Is Advertising a Social Determinant of Health—You Bet!

As a 1980s child growing up in a drug-infested housing project, mass advertising by hospitals and insurance companies had no bearing on my community. On the airwaves, private hospitals promoted state-of-the-art facilities and rehabilitation centers.  TV commercials touted porcelain, well-heeled, young couples bringing rustic floral arrangements to smiling elders in cozy post-surgical suites. These private hospital ads targeted middle and upper class, picket-fence, insured America. Poor folks were not their goal. We were not stakeholders in the eyes of competing hospitals.  Instead of rustic flowers, we saw dilapidated placards and billboards that advertised cigarettes, malt-liquor, and funeral homes.

While most of us do not fear the effects of advertising on our healthcare choices, we should. In 2015, health insurance companies spent $1.1 billion advertising their policies; still healthcare advertising is not equitably distributed in all communities.¹  Customarily, insurers have targeted healthier and more affluent risk pools and highly profitable seniors, with little regard for low-income Americans.  So, when the Trump administration drastically reduced the advertising budget for the federal Marketplace by 90 percent for the new open enrollment on the health insurance Marketplaces, many questioned the impact of the absence of affordable health insurance advertising on the well-being of lower-income Americans.²

It could be asserted that the Trump administration is protecting vulnerable Americans from predatory healthcare marketing.  Research has shown that advertisements influence cognition, behaviors, emotions, and consequentially health and healthcare decisions.³  For nearly 150 years, the American Medical Association affirmed this belief as physicians were prohibited from advertising, recognizing the lay public’s susceptibility.⁴  By the late 1970s, healthcare marketing had become invaluable in our new world of self-actualization.  Americans, no longer viewed as naïve consumers reliant on physicians, became seen as authentic stakeholders whose choices were their own.¹  Americans had women’s liberation, black power, and now healthcare alternatives – if you could afford it.

I was one of millions of vulnerable low-income American families who used ERs for urgent physician care.  In 2007, my peripatetic 51-year-old father listlessly presented to the ER after fainting on a roofing job.  He died 13 months later of stage 4 colon cancer.  The ER was his first adult visit to a doctor as a blue-collar, low-income, American.  One year later, I weighed whether to take my lymphoma affected teen brother whom I was rearing to the ER because he didn’t have insurance. This lack of healthcare access in my community motivated me to pursue a career in health policy.

With the passage of the Affordable Care Act (ACA) in 2010, marginalized lower-income Americans were finally invited into healthcare consumerism. Social media, airwaves, and TV buzzed with invitations to join low-cost Marketplace plans. Marketplace ads empowered lower income-consumers to explore insurance options looking beyond barriers. A 2014 Health Affairs study conducted found that people living in counties with more Marketplace ads “sponsored by the federal government were significantly more likely to enroll in healthcare exchange plans.”^[2] Other studies showed that healthcare insurance commercials are most effective in enrolling lower-income Americans.

Had my Dad been alive and healthy today, most likely he wouldn’t know to enroll.  Last year, the Trump Administration slashed Marketplace advertising from $100 million to $10 million. The U.S.  Department of Health and Human Services cut funding by 41% to nonprofit groups that effectively help people to understand at-times complicated marketplace options and enrollment.⁵ Trump’s intention to undermine the ACA has been realized, at the expense of America’s most vulnerable.

Advertising has real long-term effects on behavioral choices. Consumer culture, television and social media, and the globalization of industries has warped advertising into a social determinant of health.  Conflictual public-private health partnerships might explain why advertisement has not been thoroughly explored by the public health community. ⁶ Food and beverage corporations almost exclusively target Blacks and Hispanics with nutritionally poor products (e.g. fast foods, candies, sodas, and sugary beverages), as is evident from the chronic morbidities of cardiovascular disease, diabetes, and obesity that are disproportionately higher in communities of color.  Though national food-related television marketing dollars decreased, spending on ads during Black-targeted TV programs increased by more than 50% from 2013 to 2017. ⁷

During this same period, juxtaposed to adverse fast-food marketing, credible government television ads were the “number one” driver of Marketplace enrollment.⁸  Though private sponsors filled the government advertisement void in 2018, the content was insurer specific, rarely specified the enrollment period, and did not promote the federal Marketplace. ⁹ Thus, removing educational websites, billboards, TV ads and non-profit support worsen knowledge gaps that fuel adverse health consequences for vulnerable Americans.  Low economic status and poor access contribute to poor health and shortened life expectancy.  Marketplace exchanges help to close the health gap for lower income Americans.

While the Trump Administration’s veiling of the health insurance Marketplaces may seem inconsequential to some, for many low-income health-challenged Americans, the cost is too high. Admittingly, other strategic methods (mandatory work requirements, removal of the individual mandates, short term limited duration policies) that were enacted to dismantle the ACA have garnered public attention, many Americans, like my family,  may never know how the lack of affordable insurance advertising has contributed to their worsened health status.