Social determinants play a key role in determining the health and health outcome of individuals. These factors are non-medical but directly affect overall health, mortality, and life expectancy. CDC (2020) defines social determinants as the conditions in which "people are born, grow, live and work, and directly affect their health outcome." The two major social determinants of health include income level and access to and quality of care. The healthcare social determinants impact the health outcome, leading to long-standing disparities in health and health care in the United States. Throughout the history of U.S. health care systems, income, and access to care as social determinants have impact policy changes and changed the way health care is delivered.
The level of an individual income directly affects the health and health outcome in many perspectives. Low income and poverty affect health across many physical and psychological measures. The income level is directly associated with living standards, lifestyles, stress, and access to quality care, which affects the overall health outcome. Similarly, the ability to access quality care can directly affect the overall health outcome (Koh et al., 2020). The ethical foundation of these determinants is based on the theory of justice and fairness; fair and equitable treatment. As an important area that informs the policy choices to improve health, the existence of social inequalities in health care leads to health care disparities. The ethical theory of justice holds for the fair distribution of primary goods, including quality health. In the social inequality system, the disadvantaged group usually have low income and limited access to quality care, which then affects the overall health outcome ( Daniel, Bornstein & Kane, 2018 ). Income inequality and unequal access to care in America can be traced back to the colonial periods, especially amongst the minorities. This long-standing history of inequality founded on racism has led to low income and poor health outcomes that transmit from one generation to the next.
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Income inequality and access to care have led to many changes in health care policies over time. The creation of the Medicaid insurance program was to help provide a range of payments for the medical bills for persons will low income. Due to the increased risks of illnesses among low-income and unequal access, Medicaid has been at the forefront in increasing access for low-income and vulnerable groups ( Saunders & Hamelmann, 2017 ). The goal of the policy changes to eliminate social determinants has been to reduce health disparities. Lack of access to quality health care is usually due to inadequate or no insurance cover amid the high cost of care for the poor. Many policy initiatives and changes have occurred to Medicaid since the 1980s to help address these social determinants of health. In the 1980s, the Medicaid benefits were extended to cover low-income pregnant women and children. The Omnibus Budget Reconciliation Act of 1981 required the appropriation of funds to help expand coverage for low-income individuals.
More policy changes followed in the 1990s, with the introduction of the State Children's Health Insurance Program in 1987. The program meant to provide more funding to extend Medicaid to children from low-income families ( Daniel, Bornstein & Kane, 2018 ). These policy changes were to help reduce inequality in income and lack of access to quality care amongst the low-income groups. Further policy changes followed in 2010 with the introduction of the Affordable Care Act (ACA) to reduce insurance costs for low-income and expand insurance coverage ( Saunders & Hamelmann , 2017). Lack of access to quality care as a determinant of health is mainly due to low insurance coverage, which ACA aimed to eliminate.
The current policies to address social determinants have been witnessed in the Medicaid-specific initiatives, Medicaid delivery system, and payment reforms. The Center for Medicare and Medicaid Innovations (CMMI), established in 2016 under ACA, has been focusing on identifying and addressing the health-related social needs of the beneficiaries ( Saunders & Hamelmann, 2017 ). The multi-payer delivery model and payment reforms also seek to decrease the cost and improve the quality of care, especially for the vulnerable. These policy changes initiated over time has been aiming to reduce social determinants of health and promote access to quality care.
Through the health care policy reforms, social determinants have greatly impacted health care. Reforms in the Medicaid programs have seen a shift away from quantity care and towards quality care. The need to improve access to quality care and to reduce costs has seen health care organizations and nurses shift more towards quality and efficiency. New health policies also require health care workers to do a social risk screening for vulnerable patients and provide patient-centered care. Patient-centered care seeks to promote health care outcomes and eliminate health disparity caused by income inequality and lack of access to quality care ( Daniel, Bornstein & Kane, 2018 ). These two social determinants have directly impacted health care delivery by initiating a shift towards high quality, less costly care. It has also led to a patient-centered and more community-based care to address community health care needs.
In conclusion, income inequality and lack of access to quality care are two major determinants that affect health outcomes. Throughout time, health care policy reforms have occurred, especially in the Medicaid programs, to address these social determinants of health. The expansion of insurance coverage to target low-income families has promoted access to quality care. Besides, a shift towards quality, low-cost care has dramatically increased the ability of the vulnerable groups to access care.
References
CDC. (2020). Social Determinants of Health | NCHHSTP | . Retrieved 29 May 2020, from https://www.cdc.gov/nchhstp/socialdeterminants/index.html.
Daniel, H., Bornstein, S. S., & Kane, G. C. (2018). Addressing social determinants to improve patient care and promote health equity: an American College of Physicians Position Paper. Annals of Internal Medicine , 168 (8), 577-578.
Koh, H. K., Bantham, A., Geller, A. C., Rukavina, M. A., Emmons, K. M., Yatsko, P., & Restuccia, R. (2020). Anchor Institutions: Best Practices to Address Social Needs and Social Determinants of Health. American Journal of Public Health , 110 (3), 309–316. https://doi-org.libraryresources.columbiasouthern.edu/10.2105/AJPH.2019.305472
Saunders, M., & Hamelmann, C. (2017). Key policies for addressing the social determinants of health and health inequities (Vol. 52). World Health Organization.
