Health care for the poor: A race to the bottom

There are over 16,000,000 American children (21.8%) who live in official poverty and double that number who are just poor. This is not happening in an obscure country, in a continent far away. It is happening right here, across the street from you. For those enjoying a good episode of Duck Dynasty, these are not children of illegal immigrants, and the vast majority is white kids.

Over 44,000,000 American children (more than 1 in 3) were served by Medicaid and the Children’s Health Insurance Program (CHIP) in 2012. You can look at these numbers and be proud that we are helping more kids get proper health care, and you can listen carefully and hear the underlying narrative of an America raising its future self in abject poverty. Redirecting your gaze to our health care reforms, you should now understand that American health care is being transformed precisely to service this impoverished future. We are now building a health care system for the poor, the jobless, the uneducated, the huddled masses, rising from within.

It would have been much easier to reform health care in America if we had the patience to wait a couple more decades until 80% of our children end up living in poverty, but in its infinite wisdom, our progressive government has decided that it is better to be prepared for this inevitable future of ours, and the sooner the better. Unfortunately, the remnants of what was once America the beautiful, are having a hard time understanding the dire need to reform health care for a posterity that looks eerily like Charlie and the Chocolate Factory. Fortunately though, we do live in the disinformation age, hence reeducating the public to see the preemptive benefits of the new ways, is just a matter of devising a solid marketing campaign.

Less is more

Simplicity, as any marketer can tell you, is the key to effectively inducing mass acceptance of new ideas.  Less is more. In this case less verbiage is more effective, but we don’t really need to get into subtleties. Plain less is just more of whatever you want more of. Let your imagination complete the message. Less is more, and less is always more, and more is actually less, and why would you settle for less, when you should rightfully have more by having less. Is there anyone out there that doesn’t know for sure by now that in health care less is more? Less superfluous tests, less useless screenings, less harmful drugs, less dangerous treatments, and all the misfortunes resulting from more of the same, in article after article, book after book, interview after interview, spread far and wide, less is more.

Note how everything is prepended with an onerous adjective to soften the ground and minimize resistance to the idea that less is not just more, but less is good. The next step is to point to research showing that more bad things are bad for you, and then extrapolate to stating that more of everything is bad for you, while all the time using undesirable adjectives before every noun. Less paternalistic doctors, less irresponsible ER visits, less murderous hospital stays, less confusing choices, less is always more. Always, because poor people need to internalize and accept that less is all they can ever hope for, and less is better than nothing at all.

Too many choices

Having no choices at all is usually associated with totalitarian regimes, but even in a free country beggars cannot expect to be choosers, or as insurance executives tell us, we are more “sensitive” to prices than we are to choices when we shop for health insurance. It seems we relish the idea of having less choices (less is more, remember?). Therefore, we have narrow networks, which are being rebranded to high-performing networks as we speak, to improve moral. The talking points say that narrow networks are cheaper because in return for lots of customers, doctors and hospitals, hungry for more patients, are giving the insurer greater discounts.

So let’s see: It would be cheaper to only have New York University’s Langone and maybe Sloan-Kettering and their doctors in your narrow network, than having dozens more area hospitals and thousands of other doctors, right? Well, not quite, because poor people do better with surroundings more concordant with their station in life and we should be more thoughtful in the choices we make for them.

We are very fortunate to already have a health care program designed from the ground up for the poor, so there is no need to start from scratch. As millions and millions of American Homo sapiens are descending from trees and gaining health insurance for the first time in their life, two distinct choices are emerging from innovative public/private partnerships. Those who have reached stable poverty are rewarded with free access to tailored networks custom built for their needs, and those who are still struggling to get there, are gradually eased into similar networks, while all obstacles to achieving perfect poverty are slowly removed from their wallets. The hope is that all our citizens will one day benefit from Medicaid, at which point we can truly begin to mold our nation for the future.

Who’s your daddy?

