Presidential Candidates Must View Health Care Through a Different Lens

As the presidential debates continue to unfold, presidential hopefuls are declaring their commitment to ensuring health care coverage, as many Americans remain unable to afford high premiums and deductibles and thus may forgo needed medical care. 

For instance, during the Democratic debates, some presidential candidates proposed a total overhaul of our health care system by supporting “Medicare for All,” and others suggested that Medicaid should be expanded or the Affordable Care Act should be made more comprehensive. Regardless of a candidate’s position or platform, health care continues to be a contentious issue in the upcoming presidential election.

A poll by the Kaiser Family Foundation found that health care was listed by over 8 in 10 Democrats as the most important topic to be discussed in the Democratic presidential debates currently underway. As well, there is consensus that our country needs to do something about the increases in health care expenditures that toppled over $3 trillion during 2018. 

However, as a former emergency room nurse with decades of experience delivering care in an inner-city community in Chicago, I’ve noticed that time and time again, the upstream factors that affect health care costs are seldom discussed. As a public health nurse, I also know the value of applying a proactive preventive lens when looking at what we can do about rising health care costs and the ongoing poor health outcomes that many Americans continue to experience.  

These upstream factors are termed the “social determinants of health,” and include education, housing, employment, income and environment, to name a few. These are strong predictors of health status, longevity and account for the majority of health outcomes. 

Despite the evidence, these determinants are not well-integrated into the policymaking discourse on issues surrounding the health of our nation. It is time that all candidates propose ways to improve these factors for all Americans, especially the most marginalized. Here are three ways to do this.

First, consider children in poor communities who are plagued by environmental toxins such as waste dumps or other polluting factors and experience a higher incidence of asthma. While it may seem easy to medically treat the asthma, medical treatment alone does not address some of the other underlying triggers for asthma for communities that are living with adverse conditions such as poor air quality and pollution. Candidates should propose ways to eliminate adverse environmental exposures that negatively impact health, quality of life and longevity.

Second, widespread homelessness and precarious housing in major American cities such as Chicago provide another example of the need to attend to the determinants of health. Health care systems are beginning to invest in housing to improve health care outcomes for this population and decrease escalating health care costs associated with non-emergent emergency room utilization. 

Homelessness is considered in some circles a medical condition and needs to be treated accordingly. Looking at success stories might be one place to start in order to build a strong national homelessness policy.

Third, education is another determinant of health believed to impact health outcomes and health care costs. Individuals with less than a college education have poorer health outcomes and may experience a shortened life expectancy by as much as nine years compared to those with a college education. 

Graduation from high school has emerged as one of the most significant predictors of health outcomes. Thus, investments in early childhood education and support to complete high school and beyond is needed.

As a health care professional, I’m heartened by the recognition of health care as one of the most crucial issues in next year’s election. Yet, as aspiring presidential candidates from both sides of the aisle present their platforms and agendas for affordable health care, they must broaden the conversation to include a focus on the determinants of health, a major underlying cause of disease, disability, premature death and rising health care costs. 

This perspective requires that we shift from our traditional way of thinking about health from a sick care perspective to a more preventive focus on health and its relationship to social and economic factors that are driving poor health outcomes and escalating health care costs. Failing to do so leaves us to do what we have always done, leaving us with the same results. We deserve better.  


Janice Phillips, RN, CENP, Ph.D., FAAN, is an associate professor at Rush University College of Nursing, the director of nursing research and health equity at the Rush University Medical Center and a public voices fellow of the OpEd Project.

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