankings, school expenditure per student, college matriculation and graduation rates of alumni) 
• Access to affordable social and emotional learning opportunities that create the foundation for effective social engagement later in life (e.g., rate of engagement in arts, cultural, sports and faith-based youth development programs)
• Access to quality, affordable post-secondary institutions including graduate education (e.g., affordability rankings of local colleges, knowledge of financial aid system among adult population, graduation rate, percentage of degree attainment among U.S. citizens)
• Access to affordable information technology that enhances educational achievement (e.g., percentage of household Internet access, presence of home computer, public computing centers, access to smartphones per capita)

Equal opportunity in employment is dependent upon access to the full range of educational opportunities outlined above, and also involves access to and ability to perform work providing sufficient income to sustain opportunity in health, education, and access to social and financial capital. Examples of indicia in the field of employment would include the following:

• Merit-based internships, hiring, advancement and compensation without invidious discrimination (e.g., Equal Employment Opportunity Commission adherence/number of charges and violations among local employers, workplace diversity among all positions that reflects local population distribution, equal pay for equal work) 
• Access to programs that increase job and trade specific skills relevant to the local labor market (e.g., audit of training programs mapped to employer needs and number of un- or underemployed adults)
• Access to information about job opportunities (e.g., number of gainfully employed persons in social network, Internet access)
• Geographic mobility to access employment locations (e.g., reasonable commuting time by car and public transit, access to reliable form of transportation)
• Social mobility to access and learn how to operate in social networks related to employment (e.g., mixed income residential areas, exposure to professional work environment)

Equal opportunity in terms of access to capital is the most challenging arena to define. At the top of the social pyramid, participants engaged in the free market enjoy substantial advantages through increased access to financial, social and information capital. Their social networks create information asymmetries, and access to wealth allows them to exploit opportunities further promoting success and driving up overall inequality. People at the top of the social pyramid are able to endure failure and financial setbacks, and they are able to spend many more years investing intensively in their educational capacity and social network development than populations who lack advantages derived from access to capital. Promoting equality of opportunity in this arena requires identifying and benchmarking key indicia of access to capital. Examples of indicia in this lane would include:

• Economic information transparency (e.g., knowledge of banking system, formal economy and basic business practices across adult population, percentage of adults with checking accounts)
• Political and policy information transparency (e.g., equal access to information about proposed laws and regulations, equal access to policymakers and service on public boards, equal access to government contracts and sources of funding) 
• Access to nondiscriminatory pools of financial capital for investment in education, skill development and entrepreneurship (e.g., distribution of bank lending reflects diversity of local population, knowledge of financial aid system among adult population)
• Access to qualified, nondiscriminatory mentors and other sources of reliable know-how in career and business development (e.g., participation rates in high-quality civic, professional and economic development organizations such as Chamber of Commerce, Urban League, Rotary, etc.)
• Geographic mobility (e.g., feasibility of physically accessing communities different from one’s own, ability to exercise choice in housing location, fair housing compliance among realtors) 
• Social mobility (e.g., comparison of parent/child income, occupational status and wealth accumulation, number of persons in personal network with household incomes >25% above median household income for locality, number of persons in personal network with educational attainment levels of Bachelor’s Degree and above, number of persons in personal network with investment portfolios and/or own a business)

The More Perfect Union

When we remember the inspiring words of leaders such as Jefferson or Lincoln or King emphasizing our shared American project toward the compelling vision of equality, we feel the outrage triggered by the ongoing media accounts of societal injustice, particularly through incidents of violent racism. Americans are not seated together at the table of brotherhood and sisterhood; some of us do not even have seats. Some of us are not yet seen as being worthy of respect. Oppression and inequality are a reality of daily life in our homes, on our streets, within our schools and workplaces, and within our economy. But outrage alone is not action, and even the most complete understanding of the problem is only a precursor to action. Only data-driven policies that are actually implemented qualify as meaningful action. In this cause, data can serve as the bridge between vision and reality, spanning the reality of the injustice that so many endure, and leading toward a new reality of justice that communities create. In our free market economy, equality of opportunity is the most politically viable pathway to more equal outcomes. Using an opportunity census that serves as a continually evolving foundation for all social policy objectives, we can open pathways for the oppressed to rise. Then those whom we believe were created equal at the beginning of their lives may have a chance to experience genuine equality—perhaps for the first time.

The author wishes to thank Cynda Clyde for her assistance in the background research for this essay.

References

1. Z.G., “Measuring Inequality, A Three-Headed Hydra,” The Economist (7/16/2014), accessed November 12, 2016, http://www.economist.com/blogs/freeexchange/2014/07/measuring-inequality.

