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(As explained on the podcast home page, this is the last of eight interviews concerning federal healthcare policy reform.  This discussion is with UCSF's Dr. Paula Braveman and Dr. Laura Gottlieb and was conducted in early January.   As you will hear this podcast like all others is introduced by ProMedica's CEO,  Randy Oostra.  This series was produced in an effort to interest or persuade federal healthcare officials to pursue substantive healthcare policy reform.)

The US ranks last or near last in healthcare access, affordability and outcomes and this holds true even for white, educated, insured and upper income Americans.  What largely explains this high spending - poor health paradox, or our health disadvantage, are the social determinants of health: generally defined as education, economic circumstances, food security, housing and social, environmental and related exposures.  Where people live, work and socialize determines approximately 60% of their health status whereas medical care accounts for approximately 10%.  Despite the essential role social determinants play, the US has the lowest ratio of health care spending to social services spending in the OECD.  For every dollar spent on HC, the US spends one dollar on social services.  Across the remaining 36 OECD countries, the ratio averages $1 on healthcare to $2.50 on social services.  As for the health care industry’s investment in social determinants, a study published in February 2020 found that among 57 health systems that include 957 hospitals, or one-sixth of total US hospitals, researchers found that they had collectively invested only $2.5 billion in social determinants programming over a two-year period, or just 4% of their overall community benefit spending.      

This interview begins by Dr. Braveman and Dr. Gottlieb providing general comments about social determinants.  The interview progresses to their commenting on the ill  health effects of economic inequality due in part to economic inequality, in turn, causing/creating a profound lack of social solidarity or social cohesion, exacerbating racism and undermining our ability to invest in the social determinants or social service spending, discuss related for-profit, industry silos and misaligned incentive problems, address the success of pay for performance programming to address social determinants moreover under the Medicaid program, the extent to which there is for providers a return on investment and the problem in expecting and/or calculating a return, how social determinant spending is prioritized, i.e., the importance of making higher level community level investments, not just spending on immediate, e.g., transportation problems, and identifying a percent of spending on social determinants and discuss recommendations on how to increase social spending in Medicaid and Medicare.          

Paula Braveman, MD, MPH is Professor of Family and Community Medicine and Director of the Center on Social Disparities in Health at the University of California, San Francisco (UCSF).  For more than 25 years, Dr. Braveman has studied and published extensively on health equity and the social determinants of health, and has worked to bring attention to these issues in the U.S. and internationally.  Her research has focused on measuring, documenting, understanding, and addressing socioeconomic and racial/ethnic disparities, particularly in maternal and infant health.  During the 1990s she collaborated with World Health Organization staff in Geneva to develop a global initiative on equity in health and health care.  She has been the Research Director for a national commission on the social determinants of health in the U.S. supported by the Robert Wood Johnson Foundation.  Throughout her career, she has collaborated with local, state, federal, and international h