If our nation’s goal is to improve the health and lifespan of people living in socio-economically disadvantaged communities, a focus on chronic disease prevention and management is the most rapid and effective approach.
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For decades, policy and public health experts have recognized that social determinants of health (such as economic stability, employment opportunities, and housing safety) account for 30% to 55% of a population's health status.
These “non-medical” factors contribute significantly to health inequalities and disparities.
Why social determinants lead to poor health
Despite being one of the wealthiest countries, the United States faces severe and widespread health challenges driven primarily by the social determinants of health.
Nearly 38 million Americans live in poverty, more than 34 million struggle to put enough food on the table, more than 500,000 people experience homelessness every night, and gun violence, suicide and other manifestations of social unrest claim nearly 100,000 lives each year.
These social and economic hardships are not just statistics; they are the root causes of life-threatening health disparities. People who suffer from hunger, unsafe housing, inadequate education, and limited employment opportunities are at much higher risk of disease and premature death than their more affluent neighbors.
These disparities steadily erode the mental, emotional and physical health of entire communities. Poor nutrition is commonplace in food deserts and low-wage areas, where diabetes rates are higher. Chronic stress from unemployment, homelessness and racism creates inflammation, elevating blood pressure and increasing risk of heart disease and other illnesses. Additionally, limited access to education and health resources impedes preventive care, making chronic diseases even more difficult to manage.
The results are devastating: U.S. life expectancy is the lowest among high-income countries, at just 76 years; maternal mortality rates are shockingly high and rank last among developed countries; and child mortality rates remain unacceptably high.
These grim statistics highlight the significant impact of social determinants on health outcomes in America.
American Communities Struggle to Address SDOH
A few years ago, I spoke with leaders in Rochester, New York, who pointed this out to me. At the time, two neighborhoods just five miles apart had a difference of more than a decade in life expectancy. The wealthier areas had better housing, education, safety, access to food, and job opportunities — advantages rarely found in lower-income neighborhoods.
Early in my career, I believed that once these disparities were exposed, change would come naturally. But now I understand that breakthrough solutions will only come when there are economically viable solutions and strong economic incentives to implement them. Without this momentum, the problems in our communities will only get worse.
The simplest solution is still the best solution
I believe that by rethinking how we approach health issues in underserved communities, we can save thousands of lives. To guide this shift in thinking, let's look to the centuries-old wisdom of 14th century monk and philosopher William of Ockham, who taught that the simplest solutions are usually the most effective.
This principle, known as Occam's razor, indicates that attempting to address every social determinant of health at once is an approach doomed to fail. The scope of such efforts has proven to be underfunded and easily rejected by elected officials in the country's polarized political climate and limited funding for social programs.
Instead, our country can create immediate, positive change by focusing on simpler, achievable solutions: preventing and managing chronic disease.
These lifelong conditions are often a direct result of social determinants of health and lead to poor health, life-threatening complications, and premature death. According to CDC data, 30-50% of heart attacks, strokes, cancer, and kidney failure can be prevented by effectively managing chronic diseases.
In underserved areas where medical resources are scarce, doctors have little time to address emergencies and acute medical problems, and as a result, prevention and chronic disease management are often overlooked.
Improving chronic disease management is no substitute for addressing the underlying causes found in social determinants of health, but it is a real and achievable step forward. By leveraging generative AI technology – a tool that didn’t exist two years ago – communities can empower patients, improve overall health, and help people live longer.
Concept: Community Health & Technology Hub
Think of these hubs as a complement to the existing Medicaid system: providing affordable, targeted, and technologically advanced support to individuals in areas with limited medical resources.
Implementation: In the first phase, we will launch pilot hubs in 10 low-income communities across the U.S. They will be strategically located in existing community centers or other easily accessible facilities. Each hub will be staffed with 10 community workers in social services who are familiar with the community, speak the local language, and understand how to navigate local bureaucracy to maximize government resources.
Hubs will also include one clinician, nurse, or doctor who will provide medical assistance for unexpected emergency issues (rather than as a regular emergency care provider). These hubs provide essential services such as childcare, allowing time for parents to meet with staff, attend education sessions, and conveniently access health resources.
Additional medical support for all 10 locations is provided by a small number of specialists connected via telemedicine, providing expertise when cases are unusually complex.
Integration of AI technologies: Generative AI will be central to the operation of these hubs. Community workers will be trained to use GenAI to manage lifestyle medicine, monitor chronic diseases and help detect acute issues early.
As detailed in Dr. ChatGPT’s book, “How AI Can Help Patients and Doctors Take Back Control of U.S. Healthcare,” GenAI has already made great strides in the medical field. GenAI has the ability to rapidly analyze an individual’s medical history, current health status, and lifestyle factors to provide personalized health recommendations.
With careful training and human oversight, AI tools can suggest optimal diets based on an individual's financial situation, identify environmental factors that impact health, and recommend preventative measures tailored to specific needs.
Additionally, GenAI can analyze data from health devices, such as blood pressure cuffs and glucose monitors, either on the hub or at home to monitor chronic conditions and flag when intervention may be needed. This real-time analysis can help differentiate between stable patients (those who don’t need additional medical care) and those who need medication adjustments (which can often be done virtually), reducing the burden on busy physicians.
By empowering individuals through this technology, these hubs will improve chronic disease management and help patients avoid complications that lead to emergency room visits and hospitalizations.
Scalable and cost-effective: Each hub costs less than $1 million per year to set up and operate, including salaries, services, and technology. With a total investment of $10 million, the United States could establish 10 hubs and the centralized specialized telehealth centers to support them. Given that Medicaid's 2023 budget is estimated at $853 billion, the investment required for these demonstration hubs is minimal.
The hub model is designed to have zero costs in the short term and a positive return on investment in the long term. The savings from preventing just one major health event, such as a heart attack, kidney failure, or stroke, offset the operational costs of serving 1,000 individuals for a year. As savings are generated in one community, Medicaid officials reinvest in new locations to continue expanding the program.
Practical Steps Forward: If our nation’s goal is to improve the health and lifespan of people living in socio-economically disadvantaged communities, a focus on chronic disease prevention and management is the most immediate and effective approach.
Ideally, we would address the broader social determinants of health, such as housing, education, and employment, but these complex issues are unlikely to be resolved anytime soon. In the meantime, reducing the burden of chronic disease offers a concrete way to improve health outcomes right now. What's more, when people's health improves, communities have less absenteeism, more access to well-paying jobs, and better health outcomes for their residents.
This model isn't perfect. But it's a big step in the right direction. It's affordable, practical, and scalable. And it's clear that what we're doing currently isn't working. It's time to try something new.
