The Politics of Population Health

Abstract

Policy Points.

• Despite increased spending and consuming more health care services than any other country in the world, the United States global health rankings experience continued decline, including worsening performance in life expectancy and mortality owing to lack of investment in and strategies on the upstream determinants of health.

• These determinants of health are found in our access to adequate, affordable, and nutritious food options; safe housing, blue and green spaces; reliable and safe transportation; education and literacy; opportunities for economic stability; and sanitation, among other important factors and all share a common root driver in the political determinants of health.

• Health systems are increasingly investing in programs and exerting influence over policies to address these upstream determinants of health, including population health management, however these programs will continue to be hindered without addressing the political determinants through government, voting, and policy.

• Although these investments are laudable, it is important to understand what gives rise to the social determinants of health and—more importantly—why have they disproportionately and detrimentally affected historically marginalized communities and vulnerable populations for so long? Deeply entrenched and pervasive throughout society, the political determinants of health are the fundamental instigators of these unjust and inequitable outcomes.

NOT WITH STANDING ITS STATUS AS A WORLD leader in developing the latest health care advances as well as for spending on health care, the United States has continued to fall behind other developed countries in health rankings. Even though it spends more on health care than any other country and consumes more than half of the world's health care resources, the United States has seen increasing mortality and falling life expectancy for people ages 25–64, who should be in the prime of their lives. ¹ , ² When disaggregated by race, ethnicity, geography, and other demographic variables, the inequalities in health status and health care are quite striking.

It is now well understood and widely accepted that the social determinants of health affect all aspects of people's daily lives. In fact, it is known that the social determinants of health directly affect and often even determine or drive populations’ health choices and access to adequate, affordable, and nutritious food options; safe housing, blue and green spaces; reliable and safe transportation; education and literacy; opportunities for economic stability; and sanitation, among other important factors. In addition to genetics, health care, and behavior, the direct significance of all the social determinants of health variables and their contribution to health, wellness, and life opportunities have come to light. The clear link between health risks and the conditions of the places where people live, learn, work, and play have now been illuminated. ³

Health systems—organizations that provide health care services to populations in the communities they serve—are increasingly investing in programs and exerting influence over policies to address upstream determinants of health, which include the macrolevel forces that comprise social–structural influences on health and health systems, and the social, physical, economic, and environmental factors that affect health. In the United States, health systems, for example, have mostly invested in addressing the social determinants of health of their patient populations. From 2017 to 2019, health systems in that country collectively spent $2.5 billion on programs targeting social determinants of health. ⁴

Although these investments are laudable, it is important to understand what gives rise to the social determinants of health and—more importantly—why have they disproportionately and detrimentally affected historically marginalized communities and vulnerable populations for so long? Deeply entrenched and pervasive throughout society, the political determinants of health (PDOH) are the fundamental instigators of these unjust and inequitable outcomes. As part of the fabric of society, political determinants often go undetected, and worse, ignored—despite the incredible driving force they have on population health. Understanding this requires individuals to grapple with how the PDOH inequitably distribute social, medical, and other determinants and create structural barriers to equity for population groups that lack power and privilege. For virtually any social determinant of health, there was some preceding legal, legislative, ordinance, regulatory, or other policy decision that was first made, resulting in the subsequent social determinant. These decisions are the PDOH, which have significant influence on population health factors. Collectively, these determinants, experienced across the life course, are what have given way to health inequities.

All political determinants affect everyone because they encompass the systematic processes of structuring relationships, distributing resources, and administering power. However, there are stark differences in how negatively or positively they affect certain individuals and communities. For example, when a transportation policy removes a bus route that runs through a community with residents who heavily rely on affordable public transportation to get to health care appointments, the individuals and families living in that community suffer from a negative political determinant that creates an inequitable resource distribution of public transportation services. Forward‐thinking community health centers, hospitals, and other health care service providers have launched programs to pay for taxis and/or rideshares to bring people to appointments. However, such efforts—although effective in their immediacy—only treat the symptom, not the root cause of the problem. When such an affected community comes together to advocate for themselves, gathering momentum by convincing more individuals and even local businesses to join their effort, and when they succeed in getting their route reinstated, they have understood the chance to restructure their relationship with the transportation authority. They will have exercised the power inherent in understanding and addressing the PDOH.

