How Does Your Financial Wellbeing Shape Your Health Outcomes?

Kenneth Shropshire: Welcome to Opportunity Matters. In this episode, we’ll explore the impact of the racial wealth gap on the health care industry, and we’ll strive to figure out some paths to have better outcomes and to close the impacts that the wealth gap has on health care issues.

We’ve got three great guests. One is my co-pilot with the Coalition for Equity and Opportunity, Dr. Fareeda Griffith. She’s the managing director of Wharton CEO, and she’s trained as a quantitative sociologist and demographer. She received her Ph.D. here at Penn, and she left us for 13 years to be a professor at Denison University. There, she focused on a number of issues — anthropology, sociology, and global health. She returned to Penn to work with us. Thank you for coming back.

Guy David is one of my colleagues here. He’s the Allen B. Miller Professor and professor of health care management, professor of medical ethics and health policy at the Perelman School of Medicine. His research focuses on the economics of nonprofit providers, challenges in primary and post-acute care, and the health care workforce. He’s been active in promoting diversity in graduate education, a lot of work with Meharry [Medical College], and provides lectures about health equity in degree and non-degree programs at Wharton. Welcome, Guy.

And Surya Kolluri, who’s become a good friend over the past year as we’ve gotten underway with Wharton’s CEO. He is the head of the TIAA Institute, and he’s a Wharton grad. He’s been overseeing research on enhancing lifelong financial security and organizational effectiveness in higher education and the broader nonprofit sector. He sits on the board of the Wharton Pension Research Council, the Advisory Councils of Georgetown Center for Retirement Research, the Retirement Research Center of DCIIA, and the MANH Chapter of the U.S. Alzheimer’s Association. In 2021, Surya received the President’s Volunteer Service Award via AmeriCorps in recognition for his commitment to strengthen communities. Surya, good to see you again. Thank you for joining us.

Guy, as the professor in this business, give us some insight as to what the biggest equity gaps are in health care. Where do we see the kinds of impacts that we’re most concerned about as we’re trying to look for opportunities to make things better for the broadest number of people?

Guy David: I think it may be easier to ask where we don’t see gaps. I would argue the biggest gaps in health care from a disparities perspective are going to be in health insurance coverage and in access to health services. I don’t just mean hospital care, but also primary care, even pharmacy. Now, you can argue that these are the disparities in health care. But they’re not just stemming from the health care system. We have to understand that there are disparities in a lot of other dimensions, and I know we’re going to touch on several of them today, that will affect people’s health status. The lack of economic stability, housing, transportation, health and financial literacy. You can think about the entire education system, food insecurity, exposure to violence, to trauma, the justice system. All those disparities are basically spilling over into disparities in health status. And if health equity means really ensuring that everyone has a chance to be as healthy as possible, it starts with realizing that not everyone has the same opportunities to achieve the same level of health.

Shropshire: The whole idea of the ZIP code that you reside in or were born in has a huge impact on health care — that’s a true statement.

David: Absolutely. The ZIP code you are born in will affect how affordable care will be for you, how you’re going to navigate health insurance, how you’re going to access technology, your literacy level, how you’re going to access transportation, the level of outreach and prevention that you’re going to encounter, your education, your mental health, and your personal safety. All of those things are going to have an effect. And they will translate into effects on the quality of life and your life expectancy.

Shropshire: You said health insurance. Are you saying in some cases it’s the complete absence of insurance? Or is it more the underinsurance?

David: It’s both the lack of insurance completely, and underinsurance. You have programs like Medicaid, which is not distributed evenly across states. It’s really state-administered. We have a lot of issues with access across states. We also have a lot of people that just don’t have insurance. Even after the Affordable Care Act, we have millions of Americans who don’t have insurance.

Shropshire: Fareeda, before you joined us you focused a lot on health care issues internationally. I know specifically you did some work in your doctoral studies on South Africa. How are these issues the same or different globally?

Fareeda Griffith: Thank you, and thank you for the opportunity to join this conversation. This is something I’ve been thinking about for a long time and I think the reason why I was drawn to do this work. The short answer is yes. But the question to get to that answer may be a little bit different, right? The variables and way in which we think about health insurance in the context of South Africa, and the way in which the South African census denotes it, is that the majority of the population does not have private access. Publicly administrated medical aid is something that most individuals rely on.

My research really was trying to tackle not only it’s not just health care, but there are these other factors that are contributing to this. As we think about within the context of my research, look at racially residential segregation patterns. Where people live, right? If we think about it in the post-apartheid context, we would imagine a place where segregation was no longer an issue.

What my research really tried to understand and explain is that even looking at data 10 years post-apartheid, we were still seeing segregation levels at the same level or higher than it was during apartheid. These policies that are in place in terms of where people live — and once those policies were removed — have long-term effects on individuals. Not just where they live, but their health outcome. I was looking at and mapping those outcomes, particularly as it looks at chronic health condition, educational attainment, social class. Because it’s not just the health status of the individuals. It’s all of those other things that poke holes or impact the overall health status of the individuals.

