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Socio-Ecological Influences on Health Outcomes for Individuals Below the Poverty Line
Taralynn Norman, Julia Scales, Carter Williams, Kevin Lu, Vera Pasmanik
University of South Florida
PHC 4464.311 Introduction to Health Disparities
Rashida Jones, PharmD
November 19, 2023
Abstract
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Health disparities refer to discrepancies in health outcomes, disease prevalence, and access to healthcare services within specific populations. These variations are frequently tied to social, economic, environmental, or demographic factors and can lead to unequal health outcomes among different groups within a given population. This essay analyzes the multifaceted factors influencing the health outcomes of individuals living below the poverty line across various socio-ecological levels. It will explore the various characteristics contributing to this disparity and health outcomes, such as limited access to healthcare, inadequate nutrition, exposure to environmental hazards, and elevated stress levels. Additionally, it will delve into the social determinants of health that play a crucial role in shaping health outcomes, such as education, employment, and social support. Finally, it will discuss how organizations such as the Family Healthcare Foundation and Florida Voices for Health are pivotal catalysts in addressing healthcare disparities through advocacy, community engagement, policy initiatives, and resource
allocation. These organizations actively work to dismantle barriers to healthcare access, advocate
for policy changes, and enhance health equity for underserved populations. By analyzing these factors, this essay aims to comprehensively understand the complex interplay between poverty and health outcomes and shed light on potential solutions to this pressing issue.
Overview of the Health Disparity
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People living in poverty are more susceptible to negative health outcomes due to inequitable socio-economic determinants such as unstable housing, food insecurity, lack of access to basic healthcare and preventive care, education, and countless other individual hindrances to healthy living. Impoverished people are disproportionately affected by these health
determinants because of socio-economic barriers that prevent basic tools of life sustainability from being easily accessible to the underprivileged in the United States. It is inequitable to deny people basic care based on their social or economic class. Without consideration of any other factors, people below the poverty line are already more likely to be unhealthier than privileged people because their stress levels are greater than average which makes them prone to mental health issues, obesity, and drug usage (Cunningham, 2018). The stress faced by this population can be partially accredited to a sense of insecurity caused by a lack of stability in low-income jobs, unsafe neighborhoods, and food security (2018). Impoverished people are more likely to struggle with obesity because fast food is more accessible and cheap than nutritious food. Also it is difficult for poorer people living in food deserts to seek out affordable healthy foods without reliable transportation. Low-income housing
is associated with crime and violence which causes a feeling of distrust among the residents and breeds anxiety. Low-income jobs commonly have a high turnover rate and inconsistent hours. These high stress factors cultivate an unhealthy environment for the mental health of people living in poverty. Poverty is a nuanced health disparity with a wide spread of repercussions that seep from an economic vulnerability and hinder the health and social standing of those inflicted. It is important and necessary for the healthcare system to aid the 37.9 million people facing the health consequences of poverty to improve the overall health and wellness of the nation (US Census Bureau, 2023).
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According to the Florida Department of Health, nearly 70% of adults had a medical check up in 2010 (2021). In current times, the number of adults who had at least one medical check up rose to nearly 80% in 2021(2021). Despite the rising rate of medical checkups among adults, in a poll conducted by the Florida Health Justice Project, over half of participating Floridans are worried about healthcare bills in 2019 (Yager, 2019). If healthcare is unaffordable, it is less likely to be utilized, and preventive care becomes especially underutilized. Preventive care is an indicator of the quality care of a state and greatly reduces the number of negative health outcomes; the faster a health issue is identified, the sooner it can be rectified. Unfortunately, 20% of Floridans do not even complete necessary medical procedures or get their prescriptions filled, even if they attend a medical check up (2019). If low-income households go to medical check-ups but do not acquire additional, prescribed medical assistance, their health outcomes remain negative. A high rate of medical check ups among adults is a step in the right direction but inconsequential if patients can not even treat their identified problems. Poverty is a health disparity that can strike any population if healthcare aid is not in place. However, it is important to consider intersectionality in any nuanced conversation. Over half of the uninsured people accounted for in Florida are people of color (2019). Ethnic and racial minorities who live in poverty are the most impacted by this health inequity. In addition, people living with disabilities without insurance lack access to costly accommodations and aid. These minorities must be especially considered in future plans to minimize the effects of poverty
on Florida health outcomes. Selected Population
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The selected population is the people living in the United States who live below the poverty line. An individual is considered impoverished if their income is below $12,880. As of 2022, the poverty rate in the U.S. was 11.5 percent which amounts to 37.9 million people who live in poverty. (Shrider & Creamer, 2023). The problem is that because of the limited resources of those who live in poverty they often do not have adequate access to healthcare, with also a disparity between those of different gender, race, and ethnicity. The population might not have the transportation to go to hospitals, not have a hospital nearby, and not being able to afford treatment due to not having healthcare. Those who live in poverty also are much more likely to not have stable housing, healthy foods, and safe neighborhoods, which limit their educational and employment opportunities causing the cycle of poverty to repeat. (
Poverty
, n.d.). The impact
of such factors is that those in poverty suffer more from the consequences of diseases. Poverty at the county level was associated with mortality for certain chronic conditions such as heart disease, liver disease, and kidney disease. (Moore & Witting, 2023). In infectious diseases such as Covid-19, those in poverty are more likely to be infected, suffer larger effects from the symptoms, and have a higher mortality rate.
