What We Need To Be Healthy—And How To Talk About It

In COVID-19’s wake, millions of Americans have been struggling with the basics—feeding their families, paying their rent, or earning enough to make ends meet—at unprecedented levels, especially in communities of color. Faced with the convergence of their patients’ clinical and economic needs, front-line physicians and other health care providers have been likewise taxed as never before. The distribution of the COVID-19 vaccine is beginning to ease these twin clinical and economic crises, but slowly and only partially.

As federal and state policy makers grapple with how to best mitigate COVID-19’s devastation, and health care institutions seek to make real their stated commitment to patient-centered care, we would point them to insights from those closest to these challenges: people in communities and the providers who care for them.

Our organizations—Blue Cross Blue Shield of North Carolina and the North Carolina Medical Society (NCMS)—partnered with The Health Initiative (THI) to understand how North Carolinians think and talk about health. This research yielded two key insights, which should inform the decisions of policy makers, payers, and providers: First, while health care may be a politically divisive issue, health can be a unifying one, with voters agreeing on what they need to be healthy. And second, the language we use matters, by revealing (or obscuring) a shared understanding of what we all need to be healthy.

A microcosm of the country, North Carolina is a purple state spanning economic, political, racial, and rural/urban divides and facing poverty, hunger, obesity, opioids, and now COVID-19. While there has been extensive polling on health care in the state, and across the country, to our knowledge there has been no polling on voters’ views on “health.”

In 2017–18, THI engaged a Republican polling firm (Public Opinion Strategies) and a Democratic polling firm (ALG Research) to conduct six focus groups with approximately 120 registered voters in the urban areas of Raleigh and Charlotte and in rural Hendersonville, North Carolina. These focus group findings spanned race, gender, income, political affiliation, and geography—and are only more significant in the context of COVID-19 and the food insecurity, housing instability, and economic havoc it has left in its wake.

Voters Agree On What Drives Health, And It Is Primarily Not The Health Care System

In the focus groups, voters were provided the following information:

“Research shows that only 10 percent of health outcomes are attributable to medical care—the treatments a patient receives at the hospital or clinic. More than 70 percent of outcomes are tied to social and environmental conditions and the behaviors influenced by them—that is, everything that happens in people’s lives for that vast majority of the time when they are not at the hospital or clinic. The remaining 20 percent are from non-attributable factors such as genes.”

The voters were then instructed as follows:

“[L]et’s imagine that you are in charge of funding health‐related organizations and programs in the [this] area. [Y]ou have $100 that can be spent on health-related programs. Here you will see 8 organizations or programs listed. Each of you can spend all of it on one area, spread the money around, spend it in just a couple of areas which you feel are more important or are more needed, however you wish:

• Hospitals and clinics;
• Community-based health centers in local neighborhoods;
• Affordable housing that is safe and clean;
• Easy access to farmer’s markets, grocery stores, or other programs that bring healthy food into neighborhoods;
• Food banks or other programs that provide food to those who need it;
• Affordable childcare and after‐school programs that allow parents to work;
• Programs that help families afford utility bills;
• Transportation options that help patients get to/from medical or dental appointments.”

Across demographics, their answers were strikingly similar (exhibit 1). All but one of the focus groups chose to spend 26–33 percent of their dollars on health care (hospitals, clinics, and community-based health centers) and 67–74 percent of their dollars on the drivers of health; in particular, the focus groups chose to spend more money on food and housing (40–46 percent) than on health care. The exception was the focus group of white, mixed-gender Republican seniors in Hendersonville, who might reasonably be expected to use more health care, and thus prioritize health care spending, at a more advanced stage of life. (Percentage allocations represent the total dollars allocated in each category by focus group members, divided by the total allocation for all categories for that focus group. While the focus groups were organized by race, gender, geography, political affiliation, and economic status, they were not intended to be statistically representative of their members’ demographic categories; results do not necessarily indicate the overall views of members of these categories but indicate that the focus groups of differing composition reached similar conclusions when presented with basic information and prompted to discuss the appropriate allocation of health-related spending.)

Exhibit 1: North Carolina focus group results

Source: Authors’ analysis.

These results were echoed in focus groups that THI conducted in three other localities across the country (exhibit 2): Cleveland, Ohio; Dallas, Texas; and Seattle, Washington. Again, across demographics, the voters voiced notable agreement, with all six of these focus groups choosing to spend far more dollars on food and housing (38–63 percent) than on health care (9–37 percent). Notably, these groups were conducted pre-COVID-19, before rates of food insecurity and housing instability escalated across the country.

Exhibit 2: Ohio, Texas, and Washington State focus group results

Source: Authors’ analysis.

In all the focus groups, voters repeatedly stated that the US is spending money on the wrong things and urged allocation of funds consistent with the pie charts above. As one of the white Republican women in Charlotte, North Carolina said: “Instead of putting all this money into the hospitals, put some of this money towards affordable housing. You know, like take and distribute it in a different way.”

