Our health care system is waking up to the fact that the health of individuals and families does not depend solely on good coverage and good medical care; it also requires us to address social and other factors that are major contributors to a person’s physical and mental well-being. That’s why more and more clinics are screening incoming patients for challenges in areas ranging from housing conditions, nutrition, access to transportation, and even their ability to afford utilities. It’s why the American Academy of Pediatrics urged its members not only to screen all patients for food insecurity but to refer parents to appropriate agencies. It is also why some hospitals, to reduce readmissions, have brought organizations like Health Leads into their discharge planning to connect patients with social services.
There has been much less progress, unfortunately, in realigning the health care system itself to reflect the importance of social determinants. Even taking into account relatively high health care prices, the United States remains an outlier among industrialized countries in the proportion of gross domestic product spent on medical care relative to social services, despite research indicating that countries (and even individual US states) with more balanced spending patterns have significantly better health outcomes.
What is needed to get our system to alter direction? A number of things, but some basic steps are needed to create the environment for change.
1. Make the Case With More Research
The evidence on social determinants of health is growing, but is still insufficient to convince many key decision makers. For instance, there is good research on the link between such housing problems as mold or substandard accommodations and health, and between family or social “toxic” stress and long-term mental health and other patterns. But purported linkages between health and other social conditions, such as general poverty, lack reliable evidence. Much more basic research is needed to understand the key determinants.
2. Develop Better Techniques to Show How Increases in Social Services Lead to Better Health
There is always resistance to change. So jurisdictions and government budget committees, as well as private managers, need strong evidence to build the case that investments in social factors rather than just more medical services results in a good return on investment (ROI). But it is often lacking. In part that is due to the data collection challenges faced by innovative community organizations that are exploring social welfare strategies to improve health. Meanwhile, few government jurisdictions have well-developed analytical capabilities to measure the health ROI of addressing social determinants and procedures to incorporate that information into decision making.
Fortunately, elements of a data infrastructure are emerging. For instance, the National Neighborhood Indicators Project, based at the Urban Institute, is helping communities and governments build and use better data systems. In addition, the Washington State Institute for Public Policy, created many years ago by the state’s legislature, conducts (in conjunction with state universities) cost-benefit analyses of programs and initiatives to inform legislative and agency decisions. But most communities and states still lack such tools, hampering the ability to make the case for a greater emphasis on social determinants.
3. Imagine New Business Models
Within the health care industry itself, there needs to be new thinking about the business models of key institutions, such as hospitals, as well as the use of intermediaries to improve the cooperation of health care and other sectors, such as schools and housing. However, the range of potential models being seriously considered is constrained by such barriers as insurance reimbursement and the payment policies of Medicaid and Medicare, since these affect the financial viability of different approaches to improving health. Fortunately, Medicaid is slowly providing more payment and organizational flexibility for approaches that address social factors in health. Such flexibility is encouraged through the use of Medicaid Managed Care Organizations and through experiments made possible through Medicaid Section 1115 waivers, which allow states to experiment with different payment and organizational arrangements.
4. Improve Agency Coordination and Budget Flexibility
Government at all levels is responsible for much of the funding of services and initiatives associated with social conditions affecting lower-income people. Thus, improving health through a greater emphasis on social determinants for these individuals depends on better coordination and planning between agencies, as well as greater flexibility in the use of funds. That requires strong leadership, but it also needs structures to make coordination and flexibility more routine. Children’s cabinets, established in more than half the states, are a possible model for how to coordinate medical and social services to improve health. These groups bring together senior agency officials of departments responsible for programs that provide services to young people to coordinate and jointly plan those services and budgets. Federal and state-level “health cabinets,” including departments dealing not just with medical care but also with housing, transportation, social services, and education, could be similar, valuable institutional tools.
Breaking down agency budget silos is particularly challenging, but it is ultimately essential if the United States is ultimately to rebalance spending between medical and social programs to improve underlying health. As a step toward that goal, the federal government needs to widen the use of waivers to permit more experiments to test the effects of investments in social determinants on health. In the meantime, more states could adopt versions of Maryland’s use of local management boards. These are county-level bodies that have some discretion to blend budgeted money from different departments and private funds, to support innovative local organizations and programs.
The growing attention to the importance of social factors in health is a welcome development. By understanding these factors, and incorporating that knowledge into the design of our health care system, we will be more successful and efficient in improving the health of individuals and families. But getting there requires some very important building blocks.
About the author: Stuart M. Butler, PhD, is a senior fellow, Economic Studies, at the Brookings Institution in Washington, DC, where he focuses on developing new policy ideas. He is also an adjunct professor at Georgetown University’s Graduate School, and serves on the board of trustees for the Convergence Center for Policy Resolution. (Image: The Brookings Institution)
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.