Hospitals in Texas serving some of the most vulnerable populations are expected to do more with less

Hospitals have the opportunity to play a significant role in addressing inequities in the communities they serve. This is particularly true in Texas, a state that exhibits some of the starkest disparities in health care coverage and access and other socioeconomic outcomes. But Texas hospitals serving some of the most vulnerable groups may be less capable of investing in the unmet needs of their patient populations, due to limited resources.

Hospitals serve as anchor institutions: they remain in place, even as conditions around them change, and have long-term, deeply-rooted investments in the communities they serve. This positions hospitals to understand and address the factors in the community that shape people’s health — the conditions in which people are born, grow, live and work — in addition to serving patients’ direct health needs.

Unequal access to employment, housing, education and social integration and support systems can deepen health inequities. For example, people who are chronically homeless experience higher morbidity and increased mortality. And beyond facing poorer health, unstable housing, such as moving frequently or falling behind on rent, can result in disruptions to employment and the receipt of social service benefits, among other adverse outcomes.

By leveraging their central role in their communities, hospitals can play an important role in intervening in some of these upstream challenges. For example, hospitals can connect patients with resources outside of the health system, like housing advocacy organizations and employment agencies.

In Texas, the need for this type of engagement is particularly acute.

Texans face more problems related to social and economic factors than people elsewhere in the nation. Among the 50 states, Texas ranks sixth in food insecurity and seventh in income inequality. The state has also invested significantly less in its  social safety net programs. For example, despite overwhelming public support for expansion, Texas is among the 11 states that have not expanded their Medicaid programs. About one in five residents lack health insurance — the highest uninsured rate in the country. Nearly three in ten people in the state report having no usual source of medical care, and almost half report affordability challenges.

Hospitals in Texas — especially those serving some of the state’s most vulnerable populations — could play a particularly important role in addressing these pressing needs. But a recent study from our Harvard research team suggests that they may not be equipped to do so.

In our study, we took a look at what hospitals serving people with more need (like rural hospitals, critical access hospitals, and safety-net hospitals) are doing to address community drivers of health. We found that, across the country, these hospitals aren’t playing as big of a role as one would expect. They aren’t asking patients about whether they experience problems like housing and food insecurity any more than hospitals expected to serve less vulnerable patients (like urban hospitals, non-critical access hospitals, and non-safety net hospitals). They also aren’t implementing more programs or interventions targeting social needs; in some cases, they’re actually doing less. These hospitals also have fewer partnerships with community organizations that focus on these areas compared to hospitals not specifically serving vulnerable populations.

Texas is no better than average on these measures; what’s happening in the state largely mirrors what’s happening at the national level. And, on one of the measures we looked at (number of community partnerships), Texas is actually worse than average when compared to the rest of the country.

Addressing what makes us healthy should be a priority for all hospitals, especially in Texas. But hospitals serving patients with greater need oftentimes lack funding to even provide sufficient medical care to meet the needs of their communities. More attention has been devoted to easing financial pressure on hospitals at the federal level; pandemic relief legislation has provided enhanced financial support for hospitals, with an eye towards hospitals that provide care to underserved groups.

But more needs to be done at the state level. Last year, the Texas House passed a bill to establish an Office of Health Equity. Among other things, this office would’ve studied health outcomes in rural and underserved parts of the state; this work could’ve helped policymakers identify regions with higher need. This bill died in the Senate, taking a back seat to other issues.  But just because attention waned doesn’t mean the need hasn’t. Allocating resources to high-need hospitals should be a priority for the state; increased funding would significantly help these hospitals address their patients’ needs. The state’s inattention to the factors that give rise to poor health is a missed opportunity.

Research for this piece was supported by the Episcopal Health Foundation.

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