Social Determinants of Health

Data sourcing

Our tracker's data on some social determinants of health including preventable hospitalizations are sourced from America’s Health Rankings (AHR) and County Health Rankings (CHR), both of which primarily rely on the Behavioral Risk Factor Surveillance System (BRFSS) survey run by the CDC, augmented by CDC WONDER and the U.S. Census.

A note about the CDC's Behavioral Risk Factor Surveillance System (BRFSS) survey. It's important to note that because BRFSS is survey-based, it sometimes lacks sufficient data for smaller or marginalized racial and ethnic groups, making some estimates less statistically robust. America's Health Rankings provides its BRFSS analysis at the national and state levels only. Where we show county-level data for these topics, it comes from County Health Rankings, which publishes its own county estimates derived from BRFSS. Because the two analyses are produced differently, county figures are not directly comparable to the state and national figures shown alongside them. Most of these measures describe adults only. For the population comparison bar charts and relative inequity calculations, we therefore compare each group's share of cases to its share of the adult (18+) population rather than its share of the total population.

AHR provides data for several social determinants of health topics via their GraphQL API. Care avoidance due to cost and uninsured individuals are displayed as percentage rates with no conversion applied. Preventable hospitalization is provided as a rate per 100,000 people.

Poverty and Uninsurance: American Community Survey

Data on poverty and uninsured people comes directly from the American Community Survey (ACS) 5-year estimates, a continuous survey conducted by the U.S. Census Bureau and collected annually, then pooled into 5-year rolling estimates to provide reliable data at the national, state, and county levels. For example, the 2022 release covers data pooled from 2018–2022, not calendar year 2022 alone.

Poverty is measured using ACS table series B17001 (Poverty Status in the Past 12 Months by Sex by Age), which identifies individuals whose income in the past 12 months was below the federal poverty level. Race-stratified counts are drawn from race-specific variants of this table (e.g., B17001A for White alone, B17001B for Black or African American alone).

Health insurance coverage is measured using ACS table series B27001 (Health Insurance Coverage Status by Sex by Age) for the overall, sex-, and age-stratified breakdowns, and C27001A–I (Health Insurance Coverage Status by Age, by race) for race-stratified counts (e.g., C27001A for White alone, C27001B for Black or African American alone). Both series identify individuals without any comprehensive health insurance plan. The ACS definition excludes plans that cover only specific conditions (e.g., cancer policies, long-term care) and does not count dental, vision, life, or disability insurance as comprehensive coverage.

For each of these tables, rates are calculated using the table's own population universe as the denominator, the sum of everyone with and without the condition in that specific table, rather than the ACS's general population totals. This is why the tracker exposes poverty_pop_estimated_total and uninsured_pop_estimated_total as separate denominators from overall population figures.

The tracker uses ACS 5-year estimates from 2012 through 2022, covering national, state, and county geographies broken down by race/ethnicity, age, and sex.

• Care avoidance due to cost (Ages 18+): race/ethnicity: Available; age: Available; sex: Available
• Uninsured people: race/ethnicity: Available; age: Available; sex: Available
• People below the poverty line: race/ethnicity: Available; age: Available; sex: Available
• Preventable hospitalizations (Medicare beneficiaries, Ages 18+): race/ethnicity: Available; age: Not available; sex: Available

Care avoidance due to cost

Measurement definition: Adults who reported a time in the past 12 months when they needed to see a doctor but could not because of cost.

Clinical importance: Avoiding care can lead to worse health outcomes. Studying avoided care in regard to health equity can help us to understand why people avoid care and how to reduce these barriers.

Uninsured people

Measurement definition: Health insurance coverage in the ACS and other Census Bureau surveys define coverage to include plans and programs that provide comprehensive health coverage. Plans that provide insurance only for specific conditions or situations such as cancer and long-term care policies are not considered comprehensive health coverage. Likewise, other types of insurance like dental, vision, life, and disability insurance are not considered comprehensive health insurance coverage.

Clinical importance: Health insurance is important for ensuring that people have access to quality healthcare. People of color and people with low incomes are less likely to have health insurance. Studying health insurance can help us understand why these disparities exist and how to address them.

People below the poverty line

Measurement definition: Following the Office of Management and Budget's (OMB) Statistical Policy Directive 14, the Census Bureau uses a set of money income thresholds that vary by family size and composition to determine who is in poverty. If a family's total income is less than the family's threshold, then that family and every individual in it is considered in poverty. The official poverty thresholds do not vary geographically, but they are updated for inflation using the Consumer Price Index (CPI-U). The official poverty definition uses money income before taxes and does not include capital gains or noncash benefits (such as public housing, Medicaid, and food stamps).

Clinical importance: Poverty is a major determinant of health. People who are poor are more likely to experience a number of health problems, including chronic diseases, mental illness, and substance use disorders. Studying poverty can help us understand why these disparities exist and how to address them.

Preventable hospitalizations

Measurement definition: Discharges following hospitalization for diabetes with short- or long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, angina without a procedure, asthma, hypertension, heart failure, dehydration, bacterial pneumonia or urinary tract infection per 100,000 Medicare beneficiaries ages 18 and older continuously enrolled in Medicare fee-for-service Part A.

Clinical importance: Studying preventable hospitalizations can help us understand why these disparities exist and how to address them.

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