There is a growing understanding of the connections between poverty and poor health, but one doctor in particular has documented how economic status impacts diagnoses, access to treatment, health outcomes, and more in a book that argues America should spend more — not less — to keep our citizens healthy.
Supporters of Dr. Richard (Buz) Cooper — who published “Poverty and the Myths of Health Care Reform” in August 2016, after more than 50 years of practice — said his findings are particularly important now, as leaders in Washington, D.C. wrestle with healthcare funding and reform proposals that could have a tremendous impact on states like New Jersey that depend heavily on federal funds to care for poor populations.
Cooper, an oncologist and hematologist, died of complications from cancer at age 79, just six months before the book was published.
Focused on saving money
Despite efforts to invest more in prevention and better connect social services to medical care — like Garden State programs created by the Camden Coalition of Healthcare Providers and others — Cooper and his allies have argued that the national healthcare policy debate fails to account for the impact of poverty and remains unrealistically focused on savings.
“Dr. Cooper was a visionary in this field,” explained Dr. Joseph Valenti, an OB/GYN in Texas and board member of the Physicians Foundation, an advocacy group for doctors that commissioned Cooper’s book. “He had a theory that being poor makes you sick, and he was right.”
Valenti said that policy experts tend to focus on the fact that healthcare spending eats up a significant portion of our economy, instead of looking at how little we spend, comparatively, on social welfare programs to improve nutrition, provide housing, protect the environment, and other actions that can help prevent or reduce the impact of disease.
By the book
He said the lessons in Cooper’s book should be carefully considered as federal officials seek reforms to the landmark Affordable Care Act that would cut investment in the program by as much as $246 billion over a decade and are poised to cut by 70 percent one funding stream to the network of Federally Qualified Health Clinics that provide comprehensive services to 27 million low-income Americans.
“Our problem is because we don’t spend the dollars up front, we spend two or three times more for things later on,” Valenti said, stressing that medical solutions are often more expensive than these other investments. “Poverty has just become the third rail of politics.”
While the now-embattled ACA, or Obamacare, extended insurance to some 20 million Americans since 2014 — including more than 800,000 in New Jersey — and involved insurance reforms that increased spending on wellness and prevention, Cooper and his allies believe that it also contains a serious flaw: a continued focus on achieving savings. They insist this push ignores basic truths about patient needs and treatment costs, and falsely assumes lower spending equates with more efficient care.
Cooper graduated from Washington University School of Medicine in 1961 and went on to train at Boston City Hospital and the National Cancer Institute. He taught at Harvard Medical School and the University of Pennsylvania’s department of medicine, where he founded and led the Penn Cancer Center and later worked with the school’s health economics institute. He also served as dean of the Medical College of Wisconsin.
The economics of health
Through this work, he came to better understand how a community’s economic and social status impacted its population health and options for care. While researchers once blamed physician density for contributing to patient demand and rising medical costs, healthcare spending in America is actually governed by poverty levels, Cooper reported.
“In each case, poverty distinguishes areas where health care spending is high from others where it is low,” he wrote, adding, “Don’t blame the victim! Poor patients do not use more health care because they want to. They do so because their health is poorer and their social circumstances are weaker. The basis for their high health care spending is embedded in the fabric of their lives.”
In the book, Cooper writes that it is unfair for researchers to compare healthcare costs from Grand Junction, CO to those in Newark, NJ, without considering the fact that Newark is a largely impoverished community while Grand Junction, near Denver, is not. Valenti said these studies often end up blaming doctors for overprescribing specialty treatments and charging too much for their services, without fully considering the underlying costs.
“There’s a reason ‘it’s the doctors’,” explained Lawrence Downs, CEO of the New Jersey Medical Society and a Physicians Foundation board member. “And it’s because the social welfare needs of people in this community are so much higher (in impoverished areas) that they require so much more (care) to get well.”
To illustrate this impact of poverty, Cooper compared the health inequality along some of New York City’s subway lines, which connect poor communities with wealthy neighbors a few miles away. Research funded by the Robert Wood Johnson Foundation shows the phenomenon is alive and well in New Jersey too: the life expectancy in well-to-do Princeton is 14 years longer than that in impoverished Trenton, just a few miles to the south, the analysis of death rates and zip codes revealed. (Robert Wood Johnson is a financial supporter of NJ Spotlight.)
Downs said the Garden State has made some strides in addressing the underlying issues through programs like those run by the Camden Coalition, a network of nonprofits and healthcare providers that have teamed up to improve care for some of the city’s most vulnerable residents. Among other things, the work — which has since become a national model — has led to investing more in housing and other support services to help improve health outcomes.
In the capital city, the Trenton Healthcare Team has worked with officials, local providers, and state and local partners to better coordinate care and invest in community assets — like community gardens and places to exercise — that support healthier lifestyles. The Nicholson Foundation is also supporting similar efforts in other communities.
Other advances, like policy changes and programs instituted by insurance providers to reward outcomes — generally known as “value-based care” — are also starting to place more emphasis on investing in preventative programs, some of which address elements of poverty, Downs said. “But they’re not getting traction fast enough,” he noted.
Too often, state and federal resources are directed largely toward emergency care, which is the most expensive option, Downs added. “What can we do to put a little more in the prevention side?” he wondered.