Chapter 7 – Social Determinants of Health

FAST FACTS

  • The World Health Organization defines social determinants of health as the conditions in which people are born, grow, live, work, and age (source).
  • The Centers for Medicare & Medicaid Services (CMS) has made $157 million in funding available to support 44 organizations attempting to bridge the gap between social and clinical services (source).
  • One in five Americans lives in a neighborhood with high rates of crime, pollution, inadequate housing, lack of jobs, and limited access to nutritious food (source).
  • The children of black high school dropout mothers are more than three times more likely to be born with a low birth weight than the children of white college educated mothers (source).
  • Athsma is more prevalent in minority and low-income communities, affecting 11.2 percent of those below 100 percent of the poverty level, compared to 7.3 percent of those with incomes over 200 percent of the poverty level (source).
  • A 2012 analysis found that households who spent more than 50 percent of their income on housing spent less on food and health care than similar households spending 30 percent or less of their income on housing (source).
  • People who are socially isolated have a death rate two to five times higher than people with close relationships to friends, family and community (source).

The United States is the highest health spender among OECD countries at $9,086 per person, but it has worse population health outcomes than its international counterparts (source). Research is increasingly showing health care is just one of many health determinants, with social factors such as individual behavior, socioeconomic status, and the physical environment having a significant impact on outcomes (source). These social determinants give rise to health disparities, which result from multiple social, political, and economic factors that do not give individuals an equal opportunity to make healthy choices.

Increasingly, efforts to reduce health spending and improve health outcomes have highlighted non-medical factors. Indeed, federal and state governments, as well as the private sector, are testing ways in which to address social determinants of health. The goal is to break down silos in the system to overcome the challenge of paying for these efforts, and health care experts are closely watching the movement toward new delivery system and payment models involving such approaches as global payment and accountable care organizations as a means of doing so (source).

WHAT ARE SOCIAL DETERMINANTS OF HEALTH?

The World Health Organization defines social determinants of health as the conditions in which people are born, grow, live, work, and age (source). They are the factors mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between different geographic locations (source). Approximately 80 percent of physicians maintain that addressing patients’ social needs is as critical as addressing their medical needs (source). There are five major determinant areas:

  • economic stability (poverty, employment, food security, housing stability);
  • education (high school graduation, enrollment in higher education, language and literacy);
  • social and community context (social cohesion, discrimination, incarceration);
  • health and health care (accessibility and health literacy); and
  • neighborhood and built environment (food deserts, quality of housing, safety) (source).

These factors can impact population health outcomes by establishing a negative social and physical environment and deepening the inequities that certain populations face (source).

Health Disparities

It is impossible to discuss social determinants of health without examining health disparities. Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations (source). These disadvantages are largely attributed to the unequal distribution of resources based on factors such as race/ethnicity and socioeconomic status (source).

In order to utilize high-quality care, it is important to first have access to care, which has historically been overwhelmingly worse for minority populations than for whites. A 2015 Agency for Health Care Research and Quality (AHRQ) report found that across most of the access measures studied, Blacks and Hispanics fared worse than whites (source). Access to, and affordability of, health insurance is a major component of these disparities. Compared with those who are insured, the uninsured are less likely to have a regular doctor or to get timely and routine care, and more likely to use the emergency room as their only source of care.

Health and health care inequities affect everyone. They not only lead to disproportionate health outcomes for minority populations, but also limit improvements in quality of care and result in high costs (source). Between 2003 and 2006, 30.6 percent of direct medical care expenditures for African Americans, Asians, and Hispanics were excess costs due to health inequalities; eliminating health disparities for minority populations could have reduced these costs by $229.4 billion (source). Although it is clear that there are disparities between different populations, there is little consensus about what can or should be done to lessen the gap in health outcomes.

Culture of Health Action Framework

The focus on social determinants of health fits within the Robert Wood Johnson Foundation’s efforts toward a culture of health. In November of 2015, the Robert Wood Johnson Foundation, in collaboration with the RAND Corporation, introduced a Culture of Health Action Framework to identify four interconnected action areas with a goal toward improved population health, well-being and equity. The four action areas are making health a shared value; fostering cross-sector collaboration to improve well-being; creating healthier, more equitable communities; and strengthening integration of health services and systems (source).

