When poverty is the diagnosis

By way of Jubilee, I came across this list of healthcare principles by Tyler Cowen.  It brings to mind one of the things I considered writing about for the Inequality Symposium (but ended up cutting from my piece, as otherwise it would have gone in too many directions) — to what degree are we willing to accept that poor people will have access to lower quality healthcare?

Elias highlights this paragraph from Tyler’s piece:

2. A rejection of health care egalitarianism, namely a recognition that the wealthy will purchase more and better health care than the poor.  Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence.  We need to accept the principle that sometimes poor people will die just because they are poor.  Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree.  We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes. [emphasis added]

I suppose it is admirable, in its way, to be so blunt.  But I question whether it is indeed something we need to accept, that poor people will die because they have less access to quality healthcare.

As I wrote in my Inequality Symposium piece, almost everyone will need access to healthcare at some point in their lives.  Live long enough and you’ll get injured or sick sooner or later.  By those lights, I would call access to healthcare a need.  How much of the healthcare administered in the United States is truly necessary is an open question, but I’m going to take as a given that it’s better to get medical attention when you’re sick than to go without.

Now Cowen is obviously right that the rich enjoy nicer stuff.  But there is a difference between the need for healthcare and our other needs.  The same ingredients, prepared in roughly the same way, will nourish you just as well if they are served to you at Per Se or the local soup kitchen.  Four walls and a roof will protect you from the elements, whether they are in a housing project or a suite at the St. Regis.  And a coat from the local thrift shop will keep you as warm as whatever monstrosity Comme des Garçons is sending down the runway.  (Probably more.)  The added luxury of the higher quality items or services does not necessarily make them more sustaining.

Not so with healthcare.  A bad doctor can actually make you worse.  Not just keep you less healthy in the long run, but actually make you sicker.

I see this in my own practice all the time.  We direct all patients to Boston Children’s Hospital for emergency or subspecialty care, even though it is much farther away than many more convenient local hospitals.  Most comply with this recommendation.  Unfortunately, some do not.  And the ones who go to the local hospitals almost always get substandard care, be it cursory or outmoded or simply incompetent.  While Boston Children’s is not without its flaws (and not everyone reports a wonderful experience after going there), the care delivered is unquestionably better in my estimation.

It is also more expensive.  For patients who are covered under a tiered insurance plan, Children’s is almost always in the most costly tier.  (I have no idea where my own practice falls for any given plan, and have no good way of finding out.  But that’s a different post for a different day.)  Which means that parents may have to choose between taking their chances somewhere cheaper, or paying more than they can afford.  And I gather that Cowen thinks that’s meet and proper.  I am not so sure.

Now, quality and cost of healthcare do not correlate perfectly.  Some of the richest (and most expensive) pediatricians I’ve ever known were also some of the very worst, and when patients are treated too much like customers problems can arise.  Conversely, I know many dedicated, excellent medical providers who work in clinics that serve the poor.  But to the degree that higher quality care tracks with higher cost, to what degree are we willing to say that the poor should take what they get and be glad of it?  If their kid ends up with a worthless prescription for albuterol syrup, is that just the brakes for being poor?

I fear that some of Cowen’s other suggestions would only compound this problem.  He suggests:

4. Price transparency (mandated if need be) and real competition in the health care sector, including freer immigration for doctors, nurses, and other caregivers, and relaxation of medical licensing and encouragement of retail medical clinics, a’la WalMart style.  This helps keep the cost of the mandate to reasonable levels.

I’m all for price transparency.  The opacity of healthcare pricing is a significant problem.  But I’m not at all sure that relaxing the rules for licensure and allowing freer immigration for healthcare providers per se is the right answer.  (I favor looser immigration rules writ large, not just as pertains to healthcare workers.)  Not to be terribly chauvinist about medical education in the United States, but we at least know what the requirements are for accreditation for medical schools in this country.  If Cowen is referring to medical providers trained in developed nations, then I don’t have many worries.  But I’m not at all sure that a doctor trained in Germany or Japan is going to be any cheaper once imported.  If he’s referring to providers trained in the developing world, where standards are less clear and who we might thus expect would charge less for their services, isn’t that just another way of saying that poorer people will be getting less reliable care?  Isn’t it reasonable to presume that providers who would have a hard time meeting current licensure requirements would also be less apt to deliver good care?

I’ve already expressed my concerns about retail clinics, and shudder to think of Wal-Mart doing to medical care what it’s done for other retail products, though I will admit that they may be a good alternative for urgent medical needs provided there is good follow-up communication with primary care providers.  But I’m skeptical that the price differential between private providers and urgent care clinics will be a significant source of healthcare savings.

