The Problem: The use of preventive care is linked to improved healthcare outcomes. Especially effective preventive care includes vaccinations and prenatal care. While preventive care is not used optimally by any population, its use is particularly low among lower-income individuals in the United States. This is true even when government-funded healthcare is available. Can new strategies be identified for improving healthcare outcomes via preventive care, specifically within the lower-income US population?
It is recognized that those who need healthcare the most often receive the least healthcare. Preventive care is far more efficient than Emergency Room-based healthcare.
Those most in need of advocating for their own health often seek to continue detrimental habits. While smoking can be held up as the classic example of self-destructive behavior, there are other examples. Physicians are faced with the dilemma of obese patients trending towards diabetes. As one put it, “If I tell my patients to stop eating six jelly doughnuts for lunch, they will simply seek another doctor who will tell them it’s okay .” Patients may seek exoneration for their behavior rather than guidance in lifestyle changes.
A true solution to the question of minimizing the need for healthcare requires a comprehensive solution that is far beyond the scope of any single Problem. Such a nationwide solution is currently beyond the means of political or financial feasibility. There are deeply entrenched vested interests that successfully fend off attempts to lessen their profit stream. Can people choose to become their own active advocates?
A complete and comprehensive Solution must convince people to advocate for their own health. It must also convince health providers to do likewise – in the face of opposition from budget-conscious administrators and third-party payers, as well as the patients themselves.
According to NPR’s “How The Poor, The Middle Class And The Rich Spend Their Money,” households with income below $20,000 per year spend almost twice the percentage of that income on healthcare as households above $150,000 . The issue of preventive healthcare thus includes underutilization – along with overuse of more expensive care once medical conditions become serious.
The following are assumptions both in the scope of the Solution and in the Problem itself.
• Target recipients avoid being preached at. One problem with awareness heightening campaigns is their [real or perceived] preaching down to the intended recipients. Offers of meals and shelter suffer from this dilemma, in that the most needy refuse to be pandered to.
• Limited scope of Solution. A proposed Solution will remain within the confines of the current political and economic system as we find it today. It may need to be posed as a pilot project, initially targeting a single area or neighborhood to demonstrate efficacy.
• Habits are difficult to form and break. Many healthcare options aim at solving a crisis point because a long-term bad habit cannot be stopped, or a long-term good habit cannot be started and maintained.
• Resistance from established healthcare providers. In cases where healthcare is brought to those who need it, this may be seen as an attempt to circumvent a physician’s office visit along with its co-pay (including the practice of ‘churning’). Healthcare is reimbursed based on the number of procedures performed, not on the level of healthcare provided. It is recognized that control of medical decisions and expenditures rests in the hands of doctors (cf. Relman, 2009 ). The Dartmouth Atlas Project is one organization that has studied healthcare delivery efficiency and efficacy in the US over 20 years. It recognizes that
It is well known that poverty goes hand in hand with poor health, and we know sicker people generally need more care. Yet people with low income also suffer from limited access to care, so they don’t always get the treatments they need .
• There is no single solution. Situations and reasons why current preventive opportunities are not fully used differ across the country. There are several studies of Emergency Room use, specifically asking why patients used the ER instead of another alternative . No one can address all cases simultaneously, although good suggestions may cover a large number of people. This proposed Solution will include specific examples of more generalized principles.
• Pay to stay healthy. Parents have wrestled with the concept of paying for children to complete their homework or obtain better grades. While we might regret that children do not seek straight As for their own long-term good, the parent might realize that a few dollars invested today beats wasting thousands on a 30-something living on their couch and delivering pizza for a living. Healthcare advocates may or may not be interested in investing directly to convince people to invest long-term in their own health. Such direct payments may be counterproductive if they create a new channel of dependency.
• The Immediacy Problem. Human nature values short-term benefits at the expense of long-term benefits. This is exacerbated by the fact that a sacrifice today does not guarantee benefit tomorrow. A non-smoker might still get lung cancer, and an avid smoker might not. This is seen in other societal areas. Communities that deny bond issues for schools will instead fund construction of new prisons. The Solution may need to focus on short-term benefits, real or perceived, that are obvious to the target population.
Specific targets (prenatal and postpartum, and well-child visits) are often single mothers with limited financial and time resources. According to Harper’s Index, one in four American children live in families headed by single mothers. They may need to see clear and immediate benefits to efforts expended on preventive healthcare.
• The Checklist Manifesto. Healthcare providers themselves are not operating at peak efficiency. The 2009 book by Dr. Atul Gawande points out the efficacy of checklists for simple medical procedures in improving patient healthcare. Such a checklist was prepared for operating room use a decade ago by Dr. Marty Makary at Johns Hopkins, and is used by WHO as a model for the list it promotes worldwide. Since the procedures include very basic items such as washing of hands, it is understood that healthcare can be significantly improved by implementing commonly recognized good practices. This is a concept that can readily be applied to Preventive Care as well.
