As reported by the Tribune in 2019, a study by New York University’s School of Medicine, which built on similar, earlier research, found that Chicago residents living in Streeterville could expect to live 30 years longer on average than their neighbors in Englewood just 10 miles away. That is the largest urban disparity in the U.S.
How could residents in the same city have such drastically different health outcomes? It boils down to social determinants of health, or SDOH. As defined by the U.S. Department of Health and Human Services, SDOH are “are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
Environmental factors affect so many dimensions of our lives. This isn’t surprising. But their relation to our mental and physical health is underexplored. Researchers and health care practitioners are realizing how deeply connected all these elements are and how they combine to create either ideal, or poor, health outcomes.
There are the obvious health-related questions: Are clinics and hospitals in your neighborhood? Accessible? But what about the quality of education in your community? Do you have access to fresh and affordable foods? Are there opportunities for gainful employment? Does your neighborhood have clean air? Safe drinking water? Does your apartment have heat in the winter? Unaddressed mold? Do you live near a highway or factory? Is there accessible public transportation?
All of these factors account for the community health of a population and in the worst scenarios can cause the life expectancies of our neighbors and ourselves to plummet. Historical redlining and systemic racism shamefully set the stage for Cook County to see some of the worst SDOH disparities in the nation. And there is still much work to unpack that legacy. And yet, in response to this grim reality, Chicago has also been an incubator for some of the most creative responses to health inequity.
Chicago’s Cook County Hospital, founded in 1834, was known as “Chicago’s Ellis Island” due to its practice of providing care to immigrants and the poor. It housed the country’s first blood bank in 1937 and one of the first AIDS wards in 1983.
Cook County was one of the first municipalities to expand Medicaid to qualifying residents via an early expansion initiative called CountyCare in 2012. In the first year, 82,000 adults living in the county with incomes at or below the federal poverty level were provided with low-cost, quality health insurance.
Affordable, quality health insurance is one of the most efficient ways to make health care accessible — emphasis on affordable. Per the 2021 census, the uninsured rate fell to 8.3%, meaning more than 90% of Americans had health insurance that year.
Yet medical debt remains a crisis for many. More recently, Cook County became the first local government to initiate a program to abolish medical debt for residents with incomes up to 400% the federal poverty level through its Medical Debt Relief Initiative. Medical debt is a huge cog in the wheel of social determinants. It prevents people from seeking the care they need, and it can create financial instability by suppressing credit scores and leading to wage garnishment. An underexplored dimension of this crisis is mental health: Those with debt are three times more likely to report struggling with anxiety or depression.
Medical debt is increasingly acknowledged as a SDOH, and yet again, Cook County is stepping up to show that modern leadership can heal old wounds by being daring and creative.
This of course isn’t an issue unique to Cook County. America as a whole spends more on direct health care costs than other developed nations with worse health outcomes, and inversely, we spend less on “social care” — safety net programs that address housing and food insecurity, education, etc.
Other municipalities struggling with the generational impacts of inequity, I encourage you to follow Cook County’s lead. Toledo and Lucas County in Ohio already have.
By removing systemic barriers to care such as lack of insurance and medical debt, you can ensure your citizens have the best chance to live healthy lives.
Dr. Ram Raju is a physician who held leadership roles at Northwell Health, NYC Health + Hospitals and Cook County Health, where he was CEO from 2011 to 2014. He teaches at the Roosevelt House Public Policy Institute at Hunter College in New York and is a board member for the nonprofit RIP Medical Debt.
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