Guy (00:01.17)
Hello and welcome to this Facts Matter podcast. I’m Guy Gordon, brought to you by the Citizens Research Council of Michigan on a vastly unbiased, passionately nonpartisan and deeply dedicated to the notion that facts matter, not politics, when it comes to good policy. Today, we’re going to look at health. And before we make that leap, we’re not just talking about healthcare or healthcare coverage, we’re talking about health in general, just how healthy

Michigan is. We’ve got a beautiful paper that you can find at CRCmich.org on the social determinants of health. And we’re going to do a deeper dive into what it means. But to start us out, we know that we are no longer the industrial powerhouse we used to be here in Michigan. We know that our educational attainment has fallen. We also know that higher unemployment and also falling incomes, all of it is now literally making us sick.

because all of it has an impact on our health. And to do a deeper dive at SDOH is the young woman you see nodding her head there in agreement at what we’re going to do. And that’s Kelly Abramson, who is our research associate for healthcare at Citizens Research Council. Hi Carly. I guess we should make a disclaimer right off the top because people think that the minute you talk about health, well, you’re going to start debating about, you know, universal healthcare coverage or, you know, it all ends up being about money and

Karley Abramson (01:15.672)
Hi, nice to talk to you again.

Guy (01:28.53)
healthcare, we’re really talking about health here.

Karley Abramson (01:33.473)
Yes, exactly. And I think that’s one of the key takeaways from this paper is the need to zoom out from just those discussions about health care, which includes coverage and access and affordability, but expanding out even farther to all of the other factors that influence health outcomes that exist in policy areas that people don’t always think of as directly related to health. But as you mentioned, all of these things that Michigan struggles with

Guy (01:57.02)
Mm-hmm.

Karley Abramson (02:01.462)
are things that both directly and indirectly contribute to health outcomes. And they do so even more, they sometimes do so even more powerfully than the coverage or access to healthcare services themselves. So it’s really important for policymakers to be focusing on those.

Guy (02:17.842)
So let’s start with the baseline and it’s kind of hard to wrap your head and hands around, which is how healthy or how unhealthy are we in the state of Michigan relative to other states?

Karley Abramson (02:29.248)
Right, and so we, in the paper, we do a pretty thorough analysis of health outcomes. We use kind of as many measures as we can think of to try to cover the range of how Michigan fares. And essentially, the takeaway is Michigan is less healthy than other states in the country. We’re below the national average on many of the metrics. We’re also below our regional states as well. So we do a comparison to the Great Lakes states and…

see kind of how we do on different health measures. And so not only is Michigan overall generally has worse health outcomes, we also have health disparities. And so health disparities, essentially different groups of people will experience different health outcomes based on race, gender, income, all of those kinds of things. And those health disparities, while they exist in every state, are even wider in the state of Michigan. So those are kind of the three takeaways from just

Guy (03:24.05)
Okay.

Karley Abramson (03:27.168)
examining where Michigan is on the health outcomes.

Guy (03:29.936)
So I’m curious when we talk about kind of taking our temperature on health, do we include mental health metrics in that as well?

Karley Abramson (03:38.593)
Yes, and there are some mental health metrics. in the paper, there’ll be more, you know, there’s a specific breakdown, so don’t get too far into the weeds. But there are, and there’s some self-reported measures as well that include mental health assessments and, you know, assessing your own quality of life and, you know, how you feel on a daily basis. But it includes the whole gambit of different kinds of measures of

Guy (03:46.438)
Mm-hmm.

Guy (04:03.48)
Okay, so we should probably add a little bit more context here, which is we underperform nationally, we underperform regionally, and if you take a wider lens and include global health outcomes in developed countries, the picture gets even uglier, doesn’t it?

Karley Abramson (04:09.72)
Mm-hmm. Yep.

Karley Abramson (04:21.474)
That’s correct. We also make sure to point out where Michigan ranks, not just in the state, but then how the state or how the country compares to other developed countries. Because there’s some policy areas that there’s only so much that Michigan can do as a state. Some things have to happen on the national level. And so we make sure to point out when there are national problems about the system that Michigan is unable to change directly, but has to work under.

