Health Care: Pain City in the Burbs

And we go to Happyville, instead of to Pain City. –Thomas Pynchon, Gravity’s Rainbow

One of the things that drives me the most crazy about ObamaCare is that its putatively universal benefits are so randomly applied. As I wrote back in 2013:

In this continuing series, we’ve been looking at how ObamaCare, through its inherent system architecture, relentlessly creates first- and second-class citizens; how it treats citizens, who should be treated equally, unequally, for whimsical or otherwise bogus reasons. It’s all in the luck of the draw! If you live in the right place or have the right demographic, you go first class to Happyville. If you don’t, you go in coach to Pain City.

If Social Security were implemented like ObamaCare, citizens in Libby, MT would get a bigger check, because; you couldn’t get a Social Security payment if you were debanked, and didn’t have a checking account; you’d get one kind of Social Security from the government if you were poor, and several other kinds of Social Security from private companies if you were not; you’d get a bonus Social Security check if you worked on Capitol Hill; you’d be encouraged to collect your benefits if you were in the right demographic, but otherwise not; your benefits would depend on your projected income, which would be checked by a private credit reporting agency; and your check would vary wildly from state to state, and even from county to county. Who could possibly support such a crazy system?

We now have addititional confirmation, were additional confirmation needed, of this thesis. I want to draw your attention to the following new study, “Health Care In The Suburbs: An Analysis Of Suburban Poverty And Health Care Access,” by Alina S. Schnake-Mahl and Benjamin D. Sommers, in October’s Heatlh Affairs; The Schnake-Mahl/Sommers study is said to be “the first national analysis comparing health care coverage and access between people living in the suburbs and people in urban and rural areas.” From the abstract:

There are 16.9 million Americans living in poverty in the suburbs—more than in cities or rural communities. Despite recent increases in suburban poverty, the perception of the suburbs as areas of uniform affluence remains, and there has been little research into health care barriers experienced by people living in these areas. The objectives of this study were to compare patterns of insurance coverage and health care access in suburban, urban, and rural areas using national survey data from 2005 to 2015 and to compare outcomes by geography before and after the Affordable Care Act took effect. We found that nearly 40 percent of the uninsured population lived in suburban areas. Though unadjusted rates of health care access were better in suburban areas, compared to urban and rural communities, this advantage was greatly reduced after income and other demographics are accounted for. Overall, a substantial portion of the US population residing in the suburbs lacked health insurance and experienced difficulties accessing care.

The Harvard School of Public Health summarizes the numbers:

The findings showed that:

  • The suburbs were home to 44% of the overall population and 38% of the uninsured population, and the uninsurance rate among suburbanites was 15%.
  • The probability of having no usual source of health care in the suburbs was 19%, and for having no routine annual checkup, 34%.
  • Among low-income suburbanites, 36% had an unmet health care need due to cost and 42% had not had a recent checkup.
  • All poor adults—whether they lived in cities, rural areas, or the suburbs—had 8 times higher odds of being uninsured and 1.7 times higher odds of no recent checkup compared to higher-income adults.

That’s just bad, no matter how you slice it. And (as usual) ObamaCare helped, but not enough. The authors were kind enough to send me a copy of the study, so quoting from page 8:

Exhibit 4 compares outcomes in each type of geographic region before and after implementation of the ACA. In all three types of areas, our coverage and access outcomes significantly improved in the post-ACA period. For suburban areas, there was a 3.8-percentage-point drop in the uninsurance rate in the postACAperiod compared to the pre-ACA trend; for urban areas, the comparable estimate was 4.6 percentage points, and for rural areas, it was 4.2 percentage points. …. Across these models, rates of coverage and access challenges remained high among low income adults in suburban areas, similar to those in urban and rural areas. Despite improvements in access and coverage after the ACA took effect, our results also suggest that sizable barriers remain and that, if anything, gains may have been more limited in suburban areas.

And interestingly, from page 9, on Medicaid: Medicaid expansion also helped, as we know; but not enough. It didn’t help as much as we might have expected, given the high proportion of residents of expansion states that live in suburbs:

Despite this disproportionate presence of suburbanites in expansion states, our findings indicate that the ACA has not differentially improved coverage and access for those in the suburbs.

