× Expand Thea Aadizookaan Will Copeland, an organizer with Breathe Free Detroit, has seen firsthand the effects of an incinerator on his community.

Typically, when politicians discuss health policy, they’re talking about health care policy. The fixation on health care is obvious and understandable: We know that the United States spends more on health care per person than any other country in the world, even though it does not have the best health care outcomes.

Pharmaceutical companies, armed with patents, wield great power over prescription drug pricing and accessibility, and thus over our very lives. Families must often try raising money for their own medical care, through GoFundMe and similar crowdfunding platforms. Stories of people unable to receive medicine or a procedure due to cost are common; some of those people die.

We must change the structure of our health care system and guarantee health care as a human right. We need Medicare for All. But much more must be done than just guaranteeing insurance and access. Health care alone does not mean health.

In fact, researchers have found that only about 10 to 20 percent of health outcomes are related directly to care. The rest are due to what doctors call the “social determinants of health”—a mix of factors including housing stability, access to transportation, education, employment, food, and the built environment.

In other words, “The social and structural context in which health care occurs is more important than health care itself,” Dr. Philip Alberti, senior director for health equity research and policy at the Association of American Medical Colleges, says in an interview. “That conversation—about the social influences of health—has largely been absent from our national dialogue.”

Social determinants related to race, gender, class, and sexual orientation affect how illness and disease are handled at every level, from initial screening to treatments.

Consider the city of Detroit, where an incinerator built in 1986 turned more than 3,000 tons of garbage into toxic ash each day while pumping pollutants into the surrounding neighborhood. Since 2013, according to the Great Lakes Environmental Law Center, it was flagged for violating emissions standards 750 times. The community near the incinerator, which is majority low-income and majority people of color, has some of the highest rates of asthma in the state of Michigan.

In 2015, the law center found, 66 percent of the waste came from the mostly white and very wealthy Oakland County, and just 19 percent from Wayne County, which includes the city of Detroit. Will Cope-

land, an organizer with Breathe Free Detroit, the campaign that arose to shut down the incinerator, calls what was happening “an environmental justice issue in terms of other people throwing trash away [that] was going straight to the lungs of black Detroiters.”

In spring of last year, the company that owns the incinerator, bowing to mounting public pressure, agreed to shut it down. It was a health win that had nothing to do with access to care or insurance.

Take, for another example, the shortage of safe and secure housing, which is necessary for physical, and psychological, well-being. Housing that contains lead paint or asbestos might literally make people sick, while not being able to afford housing can cause dangerous levels of stress. The people most likely to live in subpar housing or have trouble making rent are those with low incomes, and are disproportionately people of color. And often they live in communities segregated by racist redlining policies and biased zoning laws.

Social determinants related to race, gender, class, and sexual orientation affect how illness and disease are handled at every level, from initial screening to treatments.

For example, people of color face higher rates of cancer yet are underrepresented in clinical trials. Black mothers have higher rates of maternal mortality and also higher rates of infant mortality, even when controlling for income. Health care for Native Americans is severely underfunded. Life expectancy varies greatly across the income divide—and recently, life expectancy has been falling in the United States, partly due to the opioid crisis.

Copeland tells me about a cousin of his who went to the emergency room—as many low-income people without insurance do when they’re sick—complaining of a severe headache. She was given Tylenol. She didn’t need Tylenol, he says. She had “some sort of brain embolism that wasn’t diagnosed.” The next day, she died.

It is hard not to hear that story and wonder if she may have been treated differently had she been wealthy and white. Perhaps then, her pain might have occasioned an MRI.

Another problem is that, in poorer areas, as in rural areas, there are simply fewer doctors. Some have even coined the term “health care deserts.”

None of these problems are new: We’ve known for decades about health disparities based on social factors, yet little has been done to move the needle.

Even though poverty, housing, and education are all related to health policy, each still has its own department in the federal government. For health disparities, Alberti says what’s needed is a “community-engaged structural intervention” that includes education, housing, transportation, and economic development.

One way to look at this problem involves the upstream/downstream parable. Downstream care prioritizes giving equitable treatment when people need it. Upstream strategies aim to get at the root causes of health disparities across different groups—and swimming upstream is a little more difficult.

Alberti says one positive upstream intervention he’s seen is the introduction of legal aid in medical care settings. For example, if a doctor screens an asthma patient and discovers that they live in a home with roaches (a trigger for asthma) and have an unresponsive slumlord, lawyers on the care team could intervene to force the landlord to correct the problem.

