Part IV: Proposes Certain Additional Legal Mechanisms
HP 2020 includes for the first time an explicit focus on the social determinants of health as one of the Project's four overarching goals and as a distinct topic with its own objectives. As the precise objectives for the social determinants of health have not yet been determined, suggestions for incorporation of specific coercive legal mechanisms in the objectives may be useful to fulfilling the broader goal of achieving health equity, given the extensive overlap between the social determinants of health and health disparities.
HP 2020's broad goal regarding the social determinants of health is to “identify ways to create social and physical environments that promote good health for all” across diverse sectors, including education, childcare, housing, business, law, media, community planning, transportation, and agriculture. As many scholars have observed, no amount of health care can provide population health in the absence of measures to remedy disparities in the social determinants of health. Examples of non-health specific factors that influence health include “safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.”
Two interrelated approaches show particular promise in incorporating a broader focus on the social determinants of health in law and policymaking: a “health in all polices” (HiAP) paradigm and the use of health impact assessments to guide policy decisions. Under an HiAP approach, all sectors of society consider the health implications of their policy decisions, including benefits, harms, and health-related costs. Kickbusch and Buckett explain HiAP as involving “public service agencies working across portfolio boundaries to achieve a shared goal and an integrated government response to particular issues.” However, as the IOM LPH Report observes, HiAP, taken to its logical conclusion, must include stakeholders in addition to government, particularly in the private sector, whose actions have a significant effect on health and on health equity. HP 2020 refers briefly to an HiAP approach as an “emerging strategy” to address the social determinants of health, but does not elaborate. Encouragingly, however, the ACA created a National Prevention, Health Promotion, and Public Health Council, comprised of seventeen heads of federal executive departments, agencies, and offices and charged with developing a national prevention strategy in which all government sectors work together to improve population health.
Use of HiAP as a framework for policy decisions could dramatically improve health equity by addressing the social determinants of health. For example, zoning restrictions for fast food restaurants would be considered not just in view of their environmental and commercial impact, but also in regard to health effects and how those effects are distributed across population groups. However, the relative coerciveness of an HiAP strategy could significantly impact its ultimate effect on disparities reduction. The IOM offers a view of the various ways in which an HiAP approach could operate, with one end of the spectrum being that HiAP should be seen as, at minimum, a “manifestation of the precautionary principle: first, do no harm to health through policies or laws enacted in other sectors of government.” However, this approach speaks to population health, not to relative effect on disparities. Nonetheless, HiAP could also be used to require maximization of positive effects of non-health policies, and, even more directly, to address the social determinants of health by crafting relevant non-health policy with the goal of improving population health outcomes and health equity. The challenge will be in the details, particularly the degree to which various agencies and private interests are required to assess health effects of their projects, and to what extent projects will be required to be modified in view of projected health effects.
Projecting and measuring health effects, particularly those of legal interventions both before and after implementation, present difficulties. However, in that regard, “health impact assessments” (HIAs) are a promising starting point. The Health Impact Project defines an HIA as:
[A] systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program or project on the health of a population and the distribution of those effects within the population.
In addition, an HIA “provides recommendations on monitoring and managing those effects.” Of course, as the IOM observes, conducting an HIA would require time and resources, and not every policy or intervention will require a full-scale HIA prior to implementation. Thus, to the extent HIAs are required by law, the law will have to set a minimum impact threshold of some sort in order to avoid inflicting needless administrative burdens. However, notwithstanding the procedural difficulties, HP 2020's final objectives for the social determinants of health should include a recommendation for HIAs in appropriate circumstances.
A similar but slightly different proposal for quantifying health effects of both health and non-health policies is the use of a “health disparities index” (HDI) to measure over time how various policies impact disparities. The idea is somewhat analogous to the Gini coefficient and other statistical tools developed as a means of measuring the relative level of income inequality within societies. The HDI authors (Webb et al.) recently conducted a quantitative analysis with three goals:
(1) to establish an index depicting variations in U.S. racial health disparities;
(2) to evaluate the association between this health disparities index (HDI) and known social determinants of health; and
(3) to use statistical correlations to help guide minority health legislative interventions at the state and federal levels.
The authors examined racial and ethnic disparities in each state in six priority areas: cancer screening and management, cardiovascular disease, diabetes, HIV/AIDS, immunizations, and infant mortality, and evaluated raw disparities in mortality rates across the six categories in consideration with certain known social determinants of health--income and social status, education and literacy, health services, culture, and social environments. The authors then ranked the states with sufficient data (thirty-two of fifty), finding that certain states had much lower HDI values than others. Moreover, and perhaps unsurprisingly given what is known about the social determinants of health, the authors found the HDI was positively correlated to racial disparities in median household income, state black population, and Medicaid eligibility scores. Particularly interesting in light of current health care debates, the authors found a negative correlation between HDI scores and state health spending, demonstrating that more spending on health without strategic efforts to address disparities will not result in better health or a narrowing of disparities. The authors consider that the HDI can and should be used as a mechanism to measure state progress in reducing health disparities among racial and ethnic groups. Moreover, the statistical methods employed would allow for the expansion of this methodology to consider health disparities among other classifications, including gender, income, educational status, etc., which would enable precise targeting of policies and laws toward addressing the social determinants of health.
Governments can use tools like the HDI to create legal mechanisms that will assist the effort to reduce health disparities--for example, by creating financial incentives for states and private sector entities to reduce disparities that are drivers of health inequity. In addition, more precise measurements and comparisons among the states regarding health disparities can enable governments to more directly target those variables that seem to be driving the disparities. For example, knowing that Medicaid eligibility positively correlates with racial health disparities would allow governments to make targeted changes to eligibility requirements (and barriers to enrollment) and measure the correlation between those changes and changes in the HDI. Similarly, the lack of correlation between health care spending and HDI rebuts what is already known but often not internalized--that good health is driven only in relatively small part by health care spending and, importantly, that more spending does not necessarily correlate with better health outcomes.
The use of a HiAP approach, including the use of HIAs and the HDI, would be a powerful legal mechanism for furthering the broad disparities reduction and social determinants of health goals of HP 2020. Mandatory use of these tools in certain circumstances is consistent with the principles of health equity, which demands the use of coercive legal mechanisms in instances where voluntary efforts would worsen disparities. Although HP 2020 has not yet specifically urged the adoption of requirements for use of HIAs and/or the HDI, it has the opportunity to do so as it issues its specific objectives regarding the social determinants of health. Much as HP 2020 advocates for legislation in areas of children's access to unhealthy foods at school and in tobacco control, both of which would further health equity, so too should it be advocating for coercive legal mechanisms in other areas where disparities are significant and legal mechanisms are likely to be effective.
