Health Is More Than Health Care
Authors: Karen B. DeSalvo, J. Nadine Gracia
Journal: Annals of Internal Medicine (2020)

Supplement: Vision for U.S. Health Care21 January 2020Health Is More Than Health CareFREEKaren B. DeSalvo, MD, MPH, MSc and J. Nadine Gracia, MD, MSCEKaren B. DeSalvo, MD, MPH, MScGoogle Health, Palo Alto, California (K.B.D.)Search for more papers by this author and J. Nadine Gracia, MD, MSCETrust for America's Health, Washington, DC (J.N.G.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3895 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Improving the public's health requires more than access to high-quality, affordable health care. Achieving health equity will require attention to social determinants of health, including important underlying barriers to health and well-being, such as racism and poverty. The American College of Physicians' (ACP) vision for a better U.S. health care system includes an important call to action for medicine to do just that—shift toward a more comprehensive approach to addressing health drivers of our patients and communities (1).Attention to the broad drivers of health is more than a “feel good” effort. Life expectancy in the United States has declined for a third year in a row. “Deaths of despair,” including suicide, homicide, liver failure from alcohol use, and opioid overdose, account for the decline in longevity. Underlying this disturbing decline in the public's health are an array of drivers that include poverty, racism, housing, food security, social isolation, discrimination, environmental exposures, and limited educational and economic opportunities. These social determinants of health account for an estimated 60% of U.S. health outcomes, and intervention to address these factors has the potential to improve health outcomes and lower health care costs (2, 3). Ongoing and widening health disparities in the United States and the economic impact of these poor health outcomes add urgency to bringing health equitably to all (4).Medicine Has a Critical Role to PlayThe social determinants of health are not abstract concepts. All physicians can recall patients whose social and economic conditions, community context, and life experiences have been barriers to optimal health and wellness. Consequently, physicians have an important role in understanding and supporting interventions to address the social needs of their patients. Our patients trust us and share insights about their social risks and needs. Knowing about the context of patients' lives helps physicians make more accurate diagnoses and develop more appropriate care plans.Achieving the ACP vision of a health system capable of addressing the social determinants of health and advancing equity will require an organizational commitment to addressing health-related social needs and health disparities. It will also require changes to expectations of the current and future physician workforce. Much work needs to be done to provide medical education and training opportunities to prepare physicians to address these issues (5). There is evidence that understanding and addressing the social determinants of health and disparities is associated with both better patient experience and greater physician satisfaction (6).Driven in part by the shift toward value-based care, the U.S. health care system increasingly recognizes that clinical excellence is only part of a solution to improve health and well-being. Many systems have begun to screen patients for social needs and provide assistance in accessing services to address those needs. The National Academy of Medicine recently provided a framework for action for the integration of social care in health care delivery (7). Payers and policymakers have also begun to build insurance benefits for Medicare and Medicaid populations that support social needs, and some insurers even provide funding for rent (8). Although this sounds encouraging, medicalizing social determinants can have unintended consequences. For example, offering housing as a benefit of a Medicaid plan sounds helpful, but does a person then become homeless if they change insurance providers to one that does not offer this benefit?The Interplay of Social Determinants of Health and Health EquityThe impact of inequities in social determinants of health is most striking for certain U.S. populations, such as the poor, people of color, and those facing other forms of discrimination (9).We agree with the ACP that equitable health care access and quality initiatives must be a priority alongside addressing social determinants of health. Actions required include strengthening the provision of culturally and linguistically appropriate care, addressing provider-level and institutional bias in the delivery of care, increasing the diversity of the physician workforce, and making health equity a core measure for health care payment and delivery system reforms (10). Achieving health equity, in which everyone has a fair and just opportunity to be as healthy as possible, necessitates intentionally addressing underlying structural drivers, such as individual and structural racism and discrimination; policies, such as redlining; and inequities in education and economic opportunity (11).Medicine should also pay attention to aggravating disparities in its efforts to address the social determinants of health (12). While health systems and providers are beginning to pay greater attention to addressing health-related, nonmedical social needs of individuals and families, medicine should support changes in laws, policies, practices, systems, and environments that are vital to addressing root causes of inequities and ultimately eliminating these inequities (13). For example, it is critical to avoid penalties to providers serving more disadvantaged populations when health equity becomes a core measure of health care