Red County and Lowest Health Care Workforce Counties Matter

Designs for health care consistently send fewer dollars for the basic care of most Americans - the ones who are most behind. Many Americans recognize some of the challenges facing racial or ethnic minorities, or those lower in socioeconomics and social determinants, or those with geographic inequities - but few realize that half of the United States is compromised. They are least valued and most abused. Health care design is an example of this inequity by design.

The US has many smaller minority populations that face inequity. But there are large US populations that are not recognized as suffering the abuses of bad designs. For example about 32% of the urban population or 90 million people are behind in health care in 2621 counties lowest in health care workforce. This essentially maps out as the Red Counties in the last election.

• Red County People need their lives to matter.

This is a Controversial Phrase at the current time, but there are reasons to be supportive of the Red Counties where at least a majority voted for Trump the last election. And in past elections there are important differences. Do you fault people for desperately wanting some change when they have been behind so long?

All of those who have stood alone - should stand together.

The Red Counties plus the Predominantly African American and Hispanic and Native American counties in rural areas together make up 40% of the US population. They share common ground regarding designs that hurt them, even those intended to help them. They have often had to compete for the same declining portions of state and federal spending in health, education, and other areas.

• Pitting minorities against one another has been a great way for those in charge, to prevent necessary changes and reforms.

If Black Lives supporters understand the long term mistreatment of the 40% of the nation in lowest concentrations of health care, they would stand up for Lowest Concentration Counties also. The same would hopefully be true of those in lowest concentration counties standing up for minorities being abused. None of us should tolerate bad mouthing of those in poverty or those behind in education or those on welfare.

Minorities behind by design make up a majority of the US population

These population should become one and should demand and get better policies. Medicare and Medicaid represent such a coalition as those advocating for the elderly and those advocating for the poor stopped competing and cooperated to establish the initial Medicare and Medicaid designs. Sadly these designs have been changed such that they cause injustice, inequity, and declines in basic health access.

To Understand Disparities Impacting Most, Categories Must Include Most Americans.

The Occupy Movements focused on necessary economic and financial changes - and tried to fight designs that shape 1% doing well and most doing poorly. This is indeed the case, and they are losing like most of us.

But health care design has not been seen as a reason for worsening disparities - until you begin to categorize and put the various minorities together. Categorizing counties by concentrations of physicians is one way to do this.

About 40% of the US population is clearly behind and is falling more behind, by the designs of health care and other designs. When you combine this 40% with minorities segmented off and living in counties with higher to highest concentrations of workforce, you have more than a majority behind.

Together they could support all who are suffering by health and education and economic designs. They need a political base to establish the fact that a majority of the population of the nation is behind by health, education, economic, and other designs. Instead of focusing on "change" they could focus specifically on design changes that would help address longstanding disparities.

Once again the beginning of the end of disparities, is an understanding the situations faced and how those adverse situations, environments, and conditions are maintained.

Protest Needs to Move Americans to Action

Media exposures are great for attention and reaction, but do little to accomplish change. Changes in health, education, and economic policies represent a positive way to begin to redirect our nation and to impact future generations to reduce disparities.

The Lowest Concentration Counties Include

• The Predominantly African American and Native American and Hispanic rural counties
• Lowest income and least educated white populations most lacking in health care dollars, practices, hospitals, and access to care. These include about 40 million rural Americans and 90 million urban Americans for 40% of the US population.

The following designs and policies have worsened disparities for these populations

Health care designs for overall health spending

Less than 13% of health spending goes to support local health care for 40% of the US population, based on local physician workforce share and not counting health spending unrelated to physicians. The actual spending locally to these counties is likely less than 10%.

American health care designs concentrate workforce and health care dollars together where there are concentrations of training and research and associations and foundations and institutions and VA Hospitals. Over 50% of health spending and 45% of physicians are found in 1% of the land area in super medical center sites that are 1100 zip codes comprising 10% of the US population. In may ways most Americans are behind involving trillions of dollars - by design.

The experts would say that some concentration of health care workforce is necessary so that subspecialties can have enough patients and the proper equipment - and they would be right. But there is no excuse for the deficits of generalists and general specialists. And no one should excuse designers for paying less by 15% or more where most Americans have half enough generalists and general specialists. There is no excuse for paying hospitals in these counties most behind by 30% less.

• In health care, less than 25% of primary care spending goes to these 2621 counties via primary care practices despite 40% of the population and 45% of need
• Only 23.5% of mental health providers and 15% of psychiatrists for this 40% with 45% of mental health need
• Only 15% of geriatricians for this 40% with 45% of geriatric need
• Hospitals are closing in these counties at 1 to 2 per month with more to come because of the weakest financial design abusing these populations.

And Health Professional Leaders Constantly Use Shortages as an Opportunity to Further Their Own Goals

Deans and leaders in medicine and nursing continue to claim that training more of their kind will fix deficits. It cannot.

• When you hear that more training can fix deficits of workforce, you should get angry. Not only are they not helping, their are promoting their self interest.
• Health Care Leaders should fix disparities, not make them worse.
• And now that we have four sources producing too many, this is bad for the graduates that they produce, bad for increasing health care costs, and bad for the necessary autonomy needed for health professionals to take a stand in favor of patients rather than being subservient to their employers.

