A jagged landscape  

A patient in one of our residency clinics, a refugee, was referred for a temporal artery biopsy. In accordance with the U.S.’ No Surprise Billing Act, she received a letter stating that she was responsible for the full charges of the specialist visit. Without any guarantee of financial assistance, the patient canceled her appointment. Although we encourage patients to seek medical care when needed and apply for financial assistance, the policy around monetary assistance is a jagged landscape for them to navigate. 

Patients who live at the intersection of poor health and poverty, language barriers, and discrimination are caught in a catch-22: they need to engage with bureaucracy and complex systems to secure support and resources, but the stress and burden of proving their poverty and need can be overwhelming, leading some to disengage, especially if they’re experiences discrimination or structural racism.

Structural racism continues to shape modern policies by allocating resources in ways that disempower and devalue members of racial and ethnic minority groups, people with low incomes, and rural communities, which results in lack of access to high-quality care.  

Reducing structural discrimination requires taking actions to minimize bias at all levels of the healthcare system by using policies and processes to challenge and dismantle historical oppression. Health systems can engage in creating new ways for all to be healthy. Healthcare professionals can advocate for the following: 

1. Policies and initiative related to improving access to healthcare that’s inclusive regarding eligibility and implementation. 

2. Policies that influence how the social drivers of health inequity shape access to resources for health, safety, and well-being. 

3. Policies to ensure that patients of all ages have healthy options and social support.  

4. Policies that promote equitable opportunities for employment and a stable income.  

The civil rights act of 1964 prohibited discrimination based on race, color, religion, sex, and national origin. Title VI of the act prevented discrimination by programs and activities that receive federal funding, including hospitals and other healthcare facilities. However, either consciously or inadvertently, policies have made unfair treatment worse. As a result, inequities have persisted causing striking gaps in health outcomes. When medical needs are immediate and complex, we see patients struggle to access care because of invisible but insurmountable barriers that policies can create. 

We must shift the perception of our colleagues, leaders, and systems from what patients experiencing poor health and overwhelm “should be” doing to what WE can do to support their efforts. Until we hold ourselves accountable for establishing trust with communities that are disconnected from our healthcare system and living with the burden of chronic disease and the tragedy of lower life expectancy, we will not be able to address health inequity. Listening to patients and seeing the multi-level impacts of poverty on their health and ability to manage it is a first step, but there are other actions we can take: 

1. Identify patients who need financial and social support and if they’re receiving it. Disaggregating data by race and ethnicity will show us who we are failing and provide a roadmap to health equity initiatives. 

2. Implement a medical legal partnership. This collaboration with Legal Aid or local law resources can help patients navigate and advocate within complex bureaucracies.  

3. Consider reciprocal eligibility for hospital-run programs. If patients qualify for WIC, SNAP-EBT or other local or state-run programs, this eligibility can be documented and accepted in lieu of an application. 

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.