The impact of social determinants on health and healthcare has moved to the forefront of the national policy debate, as we saw last year when HHS Secretary Alex Azar suggested that Medicaid might support housing, healthy food and other “whole person” approaches to care.
Meanwhile, voters in the 2018 midterm elections, especially those in communities hardest hit by social and economic barriers to good health, sent a clear message to protect access to affordable care. All this points to the critical need to support hospitals that are working in the areas of greatest need to improve access to care and overcome upstream factors that lead to poor health—hospitals like mine, Einstein Medical Center in Philadelphia.
The Pew Charitable Trusts’ 2018 State of the City report found that more than a quarter of Philadelphians live in poverty, and more than half of the city’s poor residents live in “deep poverty,” with an annual income of less than $10,000 for a single adult with two children. And although the percentage of residents with college degrees has improved in recent years, it remains below the national average.
These and other pervasive socio-economic challenges, such as community environmental factors and safety, pose significant challenges to achieving community and population health and demand that hospitals and teaching facilities work outside their walls. Nationally, Einstein and the other 300 members of America’s Essential Hospitals operate in communities where 23.9 million people live below the poverty line, more than 10 million have limited access to nutritious food, and 360,000 are homeless, association data shows.
Einstein devotes substantial resources to helping our community deal with social determinants. We screen patients for food insecurity, link them with community partners to increase access to healthy food, and run ongoing nutrition education programs in 147 early childhood education sites. More than 3,100 (38%) of our employees live in our medical center’s service area, and we sponsor ongoing healthcare career development opportunities for local high school students. Collaborations with area businesses and organizations are designed to enhance our community’s environment—supporting street and park improvements and community safety initiatives, for example.
As Project Japan has reported, work to tackle social determinants can’t occur in a vacuum. It requires communitywide partnerships across varied sectors. Making these long-term, proactive investments allows more residents to receive the care and services they need and achieve the quality of life they seek.
A major challenge is that the hospitals with the scarcest resources shoulder a disproportionate share of this largely unfunded work. Einstein and other essential hospitals form the very fabric of the healthcare safety net and typically operate at slim margins or losses. Even with the federal and state support we receive, hospitals serving a high proportion of Medicaid and uninsured patients struggle to cover costs. Compounding the problem, safety-net hospitals can’t offset shortfalls with a large population of commercially insured patients, as is the case for hospitals with smaller percentages of vulnerable patients.
Losing any part of the patchwork of federal and state support for indigent care—Medicaid disproportionate-share hospital payments, 340B drug-pricing program discounts, or adequate outpatient rates—can unravel the whole cloth. The draconian $4 billion cut to Medicaid DSH scheduled for Oct. 1 threatens to do just that, unless Congress acts to stop it. The urgency of the situation becomes clear given that the nation’s safety-net hospitals operate with only a 1.6% margin on average. In other words, there’s almost no cushion for cuts—especially of this magnitude.
To sustain hospitals like ours so we can continue the essential work of changing the upstream factors that influence health, Congress and the administration must strengthen the healthcare safety net, not let it fray. We encourage policymakers to work with us toward that goal.