In the latest edition of Health Affairs and at the journal’s recent Washington briefing, “caring for the vulnerable” was the major agenda. It was a bittersweet occasion. Health Affairs deserves much credit for challenging us on how well we care for the vulnerable.
However. “Caring for the vulnerable” is an important mission, like the heroic efforts of an emergency room staff or emergency responders. “Reducing personal vulnerability” is the most important mission, more like high performance, outcomes-driven, public health addressing health and its determinants. That change in primary focus is what the next 25 years can and must be about.
But changing the focus is not enough. For the past 25-plus years, policies and programs helping people have struggled. The people we wanted to help were complex individuals. Unfortunately, the policy making and program development generally addressed only sets of people with a common characteristic (for example, old age; disability; poor housing; poverty; lack of education; a specific illness; or racial or ethnic status).
Not surprisingly, most policies and programs either failed or produced relatively limited success. Valuable resources were wasted. Important needs were unmet.
Again, the next 25 years can and must be different and better. A new model needs to be put into play that greatly improves the policies and programs we so desperately need. Does such a “reducing vulnerability” model or set of models exist? Why haven’t we used them before now? What makes them better? Are they truly ready for “prime time”?
Fuller answers to these questions will come in another venue, but let me respond with the basics. The underlying models and tools for addressing outcomes, human behavior, and personal and external factors have existed for over 30 years. Only recently have these been integrated into operational models for reducing vulnerability.
So, why haven’t they been used? A key limitation to their use has been the lack of necessary data on personal and external factors to drive the models and their application for policies and programs. In addition, they have been restricted by our limited knowledge of human behavior and its determinants. Further, policymakers have been more comfortable with simpler models focusing on single issues.
Why are these models better? First, they are person-centered models where the analysis and the policy/program design are focused on individuals. In the case of the United States, that is as many as 300 million very different individuals. Second, they address human behavior as integral to the success of any policy or program. Much progress has been made in this area with much more yet to come.
Third, they can handle multiple issues simultaneously in a more comprehensive and systematic way. This helps us better target and coordinate the use of scarce resources. Fourth, they are outcomes-oriented while incorporating the processes and measures producing those outcomes.
But are they really ready for “prime time”? My cynical reply is: “Compared to what?” Sadly, the current models have repeatedly demonstrated they are not sufficiently successful in “prime time.” In any case, we are not discarding current policy and program models; we are going to use the best of them in a more integrated, systematic, person-centered way.
To more directly answer the question, “reducing vulnerability” models are ready for “prime time”. First, they and their underlying models have existed and been used for some time. We are just using them better and more systematically. Second, the individual-level data (subject to strong privacy protection) are sufficient to begin while we continue to develop better data. Third, the human-behavior models are sufficient to start but need to get much better. Fourth, these models are capable today of helping us more successfully tackle multiple issues within and across individuals.
Again, Health Affairs deserves much credit for 25 years of shining light on the vulnerability issue. But, it is the next 25 years over which reducing vulnerability can really happen. I trust that Health Affairs is in this for the long haul and for truly reducing vulnerability in America and beyond.