Guy (04:48.292)
understand. So this this kind of catch-all phrase that we’re talking about social determinants of health S-D-O-H some of it is going to be a little bit obvious some of it is much more nuanced but just give us kind of a definition of what this umbrella phrase means.

Karley Abramson (05:06.904)
Sure, and it is very, very much an umbrella phrase because essentially it means anything that affects your health outcome. But when we talk about social determinants of health, we are usually trying to steer the conversation away from the idea of personal choice and personal responsibility. A lot of health messaging centers around the idea of here’s what you need to know to make choices, here’s what you can do as an individual to try to be healthier, exercise, eat right, sleep more, all of those things.

What the conversation about social determinants of health does is expand out all of the circumstances and focus on those limitations to those particular health behaviors. so social determinants of health can be, again, cover a wide range of different domains, employment, education, built environment, access to food and nutrition. And so there’s a lot, and different health organizations kind of define

or organize these social determinants of health differently. In the paper, we organize them into kind of essential fundamental resources that you need in order to improve your health outcomes.

Guy (06:17.146)
Okay, so let’s explore some of those resources because it seems like the three-legged stool here is coverage. Obviously, if you have access to healthcare and healthcare coverage, you’re going to be in a somewhat better place because you’ve got monitoring and oversight, availability, whether you do or don’t live in a doctorate desert, I guess, and affordability. So let’s take those pillars. How does Michigan do on those social determinants?

Karley Abramson (06:19.341)
Yeah.

Karley Abramson (06:27.618)
Mm-hmm.

Karley Abramson (06:38.798)
Mm-hmm.

Sure.

Karley Abramson (06:46.658)
Well, that’s interesting. So if we focus on the healthcare leg, so if we’re talking about these fundamental resources, we generally focus on these five different ones in the paper. And the coverage access affordability are related to that healthcare piece, which is oftentimes the focus of most health policy discussion. And so if you focus on that piece alone, Michigan actually does pretty well relative to other states. So in terms of

making sure that people are covered. That compared to how Michigan ranks when it comes to employment and education and income and different measures of safety and food and nutrition, the healthcare domain is actually one that Michigan compared to other states is not lagging behind.

Guy (07:41.252)
No, and I guess, some degree, historically, to the UAW, who instituted this notion that healthcare coverage matters in early contracts, and that kind of was a rising tide that lifted all boats, because it was a cultural shift, that this is something that is important.

Karley Abramson (07:51.31)
Yes.

Karley Abramson (07:58.307)
Right, right. And it is, it is still an essential piece of producing better health outcomes, but it is a necessary but insufficient condition. And zooming out to all of the rest of the things that act as barriers or impediments to good health is what the paper does.

Guy (08:16.06)
So, but on coverage and availability and affordability, if we do better than others in the region, if we do better nationally, help me with this dilemma that, because I mean, so often the minute you start talking about health, it goes to healthcare coverage and we need to broaden healthcare coverage. We need universal healthcare coverage. We need to expand subsidies. It seems that we do better on those metrics here.

Karley Abramson (08:23.843)
Mm-hmm.

Karley Abramson (08:27.82)
Yeah

Karley Abramson (08:34.893)
Right.

Guy (08:44.396)
Why don’t we see a corresponding positive outcome or more positive outcome?

Karley Abramson (08:50.87)
And again, and that takes us back to what the social determinants of health are. so expanding out from that healthcare field, know, if you, first of all, even to get access to healthcare for most people still requires a certain amount of financial resources, which means you potentially need to have a job. In order to have a job, you need to be educated.

in order to receive an education that is of high quality. Sometimes you have to live in a certain area. You have to be in an environment and have a community that supports and encourages education. You have to be well fed and you have to be able to be present and aware to get that education. And so going back down the line to all of those things that you need to access those different tools for healthiness is…

is where we want to focus.