After completing the allocation-of-funds exercise described above, voters in the Raleigh and Hendersonville, North Carolina, focus groups were presented with charts showing that in 2005, the US spent a greater proportion of total health and social services expenditures on health services, while peer Organization for Economic Cooperation and Development countries spent a greater proportion on social services; and the US ranked at or near the bottom in indicators of infant mortality and life expectancy compared with other developed and many developing nations. When asked to respond to these data, these voters expressed outrage that the US has poor health outcomes yet spends so much on health care and, consistent with the findings in exhibits 1 and 2, asserted that more dollars should be invested in what drives health.

In 2019, THI partnered with the NCMS, which represents more than 10,000 physicians, to conduct two focus groups, including 60 percent primary care physicians and 40 percent specialists. The majority of the 29 participating physicians practiced in and around Asheville and Raleigh; a minority practiced in rural Appalachia and Southeast North Carolina. All participants stated that their patients are affected by social conditions, reflecting the 2018 Physicians Foundation survey of 8,744 physicians, in which 88 percent indicated that some, many, or all of their patients have a social situation (poverty, unemployment, and so forth) that poses a serious impediment to their health.

When asked the same question as above (regarding how they would spend $100 on health-related programs), the physicians’ answers mirrored the voters’. Remarkably, the physicians would spend even less on hospitals and health centers than the voters (exhibit 3). Specifically, they chose to allocate only 19–20 percent of their dollars on health care and 49–50 percent on food and housing.

Exhibit 3: Physician focus group results (North Carolina)

Source: Authors’ analysis.

The Health Care Sector’s Language Obfuscates What Voters Want

In recent years, the term “social determinants of health” has morphed from academic standby to health care buzzword, headlining conferences, white papers, initiatives, and articles. At the same time, the term’s broad adoption has prompted consternation.

Most prominent is the caution that the health care sector is conflating “social determinants of health” (the underlying social and economic factors that affect the health of everyone in a community), “social needs” (an individual’s need for food, housing, transportation, or other resources), and “social risk factors” (the adverse social conditions associated with poor health, such as food insecurity and housing instability).

The primary concern is that imprecise language will obscure the distinction between, on the one hand, the important work of screening patients for unmet social needs and navigating them to basic resources in their community and, on the other hand, the distinct imperative to tackle the underlying social determinants of health, which requires community- or societal-level action. Likewise, others have argued that fuzzy language will impede policy makers and those working across health care, public health, and the social sector in defining the appropriate roles and limits of these sectors.

These are valid concerns, but there is another troubling failure of language, which has received far less attention: People—voters, patients, members, and consumers—find the language of both “social determinants of health” and “social needs” confusing, alienating, and even demeaning. As has been observed, words matter. In the present context—with the pandemic having yielded devastating unemployment, thousands of cars waiting in line at food pantries, a flood of imminent evictions, political discord, and racial inequities laid bare—they are more important than ever.

In the voter focus groups described above, the pollsters provided participants with a list of things that might impact their health—such as access to safe housing, healthy food, or wages that allow people to stay out of poverty—and a list of phrases that might be used to describe those things. Participants were invited to highlight those they liked and “X” out those that they did not.

Overwhelmingly, the voters rejected the terms “social determinants of health,” “social needs,” or “non-medical needs” for a variety of reasons. In particular, voters struggled with the term “social.” Some voters confused “social” with “social media.” Others rejected “social” as suggesting that the underlying need (for example, food, housing) was optional or a “nice to have,” such as socializing, rather than essential to well-being. For others, “social” evoked entitlement programs, instead of “access” to food or housing that had more positive connotations for the voters.

Voters also objected vigorously to “determinants,” asserting that it stripped them of their agency to manage their own health and well-being—as though their struggles to access food or housing were pre-determined and thus unalterable. Finally, voters found “non-medical” technocratic and obscure, not resonant with their lived experience.

By listening carefully to Americans and the physicians who care for them, we gain crucial insights. Voters across the political spectrum believe that our focus should be on health, not just health care. Likewise, physicians are concerned that our country chronically under-invests in addressing those community and societal factors outside the clinic that drive poor health outcomes. Yet, despite this concordance in values, we lack concordance in action.

One way to spur action is to adopt language that reflects these shared values. A growing number of institutions (including our own) have adopted the term “drivers of health,” viewing it as more respectful of community members and less suspect to the separation of the self from the “other” that fuels racial inequities in health care. This language also allows us to distinguish between “individual drivers of health” and “community drivers of health,” mitigating the confusion described above and recognizing that these each require different approaches.

Now more than ever, it is crucial that we use language that speaks to the realities of peoples’ lives and illuminates, rather than obscures, our shared understanding of and responsibility to act on all the factors that drive health.

Authors’ Note

The authors acknowledge Health Leads for its contributions to the voter focus groups.