Writing a new health story in four Newark ZIP codes

In Newark, New Jersey, the South Ward was once a middle class neighborhood with jobs and green spaces. But the past few decades haven’t been kind. Chronic health conditions are more prevalent here. More than a third of residents live in poverty. And they’re at much higher risk for serious health problems than residents in other parts of the city. The reasons - and the solutions - aren't easy to pin down.

The state’s largest health insurer, Horizon Blue Cross and Blue Shield of New Jersey, wanted to take on the challenge. They started by analyzing medical claims data, looking for trends in the bills hospitals and doctors submit when someone comes in for care. But that sketched in only part of the picture of what underlies the residents' poor health. So they looked at the data through more lenses: demographics, like poverty and education levels, and neighborhood characteristics, like access to healthy food or doctors. They built, essentially, a layer cake of maps and data. And what has emerged is the story of four ZIP codes, connected not only by city blocks, but a history of poor health. 

Here’s how Horizon and a local health system decided to change that story, one ZIP code at a time.