Dr. Richard Besser: A Prescription for Equity in Health

Jennifer Tescher:
Welcome to EMERGE Everywhere. I’m Jennifer Tescher, journalists turned financial health champion. As founder and CEO of the Financial Health Network, I’ve spent my career breaking down silos by engaging with innovators across industries, and now, I’m sharing those conversations with you. Meet the forward thinking leaders challenging the status quo and unleashing creative new ways of improving financial health by seeing their customers, employees, and communities in 3D.

The twin crises of the COVID-19 pandemic and the economic downturn that spawned, are maybe the best example yet of the link between physical, mental, and financial health. My guest today is uniquely qualified to explore these intersections. Dr. Richard Besser is a global public health expert and the president and CEO of the Robert Wood Johnson Foundation, the largest private foundation in the country devoted solely to improving the nation’s health.

As a pediatrician and the former acting director of the Centers for Disease Control, Dr. Besser has worked in communities around the globe to ensure families are able to raise healthy children. Today, he is particularly focused on achieving health equity, ensuring that communities of color aren’t left behind. Rich, welcome to EMERGE Everywhere.

Dr. Richard Besser:
Thanks, Jennifer. It’s really good to be here.

Jennifer Tescher:
So, this show, EMERGE Everywhere is really about intersections. It’s about the idea that your patient, and my worker, and his student and her renter are actually all the same person. We just tend to see them in a silo. And if there’s one thing that COVID has really reinforced for me, it’s that everything is interconnected. Absolutely everything is interconnected.

You lead the Robert Wood Johnson Foundation and your North star as you’ve said, is to build a culture of health.

Dr. Richard Besser:
Yeah.

Jennifer Tescher:
I see the culture of health as being all but intersections. So talk to me a little bit about what is a culture of health and why is it so important?

Dr. Richard Besser:
Yeah. It is absolutely critically important. And as you’re saying, COVID shines a bright light on it. The idea of a culture of health is really a recognition that health is about much more than having access to high quality, comprehensive, affordable health care. You have to have that, but if you have health care, it doesn’t mean that you truly have opportunities for health.

Health is what takes place in the communities in which we live, where our kids go to school and where they play, where we work. Those are all the settings that play such a role in terms of health. And we don’t talk about the culture of health without talking about the concept of health equity. And by that we mean the idea that everyone has a fair and just opportunity for health and that the barriers to health that are there for so many, related to structural racism, and sexism, and homophobia, and able-ism and classism; you go on and on.

But if you don’t remove those barriers, if you don’t look at those barriers and recognize that for some people in our society, health is the easy option. And for some people in our society, it’s a near impossibility. If you don’t recognize that and move away from this idea, that health is all about individual choice, you will never reach the goal of a culture of health.

Jennifer Tescher:
This idea of a culture of health is not a COVID idea. The foundation was at this pre-COVID, I think even before you came to the foundation in 2017. What does that work look like? How does trying to create a culture of health show up in the grants you made, in the calls to action that you are making out in the world?

Dr. Richard Besser:
Yeah, I mean, we’ll talk a lot about COVID because COVID has shined a light on the inequities in our society and in just a stark light. When we think about a culture of health, it’s really everything. And so for us, as grantmakers, as a philanthropy, we’ve had to pick areas where we think we can have the most impact.

So we do a lot of work around healthy communities and the connection between housing and health. What kind of development takes place in communities? How do you ensure that people live in communities where they have access to affordable, safe housing, stable housing? How do you ensure that there are jobs and transportation systems that are linked to where people are living, so that they can work. There’s a lot of attention there. And how can we shine a light and let people see the connection between housing and health?

Last year my president’s message was all about this connection between housing and health. And it’s pretty easy to understand I think, that if someone is spending more than half of their income on housing, it’s hard to have a lot of money left over for healthy food, for all of the things that you know people need to lead a healthy life. If you are in a household where your risk of eviction is very high, it’s pretty hard for you to provide the stable environment you want to for your children. It’s hard if you’re in a household where eviction is a challenge, to have your child in a stable school environment where they can develop the peer relationships that are so important, the educational development that’s so important. There’s clear connections there between housing and health.

