A recent experience has changed my view on solving homelessness

I put in my first volunteer shift last week at a recuperative care center for the homeless in downtown Denver. The program and the facility are part of Coalition for the Homeless. During my two hour shift I helped serve dinner and clean up, and tried my best to be pleasant and welcoming to the clientele.

The recuperative care center works in collaboration with local hospitals. The hospitals can only hold patients for so long before they have to be discharged to make room for new patients. The problem is that, unlike you or I, when these patients are discharged they don’t have a place to go. So they end up back on the street, where it is challenging, if not impossible, to fully recover. Making it very likely that they’ll end up back in the hospital.

So, this left the hospital with a couple of choices.

Discharge them anyway and let them recover on the streets, knowing that the patient would be back soon;

or, 

Keep them in the hospital longer, which is expensive, and does not solve their need to free up beds;

or,

Partner with a recuperative care center and give their patients experiencing homelessness “safe, dignified, and quality spaces… to heal and stabilize from medical issues.”

Luckily, a number of hospitals have chosen the latter. The recuperative care center can house and care for up to 75 patients at one time.

The patients here are suffering from a plethora of acute injuries and illnesses. Everything from limb and digit amputations, wounds, broken bones and gun shots, to complications associated with chronic diseases such as cancer, diabetes, and stroke. The recuperative care center gives patients two weeks to recover in a new, clean, and comfortable facility, where they are provided three warm meals a day and a snack, and are able to engage in activities such as yoga, bingo, meditation, and poker night. 

If a patient needs more time to recover, then usually the facility can provide that to them. Repeat customers are common, as you might expect, and, at least from the handful of patients I spoke to, patients are always sad to leave. When they are finally discharged the recuperative care center does everything in its power to find them housing. But not everyone is so lucky, and many people end up back on the streets, only to return again one day.

Prior to moving to Los Angeles in 2019 I had very little understanding or involvement with people experiencing homelessness. But in Los Angeles, especially after the pandemic, the homeless issue was not something you could ignore. And like everyone, I had an opinion. 

My opinion was formed based on what I saw around me, and based on my experiences. In 2022 I joined a group of people and went to various encampments around the city to feed the individuals who lived there. What we witnessed was at times very hard to see, and it influenced my views.

Most of what I saw was a lot of people suffering my various mental disorders. For some people it appeared that substance abuse brought on the mental disorders, and in others the substances exasperated an existing condition. And for many of them, it looked like their mental condition and substance abuse had gone untreated for so long that I doubted if they could ever truly recover, and become a functioning member of society. I sympathized with all of them, but the prognosis was grim.

So when it came to the debate over building free housing or not, I leaned more towards the not side. I couldn’t see how without intensive mental interventions anyone I had met would all of a sudden thrive because they were given a home. It didn’t add up to me, and I felt strongly that we first needed to provide them with mental and physical support services, before we did anything else.

And I still believe that that is an extremely important first step in any plan, however, after just one shift at the recuperative care center, I now understand how important it is to also give people a place to call home.

Just looking around the halls and around the dining room at the recuperative center I saw a lot of the same “faces” that I saw in Los Angeles. Most of the patients I saw looked like they had lived on the streets for a long time, and had battled substance abuse at one time or another in their life.

But despite what felt familiar about the population, there was one thing that felt drastically different. The energy throughout the whole facility was completely serene. There was a sense of calm that I could feel radiating through these patients as they understood that for at least today, they didn’t have to fight to survive. That their nervous system could take a breath, and they could start to think about how to improve their situation, and focus on getting better.

There is tremendous value in bringing structure, routine, consistency, and predictability, into someone’s life, and surrounding them with a team of people who care. It’s something that those of us who have grown up with a safety net or a support system take for granted. I get to sleep easy knowing that if shit hits the fan and everything goes terribly wrong in my life, that there are at least three different houses that I would be welcomed into. And that’s being ultra-conservative.

For many of these people there is no one to catch them.

All volunteers are required to attend an online orientation before signing up for their first session. On my call was a young man from Louisiana. He said he grew up in a small rural town, and just recently moved to Denver. He lives in downtown Denver and said he had culture shock when we saw the homeless problem in real life. He said:

“Where I’m from we live in poverty, but there is no homeless population. There’s always somewhere for you to go, or someone to help.”

It was eye opening to hear, but not hard to understand why what he said made sense. In a small town where everyone knows everyone it is hard to walk by someone struggling. In a small town you don’t make assumptions about why someone is on the streets, chances are you know why or you know what that person is going through. In a small town the actions of a few can affect the lives of the majority. So not helping is not an option, lest you want it to impact you.

