An Open Letter to Every Health Care Provider Who Treats the Uninsured Poor in America [View all]

[McCamy Taylor]

(And yes, there are still a lot of them, thanks to the states that refused the Medicaid expansion like my own state of Texas)

All health care for the poor is not the same. There are two, almost opposed rationales for indigent health care in this country.

Indigent Health Serves the Poor

There are two missions of any publicly funded endeavor to improve the health of the poor. One is a humanitarian goal---help those who are less fortunate than ourselves with their health problems which cause them pain, disability, loss of enjoyment of their family and lives and premature death. This aspect of public health is especially popular when it comes to children and the elderly and is probably why we have had Medicare for so long and why SCHIP was passed a decade before we tackled health care for working adults. As LBJ said back in the 1960s (more or less) it ain't right when Grandma has to suffer needlessly after she spent her life taking care of us. And no one wants to see a child suffer from medical neglect.

In between the helplessness of childhood and the golden years, there are working poor, many of whom are poor precisely because they have inherited diseases such as asthma, arthritis, heart disease, diabetes, sleep disorders and other problems that caused them to be raised in poverty, missed education opportunities, forced them into low paying, no benefit jobs at early ages to support their ailing parents and then struck them in the prime of their life when they had no insurance either, leaving their own families vulnerable. These folks are another excellent reason why bleeding heart you know what's like me believe that we should care for the health of the poor.

And there is a side benefit of showing compassion for those who are poor in an affluent society. Wealth disparity is a health problem in itself. If you tell poor folks "You don't count" their burden of certain stress related illnesses---including mental illness and substance abuse and domestic violence---goes up. Compassion that is true compassion---not crumbs tossed down from on high but a helping hand offered in a sense of brotherhood can go a long way towards showing those who have had some bad breaks in life that they still have something of value to offer. We saw a lot of this during the Great Depression, when the photographers of the WPA showed us a Poor America that looked just like ourselves--- with a family, with a farm, poor through no fault of its own. We held out our hands. We got through the hard times. We created Social Security. As a nation, we got stronger. And richer. The fifties and sixties were times of prosperity for all, thanks to the compassion we showed one another during our worst of times.

Indigent Healthcare Protects Society Against the Poor

Then, there is the other argument for public health. We pay for public health to protect hard working, tax paying citizens from the consequences of the diseases of the poor. Infectious disease is at the top of this list. Those who espouse public health as self-protection want all those breeders and their "little nits" immunized. When they get diseases such as Tb, they want them treated so that they do not cough and spread it at the mall. They want the mentally ill to have a place to go to be treated so that they do not exercise their right to buy a gun and shoot up the mall. They do not want to see people die on the streets of heart attacks---it might disturb our kids. They want to make sure that their minimum wage workers without benefits will be healthy enough to go in to their jobs (think Wall-Mart). These people begrudge the poor anything that is "given" to them---but they realize that if the poor do not receive at least a few crumbs of health care, we could all go down in a big epidemic of drug resistant Tb.

They believe that the poor should be content with second rate health care delivered by doctors in training. If a resident or medical student makes a mistake---ah, who cares? It's just a poor, uninsured undocumented immigrant who should not be here anyway. And the student has learned a valuable lesson that he will carry with him when he treats real hard working insured Americans later. Since people learn from their mistakes better than they learn from being told, this type of health care system is not too cautious. Let them learn is their motto. If something really bad happens--say, a patient dies needlessly, due to a system wide failure---then a new policy is put into place. This is called being reactive. But since mistakes in and of themselves are ok as long as you are treating an undeserving population and no one actually dies or suffers permanent harm, there is no need to be proactive. That's for paying patients at private hospitals.

The poor should be grateful for whatever scraps they get and not even think about asking for more. Or for the same standard of care that folks with real insurance get---you know, like access to the same tests and treatments for diseases, say transplants or sleep apnea treatment or home health or hospice, because rationing of health care resources is unethical when it comes to you and me but it is the rule of the land when it comes to the poor.

The members of this second group of health providers are the ones who have screaming fits when they discover that public health dollars are being spent to pay for pain medication for poor folks. In my own state of Texas, the Medical Board has decreed that patients in pain have a right to have their pain evaluated and treated with effective medications and other therapies. However, at some public health facilities the poor are not extended this right, because "The poor are not good candidates for treatment with opiate pain medications. They may be tempted to sell their meds." Real quote--one that led me to question my place in my current place of employment. How can a public health worker espouse this value? Easy. This is "protect the public from the poor" type thinking. If the poor are treated for pain, some of them may sell their drugs---oh, to buy milk or cereal for the kids--at which point society as a whole has a prescription drug problem. So, the poor lose their right to be treated for pain, because they are statistically more likely to need money and opiate pain medications can be sold for money.