Finally, I’ll raise a question that occurs to me whenever cost controls are mentioned (as Cowen does in his point 5).  Should providers at a place like Children’s be allowed to charge more?  Should I, who have gone to the trouble of getting and maintaining privileges there, be allowed to have higher fees than someone on staff at Our Lady of the Worthless Miracle?  (Since pediatric care contributes a relatively small amount to overall healthcare expenses in this country, perhaps [as with Robin Hanson] my specialty will be spared the knife.)  Which costs are to be controlled and how is a remarkably fraught question.

As far as publicly provided professional services are concerned, medical care isn’t unique in its difficulties.  The plight of students in certain failing public schools is well-known, as are numerous examples when public defenders have neglected to give their clients effective counsel.  I am not suggesting that all disparities in healthcare be eradicated, any more than I am suggesting that all children are entitled to attend Phillips Exeter or all defendants are entitled to retain someone from Debevoise & Plimpton.  I’ve said before that people who are willing to pay for extra tests or referrals should be allowed to get them, even if I think they’re superfluous.  (This may or may not equate with “better” care.”)

But just as we would (hopefully) recoil from bland acceptance of an innocent man being executed because of incompetent counsel or of students graduating from high school functionally illiterate, so I would hope we would recoil from blithely accepting that some people will die because they can’t afford to go to a decent medical provider.  As in my response to the Hanson piece above, I have more questions than answers.  But I cannot believe that the best answer to the questions that persist, intractable as they may seem, is to shrug and say “that’s just the way it is.”

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. Not so with healthcare. A bad doctor can actually make you worse. Not just keep you less healthy in the long run, but actually make you sicker.

    One of my solutions to the health care crisis is to flood the market with health care provision from doctors to nurse practitioners to the guy who does little more than put forceps in the autoclave.

    To what extent would this regress doctors and/or medical care in general to the mean?

    Now, I wouldn’t argue that “anybody can do medical care” because that’s obviously not the case. (Heck, it’s not true that anybody can do windows support.) That said, it does seem like it’s something that we could be training *MORE* people to do than we are and perhaps even substantially more.

    Is this not the case? If I may use IQ as a proxy for intelligence (and, of course, we have dozens of reasons to not do that), would having doctors go from being, on average, two standard deviations to the right (if not three) to one standard deviation to the right (if not two), would that result in things being made worse off for everybody overall?

    In a nutshell, is my solution not only not practical but also likely to result in more harm than good?

    • First off, I don’t think you need to be a super-genius to be a good medical provider. I certainly don’t fancy myself one. But you do need a certain kind of willingness to deal with certain kinds of problems. What would your method of flooding the market be? How would you guarantee that what the market would get wouldn’t be a bunch of quacks delivering cheap but crappy care?

      • Well, my biggest thought would be to invoke some measure of medical school debt forgiveness in replace for placement a la Northern Exposure. Stay for five seasons, get 100% forgiveness (and back-load it to make it better to stay longer… something like 0%, 10%, 20%, 30%, 40%) seems like it would work. Sure, if you’re ultra-rich, you can pay your own way and go straight to Beverly Hills. If you’re not, you can go to Cicely, Alaska or Elephant Butte, Montana or BF, Egypt and stay there for five years and *THEN* you can go to wherever you want. Or, hey, you can put down roots. Which would also be good.

        It also seems to me that medical care, for the vast majority of cases, is not the crazy bullshit that House has to put up with. Like an airline pilot, you receive special training for when you encounter absolutely insane situations… but, for the most part, situations aren’t insane. Nurse Practitioners can do a good job fielding much of the run-of-the-mill-all-other-things-being-equal reasons that, oh, 80% of the doctor visits freeing up doctors to focus more on the wacky stuff that requires much more specialized knowledge than is required by, say, sinus infections and/or telling people to quit smoking already and/or dealing with blood work numbers that are within acceptable parameters (and the ones that aren’t can be kicked down the hall to the doctors)… and it’s less intensive to create a Nurse Practitioner than a full-blown MD.

        Is that a grossly inaccurate look at things?

        • I never before realized that some of the phrasings that I grew up with in the 80’s and 90’s meaning “middle of nowhere” had homophobic undertones.

          I would like to apologize for using them thoughtlessly and I will try to not use them in the future.

          • FWIW, I read those phrases as a dead metaphor, and don’t take umbrage when I come across them. I took no offense, and know you too well to impute anything homophobic to your motives.

          • I always assumed that the logic behind that phrase was that there’s a severe shortage of women in the hinterlands.

        • I have decided to spare you a rant about “House.” (Take that as a sign of my affection for you.)

          Both of the things you describe above already exist to a great degree. My first job out of fellowship was in an area considered “underserved” (which it was) and partial loan repayment was one of the benefits. But the area still had major recruitment problems, despite this benefit. The loan repayment program probably wouldn’t have covered the full amount of most people’s loans (I was blessed to have little debt leaving school), so perhaps it would be more effective if it were full repayment.