If I may add, my research post-Penn and something that I was really interested while I was at Denison, was looking at Somali immigrants. If you look at Somali women who had newly immigrated to the United States or had been in the United States for several generations, the way in which they navigated the Western medical system, and the way in which they felt an outsider— they talked about language. They talked about religion. And they talked about these cultural customs that were norms to them as a way to really understand how to navigate this, and then also to navigate that in the context of their new world.

That was really something I remained interested in. You can’t just talk about health, right? We have to talk about all of these social and economic factors that also are interrelated to that.

Shropshire: I’m fascinated. I’m thinking about ZIP codes and what you just said about Somali immigrants. You carry those ZIP codes with you. Just because you can move from a neighborhood doesn’t necessarily mean your life transforms.

Griffith: Right. An individual may live in a place, but then if they are not making a livable wage where they have enough to buy food. Or while they’re at work, they’re stressed about childcare for their children. All of those things don’t just leave once you leave your house, right? Those things are the baggage that you take with you, and you’re no longer able to put them in a vacuum. I had a really in-depth conversation with the Somali women and talked about their journey and talked about the space that they were currently in as the head of the household, and what that meant for their children, for their spouses. Those things were very complex and very layered, and really important to think about.

Shropshire: Surya, the work the TIAA Institute does has fascinated me over the course of this past year as I’ve gotten to know more of it and see the kinds of research that you support. With that connection between finances and health, what are some of the biggest issues that we need to bring to the forefront?

Surya Kolluri: Thank you so much, Ken, and what a rich discussion so far already. One mantra that I carry and that we carry at the institute is, health and wealth could be considered two sides of the same coin. For example, Guy was talking about financial and health literacy, so let me pull on that thread to talk about some of the research we’ve done. And Guy, I’m happy to share this research with you going forward. We investigated the topic of longevity literacy, which means do people have an appreciation of how long they can live? We have actuarial data to be able to test that question against. If you’re a male or a female, etc. You know, I’m fascinated by the ZIP code conversation, that we can add some sophistication to this.

But what we learned was that a staggering number of Americans do not have an appreciation of how long they can expect to live in retirement. If you think about what our life expectancy was when Social Security was passed, to what it is today, we’ve added 17 to 20 years. So, our cultural knowledge is not keeping up with the actual facts on the ground.

One of the things we’ve learned when we look at people with higher longevity literacy, their financial behaviors are much more amenable to what we would teach in terms of proper retirement planning. For example, those with a high longevity literacy actually thought about how much they need in retirement. Those who had a higher longevity literacy took action to save on a regular basis, and also had confidence. If you think we can impact some positive behavior, we think we can do that by enhancing people’s longevity literacy in addition to financial literacy. And all the points that Guy and Fareeda were making about disparities is showing up in this data. Longevity literacy levels are different by gender, ethnicity, and race.

Shropshire: It’s such a striking observation. My father passed away at 64 years old, and I’m not beyond 64. My brother was beyond 64 before me. In my more sophisticated life now, I speak with financial advisors, and they’re talking about, “OK, let’s do a Monte Carlo scenario and see if you make it to 95.” I’m like, “Wait a minute. That would be phenomenal in a way that I may or may not have the right perspective on trying to deal with that reality, even with all of this education and all else that I have.” Any thoughts about that kind of transition? Again, this goes to that whole ZIP code kind of thing, too. Can you move from being a person that’s in a world where, “Eh, nobody’s living that long anyway, so I can go paycheck to paycheck and I’ll be OK?” Are there any studies out there that anybody’s seen that look at this transition?

Kolluri: There’s a study that we funded at Boston College Center for Retirement Research that distinguished between objective life expectancy and subjective life expectancy. Ken, in your anecdote, you’re expressing your subjective life expectancy. “My father, my brother, me, my family, my situation, where I grew up,” which is very important to your self belief. But if you were offered objective life expectancy: Here’s your education. Here’s your ZIP code. Here’s your physical situation as you stand today. And people like you, unlike others in your family or lineage, live this long – that is more objective education. And we’ve found that people’s behavior changes if you give them that objective knowledge.

Griffith: I hear you saying that the objective and the subjective perspective must marry each other in order for this to work.

Kolluri: They complement each other.

Shropshire: I’m ready to be studied! We’ll see if I continue to act like I’m playing with house money. These are extra years. There are all these books that have titles like Die Broke. I have those in my house, which is the counter path. TIAA is not supportive of that kind of way of looking at life. Spend as much before somebody else gets their hands on it.

But Guy, I want to circle back. Let’s talk some more about interventions and paths that can change what’s out there. We’ve got a brief snapshot of some of the major issues that are out there. You mentioned in your initial list of problems that exist also the absence of pharmacies, for example. And I’ve heard talk about it in some communities. Again, the ZIP code issue. It’s a pharmacy desert.

