Introduction
For decades, health experts have recognized the decisive influence of social and environmental factors on people’s health, especially among poor and disadvantaged populations. Visual models showing that medical care has less of an impact on health outcomes than social and environmental factors have been circulating for years. Public health experts find this to be no surprise. From the early days of water sanitation and waste disposal to more modern public health interventions such as water fluoridation, public health experts have known that environmental factors can have an outsized impact on individual health. In fact, social and economic factors may have the largest influence on health.[note]Minnesota Department of Health, “Advancing Health Equity in Minnesota: Report to the Legislature,” February 2014, available at http://www.health.state.mn.us/divs/chs/healthequity/ahe_leg_report_020414.pdf. [/note] However, efforts in the U.S. to address structural problems in health care systems by controlling health care expenditures and increasing efficiency have done little to tackle the social, economic, and environmental factors that influence health to a much greater degree than medical care.
Addressing the social determinants of health (SDOH) has long been a priority for global, national, state, and local public health efforts. But until recently much of the health care delivery system in the U.S. has focused almost exclusively on its role of providing clinical care to individuals. The U.S. spends $3.3 trillion dollars on health care annually[note]Centers for Medicare & Medicaid Services, National Health Expenditure Data, “NHE Fact Sheet,” available at https://www.cms.gov/research-statistics-data-and-systems/statistics-trendsand-reports/nationalhealthexpenddata/nhe-fact-sheet.html.[/note] —more than 2.5 times more than any other country. But with studies showing that the impact of medical care on health may be as low as 10 percent, the health care sector is beginning to embrace a new reality— reducing health care costs and improving health outcomes necessitates addressing the root of the problem: SDOH. There is a growing interest among policy experts and health care leaders to explore opportunities to address the social determinants. Recently, Politico reported that a February 2018 Health Affairs summit on health spending included, “much glumness about all the rainbows and unicorns that have been chased and proved illusory . . . but the topic that got the overflow crowd jazzed…was spending on social determinants of health.”[note]A. Cancryn, Politico Afternoon Pulse newsletter, February 1, 2018.[/note]
What better place to innovate than in Medicaid? After all, it is the single largest health insurer in the U.S. serving more than 74 million people,[note]Medicaid and CHIP Enrollment Data, November 2017, available at https://www.medicaid.gov/medicaid/program-information/downloads/november-2017-enrollment-data.zip.[/note] including the lowest-income and most vulnerable children and families whose health is more likely to be impacted by economic, social, and environmental conditions.
This brief is intended to ground health care advocates on SDOH basics and describe ways Medicaid, in partnership with the health plans and providers that deliver public coverage benefits, can improve the health of enrollees by addressing the SDOH. It provides background and highlights resources that can support advocacy efforts to drive change in how our public coverage programs evolve in order to achieve better health outcomes and reduce health disparities for low-income children and families.
What are the social determinants of health?
Social determinants of health are most often defined as the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources: complex issues that need to be addressed at multiple levels.[note]O. Solar and A. Irwin, World Health Organization, “A Conceptual Framework for Action on the Social Determinants of Health,” Social Determinants of Health Discussion Paper 2 (Policy and Practice), 2010, available at http://www.who.int/social_ determinants/corner/SDHDP2.pdf.[/note] Importantly, SDOH are largely responsible for health disparities and inequities.
Affordable housing, economic security, safe neighborhoods, and access to adequate and healthy foods are major factors that impact the health of low-income children and families every day. Medicaid could play an even bigger role in addressing these issues in today’s health policy landscape.