We’re also focused on the issues of healthy children and families. And there it’s, how do we ensure that every family has what they know their children need to succeed? Very different than saying, “Wow, let’s provide some education so people know that you’re supposed to exercise an hour a day and you need to eat properly off your food pyramid or your food plate.” And it’s, how do you ensure that parents have those resources they know they need to raise healthy, successful children?

And a lot of our work focuses on issues of policy, what policies need to be in place, around mindsets of who do we, as a society view as worthy, and who do we not? Where do we yell out for opportunity and where do we not? And more and more, looking at community power; how do we provide resources to those in communities who are closest to the problem who are living these issues every day, who clearly see the solutions for those problems and need resources to help effect the changes that they know are necessary.

We do a lot of investment in leaders. Across our history we’ve had leadership programs, the Robert Wood Johnson Clinical Scholars Program trained people to do health services research. And you’ll find incredible graduates of that program in leadership positions across the country. We have moved away from that to change leadership programs. So how do we provide resources to those in communities who are trying to affect change? And that’s really, really exciting work.

Jennifer Tescher:
It’s one thing to talk to healthcare professionals or administrators or public health professionals about the upstream inputs to health, the social determinants of health, but it’s another to engage with say, employers or big corporations, or folks in community or home builders, who don’t see themselves necessarily as being in the health business.

How do you make the case to them? I mean, it seems obvious to you and me that there’s a connection, but how do you make the case to these audiences, which wouldn’t have been your traditional audience as a health foundation?

Dr. Richard Besser:
Yeah. I’m finding that with the COVID pandemic and the economic crisis in America and the movement for racial justice in America, it’s become easier and easier to make the case for the connection between economic health and overall health. It’s easier to make the connection between structural racism and barriers to health.

If you look at this pandemic, it’s hitting every community in America, but it clearly is not hitting every community, every population at the same level. Black, Latino, Native Americans being infected, being hospitalized, dying at three to five to seven times the rate of white Americans. And it begs the question as to why, and a lot of that comes down to economics. A greater proportion of people of color are paid lower wages, they’re in lower income jobs, have less wealth, have less savings. The idea of staying home and working remotely is not an option if you work in food production, if you’re a frontline healthcare worker, if you work in a transit system. So many of these jobs have a greater proportion of individuals who are people of color. And so you can’t do those jobs remotely.

The wealth gap in America is enormous. The ratio of wealth between whites to blacks is something like 10 to 1. And so the resources that people have to be able to say, “You know, I’m not feeling great today,” or, “I’ve been exposed to somebody who may have COVID. I’m going to stay home and make sure that I’m not spreading this out there.”

Well, if the choice is between going to work with a slight risk so that you can put food on the table and pay the rent, or staying home to follow public health recommendations, well, it’s an easy choice. It’s a rational choice. You have to go to work. And while the federal government puts some resources out there to support people last spring, most of those are gone and the rest of them are gone by the end of December. And the idea that as the wealthiest nation on the planet, we are going to allow tens of millions of people to be evicted in January, in the middle of winter, in the middle of a pandemic, is absolutely criminal.

Jennifer Tescher:
Yeah. I am very, very concerned about the financial health of Americans. At the same time we see the stock market hit the 30,000 level. There’s such a disconnect between the typical measures that we use as a country to assess our economic health and the economic realities for frankly, the majority of Americans. And certainly if those living at the margins, and it creates a sense of cognitive dissonance to hold those same set of facts in your head at the same time and try to make sense of them.

Dr. Richard Besser:
Yeah.

Jennifer Tescher:
We’re going to get back to your sort of call to action for the incoming administration. But first, I want to make sure that we continue to unpack a little bit, these intersection between physical, mental, and financial health, because it’s really bi-directional. So healthcare costs can disrupt financial health, but also, financial insecurity impacts health outcomes.

Dr. Richard Besser:
Yeah.

Jennifer Tescher:
One of the things that we haven’t yet talked about is the role that stress plays in causing so many of the chronic health conditions that many people face or at least contribute to them. So we do a lot of survey work to assess the state of financial health in America. And we ask a whole set of other questions, including a bunch of basic health questions, physical health questions, so that we can understand the connection.

And according to our research, 43% of our respondents, this is nationally representative. It’s a panel of about 6,000 people. 43% say that their finances are causing them moderate to high stress. 58% of them believe that their financial stress affects their physical health. 65% believe financial stress impacts their mental health. So people are aware, themselves, of the intersection.