Guy (09:48.614)
But it still gets to the point that we kind of maybe miss the point when we constantly default to a discussion about healthcare coverage. I’m curious though, that when you look on a state by state basis, do other states have the same weird dilemma that we have where they don’t have, are there others that are outliers?

Karley Abramson (10:00.013)
Yes.

Karley Abramson (10:12.33)
Yes. Yeah, yes. So in every, there are many other states in which social determinants of health is going to be relevant in every state. And so I don’t know exactly if there’s the exact same parallel of doing well in the healthcare coverage, but falling behind in these other areas. But what’s interesting about Michigan is that when we go through the paper and we look at

different measures of social determinants of health to see where Michigan is falling behind. And the areas that Michigan is falling behind the most is in that income inequality, generally low incomes, employment and education. And the reason that it’s important to point that out is that those are the places that Michigan is falling behind, but those are also the core pieces of what you need to obtain the resources for good health.

And so it’s the fact that these particular things, Michigan is ranking low. And also these are the things that are crucial for better health outcomes.

Guy (11:16.242)
Let’s personalize this and let’s put it, if we can, into maybe an anecdotal context. We’ve got a mother of two. She’s got a high school education, maybe a little bit of college. She’s making an okay income, but not great. And yet she has some health issues. Her kids are maybe have childhood obesity issues. You know, we cover 98 % of the children in this state.

Karley Abramson (11:21.336)
Sure.

Karley Abramson (11:41.453)
Hmm.

Guy (11:46.044)
There’s really no reason for our kids to be unhealthy. Tell me what the barriers might be in her and just, you know, let’s humanize this a little bit.

Karley Abramson (11:51.663)
Sure. Yeah, no, and there’s the barriers could be a very wide range. So first we could talk about transportation depending on what the transportation issue is. If they have access to a car, if there’s access to public transportation, being able to go to preventative appointments, which is going to be the most helpful thing to be able to maintain healthy outcomes.

So, you know, just having that physical access, right? Potentially if having the insurance coverage, being able to afford those co-pays, even if you are covered, right? So if you’re on a tight financial budget, it might not make sense for you as a family to prioritize that preventative care, even if that means, you know, because nothing might be wrong and you need to buy groceries that week. And so working in that kind of high stress,

limited budget environment means that you don’t always prioritize your health because the best way to prioritize your health is to think ahead and act while you’re healthy. But if you don’t have the time or the energy or you have to prioritize other things that are more urgent, you’re not going to be able to spend those resources on that, which will then lead to further health problems down the line. So there’s also potentially, you know,

social support issues or stigma or the fact that if you’re in a specific community that doesn’t necessarily trust the healthcare industry or doesn’t trust doctors or hasn’t had positive experience with the doctors, you might be less inclined to prioritize that as well. So when people are making these decisions in their lives on a daily basis, there’s all these other things working against them that make that execution very difficult.

Guy (13:27.59)
Mm-hmm.

Guy (13:47.28)
One of the things that stood out to me in your paper was the idea of one of the other SDOH pillars is food and nutrition. And I just found it so ironic that here we are in Michigan, which has the greatest agriculture diversity outside of California. mean, access to fresh produce shouldn’t be a problem. And yet that seems to be one of the areas where we really fall down.

Karley Abramson (14:14.668)
Right, and it’s because, you know, that we live in that type of state where the actual, you know, availability is not, we’re not drastically behind, but in terms of getting that availability and access to the communities that need it is where we see some of those issues. And so what social determinants of health tries to get us to focus on is that connection between

what is going on in someone’s circumstances that does change those behaviors that might limit someone’s access or choices when it comes to healthy food options. So even if it’s available, even if it’s near you, even if you have the transportation to go get it, what other things might be working against you culturally, socially to prevent you from making healthy choices.

Guy (15:03.42)
So I’m curious, if we look back in Michigan history, when we were this industrial powerhouse and we had median incomes that were significantly higher than the rest of the nation, I mean, I found an old video and we were trying to get the Olympics here in the early sixties. was the mayor Kavanaugh was in the video when he said, we have the highest per capita net worth of any city in America. And it just hit me like a,

by four, just where we stood in terms of economic might and economic well-being here in Detroit. Were we healthier back then?

