Access to Health Care Isn’t Enough

We’re well into the 2020 presidential election cycle and there are a lot of health care proposals floating around. Most of them want to increase access to insurance and some have a plan to reduce the cost of care. But unfortunately, universal access to health insurance does not equate to health equity or better health outcomes. Health care systems are designed to handle individual medical needs, not the most critical causes of poor health – socioeconomic factors. In the United States, the development and provision of health care has fundamentally misunderstood what health is and what it requires.

A 2017 study in Health Affairs conveyed that the U.S. has one of the largest income-based health disparities in the world. Among the poorest third of Americans in the study, 38.2 percent reported being in “fair or poor health,” compared with 12.3 percent of the richest third. Most of the nations studied had an income-based health disparity, with the exception of Japan and Switzerland.

An article in the New York Times made the case that a steady paycheck can improve the health of an individual. This particular article featured investments made into a community by Kaiser Permanente through employment of local workers on a new construction project. There are also other efforts by non-profit health care organizations to revitalize the community with family housing, an art community space, an early childhood learning center and a park.

Across the board, there is increasing recognition that improving health and achieving health equity must involve a broader approach that includes social, economic, and environmental factors that impact health. These are commonly referred to as social determinants of health, which was coined by the renowned epidemiologist Sir Michael Marmot. The World Health Organization defines social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”

There is no formal or finalized publication of what makes up SDoH, but this table from the Kaiser Family Foundation nicely outlines the broad categories and factors that contribute to health outside of medical care.

For better or worse, politics plays a significant role in health. This has lead to an understanding that public policy and public health efforts should place an emphasis on “health in all policies.” This is the idea that any proposed public policy should consider the health implications, positive and negative, of implementation. The American Public Health Association outlines five key elements to health in all policies:

• Incorporate health, equity, and sustainability into specific policies and programs and embed these considerations into government-decision making processes.
• Support intersectoral collaboration by bringing together partners that play a role in shaping economic, physical, and social environments in which people live.
• Benefit multiple partners with policy and programmatic goals.
• Engage stakeholders, including community members, policy experts, advocates, the private sector, and investors.
• Create structural or processes change over time to institutionalize health in all policies throughout government.

Physicians and medical students have a role to play in identifying issues that affect patients outside of the clinical setting. The American Academy of Family Physicians launched the EveryONE Project to address social determinants of health. Their online toolkit includes a Social Needs Screening Tool that can help physicians identify and addresses patient concerns around housing, food, transportation, utilities, childcare, employment, education, finances, and personal safety. We should be screening for social needs just like we screen for hypertension and cervical cancer. And yes, we should appropriately compensate physicians for this part of visit – I would even make the case that we should ask these questions of almost every patient at every visit. After social needs have been identified, the AAFP Neighborhood Navigator can be used to connect patients to resources and programs in their community.

Understanding the links between health outcomes and public policies is essential to ensuring that health equity is adequately addressed. Physicians should be advocates for their individual patients and communities but they cannot do this work alone. Illness and injury does not occur in a vacuum and neither should our solutions. Universal health care is a great goal but it is meaningless without changes to our social structures.