2. Pius Chaya, “Measuring Inequality,” PowerPoint presented to class Intro to Inequality Studies, University of Texas, accessed November 12, 2016, downloaded from utip.lbj.utexas.edu/tutorials/intro_ineq_studies.ppt.

3. Drew DeSilver, “The Many Ways to Measure Inequality,” Pew Research Center (12/18/2013), accessed November 12, 2016, http://www.pewresearch.org/fact-tank/2015/09/22/the-many-ways-to-measure-economic-inequality/.

4. Ashley Crossman, “Sociology of Social Inequality: An Overview,” about.com (11/1/2016), accessed November 16, 2016, http://sociology.about.com/od/Disciplines/a/Sociology-Of-Social-Inequality.htm.

5. Clayton Aldern, “There is no real case against equal opportunity,” gristorg (9/22/2015), critiquing Dylan Matthews, “The Case Against Equality of Opportunity” for vox, 9/21/2015, accessed November 12 2016, http://grist.org/politics/there-is-no-real-case-against-equal-opportunity/.

6. Richard B. Howarth and Richard B. Norgaard, “Intergenerational Resource Rights, Efficiency and Social Optimality,” Land Economics 66, no. 1 (February 1990): 1-11, doi: 10.2307/3146678.

7. Aristotle, Politics, Book 7, Part III.

8. Paolo Brunori, summarizing Roemer and Fleurbaey and Maniquet in “How to Measure Inequality of Opportunity: A Hands-On Guide,” Dipartimento di Scienze Economiche e Metodi Matematici, University of Bari, May 2016.

9. Sandy Baum, Jennifer Ma, and Kathleen Payea, “Education Pays 2013: The Benefits of Higher Education for Individuals and Society,” The College Board (2013), accessed November 12, 2016, http://trends.collegeboard.org/sites/default/files/education-pays-2013-full-report.pdf.

Author Bio

David Castro a graduate of Haverford College (1983) and the University of Pennsylvania Law School (1986). In 1993, following a successful career both in private practice and as a Philadelphia prosecutor, David was awarded a Kellogg Foundation National Leadership Program Fellowship. As a Kellogg Fellow he studied community leadership and its relation to improving quality of life. Based upon this work, working with his mentor and colleague Lynne Abraham, in 1995 David founded I-LEAD, Inc., a school for community leadership development that has served several thousand emerging leaders across Pennsylvania through its affiliation with Pennsylvania Weed and Seed, and its development of an accredited Associate Degree program in Leadership. David is also one of the founders of I-LEAD Charter School, a high school that combines leadership development with academic remediation serving at-risk high school age youth in the economically challenged city of Reading, Pennsylvania.

In 2002, in recognition of David‘s work on behalf of Pennsylvania communities, he was awarded an Eisenhower Fellowship, which he used to study leadership and its impact on economic and community development in Turkey. In 2009, in recognition of David‘s work in community leadership and education, he was named an Ashoka Fellow by the Ashoka Global Funds for Social Change. Ashoka is an international community of the world’s leading social entrepreneurs. David is a teacher at heart, frequently consulted as a speaker, serving on panel discussions and contributing regularly via blogs and articles posted through the Ashoka network, the Kellogg Leadership Alliance and the Philadelphia Social Innovations Journal.

David is the author of Genership: Beyond Leadership Toward Liberating the Creative Soul, now available in print and e-book formats. He is also the host of Innovate Podcast, a biweekly podcast featuring dialogue with social entrepreneurs, writers, visionaries and researchers engaged in transformative thinking, action and creative collaboration. Innovate has featured renowned guests such as Kailash Satyarthi, winner of the 2014 Nobel Peace Prize. Innovate is produced by Ashoka, the Kellogg Fellows Leadership Alliance, the Philadelphia Social Innovations Journal and I-LEAD. Innovate is sponsored by Arch Street Press.

Introduction

Philadelphia is ripe for healthcare delivery innovation. The new administration has recognized this via its interest in embedding more health services within the city’s schools. Many have already begun to consider the potential for new partnerships among and between health centers and other city agencies, hospitals, medical schools, community-based organizations and entrepreneurs. 

Historically, local public interest in healthcare has focused on large public health issues, particularly the prevention of communicable diseases, and providing for children’s and young adults’ healthcare, including providing immunizations that are part of a larger public health strategy. Conversely, providing geriatric healthcare services has been mostly viewed as a federal government concern via the Medicare program, and to a lesser extent a state government concern through the Medicaid program, for which states pay about half of the cost of acute and chronic medical care for the poor, including the elderly poor.

