Poverty and Health - The Family Medicine Perspective (Position Paper)
The vision of the American Academy of Family Physicians (AAFP) is to transform health care to achieve optimal health for everyone. In today’s era of population health management, the AAFP’s vision is especially relevant, focused, and clear. Implementing mechanisms to measure and improve the health of diverse populations is a goal that is not just “the right thing to do.” It is essential for improving the health status of all patients and is becoming standard work as the nation moves toward pay-for-value reimbursement. Success in this new era means achieving better outcomes by transforming health care to overcome obstacles to population health improvement, such as poverty.
As family physicians, we have a unique perspective on the health challenges of local populations because we serve generations of families and follow individual patients through different life stages. We are privileged to share the complex stories of individuals and families in both sickness and health over long periods of time and across different care settings. Rather than viewing a single snapshot of a patient during an episode of illness, we know the patient’s whole story. We know about the environmental and patient-/family-specific factors that led to the illness and what the patient needs in order to manage the illness effectively. As lifelong collaborators in care, family physicians are well positioned to understand each patient’s individual obstacles to health and help overcome them.
Poverty is one obstacle that can affect our patients’ health. It is an insidious, self-perpetuating problem that affects generations of families. Beginning in utero and continuing throughout an individual’s life, poverty affects health via complex mechanisms. Life expectancy, learning abilities, health behaviors, and risks for developing disease are affected by poverty, as are educational, work, and lifestyle opportunities. The degree to which an individual’s health outcome is affected is filtered by his or her level of “host resistance” to poverty. Poverty does not automatically determine an individual’s health status, although it can significantly influence it. This distinction opens a door of opportunity at both the individual and population levels. Society can intervene to increase host resistance and mitigate poverty’s negative effects on individual and population health by expanding access to health care, providing infrastructure that supports healthy habits, and promoting strategies to reduce poverty.
At the practice level, family physicians are well positioned to mitigate the effects of poverty on health by understanding each patient’s unique challenges and coping strategies, and knowing what community resources are available. We do not need to act in isolation. In the era of population health management, diverse private and public resources are recognizing each other and aligning to improve health outcomes. Health and social service resources can connect patients and physicians directly to solutions that mitigate poverty’s effect on health.
Caring for a patient of limited material means requires sensitivity to and understanding of the patient’s specific challenging circumstances in order to design a treatment plan that is achievable and sustainable. Such an approach requires a culturally proficient medical home and a well resourced medical neighborhood that supplies readily accessible solutions. When these solutions are incorporated seamlessly into everyday practice workflows, family physicians and care teams can be true to the AAFP’s vision by achieving positive change for individuals, families, and communities and improving population health.
To understand poverty, we must first define it. The Centers for Disease Control and Prevention (CDC) defines poverty simply as a condition in which “a person or group of people lack human needs because they cannot afford them.”1 In the United States, the federal poverty line is expressed as an annual pre-tax income level indexed by size of household and age of household members. For example, in 2014, the federal poverty line was $12,316 for an individual younger than 65 years of age and $24,418 for a family of four.2 The American Community Survey revealed that 14.5% of all U.S. citizens fell below the poverty line in 2013 and that youth, racial and ethnic minorities, those without a high school diploma, and the unemployed had the highest rates of poverty.3
The term “low-income status” describes individuals and families whose annual income is less than 200% of the federal poverty level. Nearly 40% of the U.S. population meets this criterion.3
Poverty and low-income status are associated with a variety of adverse health outcomes, including shorter life expectancy, higher rates of infant mortality, and higher death rates for the 14 leading causes of death.4,5 These effects are mediated through individual- and community-level mechanisms.6 For individuals, poverty restricts the resources used to avoid risks and adopt healthy behaviors.7 Poverty also affects the built environment (i.e., the human-made physical parts of the places where people live, work, and play, including buildings, open spaces, and infrastructure), services, culture, and reputation of communities, all of which have independent effects on health outcomes.8 Location matters, and there are often dramatic differences in health care delivery and health outcomes between communities that are only a few miles apart. For example, the Robert Wood Johnson Foundation (RWJF) found that there is a 25-year difference in average life expectancy between inner city and suburban neighborhoods for babies born in New Orleans, LA, and there is a 14-year difference in average life expectancy between two Kansas City, MO, neighborhoods that are roughly three miles apart.9
