Research supporting the Biden administration’s favored “social determinants of health” theory of “health equity” is flimsy, according to a study from the Manhattan Institute.
The doctrine is being pushed through Medicaid. In February, Vox reported that six states will be part of a pilot program providing six months of rental assistance to Medicaid enrollees. On May 15, the Centers for Disease Control and Prevention posted an article on “Social Determinants of Health,” on the CDC website. On July 1, KFF released a report titled “Medicaid Efforts to Address Racial Health Disparities.”
White House Playbook
A November 2023 White House policy guide, titled “The U.S. Playbook to Address Social Determinants of Health,” made the case for government spending to improve Americans’ health by addressing “social circumstances and related environmental hazards” pertinent to health outcomes.
The guide argues that poor Americans and groups suffering from social disparities are more likely to have chronic diseases and disabilities, and other adverse health situations, such as exposure to pollution or hazardous waste.
The logic of the guide, backed up by various studies, is that public health can be improved by improvements in social conditions such as housing, early childhood education, support services to homeless people, and nutrition.
Shoddy Scholarship
Most of the research backing the administration’s claims about social determinants of health (SDOH) is substandard and inappropriately confuses causation and correlation, finds a Manhattan Institute report by Senior Fellow Chris Pope, and published on July 11.
Pope found that randomized controlled trials reveal SDOH expenditures to “have weak effects on health and few offsetting savings.”
In addition to being tainted by political advocacy, SDOH research is subject to financial conflicts of interest and basic logical errors, Pope told Health Care News.
“The main problem with most studies is they take correlation to mean causation and fail to eliminate possible confounding factors,” said Pope. “For instance, poorer people are sicker, but poor people also smoke more. The correlation between income and health does not prove whether the poor are sicker due to lack of money or higher rates of smoking.”
Furthermore, SDOH spending is tied to financial conflicts of interest in more ways than one. “Private entities, such as insurers, are nudged to undertake SDOH expenditures by government subsidies, taxes, and regulations,” said Pope.
Carrots for States
States are also incentivized to fall in line. “States can get $1 to $3 in federal funding for every $1 they spend on Medicaid,” said Pope. “So, by classifying spending on social services as influencing health care, they can claim Medicaid matching funds from the federal government.”
In an op-ed for The Wall Street Journal, Pope wrote that reclassifying social service funding as health care funding gives states, nonprofits, and policy advocates access to the “much larger pool of federal funding that is allocated to healthcare.”
Additionally, the mechanism for SDOH spending is less accountable than typical social programs.
“We have dedicated social welfare programs and an appropriations process for them,” wrote Pope. “Steering funds through the healthcare system certainly reduces accountability.”
Illogical, Preconceived Ideas
“SDOH tends to place the real need for improvements in health measures (such as obesity, heart disease, substance abuse disorder, etc.) within subjective preconceptions about race, age, religion, and familial status,” said Matt Dean, senior fellow for health care policy outreach at The Heartland Institute, which publishes Health Care News. “Many of the measurements buried within the conclusions are themselves biased.”
Dean says the Biden administration guide makes logical leaps to argue that disparities lead to poor health outcomes.
“Our betters determine that if it can be shown that people who are actively engaged with government are healthier, then the government needs to step in to help (some) people vote to improve their health,” said Dean. “Of course, it begs the question of ‘who needs more help voting?’”
Dean agrees with Pope that SDOH is boosted by financial interests.
“The medical economy tends to bill for what gets paid for,” said Dean. “Once states began measuring outcomes that showed correlation for SDOH, it didn’t take long for payment models to be developed to pay for outcomes along subjectively drawn SDOH lines.”
Camouflages Social Engineering
Associating unrelated programs with SDOH allows politicians to access funding for programs that would not be approved on their own, says Dean.
“Health care is a $5 trillion source of funding for everything from housing to get-out-the-vote,” Dean said. “The Green New Deal could not be passed with appropriations on its own, but if Medicaid starts paying for green roofs, solar panels, and electric buses, the Green New Deal is funded. But there might not be a pacemaker for you when you need it.”
Value-Based Purchasing Models
One solution is to change current payment models for health care, which can be manipulated, says Dean.
“Value-based purchasing models promote some providers by scoring them higher for whatever metric is chosen,” said Dean. “If doctors primarily see Medicaid patients, they will be (as a group) sicker and more complex (expensive) than their fellow patients in the individual insurance market.”
Dean added, “The more subjective the payment model, the more the measurement and associated reimbursements will be tweakable for the purposes of remuneration.”
Harry Painter (harry@harrypainter.com) writes from Oklahoma.
Internet Info:
Chris Pope, “Is Everything Health Care? The Overblown Social Determinants of Health,” Manhattan Institute, issue brief, July 11, 2024: https://manhattan.institute/article/the-overblown-social-determinants-of-health
“The U.S. Playbook to Address Social Determinants of Health,” The White House, November 2023: https://www.whitehouse.gov/wp-content/uploads/2023/11/SDOH-Playbook-3.pdf
“Social Determinants of Health Literature Summaries,” U.S. Department of Health and Human Services (accessed July 31, 2024): https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries#block-sdohinfographics
