Social Determinants of Health

May 2009

An individual's health is determined by many factors and the health care system is just one piece in a complex web. Outside the realm of the clinical health care setting, individuals' health is affected by the environment in which they live, their socioeconomic status, education, access to insurance and providers, and their personal behaviors. These factors are collectively known as social determinants, and play a key role in shaping a person's health and well-being. As the economy continues to remain uncertain and policymakers look to health reform, it is critical that social determinants be recognized for the unique role they play in shaping the health of every individual regardless of income, race, or location.

Insurance coverage is a critical social determinant of health and one that can radically affect a person's health. States regulate which types of insurance products are available for purchase by employers and individuals, so the types of products and plans available vary depending on the state in which you live. Medicaid and the Children's Health Insurance Program (CHIP) also vary by state; while a core set of individuals and services may be covered, many program details, including payment rates, vary. Consequently, the supply and access to providers also varies by locale. Provider access has been a large issue for the Medicaid program. Currently, HCFO has funded Thomas Buchmueller, Ph.D., from the University of Michigan to look at the effect of public insurance coverage and provider reimbursement on access to dental care for children. More information on this study can be found at grants/effect-public-insurance-coverage-and-provider-reimbursement-access-dental-care-evidence-schi-0.

Where you live matters to your health. Dartmouth researchers have shown that utilization of some services for Medicare beneficiaries varies by geographic area.1 Regardless of insurance coverage, in some cases an individual will have no guaranteed access to care due to insufficient provider supply. Dwindling primary care physicians coupled with increased demand for physician services could strain the availability of providers, regardless of payer source and type.2 
Socioeconomic status is a strong health determinant. Often, neighborhoods that are lacking basic necessities, such as grocery stores, are located in low income areas. Thus, vulnerable populations often do not have access to fresh fruits and vegetables, staples of a healthy diet.3 Low income neighborhoods often may lack sufficient resources to rectify these issues. Individuals living in these lower income neighborhoods often have worse health outcomes. A report by the Robert Wood Johnson Foundation details how poor adults are nearly five times more likely to be in poor or fair health compared with individuals in the highest-income brackets.4

In addition, when assessing an individual's propensity toward disease, education is also important. A report by the Robert Wood Johnson Foundation has shown that adults with lower levels of education have higher proportions of physical inactivity compared to higher educated individuals.5 This gap has persisted over time and does not appear to be narrowing.6 This same pattern is repeated when smoking rates and education are compared. In fact, in terms of cigarette smoking rates, the gap that exists between college graduates and those with lower levels of education appears to be widening.7

At the core of factors affecting health is personal behavior. Not smoking, exercising, eating a balanced diet, controlling stress, and getting enough sleep may be the most important components of good health. Some people are more activated to live a healthy lifestyle and remain in compliance with medical treatment. HCFO grantee Judith H. Hibbard, Dr.P.H., from the University of Oregon, has also looked at consumer activation in terms of consumer-driven health plans. The study examined whether or not enrollment in these plans increased consumer engagement by seeking information about health, cost, and quality. 8 HCFO grantees Penny Feldman, Ph.D., Visiting Nurse Service of New York, and Linda Gerber, Ph.D., Weill Cornell Medical College, are currently looking at how patient activation occurs, and under what circumstances in those who suffer from high rates of chronic illness. The findings from this project will hopefully provide recommendations for overcoming patient-related barriers to self-management. More information on this grant can be found at grants/promoting-readiness-and-interest-self-management.

As health reform takes shape in the coming months, it will be important to keep in mind the important role of social determinants of health. While many of the issues that affect health are systematically embedded in society, there are some individual characteristics that can be altered to promote healthier lifestyles. Better nutrition, physical activity, and not smoking can dramatically improve health outcomes. Given the systemic issues that then create barriers for people to engage in these healthy behaviors, it will become increasingly important to identify ways to improve education, reduce geographic variation, and strengthen neighborhoods. While health reform will look to create quality, affordable, and accessible health care, it is also important to remember the social determinants that lie outside the realm of the health system that in the end impact health. Understanding all the factors that influence health will help to improve health outcomes in the long run.

HCFO Sponsored Work on Insurance Coverage

Despite the complexities in understanding the social determinants of health, the HCFO program currently has several studies underway which will help to inform policymakers on how social determinants affect health and well-being. For other HCFO grants, see

Title: The Effect of Public Insurance Coverage and Provider Reimbursement on Access to Dental Care: Evidence from the SCHIP Expansion
Institution: University of Michigan
Principal Investigator: Thomas C. Buchmueller, Ph.D.
Grant Period: April 2009 - March 2011

The researchers will examine the role that public health insurance plays in improving access to dental care for poor and near-poor children. Specifically, they will study low-income children to assess how Medicaid/SCHIP eligibility generosity affects dental care utilization. They will investigate how changes in program features and market conditions affected the supply of dental care to the publicly insured, addressing the following research questions: 1) What is the effect of public insurance on the probability a child has an annual dental visit? What is the effect on the total number of visits per year? 2) How does the effect of public insurance on dental utilization vary with key program parameters? 3) How do changes in public dental insurance programs affect provider participation? 4) What was the public dental health insurance environment in the states prior to SCHIP, and how did it change as a result of SCHIP implementation? and 5) How did states change dental provider reimbursement rates with the implementation of SCHIP? The purpose of this project is to better understand the effects of public dental coverage in order to inform related Medicaid and SCHIP policymaking.

