Getting under the hood of social determinants: Thoughts from the Cambridge meeting
By Austin Frakt
In an illuminating set of conversations on Monday at the Drivers of Health event in Cambridge, a diverse group of experts discussed how health care providers, local policy makers and community groups can work together to provide everyone in society with “a fair and just opportunity to live their healthiest life possible,” as Julie Morita, Executive Vice President at the Robert Wood Johnson Foundation, put it.
“Although the health sector can’t address everything, there is a moral obligation and opportunity to work with various sectors and to start thinking about systems working together,” said Shola Olatoye, former chair of the NYC Housing Authority. “We need to pay attention to not only the social needs (housing, food, transportation) of our members, but also the structural drivers behind these needs, such as investment,” added Bechara Choucair, Chief Community Health Officer at Kaiser Permanente.
One of the key drivers of social determinants of health is structural racism, as Ms. Olatoye conveyed. Though widely acknowledged by experts, if quietly, it’s rarely discussed by policymakers. In this climate of immense interest in social determinants, it is important to repeatedly acknowledge and communicate the role of racism, both in health care and outside it. I’m glad it came up, albeit relatively briefly.
Another recurring theme emerged early in the day when Kathy Ko Chin, President and CEO of the Asian & Pacific Islander American Health Forum, shared a stunning set of facts. In 2013, before the Affordable Care Act’s coverage expansion, Asian and White Americans had the lowest rate of uninsurance, compared to other racial and ethnic groups in the U.S., just 13%. But, she pointed out, racial/ethnic groupings are aggregates across diverse populations.
Among Asian Americans, there was a wide range of uninsurance rates in 2013. Nearly 30% of Nepalese-Americans were uninsured while, at the other end of the spectrum, only about 7% of Japanese-Americans were. The overall message Ms. Ko Chin conveyed was that we need to disaggregate data to obtain a more actionable picture of the state of coverage and health. We need to look not just within ethnicities, but also within specific communities. The point of disaggregating data and engaging communities with accessible and respectful language came up several times, including eloquently by University of Chicago professor Harold Pollack. “We need to think about ways to talk to people in ways that honor their identities,” said Dr. Pollock.
In particular, understanding how communities and individuals define health is essential, said Linda Goler Blount, President and CEO of the Black Women’s Health Imperative (which, for 37 years has been the only national organization focused on Black women’s health). Though not explicitly stated, I would imagine that we are likely to make more progress helping people go the direction they already find important, rather than imposing one they may find inconsistent with how they think about their own health.
In order to begin this process of collaboration and deep understanding, Alva Ferdinand, assistant professor and director of the Southwest Rural Health Research Center at Texas A&M, said, “We need to talk to people.” Dr. Ferdinand emphasized the importance of quantitatively and qualitatively understanding the needs of sub-populations, and of stepping outside the office to listen to (and heed) what people want for their health and well-being.
Though there was wide agreement that the health system may not be the right actor to address some social determinants, it is where the money is. One way to square this circle is for the health system to partner with other community organizations. Betsy Tilson summarized how North Carolina, where she is State Health Director and Chief Medical Officer, is doing that in the areas of food, housing, transportation, and interpersonal safety. She, too, emphasized the need for data and evaluation.
These changes will have to be incremental. As Gary Sing, Director of Delivery System Investment and Social Services Integration at MassHealth explained, some of the health-related social needs benefits MassHealth is beginning to roll out are still in the testing phase; it will take some time to understand if they were successful and how they can be improved. Dr. Sing said that sometimes changes must start small: “It’s okay if when you roll out a program, it’s not huge.”
If there is one thing we know for sure, it’s that we don’t know enough about how to design and implement interventions to address social determinants and social needs. We need deep thinking and investigation in these areas. The meeting discussions suggest that we have a few good places to start.
You can watch the full day of discussion here.