Karley Abramson (15:44.143)
That’s a good question. I would need to do a better deep dive into the… So it’s the reason that those comparisons are very hard to make is because there are so many other drastically different things about the world other than just the income level. we can’t just, it’s very hard to isolate that one variable when we’re comparing time periods that are…

Guy (15:45.816)
I’m just, I’m, I’m, or even, even in the, even in 70s before we took on the Rust Belt image.

Guy (16:05.157)
Yeah.

Karley Abramson (16:11.872)
are drastically different in the state, nationally, and globally. So even if we had the data, I’m not, you know, to be able to make that comparison. There’s so many confounding variables there that it would be hard to draw conclusions from that.

Guy (16:21.873)
Yeah.

Guy (22:43.824)
And that is that there is a tendency that when we talk about health and health care to view it solely through a social issue lens. And I think we kind of miss a larger point here, which is if we have a workforce that is not as healthy as the states we compete with, if we, that makes us a

Karley Abramson (23:00.525)
Right.

Guy (23:13.596)
higher cost place to do business that makes our workforce less appealing to prospective employers. It becomes a pretty important economic issue and business issue as well. And I guess the problem is it now becomes a bit of a catch 22, doesn’t it? Because we need the jobs, we need the income to make state residents healthier. But if they’re not healthier, it gets harder to bring that economic activity here.

Karley Abramson (23:33.678)
That’s it.

Karley Abramson (23:43.279)
That’s exactly right. That’s the cycle and that we need healthy people to be a more prosperous state, but to maintain better health outcomes, we need to be a more prosperous state. And so that’s why trying to refocus when we’re talking about health policy, that without those larger changes in those other policy areas in employment and education and income, those things that will affect things outside of health that will be beneficial for

different aspects of how the state functions, that those will also directly impact health outcomes, which will then make it easier to become a more prosperous state.

Guy (24:17.425)
Right.

Guy (24:25.202)
And it’s funny, not funny, but it’s interesting for the Michigan Chamber to, you know, certainly the Detroit Chamber to policymakers in Lansing. I think educational attainment and better economic outcomes and elevating Michigan’s median income, all of those things are being very, very assiduously targeted for improvement.

But if you were to have one things in the year of a policymaker right now based on this SDOH look, what would you say is the other one piece that might be the best starting point to addressing the others outside of those, yeah, those other big issues? Would it be food and nutrition for instance? Or what would you think it would be?

Karley Abramson (25:01.742)
outside of

Karley Abramson (25:05.838)
That’s a good question. I generally, the takeaway of the paper is those building blocks, right? Employment, income, education. Outside of that, I think actually the biggest change is a potentially larger change to the healthcare system that is a more national level than anything that Michigan can do.

Guy (25:21.052)
Right.

Guy (25:35.343)
Okay.

Karley Abramson (25:35.404)
So one of the reasons that we focus on those three is because these are areas also that is in Michigan’s power. There’s larger structural changes nationally in how the healthcare system works that could potentially change the baseline foundation that you need financial resources to navigate your way to good health. If we had a different system, the dependence on those financial resources to navigate

to better health outcomes might not be as relevant if the overall system changed, if that makes sense. that’s the, but that’s not necessarily, that’s not something that Michigan can accomplish in state.

Guy (26:14.446)
Okay, fascinating report. It is quite comprehensive, but certainly, certainly worth the read. And we invite our listeners and viewers to do that at crcmish.org. And Carly Abramson, thanks so much. And as always, we want to remind you that we do not rely on any lobbying revenues. We do not rely on any support from any specific government entity.

Karley Abramson (26:29.656)
Thanks.

Guy (26:41.616)
We rely on support from you. So if you like this kind of research and unbiased reporting on issues and policymaking, we invite you to make a donation at CRCMISH.org and support the mission of the Citizens Research Council. Thanks again for tuning in to Facts Matter. I’m Guy Gordon. Until next time, take care.