America Is Where Majorities Face Discrimination By Design

Majority rule is valued in America as are protections for minorities. But America is a land where majorities are treated poorly and small numbers benefit most. Health care is a great example of reversals of American values and value based care may be one of the worst examples.

The United States designs increasingly favor those most associated with concentrations of dollars, education, people, and health care with most of the US population left behind – and getting worse by design.

Majorities Left Behind

• Racial and ethnic populations will become a majority sometime in the 2030s. Improvements in this future majority are lacking.
• Primary care is a majority of health care services most abused by design. This 50% of services is valued least with only 5% of health spending. Primary care faces long term payment discrimination along with mental health, women’s health, and basic surgical services.
• The 2621 counties lowest in health care workforce will increase from 40% in 2010 to 50% of the US population by the 2050s. These fastest growing counties include 32% of the urban population or 90 million people that represent a previously unrecognized population facing discrimination in health and other designs.The lowest concentration counties include 97% of the low education counties in the US.Their lowest concentrations of health care workforce will get lower as their populations increase. There is little or no evidence of any improve in their workforce levels. They also face discrimination across health, education, economic, and social support lines that will compromise what remains of health care and health outcomes.
• These lower concentration county populations that are least valued by designers, depend most on lowest valued generalist and generalist services that are 90% of locally available health services.
• Attempts to expand health insurance appear to be a great idea, but what good are health insurance expansions that fail to return dollars to these counties because the workforce is paid less and is largely missing by design? These counties have long faced the discrimination of concentrations of the worst public and private health insurance plans. Expansions of plans that treat patients, providers, and populations worse have hurt, not helped.
• Over 50% of the population will have significant challenges as Americans are getting older and poorer and the health care insurance design is making them poorer. The housing design is failing in higher concentration counties as affordability of housing worsens and availability declines. This forces millions of Americans into difficult choices - to become homeless, to move in with family or friends, or to depart counties higher in concentrations of workforce and social supports to go to lower cost counties with lower concentrations.

The Basis for My Concerns

I have been teaching, researching, and delivering basic health access for over 30 years. My concerns were raised by the economic maldistributions with 1% doing best and most doing poorly. My initial physician concentration studies using census data and the AMA Masterfile demonstrated that 1% of the land area of the US or 1100 zip codes with 10% of the population had 45% of physicians and well over 50% of health spending. Over 60% of the nation was left behind.

I moved to county based studies to look at county groups behind by design. I stacked counties by concentrations and tallied up population numbers to examine the 40% of the US population lowest in local health care workforce. There were 79 Counties with Top Concentrations and 10% of the US population, 152 with 20% of the population with higher concentrations, 286 with 30% of the population in med to lower concentration counties, and 2621 counties with Lowest Concentrations of MD DO NP and PA. 

The adjacent counties were also examined for physician concentrations in the final selection of lowest concentration counties. Those adjacent to counties with higher concentrations were omitted from the lower concentration category. This translates to greater travel across a county or two just to get basic health services.

The Undiscovered Country - Red Counties

In the process of examining the lowest concentration counties, there were discoveries regarding the demographics. Not all rural populations have lower concentrations of workforce. Rural is a designation for population density, but is not specific to workforce density. Large systems that happen to be in rural settings are a major reason.

In contrast, lowest concentration counties are specific to densities of health care professionals and densities of health care dollars spent. It is a better measure of what is valued and what is not - in health care and in populations.

• About 75% of the rural population is found in these counties or about 40 million people.
• About 32% of the urban population or about 90 million are found in lowest concentration counties.

These lowest concentration urban populations that are predominantly white that also lose out and get little attention. They have little political power and their health and education areas demonstrate this. They do not rate well in their states or in the federal designs. They map out as the Red Counties in the last presidential election.

Not all in Red Counties have voted Red over time as their vote has not been consistent. But what is consistent is their abuse by both parties and by federal health care policies and administrations.

Consider that the Red County voting patterns may reflect the awareness of being abused but not the specific understanding of the methods of the abuse. Sadly many believe the deceptions showered upon them and fail to grasp the importance of various health, economic, and social support designs. For example they may believe the stories about people milking the disability and welfare funds, not realizing that their local economics, jobs, and more are at stake. They certainly can see examples in their communities.

But they do not realize the importance of the dollar distributions. About 42 - 45% of the Food Stamp, Disability, and Social Security dollars go to this 40%. These dollars also go directly to them and not to someone who diverts the funding - as seen with agriculture support programs or education funding. If they understood that their difficulties with food deserts and supporting local business and health care, they might be more supportive.

Lowest Concentration County Health Care has clearly been compromised.

The practice and hospital closures are specific to these counties and are specific to the health care design. The discrimination is not hard to see after you examine health care workforce and dollars from their perspective.

