The importance of social factors in determining individuals’ health status and their use of health care services has been receiving increasing attention. A recent report from the Bipartisan Policy Center suggests that opportunities to control health care costs reside primarily in addressing patients’ social and behavioral care needs. The report lays out the arguments for integrating social and medical services and, ideally, their funding, to better serve vulnerable patients with complex care needs.
To date, most of the experimentation within the health care system to address underlying social determinants of health has occurred within the framework offered by Medicare. Such interventions have focused on home-based, patient-centered care, supportive housing, in-home meal delivery, and community-based assistive services. They have yielded improvements in the health of the individuals served and some reductions of health care use. Some states have used Medicaid waivers to allow provision of certain community-based services. Within child health there have been experiments offering similar service options, such as intensive, comprehensive case management to patients and families, housing assistance, and referral for social and legal services.
With a very few, notable exceptions, all of these early efforts to address social determinants of health were built on a medical model, i.e., identifying and treating specific factors contributing to the individual’s poor health. Our existing service delivery systems, which are designed to hew to this traditional model, have had some success but at unsustainable costs.
A public health approach to better serve populations as opposed to individuals would be more efficient and effective. Implementing broad changes in social programs can reduce potentially adverse circumstances that contribute to poor health and harmful health behaviors. Fee-for-service payment schemes perpetuate an individual-based approach to solving health problems. Adopting a capitated model in which all costs are covered by a single advance payment, such as those used by accountable care organizations, can encourage but does not necessarily assure that population-based, integrated approaches will be adopted.
Some health care systems, guided by their own cost-benefit analyses, are addressing social determinants of health, not as their mission but rather as cost-saving strategies for individual or targeted groups of high-risk patients, under the rubric of value-based purchasing. This is a step toward, but still a long way from, adopting the changes in social policy that are necessary to improve the standard of living and quality of life of Americans. Until such changes occur, health care costs will continue to rise and the health of the nation will remain poor in contrast to the rest of the developed world.
Data on Social Determinants of Health
There is substantial evidence that children’s health is directly correlated with income and inequities in access to resources and services. The American Academy of Pediatrics has called for an effort to reduce childhood poverty and to mitigate the adverse outcomes of challenging social circumstances in order to obtain and maintain good health.
Many indicators on kidsdata.org describe social determinants of health, the family and community factors that affect individuals’ health and well being. Social determinants can help make individuals’ health better or worse. Examples include economic well-being, housing stability, community connectedness, and parents’ physical and mental health.
By Edward L. Schor, MD