The American College of Physicians (ACP) released a set of 9 recommendations today meant to address social determinants of health (SDOH) in order to improve patient care and health outcomes that are negatively impacted by the conditions in the United States under which patients live, grow, and work.1
However, in an accompanying editorial, 2 physicians wrote that they feared inequities that widen gaps in SDOH would worsen, citing last year’s tax law passed by President Trump and Congress, growing deficits, and the president’s own words and actions, which they called “intemperate.”2
, often stemming from social, economic, and environmental factors, can influence health. SDOH are those nonmedical factors that impact an individual’s overall health and health outcomes that happen outside of a medical setting. These conditions include income, social status, and education; physical environment, including access to safe water and clean air; safety and conditions of residences and workplaces; employment opportunities and social support networks; and access to health services.
The ACP said it recommends increasing awareness of SDOH through increased funding of federal, state, and local programs, including investments in programs and social services, and focusing more research on the causes and effects of SDOH. The paper
was published in the Annals of Internal Medicine,
the official journal of the ACP.
Additionally, the ACP urged Congress and the administration to implement policies
that address the socioeconomic and environmental inequalities that significantly impact patient health, with an increased focus on wellness and prevention.
However, there is a 15-year difference in life expectancy between the most well-off and most disadvantaged US residents, and the blistering editorial noted that for the first time in decades, life expectancy fell in 2015 and 2016 even as medical care for many improved. The gains are not equal, the editorial said, with income inequality widening between the richest and poorest Americans and blacks and whites. The richest 1% of Americans have nearly doubled their share of income since 1980, from 10.7% to 20.2%. For the poorest 40%, inflation-adjusted incomes decreased between 2000 and 2016.
Health inequities follow these trends, not only in “diseases of despair” such as substance use disorders, injuries, and suicide, but also in other ways not fully captured in the paper, such as the effects of racism.
The editorial was written by David U. Himmelstein, MD, a professor at the City University of New York School of Public Health at Hunter College, and Steffie Woolhandler, MD, MPH, FACP, of Cambridge Hospital at Harvard Medical School. Both are founders of Physicians for a National Health Program, which advocates for universal, single-payer, national health insurance.
“The President's intemperate words and deeds also affect social determinants of health,” they wrote. As examples, they cited present and future negative effects stemming from administration policies regarding immigrant healthcare
; race-based health disparities and inequities; women’s healthcare and access to abortion; and changed environmental and air quality standards as well as denials of climate change, which they said will increase cardiovascular and pulmonary deaths and have other disastrous health consequences.
The paper highlighted several areas of SDOH, including socioeconomic status, housing, transportation, food and agriculture, the digital divide, racial and ethnic health disparities, federal and local initiatives related to social determinants, and the complexities of addressing SDOH.
As one example, the paper used the example of Flint, Michigan, where a man-made disaster was created when the state switched the city water supply to river water using old pipes that contaminated residents, including pediatric patients, with lead. Last week, the state said the water is safe to drink and ended free water distribution, angering some residents. Flint, a predominantly black city, has only 1 major grocery store, and 41% of the city’s residents live below the federal poverty level and are unable to afford bottled water.
“Taking a closer look at social determinants of health can help us better understand and address the social factors that have an impact on patient health,” said Jack Ende, MD, MACP, president, ACP, in a statement. “It’s important that physicians and other medical professionals recognize and account for social determinants of health to create a more comprehensive approach with our patients. Moreover, such an approach can to help eliminate significant health inequalities often associated with social determinants of health, such as homelessness, food insecurity, and mental health stressors such as domestic violence or social isolation.”
The ACP said it supports:
- Increased efforts to evaluate and implement public policy interventions with the goal of reducing socioeconomic inequalities that have a negative impact on health. Supportive public policies that address downstream environmental, geographical, occupational, educational, and nutritional SDOH should be implemented to reduce health disparities and encourage health equity.
- Recommendations that SDOH and the underlying individual, community, and systemic issues related to health inequities be integrated into medical education at all levels. Healthcare professionals should be knowledgeable about screening and identifying SDOH and approaches to treating patients whose health is affected by SDOH throughout their training and medical career.
- Increased interprofessional communication and collaborative models that encourage a team-based approach to treating patients at risk to be negatively affected by SDOH.
- The adequate and efficient funding of federal, state, tribal, and local agencies in their efforts to address SDOH in programs and social services shown to reduce health disparities or costs to the healthcare system and agency collaboration to reduce or eliminate redundancies and maximize potential impact.
- Increased research into the causes, effects, prevention, and dissemination of information about SDOH. A research agenda should include short- and long-term analysis of how social determinants affect health outcomes and increased effort to recruit disadvantaged and underserved populations into large-scale research studies and community-based participatory studies.
- A “health in all policies” approach and the integration of health considerations into community planning decisions through the use of health impact assessments.
- The development of best practices for utilizing electronic health record systems as a tool to improve individual and population health without adding to the administrative burden on physicians.
- Adjusting quality payment models and performance measurement assessments to reflect the increased risk associated with caring for disadvantaged patient populations.
- Increased screening and collection of SDOH data to aid in health impact assessments and support evidence-driven decision making.
1. Daniel H, Bornstein SS, Kane GC. Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper. Ann Intern Med
. 2018;168(8):577-578. doi: 10.7326/M17-2441.
2. Himmelstein DU, Woolhandler S. Determined action needed on social determinants. Ann Intern Med
. 2018;168(8):596-597. doi: 10.7326/M18-0335.