For ye have the poor with you always, and whensoever ye will ye may do them good…
– Mark 14:7
We’ll be the first to admit that there are many, many people who are more observant, eloquent and articulate than we are. Many of those people are physicians. So when one of them speaks up on an important subject that does not normally receive a great deal of attention in the conventional media, it is only right that we try to draw some attention to what they have to say.
This is certainly the case with a comment written by Dr. Edward A. Cutler that we recently read on a physician networking website. It was written in response to a post that expressed the utter frustration felt by a doctor who was taking care of a Medicaid patient who was clearly abusing this publicly funded healthcare system for the poor. Here’s how Dr. Cutler, a pediatrician, responded:
“There are two kinds of Medicaid patients. There are those who need Medicaid and other benefits to get minimal health care, and there are those who simply game the system to get others to pay for their needs while they pay for their wants.
This afternoon I saw Robert, a 19 year-old boy, to re-evaluate his ADHD and to refill his medications. He is home schooled in ECOT, “the electronic classroom of tomorrow,” but he is nowhere near graduating from high school. His parents can barely read or write.
Robert was playing a video game, and I asked him to show it to me. It was so complicated I could not figure it out.
He asked me if I had a Play Station 3, and I replied, “No.” He had one.
He asked me if I had cable TV with hundreds of stations and HBO. I said I did not; he said he did.
He wore better clothes than I have.
He has lived in the same house in The Bottoms for most of his life. His family has section 8 housing and pays about $100 per month to rent it, and gets subsidized utilities, and food stamps. The family of four receives more than $30,000 per year from SSI.
I have lived in the same house in The Bottoms for 30 years. The Bank of America has foreclosed and will not let m pay it off and will probably sell it on Friday. I pay hundreds of dollars per month for property taxes, water, sewer, electricity, and gas.
Robert eats steak, burgers, and a lot of fast food. Often I eat porridge, potatoes, and eggs because they are inexpensive and nutritious.
I asked Robert why his brother, Michael, did not show up for his appointment.
“He had to work,” Robert told me.
“What kind of work does he do?” I asked.
“He is getting $400 tonight for removing some trash from a basement.”
The members of this family let us pay for their needs; they pay for their wants, and they pay plenty.
My next patient was different. Sadie, an eight year-old girl arrived with her father one hour early. Father said they had to walk 4 miles to get here (and it was a cold day) and didn’t know how long it would take and didn’t want to be late.
Their clothes were obviously from the thrift shop, adequate but not stylish.
I asked what they were going to eat for dinner, and they said beans and cornbread.
“Could you schedule next month’s appointment on a Tuesday instead of Monday?” father asked after I gave them a Monday appointment. That way I’ll be able to sell my blood on Monday, and we’ll have the money to take the bus.”
Our challenge is to eliminate freeloaders like the first family without hurting those like the second.”
In terms of Dr. Cutler’s message itself, we really have nothing to add. He is as right as the Earth is round, water is wet and the Sun is bright. However we would like to comment about why his thoughts are so unusual in public discussion, so powerful and so important.
Just about every clinician can tell you stories about patients who might as well be stand-ins for Robert and Sadie. One of the blessings and curses of life as a physician or nurse is that one gets an unadulterated view of people as they really are, warts and all (no pun intended). Quite frankly, this sort of personal, real-life contact is one of the most important things that differentiates those who would be wise from the vast majority of administrators, politicians, academics and the sort of people who would wage class warfare by invoking the sanctity of the “poor” over the greed of the “rich”. If you deal with enough of them, one inevitably comes to realize that the innate behavior of homo sapiens is perfectly immune to petty distinctions such as race, gender, income level or social status. The rich have no monopoly on greed and selfishness, just as the poor have no corner on the market for either hard work or laziness.
These are the sorts of details that never seem to make it into position papers, scholarly books and political discourse, mostly because the people writing them have never actually had to work with whole segments of the population such as the poor, the sick, the addicted, those in private industry. It’s why one can make calculated, meaningless statements like “the rich need to pay their fair share”, while “the poor are just trying to make a living”. “The rich” – especially if you define them as households making over $200,000 per year are no more a homogenous group than “the poor” if you define them as those having an apparent income of $22,350 for a family of four. These things say nothing about the behavior or character or deservedness of the individuals involved any more than the color of their skin.
The heterogeneity that exists within arbitrary groups of people – and conversely the consistency of human behavior across social divides – is typically what dooms most of the well-intended social policies that are broadly intended to benefit those who are perceived to be in need of assistance. This is because the vast majority of these policies assume that the occupants of this group or that are equally needy, and that individual attitudes and behaviors are somehow irrelevant to the desired outcomes. Nowhere is this truer than in healthcare, where individual attitudes and behaviors are often the single most important deciding determinant of who gets sick and who stays well – of which patients incur large costs, and which one utilize care cost-effectively.
One result is that many of society’s efforts are completely unappreciated, and therefore wasted. If individuals do not appreciate or value the resources that they are given, those resources will be squandered. This is especially the case if those resources belong(ed) to other people and frittering them away carries no personal penalty.
A simple example can be seen at a large medical clinic of our acquaintance. As a result of long experience, all of their Medicaid patients are always scheduled at the end of each day? Why? Because 70% of them fail to show up for their appointments; appointments that others would have taken gladly. Management would like to charge a no-show fee in order to motivate patients to keep their appointments, but Medicaid forbids this because the patients are “poor”. But since the no-shows have wasted appointments others could have used, new patients (Medicaid patients included) must wait 2-3 months before they can be seen.
So month after month, some poor people are depriving other poor, sick, and even desperate people of healthcare. Technically this is not a crime, but shouldn’t it be? If the patients who are waiting to be seen suffer a heart attack, or die of their uncontrolled asthma, or wait too long before their cancer is diagnosed, who really killed them? Was it the unthinking, uncaring people who used up all of the appointments without keeping them, or the people in state government and Medicaid who decreed that there should be no consequences for depriving others of the care they needed?
This is problem with governing from an ivory tower, or even running a political campaign from one. All of those nice, stereotyping generalizations one makes to establish policy from the far right or the far left simply don’t survive their first encounter the messy reality of human nature. Not in medicine. Not in anything. People who try to make policy that way may or may not be well-intentioned, but they are certainly ignorant. Even worse, we let them keep trying it over and over and over again.
Dr. Cutler’s challenge to all of us is to resist the urge to think of how to fix groups, and concentrate on fixing individuals. This means holding people accountable for their actions as individuals. Oh sure, it’s not as easy as blithely throwing other people’s time and money at a problem. But in the long run, it’s the only thing that’s ever going to work.
[Ed. note: Many thanks to Dr. Cutler for allowing us to reprint his comments here.]