JAMA Forum: Tackling the Social Determinants of Health: Small Steps on a Long Journey

Image: Aubrey LaMedica/Harvard T.H. Chan School of Public Health

Image: Aubrey LaMedica/Harvard T.H. Chan School of Public Health

In 1848, German physician Rudolf Virchow, the father of modern pathology, wrote: “Do we not always find the diseases of the populace traceable to defects in society?” And for the last 2 centuries, we have been struggling with these “social determinants of health,” from housing quality to education to availability of healthful foods. Although we have known for generations that social factors affect health, the issue of uncontrolled health care costs has refocused attention on how social factors harm health and lead to preventable spending.

This interest has become widespread. Medical schools are adding courses in social medicine and health care organizations are hiring social workers and care managers to address patients’ nonmedical problems.

The idea that social factors influence health is both obvious and evidence-based. It is intuitive that patients with diabetes who are homeless will have a harder time managing their disease, and the evidence bears this out. As the United States marches towards spending 20% of our economic output on health care, and as the government takes on an increasing share of that spending, policy makers are realizing that we need a new approach to tackling health care expenses. Our current approach, in which the public finances most health care expenses but looks skeptically at covering nonmedical spending, appears unsustainable. Homeless persons struggling to manage their diabetes can expect taxpayers to pay thousands of dollars for their hospitalizations but not necessarily the housing and food that would help them manage the disease and avoid hospitalization.

Complex Issues

The current approach might appear to be “penny-wise but pound-foolish,” but the issues are far more complex. Paying for the use of health care services is easy; these are discreet events and there is the moral argument that when people are sick, society should help them get better. But paying for social determinants is much more complex. Should the government provide housing, food and clothing for everyone who might benefit from it? What about for those with chronic illnesses?

Unfortunately, there is little evidence that these “upstream” interventions save money. Yes, providing housing to a homeless person can improve health and reduce the use of health care services, but the aggregate cost of the housing generally swamps any money saved in the health care system. Investing in social determinants can be a good thing because it improves health, but it rarely saves money.

The Center for Medicare & Medicaid Innovation (CMMI) recently announced its latest demonstration project, “Accountable Health Communities (AHCs).” The AHCs will “assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.” The AHC model is based on “universal, comprehensive screening for health-related social needs,” and will be implemented in 44 communities across the United States, each of which must include a state Medicaid agency, health care provider organizations, and community-based organizations that provide social services. The government has allocated $157 million over 5 years to implement and evaluate the program.

An Important Step

The launch of the AHC program, an acknowledgement of the significance of social determinants of health, is an important step. A key strength of the program is its focus on empowering local, geographically defined communities. This approach is used successfully in countries such as Sweden and Switzerland, and enables communities to capture the returns on their investment in social services. The AHC program’s goal is to encourage communities to systematically measure the social needs of their Medicare and Medicaid populations, and eventually realign their payment systems to address these needs.

We should laud efforts to integrate the health care system with the communities it serves, and the AHC has potential to move that agenda forward.

But several things in the AHC program should give us pause. The first is the notion of accountability. Who is accountable for the health of a community? Individual health care provider organizations such as hospitals might care deeply about the health of their communities, but ultimately they must tend to their own financial health. Governments can be accountable, but most states are too large to understand local needs. Models like AHCs work well in Sweden because local governments there control health care and social spending budgets, and therefore have both power and accountability for the health of their citizens, a difficult model to replicate in the United States. Prior policy efforts to create and/or support local entities that can act on behalf of the community have not been able to sustain themselves when federal funds run out.

There also are the issues of funding levels. The amount budgeted for this experimental program is small; CMMI has allocated $157 million over 5 years, during which time the United States will likely spend approximately $15 trillion on health care. Given that CMMI is primarily trying to create awareness and knowledge of the issues of social determinants, it might be enough, but we should keep our expectations low. The current budget, which works out to approximately $700 000 per community per year, may not be enough to make an observable difference.

Learning What Works—and What Doesn’t

Finally, there are issues around our ability to learn from the AHC program. Demonstration programs are most effective when they generate knowledge about what does and doesn’t work. Failures are a necessary part of experimentation. But failing to learn when projects don’t go well is a problem we can avoid. The agency promises a “robust evaluation,” and let’s hope it delivers on its promise. There is no single right approach, but having strong control groups and using validated metrics will help ensure that we learn which programs actually made a difference, which ones did not, and why. And it’s fine to focus on whether AHCs saved money, but we should pay attention to whether they improved outcomes. After all, what we care about most is better outcomes for people.

In wading into the complex set of issues that are “social determinants of health,” the US administration deserves praise for taking on one of the most difficult problems facing us: how do we reduce the effect of social ills on the health of our population? But we should be clear-eyed about the difficulty of the work ahead and ensure that we learn as much as possible with each step and iterate to improve. For more than 150 years, health care leaders have wondered how to address the “defects in society” that both cause illness and hamper our efforts to treat it. Although social ills will always be with us, we can surely do better at mitigating their harmful effects on health.

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About the author: Ashish K. Jha, MD, MPH, is K. T. Li Professor of International Health and Health Policy at the Harvard T. H. Chan School of Public Health and a practicing internist at the Veterans Affairs Boston Healthcare System. He received his doctor of medicine from Harvard Medical School and was trained in internal medicine at the University of California, San Francisco. He received his master’s in public health from Harvard School of Public Health. Dr Jha’s major research interests lie in improving the quality and costs of health care. His work has focused on 4 primary areas—public reporting, pay for performance, health information technology, and leadership—and the roles they play in fixing the US health care system.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



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