Finally, the authors speculate on why suburbs face difficulties of their own distinct from urban and rural areas. Quoting from pages 7 and 8:

Our results show a large affordability gap based on income, with substantially worse access rates for the poor than the non-poor across all geographies. Poverty in the suburbs likely poses unique challenges and consequences for residents, particularly for low-income and uninsured residents who seek care from the health care safety-net…. [T]here is reason to suspect that unique nonfinancial barriers to care may exist in the suburbs, which may require different solutions than those needed in urban or rural areas. Previous research shows that even after area poverty rates are controlled for, services and publicly funded infrastructure targeted to the poor are scarce in many suburban areas. For instance, there are important gaps in the availability of health care services such as mental health, substance abuse treatment, and hospitals in suburban areas. And though care systems and provider networks are often and increasingly located in high-income suburban areas with large privately insured populations, many suburban physicians are less willing than their urban counterparts are to treat the uninsured and Medicaid beneficiaries, leaving poor suburban residents with limited options for physician care.

Given the lack of health centers in suburban areas, emergency departments are often the primary source of care for the suburban poor. Even accessing hospital or emergency care can be difficult for this population because of insufficient availability of safety-net hospitals, especially in high-poverty suburbs. Because fewer suburban providers appear to be willing to treat uninsured patients, suburban patients often must travel long distances to urban safety-net providers. On a broader scale, limited public transportation systems and sprawl in the suburbs may present unique barriers to low-income patients, given the long distances they must travel to obtain care.

Current policies that identify areas of medical need and determine safety-net location have not adapted to shifts in the geography of poverty, which makes it difficult to locate services and providers in suburban areas with high levels of need for free or low-cost care. Recent proposals by some states to limit medical transportation services in Medicaid in particular could hamper access to care for suburban populations.

Of the structural issues, the one that leaps out at me is a “tax on time” for travel, variously expressed as “sprawl,” “limited public transportation,” and “travel long distances.” It seems that the burbs, having been designed for the age of cheap gas, aren’t structured so well for those who are “transportationally challenged.” (It takes me an hour by bus each way to get to my nearest health clinic, and my needs have been simple. If I had to travel all over the Bangor area, by bus, for tests and treatment, the tax on my time would quickly become inordinate). I also wonder how much the medical profession’s specialization has led to scattered facilities, each requiring a separate trip. Do any of our suburban readers have thoughts on this? Frankly, I’m reading that long extract just above, and translating it into human terms, and the whole situation looks like it could rapidly transform into a hellscape. Why do we make sick people go through this nonsense, especially when they’re poor?


We’ve heard a lot from Democrat centrists about appealing to the suburbs; but I think it’s safe to say that these suburbanites — the ones who are sent to Pain City by the luck of the draw — aren’t the suburbanites the centrists have in mind. After all, if you don’t have health insurance, you’ll be unlikely to fork over fifty bucks for a rubber chicken dinner with your Congress critter. For the suburbanites in Pain City, Medicare for All would be far more appealing.

In any case, I don’t see the Schnake-Mahl/Sommers study getting much attention outside the professional journals; I think it should, and I hope it does, so please circulate it, especially the Health Affairs link.

NOTE: Methodology

The statistical techniques used are above my paygrade (“[W]e used logistic regression models to examine the association between the outcomes (access measures) and the three geographic areas, before and after adjustment for demographic factors (age, sex, race, ethnicity, marital status, education), employment, household income, survey year, and state of residence.”). However, I feel competent to extract information the dataset:

