or years, experts have blamed problems in health care delivery and its rising cost on waste and inefficiency. While they are certainly contributors, it’s time to acknowledge poverty as an even larger determinant.
That’s the message of “Poverty and Myths of Health Care Reform,” written by Dr. Richard (Buz) Cooper, who died last year before seeing the book in print. The author, a respected researcher and a colleague of mine at the Physicians Foundation, questions conventional policy assumptions about the state of health care and explains why it’s imperative for us to address the costs of social determinants in health care before we can fix the system.
Looking at health care through the lens of poverty, Cooper provides both a macro and micro evaluation of specific cities and regions, zooming in on locations from New York City to Los Angeles.
Cooper’s findings are fascinating and eye-opening. In New York City, for example, he mapped health care utilization using the subway system — specifically along the route of the A train, which runs through some of the most affluent neighborhoods in the Upper West Side and some of the most poverty-stricken areas of Harlem. Impoverished neighborhoods had a much higher level of illness and use of health care services than more affluent areas. In other words, poverty makes people sick.
Across the country, life expectancy in the poorest neighborhoods is a full 10 years shorter than in the richest. Based on the distribution of household incomes throughout the U.S., Cooper found that if people living in the poorest areas were as healthy as the rich, and therefore used health care at the rate of the most affluent, overall utilization and spending could be as much as 30 percent less than what it is currently.
I see these statistics played out in a personal way in my own practice in Denton, Texas. The sickest patients — the ones in the greatest need of care who are the most expensive to treat — are typically the most impoverished, the least educated, and face the greatest number of social issues. They often cannot afford deductibles, follow-up appointments, and medications. So when they finally come for medical care, their illnesses are often more acute and they are sicker — and so more expensive to treat. My experience is likely shared by the majority of physicians.
When most people think of health care, they usually think of it in simple terms — going to the doctor, or the clinic, or the hospital — but don’t think about what happens to patients when they go home. Some may not have homes to go to. Others may not have enough money to buy food. Some don’t have cars or don’t have access to public transportation or can’t afford a taxi to come back for follow-up visits.
If a patient with diabetes can’t refrigerate her insulin, and it becomes inactive, she may end up in the emergency department or intensive care unit. Could a $200 college dorm refrigerator have saved a $20,000 hospital admission? Yes.
We don’t often talk about the role of social determinants in health care because it has become such a politically controversial issue. It’s one of the most difficult topics to address because poverty has been largely ignored by lawmakers — there aren’t many paid lobbyists for the poor. Yet the problem is expanding, driving up costs everywhere, including government programs like Medicare, Medicaid, and Veterans Affairs.
Hospitals in low-pay demographic areas are closing across the country while they are being built in affluent areas. Would we tolerate this with police and fire station closures?
If policymakers continue to focus on eliminating perceived waste and inefficiency, their myopic approach will miss the bigger and more relevant picture. It’s critical that we work to reshape clinical practice in ways that will not punish providers who care for the poor. Spending on social programs for children and young adults will yield savings that can be used to provide incentives for physicians to care for our poorest citizens.
Taking care of every patient is a moral imperative. If we don’t pay attention now to the impact of poverty in health care, we will leave behind the problem as a burden for future generations to carry.
Joseph Valenti, M.D., is a board-certified obstetrician and gynecologist, the founding senior partner of Caring for Women in Denton, Texas, and a board member of the Physicians Foundation, a nonprofit 501(c)(3) organization that seeks to empower physicians to lead in the delivery of high-quality, cost-efficient health care.