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Meet the Canadian doctor who prescribes money to low-income patients

Vox.com logo Vox.com 5/5/2019 Sigal Samuel
Doctors can add a crucial piece to the puzzle of their patients’ health: higher income.© Getty Images Doctors can add a crucial piece to the puzzle of their patients’ health: higher income.

Boosting people’s incomes to help boost their health outcomes — could this model work in the U.S.?

Gary Bloch became a doctor because he wanted to help people who were less privileged than him. For years, he tried his best to treat patients coping with poverty and homelessness.

But no matter how many blood tests he ordered and prescriptions he wrote, many of his patients’ health problems persisted. He realized it was because he wasn’t addressing the issue that most plagued them: poverty.

So in 2005, instead of prescribing only medication, he started developing the concept of prescribing money. And for the past 10 years, he’s been putting that concept into practice.

In concrete terms, that means that Bloch connects his patients to ways of boosting their income, like applying for welfare or disability support. Often, it means guiding patients to fill out their tax forms so they can access government benefits. Is it a doctor’s responsibility to do this? Yes, Bloch says, because if you don’t treat the social determinants of health (like income and housing), you’re not actually doing what you can to ensure your patients get healthier.

Similar to the notion behind universal basic income, the idea here is that if you really want to help people, the most effective starting point might be to simply give them more money.

As a family doctor at St. Michael’s Hospital in Toronto, Bloch hasn’t contented himself with prescribing income in one-on-one appointments: He’s also been pushing for broader social policy change. Treating individuals’ poverty may be a good step, but he wants to see systemic change, including a more robust social assistance program. In 2016, he was appointed to an Ontario government commission tasked with creating a 10-year road map to income security for the province (you can read the resulting recommendations here).

Although some doctors have told him they just don’t have the time or resources to prescribe money, Bloch says he’s gotten an overwhelmingly positive response from across Canada and beyond. As a Canadian who now lives in the US, I was curious whether his model could work within the (very different) American health care system. I spoke to him about that, and about how exactly he prescribes income and what the results have been so far.

A transcript of our conversation, lightly edited for length and clarity, follows:

Sigal Samuel: What inspired you to start prescribing money when most other doctors weren’t thinking along those lines?

Gary Bloch: Seeing patients, it became clear to me very quickly that until we worked on the basic social foundations of health, we wouldn’t be able to do much about traditional medical issues. There’s an incredibly strong body of evidence that proves the link between poverty and poor health outcomes. Most health providers get the evidence, but they pass it off, saying, “It’s not really my domain to deal with that.”

I disagree. That’s why I went back to the drawing board and said, “How can I start to insert real action in the front-line practice — and find ways to do that that feel doable for busy front-line practitioners?”

Related video: Gary Bloch at TEDxStouffville

Replay Video

Before we get into your technique for doing that, can you talk a bit about that body of evidence linking poverty and poor health? 

In the 1800s, the German pathologist Rudolf Virchow, the founder of modern pathology, traveled to many industrial work sites around Central and Eastern Europe and came to very strong conclusions about the link between poor social conditions and health outcomes. He said you cannot separate medicine from political or social life — politics is just medicine writ large.

From the 1960s or so, there’s been a pretty constant stream of studies looking at the link between people’s social situation and their health. They looked across every geographic location, across every disease, across accidents and trauma and growing up in poverty. Then they drilled down further into the biological markers and epigenetics — changes in the way genes are expressed as a result of people living in adverse social situations.

An important inflection point that’s worth noting is the World Health Organization’s Commission on Social Determinants of Health, which came out in 2008. It said that there is no real separation between social conditions and health, and that health practitioners must do something about this. 

So how did you start making a change? 

The first thing I developed was something very simple called a clinical tool on poverty, a three-page handout offering a three-step approach to dealing with poverty in the context of a typical primary care appointment. It’s basically: Ask everybody about their income, be aware of the evidence linking poverty to poorer health outcomes, and then actually do something about it — connect patients to supports.

The first version came out in 2009. This [handout] took off like wildfire, which was a real surprise to me. It was picked up by major medical organizations in Canada, it was replicated in every province and territory across the country, and it got international pickup as far as Japan. It seemed to touch on a real area of interest and need.

Can you walk me through the logistics of this in a bit more detail? Someone comes into your office. What exactly do you say in order to “prescribe money” to them?

Say someone comes in and you find out they have low income and they have some degree of disability. You ask them if they’re getting disability support, and tell them about the different supports available — federal programs, provincial programs, etc. It’s not a long conversation if you have a basic sense of the landscape. You can say to people, “You know what? I think you should get an application for the Ontario disability support program. Bring it back and we’ll go through it together and fill it out. If you’re living on basic welfare, in Ontario that’s $700 a month — if we can get you disability support, that will jump up to $1,100 a month.”

