Social Determinants of Health

BE 608

Life Expectancy Over Time

Life expectancy 1900: 47.3 years
Life expectancy 2023: 79.1 years
Value of life expectancy increase from 1970 to 2000: $95 trillion -- 3x the amount spent on medical care.

Why did life expectancy improve?

Source: Brookings Institution

About half of the mortality gain from 1900 to 1940 due to water chlorination and filtration (Cutler and Miller 2005).

A large percent (10-15%, depending on source) due to improved nutrition.

Gains in later years partly attributable to decreased smoking rates and improved seatbelts/car safety

All are factors unrelated to "medical care" (as traditionally conceived)

Income and Health

There is a strong relationship between income and health

Emerges early in life (e.g., Case, Lubotsky and Paxson 2002 AER).
Present in every country for which we have data, every time period for which data exists.
True for many measures of health (longevity, obesity, chronic illness).

Income and Health

Chetty et al 2016 JAMA: Descriptive paper

Uses massive data from tax records to describe income/health relationship in US.
How has health/income relationship changed over time?
What is correlated with health of the lowest income individuals?

Income and Health

Data on earned income:

Tax returns for filers
Sum of W-2 and 1099-G (unemployment) for non-filers
Excludes social security benefits and disability benefits

Data on death:

Social security death master index
Look at individuals age 40 to 76

Income and Health

Text

Some places particularly bad for low income individuals -- what is correlated with low life expectancy among low income?

Determinants of Health

The strongest correlates of health expectancy are, for the most part, things that do not involve accessing and using medical care.

Strongest correlates:

Health behaviors
Demographic composition (education, immigrant presence, homeownership rates, etc).
Local govt expenditures (parks, libraries, streets, trash removal etc)

Not correlated:

Insurance coverage
Amount of preventive care used on average
Medical spending

A Tale of Two Experiments

Oregon Health Insurance Experiment:

Directly targeted health care access
Significantly increased use of health services
Improved mental health
No improvements or inconclusive effects in physical health

Moving to Opportunity:

Demonstration for residents of government housing projects.
Randomly selected families to be given voucher to move to low poverty neighborhoods.
No direct health component.
Biggest effects: improvement in health (lower obesity rates, lower blood glucose, fewer hospitalizations)

A Tale of Two Experiments

Ludwig et al New England Journal of Medicine 2011

Baicker et al NEJM 2013

Oregon Health Insurance Experiment

Some of the most dramatic effects were about financial outcomes

Non-Medical Care Determinants of Health

Factors affecting health not directly related to medical care:

Education

Nutrition

Racism

Substance abuse/opioid crisis

Housing stability

Environmental quality

Behaviors

Peer effects

Camden Coalition and Hotspotting

Healthcare hotspotting

is the strategic use of data to reallocate resources to a small subset of high-needs, high-cost patients.

Super-utilizers, small number of patients with complex, hard-to-manage needs and chronic conditions, can generate a lot of costs.

Are Companies Buying It?

United HealthCare covers 6.4 million Medicaid beneficiaries.

A small percentage of them account for a large amount in spending.

(Quote from Forbes, 2018):

"A homeless man in Phoenix named T.J. made 254 trips to the emergency room, had 32 hospital admissions and cost UnitedHealth Group, the nation’s largest health insurance company, and the U.S. healthcare system more than $294,000 since 2015."

Moved to temporary housing
Helped apply for disability
Counseling for depression

Are Companies Buying It?

“Social determinants of health, like food security or stable housing issues, sit upstream from and weigh heavily on gaps in care,” UnitedHealthcare CEO Steve Nelson told analysts on the company’s first quarter earnings call. “Data from other countries and our own experience indicate social investments reduce health care costs, and addressing these social determinants is the next frontier in serving the whole person here in the U.S. "

Anthem and UnitedHC both making substantial investments (over $350 mil) in affordable housing for their Medicaid populations.

Is the Best Health Care Dollar not Spent on Health Care?

Source: ABC News. Ohio Health family practice partnering with local food banks to provide nutrition support. Costs ~$7 per person.

The $1.5 trillion question: does it work?

Everyone wants to reduce cost and improve outcomes.

Is the path forward through targeting healthy behavior, the environmental setting, access to housing, nutritional assistance or cash assistance (or something else)?

How can we turn these insights into something that actually works to save money?

Companies are eager for an answer to this question!

The $1.5 trillion question: does it work?

Randomized controlled study of the Camden Coalition "hotspotter" program:

We randomly assigned 800 hospitalized patients with medically and socially complex conditions, all with at least one additional hospitalization in the preceding 6 months, to the Coalition’s care-transition program or to usual care. The primary outcome was hospital readmission within 180 days after discharge.
The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, −5.97 to 7.61).

Finkelstein, Zhou, Taubman and Doyle

New England Journal of Medicine 2019

The $1.5 trillion question: does it work?

One attempted solution for firms: the "Workplace Wellness" program.

Offer incentives to lose weight, quit smoking, visit the gym more etc.

Currently 50 million employees have access to these types of programs, according to a recent United HC survey. An $8 billion industry!

Workplace Wellness Randomized Controlled Trial

Jones, Molitor and Reif 2019 randomly assigned eligibility for a workplace wellness program, and the size of financial incentives, at the University of Illinois.

Wellness program offered employees an incentive of $75 per semester if they engaged in at least one "wellness activity" that met once a week for 6 to 12 weeks, plus $200 for signing up and taking a health risk assessment.

E.g., weight watchers, stress management class, smoking cessation program

Workplace Wellness Randomized Controlled Trial

Authors find that previous literature looking at differences across wellness plan participants and non-participants was driven by selection, i.e. those who choose to participate in a wellness program tend to be healthier anyway.

If workplace wellness programs save employers money, it is only because it is a "perk" that helps retain healthy employees and not sick employees.

Social Determinants of Health: Is There Value to Capture?

Other ongoing randomized controlled trials:

Nutritional Supports for At-Risk Patients

Smoking Cessation Commitment Devices

OpenAI/OpenResearch Universal Basic Income

And other projects--more evidence will be here soon!

Discussion?

(Bonus slides)

Nutritional Inequality

Allcott et al. 2019 Quarterly Journal of Economics based on Neilsen Scanner Panel

Nutritional Inequality

Allcott et al. 2019 QJE

Nutritional Inequality

Why? Differential availability: explains only about 10%

But lowering the prices on healthy food could eliminate disparities (at a cost of about 15% of the FNS budget)