This paper maintains that the city of Philadelphia, working directly through its health centers and in coordination and cooperation with the city’s hospitals, medical schools, community-based organizations and the private sector, is in a unique position to improve the health and safety of tens of thousands of the city’s elders, and that in doing so the city can also economically gain.  We begin by noting that:

1. Large numbers of Philadelphia elders are in a healthcare crisis and the demographic trends within the elderly (and the soon-to-be elderly) population indicate that this crisis will worsen absent new policies and programs.
2. Overwhelmingly, the city’s elders are insured by the federal Medicare program, the state and federally funded Medicaid program, or both, and as such, the inability to pay providers is generally not a barrier to accessing services.
3. Federal and state officials are eager (desperate) to control the costs of these programs and improve healthcare outcomes and are therefore open to new partnerships and innovations as never before.
4. Philadelphia has a healthcare infrastructure that could be readily positioned to catalyze and participate in new, geriatric-focused healthcare partnerships that would save and improve the lives of tens of thousands of Philadelphia older citizens.
5. Unlike other areas of public policy which the city would like to address, no new laws or appropriations are needed in order to act. Most of the money necessary to undertake these efforts is available through Medicare and Medicaid. Doing so would likely enable the city and other providers to draw down tens, if not hundreds, of millions of state and federal dollars that would be added to the city’s economy.
6. In implementing these efforts new jobs at all skill levels would be created.
7. If creatively implemented, some of this investment could be focused into new geriatric healthcare zones in which new healthcare and associated facilities might be built, and new state-of-the-art, health-enhanced senior housing constructed along with housing for care and service workers working with this population. The impact of this investment would be a source of, and undoubtedly spur, additional neighborhood revitalization.
8. This new focus on the delivery of geriatric services could be leveraged by the city’s high tech community by creating opportunities whereby entrepreneurs could demonstrate the efficacy of their inventions, helping inventors overcome a significant barrier to bringing products to market. In return, marketable products might be manufactured in Philadelphia. 

Background

Philadelphia is home to about 186,000 residents who are age 65+, or about 12% of the city’s total population. Virtually all of these residents will need increasing levels of acute and chronic healthcare services in the years ahead. Demographically, the “older elderly,” those who are 85+ years of age, are the fastest-growing population among the city’s elderly, and these seniors will be poorer relatively, and absolutely, in comparison with the emerging younger elderly population. Overwhelmingly, Philadelphia’s elderly are insured via Medicare. In addition, roughly 46,000 of Philadelphia’s elders are so poor that they also qualify for Medicaid, the so-called “dual-eligibles.” 

Yet, even with insurance coverage tens of thousands of elderly Philadelphians do not receive the preventive care for which they are eligible; care that would cost them nothing, or close to that, to receive. Reasons for this include poverty and the absence of skills necessary to access providers, geographic isolation and/or medical conditions that limit mobility and access. About 16%, or nearly 30,000 elderly Philadelphians, are effectively “shut-ins,” for example. As a result, Philadelphia’s elderly population incurs acute and chronic health problems at rates exceeding state and federal averages as well at rates that exceed comparable cities nationally. For example:

• Older Philadelphians have higher rates of heart disease, stroke, diabetes high frequency cancers, hypertension, respiratory disorders and dementia relative to the state, the nation and comparative jurisdictions. 
• Philadelphia elders have the highest chronic disease rate leading to premature death in the nation. 
• The preventability of most of geriatric chronic illness episodes and injuries can be seen in the fact that large and disproportionate numbers of Philadelphia elders are:
  • Not receiving immunizations for flu and pneumonia.
  • Untested for heart disease and various cancers.
  • Not screened for osteoporosis.
  • Have higher rates of smoking, binge drinking and overweight/obesity.
• Philadelphia elders will make about 200,000 emergency room visits each year, taxing these facilities, municipal emergency services and taxpayers. Annually about 11,000 senior citizen falls require at least emergency room treatment. 

In short, despite high levels of insurance coverage and the presence of a world-class hospital and medical school infrastructure, Philadelphia’s healthcare delivery system, as experienced by tens of thousands of elders, does not meet their most basic healthcare needs. Worse yet, operating this healthcare delivery system is also incredibly expensive for Medicare and especially Medicaid, where these expenditures represent a huge portion of the state budget.

Philadelphians cannot be satisfied with the state of public health in the city when 98% of neighborhood health centers show disproportionate incidence ratios by race (e.g., racial disparity): 59% of the disparities state black Philadelphians as significantly less healthy, 28% have Hispanics disadvantaged and 11% show Asians as less healthy. However, knowing about these disproportionalities does not yield a health improvement strategy because all of the differently-impacted ethnic subpopulations are widely distributed throughout the city and because the disparities, while real, tend not to be large enough to justify race-based targeting efforts. In other words, the city is in a public health crisis together and a citywide health improvement strategy is what is needed now.

