By Justin W. van Fleet, Ph.D and J. Robin Moon, DPH, MPH, MIA
Disparities and disadvantages start in utero and birth, setting young people on vastly different life journeys. In the United States, the result of differential investments in health, education and well-being, alongside other structural inequities, combine to formulate differing life prospects for children. In short, despite the overall wealth of the country, the zip code someone lives in, the color of their skin, and who their parents are will largely affect an individual’s life chances.
Fast-forward to 2020, the ravages of COVID-19 are exacerbating, deepening and widening the gaps between our citizens. When upwards of 50 million American children were forced from physical schools, those who were on the margins of society were even further sidelined from opportunity.
We know our health and education systems have been seriously broken long before the pandemic. Yet as COVID-19’s reach extends to all people, even if it is proving not to be the great “equalizer” as some initially thought, has presented an opportunity for systemic reform and embracing a “build back better” mentality at the local and national level. When overhauling any system, it is often said to be difficult to “fix an airplane while flying.” During this unprecedented “full-stop, restart, stop-again” response, there is new prospect to think beyond the immediate response to galvanize this moment and reimagine a health and education ecosystem that promotes equity and growth for all.
Making such a transformational change does not necessarily require substantially more funding. But it does require keeping public health and education budgets off the chopping block, and a more efficient investment in what we know works to reduce inequities and promote whole-person growth.
In its most simple form, five principles for reimagining the investments in the health and education of the youngest and most marginalized Americans will allow our country to truly build back sustainably on a level field and become more resilient for future shocks like the current pandemic. But we must first address deep-rooted misconceptions of our health and education systems.
Current funding: More doesn’t mean better education and health for children
Before COVID-19, it is well known that our healthcare system consistently ranked worst among developed countries even as the US spends the most on healthcare per capita. Poor health results in further deprivation in quality of life including income, wealth and education.
Analogously, while the average OECD country spends $8,470 annually per student’s primary education, the US far surpasses the average, spending $12,184. But higher spending has not contributed to higher outcomes. Korea, Finland, Canada and Ireland all generally out-performed the US in global assessments of reading, math and science skills, yet spend much less per student.
More troubling are the compounding inequities of public finance for the health and education of young people. Let’s start with education. In a recent ranking of state-level school systems by examining indicators including school finance, academic achievement, and state-level socioeconomic factors, states in the top-five bracket spent nearly twice as much per child as the bottom-five bracket. What’s more, is the inequitable funding formulas within states who allocate more money to richer neighborhoods. Here’s an example. Maryland and Ohio both spend slightly more than the national per-pupil spending average of $12,756. And in Maryland, 100% of students received funding at or above the national average. Yet in Ohio, despite spending $13,051 per student, its funding formula based on a combination of state funds, local sources such as property taxes (and in some cases income taxes) and federal funds, means that two-thirds of all students in the state receive below-national average spending on their education. A recent study shows that when taken to the aggregate, school districts with majority students of color receive $23 billion less than predominately white school districts, despite serving the same number of students.
What about health? Pre-COVID-19, frequent users of healthcare services – often low-income, people of color – have complex medical, behavioral and social needs. Social determinants of health – the conditions in which we are born, grow, live, work, age and worship that shape our health trajectories – drive more than 80% of health outcomes. For example, racial minorities have early onset of chronic conditions – obesity, hypertension, diabetes, heart disease – at younger ages. Yet, up to 88% of the US healthcare budget goes to providing medical services. This leaves many patients’ fundamental, social needs unaddressed as they remain caught in a cycle of requiring more clinical care.
Our broken public education and health systems are old news. But COVID-19 has brought laser light into every fissure that needs repairing, namely, unconscionable structural resource inequity, systemic defunding of health and underfunding of education.
In 2020, these factors combined with economic realities and have left behind our youngest, poorest and most marginalized children in the US. Pre-COVID-19, for every dollar that white households earned, 59 cents for Blacks and native Americans, and 72 cents for Latinx, identical to racial gap in income in 1978. When the crisis hit, about 24% of US civilian workers – about 33.6 million – were left without paid sick leave. For the lowest wage earners, this reduces to only 1 of every 2 workers. About 45% of adults (ages 19-64) are inadequately insured when it comes to health coverage. And the lack of household reserves to cushion shortfalls of income highlighted deeper issues. The latest report from the Federal Reserve Board indicates that for every dollar of wealth white households have, Black households have 10 cents, and Latinx 12 cents, meaning basic health and necessary goods like internet or childcare take a backseat.
Building back better: Bouncing forward with better health and education investment
COVID-19 is still on a precarious trend, globally and nationwide. Yet, states are reopening their economies and schools with various hybrid plans and formats, many still lacking consideration for the students of essential workers or at-risk families. And as the fall school term is very much still a crisis response, it is not too soon to start a much-needed systemic review and to avoid exacerbating the profound scars for generations marked by further wedging the existing inequities in the absence of a more equitable and sustainable strategy for children on the other side of the pandemic.
