Social determinants of health — health care isn’t just bugs and bacteria
In an otherwise fractured Congress, Democrats and Republicans are coming together around newly proposed, bipartisan legislation to help states and communities manage costs and improve outcomes for Medicaid recipients. Called the Social Determinants Accelerator Act, the bill was introduced on July 25 by Reps. Cheri Bustos (D-Ill.), Tom Cole (R-Okla.), Jim McGovern (D-Mass.) and Cathy McMorris Rodgers (R-Wash.).
The bill received support from health-care industry groups like the American Hospital Association and Aligning for Health. It proposes planning grants and technical assistance for states and communities to address individual patient non-medical needs that are closely tied to health, like food security, housing stability and employment. It also targets high-need Medicaid patients and improving the coordination of health and non-health services.
The proposed legislation shows a growing recognition among political leaders that better health will mean addressing issues outside of medical care. They seemingly recognize issues that have less to do with bugs and bacteria, and more with the conditions and circumstances in which we live; and issues over which individuals have very limited influence or control.
With its focus on Medicaid and care coordination, it reflects the growing recognition among leading health-care systems that mediating individual social needs can be less expensive than providing repeated medical services for their highest cost patients and they can be life-saving.
However, as Congress warms to the idea that achieving health requires more than just traditional medical care, it is important to remember that while there are instances when it is necessary to help a patient with an urgent need — like access to a food bank or to temporary emergency housing, if we stop there — we will only achieve short-term, individual gains.
Everyone understands how the flu, diabetes and heart disease drastically impact our health, but social determinants like income inequality, poor public transportation and housing instability can have an even greater effect on well-being.
For example, life expectancy increases with income. More than one-fifth of the people living in households earning less than $35,000 annually say their health is fair or poor, which is four times greater than what is reported by people living in households earning $100,000 or more.
Poorly planned public transportation increases pollution, sedentary living and miles driven, which collectively can contribute to cancer, congenital anomalies, heart disease and stroke. Poor quality housing exposes its occupants to mites and other pest infestations and damp, moldy conditions lead to asthma and other respiratory illness.
These are just a few of the community-level factors that not only increase medical costs but also lessen children’s school performance and achievement and limit our economic productivity by increasing absenteeism and decreasing presentism at work. Yet, despite the tremendous, lifelong impact of our community conditions on our health, we focus most of our energy and resources on treating the outcomes of these problems but lack the essential urgency for attacking the root causes of poor health.
The Social Determinants Accelerator Act is a good first step focusing on low-income Americans and the specific social needs affecting their health. But our nation’s problems of excessive medical care costs coupled with worsening life expectancy can only be solved when we address the impacts of larger, systemic problems, like multi-generational poverty, institutional racism and historic trauma.
Efforts focused on specific patients or insurance plan members need to be balanced with policies that change the community conditions that influence people’s decisions and their health.
We can increase the federal minimum wage; unlock opportunities for city residents to safely walk, bike, drive and take public transit; or create more affordable housing, incentivize rent control and ensure housing quality.
These are examples of evidence-based policies proven to improve our health and quality of life while strengthening our businesses and reducing our medical care costs; these are the opportunities to change our communities.
We often look toward hospitals, medical providers and the pharmaceutical industry for pills and procedures to improve our health, but the problems we are asking them to solve are entrenched social problems. Medical care alone can’t fix the problem or achieve the healthier, more productive nation we want. We laud the direction of the Social Determinants Accelerator Act but urge its sponsors to be bolder.
Political leaders from both parties ave an opportunity to advocate for policies that can change the trajectory of health in our nation. When we have healthy places to live, access to good education and consistent access to healthy, high-quality food, we can create a stronger economy and more thriving communities with healthier people and lower medical care costs.
Brian C. Castrucci, Dr.PH., M.A., is president and CEO of the de Beaumont Foundation. Jonathan Fielding, M.D., MPH, is a distinguished professor at UCLA in the Fielding School of Public Health and the Geffen School of Medicine and the former director and health officer at the Los Angeles County Department of Public Health. John Auerbach, MBA, is president and CEO of Trust for America’s Health.
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