All You Need is Love: Yet Another Social Determinant of Health

Forty-five years ago, the Pulitzer Prize for non-fiction was awarded to our mentor and friend, Robert N. Butler for his book, “Why Survive? Being Old in America”[1]. Butler, who had coined the term ageism a decade earlier, described in his book the contributions that older adults make to society’s well-being and the hope, joy, and sense of accomplishment that can accompany one’s later years. Yet, “Why Survive” had a darker side. In stark terms, Butler identified the range of problems – what we now collectively refer to as social determinants of health – that were contributing to poor health and quality of life for older Americans. Over the past half century, all but one of the problems that Butler identified - poverty, the absence of age-appropriate housing, an inadequate caregiver workforce, disparities in access to medical care, universal lack of access to geriatric medicine expertise, and gaps in Medicare and social security coverage and funding have been thoroughly studied and the links to adverse health outcomes including reduced life expectancy[2] conclusively demonstrated. Recent research on loneliness and social isolation,[3] as exemplified by Kotwal’s and colleagues manuscript in this issue of JAGS completes the evidence base of Butler’s book. Loneliness (as demonstrated in Kotwal and colleagues paper) joins an increasing list of distressing symptoms - pain, depression, and global symptom distress[4] that have now been linked to socioeconomic deprivation. Not surprisingly, the stresses of racism, poverty, and violence compromise the ability to build close, loving, and consistent relationships at the end of our lives. Nearly a half century of research has provided abundant evidence on the causal links between the social factors Butler described and health[5], yet our society is stubbornly unable or unwilling to act on what we know. Robert Butler’s question remains as relevant today as it did when he first posed it: Why Survive?

What do people want aside from food and shelter? Human connection. In the context of health care, patients rank relationships with their clinicians as the top characteristic of quality[6]. In qualitative research the three factors most cited as critical to their health care experiences are having a doctor who listens, who is caring and compassionate, and who explains well[6]. When people are asked about their health care experiences, they speak about the quality of the connection and interaction between them and their clinicians. Yet we do not incentivize the time required to build a strong human connection- the average primary care visit lasts 18 minutes[7]. We do not incentivize continuity of clinical relationships- about a third of Medicare beneficiaries see 10 or more clinicians during their last 6 months of life[8]. Other studies of the priorities of older adults rank remaining independent and relief from pain and symptoms ahead of living longer[9]. Meaningful human interaction is at least as important outside of health care[10], with recent data from the United States of Aging Survey showing that relationships with others are the number one priority of older adults[11].

Our failure to address the social factors influencing health is strikingly visible in the disparate impact of COVID-19 on Black, Indigenous, and people of color (BIPOC), older adults, and those living in poverty[12, 13]. COVID hospitalization rates are 4 times higher and death rates 2.5 times greater in Black and Hispanic patients as compared to whites[12]. Mortality increases are also greatest for older adults – particularly those in nursing facilities- as well as those incarcerated, without health insurance, with family incomes below the federal poverty level, or in occupations precluding working from home. Given what we already know, none of these findings should surprise us. Racial and ethnic minority status is tightly linked to socioeconomic status in the US. BIPOC routinely live in crowded multigenerational households often in low income and violent neighborhoods, and hold ‘essential’ jobs working in public transit, as store clerks, and as nursing aides that require face-to-face contact[12]. More than 15 million adults ages 65 and older had incomes below 200% of the official poverty measure in 2017 (30.1%). The poverty rate increases with age and is disproportionately higher for women, blacks and Hispanics, and those in poor health. [14] Once infected, people in under-resourced communities are at higher risk for serious illness because of job and insurance losses, lack of sick-leave, prior comorbidities, chronic stress, and poor access to quality care[15].

Despite recognition of the foundational role of social factors in achieving health we continue to put nearly all of our tax payer funded health care dollars into direct medical services (more than 95% of healthcare dollars at a cost of >$10,000 per person per year)[16]. This mis-match between spending and need results in our healthcare quality being ranked 37^th among that of 100 developed nations, behind Costa Rico, and just ahead of Cuba and Slovenia. Compared to the other 10 countries in the Organization for Economic Collaboration and Development (OECD), the U.S. spends nearly twice as much on health care as the average OECD country — yet has the lowest life expectancy, highest number of hospitalizations from preventable causes, highest rate of avoidable deaths, and highest suicide rates among the 11 OECD nations[16]. Addressing our poor performance as a nation on stewarding the health and well-being of our citizens requires changes in policy and spending priorities in a manner that would address these root causes – remediation of poverty and the racism and ageism that underly much of it[17].

If the purpose of the health care system is to improve the overall well-being of society, our one trillion dollars annual health spending budget should be redirected to facilitate human connection, reduce poverty, assure safe housing and neighborhoods, and provide access to healthy food, primary medical care, and social support - the remediable social and behavioral forces linked to health that we have now so exhaustively studied. Yet, lobbying by entities that profit from the current medical-industrial structure, racism, denial, and our cultural unwillingness, supported by an unrepresentative democracy, to invest in antipoverty policies and services that flow to under resourced communities[18], and deep-seeded cultural distrust of government intervention[19] pose substantial barriers to improving our nation’s health. Recent FDA approval of a $56,000+ per year of a drug for Alzheimer’s Disease, despite no data on beneficial clinical impact is only the latest expression of sacrificing the actual needs of our citizens to those seeking to profit on those citizens[20]. If the FDA approval is not reversed, it is estimated that aducanumab will cost Medicare between 29 and 57 billion dollars per year[21] -- enough to eliminate food insecurity ($30 million)[22] and poverty ($390 million) [23]for every older adult more than seventy times over[24].

Gesturing towards recognition of the gap between spending and root causes, some commercial payers[25], Medicare Special Needs Plans launched by housing organizations[26], Medicaid Managed Care plans[27], and a few health systems[28], have begun to act on remediating social factors (such as lack of food and housing) driving poor health. Without government action to bring these initiatives to scale, however, these constitute more examples of admiring the problem, rather than solving it. The disconnect between the root (social and political) causes of ill health and our healthcare spending joins climate change, pandemic infection, and political paralysis as the major threats to American longevity and quality of life.

In 1975, Robert Butler warned that the time to address these root causes was running out as the baby boomers aged. Time has run out. In nine years, adults over age 65 will represent one in five Americans and outnumber the pediatric population for the first time in human history. The quality and length of life that we can expect as a society hangs in the balance, awaiting public demand and political will.