The overriding demographic description of public health in Philadelphia is simply this: 80+% of chronic illness deaths and about 50+% of hospitalizations for all causes are age-related in nature.  The 65+ subpopulation live with, and die from, just about all of the chronic diseases, usually, more frequently than do their younger age cohorts. Accordingly, achieving improvements in geriatric health is not only mission critical for the city’s health professionals but crucial for the crucial for the fiscal health of healthcare providers.

New Advanced-aged Geriatric Healthcare Initiatives

Below we call for five new and specific, evidence-based initiatives to improve the health and safety of the city’s elders. Per the theme of social innovation, each of these initiatives would rely on the city health center network accepting a new mission of leading and coordinating new geriatric activities largely paid for through new partnerships with Medicare and Medicaid. Additionally, the city’s hospitals, medical schools and other nonprofit and for-profit entities would all have new opportunities to participate in new ways of delivering health services to the city’s older population.

1. Preventing Fall Injuries Among the City’s Elderly

In any given year more than 11,000 city elders visit a hospital emergency department for a fall-related injury. About 3,350 will be hospitalized, with 2,000 to be discharged to a nursing home (where almost two-thirds will require a stay of more than 836 days). In short, 863 persons are projected to be on Medicaid, in a nursing home, for at least two years at a cost of $73 million.

Between 2000-2003, Pennsylvania Medicaid oversaw a large-scale fall prevention program in Philadelphia for 3,000 elders. This effort documented a 60% reduction in nursing home admissions for geriatric falls among the participants. A reconstituted program for 11,000 elders who are recognized as being at the highest risk of falling (as they had already been to a hospital emergency room for a fall injury) would cost about $9 million to offer and save about $73 million in hospitalizations and post-critical treatment, including nursing home stays, for a net savings of about $64 million. 

One approach might be to refer patients to new Fall Prevention Centers. Such centers would coordinate with hospital emergency doctors and be operated by for-profit or nonprofit sponsors. Each center could be expected to produce dozens of jobs and perhaps as much as twenty million dollars in new local economic activity. State Medicaid officials have the authority to enter into partnerships with the city Health Department and/or other geriatric healthcare partners without legislative action, and a program with a proven track record of producing savings would likely be very attractive to state officials eager to reduce the state Medicaid budget.  

2. Providing Free-to-the-Elderly Preventative Health Services

Medicare covers 20 types of screenings, immunizations and treatments, most of which are 100% free to the elderly patient. These services include pneumonia, flu and shingles vaccinations, Hepatitis B vaccination, PSA testing, smoke cessation and counseling programs, low-dose CT scans for lung cancer, colonoscopies, glaucoma screening, obesity counseling, cholesterol screening, aortic aneurism testing, annual wellness visits, physician-based health planning for preventative chronic disease and much more. Unfortunately, a significant number of Philadelphia’s elderly do not access these preventive services. For example, 46% of elders don’t get flu shots, 33% haven’t received pneumonia immunization, and about half of eligible men don’t get prostate screenings. 

Some of the difficulty in accessing preventive services are explicable when one understands that at least 16% of Philadelphia elders are “shut-ins” and in need of mobile health delivery and about 18% of older citizens report lacking a personal physician. But mostly the healthcare community just has not gone out to the locations where elders congregate with an effective message of how they can obtain these lifesaving treatments. 

A health center network that was interested in providing these services and effectively communicating the availability of these services backed by new mobile outreach programs using health vans and the like would do much to make these valuable preventive programs available to Philadelphia’s elderly. Medicare, and certainly Medicaid, would have strong interest in providing resources to conduct outreach as these interventions reduce high-cost hospitalizations and too often, nursing home admissions. 

Targeting the more than 37,000 elders who lack a primary care physician and therefore are not receiving most of this preventive care would alone likely trigger more than $20 million in new healthcare expenditures within the city including salaries and other items that ultimately yield revenues to the city. In addition, of course, the actual cost of providing treatment is fully reimbursable for the provider, including city health centers.

3. Keep Seniors Living in the Community

Philadelphia is the obvious place for Pennsylvania Medicaid to look to achieve savings in its annual multibillion dollar Medicaid budget. Statewide data indicate that elders constitute 14% of the state’s Medicaid enrollees, but 32% of the Medicaid budget, with a disproportionate amount of elderly expenditures being on nursing home care. In Philadelphia, roughly 480,000 persons are on Medicaid, of whom about 10% are classified as elderly. There is no reason to believe that local elders proportionately cost Medicaid any less than the statewide figures, and good reason to believe Medicaid spends more here since prices in the city tend to run ahead of rural Pennsylvania.

