By Joseph Williams, U.S. News & World Report —July 27, 2018
IF YOU’RE POOR, A minority or a homeless person living without health care, Lloyd Dean wants to save your life – or at least help you live a healthier one.
The longtime CEO of Dignity Health, the fifth-largest health system in the nation, Dean is on a mission to expand health care access to underserved communities. His access point: housing, which research shows is a key determinant of health and health outcomes.
Housing stability “is so important,” says Dean, whose company is headquartered in San Francisco, a city grappling with twin crises of an affordable-housing shortage and chronic homelessness. His focus on the poor and uninsured makes sense, particularly given Dignity’s former identity as Catholic Healthcare West, a health system founded by the Sisters of Mercy.
For Dean, however, the drive to provide medical care for those who struggle “goes way back kind of in my whole upbringing. I come from a big family, a welfare family,” he says.
One of nine children born to a factory worker and a homemaker, Dean grew up poor in an African-American area of Muskegon, Michigan, a city on the eastern shore of Lake Michigan. Dean’s first trip to a doctor came in junior high school, when he needed a physical exam to play football. Bussed to an affluent, mostly white public school, Dean says he was puzzled by classmates who were excused from class for medical appointments.
Over the years, questions began to form, Dean says: “Why do people in my community die earlier, why do people in the other communities seem to be healthier? And why, when people in my community were in need of health care, they had almost zero options?”
Witnessing the impact of health disparities between blacks and whites – including the premature deaths of both his parents, and a brother who died from AIDS – led Dean on a path that could have been penned by Horatio Alger: The poor kid who barely saw a doctor grew up to become one of the nation’s most influential African-American health care executives, a well-regarded leader who helped former President Barack Obama craft the law known as Obamacare.
“I was super hopeful and excited when the Affordable Care Act was passed and worked really hard (with Obama) on that,” says Dean, whose first career was as a public school teacher. “I think we’re losing ground. I’m frustrated but not defeated.”
In a wide-ranging interview with U.S. News, Dean spoke about the ties between housing and health, racial disparities in well-being and his intent to press on despite efforts to dismantle the law known as Obamacare. The interview has been edited for length and clarity.
What led you to connect the dots between housing and health care?
I always say it’s almost impossible but certainly difficult to be healthy without a home.
When you think about the fact that there are so many people in this country who are homeless on a given night, and then you zero in further and begin to sort that data and you see that a large proportion of those individuals that are homeless are African-American, it just caused me to say we’ve got to be more than just a comprehensive health care provider. We’ve got to be in and of the community, and we’ve got to do the work here to try to make sure that we address the totality of the individual.
That’s led us at Dignity to look at communities and try to implement some effective programs. One of those is the Social Innovation Partnership program. And that’s something that we’re doing in Los Angeles and San Bernardino County.
What’s the goal?
What we’re doing is working to make sure that homeless patients who present in our facilities and our hospitals, that we’re working with the community and other community resources to get them into permanent housing and to provide them with the skills and the training, so that they’ll be able to keep their homes. Because otherwise, you just get this churn, where people come into the EDs and ERs, and we treat them. But imagine if it were you or I, we’re going back out into the unsafe environment on the street, or people are sleeping in their cars. It’s just not going to lead to the kind of health status and condition that I think this nation owes its citizenry.
You’re based in San Francisco, which some say is ground zero of the affordable housing crisis in America. How has that affected your view of the housing-health care link?
I came to Dignity from Chicago. Certainly I had seen homelessness, and we provided services at (Illinois-based) Advocate Health Care, where I was executive vice president of operations to all of the projects. So I saw homelessness through one lens.
But when I got to San Francisco, I saw it scaled up. You’ve got the weather, but you also have a different political environment. Our emergency departments became the only primary method of care for the homeless. And I said, “We’ve got to stop this.” People would come in, we’d treat them and then put them back out on the streets. And inevitably, sometimes in days, they would be back in our facility.
I said, “We’ve got to look at this more holistically than just what we are doing on the care side.” So we began to engage in a really focused way, working with housing organizations, investing in community-based partnerships. We have a program called the Coordinated Community Network Initiative, which helps people, when they get out of the hospital, to put them in an environment where they can get some coordinated referral resources to, again, try to address this issue.
We just had to change our whole approach. We have a very robust community grant program. We invest and seed other community-based organizations. Because we can deliver the care, but if people don’t have a home – if they’re sleeping out on the street with infections, it’s a problem. So we started working with organizations like Mercy Housing, which is a national group that addresses homelessness. We started working with the city – with the office that deals with homelessness.
I have had friends who ended up on the streets. So to me it’s the real deal, and something that I am passionate about.
It’s a lingering problem, however – not just in San Francisco but nationwide. There have been repeated attempts to address it, but it seems to be a stubborn problem, and not necessarily high on the national agenda.
I think it’s a moral imperative that we act. We live in one of the wealthiest nations on the planet. It’s the humane thing to do. But then when you look at it from a health care perspective, the science is on our side. A lot of times the people that are out there – not always, but a high percentage in places like Chicago, in major cities but even in some of the suburban areas – folks present with multiple diagnoses. It’s mental health. And we’re going to pay for that. We pay for it over and over again. We know that ERs are the most expensive way for people to get treatment. We know the cost of our health care is continuing to go up and one of the drivers of that is people getting the wrong care in the wrong setting at the wrong time. I think that everybody should be concerned.
