The troublesome poor

In recent times, the issue of providing for the poor (and “undesirable”) people in this rich society has become divisive, posing the “liberal” against the “conservative,” and becoming more and more inflammatory. Why is meeting their needs even a question?

It is obvious that the basic necessities of the poor and disabled must be provided, and equally obvious that they cannot provide it for themselves.

The current debate in the Maine legislature is that of health care for the poorest (and most “undesirable”) of our people under the Medicaid program. “Health care” includes health- related services for the lowest 5-10% among us. In some quarters, health care is interpreted in a very narrow way, so that literally the only services are those by physicians (M.Ds.). Other doctors (such as podiatrists, psychologists, dentists, etc.) and non-doctoral providers (such as Occupational Therapists, Physical Therapists, Speech Therapists, social workers) might then be excluded as providers under Medicaid (“MaineCare”). If the number and type of providers is limited, then the program will be cheaper. Yes?

No.

There are hidden costs. These will be revealed in unpleasant ways, at some unpredictable time, perhaps as a surprise.

Suppose, for example, that the only “health” services under MaineCare will be visits to the poor citizen’s family doctor. Keep in mind that this poor citizen is more likely than most of us to have multiple, complicated and refractory medical problems, probably the reason he/she is on MaineCare in the first place. How many visits are allowed? At which pharmacies to get the medicines? How to get to the doctor’s office if there is no transportation system? How to keep to the correct and healthy diet that the doctor recommends, if he/she cannot afford the more expensive foods? How to keep motivated in spite of depression? How to take the medicines, or do the exercise program, when there is no way to understand them or remember them?

The typical family physician has hundreds of patients in his/her rolls, and may spend 5-10 minutes with each. Imagine these caseloads going way up, the proportion of severely ill patients going up but less time for each, and the reimbursement for each staying the same or going down. Who will take care of the physicians when they burn out?

A mentally ill patient simply cannot be adequately cared for solely by a family physician, no matter how well meaning he/she is. The average family practitioner does not have the training in mental health, the time, and often not the interpersonal skills to handle a person with serious mental illness. Most family doctors rely heavily on other mental health professionals to assess, consult and treat this group of patients. There are thorny diagnostic issues that the family doctor cannot cope with without the help of mental health workers, especially doctoral-trained clinical psychologists and neuropsychologists. So, the mentally-ill patient will be seen for a few minutes, a drug (or another, and another. . .) will be prescribed and sent home. Once home, the patient may or may not take the medicine, as prescribed, if at all. There may be no one at home to organize and remind the patient about the medicines. There may be no one to notice bad side effects or interactions. Back to the family doctor, see the patient for a few minutes, again, adds another medicine, sends him/her away again. Repeat the cycle.

Let’s complicate the picture a bit. Suppose this disabled citizen has physical limitations and cannot walk alone, get him/herself dressed in the morning, see well enough to cook, read the prescription label, or figure out how to pay the bills. Cannot take care of or supervise the children. Can the family doctor teach ambulation? How to write a check? How to shave or tie shoes one-handed? I think not. Other therapies would be needed to teach or help rehabilitate this disabled citizen.

Okay, Mr. Poor Citizen (P.C.) has to make it on his own. Okay, buck up and deal with it, bub! Figure it all out for yourself, you’re a grown man. Be tough. Mr. UD. (Undesirable) will make it on his own all right, right out onto the streets and into a shelter, or into a jail. Any illness requires a visit to the emergency room, because Mr. P.C. has no money, no insurance, no family doctor. Depressed? Suicidal? Sorry, nothing we can do, we don’t pay for that. Upset, frustrated and angry, want to kill somebody? We’ll deal with that, in prison. No shrinks for you, they’re too expensive.

When we look at an example like this, the hidden costs are transparent: greater dependence on drugs (many are prohibitively expensive), on last-ditch services such as jails, shelters and emergency rooms. Those facilities are very expensive, already inadequate, and will be taxed beyond reason if the other support services are withdrawn. It costs a lot more to keep a patient in a hospital or nursing home than in their own place with in-home supports, even though they obviously cost more than none at all. Is none an option?

Mental health and community support services for the MaineCare client have become an industry, some critics say. This is not because the providers are greedy, lazy or fraudulent. It is because the services are needed by the clients. True, if these services are no longer provided through MaineCare, the providers will have less business, some will go out of business and themselves become unemployed. This group of employers will have to lay off some of their staff, cut health insurance or other benefits for them. Where’s the thrift in that?

The number of disabled persons has gone up as an unintended consequence of greater survival of catastrophic injuries, illnesses or birth defects. By saving the person who has a severe brain injury, a massive stroke or heart attack, we assume an obligation to continue their care, much like the old proverb that you become responsible for the life you save. We should sustain treatment until the time the injured becomes able to return to work or independent living. What would be the point of saving a life medically to then abandon it in every other way?

We cannot expect the unemployed to pay for their own retraining, the disabled to pay for their own rehabilitation, the mentally disabled to pay for their own therapy. Neither can we expect them to beg piteously for what they need; just because they are poor or disabled doesn’t mean they have no pride or dignity.

As a community (in the greater sense of the word), we have an indisputable responsibility to provide for these folks, many of whom are our own loved ones. We must come together to find ways of financing these programs, although it may require some small sacrifices from all of us. A few dollars more in taxes is a small price to pay for saving a life, or making a struggling life more palatable. Some beliefs include something like this: a key to heaven is what we do for a poor man.

Anne L. Hess is a neuropsychologist in Bangor.