The vast majority of Pennsylvania’s older residents, poor or not, want to stay out of a nursing home and most current nursing home residents would like to return to the community if they could be properly cared for. This fact, and the need to control these Medicaid costs, is why Governor Wolf’s budget proposes to help 5,500 additional elders stay out of a nursing home. His budget calls for saving $168 million annually by providing services and alternative housing assistance (an average of almost $30,000/case, which can cover a lot of services and rental assistance) to keep elders out of nursing homes. In a separate budget category, $50 million is being set aside to provide additional services to Medicaid recipients of all ages and PHFA is proposing to spend an additional $15 million on home modifications and other assistance. The city should be seeking to actively cooperate with these proposals and stake its claim to these resources. 

For example, some elders cannot return home because their home is simply unsafe for them to be in. The City’s overwhelmed basic systems repair program might have the expertise to do the repairs but it has neither the financial wherewithal nor the capability to do repairs quickly so that elders can be discharged back to their home. Money from this state initiative could pay for these repairs, as well as the emplacement of other safety enhancements, but the city would need to build a system capable of acting expeditiously.

On the other hand, some elders will need more care than they can obtain at home, but still do not need to be in a nursing home. Here, the city could take the lead in producing a new generation of senior housing that is designed for these frail elders and uses a lower reimbursement rate than nursing homes receive as a subsidy stream to operate this housing. These subsidies could be combined with existing housing subsidy programs, or in some cases avoid them, in return for Medicaid guarantees of a “patient stream” as units became available over time, ensuring the full occupancy of this housing. 

Neither the city’s housing authority, nor much of the nonprofit community has been very interested in developing new senior housing, but such a program could provide them with new development opportunities, or opportunities for new organizations to specialize in developing this housing if properly incentivized. In addition, it is likely that elders living in PHA housing would qualify for this housing, freeing up federally-subsidized housing for families and others.

4. Helping hospitals and physicians improve emergency care for elders

Various data suggest that Philadelphia elders make as many as 200,000 emergency visits a year. Aside from the personal tragedies of those elders who arrive at an emergency room because they were unnecessarily injured or sick due to a lack of earlier access to medical care or other services, and the cost, including to local emergency services, there is a secondary serious problem----many elderly patients leave the emergency department with little or no documented follow-up, unsure of what they need and not knowing where to get necessary services. 

There is a need for a greater coordination of care, better transitioning from the emergency department to the community and better triage within the emergency department to minimize inappropriate use of emergency services. The city’s health centers can help and should be organized to be a provider or gateway for this assistance. 

As indicated above, 18% of the elderly in Philadelphia lack a personal physician and 20% do without medical services because of cost, or perceived cost. From the perspective of hospitals, the current system is failing and likely to get even more expensive with the specter of federal rapid readmission penalties looming. This problem is in part evidenced by the fact that a relatively recent survey of the ten largest Medicare certified home health agencies operating in Philadelphia scored 75% below the state average on reducing re-hospitalizations.  The twenty largest agencies, representing well over 50% of home health discharges from Philadelphia-area hospitals, scored 61% below state averages on reducing re-hospitalizations!  

If geriatized city health centers were established where elders could go to receive information, additional discharge planning and medical follow-ups, local hospitals, Medicare and Medicaid would all have strong interests in working with and funding the development of this new health center capacity.

5. Better integration of mental health services with physical health services

At least 30% of Philadelphia elders hospitalized for all causes each year have a mental health condition in addition to whatever may have caused the hospitalization. These mental health problems are vastly under-reported, under-diagnosed and under-treated. Untreated, these mental health conditions result in otherwise preventable suicides, homicides, drug abuse and alcoholism,  tax the city’s emergency services system, and impose additional costs upon local hospitals and other providers. Mental health disorders trigger a 200% increase in rapid re-admissions and a 311% increase in nursing home admissions. Under new Medicare rules these rapid re-admissions trigger new costs on hospitals.

Doctors and hospitals, understandably, focus on the primary (physical health) diagnosis, but by undertreating comorbid mental health illness conditions, additional and earlier elder deaths occur. Screening for depression, anxiety disorders and cognitive impairment (including drug and alcohol problems) is almost universally a good option for aged chronic- illness patients. Establishing a strong network that encourages and facilitates primary care physicians and emergency care doctors to undertake some preliminary patient screening for these conditions and then refers patients in need to existing providers, or to an updated health center network, including city health centers, is called for.  

