A Tale of Two Americas Through the Lens of Health Care

(Christopher Furlong / Getty Images)

Two articles published by the Washington Post and the New York Times this weekend focused on extremely different versions of the U.S. healthcare system: The Post feature— part of a series on “Disabled America,” which focuses on rural populations receiving federal disability checks — bears the dateline of Pemiscot County, Missouri, a place where the dwindling population has an unemployment rate of eight percent. The Times’ feature is part of the series “The Velvet Rope Economy,” which focuses on “how growing disparities in wealth are leading to privileged treatment of the rich.” Nelson Schwartz reports from San Francisco, currently the second-most densely populated major city after New York, with the third-highest median household income. Known for being plagued by homelessness, the poverty rate is 12 percent, lower than the national average, and the unemployment rate is 2.6 percent.

In the Post, Terence McCoy reports on a multi-generational family on disability that struggles to make ends meet in “a county of endless farmland, where the poverty rate is more than twice the national figure, life expectancy is seven years shorter than the national average and the disability rate is nearly three times what it is nationally.”

McCoy offers up a host of statistics gleaned from his own analyses of federal data and interviews both with rural residents and with professionals like social workers, lawyers, school officials and academics. An average of 9.1 percent of working-age people are on disability in rural areas, nearly twice the urban rate and 40 percent higher than the national average. The rate spikes in areas from Appalachia to the Deep South and into Missouri, dubbed “disability belts” by economists, and is highest in 102 counties within those belts, where McCoy estimates a minimum of one in six working-age residents are on disability.

“Multigenerational disability, the Post found, is far more common in poor families,” writes McCoy, gesturing at the difficulty American families face in attempting to climb out of poverty. When the family he follows loses the disabled status of their youngest members, they must convince the government to reinstate it in order to “climb from crushing poverty into manageable poverty.”

Meanwhile, in San Francisco, reporter Nelson Schwarz goes behind the scenes of boutique medical services with “concierge doctors” who target Silicon Valley’s millionaires and billionaires with five-figure annual fees that afford “a chance to cut the line and receive the best treatment.” (As one doctor says, “this is cheaper than the annual gardener’s bill at your mansion.”) 

Both patients and doctors express some misgivings: One patient professes “guilt over what he admits is very special treatment” and physicians are “quick to admit they struggle with the ethical issues of providing elite treatment for a wealthy few, even as tens of millions of American struggle to afford basic care.”

Several of the doctors who joined these boutique enterprises say they wish they could have afforded patients at their old practices “the time and energy” they have for their new, ultra-wealthy patients, but none explain why they couldn’t. The insinuation is either pressure from insurance companies or a need to squeeze in as many patients as possible, or a combination of both, but it’s never made explicit.

Catering to the wealthy isn’t just for individual doctors — hospitals are also on board with putting up a velvet rope. Stanford recently committed to a $2 billion wing designed by “star architect” Rafael Viñoly, which features a rooftop garden and a glass-paneled atrium topped with a 65-foot dome. (Until then, red blankets are given to benefactors when they check in for treatment, so anyone who stops by their room knows their status.)

One doctor balked at the notion that healthcare should not be a polarized system. “Whenever I bump into a bleeding-heart liberal, which I am, I mention that schools, housing and food are all tiered systems,” he said. “But healthcare is an island of socialism in a system of tiered capitalism? Tell me how that works.”

“In my old waiting room in Seattle, the C.E.O. of a company might be sitting next to a custodian from that company,” he recalled. “While I admired that egalitarian aspect of medicine, it started to appear somewhat odd. Why would people who have all their other affairs in order — legal, financial, even groundskeepers — settle for a 15-minute slot?”

The Times rejoins, “It’s a fair question.”

But is it? Or is healthcare — like food and housing — a basic human right that should be afforded to everyone, whether they are a CEO or a custodian? A hospital executive argues that courting the ultra-wealthy allows them to provide care to the less wealthy “as reimbursements from private insurers and the federal government shrink.”

In the Washington Post story, the family matriarch has taken to diagnosing illnesses based on her own research, convinced her hyperactive twin grandsons have a slew of disorders. Her daughter lives a life in which “for as long as she could remember, what she couldn’t do had defined her far more than what she could,” and the only medical professional who appears in their life is a therapist “who drives all over the county counseling distressed families.” It doesn’t seem like any substantive care is getting to the people who need it most.