Health Savings News - Episode 18: Social Determinants of Health

Note: This is a rough transcript of episode 18 of Health Savings News and has been lightly edited for clarity. Copy may not be in its final form.

Evan (00:09):

Hello and welcome to Health Savings News, the podcast about healthcare costs in America, and how to save money on the often expensive care all kinds of people need. I’m your host, Evan O’Connor, joined by retired doctors Rich Sagall and Mike Woods. How are you guys doing today?

Mike (00:23):

Good.

Rich (00:24):

Doing well.

Evan (00:25):

Each episode we discuss healthcare costs in America, offer tips for saving money, and relevant news that affects and reflects the expensive landscape of healthcare in America. This week’s topic is the social determinants of health. Social determinants of health include things like housing, clean air, public sanitation, access to healthy food, and clean water, social supports, in-home aid, even the impacts of climate change, which all have an effect on individual health and life expectancy just as much as things traditionally thought of as healthcare do. Chronic illness and disability is often driven by the social determinants of health.

Rich (00:59):

The availability of healthcare is extremely unequal, both in terms of quantity and quality. The disparity has led to widespread inequities in health and health status and risk factors for poor health outcomes, impaired functioning, and lower quality of life.

Mike (01:15):

It’s amazing to look at this, but 80 to 90% of what contributes to our overall health involves our social situation and not the type of medical care that we have access to. We can determine what these social determinants are, but it’s still not very well understood how they contribute to health, how much overcoming them will improve health and how effectively we can remedy them going forward. One thing is clear, though, is that poor situations with these social determinants significantly increase the cost of medicine, and perhaps remedying some of them will help decrease the cost of medical care over time.

Rich (01:55):

According to the World Health Organization, the social determinants of health are the conditions in which people are born, grow, live, work, and age that affect a wide range of health, functioning, and quality of life outcomes and risks. Social determinants of health are non-medical causes that can shape the conditions of daily life through the distribution of money, power, and resources at global, national, and local levels. This can result in differences in social environments, situations experienced by individuals and communities. They can also result in avoidable and unfair differences in the healthcare availability and affordability between groups of people or communities. The COVID-19 pandemic has exposed and magnified some of these differences, especially the availability of widespread vaccinations, COVID testing, and effective treatment. Social determinants of health can be divided into five categories: physical and environmental — including access to food, employment, and economic status, education, healthcare access and quality, and social environment and community support.

Mike (03:05):

Yeah, will we live at work in our ability to access healthy food have a significant impact on our health.

Evan (03:12):

America spends a hundred billion dollars on hunger relief every year, but more than 50 million Americans remain food insecure. Food insecurity is a significant problem in this country with too many people not having access to adequate or quality food. Some may lack the knowledge to create a healthy diet, and some may live in food deserts, which are areas where grocery stores are non-existent or too far away. More than 23 million people in the United States live in food deserts, nearly half of whom are low income, and it is often underreported due to small corner grocery stores which primarily sell processed packaged food being counted alongside supermarkets that sell a variety of fresh fruit and vegetables. People living in food deserts also have a hard time finding foods that are culturally relevant or meet their dietary restrictions, and are more likely to eat low-nutrient fast food.

Mike (04:01):

Yeah. Some of the resulting problems are malnutrition and vitamin and mineral deficiencies, which are a significant contributing factor to poor health at all ages, and brain development in children. Food insecurity can also result in obesity because of less costly high-calorie foods being the only ones available to them, poor diabetes control and worsening of many diet related chronic conditions such as renal disease, and certain GI conditions such as celiac disease where one needs to avoid gluten. If there’s no option for gluten-free food in your area, then it will very much adversely affect your celiac disease. Another thing to think about is access to clean water. Not everybody has access to clean water in their communities, and it can really result in a number of medical conditions. The two most important are toxic ingestions of chemicals in the water or infection by waterborne illnesses. Most of us are familiar with the waterborne illnesses based on some of the epidemics that have occurred after hurricane related storms in many areas.

Evan (05:12):

Inadequate housing may be one of the most important contributing factors to poor health. Poor housing or homelessness can contribute to people being exposed to extreme weather, unsafe and unsanitary living conditions, exposure to toxins, or overcrowding which can increase transmission of infectious disease. Homelessness can take many forms with people living on the street and encampments or shelters, in transitional housing, or staying with family or friends. Being excluded from access to affordable healthcare can be a barrier in itself to escaping poverty. Unhousedpeople face significant barriers when trying to access healthcare, despite high risk of pneumonia and infections. Lack of affordable healthcare on its own can contribute to homelessness for families and individuals who struggle to pay rent, a serious illness or disability can lead to a downward spiral into losing housing. A person could lose their job due to inability to work, deplete their savings to pay for healthcare, and eventually be evicted from their homes with reduced or no incomes. And it could happen to almost anyone — 56% of Americans cannot afford a thousand dollars emergency expense with savings.

