JAMA Forum: Health Care and Poverty

Joshua M. Sharfstein, MD

Joshua M. Sharfstein, MD

I recently had the opportunity to moderate a fascinating discussion at the Johns Hopkins Bloomberg School of Public Health on the role of the health care system in addressing poverty.

One of the 2 speakers was Kathryn Edin, PhD, a sociologist who has written extensively about the lives of the poor in the United States. The other was Rebecca Onie, JD, a MacArthur Fellow who began a national effort called Health Leads, which brings teams of college students to medical clinics to connect patients with social services and resources.

Should there be an expectation for health care institutions to take on entrenched social inequality? It’s a fair question. Some would point out that just getting health care right is hard enough, and good health care alone helps people and families to remain productive and stay out of poverty. Others would note that in recent years, an overdue focus on the social determinants of health has led to a greater focus on “upstream” contributors to poor health, such as substandard housing, few employment opportunities, and an underperforming educational system. From this perspective, it’s possible to see interventions in health care settings as “too little, too late” in addressing underlying inequity.

But the discussion challenged both of these shades of skepticism. Edin, who has spent years interviewing individuals and families in extreme poverty, noted the breakdown of many community institutions that existed to provide information and help to families in need of resources.

“If you look at the poorest of the American poor . . . only half of this group gets anything from [food stamps]. It’s really stunning,” Edin said. “Only a tiny portion gets a housing subsidy. But most everybody has some sort of health care, either for their children or for themselves. So if you want an institutional point of connection for these families, it is the health care industry . . . . It’s such a marvelous point of contact.” She noted that families may never learn about opportunities for assistance with food or energy bills outside of a medical setting.

Onie spoke about the college students’ passion for helping connect low-income families to resources. Health Leads tracks the thousands of times that students have identified eligibility for assistance and then assured that patients receive it. The students then teach the medical students, residents, and physicians in the clinic about the social needs of their patients, leading them to refer families for assistance back to the students in the future. Onie said she frequently heard from physicians that they never asked about social needs, because they had no idea how to address them. The root cause of avoiding questions of poverty was not cynicism, but rather ignorance.

With assistance from a student team, many physicians began to regularly talk to patients about their needs and work to address them. These clinicians have started to see confronting poverty as part of the job. And the students themselves, many of whom have gone on to medical school, start with a practical understanding of the relationship between poverty and health. Both have learned from experience that addressing poverty—even in part—can make a huge difference in health outcomes. Homes without electricity do not keep refrigerated medications. Hunger and food insecurity are associated with obesity because of the reliance on cheap sources of calories.

Patients, too, have sensed the difference in clinics that ask about their social needs. “Our patients now come in expecting to be able to talk to their physician about whether or not they have food at home,” one doctor told Onie. “That’s pretty powerful,” Onie remarked. “It’s a really profound shift in both the patient’s understanding of what health care can be and also the provider’s identity in that system.”

Of course, helping patients in a health care setting alone will not reduce rates of violence, control pollution, expand healthy food offerings, improve failing schools, or add new jobs—at least not directly. But breaking down the wall between poverty and health care is a step in the right direction. It leads to a greater understanding of the full set of challenges and potential solutions to those challenges. It also opens the door to different kinds of collaborations with communities.

And the timing could not be better. New payment incentives for better health outcomes are creating opportunities for new and innovative partnerships.

At the end of the session, students flocked to Edin and Onie to ask questions, talk over ideas, and ask how to get involved. It was a fitting end to a discussion about a future vision for health care.


About the author: Joshua M. Sharfstein, MD, is Secretary of the Maryland Department of Health and Mental Hygiene. He has previously served as the Principal Deputy Commissioner of the US Food and Drug Administration and as Commissioner of Health for Baltimore. A pediatrician, he lives with his family in Baltimore.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.


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