When asking about the most pressing issues in health care today, the two most common responses involve cost and access. Left out of these dominant themes of discussion are socioeconomic determinants of health. The influence of social determinants of health is one that is well documented and almost universally acknowledged, yet given little regard in the grander discourse of problems that plague the national health care system. Socioeconomic status has historically been measured through metrics of education and income. A 2011 report from the Center for Disease Control (CDC) found that men and women from disadvantaged backgrounds without a Bachelor’s degree have a life expectancy of 9.3 and 8.6 years less than those with a Bachelor’s degree or higher . Similarly, the pattern holds for income: men and women in higher income brackets have higher life expectancies by 6-8 years than those with incomes under the federal poverty level . However, with the passing of the 2010 Affordable Care Act (ACA), many argue that this socioeconomic disparity should no longer impact health.
The notion that post-ACA, all low income individuals will be covered and therefore will have a higher quality of health is flawed on several levels. First, in the aftermath of the Supreme Court’s decision on the Affordable Care Act of 2010, the Medicaid expansion has been thrown into question, its fate resting on the decisions of individual states. Additionally, the issue of improving the health of low-income individuals is far larger in scope than simply increasing access to affordable health insurance. Numerous structural and environmental conditions will continue to create poor health outcomes.
Offering broader insurance options does not solve the problem of why many low income patients come to the clinic or hospital in the first place: for example, a patient who has medications but insufficient food and heat, or an asthmatic child living in an allergenic environment. Access to food, transportation, and safe living conditions are strong determinants of proper health. A variety of programs that span federal, state, and local levels exist to combat such problems, including the Food Stamp Program and Healthy Homes, a CDC funded initiative to prevent housing-relating hazards. Yet, clinics, which regularly refer patients to Healthy Homes, food supplemental programs, and housing assistance, are rare across the United States.
The fact that we do not fully utilize all of the existing solutions to mitigate this disparity in health seems counter intuitive. Perhaps, a model of providing social services to disadvantaged populations has not been proven to improve health.
Yet, one needs to look no further than the organization known as Partners in Health and their successful model of providing health care to find evidence for the importance of socioeconomic determinants of health. In addition to increasing access to physicians and medications, a core mission of Partners in Health (PIH) is to form community partnerships and address basic social and economic needs in locations as diverse as Haiti, Rwanda, and Russia . In Rwanda, Partners in Health supports its patients by paying the school tuition for needy pediatric patients and constructing homes for those with inadequate housing. Additionally, PIH employs community health workers they refer to as “accompagnateurs” to provide preventative tools such as mosquito nets to prevent malaria. Despite the fact that Partners in Health operates on a vastly different landscape than the average community in the United States, its lessons are largely applicable domestically.
In fact, a similar case study through Healthy Homes has proven successful in Seattle County, Washington. Community health workers were referred to asthmatic children, inspecting their homes, and providing bedding encasements, and eradicating pest.. Children receiving assistance from Healthy Homes significantly reduced their urgent care visits. The study also found that an estimated $1,316-$1,849 of health care costs were saved per high-risk asthmatic child through the use of the Healthy Homes initiative .
Taking the experiences of Partners in Health and Healthy Homes into account, a more holistic definition of health care seems to be an appropriate step to combat socioeconomic disparities in health. With the passage of the Affordable Care Act of 2010, a focus on preventative care has risen dramatically. This provides a prime opportunity to look at preventative care through a broader lens – considering not only mammograms and health screenings, but also referrals to job training programs and food pantries.
On the local level, the Agency for Healthcare Research and Quality has recently funded a program in Tucson, AZ that has made headway targeting individuals in need. The Human Service Referral Program connects frequent 911 callers who call for non-emergency reasons to community health centers and social services. The unique innovation of this program is lateral integration of various agencies and successful transfer of information. Once an individual is referred, he or she is assigned to a case manager who helps connect the individual to resources to help resolve the underlying reason for the 911 call. 5 These concerns are all documented on a web-based system and then transferred to the local health system, behavioral health programs, and other necessary community organizations. This individualized integration of health care and social services provides a promising model for national replication.
However individual programs and organizations such as the Tucson Human Service Referral Program cannot resolve the immense task of reducing socioeconomic disparities in health on a national scale. Despite the significant impact these programs have made, they exist in distinct locations with limited resources. An innovative movement to streamline access to integrated social and health care must be undertaken on a national scale. The mix of federal, state, and local agencies that address unmet social needs create a confusing patchwork that is difficult to navigate for patients. Yet, the investment in connecting patients with basic resources could result in a far greater return by reducing preventable hospitalizations.
Connecting low-income patients to social services would be a modest expansion to the scope of healthcare services. The returns from that investment would address both cost and access, two of the primary issues in modern health care. At the same time, creating this bridge between health care and social services will not completely resolve all socioeconomic disparities in health. Budgetary limitations of social services aside, many problems cannot be addressed as easily as referring a patient to a social service agency. Creating a more holistic definition of ‘health care’ is just the first step in confronting the impact of socioeconomic disparities on health.
- “Health, United States 2011 With a Special Feature on Socioeconomic Status and Health.” US Department of Health and Human Services. http://www.cdc.gov/nchs/data/hus/hus11.pdf
- Braveman P. et al. “Overcoming Obstacles to Health.” Robert Wood Johnson Foundation Commission to Build a Healthier America. www.commissiononhealth.org
- Pabo, E. et al. “HIV Voluntary Counseling Testing in Hinche, Haiti. Harvard Medical School Cases in Global Health Delivery.” http://www.ghdonline.org/casesnew/hiv-voluntary-counseling-and-testing-in-hinche-hai/
- Krieger, J. W. et al. “The Seattle-King County Healthy Homes Project: A Randomized, Controlled Trial of a Community Health Worker Intervention to Decrease Exposure to Indoor Asthma Triggers.” American Journal of Public Health (2005): 652-659. Accessed October 11, 2012. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449237/
- “AHRQ Innovations Exchange. Referral System Allows Responders to Connect 911 Callers to Needed Community-Based Services, Reducing Nonemergency Calls.” http://www.innovations.ahrq.gov/content.aspx?id=2809.
- Image Credit: Matthew Boyle
- Image Credit: Lori Marx-Rubiner
Arifeen Rahman is a sophomore at Harvard University concentrating in Human Developmental and Regenerative Biology. She is also the Publishing Editor of the Harvard Health Policy Review and is interested in the intersection of society and medicine. Follow The Triple Helix Online on Twitter and join us on Facebook.