Human Services

The mission of the US Department of Health and Human Services (HHS) is to enhance and protect the health and well-being of all Americans. ¹ In my work as deputy assistant secretary for human services at HHS, I have noticed that people think that HHS focuses solely on fostering advances in medicine and public health and ensuring access to effective clinical services through Medicare and Medicaid. ² Far fewer people know about our work in human services and how it relates to the health of Americans. In this Executive Perspective, I explain why the second part of the department’s name, human services, is equally vital to health services in achieving the goal of a healthier US population. I will tie this to Public Health 3.0, the new vision of public health introduced by Acting Assistant Secretary for Health Karen DeSalvo, as the framework. ²

Our nation’s health and well-being have long ranked poorly when compared with other developed nations. ³ Within the United States health outcomes vary greatly across communities, counties, and states and among populations, with racial/ethnic minority groups, low income, and low education levels consistently associated with poor health. ^4,5 The lower health status in these populations likely reflects insufficient progress in addressing the fundamental social and economic conditions of our society and the health-related behaviors (eg, tobacco use, consumption of excess calories) that accompany these conditions. ⁶

Healthy People 2020 enumerates the social determinants of health as economic stability, education, social and community context, and neighborhood and built environment. ⁷ Healthy People 2020 also lists access to health care services as a social determinant of health, but the public health community has long known that health care services predict a relatively small proportion of health outcomes. For example, the County Health Rankings & Roadmaps program supported by the Robert Wood Johnson Foundation found that among social determinants, health care services account for only about 15% of variance in health outcomes, whereas health behaviors and the socioeconomic conditions that influence them account for at least 60% of variance. ^8,9 Similarly, the Centers for Disease Control and Prevention positions socioeconomic conditions at the base of its health impact pyramid, indicating that these factors have the biggest health impact, followed by changing the context (neighborhood and built environment, policies influencing behaviors) and—with more limited reach and greater cost—direct health care services. ¹⁰

Human services have a dual purpose. They strive to protect vulnerable populations from harms such as food insecurity, housing instability, abuse, and neglect. In addition, they seek to help people provide for themselves, thrive, and contribute to society. By engaging in this work, human services directly affect the social determinants of health. Although not designed to influence health per se (except when using the World Health Organization broad framing of health; ie, the complete state of well-being), human services can profoundly affect traditional health outcomes. Indeed, they may have as great an impact or an even greater impact on traditional health indicators (eg, life expectancy) as medical services alone once basic health care services are in place.

Examples from one of our HHS agencies, the Administration for Children and Families (ACF), demonstrate this concept in practice. Many of HHS’s human services programs are based at ACF, particularly those affecting children, adolescents, young adults, and families (human services programs affecting older Americans and those with disabilities reside within the Administration for Community Living). I will briefly describe the focus of several of these programs and highlight how their efforts directly and indirectly affect the social determinants of health among their constituents.

One of ACF’s largest programs, Head Start, which includes the Early Head Start program, provides early childhood care and education. Head Start is a signature human services program. It provides high-quality early care and education services, along with access to healthy foods, linkages to health care services, and parent engagement—all of which are essential to a child’s success in school and ultimately to economic and social success. Early care and education are highlighted as a nonclinical, community-wide approach that has positive health impacts. Evidence shows that this intervention can produce results within 5 years and is cost effective and/or cost saving during the lifetime of the population. ^11,12

Other ACF programs provide financial and work supports for low-income families. The Office of Child Support Enforcement and the Temporary Assistance for Needy Families (TANF) program address financial stability for families with children by providing cash, either from the noncustodial parent (usually the father) or from the state. State TANF agencies provide work support for eligible recipients, and several state child support programs provide job training for unemployed low-income men. These programs have the potential to affect social determinants of health directly by providing adequate financial support during childhood, which is associated with improved school performance and health, and by building the capacity for self-sufficiency, which creates long-term economic stability for families and communities. ¹³ These ACF programs are long-standing. Head Start was instituted in 1965, and TANF, which replaced the Aid to Families With Dependent Children program, has been operating since 1996.

In 2015, the acting assistant secretary for health introduced Public Health 3.0, a new framework for public health that emphasizes the need to focus on changing the social determinants of health and suggests the capacities needed for public health to be successful. Under Public Health 3.0, community public health agencies are urged to take on a new role as community health strategists. ¹⁴ To be successful in this role, agencies must develop more workforce capacity for leadership and partnership; build more enduring partnerships, including the ability to obtain and pool funding; gain access to actionable data and improve their capability in using these data; and develop sufficient funding for both service delivery and a sustained infrastructure.

To realize improvements in these social determinants of health, public health departments will need to forge effective partnerships with public human services agencies and their community partners. These entities are already on the ground and are designed to improve many of the social determinants described in Healthy People 2020. For example, community action agencies—supported by another ACF program, the Community Services Block Grant—facilitate enrollment in the Low Income Home Energy Assistance Program. This program ensures that families have adequate heat, which leads to improved health outcomes for children with chronic conditions. ¹⁵ These same agencies often serve as Head Start providers and also act to strengthen the social networks within communities. Collaborating and linking with such community agencies and with the full spectrum of human services providers are proven ways to enhance the social conditions of a community.

To achieve the goals of Public Health 3.0 (ie, addressing the fundamental conditions in which we work, live, learn, age, pray, and play), both policymakers and community members need to know which programs are most effective and how they can be best implemented to improve outcomes. Within HHS, human services research related to children and families takes place both in the Office of Planning, Research and Evaluation at ACF and in the Office of Human Services Policy in the Office of the Assistant Secretary for Planning and Evaluation. The key research questions being asked are not whether poverty, food insecurity, or housing instability impair health. In the field of human services, poverty, food insecurity, and inadequate housing are considered harms in and of themselves. Rather, the research questions aim to understand which services, programs, and policies we can implement, and how we can implement them, to reduce or eliminate these impediments to well-being. For example, in March 2016, the Office of Human Services Policy released a 50-year report on the war on poverty. ¹⁶ The report indicated that 2 federal tax credits, the earned income tax credit and the child tax credit, and the Supplemental Nutrition Assistance Program (formerly food stamps) have the greatest population-wide impact on reducing poverty among children. Other programs—housing subsidies in particular—have a more profound poverty-reducing effect among those who receive the subsidies, but these benefits reach only a small proportion of those who are otherwise eligible, because of severe funding limits.

During my service at HHS, I have worked to ensure that health and human services work well and work together to improve the health and well-being of the American people by addressing social determinants of health. Public Health 3.0 amplifies this call and identifies what public health and human services agencies can do together to be most effective and have the greatest impact on the populations we serve.