FEDERAL AND STATE INITIATIVES

With increased attention in this area, federal, state, and private initiatives are emerging to integrate community services with clinical health.

Accountable Health Communities

In January of 2016, the Centers for Medicare and Medicaid Services (CMS) announced the creation of the Accountable Health Communities Model, a new version of accountable care organizations and the first CMS innovation model to focus on social determinants of health. The five-year program will focus on the health-related social needs of Medicare and Medicaid beneficiaries. CMS has made $157 million in funding available to support 44 organizations that bridge the gap between community and clinical services. CMS will consider the model to be effective if organizations achieve a reduction in total health care costs, emergency department visits, and inpatient hospital readmissions (source).

HHS Disparities Action Plan

In November 2010, the Department of Health and Human Services (HHS) developed the Disparities Action Plan to reduce racial and ethnic health disparities. The five goals between 2010 and 2015 were to transform health care; strengthen the nation’s health and human services infrastructure and workforce; advance the health, safety, and well-being of the American people; advance scientific knowledge and innovation; and increase the efficiency, transparency, and accountability of HHS programs (source). The plan was built on the foundation of the Affordable Care Act (ACA) and is aligned with programs and initiatives such as Healthy People 2020, first lady Michelle Obama’s Let’s Move Initiative, and the National HIV/AIDS Strategy.

Medicaid Expansion

Under the ACA, some states have chosen to expand their Medicaid coverage to all adults earning up to 138 percent of federal poverty level. By helping disadvantaged populations to access health services, Medicaid expansion could ease the effects of two determinants of health: socioeconomic status and health care access. A study conducted by the University of Maryland School of Public Health found that the ACA significantly improved insurance coverage and use of health care for African Americans and Latinos, suggesting that the ACA can reduce disparities in these minorities through coverage and utilization (source).

Safety Net Institutions

The ACA includes provisions aimed at reducing racial and ethnic health disparities, including an additional $11 billion in funding for community health centers (source). Nearly two-thirds of the 20 million individuals receiving care at these community health centers are racial and ethnic minorities (source). One type of community health center is a federally qualified health center. By definition, these centers must serve an underserved area or population, and many face enormous challenges, such as limited workforce and funding. They offer a sliding fee scale, provide comprehensive services, and participate in an ongoing quality assurance program. The centers have been at the core of safety net providers, expanded through the ACA as coverage increases, but this increase in coverage has also resulted in community health centers being stretched to their limit.

The ACA also grants funding for community-based collaborative networks of safety-net providers and health care providers for integrated services. Investments in these integrated models have been shown to have economic benefits, including lower health care costs, increased patient satisfaction and loyalty, and improved provider satisfaction and productivity (source).

Health in All Policies

Since the early 2000s, public health advocates have promoted a “health in all policies” approach to address factors influencing social determinants in decision-making across sectors (source). The concept builds on the impact that diverse areas from education to food policy have on health and health equity (source). California established a California Health in All Policies Task Force in 2010 to bring 22 state agencies, departments, and offices together to develop interagency initiatives for a healthier California. Community Care of North Carolina (CCNC) is a public-private partnership between the state and 14 local, nonprofit networks that coordinates care for members and has been cited as a key factor for improved health care quality at lower costs (source).

State Innovation Models

The Centers for Medicare and Medicaid Innovation (CMMI) is encouraging integration of social determinants into health care through its State Innovation Models (SIM) Initiative by providing financial and technical support to develop new payment and delivery models improving performance, quality of care, and decreases costs. The SIM program is currently in Round Two of Model Testing, with most of the 11 participating states receiving funding implementing projects that link primary care with behavior health, public health, and social services. Innovative demonstration models aimed at improving quality while lowering costs will be spread voluntarily to Medicare, Medicaid, and CHIP providers (source).

