Uninsured Rates Decline; Healthcare Access Challenges Persist: SDoH Series, Part 6

Following the Healthy People 2030 model, this series focuses on 6 aspects of social determinants of health(SDoH), including food insecurity, economic stability, neighborhood and the physical environment, education, community and social support, and healthcare access. In this article, we examine healthcare access as a SDoH or a nonmedical factor that influences health outcomes.

Healthcare access struggles impact health outcomes

Even as the number of uninsured in the US has dropped to historic lows, healthcare access still alludes many people. From lack of transportation to high out-of-pocket costs, there are persistent and pervasive barriers to accessing comprehensive quality healthcare.

These access challenges impact people's health in myriad ways. Some might forego medications and treatments for chronic conditions such as diabetes and cancer. Parents may skip their children's vaccinations, dental treatments, or wellness visits that track developmental milestones. Delaying care can impact life expectancy and lead to higher treatment costs.

Uninsured population drops to historic low

In recent years, the US has made significant strides in reducing the number of people without insurance. The passage of the Affordable Care Act, individual state efforts, and other federal steps—including pandemic provisions that prevented people from being disenrolled from coverage—have resulted in a historic low in uninsured rates. In 2022, the government released a report showing the country's rate had dipped to 8%.

During the COVID-19 public health emergency, a federal rule prohibited states from disenrolling people from Medicaid, even if they otherwise would no longer qualify. Now, health policy experts fear that millions will lose coverage—including some beneficiaries who still qualify, but are unable to complete administrative paperwork. Those concerns are already playing out, so much so that the government has temporarily paused the disenrollment efforts in some states.

Inequities in health insurance and healthcare access remain

Since most individuals on Medicaid are from historically marginalized populations, those enrollment losses could disproportionately affect those groups. More broadly, historically marginalized communities still bear a disproportionate share of both being uninsured as well as facing barriers to accessing care.

For example, nonelderly American Indian/Alaska Native (AIAN), Hispanic, Native Hawaiian or Pacific Islander, and Black people are more likely to be uninsured compared to their White counterparts, points out a 2023 Kaiser Family Foundation report. Black, Hispanic, and AIAN people fare worse compared to White people across most examined measures of health coverage and access to care.

What are barriers to health access?

A lack of insurance is one of many potential barriers to quality healthcare. People with health insurance may face substantial out-of-pocket costs with high deductible health plans or co-pays, putting them in the underinsured category. Their coverage might have narrow networks that greatly restrict which providers and specialists are covered. People with Medicaid may encounter providers who prefer private insurance's higher reimbursement rates.

A 2022 survey from The Commonwealth Fund found that 46% of people surveyed had skipped or delayed care because of cost. About half of people said they would be unable to pay for an unexpected $1,000 medical bill within 30 days, a figure that's higher for Black adults (69%), adults with low income (68%), and Latinx/Hispanic adults (63%), the survey found.

SDoH contribute to health access challenges

The complex social determinants that influence one's health don't exist in isolation. Other factors, such as where someone lives, can also play a significant role in their ability to access healthcare. For example, about 80% of rural America is considered to be medically underserved. Even people with cars may have to take time off work and spend money on gas to make healthcare appointments. Still others might experience mistrust of the healthcare system or struggles to find providers who share their cultural and linguistic background.

Heart disease example underscores what's at stake

In a 2022 statement on social determinants of health and people with congenital heart disease, the American Heart Association highlighted access inequities through the example of people with congenital heart disease. Specialty care services are often concentrated in denser urban areas, making it challenging for people in rural or smaller towns to access the same care levels. The type of insurance one has can also influence where they end up for care. At the same time, systemic inequities and structural racism impact the health of people with congenital heart disease from prenatal care through adulthood.

Among the strategies the group suggested for addressing these access inequities are increasing specialist availability via satellite clinics in nonurban areas and bolstering telehealth capacity. The group also referenced studies demonstrating the value of concordant care and a clinician workforce that resembles the population.

Innovative models for healthcare access use hub and spokes

Some underserved areas are also exploring the use of a "hub and spokes" model, which links a larger, central hospital with smaller facilities. This approach connects primary care clinicians at smaller hospitals with the support and training that would allow them to provide specialty care services for people with more complex conditions.

In New Mexico, for example, primary care providers have used this model to provide care for people with Hepatitis C in underserved areas.