Mike (06:20):

Yeah, inadequate housing can result in a myriad of health problems, some of which Evan has mentioned, such as increased illness in hospitalization, but it can also result in chronic depression, anxiety and distress, neglect especially of children, Childhood/domestic abuse, and failure to thrive in children can also impair cognitive development in children and cause increased behavioral problems at all ages. And in fact, a study done in 2019 estimated the savings that would come from just removing lead paint from old houses. It would save about $3.5 billion on all future healthcare costs, including $60 million in health savings and $110 million in health benefits. If you add removing lead service lines such as lead water pipes, this would also result in an additional savings of $10 million in health savings and $30 million in health benefits. Just imagine how much money we could save if we were able to make a significant impact on a lot of these problems that we’re talking about.

Evan (07:28):

Mental illness is prevalent in unhoused populations, with 25% of people without housing living with a serious mental health condition and estimated 46% with any mental illness. Several studies have shown that people with mental illnesses often find themselves unhoused primarily as a result of poverty and lack of low income housing, not as a direct result of their mental health. Homelessness is often a traumatic event in itself and can further influence a person’s symptoms of mental illness.

Rich (07:54):

We don’t wanna forget the educational impact of homelessness or inadequate housing. If students don’t have a place to do their homework, to read quietly, to concentrate, it will affect your academic development.

Mike (08:06):

Where we live can have a significant impact on the social determinants of health, including the availability and quality of healthcare, quality and quantity of food that’s available, safetyness and cleanliness of the environment, social networking and social opportunities, and availability of type of employment and education. And remember, this is apart from all of the other determinants that we’re talking about. Again, its geography alone can have these effects irrespective of all of the other determinants.

Evan (08:38):

In rural areas. Healthcare can be hours away or in places where it gets really hot or really cold like that geography definitely affects people’s health.

Mike (08:48):

Yeah. Again, I just wanted to stress that geography is a separate risk factor irrespective of, of anything else that’s associated with that, whether it’s poverty in certain rural areas or lack of services in those area, whatever. It’s alone is a risk factor.

Rich (09:08):

Another fact we wanna take into account is transportation. Within geographic areas, lack of adequate or low cost transportation limits access to healthcare and resources, and all this can contribute to poor health. It also may impact on the ability to find good employment, educational opportunities, and healthy food outlets.

Evan (09:27):

The conditions in a community also have an impact on health. Unhealthy and even dangerous conditions can include overcrowding, a lack of playgrounds, parks, recreation areas, libraries, or just places where people can relax and meet safely. Bullying, gangs, street violence, ready availability of drugs and guns, lack of pedestrian safety due to inadequate sidewalks, crosswalks, street lights, and other traffic safety measures, bike lanes, inadequate protection from law enforcement and other public health offices and inability to access or afford legal services which can sometimes help combat discrimination, remedy unsafe workplace or housing, provide criminal defense or victim representation, address immigration status, or resolve guardianship or custody issues. Many jobs can have poor and dangerous working conditions that result in injuries, toxic exposure, and many types of illnesses. The workers who are employed at the most dangerous working conditions tend to be not covered by unions, tend to be Black or otherwise minority people, and have less access to recourse to workplace conditions and discrimination.

Mike (10:42):

In addition to your geographic location. A lot of the environmental conditions in your local area contribute to health. For example, trash and other unsanitary conditions that may exist due to lack of community resources for this can increase the risk of illness and injury. Pollutants, allergens, and secondhand smoke can affect respiratory and other health conditions. Excessive and loud noises can impair hearing in the long term, and global climate change can have a wide range of impacts. For instance, higher temperatures can produce a wide variety of heat related problems, such as dehydration and stroke, the increased amount of storms and flooding, erosion, and other weather condition can destroy homes, displace residents, limit access to needed services and food, close schools and workplaces, and spread diseases. About 10 percent of people in our country live in poverty. Poverty very definitely affects health and access to healthcare in many ways, including more and increased severity of chronic illnesses, shorter lifespan, impaired cognitive development in children, increased risk of dementia in elderly, more mental health and behavioral problems, and an overall reduction in the quality of life, which in and of itself can result in poor health outcome.

