The Least Healthy Counties Across the United States
Journalists and researchers find common ground in dramatic presentations that illustrate the extremes of those doing best or those doing worst. What works to gain publication or to reap advertising revenue does not help in understanding disparities - especially those shaped by the health care design.
Choosing the worst county is a poor choice because these counties are so few and so atypical. Rural counties are also atypical as the counties have lowest concentrations of people, but not necessarily other demographics. A measure more consistent in health representation can be helpful in understanding disparities in outcomes. Categorizations that compare counties by concentrations of physicians illustrate important concepts regarding health workforce, outcomes, insurance, and demographics.
Few Ahead and Many Behind
There are only about 5 - 10 counties in most states - that have higher to highest concentrations of
- physicians and health spending,
- education spending,
- economic impact,
- income, education, resources, costs of housing, and
- best outcomes
The rest of the counties are left behind by many designs and most demographics. This includes 40% of Americans behind in 2621 lowest physician concentration counties (75% of rural, 32% of urban).
Note that 25% of the rural population is doing reasonably well. This is often in counties that have highest concentrations of physicians due to rural based large health care systems. The incredible growth of these small counties indicates just how important concentrations of health care workforce and spending can be.
The doughnuts shaped in adjacent counties surrounding these rural top concentration counties are also seen in highest concentration counties where top physician concentration zip codes have a halo of lowest concentration zip codes. Much for few and less for most is a dominant theme of the US health care design.
Highest Growth of Populations Left Behind - the Role of Housing Costs
The disparities are magnified due to lowest housing costs that concentrate the worst paying insurance plans that pay the least for health and have created shortages over past decades of policies. These are counties not lacking for insurance coverage more than other counties (40% of pop, 41% of uninsured before ACA), they just have the plans least supportive for workforce, services, and access in these counties (Medicaid, high deductible, Veteran, lowest paying insurance). Since they have lowest concentrations and most access problems, health insurance expansions involving the worst plans really did not work - in contrast to highest physician concentration settings that could take more patients and spend more dollars.
Not as easily tracked are those left behind deep within highest concentration counties where the disparities are greatest within counties as compared to greatest disparities between highest concentration 79 counties (10% of US pop) and lowest physician concentration 2621 counties (40% of US). It is safe to say that within disparities and between disparities include a majority of the US population in various ways.
It is important not to ignore the impact of costs of housing and living so high in higher concentration counties such that many (elderly, Veterans, poor, middle income, fixed income) must leave higher for lower concentration counties. Better climate and targeted conversion/destruction of low income housing in top concentration counties (developers, government planners, eminent domain) feed the migration.
The US has payment designs and training designs that virtually assure lowest concentrations will continue for decades to come.
Behind in Concentrations Means Behind in Outcomes
Behind in lowest concentrations also includes outcomes in health, education, economics, and other areas that are shaped by the designs and demographic characteristics of the populations. Those with most difficult and most unhealthy situations, environments, behaviors, and chronic diseases are concentrated in lowest concentrations. Measurements used to generate penalties make matters worse.
The Folly of Measurement Focus
Measurement attempts to improve outcomes are doomed to failure because so many areas are influencing the outcomes. It is not possible to change a few arbitrary health care measures and accomplish any real change in the personal, community, and local factors that shape outcomes.
Measurement focus works best for those in top concentrations receiving the dollars from measurement and its promotions - much like mining occurs in lowest concentrations shaping profits for highest concentrations. The education and health team members are compromised caught between so many changes that compromise their support and complicate their most complex tasks.
Any time you hear the words pay for performance or value based, you are hearing about designs that are not evidence based for significant outcome improvements
- “In summary, we found low-strength, contradictory evidence that P4P programs could improve processes of care, but we found no clearevidence to suggest that they improve patient outcomes.” from The Effects of Pay-for-Performance Programs on Health,Health Care Use, and Processes of Care: A Systematic Review, Annals of InternalMedicine 1/10/17.
These reviews and others indicate little benefit in outcomes, higher costs, and discrimination against providers who are for the patients most left behind.
Diversions and Distractions for Decades
Austerity focus, waste, profiteering, diverted funding (demonstrations, privatizations), poor awareness of the needs of most Americans, intentional confusion/misinformation, 1 trillion too much for health care spending with 1 trillion too little for populations most behind, new diversions of funding from lowest concentration to highest concentration counties (EHR, measurement focus in health and education, practice consultants) - these are what leave most counties behind.
We though disease focus was bad and then diversions of funds for managed care and managed costs and then cuts across the board, but it really takes stagnation in payment plus more dollars forced to depart lower concentration counties to really impact morale, productivity, revenue generation, and turnover in adverse ways - by national design. Of course massive replication of austerity focus in health care could have made matters worse.
Regardless of the administration or party in power since 1978, ways have been found to compromise increasing proportions of Americans by design.
The Totality of Leadership Failure
This is all a steady indication that American leaders fail in the awareness of the daily lives, challenges, and needs of most Americans.