Poor people all over the world are acutely aware of being powerless to change their circumstances. Previously free and proud Americans are not likely to march willingly into the confines of poverty, unless of course, we can convince them that health care for the poor is actually an exercise in empowerment for the people. That’s a tall order for the best marketers, but we are executing on it flawlessly and brilliantly, because we had the wisdom to learn from past mistakes. Back in the nineties, America and its doctors rebelled against the yoke of managed care, and the HMOs pretty much failed. Today, we start fresh by breaking the unholy alliance between patients and their doctors, instead of expecting this to be an outcome of reform.

First we tell people that doctors are bossing them around too much, and that they keep secret documents about their patients. Empowered patients have a right to not let doctors advise them, and to see those classified files where all sorts of horrible things are written about each patient. Then to support our case, we establish through well researched anecdotal innuendos that doctors are greedy, incompetent, careless, and cannot be trusted. Next we make fun of people who “like” their doctors and want to “keep” them (like pets or old tee shirts), and we make sure that having the same doctor for lengthy periods of time is impossible going forward. Finally, we establish the insurer or the government to be your lord and protector in the perilous journey through the doctor infested waters of a “fragmented” health system. So let’s try that again, and this time we want the right answer: Who’s your daddy now?

The new normal

The transition from being a free and wealthy nation to being just another medium size impoverished country, studded with magnificent sultans, may trigger a bit of anxiety, some anger and certainly lots of sadness in America. It is also well documented that mental disease is rampant among the poor, so we need to prepare. The old premise of an individual right to pursue happiness is now being upgraded to a personal responsibility to be happy. Screening for depression is becoming mandatory for all adults and children over thirteen years of age, and depression is assessed based on answers to nine questions, sometimes over the phone. Back in 2005, studies estimated that almost half of Americans experience some sort of mental disorder during their lifetime. With the recent expansion to the definition of mental disorders, it is clear that by now the vast majority of Americans are pathologically disturbed.

But then again, if we are all hopelessly sad, overly angry and addicted to caffeine and such, aren’t we the ones that are “normal”? And perhaps the minority living in gated communities, unaffected by the looming better tomorrow, should be labeled with some sort of new disorder. We’ll leave that to the DSM VI (and the courts), and for an immediate solution to the poverty induced new normal, I would like to suggest a little innovation derived from dental medicine. Instead of wasting time and money on integrating behavioral health into routine primary care, why don’t we just cut through the chase and throw some Lexapro into the water supply? The new abnormal minority is not very likely to drink from a faucet anyway, so they should be safe.

High tech

Our success at keeping everybody informed, empowered and controlled, hinges on getting high on technology. This was the one missing piece in past attempts to create proper value chains, and just plain chains, for our citizens. Now that we succeeded in gluing most humans to a miniature computer permanently connected to our grid (sticking with calling it a phone was a brilliant marketing achievement), the rest is history in the making. If health care were a product, we could ship its manufacturing to where we ship all manufacturing, and make enough plastic versions of the original to satisfy our poor.

But health care is a service, and here is where high tech comes to the rescue. By making enough hardware and enough software, and by strategically repositioning venues, you can productize services into manufactured goods. That’s how we replaced mom’s laborious cooking with packaged foods, for most poor people. And that’s how we will replace health care with health maintenance for the same. It will take time, thoughtful planning, lots of innovation and a carefully cultivated disdain for human life, but I have no doubt that our leaders will guide us safely to the bottom.

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • ninguem

    “…..That’s how we replaced mom’s laborious cooking with packaged foods, for most poor people…..”

    The result is lots of obese yet malnourished Americans. The rest of the world rapidly catches up to American obesity rates.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I can only wonder about the analogous long term effects of “packaged care”…. ?

      • ninguem

        I’m still not sure what you’re advocating in this article.

        I like to think it’s that levitating robot obstetrician that delivered Luke and Leia Skywalker in Star Wars 3

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Yeah… cute little critter…. I’m sure every slave on Tatooine had access to one of those things….