Evan (12:07):

Healthcare and healthcare insurance are expensive. Availability and affordability of medical care are often dependent on employment, income and expenses. Those with better jobs and higher incomes have access to better healthcare and healthcare insurance while unemployment and job insecurity limit access. Unfortunately, the employment programs, career counseling, and education support programs that attempt to make a difference for the people who can’t afford healthcare and insurance tend to be inadequate. Debt, including medical debt, is a major contributor to poor health in the form of avoiding needed medical care and not having the resources for a healthy lifestyle. We’ve said before, medical debt is one of the most leading causes of bankruptcy in the United States. Lack of affordable and high quality childcare can also contribute to preventing many to seek employment or further education or their own healthcare.

Mike (13:02):

Yeah. They can’t get away from the home for their own healthcare because they need to take care of the children.

Evan:

Exactly.

Mike:

All right. Studies have shown that those with higher education are healthier overall. Unfortunately, access to education in this country is quite variable. It can be difficult for those with lower incomes, in remote areas, with no transportation, or in certain ethnic racial groups to access child development programs, language appropriate learning programs quality, primary and higher education and adult education programs.

Rich (13:38):

Being a science denier can also have an adverse effect on healthcare if it results in vaccine avoidance and relying on medical care that is not evidence-based. Not everyone has the same access to healthcare, medical services, and insurance. Limited access to quality healthcare is a significant problem for many. It can result in a higher risk of infant and maternal mortality, heart disease, diabetes, hypertension, cancer, and other chronic illnesses, disability and other functional limitations, mental illness, substance abuse, and overall decrease in life expectancy. Poverty, unemployment, and limited income are primary causes of limited access. Even for those who can afford it, there can be limited availability and access to quality healthcare, pharmacies, and family, social, and mental health services. This most frequently depends upon where people live in the services available in the area. It can also be due to other factors as discussed in the podcast, such as transportation, discrimination, or disabilities.

Mike (14:41):

Yeah, the availability and quality of healthcare insurance have a major impact on the access to healthcare and overall health in this country. In general, those with higher quality health insurance have better health. But aside from the financial part, including your income, the cost of premiums, deductibles, and other out-of-pocket costs, there are other ways that health insurance can affect your healthcare. For instance, most insurance policies partially limit access to certain medical care by creating networks and formularies. Many policies don’t cover dental or vision care. They can limit the number of visits to some services like physical therapy or even not be responsible for long-term car iIn long-term care facilities. Approximately 10% of people are uninsured and they have the least access to affordable quality care. They may either forego medical care due to high out-of-pocket costs or seek medical care in inappropriate places, and when they can’t pay for it, the costs are passed on to hospitals, taxpayers, and others who are insured.

There are actually some other limitations to healthcare. Health literacy is being able to understand medical conditions and the need for preventive healthcare, which includes screening and immunizations, which can significantly improve health. While health literacy is important, many do not take the time to understand health problems and treatment plans. It’s even more difficult for people with learning disabilities, lower education levels, and a poor understanding of English or any other language spoken by their provider. People’s medical choices can also be influenced by the attitudes of health and healthcare held by those around them, including family, friends, coworkers, and other contacts, elected officials, trusted advisors, educators, and the media, and multimedia. Those with disabilities and other physical limitations often find it difficult or even impossible to request or access appropriate healthcare. Immigrants may experience discrimination based on country of origin, race, ethnicity, or religion. They may have problems accepting medical care related to culture and customs. These include different medical practices that exist in other countries that aren’t offered in the United States. Some face actually discourage or prohibit regular healthcare, and unfortunately, in many cases, women are treated very differently in different cultures.

Evan (17:26):

Even in the United States, women with chronic illnesses are often misdiagnosed with depression, anxiety, or hypochondria. Instead of receiving the healthcare they need and are more likely to be given sedatives instead of painkillers to address their symptoms.

Socioeconomic status, community and involvement in it, neighborhood social structure, educational systems and community support services also affect physical and mental health. Social connectedness is defined as the relationships and interactions with friends, family, coworkers, and community. Isolation is its opposite. Family has a significant contribution. Poor health, especially for children, can result from neglect and lack of close family or nurturing environment, Family turmoil, including violence and instability, single parent home, families in divorce, and addiction such as substance abuse or gambling. Isolation and its medical consequences can result from unemployment, disability, chronic illness, including mental health, limited opportunity for social contact due to geography, opportunity or resources, discrimination and lack of community support and/or services. Mental health can be both a cause and a result from isolation, especially for children and the elderly. People with untreated mental illnesses are overrepresented in every part of the carceral system, including deadly encounters with law enforcement.

Mike (18:47):

Who we are also has a significant impact on our health independent of any of the other factors we’ve already talked about.

