Category Archives: Social Determinants of Health

The Drivers of Health: What makes us healthy?

Posted on by • Posted in Access & Quality of Healthcare, Causation, Centers for Disease Control & Prevention (CDC), Correlations, Education, Environment, Gender Identity, Genetics, Health Behaviors, Health Policy, Household Structure, Income/Wealth, Interventions, Marginal Effects, Occupation, Outcomes, Racial Indentity, Social Circumstances, Social Determinants of Health, Social Support & Isolation, Timespan • Leave a comment

The Drivers

 

What makes us healthy?

We have an intuitive sense that things like what we eat, how much we exercise, the quality of our water and air, and getting appropriate health care when sick all help us stay healthy, but how much do each of these factors matter?

Studies have also shown that our incomes, education, even racial identity are associated with health — so-called “social determinants of health.”

How much do social determinants matter? How much does the health system improve our health?

In the 1970s the Centers for Disease Control and Prevention tried to answer these questions but had little rigorous science to guide it. Though we know a great deal more today, they still have not been fully answered. This is no mere curiosity — knowing what makes us healthy will help us direct investments into the right programs.

Over the years, many frameworks have been developed to illuminate what affects health. The relationships are so complex that no single framework captures everything. To get us started on this research project — and our broader conversation about what drives health — we created a model that allows us to explore some of the dimensions of these drivers, and their relationships to each other.

The Framework

We developed our framework by reviewing research on factors that influence health and surveying similar projects and tools from prominent organizations . It is not meant to be complete, but a starting point that allows us to think about what drives health and how.

Indirect vs. Direct Factors
Many things affect health, some directly and others indirectly. Government/policy, income/wealth, education, and racial identity don’t necessarily affect health in an immediate way. They are indirect factors that tend to affect health through complex pathways. Those pathways usually involve other factors that more immediately affect health. These are the direct factors such as occupation, health care access, and health behaviors.

Why these Outcomes?
There are many possible health outcomes. The framework includes four examples—age-adjusted mortality, life expectancy, quality of life/well-being, and functional status. These outcomes are commonly studied, prevalent in the literature, and reflect the kinds of things people care most about.

The Drivers

Government/Policy
A wide range of government policies can affect health. For example, in 2007, Australia became the first country to introduce a government-funded human papillomavirus (HPV) vaccination program. For years later, significantly lower levels of HPV were present in the population. As another example, studies show that Medicaid expansion in the US facilitates access to care and improves self-reported health outcomes. Policies outside the health system can affect health too. Those pertaining to deportation of undocumented immigrants and same-sex marriage have been linked to health outcomes, for example.

Income/Wealth
Income and wealth are associated with health, but through complex pathways. While income and wealth facilitate access to health care, food, and housing, it’s also true that good health facilitates labor force participation, potentially leading to higher income. Several studies suggest that income and resources have profound effects in early life and development, but a much smaller effect on adults.

Education
Evidence suggests that education has a causal effect in reducing mortality. Among all age groups, every additional year of school is associated with increased self-reported health status.

Racial Identity
Racial Identity is closely associated with health outcomes in the US. For example, African-American adults experience much higher levels of mortality than white adults, from all causes. Racial Identity also plays a role in the accumulated stress from discrimination and in the quality of health care received.

Gender Identity
Evidence suggests that gender identity plays a role in health and health care. For example, one study found that women with angina pectoris and low socioeconomic status were referred to cardiologists less frequently than men.

Genetics
Genetics play a role in the development of certain disease. For example, while cancer is not caused by genetics, most cancers have some genetic determinants. The BRCA1 and BRCA2 genes play a role in tumor suppression, and, when mutated, increase the risk of female breast, ovarian, and other cancers.

Environment
Environmental factors — natural and built — have profound effects on our health. Of course, factors like air quality affect our health, evidenced by a study that demonstrated an association between higher levels of air pollutants O3 and PM2.5 and pediatric pneumonia. Environmental conditions even before birth (present during fetal development) can affect health and well-being into adulthood.

Medical Care
Medical care is designed to facilitate good health, so both the quality of medical care and access to it influence our health outcomes. One study found that the medically uninsured receive 20% less care after auto accidents and have significantly higher mortality rates than people who are insured.

Health Behaviors
Health behaviors encompass a wide range of human behaviors that affect health including: physical activity; diet; sleep; and tobacco, alcohol, and other substance use. Just as one example, reducing exposure to tobacco has been identified as the single biggest way to prevent morbidity, disability, and early death.