          Not advocating anything. Just observing how the entitled class is making itself more comfortable…

          • ninguem

            One thing I never could understand about Tattooine.

            If you had those levitating thingy’s, why did they have slaves?

            I’m thinking they were all unemployed obstetricians.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Funny :-)
            Slaves do accessorize well with levitating things

  • doc99

    Mr. Chambers, don’t get on that ship. “To Serve Man” – it’s a Cookbook.

    “To Serve Man,” Rod Serling – based on a story by Damon Knight

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      No ships this time around… the pigs are all here :-)

    • buzzkillerjsmith

      When the Kanamits knock, pretend you’re not home. Too tall, heads too damn big.

      Words I try to live by.

  • RuralEMdoc

    I especially enjoyed the part about mental illnesses, and the “new normal”.
    You wonder how we arrived at such a place, and looking back you realize it wasn’t a huge leap, but several tiny baby steps that add up to a huge chasm over half a century.

    Good Food for Thought

  • Rob Burnside

    You have a great voice Margalit, but you’ve been hanging out with the cynics too long. How about a few bars of “Accentuate the Positive”? The ACA, for all its flaws, has helped many, and there is, in my estimation, a heightened awareness of healthier living among the poor, though many obstacles remain. Why not focus on what can be done, such as an increase in the minimum wage? The moderates need you, and we want you back!

    • buzzkillerjsmith

      No, Margalit sees pretty clearly, although from time to time she does get carried away by the optimists.

      • Rob Burnside

        You have a fine voice too, Buzz, but wouldn’t you rather “live with the sinners than dies with the saints”?

        • Dr. Drake Ramoray

          Actually buzz and I usually cry with the pessimists. We usually only laugh at the med students and the ivory tower types

          • Rob Burnside

            Ha! And don’t forget, Dr. Drake–I’ve already been diagnosed: “superannuation syndrome” (Ninguem, a month or two ago)

        • buzzkillerjsmith

          No. I’d rather laugh at the saints.

          • Rob Burnside

            Talk about cheap thrills!

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Hi Rob, you are correct, I do think of myself as a moderate, and in the past I could look both right and left and there was plenty of room on both sides. However, the lines keep shifting to the right and I refuse to shift with them, so I guess that places me in the cynical spectrum which nowadays seems to consist of lefty liberals and libertarians, of all people. You know something is afoot when Drudge sports a link to Salon as its main headline of the day :-)

      As to the (cynically titled) ACA, here is how I see that. We had roughly three types of people before the ACA: Those with good insurance, those with crappy insurance and those with no insurance. The ACA lifted many without insurance into the ranks of people with crappy insurance, and it set in motion a trend for moving most people with good insurance into the crappy insurance category by redefining the term health insurance to better suit corporate entities inside and outside the health care industry.

      I guess, I could look at the “bright side” of extending Medicaid and subsidizing catastrophic insurance to the very poor. But I am not interested in a system that fosters “healthier living among the poor”, which I think is a perfect way to describe our current policy goals.
      I want poverty to go away. I want equity. And I want every single American to have the best health care in the world. And I find it sad beyond belief that this simple goal seems more of a fantasy to us than having robot doctors tending to Borg citizens, any day now….

      • Rob Burnside

        Ah, Margalit, in the best of all possible worlds, you’d have a desk in Washington D.C.–a very large desk, with lots of room left and right–and I’d be your bodyguard. Yes, the ACA is a disappointment in many ways, and we certainly should have the best health care in the world, all of us. Some of the pieces are in place and maybe, just maybe, the riddle will be solved someday, though not if we give up. I won’t if you won’t. Back to the front!

