Experts eye government's role in reducing public health inequalities

A report released earlier this month by CMS predicted healthcare spending will top $10,000 per American in 2016—a lot of money for individual patients and the insurance programs, both public and private, that subsidize them.

By focusing on long-term legislative and policy avenues to improving public health, can government be part of the solution in reducing spending on individual health outcomes?

During a webinar called “Exploring Social Determinants of Health Through a Public Health Law Lens,” Director of Public Health Law Research Scott Burris, JD, explained the general relationship between individual healthcare costs and public health solutions: If governments focus on improving health at a population level, spending on individual healthcare costs generally decreases, he said.

The webinar was put on by the CDC with the Network for Public Health Law and the American Society of Law, Medicine and Ethics. Other speakers echoed some of Burris’s sentiments and included examples of ways legislation can positively influence social determinants of health, which include the opportunities for exercise in a community, stress levels in a community, a population’s average education level, access to healthcare and available safe housing.

Burris explained the way public health policy influences individual health spending by focusing on the inequalities experienced by different communities when it comes to public health.

He said the reason mortality is on the rise in the U.S.—an unexpected and unusual phenomenon, he noted—because rising inequalities in those social determinants of health are creating unhealthy environments for some Americans.

“We’re ahead of where we were in terms of income inequality in the Gilded Age, in the period of [the] worst income inequality in the United States,” he said.

In fact, Burris pointed out that 176,000 and 245,000 deaths a year can be attributed to racial segregation and poor schooling, respectively, because poor social health outcomes resulting from inequalities. A recent study in the Journal of the American Medical Association Internal Medicine found that black men who live below the poverty line have the highest mortality rates of any racial, socioeconomic or gender group.

Experts point to other poor health outcomes that can be linked to social inequalities such as racial discrimination. According to information from the American Psychology Association and a study in the journal Psychoneuroendocrinology (reported by the New Yorker), black Americans are at a higher risk of having unhealthy blood pressure levels and heart disease, possibly because of the inherent stress that comes from discrimination or the fear of discrimination.

By reducing inequalities in education or reducing incarceration rates, for example, Burris said money will be required to deal with resulting health problems, such as high blood pressure, higher incidence of drug use, etc.

Burris also said laws have an important role to play in eliminating such inequalities, partly because legislation caused some of the inequalities in the first place.

“It doesn’t happen by accident,” he said. “The law has been a part of creating all this inequality.”

The federal government says one way it is trying to address these inequalities through the Affordable Care Act.

The CDC’s Dawn Peppin, JD, MPH, outlined efforts made by the Obama Administration to improve civil rights protections in section 1557 of the ACA, which was passed in May. The section focuses on clarifying existing protections to apply to healthcare situations and adds a few new protections.

Peppin explained that section 1557 prohibits healthcare discrimination on the basis of race, color or national origin, sex (which practically is interpreted to include gender expression), age or disability. The protections apply to any program that receives federal funding and to any part of the healthcare system created by the ACA.

Peppin gave an example of why clarifying those protections can be important for shrinking the inequality gap in the healthcare system: Only 77 percent of lesbian, gay and bisexual Americans have health insurance coverage, compared to 82 percent of heterosexual adults. Additionally, only 57 percent of transgender American adults are insured.

This change in policy can even affect people’s motivation to seek help.

“We know that discrimination has an impact on a person’s ability to want to get care. For instance, if you’re concerned that your doctor is going to discriminate against you or might say something that makes you uncomfortable, you’re going to delay care or you might not get care at all,” Peppin said.

And that in itself can have long-term economic effects when considering lost productivity from being sick, widening the inequality gap.  

But she also pointed out that there is still not explicit protection against discrimination in healthcare because of sexual orientation or certain chronic diseases, meaning patients can be denied certain types of treatment based on those two factors.

Another presenter at the webinar, Ellie Gladstone, gave an example of a way the law can work in the top left quadrant (social determinants of health/structural interventions) of Burris’s chart to improve public health beyond federal legislation.

Gladstone, a lawyer at California-based public health non-for-profit ChangeLab Solutions, explained the physical difference laws can make on the aspects of a community’s environment that affect health, especially through shared use laws.

Shared use agreements, often made between municipal bodies and state-run school districts, can allow members of a specific community to use a school’s recreation facilities (a playground, gym, track, open field, etc.). Access for kids outside of school hours (and non-school aged residents) can create a safe space for organized or informal recreation and physical activity.

Such access is important in maintaining the health of the community, Gladstone said, especially because at-risk communities—mainly communities of color and low-income communities—are less likely to have other spaces for physical activity.

There are several ways cities and the school districts in them can use the law to shape these agreements, Gladstone explained. They can sign a contract allowing city-organized sports leagues to use a school’s field at a particular time for the duration of a sports season, for example.

One school district in Lemon Grove, California, entered into an agreement with the city in 2012 that allows for organized sports league use and casual use for outdoor recreation during weekends. As part of the contract, the city takes on liability responsibilities during the time the facilities are open to the community, while the school is responsible during normal school hours and events.

Or, in the school district’s charter, created by state law, officials can write in an ordinance allowing public use of school facilities. That would constitute an open-use policy, such as one adopted by a school district in Hamilton County, Tennessee.

Either through a shared use contract or an open use policy, Gladstone said, the result is more opportunities for physical activity (a universally acknowledged important factor in individual health outcomes) where there wouldn’t usually be. These benefits have long-term impacts, which is the scale Burris said the law should be working on.

“All great legal change has come long term schedule…to developing the arguments that are going to work 20 years from now. And those are the ones that ultimately will have the real impact for change,” Burris said.