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Meet the doctor who prescribes money to low-income patients
Boosting people’s incomes to help boost their health outcomes — could this model work in the US?
Sigal Samuel | May 3, 2019
Topic category: Social Justice
FROM:Vox
Basic Income Today

Doctors can add a crucial piece to the puzzle of their patients’ health: higher income.

Fair point. We control the titles though so we can just drop the Canadian doctor part and just have doctor. The conversation itself is about if what he's doing would work here in the US. We could also use the subtitle as the title "Boosting people’s incomes to help boost their health outcomes — could this model work in the US?" The point is to get people understanding that much of healthcare in general is treating the results of lack of income and lack of stability in income, and that we could save money by avoiding treatment. — Scott Santens, Editor, Basic Income Today

Gary Bloch became a doctor because he wanted to help people who were less privileged than him. For years, he tried his best to treat patients coping with poverty and homelessness.

But no matter how many blood tests he ordered and prescriptions he wrote, many of his patients’ health problems persisted. He realized it was because he wasn’t addressing the issue that most plagued them: poverty.

So in 2005, instead of prescribing only medication, he started developing the concept of prescribing money. And for the past 10 years, he’s been putting that concept into practice.

In concrete terms, that means that Bloch connects his patients to ways of boosting their income, like applying for welfare or disability support. Often, it means guiding patients to fill out their tax forms so they can access government benefits. Is it a doctor’s responsibility to do this? Yes, Bloch says, because if you don’t treat the social determinants of health (like income and housing), you’re not actually doing what you can to ensure your patients get healthier.

Similar to the notion behind universal basic income, the idea here is that if you really want to help people, the most effective starting point might be to simply give them more money.

As a family doctor at St. Michael’s Hospital in Toronto, Bloch hasn’t contented himself with prescribing income in one-on-one appointments: He’s also been pushing for broader social policy change. Treating individuals’ poverty may be a good step, but he wants to see systemic change, including a more robust social assistance program. In 2016, he was appointed to an Ontario government commission tasked with creating a 10-year road map to income security for the province (you can read the resulting recommendations here).

Although some doctors have told him they just don’t have the time or resources to prescribe money, Bloch says he’s gotten an overwhelmingly positive response from across Canada and beyond. As a Canadian who now lives in the US, I was curious whether his model could work within the (very different) American health care system. I spoke to him about that, and about how exactly he prescribes income and what the results have been so far. A transcript of our conversation, lightly edited for length and clarity, follows.

Sigal Samuel

What inspired you to start prescribing money when most other doctors weren’t thinking along those lines?

Gary Bloch

Seeing patients, it became clear to me very quickly that until we worked on the basic social foundations of health, we wouldn’t be able to do much about traditional medical issues. There’s an incredibly strong body of evidence that proves the link between poverty and poor health outcomes. Most health providers get the evidence, but they pass it off, saying, “It’s not really my domain to deal with that.”

I disagree. That’s why I went back to the drawing board and said, “How can I start to insert real action in the front-line practice — and find ways to do that that feel doable for busy front-line practitioners?”

Sigal Samuel

Before we get into your technique for doing that, can you talk a bit about that body of evidence linking poverty and poor health?

Gary Bloch

In the 1800s, the German pathologist Rudolf Virchow, the founder of modern pathology, traveled to many industrial work sites around Central and Eastern Europe and came to very strong conclusions about the link between poor social conditions and health outcomes. He said you cannot separate medicine from political or social life — politics is just medicine writ large.

From the 1960s or so, there’s been a pretty constant stream of studies looking at the link between people’s social situation and their health. They looked across every geographic location, across every disease, across accidents and trauma and growing up in poverty. Then they drilled down further into the biological markers and epigenetics — changes in the way genes are expressed as a result of people living in adverse social situations.

An important inflection point that’s worth noting is the World Health Organization’s Commission on Social Determinants of Health, which came out in 2008. It said that there is no real separation between social conditions and health, and that health practitioners must do something about this.

Sigal Samuel

So how did you start making a change?

Gary Bloch

The first thing I developed was something very simple called a clinical tool on poverty, a three-page handout offering a three-step approach to dealing with poverty in the context of a typical primary care appointment. It’s basically: Ask everybody about their income, be aware of the evidence linking poverty to poorer health outcomes, and then actually do something about it — connect patients to supports.

