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“Research suggests that social determinants of health are related to transportation, the environment, wealth, agriculture, education, employment and housing. Overall, the United States does poorly on social determinants of health indicators and on aligning policy across sectors (Raphael, 2007; Marmot & Bell, 2009). For example, the generosity of family policy – as measured by the total expenditure level – is correlated with child poverty levels, and the United States has the poorest performance among the high-income countries on this measure (Baker, Metzler & Galea, 2005; Commission on Social Determinants of Health, 2008, p. 11).
“While it is generally agreed that health disparities across racial and ethnic groups are mainly caused by factors outside the healthcare system, access to medical care is nonetheless one critical factor in reducing these disparities. However, there is no government department in the United States that focuses on the intersectoral policy topic of the social determinants of health and how they influence the health of the population. There is little doubt that policies related to these variables influence health. These include racism (both individual and institutional), income inequality, socioeconomic status, the distribution of power, social support networks, stress levels, early life experience, social inclusion / exclusion, unemployment, physical activity / inactivity and the redistribution of other resources (Lynch et al., 1998; Wilkinson & Marmot, 2003; Feagin and Bennefield, 2014).”
Source: Rice T, Rosenau P, Unruh LY, Barnes AJ, van Ginneken E. United States of America: Health system review. Health Systems in Transition, 2020; 22(4): pp. i–441.
“Black and Indigenous individuals and other people of color face significant barriers to obtaining quality health care services in the US.1 Inequalities by race and ethnicity in access to care have been attributed to variation in insurance coverage2; socioeconomic and geographic inequities that affect health and access to health care3,4; and structural, institutional, and interpersonal racism within the health care system.5,6 These barriers to health care utilization and treatment reflect and perpetuate structural racism in US society more broadly.7“
Source: Dieleman JL, Chen C, Crosby SW, et al. US Health Care Spending by Race and Ethnicity, 2002-2016. JAMA. 2021;326(7):649–659. doi:10.1001/jama.2021.9937
“Evidence Review Analysis of 2016-2019 data from the Medical Expenditure Panel Survey (MEPS) and state-level Behavioral Risk Factor Surveillance System (BRFSS) and 2016-2018 mortality data from the National Vital Statistics System and 2018 IPUMS American Community Survey. There were 87 855 survey respondents to MEPS, 1 792 023 survey respondents to the BRFSS, and 8 416 203 death records from the National Vital Statistics System.
“Findings In 2018, the estimated economic burden of racial and ethnic health inequities was $421 billion (using MEPS) or $451 billion (using BRFSS data) and the estimated burden of education-related health inequities was $940 billion (using MEPS) or $978 billion (using BRFSS). Most of the economic burden was attributable to the poor health of the Black population; however, the burden attributable to American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander populations was disproportionately greater than their share of the population. Most of the education-related economic burden was incurred by adults with a high school diploma or General Educational Development equivalency credential. However, adults with less than a high school diploma accounted for a disproportionate share of the burden. Although they make up only 9% of the population, they bore 26% of the costs.”
Source: LaVeist TA, Pérez-Stable EJ, Richard P, et al. The Economic Burden of Racial, Ethnic, and Educational Health Inequities in the US. JAMA. 2023;329(19):1682–1692. doi:10.1001/jama.2023.5965
“Consistent with recent reports, our epidemiologic assessment at the county level indicates that the burden of COVID-19 mortality is higher in counties with high proportions of Black residents [4,5,6,7,8, 13]. We found that this association is independent of clinical risk factors [39] – many of which disproportionately affect Black residents [7]. Importantly, the full SDH [Social Determinants of Health] model results showed that when all SDH measures are included in a regression, there is no longer a relationship between Black race and COVID-19 mortality. Furthermore, in our subgroup analysis stratified by SDH, we found that percent Black residents in a county is a predictor of COVID-19 mortality only in counties with higher degrees of adverse SDH, thus suggesting that social constructs and policies mediate the disparate COVID-19 outcomes in Black Americans. This precludes genetic differences as a possible explanation for COVID-19 racial disparities and challenges the harmful belief that racial disparities in illness primarily have a biological basis. Overall, this study provides both qualitative and quantitative evidence that SDH play a significant role in influencing increased COVID-19 mortality for Black Americans.