Evan (18:55):

Unfortunately, racism exists and prejudice and segregation are still prevalent in the United States, resulting in more limited access to quality healthcare for certain racial and ethnic groups. Multiple studies have shown that Black Americans and Hispanic citizens and immigrants have less access to care and worse medical outcomes as a result. Black women are three to four times more likely to die from pregnancy related causes compared to white women. Black children are more than three times more likely to die after surgery than white children. Health services are often more expensive for Black Indigenous people of color with 30% of their medical expenses being associated with health inequities. Black people are less likely to use psychiatric medications or administer them to a child in their care — even when they have equal access. Aside from a lack of diversity, experts say this is possibly due to a general lack of cultural competence among healthcare and psychiatric professionals. Black and indigenous people are more likely to report a distrust of healthcare institutions,having historically been the subject of harmful experimentation and forced sterilization. Black, indigenous, people of color are underrepresented in medical research, making the available information about their health, sometimes less valuable or reliable. In dermatology, where images are critical for diagnoses, the lack of images of darker skin poses significant barriers to proper treatment and medical education. Even regularly used instruments such as pulse oximeters do not work as well on non-white skin, often leading to people of color receiving less supplemental oxygen than white people.

Mike (20:29):

Age can affect medical care in many ways. Our medical system is very well set up to provide adequate and quality care for our children, and while we are invested in children getting the benefit of healthcare, the same is not true for a lot of adults. Many adults who are young or middle-aged and in good health avoid preventive medical care, including immunizations and are less likely to seek medical care when it is needed, often finding themselves being sicker and actually needing a higher level of medical care. A lot of adults of any age are not consistent about visits that help improve control of their chronic diseases. The elderly are very frequently do not get the amount of medical care they need and not often understood by caretakers when elderly actually need the medical care.

Evan (21:24):

Though women tend to be more proactive about their health and healthcare, they often experience gender bias (as we’ve mentioned) when receiving that care. Recent laws limiting a woman’s control over their reproductive choices have had a very harmful effect on women’s health. We covered abortion in an older episode — would like to cover it again someday, maybe — But abortions are essential healthcare and multiple studies indicate that the inability to receive an abortion places pregnant individuals further into poverty and harms their health as well as wellbeing of their current and future children. Many people lack the means and access to decide whether to continue a pregnancy, particularly communities of color, LGBT people, and residents of rural areas.

The healthcare requirements for LGBT people are still not well understood and accepted and result in inadequate and sometimes inappropriate care. Transgender children are experiencing significant difficulty receiving medical care, especially gender affirming care due to poor understanding by many healthcare providers and elected officials. The Florida Medical Board recently voted to ban medications and surgery for adolescent patients seeking gender transition. It is kind of important to note that no children receive gender affirming surgeries in the United States — that simply has not happened. Federal court and Texas has recently ruled that the Affordable Care Act doesn’t prohibit discrimination in healthcare based on gender identity, despite explicitly doing so. Transgender people face significant barriers when accessing healthcare. Most insurance doesn’t cover gender affirming care, nor do state Medicaid programs. Most ID-issuing agencies in the United States require proof of having undergone gender affirming healthcare — usually surgery — before changing a gender marker on driver’s licenses, birth certificates, and other IDs. Since most health insurers and state programs don’t cover that care, many people are inevitably left unable to pay for the expensive procedures out-of-pocket presenting as a gender or going by a name different from those marked on state issue IDs can lead to difficulties and risk of danger when dealing with employers, the police, while traveling, or even accessing your own bank accounts.

Mike (23:35):

Government involvement can affect communities and your healthcare. Depending on the type and degree of involvement, it can either have a beneficial or harmful effect on health and healthcare. The governments do provide many programs at many levels to help those in need, including those with inadequate healthcare. These programs are also, unfortunately, quite variable in distribution scope and those who benefit from them. But some of the good things that the government is doing is providing healthcare, especially Medicaid and CHIPs (Children Health Insurance Program), which is insurance for disadvantaged children, financial aid for childcare agencies such as HUD or Housing and Urban Development sponsors programs that provide safe and adequate housing development and housing improvement. Government sponsors a lot of education programs. WIC and school meal programs are examples of the government helping to provide good nutrition for the children. They also fund social programs, civic and community improvements, and the Environmental Protection Agency is invested in monitoring and cleaning up our environment.

Rich (24:48):

The government is also involved with legislation and oversight. Like most situations where politicians are involved, the results are mixed. As was mentioned, legislation affects all aspects of our life. Most impact the many social determinants of health while some directly affect healthcare. Laws are created to oversee and regulate healthcare, which can either enhance it or interfere with it. Many times our elected officials do not make the effort to understand the science behind the medicine and healthcare.

