Social determinants of health: an economist’s view [PODCAST]

Matthew Arnold discusses social determinants of health with Dr Kenton Johnston, PhD, Associate Professor at Saint Louis University



Social determinants of health are increasingly focus for policy makers and patient advocates in the healthcare industries. They are looking beyond clinical environments for factors that can contribute to illness, whether that’s lack of health insurance or living in a so-called food desert without access to fresh produce and other health foods. In the U.S., we see enormous disparities in health outcomes and access to care because of these factors.

For example, in September, the Washington Post reported that one in 1,300 White Americans died of COVID-19 while among Black Americans who continue to face systemic racism in many avenues of life including healthcare, that number was one in 480. One in 390 Hispanic Americans died of COVID-19 as had one in 240 Native Americans.

Matthew Arnold, Principal Analyst at Clarivate, recently spoke with Dr. Kenton Johnston, a health economist who teaches at Saint Louis University’s College for Public Health and Social Justice. Dr. Johnston has done a lot of research on barriers to healthcare impacting racial and ethnic minorities in America and on Medicare.


Matthew Arnold:
You’re based in St. Louis. What do social determinants of health look like in St. Louis?


Dr. Kenton Johnston:
It’s important to be really concrete and specific when we talk about things like social determinants of health, health disparities and health inequities because these terms are often thrown around in ways that are very abstract. In order to really understand them, it’s important to be concrete. One way of being concrete is talking about geography, and a lot of social determinants of health are very much tied to geography and, in the city of St. Louis, to local geography.

In the city, there is what’s often called the Delmar Divide. Delmar is a street in St. Louis that runs east to west and divides North St. Louis from South St. Louis. North of Delmar, north of the Delmar Divide is very racially segregated and also segregated by socioeconomic status. In North St. Louis, a much larger proportion of the population would be Black or African American. You immediately notice things like housing. There’s a lot of undeveloped housing, a lot of housing that hasn’t been kept up, and a lot of this goes back, if you really want to understand it, to the practice of redlining where Black or African American homeowners were kept out of certain areas of St. Louis.

When we use terms like structural racism or structural inequities, there’s actually a literal, concrete line in St. Louis that’s associated with those. Access to grocery stores is not good in North St. Louis. Access to healthcare is not good. It’s a pretty marked difference when you drive around in North St. Louis. You’ll notice it right away if you don’t see nice shiny new outpatient health facilities or hospitals, for example.

The other geographic social determinant of health in St. Louis would be East/West. As you move west in St. Louis, away from the Mississippi River, away from Illinois and away from East St. Louis, it gets wealthier and wealthier, and Whiter and Whiter. This is a legacy of the practice of redlining and the practice after the 1950s when people fled to the suburbs. The reason I’m bringing it up, is when it comes to access to healthcare, the access that you’re going to get in the county, in the St. Louis area, West County, is very different. You can see it in the hospital buildings and the outpatient facility buildings.

St. Louis is kind of a microcosm of what goes on in a lot of American cities. This isn’t unique just to St. Louis. Things like access to high quality healthcare are geographically determined based on race and etFhnicity, based on some historic structural practices that led to racial segregation, and by socioeconomic status, because as people fled to the suburbs or as red lining occurred and people were segregated in these different areas, home values and economic value of the area of North St. Louis went way down, and they’re still much lower than if you go south of Delmar or to West St. Louis. Really, geography is very important, and it is a determinant of health in St. Louis.


“Really, geography is very important, and it is a determinant of health in St. Louis.”

Dr. Kenton Johnston, Associate Professor of Health Management and Policy at Saint Louis University


Matthew Arnold:
There are far fewer healthcare facilities in poor neighborhoods and Black neighborhoods in St. Louis. On top of that, lower income people, and disproportionately Black people, are more likely to be uninsured or underinsured, is that correct? There’s a number of problems here. People can’t access care financially, and they can’t access care physically.


Dr. Kenton Johnston:
Yes, in poorer areas, there will be things like federally qualified health centers, which it’s great that they’re serving a poor population; however, it’s pretty evident when you enter these kinds of facilities and compare them to what people are getting in the richer area – the Whiter area in Western St. Louis – there’s a pretty big difference. One facility is state-of-the-art, very inviting and welcoming versus the other facility, it’s probably understaffed, under-resourced, and doesn’t have the same resources as richer areas.

In the middle of St. Louis, the two universities, Saint Louis University where I’m at, and Washington University in St. Louis, both are affiliated with large hospital systems that provide a lot of charity care and care to Medicaid patients, in particular. Some doctors won’t accept Medicaid or limit their patient panels because the payment rates to doctors and hospitals are so low. If you’re a doctor, you have to stay in business, and you might not be able to do that if you serve a high proportion of Medicaid patients.


Matthew Arnold:
Not only does the healthcare system adversely impact some patients, but it adversely impacts the healthcare professionals and the provider institutions that care for those adversely impacted populations. It’s kind of a medical double jeopardy.


Dr. Kenton Johnston:
Yes. It really is. It’s unfortunate because we want doctors and hospitals to be part of a safety net that serves the most vulnerable patients. It does end up impacting them in some ways negatively – one example is CMS hospital star ratings. If you look up the hospitals in the city of St. Louis that serve more socio-economically at-risk patients, their star ratings are a lot lower than if you go West out to the county and look at the star ratings of those hospitals.

There is always an argument from the hospital executives, that they serve a sicker, more at-risk population, so they are going to have poorer outcomes. This is partially true, and then the counter argument is that the care that they are providing isn’t as good to these lower income, more vulnerable populations as the care they are providing in the county. There is evidence that suggests both of these things are true. They’re not mutually exclusive.


Matthew Arnold:
Is there any way to know how much of one and how much of the other?


Dr. Kenton Johnston:
That is part of the job of economists using appropriate methods to try to, what economists would say, decompose or identify how much is due to actual lower quality of care versus how much is due to the risk of patients. One way of doing this is to take a single hospital and look at the care that hospital provides to different types of patients versus comparing that hospital to another hospital. I won’t get into details on these methods, but there are ways of doing it.


The above is a partial transcript from this episode, additional questions discussed include:

  • Why have we seen such little progress in disparate outcomes over the last 10 years since ACA was passed?
  • What is the next big healthcare policy challenge in the United States?
  • How has the introduction of accountable care organizations in Medicare impacted the healthcare system?
  • What role do clinicians and other stakeholders in the healthcare landscape–including insurers and drug and device companies–have in addressing social determinants of health?


Click here to listen to the full episode.

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