If You Doubt That There Is a Healthcare Crisis, Come to Michigan

Before my present gig, I taught public health at University of Michigan. I and my colleagues were involved with several ventures to address that state's urban poverty and related health ills. It's not news that Flint, Detroit, and other urban centers have struggled. Despite serious economic challenges, Michigan was relatively fortunate to have a strongly unionized workforce, well-financed retirees, strong philanthropy, and other assets that somewhat buffered the health system against from the worst consequences of deindustrialization. I left Michigan in 2003 to do similar work in Chicago. It's not entirely my fault, but things in Michigan have worsened since my departure.

My former UM public health colleague Paula Lantz and UCLA political scientist Mark Peterson note in Friday's Free Press, that one million Michiganders are uninsured. They note the large hole Medicaid is placing in the state budget.

Earlier this week, the excellent, real-newspaper part of the Wall Street Journal had an amazing story about hospital closures in Detroit.

The title speaks for itself: "Nonprofit Hospitals Flee Cities for Suburbs, Leaving Poor Behind." The Journal's opening paragraphs captures the raw emotion I encountered many times within the economically and racially segregated environment of greater Detroit:

After nonprofit giant Ascension Health closed the doors on Detroit's Riverview Hospital, the only hospital on the city's blighted east side, some residents directed their anger at St. John Hospital and Medical Center, the system's lone remaining outpost in the Motor City.

In renovations at St. John, the local Ascension subsidiary moved the lobby so that it overlooked the wealthy and almost exclusively white suburb of Gross Pointe Woods rather than Detroit, which it had faced for more than 50 years. William Anderson, who had directed medical education at Riverview, told the WSJ that he believed the health system was saying, "We do not want to be in Detroit where there are so many poor, black people." The hospital system denied that charge, saying the change was dictated by the particulars of the site.

You can imagine how that went over in Detroit's hyper-segregated environment.

Of Detroit's 42 hospitals that operated in 1960, four remain. Locals know a thing or two about the agony of auto plant closings. Local hospital closings are also a heavy blow. A hospital is more than a site of care. It provides employment to hundreds or thousands of people ranging from brain surgeons and nurses to the telephone operators and custodial staff. Hospitals provide an economic anchor for local medical offices, pharmacies, and sandwich shops. Hospital security personnel generally outnumber city police in the immediate vicinity, providing needed protection from crime. Hospital closures are especially demoralizing when they come to symbolize a community's economic decline.

Retaining healthcare providers is becoming more difficult with each passing year. Within a $2.4 trillion healthcare system, providers have opportunities to make money. Few of these opportunities are in stressed locations like east Detroit. One in four people in Detroit lack health coverage. Many of the rest have Medicaid, on whom hospitals often lose money. If you are a hospital executive, locating in a poor Detroit neighborhood is not a marketing advantage when you are trying to court well-insured suburban yuppie patients.

Hospitals, for-profit and nonprofit too, have generally responded the way big institutions do. Ascension's local subsidiary shut down three Detroit hospitals in the past decade. Meanwhile, Ascension opened a new $224 million hospital in a nearby suburb. Ascension does provides significant charity care. The Journal pointedly notes the church-based nonprofit chain makes a lot of money. It owns 67 hospitals, and reported a net income of $351 million last year.

Detroiters are understandably bitter. Ascension has indeed behaved rather shabbily. Yet the underlying problem is not the refusal of some chain to retain a money-losing facility. The real problems reside in a public and private insurance system that makes it very, very hard for hospitals to survive in this environment.

I recently visited Detroit on a research project examining HIV screening in emergency care. In many ways, Detroit gets a worse rap than it deserves. When I tell my friends I am going to Detroit, they have visions of Kurt Russell's travails in Escape from New York. "Don't go roaming around," my mom tells me with some concern.

