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No Money, No Mission
Nov. 9, 2018
SMC Campus Center
I grew up on the west side of Chicago, the son of Jewish immigrants, both from Ukraine. We had little money when I was growing up. My parents ran a laundry. My mother was a seamstress, she worked in the back of the shop.
My parents’ clientele was largely African American, largely poor. The clients would come into the shop to have their clothes cleaned, and my father would often notice a ripped pocket or a ripped hem. He’d go to my mother in the back and say, “Please sew the pockets”—they always spoke in Yiddish to each other.
And my mother would say, with a sharp look my father knew well: “Will he pay?” My father would say, “He hasn’t got a penny to his name; please just sew up the pockets.”
Year after year—watching that interaction—I learned the compassion of my father. But I also learned the pragmatism of my mother. I learned that if you don’t have money, you can’t have a mission. If you don’t have money, you can’t have a mission.
My parents’ interaction also shaped what I was to become—a physician. I chose to go into an industry where “No money; no mission” rules the day. And yet once a week I treat young patients in a clinic in Baltimore City, where one in three children lives in poverty.
Three-quarters of my patients are on Medicaid or other public assistance, and Medicaid doesn’t pay very much. In Maryland, it pays physicians about one-third less than private insurers do. In fact, the only way my practice can afford to treat these patients is to rely on our five satellite clinics across Maryland, where most of our patients are covered by private insurance.
But many physicians don’t have that calculus to make—their margins are slim. They don’t have a string of offices operating in the black in order to subsidize one operating in the red. And so they don’t treat poor patients. They simply don’t.
Nationwide, 41 percent of primary care physicians either limit the number of Medicaid patients they see, or refuse to see them altogether. And that’s when these patients end up in the emergency department, where the cost of care is three to four times higher than it is in the doctor’s office.
The U.S. already spends more money on health care than any other nation—more than $10,000 for every single person—while most other high-income countries spend half that. This country simply hasn’t figured out how to spend our money in a way that achieves our mission: high-quality health care for all.
Before you get too excited, I should tell you that I don’t know how to solve America’s health care crisis. If I did, I might have a little more power than I do as a university president. But I think part of the solution is reconsidering what we ultimately want—our mission—and how we’re willing to pay for it—our money.
Because our mission is bigger than good health care for all. Our mission is good health for all. And that often has more to do with what happens outside the doctor’s office than inside it.
When I was at Johns Hopkins University earlier in my career, I ran an agency that provided pediatric services to children in their own homes. My colleagues had an 8-year-old child whose diabetes was out of control, and she was repeatedly admitted to the ICU. The doctors couldn’t figure out what the problem was, so they asked me to send a nurse to the child’s home. And that’s when we found out there was no electricity in the house. The utility had shut off the family’s service for non-payment.
So when the mother was measuring insulin doses in the kitchen, she couldn’t actually see how much she was drawing into the syringe and then injecting into her child. What we needed to do wasn’t medical at all. We needed to get the lights turned back on! And I guarantee you, as taxpayers, paying that mother’s electric bill would’ve been a LOT cheaper than paying for emergency care—over and over and over again. And as far as outcomes go, I’ll tell you this: Once the electricity was turned back on, there were no more ICU admissions.
And so that’s why I say that sometimes health care is just paying the BGE bill. As a pediatric gastroenterologist, I often see children with dysphagia, which just means trouble swallowing. It can have a number of causes—usually some sort of disease or physiological condition.
Some years ago, I had a group of children who all had trouble swallowing. The standard of care was to send a skilled nurse to the child’s home during mealtime to supervise the child and work through problems. Of course, that’s expensive.
But I noticed there was a child care center that was convenient to all of the patients, and I costed out enrolling them in the center and then sending just one nurse there at mealtime. Enrolling all eight children in high-quality child care—accompanied by one nurse—was cheaper than sending eight nurses to eight different homes. And the outcomes were better. Eating became a social activity for the children. They wanted to be able to eat with their friends and join in this most fundamental way we have of connecting with one another. Eating was no longer stressful; it was fun. And eventually the children overcame their swallowing problems.
But of course, the benefits went far beyond better health. These kids were enrolled in high-quality child care; they were socialized to interact well with other kids. It was win-win-win … however many wins you can have. And so sometimes health care is child care.
As taxpayers, shouldn’t we be able to talk about whether we’d rather pay for someone like me to keep taking the lead out of a child’s body—or instead pay for the lead to be taken out of the house that keeps making her sick in the first place? Whether we’d rather pay for the ambulance that takes an elderly man to the emergency room—or instead for an Uber that takes him to the doctor’s office for regular preventative care?
I don’t pretend that spending money always saves it, but we’re already spending so much—more than anyone else. Shouldn’t we have a meaningful conversation about where those dollars go and what we should expect from them?
We already know that good health is about a lot more than good health care. And if our mission is good health, and that’s what we want to fund, then let’s think broadly and creatively about how we do it.
I’m a pediatrician and I most often have kids on my brain, and I believe that every day we don’t explicitly tie our money to our mission, we’re breaking promises to children who’ve been lied to all their lives.