People’s foundation for physical and mental well-being starts with access to fresh air, clean water, and nutritious food. We all need a balance between physical activity and sleep. We need healthy relationships, with freedom to express our gender and sexuality. We need to support the health and needs of women of reproductive age to ensure the conditions exist to nurture healthy babies. We need to feel safe from violence, crime, and injury. And we need to be free from addiction, trauma, and toxic stress.

Meeting these basic needs allows us to be healthier today by avoiding hunger, exhaustion, disease, and injury. It also means we are more likely to thrive tomorrow by supporting our ability to withstand adversity.

Freedom from Trauma, Violence, & Addiction

Health Care

Food

Changing Course

Changing Course summaries feature working definitions, recent facts, key issues, and a short list of pivotal moves that stand out as high priorities for quick action.

Changing-Course_Basic-Needs

Deep Dive

Deep Dives are the full source documents contributed by colleagues on the various topics selected in the Changing Course summaries.

Deep-Dive_Basic-Needs

FREEDOM FROM TRAUMA, VIOLENCE, & ADDICTION

1,000% increase in calls to the federal Disaster Distress hotline

50% of American children experience at least one adverse childhood event

33% of Americans wait more than a week to access a mental health clinician

67% of American adults believe their sleep was healthier before the pandemic

45% of Americans said they felt “down, depressed, or hopeless” for several days in the previous week

Facts adapted from the Freedom from Trauma, Violence, and Addiction
Deep Dive

THE IMPACTS OF TRAUMA, VIOLENCE, AND ADDICTION on human life are far reaching. Adverse childhood experiences and toxic environments can harm health and well-being across a lifespan and generations. Unfortunately, quality mental health and addiction care has long been difficult to access, hard to afford, and too uncoordinated, and underfunded to provide real healing.

To address our mental, emotional, and social health needs as whole persons, and particularly the loss, trauma, and substance misuse occurring in the wake of COVID-19, we must move toward ensuring everyone has access to integrated, comprehensive, multi-sector, community-based care, solidly anchored in the promotion of mental health and emotional resilience.

Key Issues

Depression is the leading contributor to disability, with far-ranging effects on physical, social, and emotional health.
With increasing rates of unemployment, the number of uninsured is rising even as the need for care increases.
Without viable community treatment options, those in need often go without care, or are forced into more expensive emergency services.
COVID-19 has highlighted vulnerabilities within our current delivery system, underscoring that care in the clinical or hospital setting is not always feasible or the most effective approach.
The traditional mental health workforce does not have the capacity on its own to meet the demand for services. This was true prior to COVID-19 and is even more evident now.
A large body of research on “task-shifting” demonstrates how many of the tasks of treating addiction and mental health needs—such as screening and tracking improvement, providing aspects of supportive counseling, coaching skills in self-care—can be done by trusted nonclinical health professionals.

Pivotal Moves

A Selection of Ideas for Changing Course

ENSURE ACCESS TO CARE, NOW

Emergency funding must be dedicated to clinicians and organizations treating individuals with mental health and substance use disorders.

A significant portion of emergency funds should be set aside for organizations serving those enrolled in Medicaid.

CHANGE DELIVERY OF MENTAL HEALTH CARE

Integrate mental health staff and universal screening into primary care, improve assessment and referral pathways, undertake outreach into communities and schools, and ensure that digital care is available.

Adopt a “no wrong door” approach that allows people to secure the appropriate level of care without imposing burdens that worsen their distress.

Distribute the workforce to reach people where they are.

TRANSFORM THE MENTAL HEALTH WORKFORCE

Implement a Community Health Service Corps that is dedicated to prevention and to meeting distinct needs with culturally sensitive approaches.

Embrace task-shifting—package clinical and cultural knowledge with methods that heal and prevent harm, led by the community.

Leverage clergy, teachers, community health workers, parents, trusted peers to change the character and expand the reach of mental health services.

Large-scale efforts to shift care into communities will require strong community leadership and a unifying infrastructure, as well as steps to ensure availability and equitable distribution.

GET THE FACTS & PUT THEM INTO ACTION

Implement real-time surveillance of critical issues like suicide, drug overdose deaths, and the incidence of mental health diagnoses in crises.

Devote additional resources to evaluating community and clinical interventions that mitigate or even prevent behavioral health conditions.

Translate findings into effective education and skill-building rooted in best practices and enhanced by technical and peer assistance.