A recent study by The Commonwealth Fund assessed 30 indicators of access, prevention, quality, potentially avoidable hospital use, and health outcomes. The study found that low-income status populations suffer disparities in every state. However, it also identified significant differences among states’ performances. In fact, in top-performing states, many health care measures for low-income populations were better than average and better than those for higher income or more educated individuals in lagging states. These findings point out that low-income status does not have to determine poor health or poor care experience. Interventions seen in top-performing states, such as expanded insurance coverage, access, and coordination of social and medical services, can help mitigate poverty’s effects on health.10
The Complex Ways that Poverty Affects Health
Societal resources (e.g., social institutions, built environments, political structures, economic systems, technology) sustain health. Prosperity provides individuals with resources that can be used to avoid or buffer exposure to health risks (e.g., knowledge, power, prestige).11 By contrast, poverty affects health by limiting access to proper nutrition; shelter; safe neighborhoods in which to learn, live, and work; clean air and water; utilities; and other elements that define an individual’s standard of living. Individuals who live in impoverished neighborhoods are likely to experience poor health due to a combination of factors that present obstacles to health maintenance.12
Violence is prevalent where there is poverty. From 2008 to 2013, individuals in households at or below the poverty level had more than double the rate of violent victimization of individuals in high-income households, according to the National Crime Victimization Survey.13 This pattern was seen in both urban and rural areas. Victimization of violent behavior is experienced by both the family of the victim and the family of the perpetrator (through incarceration), which can create a cycle of stress, helplessness, and despair.
Life expectancy is significantly affected by poverty due to multiple factors, some of which are more obvious (e.g., violence) than others (e.g., lack of educational opportunities). Education and its socioeconomic status correlates of income and wealth have powerful associations with life expectancy for both sexes and all races, at all ages. It is notable that students from low-income families are five times more likely to drop out of high school than students from high-income families.14 In 2008, the life expectancy among U.S. adult men and women with fewer than 12 years of education was not much better than the life expectancy among all adults in the 1950s and 1960s.15
Poverty affects individuals insidiously in other ways that we are just beginning to understand. Mental illness and substance misuse are more prevalent in low-income populations; the argument about whether poverty is a cause or effect of this higher prevalence is ongoing.16 Poor nutrition, toxic exposures (e.g., lead), and elevated levels of the stress hormone cortisol are factors associated with poverty that may have lasting effects on children beginning in utero and continuing after birth. These effects, which can influence cognitive development and the development of chronic disease, are dose dependent (i.e., the duration of exposure matters).17-19 For example, the greater the number of years a child spends living in poverty, the more elevated the child’s overnight cortisol level is and the more dysregulated the child’s cardiovascular response to acute stressors is.18 Impaired development of the nervous system affects cognitive and socioemotional development, and increases the risk of behavioral challenges, adverse health behaviors, and poor school performance.18,19 These insidious biological effects of poverty contribute to its self-perpetuating cycle: low educational achievement leads to limited occupational options which leads to continued poverty.
However, the effects of poverty are not predictably uniform. Longitudinal studies of health behavior describe positive (e.g., tobacco use cessation) and negative (e.g., decrease in physical activity) health behavior trends in both lower and higher socioeconomic populations. However, there is a socioeconomic gradient in health improvement; in other words, lower socioeconomic populations lag behind higher socioeconomic populations in positive gains from health behavior trends. Health behaviors are important in that they account for differences in mortality.20 The fact that positive changes in health behaviors are possible in spite of the challenges of poverty points to the importance of developing and implementing interventions that promote healthy behaviors in low-income populations.
Poverty affects health in many different ways through complex mechanisms that we are just beginning to understand and describe. It is important to note, again, that an individual’s poverty does not necessarily predetermine poor health.21 Poverty will not “cause” a disease. Rather, poverty affects both the likelihood that an individual will have risk factors for disease, and his or her ability and opportunity to prevent and manage disease. An individual’s health outcomes (a physiologic expression) ultimately will be influenced by genetic and environmental factors, as well as health behaviors, all of which may be influenced by poverty. The material conditions; discriminatory practices; neighborhood conditions; behavioral norms; work conditions; and laws, policies, and regulations associated with poverty make it a “risk regulator.”21 This means that poverty functions as a control parameter at a system level to influence the probability of exposure to key risk factors (e.g., behaviors, environmental risks) that lead to disease (Figure 1).
Figure 1: An Illustration of Risk Regulators in Social and Biological Context
Reprinted with permission from Glass TA, McAtee MJ. Behavioral science at the crossroads in public health: extending horizons, envisioning the future. Soc Sci Med. 2006;62(7):1650-1671.
