The COVID-19 pandemic has jeopardized Americans’ health and economic well-being, with the greatest impacts on women, communities of color, individuals with disabilities, and LGBTQ+ people. Rebuilding a stronger more equitable future requires investing in the factors that influence health and well-being, from sustainable quality jobs to quality child care and education to food and housing security to healthy environments. These social determinants of health (SDOH)—defined as conditions in the environment where people are born, live, learn, work, play, worship, and age—have a wide-ranging impact on people’s health, well-being, and quality of life, contributing to health disparities and inequities.
Health inequities impose significant, often preventable, health and economic burdens on individuals and communities, including poor health, excess medical costs, lost productivity, and economic loss. Racism negatively affects the mental and physical health of millions of people in the United States and has been declared a serious public health threat—an underlying cause of health inequities, health disparities, and disease. It is therefore critical that coronavirus recovery efforts place a deliberate and explicit emphasis on racial, gender, and disability equity and environmental justice, accounting for the disproportionate impact of the pandemic and exacerbation of existing disparities that stem from systemic racism, ableism, and historic disinvestment. Addressing SDOH improves health, reduces racial disparities, and creates more accessible, affordable, and equitable systems.
Five domains of SDOH are detailed in this column, as well as each’s impact on health and equity. The column also includes recommendations for budget reconciliation priorities to ensure that the Biden administration’s Build Back Better agenda prioritizes investments in programs that deliver health, economic, and environmental benefits to the individuals, neighborhoods, and communities that need them the most.
Education in all its forms—from intellectual to social-emotional learning—is a contributing factor in health.
Childhood development is a significant determinant of health, providing a foundation for academic success, physical and mental health, and lifelong well-being. Investing in the health and educational development of young children provides social benefits and outcomes that vastly outweigh their costs. Access to affordable child care and universal preschool are powerful levers to support the health and development of babies, toddlers, and preschoolers. The earliest experiences—including the quality of adult interactions—matter to young developing brains and bodies, so providing families with strong supports and educators with fair wages is essential.
Education continues to affect health throughout the lifespan. People with more educational attainment are more likely to be healthier and live longer. High school and college graduation expands employment options, which can affect health. Interventions to help children and adolescents do well in school and to help families save and pay for college can therefore have long-term health benefits.
Federal policymakers should use proposed budget reconciliation bills to strengthen the education system, making policies and investments that support all children and students, families, and educators, regardless of where or how learning is happening. A comprehensive child care approach in the budget reconciliation package would dramatically move forward the health and economic security for families, making child care free or affordable for more than 76 percent of working families. Specifically, universal preschool would allow more 3- and 4-year-old children access to convenient and affordable programs of their family’s choosing. Investments in school infrastructure—including training and diversifying the education workforce—would provide environments that help prepare students for the future. And investments in higher education would support students from low-income backgrounds, strengthen community college and minority-serving institutions (MSIs), and make college more affordable and racially just.
The Build Back Better agenda should include policies and programs to improve education, and its health implications, particularly for the most vulnerable:
- Invest in high-quality, affordable, and accessible child care and universal preschool, including better compensation for the early learning workforce.
- Invest in replacing and rehabilitating school buildings to provide healthy environments.
- Invest in culturally responsive, affirming, and sustaining education practices.
- Invest in mental health supports for students and educators.
- Support community schools in which families can thrive.
- Provide tuition-free community college.
- Increase investments in MSIs, such as historically Black colleges and universities, Hispanic-serving institutions, and tribal colleges.
- Increase the federal Pell Grant for students from low-income backgrounds.
- Establish a College Completion Fund to invest in efforts to improve completion and retention at community colleges and other institutions serving high numbers of students from low-income backgrounds.
- Invest in training and building a racially and linguistically diverse education workforce.
Lack of access to high-quality, affordable health care can negatively affect health outcomes. In particular, lack of health insurance coverage, or inadequate coverage, is one of the greatest barriers to health care in this country, putting vulnerable populations with less access—such as people with lower incomes and minority populations—at even greater risk. At the same time, health care costs, including prescription drug prices, continue to rise. Moreover, systemic racism and inequity within the health care system have contributed to great disparities in health outcomes. Access to affordable, high quality health care is critical to eliminating these disparities. Strategies to increase health insurance coverage; expand access to health care, including preventive care, treatment, and medications; and reduce health care costs are critical for improving health outcomes and building a healthier America.
Federal policymakers should use proposed budget reconciliation bills to expand on the Affordable Care Act (ACA) by closing the Medicaid coverage gap, make health insurance coverage more affordable, and address the maternal health crisis, particularly among Black women, by adding benefits that are essential to protecting the health of the most vulnerable.