Changing Distributions of Workforce Requires Changing Financial Designs, Period

You cannot increase the workforce without doubling or tripling the dollars spent on these practices in these counties growing fastest - the ones with growing deficits of workforce as shaped by the financial design. You must reshape the financial design specific to these practices and hospitals and populations and basic services.

Health care is not alone in discrimination and abuse.

Education Designs

Education design is a dismal failure and property tax based education designs are a major reason. Federal and state micromanagement is a costly failure that causes worsening disparities. Billions more a year are spent by schools, districts, and communities to Race to the Top but these dollars go to CEOs, consultants, and corporations at the top, leaving most Americans moving further to the bottom. Federal education support is less than 7% of the budgets of the school districts left behind, but federal regulations punish the districts, schools, and teachers making their task of education more difficult. And the funding support for school districts with high levels of poverty can go two ways - to districts where poverty is high in the proportion of students (like these counties) or to districts with high numbers of such students in major metro and suburban areas. Directing support to populations with higher proportions of poverty is more likely to be helpful to these counties. Lower concentration schools that do stand up to abuses - can find themselves being closed up.(analysis by Marty Strange). And the state politicians are busy running for national level elections.

Standardized testing design discriminates against most children lower and middle income and with English as a Second Language and all of the children different than the highest income most urban children of highly educated and professional parents. All who are different are going to test differently for college and professional school. These tests also predict performance poorly. This was indicated by Thorndike and others who created and developed intelligence testing 100 years ago.

Economic Designs

Those behind have some of the most neglected and abused employees and situations - mining, manufacturing, agriculture, and other interests that force them to work harder and offer them little reward - while those who profit do better and better.

I see the need to unify all of the various minority populations into a majority that is tired of the discrimination. And health care designs clearly discriminate against them. So what is this lowest concentration population?

• About 75% of the rural population and
• 32% of the US urban population
• These counties also have 48 - 50% of veterans, disabled, and likely others lower income and having chronic diseases - that can force movement to these counties that have lower cost of living, lower cost of housing, and available housing.

Turns out that our national policies for housing are failing - and are driving more millions to lowest concentration Red Counties. Locals are forced to remain so.

• And Americans are getting older
• And Americans are getting sicker as they age
• And Americans are getting poorer as they get older and sicker - often because of our health care design.

Turns out that that these county populations have been treated poorly generation after generation. This is seen in the designs for the nation involving health, education, economics, housing and more.

These are populations sent more to war who suffer most in peace. Their lot has been cuts in areas important to them like Veterans benefits. And the VA system is least found in these counties. This design has been concentrated in concentrations - leaving most veterans outside. Only recently has some progress been made in access for this 50% of veterans distant from VA facilities. Decades ago the local providers could have been providing local care - but the designers failed to make this bold change - and caused unmeasurable suffering.

The deceptions of our time shape future discrimination. These are populations told that Food Stamps, Disability, and Social Security are bad for our nation - when they are critically important for lowest concentration counties. This 40% of the population actually gets about 42 - 44% of these "socialist" programs - the ones that are supposed to go to deadbeats. Sadly great deceptions are pushed in our nation and believed.

These are not deceptions. They go to Veterans, lower income, disabled, new family, chronically ill, and other populations concentrated in these counties. These are counties that do not have the local social support resources or the major food banks of the bigger cities.

These counties have many deserts - a popular term right now. And food deserts are made worse by worsening Food Stamps, Meals on Wheels, and other support programs.

The 32% of the Urban Population in Lowest Concentration Counties has yet to be recognized.

Black Lives Matters is a recognition of the need to change discrimination. The US has many such populations. Some are recognized and others are not.

Rural populations are recognized, even though they are not pure for disparities. About 25% of this population is found in higher concentration counties - generally where the few major rural health systems are found such as Geisinger and Marshfield. Those systems boost their economies and bring in substantial cash flow. Does anyone remember when Mayo was in small rural America - and now is major urban fueled by health care dollars? Isn't it amazing when the health care design works for you locally?

But being smaller and farther from the treasury feeding trough does not work out for these urban populations or the 75% of the rural population unified with them in lowest concentration counties. Usually these counties get little and pay a lot.

• Only 13% of health care dollars, and likely less, go to these counties with 40%
• Their generalists and general specialists are paid 15% less for office visits and are penalized more and suffer from lowest collection rates. CMS intended the data on billing to expose doctors getting too much. The date exposed the Discrimination in the CMS designs.
• Only 22 - 26% of primary care, mental health, women's health, and basic surgical specialties are found in these counties - and deliver 90% of local services. These practices largely do not get the facility fee bail out because they lack a hospital or the practices are not associated with a hospital. Without this bailout, they suffer from costs too high and revenue too low - and costs of delivery are being made higher. Discrimination by design
• And those who design health care fail to understand and compensate them for the usual disruptions of practice that hit them hardest.
• And even worse, the designers force them to pay billions more each year for meaningless use.
• Their hospitals are paid about 30% less and are penalized more and about 1 to 2 per month of their hospitals are being closed by design - before COVID. They have lost hundreds of hospitals since DRG and PPS designs discriminated against them in the 1980s. Studies clearly show that certain populations have been dealt harm by DRG design. But the designs remain.