Thinking of poverty as a risk regulator rather than a rigid determinant of health allows family physicians to relinquish the feeling of helplessness when we provide medical care to low-income families and individuals. We can devise solutions to mitigate both the development of risk factors that lead to disease and the conditions unique to low-income populations that interfere with effective disease prevention and management. We can boost an individual or family’s “host resistance” to the health effects of poverty. We can tap into a growing array of aligned resources that provide patients and families with tangible solutions so that health maintenance can be a realistic goal.
Provide a patient-centered medical home (PCMH)
Strong primary care teams are critical in the care of low-income patients. These populations often have higher rates of chronic disease and difficulty navigating health care systems. They benefit from care coordination and team-based care that addresses medical and socioeconomic needs.
Across the United States, there is a move toward increased payment from government and commercial payers to offset the cost of providing needed care that is coordinated and team-based. Some payment models provide shared savings and/or per patient/per month care coordination payments in addition to traditional fee-for-service reimbursement. The rationale behind alternative payment models, particularly regarding the care of lower socioeconomic populations, is that significant cost savings can be realized when care moves toward prevention and self-management in a patient’s medical home and away from crisis-driven, fragmented care provided in the emergency department or a hospital setting. By recognizing and treating disease earlier, family physicians can help prevent costly, avoidable complications and reduce the total cost of care. We should be compensated appropriately for this valuable contribution to population health management.
Practice cultural proficiency
PCMH team members can have a positive effect on the health of low-income individuals by creating a welcoming, nonjudgmental environment that supports a long-standing therapeutic relationship built on trust. Familiarity with the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (available online at www.thinkculturalhealth.hhs.gov/content/clas.asp(www.thinkculturalhealth.hhs.gov)) can prepare practices and institutions to provide care in a manner that promotes health equity.
Low-income patients may be unintentionally shamed by the care team when their behaviors are seen as evidence of being “noncompliant” (e.g., missing appointments, not adhering to a medical regimen, not getting tests done). These patients may not be comfortable sharing information about the challenges that lead to their “noncompliant” behaviors. For example, a low-income individual may arrive 15 minutes late to an appointment because he or she has to rely on someone else for transportation. A patient may not take a prescribed medication because it is too expensive. A patient may not get tests done because his or her employer will not allow time off from work. A patient may not understand printed care instructions because he or she has low literacy skills. Such patients may be turned away by staff because their tardiness disrupts the schedule, or they may even be dismissed them from the practice altogether because of repeated noncompliance. PCMH team members can tease out the “why” behind noncompliance and promote an atmosphere of tolerance and adaptation.
Patients in lower socioeconomic groups and other marginalized populations rarely respond well to dictation from health care professionals. Instead, interventions that rely on peer-to-peer storytelling or coaching are more effective in overcoming cognitive resistance to making positive changes in health behavior.22 PCMH team members can identify local groups that provide peer-to-peer support. Such activities are typically hosted by local hospitals, faith-based organizations, health departments, or senior centers.
Screen for socioeconomic challenges
Family physicians screen regularly for risk factors for disease; screening to identify patients’ socioeconomic challenges should also be incorporated into the practice. Once socioeconomic challenges are identified, we can work with our patients to design achievable, sustainable treatment plans. The simple question, “Do you (ever) have difficulty making ends meet at the end of the month?” has a sensitivity of 98% and specificity of 60% in predicting poverty.23 A casual inquiry about the cost of a patient’s medications is another way to start a conversation about socioeconomic obstacles to care.
A patient’s housing also has an effect on his or her health.24 The care team should ask the patient whether he or she has a home that is adequate to support healthy behaviors. For example, crowding, infestations, and lack of utilities are all risk factors for disease. Knowing that a patient is homeless or has poor quality, inadequate housing will help guide his or her care.
Set priorities and make a realistic plan of action
As family physicians, we direct the therapeutic process by working with the patient and care team to identify priorities so that treatment goals are clear and achievable. In many cases, we may need to suspend a “fix everything right now” agenda in favor of a treatment plan of small steps that incorporate shared decision making. It is likely that a low-income patient will not have the resources (e.g., on-demand transportation, a forgiving work schedule, available child care) to comply with an ideal treatment plan. Formulating a treatment plan that makes sense in the context of the patient’s life circumstances is vital to success.