Social Circumstances
Social relationships can affect mental and physical health as well as behaviors and mortality risk. The people we are surrounded by (at an early age, parents, and later in life, peers and romantic partners) strongly influence health through mechanisms of stress, social support, and pressure to engage in or avoid risky behaviors.

Occupation
Occupation is linked to health outcomes, and may both cause health due to the conditions of the job, and be caused by health due to the limitations particular to certain conditions.

Let’s Dig Deeper

Historical vs. Current, Marginal Effects
When attempting to quantify the impact of direct health-related factors, it is important to make a distinction between how much of our current health is related to these factors versus how much of our current health can be improved by interventions that target particular factors. Grasping this distinction is critical so that we know where our dollars are best spent to maximize health improvement. In other words, how much have each of these factors affected our health in the past through today versus how much could they affect health in the future if policy was immediately changed? For example, a disease like smallpox has a huge direct effect on health outcomes, but it has essentially been eradicated, so an additional investment in eradicating smallpox has virtually no marginal gains, even though the disease is closely linked to health.

Timespan
It is also relevant to consider the timespan on which we see certain effects taking place, especially when considering policy intervention. For example, with an environmental change such as improving the air quality, it would take a significant amount of time for all measurable changes in health outcomes to manifest; other interventions, such as dramatically increasing flu vaccination rates, could have significant health outcomes that would be observable on a much shorter timescale.

Correlations vs. Causation
Considering the available literature on social determinants of health and the links between these factors and measurable health outcomes, it is critical to clarify whether what we are observing or seeking is a correlation or causation. Correlations can guide hypothesis generation, but only causation is actionable in terms of policy.

Interventions
Finally, it is worth considering how a framework like this relates to policy intervention. The specific interventions that might be effective within a category (e.g., health behaviors) could change over time. For example, promotion of wearing motor vehicle seat belts was an important area for policy interventions in the 1970s and 1980s, but is less so now because doing so has become commonplace. Though health behaviors remain relevant to health today, the class of interventions that would have the largest impact are different.

 

 

 

 

Health system cost-effectiveness

Posted on by • Posted in Health Policy, Mortality, Social Determinants of Health • Leave a comment

Health system cost-effectiveness

How much value do we obtain per dollar spent on the health system? How has that changed over time? How does it compare across countries? These are tough but important questions.

To explore them, this chart is worth close study. It’s an updated version of one that appears in this 2017 Lancet article by Reinhard Busse, Miriam Blümel, Franz Knieps, and Till Bärnighausen. It represents how much health systems reduce mortality per dollar spent.

Let’s unpack it. Seven countries are represented: US (red, labeled “USA”), Denmark (yellow), France (dark green), Germany (light green, labeled), United Kingdom (red), Switzerland (blue, labeled), Canada (grey). For each country, about a dozen points are plotted, roughly 2006 – 2016 (some start in 2005 and some end in 2015).

Each plotted point represents a year — earlier years are toward the upper left, later ones toward the lower right. And each point, for each country, conveys how many lives were lost that could have been saved by the health system and how much is spent by the health system.

Specifically, the horizontal axis is per capita health spending, in US dollars and adjusted for purchasing power (meaning a dollar equivalent of another currency buys the same amount of goods and services as a US dollar does in the US). All else held constant, one would prefer to spend less on health care, so movement to the left along the axis is preferred.

The vertical axis is amenable mortality per 100,000 people, for those under 75 years old. That is, it’s the number of 0-74 year olds that die per 100,000 due to factors that they health system can address with accessible, timely, and effective health care. All else held constant, one would prefer fewer deaths, so movement downward along the axis is preferred.

With that in mind, points more to the left and further downward are to be preferred than points upward and to the right. That’s because they imply fewer deaths for less money. I don’t care what your values are, you should always prefer less death at lower cost. I’ll let you conclude from that what to make of US health care spending relative to that of any other country represented.

There’s another way to look at this chart, though. Just focus on one specific country— let’s take Germany. As the years passed, Germany (and every other country) spent more on health care. How much reduction in death did it achieve as it did so? The spending is more efficient the greater decrease per dollar. In other words, the steeper the downward slope of a country’s line, the more efficiently it is investing in health care.