But in big cities across the country and around the world, the view is very different. Chances are you’ve never seen the person you’re stepping around on the side walk, or the guy you’re driving by holding a sign at the corner. In those situations it’s easy to make assumptions about how that person ended up there and why they’re unable to get it together. 

In a big city it is not your problem. There are hundreds of thousands or millions of other people and surely someone else must be helping. There is no reason why I should do anything. Someone else has got it. And regardless of the outcome, I’m able to continue on with my day.

These beliefs and views don’t work in a small town. It’s clear who’s getting help and who’s not. It’s hard to step around or drive by a face you recognize and have likely spoken to. The person or people living at the park or at the bus stop directly impacts you. There’s only one park, and you need to get to work.

We need to adopt small town mentalities in our big cities if we ever want to truly make an impact. We need to give people free and unlimited mental and physical therapy, and support services. And we do need to give people a place to call home. Whether it’s part of a larger program, or a place like the recuperative care center. They need a place where they can feel safe and heal.

My opinion hasn’t changed in that I don’t believe housing alone is the answer. But I do think that housing needs to be part of the solution.

Another Reason for Universal Healthcare

And just like that UnitedHealth Group reduced the work required for patients to receive their medication. It’s as if there was no real reason for anyone to jump through these hoops to begin with. It’s as if all the requirements for reauthorizations were made up. As if they were only in place to make it difficult for people to receive their medication and deny or delay peoples prescriptions and save UnitedHealth Group money.

It seems that way, because it is.

Once you see the truth you can’t unsee it, and that’s how I feel here. After learning about universal healthcare systems in other developed countries around the world my views of healthcare in this country have totally changed. Perhaps the most eye-opening fact I learned was that in developed nations with universal healthcare insurers, whether they are private or public, are not allowed to deny or delay claims. I can’t help but see this situation through that lens.

The problem is that UHG, a for profit health insurer, is allowed to implement their own set of made up requirements that do nothing but make it more difficult for patients to receive medical services and medication. And the arbitrary nature of these requirements is confirmed by the fact that, after receiving some “pressure,” at a moments notice they can change those requirements. So much so that they anticipate a 25 percent reduction in paper work associated with reauthorizations for the 80 drugs they selected.

When you see that you have to ask the question: If they can so easily and quickly eliminate those requirements, then why were they there in the first place? And, what other “requirements” could just as easily and quickly be eliminated? How could insurance make it easier for doctors and patients to receive the care they need and are entitled to instead of making it more difficult?

It’s a big game to them. The prize is money. The consequence is suffering.

I know because I saw it firsthand after the company I worked for was acquired by UnitedHealth Group. The focus was never on patient outcomes or the level of care patients received. Not when it got in the way of profits. UHG executives didn’t fly in for meetings to discuss how patients were doing. They flew in to ask: why we weren’t making more money, how could we make more money, and when we would make more money.

I was never a proponent of universal healthcare, especially when I was working. It took me a long time to come around to it. Reading The Healing of America was the last piece for me. I realized I wasn’t a proponent of it because I didn’t understand it and because I had succumbed to the propaganda that opposed to. TR Reid’s book gave me the information I needed to understand how it could work, and why it was so important.

Healthcare is not something to mess around with, that suits in a board room should be pontificating on. Healthcare should be easily obtainable, accessible, and affordable for everyone. And people who actually study medicine should be making the decisions. Decisions shouldn’t be made based on their impact on a stock price.

From my time working under UnitedHealth Group I still own some shares of their stock. When their CEO was murdered, the stock took a dive. When the DOJ opened up an investigation into improper billing of Medicare it dove further, and it hasn’t recovered. I told my brother I’m stuck between a rock and a hard place.

“On the one hand, my stock is down 30 percent. On the other hand, UHG is finally getting what it deserves, and even though it hurts my wallet, I’m happy that they’re facing a reckoning.”

Ignoring the root cause in healthcare

Every book or long form podcast contains at least one gem of information, new perspective, or piece of context that shines new light on an old topic. That’s the opening sentence from my last post: War Good. Trump Bad. But the theme continued when listening to another Joe Rogan podcast (I’m on a Rogan roll). This one was with Chris Williamson.

They were discussing a wide range of topics when Chris dropped this piece of knowledge on me. He said that patients who undergo bariatric surgery have higher rates of suicide post surgery. The reason, he explained, was because obese patients get that way by using food as a coping mechanism for whatever trauma they are trying to deal with. No different than the way an alcoholic drinks, or a drug addict drugs. They are all dealing with the same thing, unaddressed trauma, their substance of choice just differs.