• Vaccines. Vaccines and their uses are classic examples of Preventive Care. It is assumed that requests for vaccination may be increased by advertizing campaigns.
Summary of Solution
The Solution may be summarized by three points:
1. Seek to ensure correct understanding of the actual issues faced by the target population.
2. Bring healthcare to the patients based on patients’ priorities, not based on the healthcare providers’.
3. Advocate for bringing the healthcare provider level from the MD to the Nurse Practitioner level, in order to increase the availability of preventive healthcare providers.
The Solution described below is especially appropriate to wellness visits such as prenatal and postpartum, well-child visits, and weight management. Immunization is also discussed. Cancer screening applications are apparent, but are not explicitly discussed. Recently, medical advice is reconsidering the recommendations for mammograms and PSA testing. Pap smears and HPV testings for cervical cancer are in flux and may become more efficient in the future. These changes may bring unnecessary confusion to a population that may need simple and straightforward arguments for implementing new habits. The difficulties of changing habits to include annual (or less frequent) screening may require a separate avenue of Solution.
Novel Strategies and Additional Efforts
Check underlying assumptions. It is possible that the underlying assumptions upon which solutions are based do not represent the reality as experienced by the target lower-income US population. Prior to implementing any solutions, investigate reasons for avoidance of preventive healthcare as close to the source as possible. The CDC issued a report on reasons for ER use in adults, which can be used as background material (see footnote 4). It will be harder to determine from non-patients why they are not investigating available preventive care options. One alternative is to explore those for whom this results in a visit to an Emergency Room.
Interviews in Emergency Rooms. Many lower income patients feel forced into using ERs as their main source of healthcare. Why? Direct interviews may be revealing, as long as they are conducted under conditions that are not seen as invasive. Rather than questioning by nurses or other medical staff, interviews may best be conducted by people who appear to be fellow patients. This includes reflecting the ER demographics in terms of ethnic, gender, and age considerations. This may involve contacting the journalism departments of colleges with a proposal for a class project. One suggestion is the Johns Hopkins University writing program, which might be coupled with either University of Maryland Medical School or Johns Hopkins Hospital. Current surveys conducted by medical staff use specific agenda-driven questions  and do not allow patients to tell their own stories.
Because the result is a set of anecdotal narratives, the result may be a book that portrays the ER waiting population. While the market for such books may not appear large, similar books by authors such as Barbara Ehrenreich (Nickeled and Dimed among others) have sold well and raised awareness of the issues in the general reading population.
Formation of New Habits. How do good habits become part of one’s life? There are many good intentions, including exercise machines that now serve as towel racks and dust collectors. There are many bad habits such as collecting tattoos and lottery tickets that make no sense intellectually. These latter may hold the promise of immediate wealth, no matter how unlikely.
Habits: The Bad With the Good. Why is it that about 25% of young adults get tattoos but not vaccinations? One needs a bridge between healthcare and, e.g., the tattoo parlors. The ultimate outcome is the parlor offering vaccinations [and later, other screenings] with each tattoo. This must become a boon for the parlor as well as recipient in a tangible form. One suggestion is offering the parlor a fixed reimbursement for each delivered form [vaccination or other]. This requires a licensed healthcare provider, and may need further considerations. One person receiving a tetanus booster every month to get $100 off the tattoo price is not the healthcare profession’s intention. Screenings for blood pressure, diabetes, and so on may be more appropriate. Clearly, this is a single example of an underlying concept of coupling the target population’s priorities with the priorities of healthcare providers.
Generalizing the Parlor Link. In order to maximize a local connection link, one may need to delve into economic evaluations that specifically ask: Where do the target populations spend their money? This will have obvious components of rent, utilities, and such. The question must seek an analysis of where the target population spends what it perceives to be discretionary funds. That result may point to tattoo parlors (simply one illustrative example) or elsewhere. This gives a better assurance that contact is being made with the partners that may be most effective. This may be fast food restaurants, video arcades, or other places of business. The location of time spending may differ from places where money is spent, but may include potential partners if healthcare providers can gain their confidence and cooperation.
A good start is the US Bureau of Labor Statistics, which has a Consumer Expenditure Survey available at http://www.bls.gov/cex/. Tables indicate income levels and percentage expenditures on categories such as food, and subcategories such as fresh vegetables. These tables do point out 3.3 times the proportional spending by the poor of tobacco-related products. These tables, the only federal surveys available, do not drill down to details of discretionary spending. The poor spend almost twice as much on healthcare (8.2% of income) as the rich (4.5%). Yet the stated Problem indicates that it is not spent efficiently. Focusing on the extra spending, especially if it is emergency care that could have been avoided, may help generate incentive in changing habits. This may require translation into X cartons of cigarettes or Y tattoos per year that could have been purchased – the translation brings home the point that better health can also be less expensive in the long run.
