Poverty has long been associated with frequent ED use, so could moving low-income families from high-poverty areas to low-poverty ones with better resources reduce ED visits in this population? Not according to a new study.
The study by Craig E. Pollack, MD, an associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, leveraged the Moving to Opportunity for Fair Housing Demonstration program that began in 1994 by the Department of Housing and Urban Development. (Health Aff [Millwood]. 2019;38:1442; http://bit.ly/32UPtuw.) This social experiment randomized 4600 households that received federal housing assistance to a control group, a group that received traditional Section 8 vouchers without restrictions on where the recipients could lease a house, and a group with vouchers that required them to leave low-poverty neighborhoods, and then examined how environments affect low-income people living in government-sponsored housing in Baltimore, Boston, Chicago, Los Angeles, and New York City.
Dr. Pollack and his colleagues hypothesized that decreased exposure to neighborhood poverty lowers rates of emergency department use. They used all-payer data for California from 2005 to 2015 and those for New York from 2003 to 2015 to identify ED visits. They also used Medicaid data for California, Illinois, Maryland, and New York to supplement information on emergency department use in different years.
They first compared the two voucher groups, but found no difference in ED use. The researchers then combined the voucher groups and compared them with the controls, finding little difference in ED use: 0.518 visits per year for the voucher groups v. 0.555 visits for the control group. (Health Aff [Millwood]. 2019;38:1442; http://bit.ly/32UPtuw.)
“We didn't find the relationship we anticipated,” Dr. Pollack said. “There did not seem to be a strong relationship between neighborhood poverty levels and emergency department use.”
The results could partly be explained by the fact that many factors changed over the years. “The control group was not locked in place,” Dr. Pollack said. “Many relocated for varying reasons.” Other factors include the location of health care facilities and the long history of segregation in poor neighborhoods that has contributed to emergency department use. This is often because other facilities are not available or because doctors' offices and clinics are not open.
Ellen Weber, MD, a professor emeritus of emergency medicine at the University of California San Francisco, acknowledged the importance of Dr. Pollack's work, but pointed out that his study did not look at patients who were frequent users of the emergency department or consider individual emergency department use.
“You just can't put someone who is poor in a good neighborhood and expect to have good outcomes,” she said. “You see poorer health in poor people. Putting them in a nicer neighborhood may improve access to care, but if they don't have insurance and are using county resources, they are more likely to go back to their old neighborhood.”
It's also unclear if there was improved access to care in the new neighborhood, Dr. Weber said. “There are so many factors to consider beyond the issue of where you live,” she said.
Insurance could be part of it, said Dr. Weber. Uninsured and low-income people are reluctant to go to the emergency department, but insurance gives them access to the health care system. “People afraid of the bills do not go,” she said. “Delayed care creates a backlog of illness. Then people end up in the emergency department or worse. The poor are actually lower utilizers of emergency care.”
Dr. Weber was the co-author of a population-based study looking at the characteristics of frequent emergency department users. Using the 2000-2001 population-based, nationally representative Community Tracking Study Household Survey, they found that 33 percent of frequent users had family incomes below the federal poverty level, while 16 percent were at or above 400 percent of the federal poverty level. (Ann Emerg Med. 2006;48:1; http://bit.ly/37l1YCX.) The absolute number of frequent users who were poor, lacked a usual source of care, or were uninsured was small relative to the number of less frequent users with similar characteristics. Ninety-two percent made three or fewer visits while eight percent made four or more. Those who made four or more visits accounted for 28 percent of all ED visits.
Many of the frequent users had poor health, poor mental health, at least five outpatient visits in the study period, and an income below the poverty level. Eighty-four percent of frequent users had health insurance, and 81 percent had a usual source of care. While those uninsured were more likely to report frequent ED use, the difference compared with the insured was minimal.
Only a Social Marker
Dr. Weber, the editor-in-chief of the Emergency Medicine Journal published in England, said they see there, as in the United States, what they call deprivation postal codes. “They don't do as well,” she said. “They have worse health status, even in a situation where people can get care. Neighborhood is not the improving factor. It's a marker of economic status.”
Poor neighborhood could have good social care and county services, but other things contribute to poor health, said Dr. Weber. “What do they eat? Do they exercise? All the things that contribute to health are not fixed by better resources in a neighborhood.”
People in both countries also often work two or three jobs. “They can't get off in the day to go to the doctor,” she said. “None of these things get fixed by changing the neighborhood.”
While some people are reluctant to go to the emergency department because of the long wait, others trust it. “People want to go to the emergency department because they feel they will get a thorough examination,” Dr. Weber said. “It's still better to have a PCP who will follow you rather than go to the emergency department where they will have to do many tests right away.”
Dr. Pollack and his authors concluded that the effects of the Moving to Opportunity for Fair Housing Demonstration Program on health outcomes were mixed, with relatively few statistically significant health impacts across a range of outcomes. “The impacts that we do observe for adults involve some of the most important health outcomes—specifically, obesity and diabetes—and as such speak to the potential public health importance of these findings,” he said.
Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.