Identifying steps to improve healthcare access

In an article looking at ways to improve healthcare access, the University of Southern California Sol Price School of Public Policy offers a series of steps to address some of these barriers. Along with efforts to expand overall health insurance coverage, here are some key strategies to improve access:

• Adding telehealth services
• Investing in mobile clinics
• Educating people about healthcare locations and their distinct roles such as primary care, urgent care, and the emergency department
• Training staff and providers in cultural competency and expanding medical interpretation services

Attracting providers to medical deserts

Since doctors often settle in places where they have personal and professional connections, other efforts have focused on building medical school and residency programs in underserved regions.

One example is the SJV PRIME program in which University of California San Francisco (UCSF) medical students spend 2.5 years at the UCSF Fresno campus in California's rural San Joaquin Valley. The program also includes seminars that explore the health of underserved populations and the impact of SDoH on the region's populations.

Throughout the country, community-based physician residency programs in rural and underserved areas offer a way to improve provider access. Creating health center-based residency programs are associated with increased provider recruitment, expanded patient service, and improved health outcomes, according to findings published in Family Medicine.

Building pipelines, promoting humility

Improving the pipeline of providers who reflect the communities in which they serve can also build trust in historically marginalized communities.

But even providers who may not share the same cultural identity with their patients can improve access by using a culturally humble approach. This practice involves approaching patients with curiosity and trying to understand the distinct interplay of SDoH that may be influencing their experiences. Numerous states recognize the importance of delivering care that meets the diverse needs of a community and require, or are considering requiring, cultural competency training for healthcare providers.

Healthcare providers can help with unmet health needs

That understanding might lead to tailored care plans that better reflect social needs.

Take the example of someone with a chronic health condition who doesn't own a car and lives in an area without strong public transportation. If the clinical team understands that social risk, they might adjust the prescription to a mail order service or connect the patient with social services that can help with transportation.

“This tailoring of care plans, known as social risk-informed care, may help reduce barriers to adherence, and, in turn, improve clinical outcomes," explain the authors of an article published in the Journal of General Internal Medicine.

Trust key in patient/provider relationship

The decision to share one's social risk may depend on the level of trust one feels with their medical team. Having a provider whose language and culture doesn't reflect your own can influence how people access care—and their related outcomes. In a Tulane University article on cultural competency, authors explain how race, socioeconomics, health literacy, and other factors such as disabilities can influence the following decision and experiences:

• How patients perceive their symptoms and health conditions
• When and how they seek care
• Expectations of care
• Preferences on procedures or treatments
• Willingness to follow provider recommendations
• Sense of who should be involved in healthcare decisions

What's the role of hospitals and health systems?

On a broader scale, hospitals and academic medical centers can play a role in addressing SDoH themselves. These “powerful institutions" play a critical role in everything from purchasing and community investments to hiring opportunities, explains an article published in Preventative Medicine Reports.

“They have an economic and moral interest in helping to ensure that surrounding communities are safe, vibrant, healthy, and stable," authors write. “We posit that the anchor institution role of hospitals uniquely positions them to target powerful underlying forces that shape adverse SDoH within their communities."

Indeed, there are numerous efforts nationwide of health organizations directly addressing SDoH, from creating mobile health services to partnering with the community to create a new park for youth. For these programs to be most effective, hospitals must involve community members in the development, a vital step in ensuring the efforts meet community-identified needs.

Coding for SDoH can inform interventions

Others point to coding as a key way the healthcare system can better address SDoH. More consistent and improved tracking and coding of social needs can demonstrate the value of addressing these factors on both the individual and system level.

That's because adding social needs data to hospital claims can educate research on how these factors influence health. Those findings can, in turn, impact federal programs that meet these needs, explains the American Hospital Association (AHA). Plus, having claims data connected to social needs can inform policy and payment changes, such as better risk adjustments.

Widespread benefits come with SDoH coding

The AHA explains the following benefits of creating and utilizing a standardized approach to screening for, documenting and coding social needs:

• It will help hospitals track the social needs affecting patients, allowing more customized care that addresses both medical and nonmedical needs
• Collecting data will help focus a SDoH strategy
• It can help identify population health trends, which could help inform and create community partnerships

Lack of standardized healthcare tool presents barrier

SDoH coding efforts aren't without challenges. The Centers for Medicare and Medicaid Services (CMS), for example, has pointed to barriers, such as a lack of knowledge among providers and medical coding professionals and the lack of a standardized screening tool that's connected to a electronic health records. These barriers are easily observed in 2019 CMS data that found only 1.59% of 33.1 million Medicare beneficiary claims included SDoH-related Z codes.

RTI can help you address SDoH

As you consider the best tools and strategies to address SDoH in your patient populations, our team of health experts can help you understand the root causes of health-related inequities and barriers to accessing quality healthcare. We design practical and effective solutions to address the countless ways SDoH influence individual and population health outcomes. Contact us.