Adapted from Freedom from Trauma, Violence, and Addiction Deep Dive

Path to Renewal

We need to face the reality of a broken, fragmented system of mental health care. Effective action to address this failure will impact each area of renewal discussed in the next section of this document. It will enhance civic life through commitment and investment in community solutions. It will strengthen the economy by providing meaningful jobs, improving improved educational attainment, increasing productivity, and reducing costs. It will improve social, emotional, and spiritual well-being by creating accessible and culturally competent support services.

Public Health

3% of all US health care spending goes to public health

51% of Americans are served by a comprehensive public health system

30,000 local public health jobs have been lost since the Great Recession

12 public health emergencies were federally declared in 2019, compared with only 2 in 2010

$4.5B is needed to modernize the foundational capabilities of state, local, tribal, and territorial health
departments

Facts adapted from the Basic Needs: Public Health Deep Dive

THE GOVERNMENTAL PUBLIC HEALTH SECTOR has agencies at the federal, state, local, tribal, and territorial levels focused on the protection and promotion of good health among all the members within its jurisdictions, with special attention to those at elevated risk of poor health. All agencies are engaged in core activities: data collection and analysis; disease and injury prevention and control; and the promotion and/or implementation of health-oriented policies and practices.

In addition to core activities, health departments are:

Addressing a variety of new issues: the opioid epidemic, the dramatic rise in suicides, widespread vaping and vaping-related lung injuries, weather related emergencies, and the reemergence of vaccine- preventable infectious diseases, like measles
Developing partnerships with other sectors that impact health and well-being, such as health care, education, criminal justice, housing, transportation and economic development

More health agencies have refocused their attention on the promotion of equity. Systemic inequities have led to higher rates of underlying medical conditions in Communities of Color, increasing vulnerability for severe COVID-19 illness. While everyone is at risk for COVID-19, Black people, Latinos, American Indians/Alaska Natives, Asian Americans, Native Hawaiians, and Pacific Islanders are at elevated risk. The root causes of racial and ethnic health and health care disparities are complex and interconnected, and these inequities existed long before COVID-19.

Key Issues

Chronic underfunding of public health has limited health departments’
ability to:

Modernize labs, surveillance systems, and informatics
Hire and retain workforce
Address the underlying health conditions that put communities at heightened risk from COVID-19

Root causes of racial and ethnic health and health care disparities
limit communities’ ability to be prepared against and recover from
public health emergencies, like COVID-19.

Public health is increasingly focused on equity and the vital conditions
for community well-being.

Pivotal Moves

A Selection of Ideas for Changing Course

STOP SHORT-CHANGING PUBLIC HEALTH

We need to ensure state, local, tribal, and territorial health departments have the tools, workforce, and systems in place to address existing and emerging health threats.

REDOUBLE EQUITY EFFORTS

We need to collect and publicly report comprehensive demographic data, and information related to COVID-19 cases, hospitalizations, and deaths. This disaggregated data is necessary for identifying impacted areas and supporting outreach, prevention, and access to care.

END AGENCY SILOS

Prevention, health screening, and treatment services have been siloed in specialized agencies. A transformative approach is needed: All federal agencies impacting any aspect of behavioral health need to collaborate.

EXPAND AGE-FRIENDLY PUBLIC HEALTH

COVID-19 has exposed the need for a specialized public health focus on the growing older adult population. Public health agencies at the federal, state, and local levels need funding to protect older adults from COVID-19 infection, as well as from the consequences of social isolation and interruptions in care.

PREPARE FOR THE NEXT MAJOR THREAT

To avoid a repeat of the COVID-19 public health emergency, we must increase funding to build preparedness capabilities in all states, territories, and Tribal Nations.

Adapted from Basic Needs: Public Health Deep Dive

Connections

Meaningful Work and Wealth
Lack of sick leave benefits may result in workers coming to work when they should be in quarantine or isolation. Low-income workers are much less likely to receive paid sick leave even though these workers are often less able to miss work when they are sick because they rely on their full pay.

Path to Renewal

Public health departments are uniquely situated to build collaborations across sectors, identify priorities in communities, and help address policies that inhibit health.

Health Care

4000% more nonurgent telehealth visits occurred in March and April within one health system

20% of the average American’s paycheck is spent on health insurance

67% of COVID-19 deaths in Chicago were Black people, even though the city’s population is only 32% Black

54% of providers and 60% of medical students and residents have substantial symptoms of burnout

Facts adapted from the Basic Needs: Health care Deep Dive

EVEN PRIOR TO THIS GLOBAL PANDEMIC, health care in the United States has held a tension. There are incredible contributions, breakthroughs, and improvements that the health care delivery system can proudly claim, as well as systemic problems that chronically plague the sector. Despite pockets of excellence and innovation, the United States health care system continues to experience inefficiencies, challenges, and poor outcomes for populations in relation to the investment made.