The PDOH are equal opportunity offenders and create the milieu that benefit or undermine individual and population health. They result in all people on the social and economic downside of opportunity, access, and advantage—regardless of their political ideologies or how they vote—living and struggling with and suffering from less access to affordable, reliable health care; worse health outcomes; and greater risk for early and often‐preventable mortality. ⁵ Population health outcomes, like many health‐related issues, have separate and distinct political underpinnings that either help or hinder a person's ability to achieve an optimum level of health. These PDOH demonstrate a direct link to decisions made, or not made, in how health care is delivered, and accessed, as well as the level of quality available to patient populations interacting with the health care system. ⁶ They also directly impact social determinants of health, including poverty, housing, transportation, food security, and other community attributes associated with social vulnerabilities, which places populations at a higher risk for increased adverse outcomes. ³

PDOH create, perpetuate, or exacerbate the structural conditions and the social drivers—including poor environmental conditions, inadequate transportation, unsafe neighborhoods, poor and unstable housing, and lack of healthy food options—that affect all dynamics involved in health. ⁶ These determinants are more than merely separate and distinct from social determinants of health: They serve as the fundamental instigators of the social determinants of health. Although the social determinants are quintessential for understanding why so many disparate groups have historically faced, and continue to grapple with, health inequities, they do not paint the full picture of how these disparities may be addressed. Looking at health through the lens of political determinants means analyzing how different power constellations, institutions, processes, interests, and ideological positions affect health within different political systems and cultures and at different levels of governance. ⁷

Dawes explains that the PDOH “operate as a systematic process of structuring relationships, distributing resources, and administering power, all mutually reinforcing or influencing one another to shape opportunities that either advance health equity or exacerbate health inequities.” ⁶ In developing a deeper knowledge and understanding of the politics of population health management, it is important for health care providers, payors, and other stakeholders to understand, from a macro‐ and microlevel, how this systematic process operates and evolves to the benefit or detriment of population groups. Resource allocation strategies, health care plans, payment models including fee‐for‐service and value‐based care, and other incentive and monitoring programs directly impact how the health of populations are measured, reported, and ultimately acted on.

When current health inequity challenges are viewed through the PDOH lens, tangible and meaningful steps within the scope of human control emerge—actions that can be taken to more equitably and justly protect and preserve the health and well‐being of everyone. That statement—although arguably true—is not meant to suggest that it is an easy or straightforward path forward. However, the PDOH framework encompasses myriad points of influence within and throughout the social, economic, and political systems (e.g., voting, government, policy, etc.) that independently and in tandem exert positive or negative pressures on all individuals and communities. This paper explores the intersection of politics and population health, focusing on population health management specifically and providing a landscape analysis with implications for health equity. The intent is to understand past gains and successes, as well as failures and continuing problems, to discuss implications for policy, research, and leadership to design and support equitable population health management strategies.

Population Health Management

Population health management has become an increased area of focus and a central competency for stakeholders operating in the health care system including providers, insurers, consumers, and policymakers. ⁸ Despite the increased investment and strategic focus, there is substantial variation in incentive, measures, and underlying motivations that result in inconsistent population health practices. Even today, the term population health management is broadly defined, and there is little consensus for a unifying definition that encompasses the range and scope of the concepts included. Definitions of population health include the aggregate health outcome of health‐adjusted life expectancy (quantity and quality) for a group of individuals. ⁹ However, depending on the area of focus, this definition is sometimes expanded to include the economic framework and management practices for populations. ¹⁰ For organizations with a financial interest, this definition is often expanded to include measures for cost‐effectiveness and return on investment for population health management initiatives. ¹¹

For clinicians and other providers delivering care, however, the focus of population health management is often on the implementation of procedures and adoption of technologies to guide preventive care and disease management practices beyond an organization's brick‐and‐mortar locations into the environment where people live, work, and play. As such, the social determinants of health are heavily associated with specific measures in health outcomes and an increased interest in understanding the downstream impact of these determinants on the health of patient populations.

