Monday, May 30, 2011

The Re-segregation of health care

This is very sad. Just as US wealth is being increasingly concentrated at the very top, health care is being re-segregated at the very bottom. The segregation of facilities is primarily by wealth, and then secondarily by race, because that is the way wealth is distributed.

In the beginning, say the 1940’s when my Dad started practicing, the middle and upper classes received their health care in private offices and private hospital rooms, and the poor received their care in public clinics and hospital wards. My Dad told me about it. Back then there were fewer doctors, fewer medicines, fewer procedures, much lower cost, less health insurance, and no Medicare or Medicaid. My Dad and others like him felt a social responsibility - plus there were training needs – and hospitals functioned more for public service rather than for profits. My Dad served at PGH, Philadelphia General Hospital. He pronounced “PGH” with a tone I couldn’t identify, and maybe it was reverence. “This is what we did at PGH,” he said. He was nostalgic. “We treated the patients the same as we treated our private patients,” he said. “We took a day or a half-day a week and worked there for free. It was an honor to be chosen to work there.”

By “the same,” he didn’t mean the same dignity and convenience, but rather the same basic medical care. The clinics were big and impersonal, the ward beds were like you would see on M*A*S*H, no frills, but the treatment was good. The doctors and hospitals didn’t get paid, they just did it.

But of course everything was different back then. I suppose noblesse oblige worked for those times. Poor people were grateful to get the care and there were no complaints about dignity, and few about racism. Different days, to be sure.

But in 1965 Medicare and Medicaid were passed and that changed everything. Medicaid covered many of the poor and gave them to right to be seen in offices rather than clinics, just like middle class patients, if the practitioners agreed to be paid by Medicaid. Most practitioners did take it at the beginning, when payments were fairly competitive. So did most hospitals, which improved their bottom lines. Public clinics and hospital wards persisted, since there were still relatively few doctors and hospital habits were hard to break. Even into the 1980’s at the largest of my local hospitals, private patients on the maternity wards had private or semi-private rooms, and most Medi-Cal patients were placed in larger wards with only curtains walling off the beds from one another. Yet even those larger wards vanished by the 1990’s. Still, the staff sought to place culturally similar patients in semi-private rooms (which was a good thing, I think. Picture yourself as a new mother with a roommate who keeps the TV on all the time, and is on the phone all the time, etc. Cultural clash.)

Coverage vs. Access

But then what happened is what always happens. The money devoted to care for the poor, governmental money, was whittled down. The original fees for doctors weren’t too bad – but they never changed as the years went by and inflation occurred. Is a separate program of health insurance for the poor equal to health insurance for the middle class? Maybe at first, but in time it won’t be. Separate is just never equal.

Gradually, the diminishing fees pushed more and more doctors out of Medicaid. Government didn’t acknowledge this movement, it claimed increased coverage, as more patients qualified for the program. But “coverage” does not equal “access. Here in California, the worst case scenario in the United States, we have extensive “coverage,” but the Medi-Cal fee schedule calls for about 35% of Medicare fees – which many think are already too low. Try to fathom that -- 35%!

Alameda County

Here in Alameda County our primary care pediatricians have been protected to a certain extent. Our Managed Care Medi-Cal, contract allows pays our pediatricians at maybe 80-85% of Medicare rates. These are low rates, but just about manageable to be able to keep serving our Medi-cal patients. At our practice we started with Medi-Cal patients as most practices did, but then instead of abandoning them as we attracted more private patients, we kept the Medi-Cal patients and just got bigger. This is what Medicaid envisioned, I think – one class of care. It takes some forbearance on the part of our private patients, since there are cultural differences that can grate as classes mix, but on the whole, this being the Bay Area, we have been successful.

What do patients want? The Alameda County Medi-Cal population has voted with its feet. Despite an extensive clinic system, 65% of Medi-cal patients choose private practices as their primary care practitioners. This didn’t just happen. The planners of Medi-Cal Managed Care mandated a two-plan system for each county, so the doctors had competitive plans to contract with. It also took a very public spirited Director of Health Care Services, David Kears, who believed in primary care, and believed in giving the choice of provider to the patient, and did not take the usual public health department bureaucratic route of trying to steer all the patients and all the money to their own clinics. And in addition, we primary care pediatricians got together and negotiated ourselves a decent deal, we didn’t just take what they gave us. As a result, many private pediatricians have stayed in Medi-Cal, and the original intent of Medicaid seems to work here locally in pediatrics.


But it’s not going to last. Time, finances, and the inexorable drive to discriminate is catching up with us. Nationally, the Affordable Care Act (ACA) grants $13 billion to the clinics. There will be a mandate for 2013-2014 to pay 100% of Medicare for certain primary care visits, which might actually stay in the bill, we’ll see, but that may or may not apply.

Locally, the current Department of Health Care Services and the Medi-Cal managed health care plan tied to the county, the Alameda Alliance for Health (AAH), are applying to the Feds to become a County Organized Health System (COHS). They dress up this proposal as “saving money,” although exactly how this would happen is mysterious. They say that if there were a single system they could “coordinate care” better, although the only concrete proposal to do that is to hire more administrative staff. Essentially, the COHS application is an application for county monopoly over the Medicaid program.

We have met with AAH and the County. It’s pretty clear – they want more money and power, they will increase their administrative staff, and they will reduce our payments. Like every other county government, alas. Currently, as we pediatricians negotiate with AAH, we can sign with them or leave them and switch our patients to Blue Cross Medi-cal. With a COHS in place, our new choice will be to sign or leave Medi-cal completely. That’s what a monopoly looks like.

So, add it up -- more federal money for the clinics, more money for the health department, and less money for the private doctors. Most private doctors will bolt; they will have to. The private doctors who remain run offices that you would not want to patronize. “Coverage” will once again not equal “access.”

Once again, the poor will be served in clinics, the middle class in offices. Idealistic liberals, supporters of the clinics -- socialists, really – imagine that the clinics will actually give better care than private offices, no matter patient preference.

But you have to know that their dreams ain’t gonna happen. If you think for one minute that poverty medicine will be superior to private medicine, think again. What will happen is that care will be re-segregated by income, and hence by race as well. This will be congruous with the increasing inequality of wealth and income of the last 30 years as we Latin Americanize our social fabric. I wonder what my Dad would think.

It is such a damn shame. I can only hope I’m wrong, and that things will turn around. We are fighting the COHS proposal, and maybe it won’t happen. I would so hate to see our patients who have come to our office these past decades disappear to the clinics.

Here’s hoping!

Budd Shenkin


  1. It seems that you could have a head-to-head friendly competition: AAH's COHS enrolled patients with their "coordinated care" vs. the medical home model practiced by Bayside and private colleagues.

    If private physicians can produce superior quality results in, say, childhood immunizations as community health clinics -- then that's an excellent argument to do exactly the opposite of what the AAH is pushing for. This is what ACOs *ought* to be, don't you think?

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