One of the things we were thinking about as we were talking about doing this series of podcasts was AI and what kind of technological interventions can be provided to try to address these issues. I only know briefly about Amazon’s venture into this pharmacy space. As the CVS in my old neighborhood in LA closed down, my brother and others are trying to figure out, “Why do I have to drive three or four miles to try to get prescriptions?” Or at worst case, “Ah, never mind. Maybe I’ll get it tomorrow,” and they actually need it today.

Besides the Amazon example, what else do we see out there that’s trying to address these issues in ways we haven’t done before, or we should do more of?

David: I think three’s a lot of innovation that is coming out. But I want to go back to the Amazon example, because we’re trying to look at innovation through the lenses of equity and health equity in particular. It’s very easy to think about innovation that serves to benefit segments of society, but actually exacerbate equity issues. This is a good question, whether Amazon pharmacy will be improving health equity or not. My gut feeling is the answer is probably yes, but there are pros and cons that we have to weigh here.

I think that there’s definitely a lot of pros. The obvious one is that today, over 60% of the U.S. population are Amazon Prime members. That’s about 167 million Americans, so Amazon Pharmacy can potentially reach the underserved population with limited access to a physical pharmacy. This could be because they live in remote or rural areas, but also because they face other barriers like transportation or branches that are closing, like you described. But honestly, I think it goes well beyond accessibility. The hope is that Amazon might actually affect prices. Creating more competitive pricing and discounts will make medication more affordable. And in my perspective, the studies that I’ve been involved in around the importance of medication adherence — the convenience of having drugs delivered to you can have a big effect on that. And this is a major issue in health care. Because not having adherence to medication causes a lot of unnecessary hospitalization, emergency room visits, and so on. These are activities that are both expensive and avoidable.

I would say Amazon has another benefit, beyond being just a delivery mechanism. It’s also a platform. They can leverage this platform to provide more health information and more education, which we’ve discussed here really nicely in this podcast is a key component for health equity.

Now, there’s not a lot of cons here. But probably one obvious one is that not everybody in the U.S. has access to the internet. And this could limit the reach of Amazon pharmacy to only those that are connected. Fortunately, 92% of individuals in the U.S. have accessed the internet. But obviously this problem of no access is more pronounced in rural states. In states like Mississippi, New Mexico, Arkansas, almost 20% of homes are with no internet access. So, there is a chance that our most vulnerable population will not be able to benefit from this innovation, and this can exacerbate existing disparities.

Shropshire: That’s very interesting to think about the idea of the absence of technology. There’s also, as you get older, the difficulty in using technology. That demographic ends up having issues with the greatest next technology that comes up. Fareeda and Surya, what else do you see out there as interventions that we should embrace going forward?

Griffith: I’ll jump in and speak a little bit about what we’re trying to do here at the Wharton School. The Coalition for Equity and Opportunity, which Ken has so nicely presented earlier in the podcast, has really been trying to think about ways in which individuals who typically don’t have access to the Wharton School are now having access to, as we think about financial literacy, as we look at health equity particularly for this podcast. We have been working within the West Philadelphia community. We had a partnership this past summer where we were thinking about wellness and the entire being, the entire person. Their financial wellness, as well as their health outcomes.

We had the community event in which we partnered with the Office of Diversity and Inclusion here at the Wharton School, as well as Penn Medicine, to provide things like fresh fruit and vegetables for the community, provide financial literacy. We had individuals who are doing this work in the community talk with individuals who were attending the event, and then being a kind of partner within the community to make sure that we’re putting our best foot forward. We have lots of resources that I think not only the West Philadelphia community, but Pennsylvania, as well as nationally and globally, could access through the internet.

We’re also creating these short toolkits where we take faculty’s research that they spent a lot of time working on, that sometimes is not accessible to a larger population, and making it digestible in ways in which they’re thinking about as we look at health outcomes.

And we’re partnering with organizations like TIAA Institute to make sure we are touching multiple parts of the population and providing information and using it to elevate that work. Not only the research that faculty are doing, but creating new research that faculty could be doing as well. We’re continuing to support those endeavors.

Shropshire: Surya, closing thoughts from all the research you have?

Kolluri: Indeed. We can think about micro interventions, and we can also think about macro interventions. I’d like to address a macro intervention point that we are very excited about. We call that the Retirement Bill of Rights. Talking about health and wealth being two sides of the same coin, we know about the Patient Bill of Rights. Why don’t we marry a Retirement Bill of Rights with it to improve access to retirement savings? Expanding access would be one aspect of it. Providing the right kind of information, so people can make the right decisions, and low-cost investment opportunities, because there are lots of concerns around things being overpriced or people being overcharged.

And then finally, income. We have gotten away from pensions to completely managing investments on our own. If you can give people some stable income along with Social Security, you can put them on solid financial footing as well. So, the Retirement Bill of Rights would be the macro level innovation and intervention that we would propose.

Shropshire: Guy, Fareeda, we’ve gotten some progress in terms of the things that we can do. Obviously, a lot more to cover. But the idea that you’re not bound by your ZIP code, that technology might help, that there is this intertwining of health and finances that we need to address further.