The important role of socio-economic status in the overall health in the USA: Whose job is it anyway?

Health, as defined by WHO, is not just the absence of disease, but an overall sense of wellbeing. Determinants of population health and their relative contributions to health have been previously defined as follows: individual behaviors (40-50%); genetics (20-30%); socio-economic status (20%); healthcare delivery (10%). As stated in our previous blog, the COVID pandemic has highlighted the important role of socio-economic status (SES) in health status and disease outcomes of our citizens. 

Circumstances associated with low SES have broad reaching impacts, including on personal opportunities for a better future (e.g., education, jobs, etc), safety, well-being, and health.

The living environment related to low SES: 

• Close, crowded, and closed off living and working conditions   
• Less access to quality education
• Weaker public health efforts
• Higher rate of environmental pollution
• Lower levels of sanitation
• Less high-quality food, poor nutrition
• Economic instability
• Lower job security
• Lower housing security
• Fewer choices in all these categories

Healthcare insecurity:

• Less likely to have insurance
• Less access to healthcare
• Less primary care
• Variable quality of care

Health status: 

• Higher rate of chronic medical conditions
• Higher rate of obesity
• Higher rate of smoking
• Less health education 
• Less physical activity

The Ochsner study (referenced in our previous blog) highlighted that once health status is accounted for, the impact of race/ethnicity alone disappears. All of the low SES circumstances, listed above, influence personal choices, behaviors, healthcare, health and lead to higher vulnerability for COVID infection and death. Therefore, the task before us is to improve the SES of people to provide better choices, education, jobs, environment, access to healthcare insurance, and improved healthcare delivery that focuses on the needs of each individual. 

Given these observations, what sectors of society have the responsibility to do what they can to improve the health of our people?  

Personal Responsibilities

All of us, regardless of SES status can do more to embrace healthier lifestyles and ensure that we comply with prescribed treatments (if necessary). We all know what to do to stay healthy – follow Lester Breslow’s healthy habits, e.g.,

1. Don’t smoke or abuse drugs 
2. Eat a balanced and healthy diet 
3. Get regular exercise and control your weight 
4. Do not drink a lot of alcohol 
5. Take care of your teeth 
6. Manage high blood pressure 
7. Follow good safety practices

By doing this, we not only stand to improve our own health, but also the health of those around us, as research shows that behavior is “contagious”: One is at an increased risk of smoking, obesity, and alcohol consumption when one’s closest peers smoke, are obese, or consume alcohol. However, healthy choices can also be extremely contagious. If that same peer quits smoking, we are more likely to quit smoking ourselves

Government: State and National Politicians, Regulators, and Agencies

All of the items in the first category are influenced by government decisions and policy. In the second and third categories several factors can be accomplished (e.g., universal healthcare coverage, with means-tested government support), influenced (e.g., pay for value in healthcare; health benefit design that promotes healthy lifestyles; “sin taxes” and/or social benefit plans that promote healthy nutrition choices) or nudged by government (e.g., create public infrastructure conducive for walking and cycling; re-introduce physical education into schools). The issue is that while various state and federal governmental leaders give voice to health-related concerns, perhaps even some with a vision for a better state of health, there is no courage, will, or commitment to a shared vision that will take many years of constant focus and continuous adjustment to improve all the elements included in the social determinants of health (SDOH) in the USA. We have had several “moonshots” for cancer and genomics. How many for HEALTH in the USA?

Healthcare Delivery System and Delivery Organizations   

In the short term, all delivery organizations must focus on their primary role of producing high value care: best outcomes, highest safety, excellent service, and with lower overall spending, less waste, and appropriate rates of utilization. These are their “compulsories”. Medicalization of the SDOH too soon, before the healthcare delivery system has “nailed the compulsories,” will be expensive and a distraction from healthcare delivery system’s primary responsibility. 

As we mentioned in our last blog, providers should be aware of SES and the social circumstances of their patients and take them in consideration during medical decision making. This is especially critical for patients with chronic conditions. Designing a treatment plan that takes into consideration the social, environmental, educational, and emotional circumstances surrounding an individual, is more likely to produce better results for said individual. We must not lose sight of the individual. Better individual results for each individual in a population will result in better health for the population.

For instance, treating a population of children with asthma using standard protocols might be effective for 70-80% of individuals.  However, if we want to improve the well-being of all the children in that asthma population, we will need to focus on the 20-30% of children who might need continuous monitoring, virtual contacts and reminders, visits to the home and school.

There are screening tools that can provide information about the SES of individual patients and can inform medical decision making, such as HOUSES. The information from these tools can be incorporated into the design of individual treatment plans.

 Finally, the healthcare system could substantially benefit from funding for studies within actual delivery organizations to discover the most effective ways to improve the factor that is most influential on health over a lifetime – namely, individual personal behaviors.

National Institutes of Health

The National Institutes of Health have a role to play in setting a vision for health in the USA; setting priorities for each of the items listed above; catalyzing action; coordinating efforts; providing funding for basic, translational, and operational research; integrating and promulgating the knowledge; promoting changes that actually improve health of our citizens.