The U.S. health system, if it were a separate economy, would be equivalent to the fifth or sixth largest economy in the world. Sadly, although our nation under Republican and Democratic administrations alike spends more on health care per capita than every other developed nation and twice as much as most of them, Americans have distressingly poor health outcomes. Our life expectancy is up to four years shorter than that of other developed nations and we have one of the worst infant mortality rates among industrialized countries.
Medical leaders increasingly recognize that health is driven only to a small (10-20 percent) extent by clinical care delivery. Much more powerful predictors of health or illness are the social determinants of health – the circumstances into which we are born, live, work and play. These “upstream” determinants include race and ethnicity, economic status, access to healthy foods, safe neighborhoods, education, job security and social support.
Consider the far ranging impact of the social determinants of health: African Americans die on average four years younger than white Americans. White men with advanced degrees live 13 years longer than white men who never finish high school (the difference for white women is 10 years). Life expectancy of the top 10 percent of male earners born in 1950 is 14 years longer (13 for women) than those in the bottom 10 percent. These statistics are troubling and just a sampling.
When we fail to address the social determinants of health, we miss opportunities to prevent some illnesses altogether and too often see patients presenting to clinical care with more advanced conditions which cost more to treat. With timely intervention, we could ensure some illnesses never develop at all; we could attenuate disease severity (removing mold in housing to decrease asthma attacks in vulnerable children) and treat earlier before complications develop (educate diabetics to prevent hospitalization for diabetic ketoacidosis).
If you compare the total of what we spend “downstream” on clinical care (currently twice as much per capita as other western democracies) with what we spend “upstream” on social services (excluding clinical health services), the imbalance is clear. Research on health care funding priorities corroborate that greater upstream investment could significantly lower downstream costs.
The U.S. spends less per person on “upstream” social services (such as housing, education, job opportunities and other social support) than 10 other OECD countries. A recent study showed that a mere 20 percent change in the median ratio of social services to clinical care spending in the U.S. would result in 85,000 fewer obese adults within a year, and therefore fewer cases of diabetes, less morbidity and lower mortality. Likewise, for every additional African American man who graduates high school, lifetime health costs would decrease by more than $30,000, with a resulting savings for the entire population of more than $6 billion in total health care costs each year.
Lawmakers should take heart in promising initiatives such as the Accountable Health Communities Model recently launched by the Center for Medicaid and Medicare Services (CMS) through its Center for Innovation. The program provides funds to allow health delivery systems and social services organizations to partner on connecting beneficiaries with community-based services that provide assistance with housing instability, food insecurity, and transportation needs – all important to supporting poor and vulnerable individuals. This “experiment” in upstream investment will provide valuable insights into the efficacy of new funding models to address social determinants.
Prioritizing research on the social determinants of health will be critical to success. We still don’t understand all the causal links between social circumstances and health. How much of the effect of social circumstances is due to access to care and how much is a reflection of psychosocial and behavioral drivers of health? What are the biological changes induced by social determinants? An emerging body of evidence on the impact of adverse child experiences and the ways in which abuse and neglect lead to poorer adult health is emphasizing the life-long importance of protecting our children. Research to develop a stronger evidence base, and identify important factors that can and must be addressed, can serve as a foundation for health care design. As we understand which interventions are the most effective and which have the greatest impact on health for which populations, we can spend our resources most appropriately.
Innovations in health spending and expanded research on the social determinants of health can ensure that we become a healthier nation. The American health care system should lead, rather than lag the world, and ensure that all our citizens achieve optimal health.
Claire Pomeroy, M.D., M.B.A., is president of the Albert and Mary Lasker Foundation, dedicated to improving health by accelerating support for medical research.