Articles by "Red Counties"
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A popular video on social media lists 20 areas of improvement around the planet. It lists a 50% decrease in homeless veteran numbers. The rapid declines in Veteran homeless counts in metro areas are not necessarily a positive result. The media has a hard time understanding demographics and this makes it difficult when attempting to report on positive and negative areas.

Another popular poster notes that homeless veterans need attention before refugees. The fact of the matter is that many Americans are treated like refugees - as those who do well plan ways to do even better. Their designs continue to leave most Americans behind.

The relevant areas to consider for Veteran situations are not immigrants. The relevant areas are declines of veteran benefits, deteriorations involving lower income, disabled, fixed income, and less healthy populations of which Veterans are part. Most important is the consideration of available and affordable housing.
Factors Regarding Veteran Homeless Declines
It would be nice if all of these declines were about improved support for Veterans, but the fact is that Veteran benefits have been cut. Also, declines are explained by 
  • Homeless counts are done in metro areas and may not reflect homelessness or housing in other parts of the nation
  • Natural deaths - WWII to Vietnam Veterans age 64 - 98 years
  • Deaths from Veteran System neglect - too little, too late
  • Suicide - 22 per day all ages
  • Forced migration from metro and higher concentration settings
Natural Deaths
The World War II veterans were 80% of the male population of the US for their age group. Few remain as illustrated. Korean veterans were 60% of the male population of the US and are about 8% of the Veterans.
Vietnam veterans are about age 64 to 74 - a longer time period and many are still around although their health care needs are increasing. Veterans that are younger are a smaller portion with somewhat less health care need.
Forced Migration

Places with concentrations have the lowest levels of 



Light green counties lack available housing in high amenity areas and high concentration settings (people, income, education, professionals). Blue and green counties are lower concentration counties and have higher levels of available housing. Many populations with less are forced to depart higher concentration counties because housing is less available, making it more costly.

Migrations of Veterans, poor, working poor, lesser employed, elderly, disabled, and fixed income populations continue as they are forced to move to places with lower cost of housing and lower cost of living. 

45 - 50% of living Veterans are concentrated in 2621 lowest physician concentration counties with 40% of Americans left behind in places with lowest concentrations of health dollars, health facilities, and health workforce.

Some places used to give bus tickets to dump unwanted people 
from their metro areas. The modern way to do this is to dump them 
via housing leaving them only the choice to be homeless or depart. 

By taking out affordable and available housing, highest concentration settings can accomplish many desirable goals for them while sending people elsewhere. They do this by intention (greed), lack of awareness, and by neglect. Alarms are sounded daily about the lack of affordable or available housing in metro concentration areas and yet there is little response.

Veterans Are Treated Poorly As Are Similar Types of Americans
 
Veterans have high rates of disability, mental health, and chronic conditions. They also have lower income, fixed income, and are older. People with these characteristics are not treated well. Veterans are forced to move with all of these populations to lower concentration settings because they have few options for affordable or available housing in higher concentration settings. 

Greed Drives Departures
 
High levels of available housing result in lower costs of homes and lower rental costs. It is best for those who own housing. It is worst for those who need housing, especially those that have less to spend on housing.

Greed is what drives homelessness, migration, and poor access to affordable housing, available housing, and available health care. Those who are greediest benefit the most with posters and postings that distract people from the real causes of most Americans behind by design.

Developers continue to convert low cost or public housing to high profit purposes. Government or government working with developers claim land by eminent domain for roads, facilities, health care, and other purposes. Government housing was often built poorly and fell apart - and the same mistake is being proposed again because as we would not want people too comfortable (Dr. Ben Carson, HUD). Suppression of government funding can make housing shortages worse and increase costs of housing. Homeless shelters on valuable land have been sold off. Even not for profits caring for the homeless caved for the greater good of others in need of food and services. 

Where Is the Anger Regarding Mental Health Neglect?

Mental health is a key factor in homelessness. Low income, lack of income, and mental health go together. We spend half enough for mental health, half of mental health services are provide by primary care which is also underfunded by half. The spending on mental health goes to places far away from where most Americans in need of mental health are found. Another way that insurance companies or health care systems can lower costs and improve outcomes is to drive off mentally ill patients and populations. 

Castaways By Design 

The cast off Veterans join cast off elderly and cast off poor and cast off disabled and cast off mentally ill and cast off indebted people (medical, business, or finance failure) in being forced into limited choices as concentrated places continue to concentrate more dollars and leave more people behind.


Greed and Concentrations of Health Care Dollars Compromising Others By Design
 
Also greed in health care consumes twice the dollars it should leaving little support for those in most need or those in lower concentration settings - as reflected in decades of state, federal, and local budgets increasingly impaired by health care costs.

As more people are sent into debt, they cannot afford to live in higher concentration settings and are forced to migrate to lower concentration places. The most complex situations, environments, and conditions are in lower concentration settings and those forced to migrate there bring higher complexity and strain the local resources - which are also least by design.

Lower concentration counties are predominantly Red Counties noted below plus some blue border counties in Texas and Black Belt counties in the southeast and Native Reservation counties. All share lowest concentration populations and situations. Metro Blue Counties have highest cost of land, housing, and living. Migrations are forced by housing design. 



