Unengaged
As many of you know, I work in health care research. Iām going to do a little bit of explaining before I get to my central point. One of the things we are working on is a collaboration between community health clinics throughout the state and the health insurance plans that serve Medicaid populations in Oregon. Oregon has a fairly unusual model (compared to other states) of providing care to vulnerable populations in the state. Oregon has taken the lead in trying to pay the insurance plans (CCOs) for keeping a population healthy rather than just paying for services. So the CCOs (which stands for Coordinated Care Organizations) get paid for quality measures (like good diabetes care, or well-child visits). They get paid from the state per person rather than just for services that health clinics provide. This means a healthy person on their plan is cheaper to care for and thus more profitable than a sick person because they arenāt getting paid each time that sick person goes and gets care. They are trying to pass along this payment model to the clinics who actually provide the care, so they spend more time focused on prevention of illness. (And yes, you people in the industry, that is a simplification. Deal with it.)
Medicaid patients must be below a certain level of poverty to qualify for the coverage. Even with the expansion of Medicaid (aka Obamacare, which mostly happened in states not run by Republican governors wanting to make a political stand), the amount of income is extremely low to qualify. In most non-expansion states, a single person has to make less than $841/month or $10,000/year, but that number varies by marital status and other factors. Even in expansion states, the number only goes up to about $30,000 per year in income for a single person. As you might imagine, this group of people is very hard to engage in preventive health care because they have so many other priorities in their lives (housing, keeping the lights on, transportation, being able to buy food).
We are conducting an outreach program for cancer screening and it is a collaboration between the CCOs and rural health care clinics. One of the things we have to do first is decide who qualifies for the screening. One of the first disconnects we stumbled upon is that the list of people a CCO thinks is in a clinic is different than the clinicās list. How is this happening? All people in an area who qualify for Medicaid are assigned to a CCO and then the CCO has to figure out where those people get care. In some cases, a person is already seeing a doctor in a clinicāthatās easy. But in many cases, the CCO has to take an educated guess and assign people to a clinic. CCOs call these patients āunengaged,ā but the clinics call these patients ānot oursā. Itās not terribly surprising that this would happen, just given the mechanics of the system. We donāt have universal health care, or a single payer, which would remove all of these barriers. What is surprising is that the amount of patients on our lists where this was happened was 40-50% of the patient lists. That is a shockingly high percent of patients.
I have been stuck with this in my head for a while now. It means these patients have never established care with a health care provider or they havenāt been into the clinic for over 18 months. (A small percent of these people had information that wasnāt up-to-date at the CCO.) This has huge implications for health care in rural America. And if you think about it, there are so many obvious reasons for this lack of routine care. Number one is cost and complexity of seeking health care in the US. Consider things like surprise bills for doctors if one person in the health care chain is not ācoveredā by insurance, the cost of co-pays for low income folks, or not having many providers that accept Medicaid coverage. Weāve basically conditioned people to not trust the medical establishment. Not to sound like a broken record, but we have laid the ground work for a vaccination effort rooted in large, big city roll-out, ātrust the medical systemsā to fail spectacularly in an environment where people donāt even see a doctor once a year (or ever). They are only going to a medical professional for acute injuries or a health care emergency. When talking with these rural clinic staff, I hear the same themes. Their patients want to come if for care when they need it and not be bothered otherwise, and that the only messages they trust are one-on-one from their doctors.
If people arenāt engaged with any medical provider, then how do you stand a chance at reaching them? But maybe I am thinking of this phenomenon with too narrow of a lens. Is this symptomatic of a much larger ethos? The American myth of self-reliance at all costs. We donāt want government or other help because we help our neighbors (but only the immediate neighbors that are similar to us, maybe?). We donāt need help (until we do because a huge fire blows through?).
And I donāt really blame people for not using health careāitās expensive even when it is supposed to be free. Most US systems set up as safety nets have huge holes in them. For example, most of the people (57%) who applied for FEMA aid after the Oregon fires received rejections and never got any supportāthey denied almost 14,000 people. Most of the people who use the health care system find roadblocks in payment or approvals to do anything. What else are people unengaged with? Society, politics, anti-racism, their own communities. The US has an āunengagedā population (and not just in rural areas). Is it a coincidence that the 40-50% of unengaged people is about same percent of people in the US who do not vote? Maybe, maybe not. If this week has shown us anything, it is that the lack of engagement can have massive, even deadly, consequences for American society. About 80% of Americans believe in a womanās right to choose. And the number of people voting for candidates who can save that right is closer to 25%. In our study as in the US overall, people who are unengaged are more likely to have adverse health outcomes, be diagnosed at later stages of disease, and generally are more at risk. I donāt have a great answer, but I feel like we are all overlooking the general apathy that is the root cause of the problems.