Biden’s Plan to End Cancer Won’t Succeed Without Social Infrastructure-The HSB Blog 6/7/21
Though President Biden’s proposed new biomedical research agency (Advanced Research Projects Agency for Health or ARPA-H, modeled on DARPA (which is credited with creating the internet) can provide “cutting edge solutions” unless healthcare’s underlying social infrastructure issues are addressed first, the initiative will not succeed. While President Biden has proposed this initiative to potentially eradicate major diseases such as cancer, Alzheimer’s disease, and diabetes, the plan will have to reach populations most impacted by these and other chronic conditions who are often those most impacted by significant health disparities. As such, the success of such a plan will be a function of President Biden’s American Job’s Plan which expands the traditional definition of infrastructure (ex: roads, bridges, ports, etc.) to include other human infrastructure elements such as broadband, childcare, and skills training. While we would not argue that every provision of the initial proposal must pass or would qualify as infrastructure even in a modern sense, we must expand our definition beyond the traditional definition for ARPA-H to succeed.
Modeled after the Defense Advanced Research Projects Agency (DARPA) the ARPA-H is a high-risk, high-rewards development agency aimed at enhancing medical advancements without the limitations of bureaucratic red tape.
While only one example, a recent study found the social determinants of health in Texas have resulted in $2.7 billion in excess medical spending, and another $5 billion in lost productivity.
The budget of ARPA-H is tied to the National Institutes of Health (NIH) where $6.5 billion is reserved for ARPA-H.
With the many competing demands on the NIH budget many researchers have urged the existing functions of the NIH be protected and suggested that healthcare-related research remain grounded in clinical trials and testing.
ARPA-H’s goals are to eradicate chronic conditions and, essentially, to improve overall population health. In order to improve population health, the definition of infrastructure must also include human infrastructure improvements such as programming and resources that also improve access to education, resources, food and water, and healthcare services. As demonstrated by the COVID pandemic, while there can be dramatic breakthroughs in healthcare and healthcare technology, these developments often bypass the underserved and increase disparities. For example, although there was a dramatic increase in healthtech funding during COVID and there was a surge in the number of telemedicine and remote care services to address healthcare needs due to the lack of in-person care, people of color were inordinately impacted by COVID and often were disproportionately unable to utilize these advancements.
These disparities were evident even prior to the COVID crisis and appear to have been magnified by it. For example, data from the National Telecommunications and Information Association revealed that “the proportion of households that accessed health or health insurance records online grew from 30 percent in 2017 to 34 percent in 2019” that “households communicating with a health professional online increased by two percentage points, and households that researched health information online grew by one percentage point between 2017 and 2019.” However this data also revealed that a majority of those who used telehealth and telemedicine type resources were higher educated, wealthier and lived in more metropolitan areas. In addition to broadband, issues like child care and prenatal care can contribute to healthcare disparities all of which hurt us economically. For example, in Texas, Black and Hispanic children are more likely to grow up in neighborhoods of poverty and their families are more likely to lack health insurance, causing large disparities in health status, disease prevalence, and premature death. According to Episcopal Health Foundation, Texas is incurring $2.7 billion in excess medical care spending annually as well as $5 billion in lost productivity due issues associated with social determinants of health. In addition, this lack of care leads to 452,000 life years lost due to premature deaths valued at $22.6 billion.
The first step to addressing the lack of broadband access and other disparities is to redefine what infrastructure means as noted by President Biden when he unveiled his proposal in the American Jobs Plan. The plan redefines what infrastructure means in modern-day America, placing an emphasis on improving infrastructure for both child and home health care. The care infrastructure notion entails improving access to healthcare services, clean water, and broadband enhancements; these elements are important to promote health and wellbeing for all Americans. Given the digital nature of our society broadband is at the heart of many problems that impact healthcare and social determinants of health. For example, according to USA Today, prior to the pandemic an estimated 10-16M of the nation’s school age children completely lacked access to the internet to aid them in their school work. Even for those that do have access, the situation may not be all that it seems. In 2019, Microsoft released a study illustrating that at least 163.2 million Americans are not accessing broadband at its optimal speed. The study, backed by 6 different independent studies, foreshadowed America's system inefficiencies marking the correlation between broadband access, and job and GDP growth. This lack of broadband access also impacts health as many health experts now have begun to classify broadband access as a “super-special” determinant of health. This is due to the fact that broadband access is needed to book appointments, monitor bus schedules and ride-share apps, navigate the health insurance platforms, and so on. The lack of broadband access has put the burden of care back onto the consumers. As a result, this can lead to consumers in underserved communities facing higher barriers to access and or even becoming unable to access digital health platforms entirely. In fact, data from the National Telecommunications and Information Administration indicate that only 12% of those with an annual household income of $25,000 or less used the internet to communicate with their healthcare provider compared to 40% of those making $100,000 or more in 2019. Hispanic, American Native/Alaska Native and African Americans had the lowest rate of internet use for health related activities, trailing White and Asian Americans. Similarly, these racial groups also represented some of the most underserved populations in America.
Redefining what infrastructure means is an uphill battle. Edward Glaeser, a Harvard University economist working on infrastructure projects for the National Bureau of Economic Research, noted that a cost-benefit analysis must be established with each proposed program to fully grasp the impact of the proposed care/human infrastructure. We risk increasing racial and health inequities if the lack of broadband access and other care infrastructure programs do not pass. In addition to this digital divide, there is also a large inequity among those suffering from chronic diseases such as cancer and diabetes and other diseases. For example, over 40% of Black females suffer from hypertension and over 10% have diabetes. Prevalence rates of many chronic diseases like these are concentrated among those who are less affluent. As noted in a 2020 study published in Health Affairs, there is a strong correlation between socioeconomic status, patient care access, and lack of health insurance and rural living. Telehealth is a vital tool and in fact one of the advancements like those envisioned by ARPA-H to improve the quality and delivery of health care to millions of underserved Americans. The proposed ARPA-H program and its mission to “end cancer” have potential but it will not reach those who are truly impacted unless it addresses issues like broadband access, education and childcare. As noted in the earlier example of Texas, the state is incurring almost $3B in additional medical costs and $5B in lost productivity. Any CFO facing a similar decision about factory equipment which would save a significant amount of money and effectively extend the useful life of the equipment would be hard pressed not to make it. Lastly, health experts agree that for an improvement in population health and to sustain the positive influence of these interventions and medical advancements, health literacy must be prioritized. The social and super special determinants of health must be sustainably addressed to close the racial and health gaps amongst Americans.
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