Title: Consequences of SCHIP for Household Well-Being
Institution: University of Michigan 
Principal Investigator: Helen Levy, Ph.D.
Grant Period: October 2008 - September 2009

The researchers will explore the consequences of State Children's Health Insurance Program (SCHIP) expansions, including "crowd out," the term used to describe the phenomenon of individuals dropping private health insurance coverage in response to expanded availability of public coverage. The researchers hypothesize that switching from private to public coverage reduces a family's out-of-pocket medical spending, freeing up more resources for other uses, making crowd-out a "windfall" not a "problem" for low-income families. They will address the following research questions: (1) How have expansions of SCHIP improved the material well-being of the low-income families the program is intended to assist, and (2) What categories of spending increase as a result of gaining eligibility for coverage? The objective of the proposed project is to reconsider the context for crowd-out and reframe the debate over SCHIP expansions with a renewed emphasis on the benefits rather than merely the costs of coverage expansions.

Title: Promoting Readiness and Interest in Self Management
Institution: Visiting Nurse Service of New York 
Principal Investigators: Penny H. Feldman, Ph.D./Linda M. Gerber, Ph.D.
Grant Period: July 2008 - September 2009

The researchers will investigate how patient activation occurs and under what circumstances in a historically under-represented population—black/African Americans—who suffer disproportionately high rates of chronic illness. Patient activation, or engaging patients in their care, can improve the quality of care and health outcomes for those living with chronic conditions. Specifically, the researchers will: 1) evaluate psycho-social and clinical/functional determinants that influence a change in patients' activation levels over time; 2) examine patients' perspectives on their involvement in their care; 3) investigate factors that may help or hinder home care nurses' promotion of self management and patient engagement; and 4) provide recommendations to improve clinician education and patient interventions. The objective of the proposed project, funded under a special topic solicitation on consumer activation, is to promote patient-centered care by identifying and providing recommendations to overcome patient-related barriers to self-management and to cultivate facilitators of clinician involvement in promoting patient self care.

Title: Local Public Health Capacities to Address the Needs of Culturally and Linguistically Diverse Populations
Institution: Social and Scientific Systems, Inc.
Principal Investigator: Claudia Schur, Ph.D.
Grant Period: May 2008 - December 2009

The researchers will examine the public health needs of culturally and linguistically diverse populations. Specifically, they will develop detailed community multicultural profiles describing the cultural and linguistic diversity of populations served by local health departments (LHDs). They will then use these profiles to analyze the relationships between population characteristics and existing public health capacity and to identify and survey select communities for more in-depth information about serving these populations. They will seek answers to the following research questions: 1) How do jurisdictions with LHDs compare in terms of the composition of the population served? To what extent do communities include substantial numbers of racial/ethnic minorities, immigrants, and/or persons who speak a language other than English? 2) Does the structure and capacities of LHDs vary with respect to the multicultural profile of the populations they serve? How do LHD resources and activities correspond to local community characteristics? 3) What are the specific strategies that LHDs engage in to meet the needs of diverse populations? What types of strategies appear to be most successful? Are community partnerships used either for training purposes or for the delivery of culturally appropriate services? 4) What obstacles appear to be most difficult to overcome in serving different types of population subgroups? Which types of services are most difficult to deliver? What characteristics or combinations of characteristics of communities and LHDs create the most substantial obstacles? The objective of this project is to develop policy recommendations for implementation of promising strategies to better serve diverse populations.

Title: Medicare Spending, Disparities, and Returns to Healthy Behaviors
Institution: University of Maryland, Baltimore
Principal Investigator: Bruce C. Stuart, Ph.D.
Grant Period: March 2008 - August 2009

The researchers will examine persistently low cost Medicare beneficiaries and determine the extent to which health behavior, preventive services, race and socioeconomic status (SES) appear to be related to low spending. Specifically, the researchers will (1) estimate cost savings in traditional Medicare spending associated with persistently good health behavior and preventive measures; (2) identify population characteristics that can be used to optimally target preventive interventions; and (3) develop simulation models to show how selectively reducing beneficiary cost sharing for primary and secondary preventive measures can achieve significant costs offsets in reduced spending on traditional Medicare services – this mechanism is referred to as “value-based insurance design.” The objective of the proposed project is to identify which disease states and beneficiary segments show the greatest promise for improved compliance and persistency in use of preventive therapies.

Title: Incorporating Disparities into State Strategies to Monitor and Improve Health Status
Institution: Mathematica Policy Research Inc.
Principal Investigator: Marsha Gold, Sc.D.
Grant Period: January 2007 - March 2008

The researchers will examine state capacity to develop the 10 leading indicators defined in Healthy People 2010 overall and by geographic group. In particular, they will study: 1) the strengths and weaknesses of data available within states to adequately assess the health of a population that includes diverse groups; and 2) the organizational, political, and other forces that promote or impede use of such data to intervene in ways that improve the health of the state's population. The three part study includes: 1) an inventory of state practices with respect to available data on leading indicators; 2) case studies of four states to learn about how the indicators and disparities in the indicators across subgroups are viewed in developing initiatives to improve public health; and 3) a dissemination plan for translating information in ways that would be useful to diverse audiences. The objective of this project is to further the vision articulated in HealthyPeople 2010, setting health goals that explicitly link overall improvements in public health to reduced disparities in health status across diverse subgroups of the population.

1 Fischer, E. et al. “Health Care Quality, Spending, and Outcomes: More Isn't Always Better.”  A Dartmouth Atlas Project Topic Brief, February 27, 2009. Also see
2 Nicholson, S. “Healthcare Workforce Supply.” Forthcoming paper, January 2009.
3 California Newsreel. Unnatural Causes Documentary, 2008.
4 Robert Wood Johnson Foundation. Overcoming Obstacles to Health. Commission to Build a Healthier America, February 2008.
5 Ibid.
6 Ibid.