With time to kill, I violated Mom's advice and walked around. I passed the Detroit Institute of Art, the Museum of African-American History, the Symphony, and much else. Like Chicago, Detroit features great architecture and a beautiful housing stock. Yet there's no escaping that Detroit has fallen on hard times. Its Amtrak station is so run-down it barely supports a candy machine. City government is under-funded, demoralized, and performs very poorly by virtually any measure.

I stopped into the huge General Motors building. Completed in 1923, it is an official National Historic Landmark, a renowned architectural achievement of Albert Kahn. I passed underneath opulent ceilings and a beautiful old Cadillac parked for display in the lobby. The complex is now called Cadillac place. They don't do much with cars there anymore. Most of the place is now used for welfare offices and other public services.

I don't know how to reverse such profound industrial decline. I do know that we can give health insurance to every American citizen. I know that we can ensure that every American city has the fiscal resources to operate effective hospitals.

My experiences in Detroit and Flint taught me something else. The Journal quotes my Michigan colleague Rich Lichtenstein on the litany of sad statistics regarding Detroit's poverty, HIV incidence, and infant mortality. The statistics would be much worse, were it not for Paula and Rich and so many others on the ground who have spent years improving breast and cervical cancer screening, enrolling kids in SCHIP, getting the word out on diabetes and hypertension, helping to link pregnant women to prenatal care, helping incredibly stressed young mothers be better, and sometimes safer, parents to their children.

This is the hard, often overlooked world of social services and public health. People who read my pieces know that I'm alarmed about the nation's dilapidated public health infrastructure, so oddly neglected alongside our nation's colossal thirteen-digit investments in personal medical services.

As we enter the election homestretch in a time of economic crisis, our nation reevaluating how we do things. This comes through both choice and hard circumstance. I'm sure many readers are wondering how they (you) should change your lives to match this moment.

If all goes well on election day, some of my students and colleagues will go to Washington to enact needed change. That's one terrific road, but you don't have to go that far. You can go to Detroit, or Chicago, or Cleveland, or New York, or LA, one of hundreds of other places and make a real difference.

Maybe you even want to go to school with those clowns or at our shop to learn how to do this stuff right. It brings many frustrations, but it's a good life. You make change on a human scale, one life at a time. These days, we certainly need the help.

Comments

[PharmacistMike]

The uninsured and under insured typically have less access to health care than the insured. Less access means less preventive care. One way for people to have a cost contained access to preventive health care is to use FDA-approved home diagnostic tests. There are test for numerous diseases, cholesterol, HIV, prostate cancer etc. The kits are available at pharmacies or online home health screening companies. The tests cost less than going to the doctor and a copy of the results can always be shared with a physician.

[LS1958]

Okay, first of all WSJ, it's GrossE Pointe, not Gross Point.

This is an article that should be read by every American. What is happening in the Detroit metro area could happen anywhere people have no health insurance, no opportunity for regular health checkups and the kind of preventive medical care that prevents or mitigates serious illness. It could happen anywhere that decimates its mental health care system, leaving scores of people with serious mental disorders on the street waiting to become another patient in a hospital emergency room or another inmate in the city or county jail.

Because we have no national health care system, hospitals are forced to pick up the slack, and they can't afford to do it anymore. Hospitals cannot turn people away who walk into their emergency rooms - and hospitals in poor communities have more of those than anywhere else, as well as fewer resources available to help them.

Now can we talk about nationalizing and taking the profit out of health care??

[kimleehan]

I'm not to familure with the health care system but I've heard that there are about 48 million americans without insurance. I also heard that theres a real problem with medicare thats even worse than s/s. Employers are complaining about having to provide coverage. Why can't we just get health care like all the other developed countrys around the world have. Every time I ask democrates or republicans if health care is a privledge or a right they say a right, but when I mention national healthcare, no one wants it. They say to much waiting time, bad service, Then I ask why doe's the U.S. have one of the worst infant mortallity rates or life expectancy rate of all the developed countrys in the world if the health care is so great. why are the Japanese & Chinese healthier than americans.I don't mind a little wait if its not life treatning, as long as everybody else is in the same boat as I'm in. If the people are willing to pay out of their pocket for extras then let them. If they don't want to share the room with me, fine.Tell me if I'm wrong, I'll change my mind if I'm wrong.