And then of course, what you would expect is true. The healthier you are physically, the more financially healthy you are. Folks who state that they’re in excellent physical health, half of them are financially healthy. Similarly, people who aren’t getting healthcare, it’s because they can’t afford it. And often, we had 17% of consumers say they stopped taking their medication or took less than directed, because they couldn’t afford the costs.

And finally, we look at what are the factors that really drive financial health? When your physical health declines, we find that you experience a three point decline in your financial health. If a financial health score is on a scale of 0 to 100, you’re losing more than three points when your physical health declines. You’re losing more than three points when you have a major medical expense. But when your physical health improves, you gain almost two points.

So, talk to me a little bit about how you see this connection play out in some of the broad changes and transformations that you are trying to affect.

Dr. Richard Besser:
Well, I’m seeing it play out again in the pandemic. If you look at the start of the pandemic, there were 28 million people in America without health insurance. The connection between how we provide health services in this country and finance is clear, given how many people get health insurance through their jobs. And the Affordable Care Act increased the number of people who had health insurance, but it was not the end state that we’re looking for. We believe that we should have universal healthcare. And there are many ways to get there, but everyone deserves access to high quality, comprehensive, affordable healthcare.

And during this pandemic, as millions of people have lost their jobs, millions of people will be losing health insurance and it’s just wrong. With the Affordable Care Act, states have the opportunity to expand Medicaid, but a number of states haven’t. There are 12 states that still haven’t expanded Medicaid. And those are primarily southern states with very large proportions of populations who are African American. So again, you see this connection between structural racism and health.

When I look at the early guidance that CDC was putting out in terms of, well, what do you do if you think you have COVID? They said, “Don’t go to the hospital because there, you can expose healthcare workers or expose yourself. Call your doctor.” Well, if you didn’t have a doctor, what are you going to do? It means that you’re going to delay getting care. You’re going to go to the hospital when you’re sick, and your outcome is going to be worse.

Your comment about stress is spot on. We know that in the short-term, a stress reaction is good. You’re outside walking in the woods, you see a bear, your stress reaction kicks in and you get out of there. That’s good. But if the bear is there every day, you leave your house and there’s the bear. You’re walking down the street and there’s the bear. The bear doesn’t go away. That’s really bad for your health. And that’s the impact of stress of all kinds.

We know now that that’s one of the reasons why we see worse health outcomes in people who are subjected to chronic racism. It’s one of those impacts there and that’s playing out here. When you look at why African-Americans are being affected so greatly by this, part of it is exposure. The biggest part is exposure. But part of it is also because of higher rates of many of the chronic diseases; diabetes, heart disease, lung disease, from environmental conditions in communities. Again, there, there’s financial issues and there’s red lining. There’s the lack of ability to move to opportunity, to financial opportunity. But there’s also the conditions in those communities in terms of air quality and such that can worsen health.

Jennifer Tescher:
Yeah.

Dr. Richard Besser:
Finances is definitely a part of it. I see a lot of that connection in terms of our thinking around who has access to high quality, good paying jobs, and who doesn’t. And when I think about it in terms of our work and why we talk about the importance of a living wage. What could that possibly have to do with health? It has everything to do about health, everything.

When we’re saying to people, “Wow, this pandemic would just go away if everyone would just wear their masks and keep apart and wash their hands,” that would help a lot, and that really has to happen over these next few months, next four or five months before we have a vaccine. But if Congress doesn’t step in and do what they need to do, people are going to be hit incredibly hard at the end of December. That’s when we see eviction protection go away. That’s where we see a lot of the financial issues, the pandemic emergency unemployment compensation, those extra 13 weeks goes away, unemployment assistance for gig workers, that goes away, paid family leave for many people goes away.

These things are tied to finance, because if you don’t have money coming in, there’s no way you can follow the CDC recommendations and quarantine and isolate when you think you may have been exposed. It’s just impossible, but yet Congress doesn’t come together and put money back in people’s pockets. It’s wrong morally. It’s wrong from a public health perspective.

Jennifer Tescher:
Let’s use this as a jumping off point though, to talk about the role of employers. Because given the lack of a sufficient response by the government, you’ve seen a lot of corporate leaders not just speak up on these kinds of issues, but have to take more significant stances and play a bigger role in helping to prop up their workers.

