over the past three decades has demonstrated that population health
is shaped powerfully by “[t]he 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 (WHO), the
Centers for Disease Control and Prevention (CDC),
and the Robert Wood Johnson Foundation (RWJF),
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 RWJF report 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).
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 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 United States
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 undeniably a
public good, but the stakes are too high for the public—and health
law scholars—to continue neglecting the robust social structures that
are shaping America’s well-being. Compared to other countries
with our resources, and even some countries without them, we are doing
poorly, and it is well past time we all got sick of it.