Motivations related to the scope of population health management practices are linked to the incentives, payment models, and strategic objectives of an organization. Payment models such as fee‐for‐service and value‐based care are strong incentives for how providers manage data and provide care. However, these models rarely incentivize preventive medicine and investments in programs created by and led in the community to directly combat the social determinants of health. A central challenge for advancing population health strategies for caregivers is aligning policies and payment incentives so that health care organizations can be financially sustainable and even rewarded for delivery of quality care. For example, the Medicare value‐based program to reduce hospital readmission (Hospital Readmission Reduction Program [HRRP]) was directly designed to improve communication and care coordination to better engage patients and caregivers in discharge plans. ¹² Programs such as these link Medicare payments to specific measures of success as defined in the purchasing program. HRRP has a demonstrated effect in improving care quality and reducing costly unplanned readmissions owing to adverse health outcomes if a patient is discharged too soon. ¹³

These conflicting definitions, goals, strategies, and prioritization among stakeholders are critical in understanding the political drivers in the context of population health management. Misaligned objectives contribute to increased complexity. Providers also face ambiguity on the health outcomes for populations they are responsible for and whether they should be held responsible for the health metrics of the communities they serve. Debates as to whether there should be incentives for providers to engage beyond their walls to understand community characteristics that impact health, including social determinants, and the extent to which these providers are held accountable to those outcomes continue to be an area for research and innovation.

Many health care systems have already engaged in the process of population health management by addressing the social determinants of health and how they manifest downstream as individual social needs. Knowingly or unknowingly, health systems pull levers that influence political, social, and structural determinants of health. At an organizational level, fiscal administration and decisions related to the direction of investments influence the level of care, quality of resources, and stability of services available to populations. Health care administrators, whether hospital executives or clinical directors, make strategic decisions to benefit and strengthen their programs. However, through understanding the reciprocal influences that pass among governments, health care systems, and communities, they can consider the broader influence of those actions on population health outside of their walls. In doing so, decision makers within the health care system may find it impossible to address the upstream social, economic, and political drivers of social inequality that harm population health. Certainly, those problems may seem insurmountable, and yet, in those cases, addressing the political determinants can arguably generate the impactful changes that are needed to reduce inequities and improve population health across the board.

Measuring and Actualizing Health Equity

Quantifying population health in terms of health outcomes and understanding the differing dynamics among groups of people is closely related with the measurement of health equity. Comparing outcomes among populations but, more importantly, going deeper into linking those outcomes to the social and political drivers continues to be an area of research in need of further attention. By understanding these determinants, their origins, and their impact on the equitable distribution of opportunities and resources, health care providers would be better equipped to develop and implement actionable solutions to improve health outcomes for everyone and more effectively close the health gaps among populations served.

The politics of health is complex and riddled with challenges. Creating equitable policy continues to be as much a challenge today as it was in 2010 when the Affordable Care Act (ACA) was enacted. But one less contentious area of health policy that has realized bipartisan support over the last 12 years is health care delivery and payment system reforms, including value‐based care and quality‐improvement programs. This area of health policy provides opportunities to address population health management issues confronting health care systems. For example, programs made possible through the ACA such as incentivizing providers to adopt and meaningfully use electronic health records and other health care information technology solutions are encouraging steps toward reducing the data gaps and producing more equitable data. This push—creating and advancing equitable health policy and controlling the downstream impacts—is an intense area of interest not only for health equity but for public and population health as well.

Velasquez and colleagues have posited that although health care institutions “have narrowly interacted with and focused on the political determinants of health through associations, alliances, coalitions, networks, and governance boards or councils by supporting or opposing policies that impact hospital revenue streams,” they are increasingly investing in efforts to address the PDOH by “upstanding voter registration drives and advocating for bold public policies to improve population health.” ⁵ They argue this shift in engaging in efforts to address the PDOH as follows:

…may be driven by the relationship between PDoH and social determinants of health or a sense of duty to holistically serve communities and promote anti‐racist policies and interventions, especially in the face of ongoing health inequities, many of which have been exacerbated by the Covid‐19 pandemic. Some health institutions may also be incentivized to engage with the PDoH out of self‐interest, such as positive media coverage, financial gain, and the countervailing freedom to advocate for less popular fiscal‐related policies. Regardless of the intent, the social, political, and economic power that health institutions harbor, such as high public support, tremendous lobbying power, and strong operating margins (outside the Covid‐19 pandemic), warrants a discussion of their actions with the PDoH. For any progress to be made in nullifying and rectifying the negative effects of the social determinants of health, addressing these upstream factors must be a priority for advancing all equity needles, including health.