          I am all for NPs (I’m slightly more skeptical of PAs, but mainly because I still don’t know enough about how they’re trained, not because of an objection per se). And I do think more NPs to practice in areas where the need is greatest is part of the solution. But my understanding is that there is a serious shortage of nursing instructors, which limits how many NPs can be trained.

          • Arapaho has a program, which Clancy is eligible for. The pay discrepancy where doctors are most needed (at least from a rural doc perspective) outweighs any benefits to it. We’d still have signed up if we were going to stay, if she’d been able to find the time to get through all of the paperwork, but as an influence to where we planned to land, it’s minimal.

            There are jobs with lighter responsibilities that pay $90k more a year (at least a couple that pay over $200k more, but we’re skeptical of the kind of medicine being practiced).

          • Of all of the black holes to pour money down, it seems to me that it’d be best to pour money down the “paying to make enough professional health care practitioners” black hole.

            Now, Trumwill, when you say “The pay discrepancy where doctors are most needed (at least from a rural doc perspective) outweighs any benefits to it.”, what do you mean? It seems to me that there are parts of the country where making $60,000/year would put you in the proverbial 1% of that region (while there are parts of the country where $100k/year would merely put you in the running for a condo). Would it be worth it to be in a part of the country where you’d “only” make $60k if it put you in the 1% and playing golf with the mayor on Saturdays? Or noodling catfish, whatever?

          • Jaybird, I can’t name names since they involve places Clancy works or would work, but as proxies I will use of Colville, Washington (a place comparable to where she is now), and Fargo, North Dakota (a place comparable to where we once looked). No doubt the wages in Colville would put you in higher social standing, and buy you a bigger house, but it would take a whole lot of student loan repayment to make it financially worthwhile.

          • So let’s assume 100% loan replacement if you can gut it out for five years. Would you guys have been willing to live in damned Fargo for wages that put you in, say, the top decile of the region?

            Hell, maybe that should be an open question to everybody.

            I mean, the idea of being a big fish in a small pond has upsides.

          • Jaybird, I could write a whole post on this and will add more when I’m at my computer again, but Fargo is actually the proxy for the big city with the high wages. Colville is a town of about 5k an hour from Spokane where pulling in significantly less might put you in the top 1%.

            So let’s frame a hypothetical of Fargo at $230k a year with less call, more amenities, but less social standing and no loan reimbursement, and Colville at $140k with a ton of call, loan reimbursement, and you’d be among the town’s elite.

            I’ll have to look up the average student loan, but we came out of the gate at $100k because my wife got a full ride for undergrad and attended an in-state medical school. So we might not be as inclined towards loan forgiveness in lieu of higher wages as some.

          • Okay, so back to this… the average student loan debt is apparently $161k. That is, of course, a lot of money. We’re sweating over less money than that. If you set up an account to pay off the student loans in return for five years of service, you’re looking at essentially adding a little less than $35k per year. Except that if you take a job that pays $35k more, you’re getting the money upfront while debt-forgiveness is likely to be backloaded.

            That’s a tough sell, except for doctors who want to be in small towns. They do exist, but not enough of them. Flood the market with providers, it’s possible that you can find more. There are logistical problems, though. Spousal work is hard to find.

            Debt forgiveness itself doesn’t make a huge dent here, unless the pay is equal. In our experience job-searching, pay tends to increase with the size of the city provided that spectrum-of-practice remains constant. A lot of city and suburban docs get paid less because they focus on clinic work. My wife performs obstetrics and c-sections, which makes her more profitable to an employer. The larger a place is, the less likely it is that they will let a family doc do the sorts of things that Clancy wants to do (it depends on the state, though, which is why the Fargo-sized city allows it while a city half that size in another state wouldn’t).

            So… it’s going to be tough, no matter how you look at it. Lifestyle takes a hit as well, though flooding the market with providers might help with that. If you can get the providers to go to underserved areas. This is somewhat self-interested of me of course (I say somewhat because Clancy is likely leaving rural medicine), but I just about think the only way is through direct financial inducement. Salary supplement. Or, alternately, accepting that people are going to have to drive a couple hours to get to the hospital.

            It’s a tough problem.

        • Why debt repayment instead of taking the more straightforward approach of paying more? It seems weird to pay people based on how much debt they have.

          Is the idea that there’s a significant number of doctors who really want to work out in the boondocks, but some can’t afford to because of student loans, so if you add a debt-repayment perquisite you can them all but only pay extra for the ones who have debt?

  2. ” so I would hope we would recoil from blithely accepting that some people will die because they can’t afford to go to a decent medical provider.”

    Insulin pumps are associated with significant reductions in diabetes-related complications, as compared to needle injections. Insulin pumps are also vastly more expensive than needle injections, both in the initial outlay and in the continuing supply.