Our study used data from the 2005–15 waves of the Behavioral Risk Factor Surveillance System (BRFSS), an annual national cross-sectional telephone survey of noninstitutionalized adults over age eighteen…. Although our study provides important comparisons of health care access in suburban, urban, and rural areas, several limitations must be acknowledged. First, our sample included only nonelderly adults, while other research in this area has not been age restricted. This limits comparison of our work with other reports. Second, though the study relied on survey data, previous research has found high levels of reliability and validity for the BRFSS health care access questions. Third, our household income measure was imprecise, since it was self-reported and measured in income categories rather than exact amounts; in addition, 12.2 percent of our sample did not provide any response to the income question. In our data, those with missing income were significantly more likely than others to be uninsured and have no usual source of care (p < 0:001); thus, if anything, this omission may have led us to underestimate the suburban health care barriers in our sample. Fourth, we excluded cell-phone respondents from our sample because data on our primary exposure, the geographic indicator, is lacking for this group. Fortunately, even after we excluded cell-phone respondents, the overall trend in the insurance rate in our data was similar to those found in other surveys of national insurance rates. Cell-phone use is more prevalent among low-income households. Therefore, our use of the landline-only sample may also have led to an underestimate of poverty rates and barriers to care. Fifth, our assessment of changes after ACA implementation in 2014 are largely descriptive. We could not determine whether these changes in coverage rates were related directly to the ACA's coverage expansions or were due to unmeasured confounders. However, we did control for several potential confounders, including income, age, state, and the pre-2014 time trend.

The bottom line for me is that from the data, at least, the situtation is no better than the study shows, and could well be worse.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Kevin Curry

    I would argue that the rejection of Medicaid expansion does have something to do with this. Medicaid provides transportation services and in home care. Medicaid also provides a steady revenue stream which better allows health services to expand into poorer suburban areas.

    That said, those expansions are usually limited to primary care and pharmacy. Specialties have gotten far too specialized and expensive to offer services to every suburban community. Suburban communities simply cannot subsidize the incredibly expensive facilities (I’m currently early in the process of writing a proposal to update my medium-size sterile compounding pharmacy to coming regulations and I’m looking at $7-10 million), specialized equipment, or specialized staff and physicians. A suburban area might be able to keep an overworked PC doc who make $150k a year running in a small medical office building with minimal equipment, but an orthopod who makes $850k a year and who needs an OR and tons of specialized equipment, not so much.

    I’m not sure there is a solution to this problem which doesn’t center around making transportation to regional health care facilities accessible and functional. Medicine has changed immensely in the last 25 years, seeing the family doc for all the ails you simply isn’t how things work anymore.

    1. Arizona Slim

      For many ailments, a trip to the doctor isn’t necessary. The diagnosis and treatment can be handled by a nurse practitioner or a physician assistant.

      1. Synoia

        Including Childbirth.

        The US turns a happy event, the birth of a child, into a massive cost, possibly a financial disaster.

        1. sierra7

          Maybe we should ask Cuba how they have managed to do so much in medicine for themselves and for so many others in other countries……….But, we don’t dare! Socially speaking this country is a disgrace.

  2. JEHR

    In New Brunswick Horizon Health Services administers health care for the province. On page 77 there is a statement of operations and elsewhere salary ranges for those who run these services. This report may be of interest to those wondering how our health care is administered and from whence comes our revenue (see financial statements).

  3. DonCoyote

    Logistic regression means that your dependent variable(s) are categorical/binomial (well also that you have more than one continuous independent variable). Given that it is self-report questionnaire data, the three questions are probably:
    1) Do you have health insurance Y/N?
    2) Have you had a routine medical checkup in the last year Y/N?
    3) Do you have an “unmet health need” (which presumably the phone script had a set definition/explanation/examples for) Y/N? (and possibly 3a) If Yes to 3, is it due to cost/finances Y/N?)

    They admit up front no old people (65+?), but my biggest problem is “landlines only” (can’t you ask people what zip code they live in? I mean, 1/8 of your respondents didn’t give you income, so yeah, you’ll have some missing/wrong zip code data, but I’m sure you could classify zips on a rural/suburban/urban scale fairly accurately). I would say younger suburban “households” (depending on your locale, plenty of suburban apartment complexes) are more likely to be cell-phone only. Thus you seem more likely to have a middle-age population only, which reduces generalizability.

    But non-perfect data is the rule, not the exception, and I’m glad to see someone is looking at this.

  4. Watt4Bob

    I’d be willing to bet that one of the big impediments to health care access in suburban areas is transportation. It’s also a problem for poor job seekers.

    Here in Minnesota, the suburban cities have fought tooth and nail to prevent light rail expansion beyond the boundaries of the Twin Cities of Minneapolis and St. Paul.

    The reason is local pols fanning fear that mass transit will result in ‘those people’ suddenly appearing in their lily white suburban utopias.

