The cost of social insecurity

People faced with financial, food and housing insecurity use more health care and in the most expensive place -- the ER. Their conditions are about to get a lot worse.

The Pitt, a new TV series on Max, dramatizes work life and patient strife in an urban hospital emergency room. Noah Wyle plays the lead ER doc, Michael “Robby” Robinavitch. Both in hunk-a-lunk looks and heroic demeanor, Wyle is an able successor to the just-passed Richard Chamberlain, who played Dr. Kildare in the 1960s, and George Clooney, who rose to fame in the 1990s playing one of the two lead physicians in the first six seasons of ER. A much younger Wyle played a medical student in that series.

This fictional Pittsburgh hospital ER is quite up to date. Its overworked docs face nurse and supply shortages. Hospital money managers meddle. And there’s an endless parade of physically and emotionally traumatized patients and staff. I was burned out after watching just two episodes.

Okay. It’s fiction and over-dramatized. But nearly every plot line reflected a contemporary reality. One lesson people can learn from watching is that the last thing the nation’s urban ERs need is an increase in patient supply.

Yet that is exactly what will happen if the Trump regime gets its way. (Note: Historian Heather Cox Richardson in her widely read Letters from an American substack has begun substituting “regime” for “administration,” which given its lawlessness is appropriate.) Already administered and planned budget cuts for housing and food subsidies, mostly used by people in the lower half of the income distribution, are all but guaranteed to increase demand for emergency room services in the years ahead.

A new study in JAMA by researchers at Kaiser Permanente found people insured by KP who were having a hard time paying bills, making rent or putting food on the table for their families were 21% more likely to use the ER than those who didn’t report such problems. Half of those insured by KP reported experiencing at least one of those issues.

Those experiencing housing instability, ranging from having trouble paying rent or the mortgage to being homeless, were the folks most likely to seek care in the ER: 31% more than those not reporting such problems. Individual assessments of social needs are routinely collected at KP (and many other health providers) for inclusion in patients’ medical records.

Everyone had health insurance in this matched cohort study of nearly 10,000 people across the eight regions where KP operates. Two-thirds were working and another quarter were retired, disabled or students. Less than a tenth were not working with many of those having caregiving responsibilities at home.

While there was a small increasing in hospitalizations among those seeking ER care, it wasn’t statistically significant. That finding suggests people facing financial difficulties, even when covered by health insurance, often skip routine care or fail to make time to visit their doctor for non-life threatening ailments. It’s only when they can’t ignore a problem that they seek care even though insured. Given the precarity of their lives, they visit the ER, often after hours when they can make time, which makes their treatment not only more intensive, but more expensive.

The authors expressed hope in their conclusion that the findings would encourage health systems to prioritize interventions that address social risk, “specifically those related to financial strain, housing instability, and food insecurity,” they wrote.

Addressing SDOH on the chopping block

Mural by Ben Shahn in the Wilbur D. Cohen Building in Washington, D.C.

Prioritizing interventions that address the so-called social determinants of health isn’t exactly what’s on the Trump regime’s agenda. They’re planning massive cuts in the Supplemental Nutrition Assistance Program by eliminating the 2021 Thrifty Food Plan, which increased benefits to meet the cost of a healthy diet. The Center for Budget and Policy Priorities estimates that will cut SNAP benefits by 22% for 41 million people.

Housing financial aid, whose 10 million beneficiaries represent just a quarter of those who qualify for assistance, is also on the chopping block. The Housing and Urban Development Department (HUD), now run by former football player and Texas Congressman Scott Turner, has announced plans to cut 50% of agency staff; terminate rules requiring communities address discriminatory zoning practices; and delay a program designed to streamline low-income housing development.

But the deep fear among housing advocates is that programs aimed at subsidizing low-and-moderate income housing will soon be slashed given the Trump regime’s close adherence to the Heritage Foundation’s Project 2025 playbook. That document’s section on housing, co-authored by previous HUD secretary Ben Carson, called for selling off public housing to private developers; sharply reducing rental assistance programs like Section 8 and the Housing Choice Voucher Program; and abandoning the Housing Trust Fund, which provides direct housing grants to very low-income households.

The current freeze in government funding under the continuing resolution already threatens to increase housing insecurity. When landlords who accept vouchers raise rents, which they do every year, the voucher’s value could remain constant. Landlords will then either raise the amount collected from their subsidized tenants or drop out of the program.

Michael D. Webb, senior policy analyst at the Public Housing Authorities Directors Association (PHADA) told Shelterforce Magazine last month that voucher programs’ guaranteed, on-time rent payment every month is “a huge draw” for landlords. “Any threat that those payments can be interrupted or delayed would result in dramatic decreases in landlords willing to participate in the voucher program. That really is the selling point,” he said.