My family and I lived in poverty. We did not have healthcare until the Medicaid Act of 1965. We relied on home remedies when we got sick because we couldn’t afford to go to the doctor. When my brother became too ill for the home remedies to be effective, my father and I walked to house after house asking for help. Finally, someone agreed to help and he was taken to the charity hospital. He had emergency surgery for a ruptured appendix. During those times, ambulance services were not an option.
According to the World Health Organization (WHO), “The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries. This unequal distribution of health-damaging experiences is not a natural phenomenon but is the result of a toxic combination of poor social policies, unfair economic arrangements, and bad politics.”
This means the well-off and healthy become even richer and the poor, who are already more likely to be ill, become even poorer. These factors influence the risk of disease for poor people. Based on numerous case studies, research and analysis, the WHO published a report on steps to remedy health inequity and combat factors that exacerbated injustices.
The 2010 Affordable Care Act (ACA) supported the ideas put in place by the WHO by bridging the gap between community based health and healthcare. In 2011, The World Conference on Social Determinants of Health called for new policies to fight health disparities. Other organizations are also taking action to address social determinants to promote good health and achieve health equity.
Prior to retiring from my civilian career, I had the privilege of working for managed care companies devoted to serving the vulnerable and under-served population. This population received Medicaid, also called TennCare. This is the state of Tennessee’s Medicaid program. According to TennCare’s 2018 Annual Report, the program provides healthcare to approximately 1.4 million Tennesseans and covers approximately 22% of Tennessee residents. The detailed annual reports include eligibility of recipients by age, race and counties. The Annual Report is published on TN Division of TennCare public website.
According to the website, TennCare is one of the oldest Medicaid managed care programs in the country and is the only program in the nation to enroll the entire state’s Medicaid population in managed care. During the last 10 years of my career, the company I worked for was one of three managed care companies that provide quality medical care to clients in all 95 counties in Tennessee.
Everyone has a right to healthcare. Inequalities in health status are persistent problems in the United States. Research indicates that poverty, racism, income disparities, and poor quality of life are some of the major risk factors. Environmental conditions such as pollution, inadequate housing, lack of education, employment and unsafe work conditions contribute to poor health outcomes. These systemic disadvantages are intergenerational.
Establishing a broad based collaborative partnership is crucial to addressing health inequities. Differences in prevalence of health conditions and status between groups of people are referred to as health disparities. People in marginalized groups experience worse health and have less access to social determinates like healthy foods, safe neighborhoods, adequate housing, quality education, transportation, and freedom from racism and other forms of discrimination. Health equity is when everyone has the opportunity to enjoy good health.
Our managed care company and other managed care companies partnered with TennCare and health practitioners across the state to address social determinants of health and reduce barriers. The goal was to promote health and achieve health equity. This partnership included but not limited to, establishment of medical homes, expanded after hours care, flexible office hours, and community outreach strategies. The development of specialized programs, in home visits by teams of nurses, social workers, behavioral health specialists, and community health workers provided a person -centered approach to healthcare.
Most poor people cannot afford healthy foods. Many live in food deserts and don’t have transportation to the larger grocery stores or supermarkets. Supplemental Assistance Nutrition Program (SNAP benefits), supplements food budgets but may not be enough to cover the high cost of healthier foods, fresh fruits and vegetables. As a result, many people may purchase unhealthy processed foods or lower cost fast foods. People with chronic or complex medical condition are at greater risk for more health problems.
There are many reasons why people do not receive proper healthcare. Providers have not made it easy for all people to receive care. Many people are illiterate or have low literacy and are not able to read and understand the lengthy health questionnaires. Some people may bring someone to the appointments with them for this purpose. Many other people hide their literacy levels and don’t go to the doctor for this reason. They don’t want anyone to know. Modern technology has made these barriers worse. Many people do not have access to computers or know how to use them. English is not the first language for many other people and there may not be an option for a translator in some provider’s offices.
Many people have difficulty understanding health information. They may have low health literacy. Low health literacy may apply to people of all educational levels and socio-economic status. During my career, I also managed the medical care of clients who were highly educated with successful professional careers. Some had low heath literacy. Literature, questionnaires and discharge instructions should be written in plain language. Plain language is usually written at a 6th grade level, is clear and to the point. Sometimes visual information is included in literature. Healthcare providers may not recognize their clients have low health literacy concerns. Clients and their families may receive an overwhelming amount of information they cannot process and understand. Hurried healthcare providers may assume their clients understand the information. When they hurriedly ask if a client understands, the client may say yes when they do not. Meaningful interactions may not occur and open ended questions are not asked to confirm understanding. When clients miss appointments or don’t follow treatment guidelines, they may be incorrectly labeled “non-compliant.” They may disengage because they are not able to engage with the providers, don’t understand the medical information or guidance.
There may be limited access to healthcare and inability to afford the high cost of some medications or co-pays. There are some cultural factors associated with seeking healthcare. Many people many not trust the medical staff. The providers may not understand the social context and lack similarities with their clients. Some of this lack of similarities may include race, culture, language or socioeconomic status. Providers may not give the clients the opportunity to ask questions, talk down to patients, and maybe rushed because of high patient loads or other reasons. These actions may translate to “not caring.” Barriers to seeking regular healthcare may lead to late diagnoses. Late diagnosis may ultimately lead to untreatable conditions.
Chronic stress may lead to poor health outcomes. In many poorer families, multiple families live under one roof. The unemployment rate may be high. Those who work may have lower wage jobs and not able to take time off from work for doctor’s appointments. There may be a common theme of discontent and feelings of discouragement. To cope with stress, many people may engage in unhealthy behaviors. People may feel that healthcare providers, employers, and politicians don’t care what happen to poor people.
Based on my research, there are multiple models that describe how social determinants influence health outcomes. According to the work book, Promoting Health Equity-A Resource To Help Communities Address Social Determinants of Health, eliminating inequalities will require consciousness raising. People need to understand the relationship between individual and group experiences and the social injustices that influence them. Eliminating injustices will require various approaches and long term commitments.
What I learned from research and the work book is that even though the models were different, there were some consistent pathways. Social determinants of health include both societal and psychosocial factors. I included a few examples.
Societal conditions
Social- Freedom from racism and other discriminatory practices.
Economic- Lack of gainful employment, food insecurity, inadequate transportation, wealth gaps.
Physical environment- Lack of stable housing, limited access to healthcare.
Literacy- Low literacy to include low health literacy.
Psychosocial factors
Social- Need for social networks, resources, civic engagement, holding politicians accountable.
Psychological- Low self- esteem, hopefulness.
Knowledge and collaborative partnerships are crucial to reducing social determinant of health inequities. The distributions of social determinants are shaped by public policies. Policies and other interventions influence the availability and distribution of these social determinants to different social groups. After understanding what is needed, action must be taken to move forward toward health equity for all.
Francie Mae. June 22, 2020.
References
Laura K. Brennan Ramirez, PhD, MPH, Elizabeth A. Baker, PhD, MPH, Marilyn Meltzler, RN. Promoting Health Equity-A Resource To Help Communities Address Social Determinants of Health. Centers for Disease Control (CDC).
TN Division of TennCare. Information and Statistics. Website. Accessed June 12, 2020.
World Health Organization. Website. Accessed June 12, 2020.