“In the full SDH regression model, the two particularly relevant SDH that emerged as significant positive predictors of COVID-19 mortality included percent adults without HS diploma and percent households without internet. Education frequently emerges as a strong predictor of health outcomes, including mortality, in studies examining SDH [26, 36]. The relationship between Black race and education is largely attributable to long-standing educational discrimination, residential segregation, and marginalization [36]. The finding that internet connectivity is also associated with COVID-19 mortality is particularly relevant in the climate of a pandemic. The internet is essential for social distancing, remote work, and online learning, as well as access to timely and accurate information from public health entities. We were only able to analyze data for this study at the county level; however, a more detailed analysis that includes rural vs suburban vs urban locales may also provide more information about how regional variations in internet connectivity may impact COVID-19 mortality.
“Ultimately, these findings support the hypothesis that SDH are important drivers of COVID-19 racial disparities for Black Americans in the U.S. Our results are consistent over a diverse set of SDH variables representing areas of economic stability, healthcare access, educational attainment, and social contexts. This suggests that racial disparities in COVID-19 outcomes for Black Americans stem from multiple sources which compound to create the overall effect. This study provides a method for public health policymakers to identify areas with high adverse SDH, which is crucial because these are high-risk areas for racial disparities in COVID-19 mortality and other harmful health outcomes. Furthermore, this study raises the possibility of targeting changes to SDH as a mechanism to reduce racial disparities in COVID-19 outcomes. These findings also may allow policymakers to monitor SDH indicators as a metric for improvement in health equity in the future. Multiple prior studies have linked SDH to structural racism, which is deeply ingrained in the U.S. legal and economic systems, shaped by historical injustices, and perpetuated by bias. As a next step, further research is needed to evaluate the effect of validated markers of structural racism on COVID-19 mortality, and to explore these associations over time as the pandemic evolves [41, 42]. Additional studies related to bias experienced within the healthcare system related to testing, triage, and treatment may also shed additional insights on COVID-19 racial disparities.”
Source: Dalsania, A.K., Fastiggi, M.J., Kahlam, A. et al. The Relationship Between Social Determinants of Health and Racial Disparities in COVID-19 Mortality. J. Racial and Ethnic Health Disparities (2021). https://doi.org/10.1007/s40615-020-00952-y.
“Wealthy and educated people are more likely to use HDHPs [High-Deductible Health Plans] with HSAs [Health Savings Accounts] and to contribute more to their accounts than people with less income and education. The inherent regressivity of this policy was originally justified by the belief that HDHPs with HSAs would generate an increase in cost-consciousness, and therefore in efficiency. In fact, however, people who have HDHPs with HSAs are becoming less likely over time to report financial barriers to access to care— the source of HDHP cost-consciousness—than are people with private insurance plans not linked to HSAs.
“In short, HSAs are a tax advantage for better-off people, masquerading as a health care efficiency increase that was never very likely and is not occurring now. There is no remaining justification for a regressive tax break that failed to achieve its policy goal and is used disproportionately by higher-income people.”
Source: Sherry A. Glied, Dahlia K. Remler, and Mikaela Springsteen, Health Savings Accounts No Longer Promote Consumer Cost-Consciousness, Health Affairs 2022 41:6, 814-820
“We found that in the past two years, health systems in the US have publicly committed approximately $2.5 billion toward directly addressing social determinants of health such as housing, food security, and job training. This figure is dwarfed by health systems’ overall community benefit spending, which is estimated to be over $60 billion per year.13 Nonetheless, it represents a substantial investment.
