The original Build Back Better Act proposed various provisions to improve Americans’ lives, including two years of free community college, child care assistance, and investments in clean energy. The steep price tag has led many to question whether or not we can afford to spend so much.

But as a pulmonary and critical care physician at a major metropolitan hospital, I have a different question: can we afford not to?

Every day in the Miami health system where I work, I find myself taking care of patients with severe or life-threatening conditions that are, for the most part, a culmination of a lifetime of stressors. While costly medical technology is often used and expensive treatments prescribed, many of these conditions are too advanced for health care interventions to have a meaningful impact. Many of my patients know they should lose weight to be healthier but cannot consistently afford the fruits and vegetables, or have spent a lifetime balancing paying for medications against providing the next meal for their family. How useful is my prescription for an inhaler if my asthmatic patient returns to a home that is crowded, poorly ventilated, in disrepair, and moldy?

The United States, arguably one of the most technologically advanced countries in the world, ranks last amongst other developed countries in health outcomes and life expectancy, even as we spend more than other nations on health care.

The Centers for Medicare and Medicaid Services project that by 2028, health care costs will increase to $6.2 trillion, or about $18,000 per person — a full 20 percent of our GDP. Quality health care is important for good health, but research shows it only accounts for
20 percent of health outcomes. Our neighborhoods and physical environment, education, economic stability, income level, access to healthy food, reliable transportation, community and social supports — what public health specialists call the social determinants of health — are fully 50 percent of what makes us healthy and keeps us healthy, according to the U.S. Office of Disease Prevention and Health Promotion and the World Health Organization. In other words, poverty and all its attendant manifestations- like low education attainment, unsafe neighborhoods, poor air quality, etc.— directly affect our populace’s health and, ultimately, result in costly chronic diseases.

A bill that begins to address the social determinants of health, such as the Build Back Better Act, should be viewed not as a frivolous outlay but as a critical investment in the future health of our nation.

Consider cardiovascular disease, which accounts for one-third of all deaths in the U.S. annually. By 2035, it is projected to cost our country $1 trillion in both direct medical costs and lost productivity. And that is just one disease! Many of the individual risk factors for heart attacks and strokes (like obesity, diabetes, or chronic stress) are disproportionately distributed among people who are marginalized in our society because of income and other stressors. What if we could reduce the burden of these costly diseases by preventing or decreasing early risk factors?

So great is the relationship between income and health that Americans with higher incomes — who fare better on the social determinants of health — live much longer. In a national study of people aged 40 to 75 years, the gap in life expectancy between the richest 1 percent and the poorest 1 percent was about 15 years. In another study published in the Journal of the American Medical Association Network, Boston University School of Public Health researchers found that cardiovascular disease was less prevalent in people with higher income. Policies that reduce poverty and improve socio-economic status can have a long-lasting impact on the population’s overall health.

The Build Back Better Act proposes measures that impact Americans along the pre-K to college education continuum, which makes sense because education is yet another important determinant of health. Studies show that individuals with lower education levels tend to be sicker and have a higher economic cost to society. Policies that improve high school graduation rates and college or technical education attainment would be cost-saving in the long run. Each student that graduates from high school instead of dropping out will save states an average of $19,250 in Medicaid spending over their lifetime. Multiply this number by the 1.2 million students who abandon high school each year, and savings on a national level can quickly accumulate.

Policy initiatives that increase income, improve education, and provide better housing and greener neighborhoods are policies that invest in us, the people, and reduce the downstream impact of these factors on our health. Our well-being as a nation, future stability, and leadership position in the world economy demands that we discuss how best to invest the $1.75 trillion and not argue about politicized calls to cut.

Shirin Shafazand is a pulmonary and critical care physician.

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