Park and colleagues,1 in an article published in this edition of Academic Medicine, strongly advocate that “given the persistence of health inequities . . . [academic health centers (AHCs)] have a responsibility to partner with communities in addressing these injustices.” They also emphasize the critical role that social, economic, and geographic factors have on the health of populations. The overwhelming importance of social determinants of health (SDOH) is indisputable.2 Who bears the primary responsibility for addressing these SDOH is a fundamental and critical issue. The responsibilities and capabilities of health care providers, especially AHCs, in addressing these issues must be thoughtfully considered. I would argue that AHCs need to be cognizant of, educate about, and participate in carefully structured attempts to address SDOH and the inequalities and inequities of health that they create. I would also posit that for multiple reasons, AHCs in general cannot assume or be assigned the principal role in addressing these issues.
The impact of SDOH is apparent throughout the United States. Communities of color and certain ethnic populations, such as Native Americans and Eskimos, are disproportionately affected by SDOH. In addition, Appalachia, which is overwhelmingly white, suffers some of the highest rates of poverty in the United States with its associated issues of food inadequacy, housing deficiency, and lack of educational attainment. Not only do the people of this region suffer some of the highest incidences of heart disease, stroke, and cancer in this country but they also have recently seen a deterioration in the ultimate and definitive measure of the health of a community—life expectancy in Appalachia is decreasing!3 I suspect that the ravages of poverty do not respect any racial or ethnic lines.
While the Affordable Care Act extended insurance coverage to a large segment of previously uninsured individuals, the number of underinsured may have concomitantly increased because of the emergence of high-deductible health plans and limited catastrophic health insurance products, which are a response to the rapidly rising cost of health insurance and are an attempt to control health care costs. These plans affect access to care for all involved but especially for low-income individuals and individuals with chronic illnesses.4 I would personally argue that such plans have substantially fueled the frenzied concern about health care insecurity in our country today. Surely, a logical first step in addressing health inequalities and inequities should be universal (or near-universal), appropriately affordable, and comprehensive health care coverage.
Who should bear fundamental and ultimate responsibility for addressing SDOH? What has been tried? What is the role of health care providers, especially AHCs? Countries that have had more success than the United States in addressing the health of their people and therefore addressing SDOH have done so by making health and underlying SDOH a fundamental national agenda and priority. Although these countries spend considerably less than the United States on health care, they spend substantially more on other social programs that impact health.5,6 These countries have also made near-universal, comprehensive health care a given.
The United States has been unsuccessful in addressing these deep-rooted socioeconomic and cultural issues at the core of SDOH. That does not mean that the country has not tried. I recall a picture of President Lyndon B. Johnson sitting on a porch in Inez, Kentucky, deep in Appalachia, launching his “War on Poverty.” Subsequent efforts such as food stamp programs, the Children’s Health Insurance Program, and the No Child Left Behind initiative are ongoing efforts to address SDOH. Clearly, I would argue that the roots of SDOH are so deep that only the federal and state governments can muster the resources to adequately address them. Addressing these issues will require an enormous commitment and will have to be recognized as one of, if not the primary, national priority.
Without question, organized, large health care providers, including AHCs, have a significant role to play in addressing SDOH and the ultimate health of the population, albeit necessarily a somewhat limited one. Health care providers, under the present, predominant fee-for-service reimbursement system, get paid for health care services and not for improving or maintaining the health of a population. Even under many of the so-called “managed health care plans,” providers still get paid by discounted fee-for-service. Some providers, who function under capitation or have their own insurance products, such as Kaiser Permanente, Geisinger Health System, Intermountain Healthcare, and others, have responsibility for well-defined populations and, therefore, have more of a financial incentive for improving and maintaining the health of the people they serve to control health care expenditures.
Even under capitation, however, there are reasons why providers may be hesitant to try to address the long-term issues of SDOH. Individuals change insurance plans and carriers too frequently for insurers to see the long-term benefits of addressing SDOH or even some preventive measures.7 Health care providers will not appropriately focus on health rather than health care until they get paid to do so. This is especially true in turbulent times when health care reimbursement is changing with an emphasis on driving down costs rather than improving comprehensive care. This era of health care reform makes many providers feel vulnerable. Health care reform efforts should explore reimbursement systems that focus providers more on health and not just health care.