Legislators occasionally display a great ignorance of our medicine and healthcare. Recently, a state passed law requiring obstetricians to try to implant ectopic pregnancies. What these legislators didn’t know is there’s no way to do this — it’s a procedure that does not exist. As was mentioned, the Florida Medical Board recently banned medications and surgery for new adolescent patients seeking gender transition, and this demonstrated a disregard for accepted medical practices. Abstinence-only sexual education programs are ineffective, yet many politicians support them. People can also be influenced by their elected officials who don’t understand the basics of science and healthcare. Political party affiliation can affect healthcare. The most devastating example is the lower vaccination rate and higher death rate among Republicans, mostly due to politicians discouraging their constituents to take the precautionary measures necessary and get vaccinated.

So what can be done? As with most complex problems, there are no simple solutions. Here are a few suggestions. We need to look at the big picture. Many different groups work on specific aspects of the social determinants of health. This leads to each group protecting their own programs and funding, even if it means not providing the best care. One example is the overuse of emergency rooms. Many people use it as a primary source of healthcare. Treating non-emergencies in ERs leads to a significant increase in unnecessary expenses, but these added costs are essential to the functioning and finance of the ER. Taking funds from the ER to fund primary care clinics makes financial sense to society, but may not to the emergency rooms. Another example is housing. Many housing programs require residents be clean and sober before they qualify for subsidized housing. Unfortunately, it’s very difficult to become clean and sober if you don’t have a place to live. Studies have shown the cost to society is greatly reduced if adequate housing is provided, even if the person is not clean and sober. Education of healthcare providers is also important. Not enough providers consider a person’s social and economic constraints when addressing healthcare issues. It’s easy to tell a patient to reduce stress, but it may not be possible if they lack adequate housing and do not know if they have enough money to feed their family.

Awareness of social determinants of health by healthcare providers isn’t good enough. Once social problems are determined, the healthcare provider needs to know where to refer patients. That means there need to be programs that address the patient’s needs. The programs that exist need to simplify the admission process. All too often, a person in need must apply to multiple programs to attain all the help required. This process can be quite difficult and not considered the needs of the applicant. For example, if a program’s office is only open nine to five, it may not be possible for a working person to take time off from work to apply for benefits. You can see how it’s a web of services and programs that must work together to provide the services people in need require. The programs are considered a person’s entire situation and custom tailor benefits package.

Evan (28:28):

Too often, illness and disability are treated in the patient’s body without taking into account the social, political, and geographical context that make up our social determinants of health. Some state health insurance programs are beginning to pay for housing, greatly decreasing the health risks for unhoused people covered by those programs. We will talk about more of the measures in place to lessen the impact of social determinants in a future episode.

Mike (28:56):

We can go over some of the things that are actually being done by various organizations in the government, as well as speculating on other measures that may be effective to counteract some of the effects of the social determinants of health.

[segment break]

Evan (29:16):

The last segment of each episode we suggested about the culture, art, entertainment, and social causes we’ve been engaged with to each other and our listeners. I’ve mentioned this show a couple times in passing on the podcast, but one of my favorite podcasts is Movement Memos from the independent news organization Truthout. Hosted by Kelly Hayes, Movement Memos is a podcast about solidarity, organizing, and the work of making change. One of the most valuable things I’ve listened to this year has been a non-sequential series with Tanuja Jagernauth about cultivating hope in challenging times, and I can’t suggest this series enough. I would recommend it to everybody. (Part 1, Part 2, Part 3)

Thank you so much for joining us for this episode of Health Savings News. Please subscribe, rate, and review us on Apple Podcast or wherever you’re listening to the show — it really does help. You can follow @NeedyMeds on Facebook, Instagram, LinkedIn, YouTube, Mastodon, and you can follow @HealthSavingPod on Twitter (for as long as Twitter remains around) for updates specific to this podcast and send questions, comments, and topic suggestions to podcast@needymeds.org. Our music is composed by Samuel Rulon Miller. His music can be found at musicisadirtyword.bandcamp.com. The Health Savings News podcast is produced by me, Evan O’Connor. All the sources we use in our research can be found in this episode’s podcast description on our website or your podcast of choice. Health Savings News is not intended to substitute professional medical, financial, or legal advice. Always seek the advice of a qualified healthcare professional or appropriate professional. With any questions, view, express and Health Savings News are solely those of the individual expressing them. Any views expressed do not necessarily represent the views of Health Savings News, other contributors, the NeedyMeds organization or staff. Thanks again for listening. We’ll see you in two weeks with our next episode.