Exploring Designs Favoring Blue Over Red

Many articles have focused upon different perspectives regarding the reasons for the election results. The red counties have been identified as having lower education levels. There are many more differences in demographics and other characteristics. Perhaps the most common ground is that these are counties that have been left behind by a number of designs or that feel that they have been left behind or likely both.

The 2700+ red counties are the same or similar to the 2621 lowest physician concentration counties that I have studied. While it is true that education statistical differences exist such as only 27% of bachelors degrees found in these counties with 40% of the population, there are a number of other demographic, policy, political, and other differences. These are important to understand regarding why voters saw red and voted red.

The bigger question is whether the red party will address the needs 
of those who turned the tide.

Newer articles (Economist) have pointed out the lesser and declining health outcomes across the red counties. Clearly there are these and other changes going on in the United States. Where populations are increasing, resources for health and education are declining, and health indicators are declining as well. Where there are declines in health, education, and futures for children and their children, there will be changes in voting and other behaviors. It would be hard to ignore what is happening in this nation and in many others when children, particularly males, grow up in places with little opportunity

Consolidating the Domination of Concentrations 1920 to 2020

Rural and counties and less concentrated (people, income, education, government spending) urban populations have always been less organized.

Education and other spending designs shifting in favor of urban settings when urban populations became the majority. In past studies it was possible to track more rapid declines in rural origin admissions to medical school when states converted from majority rural to majority urban.

Examples of the design changes include school funding formulas, property tax based education, and school consolidation. When small towns in Oklahoma faced recession in the 1980s, there were losses of local extension personnel and other government positions. Some where cut and others were moved to more central locations.

Highest concentration counties have been developed and exploited in ways that have increased their property values, their economics, and their self-focus. Those outside of concentrations are not as organized and lose out by design.

Media Bias

The media has long been a problem for less concentrated areas. At times the articles that reach national and international distribution are dramatic and are often not favorable to lower concentration populations.

The media is quite different from most Americans in origins, training, and location. Instead of working with people directly to gain awareness, assumptions are made. A red vote could indicate a vote against the establishment - including the established media. It is quite clear that health, political, media, and other experts were surprised at the election.

Demographics and Distributions, or Lack Thereof

The lowest concentration counties are lowest in concentrations in a number of areas. The exceptions are important to remember. This 40% of the population has 75% of the rural population, 32% of the urban population, 47% of poor children, 45% of veterans, 42 - 44% of SNAP and Social Security spending, and 41% to 43% of Medicaid and poor populations. These counties have higher concentrations of diabetics, preventable deaths, obese Americans, and those with poor to fair health status.

The ACA to MACRA Misfit

Instead of praise from people left behind, Democrats got the boot.

Manipulating the Independent - Only those desiring to make divisions worse or those with failed awareness regarding most Americans would design tax penalties to attempt to manipulate people into health insurance, especially in populations that value independence.

Death and taxes continue to top the list to avoid
but health care and health insurance are gaining

Insurance Expansion Fits Someone Else - The counties that are left behind in many areas are not behind regarding deficits of health insurance plans. Democrats and even more so the Obama Administration lost touch with most Americans. While it would seem to be a good thing to have insurance expansion, insurance expansion is really quite limited with regard to access to health care.

More insurance is a really good idea for poor populations surrounding academic medical centers and other largest health systems that have top concentrations of workforce and health spending.

The 2600 - 2700 counties left behind have very different needs. After 3 decades of poorly paying plans, they need local workforce. The federal, state, and insurance designs prevent the local workforce.

Lowest 40% concentration counties have the worst possible insurance coverage mix - Medicaid, high deductible, Veteran, and Medicare plans. As discussed these are the Four Horsemen of the Primary Care Apocalypse. Lowest concentration counties have insurance and coverage plans that fail to support local workforce. The plans fail for local access, local economics, local jobs, and local cash flow.

Failed Designs Across Services Most Prevalent Where Care Is Most Needed -  Policies compromising small hospitals and their emergency rooms, small practices, and associated local jobs, economics, and cashflow are a really bad idea. ACA also took away disproportionate share funds - funds that are supposed to help out where lowest local support from the Four Horsemen lack of payment plans.

Compromising Health Care and Health Care Team Members Where Needed - Millions of health care workers were impacted by worsening health care productivity, declining morale, increasing burnout, and declining revenue - but the impact once again was hardest on the least organized, smallest, and most marginal. The small practice and small hospital employers already facing declining revenues were forced to send more cash outside and were forced into lesser support for team members and local people.

Compromising Local Health Care, Jobs, Economics Where Needed - The consequences of EHR and digitalization changes were known over a decade ago. The impacts have cost the nation hundreds of billions. Those most organized and centralized that already had EHR systems were impacted least and those least organized, smallest, and most marginal in payments - did poorest.

Teasing Instead of Pleasing Changes - The one area where designers did increase payments in an important way - increasing Medicaid primary care payments to Medicare rates - was only set for 2 years. Also with Medicare not much better paid and also paid least where people most need care, the changes were minimal even for this short time.

Many if not most of the compromises have been going on for decades in areas such as health and education, but those associated with the rapid wrong way directions in recent years got the blame.

Implementation of Discrimination - Only those unaware or abusive would institute pay for performance with its know consistent discrimination against practices and hospitals caring for populations left behind. In other words pay for performance (readmission, ACA to MACRA) was a really bad idea for lowest concentration populations and counties and those attempting to provide care for them.

Future Republican Mistakes Could Make Matters Worse

The situation could be much worse for red counties with Medicaid cuts or termination, with CHIP renewal denied in 10 months (47% of poor children in lowest concentration counties), with Medicare age raised to 67 (42 - 45% in these counties), with a price freeze as in past Republican administrations (Reinhardt), or with other changes that will accelerate closures of small practices, small hospitals, and care where needed (shaped by the Four Horsemen above).