AHCs, nevertheless, certainly have some role in defining, understanding, educating about, and addressing SDOH and the health of the country; however, as Park and colleagues point out, AHCs are a heterogeneous group, and, therefore, their efforts and impact will vary by type of organization. A significant number of AHCs—50 to 75—are or strive to be research-intensive referral centers. These centers are usually characterized by advanced subspecialty programs in cancer, cardiovascular, neurologic, and pediatric subspecialties; transplantation and organ failure; and level 1 trauma services. These AHCs must often partner with a large number of providers covering a substantial geography and population base to attract sufficient referrals to justify and maintain these advanced subspecialty programs.8 These research-intensive referral AHCs may provide some limited geographic primary care, but that is often not viewed as their core mission or mandate. Through affiliated colleges of public health or departments of population or family medicine, they can and must educate and sensitize learners and faculty about inequalities and inequities in health and the critical role of SDOH. They can bring intellectual capital to research about causes and possible approaches to addressing these issues. They can also develop creative demonstration projects that can attempt to ameliorate health inequalities and address SDOH for a defined population, often with outside research and philanthropic support; however, they cannot take ultimate responsibility for addressing this national dilemma.
Other AHCs are sophisticated, advanced community providers that must compete with other community providers to maintain financial viability. This is a tough and highly competitive business space, and these institutions must focus on and invest in their core services to secure adequate patient volumes to stay fiscally secure, especially in turbulent times of health care reform. Some of these AHCs, like other large community providers, are delving into accountable health care organizations (ACOs), sometimes even assuming upside and downside risk reimbursement. ACOs that assume risk may have more of a reason to focus on the health and not just the health care of the populations that they are responsible for, especially if they are responsible for these populations for a prolonged period of time rather than transiently.
Other AHCs are predominantly safety net providers who often shoulder responsibility for geographically defined, underserved populations. By definition, these safety net providers predominantly serve populations that suffer inequalities of SDOH. They, too, under capitated systems of reimbursement, might be more incentivized to focus on SDOH, such as inadequate housing and food deficiencies to improve the health of the population they serve, thereby decreasing the need for costly health care interventions.
Certainly there are some hybrid models. Cincinnati Children’s Hospital Medical Center is a nationally recognized, research-intensive, referral pediatric academic medical center that is located in the midst of a substantially underserved community. Because of the commitment to their host community, they have accepted some long-term responsibility for the health and well-being of the children within that community. They are trying to address some of the SDOH that affect this pediatric population. As an example, the ability to read at a third-grade level by third grade is a strong predictor of academic success. Clearly, academic success is often fundamental to escaping poverty. Cincinnati Children’s, working with the Cincinnati Board of Education, has developed a reading program to achieve the stated goal of third-grade reading proficiency for every third grader.9 They have realized some notable success. Cincinnati Children’s has invested substantial corporate resources and obtained a variety of grants to fund these programs; however, it is the reimbursement system—capitation for pediatric patients through Medicaid—and the long-term relationship with Medicaid that gives this program economic stability and viability.
In conclusion, the scourge of the inequities and inequalities of health and the underlying SDOH among different populations in the United States must be addressed. Providing affordable and comprehensive health care coverage for all is a necessary first step. AHCs of all types must participate in addressing this national crisis by educating health care providers and the public about the issues, researching causes and developing new approaches to address these issues, and even, in some appropriate circumstances, taking responsibility for directly attacking these issues in well-defined, limited populations. Health care providers and especially AHCs cannot take ultimate responsibility for issues beyond their scope and financial means. Addressing poverty and the concomitant health care disparities and underlying SDOH must be a national imperative involving all parties—federal, state, and local governments; community agencies; and health care providers, both AHCs and nonacademic providers. The resources necessary to make substantial impact will be immense, but the benefits in the quality of life and the productivity of people will be worth it.
The author gratefully acknowledges Ellen Karpf for her editorial support.
1. Park B, Frank B, Likumahuwa-Ackman S, et al. Health equity and the tripartite mission: Moving from academic health centers to academic–community health systems. Acad Med. 2019;94:1276–1282.
2. National Research Council and Institute of Medicine of the National Academies. U.S. Health in International Perspective: Shorter Lives, Poorer Health. 2013.Washington, DC: National Academies Press.
3. Singh GK, Kogan MD, Slifkin RT. Widening disparities in infant mortality and life expectancy between Appalachia and the rest of the United States, 1990–2013. Health Aff (Millwood). 2017;36:1423–1432.
7. Chang CF, Waters TM, Mirvis DM. The economics of prevention in a post-managed-care environment. Appl Health Econ Health Policy. 2004;3:67–70.
8. Edwards RL, Lofgren RP, Birdwhistell MD, Zembrodt JW, Karpf M. Challenges of becoming a regional referral system: The University of Kentucky as a case study. Acad Med. 2014;89:224–229.
9. Fisher M; CEO and president, Cincinnati Children’s Hospital. Personal communication with M. Karpf, May 31, 2019.