Addressing the social determinants of health and well-being directly at the policy level may be both the most cost-effective and moral path forward.
Though inequalities in power and wealth have been central to the critiques of western capitalist societies since the earliest days of the industrial revolution, and though industrial activity’s specific harms to human health and the environment have been addressed by organized movements for nearly as long, the more diffuse and indirect effects of society’s structure and operation on its members’ health have been recognized and studied by public health professionals only relatively recently. For several decades, evidence has been revealing a complex yet certain interconnection among the structural and functional features of society and broad metrics of health and well-being. As Woolf & Bravemen describe, there is “a complex web of interwoven social and economic conditions that exert health effects over a lifetime”. The pattern that has emerged is far from surprising – yes, it’s the politically powerless, the economically poor, the institutionally marginalized, minority groups, the vulnerable, the uneducated, and the unemployed who have the poorer health – but the degree to which social determinants affect health can be shocking (though often not to those suffering from their harmful effects).
Contrary to popular perception, the social determinants are not binary, nor do they apply only to the extremes of society’s socioeconomic spectrum. Rather, the hierarchical distribution of power, resources, and opportunities in highly stratified societies creates a dose-dependent social gradient of health effects (such as reduced life expectancy and increased disease prevalence) so that harm and disadvantage flow downhill.
By recognizing the severe, fundamental consequences of classism and the disparate distribution of the resources and conditions necessary to be healthy, we can see clearer opportunities to dramatically improve the quality and quantity of life that’s possible for millions of Americans. Let’s take two simple examples of social policies that could potentially reduce healthcare spending by more than their cost (by actually improving the public’s health and preventing death and disease – things healthcare spending usually doesn’t buy, anyway).
Insufficient income and poverty are major detriments to health and well-being, and the most direct way to address these is through the guarantee of a basic income for every member of society. The idea of a basic income is not at all new. Some version of it has been the experimental variable in studies in Canada, the US, Namibia, India, Brazil, and in Native American communities. Similar ideas have enjoyed cyclical attention in policy circles in the US since at least the 1960s, but so far no national policy has been fully implemented. I would be very pleased to see this issue taken up by the public health community and experimental studies conducted that may be able to tease apart the complicated connections between income and health. But let’s be clear, we’re currently spending nearly $3 trillion per year on healthcare, about 1/2 of which is spent on 5% of the population, usually for end-of-life care or on the severe health consequences of the social determinants – like poverty – we’re discussing. It’s not hard to imagine that a guaranteed income – $10k for every man, woman, and child as an example – could fundamentally improve the health-determining circumstances of the majority of Americans for a fraction of the savings in healthcare expenditures that would likely result.
Another obvious target for policy-level social investment to improve the public’s health is public higher education.
College-level education (even without graduation) appears to be a silver bullet for ill health, at least when compared to the effectiveness of health care. Woolf et al. estimated that college education is as much as seven times more effective than medical care at preventing mortality (2007). One wonders, then, whether the ~$70 billion in tuition annually charged by public colleges and universities (according to Department of Education) wouldn’t make the smartest public investment on the market. To sweeten the thought, according to Jordan Weissmann writing for the Atlantic, the US federal government already spends about that much on Pell Grants, tax breaks, and work study funding (citing data from the New America Foundation). Considering the enormous and diverse benefits at stake, making public higher education tuition free (and expanding access for members of under-represented ethnic and racial minorities) is a simple policy solution already benefiting most other OECD countries.
It’s my belief that Americans would be shocked to discover how much more we spend on healthcare than other countries, how poor our health is compared to other countries, how relatively little it would cost us to fundamentally stabilize and radically improve the economic footing of poor and working middle-class Americans, and how cost-effective it would be to eliminate tuition barriers to public colleges and universities for everyone seeking higher education. It’s my hope that, as policy makers are forced to face the mounting consequences of our current paradigms, the public’s health advocates in medicine, but especially in public health, will build the case for strong policy action for social justice in the distribution of and access to the means and circumstances necessary for health and well-being. In the arena of healthcare economics, social justice in income and education are powerful upstream investments that could achieve what our healthcare system can’t: reducing healthcare demand (and so spending) by improving the social conditions that determine our abilities to be healthy.