The first version came out in 2009. This [handout] took off like wildfire, which was a real surprise to me. It was picked up by major medical organizations in Canada, it was replicated in every province and territory across the country, and it got international pickup as far as Japan. It seemed to touch on a real area of interest and need.

Sigal Samuel

Can you walk me through the logistics of this in a bit more detail? Someone comes into your office. What exactly do you say in order to “prescribe money” to them?

Gary Bloch

Say someone comes in and you find out they have low income and they have some degree of disability. You ask them if they’re getting disability support, and tell them about the different supports available — federal programs, provincial programs, etc. It’s not a long conversation if you have a basic sense of the landscape. You can say to people, “You know what? I think you should get an application for the Ontario disability support program. Bring it back and we’ll go through it together and fill it out. If you’re living on basic welfare, in Ontario that’s $700 a month — if we can get you disability support, that will jump up to $1,100 a month.”

I’ve seen this story play out over and over, and the impact on people’s health is palpable.

If You Want to Help Me, Prescribe Me Money: Gary Bloch at TEDxStouffville

Sigal Samuel

Is there a particular patient’s story that leaps out at you?

Gary Bloch

I think of a guy who came in a couple years ago. He’d been living [in a tent outdoors] in Toronto for about five years, he hadn’t been in touch with health care, he had a history of childhood trauma, and he was progressively separated from society. By the time he came to see me he was pretty rundown. He was ready to get out of his tent, but he had no social support or income. It was obvious that he had major physical and mental health issues — PTSD, major depression, diagnosed diabetes, terrible worms on his feet.

We managed to get him housed in a shelter, for a start. Then we got him onto the disability support program. That opened up worlds for him. He was able to get an apartment, get medications, eat properly for the first time. He’d come in and tell me excitedly what he’d been able to buy to eat, like fresh fruit and vegetables. He started making some social connections through a support group. His health just improved dramatically. He came in as an emaciated man, and within six to 12, months he’d bulked up. And he would actually smile.

Sigal Samuel

In the years since you started doing this at St. Michael’s Hospital, have you been able to hire a few people to help patients fill out applications for welfare, housing, disability support?

Gary Bloch

We managed to put in place a whole series of social risk-focused interventions. The first was income security specialists — we have two full-time people, permanent salaried staff funded by the government, who are focused only on improving our patients’ income security. They’ll sit with patients individually and work on financial literacy and getting bank accounts and getting them to file their taxes.

We also put in place a lawyer and a legal assistant. They deal with a range of issues for our patients, like housing and income.

We’re even working now to do standardized health equity assessments across departments, to see how well they’re serving those who are traditionally most marginalized. All of this has evolved within the last five years.

Sigal Samuel

As you help patients this way, have you been gathering data and studying the results of these interventions?

Gary Bloch

We have a research program trying to get a sense of how well each of these components in our program works. We’ve got a randomized controlled trial of the income support program. They’ve just been wrapping up the trial itself and now are analyzing the data. The results will be coming out soon, hopefully by the fall.

Sigal Samuel

And in the meantime, is this model being replicated elsewhere in Canada?

Gary Bloch

There are a couple of scattered examples. There’s a team in Winnipeg called My Health Team, a team in the Kootenay boundary region of British Columbia, and a team in Peterborough, Ontario. They’ve all drawn on the work that we’re doing.

Some of it will take government will. We were lucky enough to have government support for our income security program back when we started it. We have a very different kind of government in Ontario now, though, so we’ll see.

Sigal Samuel

There’s a benefit for the government in funding this, because treating poverty now will save the government money on the health side in the long term, right?

Gary Bloch

Absolutely. The challenge is getting governments to think long-term — to convince people who are elected for four years to be willing to take a chance on something that won’t see outcomes until probably long after they’re out of power.

We’ve seen this trajectory before, though, like with smoking. Fifty years ago, no one cared about smoking from a health perspective. But then the health world picked up on it, got the evidence that this was a bad thing for our bodies, and started pushing the government. Eventually, over a few decades, the government got the story that until we deal with this issue, we’re going to have worse and worse health outcomes and it’ll come at a huge cost to our society.

