Socioeconomic Status and Health

Thom Walsh PhD, MS, MSPT

The Dartmouth Center for Health Care Delivery Science &

The Dartmouth Institute for Health Policy and Clinical Practice

Health & Health Care

Clinical training teaches us to link outcomes and exposures

• Upper respiratory infection viruses• Cancer carcinogens• Obesity calories in/calories out

There Is More to the Story…

The Field Model

Another Way…

C. Monet (1840-1926)

Person

Place

Provider

Pathways

Policy 3 Policy Approaches

4 Pathways

3 Perspectives

The Road Ahead

How to put coursework on SES in Perspective

Person

Place

Provider

Pathways

Policy

The Gradient

The Whitehall Papers Defined The Gradient

Person Place Provider Pathways Policy

Line Workers

Supervisors

Mangers

Executives

Owners

The Gradient

…the gradient is fine grained and appears to have existed in all societies throughout history.

KM Cardarelli, JS deMoor, MD Low, BJ Low. Fundamental determinants of population health; in Reinventing Public Health by LA Aday. John Wiley & Sons, Inc. San Fransico. 2005.

Person Place Provider Pathways Policy

The Gradient is Fine Grained

Person

Place

Provider

Pathways

Policy

The Gap

Assumption

Based on the known relationship between the gradient and health among people, a wealthier place must also be healthier… .

Fact: Only to a point

Person Place Provider Pathways Policy

The Epidemiologic Transition

Person Place Provider Pathways Policy

The Epidemiologic Transition

Person Place Provider Pathways Policy

What is poor?

Person Place Provider Pathways Policy

Choose

A: 3,000sqft home in a neighborhood where the average home is 2,000sqft

You are here

Choose

B: 4,000sqft home in a Neighborhood where the average home is 6,000sqft

You are here

Measuring the Gap'Gini Coefficient'

• A measure of the distribution of a country's residents’ net income

• 0 =identical incomes for all• 1 = all income to one person • A wealthy country and a poor country can have

the same Gini coefficient

http://www.investopedia.com/terms/g/gini-index.asp#ixzz25jVc5wn4

Gini Coefficient

Person

Place

Provider

Pathways

Policy

Geographic Variation

How Much Does Health Care Contribute to Population Health?

• Some say as little as 10%– J. Michael McGinnis, Pamela Williams-Russo and James R. Knickman. The Case For More

Active Policy Attention To Health Promotion. Health Affairs, 21, no.2 (2002):78-93

• Others argue as much as 50%– The Value of Medical Spending in the United States, 1960–2000. David M. Cutler, Allison B. Rosen, &

Sandeep Vijan.N Engl J Med 2006; 355:920-927August 31, 2006DOI: 10.1056/NEJMsa054744

Ask Yourself…

Would you expect to find an equal distribution of all races, incomes, and education-levels among the patients in every region of the US?

Person Place Provider Pathways Policy

Of Course Not

US Census^ http://factfinder.census.gov/home/saff/main.html?_lang=en

City Name State % Pop Age

>=65 ^

Median Age

^% White

^% Black

^% Hispanic (Any Race)

^

Median Household

Income ^

% Families Below

Poverty Level

^

% Individuals

Below Poverty Level

^

% Bachelor's Degree or

Higher^

% In Labor Force (Age

>=16)^

% Individuals

<65 without Health

Insurance#

AL                      

Birmingham   12.70 36.20 22.80 74.80 2.60 30014.00 22.40 27.10 20.90 60.60 13.10

Dothan   14.90 37.60 66.00 30.90 1.90 40363.00 12.80 16.50 24.20 60.80 14.10

Huntsville   14.50 37.80 62.50 31.60 3.10 45851.00 10.10 14.00 39.00 63.70 16.30

Mobile   13.50 35.10 47.60 48.50 1.60 35239.00 18.70 23.00 25.20 59.40 14.70

Montgomery   11.70 33.80 42.60 54.30 1.70 41285.00 16.00 18.70 30.70 64.60 12.50

Tuscaloosa   11.50 27.90 52.50 43.80 2.60 28574.00 16.80 28.60 33.60 56.80 15.40

Geographic Variation

Some hospitals use effective care at higher rates than others

Hospital Quality And Intensity Of Spending: Is There An Association?Laura Yasaitis, Elliott S. Fisher, Jonathan S. Skinner, and Amitabh Chandra.

