Policy paper provides way forward for reducing disparities and providing ‘equitable access to high-quality health care’
March 6, 2020 (ACP) – Primary care physicians see the devastating effects of barriers to care every day, and they're sadly familiar with the harms facing patients from public health threats like gun violence, addiction and maternal mortality. Now, the American College of Physicians is proposing a path forward that will eliminate disparities and preventable hazards.
“To ensure optimal health for everyone, social determinants of health and barriers to care must be addressed; the provision of improved access to health care alone will not be sufficient,” ACP writes in a new policy paper. “Careful consideration must also be given to environmental health, climate change, nutrition, tobacco use, substance use disorders, maternal mortality, and firearm injuries and deaths, which can also hinder achievement of good health.”
ACP provides a road map toward a better future in a free report titled, “Envisioning a Better U.S. Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health.” The report is one of a series of policy papers released in January 2020 as part of a collection titled, “Better Is Possible: The American College of Physicians Vision for the U.S. Health Care System.” All the reports appear in Annals of Internal Medicine.
“ACP has advocated for access to affordable, quality care for all Americans for decades,” said Renee Butkus, ACP director of health policy and lead author of the report. “However, coverage does not necessarily guarantee access. More than health coverage, patients want health and there are a host of nonfinancial barriers that are keeping them from achieving optimal health. It is essential that the health system in the United States go beyond just ensuring coverage, efficient delivery systems and affordability.”
In the report, ACP highlights the role of social determinants of health. “These are nonmedical factors that can impact an individual's overall health and health outcomes,” Butkus said. “These include conditions that shape a patient's daily life, such as income, social status and education; their physical environment including access to safe water and clean air; the safety and conditions of their workplace and home; employment opportunities and social support networks; and access to health services.”
Specifically, ACP says disparities in the following fronts must be eliminated:
- Race and ethnicity: Research suggests that health care barriers exist in organizational, structural, and clinical areas. Stigma within communities about treatment such as mental health care is also a barrier.
- LGBTQIA identity: Lesbian, gay, bisexual, transgender, queer/questioning, intersex and asexual/allied patients often don't get routine treatment or care that's tailored to their unique needs. “There is widespread discrimination in health care, health insurance policies, employment, and public policy, all of which exacerbates this problem,” ACP notes.
- Gender: Women face unique challenges such as underestimation of pain and symptom severity by clinicians. Research notes that women can be hurt by “legislation, hospital policies, and business decisions to limit reproductive services.”
- Intellectual and physical disability: Patients with disabilities face a variety of barriers, from physical obstacles to disparities linked to clinicians who lack knowledge about their needs.
- Location: “Twenty-one percent of Americans live in rural areas, but less than 10% of physicians practice in rural areas,” ACP notes. “For those in both urban and rural areas, lack of transportation results in difficulty accessing care and decreased pharmacy and medication access.”
- Age: “Elderly persons see both psychological and physical barriers preventing them from getting the care they need,” ACP says.
- Language and citizenship status: “Language barriers contribute to health disparities for patients with limited English proficiency,” ACP notes. Patients with impaired hearing also face barriers, such as lack of access to American Sign Language interpreters.
- Incarceration status: “Incarcerated individuals often go overlooked and experience low-quality health care services compared with the general population,” ACP says.
- Religion and beliefs: “Certain religious, personal, and cultural beliefs can prevent people from receiving proper care,” says ACP, which notes the dangers of antivaccination efforts.
- Health literacy and access to information: “Having Internet access is insufficient; health literacy and digital literacy are important parts of gathering health information,” ACP says.
- Intersectional barriers: “Intersectionality occurs when multiple factors in a person's identity leave them more susceptible to facing barriers to care,” says ACP, such as when a patient is both black and LGBTQIA.
As for solutions, “policies and interventions must consider these numerous barriers and strive to eliminate disparities,” ACP says. ACP points to numerous strategies that prevent discrimination and support “equitable access to high-quality health care.” These strategies include implementing public policies and efforts to ensure adequate supply and distribution of physicians and other clinicians to meet the nation's health care needs; investing in public health infrastructure, research and public policy interventions; and devoting more resources to addressing environmental health.
In terms of public health, the report calls for prioritized funding and policy interventions to achieve the following goals:
- Reduce smoking and tobacco-related preventable illnesses, including health risks associated with the growing use of vaping by teenagers.
- Reduce and treat substance use disorders.
- Reduce the rate of maternal mortality in the United States, especially for African-American women.
- Reduce firearm-related injuries and deaths. “Injuries and deaths from firearms are a growing public health crisis. ACP has long-standing policy on the topic as part of our commitment to advocate for public health,” Butkus said. “Rates of firearms injuries and death are closely linked to social determinants of health and individual characteristics. Groups largely affected by barriers to care – rural communities, racial and ethnic minorities and women – were shown to experience high rates of firearm violence.”
- Improve access to and the availability of high-quality nutritional food.
Internists have their own role to play in combating public health threats, Butkus said, and ACP is available to help. “ACP has developed physician education resources on health issues such as climate change, firearms injuries, caring for socioeconomically disadvantaged patients and human trafficking,” she said.
The ACP policy paper “Envisioning a Better U.S. Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health” is available on the Annals of Internal Medicine website.