“Historically, hospitals have tended to provide community benefit through uncompensated or subsidized care rather than through investment in activities not directly related to health. In one analysis of the $2.6 billion spent by all fifty-three North Carolina tax-exempt hospitals on community benefit, only 0.7 percent ($18.2 million) was spent on community investments such as affordable housing, economic development, and environmental improvements.20 Nationally, spending on all kinds of community health improvement activities (most of which are directly related to health) is 5 percent or less of total community benefit spending.13,14 Yet spending on community activities may be effective. For instance, although a recent study found no association between overall community benefit spending and readmission rates, hospitals in the top quintile of spending that was directed toward the community had significantly lower readmission rates than those in the bottom quintile.21
“We found significant differences in characteristics between health systems that publicly announced making investments focused on social determinants and those that did not. The clear predominance of sectarian and other nonprofit institutions in making these investments and the absence of for-profit institutions suggest that health systems may be driven to invest in social determinants more by mission and values than by the potential for direct financial returns. However, the fact that investments are disproportionately being made by systems that are in Medicaid expansion states, in the BPCI Initiative, or in an ACO suggests that business-case considerations may also be playing a role. The complexity of making tangible commitments to improving social determinants of health is reflected in the fact that investing systems tend to be substantially larger and therefore potentially have more capacity than noninvesting systems.
“Our results are consistent with national survey data, such as the data from a 2017 survey by the Deloitte Center for Health Solutions. In this survey of 300 hospitals and health systems, 88 percent reported screening patients for social needs (62 percent screened them systematically), but only 30 percent reported having a formal relationship with community-based providers for their entire target population.22 The survey did not explore the extent to which health systems directly funded community programs. Compared to smaller hospitals and those that were for profit or independent, respectively, larger hospitals and those that were public or not for profit were more likely to screen patients for social needs—which is consistent with our finding that those are the hospitals that are also most likely to engage in direct community investment.
“A key feature of this study was our ability to identify the specific social determinants that each program focused on. Prior studies have been able to quantify only overall community investment. By far the most popular focus area of the programs we identified was housing, which accounted for two-thirds of total investment. Housing is one social determinant in which investing has the most immediately apparent potential return, even though it is one of the determinants in which interventions are especially complex and costly. Housing investment also has face validity, and housing is a common pain point for health care professionals, who struggle with housing-insecure patients. These findings are consistent with those in the general literature.12 In one systematic review of thirty-nine studies up to 2014 that addressed social determinants and measured health outcomes, the largest number of the studies (twelve) focused on housing, and ten of them reported benefits to health outcomes, costs, or both.12 Several subsequent publications have also shown benefits from housing-focused interventions.23–25
Source: Leora I. Horwitz, Carol Chang, Harmony N. Arcilla, and James R. Knickman, Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19, Health Affairs 2020 39:2, 192-198.
“In general, however, the evidence for health outcome improvements from interventions focused on social determinants is thin. A different systematic review of interventions related to social determinants that included sixty-seven articles published up to 2017 found that only 30 percent (twenty articles) reported health outcomes and 27 percent (eighteen) reported health care costs.26 Furthermore, only 22 percent (fifteen) showed any benefit to health outcomes, 10 percent (seven) showed a reduction in emergency department visits or hospitalizations, and 7 percent (five) showed any benefit to health care costs. In fact, programs focused on multiple social determinants, food security, and legal interventions all had more articles showing positive impacts on outcomes, compared to those focused on housing. However, the quality of studies in most of the articles reviewed was poor. This is very little evidence on which to base billions in investment and may partially explain why investments to date have lagged. In the Deloitte survey, 48 percent of respondents reported that evidence for improved outcomes would increase their investments in social needs activities.22“
Source: Leora I. Horwitz, Carol Chang, Harmony N. Arcilla, and James R. Knickman, Quantifying Health Systems’ Investment In Social Determinants Of Health, By Sector, 2017–19, Health Affairs 2020 39:2, 192-198.
Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and sixteen other nations.
Page last updated May 20, 2023 by Doug McVay, Editor.
