Tara O'Neill Hayes, Rosie Delk September 4, 2018
Executive Summary
- The United States spends significantly more on health
care than other developed countries yet has worse health outcomes, and one
possible reason is its “medicalized” approach to health care: The U.S.
health care system focuses on medical intervention while largely ignoring
other factors that have a much greater impact on health outcomes.
- The “social determinants” of health are the non-medical
factors that influence health outcomes. Where individuals live, learn,
work, and age, along with socioeconomic status and race, all have a
tremendous influence on their health.
- Policymakers
are beginning to incorporate the social determinants of health into public
policy – through, for example, a recent authorization for Medicare
Advantage plans to cover non-medical benefits – indicating a shift toward
a more comprehensive approach to health care.
Introduction
Health care spending per person has risen in the
United States for as long as expenditures have been tracked, yet population
health appears to be deteriorating. In 2016 health care spending increased 4.3
percent in the United States, reaching $3.3 trillion, but life expectancy
declined for the second consecutive year, which has not happened since 1963.[1], [2] Chronic
disease prevalence continues to grow, and 60 percent of the population is now
reported to have one or more chronic conditions.[3] Two-thirds
of individuals are overweight or obese, one-third of American adults have high
blood pressure, and the proportion of people with diabetes is expected to grow
by 54 percent in the next 12 years.[4]
Other developed countries spend about seven
percentage points less of their gross domestic product (GDP) on health care,
but they have better health outcomes, on average, including a higher life
expectancy, lower infant mortality rate, and a lower chronic disease burden.[5] One
possible cause of the United States’ inverted proportion of spending and health
outcomes is that the country over-invests in medical care while largely
ignoring the other factors that influence people’s health.
The Social Determinants of Health
While 95 percent of U.S. health expenditures go
toward medical care, most experts have long-agreed that medical services have a
limited impact on health and well-being.[6] What
determines someone’s health is a combination of genetic predisposition,
behaviors, the medical services received, and the social and physical environment.[7] Recent
estimates attribute 10 to 20 percent of health outcomes to medical care, 30
percent to genetics, 40 to 50 percent to behavior, and 20 percent to the social
and physical environment. Individual behavior and the environment are often
studied together as the non-medical determinants of health.[8] In
studies that only consider modifiable determinants and ignore genetics, the
non-medical factors account for 80 to 90 percent of a person’s health, and the
contribution of medical care remains 10 to 20 percent.[9] The
leading causes of death in the United States – cancer, heart disease, and
chronic respiratory disease – demonstrate the importance of the non-medical
determinants to health, as all three chronic diseases are tied to unhealthy
behaviors such as smoking and poor diet.[10]
The “social determinants” of health (SDOH) are a
subset of the non-medical determinants and are worth examining in more detail.
While the health care delivery system impacts health during episodes of injury
or illness, the social determinants interact with health much earlier, and on a
day-to day basis. They encompass the conditions in which people live, learn,
work, and age, along with the broader social positions in which individuals
find themselves that impact health. The social determinants can impact health
directly but also can indirectly impact health by shaping how people behave.
Poverty, unemployment, and housing insecurity are all examples of social determinants
that result in poor health outcomes. Of course, while the factors and
conditions considered here are referred to as “social determinants,”
they may be more aptly discussed as “influencers” or “predictors” rather than
direct determinants of an individual’s or community’s health status. Most of
these conditions are highly correlated with one’s health but not necessarily
causal; further, all SDOH (except race) can change throughout one’s life.
The SDOH gained renewed interest from much of
the world following publication of the report from the World Health
Organization’s Commission on the Social Determinants of Health in 2008, though
meaningful interest in the U.S. has only recently seemed to make its way to
policymakers.[11]
Where You Live
One social determinant is the living
environment, which stretches beyond housing to the economic, regulatory,
social, and physical (both natural and man-made) environment of a community.
