In his State of the Union address on January 6, 1941, Franklin Delano Roosevelt claimed that Four Freedoms are the essential foundations of a prosperous society: freedom of speech and expression, freedom to worship God in one’s own way, freedom from economic want, and freedom from fear of physical aggression.[Roosevelt]
In context, it is not hard to see why FDR espoused such a vision. The United States was in political throes of whether to remain isolated or to join our allies against Adolf Hitler’s forces. FDR sought to generate support for American participation in World War II, though that would not come until Japanese naval and air forces attacked Pearl Harbor. The Allies military victory over the Axis in 1945 served as spiritual vindication of FDR’s Four Freedoms.
Some 80 years later, FDR’s vision has spawned a level of global prosperity that few who survived World War II could have foreseen. Living in such prosperity, I believe there also ought to be freedom from ill health causing – in the words of FDR – economic want and, reciprocally, from economic want causing ill health.
The need for reciprocality arises because the two are so thoroughly intertwined. Both lack of education and financial distress are associated with health care costs.[Mohan] Recent findings substantiate the long-held belief that medical disability is associated with decline into poverty.[Banks; Whittle] The challenge comes in doing something about it.
The United States is renowned for having the world’s best medical technology, the highest health care costs and – paradoxically – among the worst health outcomes.[Peterson; Commonwealth] There is debate on the idea that the United States spends much less than other countries on social support, causing Americans with economic deficiencies to have higher health costs.[Bradley; Papanicolas] Others simply reject spending public health care dollars to provide support for health-related social needs.[Pope] Should society do something about health-related social needs (HRSN), and if so then how could we do it?
Physicians in primary care and emergency medicine shoulder the major burden of seeing patients who endure the link between economic want and ill health. Primary care because they’re the providers of first resort, emergency medicine because they’re essentially primary care of last resort for the un- and under-insured. It’s a stain on a prosperous society to have people in the latter category. The United States is the only high-income country for which this is true.[Gunja]
Medical educators have taught for nearly 50 years that biopsychosocial elements drive health and well-being. Unfortunately, America’s medical education system doesn’t train physicians with the knowledge, skills and ability to do something about the social elements.[Bolton] American medicine’s business model focuses entirely on the “bio” (and the bio-addressable “psycho”) elements through medical procedures and polypharmacy.
The question remains, then, what is America going to do about health related social needs, and who should do it?
Given that primary care and emergency medicine are where the “rubber meets the road” – the interface between economic want and ill health – it is logical that these specialties should shoulder the duty of detecting (i.e., screening) those patients whose economic want is contributing to their ill health. Unfortunately, both specialties are ill-prepared to do this, much less be effectors to address HRSN. In the final analysis, however, if not the site where persons with economic want and ill health systematically present, then where else would one do such screening? Primary care and perhaps the emergency department are the most logical locations.
After persons with HRSN are identified, then what? It is useless to obtain actionable intelligence if there is no subsequent action.
It is economically untenable to assign physicians who have a million-dollar brain mortgage with chores for which society pays a pittance. It therefore must fall on allied health care professionals, trained at much lower cost than physicians, to take on the task of providing support for HRSN. This would be community care workers, social workers, health coaches, clinical psychologists and so forth. Recent approaches have included care navigators, but separating the navigation piece from the clinical piece is “clunky” and not patient-oriented. For this reason, care navigation should be embedded in the community care worker roles.[Knowles]
The conundrum of how to pay for services to address HRSN only arises because the American medical business model restricts almost all billing to a physician’s services, constraining the allied health professions to a small suite of billable services. This policy got its momentum decades ago to empower physicians who sought (and still seek) to regulate scope of practice (ostensibly out of quality concerns but in reality for their own financial benefit).[Starr; AMA]
A fee-for-service solution would be to enable HRSN workers, as assembled in a community care hub, to bill for their services. A value-based solution would be to regard these staff as part of the “team” and pay primary care and emergency medicine practices enough compensation to pay everyone, leaving interventions to the team’s discretion. And let it be said plainly: any so-called value-based solution that counts RVUs (resource value units) as a measure of productivity is just fee-for-service by another name.
A key question remains: should Americans pay for HRSN services?
Truth is that we all pay for it now in costs that drag on America’s prosperity: higher health care premiums, efforts to cordon off the homeless and people who are psychotic, violence, alcohol and drug addiction, drug interdiction, theft, suicide as well as the cost to build walls and fences to keep all such people out of sight and out of mind.
As a physician who has seen these parts of American society close-up, it seems to me it would be better to address HRSN head-on, because these problems threaten freedom. Not just for those who endure them, but for all of us. In the words of Martin Luther King, Jr., “it's a nice thing to say to people that you oughta lift yourself by your own bootstraps, but it is a cruel jest to say to a bootless man that he oughta lift himself by his own bootstraps”.[King] The task in addressing HRSN is to make sure that everyone who wants them can have a pair of boots.
-– GE Moore
Citations
Roosevelt FD. State of the Union Address, Jan. 6, 1941. https://www.fdrlibrary.org/four-freedoms
Mohan G, Gaskin DJ. Social determinants of health and US health care expenditures by insurer. JAMA Network Open 2024;7(10):e2440467. doi:10.1001/jamanetworkopen.2024.40467
Banks LM, Kuper H, Polack S. Poverty and disability in low- and middle-income countries: a systematic review. PLOS ONE 12(12):e0189996. https://doi.org/10.1371/journal. pone.189950
Whittle HJ, Palar K, Ranadive NA, Turan JM, Kushel M, Weiser SD. “The land of the sick and the land of the healthy”: Disability, bureaucracy, and stigma among people living with poverty and chronic illness in the United States. Soc Sci Med 2017;190:181–189. doi:10.1016/j.socscimed.2017.08.031
Peterson Foundation. https://www.pgpf.org/article/how-does-the-us-healthcare-system-compare-to-other-countries/
Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022
Bradley EH, Sipsma H, Taylor LA. American health care paradox—high spending on health care and poor health, QJM 2017;110(2):61–65. https://doi.org/10.1093/qjmed/hcw187
Papanicolas I, Woskie LR, Orlander D, Orav EJ, Jha AK. The relationship between health spending and social spending in high-income countries: how does the US compare? Health Affairs 2019;38(9):1567–1575. doi: 10.1377/hlthaff.2018.05187
Pope C. Is everything health care? The overblown social determinants of health. Manhattan Institute, New York, NY, July 2024. https://manhattan.institute/article/the-overblown-social-determinants-of-health
Gunja MZ, Gumas ED, Williams RD II. US health care from a global perspective, 2022: accelerating spending, worsening outcomes. Commonwealth Fund, Jan 31. 2023. https://doi.org/10.26099/8ejy-yc74
Bolton D. A revitalized biopsychosocial model: core theory, research paradigms, and clinical implications. Psychological Med 2023; 53, 7504–7511. https:// doi.org/10.1017/S0033291723002660
Knowles M, Crowley AP, Vasan A, Kangovi S. Community health worker integration with and effectiveness in health care and public health in the United States. Annu Rev Public Health 2023; 44:363-381. doi: 10.1146/annurev-publhealth-071521-031648
Starr P. The Social Transformation of American Medicine: The Rise Of A Sovereign Profession And The Making Of A Vast Industry. 1982. Basic Books, New York. ISBN 0-465-07935-0
AMA successfully fights scope of practice expansions that threaten patient safety. May 15, 2023. https://www.ama-assn.org/practice-management/scope-practice/ama-successfully-fights-scope-practice-expansions-threaten
King ML, Jr. The Other America. April 14, 1967. Stanford University.
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