Sigal Samuel

There’s some obvious conceptual overlap between your model of prescribing income and the idea of universal basic income, which Canada has experimented with. In the 1970s, when people in Dauphin, Manitoba, were given a basic income, the town saw a decline in doctor visits and hospitalizations. How do you think about the role of basic income in health care?

Gary Bloch

It is one policy option to consider. I don’t necessarily think it’s a panacea. I think if it’s done right — meaning it provides an adequate income for everyone who needs it — then sure, it can be a really good income support program. But I think people need to go beyond just income. My fear is that putting in basic income could be used as an excuse to get rid of other social programs: disability support, health support, child care support. What you lose is the ability to individually target groups that are at high need for certain services. So I’m cautiously supportive.

Sigal Samuel

Has your model of prescribing income been tried in other countries?

Gary Bloch

In the UK, there’s been a welfare rights advice network since the early 1990s. In many cases, the [people who advise patients on their rights] are less embedded in the health team than we are — they’re often NGOs working alongside the health team — but they have been doing really good work. There’s also a really interesting offshoot in the UK called “social prescribing” that has spread like crazy in the last five to 10 years. Health providers identify social needs, including loneliness, and then connect patients to social supports.

Sigal Samuel

And what about the US? Canada’s health care system is very different from the system here. Is your model one that you can imagine being replicated in the US?

Gary Bloch

Sure. There are really strong players in this area in the US. Johns Hopkins is a great example of a health system that has really tried to pick up on this. UC San Francisco’s department of social medicine is doing powerful research in this area. There are also the groups Health Leads and Health Begins [which address issues like housing and social needs alongside medical care].

Your biggest challenge is the social policy environment — there’s less interest in the US in proper social programs. There’s only so much the health institutions can do without the government getting on board.

Tags: Gary Bloch, Poverty, Homelessness, St. Michael’s Hospital, Ontario, Canada,
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UBI and health: How it impacts the quality of public health and the healthcare system at large? Brought to you by The Fund for Humanity.
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READ: Universal Basic Income as the Social Vaccine of the 21st Century

“An ounce of prevention is worth a pound of cure.

For those not familiar with this old idiom, it means it’s less costly to avoid problems from ever happening in the first place, than it is to fix problems once they do. It also happens to be the entire logic behind the invention of the vaccine, and it is my belief that universal basic income has the same potential.

The Most Cost-Effective Public Health Tool Ever Devised

The savings provided by vaccines are staggering to the point of almost being beyond comprehension. The human suffering avoided through vaccinations are immeasurable, but the economic benefits are not, and in fact have been measured. Let’s start with polio.

We estimate that the United States invested approximately US dollars 35billionin polio vaccines between 1955 and 2005… The historical and future investments translate into over 1.7 billion vaccinations that prevent approximately 1.1 million cases of paralytic polio and over 160,000 deaths. Due to treatment cost savings, the investment implies net benefits of approximately US dollars 180billion, even without incorporating the intangible costs of suffering and death and of averted fear. Retrospectively, the U.S. investment in polio vaccination represents a highly valuable, cost-saving public health program.

For every $1 billion we’ve spent on polio vaccines, we’ve avoided spending about $6 billion down the road. And that’s purely the economic costs, not the personal costs. You might think our investment in fighting polio is perhaps as good as it gets, but it’s not.

Most vaccines recommended are cost-saving even if only direct medical costs—and not lost lives and suffering—are considered. Our country, for example, saves $8.50 in direct medical costs for every dollar invested in diphtheria-tetanus-acellular pertussis (DTaP) vaccine. When the savings associated with work loss, death, and disability are factored in, the total savings increase to about $27 per dollar invested in DTaP vaccination. Every dollar our Nation spends on measles-mumps-rubella (MMR) vaccination generates about $13 in total savings — adding up to about $4 billion each year.

Just $1 spent on a single MMR shot can save $13 and a DTaP shot can save $27 that would otherwise have been spent on the costs of the full-blown diseases they protect against.

These vaccinations save us incredible amounts of money and suffering as a society, as long as we continue vaccinating ourselves. But what kind of savings are there to be found, when we go all-in and invest in a massive vaccine program so large, its aim is to entirely eradicate something?

