The Have and Have Nots of Healthcare

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The Have and Have Nots of Healthcare

• Economic segregation in healthcare
• the District of Columbia example.
• Gloria WilderBrathwaite, MD, MPH

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The Poverty Link

• The wealthiest 5th percent of DC residents
  (average income 186,000).
• Make more than 31 times the poorest 5th percent
  (average income 6,126).
• Over the last two decades the top 5th percentile
  of residents of DC have seen their income rise
  38 while the bottom 5th have enjoyed only a 3
  adjustment in household income.

• July 2004, Washington post
• Income inequality In DC is wider than In any
  major US city.

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What Is the Significance of the Income Gap?

• Creates two cultural groups The haves and have
  nots.
• Elite class vs. Impoverished class.
• Disappearing privileged class (middle class).

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What Is Poverty?

• Federal poverty level family of three in 2004 is
  15,670.
• If you make less than this you qualify for public
  assistance, Medicaid, food stamps, temporary
  assistance to needy families (welfare), housing
  and daycare subsidy.
• A family of three receiving welfare gets 8,112
  per year (676 per month). About one half of the
  poverty level.
• Even after getting public assistance this group
  remains well below the poverty level.
• This group is not legally permitted to work to
  subsidize this income. Is this fair opportunity?

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Where Is Poverty in DC?
Distribution of Poverty by Zip
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Percent of residents below 200 of the federal
poverty level by zip code, 2000
DC Primary Care Association
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Percent of adults without health insurance,
2001-2002
DC Primary Care Association
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Percent of adults with no regular source of
care,2001-2002
Regular source of care includes doctors
offices, health centers, and outpatient hospital
departments.
DC Primary Care Association
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Adult chronic disease burden, 2001-2002
Includes asthma, diabetes and hypertension.
DC Primary Care Association
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Avoidable hospitalization rates among kids 0-17,
2000-2003
DC Primary Care Association
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Avoidable hospitalizations among adults 18-39,
2000-2003
DC Primary Care Association
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Community health centers by type, 2004

• General primary care 29
• Homeless shelters 9
• Pediatrics 6
• School-based health centers 3
• Mobile Vans 5

DC Primary Care Association
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Size of health centers ( of patients) and pct of
pop below 200 of FPL

• More/bigger centers in
• the central part of the city
• Fewer/smaller centers in other parts of the city
  Northeast and East of the Anacostia River

DC Primary Care Association
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Location of Doctors Offices by Ward and
Quadrant, 2003
Ward of establishments 1 30 2 252 3 12
6 4 59 5 131 6 38 7 10 8 29 675
DC Primary Care Association
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So What Do We Know About the Effects of Poverty
on Healthcare Delivery in DC?

• Poor people seem to be clustered in specific zip
  codes within the city.
• These areas have the fewest safety net healthcare
  providers.
• These areas have the highest chronic disease
  burden and highest admission rates.
• The highest proportion of the cities children
  live within these poverty clusters.
• What happens when children are raised in isolated
  poverty?

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Statistics on Children in Poverty DC 2004

• About 130,000 children under 21 live in DC. One
  third of these children live in poverty (more
  than any other state in the union). 16 live in
  extreme poverty (less than 50 of the poverty
  level).
• 60,000 children live with adults who are not
  their parents.
• 53 of 8th graders score below basic in reading,
  71 in math.
• Only 10 of children living here in the
  wealthiest and most powerful capitol in the world
  read on a proficient level.

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Who are the uninsured?

• There are 45 million uninsured people in the
  United States.
• Two thirds of the uninsured in this country make
  less than 200 of poverty for a family of four
  that is 37,620 per year.
• In 2003, over 8 in 10 uninsured came from working
  families-70 from families with one or more full
  time workers.

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Why Advocate?

• Ethical care doctrine
• Is it ok to prescribe treatments that you know
  the patient cannot comply with?

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Why Advocate?

• Nonmalifience Do no harm.
• When does healthcare become harmful?

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Why Advocate?

• Beneficence Do Good.
• The higher calling of health care professionals
  to use their influence for the greater good.

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What should we do?

• Support expanded primary care and preventive
  healthcare services in health professional
  shortage areas. 300,000 DC residents live in
  primary care shortage areas.
• Build less trauma centers and more medical homes.
• Reimburse primary care at a fair market rate to
  end the economically segregated healthcare
  system. Currently primary care reimbursement is
  50 of true cost.

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What should we do?

• Provide small business loans to doctors wanting
  to start practices in shortage areas.
• Advocate for universal healthcare coverage.
  Insurance alone is not enough but it is the first
  step to ending economic inequality in healthcare.
• Access is the final step. No more public health
  only for the poor. All healthcare should be
  everyones healthcare.
• The provider of healthcare should be blinded to
  the payer.

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Acknowledgement

• DC Primary Care Association
• Nicole Lurie, MD , Rand Corporation
• Alice Rivilin and Margaret Ross, Brookings
  Institution
• Bureau of Epidemiology and Health Risk
  Assessment, DC Department of Health

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• ADVOCATE!