The system’s focus on acute, episodic, fee-for-service care has resulted in fragmented, inadequate, and/or inappropriate service delivery for many chronic physical and mental health conditions. Structural inequities and interpersonal bias have been drivers of adverse experiences and stark disparities. The pandemic has only amplified those problems, as seen in the greatly higher rates at which People of Color are contracting the virus and dying from it.

In addition to the direct impacts on patients, COVID-19 has had a substantial impact on our health care delivery system, from the supply chain to the well-being of the health care workforce. Drastic reductions in elective procedures have reduced revenue for many
health care delivery systems. Hospitals and health systems that were struggling before COVID-19 are fighting to stave off insolvency. This crisis allows us the opportunity to examine the way care is delivered, coordinated, and paid for. We can use this disruptive moment to drive a radical redesign that achieves better, more equitable outcomes.

Key Issues

The United States has some of the worst health outcomes of any high-income country.
Perverse financial incentives that drive inappropriate utilization contribute to excess costs and the crisis of affordability.
Many Tribal Nations have not received promised federal health care funding for COVID-19 as of June 2020.
A significant proportion of point-of-care clinicians are experiencing extraordinarily high rates of depression, anxiety, insomnia, and distress.
We can expect a “second curve” of mental health problems among both health care workers and the public.
If we design for recovery in health care without the explicit use of an equity lens, we will maintain or exacerbate inequities and injustices.

Pivotal Moves

A Selection of Ideas for Changing Course

STRENGTHEN EMERGENCY READINESS

Formally learn from what has and has not worked in the pandemic response so that we can be ready for the next surge.

Plan for rapid shifts and redeployments of facilities, supplies, workforce, and protocols, and intentionally bringing an equity lens to emergency response planning.

DISRUPT TRADITIONAL OFFICE VISITS & PATTERNS OF OVERUSE

Partner with patients to design and improve the virtual care experience.

Attend to variable access to technology, such as the lack of internet access for some patients.

Assure ongoing appropriate payment for virtual services, language access, and access for undocumented people.

Use data and stories from this acute time of delay and avoidance to better define necessary and unnecessary services through a lens of equitable health outcomes.

CARE FOR CAREGIVERS

Provide proactive support to help caregivers manage fear and anxiety in daily work.

Ensure psychological safety and provide opt-out mental health and well-being support.

For all health care workers, address meaning and purpose, choice and autonomy, wellness and resilience.

GROW PUBLIC HEALTH & PREVENTION

Shift health care resources and the locus of control toward public health and social services.

Strengthen innovation and research in prevention and primary care.

Partner with states to launch a Community Health Service Corps that can scale up enhanced contact tracing, testing, and other crisis-management efforts.

SHARE POWER & DECISION-MAKING

Move toward shared power and decision making.

Create partnerships between health care entities and local entities to identify and solve problems, building trust at every step.

Drive toward better, more equitable outcomes by supporting prototypes of asset-based community co-design.

Adapted from Basic Needs: Health Care Deep Dive

Connections

Belonging & Civic Muscle
Health care entities have always played a prominent role in their communities, but there is increasing recognition that their value as anchor institutions extends beyond simply providing care to those who come through the door. They must form partnerships with their communities, learning from them and helping to organize around equity, inclusion, and comprehensive well-being.

Meaningful Work & Wealth
The pandemic has taken a toll on health care providers at every level, imperiling their lives even as it strains their family lives and mental health. We must address this burden and do more to care for the caregivers.

Path to Renewal

America’s health outcomes are among the world’s worst, with unacceptable levels of racial inequity. Yet America spends 18% of its GDP on health care, higher than any comparable nation. Over 60% of bankruptcies are due to medical expenses. Hospitals and health systems
that were struggling before the pandemic are being pushed toward insolvency. Renewing America’s economy will require bold thinking to restructure the delivery of health care.