A new mental health initiative would, like physical health services, attract Medicare and Medicaid administrator attention as such a program would undoubtedly yield better health outcomes and medical cost savings. Getting hospitals, doctors and other providers, including existing mental health providers onboard for such a program would not cost much money, but it would benefit strongly from city leadership. 

Meeting the Needs of the City’s Elders an Economic Development Strategy

The above five programs would all bring new funding and capacity to city health agencies and their partners, and save Medicare, Medicaid and city emergency services budgets money. Most importantly, these interventions would save lives and/or improve the quality of life for tens of thousands of vulnerable, elderly Philadelphians. However, these programs also could be components of a broader city community and economic development strategy. Below are ways the city could also create jobs, revitalize neighborhoods and catalyze new economic activities while improving and saving lives among Philadelphia’s elders. 

1. Use health centers as anchors for community revitalization

The city’s health centers presumably were located where they are for reasons now-largely known only to neighborhood historians. What is clear is that these centers have not been successfully used as engines for community investment and redevelopment, but they could be. Building on the presence of these centers in their respective communities the city could: 

• Create tax-advantaged healthcare zones around the centers. These zones would offer various tax breaks to medical practices and related services to encourage the opening of new medical arts buildings that offer complementary services to those being offered in the nearby health center. 
• Site senior, special needs and other assisted housing proximate to the health centers and require that the plans for these buildings create partnerships with the health center to meet the needs of residents of these developments. Make redevelopment of these sites a priority for the city Land Bank and the processes by which city housing subsidies are awarded. These sites should also be a priority when building a new community-based housing partnership with Medicaid that avoids unneeded nursing home usage, as discussed above.
• Create housing for care workers that these elders will need. Care work jobs are one of the region (and nation’s) fastest growing job categories. It is also a category plagued by high levels of employee turnover, and too often, poor quality care, in part because of high levels of employee turnover. By working with caregiving firms and using employer-assisted housing techniques, the caregiving workforce can be stabilized and improved.

2. Declare an intention to make Philadelphia the “Silicon Valley” for the elderly

New senior medical technologies are regularly coming into existence and additional technologies are needed. One “routine” barrier to the introduction of new technologies is that entrepreneurs have difficulty arranging for demonstration studies that test the efficacy of their products. Subject to appropriate federal and state regulation, those elders participating in various health initiatives could also be offered the opportunity to participate in the testing of new products, helping local entrepreneurs overcome a key market barrier. In return, efforts could be made to have products produced in Philadelphia, adding new high-tech manufacturing jobs to the city’s economy. 

Nationally, no community or state has declared its intent to become the nation’s geriatric healthcare technology center. Philadelphia has the medical, engineering and manufacturing infrastructures that are needed to be the Silicon Valley for geriatric innovation, and it also has land on which research and manufacturing facilities could be built. Philadelphia has a population in need. It has entities such as the Ben Franklin Partnership and University Science City that could be harnessed to bring in hundreds of millions of dollars in new capital to develop this new industry here. As Philadelphia continues to repurpose itself for the 21st century why not make this a key strategy on which to base the city’s economic future? To further this approach, the city could:

• Create an Office of Economic Development within the Department of Health that is charged with increasing healthcare investment and access. Advanced-aged Geriatric care and increasing the city’s biotech and related sciences R&D capacity should be key priorities.
• Create a “Mayor’s Working Group on the Expansion of the Healthcare Industry” consisting of leaders of the major hospitals, medical schools, etc., plus health center leaders and leaders in biotech, assistive tech and related industries, as well as the Office of Economic Development within the Department of Health. The purpose of the group would be to create a healthcare industry strategy or plan for the City that maximizes employment, investment and development opportunities through increases in service, research and manufacturing activities related to healthcare, and ultimately facilitates the City goals of increasing tax revenues and population. 
• Convene a conference that brings together city health center and community development leaders and others in the medical professions to discuss how the health and community development sectors can work together in ways that yield health and community development outcomes.

In addition to taking these actions, city leadership should also be focusing on the nearly $500 million dollars in Governor Wolf’s proposed budget to encourage the growth and expansion of urban- and technology-based economic development, including healthcare technologies. The city can and should play a catalytic role to ensure that Philadelphia businesses get their share of these incentives. More importantly, however, city leadership can spark new partnerships that yield new solutions that better address the healthcare and associated problems of the city’s, and the nation’s, aged population.

3. Link new geriatric-based health, community and economic development strategies with new educational opportunities 

There should be one or more new public or charter high schools designed to create a workforce and a leadership pool for biotech industrial expansion, as well as training for direct care service opportunities. Miami-Dade County in Florida has established BioTech High School; Philadelphia should have at least one, too. With all of the clamoring regarding charter v. public schools, and the role of the private sector in education, creating such a school (or schools) to bring the city’s technology communities, educational communities and foundation communities together to educate the city’s children for the jobs of tomorrow would be a worthy achievement on its own.

