Poverty, health closely linked

Nov. 24--Editor's Note: Second in a series on poverty in Albany and Dougherty County.

ALBANY -- The most recent statistics from the Census Bureau show that of the estimated 90,017 Dougherty County residents in 2016, about 30 percent of them live below the poverty level. The median household income for the county is $32,084, $486 below the poverty guideline for a household of six people.

The impact of these statistics is felt greatest, perhaps, in the health care sector, in terms of health outcomes and insurance coverage.

Vamella Lovett, nurse manager for the Dougherty County Health Department, said the Southwest Public Health District receives funding from the state that allow the county to offer services to anyone who walks into the health department's doors.

"We see a larger number of individuals who can't afford to pay for care (and come to the health department)," she said.

For individuals with limited means, the health department is sometimes the first point of health care contact. When a person comes in the doors, he or she is often not working and not yet on disability -- which means that person has no resources. They can be referred to a provider who will see them, get on a prescription assistance program and get their blood pressure monitored.

The demand for services does not appear to be getting any lighter.

"I have been working in the area for 26 years," Lovett said. "There are more people able to get health insurance, but there are still quite a number of people that can't do that. They fall through the cracks.

"There are a number of those with a disability and (can't) get an income. We have seen those numbers come up some. These people are looking for some means to get health care."

Southwest Georgia has high rates of obesity and diabetes already. Some do not have easy access to fresh fruits and vegetables, which in turn creates a nutrition problem.

"They have to work with what they can," Lovett said.

Public health also connects people to the Phoebe Cancer Center for certain cancer screenings they cannot afford without insurance. The gap is beginning to close, but there is work to be done.

"It just improves their lives a lot by being able to access health care," Lovett said.

Dr. Derek Heard, of Phoebe Primary Care of Albany, has been on the frontlines in the battle to provide health care and combat poverty. He said he has noticed that the two issues are very closely linked. Some of his patients do not have adequate transportation or means to receive medication, an indication that poverty has been a far-reaching problem for his patient base.

"I had one patient this morning who could not afford generic (medication)," he said.

If there is no car in the household and the closest store is a Dollar General, that does not present many options for good nutrition. All a patient may eat is packaged or processed food.

"Poverty impacts all aspects of this," Heard said. "I don't think the general public understands the depth of this problem. Some ask 'Why can't you do better?' There are some who can't do better.

"As a community, we have to do better."

Heard is a member of a recently formed coalition working to affect diabetes rates and management. One of the initiatives the coalition is closing the gap on "food deserts" and creating more environments or incentives for people to walk. Heard said he would like to work to break the cycle of poverty, health and employment that is almost impossible for people to get out of.

"If you cannot get well, you cannot be gainfully employed," the doctor said. "We complain to people about not being gainfully employed, but we (are sometimes) putting them in that position.

"I don't know if people are putting two and two together. If they have health problems, they can't work. That is something that would be easily fixed if (they) had the means. There are some lazy people, but I would say 90 percent of people don't choose to be impoverished. These people aren't choosing illness."

On the flip side, some would rather live with chest pain than miss several days of work that they cannot afford to take off.

"There are people who literally can't do that," Heard said.

The doctor said he thinks farmer's markets, embracing health insurance more broadly and lowering the costs of drugs are among the things that need to be done along with more resources in the community -- including churches and civic organizations -- addressing the problem.

"We say we are in the Bible belt, and we love God," he said. "The Bible says to love thy neighbor as thyself. I don't see us doing that anymore. Only on Thanksgiving and Christmas; otherwise we don't care."

Doctors can know what to do all day, but it still goes back to their patients not being able to afford ever-rising health care costs. The diabetes coalition will potentially, Heard said, look toward putting more resources into Albany's Samaritan Clinic, reaching out to schools to educate a younger audience, expanding faith-based community involvement and increased access to the Phoebe Diabetes Center.

Heard said he believes those with the ability to tighten their belts have a responsibility to help out, because the problem ultimately impacts everyone as long as there are groups of people choosing jail over starvation.

"If it works for diabetes, maybe we can expand it to other health care fronts," he said. "If we could become healthier, we can start affecting poverty.

"Unless we start putting resources to it, it is only going to get worse."

Kimberly Scott, vice president of community health for Horizons Community Solutions, said it is evident that poverty is one of the social determinants of health, and that is a pressing issue because it it is connected to a wide range of issues concerning neighborhood, education and social context.

"They are all intertwined with health outcomes," she said.

Scott said chronic disease rates tend to be higher among those in poverty. Horizons is directly involved with making sure those in poverty have access to cancer screenings, because those without access to screenings may not have their disease diagnosed until it is too late for most methods of treatment to be effective.

"As an organization, through the screening program, (we are) providing access to screening," she said. "There are so many people who don't have access to health care due to poverty. We need cancer screenings early, when they are most treatable."

Going to emergency care first and limited health literacy are problems across the board, but particularly among those living in poverty. It is also difficult for the impoverished to implement preventative care, as healthy food and exercise options may be limited.

"Living in poverty can make it difficult to live a healthy lifestyle," Scott said.

Horizons has target counties, Early and Terrell, in which it is working on movements to educate the public on social determinants. It is an effort to gather collective ideas to bring about change. But those involved know change cannot happen overnight.