As outlined by Dawes in The Political Determinants of Health, there are three major aspects of PDOH: government, voting, and policy. ⁶

Government

Governments have a central role influencing the upstream and downstream drivers of population health and addressing the diverse, interconnected variables that impact these characteristics. Government at every level can introduce barriers to care—including challenges in access and quality—or they can resolve those barriers either through political action or inaction. Addressing these barriers, either by generating policies that have a demonstrated impact on population health outcomes or through investments and resource allocation decisions to target the source of health inequities are among the many tools governments have as officials consider health equity in the context of population health management.

Voting

Multiple stakeholders are involved in shaping voter and civic participation. Individuals from the community, advocacy groups, health care providers, health care systems, and other commercial interests such as Group Purchasing Organizations may shape policy that determine the investments or divestments made at the local and national level. This is evidenced in the definition and measurement of population health. Understanding how the health of populations are quantified and ultimately acted on, in context of a stakeholder's relationship to the communities they serve, can shift based on how population health is defined and incentivized in addition to each stakeholder's role in the health care system. The environment these stakeholders operate in, the policies and laws they are bound by, and measures of performance are all influenced by voting.

Installing policymakers who influence the structuring of relationships, distribution of resources, and administration of power at the local, state, and national level demonstrates a strong association to the health outcomes of those communities. Engaging in the democratic process through voting is one way citizens influence or indicate support for policy that directly impacts the health outcomes of communities. Policies that determine the minimum wage, work conditions, and budgetary decisions that direct resources toward (or away from) education, child development, housing, and social services are all influenced by voter participation and have a material impact on the social determinants of health, which ultimately impact population health overall. ¹⁴ As such, it is critical to consider voting and voter participation as key PDOH. According to Velasquez and colleagues, “Voters, with or without the support of elected local and state representatives, can advocate for policies that reduce health inequities within their communities. For example, statewide ballot initiatives to expand Medicaid or strengthen tenant protections through rent control demonstrate how voting impacts a person's environment, and ultimately their health.” ⁵

Policy

As a mobilization of governance, policy is the distribution of power and resources that can either advance or hinder population health outcomes. The distribution of health characteristics, such as the incidence and prevalence of diseases among certain populations, requires a holistic policy approach to address remediation efforts as well as the acknowledgment that many of these conditions are avoidable and responsive to remediation. Policies designed to influence population health management through the social determinants of health and PDOH such as expanding care access by removing structural barriers, improving quality of programs especially in underserved communities, and aligning payment reform programs to improved patient care delivery metrics for health care providers are strategies that demonstrate how policy can be used to improve population health management practices for all stakeholder groups.

Past Gains and Successes

The National Working Group in 2009 laid the foundation for how equitable policy could be structured. ¹⁵ Efforts to create equity‐focused legislation to support high‐quality, affordable health care coverage to all populations, and especially to groups that have historically suffered an unjust burden of disease or have experienced other barriers in coverage, became central to planning and development. Ensuring access and improving programs to reduce cost, availability, cultural competence, and more also became important dimensions. The understanding of the necessity of high‐quality, complete, and equitably collected data also became an area of special interest as conversations and planning matured. Provisions focused on preventing avoidable long‐term health conditions from going undetected and worsening became a central pillar to include in population health management plans.

Promising gains have been made in terms of policy enactment since the ACA. Policymakers continue to recognize the disparities experienced by populations and the existence of the social and structural barriers that drive them. Legislation focused on improving access to health care services and increasing diversity, training, and representation in the health care workforce has been successful at the state and federal level. Expansive growth in the formation of advocacy groups, committees, education, and research with a focus on health equity and driving down disparities is a promising indicator of mobilization. One of the major priorities of health law is prevention of chronic disease and improving population health. However, before the ACA, millions of Americans were enrolled in plans that did not cover preventive services.

Many gains, however incremental, have been met with roadblocks or downright failures, which was observed when addressing disparities. Specifically, discussions aimed at addressing racial and ethnic disparities in health policy were often perceived to be too contentious to incorporate in larger health reform policy efforts. ¹⁵ Law makers, therefore, oftentimes avoided inclusion of any language specifically addressing health inequities when addressing health reform issues in general. ¹⁵ In addition to political division, the rollout of a federal statute such as the ACA also came with some complexities and challenges in itself.

