Research and data

Thinking beyond health care to improve health

people forming a map icon

As we suffer through the worst pandemic in over a century, the value of health care and biomedical science is obviously at the forefront. A new virus, with no known treatment or cure, has taken the world by storm as doctors do their best to keep patients alive and scientists race to develop a vaccine. COVID-19 is inescapable at the moment. The pandemic has taken over the news and changed our way of life, but this too shall pass. And when it does, we ought to be paying a lot more attention to things outside of the hospital or lab if we really want to improve health and our ability to handle the next crisis.

Much of my research has been focused on how to use marketing to help inform people so that they can get help with quitting smoking or affording health insurance. Information is power, and it’s essential to get it in the hands of the people who want to make a change for the better but don’t know how.

But it doesn’t solve the problem of why people become sick in the first place. It isn’t a secret that poorer and historically disadvantaged people are less healthy and don’t live as long. Understanding the many ways these social factors influence health can help us go beyond our health care-focused approach to improving health outcomes and making important changes in social policy that have been overlooked for far too long.

Social factors determine health outcomes

As the infographic below shows, those who live in the suburbs generally live longer. A few miles can mean a seven-year difference in life expectancy. Why? It goes back to who lives where and what that means for their life and livelihood.

city map showing life expectancy

Source: Robert Wood Johnson Foundation

The so-called “social determinants of health” have become a buzzword in health care of late but represent a decades-old concept. The World Health Organization defines them as “the conditions in which people are born, grow, live, work and age,” meaning everything from education and income to public transit, policing, racism, and others. How much social factors contribute to differences in health has been debated for decades and there still isn’t a consensus, but several studies put it on par or more important than actual health care.

Many of these social determinants are difficult to change in a year or even a generation, as evidenced by the constant reminders of how the police and criminal justice system kill and imprison Black Americans at much higher rates. There are huge racial disparities in wealth and income, a legacy of redlining and discriminatory hiring. Despite our love of the underdog and those who pull themselves up by their bootstraps, climbing out of poverty in America is really hard and ends up being passed from generation to generation.

Small fixes ignore the bigger health picture

These societal issues and national policy debates about how we fund education, infrastructure, and the social safety net go well beyond what the health care system can do. So health systems have tended to focus on smaller one-off fixes, like helping patients get to appointments or having enough food to eat, without making a dent in the larger problem. We try to offer help to those with low income and chronic health needs, but many slip through the cracks. The push to focus on social determinants can also clash with efforts to tackle health care spending, like pay for performance, creating a conflict between who needs the most help and who won’t hurt the bottom line.

These efforts certainly can help but there is a danger that they become the only way in which we try to make progress. Instead of reimagining housing policy or health care because they are like a political Mount Everest, we settle for the small wins, all the while funneling more and more money into the health care system and expecting it to solve these systemic problems. As I wrote in May for The Conversation, the federal response has been to rely “…on short-term measures directed to those affected by the crisis…[doing] little to address the plight of those who were already economically vulnerable and those who will be long after this pandemic.”

It is critical to get this right because disadvantages tend to pile up. In a recent study by one of my colleagues, Dr. Megan Cole, over half of low-income Americans reported an unmet social need—like trouble paying bills, affording food, or living in an unsafe neighborhood—and these unmet needs were also related to worse access to and quality of health care. We are seeing this even more strikingly during the pandemic. Lower income workers doing “essential” jobs are essentially trapped, being forced to put themselves and their families in harm’s way just to make ends meet, with communities of color suffering worse health and economic consequences from the pandemic.

Mending the social safety net

A key part of how my research is responding to COVID-19 is to better understand where the gaps and missed connections are in the social safety net. There has been a big jump in Medicaid enrollment, a health insurance program available to low-income Americans, but an early study couldn’t link it with job losses at the state level. I am currently working with collaborators at Duke and UNC to go deeper, looking at the relationship between unemployment and enrollment in Medicaid at the county level in North Carolina. We are specifically focusing on whether social disadvantage makes a difference in that connection, which is critical to maintaining access to health care and where the state targets limited resources for outreach.

The rapid pace of innovation in biomedical science has created incredible advances that we couldn’t have imagined years ago, but our society and policies have to evolve to make sure everyone can benefit from them or else maps, like the one above, won’t look any different years from now.

Dr. Paul Shafer is an assistant professor in the Department of Health Law, Policy, and Management at the Boston University School of Public Health and an investigator at the Partnered Evidence-based Policy Resource Center at the Boston VA Healthcare System. His research focuses on the effects of the structure and implementation of state and federal health insurance policy on coverage, health care use, and health.

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