There are, of course, flaws with this reasoning. People in pain are unlikely to sell their pain pills. They need them. The poor are no more likely to break the law than people with money. Real drug dealers are seldom poor. The doctors who will not prescribe pain meds to the poor probably have any number of "dealers" that they see and for whom they prescribe opiates--they just do not imagine that the sweet little white haired grandmother could possibly be a dealer. Because they are convinced that only members of certain racial minorities sell their pills.

Members of group two are especially enamored of "Bio-terrorism" public health spending, because it protects us and diverts resources that might otherwise be squandered on the poor. Remember what the Puritans knew and many Baptists know---the poor are poor because God assigned them to the ranks of the damned before they were born and their poverty in life is a mark of their damnation and any attempt by the rest of us to alleviate their physical suffering is 1) unGodly and 2) like spitting in the wind so why bother? If God wanted them to be born free of genetic disorders in an affluent suburb with access to good schools with a skin color that would not get them shot dead for making a poor fashion choice, He would have arranged things that way. Note, you do not have to be a Baptist American to look down upon the American poor. Physicians from other countries sometimes see poverty in America and they roll their eyes and tell you that poor people in their home country are much more poor in an absolute sense, but they do not drink or smoke. People from countries which have a problem with poverty but not with wealth disparity do not understand that being poor in a country that is wealthy is a disease in and of itself---one that scars you from a very young age.

If you are going to toss down some crumbs of health care to the poor, make sure that they have to scramble for them. Make it clear that they are getting these crumbs because you want to give them, not because they deserve them---otherwise, they might get a false sense of their own importance, in which case they might demand the right to start dictating how all those public health dollars are being spent---and we all know that public health administrators have a God given right to play with all that money any way they want, including awarding contracts on the basis of nepotism rather than the ability to deliver quality care. Which is more important? Keeping poor people healthy or doing a favor for the guy you play golf with?

Oh, I almost forgot the most important function of publicly funded indigent healthcare--to keep the uninsured out of private hospitals and doctors' offices. Why are rural hospitals closing in red states? There are no county hospital ERs. Big cities---which have big medical centers---feel the economic pressure to create county hospitals for the poor. If they don't, they face losing all their big private hospitals and doctors to the suburbs.

Is There a Happy Middle Ground?

Probably. Somewhere. But it may be hard to find in a state like Texas that refused the Medicaid expansion. A state that Just Said No to billions of dollars of free federal money that would have saved urban taxpayers a bundle on health care for the urban poor and kept rural hospitals open---that is the kind of state that feels pangs of remorse every time it spends even a dime taking care of someone whom God has declared must suffer in this world before he or she suffers in the next.

If we are going to eliminate the disease that is called Being Poor in an Affluent Society, first we need to recognize that everyone has the same right to basic preventive health care services that they do to an education. We educate on the grounds that universal education gives us a work force that can fill necessary jobs, keep the economy strong and raise the next generation of workers. Preventive health care accomplishes the same thing. A worker who can read and write and operate a computer but who is blind from a preventable disease such as measles is not as useful as one who has full vision.

If we maintain two separate health care systems---one a gold plated Cadillac system for "Hard working Americans" on the fast track to heaven and the other a lead lined, grudging, "I will trust that you are a drug abuser and a drug dealer until you prove to me that I can trust you" system---then the poor folks will have very little incentive to get preventive services until they are so sick that they can no longer work. No matter how many health care "metrics" you pile one on top of the other to "prove" that your organization is delivering quality care or how many sick patients you turf to other providers to "prove" that you are a cost effective doctor who achieves good outcomes, if your clients can sense that you do not trust them and are not treating them with respect, your efforts are not just doomed to fail. Worse, you have personally, deliberately chosen to make them fail, though you may not realize it. You may even wonder why those ungrateful, selfish little bastards are not snatching up those crumbs with beaming smiles and "Thank you! Thank you!" pouring from their lips. You may be secretly convinced that the reason their diseases are not getting better is because they want to spite you, they want to be sick---and not because you are doing such an extremely bad job of taking care of their health. Which is just another way of saying "Hallelujah. I am among the elect and the patients that I treat are nothing like me, so I can do whatever I want."

Want to understand love? Follow the advice of Rumi: "Don't turn your face away."