People Under Pain and Stress Make Poor Decisions. In my own experience, even people with good insurance benefits do not seek readily available medical help. People do become used to situations, and can believe that constant pain is simply a sign of aging. Families under physical and financial stress can make sub-optimal decisions or fend off decision-making altogether. Much as one’s eyes may glaze over when reading insurance policies even in the best of times, the effort to absorb and understand medical issues and choices can lead to ‘zoning out.’
There are two avenues of solution to this issue:  Direct relief of pain and stress, and  providing an ombudsman or interpreter to help evaluate the available choices. The first, direct relief, may be the goal of the Problem itself and not a reasonable initial milestone. The second is an approach taken by Habitat for Humanity and other organizations that provide free legal advice for such things as helping families navigate the forms needed for Earned Income Tax Credits. If health-related Awareness events gather large numbers of people to a given purpose, the opportunity already exists to initiate discussions. Although advocacy within crowded Emergency Rooms may be problematic due to hospital policy, the gathering of patients and families in need is an opportunity that should not be missed. The need for follow-up such that health advocates can access and evaluate relevant documents if necessary is recognized.
The Nurse Practitioner. Medical facilities operate under specific guidelines and are highly regulated. Most of us know horror stories of waiting and waiting to see an MD. Yet most of the practices involved in Preventive Healthcare can be performed by a non-MD such as a Nurse Practitioner (NP) . Solutions that bring care directly to the target population may benefit from seeking NP participation. As one example: Health Net operates the Decision Power Nurse24 nurseline to provide educational access to a registered nurse 24/7, although it is currently available only to enrollees of some companies. Included topics available include “How to make lifestyle choices to improve your health.” NPs, however, can deliver far more than educational material. Depending on their licensed specialties, they can act as the primary health care provider for pediatrics through geriatrics. A more cost-effective Solution may slant efforts towards improving access and availability to NPs rather than focusing on MDs.
Extension of Current Efforts
Rewards Programs. Healthcare advocates attempted to use Rewards Programs although it is not clear if the proffered rewards are in fact enticing to the intended recipients. People typically seek to satisfy their wants rather than needs unless forced to do so. What are the wants of the target population? It is unlikely that coupons for beer will be considered responsive to the Problem, however likely success may be. There may be other wants that can be supplied, depending on the budget and ability to elicit cooperation from providers. Candidates may include cable or internet providers, cell phone account coupons, or possibly more directly useful things such as utilities or even rent payments.
Awareness. Healthcare advocates have supported events designed to heighten awareness. These events have been successful nationwide in terms of the numbers of participants. Let us assume there are filed evaluations of long-term healthcare awareness changes as a function of such events. Do they tend to result in spikes of awareness that fade with time? This may work for single-instance issues such as vaccinations, with lower success for initiating lifelong habits. Events such as showing the movie Super Size Me might scare people away from self-destructive indulgences. The same audience might be negatively influenced by movies such as Sicko, which may instill suspicion of the medical industry. We must be aware of the need to advocate good practices while responding to publicity that creates unwarranted doubt in healthcare practices.
Transportation. Healthcare advocates have attempted to lower barriers to physical access, including transportation and hours of operation. This may be seen as similar to driving voters to the polls on elections days, which helps the motivated to overcome physical hurdles. There are nationwide programs such as Meals on Wheels that may serve either as models or as potential collaborators. Vouchers may work to some extent, but public transportation in the US [with rare exceptions such as Manhattan] requires such a juggling of timetables as to render it useless beyond the bare requirements of commuting to and from work. In some cases, the medical facility is able to provide door-to-door van service. One example is the Vista Community Clinic, a nonprofit facility near San Diego .
Mobile units are available in many areas. One example is the San Diego area, where organizations provide differing levels of care and accessibility. The Scripps Institute offers a mobile unit mostly for large events such as baseball games . The Family Health Services of San Diego offers a KidCare Express Mobile Medical Unit Program .
 Physician in Lancaster, CA, personal communication.
 AS Relman (2009), “Doctors as the Key to Health Care Reform,” N Engl J Med 2009; 361:1225-1227September 24, 2009DOI: 10.1056/NEJMp0907925
 Gindi RM et al. (2012), “Emergency Room Use Among Adults Aged 18–64: Early Release of Estimates From the National Health Interview Survey, January–June 2011,” National Center for Health Statistics. May 2012. Available from: http://www.cdc.gov/nchs/nhis/releases.htm.
 Cf., Collins et al., The Income Divide in Health Care: How the Affordable Care Act Will Help Restore Fairness to the U.S. Health System, http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Feb/Income-Divide.aspx