Poverty

In Minnesota, as in the rest of the US and the world, people living in poverty suffer from worse health and receive inferior health care when compared to people with higher incomes. Poverty contributes to poor health and poor health often results in poverty. The Minnesota Department of Health provides the following insights into how income affects health in Minnesota:

• Those living in poverty report that their health is fair or poor. 26.8 percent of individuals who earned less than $20,000 a year reported their general health to be fair or poor, compared to 3.1 percent who earned $75,000 or more.
• 67.9 percent of pregnant women who earn less than $10,000 a year received adequate or intensive prenatal care, compared to 88.2 percent of pregnant women with annual incomes of $50,000 or higher.
• People with low incomes are more likely to have an infant die in the first year of life.
• Having a low income or socioeconomic status in childhood or mid-life can be associated with developing diabetes. Working-age adults (18 to 64) who live in households earning less than $35,000 a year are two-and-a-half times as likely to report having diabetes as those with incomes higher than $35,000. In Minnesota, more than one in three working-age adults living with diabetes is not working.

Obstacles such as financial barriers, less access to employer-sponsored coverage, time required to gather necessary documentation, and navigating complex enrollment processes all contribute to a higher uninsured rate for Minnesotans with low incomes than people at any other income level.

Poverty is intertwined with other social determinants of health. A lack of financial resources can reduce access to healthy food, safe housing, educational attainment, and medical care.

• In 2014, a quarter of adults that had not completed high school were living in poverty, compared to less than 10 percent of Minnesotans that either attended or completed college. The prevalence of poverty decreases for Minnesotans with higher levels of education.
• Adults in Minnesota most often report leaving their last housing due to inability to afford rent or mortgage (36%), and 22 percent report there is no affordable housing available. 41 percent of adults in Minnesota experience homelessness are on a waiting list for subsidized housing, and another 14 percent can’t get on a wait list because it is closed.
• More than 9,300 adults, youth, and children were counted as living in homelessness in a 2015 one-day statewide survey. Young people are most at risk of experiencing homelessness.

Financial constraints often mean people living in poverty consume a diet based on inexpensive fast food restaurant offerings and processed foods, both of which are high in carbohydrates, sweeteners, and salt. Often called the “American diet,” this way of eating contributes to obesity, heart disease, and other health conditions. Although second lowest among all states, 10.3 percent of Minnesota households reported having a food hardship—not having enough money to buy food in the last year. Greater challenges were reported for households with children.

About 16 percent of Minnesota’s census areas are federally designated food deserts—areas with a high proportion of residents who live far from a full-service grocery store and a high proportion of residents who have a low- to moderate-income. Price is the most significant barrier to healthy food consumption for households with low- to moderate-income. Lack of transportation compounds the problem.

Hunger and food insecurity (i.e., reduced food intake and disrupted eating patterns due to a lack of household income and other resources for food) might increase the risk for lower diet quality and undernutrition. In turn, undernutrition can negatively affect overall health, cognitive development, and school performance.

Additional challenges can include lack of time and culinary literacy—knowledge about healthy food choices and cooking skills—and lack of access to storage and preparation supplies, especially for people who are experiencing homelessness.

• Screen and Intervene: A Toolkit for Pediatricians to Address Food Insecurity. Explore this toolkit to learn more about how pediatricians can play a critical role in addressing food insecurity. Food Research and Action Center and the American Academy of Pediatrics, January 2021.
• Individual, Household, and Environmental Factors Affecting Food Choices and Access. Describes the challenges to improving food security and access to a healthy diet for the Supplemental Nutrition Assistance Program (SNAP). Food and Nutrition Board. National Academy of Sciences, April 2013.

Research indicates that poverty-related concerns, like unstable housing conditions and food insecurity, create mental and emotional strain that can leave people living in poverty with limited capacity to do many of the things that might lift them out of poverty. In the absence of protective factors, the stress of poverty on children can result in emotional disorders and cognitive deficits.

• Adults aged 26 or older living below the poverty line were more likely to experience serious mental illness than those living at and above the poverty line (7.5% vs. 4.1 and 3.1%, respectively).
• Approximately 30 percent of people experiencing chronic homelessness have a serious mental illness, and about two-thirds have a primary substance use disorder or other chronic health condition.
• 16.3 percent of 9th grade students who receive free or reduced-priced lunch (proxy measure for income) reported having seriously considered suicide in the past year, compared to 10.6 percent of 9th graders who do not receive free or reduced-priced lunch.

Lower socio-economic status has been associated with less utilization of preventative and early detection services, which may prevent or mitigate the effects of potentially terminal illnesses. People with lower socio-economic status are at increased risk of being diagnosed with late-stage cancers compared to people with higher socio-economic status.

People with higher incomes live longer. For example, Minnesotans who live in Twin Cities’ zip codes with the highest median household income live an average of eight years longer than those who live in zip codes with the lowest median household income. The mortality rate for people living in chronic homelessness is four-to-nine times higher than for the general population.

Lower socio-economic status appears to be associated with less utilization of quality-of-life sustaining programs like palliative care and hospice.

• End Life Care, National Health Care for the Homeless Council. This webpage offers resources for advance care planning and patient-centered care for the homeless.

The American Academy of Family Physicians offers these recommendations for health care providers who see patients living in poverty:

• Practice cultural proficiency
  Create a welcoming, nonjudgmental environment that supports a long-standing therapeutic relationship built on trust. Avoid shaming for non-compliance, and make sure you understand issues like adequate housing, affording medication, on-demand transportation, accommodating work schedules, childcare challenges, and low health literacy.
• Screen for socioeconomic challenges
  Screen to identify a patient’s socioeconomic challenges, like you would for other disease risk factors. Crowding, infestations, and lack of utilities are all risk factors for disease. Knowing that a patient is experiencing homelessness or has poor quality, inadequate housing will help guide care.
• Make a realistic plan of action
  Many patients with low incomes will not have the resources to comply with an ideal treatment plan. Formulating a plan that makes sense in the context of the patient’s life circumstances is vital to success. Remember, the “best” medication for a patient with a low income is the one that the patient can afford and self-administer reliably.
• Help newly insured patients navigate the health care system
  A newly insured individual may not know how to navigate appointments or obtain referrals. Try to ensure all patients in the practice know where to pick up medication, how to take it and why, when to return for a follow-up visit and why, and how to follow their treatment plan from one appointment to the next. Without this guidance, patients may seek crisis-driven care, often from the local emergency department.
• Provide material support to families with low incomes
  Check for resources to support housing, transportation, reduced cost medicines, low-cost childcare, food support, etc. and tell your patients about these resources.
• Advocate on behalf of low-income neighborhoods and communities
  Family physicians are community leaders and can advocate effectively for initiatives that improve the quality of life in low-income neighborhoods.

• Food Insecurity And Health Outcomes. This paper examines research evidence of the health consequences of food insecurity in the U.S. and provides an overview of how food insecurity is measured in the country, followed by a presentation of trends in the prevalence of food insecurity. Health Affairs, 2015.
• Social Needs Screening Toolkit. This Health Leads resource shares the latest research on how to screen patients for social needs, 2016.