Our political system can hinder health equity, but we can also harness it to fuel positive change.
Many of us are familiar with the social determinants of health—structural conditions that we are born into, live and die in. But have you considered how our political system advances or hinders health equity?
We can trace many inequities—from banking, education, criminal justice, housing, employment, and health—back to what I call the political determinants of health: voting, government, and policy. The good news is that we can also leverage these political determinants of health to advance health equity.
To better understand the impact of the political determinants of health, let’s look at mental health. Did you know that during the pandemic, adults reporting symptoms of mental illness quadrupled, from one in ten prior to four in ten? COVID exacerbated isolation and stress for millions during a time when families and communities continued to grapple with social justice issues, political turmoil, and economic stress. This impact affected Black, Hispanic, and Asian adults at a much higher rate than Whites in the United States due to structural barriers to healthcare, family leave, and economic opportunity.
Here’s how we can apply the political determinants to creating change around mental health services.
Voting
Access to mental and behavioral health services is woefully insufficient across the United States. Improving care and advancing health equity is possible if those who face barriers to care can use their voting power to affect laws and policies that increase access to mental healthcare.
But the connection between voting and health is broken if the people who most urgently need to affect change are targets of voter suppression carried out through voter identification laws, purging voter rolls of irregular voters, minimizing early voting opportunities, and limiting polling places. Too often, that is the case today, making it difficult for those of us who most urgently need to make our voices heard to improve our access to care.
Only when we can all exercise our right to vote do we have the agency and power to improve our access to mental healthcare and, with it, our health.
Government
Making an economic case for better access to mental healthcare with both government and commercial interests is key to motivating stakeholders to make change because a health equity-focused policy must usually align with a government investment value. The data is there:
- Racial mental health disparities cost tax payers $278 billion from 2016 to 2020.
- The U.S. had nearly 117,000 premature mental and behavioral health-related deaths among Indigenous and racial or ethnic minorities during the same time period.
- If Black individuals had the same mental and behavioral healthcare as their White peers, there’d be a cost savings of $131.6 billion and if Hispanic people had the same mental and behavioral care, the cost savings would be $114.5 billion.
Also key is recognizing that improving access to health coverage overall will increase access to behavioral healthcare. Yet, 12 state governments are denying coverage to those who need it by refusing to expand Medicaid. In doing so, they are stripping readily available resources that would promote greater and more equitable access to mental healthcare.
Having health coverage has been shown to improve mental wellbeing and reduce stress and anxiety among people living in or near poverty. Some 60 percent of people in the coverage gap are people of color, and Black people are more than 34 percent more likely to be uninsured than White people, due to structural discrimination. So when we win the fight to increase coverage, we will improve mental health.
Policy
Creating and maintaining policy around mental health has been difficult, but it can be done.
For policy to be passed, we need government and commercial incentives such as economic gain or better national security. For example, the National Mental Health Act of 1946 was passed because mental health problems had reached crisis proportions in the U.S. military. Twenty percent of recruits were rejected for military service owing to mental illness, and 40 percent of military personnel were discharged owing to mental health complications.
Now, we must once again show that today’s mental health disparities are a workforce issue. Employees with unresolved depression experience a 35 percent reduction in productivity, contributing to a loss to the U.S. economy of $210.5 billion a year in absenteeism, reduced productivity, and medical costs. When employees are depressed, they miss an average of 31.4 work days per year and lose another 27.9 to unproductivity.
We can affect change by sending the message that policies that provide equitable access to mental health resources are good for business and for the country.
The Way Forward
We can leverage the political determinants of health to address the upstream drivers of mental health inequities, such as lack of health food options, inadequate transportation, and unsafe neighborhoods. First, we must look to history to understand how these inequities came to be: what policies and government actions shaped them, and who voted for and championed them. We must also educate ourselves about what policies are being considered and how candidates view them before casting our votes.
Self-reflection and education are important, but not enough. The work cannot stop here. We must also address the urgent need for novel research as it relates to the intersection of policy and equity. Addressing inequities in mental healthcare is complex and multifactorial, so the solution requires us to strategize in the same way. We need participation and cross collaboration among all sectors and their professionals, the skill and breadth of the willing, and the advocacy of the determined.
The health equity movement provides many ways to work toward a more equitable tomorrow. Those opportunities come in the form of the political determinants of health and are most effective when leveraged by an organized and determined movement. The only way we will achieve health equity is if we all work together to leverage the political determinants of health to make it so.
To learn about our latest research on policies and laws that can help achieve health and racial equity, visit Policies for Action. >>
Mental Health Support
If you are seeking support for mental health or substance abuse disorders, call the Substance Abuse and Mental Health Services Administration's (SAMHSA) National Helpline at 1-800-662-HELP (4357).
If you or someone you know is in crisis, reach the 988 Suicide and Crisis Lifeline by calling or texting 988 or chat at 988lifeline.org.
About the Author
Daniel E. Dawes is a respected author, scholar, and leader in health equity and health reform. Professor Dawes is the Senior Vice President for Global Health Equity and Executive Director of the Institute of Global Health Equity at Meharry Medical College. He serves on numerous boards, committees, and councils, including RWJF’s Policies for Action National Advisory Committee.