Learn: Health Inequities, SES, Vulnerable Populations, and US Care

Major components of SES

Income, education, and occupational status

SES and health relationship

Strong, consistent predictor of health; low SES = more disease and higher mortality, even in countries with universal insurance (e.g., England)

How SES affects health

Exposure to physical/social threats, knowledge of health conditions, environmental hazards (pathogens, carcinogens), and undesirable social conditions like crime

Vulnerability (definition)

Convergence of health risks across three categories: physical, mental, and social

Physical risk example

Fever, physical symptoms

Mental risk example

Depression

Social risk example

Poor school or job performance

Why multiple risk factors matter

Poor health in one dimension compounds the others, so people with multiple risk factors have much greater health needs

Andersen's framework: Predisposing

Demographics (age, sex, family size), social structure (race/ethnicity, education, occupation), health beliefs

Andersen's framework: Enabling

Resources available (income, insurance) and community/regional access to care

Andersen's framework: Need

Specific illnesses or health needs driving care-seeking

7 vulnerable subpopulations in the text

Elderly; chronic illness; mental illness; women and children; disabilities; homeless; HIV/AIDS

Why focus policy on vulnerable populations

Greater health needs; vulnerability is rising; driven by social forces (so can be remedied by them); linked to national resource allocation; vulnerability and equity can't coexist

Black Maternal Health Momnibus Act (2021)

Package of ~13 bills to address the US maternal mortality crisis and the racial gap (Black mothers die from pregnancy-related causes at far higher rates than white mothers)

Momnibus: social needs and WIC

Funds housing, transportation, and nutrition for pregnant/postpartum people; extends WIC eligibility through postpartum/breastfeeding period

Momnibus: workforce and data

Grows and diversifies the perinatal workforce; improves data collection on maternal health outcomes

Momnibus: other provisions

Maternal mental health and substance use support; care for incarcerated pregnant people; digital tools/telehealth for rural areas; new payment models; protections in public health emergencies; maternal vaccinations; funding for community-based organizations

US maternal mortality context

Highest maternal mortality rate among high-income countries

Chronic disease: leading cause of...

Death, disability, and healthcare costs in the US

Chronic disease prevalence

Half of all US adults have a chronic disease

Chronic disease and deaths

70% of deaths are associated with chronic disease

Chronic illness and cost share

86% of healthcare costs go to chronic illness plus mental health disorder care combined

Uninsured chronic patients: double burden

More likely to skip care, lack a regular source of care, and rely on the ED

Medicare patients and physician visits

1 chronic condition = ~4 physicians/year; 5+ conditions = ~14 physicians/year

CDC NCCDPHP

National Center for Chronic Disease Prevention and Health Promotion; leads national prevention efforts (tracks diseases/risk factors, improves environments, strengthens health systems, links clinical care to community programs)

Mental illness national burden rank

2nd (after ischemic heart disease) as a burden on health and productivity

Lifetime vs. yearly mental disorder rates

~50% of Americans in their lifetime; ~25% in any given year (DSM-IV framework)

Adults with mental illness (2018)

About 1 in 5 US adults

Treatment rate for diagnosable mental disorders

Only ~41% receive treatment

Mental illness as a risk factor for...

Early mortality, suicide, cardiovascular disease, cancer; linked to social problems like gun violence

Shift in mental health care delivery

From specialized inpatient treatment toward integration into primary care; GPs now treat a larger share than any specialist type

Mental health specialist shortage

Unmet need exists in 96% of US counties

MHPAEA (2008)

Mental Health Parity and Addiction Equity Act; requires parity between mental and physical health coverage in group health insurance

Regular source of care (RSC)

A usual place or usual provider from whom a person receives healthcare

Benefits of having an RSC

Better-coordinated care, better treatment of chronic/acute conditions, fewer care delays, better access to preventive care

RSC disparities

Minorities are less likely than whites to have an RSC, even controlling for SES, insurance, and health status

Order of least likely to have an RSC

Hispanic adults, then American Indians/Alaska Natives, then African Americans, then Asians; whites most likely

Factors contributing to lack of RSC (per HHS)

1) Lack of health insurance, 2) low family income, 3) language other than English spoken at home

Additional RSC barriers for Latino/Asian populations

English language barrier, poor geographic proximity to care, lack of culturally appropriate services

Top reason Hispanic adults lack an RSC

Inability to afford care

Medicare + Medicaid + CHIP coverage

Together cover nearly 40% of the US population

Medicaid

Jointly administered federal/state program for the indigent; ACA expanded eligibility to 133% of the federal poverty level (in expansion states)

CHIP

Children's Health Insurance Program; states use federal funds (via existing Medicaid programs) to cover children up to age 19

SNAP

Supplemental Nutrition Assistance Program; 64.4% of adult recipients are women

FQHCs / Health Center Program

HRSA-funded; provide primary/preventive care to underserved, low-income, and uninsured people regardless of ability to pay

NBCCEDP

National Breast and Cervical Cancer Early Detection Program; screening for low-income, uninsured, underserved women

Health inequities: SDOH drivers (Week 5)

Economic stability; education access and quality; health care access and quality; neighborhood and built environment; social and community context

Healthy People 2030 SDOH domains

Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, Social and Community Context

Economic stability and wealth inequality stat

US healthcare spending has outpaced economic growth; top 1% holds ~32% of the nation's wealth

Education and health inequity

Lower education/health literacy affects health-related lifestyle decisions

Health care access inequity drivers

Rising uninsured numbers, funding cuts to clinics/hospitals (especially rural), provider shortages

