For decades, policy and public health experts have recognized that social determinants of health—factors like financial stability, job opportunities and housing security—account for 30% to 55% of people’s health outcomes.
These “non-medical” factors are significant contributors to health inequities and disparities.
How Social Determinants Lead To Poorer Health
Despite being one of the wealthiest nations, the United States faces deep and pervasive health challenges, driven largely by social determinants of health.
Nearly 38 million Americans live in poverty, with more than 34 million struggling to secure enough food. Homelessness affects over half a million people every night, while gun violence and suicide—symptoms of broader social instability—claim almost 100,000 lives each year.
These social and economic hardships are more than just statistics. They are the root causes of life-threatening health disparities. People grappling with hunger, unsafe housing, poor education and limited job opportunities are at a much higher risk of disease and early death than their more affluent neighbors.
These disparities have steadily eroded the mental, emotional and physical health of entire communities. In areas with food deserts and low wages, poor nutrition is commonplace, leading to higher rates of diabetes. Chronic stress from unemployment, homelessness and racial discrimination triggers inflammation and elevates blood pressure, increasing the risk of heart disease and other illnesses. Furthermore, limited access to education and healthcare resources hampers preventive care and makes managing chronic diseases even more challenging.
The consequences are devastating. The U.S. has one of the lowest life expectancies among high-income countries, at just 76 years. Maternal mortality rates are alarmingly high, with the U.S. ranking last among developed nations, and childhood mortality remains unacceptably elevated.
These sobering statistics underscore the profound impact of social determinants on health outcomes in America.
American Communities Struggle To Address SDOH
Years ago, I spoke with leaders in Rochester, New York, who highlighted this issue for me. In two neighborhoods just five miles apart, life expectancy at the time differed by more than 10 years. The wealthier area had better housing, education, safety, food access and job opportunities—advantages mostly absent in the low-income neighborhood.
Early in my career, I believed that once disparities like these were brought to light, change would naturally follow. I now understand that game-changing solutions only emerge when there’s a financially viable way to solve them and a strong economic incentive to do so. Without these drivers, the problems in our communities will only worsen.
The Simplest Solution Is The Best One—For Now
By rethinking how we address health in underserved communities, I believe we can save thousands of lives. To guide this shift in thought, let’s turn to the centuries-old wisdom of William of Ockham, a 14th-century friar and philosopher who taught that the simplest solution is usually the most effective.
This principle, known as Ockham’s Razor, implies that trying to address every social determinant of health at once is an approach destined to fail. The scope of such an endeavor proves unaffordable and easily rejected by elected officials due to the nation’s polarized political climate and limited funding for social programs.
Instead, our nation can create immediate and positive change by focusing on a simpler, more achievable solution: the prevention and management of chronic diseases.
These lifelong conditions are often the direct result of social determinants of health and they compromise well-being, leading to life-threating complications and premature death. According to data from the CDC, effective management of chronic diseases could prevent 30-50% of heart attacks, strokes, cancers and kidney failures.
In underserved communities, where healthcare resources are scarce, clinicians have barely enough time to address emergencies and acute medical issues. As a result, prevention and chronic disease management are frequently overlooked.
While improved chronic disease management is not a substitute for addressing the root causes found in the social determinants of health, it is a practical and achievable step forward. By leveraging generative AI technology—tools that didn’t exist even two years ago—communities can empower patients, improve overall health and extend people’s lives.
The Concept: Community Health & Technology Hubs
Think of these hubs as complements to the existing Medicaid system: providing affordable, targeted and technologically advanced support to individuals in areas where healthcare resources are limited.
Implementation: The first phase would involve launching pilot hubs in 10 low-income communities across the United States—strategically located in accessible facilities, such as existing community centers. Each hub would be staffed by 10 community workers—individuals working in social services who are familiar with the community, speak the language, and understand how to navigate local bureaucracies and maximize government resources.
Hubs would also include one clinician, a nurse practitioner or doctor, to provide medical assistance for unexpected, urgent issues (not as routine urgent care providers). These hubs would offer essential services like childcare, ensuring that parents have time to meet with staff, attend educational sessions and conveniently access health resources.
Additional medical support to all 10 sites would be provided by a small number of specialists connected via telemedicine, offering expertise when cases are unusually complex.
Integrating AI Technology: Generative AI will be central to these hubs’ operations. Community workers would be trained to help people use GenAI to manage lifestyle medicine, monitor chronic diseases and detect acute issues early.
As detailed in ChatGPT, MD: How AI-Empowered Patients & Doctors Can Take Back Control of American Medicine, GenAI is already making significant strides in the medical field. It now has the capability to quickly analyze individual medical histories, current health status and lifestyle factors to provide personalized health recommendations.
With careful training and human oversight, AI tools can suggest optimal diets based on a person’s financial situation, identify environmental factors affecting health and recommend preventive measures tailored to specific needs.
Additionally, GenAI can monitor chronic conditions by analyzing data from health devices like blood pressure and blood glucose monitors, either in the hubs or at home, flagging when an intervention may be required. This real-time analysis helps reduce the burden on overworked doctors by distinguishing between patients who are stable (and don’t need additional medical care) and those who need a medication adjustment (which most often can be accomplished virtually).
By empowering individuals through this technology, these hubs will improve chronic disease management and help patients avoid complications that lead to emergency room visits or hospitalizations.
Scalability And Cost-Effectiveness: The cost of setting up and operating each hub—including salaries, services, and technology—would be under $1 million annually. With a total investment of $10 million, our nation could establish 10 hubs along with a centralized specialty telehealth center to support them. Given Medicaid’s estimated $853 billion budget in 2023, the investment required for these demonstration hubs is minimal.
This hub model is designed to become cost-neutral quickly, with a positive return on investment over time. The savings generated from preventing just one major health event—a heart attack, kidney failure or stroke—would offset the operational costs of providing a year’s worth of assistance to 1,000 individuals. As savings are generated in one community, Medicaid officials would reinvest in new locations, continually expanding the program.
A Practical Step Forward: If our nation’s goal is to improve the health and longevity of those living in socioeconomically disadvantaged areas, focusing on the prevention and management of chronic diseases is the most immediate and effective approach available.
While addressing broader social determinants of health—like housing, education and employment—would be ideal, these complex issues are unlikely to be resolved quickly. In the meantime, reducing the burden of chronic diseases offers a tangible way to improve health outcomes now. Moreover, as people’s health improves, communities will see lower rates of absenteeism, better-paying jobs and healthier residents.
This model isn’t perfect. But it is a significant step in the right direction. It is affordable, practical and scalable. And it’s clear that what we’re doing today isn’t working. The time has come to try something new.