EXPERTS

Melinda Abrams, vice president, delivery system reform, The Commonwealth Fund, 212/606-3831, mka@cmwf.org

Dolores Acevedo-Garcia, director of the Institute for Child, Youth, and Family Policy, Brandeis University, 781/736-3715, dacevedo@brandeis.edu

Laudan Aron, senior fellow, Urban Institute Center on Labor, Human Services, and Population, 202/261-5709, media@urban.org

Samantha Artiga, associate director, Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 202/347-5270

Caroline Battles, vice president, State Advocacy and Community Health, Ascension, 314/733-8650, caroline.battles@ascension.org

Joseph Betancourt, director, The Disparities Solutions Center, Multicultural Affairs Office, Massachusetts General Hospital, 617/724-7658, jbetancourt@partners.org

Paula Braveman, director of the Center on Social Disparities in Health, University of California, San Francisco, 415/476-6839, paula.braveman@ucsf.edu

Stuart Butler, senior fellow, economic studies, The Brookings Institution, 202/238-3183, smbutler@brookings.edu

Lisa Dubay, senior fellow, Urban Institute Health Policy Center, 202/261-5709, media@urban.org

Tim Englehardt, director, Medicare-Medicaid Coordination Office, Centers for Medicare and Medicaid Services, 202/690-6277, tim.engelhardt@cms.hhs.gov

Sameera Fazili, senior community and economic development visiting advisor, Federal Reserve Bank of Atlanta, 404/498-7304, sameera.fazili@atl.frb.org

Lynda Flowers, senior strategic policy adviser, AARP Public Policy Institute, 202-434-3889, lflowers@aarp.org

David Fukuzawa, managing director, health and human services programs, The Kresge Foundation, 248/643-9630, ddfukuzawa@kresge.org

Deb Gross, deputy director, Council of Large Public Housing Authorities, 202/638-1300, dgross@clpha.org

Dan Hawkins, senior vice president – public policy and research, National Association of Community Health Centers, 202/296-0131, dhawkins@nachc.org

Frederick Isasi, director, Center for Best Practices – Health Division, National Governors Association, 202/624-7872, fisasi@nga.org

Jeffrey Levi, professor, health policy and management, Milken Institute School of Public Health, 202/994-8958, jlevi@gwu.edu

Valerie Lewis, assistant professor, health policy and clinical practice, The Dartmouth Institute, 603/653-0848, valerie.a.lewis@dartmouth.edu

Leandris Liburd, director, Office of Minority Health and Health Equity, Centers for Disease Control and Prevention, 404/498-2320, leandris.liburd@cdc.hhs.gov

Marsha Lillie-Blanton, senior policy adviser, Center for Medicaid and CHIP Services, 410/786-8856, marsha.lillie-blanton@cms.hhs.gov

Steve Lopez, manager, Health Policy Project, National Council of La Raza, 202/785-1670, slopez@nclr.org

Douglas McCarthy, senior research director, The Commonwealth Fund, 970/259-7961, dm@cmwf.org

Meg Murray, chief executive officer, Association for Community Affiliated Plans, 202/204-7509, mmurray@communityplans.net

Anand Parekh, chief medical adviser, Bipartisan Policy Council, 202/204-2400, aparekh@bipartisanpolicy.org

Gary Puckrein, founder and president, National Minority Quality Forum, 202/223-7560, gpuckrein@nmqf.org

Pamela Riley, assistant vice president, delivery system reform, The Commonwealth Fund, 212/606-3862, pr@cmwf.org

Trish Riley, executive director, National Academy for State Health Policy, 202/903-2787, triley@nashp.org

Hector Rodriguez, professor and co-director, School of Public Health, University of California, Berkeley, 510/642-4578, hrod@berkeley.edu

Sara Rosenbaum, professor, Department of Health Policy, George Washington University School of Public Health and Health Services, 202/994-4230, sarar@gwu.edu

Amy Jo Schulz, professor, health behavior & health education, University of Michigan School of Public Health, 734/647-0221, ajschulz@umich.edu

Tanya Shah, senior program officer, delivery system reform, The Commonwealth Fund, 212/606-3856, tbs@cmwf.org

Lauren Taylor, co-author of The American Health Care Paradox; doctoral student, Harvard Business School, 516/662-4201 laurenannetaylor@gmail.com

Gustavo F. Velasquez, assistant secretary for fair housing and equal opportunity, Department of Housing and Urban Development, 202/708-1112

Sunia Zaterman, executive director, Council of Large Public Housing Authorities, 202/638-1300, szaterman@clpha.org


The Sourcebook was made possible with the support of the Robert Wood Johnson Foundation, with ongoing support from the National Institute for Health Care Management (NIHCM) Foundation.