We know the best thing we can do – and I say this as a major health care provider – is keep people out of the hospital and make sure they’re accessing appropriate levels of care, but early on. We owe it to children, because now we’re seeing more and more families sleeping in cars because of housing and other conditions that have put them in a plight where they just don’t have the resources.
I see people walking past homeless in cities, in San Francisco and in Los Angeles, and they have just become numb to it. But you can’t have a healthy community if people aren’t in a stable environment. To me, it’s more about what this nation stands for and what we and what I can do to improve and get people into stable environments. Or we’re never going to achieve this goal of healthy communities.
You also say you’re focused on addressing the racial disparities in health care. What do you mean, specifically, and how does it intersect with housing?
My community (in Muskegon) really rose up from African-Americans coming from the South, going up to Michigan. When my dad got out of the service, (he and) my grandparents had done the same thing, that whole, “Go north because there’s opportunity up there.” He ended up working in a factory up there that made parts for the auto industry.
I didn’t get it at the time because I was bussed to a middle, maybe even an upper-middle-class school. I noticed there was a difference between how people in my community didn’t deal with their health care needs. But yet when I would go to that school, I had friends – their parents were pulling them out of school for what I now know were inoculations and preventative treatment.
I saw people in my community who were homeless, and just kind of roving around the community. I didn’t notice it at the time, but I realized the contrast between high blood pressure, gout, cardiac kinds of problems, obesity caused the difference (between African-Americans and whites) in health outcomes.
A lot of it seemed to be people being on the street, getting sick, not exercising, not being careful about what we were eating. Then when I got into health care – when I got out of college I first started in education, but then I went to a pharmaceutical company – I just began to really focus on, “I’ve got to do something about this. I have younger brothers and sisters who are still in that community.” I wanted to be in a job or get into a career that’s going to try to change the equilibrium.
In terms of the disparities between blacks and whites in access to care and health outcomes, there aren’t many African-American CEOs of major health care companies …
We’re changing it! You’re right – proportionately there are not a lot, but we’re doing everything we can and I think there is a pipeline. But to your point, proportionately, there aren’t enough.
… but nevertheless, it sounds like you feel a responsibility to close that gap.
Now you’re really touching into my passion! Health disparities is something that just drives me crazy because it’s something that we can do something about.
I think that as health leaders and as good corporate citizens we’re mandated to speak out. I try to use the voice of Dignity Health and all of the national organizations, state organizations that we are a part of, to keep calling out the disparities. Because some people still, in 2018, when they hear “disparities,” it’s like it’s happening in some other country and not here, in the United States.
The other thing we’re invested in is education and trying to make sure that communities understand that there are disparities and set forth some architecture of how we can address it. We’re in the schools, we’re in community organizations, trying to address what it is that children are eating, get people making sure that children have good healthy lunch programs.
We are also working with some of the national organizations – like the Urban League, the NAACP, other community organizations – hand in hand to try to make sure that people of color have access to affordable, quality care. We are using our voice for Medicaid and Medi-Cal (California’s Medicaid program) expansion and making sure that we get folks involved in insurance plans. That’s why on the Affordable Care Act, we worked so hard with the Obama administration to make it a reality. People in this country have to make a choice between food and rent and pharmaceuticals and, in the aggregate, health care, because they don’t have the ability to pay. That continues to lead to health disparities.
And then when you look at the mortality rate for African-Americans – there was a CDC study showing that the mortality rate for African-Americans was 16 percent higher than whites in 2015. That’s 16 percent. So I think that there’s a lot that must be done.
From your biography, it’s clear this hits home. Yet in 2018, we’re still talking about the black-white health gap and how to fix it.
When I was able to get to a position of influence, one of the things that was stunning to me was the complacency, even among health care leaders. People would talk about disparities but they weren’t really doing anything about it – they weren’t really committed to it. So I’ve tried to use my voice not only to call attention but to launch programs and to use the resources of our system to show that we can make a difference while working with other community partners.
I also tried to use our political voice, whether it was at the White House or whether it was at the state level, to become a Pied Piper for calling this out and to demand programs and to demand to the best of our ability Medicaid expansion, and to use our employees and to use our resources to get people enrolled in health plans. Get people out and in communities of color – make sure that we would have people in communities going house to house, sitting down with people, getting them enrolled.
I dealt with it personally because my mother and father both died early. I believe – I know – that my father died because he acquired black lung disease working in this factory, a metal factory, no mask, no nothing. But he had to go. And then when the factories would shut down, we’d be on welfare. So we just didn’t have any access.
My grandfather died from prostate cancer. It’s the silent killer in African-American males. There is a preponderance of deaths from prostate cancer because of the lack of treatment. We know with testing – we know with regular checkups – that’s something we can do something about. So that’s just a part of my DNA now.
We’re still on this journey because it’s in the minority community. There’s just all this political judgment about health outcomes: “These people can do differently if they eat better.” All of those kinds of things.
I’ve been disappointed in leadership across the nation who turn a blind eye to the impact that health disparities have on the country. We were one of the first organizations nationally to come out and back the Obama administration and to advocate for the Affordable Care Act. It gave me hope and it was an opportunity to get resources to communities and get programs out there and get people in a situation where health access was available to them.
Now, with efforts to repeal the law, we have to come at it from a community level. We have to come at it from a state and local level. I haven’t given up on the federal level, but we keep pulling one leg out from the ACA stool, and I think people are underestimating the impact of the decisions that have been recently made on health disparities. And I just don’t think there’s a sensitivity to it.
That has to be frustrating for someone with your background.
But I’m not going to give up. I’m not going to give up.