Unfortunately, we’ve seen a lot of big companies pull back, dial back on some of the policies that they put in place. For instance, the extra COVID pay for emergency or frontline workers, paid leave; we’ve seen some of that get pulled back at the same time that we’re now hearing potentially about a double dip recession.

Dr. Richard Besser:
Yeah.

Jennifer Tescher:
And so whether or not there’s healthcare for all, it seems to me at least, that employers are going to continue to be a really important locus for not just health insurance and healthcare issues, but all kinds of other financial issues and issues around good jobs. And it’s kind of interesting in a way, because if I understand the history right, the creator of the foundation, Robert Wood Johnson, II really got started here by working with his employees and the community to help them through the great depression.

Dr. Richard Besser:
Yeah.

Jennifer Tescher:
And I regularly say to employers, if you’re really focusing on the health of your workforce, because you want to reduce your insurance costs, and you’re not thinking about the financial health of your workforce, you’re just bailing a leaky boat, because they’re so connected.

So I’d love to hear you talk a little bit more about if we are to move to healthcare for all, what role do you continue to see for employers? How important are they? Do they give us enough coverage, given that they’re plenty of people who are not in a traditional workforce? How do you see their role?

Dr. Richard Besser:
I think employers, in particular, large employers, could play a really important role. This summer, I spoke to the Business Roundtable, and there was a lot of focus and interest and I think real interest, in saying, what can the corporate community do to address issues of structural racism in America?

Jennifer Tescher:
Yeah.

Dr. Richard Besser:
And the question to me was, “How does this connect to health? What can be done?” And I said, “Well, first is, you can pay a living wage and make sure that every employee is paid a living wage. The second thing is you can look at your sick leave and family medical leave policies. Because if someone is exposed to COVID and the choice, as I was saying before, and the choice is between staying home for 14 days, because that’s the recommendation, but there’s no leave or someone could lose their job, they’re going to come to work and they’re going to infect your other employees and they’re going to infect your customers. And that’s a really bad thing.”

So whether it’s out of corporate self-interest or because it’s absolutely the right thing to do, everyone in America should have sick leave. Everyone in America should be paid a living wage. It seems like it’s a no brainer, but you see time and time again, when efforts are made to increase the minimum wage, that there’s real pushback on that, when it’s the right thing to do from an equity standpoint and from a justice standpoint, and it has a direct tie in to health.

Jennifer Tescher:
Yeah. It’ll be very interesting to see in the new administration, how much progress can be made. It’ll depend in part on who wins those two Senate races in Georgia. But there’s been quite a bit of work at the state level and the municipal level on some of these issues. And I think whether it ends up being a state’s game or a federal game, it’ll all depend on what we see in January.

I think many people know that you were the acting director of the CDC. And before that, you were in charge of public health emergency preparedness and emergency response. And so I feel like a lot of our listeners are going to want to hear from you a little bit about this vaccine or vaccines, I should say, that we’re hearing about. But fitting for this conversation, I’d love to hear you talk about how you think we can use vaccine distribution to promote health equity. Should there be equity considerations to guide the decisions around prioritizing who gets it, how they get it? I’d love to hear you talk a little bit about that.

Dr. Richard Besser:
Yeah. I have never been more optimistic about the pandemic and its course than I am right now, but I’ve also never been more worried about the situation. I’m worried about the situation, because all of this exciting vaccine news is I think, giving people a misconception, that it’s done, we can take off our masks and hug our loved ones. Let’s get together, have a big party and celebrate. That’s not the case. This winter is a field day for respiratory viruses, that viruses love the winter. They love cold air. They love low humidity. They love when we’re indoors and near each other, because viruses can then jump from person to person.

And if we can come together as a nation and get the politics out of this, so that wearing a mask doesn’t say something about your political leanings, it says something about your approach to public health, that you care about your own health and the health of your family and the health of people around you. If we can do that and double down and buckle down over the next three, four months, then yes, the end is in sight.

When it comes to the vaccines and FDA, they have to be allowed to do their approval process without politics coming into it, or no one is going to want the vaccines that come out the other end. And that would be the ultimate tragedy, to have vaccines that are safe and effective and no one wants them because we don’t believe that the science was done correctly.

