Higher Social Spending Correlated with Better Health Outcomes

Health Affairs Cover
Elizabeth H Bradley

Higher spending on social services and public health, relative to Medicare and Medicaid outlays, is correlated with better health outcomes, according to a new study published in the May issue of Health Affairs.

Although the observational findings cannot prove causation, “the persistent pattern across a range of health outcomes is notable,” write Elizabeth H. Bradley, PhD, the Brady-Johnson Professor of Grand Strategy and a professor of public health at the Yale School of Public Health, New Haven, Connecticut, and colleagues.

After analyzing data for the period from 2000 to 2009, the authors found that states with higher ratios of social services and public health spending to Medicare and Medicaid expenditures had significantly better health results on seven of eight measures compared with states with lower ratios. Social services spending was correlated with outcomes for adult obesity, asthma, mentally unhealthy days, days with activity limitations, and mortality rates for lung cancer, acute myocardial infarction, and type 2 diabetes. No significant correlation was found for the mortality of postneonatal infants.

Extensive evidence shows a clear relationship between social determinants of health and health outcomes, the researchers note. “Poor environmental conditions, low incomes, and inadequate education have consistently been associated with poorer health in a diverse set of populations. Taken together, social, behavioral, and environmental factors are estimated to contribute to more than 70 percent of some types of cancer cases, 80 percent of cases of heart disease, and 90 percent of cases of stroke.”

Physicians have long been aware of these influences on health, but social determinants of health have gotten more attention in recent years with the rise of population health management, which seeks to keep people healthy and prevent them from having costly episodes of care. To help manage the care of high-risk patients, some healthcare organizations, particularly community health centers, have added social workers or have begun to collaborate with community services. Medicaid programs in New York, Vermont, and other states have also started to expand the focus of healthcare to social determinants of health.

According to Dr Bradley and colleagues, “The provision of housing vouchers, assistance with covering home energy needs, and availability of supermarkets have been associated with subsequent reductions in extreme obesity, diabetes, and nutritional risk among children.” Similarly, the authors note, better prenatal care and infant nutrition have been associated with reduced infant mortality rates.

A national survey in 2011 revealed that most physicians believe unmet social needs lead to worse health, and that patients’ social needs are as important to address as their medical conditions. However, 80% of the physicians surveyed were not confident in their capacity to deal with patients’ social needs.

Dr Bradley and colleagues looked at spending on a broad range of social services, including education, income supports for the poor, transportation, public safety, and housing. Public health spending was included in the numerator of the ratio to health costs because “most public health spending focuses primarily on addressing social and environmental determinants of health for the population,” the researchers write.

States varied greatly in the ratios of social to healthcare spending. But in the average state, for every $1 of Medicare and Medicaid spending, $3 was spent on social services and public health. The ratios were relatively stable over time in any individual state, the authors write.

Whether the researchers used a lag time of 1 or 2 years after the ratio for a particular state was calculated, they found that the health outcomes were significantly better in states with higher ratios. However, with a 2-year lag time, the association with obesity became nonsignificant.

Increased social services and public health spending as a percentage of state gross domestic product was associated with better outcomes on all eight measures, but the association was significant for only three measures (mentally unhealthy days, days with physical limitations, and lung cancer mortality).

Remarkably, increased healthcare spending as a percentage of state gross domestic product was associated with worse outcomes, reaching significance for five of the eight metrics (obesity rates, asthma rates, mentally unhealthy days, days with physical limitations, and lung cancer mortality). The researchers did not speculate on what that finding means.

The authors calculated the potential effect on health of increasing social services spending across US population. A 20% change in the median ratio of social to health spending, for example, was associated with a 0.33 percentage point decrease in the percentage of adults with obesity, they note. Projected nationwide, a higher ratio of that magnitude would result in 85,000 fewer obese adults.

“Our results suggest that adequate investment in social services and public health, not just investment in healthcare, may be key to understanding variations in health outcomes across the states,” the authors conclude.