Food Security, Social Determinants of Health Lower Hospital Use

The following excerpt comes from the November 1, 2017, article by  Sara Heath on Patient EngagementHIT.

Implementing public programs to supplement food security in low-income patients can help reduce hospital use within that population, according to a study published in both BMC Geriatrics and Population Health Management. This data suggests that addressing the social determinants of health can directly improve health outcomes.

Currently, nearly one-third of senior patients live on income less than 200 percent of the poverty line, a fact which the Maryland-based research team said impacts that healthcare industry. Low-income patients have a higher propensity for utilizing hospitals and the emergency department.

Previous efforts to meet health needs include expanding access to primary care, but researchers added that caring for social needs is also essential for health improvement.

“Excess hospital utilization in this population was once believed to be preventable by improving health care access,” the research team said. “However, disparities exist among older adults who have health insurance through Medicare, and are not attributable to access to primary care providers.”

Previous research has suggested that 85 percent of patient health is determined by the social determinants of health, as opposed to genetic makeup or other health-related factors such as healthcare access.

The social determinants of health include social factors like housing, education level, and food security, among others.

The Supplemental Nutrition Assistance Program (SNAP) is one such program suitable for addressing food security. The federally-funded program has proven effective in expanding food access for low-income individuals, and shown that food access may be tied to health outcomes, the team posited.

“By targeting financial support toward food needs, SNAP can improve access to a higher quality diet for food insecure adults,” the researchers explained.

“There is evidence of reduced caloric intake, poorer dietary quality, and greater risk of hypoglycemia for low-income adults at the end of the month when funds run low,” the research team continued. “Therefore, greater SNAP benefits may facilitate chronic disease management for nutrition-sensitive conditions, which may account for evidence of reduced chronic disease hospital utilization.”

The team looked at nearly 6,900 patients over the age of 65 who were dually eligible for Medicare and Medicaid between 2009 and 2012. Matching data about days spent in the hospital, healthcare costs, and emergency department visits with SNAP enrollment data showed that the program has an impact on healthcare.

SNAP benefits reduced the likelihood for hospitalization by 14 percent, and reduced the likelihood of each individual day in the hospital by 10 percent.

The program also reduced the likelihood of nursing home admissions by 23 percent, and reduced each additional day in the nursing home by 8 percent.

SNAP benefits had no statistically significant effect on ED utilization, but the researchers maintained that the results nonetheless showed great potential for SNAP in healthcare.

Specifically, the results proved that more than just increasing access to care can help reduce hospital and ED utilization.

“It is notable that all had access to both Medicare and Medicaid because policy makers have increased access to health care for low-income groups thinking that that alone would reduce high hospital utilization in low-income groups,” the researchers pointed out.

Read the full article.



Lancet series puts spotlight on health inequity in the U.S.

From the article by Paige Minemyer on FierceHealthcare:

Societal issues in the U.S., including systemic racism, poverty and mass incarceration, contribute to health inequity, a new series of studies has found.

The Lancet released a five-part look at health inequity in the U.S., titled the “United States of Health,” and researchers found that institutional racism, the increasing income gap and high rates of incarceration are all factors that make it harder for minorities and the poor to access healthcare. And the healthcare system, as it is financially structured today, only makes this problem worse, the researchers concluded.

…Poor Americans have made limited gains in life expectancy over the past 15 years, researchers found. Since 2001, the poorest 5% have not seen their survival rates increase at all, while while middle- and high-income people have seen their life expectancy increase by two years. The richest 1% of Americans live between 10 and 15 years longer than those who are among the poorest 1%.

Economic insecurity is a key factor in some of today’s biggest public health crises, including the opioid epidemic and increasing rates of obesity, study author Jacob Bor, Sc.D., assistant professor at the Boston University School of Public Health, said in announcement. But despite their increasing health concerns, it is becoming increasingly hard for Americans in poverty to pay for healthcare, creating a “health-poverty trap,” Bor said.

Poor Americans are also the most likely to be uninsured. Though the Affordable Care Act has made strides toward decreasing the number of people without insurance, a lack of options in ACA exchanges, particularly in states that did not expand Medicaid, leaves many poorer people in the U.S. with few avenues to get health insurance, researchers found. In 2015, for instance, about a quarter of poor Americans were uninsured, compared with just 7.6% of people with middle or high incomes.