For example, for a patient of limited material means who has a multiple chronic conditions, including hypertension (blood pressure of 240/120 mm Hg) and diabetes (A1c of 12%), it is important to start by addressing the elevated blood pressure and A1c. Colon cancer screening or a discussion about starting statin therapy can come later. It may be easier for this patient to adhere to an insulin regimen involving vials and syringes instead of insulin pens, which are much more expensive. The “best” medication for a low-income patient is the one that the patient can afford and self-administer reliably. We can celebrate success with each small step (e.g., self-administering one dose of insulin a day rather than no insulin) that takes a patient closer to disease control and improved self-management.
Help newly insured patients navigate the health care system
In many states, the expansion of Medicaid has allowed low-income individuals and families to become insured, perhaps for the first time. A newly insured low-income individual will not necessarily know how or when to make/keep/reschedule an appointment, develop a relationship with a family physician, manage medication refills, or obtain referrals. He or she may be embarrassed to reveal this lack of knowledge to the care team. PCMH team members can help by providing orientation to newly insured patients within the practice. For example, PCMH team members can ensure that all patients in the practice know where to pick up medication, how to take it and why, when to return for a follow-up visit and why, and how to follow their treatment plan from one appointment to the next. Without this type of compassionate intervention, patients may revert to an old pattern of seeking crisis-driven care, which is often provided by the emergency department of a local hospital.
Provide material support to low-income families
Resources that are available to make it easier for busy clinicians to provide support to low-income families include the following:
- Reach Out and Read (http://www.reachoutandread.org/(www.reachoutandread.org)) is a program that helps clinicians provide books for parents to take home to read to their children. Studies have shown that Reach Out and Read improves children’s language skills.25
- 2-1-1 (www.211.org/(www.211.org)) is a free, confidential service that patients or staff can access 24 hours a day by phone. 2-1-1 is staffed by community resource specialists who can connect patients to resources such as food, clothing, shelter, utility bill relief, social services, and even employment opportunities. Follow-up calls are made to ensure clients connect successfully with the resource referrals.
- The National Domestic Violence Hotline (www.thehotline.org/(www.thehotline.org)) is staffed 24 hours a day by trained advocates who are equipped to provide confidential help and information to patients who are experiencing domestic violence.
Local hospitals, health departments, and faith-based organizations often are connected to community health resources that offer services such as installing safety equipment in homes; providing food resources; facilitating behavioral health evaluation and treatment; and providing transportation, vaccinations, and other benefits to low-income individuals and families.
Practices can make a resource folder of information about local community services that can be easily accessed when taking care of patients in need. This simple measure incorporates community resources into the everyday workflow of patient care, thus empowering the care team.
Participate in research that produces relevant evidence
Much of the research that exists about the effects of poverty on health is limited to identifying health disparities. This is insufficient. Research that evaluates specific interventions is needed to gain insight into what effectively alleviates poverty’s effects on health care delivery and outcomes. Family physicians can serve a critical role in this research because we have close relationships with patients of low-income status.26
Advocate on behalf of low-income neighborhoods and communities
Family physicians are community leaders, so we can advocate effectively for initiatives that improve the quality of life in low-income neighborhoods. Some forms of advocacy, such as promoting a state’s expansion of Medicaid, are obvious. Other efforts may be specific to the community served. For example, a vacant lot can be converted to a basketball court or soccer field. A community center can expand programs that involve peer-to-peer health coaching. A walking program can be started among residents in a public housing unit. Collaboration with local law enforcement agencies can foster the community’s trust and avoid the potential for oppression.27
Family physicians have local partners in advocacy, so we do not have to act in isolation. As a result of the Patient Protection and Affordable Care Act (ACA), nonprofit hospitals regularly report community needs assessments and work with local health departments to establish action plans that address identified needs. A Community Health Needs Assessment (CHNA) reflects a specific community’s perception of need, and each action plan outlines multi-sectoral solutions to meet local health needs. Local CHNAs are typically available online, as are the associated action plans. Family physicians can use information in the CHNA to access local health care leadership and join aligned forces to achieve optimal health for everyone in the communities we serve, thereby supporting the vision of the AAFP.
Patricia Czapp, MD
Kevin Kovach, MSc, CHES
The authors thank Robert “Chuck” Rich Jr, MD, FAAFP, chair of the Commission on Health of the Public and Science (CHPS) as well as members of CHPS; and members of the Subcommittee on Health Equity (SHE), for their contributions.
Additional thanks to supporting staff:
Melanie D. Bird, PhD
Melody Goller, BSHA, CMP
Bellinda K. Schoof, MHA, CPHQ
Nicole Williams, MPH
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