Despite the challenges faced, there were some opportunities for common ground. Medicaid expansion under the ACA expanded treatment options for individuals with opioid use disorder (OUD); it was the only portion of the ACA that achieved bipartisan support that was a success. ¹⁶ Mandating substance use disorder treatment as defined in Title 1 of the ACA led to a net increase in utilization of treatment services. Providing services to populations that previously had limited options for OUD, not just based on geographic distance but other limiting factors such as cost and outreach, had a demonstrated impact on reducing overdose deaths and can now serve as an important lesson in the importance of expanding access to care.

Expanding Access, Improving Quality, and Realizing Value

Limited access to health services is a key barrier for improving both population health management and population health outcomes. Many people face challenges in accessing the care they need whether because of structural, economic, or social characteristics that limit their ability to acquire timely care; this is especially challenging for chronic disease management. Deterrents in accessing resources in the community and access to care providers for conditions such as diabetes and cardiovascular disease and for routine dental and preventive care visits include out‐of‐pocket costs, poor access to transportation, inflexible work schedules, limited childcare, and many other factors.

Therefore, it is no surprise that many health equity advocates push strongly for expanding access to care and to boost resources to reach the most vulnerable. Uninsurance and underinsurance are one of the largest barriers to accessing health care services. ¹⁷ Cost of doctor visits, medications, and other services cause many individuals to skip or reduce the frequency of visits. Approximately 10% of adults in the United States reported a time in the past year when they needed to see a doctor but were deterred because of the cost. ¹⁸ Similarly, populations facing poverty can be deterred by inflexible work schedules and limited or no benefits, such as not having paid time off or sick leave, that introduce additional barriers in care access. Barriers that decrease access to services have a demonstrated link to an increase in adverse health outcomes. ¹⁹

Aside from out‐of‐pocket costs to patients and payers, health inequities directly drive overall cost for the health care industry. Socioeconomic, racial, and gender inequities in health care account for nearly $320 billion in excess annual spending and could account for $1 trillion or more by 2040, according to an analysis from Deloitte. If these inequities remain largely unaddressed, health care spending for the average American could rise from $1,000 annually today to $3,000 by 2040, and historically underserved communities could be disproportionately affected. ²⁰ Assessing direct costs to patients and families and overall health care expenditure as a nation is an important consideration, and health inequities, especially for patient populations managing chronic disease, continue to rise.

There is, however, an important difference in expanding access for those without and improving utility of care for those individuals already with a certain level of access to health care services. Improving the utility of benefits and other resources so individuals can access preventive services routinely promises improved population health outcomes. The advancement of policy to target programs that increase utility can be of special interest. For example, increasing social services for nonnative English speakers and other culturally aware services to improve institutional trust and to ensure medical services or other screenings are offered consistently to various populations, regardless of differences in race, ethnicity, and other demographic variables. ²¹ As a result, programs that expand existing access can be introduced concurrently with programs that provide access for those without—thereby reaching different populations with targeted interventions.

Expanding access and improving health care delivery to create equitable policy and practices within the health system is central to population health management. We have learned during the COVID‐19 pandemic that a diverse, multidisciplinary approach is most effective in reaching the most vulnerable and at‐risk populations. These concepts can be applied to reach populations at all levels.

Learning from the COVID‐19 Syndemic

The national conversation regarding population health management has shifted pre‐ and postpandemic. There is increased demand for policies that support public health infrastructure. Innovative areas of research and emerging data devoted to population health, documenting disparate impact among racial and ethnic groups, and understanding the social and political drivers of undue burden of disease among populations were brought to national spotlight as COVID‐19 ravaged communities and the impact was felt differently among demographic groups. We have learned during the pandemic that not all populations have the same access to resources or the same exposure to risk. How care is delivered to patients has changed drastically. Increased reliance on technology has widened the digital divide in terms of access and options for patients. Further, government response during the pandemic such as mask mandates and social distancing guidelines varied among localities, and researchers are still working to understand the long‐term effects of these decisions. As a result, it is more important than ever to integrate technology to empower informed decision making that is driven by data. Demographic‐based disparities as evidenced by data can lead to innovations in outreach, treatments, and disease management practices that further the scope and reach of population health management practices.