Readmissions penalties at the highest levels were sent to the hospitals in these counties - counties with concentrations of the population that inherently have lesser outcomes to go with lesser workforce and lesser social support. The top penalty at year 2 of Readmissions was 1 to 2% and this was forced on

• 14% of Lower Concentration County Hospitals
• 9% of Rural Hospitals
• 5% average
• 3% of Urban Hospitals

CMS was informed by consultants and advisors of the discriminations in the readmissions, MACRA, Star Ratings, and other designs. It has been specifically advised about the problems of small numbers, year to year variation, measurements that are not specific, and difficulties in regression analysis. It has ignored the advice. The discrimination continues. Those who care for populations that inherently have lesser social determinants, outcomes, workforce concentrations, and social support resources - lose along with their local population denied the cash flow, jobs, economics, and social determinants from health care spending.

CMS has also acted to favor those who measure - and these additional billions added each year are taken away from the providers, practices, and populations most in need of dollars. This also is discrimination by design.

Stop Killing Primary Care

The Deep Squeeze Financial Design

Faster Growth as Local Health Care Shrinks By Discrimination in Payment Design

This 40% of the population that was 130 million people in 2010 will become 50% of the US population by the 2050s. This is due to faster growth likely to increase as Americans have more difficulty with income, housing, and debt including medical debt. COVID issues involving jobs, health impacts, and inability to pay rent will accelerate their departure from places with costs of living and housing too high. They will join others in these counties that cannot leave as the costs are too high in counties with higher concentrations of health care workforce.

Basic services dominate local health care in these counties.

The designers fail to understand what is of most value to the 130 million in these lowest concentration counties. They do not have the highly specialized services - the ones that benefit from insurance expansion. They have the general services and not enough workforce. Insurance expansion matters little to them. In fact their problem in 2010 was not lack of insurance, their problem was worst insurance plans that support their local health care least.

About 90% of locally available health care is provided by lowest paid and least valued generalists and general specialists – mental health, women’s health, and basic surgical services. Paid 15% less and lowest in collection rates has long translated to half enough primary care and general specialists.

Designers Total Lack of Primary Care Spending Focus

Primary care spending has been a focus for me for decades. When our rural medical educators organized 2 decades ago, we planned to develop such studies. We wanted to expose the health insurance nightmares and the states that supported primary care poorly.

We found little support from family medicine associations – the physicians most abused by the financial designs.

Only recently has the Graham Center undertaken this project and published what was already known that only about 5% of health spending goes for this 50% of health services. Even then the family medicine power is revealed as powerless as only a few states have attempted to increase health insurance plan primary care spending - too little and too late given the horror story of primary care and COVID.

The failure of funding focus hurts family physicians the most.

Family physicians are 3 times more likely to be found where needed in rural or in lower concentration counties. About 36% of family physicians are found in these counties with 40%. No other source comes close. Only MD DO NP and PA serving specifically in family practice positions distribute at levels approaching parity at a ratio of 1.0 or 40% for this 40% of the pop. The 0.9 ratio is very good, considering the worthless financial design for primary care in these counties. But sadly the MD DO NP and PA are all moving away from family practice positions - following the health care dollars to more specialized care and toward higher concentration locations. See How Family Physicians are paid less where they are more likely to be the primary care workforce. FM remains the same concentration as other sources melt away with a worsening financial design.

Family physicians in the 1970s and early 1980s had 80 - 90% primary care careers with 30% rural location rates. Recent graduates have half of those contributions. There is better support outside of primary care in hospital, urgent care, and emergency room environments. Office based family physicians are down to 16% rural in location. Hospital based family physicians are 24% rural. Better financial designs work. Worse designs fail.

But family practice is once again not valued

... so it is going away as in the 1950s and 1960s. And there are no organized campaigns successful in increasing the public perception of value. This was the organization necessary in returning family medicine to a formal training specialty and building family medicine to 3000 annual graduates by 1980.

The PA family practice groups are in disarray. Too few enter and even fewer remain. They represent a small and underfunded minority - with less impact upon physician assistant and other associations. PA family practice once claimed 54% of the PA workforce in 1984 according to AAPA data. The more recent indicators are about one-third of this figure. Even in the 1990s with somewhat stable health policy involving primary care, the PA primary care workforce steadily departed from primary care as demonstrated in the Larson WWAMI studies.

Nurse practitioners enter primary care at low proportions - especially compared to 45% training as FNP. NP and PA turnover has always been higher. As NP and PA have gained more recognition and have had decreased restrictions limiting then to primary care and to locations in need of workforce - they have followed the financial design away from primary care and where most needed as have physicians. They have replaced non-primary care physicians and have added substantial health care costs with non-primary care services.

Training Cannot Fix Shortages of Primary Care and General Specialties. Only the Financial Design Change Can Do That

I have developed and promoted rural pipelines as the means to the end of rural family physicians for over a decade. So I understand the attraction. But the economic picture is very clear. These counties need 90 billion to invest in primary care. The decline to 30 billion and falling will not help them.

The myth of training as a workforce solution remains. Simplistic thinking indicates that more graduates can fix deficits - except those graduates need the funding support specific to the careers needed and the locations in need. Funding fails in both areas.

