The strongest determinants of your health are not your genes, gender, how far you can walk or even if you have good health insurance. The strongest factors that shape your health are the conditions in which you are born, grow, live, work and age.
Known as social determinants of health (SDOH), they include your education, socioeconomic status, jobs, access to health care, race, ethnicity, gender, family structure, and the condition of your neighborhood and work environment.
When we look at the groups that have the highest rate of positive coronavirus tests or who are dying from COVID-19, we find a very close relationship with unhealthy SDOH. The majority of cases live in dense neighborhoods or institutions, are minorities, have a low income, cannot work from home or have lost their job and health insurance.
Because health and wealth are so closely connected in the United States, low-income populations are especially vulnerable to epidemics and other diseases. We know that poverty, chronic illness and stress worsen the body’s immune system response to disease. In fact, SDOH are increasing the spread of coronavirus for everyone. The World Health Organization says that SDOH are responsible for most health disparities.
In turn, people who have healthy food, housing, transportation to medical appointments and other social services, have a stronger ability to manage their disease, or prevent it in the first place. Their disease is more likely to be cured or its harm reduced, they have fewer hospitalizations and lower out-of-pocket health costs.
A recent coronavirus study at Purdue University showed blacks tested positive for COVID-19 at twice the rate of whites. They are more likely to be hospitalized and tend to have more severe symptoms, compared to whites. Researchers cited poor access to healthy food, health care, stable housing and overall poor health as the reasons for the disparity.
If we are to improve health care delivery and bend our health system’s cost curve, we must address SDOH. Supporting employment and economic independence, reducing social isolation and addressing other non-medical risk factors have been shown to improve patient outcomes and reduce the cost of care.
In addition to the inequities caused by SDOH, the majority of U.S. health care costs are spent on 5% to 10% of our population. Referred to as “high need high cost” (HNHC) patients, they are very sick and require long-term or extensive care.
Most HNHC patients have multiple SDOH, are more likely to have poor health, and less able to maintain good health. HNHC patients have complex health conditions and significant functional limitations, are more than twice as likely to visit emergency rooms, and three times more likely to have an inpatient hospital stay.
Patients living with chronic conditions spend 55% more on care than those without chronic conditions. HNHC patients include disabled adults under age 65, those who have advanced illnesses, the frail elderly, and people with multiple chronic conditions that restrict their ability to carry out minimum daily tasks.
If we can reduce the costs of care for HNHC patients, our whole health care system could breathe a financial sigh of relief. Adequately addressing SDOH also reduces medical spending. One study found a 10% reduction in the 30-day hospital readmission rate (one of health care’s highest expenses) when SDOH were addressed along with health needs. A collaboration between a senior social services program and a health system resulted in an 11% reduction in the cost of care.
Decades of research tells us that it’s less expensive to prevent diseases and chronic conditions than to pay for treatment. It’s certainly better for the patient. But what value is a doctor’s orders to eat a balanced diet to speed recovery when the patient cannot shop for food or stand up long enough to cook it? Can we expect a mom making $10 an hour and no health insurance to stay home for two weeks to heal from COVID-19? How can a homeless man keep his insulin refrigerated?
Who is responsible for identifying a patient’s SDOH? Long gone are the days when the town doctor knew every patient’s family situation and individual needs.
Even more pressing questions include: who will be responsible to screen, monitor and pay for these social services? We know that coordination of medical and social services can improve health outcomes, increase patient satisfaction and reduce health care costs for patients and government providers like Medicare and Medicaid. Yet the medical and social service communities rarely work together.
Health insurance companies won’t reimburse a doctor’s office for finding a homeless diabetic a place to live. Most people with mental health needs never get a diagnosis, much less adequate treatment. Medicare does not pay for a care coordinator to manage SDOH as they relate to health care.
The coronavirus pandemic has made it even more apparent that community resources — access to food, safe and affordable housing and green spaces — are critically important to our ability to stay healthy. The social and economic disparities in certain communities influence who becomes sick, who can social distance, and who has access to coronavirus testing and treatment.
Doctors and hospitals have been asked to solve 100% of our health problems with only half the tools – effectively addressing SODH would provide the other half.
Our health care system is not sustainable unless and until we also treat the root causes of illness. We must invest in the health of every community. We cannot successfully treat a patient without treating their whole neighborhood.
Unless there are changes, U.S. health care will continue to spend vast sums of money on acute health care problems with only third-world results. We have an opportunity to create a stable and sustainable health care system by investing in the health of all our communities. The return on this investment would be enormous. It has now become a life-or-death investment and one we can no longer ignore.
Editor’s note: Ray Hanley is President and CEO of the Arkansas Foundation for Medical Care. A video interview of Hanley on the topic of SDOH can be viewed below. The opinions expressed are those of the author.