But when patients come out of bariatric surgery, and the size of their stomachs have been greatly reduced, they can no longer eat enough to sedate those depressed or anxious feelings. They can’t eat themselves into a “food coma” and feel ok. So, they turn to self harm. And it turns out, it’s true.

It’s another one of those things that after hearing makes so much sense, but not something I ever thought about before. Bariatric surgery is addressing the symptom of the disease. It’s addressing the weight gain, not the reason the patient gained so much weight in the first place. But the root cause of why they got that way is ignored.

I feel sad when I hear things like this. Because people turn to doctors, hospitals, and clinicians to help them with whatever ailments they face. And it’s the job of the practitioner to figure out what’s really going on, but most of the time they don’t. An obese patient needs to lose weight to save their life and improve their quality of life, but excess weight is not the underlying issue.

And while there are probably bariatric surgeons out there who address the whole problem, or try to by referring their patients to psychotherapy in addition to surgery, most physicians probably don’t. I worked in the system long enough to know how most physicians operate. And it’s not totally their fault.

Incentives are woefully mis-aligned. Surgery makes money, so hospitals and surgeons are incentivized to perform surgery. Spending time with a patient and coaching them to lose weight is not a money maker in the short term, so very few physicians put any real effort into it. 

It’s just another example of the failure of our healthcare system. It’s just another example of how we don’t address the root cause of issues in this country. We just try to cover them up or cut them out. Meanwhile the issue continues to lurk in the darkness waiting to rear its ugly head again.

A system that works for everybody is very badly needed in this country. A total realignment of healthcare’s incentive structures is very badly needed. So many people are suffering and not getting the help they need. Imagine if we had a system that actually worked for everyone. 

Unraveling Universal Healthcare II

When I was working one of the main reasons people said insurance companies didn’t focus on preventative care was because they were unlikely to benefit from it. That by the time a person was at the age when they would develop a preventable disease, they would be covered by a different insurance carrier, and that carrier would be the one benefitting. Because most people get their health insurance through their job, whenever they switch employers, they also switch insurance. It turns out this happens on average every 6 or so years.

I understood the logic then as I do now, but I have never agreed with it. My view was always if all the insurance carriers provided preventative care, then it wouldn’t matter which patients they were covering. Everyone in the pool, in theory, would be equal. But obviously getting every insurer to agree and comply with this idea would be a gargantuan task, and one that no one wants to take on. It is though one of the reasons that Accountable Care Organizations were born, as well as incentives for achieving certain quality metrics. Unfortunately it hasn’t been enough to change the trajectory of health in America.

But I never thought of it as a reason for universal healthcare. Not until I read TR Reid’s The Healing of America. Because under universal healthcare, and more specifically a single payer system, the government has all of the incentive in the world to keep people from getting sick. The more disease they prevent, the less money they have to spend on treating those preventable diseases, the more money that’s in the system to treat other people with acute and non-preventable illnesses.

TR Reid makes this argument in chapter 11, An Apple a Day, and it was the first time I ever realized that it could help solve this problem.

“In a nation with a unified health system that covers everybody - which is to say, all the industrialized democracies of the world except the USA - it clearly benefits both the population and the system to invest in public health. But in a fragmented, multifaceted-system nation like the United States, the economic incentive for preventative care are dissipated.”

In this excerpt from the book he calls U.S. healthcare a “system.” But in a previous chapter he more accurately defines it.

“American healthcare is not really a system at all. It’s a market. In a market, people with money can buy what they want, and many people are left out. So we thought, no, we don’t want market-driven healthcare. We want a real system, something that covers everybody and doesn’t depend on how much money you have.”

He’s quoting a Taiwanese businessman who helped set up the universal healthcare system in Taiwan in the 90s. When thinking about what they wanted their system to look like, they first turned to the US, but then realized it wasn’t a model to copy.

Healthcare as a market, as a commodity, is also not something that I ever put together even though it should have been obvious to me. The rich get good healthcare, the poor don’t. It’s not something I was ever ok with, but it’s something that I dismissed as just the way it was. The same way I thought the ability for insurers to decide which claims to deny was normal. That is until I read this book and my eyes were opened. That is until he framed healthcare as a commodity in the U.S. and it clicked for me.

Our country is so focused on making money. Everything we do as a nation is based on this. And that’s ok. That’s a good thing in most cases. Economic incentives, the ability to create a better life for yourself and your family is one of the reasons that Americas is viewed so favorably around the word. I meet people all the time in my travels who dream of coming to America, working hard, and having a better life. I meet people who have immigrated here and are so happy they have the opportunity to improve their situation. And I don’t think we should ever change that.

