What About the Other 75%? The Missing Call to Action under the Affordable Care Act

Terri Jackson Terri Jackson
 
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The Centers for Disease Control and Prevention (CDC) estimate that genes, biology, and health behaviors together account for only 25% of population health outcomes. Social determinants of health including race, gender, environment, and access to health services account for the remaining 75%.

Though troubling, this statistic actually illustrates exciting potential for improvement. Many of the populations’ greatest health challenges are not naturally occurring, but socially created. This reality demands a holistic approach to health that begins at the societal level. With deliberate and thoughtful access strategies and implementation, we can move the dial on population health outcomes and reduce health inequalities.

The realities of health inequality throughout the U.S. are inescapable.  Despite spending nearly twice as much per capita than any other nation on healthcare services, the U.S. has not seen proportionally better outcomes.  In a 2014 Commonwealth Fund report comparing the health systems of 11 Western nations, the U.S. ranks last in quality (effective, safe, coordinated and patient-centered care), access (percent of people able to access health care despite costs), and efficiency (amount spent on administrative costs, bureaucracy, avoidable emergency room use, and duplicative medical testing as a percentage of total spending). The CDC estimates the maternal mortality rate in the US to be 17.8 deaths for every 100,000 live births – higher than in Serbia and Saudi Arabia, and more than double the rate than in the UK and the UAE. What’s more, this burden splits along societal lines – while the mortality rate for white pregnant women is only 12.8 deaths per 100,000 live births, maternal mortality for black pregnant women is more than triple that figure, at 42.8 deaths per 100,000 live births.

Racial and socioeconomic disparities in healthcare are not novel constructs. The Affordable Care Act (ACA) was enacted as a way to meet these challenges and transform the U.S. healthcare landscape into one that provides high quality healthcare services at a lower cost with improved health outcomes.  The ACA offers Medicaid expansion, subsidizes medical insurance premiums, and has already insured over 16 million people who did not previously have access to insurance. In only its first three years, the ACA is already one of the most significant pieces of policy legislation to reduce healthcare disparities in recent history.

However, improved access to medical coverage is not the only missing piece for those suffering at the bottom of the health spectrum.  To take a proactive stance on health,  the U.S. needs to establish a policy on health-adjacent programs that ensures that every U.S. citizen has access to a full continuum of support services to accompany their medical care, optimizing the probability that patients are linked to care, stay in care and stay healthy.

We will not achieve the Triple Aim of ACA—improving the experience of care, the health of the U.S. population, and the per capita costs of the health system—without targeting the basic resource needs of patients before, during and after healthcare engagements with medical providers.

Simply stated, wrap-around support services are healthcare services.  When patients seek medical care, they often face critical challenges in their lives at the same time—food insecurity, unemployment, lack of transportation and unstable housing.  Not surprisingly, these challenges affect patients’ health, leading to poor retention in care, increased hospitalizations and emergency room visits.  All of this adds up to increased costs. Poor health can drive individuals into or deeper into poverty, which causes health to deteriorate even further.

 

 

Many points in the clinical pathway present stumbling blocks for patients in need of social support services.

Many points in the clinical pathway present stumbling blocks for patients in need of social support services.

 

The need for wrap-around support services is common to any chronic illness. These conditions often require a lifetime of medical care, vigilant adherence to medications and the adoption of proactive healthy behaviors to stave off sickness and disability.

The U.S. does a fairly good job of diagnosing chronic illness – – the CDC estimates that over 85% of patients living with HIV have been diagnosed, as have over 70% of adults living with diabetes. Most healthcare systems are also fairly effective at managing patient needs when the patient attends all visits.  However, there are significant drops at each stage of the care continuum, particularly between linkage to care and retention. Some patients are never linked to treatment, while others miss their visits or do not adhere to medication. Fewer than half of the patients living with HIV are retained in care, and even fewer are virally suppressed. These gaps occur in the spaces between the traditional healthcare system: a space potentially filled by wrap-around support services. These services, which may include medical transportation, housing support, child care or nutritional supplementation, are not typically regarded as essential to health. Consequentially, very little of the $2.9 billion spent annually on health services in the US is directed toward social services.

However, this perception is slowly changing. Two of the U.S.’s most distinguished health organizations, the American Public Health Association and the Institute of Medicine, have proposed a “health in all policies” approach to create inter-sector collaborations that align strategies to improve health outcomes by targeting the social determinants of health. The Delivery System Reform Incentive Payment (DSRIP) Program, a pilot program in six states, also takes this holistic approach. Noting that the top 5% of Medicaid utilizers account for nearly 50% of the health expenditure, DSRIP initiatives include coordination of support services such as housing, nutritional programming and individual care management to keep these individuals healthy and out of the hospital. Expanding DSRIP services beyond Medicaid patients could support the ACA by complementing treatment with protection and prevention.

U.S. healthcare is at a critical cross-road.  The passage of the ACA represents a historical victory that carved a critical pathway for expansion of healthcare to vulnerable populations of the uninsured. To continue this momentum, the next critical pathway is a national support services strategy to ensure that every U.S. citizen has access to a full continuum of support services.

 

 

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