Gail Wilensky: Achieving health equity in the U.S. requires a preventive approach
Social determinants of health (SDoH) present a severe challenge for our nation by perpetuating inequities both in access to care and in the quality-of-the outcomes of care.
SDoH have a significant impact on life expectancy in the United States, while also contributing to high healthcare costs. (See the sidebar included with this column online at hfma.org/hfm.) The pressing question is, Where should we begin addressing this challenge?
The need for preventive action
Although interventions that affect the SDoH are helpful throughout a person’s life, they can be most helpful if they occur early on. Focusing on the health and development of the pregnant woman and fetus can pay dividends throughout a child’s lifetime. Moreover, chronic conditions, such as obesity and mental health problems, as well as cancer — the second leading cause of death in the United States after heart disease — all have their roots in the early years of life. These conditions have a disproportionate effect on economically disadvantaged people, and reducing their incidence could help moderate the nation’s costs for healthcare while improving the health of all Americans.
Therefore, investments in early childhood education, especially for the poor, are strategically important because they can lead to improved quality of life and economic productivity while preventing disease.
Another important starting point for SDoH interventions is food insecurity, which was a problem even before the pandemic. In 13.7 million households, representing more than 35 million Americans, food insecurity was an issue at some point in 2019.a It also remains a serious problem across the nation and is a strong predictor of chronic conditions in later years.
There already are many important examples of interventions focused on enhancing early childhood education and food security.
Analyses of early Head Start programs have shown the importance of high-quality child care in enhancing child development.b Other programs such as the No Child Left Behind Act, which was replaced by the Every Student Succeeds Act in December 2015, defines federal requirements for K-12 general education but allows states to set their own goals for student achievement within the federal framework.
Many programs have been developed to address food insecurity, both by governmment agencies and by individal healthcare organizations.
Farmers to Families Food Box Program. In May 2020, for example, the U.S. Department of Agriculture began distributing food through its Farmers to Families Food Box Program, which ran through May 2021. More than 176 million food boxes were delivered to organizations that then delivered them to individuals, the U.S. Government Accounting Office reported.c
School lunch programs. Many programs that work through the schools — including the National School Lunch Program, which supported almost 30 million students in 2019, and the School Breakfast Program — were granted waivers so parents and guardians could pick up meals when the schools were closed. However, despite the waivers, 1.7 billion fewer meals were served from March to September 2020. Whether families didn’t participate because they qualified for other assistance programs or because of the stress of the pandemic is unknown, and it will take time before any effects of reduced food assistance can be measured.
Fresh Food Farmacy program. Among provider organizations, Geisinger, a regional health system headquartered in Danville, Pennsylvania, has launched a program called Fresh Food Farmacy based on the concept of “food as medicine.”d In connection with clinical interventions, fresh food is provided to patients with Type 2 diabetes with the goal of helping them manage their diabetes through food-related behavioral change. Geisinger also has expanded programs that address food insecurity to increase access to healthy food, including providing a four-day supply of food to two-person households identified as food insecure.
WIC. One of the most important programs supporting the nutrition of low-income populations has been the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which serves pregnant and postpartum women and children up to age 5. In fiscal year 2020, WIC served 6.2 million people at a cost of $4.9 billion.e It would be helpful if more credible data analysis were available on the potential longer-term effects, particularly for disadvantaged children, although establishing a causal relationship between WIC and later child development scores would be a challenge because of the lengthy time involved.
It also comes down to access
All these interventions aside, it also is important to keep in mind that access to medical care is a key social determinant. No other intervention negates the importance of ensuring timely access to high-quality medical care, which is out of reach for most people who lack insurance. Most people who are uninsured lack access to timely healthcare, which puts them and their communities at undue risk.
Therefore, to truly promote good health outcomes, there needs to be a continued focus on ensuring that everyone has some kind of insurance. And that means making sure people who are eligible for Medicaid or have health plan options under the Affordable Care Act are taking full advantage of those options.
a. NPR, “Food insecurity in the U.S., by the numbers,” Sept. 27, 2020.
b. Schanzenbach, D., and Bauer, L., “The long-term impact of the Head Start program,” Brookings, Aug. 19, 2016.
c. U.S. Government Accounting Office, “Addressing food insecurity in America before and during the pandemic,” Oct 12, 2021.
d. See geisinger.org/freshfoodfarmacy.
e. USDA, “WIC Program,” Page last updated Feb. 4, 2022.
Lower life expectancy and high healthcare costs: the impact of SDoH
The United States is recognized for its high spending on healthcare, which — at $4.1 trillion in 2020 — is more than any other nation both on a per-capita basis and relative to its wealth.a At the same time, the nation is also known to have lower a life expectancy than some countries that spend far less.
Life expectancy in the United States was initially lowered in the middle of the 2010s because of an increase in overdose death due to the opioid epidemic, but it increased again to 78.8 years by 2019 — still lower than averages in many European countries and Canada. Then came COVID-19, which struck a blow to average life expectancy worldwide, reducing it to 77 in the United States.b
But COVID’s impact also shed light on a larger truth: The decline in the U.S. life expectancy was in part driven by racial disparities, which caused it to be greater among non-Hispanic Black people and Hispanic people than among non-Hispanic white people. It was a clear reminder that healthcare outcomes reflect more than the general availability of healthcare in an area.
For at least the past two decades, it has been known that health outcomes are influenced by many factors — especially factors not related to medical care. The World Health Organization has described these factors as the “conditions in which people are born, grow, work, live and age.” And they are now widely referred to as social determinants of health (SDoH).c
SDoH include education, employment opportunities, transportation, food and nutritional support — in short, all of the services we normally associate with social services. But it is important to recognize that these determinants also encompass broader concepts such as social mobility and the potential to achieve significant economic mobility. What this means is that SDoH includes discrimination and discriminatory activities that limit individuals’ potential to achieve their maximum capabilities, which can harm their sense of self-worth and ultimately have a negative impact on their health.
a. Peterson-Kaiser Health System Tracker, “How does health spending in the U.S. compare with other countries,” Jan. 21, 2022.
b. Peterson-Kaiser Health System Tracker, “How does U.S. life expectancy compare to other countries?” Sept. 28, 2021.
c. World Health Organization, Closing the gap: health equity through actions on the social determinants of health: Final report of the commission social determinants of health, August 2008.