But I think it’s time that we grow up as a nation. That we realize as a nation that we have more than enough resources to give everyone that lives here a comfortable and secure basic level of living. That certain things like healthcare, food, shelter, and clean water, are not commodities that should be distributed based on income.

And I think providing a real healthcare system for everyone, and turning our public health efforts towards helping prevent disease, is a great place to start. And I think that while healthcare could be step number one, revamping the market around food and turning it too into a system that benefits everyone, is a very close number two. 

Unraveling Universal Healthcare, and a Good Place to Start

I started reading TR Reid’s The Healing of America in which he analyzes the main components of universal healthcare systems in developed countries around the world, and then compares them to each other, and to the U.S.’s system.

I’ve gotten as far as France, Germany, Japan, and the UK. Each one is slightly different in whether insurance is private or government funded. How much citizens have to pay (if anything at all). How much providers, physicians and hospitals make. How they maintain patient records (France maintains all patient records on a card similar to a credit card. When you visit the doctor or a hospital they simply swipe your card and all of your information pops up, and the provider can update your chart. Imagine never having to complete a new patient intake form again!).

There are a lot of small differences.

But the one thing thus far that is universal to them all is that no insurance, whether it’s private or government run, can deny a claim. If a physician, hospital, or provider, submits a claim for a procedure, test, or medication, insurance must approve it, pay it, and the patient must get the service.

The one slight caveat to this is in the UK, where a government run organization called the National Institute for Health and Clinical Excellence, NICE for short, conducts research and studies to decide what gets approved. The difference though between NICE and insurers in America is that NICE publicizes its decisions. While private insurers in the U.S. make their decisions in private.

Another difference is that NICE only has a set amount of money to fund healthcare for the whole country, so they need to be strategic. But denying a service doesn’t result in extra profits in the UK like it does in the U.S. Rather, rationing some services, like experimental treatments, means that someone else can receive the care they need.

It’s been shocking to learn because it is so contrary to the way we provide healthcare in America.

In America the insurance carrier decides what procedures, tests, and medications are approved. Not the doctor. In America, the clinic’s office staff frequently has to fight with the insurer to get approval and payment. They have to go through a lengthy appeals process, and very often the doctors themselves have to take time out of their day to get on the phone with the insurer!

It’s so engrained in us that I had a hard time accepting it. My American brain, programmed from spending 10 years working in the American healthcare system, kept saying “That doesn’t make sense. Of course they should be able to deny claims.”

I told my brother, who’s an operating room nurse manager in the largest hospital network in the northeast, about it, and he too was confused. His response was, “wow, really?”

Corollary to that thought, my next one was, “Their claims, testing, and procedures, must be through the roof. And costs as a result.”

But that’s not really the case. It is true that in most of those countries utilization rates are higher when compared to the U.S., but still the overall cost of healthcare is cheaper. One of the main ways they manage that is by having a drastically lower fee schedule when compared to the U.S.

A $200+ office consult in America might cost $20-$30, while a $1,500 MRI might be $105.

And the evidence actually says the inability to deny claims makes it cheaper by putting less strain on the system. Providers in those countries aren’t required to employ additional administrative staff to bill claims, file appeals, and fight denied claims. A huge expense, and huge time suck. I know because it’s one of the main responsibilities I had at my company.

Which made me think, “Why do we allow insurers to deny claims here?”

The answer. It’s just what we do.

I was talking to a gentleman at the airport who works for Firestone Agriculture as a farm consultant. He was a big heavy set Texas man with a handle bar mustache.

I asked him what he does in his role. He said he tries to save farmers money by implementing more efficient practices. He said the main thing he does was advise them on what tire pressure to maintain on their tractors. The correct pressure can save 1 percent on annual fuel bill of $250,000. That’s $2,500. A lot of money for farmers who typically run at a loss.

But he said despite telling them that, he often meets resistance. They don’t want to check their tire pressure and most farmers keep their tires at around 24 psi. The correct pressure is 12 psi.

When he asks farmers why they chose 24 psi, they respond by saying, “Because that’s why I’ve always done.”

It seems to me that we have a long road ahead if we’re ever going to get to a real universal healthcare system in this country. But maybe a smart approach is to start tackling it piece by piece.

It seems like, especially given recent events around healthcare and its executives, that a good place to start might be outlawing the practice of denying claims. If we can’t yet wrap our heads around universal coverage, maybe we can accept that anyone with coverage needs to be covered.