Medical-legal partnerships can also ensure people get the benefits they’re entitled to. They “are about changing the context so the health care has a greater chance of succeeding,” Alberti says.

At the same time, Copeland says he’s heard stories about how some people who lived near the Detroit trash incinerator—who had asthma—were also asked about roaches, with no mention of the massive polluting structure down the street.

Dr. Nahiris M. Bahamón, a pediatrician at a community health clinic in Chicago and a board member of Physicians for a National Health Program, a group of more than 20,000 doctors and other health professionals, stresses the importance of clinics operating within a community, so that people can access health care where they live. Providers immersed in a community are better at understanding what services are available and what dangers are present (like a nearby facility pumping out tons of pollutants).

“A patient doesn’t suffer from an inequity,” Alberti says. “That patient’s community does.” Individual screening can only go so far.

And when people do go to the doctor, beyond the social determinants that are affecting their health, they still might find themselves up against the profit motive in health care. The cold bureaucracy of the health insurance system intensifies inequity and particularly hurts people with disabilities and chronic illnesses—those who need quality health care the most.

Copeland lives with chronic illness and, given the poor treatment of people with disabilities, considers his illness part of his political identity. “People don’t realize how hard it is to do things when you’re sick,” he says. “If you’re sick and if you don’t turn in your paperwork by a certain time—your insurance will run out. And then you might get a bill for $100,000.

“But if you’re sick, it can be unrealistic to expect you’re going to be on top of that—while you’re literally trying to figure out how to stay alive.”

All of the Democratic candidates for President are currently campaigning on promises of universal health care. Of course, the phrase “universal health care” is intentionally ambiguous and can mean any number of proposals.

The Affordable Care Act passed during the Obama Administration was meant to be universal. And yet, in 2018, nearly twenty-eight million nonelderly adults were still living without health insurance, with approximately half citing cost as the reason. And “access” sometimes means getting stuck with thousands of dollars in deductibles, premiums, and out-of-pocket costs.

Dr. Abdul El-Sayed, a doctor and activist who ran for governor of Michigan in the 2018 primary, tells The Progressive that Medicare for All would be the most important piece of any progressive health agenda.

“Medicare for All has to be the framework through which we understand a progressive approach to health care,” he says. “Health care and health, they’re not the same, but without being able to provide a secure, affordable, effective, and efficient direction on access to health care, it’s really hard to get to health.”

Physicians for a National Health Program has been calling for a single-payer system since its founding more than three decades ago. “What we have [now] is not a real health care system,” says Bahamón. “What we have is a fragmentation of a quasi-system that tries to provide health care, but the incentive is not to provide health care or make people healthier—the bottom line is making profits.”

Physicians for a National Health Program has been calling for a single-payer system since its founding more than three decades ago.

Medicare for All is illustrative of what a single-payer system could look like. The phrase is refreshingly simple—people understand that Medicare is government-provided insurance. But Medicare for All doesn’t actually mean Medicare in its current, complex form. All it means is that the government is the single provider of health insurance (hence “single-payer”).

So yes, think Medicare, but in a form that is both better and cheaper, as copays and deductibles would be eliminated. Vermont Senator Bernie Sanders can be credited with turning Medicare for All into a household phrase. After all, he “wrote the damn bill,” as he said during the Democratic debates in Detroit. Others including former South Bend, Indiana, Mayor Pete Buttigieg have called for a watered-down version dubbed “Medicare for All Who Want It.”

Under the gold-standard system of Medicare for All, everybody—citizens and immigrants alike—would have access to basic health services and other essential services, like comprehensive mental health care, abortion care, drug rehabilitation, and dental care. With these bases covered, a Medicare for All system could finally focus on prevention. And additional investment would ensure that people can access doctors, dentists, eye doctors, and mental health providers, in both rural and urban communities.

Bahamón describes seeing children with asthma get taken to the emergency room and ending up hospitalized. Asthma is manageable, yet these kids don’t have insurance, so they end up in the intensive care unit “when they could have just gone to their primary care physician every three months.”

Besides the medical field, there is space to consider the social determinants of health across policymaking. El-Sayed has termed the Green New Deal a “Public Health New Deal” because it would create jobs for people in poverty and eliminate the emissions that damage the lungs of mostly low-income people. After all, it is no coincidence that a trash incinerator was built next to some of the poorest neighborhoods in Detroit.

There is no silver bullet to solve poverty and embedded systems of racism, classism, sexism, and ableism. But Medicare for All is a starting point to address health disparities and overarching inequality. So is gaining a broader understanding of what makes us sick and why.