    “sometimes poor people will die just because they are poor” is a deliberately inflammatory way of putting it–some call it “glibertarian”, others just call it “trolling”–but it’s not as though there aren’t specific instances where the reduced-cost treatment option leads to genuinely poorer health, along with reduced quality-of-life; and where the price difference is covered by the patient. (While it’s true that insurance does provide assistance for the cost of insulin-pump therapy, getting needles and lower-spec insulin to go with them is generally free with any kind of coverage at all.)


    “But just as we would (hopefully) recoil from bland acceptance of an innocent man being executed because of incompetent counsel or of students graduating from high school functionally illiterate, so I would hope we would recoil from blithely accepting that some people will die because they can’t afford to go to a decent medical provider.”

    Weeeelllll, except that the former examples you present are examples of failures, whereas according to market theory the latter case isn’t actually a failure. It might have horrible consequences, but it is not an improper functioning of a market when someone who cannot afford a good does not possess that good.

    • Your insulin pump example is a good one, and does illustrate an area where the affluent can afford better outcomes without depriving the poor of at least a decent baseline of care. I do wonder if it’s a false economy, however, in that the poorer outcomes for non-pump diabetes care don’t simply shift the shared costs down the line.

      I don’t know Mr. Cowen from a hole in the ground, so I would never presume to speak for his motives. I took him as sincere when I read his piece, and am wary of dismissing his thoughts as mere glibness. But I certainly am not willing (similar to Elias, I’d wager) to simply let poor health outcomes for poor patients simply be a norm, which is how I took his statement.

      And while I think market solutions can be a workable part of healthcare reform, I think the issues I raise in the OP argue against relying on them.

      • I understand poorly controlled diabetes is…expensive, over the long-term.

        Of course, that goes back to Ben Franklin. ounce of prevention and all.

        • But isn’t that part of how health care has gotten so insanely expensive?

          Rather than having an ounce of prevention to avoid a pound of cure we’re throwing a crap-ton of prevention in one ounce doses to avoid that pound of cure. And in some cases we’re not even sure it’d cost a pound to cure or if we even want to cure it.

          • From what I’ve seen, the evidence on the cost-saving properties of preventative care is mixed at best. However, a lot of preventative care that doesn’t actually save money does meet the lower bar of cost-effectiveness, meaning that it has a relatively low cost per QALY saved. Theoretically we could save money and get better results by spending more money on preventative care and less on treatments, but I don’t think that’s politically feasible because of the optics around denying care to dying patients.

  3. It seems to me that the bolded sentence would utterly unremarkable and true if we were just asked to accept the fact that sometimes poor people will die just because they are poor. Of course they will. We could throw everything we have at that problem and not change the fact that sometimes they will.

    But there are a variety of principles we could derive from this fact. Cowen’s basic principle is, Let’s not screw up our health care institutions by his lights (which, however he defines that, is an outcome that has to have a threshold border, however fuzzy it is to him or us) by, well you can read what he said. I don’t really know what he means by, “one very select set of factors which determine health care outcomes,” but presumably he does.

    I actually think that’s pretty reasonable, but what that principle doesn’t inherently imply is that there isn’t a lot of room within that constraint to make less unequal, perhaps much less unequal, the access to life-saving and life-extending health care enjoyed that the poor enjoy unaided (and they are of course not unaided as it is – but do we know they are aided as much as Cowen’s constraint allows?) as compared to that enjoyed by the wealthy. That is simply an empirical question that depends what it means for our health care institutions to be screwed up in the way Cowen means.

    In other words, we do have to accept that *sometimes* the poor will die just because they are poor. But we don’t have to accept that more rather than fewer should. If we can cause fewer rather than more to, we should want to do that (or at least, I’d like to ask Cowen if he agrees with that absent constraints), up until the point where compelling constraints cause us to conclude we shouldn’t do more to lessen the number. Screwing up our health institutions, assuming we can agree on what taht means, seems like a compelling threshold of constraint giving us a place where we should stop trying to lessen the number of people who die just because they are poor. The thing I’d be interested in hearing from Cowen about is whether he agrees that we should continue aggressively seeking to lessen that number through public policy including lessening inequality of access resulting from wealth and income inequality up to a point that we could in theory identify as a reasonable safeguard-stoppingplace against screwing up our health care institutions. I have a feeling he doesn’t, but if so the argument for that view, that I can see, isn’t given by the principle he asks us to infer from the fact that sometimes poor people will die just because they are poor.

  4. I believe the “very select set of factors which determine health care outcomes” refers to medical care, in contrast to lifestyle and other nonmedical factors that affect outcomes.

    Note that this isn’t an American thing—the well-off still have better health outcomes than the poor in countries with universal health care. Canada, for example.

    • That was supposed to be a reply to Michael Drew’s comment, immediately above.

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