*Patient name has been changed

Millions of Americans are expected to lose health insurance coverage with the end of the pandemic protections on health insurance enrollment, and hundreds of thousands already have. While much of the discussion has been rightfully centered around how to minimize losses in health insurance coverage, we must also consider last-mile challenges that affect access to healthcare.

Patients can struggle to obtain access to healthcare because of issues beyond insurance. The social, environmental, and economic factors that shape our lives, known as upstream drivers of health, often impede access to healthcare for many disenfranchised communities, including those with health insurance.

Take, for example, a young patient of ours, Rachel*, who received health insurance through Medicaid. As a mother of three, Rachel frequently juggled work and childcare responsibilities. When she was diagnosed with a brain tumor, Rachel missed multiple neurosurgery appointments due to her inability to find affordable and reliable childcare. Ultimately, her condition may worsen because of these delays.

Rachel is not alone. As we’ve written before, a lack of safe, reliable childcare can force patients to make unimaginable tradeoffs. In addition, access to childcare also has long-term health benefits for children, including improved cardiovascular and metabolic outcomes, as well as lower smoking rates. While having more affordable health insurance may result in savings for people like Rachel, the ongoing childcare crisis is driven by workforce shortages and a dearth of childcare centers in many areas may only exacerbate a lack of access to care.

Transportation barriers also commonly prevent patients from accessing healthcare. One of our mental health patients, Earl*, lives in a rural homeless shelter. He told us he could not follow up with his primary care provider because he lacked transportation options; instead, he had to be taken to the emergency department.

Scenarios like Earl’s are common. Studies estimate that 3.6 million people annually in the US are unable to access medical care due to transportation-related barriers. A study on Medicare patients with cancer found that patients who had to travel more than an hour for medical care had hospitalization rates that were 4-13% higher. Additionally, their out-of-pocket costs for care were 10% higher compared to those who traveled half an hour or less.

Living in a medical desert, where doctors are few and far between, also impedes access to healthcare. Nearly 84 million Americans live in a primary care Health Professional Shortage Area (HPSA), making it difficult to see a doctor even when insured. The shortage of outpatient mental health providers has led to overcrowded emergency departments, creating barriers to emergency care. Unsurprisingly, physician shortages are concentrated in poor and rural communities.

Having robust “provider networks” is critical to ensure that health insurance offers meaningful access to care. Recent investigations and research have highlighted that doctors who are purportedly covered under certain insurance plans are often unavailable to people with those plans for other reasons, including not accepting new patients, or in some cases, not practicing at all due to retirement or death.

While there is no easy solution to these barriers, each of them can be improved. Congress can expand the supply of childcare centers by significantly increasing funding for the Child Care and Development Block Grant (CCDBG) program. States have used these funds to provide generous childcare subsidies to families, recruit and provide financial bonuses to staff, and adjust reimbursement rates to childcare providers to reflect higher costs of operation — yet only 1 in 9 eligible children received these subsidies in practice. Though childcare was left out of the Inflation Reduction Act, bipartisan support led to historic investment in CCDBG in 2018, offering hope for a divided Congress.

On the public transportation front, Congress can build on its Bipartisan Infrastructure Law, which provides funding to advance equitable transportation planning and operations, by ensuring that states have the needed data infrastructure to connect people with transportation resources. When it comes to medical deserts, greater oversight of provider networks and expansion of federal programs that incentivize doctors to practice in medically underserved areas, such as the bipartisan Conrad 30 Waiver Program, should also be considered.

Writing, passing, and enacting policies that target upstream drivers of health to improve healthcare access may be palatable to Democrats and Republicans under a divided Congress. The recently created Congressional Social Determinants of Health Caucus, which aims to “improve health outcomes and maximize existing and future federal investments in health, food, housing, transportation, and other important drivers of health” demonstrates active, bipartisan political will to do so. Addressing these factors may ultimately do more to provide lower-income communities, including our patients, with a better chance at a healthy life.

Victor Agbafe is a candidate for dual MD and JD degrees at the University of Michigan Medical School and Yale Law School. Matt Alexander is a medical student at Virginia Commonwealth University and Master in Public Policy candidate at the Harvard Kennedy School. Jesper Ke is a third-year medical student at the University of Michigan Medical School. David Velasquez is a fourth-year medical student at Harvard Medical School.