"We hope, since we are working as a group, we can have a collective impact," Scott said.

The Census Bureau reported that in 2016 53.2 percent of Dougherty County's population benefited from private health insurance coverage. A third of that group received employer-based insurance only. Of those receiving private health insurance, 24.1 percent are below 138 percent of the poverty threshold.

Public health coverage in 2016 reached 41.2 percent of the county's population. A little over 26 percent had public health insurance alone, including 5.4 percent solely relying on Medicare, 20 percent on Medicaid and .7 percent on VA benefits. A full 54 percent of those on public insurance were below 138 percent of the poverty level, and 12.8 percent of those receiving public insurance were age 18 and older working full-time.

Clifton Bush, chief operating officer for Albany Area Primary Health Care, works with a clinic network that serves a large number of patients who are underinsured, uninsured or on Medicaid. His observation is that many, even some with a chronic illness, would rather let their health get worse if seeking treatment means losing their home.

This is why, he said, AAPHC has gone out into the community to take some of the services to the populace for free. It also has school-based clinics, a sliding fee scale, programs for discounted care and discounts on prescription drugs in partnership with certain pharmacies.

Bush said he has seen lack of coverage become a growing problem as increasing health care costs have compelled people to stop paying for insurance because it is no longer affordable to them.

Licensed navigators are rotating through the AAPHC clinics, getting people signed up for coverage under the Affordable Care Act in order to get people some level of coverage. There are a cases, Bush said, in which people are either eligible for Medicaid and do not know how to get connected or they turn out to have more coverage than they think they do.

So part of the problem boils down to educating people about health access and coverage options.

"Health care is available within this community, even if you don't have insurance," Bush said. "The top priority is awareness, awareness that these things are out in the community."

Based on the quality measures AAPHC tracks, Bush said there is reason to be hopeful.

"We have seen quality metric rates get better and better," he said. "As we continue to work hard to come up with ways (to reach out), I do see, hopefully, individuals (gaining) access to care."

Much of the future of health care depends on what happens in Congress. Legislators still have to act on proposed funding cuts to federally qualified health centers, including AAPHC, that could change the landscape.

"What Congress does in the coming weeks and months will make a big difference," Bush said.

Also watching the insurance coverage situation is Brian Church, chief financial officer at Phoebe Putney Health System, who said rising health care costs -- some of which are tied to poverty -- create a delicate situation, as those who are impoverished go directly to the most costly method of health care delivery.

"Poverty is a huge factor in not getting preventive care," he said. "They go to the emergency room when they do not have access. By the time they get to the ER, they are usually in a crisis. And usually it is something that could have been prevented."

Such action has an impact on cost for everyone in that the increased cost has to be made up. That is why, Church said, various entities are focusing on population health management. If problems are caught before they become a significant issue, the outcome is better for the patient as well as from an overall cost standpoint.

Mobile health units available to Phoebe through a partnership with Grady EMS contribute to preventive care by visiting some of the "frequent flyers" of Phoebe's emergency department before they walk through the hospital's doors.

"They could help fill prescriptions, or get to (patients') primary care physician and not go to the hospital," Church said. "The hospital is the highest cost (for care, regardless of insurance). (Keeping them out of the hospital) reduces the cost for everybody."

Poverty and education are linked, which Church said is not a positive indicator for whether the issue is getting worse or better.

"The trends (for education) don't show very well, not just for Dougherty County, but south Georgia," he said.

Some birth outcomes have improved, which means there is a population taking advantages of certain resources available to them. Coordination between entities has improved as well, which means resources are being used more efficiently.

"There is a lot more that can happen (with this coordination)," Church said.

Even so, he said, thousands in Dougherty County remain uncovered in part due to Georgia's decision not to expand Medicaid. This means fewer people are covered, as well as hospitals having less money to bring in staff or services to reach out to vulnerable populations.

It's part of a cycle: Less coverage means more people not seeking preventive care, in turn leading to the higher costs overall.

"(Expansion) can lower the cost of Medicaid overall," Church said. "(The other side of the argument) says they can go to the ER, but if they go to the ER it is handled as a crisis and it is very expensive to do this."

In the current climate, a person is more likely to be covered if they are older or suffer from underlying medical issues. Church said relief will be in sight when the cost is spread to everyone, not just those older individuals -- some of whom may be receiving end-of-life care that is not likely to be beneficial.

Rather than look at five or 10 years down the road, Phoebe's chief financial officer has to look at things on a monthly basis.

"To provide services to everyone, we (need) to recoup that reimbursement somewhere," he said. "Those of us with insurance, we are paying for others."

Church said he is optimistic about Ambetter, the carrier many Southwest Georgia residents will use for coverage under ACA for the coming year. He said the carrier actively engages in patients and offers incentives for preventative services.

"We can get more people with insurance than last year," he said.

Among the public resources available are the Centers for Disease Control and Prevention's social determinants of health, www.cdc.gov/socialdeterminants/index.htm; Robert Wood Johnson Social Determinants of Health, www.rwjf.org/en/our-focus-areas/topics/social-determinants-of-health.html; and Healthy People 2020, www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health.

Mary Braswell contributed research information that is used in the articles that appear in this series.

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