    A number of local state representatives have been known to demagogue this issue successfully, and they’re willing to forego millions in federal dollar subsidies available for transit, much like republicans in other states refusing to expand medicaid.

    The Twin Cities have long been known to be one of the most segregated metro areas in the country, and the lack of effective mass transit is one of the ways ‘those people’ are kept in their place.

    When I was young I lived in Chicago, where bus schedules were unnecessary because buses ran so often, there was no question that a poor person could get to work on time. I used to take the bus to work each day, traveling literally across town, southwest side to northeast side with no fear of being late or stranded.

    Mass transit in the Twin Cities is such that missing a bus often means a wait of an hour or more depending on the time of day, and buses stop late at night so forget night shifts in the suburbs.

  5. Brown

    You know, I get so sick of this crap we get stuck with by Washington and the private sector. It is so brutal what they are imposing on their fellow American citizens.

    This year my “employer” is offering a United Health care plan that exceeds 10% of my adjusted monthly income–and get this–does not cover doctor costs even when you meet the deductible. There’s a lot of other stuff not covered, too. Enough stuff to turn your hair white and deadened your soul. Covered CA is too expensive to be an alternative as I am older (54 years young).

    I used to be able to get medical care at community health care centers, but now they are not interested in seeing me because they now have poor patients with ACA (a guaranteed revenue stream).

    1. Tom

      The cheapest ACA policy for us in 2018 would be two Bronze Plans with a $1,100 monthly premium (each) and $5,000 deductibles. We don’t qualify for subsidies so we would pay the whole thing. As an alternative, we are looking at one of those faith-based plans that is not insurance, but kinda works like it.

      1. Henry Moon Pie

        I’ve heard some of those advertised on the radio. I think the idea is that you pay them money every month–less than a regular insurance company charges–and if you get sick, you pray like hell.

        1. Tom

          Or hope for a miracle, right? Actually, your monthly contributions go into an escrow account, along with all the other members’, and that money is used to pay the covered healthcare expenses of any member who needs it. There’s lots of fine print, of course, but then again, there is with the ACA plans as well. If you’re going to get screwed by your health plan anyway, you might as well save $6,000 to $7,000 in premiums by avoiding the ACA Bronze offering and setting that money aside for emergencies.

    2. perpetualPOOR

      I’m so sorry I am one of the poor ACA.

      If I can redeem myself, I have been fighting for all the homeowners (former homeowners) for many years with the banks. I have put in many hours of volunteer time to fight for our rights.

  6. Jeff N

    Here in Chicago, many of the poorest people have been driven out of the city, to the southern suburbs.

  7. Mark on LI

    I live in the New York City suburbs and commute into the city. Part of my commute involves riding the NYC subway. I regularly see ads in the subway cars (from, I think, the NYC Department of Health) urging the riders to sign up for healthcare and informing them of assistance available to low-income families.

    I know of no such comparable public service advertising in the suburbs. It may exist, but I haven’t seen it. If it does exist, I have a hard time believing it would have the reach that the subway ads have.

  8. Altandmain

    A big problem that many people in the suburbs have is that they are “house poor” or “rent poor”. This compounds if they cannot afford an automobile. Of course, people who are in need of financial care, but cannot afford it due to reasons of cost are far more likely to not be able to afford a car and other limited means of transport.

    That leaves them with limited means of transport. It is a big problem for getting to work (even with Obamacare, health insurance, not to mention income are heavily tied to insurance still). It also means they have limited means to go elsewhere. Mass transit coverage to the suburbs is usually very poor compared to Europe or Asia, whose cities have been built for mass transit and walking to begin with.

    Food deserts also suffer from this problem. Compounding this, gross inequality itself appears to be a major cause of many of society’s health problems.

  9. nonclassical

    …prefer Yves work-revelatory contrast herein, to author Pynchon…not even close…(definitively) this treatise clarifies…

    (in contrast “Crying of Lot 49”)

  10. Wisdom Seeker

    I just want to comment that a healthcare plan, of the sort prevalent today, is frequently NOT “insurance”, as traditionally understood. Insurance is shared pool of funds to protect against unlikely and random events. Car insurance and home insurance work very, very differently from healthcare plans.

Comments are closed.