Two recently released reports on the status of U.S. health spending and healthcare quality and equity describe an all-too-familiar picture: U.S. healthcare spending has continued to increase; health disparities have persisted or even widened; and the majority of Americans live in areas where health professional shortages threaten their access to much needed preventive care. The National Healthcare Quality and Disparities Report showed that the U.S. experienced a much larger drop in life expectancy between 2018 and 2020 than other high-income countries, with Hispanic and non-Hispanic Black populations showing the greatest decreases. This drop is so pronounced and concerning that it has a name: the U.S. health disadvantage. This disadvantage persisted despite the fact that the U.S. spent a staggering 18.3% of its economy on healthcare — equivalent to $4.3 trillion or $12,914 per person.
Perhaps less familiar than these trends were sections in both reports emphasizing the urgent need to focus on the “social determinants of health,” those critical non-medical/non-clinical factors that contribute to population health. The National Healthcare Quality and Disparities Report devoted eight pages to the social determinants of health; while in previous reports from 2017 and 2018, the phrase was mentioned only twice.
These reports make glaringly clear the need to rethink our nation’s economy and how we allocate healthcare funding if we hope to reverse the U.S. health disadvantage. Given the increased attention toward social determinants of health, now is the time for political action aligning policies with evidence by investing more in the social determinants of health and less on “sick care.”
We’ve known for a long time that provision of healthcare contributes only about 20% to health, while social determinants of health contribute far more (some 50% of overall health), but our policies have been fundamentally misaligned with this evidence. For instance, the National Health Expenditures 2021 Report found that more than a third of every healthcare dollar went to hospital care in 2021, just as it has for the past 3 decades. Most of that money went to tertiary care, often dubbed “sick care,” provided in hospital settings. Far less money went toward prevention and the social determinants of health. For example, in 2019, just 5-7% of total health expenditures went to primary care and 2.8% to “government public health activities.” Per capita, the U.S. spends roughly 100 times more on hospital care than on public health ($3,639 vs $326 per year).
Existing policy mechanisms can help reverse the imbalance between the social and clinical determinants of health. For instance, a decades-old Federal requirement for nonprofit hospitals was designed to do just that: the Community Benefit Standard. This standard requires nonprofit hospitals — which represent 49% of U.S. hospitals — to provide benefits beyond medical care to the larger community in order to retain their tax-exempt status, currently valued at $24.6 billion. Historically, most nonprofit hospitals provided those benefits through charity medical care, even though such care only partially fulfills their responsibility to improve the conditions of the communities they serve. To address this deficiency, new requirements implemented in 2014 sought to nudge hospitals to better meet the non-medical/non-clinical needs of their communities. As the National Academy of Medicine noted, hospital community benefits “could serve as basis of linkages between public health and clinical care.” Unfortunately, to date, most nonprofits hospitals have taken little action to meet these new requirements.
My research suggests that hospital collaborations with local health departments could be particularly effective in reallocating hospital resources to improve population health. In my studies, hospital/health department collaborations led to greater spending on broader health areas, and improved population health, specifically in regard to the substance use epidemic. I also found that hospital/health department collaboration is not the norm, and is more likely to happen if policy requires such collaborations, as was the case in New York, which was the first state to mandate such collaborations. Ohio and Oregon have also implemented similar requirements recently, although it remains to be seen whether their new policies will steer hospitals to spend more on prevention and social factors.
Meanwhile, several innovative national demonstrations have helped nudge the healthcare sector towards a “value over volume” approach, including the provision of preventive services to patients, thus shifting care away from hospitals to non-acute care community settings. Many of these polices are anchored on alternative payment models that give healthcare providers more flexibility in redirecting some funding towards community partners to improve community prevention efforts.
The reallocation of resources from hospitals towards primary care, prevention, and the social determinants of health is complex. Throughout the pandemic, healthcare workers, many of whom work in hospitals, were fundamentally important in saving the lives of thousands, if not millions of people worldwide. Additionally, with 9% of the U.S. population lacking health insurance and another 34% underinsured or with coverage gaps, safety-net hospitals still play a major role in providing charity care to these populations. However, research has consistently shown that social factors and prevention could reduce this burden by keeping people healthier. We need smarter policies that incentivize hospitals and public health organizations to work together, prioritizing prevention and the social determinants of health. Only through better balancing our resources can we transform the U.S. health disadvantage into the advantage that our citizens deserve.
Tatiane Santos, PhD, MPH, is an assistant professor of health policy at Tulane University School of Public Health and Tropical Medicine, and a public voices fellow of AcademyHealth in partnership with The OpEd Project.
Source: MedicalNewsToday.com