Minority groups are also hit hard by societal barriers that lead to health inequity, and research reflects poorer outcomes—for instance, infant mortality rates for black populations are twice those for white ones, according to the study. Structural racism relegates many black Americans to neighborhoods with poor housing options, high rates of crime and air pollution. These neighborhoods may also be neglected by public health officials, worsening the problems, researchers found.

Read the full article.


Treatment Gaps Persist Between Low- And High-Income Workers, Even With Insurance

From the article by Michelle Andrews on Kaiser Health News:

Low-wage workers with job-based health insurance were significantly more likely than their higher-income colleagues to wind up in the emergency department or be admitted to the hospital, in particular for conditions that with good primary care shouldn’t result in hospitalization, a new study found.

At the same time, low-wage workers were much less likely to get preventive care such as mammograms and colonoscopies, even though many of those services are available without cost-sharing under the 2010 health law.

There’s no single reason for the differences in health care use by workers at different wage levels, said Dr. Bruce Sherman, an assistant clinical professor at Case Western Reserve University in Cleveland and the study’s lead author, which was published in the February issue of Health Affairs.

Finances often play a role. Half of workers with employer-sponsored insurance are enrolled in plans with a deductible of at least $1,000 for single coverage. As deductibles and other out-of-pocket costs continue to rise, low-wage workers may opt to pay the rent and put food on the table rather than keep up-to-date with regular doctor visits and lab work to manage their diabetes, for example.

Likewise, convenient access to care can be problematic for workers at the lower end of the pay scale.

“Individuals are penalized if they leave work to seek care,” Sherman said. “So they go after hours and their access to care is limited to urgent care centers or emergency departments.”

The study examined the 2014 health care claims, wage and other data of nearly 43,000 workers at four self-funded companies that offered coverage through a private health insurance exchange. Workers were stratified into four categories based on annual maximum wages of $30,000, $44,000, $70,000 and more than $70,000.

Workers in the lowest wage category were three times more likely to visit the emergency department than top earners, and more than four times more likely to have avoidable hospital admissions for conditions such as bacterial pneumonia or urinary tract infections. But they used preventive services only half as often, the study found.

Read the full article.


Communities in Action: Pathways to Health Equity

From the blog article by the Robert Wood Johnson Foundation:

Americans today live shorter, sicker lives than people in other developed countries, and, across the nation, health varies by income, education, race and ethnicity, and geography. Warning that the United States will pay the high price in lost lives, wasted potential and squandered potential resources until these gaps are closed, a comprehensive report from the National Academies of Sciences, Engineering, and Medicine (NASEM) calls for leaders across sectors to make health equity a priority for the nation.

Why Does Health Equity Matter?

When health equity is achieved, “everyone has the opportunity to attain full health potential, and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance,” the report says. And ensuring that opportunity is crucial not just for individuals, but also for the nation’s economic and growth prospects, for its national security and for its communities’ well-being and vibrancy.

Data show the costs of current health inequities: The report estimates that racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018. The impact on national security is also high, with some 26 million young adults unqualified to serve in the U.S. military because of persistent health problems, or because they are poorly educated or have been convicted of a felony.

…The Cost of Inequality

  • In 2015, the percentage of low-birthweight infants in the U.S. rose for the first time in seven years.
  • Racial health disparities alone are projected to cost health insurers $337 billion between 2009 and 2018.
  • Health care spending accounted for 17.5 percent of GDP in 2014.
  • In 2014, VA-enrolled veterans accounted for 17.9 percent of suicide deaths among U.S. adults.
  • People with disabilities are more than twice as likely not to receive medical care because of cost.

Read the full article.

New Study Shows the Impact of Minimum Wage Increases on Infant Mortality and Birth Weight

An article recently published in the American Journal of Public Health  reports on an research to test the hypothesis “that increases in state-level minimum wages are associated with reduced rates of low birth weight  infants and infant mortality.” The researchers used 30 years of minimum wage laws from each state to calculate the monthly minimum wage different between each state and the federal law. They used data from the National Vital Statistics System to create frequencies and rates of low birth weight and postneonatal mortality by state and month from 1980 to 2011.