But you have to have equity considerations in this. When you look at who is being hit hardest by the pandemic, that has to factor in. And I’m seeing it factoring in, in a number of ways that I think are on target, but we’ll have to see how it plays out. In a public health crisis, you don’t want someone’s income or social connections to drive their access and where they are in line for prevention measure.

Here, the way the priority list is determined, the FDA decides whether vaccines are approved. And then the CDC gets recommendations from its federal advisory committee, the Advisory Committee on Immunization Practices. And what they’re looking at in terms of priority order, and this factors in issues of justice, factors in issues of equity, issues of maximizing benefits and minimizing harm, and it factors in the issues of transparency, so people know how the systems should work.

Their recommendation is frontline health workers get it first. And that makes sense because they’re taking care of all of us when we get sick. And if you look there in terms of equity issues, there is a high proportion of people of color who work as frontline healthcare workers. Second line are other essential workers. And again, high proportions of people of color are out there doing the work to keep society going. That’s important. The next group are those with underlying medical conditions and a great report and people of color have those conditions. And then the next group are people over 65. There you see actually a lower proportion of people of color.
And so we’ll need to see as this goes forward, but people over 65 are a high risk group, whereas we’ve seen devastating impact in nursing homes. It’s going to be really important that public health work with trusted leaders in communities. The surveys right now are showing that fewer than 20% of African-Americans trust that a vaccine coming forward is going to be safe and that they want to get it. Nationally, it’s less than 60% of people say that they’re going to trust this.

So a lot of work has to be done, and it’s not simply saying, “Oh, yes, it’s safe and effective,” it’s looking to see how do you overcome the history of how communities of color, how our African-American communities have been treated by public health? There’s a long history of experimentation and that needs to be dealt with by dealing with trusted voices in communities.

Thankfully, the vaccine trials that have been conducted, worked hard to recruit very diverse study subjects, so that there will be data on safety and effectiveness by race and ethnicity, and hopefully that will help with some of the trust issues. But each state should provide transparency and show who is getting vaccines. Show it by location, show it by race, ethnicity, income, gender. There’s a lot of factors here that will be very important so that we can feel comfortable that it was done in a fair way and will have impact.

Jennifer Tescher:
Got it. I want to talk a little about you as a leader, because the other thing we talk about on this podcast is the importance of empathy in really seeing people in 3D, really seeing all of the person, and thus being able to work on these intersections. And you have a really interesting personal journey. You are a doctor. You’ve been a public health expert. You’ve been involved in public health issues like Ebola and H1N1 all around the world. You come from a family who seems to be very focused on giving back, particularly in the healthcare arena. And I tend to find that the best and most empathetic leaders have some personal experience or personal story that connects to their passion and connects to their leadership.

So tell us about you. Sort of, how did you get on this journey? Did you always know you wanted to be a doctor?

Dr. Richard Besser:
I think I did know I wanted to be a doctor. I grew up in a household of doctors. My father is an obstetrician and gynecologist. My mom’s a social worker. My dad’s parents, who I was really close to, my grandfather was a family doctor in Philadelphia and my grandmother was the nurse at his practice and their office was in the basement of a kind of a brownstone in Philly. And I just saw the lives that they were able to live and the joy that they got in being able to be in a career of service. And my parents also believed in giving back. Each summer we would spend several weeks out on the Navajo Reservation out in Arizona. And I went out with them and enjoyed that experience.

And so I had a sense I wanted to go into medicine, but I didn’t think I was going to want to do the same approach to medicine that they did. I was really interested in global health. I’ve been an exchange student in Australia. I thought I would spend my career working around the world. I spent a year after college traveling around the world. I worked as a bartender, made some money and then took off. And it was probably one of the most important years for me, just being able to see the conditions for people in many lower income countries. So I decided that I wanted a career that was very focused on public health and went off that route.

But I’m still a pediatrician. And at heart, in terms of my identity, I view myself as a pediatrician. And I’ve been fortunate that I’ve been able to continue practicing pediatrics in all my jobs as a volunteer in community clinics. And that experience of being with families in community clinics has really grounded me in all my other work, because I see the challenges that so many people face in trying to lead healthy lives and trying to provide the best for their children.

