Social determinants of health affect all of us, though some more than others. There are financial impacts of SDOH on all, but we also carry a moral obligation for health equity amongst all, regardless of zip code.
Social determinants of health (SDOH) are the environmental surroundings that affect people’s health in upstream and downstream ways. Examples of this include access to safe housing, food and financial resources, educational background, or the support of a person’s community. Addressing these social determinants of health is shown to have a larger impact on health outcomes than genetics or access to healthcare.
Why should we care about SDOH? SDOH impact everyone’s lives, some more inequitably than others. Not only is there a moral equity component to SDOH, but also, everyone shares the cost burden.
Social determinants of health impact health equity, working in a vicious cycle where they already impact vulnerable groups, while worsening the health of these populations at inequitable rates. Since the environment directly drives health, the dynamic surroundings people live in influence health in different ways. Just as someone in America experiences different circumstances than someone in Mexico, a person in Pennsylvania may have an entirely different suite of social determinants influencing their lives than someone in Oregon. These differences even go down to zip code.
While health should not be predetermined by the ZIP code in which you live, in 2016, a joint report issued by the Virginia Commonwealth University, the Center on Society and Health, and the Robert Wood Johnson Foundation reported as much as a 20-year life expectancy difference between Philadelphia zip codes less than 5 miles apart.
Racism itself is a social determinant of health, and by many is considered the underlying structural determinant of health for all other determinants of health. Racism is associated with worse mental and physical health, and a key driver of other determinants such as housing access, financial security, and neighborhood safety. In 2019, 18.1% of Black Americans were living in poverty, facing housing segregation, higher rates of homelessness, and a higher likelihood of living in environments with environmental health hazards. Other groups disproportionately affected by social determinants of health include racial and ethnic minority groups, disabled individuals, and individuals belonging to the LGBTQIA+ community. This is particularly evident in Philadelphia as well. Let’s take a deeper dive into the five elements of SDOH within our local community and their associated health disparities.
Education Access & Quality
Access to high quality education enables individuals' financial growth, opening doors to economic opportunities, thereby better health outcomes. In Philadelphia, pre-school enrollment dropped by 9% in 2023, and while in parts of Center City, over 75% of adults hold college degrees, that rate is below 25% in certain zip codes in North and Southwest Philadelphia.
Health Care & Quality
Access to affordable and quality healthcare services is a major driver of health and when this access is limited, it may lead to increased rates of late-stage cancer, later detection of chronic illness, and poorer chronic illness management. Clear racial disparities are evident in access to healthcare in Philadelphia, with the odds of an individual being in a low-healthcare access area twenty-eight times greater for areas with a high proportion of Black Americans.
Neighborhood & Built Environment
Housing costs, green space for exercise, proximity to grocery stores, and public transportation are SDOH heavily driven by zip code, within Philadelphia and beyond. Over the past 10 years, home prices in Philadelphia increased by 88%, with some of the most significant increases occurring in the North Philadelphia area. Additionally, inequities in home ownership are apparent, with Hispanic and Black Philadelphians’ home ownership rates ranging from 7-8% below the city averages.
Social & Community Context
Just as safe, supportive neighborhoods are health promoting, those with racism, bullying, or crime can worsen health outcomes. These community contexts vary across the city. Overall, Philadelphia has seen historically high levels of homicides, violent crimes, and shootings in the past several years, with the percentages aligning with police districts. For example, while Southwest Philadelphia experienced a 24% drop in violent crimes, Roxborough saw a 32% increase.
Economic Stability
Philadelphia is a city particularly struck by economic instability, ranked as having the highest poverty rate out of the 10 most populous cities in the United States. This poverty is not blanket though, with the wealthiest neighborhoods in the area having a median income $100,000 more than the poorest neighborhoods. These numbers display a harrowing inequity within the city, which has direct impacts on health outcomes, demonstrating how SDOH are rooted in deep legacies of segregation and inequality, necessitating complex and cross-sector solutions.
In turn, these social determinants of health, and their inequitable burden on the American people, drive healthcare costs. Several cost analysis studies have been conducted to assess the future financial impact on the healthcare system of individuals who fall within high-risk categories regarding social determinants of health. For example, a cohort study in Washington D.C. found that when stratified by SDOH risk classes, future healthcare spending was significantly higher in the high-risk classes, with $2,713 for the low-risk class as compared to $17,710 for the highest risk class.
It’s not just the financial burden on the healthcare system that is a concern, poor community health affects everyone. Unaddressed mental health inequities cost $477.5 billion (about $1,500 per person in the US) annually, and if no work is done to address these inequities, driven by SDOH, this could cost a total of $14 trillion (about $43,000 per person in the US).
Food insecurity, driven by SDOH like poverty, lack of transportation, and unemployment, also is both a concerning, and expensive, issue. Feeding America found that food insecurity adds $53 billion dollars per year to the country’s healthcare costs, due to its effects on chronic illness, hospitalizations, and emergency room visits. For families, it costs an extra $2,500 in healthcare costs.
SDOH have a high cost, both to individual health, and in the larger scheme of healthcare spending and the economy. Though by investing our time, energy, and attention towards addressing SDOH, we can improve health equity and reduce spending. To start? An increase in funding dedicated to SDOH interventions. A recent study found that the implementation of evidence-based interventions targeting SDOH that would improve health outcomes would cost $60, per patient, per month. These investments are not modest, though they have major cost-saving potential in the long term, and evidence overwhelmingly shows it is imperative to address SDOH to provide better healthcare and lower associated costs.
Even the federal government is getting on board with these changes. The Centers for Medicare and Medicaid Services (CMS) now mandates that all healthcare payers and providers move toward a Value Based Healthcare model, which includes addressing SDOH to improve patient outcomes both inside and outside the physician’s office. With this expanded framework, each state is now addressing this with their payers and providers, which are starting innovative initiatives, like community care hubs to address health-related social needs (HRSN) like food and transportation. This federal alignment now holding healthcare accountable for addressing whole-person healthcare means the wave of SDOH work is coming, as well as the funding to make it possible. With that in mind, we need to be ready, which includes innovatively coming together to join healthcare providers with community organizations, creating the infrastructure to facilitate comprehensive care.
To cite: Hygieia Consulting. (2024) Why Should We Care About Social Determinants of Health?. hygieia.llc
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