payment and delivery system reforms.Medicine Is Not AloneMeaningfully addressing the social determinants of health and discrimination in health care can seem daunting. Fortunately, medicine is not alone. We applaud ACP for acknowledging that medicine will need to work with partners whose skills, reach, and experience complement our own. Medicine and its partners should develop a shared and intentional strategy to drive accountability and authentic community engagement. Medicine can and should collaborate with key partners in a multisector approach for improving health, including public health, social services, and other partner systems, and advocate to support the strengthening of these systems, which are often underfunded and under-resourced (14). For the upstream social drivers, a multisector spectrum of actions is necessary, in which diverse disciplines, sectors, and the affected communities collaborate to develop, implement, and align effective strategies (15). Such action should include not only better coordination of care and services but also joint policy action, such as for affordable quality housing. These multisector partnerships should include shared strategies to drive accountability and authentic community engagement and advance health equity. The nation should develop financing models that drive such collaboration.ConclusionUnderstanding the conditions in which our patients are born, grow, live, work, and age is a critical part of effective efforts to optimize their well-being. The systems-level changes the ACP advocates require leadership, societal action, and sustained investment, especially in communities with the most need. This ACP position statement provides guidance to allow us to achieve such positive change.References1. Butkus R, Rapp K, Cooney TG, et al; Health and Public Policy Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: reducing barriers to care and addressing social determinants of health. Ann Intern Med. 2020;172:S50-S59. doi:10.7326/M19-2410 LinkGoogle Scholar2. Centers for Disease Control and Prevention. Sources for Data on Social Determinants of Health. Atlanta: Centers for Disease Control and Prevention; 2018. Accessedat www.cdc.gov/socialdeterminants/data/ on 17 December 2019. Google Scholar3. Gottlieb LM, Wing H, Adler NE. A systematic review of interventions on patients' social and economic needs. Am J Prev Med. 2017;53:719-729. [PMID: 28688725] doi:10.1016/j.amepre.2017.05.011 CrossrefMedlineGoogle Scholar4. Ghebreyesus TA, Admasu K. Just societies, health equity, and dignified lives: the PAHO Equity Commission. Washington, DC: Pan American Health Organization; 2018. Accessed at http://iris.paho.org/xmlui/handle/123456789/51571 on 17 December 2019. Google Scholar5. Doobay-Persaud A, Adler MD, Bartell TR, et al. Teaching the social determinants of health in undergraduate medical education: a scoping review. J Gen Intern Med. 2019;34:720-730. [PMID: 30993619] doi:10.1007/s11606-019-04876-0 CrossrefMedlineGoogle Scholar6. Kung A, Cheung T, Knox M, et al. Capacity to address social needs affects primary care clinician burnout. Ann Fam Med. 2019;17:487-494. [PMID: 31712286] doi:10.1370/afm.2470 CrossrefMedlineGoogle Scholar7. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: National Academies Pr; 2019. Accessed at www.nap.edu/read/25467/chapter/1 on 18 December 2019. Google Scholar8. DeSalvo KB, Leavitt ML. For an option to address social determinant of health, look to Medicaid. Health Affairs Blog. 8 July 2019. doi:10.1377/hblog20190701.764626 CrossrefGoogle Scholar9. Artiga S, Hinton E. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. San Francisco: Kaiser Family Foundation; 2018. Accessed at www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/ on 17 December 2019. Google Scholar10. Koh HK, Gracia JN, Alvarez ME. Culturally and linguistically appropriate services—advancing health with CLAS. N Engl J Med. 2014;371:198-201. [PMID: 25014685] doi:10.1056/NEJMp1404321 CrossrefMedlineGoogle Scholar11. Braveman P, Arkin E, Orleans T, et al. What Is Health Equity? Princeton, NJ: Robert Wood Johnson Foundation; 2017. Accessed at www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html on 17 December 2019. Google Scholar12. Gottlieb LM, Alderwick H. Integrating social and medical care: could it worsen health and increase inequity? Ann Fam Med. 2019;17:77-81. [PMID: 30670400] doi:10.1370/afm.2339 CrossrefMedlineGoogle Scholar13. Castrucci B, Auerbach J. Meeting individual social needs falls short of addressing social determinants of health. Health Affairs Blog. 16 January 2019. doi:10.1377/hblog20190115.234942 CrossrefGoogle Scholar14. DeSalvo K, Parekh A, Hoagland GW, et al. Developing a financing system to support public health infrastructure. Am J Public Health. 2019;109:1358-1361. [PMID: 31415208] doi:10.2105/AJPH.2019.305214 CrossrefMedlineGoogle Scholar15. Auerbach J. Social determinants of health can only be addressed by a multisector spectrum of activities. J Public Health Manag Pract. 2019 Nov/Dec;25:525-528. [PMID: 31569189] doi:10.1097/PHH.0000000000001088 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Google Health, Palo Alto, California (K.B.D.)Trust for America's Health, Washington, DC (J.N.G.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3895.Corresponding Author: Karen B. DeSalvo, MD, MPH, MSc, Google Health, 3400 Hillview Avenue, Palo Alto, CA 93404; e-mail, [email protected]com.Current Author Addresses: Dr. DeSalvo: Google Health, 3400 Hillview Avenue, Palo Alto, CA 93404.Dr. Gracia: Trust for America's Health, 1730 M Street, NW, Suite 900, Washington, DC 20036.This article is part of the Annals supplement “Better Is Possible: The American College of Physicians' Vision for the U.S. Health Care System.” The American College of Physicians was the sole funder for this supplement. 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