Providers in all parts of the health care system recognize that troublesome social conditions drive much of their work and costs. Major challenges in people’s social circumstances — layoffs, foreclosures, accidents, violence — can create horrific health care needs, many of which become chronic and carry high price tags. These extreme needs are omnipresent in the nation’s hospitals, which care for about 37 million admissions at a medical expense of $750 million a year.
Over the past two years, we conducted more than 60 interviews with front line health care and social service providers as part of research for our newly released book, The American Health Care Paradox (PublicAffairs). Our goal was to better understand the current relationship between the two sectors. This qualitative study followed on the heels of a major report published in 2011 by the Robert Wood Johnson Foundation, titled the Blind Side. Therein, physicians highlighted the growing, negative influence of the social environment on patients’ health; 85% of physicians surveyed agreed that patients’ social needs are overwhelming their medical needs. If they had the power to write prescriptions for social support services, the surveyed physicians estimated that these prescriptions would represent one out of every seven they wrote.
Our visits to the front lines reinforced this sentiment. It quickly became clear that the health care sector is bearing the brunt of an inadequate social service sector. Since the 1986 passage of the Emergency Medical Treatment and Labor Act (EMTALA), hospitals are required to stabilize patients before discharging them even if they cannot pay for care. The understanding of the emergency room as a destination was described by one man who was formerly homeless:
It’s like you have one thing and everything leads up to, uh, like a disaster, you know? In the end, well, you end up in the hospital.
Providers we interviewed felt ill-equipped to respond to these disasters. One physician weighed in on a similar issue, reflecting on her inability to treat what they see as the most pressing medical concerns in the face of such clear social barriers.
I am sitting here, writing a prescription for this person who has limited ability to afford the medication of have insight on the situation, who can’t go outside because the neighborhood is unsafe…. And I am totally unable to do my job. I need more support to do my job and to help these patients.
Another echoed,
It’s very tough to follow up with someone who’s living on a park bench.
Importantly, it is not only the economically disadvantaged who lean on the health care industry to alleviate social challenges. In one emergency department we visited, a physician described the frequency with which he sees even well-to-do community members coming in on Friday afternoons and evenings, hoping to use the emergency department as a source of respite care.
A lot of guys bring in their parents, who have become an incredible burden, [looking for relief]. And they say, ‘Oh I think she has a fever.’ That’s very common.
Medicine, of course, remains the preferred means of treating individuals who come through the doors of most health care settings. And yet, some providers are recognizing the way in which medicine may be crowding out more socially-based interventions, which could be even more effective. One provider, who left traditional practice to create a hybrid nonprofit explained the phenomena as follows.
We kept realizing we have access to all this very high-tech medical stuff for people who, when they come back to where they live, can’t do any of the stuff that we spend a lot of money on. And then there’s no money to help sort out their social situations, so that they can actually comply with their care plan.
A deeper analysis of the full dataset we collected, including not only physician perspectives but also those of social service providers and patients, can be found in the book, but the key finding was unequivocal. The health care sector is bearing the brunt of an inadequate social service sector, and no matter how good the intentions of health care providers, the majority feel unable to meet the needs of their patients alone.
Our analysis raises key questions about the ACA, which focuses on various reforms in the financing and organization of health care services but is largely silent on ways to address non-medical determinants of health. Explicit incentives could motivate better coordination between health care and social services providers and ultimately allow physician and hospital resources to return to what they do best — medicine.
Elizabeth H. Bradley is a professor of public health, Yale University and director, Yale Global Health Leadership Institute. Lauren A. Taylor is a presidential scholar, Harvard Divinity School where she studies health care ethics. Together, they co-authored The American Health Care Paradox (PublicAffairs).