Their analysis found that an increase of one dollar above the federal minimum wage results in a 1% to 2% decrease in the number infants born with a low birth weight (defined as <2500g at birth) and a 4%decrease in postneonatal mortality (defined as death from 28 to 364 days after birth). In demonstrating the impact of the increase in minimum wage on birth outcomes, the researchers state, “On the basis of the findings, if all states in 2014 had increased their minimum wages by 1 dollar there would likely have been an estimated 2790 fewer low birth weight births and 518 fewer postneonatal deaths for the year (p.e2).”

Download the full article from the American Public Health Association.

Study: Medicaid Expansion Encourages More Poor Adults to Get Health Care

From the article at Kaiser Health News:

In states that expanded Medicaid under the Affordable Care Act, low-income adults were more likely to see a doctor, stay overnight in a hospital and receive their first diagnoses of diabetes and high cholesterol, according to a study published Monday.

Yet researchers found no improvement in adults’ own assessments of their health, a conclusion echoed by similar studies, the authors wrote in the Annals of Internal Medicine.

Two factors might explain the lack of perceived improvement. People did not sign up for Medicaid as soon as it expanded in January 2014 so there was little time to better their health. Also, survey participants’ increased contact with health providers and fresh knowledge about their health might have negatively affected their opinions, the authors said.

Researchers at University of Michigan and the University of California-Los Angeles who did the study said it provides the first evidence of low-income adults’ increased use of health services in states that expanded Medicaid. Federal surveys of adults living in poverty conducted in the second half of 2014 were the foundation for the study. Twenty-six states and District of Columbia expanded Medicaid in 2014 and five more have since then.

Medicaid enrollment has soared past 70 million people since states began expanding the program in 2014 using federal dollars from the law. Medicaid rolls have grown by more than 14 million people in that time.

…Among the study’s findings:

  • The share of respondents who said they saw or talked to a doctor increased from 58 percent before expansion to nearly 68 percent after expansion. There was virtually no change in states that did not expand.
  • Those who said they were diagnosed with diabetes rose from 8.3 percent before expansion to nearly 13 percent after expansion. In non–expansion states, the diabetes diagnosis dropped slightly.
  • Those who said they had no usual source of care due to costs fell from 13.3 percent pre-expansion to 6.6 percent after expansion. This number dropped only marginally in non-expansion states.

Read the full article.

Unexpected Benefits from the ACA Medicaid Expansion

From The big way Obamacare helps the poor isn’t really about their health by Max Ehrenfreund on the Washington Post Wonkblog:

President Obama’s health-care reform law made government health insurance available to more people living in poverty or near poverty by expanding Medicaid. The hope was to improve people’s physical health, but new research shows an important effect on financial health: The law has helped many poor Americans pay off the collection agent.

The analysis, conducted by a team of university researchers and members of the Federal Reserve Bank of Chicago, estimates that those who signed up for Medicaid under the law reduced their collection balances by $600 to $1,000 each.

The financial benefits of Obamacare for the poor are an “underappreciated” aspect of the law, said economist Robert Kaestner of the University of Illinois at Chicago, who is one of the authors of the new study. “Health insurance, like any type of insurance, is first and foremost a form of financial protection,” he said. “It is a real benefit.”

Kaestner, working with colleagues at the Federal Reserve Bank of Chicago and the University of Michigan, showed that people who benefited from the expansion used the money they saved on health care to pay down their other debts.

The economists used detailed data on people’s personal credit from the Federal Reserve and Equifax, the credit-rating bureau, comparing states that didn’t expand Medicaid to those that did. The researchers calculated a series of quarterly average balances in debt collection for each group of states, adjusting the data to account for unrelated differences between the two groups leading up to the expansion in 2014. Since the data on personal credit didn’t include information on consumers’ health insurance, the researchers focused on data from the poorest Zip codes, where the most people were likely to benefit from the expansion.

The expansion of Medicaid reduced balances in collections (excluding medical debt) by $51 to $85 on average for all working-age consumers living in those Zip codes.

The researchers then made a back-of-the-envelope calculation of how many people gained Medicaid coverage because of the expansion in those Zip codes, using income data from the Census to determine how many were eligible and assuming about half of them enrolled. The researchers concluded that those who signed up for Medicaid secured substantial savings: between $600 and $1,000.

Read the full article.

Read the study.

