The Healthcare " Gap"; chapter one.

The term "Health Care Gap" so frequently discussed in these election years is largely characterized as a problem of disparities in access to healthcare and medications. While I wholeheartedly agree that there is a criminally wide gap in access to healthcare, I don't agree on where it exists.


The majority of my patients fall within one of two groups; those who have immigrated from another culture and who are in need of assistance while they work to gain a strong foothold in the economy, and those whose people immigrated one or more generations ago from another culture and have concentrated primarily on maintaining the assistance while foregoing any assimilation into the working economy. As a inherent liberal, I have always tried to concentrate my mindset toward the first group (the minority) while trying to withold any judgement toward the second.


That position works fine for me because I don't make public policy, but those who do must stop glossing over what is REALLY behind these "disparities".


Complaint One: "Doctors are too expensive for minorities and the poor to afford. Therefore they go without."

In my experience this is false. In the poor neighborhoods where I have worked, these folks fall well within the parameters for the very generous benefits of the entitlement programs, in fact most have those benefits. They just don't use them. Any doc who has been a provider for one of the Medicaid type programs will tell you that they have or considered quitting because the patients never show up. They will repeatedly make appointments and never keep them. The visit is essentially free but these patients frequently blow them off. "Well, they can't get there" you say? My office has a bus stop directly in front of it. Besides, I can usually tell when the patient actually does arrive because the walls were vibrating from the sound system in their lavishly adorned car. "They couldn't call to cancel" you say? Any doc who has had to stop his exam for the third time because the patient's cell phone keeps ringing (which they answer) will tell you that the poor have as many or more cell phones as the rest of the population. They just don't tend to use them to cancel appointments. Hey, it's free, why worry?


Complaint Two: "Medications are too expensive for minorities and the poor to afford therefore they go without".

In my experience this is false. Most basic meds for the most common problems are available for $4 at Walmart among others. Medicaid and it's equivalents have a fairly large formularies of fully covered drugs as well. The problem really is that they don't go get them or don't take them as they're directed. I can't remember how many times I have phoned in or written a prescription for an important med just to find out that the Medicaid patient never picked it up. It's free and they just don't go get them! So many docs share this story with me. Frequently when the med is picked up, it is only taken for a short time because the condition "doesn't hurt". Even when I have an uninsured patient I usually can prescribe a $4 med that can do the job. When these patients tell me that they can't afford an exam or the med, I have to wonder how much the colored contacts they are currently wearing or the gold chain on their neck or tatoos on their arms or the cell phone they have been shouting into cost them.


The real disparity here, which seques into the other "gaps" of equality is actually behavioral. If there were a disparity in our country between head injuries in the general population and those who like to repeatedly run headlong into stone walls, the current thinking would have us blame the walls! An enormous amount of adaptation, regulation and legislation have been directed toward the healthcare establishment while a staggeringly inadequate amount has been directed at the problematic population. The problem is not with delivery (at least to this group) but in compliance, self-responsibility and initiative. The efforts should be channeled into focused education toward this population clarifying good health habits, compliance, and consequences. If benefits were contingient upon attendence of regular care (two no-shows per year and you're out) and compliance with treatment then the "gap" would probably shrink faster the average uninsured, working, middle-class wallet.