Where someone lives directly impacts access to health-promoting goods and
services, including nutritious food options, medical care services, and fitness
centers or other places suitable for exercising. One study observed that
communities with greater access to supermarkets experienced lower obesity rates
compared with communities that had a greater density of convenience stores,
which often lack healthy options.[12] Certain
aspects of the physical environment can also promote health and well-being,
such as walkable neighborhoods, public transportation options, and recreational
space including parks and playgrounds. Increasing public transportation in a
community has been shown to decrease the number of missed or delayed medical
visits, resulting in better health outcomes and lower rates of chronic disease
in an area.[13]
High levels of crime and violence, community
segregation, and a high concentration of fast food outlets, liquor stores, and
tobacco advertisements correlate strongly with poor health outcomes.
Segregation has repeatedly been found to be associated with worse health
outcomes for minority residents, as limited funding in these communities
results in less access to health-promoting goods and services and higher rates
of crime and violence.[14] Members
of segregated communities have higher infant mortality rates, poorer mental
health, and shorter life expectancies.[15]
Exposure to air, water, and land pollution in
the environment can also impact health directly. These challenges vary
geographically and tend to disproportionately affect low income neighborhoods.
One of the more prominent recent examples of a polluted living environment was
the Flint water crisis, where tens of thousands of Michigan residents—42
percent of whom are in poverty and 54 percent of whom are African American—were
exposed to lead-contaminated water for twenty months.[16] As
a result, 12 individuals died, fetal deaths increased 58 percent, the
percentage of children with lead toxicity doubled, and fertility rates
decreased by 12 percent.[17],[18],[19] While
it will take time to know the long-term consequences, past research has shown
that lead is a neurotoxin linked to hypertension, kidney damage, decreased bone
and muscle growth, behavioral disturbances, and loss of intellectual function,
especially in children.[20]
Where You Learn
Studies indicate that education has a close
association with health: More educated people have better health outcomes.
Every additional year of schooling is associated with better health and
healthier behaviors.[21] More
educated people smoke less, drink less, weigh less, have lower mortality rates,
and have lower obesity and heart disease prevalence.[22] On
average, women who receive a bachelor’s degree live 8.6 years longer than women
without a high school diploma, and men with a bachelor’s degree live 9.3 years
longer than those without a high school diploma.[23] Studies
even show that more educated individuals have healthier infants.[24] One
study found a mother’s educational level to be the strongest predictor of
motor, language, and cognitive skills among pre-term babies at 20 months after
their predicted due date.[25]
Not only is educational attainment itself
important for good health, but the learning environment is as well. As
adolescents spend most of their waking hours in school, learning environments
have a unique opportunity to promote health within the curricula as well as
through the social and built environment. School curricula can promote health
through wellness courses, physical education, and sex education. Physical
education courses combined with nutritious school lunches have been found to
mitigate childhood obesity in the short-term and may prevent children from
becoming overweight long-term.[26] A
school’s regulatory and social environment can also impact health, such as
through the implementation of smoke-free environments, the provision of and
options available within vending machines, and the establishment of social
norms.
Where You Work
On average working adults spend over half their
waking hours in the workplace, which provides an important setting to impact
health. Workplace conditions vary greatly across disciplines, resulting in
differential health outcomes. Employee compensation—through the provision of
wages and benefits—can have a significant impact on one’s health and the health
of the workforce. Employee benefits which are likely to positively contribute
to one’s health—either during their working years or in old age—or the health
of their dependents include health insurance, retirement benefits, [27] and,
particularly important for lower income employees, paid family and medical
leave.[28] The
availability of health insurance, which is typically most affordable to an
employee when offered in connection with one’s employment (especially if the
company is self-insured or able to purchase insurance in the large group
market), increases access to affordable medical services, the health benefits
of which have been well documented.[29] Individuals
without insurance are more likely to delay needed medical care, and as a result
they have higher hospitalization rates, longer hospital stays, and worse health
outcomes.[30] Income
is another important social determinant of health, as noted in more detail
below. Incrementally higher-income people may live longer because they have
more capital to spend on health-promoting goods and services, including their
education, nutritious food, and housing in a safe and accessible neighborhood.[31]
As in schools, the built and social environments
of a work place also affect well-being. From the basics, such as easy access to
clean drinking water and clean air, and an otherwise safe working environment,
to enhancements, such as areas where employees can take a walk outdoors or eat
a healthy lunch away from their desk, the physical environment can help
employees be both healthier and more productive.[32] Lactation
support in the work place has been found to increase the amount of time a
working mother breastfeeds, an important health behavior that improves infant
survival during the first year and offers many benefits to mothers as well.[33] Other
workplace conditions can hurt employees’ health, including discrimination and
harassment in the workplace. Stressful work environments are also linked to
poor health outcomes for affected employees, including high blood pressure,
substance abuse problems, and mental health issues.[34]
Where You Age
The prevalence of disease increases with age,
but conditions around one’s aging environment can help mitigate injury and
illness. Aging in a healthy way involves maintaining mental health, cognitive
health, and physical health with little to no disease or disability.[35] The
accessibility of medical care in old age helps to address physical health, and
the United States provides this access to nearly all retired individuals
through the highly subsidized entitlement program Medicare. Because the elderly
often are weaker and less nimble, ensuring their physical ability to access
their homes, public spaces, and transportation options can help promote
physical health before medical care is necessary. Ramps, public benches, and
increased public transportation are all interventions that improve
accessibility and allow seniors to remain active outside their homes.