Ranking the States on Equity in Health Care

The Commonwealth Fund’s 2015 Scorecard on State Health System Performance (Scorecard) highlighted both positive and negative changes in health equity from 2014 to 2015. The Scorecard assesses states on 42 indicators grouped into five categories: 1) access and affordability; 2) prevention and treatment; 3) avoidable hospital use and cost; 4) healthy lives; and 5) equity. To understand equity, the researchers evaluate how low income individuals and racial and ethnic minorities fair in accessing care, the quality of the care they receive, and their likelihood of living a long and healthy life.

Across the 50 states and the District of Columbia, the Scorecard found wide variations in performance “with up to an eight-fold difference between top- and bottom-ranked states.” In terms of the equity measure the Scorecard revealed six interesting lessons:

  1. Rhode Island has made the most strides in promoting equity in health care since the previous scorecard (2014).
  2. In 37 states, the percentage of low-income elderly adults receiving a high-risk prescription medication declined and the equity gap narrowed.
  3. The majority of states saw an increase in obesity among low-income and minority adults in 2014 compared with 2013.
  4. Premature death rates among racial and ethnic minority populations declined in most states.
  5. For equity gaps based on income, more states improved than worsened.
  6. However, for equity gaps based on race or ethnicity, more states worsened than improved.

In terms of the equity gaps based on race or ethnicity, half of the States received worse scores than 2014 on six of the indicators.

For more information:


Understanding Health and Health Coverage in the US South

A recent issue brief published by the Henry J. Kaiser Family Foundation uses data points to develop a portrait of the 17 states that make up the US south and current status of health in the region.

Data points describing the American South include:

  • It consists of 17 States.
  • As of 2014, the region had a population of over 118 mission or 37% of the US population.
  • The South is racially and ethnically diverse with people of color making up 42% of the population.
  • Some of the Southern states have among the highest poverty rates in the nation.

In terms of health status, the American South faces several challenges:

  • One in five adults reports a fair or poor health status.
  • The nation’s highest obesity and diabetes rates are in the South.
  • The Southern states have higher rates of infant mortality and cancer death than other areas of the country.

With the issues of high poverty and poor health outcomes, the individuals living in the American South also face challenges in terms of access to health care.

  • Southerners are more likely to be uninsured compared to individuals living in the rest of the country.
  • Medicaid and CHIP eligibility levels are more limited in the South compared to other regions.

See the issue brief for more details on the challenges facing the American south.

Both the ‘Private Option’ and Traditional Medicaid Expansion Improved Access to Care

A study published in the January 2016 issue of Health Affairs, evaluated the impact of traditional Medicaid expansion versus the ‘private option’ of using Medicaid funds to purchase private insurance. To understand the impact of these interventions, researchers conducted telephone interviews — in November-December 2013 and twelve months later– with 5,665 low-income individuals from three states: Kentucky (traditional expansion), Arkansas (private option) and Texas (no expansion). Key findings included:

  • The uninsured rate in Kentucky and Arkansas dropped 14 percentage points more than in Texas between 2013 and 2014.
  • In 2013, the uninsured rate was about 40 percent in all three states. But by 2014, it had dropped to 19 percent in Arkansas and 12 percent in Kentucky, while falling to 27 percent in Texas. Even in nonexpansion states like Texas, the streamlined Medicaid application process and the publicity surrounding the ACA helped increase coverage among uninsured populations, the authors point out. Moreover, in all states, low-income people living between 100 percent and 138 percent of the federal poverty level are eligible for subsidies when buying coverage in the marketplaces.
  • In Kentucky and Arkansas, the share of adults who said they were struggling to pay medical bills fell by nearly 9 percentage points more than in Texas. The share of those reporting not filling a prescription because of the cost fell nearly 10 percentage points more in the expansion states.
  • Low-income adults in Kentucky experienced an even larger decline in medical bill problems compared with those in Arkansas, suggesting that Medicaid provides greater financial protection than private coverage, even with cost-sharing subsidies.
  • The percentage of people visiting emergency departments (EDs) because they could not get a timely appointment in a physician’s office increased nearly 5 percentage points more in Kentucky and Arkansas compared with Texas. However, the share of adults in those two states reporting that the ED was their usual source of care dropped by 5 percentage points.
  • Among adults with chronic illnesses like high blood pressure or diabetes, the share who reported receiving regular care for those conditions increased nearly 12 percentage points more in the expansion states than in Texas.

Download the full article.

Read a synopsis from the Commonwealth fund.