(As explained on the podcast home page, this is the last of eight interviews concerning federal healthcare policy reform. This discussion is with UCSF's Dr. Paula Braveman and Dr. Laura Gottlieb and was conducted in early January. As you will hear this podcast like all others is introduced by ProMedica's CEO, Randy Oostra. This series was produced in an effort to interest or persuade federal healthcare officials to pursue substantive healthcare policy reform.)
The US ranks last or near last in healthcare access, affordability and outcomes and this holds true even for white, educated, insured and upper income Americans. What largely explains this high spending - poor health paradox, or our health disadvantage, are the social determinants of health: generally defined as education, economic circumstances, food security, housing and social, environmental and related exposures. Where people live, work and socialize determines approximately 60% of their health status whereas medical care accounts for approximately 10%. Despite the essential role social determinants play, the US has the lowest ratio of health care spending to social services spending in the OECD. For every dollar spent on HC, the US spends one dollar on social services. Across the remaining 36 OECD countries, the ratio averages $1 on healthcare to $2.50 on social services. As for the health care industry’s investment in social determinants, a study published in February 2020 found that among 57 health systems that include 957 hospitals, or one-sixth of total US hospitals, researchers found that they had collectively invested only $2.5 billion in social determinants programming over a two-year period, or just 4% of their overall community benefit spending.
This interview begins by Dr. Braveman and Dr. Gottlieb providing general comments about social determinants. The interview progresses to their commenting on the ill health effects of economic inequality due in part to economic inequality, in turn, causing/creating a profound lack of social solidarity or social cohesion, exacerbating racism and undermining our ability to invest in the social determinants or social service spending, discuss related for-profit, industry silos and misaligned incentive problems, address the success of pay for performance programming to address social determinants moreover under the Medicaid program, the extent to which there is for providers a return on investment and the problem in expecting and/or calculating a return, how social determinant spending is prioritized, i.e., the importance of making higher level community level investments, not just spending on immediate, e.g., transportation problems, and identifying a percent of spending on social determinants and discuss recommendations on how to increase social spending in Medicaid and Medicare.
Paula Braveman, MD, MPH is Professor of Family and Community Medicine and Director of the Center on Social Disparities in Health at the University of California, San Francisco (UCSF). For more than 25 years, Dr. Braveman has studied and published extensively on health equity and the social determinants of health, and has worked to bring attention to these issues in the U.S. and internationally. Her research has focused on measuring, documenting, understanding, and addressing socioeconomic and racial/ethnic disparities, particularly in maternal and infant health. During the 1990s she collaborated with World Health Organization staff in Geneva to develop a global initiative on equity in health and health care. She has been the Research Director for a national commission on the social determinants of health in the U.S. supported by the Robert Wood Johnson Foundation. Throughout her career, she has collaborated with local, state, federal, and international health agencies to see rigorous research translated into practice with the goal of achieving greater equity in health. Dr. Braveman was elected to the Institute of Medicine of the U.S. National Academy of Sciences in 2002 and has served on the Advisory Council of the National Institute for Minority Health and Health Disparities of NIH.
Laura Gottlieb, MD, MPH, is a Professor of Family and Community Medicine at the University of California, San Francisco. A former National Health Services Scholar and safety-net family physician with fellowship training in social determinants of health, Dr. Gottlieb now serves as Principal Investigator on multiple quantitative and qualitative projects examining the integration of social and medical care services. These projects range from large randomized trials on specific interventions undertaken in clinical settings to projects that explore the scope of this rapidly evolving field, including by characterizing the payment, technology, and workforce foundation for care integration. She is the founding director of the Social Interventions Research and Evaluation Network (SIREN), a national research acceleration and translation institute supported by Kaiser Permanente and the Robert Wood Johnson Foundation that brings together researchers across the U.S. to synthesize, disseminate, and catalyze research at the intersection of social and medical care. Dr. Gottlieb also is Associate Director of the Robert Wood Johnson National Program Office Evidence for Action grants program based at UCSF. She completed her MD at Harvard Medical School, and both her MPH and residency training at the University of Washington. Dr. Gottlieb is affiliated with the UCSF Center for Health and Community and affiliate faculty in the Institute for Health Policy Studies.
The 2016 RAND study, "Are Better Health Outcomes Related To Social Expenditure?" referenced during this interview, is at: https://www.rand.org/pubs/research_reports/RR1252.html.
To read a transcript of this interview or to post a comment or question, please go to: https://commissiononhealthcare.org/.