From Health Care Law to the Social Determinants of Health: A Public Health Law Research Perspective

Abstract

Research over the past three decades has shown convincingly that population health is shaped powerfully by the contexts in which people live, learn, work, and play - also called social determinants of health or fundamental social causes of disease. The World Health Organization, the Centers for Disease Control and Prevention, and the Robert Wood Johnson Foundation, have all launched major initiatives aimed at addressing the social influences on health. Neither the research nor the calls for action, however, have penetrated common knowledge, as a recent report from the Robert Wood Johnson Foundation (RWJF) recounts:

Americans, including opinion elites, do not spontaneously consider social influences on health. They tend to think about health and illness in medical terms, as something that starts at the doctor’s office, the hospital, or the pharmacy. They recognize the impact of health care on health, and spontaneously recognize the importance of prevention, but they do not tend to think of social factors that impact health.

They do, however, recognize social factors and see their importance when primed. Raising awareness of social factors is not difficult, although people more readily recognize voluntary behaviors that cause illness (e.g., smoking, overeating) than arbitrary or social factors (e.g., race, ethnicity, income).

In these tendencies, health lawyers may not differ from everyone else. Even health lawyers who are attuned to the social determinants of health - a phrase, by the way, that this RWJF report advises is just too wonky for general public consumption - often do not find themselves in a position to actively address them in their research. Yet even as health lawyers and health care policy experts celebrate the enactment of the Patient Protection and Affordable Care Act - a landmark policy achievement, no matter what its ultimate fate - we have at least two good reasons to keep social determinants in mind: first, the relatively dismal state of population health in the US is not caused primarily by a lack of health care, and second, even universal health care access will not make us substantially healthier as a society. Health care is a huge part of the American economy, and an undeniable public good, but the stakes are too high for the public - and health law scholars - to continue their neglect of the robust social structures that are shaping American’s well-being. Compared to other countries with our resources, and even some countries without them, we are doing poorly, and it’s well past time we all got sick of it.

This essay, invited to help provide a public health context to a symposium on health care reform, begins with a brief summary of key points from social epidemiology - the study of the social determinants of health. It then discusses how law fits into the picture, and more particularly how public health law research can contribute to identifying and ameliorating social causes of the country’s relatively poor level and distribution of health.

Keywords: inequality, health equity, public health law research