Some health organizations that deal with poverty and health include: the Family Healthcare Foundation and the Florida Voices for Health. The Family Healthcare Foundation is a
local health organization that covers the Tampa Bay Area. The services they provide since 1998 are to ensure access to high-quality care for those in Tampa by enrolling residents into healthcare
coverage programs, improving healthcare literacy, and mobilizing community partners to support
collective knowledge. (
About Us
, n.d.). The foundation helps underprivileged people get access to healthcare and reduces health disparities in the area. The state organization, Florida Voices for
Health works to create a healthcare system for Floridians using a coalition of community
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organizations, businesses, and individuals. (
Florida voices for health
, n.d.). They represent low to moderate income Floridians in the political health reform debate as well as bringing resources and information to communities in the state.
Many factors can influence the socioeconomic status of people in the nation. Those who grow up in less affluent neighborhoods are more likely to be victims of crime and develop physical and mental health issues. There’s a greater chance compared to the higher classes that those living in poverty won’t have good access to healthcare and education. A lack of education or a degree makes it more likely to not get a higher paying job, which prevents people from improving their situation. The two root causes of health inequities between those living in poverty and those who aren’t are the intrapersonal, interpersonal, institutional, and systemic mechanisms that organize the distribution of power and resources across different groups, and the more fundamental root cause which is the unequal allocation of power and resources which manifest in unequal social, economic, and environmental conditions. (“The root cause of health inequity”, 2017). Amongst those who are living below the poverty line, those who are African American, Hispanic, women, or immigrants experience greater disparities. Discriminatory practices, higher rates of poverty, and lack of support for these groups References
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Shrider, E. A., & Creamer, J. (2023, September 12). Poverty in the United States: 2022
. Census.gov. https://www.census.gov/library/publications/2023/demo/p60-280.html
Poverty
. Poverty - Healthy People 2030. (n.d.). https://health.gov/healthypeople/priority-
areas/social-determinants-health/literature-summaries/poverty
The root causes of health inequity - communities in action - NCBI bookshelf. (2017, January 11). https://www.ncbi.nlm.nih.gov/books/NBK425845/
Moore, B., & Witting, L. (2023, January 20). Limited access: Poverty and barriers to accessible health care
. National Health Council. https://nationalhealthcouncil.org/blog/limited-access-poverty-and-barriers-to-
accessible-health-care/#:~:text=People%20who%20live%20in%20poverty,liver
%20disease%2C%20and%20kidney%20disease.
About Us
. The Family Healthcare Foundation. (n.d.). https://familyhealthcarefdn.org/about-us/
Florida voices for health: Who we are
. FL Voices for Health. (n.d.). https://www.healthyfla.org/aboutus Evidence Based Practices/Policies
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Healthy People 2030 includes many different approaches to improving health that include
reducing the proportion of people who are unable to get their prescriptions (Office of Disease Prevention and Health Promotion, n.d. -b) as well as reducing the proportion of people who cannot access medical services when it’s needed (Office of Disease Prevention and Health Promotion, n.d. -a). Regarding prescription medications being difficult to access, the Healthy People 2030 goal notes that income is a major factor in terms of access to prescription medications as their costs being too high are often what leads to difficulty accessing them (Office of Disease Prevention and Health Promotion, n.d. -b). Since the goal was introduced in 2019, the proportion of people below the poverty line who were unable to obtain or had to delay obtaining prescription medications went from 10.8% down to 7.4% in 2021, so the policy seems to be working quite effectively (Office of Disease Prevention and Health Promotion, n.d. -b). The Florida-based group Florida Voices for Health also aims to address this difficulty by advocating for Medicaid expansion in Florida that would additionally cover as many as 500,000 Floridians that are living below the poverty line making prescription drugs much more affordable
for them (Florida Voices for Health, n.d.).