Can the savings of basic income exceed the costs?
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WATCH THE VIDEO: If You Want to Help Me, Prescribe Me Money: Gary Bloch at TEDxStouffville

0:02 / 18:07 If You Want to Help Me, Prescribe Me Money: Gary Bloch

Gary Bloch will connect evidence to action, and propose a radical rethinking of the role of doctors in addressing income and other social issues that affect their patients' health.

BIO: Gary Bloch is a family physician with St. Michael's Hospital in Toronto. He is Chair of the Ontario College of Family Physicians Committee on Poverty and Health and a founder of Health Providers Against Poverty and Inner City Health Associates. He is an educator, advocate, and innovator, focused on reducing the impact of poverty and other social disadvantage on health.

Gary Bloch will connect evidence to action, and propose a radical rethinking of the role of doctors in addressing income and other social issues that affect their patients' health.

BIO: Gary Bloch is a family physician with St. Michael's Hospital in Toronto. He is Chair of the Ontario College of Family Physicians Committee on Poverty and Health and a founder of Health Providers Against Poverty and Inner City Health Associates. He is an educator, advocate, and innovator, focused on reducing the impact of poverty and other social disadvantage on health.

In the spirit of ideas worth spreading, TEDx is a program of local, self-organized events that bring people together to share a TED-like experience. At a TEDx event, TEDTalks video and live speakers combine to spark deep discussion and connection in a small group. These local, self-organized events are branded TEDx, where x = independently organized TED event. The TED Conference provides general guidance for the TEDx program, but individual TEDx events are self-organized.* (*Subject to certain rules and regulations)

Toward a radical rethinking of social issues in medical care
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READ: UBI Discussion:

What are the health-related effects of not having basic income?

1. What are the health-related effects of not having basic income? UBI DISCUSSION: HEALTH

2. TREATING SYMPTOMS INSTEAD OF ROOTS • “I was treating their bodies, but not their social situations. And especially not their income, which seemed to be the biggest barrier to their health improving. The research evidence was pretty clear on this. Income, poverty, is intimately connected to my patients’ health. In fact, poverty is more important to my low-income patients than smoking, high cholesterol, high- blood pressure, obesity, salt, or soda. Poverty wreaks havoc on my patients’ bodies. A 17% increased risk of heart disease; more than 100% increased risk of diabetes; 60% higher rates of depression; higher rates of lung, oral, cervical cancer; higher rates of lung disease like asthma and emphysema… It became pretty clear to me I was treating all of [my patients’] health issues except for the most important one—their poverty.”—Dr. Gary Bloch

3. COSTS OF CHILD POVERTY • 2018 study by Brown School at Washington University estimated costs to the United States associated with childhood poverty total about $1.03 trillion per year, or the equivalent of 5.4 percent of GDP. • Reduces productivity and economic output by about 1.8 percent of GDP; • Raises the costs of crime by 1.8 percent of GDP; and • Raises health expenditures and reduces the value of health by 1.8 percent of GDP. • Conclusion: “For every dollar spent on reducing childhood poverty, the country would save nearly 7 dollars.”

4. POTENTIAL SAVINGS OF NO CHILD POVERTY • A report by the Chief Public Health Officer in Canada looked at this question of potential savings, and estimated that: • “$1 invested in the early years saves between $3 and $9 in future spending on the health and criminal justice systems, as well as on social assistance.”

What are the health-related effects of not having basic income?

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READ: From ‘barely surviving’ to thriving:

Wendy Moore, who has been homeless for almost two years, is looking for an apartment.

The three Hamilton residents are part of the first wave of participants in Ontario’s experiment with basic income, a monthly, no-strings-attached payment of up to $1,400 for people living in poverty. Those with disabilities receive an additional $500 a month.

Ontario basic income recipients report less stress, better health
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READ; What are the health-related effects of not having basic income

...and Dr. Adam Steacie seconded the motion, leading to a vote where the motion passed with a sizable majority, according to Danyaal Raza on twitter. This continues the nationwide momentum for a basic income throughout Canada.

Shortly after 178 physicians in Ontario signed a letter to Ontario’s Minister of Health requesting a basic income, the Canadian Medical Association as a whole decided to endorse the idea at its General Council.