Health Affairs 28, no. 4 (2009): w566–w572

Person Place Provider Pathways Policy

Geographic Variation

Patient with lower SES tend to reside near and utilize hospitals that deliver lower quality care to ALL of their patients

Person Place Provider Pathways Policy

Key Insight from Geographic Variation Research #1

Because patients with lower SES are over represented in lower quality hospitals, the poor quality of the hospital will magnify the influence of SES on health status and longevity

Person Place Provider Pathways Policy

Key Insight from Geographic Variation Research #2

Policies designed to improve the quality of care delivered will have a positive impact on reducing SES disparities

Person Place Provider Pathways Policy

Further ReadingsThe Original from Baicker, Chandra, and Skinner 2005 More recent

Justin Dimick, Joel Ruhter, Mary Vaughan Sarrazin and John D. Birkmeyer In Segregated Regions Black Patients More Likely Than Whites To Undergo Surgery At Low-Quality Hospitals. Health Affairs, 32, no.6 (2013):1046-1053

Shreya Kangovi, Frances K. Barg, Tamala Carter, Judith A. Long, Richard Shannon, and David Grande. Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care. Health Affairs, 32, no.7 (2013):1196-1203

Remember

This type of analysis does NOT argue that all inequalities in health care are explained by geography.

Geography- the quality of the hospital where care is received- plays a role that should be considered

Person Place Provider Pathways Policy

How to put SES coursework in Perspective

Person

Place

Provider

Pathways

Policy

4 Pathways

Behavioral/Cultural

• Lack of self-regulation, poorly developed coping skills, external locus of control, steep discount rates (prioritizing short term gain over future uncertainty)…

• Collection of learned behaviors existing within a community

Person Place Provider Pathways Policy

Materialistic

• Higher income affords better shelter, food, clothing

• More education affords safer, less physically demanding jobs

• Wealthier places have better schools, hospitals, transportation, etc.

Person Place Provider Pathways Policy

If behavioral or materialistic pathways fully explained inequalities….

But we don’t see this at all

Person Place Provider Pathways Policy

There is a fine gradient among people within a place.

Psychosocial Mechanisms“Stress of trying to keep up”

Short-term, Actionable Stress

• Increased HR & BP • Increased Fibrinogen

to clot wounds• Increased Cortisol

releases fats and sugars into bloodstream for energy

Chronic, In-actionable Stress

• Increased cardiovascular load

• Increased clotting factor in circulation

• Increased blood sugar levels…

Person Place Provider Pathways Policy

“ Under Pressure- The search for a stress vaccine”

by Jonah Lehrer Wired. August 2010.

Life-Course

• Early experiences• Key time frames• Chronic exposure• Accumulation

Person Place Provider Pathways Policy

Person Place Provider Pathways Policy

Adverse Childhood Experience (ACE) Studyhttp://www.cdc.gov/ace/

How to put SES coursework in Perspective

Person

Place

Provider

Pathways

Policy 3 Policy Approaches

EducationGiving Everyone the Health of the Educated: An Examination of Whether Social Change Would Save More Lives Than Medical Advances. Steven H. Woolf, MD, MPH et al. Am J Public Health. 2007 April; 97(4): 679–683

• Higher education linked to better health

• Similar to income – health link

• Long time horizon

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Absolute income redistribution on the relative income of the poorest segment

Bottom 50% of Population

Top 50% of Population

Ratio of Bottom to Top

% shares of total income (A) 27 73 0.37:1

% shares of total income (B) 34 66 0.52:1

Percentage increase (A to B) for the Ratio Bottom to Top

(0.52 / 0.37) 40.5%

Income RedistributionFlattens the Gradient and Closes the Gap

7% “Robin Hood” Tax

Person Place Provider Pathways Policy

Source: Chapter 5 Unhealthy Societies; Wilkinson

Health Care Delivery

• Quality Improvement• Shared Decision

Making• Accountable Care

Organizations• Rational supply of

resources to deliver the care an informed population needs & wants

• Potentially better care for all • Potentially “doable”• Potentially could work• Health Care Delivery has a

relatively minor impact on population health…

Person Place Provider Pathways Policy

Person

Place

Provider

Pathways

Policy 3 Policy Approaches

4 Pathways

3 Perspectives

The Road Looked Like…

How to put SES coursework in Perspective Person Gradient

Place Gap

Provider Geography

Pathways1. Behavioral2. Materialistic3. Psychological4. Life Course

Policies1. Education Promotion2. Income redistribution3. Health Care Delivery

3 Policy Approaches

4 Pathways

3 Perspectives