International and Domestic Health Equity and Leadership (IDHEAL) UCLA Emergency Medicine

Social Emergency Medicine Teaching Modules
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Financial Strain/Instability
Module 18
Dennis Hsieh, MD, JD


1. To understand the breadth of income support programs that exist for patients.

2. To understand how a lack of income affects health.

3. To learn how to help patients advocate for income support.


A 32-year-old woman comes into the ED with chief complaint of palpitations and chest pain. She has no past medical history and no past surgical history. This has never happened before. She has no leg swelling, no family or personal history of blood clots, no recent long trips, and no hemoptysis. Her vital signs are BP of 120/80, HR of 70, RR of 16, an oxygen saturation of 100% on room air with a temperature of 98.6°F. Her exam is unremarkable and her EKG is normal. She also has a negative urine pregnancy test and her chest x-ray is not concerning.

Upon further questioning, patient said this started after she got a notice from her power company that her electricity was going to be cut off because she is behind on her payments. She has 2 children and so it is difficult to work full time. They have not had enough to eat for the past two weeks since her savings ran out. She is also worried she may lose her housing if she cannot find money to pay the rent. Her phone has been shut off because she has not been able to pay the bills.

You call the social worker to talk with the patient. She educates the patient about cash aid, food stamps, utility assistance for gas and electric, and lifeline. Furthermore, they tell the patient that she can get emergency cash aid to help with the rent as well.

Discussion Questions

1. Why did this patient come to the emergency department?

2. How does financial insecurity affect health?

3. Who is eligible for cash aid? For food assistance? For utility assistance? For lifeline?

Teaching Points

1. Income insecurity affects health through factors such as increased stress, poor housing, poor diet, and poor access to care.

2. There are many programs available for low income individuals to assist with financial insecurity.
a. Food Stamps/SNAP (CalFresh in California) is based on income.
b. Cash Aid (CalWORKS in California) is based on income.
c. Utility Assistance is based on income and varies by area. Usually there are assistance programs for heating (East Coast and colder climates), electricity and gas.
d. Lifeline – cell phones for individuals on other programs such as Medicaid.
e. Note that immigration status can be a barrier to these programs.

3. Providers can help educate patients about the availability of these resources.

Practical Questions

1. What local income and utility support programs are available and what are the eligibility guidelines?

2. At your institution, how do you connect patients to these programs and how do they apply?

Recommended Screening Question(s)

1. Do you have the resources to pay for the very basics like food, housing, medical care, and heating? (Yes/No)

Paired Reading

Chokshi D. Income, Poverty and Health Inequality. JAMA 2018;391(13):1312-1313.

Discussion Points from the Reading

1. Income inequality leads to health disparities. This makes the steady increase in income
inequality in the United States over the last 50 years very concerning. There is a well- documented association between income and life expectancy – 15 years for men and 10 years for women when comparing the most affluent 1% of individuals with the poorest 1%.

2. Factors that complicate the income-health relationship include wealth, educational attainment, sex, and race.

3. Healthcare spending can worsen income inequality; poorer individuals must spend a much greater proportion of their income on healthcare than richer people do. In 2014, healthcare spending lowered the median income of the poorest 10% by 47.6% vs 2.7% for the wealthiest 10% of the population.

4. Public health declines may be triggered by policies that theoretically have little to do with health directly, such as tax policy. This is because tax cuts may trigger cuts in governmental spending in programs such as Medicaid and Supplemental Nutrition Assistance Program (SNAP, aka food stamps), both of which play a crucial role when it comes to the health of low income individuals.

Additional Readings

1. Urban Institute. Issue Brief: How Income and Wealth are Linked to Health and Longevity. April 2015. Available at and-wealth-linked-health-and-longevity.

2. Pickett KE, Wilkinson RG. Income inequality and health: a casual review. Soc Sci Med 2015;128:316-26.

3. Deaton, A. Health, Research Summary: Income, and Inequality. NBER Reporter 2003. Available at

4. Sanger-Katz, M. Income Inequality: It's also Bad for your Health. NY Times Mar 30, 2015. Available at: bad-for-your-health.html.