More Cuts and Compromises


And cuts in support for Social Security, Disability, Veterans, and Food Stamps will hit these lowest concentration counties hardest because 42 - 45% of these dollars are sent to these counties with 40% of Americans. These are counties that lack economic contributions outside of health, education, and government spending. Frying Pan to Fire for Red Counties

As the United States continues to spend more on military and health care spending, there is little left. The least organized Americans suffer the most in their lower concentration settings. Budgets squeezed by military and health spending have less remaining for basic services - services most important for most Americans.  Two Forces Shaping Declines in Health and Other Outcomes - Austerity Focus Plus Runaway Health Care Costs

 
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Recent meetings of family physicians brought up the age old question of expanded scope. Some raised concerns about threats to this scope. As is the usual, what is most important is the context. Where half of Americans are found, there is not a reason to be concerned about scope. 
 
Only in highest concentration settings are family physicians limited - since all specialties other than family medicine concentrate in higher concentration settings.


 
The competition is less and less of a problem regarding broad scope for family physicians in lowest physician concentration counties. Few of the other specialties remain and many are in decline. 
 
This places more burdens upon the remaining family practice workforce. This comes at a bad time as the practices require more time for documentation and there is less time for expanded scope such as hospital and procedural activities.
 
As discussed previously in recent blogs, the payment designs continue to be the major limitations for all of the above workforce types. Generalist and general specialty services are 90% of the services in these lowest concentration counties. The overall payment design pays less for the basics and the basic services are paid less in these counties. This is a poor design where care is more complex and resources are more limited.
 
Notably the attacks on scope have proceeded from insurance and payer designs. 
  • Liability premium costs put the brakes on many procedures - and a key route to better revenue generation in practices sent the least revenue by payment designs. This forced full scope obstetrics beyond many family physicians, unless they predominantly did such work to support the liability premiums. Hospitals are closing and obstetrical services are closing in these 2621 lowest concentration counties also a consequence of payer designs failing for the basic hospital services of these smaller facilities.
  • Government and insurance payers have also dumped assistant surgery - once a key expansion of scope and another revenue generator.
Countdown Workforce in Lowest Concentrations
  • FP positions filled by MD DO NP and PA distribute best at 36% to match up to this 40%. FM is 24% of local workforce where needed and reaches 38% when counties do not have a hospital or in the states such as Nebraska and Kansas. 
  • General internal medicine was 13% of local workforce where needed but is collapsing to 30,000 or below. The 4 times greater multiplier for top concentration settings will substantially reduce this contribution to 5% or below. 
  • Contrary to many studies indicating the need for geriatricians, they fail for distribution where the elderly and most complex elderly are found. Only 13% of geriatricians are found in this 40% of the population where 45% of the elderly are found. Geriatrics fails for financial design reasons - basic services paid too low and complexity too high. Inkind contributions from academic centers, nursing homes, rehab centers, and large hospitals insure that geriatrics remains concentrated along with the physician origins most closely associated with higher concentration settings. 
  • Pediatric workforce is only 6% and stable but pediatric physicians are stacked toward concentrations along with every other specialty other than family medicine. Gender changes, origin changes, and payment changes will further limit distribution. 
  • Mental health fails for lowest concentration counties where this 40% of the population easily has 45% of mental health problems. Only 23% of mental health providers overall and 17% of psychiatrists are found in these counties. 
  • Shrinkage of public health has long complicated care in lowest concentration counties and has also expanded scope. 
  • General surgeons were 27% with general orthopedics at 24% and general obstetrics gynecology at 22%. These and other general surgical specialties have been shrinking at 2 - 4 percentage points a year from 2005 to 2013 in the AMA Masterfile. There has been no sign of stopping. This should not be a surprise since these are the lowest paid services. These are also some of the oldest physicians - an indication that training of these basic surgical types is incapable of addressing care where most Americans are found and are increasing most in elderly, demand, and complexity.
All physician types who could act to reduce family practice scope are concentrating and contracting. This should result in lower physician concentrations overall and higher proportions of family medicine in the lowest concentration county physician workforce. 
 
In addition to challenges of scope, the challenges from patients are also significant - and are substantially increased in these places with lowest resources and workforce.

US Population 40%
SNAP/Food Stamp Spending 42%
Poor Americans 43%
Elderly Americans 43%
Obese Americans 43%
Social Security Spending 43%
Smoking Americans 45%
Preventable Deaths 46%
US Veterans 46 - 48%
Poor Children 47%
Social Security Disability $ 47%
Diabetic Americans 50%
 
40.7% Uninsured 2014 (so much for health insurance expansion as not that much different than the 40.2% of the population in lowest concentration counties)
  • 40.2% Population in 2010
  • 38.6% Population in 1990
  • 36.6% Population in 1970
The lowest concentration counties are fastest growing in numbers (30% faster than US average), in elderly, in demand, and in complexity - only the finances remain stagnant, miring these counties at 115 physicians per 100,000 and likely less.
 
Combinations such as Dual Eligible patients, homebound elderly, poor children, those with more mental health days, and those with poor to fair health status are more likely to be seen in these settings. The permutations that add to complexity are endless but the support has been limited by past, present, and future designs.
 
Housing and other lower cost of living factors shape patients with lowest paying plans into lowest physician concentration counties. Those stuck cannot leave and those driven out of higher concentration counties (financial reasons, lack of affordable housing) accumulate. The health payment plan failures shape the workforce failures.
 
Family physicians increase in proportion as local determinants of health decrease. The payments also decrease for the same office codes. The new Pay for Performance designs place additional limitations with higher costs and more penalties because of the populations in lowest concentration counties. The discrimination has been documented, but the bandwagon of Pay for Performance Rolls On.

The major battle remains the financial design that rewards non-basic services and penalizes those who most serve where needed, their patients, the communities in need of services, and basic health access in the United States.
 
But the new health care law, if enacted, will make matters worse. The impact will be substantial upon Red Counties already hurt by cuts in the supports noted above, with more to come.

 
 
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