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          I’m not giving up, Rob. I can’t…. I have three kids and it’s my job to tilt at windmills and chase monsters out of the closet… :-)

          • Rob Burnside

            Good! I’ll saddle-up Rocinante and handle the windmills. You take the monsters…(~)

          • doc99

            So if the ACA were to implode under its own weight, how would you manage Reform 2.0?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            That’s a big huge question….. :-)
            The first thing I would do is to have one pool of insureds, instead of breaking it up in ever smaller and (on paper) more expensive pools. At that point, there really is no risk because we know exactly how much this is going to cost every year, and that becomes a budget item.
            To match the pool, I would make one big network consisting of every health care delivery entity in the country. You go seek care wherever you want to.
            Payments to hospitals and doctors would be negotiated between the national payer, the hospital association and a physician union (or call it something else if union is too threatening). Since this is a huge country, we should have a base fee, and an adjustment to it based on geographical considerations.
            All providers remain private and compete on quality and efficiency – those who can thrive with the standard payment will profit. Those who are bloated with administration and vaporware, will go under. Oh yeah, we start using anti trust laws to also put an end to consolidation of systems and unfair business practices, so that our negotiations for fees are not hijacked by too big to ignore corporations. We may need to break some systems into smaller pieces to reverse the damage already done.
            Payments to suppliers are also negotiated in bulk at a national level.
            We all pay taxes to cover these expenses, including employers, or corporations, who pay a proportional share (like FICA).
            This should cover all medical care, but those with boatloads of money could purchase supplemental “insurance” for private rooms, private nurses, big screen TV and fresh baked pastries or whatever else they can get in the room, or massages and alternative therapies.There could also be small boutique facilities that may choose to only cater to the rich outside our system, and that’s fine.
            Every person in the US is given a health card that looks exactly the same, like a driver license.
            There is one and only one form for billing the payer and medical decisions are left to doctors and patients, no second guessing by the payer.
            Accounting and integrity auditing systems are put in place to weed out the few fraudsters, as in any system.

            I’m sure we will need to tweak and add lots more stuff, but that’s the basic idea, and it is very similar to the Swiss system, but ours will be better and cheaper, because we have a much larger country and way better doctors….

          • Rob Burnside

            Bingo! Margalit-1 Closet Monsters-0 Windmills-scratched

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Goaaaaaaaaaaaal….. :-)

          • Rob Burnside

            Yes, Goal, and (rather amazingly) no penalties on the play!

          • doc99

            And what of the regulatory burden which adds much to the cost and little to the true quality of care?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I am not envisioning great reductions in regulatory burden. No meaningful use, no incentives, no penalties, no treating adults like school children in a failing school…. Just do your job and do it as well as your conscience tells you to do it… I am fine with trusting the integrity of individual people in place of the integrity of a “system”.

          • Joe

            Who defines quality and efficiency? These two words are what typically get thrown around to justify the massive health care bureaucracy/administration complex. Are there too many administrative types? Sure. Is the glut as much as what people think? No. Every time there is a new “core measure” or HCAHPS question or coding change or whatever, somebody has to deal with that. Why do we have good quality? Because we were able to check all the boxes. Why are we efficient? Because all the boxes got checked.Being in a rural area, especially, that paperwork has to fall on someone. I don’t think just saying that we’re going to compete on these levels is good enough. The regulatory side must be addressed first.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            You do. And your patients. If you can’t afford to stay in business, then your business is inefficient. If your patients stop coming, than your quality must be lacking.
            The regulatory side, as it stands today, must be dismantled first, not just addressed.

          • doc99
          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            That’s right. I want ours based on the Swiss system, not exactly like it. If you look at the latest fare from SCOTUS, there seem to be all sorts of issues with how insurance is provided, but even the most conservative justices agree that if the government has a compelling interest in providing health insurance (or better yet, health care), it should just pay for it. So I suggest we take the simplest avenue here…..

          • doc99

            Just like Govt pays for the VA?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Nope. Not at all. The VA is not privately owned and managed. The government not only pays the VA but it also runs the VA. The conflict of interest alone should have been enough reason to not have this arrangement. The sheer size of the VA is the other problem.