Physical activity remains important throughout
life, and studies consistently show that high activity levels in old age are
associated with a decreased risk of cardiovascular disease, high blood
pressure, hip fractures, and obesity.[36] Social
engagement is also important for healthy aging. Living alone, small social
networks, and low community involvement are all risk factors for poor health in
old age.[37] Social
support has been linked with numerous healthy outcomes, including lower rates
of morbidity and mortality and improved mental health.[38]
Socioeconomic Status and Race
Unlike the other social determinants that
address an individual’s surroundings, one’s race and their socioeconomic status
(SES) at birth are factors that cannot be controlled. SES and race are
considered social determinants of health because different SES and racial
groups have different health outcomes and health behavior patterns. Low SES is
associated with more smoking, less physical activity, and poorer diets.[39] Low
SES has also been linked with increased risk of breast cancer, shorter
lifespan, and increased prevalence of disability.[40] By
any metric of health, individuals with more money have better outcomes.[41] The
socioeconomic group into which an individual is born is both determined by and
a determinant of the other social determinants, interacting with many of them
to dictate what choices an individual has, and thus how they behave. SES
determines where a person can afford to live, the amount and quality of
schooling one can afford, and in many cases the type of job an individual can
obtain. But despite the many obstacles that might make upward mobility
particularly challenging for those with low SES, one’s SES can change over the
course of their life.
Race, however, cannot be changed. Unlike the
other social determinants, individuals have no control over their race and
ethnicity. Although an unfortunate reality, people do experience different
health outcomes and health behaviors depending on their race, and African
Americans and Hispanic Americans are often the social groups burdened with
worse health outcomes. While some diseases affect races differently because of
their genetic predisposition, such as sickle cell and Tay-Sachs disease, most
of the difference in morbidity can be attributed to the social determinants. In
the United States, African Americans experience significantly higher rates of
coronary heart disease, obesity prevalence, and cancer incidence, all of which
are linked to poor health behaviors that, as discussed, the living,
educational, and working environments of an individual heavily influence.[42] The
poor health outcomes of particular racial groups are largely associated with
other social determinants that disproportionately impact them, including low
socioeconomic status, discrimination in the workplace, and segregation in
neighborhoods.
Legislative Attention
Based on legislation and policy discussions at
all levels of government, policymakers are coming to recognize the impact that
social determinants have on health. For example, the CHRONIC Care Act, included
in the Bipartisan Budget Act of 2018, expanded coverage under Medicare
Advantage plans to include non-medical interventions. The new authority allows
supplemental benefits to be tailored to enrollees based on their health status,
which will improve the conditions in which beneficiaries live and age. The
newly allowed non-medical benefits may include transportation for medical
appointments, meal delivery, and home improvements that increase accessibility,
such as the installation of a wheelchair ramp or hand-rails.[43]
At the state level, North Carolina is attempting
to transform its entire Medicaid system to prioritize social determinants.
