My friend and mentor, Dr. Jeff Thompson, introduced me to the concept of the poverty-healthcare vortex. I initially thought of it as a cycle. However, vortex is a more accurate description as it is a downward spiral for many people in this country.
The single greatest threat to health
In essence sixty percent of all personal bankruptcies are a result of healthcare charges. Seventy percent of those who go bankrupt due to healthcare charges have healthcare insurance.
And poverty is the single greatest threat to health even in the United States of America.
Given those inconvenient facts, the calls for taking away a safety net like Obamacare so that the public has access to the physicians they want, or that we deem it unconstitutional, seems rather disingenuous.
Rather than focusing on the government and the political blood sport around this issue, I’d like to focus on what is being done, and not being done, by hospitals, healthcare systems, and medical universities that is directly and indirectly contributing to the poverty-healthcare vortex.
Important Questions: On Missions & Salaries
To begin with, let’s ask a simple question: if one of your missions is ensuring the health of your community, is it ethical to pay your workers a wage that permanently stratifies them to the lower class, or even poverty, with no upward mobility?
Many workers in hospital systems have wages running between $13 and $19/hour. In a city like mine, it is not possible to live within the surrounding county on those wages.
Many of these workers need to hold additional jobs to make ends meet. Add a family and a couple of kids into the mix and they will have almost no savings. Throw in a high deductible on their health insurance and they are one illness away from crushing poverty.
Now let’s look at another variable in this: physician and administrator salaries.
I know of one hospital CEO who makes between $6 million and $10 million/year while running a hospital in one of the poorest cities in the country. I also am aware of surgeons pulling down seven figure salaries while nurses, surgical and sterile processing techs who are equally important to the delivery of quality surgical care fight over the scraps.
Since there is a limited pool of money in any healthcare system and margins are tight, it is equally reasonable to ask: is it ethical to pay an exclusive group of high fliers this much? Particularly if it forces you to pay others too little?
One also needs to ask why some physicians are comfortable demanding and accepting such high salaries.
One reason is the outrageous cost of medical school. Tuition alone can run up to $70,000 per year. This does not include room and board which is at least another $18,000 per year. This adds a massive amount of debt often piled on debt from college.
Furthermore, most medical school graduates may be able to make a payment on the interest on their loans once they start residency, but they won’t be able to attack the principle until they have their first real job.
Given these additional inconvenient facts, is it any wonder that that they select high paying sub-specialties in more urban settings as opposed to becoming rural primary care docs?
The migration towards non-primary care specialties also contributes to the poverty-healthcare vortex by reducing the number of physicians in rural areas. This limits access to quality healthcare and requires families of limited means to travel long distances, stay overnight, and pay out of pocket for lodging while a loved one receives specialized care. That may seem inconsequential, but $250 a night in a hotel over 4 nights can be devastatingly expensive to a family of limited means.
Three Solutions to Push Against the Vortex
In laying out these arguments, solutions become evident:
First, there is a need for a safety net. I know some will use the “S” word to describe it, but it works in wealthy successful countries like Norway, Denmark, and Sweden. We may not eliminate insurance, and we may not have to, but letting people fall through the cracks into the abyss of poverty hurts healthcare systems and communities economically as much as it hurts the very people in freefall. Without insurance, impoverished people seek care when they are the sickest and healthcare systems end up eating the bills that don’t get paid.
Second, there needs to be an adjustment to the salaries of workers on the low end of the wage scale. Jobs like sterile processing (which is high tech, high stress and high throughput) as well as environmental services are critical to the safety and performance of any healthcare system. They need to be recognized as such.
Finally, something needs to be done about medical school tuition. NYU Langone cannot be the only school waiving tuition. Other schools, really all of them, need to follow suit and significantly reduce the cost of medical education. Otherwise we will continue to generate more and more subspecialists and fewer primary care docs. And without the primary care docs how will we ever be able to manage community health?
I am not saying these three steps alone will stop the poverty-healthcare vortex, but they will ensure that healthcare systems, hospitals, and medical universities are at least no longer contributing to the problem.
Peter Nichol, MD
Beyond Clean © 2019