M2.2 - Structural and Social Drivers of Health and the Role of Law in Optimizing Health

drivers to health

• according to CDC, “drivers” or “determinants” of health are “factors that contribute to a person’s current state of health”

• drivers contribute to health and healthcare disparities

  • what is “disparity”? (differences)

  • what are disparities?

health and health care disparities

• differences in health and healthcare between population groups

  • what is health disparity?

    • differences in health

    • ex: mortality rate, disease prevalence

  • what is healthcare disparity?

    • resources/activities that make you who you are

    • ex: access, quality, cost (healthcare triangle)

  • what is health equity?

    • getting what you need

    • not equality

• disparities in health and health care are a systematic and deeply challenging problem in the US

  • has been happening for years, groups imposed keep growing

factors contribute to disparities

• many factors contribute to health and healthcare disparities, including:

  • race

  • SES

  • geographical location

  • individual behaviors

  • healthcare provider bias

  • cultural expectations

disparities

• disparities appear through different lenses

  • race, ethnicity, SES, age, geography, language, gender, disability status, citizenship status, and sexual identity & orientation

structural drivers of health

• the “root”’ “upstream”, or “top-level” causes of population level health inequities

  • nations’ system of governance

  • laws

  • public policies (such as housing, education, wage, etc.)

• how society operates

  • shape the distribution of power, resources and opportunities across the population

• outside the direct control of individuals

• some of the policies, institutions, systems, norms, and practices are outdated

  • racism and discrimination

social drivers of health

• social conditions into which people are born and that affect their daily lives and overall well-being as they move through life

  • “The conditions in which people are born, grow, live, work and age.” (WHO)

  • SDH are shaped by the distribution of money, power, and resources at both local and national levels. (CDC)

• “social determinants of health”

types of social drivers of health

• access to high-quality educational opportunities

• access to medical care services

• access to social media and other technologies

• availability of community-based resources and opportunities for recreational activities

• availability of resources to meet daily needs

• culture

• language/literacy

• public safety

• residential segregation

• social norms and attitudes

• socioeconomic conditions

• transportation options

link between social drivers and health outcomes

• while most diseases and injuries have multiple causes, and while several factors and conditions contribute to a single death, the overwhelming weight of evidence demonstrates the powerful effects of socioeconomic and related social factors on health

  • people with better SES have better health outcomes

is law a social determinant of health? why?

• yes, the law plays a profound role in shaping life circumstances

5 ways law shapes life circumstances (and health)

• can be positive or negative

• design & perpetuate social conditions

• transformed behaviors and prejudices into distribution of well-being among populations

• determinative of health through under-enforcement

• determinative of health through interpretation

• structure direct responses to health-harming social needs

the law can be used to design and perpetuate social conditions that can have terrible physical, mental, and emotional on individuals and populations

• Jim Crow laws (no longer use it)

• ways the government uses the law to protect people

  • the age discrimination in employment act of 1967

  • the pregnancy discrimination act of 1978

the law can be utilized as a mechanism through which behaviors and prejudices are transformed into distributions of well-being among populations

• incarceration rate

• healthcare discrimination (people with disability or low income)

law can be determinative of health through their under-enforcement

• residential lead-based paint hazard reduction act of 1992

  • landlord has to tell you of lead-based paint

law can be determinative of health through their interpretation

• how the judge interprets them

• medicaid expansion in the ACA

  • the states should have more power of Medicaid expansion which was interpreted by the Supreme Court

the law can be used to structure direct responses to health-harming social needs that result from things like impoverishment, illness, market failure, and individual behavior that harms others

• EMTALA

  • federal law to prevent ER patient dumping

• indian health service (IHS)

• texting and driving policies

• bicycle and motorcycle helmet laws

HIAP strategy

• health in all policy strategy

• “Collaborative governmental approach to health improvement by incorporate health consideration into an array of policy decisions, and by engaging governments and other stakeholders in a multi-sector approach to shaping the economic, physical, and social environments in which people live, work, and play”

right to criminal legal representation

• the government is required to provide legal counsel to criminal (NOT civil) defendants who are unable to afford their own attorneys (Sixth Amendment to the US Constitution)

  • Gideon v Wainwright (1963)

    • couldn’t afford a lawyer, sentenced 5 years studied law, represented himself, court believed he was deprived of right to lawyer

civil legal assistance

• there is no right to the assistance of a lawyer in civil matters

  • immigration status, domestic violence, disability law, family law, housing needs, public benefits

  • varied by state laws

• civil legal aid or civil legal services

  • promote strategies to address the severe gap in access to both criminal and civil justice for low-income and vulnerable population

medical-legal partnership (MLP)

• many “life circumstances” issues are unfixable by healthcare providers alone

• improve social conditions via civil legal assistance

• MLP includes both medical and legal professionals

• crate an interconnected care system that focuses on the whole patient, including the ways in which myriad social conditions factor into individual and population health

benefits of MLPs

• from small-scale studies:

  • impact on patient health and well-being

  • financial impact on partners and patients

  • impact on knowledge and training of health providers