Conclusion 

Philadelphia has all the components necessary to be a national leader in elderly healthcare innovation, but we have not yet organized our public, private and nonprofit sectors in ways that enable us to provide better and oftentimes less-costly care for our vulnerable elders or take advantage of the economic benefits that would derive from better geriatric healthcare policy. With the arrival of a new mayor and health commissioner in the city and a governor still early in his administration (and facing a huge budget crisis) the public sector stars are aligning with the city’s large and diverse healthcare sector to begin the conversations necessary within government and with the private and nonprofit communities for the reinvention of how the city, and ultimately the nation, can better respond to this growing public health concern.

Daniel Hoffman is a Philadelphia-based public policy consultant whose work focuses on cross-disciplinary approaches to seemingly intractable housing, community and economic development problems. He is particularly known for his pioneering work on employer-assisted housing and business improvement districts. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it.

Dr. David C. Schwartz is president and CEO of the New Jersey-based ElderCare Companies. He is Professor Emeritus of urban studies and community health at Rutgers, The State University of New Jersey, and an internationally recognized leader in the field of preventive geriatrics.

Community health assessment is not a new concept. These assessments have been a widely-used tool in public health for decades to bring community health needs to light and to focus community health programs and advocacy (Kretzmann & McKnight, 1993). The Patient Protection and Affordable Care Act of 2010 made them a hot topic in medicine when the legislation revised the conditions for a hospital to maintain its nonprofit status, including a requirement to conduct a community health needs assessment (CHNA) and community health improvement strategy based on those results every three years. This provides a new opportunity to re-examine hospital community benefits with a population health lens, and a new opportunity to address intractable health disparities occurring among the highest need and highest cost communities they serve. However, limited guidance from both the ACA requirements for CHNA and in the current community benefit standards raises questions about whether the implementation of CHNA is ensuring community health needs are being adequately assessed and met as intended (Rubin, Singh, and Young 2015).

In exchange for nonprofit status and the tax breaks that accompany such designation, hospitals are expected to provide community benefits. The current community benefit standard, ambiguous and in place since 1969, is intended for a healthcare system that looks dramatically different from today (Rubin et al. 2015). This ambiguity leads to considerable variation in the provision of community benefit between hospitals (Young, Chou, Alexander, Lee, & Raver, 2013), with variation down to the level of how hospitals are defining and measuring provision of uncompensated care (C. L. Pennel, McLeroy, Burdine, & Matarrita-Cascante, 2015). Controversy over whether nonprofit hospitals were providing enough community benefit to earn their tax status led to congressional examination and the inclusion of the CHNA requirement in the Affordable Care Act (James, 2016). Thus the new CHNA requirement is intended to guide nonprofit hospitals in their missions to providing community benefits (Roundtable on Population Health Improvement, Board on Population Health and Public Health Practice, & Institute of Medicine, 2014). 

Historically, hospitals claimed safety net services as their primary community benefit. But is improved service provision truly a community benefit that extends beyond the already existing mandate of the hospital to serve its community? This tension likely mirrors the two competing definitions of the term population health – one used in medicine that refers to populations of patients and thus focuses on improved outcomes and reduced costs, and one used in social science that refers to the social determinants of health that exist outside of the biomedical model (Diez Roux, 2016). Indeed, it is well-established that individual behaviors, social and economic factors, and the physical environment contribute more to overall health than clinical care. Researchers estimate that these social determinants of health are 80% responsible for health and well-being (Braveman, Egerter, & Williams, 2011; Magnan et al., 2012; Robert Wood Johnson Foundation, 2009). Furthermore, after Affordable Care Act provisions that extend and decrease the cost of coverage to previously uninsured and underinsured patients, the safety net services framework for community benefits no longer fits (Rubin et al., 2015). Unless hospital systems address the other 80% of factors driving patients through their doors, they will be caught in a perpetual cycle of high costs and poor outcomes.

Under CHNA guidelines, hospitals possess broad latitude to define, assess and prioritize community health needs (C. L. Pennel et al., 2015). Vague CHNA guidelines risk failing to ensure that true community needs are being assessed and addressed. These guidelines, for instance, allow health systems to create their own definition of “community” for the purpose of the assessment. Hospitals can choose to define community as their system’s service area, encompassing huge geographic regions with large and diverse populations. For example, the Children’s Hospital of Philadelphia used this service area definition for their 2013 CHNA, which included five counties and nearly 4 million people (The Children’s Hospital of Philadelphia, 2014). Although this definition is permitted under the broad guidelines and is a good place to start, focusing each triennial assessment at such a high population level risks masking differences in health and health risks in communities that span a vast continuum of socioeconomic status, racial segregation, neighborhood environments and unique health needs. Children’s heath needs on the Main Line are very different than health needs in West Philadelphia. Thus the solutions should also be different.