The Build Back Better agenda should include policies and programs to improve the health of the most vulnerable:
- Close the Medicaid coverage gap in the 12 states that have failed to expand the Medicaid program.
- Make new federal financial assistance permanent for those who purchase health care coverage through the ACA’s marketplaces.
- Lower prescription drug prices in order to lower patient costs.
- Incorporate the Black Maternal Health Momnibus of 2021, which requires Medicaid programs to provide pregnancy coverage for at least one year postpartum and to invest in community-based providers such as doulas.
- Expand home and community-based services to support disabled and elderly individuals with in-home services, enabling them to stay healthy in their homes.
- Provide Medicare dental, vision, and hearing benefits.
Poverty plays a significant role in health outcomes, making it more difficult to afford healthy foods, health care, and safe housing, all of which can increase risk for disease and premature death. Economic stability is critical to health; people with steady employment are less likely to live in poverty and are more likely to be healthy. Moreover, those who experience poverty in childhood have poorer health in adulthood.
Policies rooted in ableism and racial discrimination have led to income and wealth inequities, hindering the country’s economic growth and resilience. The racial wealth gap leaves a typical white family with eight times the wealth of a typical Black family and five times the wealth of a typical Hispanic family—with the typical household within each group defined as the median. Disabled people, meanwhile, are more likely than the general population to be unemployed and more than twice as likely to live in poverty. And LGBTQ+ people are more likely to live in poverty and report higher rates of unemployment and food insecurity, with higher rates among LGBTQ+ communities of color.
Federal investments in creating jobs that pay fair wages and include benefits such as health care, retirement, and inclusive paid family and medical leave would help more people find and keep jobs. In addition, other anti-poverty and economic security programs that help people pay for food, housing, health care, and education can reduce long-term or generational poverty and improve health and well-being, particularly for the most marginalized individuals and communities.
Federal policymakers should use proposed budget reconciliation bills to help people meet their basic needs, get back to work, and build pathways to economic security.
The Build Back Better agenda should include policies and programs to improve economic stability, and its health implications, particularly for the most vulnerable:
- Provide nutrition assistance and food access, including school meal programs.
- Permanently expand the child tax credit.
- Permanently expand the earned income tax credit.
- Create quality jobs that pay livable wages.
- Provide paid family and medical leave, with an inclusive definition of family and a guarantee of job protection for workers taking paid leave for chosen family or to access gender-affirming care.
- Provide culturally competent and affirming workforce development, job training, and apprenticeship programs, particularly in disadvantaged communities, to create pathways to sustainable careers.
- Invest in worker centers, worker cooperatives, subsidized jobs programs, and inclusive small-business supports—such as incubators and innovation hubs.
- Expand federal contracting, capital, and technical assistance opportunities for small minority-owned businesses and increase funding for the Minority Business Development Agency.
- Provide labor protections, including strong enforcement of employment nondiscrimination protections.
- Revitalize Supplemental Security Income (SSI) by increasing maximum benefits to the poverty line, increase asset limits, update archaic income disregards, and remove the in-kind supports rule.
Neighborhood and environment
The health and safety of neighborhoods has a major impact on health and well-being. Many people in the United States live in neighborhoods with health and safety risks such as polluted and unsafe air, water, and/or land; lack of affordable quality, accessible, and inclusive housing; lack of jobs and other economic opportunities; poor schools; and lack of affordable and quality child care and grocery store options. Communities of color and people with low incomes are more likely to live in places with these risks.
Extreme weather, including extreme heat, is a serious and growing public health and economic threat, with the most severe consequences for those living in low-income communities as well as Black, Latino, Indigenous, and other people of color who have experienced environmental racism and segregationist housing policy. For example, neighborhoods with minimal tree cover and green spaces, few energy-efficient buildings and homes, and high rates of energy poverty experience high economic, public safety, and public health consequences that are escalating with more extreme heat, flooding, and other extreme weather fueled by climate change.
In addition, housing instability—from difficulty paying rent that can lead to eviction to substandard housing to homelessness—is a crisis that negatively affects health and racial equity, along with economic potential and healthy child development. A history of racist housing policy and practice has resulted in Black and Hispanic households being almost twice as likely as white households to be cost-burdened, spending more than 30 percent of their income on housing. In particular, Black and Latinx female renters experience the highest rates of eviction. Housing instability also disproportionately affects LGBTQ+ individuals, disabled people, and justice-involved individuals.