In terms of access to medical care, Healthy People 2030 also aims to address this disparity in the same way as prescription drug access, by cost (Office of Disease Prevention and Health Promotion, n.d. -a). Similarly to prescription drug access, limited or no access to medical services access has also dropped significantly for those living below the poverty line. In 2019 the
percentage of people who couldn’t afford or delayed receiving care was 13.4%, and in 2021 the percentage has dropped down to 9.8% (Office of Disease Prevention and Health Promotion, n.d. -a). Another Florida-based group aiming to assist in getting those in need access to healthcare services is The Family Healthcare Foundation who have many goals for helping Floridians, but
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two in particular that help those below the poverty line are their “The Covering Tampa Bay Coalition” and “Certified Marketplace Navigators” (Family Healthcare Foundation, n.d.). These two programs aim to connect people in Tampa Bay with services and insurers with up-to-date information on plans and services as well as having marketplace navigators available to help identify which plans best suit individuals and which services would be most convenient and accessible to them (Family Healthcare Foundation, n.d.). Since so many instances of delayed or not seeking care seem to be due to the cost being too high,
both of these Health People 2030 objectives seem to be very strong in their evidence-based approach. Both objectives also have great numerical data sets to back up their efficacy in tackling costs of healthcare services and prescription drugs. The two chosen organizations are also doing great work in Florida as a whole and in Tampa Bay to ensure that those below the poverty line have better access to healthcare services that are both effective and affordable.
References
Cunningham, P. J. (2018, September 27). Why Even Healthy Low-Income People Have Greater Health Risks Than Higher-Income People
. Commonwealth Fund. https://www.commonwealthfund.org/blog/2018/healthy-low-income-people-greater-
health-risks
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Family Healthcare Foundation. (n.d.). Our programs
. Programs | The Family Healthcare Foundation. https://familyhealthcarefdn.org/programs/ Florida Department of Health. (2021). Health comparison profile | charts - flhealthcharts.gov
. Health Comparison Profile. https://www.flhealthcharts.gov/ChartsDashboards/rdPage.aspx?
rdReport=HealthComparison.Report
Florida Voices for Health. (n.d.). Strengthening Medicaid
. Florida Voices for Health | Strengthening Medicaid. https://www.healthyfla.org/medicaid Office of Disease Prevention and Health Promotion. (n.d.-a). Reduce the proportion of people who can’t get medical care when they need it - AHS-04 data
. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/health-
care-access-and-quality/reduce-proportion-people-who-cant-get-medical-care-when-
they-need-it-ahs-04/data?tab=data-table#data-table
Office of Disease Prevention and Health Promotion. (n.d.-b). Reduce the proportion of people who can’t get prescription medicines when they need them - AHS-06 data
. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-
objectives/health-care-access-and-quality/reduce-proportion-people-who-cant-get-
prescription-medicines-when-they-need-them-ahs-06/data?tab=data-table#data-table
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US Census Bureau. (2022, December 20). National Poverty in America Awareness Month: January 2023
. Census.gov. https://www.census.gov/newsroom/stories/poverty-awareness-
month.html Yager, A. (2019). Connecting the dots
. Florida Health Justice Project. https://www.floridahealthjustice.org/connecting-the-dots.html#:~:text=A
%202019%20survey%20of%20over,affording%20healthcare%20in%20the%20future.
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Proposed Creative Solution
People living below the poverty line seek out resources that claim to provide adequate assistance. However, the waiting time and requirements that must be met to actually receive help
and assistance from certain programs defeats their purpose. Majority of the issues in these programs come from a lack of sufficient funding, coordination with government agencies, and the overestimation or underestimation of the resources that are needed to provide for people living below the poverty line. Additionally, the complex application processes and criteria for eligibility discourages those below the poverty line to continue to seek assistance.
One of the organizations mentioned in this paper that actively seeks to eliminate issues for those with limited access to healthcare and those living below the poverty line, Florida Voices for Health, touches on policies that must be done to increase access to resources to meet basic needs. One of the populations that the Florida Voices for Health works with to push through policy recommendations are individuals with developmental and intellectual disabilities.