Starting in 2019, North Carolina plans to screen all Medicaid beneficiaries
enrolled in managed-care organizations for food security, housing stability,
and reliable transportation. The new system will implement a resource platform
that will allow physicians to help patients seek the social benefits they need
based on their screening results.[44] Change
is also happening at the local level. In Hennepin County, Minnesota, a pilot
medical program has been launched by local health care providers in partnership
with the state Medicaid agency to tackle the social determinants and, ideally,
decrease expensive medical care for patients. The goal of Hennepin Health, a
Medicaid accountable care organization, is to address the medical, behavioral,
and social needs of enrollees.[45] Since
the program began in 2012, Hennepin Health has placed over 250 beneficiaries
into permanent housing and reduced health care costs by 11 percent per year, on
average.[46] In
Dallas, Texas, the Parkland Center for Clinical Innovation (PCCI) partnered
with various community-based organizations to create a coordinated system,
known as “Connected Communities of Care,” in which a patient can receive direct
referral to local food pantries, homeless shelters, and other services.[47] The
patient is assigned a case manager and their electronic medical record is
shared with these organizations following a referral so that they can provide
personalized services, such as nutritional counseling and the provision of
appropriate food for a diabetic patient. The program has been so successful
that other cities are looking to replicate it, and multiple organizations,
including CMS, have awarded PCCI grants to expand the program.[48] These
initiatives demonstrate that policymakers are becoming aware of the impact that
the social determinants have on health.
Conclusion
The conditions in which a person lives, learns,
works, and ages contribute to their health more than any other factor. While
medical care receives the most funding and legislative attention, studies have
consistently shown its small relative impact on health compared to the social
determinants. Policymakers are recognizing the importance of the social
determinants and incorporating them into public policy, indicating a shift from
the traditional medicalized approach the United States has taken to solve its
health care problems. This approach offers a way to reduce medical costs for
individuals, insurers, and the government while improving outcomes, and it is
worth further consideration and creative implementation.
[1] https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html
[2] https://www.economist.com/united-states/2018/01/04/life-expectancy-in-america-has-declined-for-two-years-in-a-row
[3] https://www.rand.org/blog/rand-review/2017/07/chronic-conditions-in-america-price-and-prevalence.html
[5] White et al. Health Cost Primer:
Explaining Medical Cost Trend. Council for Affordable Health Coverage
Papanicolas et al.
Health Care Spending in the United States and Other High-Income Countries.
https://www.healthaffairs.org/doi/10.1377/hlthaff.21.2.78
https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/
[9] http://www.healthcarevaluehub.org/cost-and-quality-problems/browse-cost-driverquality-issue/social-determinants-health/
[13] https://altarum.org/sites/default/files/uploaded-publication-files/05_project_report_hsd_cost_benefit_analysis.pdf
[15] https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2017/02/15/re-balancing-medical-and-social-spending-to-promote-health-increasing-state-flexibility-to-improve-health-through-housing/
[17] http://www.pbs.org/wgbh/nova/next/body/flint-water-tied-to-fetal-death-and-lower-fertility-rates/
[19] https://apnews.com/6fe411b1ad2c48c1860012e66f96d933/Michigan-official-faces-manslaughter-trial-over-Flint-deaths
[28] https://iwpr.org/wp-content/uploads/wpallimport/files/iwpr-export/publications/B334-Paid%20Parental%20Leave%20in%20the%20United%20States.pdf
[34] https://www.forbes.com/sites/hbsworkingknowledge/2015/01/26/workplace-stress-responsible-for-up-to-190-billion-in-annual-u-s-heathcare-costs/#2950ba30235a
[44] http://www.modernhealthcare.com/article/20180803/TRANSFORMATION01/180809944?utm_source=modernhealthcare&utm_medium=email&utm_content=20180803-TRANSFORMATION01-180809944&utm_campaign=hits
[46] https://www.nytimes.com/2015/03/23/health/taming-health-costs-by-keeping-high-maintenance-patients-out-of-the-hospital.html?fb_ref=Default&_r=1
https://www.americanactionforum.org/research/understanding-the-social-determinants-of-health/#ixzz5QEt7SAUr
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