Physicians cannot clinically diagnose “poverty” like one does “hypertension disorder” for a patient’s high blood pressure. This is not to melodramatically relate poverty to being some kind of disease—though both can impair a person’s daily functioning and general wellbeing—nor does it necessarily imply that poverty can be completely “cured” when one considers the potential trauma experienced. However, in working with a free clinic that provides services to clients that are either uninsured or under-insured, I’ve found that many of the causes and effects of poverty in society are at the roots of the reasons of why many patients here seek care.The most front-line causes and effects of poverty influencing the health, well-being, and capability of many of our patients are those that are economical and political.
Consequence of Medicaid Expansion:
A recurring concept that I still have questions about is the effect of medicaid expansion on the clinic and national healthcare. Before coming to the clinic, I was only vaguely aware of the term “Medicaid”, which sounds too similar to “Medicare” for conveniency. Over the past few weeks I’ve learned that the recent medicaid expansion that went into effect in January of this year (2019) had called for a significant decrease of patients that are seen at the clinic since many of them are now eligible. While the expansion sounds promising and voices how much larger the effort is to reach people to receive proper care, there seems to be less emphasis put on the patient-convenience and potential quality of care given by Medicaid.
BFC encouraged many of its eligible clients to apply for medicaid, which meant they would no longer be able to be seen at BFC. This presented a few issues that can negatively affect the patient’s access to healthcare—a tinge of irony. One of the main issues is that there are overall not many providers and specialty doctors in the Roanoke area that are willing to take Medicaid patients: either they’ve maxed out on how many they can afford to take in or for other reasons. Additionally, there seems to be no database or advertisement (such as a site) where clients can look for doctors who accept Medicaid patients. Because of this, patients with chronic illnesses like diabetes, a condition that needs to be continuously managed and followed-up every few weeks, are without practices that are able to maintain this essential relationship between a patient and provider. BFC has experienced many patients with Medicaid coming to the clinic seeking care, but being turned away because of policy. Now, the organization is going through a transition in which they will begin seeing patients with Medicaid (many of these patients have also been long-time regulars), but will not be able to list the volume of these patients when they apply for grant funding. In other words, on paper, the clinic is providing for a lot less patients than in reality, skewing the amount of potential funding they’ll be able to apply for and receive (roughly 60% of BFC’s patients were eligible for Medicaid after the expansion). Even with fundraising and donations from the community, the model may not be sustainable to cover all of the clinic’s costs long term.
It’s been interesting to listen to how our employees feel about this change of policy. Some find it a hassle in terms of paperwork, others have said the expansion is set to change once there is a change in the administration, potentially causing another clinic-policy-makeover just after they’ve accomodated. I keep thinking back to the idea of conveniency and access to healthcare. At BFC, patients are able to return to the clinic within the week or next few months, depending on the urgency. Here, patients build a repertoire with our volunteer providers just like one does at her usual private practice. There is a sense of community that hums in the air on clinic nights. One patient has been coming in every week over that past few months for physical therapy; a nurse whispers to me,
“He doesn’t necessarily need to come in this often, but he loves seeing J. and getting on that elliptical bike.They just talk and unpack the week.”.
I am concerned that this building of trust does not grow in a circumstance where a person decides not to go in for a check-up and saves their visits until emergencies due to the lack of providers that are willing to see Medicaid patients. Good health and well-being can be built on preventative care; those that can only afford (time or money) to only come in when their health is at their weakest may often come in too late. Although the Medicaid expansion has statistically increased it’s reach in providing health services to more people affected by poverty-related issues, I press that there should be more dialogue on the quality and client-convenience of these services, with emphasis on how we can still achieve the patient-provider relationship one experiences in a private practice.
Though this issue evokes a lot of frustration, I am appreciative for the sobering realization that the translation of public policy to the organizations on the ground and in local communities still has short-comings that often cut out the individual’s outcome. This is perhaps due mainly to a disconnect between public health advisers, non-profit organizers, and policymakers. Once I return to campus, I hope to become more informed on the underlying causes of this miscommunication that is preventing patients from having equal opportunity to accessible, affordable health care.
Personal Responsibility as a (Future) Provider to Address Poverty
Though I’ve echoed that there seems to be a lack of choice that’s causing the vein of hopelessness to resonate throughout various patient narratives, there has been great moments of seeing patients use their agency as well. Tired from the long hours of sitting in machinery, one man left his job as a construction worker,
“I had to do it. I was tired of leaving projects unfinished. I like to take my time with things. Plus, I’m back to having full-range over the music I listen to. I missed it.”
His experience speaks to the sides of the story many of us don’t know from the patient’s chart, medical or social history. The importance of patient narratives informing the healthcare-received has two key benefits. One is that, through unpacking respectfully the lives and concerns of each patient, doctors, staff, and social workers can peel into the layers of social determinants of health that affect the individual. This promotes the kind of work that supports not only physical well-being, but emotional wellbeing: gaining safe housing, childcare resources, transportation.The second returns to the patient-provider relationship. When providers take the effort to know their patient’s narrative, the chances of prescribing unnecessary medication or treatments can decrease. For example, gastrointestinal issues can be a result from either a chemical deficiency or mental stress. What could that stress be caused from and how can one alleviate it before resulting to a prescription? The benefits of investing in this relationship is rooted in not only the patient’s health, but in their human dignity and autonomy. As health providers become more and more cognizant of the individual’s story, and once they take those stories as real concerns and truths, doctors can provide more-informed recommendations, resources, and treatment.
What I’ve seen give patients the most autonomy in a patient-provider interaction is not the doctor sitting back and allowing the patient to make whatever decision, rather it’s an act of radical listening, the kind of listening that requires empathy and returns conscientious information. Instead of leaning back, they lean forward.