Federal long-term investments in improving the health, safety, and climate resilience of neighborhoods, as well as addressing climate change and local pollution, would improve health and well-being. Notably, investments in stable, healthy, accessible, climate-ready, and affordable housing initiatives; preventing homelessness; and increasing the opportunity for home ownership are critical to addressing the housing crisis. These investments must center equity and justice to directly address the disproportionate threats to communities of color and low-income areas.
Federal policymakers should use proposed budget reconciliation bills to invest in economic recovery and environmental justice solutions that would improve public health, address homelessness and housing insecurity, and prevent climate-related illness and death.
The Build Back Better agenda should include policies and programs to improve neighborhoods and the environment, and their health implications, particularly for the most vulnerable:
- Expand rental supports, deposit assistance, and eviction prevention regulations.
- Expand inclusive, accessible, affordable housing, including rental assistance and homeownership opportunities for disabled individuals, LGBTQ+ people, and other underserved communities, such as formerly incarcerated individuals and those with criminal records.
- Increase affordable, climate-resilient, and accessible housing stock through construction of units and removal of exclusionary zoning.
- Invest in parks and plant trees to provide shade, lower temperatures, reduce flooding risk, and improve the safety and quality of life in communities.
- Provide rebates and grants, with additional amounts available to low-income households, to upgrade home energy efficiency and install efficient, all-electric appliances to lower energy bills, indoor air pollution, and carbon pollution.
- Provide environmental and climate justice block grants to support community-led projects that mitigate public health risks tied to high pollution levels and climate change threats.
- Provide funding for community engagement to inform federal decision-making through the National Environmental Policy Act.
- Provide incentives for clean energy and clean vehicles, reducing diesel emissions from medium- and heavy-duty trucks and supporting pollution-free and healthy ports.
- Build affordable, accessible, energy-efficient, and transit-oriented housing and reconnect neighborhoods that were deliberately segregated and divided by highways, while ensuring that these improvements do not displace community members.
- Invest in cleaning up Superfund sites and replacing lead pipes.
- Invest in solar electricity generation and community solar projects that serve low-income neighborhoods.
- Invest in climate-smart agriculture and forestry.
Social and community context
Relationships and interactions can have a major impact on health, safety, and well-being. Discrimination, prejudice, violence, and stigma all create toxic and stressful environments that can have a significant impact on chronic health conditions, depression and anxiety, and high-risk behaviors. Positive relationships and social supports, meanwhile, can reduce the impact of these stressors, improving health and well-being.
Adverse childhood experiences (ACEs), including experience and exposure to violence and parental incarceration, are associated with challenges in adulthood, such as chronic health problems, mental health disabilities, and an increased likelihood of engaging in high-risk behaviors like substance use and violence. This has potential impacts on education, jobs, and income. Similarly, children who routinely experience forms of social discrimination, such as bullying, are more likely to struggle in school and are less likely to graduate from high school or go to college, which limits their employment potential, increasing the risk of health problems such as heart disease, diabetes, and depression. The stress of living in poverty—routinely struggling with economic, food, and housing insecurity—can also affect children’s brain development, making it harder for them to do well in school. Indeed, historical and continued discrimination affects people’s safety, financial security, and health.
Federal policymakers should use proposed budget reconciliation bills to support community-based programs, advance racial equity and inclusivity, and create pathways to good jobs and sustainable careers in disadvantaged communities.
The Build Back Better agenda should include policies and programs to improve social and community context, and its health implications, particularly for the most vulnerable:
- Increase funding to support community-based violence intervention.
- Advance racial equity through a comprehensive set of policies to address discrimination and racial inequity.
- Advance inclusive programs through a comprehensive set of policies with LGBTQ-inclusive nondiscrimination provisions free from overly broad religious exemptions and support for programs that combat family rejection.
- Advance inclusive programs through a comprehensive set of policies with disability-inclusive nondiscrimination provisions.
- Develop supportive employment measures for justice-impacted individuals, such as automatic record clearance, or clean slate, and fair chance licensing laws.
- Increase access to mental health services related to stress, trauma, and adverse childhood experiences.
- Enact trauma- and equity-informed policies.
The Build Back Better agenda can build a strong, equitable future by advancing policy interventions that address the social determinants of health: education, health care, economic stability, neighborhoods and environments, and social and community supports. With equity at the center and a focus on vulnerable communities, this multifaceted agenda can improve health outcomes, advance social well-being, and strengthen the economy.
Jill Rosenthal is the director of Public Health Policy at the Center for American Progress.
The author would like to thank the following teams for their guidance and input: Criminal Justice, Democracy, Early Childhood, Economy, K-12 Education, Energy and Environment, Health, Higher Education, LGBTQ Rights, Poverty, Racial Equity and Justice, and the Women’s Initiative, as well as CAP’s Editorial and Art teams for their contributions.