HEALTH CARE/Joan Retsinas

Onslaught on the Poor: Poor Programs

Are programs for poor people poor programs? To decide, visit Sandtown, a Baltimore neighborhood within the shadow of Johns Hopkins Hospital and the University of Maryland Health Center. The Kaiser Health News (khn.org) recently cast a spotlight on this poor African-American neighborhood.

We acknowledge the ho-hum verity: “disadvantaged” (a cruel euphemism, as though a lottery were meting out “advantages”) people live grimmer lives than their “advantaged” counterparts. All the indices – whether schools, homes, crime, jobs – point to the obvious: far better to be “advantaged.” Healthwise, Sandtowners suffer disproportionately from diabetes, hypertension, substance abuse, asthma, et al. Their average life expectancy is 69.7 years, the same as in North Korea.

But, on paper at least, poor Baltimoreans should have adequate healthcare. Maryland’s solons (as opposed to solons in 20 conservative states) extended Medicaid, so – again on paper – poor people have access to physicians, hospitals, rehabilitation, and medicines.

But the system designed to serve them has glitches.

Glitch One: Enrollment. Enrollment in Medicare is easy. Whatever your income, with a few keystrokes you can enroll in Part A. Part B is harder, but not onerous. Nobody must assess your health, your weight, your smoking and drug history. You need not prove that you are poor enough to enroll.

Enrolling in Medicaid is more difficult. You need “identification.” Residents (many have no cars, no drivers’ licenses) will generally need a motor vehicle ID –which can take weeks, require a trip to the registry. To fill out the Medicaid forms, the would-be enrollee often needs help – another trek, via poor public transit, to a social service office. Then there is the time between application and enrollment. To date, for a variety of reasons, in October 2015, 133,000 eligible Maryland residents had not enrolled.

“Prison” looms as a key interrupter. Too many Sandtown residents spend time there. On paper, Medicaid is supposed to enroll them once they are released; but in fact parolees, those on probation, and ex-convicts face a time-lag.

Glitch Two: The Game of Musical Physicians, or Finding, and Keeping, One. Medicare enrollees choose a plan that lets them keep “their” physician. Physicians rarely “leave” Medicare. In contrast, physicians practicing in Medicaid find it less lucrative. In Baltimore, one nonprofit, the People’s Community Health Center, closed 3 nonprofit clinics, later declared bankruptcy. Those patients had to find new physicians. Medicaid in Maryland contracted with United Healthcare. When United terminated its contract with one network of physicians, 2000 residents had to pick a new physician.

Glitch Three: Onerous co-payments. Co-payments exacerbate the poor linkage between patients, physicians, and treatment. Poor patients will find those co-payments, from $12 to $20, barriers; and they will “shop” for lower co-payments, switching plans mid-stream. Kaiser Health News reported physician-shopping as the norm. And patients, once given a prescription, must come up with co-payments. One resident didn’t get prescribed oxygen. The reason: he owed a $27 co-pay.

Glitch Three: The Mindset of People Serving the Poor. In the world of middle class insurance, whether Medicare or a “plan,” patients expect empathy, explanations, courtesy. “Yelp” any physician or hospital to see the responses of patients-as-consumers, accustomed to “service.” And physicians and hospitals see their middle-class patients as consumers; indeed, public relations gurus hold seminars on upping “satisfaction” ratings.

In contrast, providers in Sandtown see their patients as people-to-be-treated, not consumers. At least that is the perception of patients, who reported curt encounters with staff who prescribed plans, yet offered no explanations or follow-through. Admittedly, the ghosts of the Alabama sharecroppers who participated in the Tuskegee experiment (physicians withheld treatment for syphilis, because those men were enrolled in an experiment) and Henrietta Lacks (physicians used her cancerous cervix cells to create an immortal line for research without compensating her) hover: Many Sandtowners distrusted their physicians. One woman feared that if she sought treatment for a sore leg, physicians would amputate. In Sandtown providers and patients veiw each other across a historical minefield.

In a variation of “blame the victim,” public health experts blame the poor health of poor patients on smoking, drugs, and obesity. Ironically, and sadly, the program they created for poor people may shoulder some of the blame. In Sandtown, some patients, now covered by Medicaid, reported nostalgia for the care they received when they were uninsured.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, April 1, 2016

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