Integrating sound data science methodologies to harness the power of data will lead to better understanding of patient populations and new grouping and characterizations of populations that are not strictly based on geography or demographics. Grouping populations by exposure to risk, vulnerability, and other health equity indicators could lead to new segmentations and analytical approaches in deriving meaning from data collected. Supplementing data with novel visualization techniques to create actionable and representative data is another area of opportunity. Huge volumes of data are generated, but there is an increasing challenge to integrating the data to care plans and ensuring that data are used effectively to guide best practices at the point of care. Actionable data can empower health care providers and policymakers to target specific interventions quickly for those most in need. Understanding populations who are most at risk and being able to proactively identify them by leveraging data analytics will empower providers to reach patients in a timely manner, and with the right information and resources, to mitigate the most adverse health outcomes for populations.

Forward Thinking: The Next 10 Years

The case for advancing health equity and for aligning specific, measurable, and targeted interventions in terms of population health is directly related; one cannot exist without the other. These interventions, influenced through voting, government, and policy will continue to shape research into understanding of the PDOH. Medicine will continue to incorporate social histories to create individualized treatment plans taking into consideration not only a patient's genetic makeup but their environmental conditions and personal histories as well. Many providers today consider a patient's social history in the care plan, and this practice will continue to mature as data collection and reporting improves. Relationship management will become more central for providers at every care setting. Electronic record systems will provide patient histories that include previous encounters, treatments, and data on the long‐term management of disease and even linking health outcomes to specific determinants in a patient's social environment. Considering the individual characteristics of a patient and moving away from a one‐size‐fits‐all approach will continue to gain traction as research and implementation strategies grow. Although all of these are prime examples of individually tailored approaches that are often not seen as being population health specific per se, it should be noted that each individual has a direct impact on the total effect of its population, as this is a “sum‐of‐its‐parts” game.

Equitable health care delivery and efforts to bridge the gap between health outcomes and their sociodemographic and political drivers will continue to be fueled by data collection efforts. Researchers will miss key insights into population health outcomes and management practices when they lack meaningful data. Currently, there are widespread and significant gaps in data that limit our understanding into health inequities and their root drivers in the social determinants of health and PDOH. For example, as of February 2023, there are missing race and ethnicity data for over 50% of COVID‐19 cases in the state of Georgia. ¹⁸ Meaningful interventions will continue to be limited if researchers, policymakers, public health leaders, and health care administrators do not know the whole story of who is impacted and why. Tools and data platforms that ingest large volumes of information to produce representative data will continue to be an area of innovation for all stakeholders in the health care and policy sector. Equitable data collection practices that produce complete, representative data will empower resource allocation decisions to know when and where to provide timely resources and in the appropriate amount specific to each population's needs.

The question of incentivizing population health management is another area for potential advancement over the next 10 years. Incentivizing payers to incorporate payment models that can improve member health by valuing interventions at the right time for the right populations can drive behavioral changes, especially for chronic disease management practices. The expansion of value‐based programs, particularly in clinic settings, will be key as hospitals move away from volume‐based payment models to programs that reward the achievement of benchmarks in population health metrics.

Aligning politics and population health is a multifaceted initiative. Policies that harm populations and further drive inequities in health outcomes exist and are broad in scope and impact. These interconnected and dynamic forces interact to produce disparate health outcomes throughout all aspects of our lives. Zoning codes, historical redlining, and unfair lending practices all have deeply embedded political roots, and all have demonstrated the ability to generate inequitable conditions. Unfair policies have led to decades of generational harm that continue to exist today. ²² Initiatives that prioritize research to assess actionable policies and operational best practices have the potential to counteract the harms of structural and systemic racism and improve population health management as we build toward the future. To move from simply naming inequities to addressing inequities, work must be performed upstream to address the root causes. Consequently, it is important to understand how PDOH leave all people on the social and economic downside of opportunity, access, and advantage—regardless of their political ideologies or how they vote—living and struggling with, and suffering from, less access to affordable, reliable health care, worse health outcomes, and living at greater risk for early and often‐preventable mortality.

Conflicts of Interest Disclosure: The authors have no conflicts to report.