I’ve seen this story play out over and over, and the impact on people’s health is palpable. 

Is there a particular patient’s story that leaps out at you?

I think of a guy who came in a couple years ago. He’d been living [in a tent outdoors] in Toronto for about five years, he hadn’t been in touch with health care, he had a history of childhood trauma, and he was progressively separated from society. By the time he came to see me he was pretty rundown. He was ready to get out of his tent, but he had no social support or income. It was obvious that he had major physical and mental health issues — PTSD, major depression, diagnosed diabetes, terrible worms on his feet.

We managed to get him housed in a shelter, for a start. Then we got him onto the disability support program. That opened up worlds for him. He was able to get an apartment, get medications, eat properly for the first time. He’d come in and tell me excitedly what he’d been able to buy to eat, like fresh fruit and vegetables. He started making some social connections through a support group. His health just improved dramatically. He came in as an emaciated man, and within six to 12, months he’d bulked up. And he would actually smile.

In the years since you started doing this at St. Michael’s Hospital, have you been able to hire a few people to help patients fill out applications for welfare, housing, disability support?

We managed to put in place a whole series of social risk-focused interventions. The first was income security specialists — we have two full-time people, permanent salaried staff funded by the government, who are focused only on improving our patients’ income security. They’ll sit with patients individually and work on financial literacy and getting bank accounts and getting them to file their taxes.

We also put in place a lawyer and a legal assistant. They deal with a range of issues for our patients, like housing and income.

We’re even working now to do standardized health equity assessments across departments, to see how well they’re serving those who are traditionally most marginalized. All of this has evolved within the last five years.

As you help patients this way, have you been gathering data and studying the results of these interventions?

We have a research program trying to get a sense of how well each of these components in our program works. We’ve got a randomized controlled trial of the income support program. They’ve just been wrapping up the trial itself and now are analyzing the data. The results will be coming out soon, hopefully by the fall.

And in the meantime, is this model being replicated elsewhere in Canada?

There are a couple of scattered examples. There’s a team in Winnipeg called My Health Team, a team in the Kootenay boundary region of British Columbia, and a team in Peterborough, Ontario. They’ve all drawn on the work that we’re doing.

Some of it will take government will. We were lucky enough to have government support for our income security program back when we started it. We have a very different kind of government in Ontario now, though, so we’ll see.

There’s a benefit for the government in funding this, because treating poverty now will save the government money on the health side in the long term, right?

Absolutely. The challenge is getting governments to think long-term — to convince people who are elected for four years to be willing to take a chance on something that won’t see outcomes until probably long after they’re out of power.

We’ve seen this trajectory before, though, like with smoking. Fifty years ago, no one cared about smoking from a health perspective. But then the health world picked up on it, got the evidence that this was a bad thing for our bodies, and started pushing the government. Eventually, over a few decades, the government got the story that until we deal with this issue, we’re going to have worse and worse health outcomes and it’ll come at a huge cost to our society.

There’s some obvious conceptual overlap between your model of prescribing income and the idea of universal basic income, which Canada has experimented with. In the 1970s, when people in Dauphin, Manitoba, were given a basic income, the town saw a decline in doctor visits and hospitalizations. How do you think about the role of basic income in health care?

It is one policy option to consider. I don’t necessarily think it’s a panacea. I think if it’s done right — meaning it provides an adequate income for everyone who needs it — then sure, it can be a really good income support program. But I think people need to go beyond just income. My fear is that putting in basic income could be used as an excuse to get rid of other social programs: disability support, health support, child care support. What you lose is the ability to individually target groups that are at high need for certain services. So I’m cautiously supportive.

Has your model of prescribing income been tried in other countries?

In the UK, there’s been a welfare rights advice network since the early 1990s. In many cases, the [people who advise patients on their rights] are less embedded in the health team than we are — they’re often NGOs working alongside the health team — but they have been doing really good work. There’s also a really interesting offshoot in the UK called “social prescribing” that has spread like crazy in the last five to 10 years. Health providers identify social needs, including loneliness, and then connect patients to social supports.

And what about the U.S.? Canada’s health care system is very different from the system here. Is your model one that you can imagine being replicated in the U.S.?

Sure. There are really strong players in this area in the U.S. Johns Hopkins is a great example of a health system that has really tried to pick up on this. UC San Francisco’s department of social medicine is doing powerful research in this area. There are also the groups Health Leads and Health Begins [which address issues like housing and social needs alongside medical care].

Your biggest challenge is the social policy environment — there’s less interest in the U.S. in proper social programs. There’s only so much the health institutions can do without the government getting on board.

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