Social determinants of health and the New York Health Act

I attended a conference on technology and medicine in 2019 with a focus on the ways in which changes in technology could improve medical care.

One of the presenters noted that one of his patients was losing weight. He asked the patient why he was losing weight, and he answered that he didn't have enough to eat, and frequently needed to skip meals in order to feed his family.

This doctor bemoaned that he did not know how to help this patient, and decried that, in the United States, the doctor's right to a profit was valued more than the worker's right to a sufficient diet.

Social determinants of health encompass all the non-medical factors that influence our health and wellness. Our genes are a relatively minor factor accounting for only 30 percent of our health outcomes. Seventy percent of our outcomes result from economic conditions, our neighborhood and physical environment, food, education, economic stability, community and social contexts, and our health care environment.

Each of these factors, in turn, interacts with other factors that together impact our health.

For example, the impact of food on our health depends on the availability of healthy food, and enough economic stability to prevent food insecurity. Lack of access to healthy food and food insecurity both lead to unhealthy eating habits, which can result in diabetes.

We saw during the coronavirus pandemic how neighborhood conditions such as unemployment, densely populated housing, and the absence of parks for outdoor recreation greatly contributed to the spread of disease and death. Community context has a tremendous negative impact on immigrant populations — particularly on the undocumented, where discrimination and stress can disrupt families and supportive social networks.

The interactions of these social determinants of health together contribute either to the well-being or to the distress of a community.

The health care environment comprises health care coverage, availability of providers, pharmacies, language and culturally appropriate care, and quality care. Statistically, of the 62 counties in New York state, health outcomes in the Bronx are the worst. During the last nine years, according to the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, 31 to 45 percent of the population in the Bronx lived in poverty.

Diabetes deaths per 100,000 ranged from 33 to 65 — the highest in the state. Asthma hospitalizations per 100,000 ranged from 865 to 1,637. Hospitalizations for drug use per 100,000 were the highest in the state, ranging from 605 to 1,329.

These dismal outcomes are the result of the negative impact of social determinants of health in the Bronx, and the lack of access to regular preventive medical care.

Few people are truly satisfied with the health insurance industry in the United States today. In New York state, 5 percent of our population cannot afford any insurance. Half have insurance, but cannot afford to use it because of copays, and deductibles. They put off care.

A third of those people report developing serious and costly conditions. Approximately 60 percent of people in bankruptcy court are there because of medical debt. It does not have to be this way.

The New York Health Act would cover every resident of New York state regardless of immigration or employment status. The bill provides preventive care, reproductive care, mental health care, addiction services, dental, vision and hearing care, prescriptions, and long-term care. Copays, deductibles and out-of-network charges would be eliminated, so people would be able to access care when they need it, and before they become seriously and expensively ill.

The bill would be paid for, in part, from savings resulting from the elimination of the $55 billion in profit earned by insurance companies in the state — savings resulting from the power of the state to negotiate drug prices for 23 million people in New York, and savings resulting from eliminating the administrative bureaucracy needed to manage the billing for the approximately 55 insurance companies operating here.

Another major portion of the funds for the New York Health Act would come from a progressive income tax. Estimates vary slightly, but two comprehensive economic analyses — the 2015 Friedman study at the University of Massachusetts at Amherst, and the 2019 study by the Rand Corp. — determined that 95 percent of New York residents would pay less than they are paying now for health care when deductibles, copays and out-of-network charges are eliminated.

Because of its size and complexity, the New York Health Act establishes a trustees board with representatives of all stakeholders to work on the details and timing of implementation. The board has two years to develop proposals for every aspect of the plan, from finance to integration with existing federal and state programs and institutions.

Implementation may take another two years.

We know the bill is being considered seriously because the leadership has established working groups to study the plan, and because of the dramatic increase in advertisements for insurance companies and pharmaceuticals. The bill has no budget implications at this time, but must pass this year because of the long time needed for implementation.

Answers to the most frequently asked questions can be found at NYHCampaign.org.

It is important that every one in the state learn about the New York Health Act, and contact their state representatives in the senate and Assembly. Urge them to champion bringing the New York Health Act to a vote, and to vote for its passage.