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November 10, 2021
Social determinants of health
Paula M. Lantz
Oct 23, 2023
May 23, 2022
Jan 24, 2022
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Of the three primary demographic forces in population dynamics—birth, death, and migration—mortality receives by far the most attention in population health. For example, significant attention is rightly being given to social inequality in mortality and trends in life expectancy in the United States, including the declines observed from 2015 to 2017 and the significant decline fueled by COVID-19 in 2020.
Receiving less attention is another demographic trend that also is an important indicator of population health: the recent sharp decline in birth rates in the United States. Many of the social determinants of morbidity and mortality in populations are also the social determinants of fertility and birth. As such, this significant decline in births is a warning sign regarding the social and economic factors that are the fundamental drivers of all population dynamics, including population health.
The US birth rate dropped 4% in 2020 and was already at a record low before the COVID-19 pandemic. The 2020 birth rate was 55.8 live births for every 1,000 females ages 15-44, trending downward for the sixth consecutive year. The total fertility rate (TFR), which is a population statistic that simulates the average number of children females in a birth cohort will have if they go through life with current age-specific birth rates, is also trending downward. The TFR in the United States plummeted from 2.12 in 2007 to a record low of 1.64 in 2020, which is far below the level of 2.1 needed for population stability. This decline is primarily being driven by declines in births among those under 35 years of age (including teens) and immigrants.
Forecasting birth rates is challenging, given that many social and economic factors influence fertility, and that the reported “fertility intentions” of younger people are typically inaccurate. However, demographers predict that the declining birth rate in the United States is going to persist. Most high- and middle-income countries are also experiencing declines and many already have lower TFRs than the United States, including South Korea (1.11), Singapore (1.21), Italy (1.33), Greece (1.30), Japan (1.37), Poland (1.39), and Canada (1.53).
Birth rates are an important indicator of overall population health and well-being for many reasons. First, changes in a population’s TFR are a reflection of myriad social factors, including the range of opportunities and resources afforded to women. It is well understood that, at the population level, increases in education and labor force participation among females lead to delays in or avoidance of marriage and childbearing, which in turn decreases birth rates. In addition, technology has both increased the ability to avoid pregnancy and assisted with infertility, including at older ages.
However, declines in birth rates are also driven by social and economic factors that constrain and influence people against having any or many children. Economic conditions that influence birth rates include recessions, wage levels, tax levels, the costs of child care, and other economic and opportunity costs of being in versus out of the labor force. The pressures facing young adults, including student debt, the rising costs of housing and health insurance, and ongoing gender and racial wage inequality also appear to influence decisions about family formation and procreation. In addition, while the relationship between the division of domestic labor within a household and fertility is complex and varies across countries, there is evidence of a negative correlation between a gendered, unequal sharing of household work and fertility.
Second, when the TFR drops below 2.1 (the break-even replacement level), a population will age dramatically in the absence of immigration. This, in turn, contributes to labor shortages and will also increase the population “total dependency ratio,” which is the ratio of the number of people in age groups not typically in the labor market (0-14 and 65+ years) to the number in all other age groups, multiplied by 100. The US dependency ratio was 59 in 2010, 64 in 2019, and is projected to be 73 by 2050 primarily due to population aging from the 1946-1964 Baby Boom. Additional declines in birth rates without offsets from immigration will further increase the dependency ratio, which raises serious concerns about economic stability/growth and the ability of the working population to support the social, financial, and health care needs of the dependent population.
Loud and serious alarms have been sounding about the aging of the US population and the solvency of our major social insurance programs for quite some time. These concerns are further exacerbated by steeper than expected birth rate declines and the COVID-19 pandemic, which has fueled dramatic changes in employment rates, labor force participation (especially among women), and short- and possibly long-term disability rates.
Whether or not to have children is an extremely personal matter and a decision that should be mostly free from government intrusion and regulation. Even so, public policymakers need to be concerned about birth trends in the United States and understand that even the most intense personal decisions are influenced by macro-level systems, social structures, and policy contexts that add up to population-level phenomena with important ramifications for society.
Concerns about declining birth rates should not be about resulting changes in population composition in terms of race/ethnicity or that people with a uterus are not fulfilling some sort of biological calling. The concern here is that the social determinants of health are also the social determinants of birth, and that changes in birth rates—like changes in mortality rates and life expectancy—are additional sentinel indicators of the social determinants of overall population well-being. Addressing the major upstream drivers of health and health inequities will simultaneously address the upstream drivers of declining birth rates.
Social science evidence suggests that birth rates would likely increase with public policy reforms and investments related to child care subsidies, child tax credits, paid family leave, and subsidies for health care (including care related to fertility). In addition, birth rates would likely increase with public investments that assist with long-term economic security, including student debt reduction, housing affordability, home ownership, wealth accumulation, and income security across the life course.
The Biden Administration’s “Build Back Better” framework and policy agenda is a phenomenal start with its proposed investments in universal preschool, child tax credits, child care subsidies, health insurance reform, clean energy and sustainability, affordable housing, education beyond high school, general infrastructure, and tax reform. All of these investments address the fundamental social drivers of mortality, morbidity, and fertility. However, the root cause structural drivers of racial inequality in many of these social and economic issues, such as systemic racism in education systems, housing/home ownership, and labor markets, must be addressed for the bold policy reforms being proposed to have a deep and lasting positive impact on the well-being of all. Furthermore, addressing population aging and the impact of declining birth rates must include the complexities of optimal public policy related to family planning, abortion, and immigration.
In summary, declines in birth rates, like declines in life expectancy, should be alarming to population health advocates and public policy leaders. The social determinants of health are, in fact, the social determinants of birth, death, and overall well-being in between, and require unified and bold policy agendas in response.
Paula Lantz, PhD, MS, MA, is the James B. Hudak professor of health policy and a professor of public policy at the Ford School of Public Policy at the University of Michigan. She also holds an appointment as professor of health management and policy in the School of Public Health. Lantz teaches and conducts research regarding the role of social policy in improving population health and reducing health inequities. She currently is conducting research regarding housing policy and health, including opportunities within the Medicaid program for assisting with housing security. An elected member of the National Academy of Social Insurance and the National Academy of Medicine, Lantz received an MA in sociology from Washington University, St. Louis, and an MS in epidemiology and PhD in social demography from the University of Wisconsin.
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