Beyond Clinical Interventions

Health access involves more than simply “health.” 

In a previous article titled “Health vs Healthcare: Fixing a Flawed Healthcare System,” I discuss the differences between health and healthcare and call for a shift in health policy, focusing predominantly on societal symptoms that affect health (such as access to food, transportation, and community) rather than clinical or hospital-centered healthcare. (1) I also highlighted three means by which the status quo American healthcare system may be improved: via community-focused clinics, primary care personalized to the individual, and expanding health insurance to support social determinants of health. Recent trends suggest the final aspect may be taking effect throughout the US. 

Take the example of Leo (a fictional individual living with chronic kidney disease). Leo lives in New York City where hospitals and dialysis centers are abundant. What factors might actually affect whether Leo seeks care for his chronic condition? 

• Education: Without appropriate healthcare education, Leo may not actually understand the condition he has or how to seek care. This way, he may never reach out to a local health facility to seek treatment.

• Income: Regardless of Leo’s insurance plan, Leo may not have the money to afford a hospital visit or the treatment for his condition. This may be a more pressing issue for individuals with chronic conditions like Leo, who may have to visit a dialysis center for a few days per week and for the rest of his life.

• Transportation: Leo may know where local hospitals are but not have a car or means of transportation to reach a local center. 

These factors affect Leo’s access to a clinic once he realizes he is ill; however, many social determinants may have played a role in Leo developing chronic kidney disease in the first place. Leo’s ability to access healthy food, to earn a steady source of income, to exercise, and to live within a supportive community may have affected his likelihood of developing a disease to begin with. 

A recent Washington Post article has highlighted recent Medicaid expansions into supporting social determinants of health. (2) Medicaid is a US government funded program that subsidizes clinical care to impoverished individuals. However, a recent bipartisan effort has resulted in the expansion of Medicaid from a purely clinical/healthcare focused program to a determinant/health focused one. 

The article highlights recent changes in the state of North Carolina which has broadened Medicaid funding to support housing, transportation, food availability, and support for former-prisoners and individuals who have recently undergone violence. Furthermore, over the past few years, the Centers of Medicare and Medicaid Services have worked to expand coverage in Arizona, Arkansas, California, Massachusetts, New Jersey, New York, Oregon, and Washington. 

Social determinants of health is an important concern on the patient’s end as well as the clinician’s. A 2018 survey identifies that significantly more patients wish to discuss these determinants with their providers than actually discuss them, largely because the focus of healthcare is primarily and predominantly clinical. (3)

With increased awareness of public health and the importance of social determinants of health, patients have prioritized awareness of possible determinants of their health, and many have expressed interest in speaking with their providers about these issues. However, while it is important that patients and providers both be aware of determinants of health, many of these determinants are out of the patient’s control; with the changes to Medicaid, the government has shown an interest in prioritizing these determinants and increasing funding to improve public health.

In 2022, the US Government announced increased investment in community and national organizations to reduce hunger and food insecurity for Americans. (4) As part of this concerted effort, President Biden announced the development of the “Sync for Social Needs” coalition to integrate social determinants of health into electronic medical records that are accessible to physicians and other care providers. Different providers and health systems have joined this growing coalition including Tufts Medicine, Rush University Health System, Meditech, and UniteUs.

“Sync for Social Needs” represents a larger paradigm shift within the clinical space: the inclusion of public health and social determinants within pre-existing primary and clinical care pathways. This trend seems to be continuing moving forward as the Washington Post article references a 2021 policy move requiring accredited US hospitals to ask patients about social and community needs and offering patients with a means to seek aid.

As this week is National Public Health Week, I hope policymakers, public health practitioners, and clinicians may work in tandem to recenter the narrative around alleviating determinants of health rather than solely prioritizing clinical care. While clinical care does provide concrete quantitative metrics around “lives saved” or “lives improved,” prior health access experiments demonstrate the importance of holistic healthcare in improving healthcare access and reducing patient expenses associated with clinical care. 

The Medi-Cal health access experiment in California has yielded significant data to policymakers about the role of social determinants in improving clinical outcomes. One important aspect of the Medi-Cal program was the allocation of a portion of government healthcare funds to affordable housing. Aggregated data from the Medi-Cal program from 2016 to 2021 reflects that the changes made in the program resulted in reduced hospital stays and emergency room visits, important clinical metrics that assess the health of a population and effectiveness of a healthcare system.

Healthcare is a two-armed system. One one side, primary and clinical care supported by hospital systems provides patients with treatment for acute and chronic illness. On the other side, public health reduces patients’ risk of contracting disease by reducing unmet social needs. By linking the two, specifically integrating public health and social determinants into primary and clinical care, patient care teams will not only be able to provide patients with more encompassing and holistic care but they will also be able to improve the overall well-being of individuals across the nation.