Republican and Democratic Lack of Awareness Has Been Deadly and Divisive

The policies of the last 35 years have killed off over 600 hospitals in these counties and have compromised primary care, mental health, small practices, and associated team members. Recent health care changes specific to red counties include accelerations of the costs of delivery, the declines in productivity, the burnout, and the higher turnover now over $300,000 per lost primary care physician.

The basic services and the basic Americans are not very organized, but neglect is associated with consequences that can last generations.

An Entire Generation of Workforce Has Been Shaped in Favor of Blue Over Red.

The Bluest Counties have 2 to 1 advantages while the Red Counties face 1 to 2 against.

Only 21% of physicians and 23.5% of mental health providers are found in these Low 40 counties.

General internal medicine was 13% of local workforce but will shrink to less than 4% as it collapses from 120,000 in the 1990s to 30,000 by 2025.

So many claim that nurse practitioners and physician assistants are a solution but forget that training and payment shape RN, NP, and PA into higher concentration settings and away from lower. NP and PA distribute no better than general surgeons. About 26% of active NP and PA were found in these counties in 2010 also because of payment designs that move MD DO NP and PA to more new specialties with more added to each specialty, resulting in family practice positions filled by fewer and fewer.

The family practice positions filled by MD DO NP and PA are the only equitable workforce solution with 36% found in this 40% of the population. Essentially all specialties are small contributors and are shrinking (general surgical specialties, internal medicine) - also by payment design. Family medicine distributes no less than 26 per 100,000 even in lowest physician concentration counties. FM is the 3 times greater solution for the elderly, red counties, rural locations, lowest concentration counties, frontier, CHC, and other populations - but has not been changed from 3000 annual graduates since 1980.

Blue counties have all the lines of revenue and the highest reimbursement in each line, although only 1100 zip codes in these blue counties really benefit with 10% of the population and 45% of physicians and well over 50% of health spending. About 6 states and about 100 counties with top physician concentrations do so well that the rest fall behind.

The worst disparity so far discovered is 6.5% of graduate medical education positions found in these counties with 40% of the US. The 10% of the population with top concentrations of physicians have 130 residents per 100,000. The lowest physician concentration counties with 40% of the population have only 110 physicians per 100,000.

By the way, expansions of GME in these counties cannot solve local workforce woes - also because of payment design. Payment design insures that no training intervention can work. The most needed 2010 reform was higher payments for basic, cognitive, office services. This did not happen. Since many of the other reforms required this change years ago, they failed also as did the managed care reforms of the 1990s. The managed care reforms were based on primary care gatekeepers that were largely missing in a nation near last in generalists among developed nations. The red counties or lowest physician concentration counties rank below 50th in generalists - far below all developed nations.

Economic Disparities Are Shaped By Health, Education, Other Payment Designs

The dollars going to these counties are not increased by design and the dollars leaving these counties are increasing by design

Red counties more dependent upon the basics face cuts in health and education - cuts that force compromises in those who educate or deliver health care.

Red county care has also been the most efficient - the best value. This is also due to decades of low payments. The value has been high due to reasonable outcomes despite lower payment and more complex populations. This is also not understood by health care designers or the slash and burn politicians - or those in these counties that feel the consequences. Whether the dollars are designed away to others or slashed away, the consequences are much the same.

Red, Lowest Concentration Counties Depend Upon Health, Education, Government Spending

Counties that have fewer types of economic contributors depend upon the basics. Studies recently indicated that red counties have only 30% of the US economic impact
  • Therefore they are more dependent upon health, education, and social spending
  • They are dependent upon funding that is being cut
  • They are dependent upon areas such as health and education that are being forced to send dollars outside of local counties for software, hardware, measurement focus, consultants, or other innovation focus. Measurement focus forces health care and schools to ship what remains of their dollars outside entities. 
  • Schools receive less in these counties due to property tax based funding as these are locations with lower property values or untaxable government land. 
  • Schools and health care entities and government jobs have been consolidated and centralized away from local counties in need of jobs, economics, and cash flow. 
Those more familiar with school and education changes and state diversions of education and child development dollars could add more to this.

Populations May Understand that They Have Been Compromised, But Not How

Many do not understand the specifics of compromise (or discrimination) but they have figured out the compromise. Neither side has helped them to figure out what is wrong and what might improve their situation.

Micromanagement Is a Really Bad Idea

People resent manipulations of their behaviors such as having to buy insurance. The whole process of trying to get care has become a nightmare. Those associated most with health care are likely to get blamed for what is wrong.

Those in past administrations that have tried to micromanage otherwise have contributed to the consequences, the growing frustration, and the election results.

It is hard to figure which side contributes more to the problems. The Democrats and many Republicans have been convinced that people and providers can be manipulated. This has always been a bad assumption as it is situations, behaviors, environments, social determinants, and other people and local factors that shape outcomes.

Future Elections Will Be Shaped By Red County Voters

Lowest concentration counties are growing fastest in numbers at 13% growth per decade versus 5 - 8% for Blue and top concentration counties. The lowest concentration counties are growing fastest in elderly and complexity and demand. There is no solution for their health workforce or other local needs - by state and national design.

The 2700 red counties are the same or similar to the 2621 lowest physician concentration counties. The distributions and demographics are important to understand regard recent elections and longstanding divisions in the Untied States (sorry, I type this by accident so many times that it has to stay at least once).

United, Untied, or Divided - We Still Need Better Understanding of the Basics such as Basic Health Access or lack thereof.

As the United States has concentrated people, resources, economics, and power - the less concentrated have been losing. 

The 25th Anniversary of the COGME Third Report and No Change By Design

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.



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