Corporate Efforts to Adopt and Distort the Social Determinants of Health Framework

When the corporate class adopts concepts championed by progressives, it is both encouraging and concerning. That's why we have mixed emotions about the current corporate vogue for Social Determinants of Health (SDOH). When the UnitedHealth Group—a U.S. health insurance firm with $287.6 billion in revenues and $17.3 billion in profits in 2021 ¹ —declares its commitment to “Advancing Health Equity Through Social Determinants of Health” ² and Envision Healthcare (owned by the giant investment firm KKR) commits to “educating stakeholders about these [SDOH] factors and their impact on health equity,” ³ we’re by turns glad and worried.

The modern understanding that social conditions decisively shape health traces to Friedrich Engels, Karl Marx's partner in revolutionary analysis and advocacy. Engels’ meticulous dissection of statistical and sociological data on England's working class led him to ask: “How is it possible, under such conditions, for the lower class to be healthy and long-lived? What else can be expected than excessive mortality, an unbroken series of epidemics, a progressive deterioration in the physique of the working population?.” ⁴

Rudolf Virchow (physician-revolutionary and founder of the public health movement and of modern pathology) sounded a similar note in his 1849 report on the typhus epidemic in Upper Silesia: “There cannot be any doubt that such a typhoid epidemic was only possible under these conditions and that ultimately they were the result of the poverty and underdevelopment . . . . If you want to intercede in Upper Silesia, you must start by inciting the population to the united effort. Education, freedom, and welfare can never be fully attained from the outside . . . but from the people's realization of their real needs.” ⁵

Much of the public health community came to acknowledge the social etiology of disease. Notably, the Black Report, commissioned by Britain's Labour government in 1977 (but issued after Margaret Thatcher came to power), and the 1974 Lalonde Report in Canada ⁶ sounded similar themes. “While the health care service can play a significant part in reducing inequalities in health, measures to reduce differences in material standards of living at work, in the home and in everyday social and community life are of even greater importance.” ⁷ Such unpalatable conclusions led Thatcher's government to try (unsuccessfully) to bury the document by issuing it during the August Bank Holiday and distributing only 260 copies (oddly, we got one).

Similar calls to address social class inequities in health followed, most prominently the World Health Organization's Commission on Social Determinants of Health's 2008 report, “Closing the Gap in a Generation.” ⁸

But neither that report nor most other SDOH analysts and advocates followed Engels and Virchow in analyzing the roadblocks to needed social interventions inherent in capitalism. The Latin American Social Medicine movement is a notable exception. It has critiqued the SDOH approach for failing to elucidate the roots of individual social determinants (e.g., food insecurity) in the complex web of political, economic, and social power. ⁹ Howard Waitzkin introduced this critique to English-language readers and excavated and extended Engels’ and Virchow's observations. ¹⁰ And (as Virchow's translators noted) “Vicente Navarro has . . . himself published a series of masterful papers and monographs, and through his editorship of the International Journal of Health Services he has brought about a renaissance of the kind of critical analysis exemplified in Virchow's 1849 Report.” ⁵ (e.g., see Navarro ¹¹ ).

Although few in Europe or North America followed Navarro or Waitzkin in identifying a transition from capitalism as a prerequisite for fully addressing SDOH, until recently, most at least advocated a vigorous social democratic program that would redistribute resources and, to some extent, power.

But that has changed over the past decade, at least in the United States. Firms and organizations squarely in the seat of power (and responsible for many of the inequities that undermine SDOH) have come to embrace SDOH, at least rhetorically. UnitedHealth isn’t alone. A recent article by AHIP (America's Health Insurance Plans), the private health insurers’ trade and lobbying organization, touted more than 320 actions by private plans to address SDOH. ¹²

Meanwhile, politicians of all stripes have adopted the rhetoric of SDOH. The Trump administration's embrace of SDOH took a particularly Orwellian twist in a 2018 letter encouraging state officials to deny Medicaid coverage to poor individuals who remained unemployed: “While high-quality health care is important for an individual's health and well-being, there are many other determinants of health. . . . CMS recognizes that a broad range of social, economic, and behavioral factors can have a major impact on an individual's health and wellness, and a growing body of evidence suggests that targeting certain health determinants, including productive work and community engagement, may improve health outcomes.” ¹³

Subsequently, the Trump administration promulgated regulations that encouraged the privately managed care plans that subcontract to provide Medicare coverage (and derive tens of billions of profits from those contracts each year) to pay for “SDOH interventions” (e.g., air conditioners for their enrollees with asthma). ¹⁴ By the time of Trump's reluctant departure from the White House, encouraging Medicaid programs to adopt a broad range of SDOH interventions had become official policy. ¹⁵

The Biden administration has ramped up financial incentives for insurers and health systems to intervene in SDOH. The Medicare REACH program, which will direct even more Medicare funds through privately managed care firms, requires that those firms collect data on SDOH among enrollees and develop intervention plans. The promise of a growing market for SDOH data and interventions—both to meet Medicare's current requirements and to game future Medicare incentives likely to offer SDOH-based bonuses—has spurred private equity firms to pour $2.4 billion into for-profit SDOH firms (e.g., those selling tools to measure patients’ or populations’ SDOH), whose total value now tops $18 billion. ¹⁶

Is it bad that authoritarian politicians and rapacious private firms and investors have embraced SDOH? Hitler's embrace of the term “National Socialism” didn’t turn socialism into a bad thing.

The most obvious, though not widespread, problem is the use of SDOH arguments to justify attacks on SDOH—for example, the Trump administration's endorsement of purging unemployed people from the Medicaid rolls.

But private insurers’ and health care investors’ adoption of the SDOH framework is also problematic. Extracting profits from their workers, patients, and taxpayers is their raison d’etre. Medical debts, driven by the inadequate coverage that insurers promulgate to maintain profits, undermines SDOH—causing food and housing insecurity, and even eviction. ¹⁷ The low wages inflicted on millions of health care workers—especially women of color employed in the for-profit-dominated nursing home and home care industries—leaves 1.7 million of them and their children below the poverty line, and more than 10% without health insurance. ¹⁸ And insurers and health firms spend vast sums lobbying to block policies that would redistribute wealth and income, key determinants of many other SDOH.

The corporate uses of SDOH are akin to oil firms’ (and Saudi Arabia's ¹⁹ ) green initiatives; “greenwashing” their immoral conduct, as well as creating future profit opportunities by molding policy responses to the damage they have caused. The medical–industrial complex uses its dominance of discourse on SDOH to deflect the identification of capitalism as a driver of ill health.

Current approaches to SDOH in the United States pose at least two additional threats. First, vesting the commercially dominated health sector with the responsibility to address SDOH effectively privatizes a broad range of social welfare interventions. Should insurance and hospital firms determine who receives housing, transportation, or food subsidies—all ultimately paid from government funds? Should seniors who opt for traditional (publicly administered) Medicare coverage be excluded from benefits available to those choosing a privatized Medicare Advantage plan?

Finally, in the U.S. context, calls to shift funding from medical services to SDOH interventions ²⁰ will surely take medical resources from the poor and minoritized patients who are already medically underserved,^21,22 rather than from the bloated care of wealthy Americans.

There can be no doubt that the way people live and work are the most important determinants of their health, and exploring the social determinants of health must remain a central priority for this journal. But the progressive analysis must go beyond conceiving of SDOH as a laundry list of social factors that influence health and focus attention on the political–economic arrangements that cause the maldistribution of those factors. Absent such analyses, SDOH insights risk being twisted by powerful corporate actors to nefarious purposes, and uncritical embrace of their SDOH discourse may bolster the power of those most responsible for undermining health.