Going back to the “old” normal is not an option. For a large proportion of the population this would mean returning to a failing, disjointed, yet expensive, health and education system: large classroom sizes with many kids going unnoticed; absenteeism and presenteeism by students; chronically under-supported and over-worked teachers; test-based performance system that perpetuate systemic biases; many kids falling behind academically and health-wise due to adverse social determinants; disproportionate number of adolescents in low-income, racial/ethnic minority groups, likely to receive mental health services exclusively from underfunded school health settings, to name a few.
But given the experience, expertise and financing available, an alternative option is rebuilding through up-front investment and reform a quality and equitable health and education ecosystem at the local- and state-level, supported by national incentives. There are five principles for children and youth, which coupled with progressive financing formulas, could transform life outcomes for the next generation of Americans.
Five principles for reform and investment
1. Get every child and family online.
Expanding access to technology was an emergency response during COVID-19 but now must become the norm. Across all age groups and demographics, every child should have access to devices, strong internet connection, adult supervision and tech support. Access opens up opportunities for remote health services, distance learning, supplemental learning materials, and support for tutoring and counseling in real-time, as well as group study remotely with peers at similar learning levels. Federal infrastructure finance for broadband equity coupled with the incentive of tax deductions for connectivity for families with school-aged children is a start.
2. Expand education to let children learn early and learn well.
First, early childhood education must become universal. About 90% of the human brain develops before the age of five. Quality early childhood affects longer-term life outcomes: future learning, emotional well-being, social competence, earnings and upward mobility. It also saves the government money – a low-income child with one year of quality Pre-K is less likely to need remedial education in the K-12 system, less likely to be justice-involved, and less likely to need welfare in the future. With post-COVID era of virtual education, not addressing this would likely have an irreversible, adverse impact on our society. Moreover, the nature of learning and assessment must change to promote actual learning. During COVID-19, standardized tests were suspended and families teased apart from traditional “schooling” and rigid testing structures. Moving towards portfolios-based learning assessments can allow more comprehensive review of multiple intelligences and inclusion in the classroom. This will make room for perhaps the most challenging aspect of virtual learning – developing skills needed for the future of work and society, ranging from critical social skills such as relationship-building, compassion, collaboration, communication, and conflict resolution, with peers as well as teachers. Federal student aid incentives to train in early childhood and caregiving could provide a new cohort of much-needed expertise to this sector of the economy.
3. Build new school-based workforce combining the best of education and health.
The link between education and health is not only intrinsic but opportunistic. And schools are a place to not only deliver learning, but promote quality health, ranging from health and wellness education, health screening and services, and mental health counseling. Public school teachers are traditionally under-invested in and chronically over-stretched. Already under-trained to perform the vast array of duties beyond teaching, teachers must now also re-learn everything they know to transfer their in-classroom knowledge to virtual settings. Currently, school-based health centers disproportionately fail to reach low-income students and those living in rural areas. Within a re-imagined, comprehensive ecosystem, school-based health centers could be bolstered to be places to ensure primary care and access to mental health resources. By investing in teachers’ training and allowing them to focus on teaching, and empowering other professionals to provide nutrition, physical and behavioral health services alongside education – including virtually – schools become a cost- and time-efficient point of delivery of a bundle of developmental social services. Using these hubs as community centers with other local, state and federal services could drive greater efficiencies.
4. Engage the community as stakeholders.
It is a unique moment in history where nearly every family has been more engaged in how their child receives an education. For a new ecosystem, the whole community must be engaged as stakeholders, participating in structured conversations about reopening and rebuilding over the next several years. This starts with students who have the firsthand experience of remote schooling and includes parents who spend more time with their children engaged in the teaching and learning process, as well as teachers, administrators and community health professionals. Giving a voice to everyone, with greater appreciation for the complexity of education and development and bringing forward traditionally marginalized populations in schools to make planning decisions, can set priorities and recreate a new community blueprint.
5. Support families, not just students.
Evidence shows that gaps in outcomes for both public health and public education are associated with lack of investment in social and human services. These services complete a comprehensive health and education ecosystem. Providing support for students and parents – especially essential workers – will improve overall outcomes for children. Community-centered mechanisms need to develop to address families’ various social needs including childcare, transportation, and various occupational benefits; in emotional needs, including connecting virtually, linking to mental health aids; and in physical health needs, such as food, primary care and access to medications. This may be the most crucial gap that the new normal would has the opportunity to reimagine.
Education is a predeterminate of health outcomes. Simultaneously, health is a prerequisite for education. There is an opportunity to dismantle what was costly and dysfunctional and reimagine sense-making. Certainly, it is naïve to think a new normal would naturally include equity, even through this rare window of opportunity. But an intentional approach to providing access(ibility) and building true resilience in our future generation will set a foundation for growth, development and equity which is more robust during any future systemic shock. Rebuilding American communities with high-quality programs starting in the early years – where every child is given a fighting chance to be successful through learning and good health – will transform the country.