Relative to other countries depicted, Germany has a moderately steep downward slope. From about 2010-2015, Denmark’s slope is the steepest shown—vast improvements in mortality per dollar spent. Switzerland’s really flattens out in recent years, indicating very little gain for a lot more spending.

Now look at the US. Recently, it’s line has sloped a tad bit upward. More spending and more death. That’s the worst deal of all.

 

 

 

 

 

A Secret to Better Health Care

Posted on by • Posted in 2020 Election Issues, Health Policy, Social Determinants of Health • Leave a comment

https://www.realclearhealth.com/2019/05/28/a_secret_to_better_health_care_279059.html?utm_source=morning-scan&utm_medium=email&utm_campaign=mailchimp-newsletter&utm_source=RC+Health+Morning+Scan&utm_campaign=e0c8de7485-MAILCHIMP_RSS_EMAIL_CAMPAIGN&utm_medium=email&utm_term=0_b4baf6b587-e0c8de7485-84752421

 

A Secret to Better Health Care

 

It seems obvious: better social services. So why are things like food stamps and housing not part of the conversation?

Health care is at the center of the national policy conversation, and with the 2020 presidential election now in full swing, that is where it will probably remain. But for all the talk about how to increase access and reduce costs, we’re missing a critical piece of the puzzle: the inverse relationship between health care costs and spending on social programs.

One reason the United States spends more on health care than any other nation — more than 17 percent of gross domestic product, compared with an average of 9 percent for other advanced economies — is that we spend far less on social services like food stamps, free school lunches and public housing.

If our spending on social programs were more in line with other developed countries, our health care costs would fall. That means that as policymakers evaluate a social program, they should weigh not only its direct and second-order benefits — from reducing crime and recidivism to increasing productivity — but also its effect on lowering federal health care costs.

These safety net programs can lower health care costs by strengthening what medical professionals call the “social determinants of health”: the environment in which people are born, grow, live and work. Effective social programs provide access to good nutrition, clean and safe shelter and a subsistence income, which are critical to avoiding disease. They help food-insecure children receive nutrient-dense meals rather than empty calories, and families with incomes below the poverty line to live in sanitary environments free of serious health risks.

Especially important are programs that ameliorate poor housing conditions and prevent disease, including lead abatement, control of mold and dampness and heating-system repairs. Consider a real-life example.

Days after an elderly patient was treated for heart failure at Mount Sinai Hospital and returned home, the elevator in his apartment building broke down. Lacking the ability to climb stairs, he became a prisoner in his own home, unable to go out for a walk, shop for fresh food and visit his doctors for follow-up care.

A social service worker took up his case, and the elevator was repaired. His substandard housing was literally a threat to his health; the intervention of the social worker may have saved his life — and certainly saved him from a possible relapse and expensive hospital care.

Two programs — one in Chicago, the other in Los Angeles — show the multidimensional benefits of social spending. The Chicago program supplemented federal housing subsidies to help patients with chronic health problems afford stable housing. It reduced health care costs in the University of Illinois hospital system for participating patients by roughly 18 percent. And once in stable housing, beneficiaries can better pursue public benefits and job opportunities.

The Los Angeles program showed even greater cost savings, according to a study by the nonpartisan RAND Corporation. After receiving housing assistance, beneficiaries’ costs to the public health system plummeted. Inpatient services fell by 75 percent. Over all, the study found that, even accounting for the increased housing costs, recipients’ total social service and health care costs fell by 20 percent. And beneficiaries showed signs of reduced involvement in crime and improved mental health.

All of this is intuitive and supported by reams of data. But the United States continues to spend a relative pittance on such programs. Housing programs, including rental assistance, public housing and homeless-assistance grants, account for one-quarter of 1 percent of G.D.P. Nutrition programs, such as food stamps and the Women, Infants and Children nutrition program, amount to one-half of 1 percent of G.D.P.

Our underinvestment sets us apart from other advanced nations around the globe, particularly in Western Europe. France, Sweden and Britain commit far more than the United States to social services, as a percentage of their economy, while spending significantly less per capita and as a percentage of their economy on health care — and boast a higher life expectancy.

Many factors influence discrepancies in health care spending and outcomes between the United States and its counterparts: vastly different views about the financial incentives in health care; the high cost of prescription drugs, diagnostic tests and administrative expenses; and cultural expectations about end-of-life care. But we won’t effectively reduce costs, and improve outcomes, until we think bigger and recognize the critical link between health care spending and social programs.