Neighborhood/built environment inequity drivers

Environmental destruction, overdevelopment, weaker regulations affecting air/water/soil quality

Causes of healthcare disparities and access barriers

Lack of insurance; low income; language barriers; lack of culturally appropriate services; poor geographic proximity; discrimination/perceived bias; provider shortages (esp. rural); SDOH factors (low SES, low health literacy, under-resourced neighborhoods)

Effects of being uninsured

Delayed care, more preventable hospitalizations, fewer preventive services, ED as default care site

Language barriers and care

Lack of English proficiency reduces both access and quality of preventive care

US health spending vs. other countries

Highest health expenditure per capita in the world, yet high prevalence of overweight/obese adults relative to spending

Lowest health expenditure per capita (slide examples)

India (private, out-of-pocket system); Ukraine is second-lowest

Public vs. private funding and cost

Publicly/government-funded systems (Canada, Japan) tend to cost less per capita than the privately funded US system

Japan (global comparison)

Highest life expectancy and lowest infant mortality rate among the examples; costs close to Canada's

Key takeaway on US spending

High spending does not equal better outcomes (WHO/Commonwealth Fund: US ranks 37th worldwide / last among 11 peer nations)

National health expenditures (NHE)

Estimates of annual US spending on health services, supplies, and health-related research/construction; expressed as share of GDP or per capita

NHE as share of GDP

17.9% in 2016, more than triple the 1960 level of 5.2%

Per capita health spending change

$146 (1960) to $10,348 (2016)

Top NHE categories (2016)

Hospital care 32.4%; physician/professional services 22.7%; prescription drugs/medical products 9.8% (~65% combined)

Other NHE categories (2016)

Nursing home/home health 7.7%; research/structures/equipment 4.7%; public health 2.5%; administration 1.3%

Largest institutional source of healthcare spending

Hospitals

ACA Medicaid expansion: who is covered

All non-Medicare-eligible individuals under 65 (children, pregnant women, parents, adults without dependent children) with income at or below 133% of FPL

ACA expansion goal (CBO)

Raise nonelderly insured rate from ~83% to ~94%, cutting the uninsured by ~32 million by 2019

Is Medicaid expansion mandatory?

No, it is state-optional; expansion states saw significant coverage gains and drops in uninsured rates

ACA funding mechanisms

Tax credits; grants (community prevention, health centers, long-term care, market reform); special programs (workforce development, maternal/child health, Medicaid/CHIP expansion, Medicare innovation); taxes (corporate penalties, "luxury" medical services)

ACA state health insurance exchanges

Marketplaces for individuals/small businesses to buy qualified, affordable plans

Is there one US healthcare system?

No, there are multiple subsystems, each with its own eligibility rules

5 subsystems of healthcare delivery

1) Managed care plans, 2) safety net providers, 3) public health programs, 4) long-term care services, 5) military-operated healthcare

Managed care plans

HMOs, PPOs, POS plans, HDHPs; providers paid via capitation, discounted fee-for-service, or salary; covers 99%+ of insured Americans; PCPs often act as gatekeepers

Safety net providers

Federally funded health centers, physicians' offices, hospital outpatient/ED; serve the poor, uninsured, minorities, and immigrants; strained by uncompensated care

Public health programs

Run by state/local agencies; 5 most common: preparedness, vital statistics, tobacco prevention/control, public health research labs, WIC

Long-term care (LTC) services

Nursing homes, skilled nursing, hospice, home health, adult day care; mostly serves the elderly; mostly paid by Medicaid (Medicare Part A covers only limited stays); measured via ADLs/IADLs

Military-operated healthcare

Free care for active-duty members; families covered via TRICARE; retired veterans via the VA system

Emerging delivery models

Value-based healthcare and integrated healthcare delivery (ACOs, patient-centered medical homes)

Fee-for-service

Providers are paid per service rendered

Capitation

Providers are paid a fixed fee per patient regardless of outcome

Value-based healthcare payment

Providers are paid according to patient health outcomes and the value/quality of care, not just volume

Benefits of value-based care

Better outcomes at lower cost to patients (prevention, prompt recovery); greater provider efficiency and patient satisfaction; lower payer costs (fewer claims, bundled payments); suppliers can align products/pricing with outcomes

Patient-Centered Medical Home (PCMH)

Primary-care-physician-led, coordinated team approach; shares EHRs across providers; most state Medicaid/CHIP programs already include it

Accountable Care Organizations (ACOs)

Coordinated provider teams paid for best-quality care at lowest cost for Medicare patients; do not incentivize more tests/procedures (opposite of fee-for-service); e.g., Vermont All-Payer ACO model

Hospital Value-Based Purchasing Program

CMS program tying hospital payment to quality metrics (minimizing adverse events, using evidence-based protocols)

Pay for performance (P4P)

Medicare price-control initiative reimbursing based on quality of care; IOM found it could worsen access/disparities if not carefully monitored

OT in value-based care: acute care evidence

OT adds value via lower cost and better outcomes in stroke, TBI, and hip replacement (Wales et al., 2022)

OT in value-based care: readmissions

Higher-frequency OT/ADL training linked to lower hospital readmission (Edelstein et al., 2021)

OT in value-based care: patient-valued factors

Collaborative goal-setting and therapeutic relationships (Wong et al., 2022)

Overall state of OT evidence in VBHC

Not enough OT-specific evidence published yet to strongly establish OT's role in value-based healthcare