Family medicine leaders constantly promote more graduates and so do DO NP and PA leaders. New sources see the opportunity to chime in and some old sources want air time such as international graduates. They have little hope of working as a solution. International Graduates have been some of the worst when you consider low contributions over a career

DO and PA studies clearly show no gain. Each doubling of graduates has been accompanied by half as many in primary care for no gain. NP numbers in primary care are up - as NP replace departing primary care physicians - also for no gain. The proportions of NP in family practice continue to decline. NP and PA have followed the financial design to more new specialties and subspecialties with more added to each new addition - leaving primary care and especially family practice position result farther and farther behind. Independent practice and deregulation have also contributed to the decline of primary care, rural, and underserved positions for NP and PA.

Expansions of family medicine residency graduates or pipelines to rural practice or primary care cannot work. More graduates contributing less is inefficient and ineffective.

FM residency graduates of the 1970s and 1980s had 80 - 90% in primary care for a career with 30% rural distribution. The more recent graduates will have half of the primary care and rural primary care contributions. About 1400 of the 1980 graduates will provide the same primary care contribution as 3200 more recent graduates.

To fix the pipelines, recruitment problems, retention problems, lower productivity issues, and address burnout - a financial design change is required.

From solo rural practice and across 4 states and 4 institutions and numerous research projects – there is no hope for training to address deficits.

There Is No Logic with Regard to Training More MD DO NP PA or FM.

Indeed, the massive overexpansions of MD DO NP and PA graduates would have easily resulted in sufficient workforce with any reasonable funding design.

• It is the funding limitation that prevents any and all training interventions from increasing these counties from half enough toward sufficient.

Medicare for All cannot work because primary care remains least valued and lowest paid. Much background work is needed until a Medicare for All would be meaningful in key areas such as redistribution of health care dollar to the places and populations most behind and those who serve them, who are half enough by past and present designs.

Even Primary Care for All cannot work.

Having a card to access primary care is meaningless unless the local investments in primary care move from 30 billion to 90 billion for these 135 million Americans. A 25% share of primary care spending adjusted for 15% lower office payments in Medicare 2011 data results in about 38 billion to invest in primary care in 2008. There is no progress toward a doubling of team members and health professionals to resolve deficits for these 2621 counties most behind. In fact we are going the wrong way with stagnant spending and increasing costs of delivery.

You can make the case that more specialized care will need to be centralized and concentrated - but this argument fails for basic services and basic health access. If you want to fix Basic Health Access where most Americans most need care - you must finance it. You cannot fix it with technology, rearrangements, and innovations. Primary care is about people serving people and these people that deliver care and caring require support.

The 2010 reforms and innovations since have devastated primary care where needed.

They have resulted in 8 billion less to invest in primary care because of HITECH, MACRA, and Primary Care Medical Home at only 30% penetration. Many practices could not afford these and get penalized for a double or triple discrimination.

Primary care expanded for all requires the successful organization of primary care specific to rural and lower concentration county health needs.

Local organization is important such that health care is specific to those lacking in health care. See SERPA. Also our nation needs to understand the abuses that arise from the current health care design specific to these counties. Punishments designed to curb overutilization and punitive to areas that suffer from underutilization and discriminatory payment designs.

Primary Care Forced Away from Higher Functioning or Patient Centered Care

The popular reforms that might improve primary care indicate the need for more and better team members to deliver the care. The designs steadily result in fewer and lesser delivery team members. Small and medium size practices also face greater consequences from the usual disruptions such as changes in billing, EHR, key team members, location, and ownership.

The inevitable result is the continued compromise of care and caring and productivity with turnover and burnout increasing to make finances even worse.

Our nation would be wise to recognize these counties and their substantial role in politics.

The 2621 counties lowest in health care workforce are a combination of Rural and Urban as well as Red and Blue in the last election. These counties have 75% of the rural population and 32% of the urban population.

This 32% is currently not recognized as a population facing discrimination, but the designs of health care, education, and economics treat them as poorly as rural populations are treated. And they have many of the same characteristics involving deficits of health care workforce, lesser social determinants, lesser outcomes, and more chronic diseases.

The Red Counties combine with the predominantly Black, Hispanic, or Native rural counties to tally up the counties lowest in health care workforce across physicians, physician assistants, and nurse practitioners.

In combination with inner city and other populations most behind – there is already a majority of the US behind by design.

But it will not be long until these 2621 counties will represent a majority of the US Population.

Their practices and hospitals are paid 15 to 30% less. Their costs to address innovation and regulation have been relatively higher. Their costs of delivery often go up faster – a function of being smaller and less organized. Their health insurance payments also suffer for the same reason.

Power to the People - Time to Organize

The lowest concentration counties need to understand just how much the health care design discriminates against them and how important basic health services are in contributions to the local economy. They need to know other major contributions to their well-being such as Meals on Wheels, Food Stamps, early education and child development funding, and funding for disability, Veterans benefits, and Social Security. These represent improvements in cash flow, jobs, social determinants, and basic health access as well as better outcomes across health and education. Politicians should not even be able to discuss cuts in these areas without a chorus of protest.