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Diagnosing social problems only helps if treatment is available

Diagnosing social problems only helps if treatment is available

Picture of Anna Maria Barry-Jester
A social worker talks with a mother about signing up her son for food steps in Fort Lauderdale, Florida.
A social worker talks with a mother about signing up her son for food steps in Fort Lauderdale, Florida.

When a doctor sees a patient for chronic headaches or stomach pain, they’ll likely prescribe a pain reliever, or an antacid. But what if those pains are stress induced, and that stress comes from not having a stable place to live, or not knowing where your next meal will come from? All too frequently, our health needs stem from issues not easily treated by the medical system.

That’s an issue that the American College of Physicians tried to address recently in a position paper about the social determinants of health. It argues, among other things, for the importance of screening for underlying social issues at regular patient visits, and collecting data on those issues. The American Academy of Family Physicians and the American Academy of Pediatrics have issued similar recommendations.

Surveys suggest that physicians understand these underlying needs are a huge factor in their patients’ health, and research has shown how influential they are. Our wealth and education, the neighborhoods we live in, or the environment we grow up in can all change how long we live, or how well we live. Collectively, these things are called the social determinants of health, and they are believed to be responsible for a large share of people’s overall health. And yet, for many physicians, the people we go to see when medical issues manifest, they are hard problems to treat. The majority of physicians don’t believe it’s their responsibility to address these social drivers of health, according to a recent national survey.

That’s partly because if doctors are going to screen for housing issues, food insecurity or other social determinants, then they should in theory be able to change their treatment plan if a patient screens positive. In the U.S., this can be a complicated task. At the same time that there’s a growing recognition of the need for social support services to improve health, recent actions by the Trump administration could reduce the treatment options available.

This year, the federal government allowed states to enact work requirements for Medicaid. As Emily Badger and Margot Sanger-Katz explained in The New York Times, the concept is tied to a centuries-long debate over who among the poor is “deserving” of help. The work requirements allow states to remove some people from the program if they aren’t working, searching for a job or completing other community work. The Department of U.S. Housing and Urban Development is looking to increase the amount of rent low-income families will have to pay to live in government-subsidized housing, even as housing costs are soaring in many parts of the country. The administration has also said it wants to cut back on food stamps, one of the main mechanisms the federal government has for helping food insecure people buy food.

If doctors are going to screen for housing issues, food insecurity or other social determinants, then they should in theory be able to change their treatment plan if a patient screens positive. In the U.S., this can be a complicated task. 

This is certainly not the only presidential administration to try and shrink the social safety net; the U.S. has had long had a complicated relationship with social support services. Unlike most of our peer countries, we have rejected the idea that things like housing and health care are basic rights. We are in the bottom 10 among developed countries when it comes to social spending.

Still, some states are making clever use of the public programs we do have, such as Medicaid, to address health care needs more broadly. Nineteen states already require Medicaid managed care programs to screen or provide referrals for social needs, according to research by the Kaiser Family Foundation. In fact, Medicaid, one of the largest programs for people with low-incomes in the U.S., is being used in a variety of ways to try and address health concerns not readily treated with a pill. Though Medicaid won’t pay for housing, in Louisiana, it can be used to do some of the work to get people into housing. Washington state is piloting a similar housing support program. Other states use the insurance program to pay for community health workers or other professionals that can help patients access and coordinate care for their broader set of needs.

Some organizations are finding ways to integrate “treatment” for some of these basic needs directly into the medical system. In the hospitals where the nonprofit Health Leads operates, doctors can prescribe things such as exercise programs and healthy food. There are a variety of other “food as medicine” programs currently running in California and other states, as the New York Times recently reported. And in South Side Chicago, some patients leave a doctor’s visit with a list and map of resources in their neighborhood tailored to the needs identified on their electronic health record. In Los Angeles, primary care providers at the county’s largest public hospital now screen patients for unmet needs such as housing, food and mental health.

These are not necessarily new ideas. During the civil rights movement, physician Jack Geiger, who helped found the community health center system in the U.S., wrote prescriptions for milk and vegetables, directing the local grocer to send the bill to his pharmacy. When Thomas Ward Jr., a professor at Spring Hill College in Alabama, was working on the book “Out in the Rural,” which tells the history of the community health center movement, he found that physicians at the time were wrestling with many of the same questions we are today: What is the government’s role in health care? What are the economic costs of providing social services? And what are the economic benefits?

Hospitals and doctors’ offices can be a great place to diagnose the social problems at the root of many diseases. But a physician will be hard pressed to provide a patient with safe housing or a well-paying job. In its position paper, the American College of Physicians also called for adequate funding for federal, state, tribal and local agencies to address the social determinants of health. What role the government should play in providing services that get at the root causes of health is an issue we’ve long wrestled with as a country. The political debate isn’t likely to be settled any time soon, but the basic fact remains: Diagnosing health problems only helps if there are good treatments available, at prices patients can afford. For many patients, “treatments” such as housing, nutritious food or safe neighborhoods remain out of reach.



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Elders living with the progressive disabilities associated with aging, such as Parkinson's, dementia, and frailty, are especially dependent upon the services available in their community. We need to follow Singapore's lead and make virtually all housing in "universal design" so there are lots of places to live in a wheelchair. We need to make home-delivered food available without a waiting period. How is it that a doctor can write for a drug costing $100,000 for a person who can't get supper! If 90 year-old women living alone in second floor walk-ups with just Social Security incomes designed Medicare, I'd guess they'd start with housing, food, transportation, hearing aids, eyeglasses, podiatry, dental care, and social opportunities -- none of which are covered services in Medicare. They might well have been willing to make long-shot surgeries and medicines rather less available. At the least, they would have made those things subject to careful informed consent. When advocates say, "Medicare for all," I add an asterisk to a footnote saying "except for disabled elders for whom it is already in place!" It's the wrong set of priorities for persons of advanced age living with serious disabilities. And the supportive services of the community are regularly starved of resources while medical care continues apace.


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