Missouri Health Equity Collaborative

On December 8, 2011, Dr. Elizabeth Bradley, a professor of public health at Yale’s Global Health Leadership Institute, wrote an interesting editorial. In the editorial, she discussed findings from a recent study comparing United States health expenditures to those of other countries.

Where we live has a profound impact on health and well-being.

While not a health disparities editorial, it is highly relevant. Most people interested in health disparities in the United States have heard that we spend more on healthcare than other industrialized nations, but still rank among the lower half of our peer countries on health outcomes, including infant mortality. The issue of lagging U. S. health indicators is particularly acute among low-income, and racial and ethnic/minority individuals. The relationship between low socio-economic status and poor health has been reported for life expectancy, mortality, health behaviors, mental health, and other health outcomes and, in general, ethnic and racial minorities have poorer health outcomes than majority group members (LaViest, 2005; Thomas & Quinn, 2008).

Dr. Bradley took a novel and more nuanced approach to the issue of U. S. healthcare expenditures. Her approach fell in line with the thinking of those who are focused on the social determinants of health as the primary factors producing health disparities. Dr. Bradley’s team examined spending on social services, in addition to direct healthcare expenditures. The social services spending included rent subsidies, unemployment benefits and training that are not subject to reauthorization, and family supports. Guess what she found? The United States does not spend more on health than other nations; we spend less! That finding might make small government advocates happy, but before anyone takes comfort in this finding, be clear that what it shows is that we as a nation are “penny wise and pound foolish” where health is concerned.

We have evidence developed in the United States, but also around the world, that documents the role that social determinants– income, education, employment, access to quality housing, food and recreation–play in the production of health (Adler & Coriell, 1997; Link and Phelan, 1995). However, we choose to ignore these front end expenditures, simply deferring them until we have to pay for more costly chronic conditions and social supports for individuals who are disabled and unable to work. This is an unnecessary loss of human capital and productivity that we do not and perhaps cannot measure.

And yet, there are examples of progressive leadership to address what many know are requirements for healthy individuals, families and communities. For example, Massachusetts led the way in assuring increased access to healthcare coverage. Others have acted to assist those who fall through the cracks of our social service system. A study of the newly homeless in New York City suggested that the strategy there of concentrating social and health services in the homeless shelter system may actually  result in improved health for both those who become housed and those who remain homeless (Schanzer, Dominguez, Shrout & Caton, 2006). In addition, many state and local governments are experimenting with school-based health clinics (Center for Health and Health Care in Schools, 2011). These initiatives suggest that we can do what needs to be done when and where there is the political will.

What are my top five suggestions for action based on the existing evidence base, as well as Dr. Bradley’s findings?

1. We must assure that all children and families in the United States live in quality housing.
2. We must assure that income supports are available to elderly and unemployed citizens, accompanied by opportunities for job training for those seeking employment until it is located.
3. We must assure that every community has access to nutritious foods and safe places for community gatherings and recreation.
4. We must assure that all children receive a high quality education beginning in preschool, regardless of income. This will mean changing how we fund education.
5. We must assure that parents can work without concern for the quality of the care that their children receive by providing family supports for daycare and setting national standards for daycare quality.

Imagine what might be accomplished if all citizens could access an array of social and health services, with minimal barriers, before they became ill, unable to work or homeless?

Vetta Sanders Thompson, PhD, is currently on faculty at the Brown School of Social Work at Washington University in St. Louis and was an associate professor at the Saint Louis University School of Public Health.

The opinions and views expressed in this blog and/or comments are those of the author(s) and do not reflect any position of the Center or the University.

References

Adler, N. E., & Coriell, M. (1997). Socioeconomic status and women’s health. In S. J. Gallant, G. P. Keita, & R. Royak-Schaler (Eds.), Health care for women: Psychological, social, and behavioral influences. Washington, DC: American Psychological Association

Center for Health and Health Care in Schools (2011). From the margins to the mainstream: Institutionalizing school-based health centers. http://www.healthcareinschools.org/en/Model-Programs

LaViest, T. A. (2005). Minority Populations and Health: An introduction to health disparities in the United States. San Francisco, CA:  Jossey-Bass, Inc.

Link B. G., Phelan J. C.  (1996). Understanding Sociodemographic Differences in Health: The Role of Fundamental Social Causes.” American Journal of Public Health. 86:471-3, 1996.

Schanzer, B., Dominguez, B., Shrout, P. E., & Caton, C. L. M. (2007). Homelessness, health status and health care use. American Journal of Public Health, 97(3), 464-469. doi:10.2105/AJPH.2005.076190

Thomas, S. B. & Quinn, S. C. (2008). Poverty and Elimination of Urban Health Disparities Challenge and Opportunity. Annals of the New York Academy of Sciences, 1136, 111–125. DOI: 10.1196/annals.1425.018