by James A. Bacon
As it takes up the issue of “social determinants of health,” the Joint Commission on Health Care is probing the social and economic origins of unequal health outcomes for different population groups in Virginia, according to Radio IQ.
By defining the issue as social determinants of health, as opposed to social correlates of health, the political left has already won the battle. The inevitable result will be pressure to increase state spending on programs asserted (but never proven) to ameliorate social inequities.
“There is a 20-year difference between the localities with the highest and lowest life expectancy rates in the state with Manassas Park at 89.3 years and Petersburg at 64.9 years,” said commission staffer Jen Piver-Renna yesterday when briefing the Commission.
“These are lifelong challenges people are facing: housing, health access, food access, crime, education,” Commission Chair Rodney Willet, D-Henrico, told Radio IQ.
Delegate Cia Price, D-Newport News drew the inevitable political conclusion: “If improving community conditions includes a healthy and safe place to live, we need to be thinking about that not just in this joint commission, but in general laws meetings too. There was redlining, underfunding, all of these things that have happened to communities which have caused these health issues.”
It is now established wisdom that group disparities in health outcomes, such as average life expectancy, are due mainly to environmental factors such as housing, education, crime and access to health care.
Proponents of the “social determinants of health” (SDH) paradigm contend that pointing to individual behaviors and beliefs — smoking, substance abuse, unsafe sex, poor diet, less impulse control, fatalistic attitudes about health, distrust of the healthcare system — amounts to “blaming the victim.” Such a view downplays policy initiatives that focus on changing individuals’ behavior.
The SDH paradigm also ignores the well-known “Hispanic paradox”: the fact that Hispanics, in defiance of social determinants that would predict worse health outcomes, have lower mortality rates than Whites. Remarkably, 40% of the population of Manassas Park, which the Commission identifies as having the longest life expectancy in Virginia, is Hispanic — a fact that never appeared in the Radio IQ article.
That’s not to say that social factors have no impact. It seems intuitively obvious that differential access to healthcare is an important variable. Based on the conviction that inadequate access to healthcare was harming the health of poor Virginians, the Commonwealth undertook a multibillion-dollar expansion of Medicaid in 2019. Over the past five years Virginia has conducted a real-world social experiment. Has Medicaid expansion made a difference?
I’ve found only one study by anyone willing to take a stab at answering the question. A 2022 study, “Effects of Virginia’s 2019 Medicaid Expansion on Health Insurance Coverage, Access to Care, and Health Status,” found that Medicaid expansion did improve lower-income Virginians’ access to healthcare but… showed “overall no discernible change in health status outcomes.”
That’s a remarkable finding, and it’s no surprise that the advocates of more government spending have ignored it. I suppose one can argue that it’s just one study and three years isn’t enough time to show measurable results, so it doesn’t count. Why, then, doesn’t the Joint Commission undertake a more authoritative study to find out if five years of Medicaid expansion has delivered on its promises? The reason, I expect, is (1) the political left fears the answers; and (2) the political right doesn’t have the wits to press the matter.
By defining social inequities as the “determinants” of health disparities, lawmakers are predisposed to address those inequities rather than do the hard work of identifying whatever deficiencies in the healthcare system that might exist — not enough primary care physicians, to pick an example — and crafting solutions to address them.
If we can’t document a tangible health benefit from Medicaid expansion, which attacks health-outcome inequities directly, how can we possibly demonstrate a benefit to housing or education initiatives where the theorized health impacts are far more tenuous?
One might hope that the Youngkin administration would ask the tough questions. But Team Glenn learned its lesson in 2022 when Colin Greene, the administration’s pick for Commissioner of Public Health, was tarred and feathered for questioning the dogma that racism has a significant impact on health outcomes in today’s healthcare system. He had the temerity to wonder if the racial disparity in maternal mortality rates could be explained in part by group differences in making it to medical appointments. Incensed by his insensitivity, General Assembly Democrats scuttled his nomination.
Back in the real world, if the political fixation on the “social determinants of health” creates a misallocation of public resources, we can be assured that it will only make health outcomes worse.