          • doc99

            You’re asking for a Private SinglePayor program funded by the Government – UNH Mega?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I am asking for a tax financed health care program that contracts services with independent, private care delivery entities at fairly negotiated rates, and with minimal interference from the payer.
            UNH is in this for profit. The Government of the people, by the people, should be in this for the people (keyword being “should” – I am not delusional regarding the odds for this to actually happen….)

          • doc99

            I’m glad we agree that what you are asking for in this era of Crony Capitalism most likely would result in more empowerment of the insurers. How about empowering a different group entirely, the patients?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Sounds good, but how would you do that?

          • doc99

            I’m thinking to use the old Chinese Restaurant menu concept of ideas, not food – one from column A, one from column B.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Love Chinese Restaurants, particularly the custom of ordering a whole bunch of different dishes for sharing, so everybody can have a nice variety of everything…. :-)

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Great minds…. :-) I am right now in the middle of writing a blog post about regulatory stuff in general, and about the telemedicine wonder in particular…..

  • Dr. Drake Ramoray

    I practice in a rural area. In my state at least it isn’t the pay as that is actually pretty good. It’s the hassles and red tape to prescribe any modern medication, obtain any radiology study regardless of cost, and fighting the denials for pretty much anything and everything. When I interviewed a few years back for jobs in Florida not a single one of the private groups took Medicaid (I do not know the reimbursement rate in Florida). What is the point of expanding Medicaid if none of the doctors will see patients covered by it?

  • Dr. Drake Ramoray

    Yes I see Medicaid although on a limited basis (an Endo problem during pregnancy is a guarantee to be seen)

  • Rob Burnside

    No, I’m thinking of my neighbor who previously paid triple her current OBC premium for a shabby policy. But I’m not a big fan of compulsion in any case.

    • PCPMD

      Has the cost of insuring your neighbor’s health actually gone down under the ACA, or has the burden simply shifted to the taxpayer?

      • Rob Burnside

        Good question. Answer: c) All the above

  • Dr. Drake Ramoray

    The pay is fine of you can actually get paid. The red tape isn’t as bad for preggers I you use the right coded. Still get tripped up sometimes. I have a fee pro-bono patients too. We don’t make money on everyone.

  • buzzkillerjsmith

    19 bucks for a level 3 neurology followup in rural northwest Ca. That’s what my buddy told me. I have no verified the number.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      MediCal is notorious for paying peanuts… I wish some of the data geeks would put together one of those gaudy infographics showing how much Medicaid pays in each State… or maybe there is one already?

      • DeceasedMD

        No wonder the poor stay without care. Medicaid is unwilling to pay adequately for medical services. In the 60′s and 70′s I believe, there was not such a huge discrepancy between how services were paid for the poor vs. the more well to do. A doc could make a living off of medicaid back then from what I have heard. And as I mentioned already, it is interesting there are a large number of docs from rural areas in these parts that face different challenges than the rest of us from suburbia land…

      • Dr. Drake Ramoray

        It appears I should move to Alaska. Rhode Island…. ouch.

        http://kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/

        • ninguem

          One doc, my medical school days, in Rhode Island. He showed me the books in his practice.

          1980, Rhode Island Medicaid was paying five dollars for an office visit.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Perfect.Thanks. One thing that strikes me is that in most states the ratio is lower for primary care. So it seems that Medicaid devalues primary care even more than the customary RUC racket… Interesting…. considering that a good amount of primary care in Medicaid is really pediatrics….

          • Dr. Drake Ramoray

            Agreed. The other irony I noted is that even DC Medicaid is worse than Medicare.

    • DeceasedMD

      I guess I remembered the dollar amount on that right. LOL. Extrapolating a bit, it is no wonder that the poor in rural areas have no docs. And it is interesting that a lot of docs on this board are from rural areas and have expressed dealing with more difficulties because of this. Just read a post or 2 from Drake, ninguem, newmexicoram, pamela wible, the list goes on. Don’t think I will be moving out of suburbia anytime soon.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Yes, of course… I was just looking for a formal comparison across states that was already done by someone else :-)
    You should try that link above from “Dr. Drake”. It’s very nice….