The idea that the Kirwan Commission’s recommendations for K-12 education could significantly improve Maryland’s health might startle many readers. The idea that health care should play a significant role in implementing Kirwan is equally startling. But behind these ideas are three links:
First, the United States invests much more in health care and far less in education and social services than do other high-income countries. Public health advocates argue that it is no coincidence that Americans have shorter life expectancy than those other countries, or that, for the last few years, life expectancy in the U.S. has been falling and the difference has grown. Public health advocates have also provided extensive evidence that education and social services enhance health and that poverty, poor housing and bad jobs are killers. The evidence — for example the health benefits of Head Start — only becomes stronger as the data accumulate.
As emerged with brutal clarity during the Baltimore uprising of 2015, measures of neighborhood “disadvantage” (e.g., lower levels of income, employment, education and housing quality) predict shorter life and social unrest. The 14-years shorter life expectancy in Sandtown-Winchester compared to Roland Park, like the 14-years difference between high-school dropouts and graduate school diplomates, should be no surprise. Pouring more money into hospital-based health care is unlikely, based on experience of the last 10 years, to generate substantial gains in life expectancy or health; investing in education might.
The second link is that health and education are intermingled priorities that draw from the same state budget. Hospitals are doing well in Maryland, whether judged by regulated profit margin, CEO salary or total operating profits and revenue. Education is not doing well, as extensively documented in the Kirwan Commission report. One reason is that, for the last decade, growth in the fraction of state revenues going to Medicaid roughly parallels shrinkage in the fraction of state revenues going to K-12 education, which is the unsurprising consequence of a “no new taxes” environment. “No new taxes” is an effective political slogan because real wages for the middle class have barely increased over the last 25 years. Stagnant wage growth is partly due to the escalation of health costs.
A third link between education and health is in the Kirwan Commission’s recommendation that health centers should be established in schools with high rates of poverty or student problems. This recommendation is important to schools, to hospitals and to the general public. For schools, it is important because impoverished kids so often lack a readily accessible source of general medical care. Mental health counseling services are especially important for a school system that seeks to retain and serve its most troubled students. For hospitals, investments in school health are the kind of community service that is legally required of them as non-profits. For the public, this recommendation would address a pressing need in our schools and move Maryland’s heath system toward preventive and low intensity services, which can reduce the need for acute inpatient care.
Maryland’s long-running hospital rate setting experiment uniquely positions us to invest in school health centers some money that might otherwise go to inpatient care. The Health Services Cost Review Commission (HSCRC), which regulates hospital rates in Maryland, has been operating an arrangement for many years that creates a statewide pool of funds to reimburse hospitals for the care of patients who cannot pay. In a similar way, or through other means, the HSCRC could apportion funds to hospitals that work with the school authorities in the creation and operation of health centers in impoverished community schools.
The Kirwan Commission projected an annual cost of $300 million for these clinical centers when their proposal is fully implemented in 10 years. In Fiscal Year 2018, Maryland hospitals were paid approximately $17 billion and generated more than $500 million in operating profits. We are confident that the hospital system could absorb the cost of providing some financial support to clinical centers in schools without serious problems even if no additional funding were available to the hospitals.
This proposal may challenge some bureaucratic boundaries, but it provides a model for the kind of collaborative thinking that will be required to implement Kirwan’s recommendations and reshape the priorities of our health system.
Dr. Stephen F. Jencks (email@example.com) and Jack C. Keane are former commissioners of the Maryland Health Services Cost Review Commission.