These urban populations behind in health care design and in education design. They include some of those most solidly for Trump. They are hoping for a change perhaps, as there have been differences in past elections. They are not being helped by either party at the state and the federal level - not for some time.

It is a mistake to ignore these counties as they have been growing fastest decade after decade for the past 5 decades tracked. The Blue, most urban, highest income, and most favored counties have been lower growth and stagnant. This is a likely result of cost of living and housing higher and higher and deficits of available housing. This forces a move from Blue to Red - or highest to lowest concentration settings.

Their primary care practices had 38 billion to spend locally delivering primary care and now have less than 30 billion - thanks to HITECH, ACA, MACRA, and Primary Care Medical Home. They have lost a billion a year for innovation and regulation and another billion a year in the usual cost of delivery increases.

Discrimination By Health Policy Reforms Such as Obamacare/ACA

What seemed good, was devastatingly bad. These cpimtoes have suffered the most from hospital closures and the closures and compromises of generalist and general specialty practices - the ones that deliver 90% of the remaining local health care services. CMS has long ignored RAND, MedPAC, and others raising red flags about their discriminations by design. But CMS fails to recognize that lower workforce and lower social resources and lower social determinants and most chronic physical and mental diseases shapes outcomes. This myth of providers shaping outcomes translates to Red Lives Don't Matter.

HITECH to ACA/Obamacare to MACRA to Value Based regulation

• Readmission penalties at the highest levels were visited upon them in year 2 (1 to 2% stolen from them) despite having lowest margins already. About 14% of their hospitals were hit compared to 9% for rural hospitals, 5% overall, and 3% of urban hospitals.s and innovations were focused on improving outcomes - but clearly cannot change outcomes because of the situations, conditions, deficits, and discriminations in these populations.
• Even worse these designs required billions more a year from local providers and local populations. Primary care in these 2621 counties has had to pay 1 billion more a year - leaving less than 30 billion to invest in local primary care and jobs and social determinants where there was once 38 billion.
• Unfortunately the consequences are only seen if you understand that social determinants determine outcomes with minor changes if any from clinical interventions. If you see this, then you can understand that performance based designs discriminate against providers that care for populations that inherently have lesser outcomes. If you magically believe in micromanagement without critical review, you will not see this discrimination by design.
• Obamacare/ACA mandatory insurance coverage seems to be good only if your managed care/micromanagement focused mind equates health insurance access to basic access to health. It works if you do not consider that half of the US population suffers from proximity to have enough generalists and general specialists. It works if you think that there is health care workforce around instead of realizing that health care design has long prevented enough local workforce for most Americans. With reflective consideration of the population impacts, it is quite easy to see the harm done.
• First of all, these counties did not have a greater problem of uninsured populations. They had 40.2% of the people and 40.6% of the uninsured prior to ACA. Their deficits in workforce and health care dollars have always been about the worst public and private health insurance plans concentrated in these counties. The Medicaid and high deductible and other worst Medicare and private plans that have been expanded - were little help to local providers and remain little help. They are the ones that require costly changes for those who deliver care. They are the ones that fail to pay enough to support the care of the patients with these plans. Medicaid in particular only pays 70 - 90% of the cost of delivering care to Medicaid patients. How does expanded Medicaid help expand access when practices are paid less than the cost of delivering care?
• Generalists and general specialists where most needed do not do the procedural, testing, hospital, and subspecialty areas that reap the highest revenues to help large systems and practices make up the gap in revenue in basic areas such as office visits. If you lack concentrations of health care and lack more specialized care providers, you lose out as Procedural, Technical, Subspecialized, and Newest Created are reward. Cognitive, office, basic, and older existing services lose by design.

For the populations in these counties with lowest concentrations of workforce, the mandated health insurance costs and the tax penalties hit hard.

• Many billions more were taken from these populations with the least to give. And only ten cents on the dollar were returned to local providers for local jobs, economics, and social determinants. Often the locals could not access local health care because of deficits of health care workforce present locally and because the plans actually prevented local people from using local providers. Most people forced to add insurance did not need insurance. And the insurance received often did not protect those that needed insurance from financial ruin. Many received insurance that did not help with local health services access or abused local providers. The payments for the worst public and private insurance plans cause the deficits in workforce to a major degree. The key to understanding disparities and the way out of disparities, is working to understand how disparities are made worse by those who do not understand what they are doing.

How About Medicare for All?

Obamacare is a prime example of people trying to do good, but causing harm. ACA did not redistribute more dollars to these counties and stole more dollars from people, places, and providers in most need of those dollars.

• Keep on Task to Accomplish Real Change

You must not get distracted by a superficial change such as Medicare for All that will not address true reform until we acknowledge the abuse and reshape what we value. 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.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. Martin Luther King, Jr.