Beyond the zip code

I racked my brain trying to understand why the patient was adamant about not being discharged from our inpatient medicine service. We did all the things—determined the cause of his newly reduced cardiac ejection fraction and scheduled close outpatient follow up with a new cardiologist. He was medically ready, yet every time the word “discharge” was said, he turned pale.  

I decided to spend extra time with him after rounds to get a better understanding of his concerns and was surprised by what I learned. The patient said the roof of his home had a gaping hole that he couldn’t afford to fix. It was February, and the hospital provided him with warmth and shelter. He lived in Columbia, Maryland, a wealthy suburb of Baltimore, and owned his home, but was desperate to stay in a shared hospital room. 

There’s a well known association between urban, low income communities and poor health outcomes. But what about suburban communities and patients from these neighborhoods who may face a similar set of challenges? Our focus as healthcare professionals has been on patients whom we consider to be from “vulnerable” populations. These are patients from low income neighborhoods, maybe with high crime rates and limited access to healthcare, who face challenges brought on by social determinants of health. As a system, we’ve made strides to address these barriers and increase health equity—but are we missing the suburban population? 

Suburban communities are typically associated with a wealthier demographic with higher socioeconomic status, and more readily available healthcare services, including subspecialty care. These notions date back to “white flight,” a phenomenon that led to a divestment from urban/metropolitan areas to suburban communities.  

In recent years, suburban neighborhoods have become increasingly diverse in racial, ethnic, and economic status. A 2017 study showed that the suburbs were home to about 17 million Americans living in poverty. It noted that 40% of all uninsured Americans live in these communities. The previous infrastructure and demographics of suburbia are no longer a reality, and these harmful associations may cause healthcare professionals to make incorrect assumptions about patients who live there. 

Reflecting on my patient, I realized that I had preconceived notions about his healthcare accessibility and affordability simply because I knew he lived in a wealthy community. I assumed that he didn’t want to leave the hospital because he was anxious about his new diagnosis. It never occurred to me that he wanted to stay warm and safe because he didn’t have the means to resources outside of the hospital. This experience taught me:  

1. Quality housing is a basic health need. 

All patients should be asked about home safety. Making assumptions about this necessity based on zip code can impact the care patients receive and being connected to resources available to improve home quality.  

2. Income greatly affects access to care no matter the geographic location. 

Economic status is still a top predictor of healthcare access, and many patients living in suburban communities have unmet health needs due to financial constraints.  

3. Apply social determinant of health approaches to all patients. 

All patients should be asked about medication affordability, transportation access, and support. These practices shouldn’t be limited to patients we deem to be a part of “vulnerable” populations.  

By doing the above, we can help bridge the gap in healthcare access and ensure all patients receive the care they need, regardless of zip code or socioeconomic status. This shift in perspective, from assumptions based on location to a holistic understanding of individual circumstances, is essential to achieving true health equity within our healthcare system. 

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