Jake’s Journey: Social Factors that Improve Health Part VI


Dr. Bob Crittenden is the Cambia Grove Executive in Residence Emeritus and brings a wealth of experience and knowledge as a practicing family physician and as a senior policy advisor. Dr. Bob’s blog series weaves learnings from his career while highlighting broader barriers to health care innovation and possible paths forward. Read more about Dr. Bob and his writings here

Our patient Jake would like to live a long and healthy life. He believes he has a good doctor and should be fine. Unfortunately, his confidence is not based on the facts. 

We all want to avoid illness, have a healthy functional life, and dread diseases. We often equate health care with avoiding disease and improving our health. Our health system is one of the best in the world, and we are good at treating diseases and fair at clinical prevention . As we have mentioned before, our health is improving at a slower rate than other countries. And, for some people, their health status is worsening

Why is this happening? We may be getting good health care, but health and longevity - or the real concern - sickness and early death - are driven by factors other than health care.

It is estimated that health care contributes less than 20% to overall health. Genes are important and we have zero control over who our parents are. But we do have control over important factors that account for about 60-70% of our health and longevity.

Looking at the factors that we do have control over, only a fraction is actual health care. Our zip  code is more important than our genes. Some people have control of where they live, but many people cannot relocate given the cost of housing, historic redlining (exclusions made systematically in many cities) and other constraints. Poverty, poor housing, social stress, schools, transportation, food availability, mental health, housing affordability and other social factors are issues the health system has little control of and have an outsized impact on people’s health. Most of the above issues are affected by social policies. 

Many of the social factors that affect health are medicated through chronic illnesses like high blood pressure, diabetes, depression, chronic stress, and drug use.   

People deflect the impact of the above factors by considering them personal choices. Having worked my whole life with people affected by these social factors I have two observations:

  • The first is that all people affected by these factors would like to improve those issues.  People want affordable housing, good food, good schools for the children and certainly access to good medical and mental health services. 
  • The second is that people make the best choice of the options they have available. If people have limited choices, they may appear to be making bad choices, but in their reality, almost all people are making the best of a bad situation. The goal of our social contract should be to ensure we remove the barriers to good choices for all people in our country.
Many will think that the underlying forces causing these social problems are too great or too expensive to address but in actuality, most of these problems are too expensive not to address.

We pay for these barriers through expenditures in our health system, corrections costs, fire department responses, and emergency services for the homeless to name a few. An example, the cost incurred by a homeless person in the above categories in current public expenditures is about $60,000 per year. The cost of housing that person is $20,000. If housing stability can decrease the other medical and social costs by a third, this becomes the economical choice… and a social bargain. 

Another example, we know that treating severe mental health illness decreases medical cost and can decrease the 25 years of life lost by those so afflicted…again, economic and social improvements.

There are three categories of investments in social determinants. Some are economic like income, some are mostly social like racism and some are mediated by focusing on those health conditions that mediate between social problems and health – metabolic and behavioral care. 

Those social investments that improve health and have an ROI are no-brainers. Homelessness, mental health, emergency food for diabetics, transportation to medical care, case coordination of complex patients and similar other issues where there is known ROI should be evaluated  and appropriate targeted investments made. 

There are reasons we fail in this situation. One is that savings are in one pot and costs in another. We treat opiate use in the medical system and save in the corrections system. Building housing requires complex financing - private philanthropy, federal, state and local revenue and overlapping with a complex decision-making process. However, savings are mainly found in the health, corrections, emergency response, emergency shelters and private philanthropy

Mental health is paid for by federal, state, local governments and private health insurance, but the savings are found in hospitals, emergency response and acute services.

Our own complexity - a product of piecemeal solutions - obstructs our ability to address these issues.  

Financing solutions and recovering savings is obstructed by this complexity. Agencies and organizations that do save on certain patients can always use the saved funds in other ways and no organization will identify and release those savings to another agency or organization. While it makes sense to the system to reclaim those savings and invest them up stream, it does not make sense to most organizations individually. A hospital that saves money by diverting mentally ill patients to an appropriated mental health setting has fixed costs associated with running the emergency room and more patients who come in to get care. They will not usually take the apparent savings and give them to a mental health service…unless there is a mechanism in place to make this happen. 

Another factor that obstructs worthwhile investments is that investing in an upstream and effective service like housing requires an ongoing revenue stream to pay off the investment. While vulnerable patients with multiple medical problems who would greatly benefit from stable housing are often covered by Medicaid, there are rules that say that Medicaid funds cannot be used for permanent supportive housing - even if such an investment would save the Medicaid program money. 

Overcoming these barriers to identify and pay for needed investments is a solvable problem if there is cooperation and a focus on changing the rules so smart investments can be made, so patients are healthier and so the public and private investment are made. 

For those services where there is insufficient evidence that there is savings to be had, there are good reasons to pilot and rigorously test interventions to identify that they actually do make a difference. Sometimes we need to invest in social determinants, even when they’re lacking evidence that they save money. We agree that pregnancies should result in healthy mothers and babies. Children should be able to grow up healthy with few stresses that can affect future health. Whether we can prove cost savings or not, many of these interventions are broadly agreed to as being worth the investment.    

The issue of investing in social determinants of health as above can be seen through an equity lens. People most impacted are low-income families and people of color. The disparities in health outcomes can be ameliorated by addressing the social determinants as above. Also, the impact on health of these problems is manifested in certain diseases. People who have poor housing, food stability, and poor transportation die most frequently and prematurely from metabolic and behavioral diseases. Aggressively addressing those diseases including clinical prevention and addressing the precursor social issues can greatly decrease the health disparities we see in our communities.      

There are great opportunities in the United States to effectively improve the health of many of the people in our country and erase a large chunk of the health disparities that plague our nation. We need to change federal rules, align agencies and insurers so health is the goal and funds may be used to maximize health outcomes, develop revenue streams from the savings so they pay for needed social investments and we need to pilot and evaluate potential innovative interventions to better improve the health of all of us.      

The Cambia Grove is hosting a three part series that will unpack topics that are addressed during our 5 Points of Health Care Summit™ (being rescheduled for the fall) focused on improving outcomes and decreasing costs. The issue will be examined from clinical, social and prevention perspectives and will be a great resource to people, with a vigorous discussion about evidence-based approaches to make progress on this important issue. Join us!


About Dr. Bob Crittenden

Executive in Residence Emeritus

Dr. Bob Crittenden joined the Cambia Grove as the first-ever Executive in Residence. He has practiced as a family physician for over 28 years in central and southeast Seattle with urban underserved populations, worked for the state legislature, been a Robert Wood Johnson Health Policy Fellow with Senator George Mitchell, was special assistant to Governor Gardner for health, and is a Professor Emeritus in the Departments of Family Medicine and Health Services at the University of Washington.

His work on projects at the local, state and national levels focuses on improving the access and effectiveness of health services for all populations. Most recently, he served as Gov. Jay Inslee’s Senior Health Policy Advisor, where he was instrumental in the implementation of the ACA in Washington state and the successful Medicaid Transformation Waiver. He has also played a key role in initiating the Kids Get Care program, actively participating in rural and urban underserved health systems improvements, and working with insurers, employers and providers in improving systems of care for chronic conditions.

Dr. Crittenden received his BA in Communications and Public Policy from the University of California, Berkeley and a diploma in Political Theory and Development Economics from Oxford University. He went on to earn his Medical Degree at the University of Washington School of Medicine and his Masters of Public Health in Health Services from the University of Washington. He loves any sport and enjoys his time on the lake or in the mountains.