Discussions on health, health policy, and health care in the United States often concentrate on narrowly focused approaches to health improvement. Traditionally, clinical care and doctor’s visits are touted as the primary drivers for good health. Although these are important for overall health, they ignore the broader societal factors that have an impact on health and quality of life. It is simple to blame an individual for not seeking clinical and primary care, not having health insurance, or making poor food and exercise choices instead of seeing the big picture of the social and political determinants of health.
Health Goes Beyond Health Care
Social determinants of health are often described as societal factors and the environments where people are born, live, work, play, worship, and grow up in that impact their health, ability to prosper, and quality of life. They affect a wide range of life outcomes and are impacted by other broad social policies that are known as political determinants of health. These are systematic processes like the administration of power, creation of policy, and distribution of resources that can improve social contexts through “good” policy and advocacy or worsen social contexts through “harmful” policy. The political determinants shape the social determinants.
A growing body of research is showing that health care and access to that care make up only 20 percent of health, while the social determinants and other lifestyle factors make up the remaining 80 percent.
Social determinants include:
- neighborhood and built environment
- social and community context
- economic stability
- health care and quality
- education access and quality
A wide range of indicators are considered in these social factors. For example, the social and community context includes social support and wellbeing and whether children and families have the emotional support to deal with adverse conditions. It is also important to consider civic engagement, being informed about one’s community, and being empowered to voice concerns. Additionally, factors include racism, discrimination, and how that impacts sense of belonging and upward mobility, along with how safety impacts people’s ability to thrive. Are people able to walk safely to their destinations, or do they live in a high-crime environment that exacerbates conditions such as Post Traumatic Stress Disorder due to violence? Is there adequate transportation, or is the neighborhood inaccessible? Are there parks available for children to play in? Is the air quality safe? Are the streets clean?
A growing body of research is showing that health care and access to that care make up only 20 percent of health, while the social determinants and other lifestyle factors make up the remaining 80 percent. If most of people’s health is determined by what happens outside of the hospital or health care setting, then the approach to policy change for health must focus on interventions that go beyond — and still include — impacting social programs like Medicaid.
Medicaid Policy and Political Determinants of Health
Medicaid is a national program that was established in 1965 to provide health care coverage for certain families and people with low incomes and low resources. It is the largest source of funding for medical and health-related services for individuals with low income in the United States, despite the fact that those who qualify must fit specific parameters, and each state implements its Medicaid program differently.
Advocates have long noted that the “states’ rights” structure of the Medicaid program and many other social safety net programs in the United States are rooted in racism.
Before the implementation of the Affordable Care Act in 2014, Medicaid only covered individuals who were children, the parents or caretakers of eligible children, aged adults, or people with disabilities. Able-bodied adults without children did not qualify for the program. Broadly, the inclusion of new criteria to require states to extend eligibility to this population up to 138 percent of the Federal Poverty Level was not adopted by each state. Ten states, including Florida, have yet to provide health care to over 3.4 million people with low income who could qualify for Medicaid.
Advocates have long noted that the “states’ rights” structure of the Medicaid program and many other social safety net programs in the United States are rooted in racism. It is no coincidence that a majority (70 percent) of states that have yet to increase Medicaid program eligibility are concentrated in the South. This leaves many individuals, especially people of color, without health care. This is significant, and it is important to advocate for the expansion of the program. However, as health care access is only a small percentage of an individual’s health, we must also focus on the political and social drivers that exacerbate poor health for everyone.
Political and Social Drivers of Poor Health
Systemic Racism and Discrimination
Many policies have their roots in historical racism. Florida Policy institute (FPI) has long noted that when the government has stepped in to intervene on behalf of providing a safety net for American families, policies have been exclusionary, limiting who could receive benefits. This can specifically be seen in the history of the Temporary Assistance for Needy Families (TANF) program, which provides a critical safety net for families who are struggling to make ends meet. This program was modeled after mothers’ pension programs created in the early 1900s to help women who cared for children on their own due to divorce, abandonment, death of a husband, or disabilities. Black mothers were often excluded from these programs and had the highest work rates, while being forced into low paying jobs to support their families. Even though the program has transformed, the flexibility of the program has allowed Florida to embrace many of the harmful measures discussed at the national level in response to racial stereotypes about who deserves care.
In his latest book “Poverty, by America,” sociologist Matthew Desmond writes: “Poverty isn’t a line. It is a tight knot of social maladies. It is connected to every social problem we care about — crime, health, education, housing — and its persistence in American life means that millions of families are denied safety and security and dignity in one of the richest nations in the history of the world.”
Even though America spends an exorbitant amount of money on health care, and a large amount on safety net programs, much of the money earmarked for those with low income does not reach them. Desmond notes that for every dollar budgeted for direct cash assistance through TANF, only 22 cents went directly to families in the program. Furthermore, of the $31.6 billion in social safety net dollars, $7.1 billion reached those in need as cash.
As families languish without receiving the help they need, more health problems arise. This is why it is critical to think about health beyond and outside of the health care system while also trying to improve it.
Building Awareness of Florida’s History
Effectively addressing the root causes of poor health in the United States requires taking a critical look at the country’s policy past. This can lead to calls for action (policy) that can start to alleviate some of the issues that persist today.
The Florida Timeline is an ongoing initiative to draw awareness to the systemic racism that has permeated historical laws in Florida and continues to reverberate in modern-day policy. The information presented on the timeline is the culmination of extensive research on the part of FPI and partners. While the research is organized by policy topic to make clear how systemic racism impacts various aspects of life, FPI recognizes that inequity does not occur in policy silos. Floridians experience the simultaneous impact of all these policy decisions made in different areas along the same timeline.
Effectively addressing the root causes of poor health in the United States requires taking a critical look at the country’s policy past.
In other words, a holistic approach is taken to advancing quality of life, which includes health, through imagining beyond the current narrative that people simply cannot do more. It is crucial to concentrate on ALL things that impact health, which include the social and political determinants of health, health policy, and health care in the United States, to ensure a brighter future for all.
 Matthew Desmond, Poverty, By America (2023) pg. 28