At an individual level, the U.S. spends about twice as much per person on health care costs than other wealthy countries. Since 2014, health expenditures per capita and as a percentage of the gross domestic product have been gradually rising. At the same time, the average life expectancy has been dropping, especially for Black Americans.
Along with the soaring costs of health care comes a growing health equity gap, meaning more and more people lack access to a consistent quality of care, which results in avoidable, unfair and unjust health care gaps. What are we getting for those increasing costs? Do we see better outcomes? And does everyone have the same access to high-quality, affordable health care? The answer, quite simply, is no.
Unfortunately, in the United States, your ZIP code is a better predictor of health than your genetic code.
I am the chief medical officer and vice president of medical affairs at Broadlawns Medical Center in Des Moines, Iowa. The ZIP code for Broadlawns, 50314, is one of the poorest in Polk County. Social determinants of health, the conditions under which people are born, grow, live, work and age, has a massive impact on our community's overall health. As it turns out, the average life expectancy for babies born in this ZIP code can vary by as much as eight years across neighborhoods just a few miles apart.
Family physicians provide the majority of health care for underserved populations in the United States. As the only county hospital, we treat a more diverse population of patients at Broadlawns than any other hospital in Polk County. As leaders, family physicians have an essential role in raising awareness about health disparities and helping communities address social determinants of health through education and resources.
As a determinant of health, medical care alone is insufficient for better health outcomes, and in the United States, we're falling behind. In most industrialized countries, for every $1 spent on health care, $2 is spent on social services. In the United States, for every $1 we spend on health care, between 55 cents and 90 cents is spent on social services. This causes health disparities that contribute about $93 billion in additive medical costs and $42 billion in overall lost productivity. If health equity were improved in the United States, we could save over $230 billion in health care costs alone.
So, how do we adequately address these problems? Ultimately, it comes down to upstream investment in social services and health equity. The ratio of social spending to health spending is significantly associated with health outcomes.
I'm passionate about building healthy communities through improvements in SDOH and health equity, which are influenced by policies and programs. So when I heard about the AAFP’s Health Equity Fellowship program, I thought it would be an excellent way to build healthy communities (by improving SDOH) and to build health equity (by strengthening collaborations between health care communities and faith-based communities in central Iowa). I also hope through this fellowship to learn ways to influence policies and programs at the local and state level.
During my fellowship, I will work with Corinthian Baptist Church in Des Moines. We will focus on three areas:
People who have less access to, and greater need for, the system of support provided by the government are often people who feel disconnected from government. Therefore, we will use an intentional strategy to address inequities and will ensure equitable access.
In many communities, people have more trust in their religious leaders than in the health care system. As such, a key component of my work will be the creation of community health care workers, or “health ambassadors.”
Health ambassadors will be trusted members of vulnerable communities who are part of the state’s equity groups. They will not provide medical services, and they do not necessarily even need to be health care professionals, but for this project they will work in the community as sources of good information and provide coaching on issues related to health equity. This may include work related to population-specific chronic illnesses to reduce inequities in access to wellness opportunities and health care, along with other initiatives to improve the health and well-being of vulnerable people.
Our health ambassadors will be trained and positioned to credibly provide understandable and accessible information to individuals, organizations and businesses in their communities. With additional training, they will also have the knowledge to answer critical questions and reduce the fear associated with health conditions such as diabetes and hypertension.
Much of the work behind the health ambassador program will be conducted at Broadlawns. We will approach this via a two-pronged strategy. First, we will create community enrollment events to attract individuals who are living with diabetes and/or hypertension. We will then identify and train health ambassadors to serve as staff at the enrollment events and to provide followup care with individuals who enroll at these events on a regular basis. Overall, the number of health ambassadors should be sufficient to provide for roughly 100 Iowans currently on Medicaid.
There are so many ways that family physicians can make a difference in their patients’ lives. The work that we are doing here in Iowa may seem like a drop in the bucket when you consider the breadth and depth of health inequities that exist in the United States, but even a small difference here and there can add up over time. I am proud to have been chosen as a Health Equity Fellow by the AAFP, and I am proud to know that together, we can accomplish great things for family medicine and for the patients we serve.
Yogesh Shah, M.D., M.P.H., C.M.P., is the chief medical officer and vice president of medical affairs at Broadlawns Medical Center in Des Moines, Iowa, and a 2021-2022 AAFP Health Equity Fellow.