Barack Obama, welcome home. Now, please stay home. We need your undivided attention, and brilliance. We need your ability to connect with the American people. We need your wisdom to elevate the parochial concerns of lawmakers facing re-election next year, to craft something many American presidents have tried to do, without success.
Those of you with insurance who think you don't have a dog in this fight: Listen up. Your health care costs are rising three times faster than your wages for a reason. For every 1% uptick in the unemployment rate, approximately 1 million Americans stand to lose their health insurance. Uninsured folks still receive medical care; only it's expensive care, typically provided in the emergency department, when the problem is more extensive, and therefore, more expensive, than it should have been. Those of you with health care insurance---you and your employers are footing this bill through cost-shifting so you need to care, because employers are facing tough decisions: Get rid of your job or your health insurance, or raise your out-of-pocket costs...again. Or all of the above. You need to pay attention to what's being hawked by insurance companies and, unfortunately, some lawmakers who cannot, or will not take the time to get into the weeds as proposals are coming out of Congress that could further segment the urban poor, from everyone else.
Hillary Clinton was faulted the last time around for keeping Congress out of the mix. Barack Obama's advisors learned that lesson, and are attempting to shape reform from afar. Perhaps it's time to re-think this strategy and come up with a middle ground. Because the sausage being born this summer is ugly.
Consider, for example, the current proposal to reward providers from so-called 'high-efficiency' states like Minnesota, New Hampshire and Washington by re-distributing scarce Medicare dollars from so-called low-efficiency areas like Miami and Los Angeles. Sounds reasonable enough on the surface. Everyone agrees that there's waste and inefficiency in the health care system and we need to make every effort to curtail spending that doesn't have a proven health benefit.
The Medicare Payment Improvement Act of 2009 is predicated upon findings of the Dartmouth Atlas of Health Care that followed Medicare beneficiaries over the last two years of their lives, recording the amount of medical care they received according to the state and region where the lived.
While this bill contains guidelines that are laudable attempts at controlling health care costs, they may lead to paradoxical and unintended consequences with devastating consequences to the urban poor and to those providers who treat them, as well as compromising our ability to educate the next generation of health care providers. And let's not forget the middle class who happen to get into a car accident or have a heart attack while passing through town.
So look a little closer, President Obama, please. This proposal has the potential of taking "No Child Left Behind," to a whole new industry and creating instead, at a time we can scarcely afford it: "No Safety Net Hospital Left Behind." This is a proposal that could, once and for all, devastate poverty corridors serving the urban poor, and the middle class that are unfortunate enough to need trauma, burn or complex medical services, who live nearby.
What do Minnesota, New Hampshire, and Washington have in common? Hmmmmmm.....Well, for starters, their average poverty rate is 9.4%. Mississippi, a so-called low-efficiency state's is 20.7%. California's is 12.4%, and when you zero in on the region called SPA 6, the area in the South Central area, that accounts for the majority of high-end Medicare spending in LA, you'll see that the poverty rate there is 28%.
But wait, your friends in overwhelmingly white states like Minnesota, New Hampshire, and Washington, (average rate of Caucasian population is 85.1% to an average rate of 59% for Florida, Texas, California, Mississippi, Illinois, New York and Michigan) will tell you that we know that places like McAllen, Texas prove that over-utilization accounts for high Medicare spending, and that social-economic status doesn't change the equation.
Well, I heard once that there was a Welfare Mom somewhere who drove a Cadillac, and we all know what happened to millions of hard-scrabble moms who ended up living under bridges because of that singular Cadillac Welfare cheater. Sure there are over-utilizers, and we need to weed these folks out. But most patients who end up in poverty corridor hospitals in L.A., or Milwaukee, or Miami, don't incur more Medicare costs because the health care providers there are performing too many tests. The majority of these folks have gone without health care for so long, by the time they get to a hospital, they are so darned sick, and have so few resources at home to help them live healthy lives, they've got multiple health problems with hefty price tags.
We wall want solutions. But without your leadership, President Obama, we stand to be bamboozled by quick and easy fixes, even by well-meaning legislators, who see data, and unless they work in the health field, day in and day out, stand to be misled by what it all means.
I am in an interesting position. I am a former public health nurse who used to care for Spanish-speaking migrant workers in the Central Valley of California. I became a health care lawyer and have represented just about every constituency in the industry. I now commute between two states: California & Minnesota; managing health policy for one of the largest health systems in the country, and teaching health policy in a graduate program to young doctors, lawyers and health care executives, in the other state.
How do California & Minnesota differ in terms of patient populations, availability of resources, and underlying health of the populations? How much time do you have?
Here are some interesting factoids to consider:
- There are almost twice as many R.N.s per 1,000 residents in Minnesota than there are in California.
- Minnesota has 50% more hospital beds per 1,000 residents than California does.
- Minnesota has the lowest rate of childhood obesity in the nation. Los Angeles, which, by the way, has by itself, about twice the population of Minnesota, has one of the highest rates in the nation, along with higher rates of asthma, HIV and diabetes.
- Minnesota is one of the whitest states in the nation with one of the highest rates of insurance, second only to Massachusetts.
This isn't to say we can't learn from states like Minnesota. Let's look at their extensive park system, for example, with miles of bike paths, and a healthy living culture that entices kids and adults alike outdoors, even in subzero temperatures. Let's also look at the number of primary care practitioners being produced in Minnesota, a rate second only to that of Washington's.
Why does all of this matter? Because we have to do this right and we have to do this now. Controlling the rate of growth of health care spending is crucial. But it will require tough societal decisions about what constitutes value, particularly at the end of life. Equally importantly, President Obama, it means that we need to address the underlying causes of health care disparities, something you started in your race speech in Philadelphia during your campaign. We cannot afford heath care reform that exacerbates these disparities. Not now, not during this economic downturn.
President Obama, you are the right person to help us sort this out.
Cross-posted on THE ENVIRONMENTALIST