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This post was contributed by Tim Norbeck, CEO of the Physicians Foundation, and Walker Ray, MD, past president and current board member of the Physicians Foundation.
“Los Angeles is no ordinary place.” These are the words of Dr. Richard “Buz” Cooper whose life work explored the effects of poverty on healthcare.
Dr. Cooper used Los Angeles as one lens to explore the relationship between income and healthcare costs in his 2016 book, Poverty and the Myths of Health Care Reform. Ranking just behind New York in the number of millionaires, Los Angeles ranks first in the number of poor. The cost of living in Los Angeles is 30 percent above the national average, however, almost 30 percent of the population – that’s more than the total population of Chicago – lives on an income of less than $12,500.
What’s different from other areas in the U.S. affected by poverty is the broad geographic dispersion of Los Angeles. Poverty is more widely spread across many separate municipalities, versus concentrated to a specific region. In L.A., Medicare spending per enrollee is 60 percent more than in the lowest spending regions of the U.S.
Identifying how impoverished populations contribute to healthcare utilization and cost isn’t simple to nail down. Dr. Cooper noted that the answer extends across varied social and economic factors that have compounded over the years. Elements like income, education, employment and disability have greatly affected Los Angeles. Yet so have more elusive characteristics like empowerment, economic security, social networks and trust relationships (or the lack thereof). Also critical are overall living conditions – particularly in areas where personal safety and adequate housing are challenged, nutritional food is difficult to consistently or affordably access, air quality is compromised and there are limited transportation options to get to doctor appointments or other medical care.
Dr. Cooper observed that “poverty not only applies to people, it applies to neighborhoods.” These living conditions and illnesses spread, creating their own communities. Ultimately, he asserted that what we face is not an unnecessary overuse of care by those in poverty, but rather “the necessary use of extra care for patients who are unnecessarily poor.”
The dominant emphasis of healthcare reform over recent decades has been on eliminating perceived waste and inefficiency. Dr. Cooper directly challenged this paradigm by documenting how ignoring the impact of low income on healthcare utilization has led policy makers to miss the bigger and more relevant picture. He estimated that if the poorest areas utilized healthcare at the rate of the most affluent, overall utilization and spending could be as much as 30 percent less. Even more striking, life expectancy in poor neighborhoods is a full 10 years shorter than in the richest areas. By shining a light on the patterns of poverty, wealth and healthcare spending across our country, we have the opportunity to finally address healthcare cost drivers that, until recently, have been largely ignored.
The Physicians Foundation recently released a 2017 patient survey which measured the attitudes of healthcare consumers on a number of different issues, including the cost of healthcare and social determinants. Survey results revealed that 28 percent of consumers had a medical problem in the last year, but did not visit a doctor because of the cost. Twenty-five percent did not fill a prescription for medicine because of the cost, and 19 percent skipped doses of medicine because of the cost.
Social determinants exist both in and outside of the doctor’s office. While patients and physicians must work together to navigate the hardships that hinder proper care and drive up costs, they cannot do it alone. It’s time for health policy experts and regulators to actively acknowledge and engage with this issue. Neither the blame – nor the solution – can rest on one person or group. It will require collective effort to change our thinking and help Americans become healthier by becoming more economically secure.