[floib]

Our health care is totally broken. Why is it that we are the only country that has its citizens losing their homes due to medical bills? If we had universal health care like England, France, Japan, and Canada, everyone would be covered. For what we pay now, we could pool all of our money and we wouldn't have to pay extra for dental, hospital visits, vision care, chiropractic care, mental reviews, rehab, medicines, and much more.

This mentality that everyone is on their own is what is wrong with this country. I am my brother's keeper. I am my sister's keeper. A healthy country is harder to govern. An intelligent country is harder to govern. A country with ignorant and sick people are prone to be taken over by a dictator.
Sick people don't work and don't pay taxes. Healthy people work, shop, and pay taxes.

[readyforchange]

floib, I think you're on to something! We are a country that pumps its financial resources into weapons and war (which speaks volumes). The profit motive should be taken out of healthcare. It is absurd that the term "socialized" medicine is used. Many services in this country are "socialized."

The sociology of medicine, i.e., fees for service, will never encourage PREVENTION. It's time we step up and take care of all citizens. It would not require additional taxes, just a new priority and distribution of the outlandish taxes already paid.

[lifesaver]

If we were to pass HR 676, everybody would have full coverage from the cradle to the grave. Check out Michael Moore's website (michaelmoore.com) to sign the petition that asks senators and representatives to support HR 676. Go to YouTube and watch videos about HR 676. Dennis Kucinich will explain HR 676.

[Paul]

Think about it.

Michigan has been cursed by the auto industry.

It would have been better for Michigan if Henry Ford had been born in Kansas.

[thebluecrayon]

You described well a problem that is rampant throughout the country and sorely needs our attention. In this case, healthcare is a national security need. If God forbid something catastrophic would happen, many cities across the country would not have enough emergency rooms to handle and emergency! One hospital in my city was closed for no reason other than another hospital wanted to buy up more property and turn it into something other than a hospital. What many don't realize is that when a hospital closes, patients also lose access to specialists who there. These are doctors like rheumatologists, cardiologists, general practioners, all of whom have patients who have regular appointments with them.

Great work on the article.

[wolfgangmo]

Health care is bigger than most people seem to think. Besides our out of control war spending, health care is the 800 pound gorilla in the room.

I hope something gets done but I doubt it will. This is America after all. We don't fix things until WAY after they are broken.

[sickwillie13]

Thank you, for acknowledging our healthcare and economic problems in Michigan. I'm a skilled tradesman, I've been married for thirteen years and have two children. I am also one carpentry accident away from leaving my family destitute. I do not receive healthcare through my employer. Work is scarce and has been for some time, I may only get one or two days of work a week. Every one or two months I'll have a spurt of regular work and recieve one or two good paychecks. The construction business is not doing so well in Michigan. These random "good" paychecks disqualify my family from recieving medicaid, they say I earn too much money and yet I can barely afford to pay the bills.
My wife has been advised by Social Services to divorce me, this way, as a single parent she will be eligible for medicaid as well as rent and food assistance. My wife and I have chosen not to accept the states advice and remain married and very much in love. We have chosen to deal with and work through whatever problems come our way, but it makes me wonder how many families took the advice from Social Services? Is this the meaning of "family values" that I hear so much about?
It feels like our only hope is that Mr. Obama is voted into office on November fourth. Many things in our society are not only due for a change but in desperate need of a complete overhaul.

[Linda Bergthold - Huffpost Blogger]

The impact of the recession on the health care system won't be known for awhile -- but for sure, as you point out -- the impact will be felt first by those who have the least resources to deal with it. I applaud your article for raising these issues and hope many people will read it and better understand the challenges we face. I'm so glad that it looks like Obama will be our President, because he truly "gets" public health and in addition to his vision, he will bring people to Washington who care just as strongly as he does about fixing things!