Addressing social determinants of health is key, Part 3 of a 3-part series

When the American College of Physicians issued a white paper outlining its support for the establishment of a single-payer or public option healthcare system, there was no hint that 2020 would unfold as the most perilous year for U.S. medicine in more than 100 years. Nonetheless, the case made by the ACP remains a compelling one—so much so that BreakingMED is offering its users as chance for a second look. This third installement of a three-part deep dive into the ACP proposals was originally published Jan. 22, 2020.

The American College of Physicians’ call for universal health coverage and delivery and payment system reforms is a heavy lift, but this is not all the physician group is envisioning. The ACP is also looking at how the United States can achieve health equity by addressing the social and economic conditions that lead to disparate care.

Reducing Barriers to Care and Addressing Social Determinants of Health” is the third position paper published in the Annals of Internal Medicine supplement outlining the ACP’s “Envisioning a Better U.S. Health Care System for All.”

“Ensuring not just health care, but health itself, is the goal of ACP,” Renee Butkus, BA, from the American College of Physicians, and colleagues wrote. “The constitution of the World Health Organization says, ’Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.’ The ACP continues to support efforts to achieve this level of health. To ensure optimal health for everyone, social determinants of health and barriers to care must be addressed; the provision of improved access to health care alone will not be sufficient. Other factors shown to influence health outcomes include race/ethnicity, gender, LGBTQIA identity, intellectual and physical disability, location, age, language and citizenship status, incarceration status, religion and cultural beliefs, health literacy, and access to information. The impact of these factors demonstrates the need to go beyond health care coverage, cost, and delivery systems in order to improve health.”

Butkus and colleagues noted that in the United States, rather than seeing an increased life expectancy among its populace, it has actually been decreasing since 2014, “and, at 78.9 years, ranks last compared with peer countries.” They cited “environmental health hazards, poor nutrition, tobacco use, substance use disorders, firearm injuries and deaths, and maternal mortality” as contributing to the decline, as well as the other factors cited above.

“The social determinants of health are not abstract concepts,” Karen B. DeSalvo MD, MPH, from Google Health, Palo Alto California, and Nadine Garcia, from the Trust for America’s Health, in Washington, DC, wrote in an accompanying editorial. “All physicians can recall patients whose social and economic conditions, community context, and life experiences have been barriers to optimal health and wellness. Consequently, physicians have an important role in understanding and supporting interventions to address the social needs of their patients. Our patients trust us and share insights about their social risks and needs. Knowing about the context of patients’ lives helps physicians make more accurate diagnoses and develop more appropriate care plans.”

After a literature review looking at barriers to care and social determinants of health, Butkus and colleagues came up with several recommendations.

Assure equitable access to care

Butkus and colleagues noted that an intersectional approach is needed to understand the circumstances that limit access to high-quality care.

  • Isolated and rural areas. One of the barriers to care the paper cited is living in isolated rural or inner-city areas, which limits health care access. “For example, quality of care for the HIV-positive population, BMI and obesity level, and access to nutritious food, have all been shown to be affected by location,” they wrote.
  • Disparity of care for certain groups. The study authors noted that how to address racial and ethnic disparities, LBBTQIA disparities, and those faced by women have all been outlined by relevant ACP position papers.
  • Care for the aging population. Aging is another barrier that Butkus and colleagues note needs to be addressed. “Persons aged 65 years or older make up almost 15% of the U.S. population, and elderly people face both physical and psychological barriers when attempting to access care. Future action and policies must ensure that the aging population is able to safely and independently access health care services,” they wrote.
  • Religious and cultural beliefs. The authors noted that religious and cultural beliefs need to be respected as outlined in the First Amendment, but then noted that things such as exemptions from “evidence-based immunization requirements should be limited to medical indications in order to protect the public’s health.”
  • Immigrant population. The authors noted that more than 21% of people older than 5 speak a language other than English and languages services need to be available. They point to two ACP position papers — one addressing immigration and the other addressing racial and ethnic disparities.
  • Improving health and digital literacy. “In the United States, around 23% of people living in urban areas and 28% of people living in rural areas do not have access to or cannot afford broadband. Lack of Internet access prevents people from accessing health information,” Butkus and colleagues wrote. “Even when a person has access to the Internet and access to health information, it is not a guarantee that the individual is able to understand and process the information.”
  • Incarceration. Acknowledging that the U.S. has more people behind bars than anywhere else in the world (2.2 million), the ACP said their health needs, which can include addiction, mental illness, increased risk for HIV, STDs, and other infections, need to be addressed with policies to advance public health and access for this population.
  • Disabilities. Noting that about 12.8% of the U.S. population have either intellectual or physical disabilities, which impedes access to care, they argued that policies are needed to address their unique needs.

Recruit and retain an adequate physician workforce

“Particular attention should be directed at recruiting and retaining ambulatory-based internal medicine specialists in recognition of their unique training, skills, and contributions in providing high-value primary, preventive, and comprehensive care to adolescents and adults throughout their lifetimes, particularly for patients with more complex medical problems,” Butkus and colleagues wrote. “In addition, a diverse and culturally competent health care workforce that is more representative of those they serve is critical to improving health care access and outcomes.”

They also noted that bold moves are needed to address the “shortages and maldistribution of clinicians.” Their suggestions include:

  • Increase graduate medical education training slots in specialties that are in short supply, such as internal medicine.
  • Reduce administrative burdens.
  • Ease medical school debt.
  • Reform payment policies.
  • Support primary care physicians who choose to practice in underserved areas.
  • Leverage government and institutional resources (financial incentives, technical assistance) to help recruit and retain physicians in underserved areas.
  • Hospital closures, “particularly critical access and safety-net hospitals,” impact patient access to care, especially emergency care. Also, in certain areas, emergency departments become a surrogate for primary care “because access to such care in community-based outpatient settings is limited.” These need to be addressed, and policies enacted, to ameliorate these scenarios.
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Environmental health and climate change and its effect on health should be addressed, according to the appropriate ACP position papers.

Public Health Initiatives

The ACP, as part of its position paper, is also supporting a focus on what it calls “critical public health objectives,” which include:

  • Reduce smoking and tobacco-related illnesses —particularly the health risks associated with e-cigarette use among teens.
  • Reduce and treat substance use disorders.
  • Reduce rate of maternal mortality, especially among blacks.
  • Reduce firearm injuries and deaths.
  • Improve access to high-quality nutrition.

DeSalvo and Garcia noted that addressing these social determinants of health and disparity in care “can seem daunting. Fortunately, medicine is not alone.”

They applauded the ACP’s efforts and its acknowledgement “that medicine will need to work with partners whose skills, reach, and experience complement our own.”

Candace Hoffmann, Managing Editor, BreakingMED™

Butkus disclosed no relevant relationships.

DeSalvo disclosed formerly serving on the Humana Board of Directors.

Garcia disclosed no relevant relationships.

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Topic ID: 88,150,585,791,730,192,150,151,590,61,925