According to Alice in Focus, 55% of people with disabilities in Central Florida are living in financial hardship (Alice in Focus, 2022). This means that while 15% of Central Florida Residents living with disabilities are considered to be below the poverty line, 40% more of residents are considered to be “ALICE”, meaning asset limited and income constrained meaning making less than what it costs to survive in the economy.
Furthermore, 500,000 Floridians living in poverty struggle with the extremely restrictive Medicaid program, which is considered to be one of the most restrictive in the US (Florida Voices for Health). Just like residents living with disabilities below the poverty line, the waiting list for the Medicaid HCBS can be as long as a decade. Currently, there are over 22,000 people
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on the waiting list according to Florida Voices for Health. Such waiting lists discourage residents
from utilizing these resources and make it extremely difficult to those who struggle to provide for themselves on a daily basis. Florida Voices for Health encourages the removal of these waitlists by funding as well as the creation of an accurate budget.
A solution for the major delay in assistance to individuals living below the poverty line is
the ultimate removal of the waiting list for the Medicaid HCBS waiver, or the very least, lowering the waiting time. Many residents experience life events which force them into poverty suddenly with no time to adjust. However, just like all other individuals living below the poverty line, they must go through the Medicaid waiver waitlist which forces them to wait an average of 7 years. A main change that would change the disadvantages of such a waitlist, is increasing funding for emergency cases especially for those that are critically below the poverty line. Of course, this funding must come from increasing taxes or allocating proper funding. A majority of
the time, accurate budgets for Medicaid HCBS are not created fairly. These budgets and funding allocations are made with severe limits, covering the bare minimum (ASPE, 1994). These proposed budgets go through a review by other political processes, which further limit the budget
decision. As suggested by the Florida Voices for Health, allowing proper agencies to contribute in forming and defending budgets, such as the Agency for Persons with Disabilities, would allow
for the discussion of a proper budget which fits the needs of individuals at the target of such agencies. Budgets which are suggested and officially formed for the HCBS are currently not formed based on the needs of the people which need to be served, and are a general estimation. They are not created with the consideration and careful analysis of the people that HCBS serves. Allowing proper and more carefully structured funding through the contribution of appropriate agencies and limited external political interference could contribute to more fitting funding for
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Floridians relying on the HCBS program, Exposure and awareness of the specific needs of Floridians living below the poverty line may increase the likelihood of appropriate funding to meet the needs of residents.
Another pressing issue is the application process for individuals living below the poverty line. The complex process requires extensive paperwork with proof of several components. In a study by Stuber et al, they found that 80% of respondents who applied or attempted to apply for Medicaid found some problem associated with the application process, with 50% of people reporting stigma-related problems The process of seeking healthcare assistance should not be intimidating or discouraging. It is important that people below the poverty line that seek out the help of Medicaid and other programs do not feel like they will be mistreated once they are enrolled. This is an unfair and avoidable feature of Medicaid application which discourages applicants from applying or leads to fear that they will not be helped once enrolled. For individuals living below the poverty line with disabilities, filling out such applications can be extremely difficult especially for those that lack assistance personnel. Applications for programs for those living below the poverty line should give individuals hope that they will be helped. However, due to the long wait times, extensive application processes, and inappropriate funding, individuals living below the poverty line cannot be confident in these programs.
These solutions are aimed at the public policy and community levels of the SEM model. In order
to encourage support for policies, each community should continue to share stories of the inequities of programs for those living below the poverty line in order to contribute to the overall
societal awareness. Through continued awareness, policy recommendations can become a reality
and eliminate the effects of the health inequities of programs for those living below the poverty line. However, these solutions must start as a community effort.
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References
1.
Alice in Focus: New Research reveals 55% of people with disabilities in Central Florida are living in financial hardship
. United Way. (2022, July 26). https://www.hfuw.org/aliceinfocuspwd/
2.
An Examination of Issues Related to How HCBS Programs Operate Within Fixed Budgets and to the Administrative Linkages Between Eligibility Determination, Needs Assessment and Care Planning Functions
. (1994, November 30). ASPE. https://aspe.hhs.gov/reports/examination-issues-related-how-hcbs-programs-operate-
within-fixed-budgets-administrative-linkages-0#summary
3.
Stuber, J., Maloy, K., Rosenbaum, S., & Jones, K. (n.d.). The George Washington University Health Sciences Research Commons Health Policy and Management Issue Briefs Health Policy and Management
. https://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?
referer=&httpsredir=1&article=1052&context=sphhs_policy_briefs#:~:text=In%20terms
%20of%20application%2Drelated
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