How Do We Fund Flourishing? Maybe Not through Health Care

The health policy community has a growing interest in the impact of nonmedical determinants of health, such as housing, nutrition, and social supports, on both health outcomes and costs. This interest has been spurred by the Affordable Care Act's emphasis on prevention, Robert Wood Johnson's grant-making focus on a Culture of Health, and an uptick of research demonstrating the potential returns to health care from investments in social services. Much of this policy-making, grant making, and research has focused on older Americans. The direct policy implications of this strategy can be elusive. It has become clear that more than medicine will be necessary to improve older Americans' health status. Real improvement likely requires the development of additional social service offerings, including housing that is accessible to people with disabilities, Meals on Wheels-type nutrition supports, and transportation. But who should bear the costs and control the finances associated with these programs? In this essay, I explore the question of how policy-makers should consider financing nonmedical investments in older Americans' health. As the reader will recognize, I stop short of arguing for what will work. Rather, I identify the strands of an emerging strategy-namely, for health care dollars to be diverted into social service programming-and offer several cautions. It may be that policy-makers still wish to continue down this path, but my hope is that this essay will allow them to so with greater attention to the risks and unintended consequences of that strategy.