Food

500% increase in US obesity rate since 1950

4M fewer farms exist now than in 1950 (from 6 million to 2 million)

95% decline in US agricultural workforce since 1950

Facts adapted from the
Basic Needs: Food Deep
Dive

THE MID-20TH CENTURY WAS A TURNING POINT in the American food system, ushering in a precipitous decline in farm populations. With the shift toward highly consolidated, vertically integrated, and industrially efficient agriculture came a rise in obesity, a loss of agricultural biodiversity, and a rise in nitrate pollution and greenhouse gas emissions due to concentrated methods of farming and animal rearing.

COVID-19 has highlighted that farmers and small businesses have precarious livelihoods that are threatened by even a short-term loss of revenue. The shutdown of the food service pipelines on which their businesses are built left many farmers and food processors dangling, imperiling their livelihoods. And yet, while the farmers and food processors were desperate to find markets for their supply, food banks were stretched beyond capacity, with not enough food to meet the dramatically sudden increase in demand.

Key Issues

The higher rates of mortality in Communities of Color can be attributed, at least in part, to the greater incidence of chronic diseases— diabetes, hypertension, obesity—that are closely linked to nutrition.
Low-income communities have limited access to affordable, nutritious food, relying instead on cheap processed foods that are high in calories but low in nutrient density.
Although school districts nimbly met the challenge by diverting their cafeteria food programs to emergency meal delivery at pick-up locations, they did so at great sacrifice to their budgets.
The lack of safe working conditions has left food system workers, who are 1/6 of the nation’s workforce, highly vulnerable to contracting COVID-19.
Fifty plants produce 98% of the meat in the United States. With six multinational companies in control of global meat production, the supply chain is efficient but not resilient.
With financial and policy support from their national and state governments, cities can lead the way toward a regionally resilient food system that supports their local as well as neighboring rural economies.
The financial value of the long-term, high-volume contracts of schools and other large institutions is a de-risking opportunity for the supply chain, which allows for price adjustments according to that economy of mid-scale.

Pivotal Moves

A Selection of Ideas for Changing Course

LEVERAGE THE POWER OF PUBLIC CONTRACTING

Cities and counties should adopt purchasing targets for all their large food service institutions that align purchases with a commitment to local economic support, fair wages, safe working conditions, healthy people, and a healthy environment.

The targets of cities, counties, and institutions should then be aggregated into regional targets. These combined dollars can drive entrepreneurial responsiveness to community needs and make a difference in the regional food economy.

Targets should be backed up with contractual commitments to producers and distributors, and progress toward targets should be shared in publicly presented progress reports.

Nationally networked city procurement goals could be leveraged to influence the federal role in funding aspects of the food system.

Goals supporting local economies, sustainable production practices, fair labor practices, nutritional health, and societal equity should be targeted and implemented with equivalent priority.

COORDINATE FOR REGIONAL CHANGE

Dedicate a permanent stream of government funding for value-chain innovation among regional suppliers to create shorter, more resilient supply chains.

Promote the development of food hubs that operate as intermediaries between public institutions, neighborhood markets, community serving organizations, and local small- to mid-sized farmers and food businesses.

Use bond measures and other public finance mechanisms to fund food-focused capital projects, such as modern warehouses and logistics networks or incubator-style experimental kitchens.

Invest in the knowledge and tools to support a resilient ecosystem of food production and distribution, integrating sectors across an entire region.

ACCOUNT FOR FOOD’S TRUE COST

Begin to reverse the economic dynamics that incentivize the production of unhealthy and environmentally destructive food. This can be done by accelerating the implementation of True Cost Accounting in Food, which integrates cost-benefit analysis, life-cycle assessment, and multi-criteria analyses to capture the systemwide impact of food production.

Use the information from True Cost Accounting to set policies that address affordability by adjusting prices to reflect full societal cost (e.g., reflecting the additional cost of producing a strawberry in a manner that doesn’t harm the environment or workers).

Implement programs that match nutrition assistance benefits dollar for dollar when used for purchasing fruits or vegetables at a farmers market or similar venue.

Adapted from Basic Needs: Food Deep Dive

Connections

Thriving Natural World
A 2017 study of 67 countries placed the United States in the bottom half in terms of nutrition, sustainable agriculture, and
food waste. We must develop sustainable food systems that are inclusive, resilient, safe, and diverse. This means providing healthy and affordable food, minimizing waste, and conserving biodiversity—all while adapting to and mitigating the impacts of climate change.

Path to Renewal

American consumers spend an estimated $1 trillion a year on food. We must advance the development of a supply-chain infrastructure that includes food hubs and leadership from local government. It is important to include the workforce and teams focused on economic development, recognizing that the food system is an economic one that responds to financial incentives and investments.