One Year into the Pandemic: Implications of COVID-19 for Social Determinants of Health

Even as the adoption of COVID-19 vaccines across the country accelerates, the public health and economic impact of the pandemic continues to affect the well-being of many Americans. The American rescue plan provides additional funding to not only tackle the public health crisis of the pandemic, but also provide economic support to many low-income people who are struggling to make ends meet. Millions have lost jobs or incomes in the past year, making it difficult to pay for expenses including basic necessities like food and housing. These challenges ultimately have an impact on people's health and wellbeing as they affect the social determinants of health. This letter provides an overview of the social determinants of health and a look at how adults are doing over a range of measures a year after the pandemic started.

What are social determinants of health?

Social determinants of health are the conditions in which people are born, grow, live, work and age. These include factors such as socio-economic status, education, neighborhood and physical environment, employment and social support networks, and access to health care (Figure 1).

Figure 1: Social determinants of health

While health care is essential to health, research shows that health outcomes depend on a number of factors, including underlying genetics, health behaviors, social and environmental factors, and financial distress and all of its effects. While there is currently no research consensus on the extent of the relative contributions of each of these factors to health, studies suggest that health behaviors, as well as social and economic factors, are the main drivers of health outcomes, and that social and economic factors can affect individuals' Health behavior. There is extensive research that concludes that considering social determinants of health is important in order to improve health outcomes and reduce health inequalities. Prior to the pandemic, there were a number of initiatives to address social determinants of health in both the health and non-health sectors. The COVID-19 pandemic exacerbated pre-existing health disparities for a wide range of population groups, especially people of color.

How are adults doing on a number of social determinants of health during the pandemic?

Large segments of people suffer from difficulty across a variety of metrics. The Census Bureau's Household Pulse Survey is designed to quickly and efficiently collect and compile data on how people's lives have been affected by the coronavirus pandemic. For this analysis, we looked at a number of measures taken over the course of the pandemic. Since the start of the pandemic, the proportion of people reporting difficulties across different measures has been relatively constant, with a slight high for the reporting periods in December (Figure 2). For the last period from February 3rd to 15th:

• Almost half of adults (47%) reported that they or someone in their household had suffered a loss of income from work, and one in five had applied for Unemployment Insurance (UI) benefits since March 2020.
• More than six in ten (61%) adults said they had had difficulty paying normal household expenses in the past seven days, and 27% used credit cards or loans to meet household expenses.
• More than 7% of adults had no confidence in their ability to make the housing benefit payment for the next month (between tenants and owners) and 11% said their household was inadequate with food.
• Three in ten (30%) adults said they had delayed medical care in the past four weeks due to the pandemic, and 39% reported symptoms of depression or anxiety.

Black and Hispanic adults perform worse than white adults on almost all measures, with large differences in some measures. For example, just over 75% of black and Hispanic adults reported having difficulty paying household expenses, compared with 53% of white adults. About 13% of black and Hispanic adults said they had no confidence in their ability to make the housing benefit payment for the next month compared with 5% of white adults, and 20% of black adults and 18% of Hispanic adults said they were not eating enough in the household compared to 8% of white adults. While these differences in social determinants of health existed before the pandemic, the high current level among certain groups underscores the disproportionate burden of the pandemic on people of color.

While the differences between age and sex were not as great, younger adults (18 to 44 years old) and women generally performed worse on most interventions compared to older adults and men. For example, higher proportions of younger adults and women reported symptoms of anxiety and depression and difficulty paying normal household expenses. Higher proportions of younger adults reported food shortages in their households and higher proportions of women said they had delayed medical care in the past four weeks due to the pandemic. As with race / ethnicity, some of these differences in social determinants were present before the pandemic, but understanding these differences in the context of increased needs over the past year highlights these differences and who may benefit most from the support.

For most interventions, adults with children in their household fared worse overall than adults. For example, 53% of adults with children in the household had a loss of household income compared to 47% of adults as a whole, and just over two-thirds of adults with children in the household reported having difficulty managing household expenses compared to to pay the total population of 61%. In particular, adults in households with children were more likely than the general population to report food deficiencies.

What to see in the future

The US rescue plan provides $ 1.9 trillion in funding to help address the ongoing health and economic impact of the pandemic. Some of the provisions that provide important economic support to individuals include direct stimulus payments to individuals, an extension of federal unemployment insurance payments, a child tax credit of up to $ 300 per child per month from July through the year end, and additional funding for combat food insecurity, emergency rental assistance and emergency shelter vouchers. In terms of provisions to combat COVID and health care, the plan provides additional funding for the Centers for Disease Control (CDC) related to the administration and distribution of COVID-19 vaccines, as well as an increase in funding for testing and tracing of coronavirus -Infections as well as tests before deliveries and personal protective equipment. The plan includes provisions to make health insurance affordable by temporarily widening and increasing market subsidies and tax incentives to encourage states that have not adopted the Medicaid expansion.

Additional funding and policy changes could improve many of the indicators of economic security and access to health highlighted in this letter. As more people receive the vaccine, government restrictions can relax further and economic activity can increase. Future data from the Pulse survey may reflect these changes. Many of the issues and differences highlighted in this data existed before the pandemic, but the economic crisis has increased the scale of the challenges many face. Changes to address COVID-related and underlying economic security issues related to poverty, access to food and housing are directly related to improvements in health and can also help address health inequalities. While these underlying social determinants of health can be difficult to address and would likely require significant government spending, without it we are unlikely to make significant progress in reducing health inequalities.