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If our nation’s goal is to improve the health and longevity of people living socio-economically … [+]
For decades, policy and public health experts have recognized this social determinants of health– factors such as financial stability, employment and housing security – are responsible for this 30% to 55% of people’s health outcomes.
These ‘non-medical’ factors contribute significantly inequality and health inequality.
How social determinants lead to poorer health
Despite being one of the wealthiest countries, the United States faces deep and pervasive health problems, driven largely by social determinants of health.
Almost 38 million Americans live in povertywith more than 34 million people struggling to secure sufficient food. Homelessness affects more than half a million people every night, while gun violence and suicide – symptoms of broader social instability – claim nearly 100,000 lives every year.
These social and economic hardships are more than just statistics. They are the root causes of life-threatening health disparities. People struggling with hunger, unsafe housing, poor education and limited job opportunities are at much greater risk of disease and early death than their affluent neighbors.
These disparities have steadily eroded the mental, emotional and physical health of entire communities. In areas with food deserts and low wages, poor nutrition is common, leading to higher diabetes rates. Chronic stress due to unemployment, homelessness and racial discrimination causes inflammation and increases blood pressure, increasing the risk of heart and other diseases. Furthermore, limited access to educational and health care resources hinders preventive care and makes chronic disease management even more challenging.
The consequences are devastating. The US has one lowest life expectancy among high-income countries, at just 76 years. Maternal mortality is alarmingly high, with the US ranking last among developed countries, and infant mortality remains unacceptably high.
These sobering statistics underscore the profound impact of social determinants on health outcomes in America.
American communities are struggling to address SDOH
Years ago I spoke with leaders in the… Rochester, New Yorkwho brought this problem to my attention. In two neighborhoods just five miles apart, life expectancy at the time differed by more than ten years. The wealthier area had better housing, education, safety, access to food and employment – benefits that were largely missing in the low-income neighborhood.
Early in my career, I believed that once these kinds of differences were exposed, change would follow. I now understand that breakthrough solutions only emerge when there is a financially viable way to solve them and a strong economic incentive to do so. Without these factors, the problems in our communities will only worsen.
The simplest solution is the best for now
By rethinking the way we address health care in underserved communities, I believe we can save thousands of lives. To guide this shift in thinking, let’s look to the age-old wisdom of William of Ockham, a 14th-century monk and philosopher who taught that the simplest solution is usually the most effective.
This principle, known as Ockham’s Razor, means that trying to tackle every social determinant of health at once is an approach that is doomed to failure. The scope of such an undertaking proves prohibitive and is easily dismissed by elected officials due to the country’s polarized political climate and limited funding for social programs.
Instead, our nation can create immediate and positive change by focusing on a simpler, more achievable solution: the prevention and management of chronic diseases.
These lifelong conditions are often the direct result of social determinants of health and compromise well-being, leading to life-threatening complications and premature death. According to data from the CDCEffective management of chronic diseases can prevent 30 to 50% of heart attacks, strokes, cancers and kidney failure.
In underserved communities, where health care resources are scarce, doctors hardly have enough time to address emergencies and acute medical problems. As a result, prevention and management of chronic diseases are often overlooked.
While improved management of chronic diseases is not a substitute for addressing the root causes of the social determinants of health, it is a practical and achievable step forward. By using generative AI technology – tools that didn’t exist two years ago – communities can empower patients, improve overall health, and extend people’s lives.
The concept: community health and technology hubs
Think of these hubs as complementing the existing Medicaid system: providing affordable, targeted, and technologically advanced support to individuals in areas where health care resources are limited.
Execution: The first phase involves launching pilot hubs in ten low-income communities across the United States, strategically located in accessible facilities such as existing community centers. Each hub would be staffed by ten community workers: individuals who work in social services and are familiar with the community, speak the language and understand how to navigate local bureaucracies and maximize government resources.
Hubs could also include one physician, a nurse practitioner, or a physician, who provides medical care for unexpected, urgent problems (not as routine emergency care providers). These hubs would provide essential services such as childcare, so parents have time to meet staff, attend educational sessions and easily access healthcare facilities.
Additional medical support to all ten locations would be provided by a small number of specialists linked via telemedicine, providing expertise when cases are unusually complex.
Integrating AI technology: Generative AI will be central to these hubs’ activities. Community workers would be trained to help people use GenAI to manage lifestyle medicine, monitor chronic diseases and detect acute problems early.
As detailed in ChatGPT, MD: How AI-enabled patients and doctors can take back control of American medicineGenAI is already making significant progress in the medical field. It now has the ability to quickly analyze individual medical history, current health status and lifestyle factors to provide personalized health recommendations.
With careful training and human supervision, AI tools can suggest optimal diets based on a person’s financial situation, identify environmental factors that impact health, and recommend preventive measures tailored to specific needs.
In addition, GenAI can monitor chronic conditions by analyzing data from health devices such as blood pressure and blood glucose meters, both in the hubs and at home, and signaling when an intervention may be necessary. This real-time analysis helps reduce the burden on overworked physicians by distinguishing between patients who are stable (and do not require additional medical care) and those who require a medication adjustment (which can usually be accomplished virtually).
By empowering individuals through this technology, these hubs will improve chronic disease management and help patients avoid complications that lead to emergency room visits or hospitalizations.
Scalability and cost-effectiveness: The cost to set up and operate each hub – including salaries, services and technology – would be less than $1 million annually. With a total investment of $10 million, our country could set up ten hubs, along with a centralized specialized telehealth center to support them. Given Medicaid’s estimated budget of $853 billion in 2023, the investments required for these demonstration hubs are minimal.
This hub model is designed to quickly become cost neutral, with a positive return on investment over time. The savings generated by preventing just one major health event – a heart attack, kidney failure or stroke – would offset the operational costs of providing care to 1,000 individuals for a year. As savings are generated in one community, Medicaid officials would reinvest in new locations, continually expanding the program.
A practical step forward: If our nation’s goal is to improve the health and longevity of people living in socioeconomically disadvantaged areas, focusing on the prevention and management of chronic diseases is the most direct and effective approach available.
While addressing broader social determinants of health – such as housing, education and employment – would be ideal, these complex issues are unlikely to be resolved quickly. In the meantime, reducing the burden of chronic disease offers a tangible way to improve health outcomes now. Additionally, as people’s health improves, communities will experience lower absenteeism rates, better-paying jobs and healthier residents.
This model is not perfect. But it is an important step in the right direction. It is affordable, practical and scalable. And it’s clear that what we’re doing today isn’t working. The time has come to try something new.