The Intersection of Social Determinants of Health  with Health Insurance  and their Association with Mortality

Wang, Andrew C

doi:https://doi.org/10.21985/n2-62ej-0x82

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The Intersection of Social Determinants of Health with Health Insurance and their Association with Mortality

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Social factors are a major contributor to deaths in the US. The literature suggests that socioeconomic status and other social and environmental factors influence an individual’s mortality. These factors encompass six domains that comprise factors such as poverty, unemployment, poor access to healthy food, limited access to health care, limited education, and neighborhoods with vacant homes, which together represent characteristic of the Social Determinants of Health (SDOH). In particular, patients with chronic diseases suffer from health disparities because of variation in SDOH characteristics, even among patients with diseases that are preventable and treatable. Thus far, health policy has primarily focused on addressing health outcomes by improving access to care, such as the passage of the Affordable Care Act (ACA). However, relevant to health policy, there is still a current gap in knowledge in understanding how health insurance interacts with SDOH and how its integration will impact mortality among individuals with care utilization in inpatient and emergency department care settings. Using inpatient (years 1995 to 2014) and emergency department (years 2005 to 2014) claims data from two large states (California (CA) and New York (NY)) linked to SDOH measures from the US Census, the United States Department of Agriculture, and the Dartmouth Atlas, we addressed this key gap in knowledge as it relates to social and economic risk factors and health insurance. Using the Anderson healthcare utilization and outcomes model, the objectives of this dissertation were to: (1) develop a novel SDOH index measure that comprises all six SDOH domains and compare it to other known socioeconomic indices in estimating all-cause mortality; (2) estimate the association of all-cause mortality with SDOH relative to the six individual SDOH domains, among adults with cardiovascular and cerebrovascular disease with a comparison to pneumonia; and (3) evaluate the interaction of health insurance with SDOH and its relationship with all-cause mortality among adults from inpatient and emergency department settings. In all three studies, we identified adult patients with hospitalizations and emergency department visits from CA and NY. We first showed that an SDOH index measure, which comprised all six SDOH domains, could be developed and was comparable to other socioeconomic and deprivation measures. We next found that hospitalized and ED patients had lower all-cause mortality among those with better SDOH characteristics considered as higher socioeconomic status. In addition, lower all-cause mortality was also associated with better SDOH characteristics for patients with chronic diseases (cardiovascular and cerebrovascular diseases) relative to acute diseases (pneumonia). The privately insured patients had higher survival than other insurance groups. Importantly, patients with better SDOH characteristics had lower mortality for those with private insurance or Medicaid. Overall, this work expands upon existing knowledge in two main areas: SDOH and health insurance. Our results show the importance of prioritizing and addressing SDOH characteristic in preventing both short and long-term mortality after an inpatient or emergency department admission, especially among patients with preventable and treatable cardiovascular and cerebrovascular diseases compared to pneumonia.

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