Social Risk Factors and Desire for Assistance Among Patients Receiving Subsidized Health Care Insurance in a US-Based Integrated Delivery System

To the Editor:

We read with great interest the results of a study of 438 Kaiser Permanente members in Southern California who were on subsidized exchange health insurance plans during 2018-2019 [1]. The study assessed the prevalence of four social risks – housing instability, food insecurity, trouble paying for utilities, transportation difficulties – among the survey participants. In the study, participants were asked about their comfort with screening for social risks. Overall, a majority of them felt screening for social risks was appropriate and believed health systems should play a role in offering resources to help them address these risks. However, participants with social risks reported more discomfort with screening than those participants who reported no such risks (14.2% versus 5.4%); non-Hispanic Blacks also had more discomfort with screening than non-Hispanic Whites. In general, study findings were consistent with prior research [2,3], and the research to characterize the burden of social risks in this subgroup was relatively novel, adding some value to the evidence base.
As illustrated by this study, screening for social risk factors and addressing them is a complex process. For example, the higher discomfort with screening among participants with social risks versus participants without such risks suggests that experiences of stigma [4,5] and distrust with large systems (e.g., government, healthcare, social services) were prevalent in this lower income population. The impact of these experiences will not be easy to overcome.
Given Kaiser Permanente’s reputation as an industry leader in healthcare, the present study is a welcomed contribution to practice, as it further raises awareness about this public health problem. This increased awareness could be leveraged to advocate for more upstream actions by federal, state, and local governments, as policy interventions that align funding and infrastructure to support cross-sector coordination of care and community resources will be needed to address these social risks. In addition, further research on the circumstances under which people will accept help should be conducted. Results from such studies will be invaluable to policymakers and health systems alike, as they design interventions that can better mitigate these risks and the root causes that drive them [3,5].

Tony Kuo, MD, MSHS
Department of Family Medicine, David Geffen School of Medicine at UCLA
Department of Epidemiology, UCLA Fielding School of Public Health
Population Health Program, UCLA Clinical and Translational Science Institute

Noel Barragan, MPH, MBA
Department of Public Health, County of Los Angeles
 
References
1. Tuzzio et al. Ann Fam Med. 2022;20(2):137-144. https://doi.org/10.1370/afm.2774
2. Steeves-Reece et al. Am J Prev Med. 2022;62(5):e303-e315. https://doi.org/10.1016/j.amepre.2021.12.002
3. Kreuter et al. Annu Rev Public Health. 2021;42:329-344. https://doi.org/10.1146/annurev-publhealth-090419-102204
4. Keene et al. Am J Public Health. 2015;105(5):1008-1012. https://doi.org/10.2105/AJPH.2014.302400
5. Grub et al. J Am Board Fam Med. 2021;34(5):914-924. https://doi.org/10.3122/jabfm.2021.05.210069