So how can the opportunity and spirit of the Affordable Care Act requirement be used to drive effective community health improvement plans and make a dent in widening health disparities? Public health has struggled to slow pervasive health disparities driven by widening societal inequalities. Evaluating and sharing what has worked before becomes the evidence base for best practices to improve health at the population or community level. But until we do a better job of including communities in the identification of best practices - through identifying health priorities, assessing existing assets as well as needs, and tailoring programs to their unique context - we will continue the same cycle of dropping prepackaged programs into the community without ownership, or even buy-in, and then continue to wonder why they didn’t work. 

A solution lies with true community engagement in the process of conducting CHNAs and developing and implementing the community health improvement plans. Community-engaged research is an approach to research that includes individual and organizational representatives of the communities being researched in the research process (Meredith Minkler, 2012). Community-engaged research includes a variety of settings and intensity of community engagement, including community-based or practice-based research; levels of community engagement in at least one phase of the research process (e.g., planning, data collection, data analysis or interpretation, results dissemination); or the gold standard, community-based participatory research, where community stakeholders are involved in all phases of research (Anderson et al., 2012; Israel, Schulz, Parker, & Becker, 1998; Lasker & Weiss, 2003; M. Minkler & Wallerstein, 2003). 

A June 2013 Institute of Medicine report identified community engagement as a key priority for its national Clinical and Translational Science Awards, arguing that community stakeholders are essential for identifying health needs and priorities, providing data and input, and promoting successful participation in important research (National Academy of Sciences, 2013). Indeed, growing literature demonstrates clear benefits to research from community engagement, including community member recruitment, improved data collection design, and better use of results to inform interventions (Heaney et al., 2011; Jagosh et al., 2012; Santilli, Carroll-Scott, Wong, & Ickovics, 2011; Wallerstein & Duran, 2010). It also serves to address the pervasive mistrust associated with academic and medical research among minority populations experiencing the worst health disparities (Corbie-Smith, Thomas, Williams, & Moody-Ayers, 1999; Freimuth et al., 2001; Fryer et al., 2015).

Recent reviews of the first rounds of CHNAs are finding that although community stakeholders are engaged in some aspects of the CHNAs, few engage diverse community members and community-based organizations in “meaningful participation” throughout the CHNA and community health improvement plan development process (C. L. D. Pennel, McLeroy, Burdine, Matarrita-Cascante, & Wang, 2015). Yet there exists high demand from community-based organizations to conduct their own CHNAs or to be knowledgeable and equitable partners in the process (Carroll-Scott, Toy, Wyn, Zane, & Wallace, 2012). As has been found in a community-engaged CHNA model in New Haven for Yale-New Haven Hospital, engaging communities in their own assessments reveals needs and assets not apparent in a catchment-level assessment, and can begin to drive more effectively tailored solutions to health improvement efforts (Santilli, Carroll-Scott, & Ickovics, 2016). 

Another answer lies in the collection and dissemination of such data collected at the neighborhood or community level, as has been addressed by Axler and colleagues.A new and innovative movement in open data, invigorated by technology that enables web-based data visualization more intuitive to lay audiences than traditional scientific publications (Kingsley, Coulton, & Pettit, 2014; Pettit, 2014). By sharing CHNA results and aggregated data routinely collected by hospitals at the neighborhood level, communities can define their own neighborhood or community boundaries themselves and use the data they need for identifying community health priorities and planning for community-driven interventions. 

The solution is not that hospitals themselves collect new data in each neighborhood or use the data to address each community’s health needs, but partner and invest in existing population-based health data collection processes and use the CHNA as an opportunity to creatively and strategically share these data and other routinely-collected information with those who are the natural leaders in the community. This will enable the needed paradigm shift from service delivery planning to population-based community health planning (Rice, 1993). 

Rather than looking at the CHNA as a requirement to be minimally met, hospitals should see them as an opportunity to think more broadly about how to address pervasive health disparities among the communities they serve, in turn avoiding the intractable “hot spots” of high costs and poor health outcomes. This presents the perfect opportunity for hospitals to develop mutually-beneficial partnerships with community members and the public health workforce so that all involved can use their professional and shared experience to understand community health needs, and then empower community-driven solutions. This approach can amplify a hospital’s community benefit well beyond their patient population, and into the communities where they live, work, worship and play. 

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