A large and growing body of research tells us socioeconomic factors influence personal and community health. From housing to personal finances to education, policymaking at all levels of government can work toward making that influence positive.
Factors not directly within the health care field but that can significantly impact health are called social determinants of health. The World Health Organization more simply defines social determinants as “the conditions in which people are born, grow, live, work and age.”
By way of example, think about supermarkets. You might not consider proximity to a supermarket as a measure of health in the same way as blood pressure or another biological metric. But living in an area without regular access to healthy, affordable food options — a food desert — significantly jeopardizes health outcomes, makes prevention and control of chronic conditions, such as obesity and diabetes, more difficult, and continues cycles of poor health in communities.
The economic and social circumstances in which people live are inextricably linked to disparities in health outcomes. If we want policies that codify a commitment to improving health, particularly in vulnerable communities, we need to broaden the conversation beyond the health care system itself to those conditions “in which people are born, grow, live, work and age.”
Essential hospitals play a central role in improving social determinants of health in their communities. They share a commitment to care for the most vulnerable and other defining features, including training the future health care workforce and advancing public health. As leaders in population health, essential hospitals create partnerships and programs that reach far beyond their walls to improve health outcomes in vulnerable communities. Those communities include more than 275,000 homeless individuals and 4.6 million families living below the poverty line, putting essential hospitals on the front lines of efforts to improve communities through social determinants of health.
Changing Social Determinants of Health through Public Policy
Public policies can influence social determinants of health in manifold ways, including by creating federal tax incentives for investments in people and communities. The current debate on federal tax reform, including recent passage of the Tax Cuts and Jobs Act (H.R. 1), intersects with social determinants of health in three specific areas: housing, personal finance, and education. Communities have leveraged existing tax policies for each to mitigate harmful effects on health outcomes and empower vulnerable populations.
Access to safe, stable housing is a crucial social determinant of health. Shortages of affordable housing give families fewer choices of where to live and often relegate them to unsafe conditions and neighborhoods, where they struggle to access resources that could improve their health. The impact of housing instability can extend to other social determinants — for example, making it difficult to store and eat healthy food or adhere to a physician’s guidance. A robust body of research tells us that policies that promote affordable housing also lead to improved health, particularly for populations with chronic conditions, such as asthma and substance use disorders.
The low-income housing tax credit (LIHTC) is one of the most important tools to promote low-income housing. The tax credit works by giving investors incentives to include affordable housing units in development projects, and the credit has been responsible for most new, federally financed affordable housing. Since its creation in 1986, the LIHTC has enabled the financing of about 3 million units of affordable housing.
The Tax Cuts and Jobs Act (H.R. 1), which recently passed both the House of Representatives and the Senate in slightly different forms, will undermine the impact of the LIHTC by removing incentives to develop new affordable housing. Stalling the progress communities have made as a result of the LIHTC will represent a large step backward in how we help vulnerable people meet one of their most basic needs.
Financial stability allows individuals and families security and choice in many aspects of life, including health care. When people struggle to pay their medical bills, they are more likely to forgo necessary care, delay follow-up care, and fail to fill prescriptions. In addition, medical debt often fuels bankruptcy and poor credit, which can snowball into further financial consequences.
The current medical expense deduction policy helps alleviate this burden for some families. The tax provision allows individuals and families who spend more than 10 percent of their adjusted gross income on qualified medical expenses for themselves or their children to deduct these expenses. In 2015, taxpayers took the medical expense deduction nearly 8.8 million times. This deduction allows people already struggling with long-term, serious illnesses or disability to stay afloat financially so they can focus on treatment and other day-to-day concerns for themselves and their families.
Unlike most itemized tax deductions, the medical expense deduction is more likely to be used by people with lower incomes. Thus, eliminating this deduction would disproportionately hurt low- and middle-income families. According to AARP, in 2015, 55 percent of those claiming the deduction were 65 or older. Without the deduction, seniors and low-income people are less likely to be able to access the care they need. Financial status is a strong social determinant of health. Preserving the medical expense deduction promotes financial stability for those facing difficult health circumstances, rather than adding financial stress to individuals and families in their time of need or prompting them to forgo needed care.
Educational attainment undoubtedly helps improve the economic prospects of individuals and their communities. It also is important to improving health. Studies show the links between the years or level of schooling one reaches and improved health outcomes. But education also is key to a well-trained, diverse health care workforce that can recognize and improve social determinants of health.
The health care field benefits from having a highly engaged, talented, and diverse workforce. Patients interact with a variety of health professionals who support their health needs through medical interventions and other services. Essential hospitals employ social workers, dietitians, nurse practitioners, physicians, and other professionals that help create a patient-centered experience that reaches social determinants beyond the hospital walls. The diversity of the professionals trained and employed at essential hospitals is crucial to ensure they provide the most culturally and linguistically competent care in underserved communities. In fact, research has linked such diversity to improved outcomes in the context of social determinants of health.
But pursuing a career in health care is expensive, often requiring years of training and tens or even hundreds of thousands of dollars in debt. Many of the professionals who help patients experience better outcomes and reduce disparities require extensive training through varying levels of graduate education. Both the doctor prescribing a medication to help a patient lower her blood sugar and the dietitian teaching that same patient about healthier eating habits have undergone extensive advanced training in their respective fields.
Taking on debt to pursue a graduate education in health care can be a difficult decision. But policies exist to reduce the financial burden of this education, encouraging more people to pursue careers in health care. Under current law, individuals can deduct the interest they pay on any loan used to pay for higher education expenses, up to $2,500 a year. According to the Association of American Medical Colleges, 75 percent of the medical class of 2017 graduated with student loan debt. Savings from the student loan interest deduction, especially when taken cumulatively over the life of a loan, can provide significant relief and serve as an incentive to pursue advanced degrees in health-related careers.
Essential hospitals take pride in training the next generation of health care leaders, including more physicians on average than other hospitals. They see firsthand the talent and drive of individuals pursuing careers at all levels within health care, as well as the financial burdens they take on to pursue these jobs. Lawmakers should preserve policies, such as student loan deductibility, that encourage people to pursue needed careers in health care.
Promoting Policies to Improve Health Makes Fiscal Sense
Advancing public policies that promote better health makes fiscal sense. When communities have access to resources that promote better health, they see improved outcomes and are better able to manage chronic conditions. This saves money in the health care system overall by preventing costlier services that otherwise would become necessary.
Healthy people are also more likely to be employed and contribute to economic growth in their communities. Evidence shows that the indirect costs of poor employee health, like low productivity and high rates of disability, are even higher than direct medical expenses. When we promote health, we also build a more productive workforce.
Fostering community health also reduces the financial burden on essential hospitals by reducing their uncompensated care costs. Essential hospitals operate with margins less than half that of other hospitals — 3.2 percent compared with 7.4 percent. Every dollar saved by essential hospitals helps them to invest in the overall health of their communities.
Addressing social determinants of health is integral to improving the health and financial well-being of patients and populations. Public policies that encourage these improvements should be promoted whenever possible — including in the current tax debate.