And so little of it has to do with lack of knowledge, yet we continue to approach every single problem that, “Oh, wow, just hit it with an ad campaign. If people just knew what to do, they would change their behavior.” Instead of doing what we are doing at the Robert Wood Johnson Foundation, which is saying, “Okay, how do we address the structures that allow this to continue?”

And it’s not just saying, “Wow, this person is about to have their utilities shut off. Let’s connect them to an attorney so their utilities aren’t shut off. This person’s hungry, let’s connect them to a food bank.” It’s saying, why are people stuck in communities where there’s little opportunity? Why are they stuck in communities where they’re having to pay such a high proportion of their money on rent? Why are they stuck in jobs that don’t pay them enough to feed their family without going to a food bank? And it’s very different.

So when we talk about social determinants of health, we want to go upstream and look and say, what is it about the fundamental nature of our economy? What is it about the fundamental nature of our society that says that some people are worthy and some people are not, some people lack opportunity, and some people are lifted up and it’s pretty hard not to succeed. We want to address those fundamental issues.

And it speaks to my passion around social justice. And this is about justice. These are justice issues, and I’ve been very fortunate that I’ve been able to work in public health in many different ways. And in each one, I see a different set of tools to come at the problem. So governmental public health and academic public health, and then practicing public health on the air at ABC, and now at a philanthropy. We all come at these issues from different perspectives, but they all I think, are really valuable and contribute to the solutions.

Jennifer Tescher:
Yeah, well, you and I, it sounds like we have a few things in common. Because for me, as a former journalist, I’m a question asker. And I think the most powerful question you can ask is why.

Dr. Richard Besser:
Yeah.

Jennifer Tescher:
And it’s important to understand the details and to get into the details, but in financial services, as an example, the question why is often, “Well, because that’s how it’s done.” I expect that is often the case in medicine and frankly, it’s often the case in many fields and it relates in part to the importance of continued innovation and connecting that innovation to what’s actually happening in the world. So I think asking good questions is something that I think we both find to be a powerful tool.

The other thing it sounds like we have in common, is that we are frequently having to tell people that it’s not about education. Because often, the very first thing that you hear when you talk about challenges in pure financial services is, “Let’s teach them how to budget.” I can tell you people who barely make enough money to make ends meet, are better budgeters than anybody, because they know how to stretch a dollar.

Dr. Richard Besser:
Yeah.

Jennifer Tescher:
I often talk about the know do gap, right? We all know we should save, but it’s hard. And frankly, some of it is just the way that our brains are wired from a behavioral economics perspective. We all know we should eat healthy. I’m the person who cuts the donut in half and then I go back for the other half a donut, right?

Dr. Richard Besser:
Right.

Jennifer Tescher:
So we all know we shouldn’t overspend and then we spend. So that’s not about knowledge, that’s about behavior. And I think one of the most challenging aspects of the equity conversation that we’re having today is recognizing that so much of behavior is predicated on systems and on past history. And that there’s a deep connection between what appears to be a choice. You have to consider what the choice set was in the first place.

Dr. Richard Besser:
Right. We talk about that a lot in our work, that yes, the choices people make matter in terms of health, but the choices you make depend on the choices you have. And for too many people in our country, healthy choices are just not an option, or they’re not an easy option. And we want to work towards a day when everyone has those healthy options as the easy way, as the default.

Jennifer Tescher:
Exactly.

Dr. Richard Besser:
We have a long way to go. But I am optimistic that the existence of this pandemic, and the economic downturn, and the movement for racial justice could represent a real inflection point. And as a society, we have the opportunity to say, “Is this the society we want to have? Is this as good as it can get?” And if not, we have to make some fundamental changes in America.

Jennifer Tescher:
Rich, thanks so much for joining us on EMERGE Everywhere.

Dr. Richard Besser:
Thanks so much for having me. I really enjoyed the conversation.

Jennifer Tescher:
This has been EMERGE Everywhere, a Financial Health Network production. I’m Jennifer Tescher, and I’d love to hear your ideas for future guests and your reactions to the show. You can connect with me on Twitter @JenTescher. If you liked this episode, please review the show and subscribe wherever you get your podcasts. To learn more about the work and research we do, please visit emerge.finhealthnetwork.org. See you next time.