Poor People's Medicine: Medicaid and American Charity Care Since 1965

by Jonathan Engel

Poor People’s Medicine is a detailed history of Medicaid since its beginning in 1965. Federally aided and state-operated, Medicaid is the single most important source of medical care for the poorest citizens of the United States. From acute hospitalization to long-term nursing-home care, the nation’s Medicaid programs pay virtually the entire cost of physician treatment, medical equipment, and prescription pharmaceuticals for the millions of Americans who fall within government-mandated eligibility guidelines. The product of four decades of contention over the role of government in the provision of health care, some of today’s Medicaid programs are equal to private health plans in offering coordinated, high-quality medical care, while others offer little more than bare-bones coverage to their impoverished beneficiaries. Starting with a brief overview of the history of charity medical care, Jonathan Engel presents the debates surrounding Medicaid’s creation and the compromises struck to allow federal funding of the nascent programs. He traces the development of Medicaid through the decades, as various states attempted to both enlarge the programs and more finely tailor them to their intended targets. At the same time, he describes how these new programs affected existing institutions and initiatives such as public hospitals, community clinics, and private pro bono clinical efforts. Along the way, Engel recounts the many political battles waged over Medicaid, particularly in relation to larger discussions about comprehensive health care and social welfare reform. Poor People’s Medicine is an invaluable resource for understanding the evolution and present state of programs to deliver health care to America’s poor.

344 pages, Paperback

First published February 1, 2006

Reviews

[Jennifer · Rating 5 out of 5]

Excellent academic public health text.

[Sarah · Rating 4 out of 5]

I picked this up while doing research for my final paper in Health Policy, which is one segregation in medicine, etc. To my shock this book is actually really good and I plan to read the whole thing and be really nerdy.

[Laura · Rating 4 out of 5]

I only read excerpts for this for a class. It is very well written. Lots of info on medicare and medicaid if you are interested in these things.

[Javier · Rating 3 out of 5]

non-fiction

[Pacific Lee · Rating 3 out of 5]

Having finished this book, I am struggling to figure out exactly what point the author was trying to get across. The whole piece seems like a bittersweet lamentation at the current unreality of single-payer, combined with the strides that have already been made in Medicaid. There is no clear thesis, though, and as such really is just a descriptive textbook for people that are very interested in the development and (now dated) state of charity care in the United States.

An interesting paradigm shift mentioned was from the more traditional view of charity, where there was a distinction between the deserving and non-deserving poor, to the 60s liberal “war on poverty” mentality which essentially saw ‘the poor’ as a class of blameless victims:

“Remove social barriers […] and the poverty itself would wither away. Since the removal of barriers was largely a financial matter, the solution was simply to spend more […] Poverty could fall as easily as infectious disease.” (p.26)

It almost seems like a maxim, where government programs initially conceived of good intentions go awry. Food stamps designed to help supplement nutrition for Depression era families now subsidize people buying unhealthy luxury food items (p.155), the Aid to Families with Dependent Children now incentivizes single-motherhood (you lose eligibility with a husband) and 85% of recipients have able-bodied fathers (p.156).

There were similar unintended consequences with government involvement in poor-care as well. Medicaid as a Federal program shifted patients away from the already existing network of charity care, which was often rooted in local communities (p.126). Physicians who had always dedicated themselves in the past to altering their fee scales, writing off bad debts, and doing free rounds at hospitals began to see the poor as no longer meriting free care once they were covered (p.111). Medicaid shifted the entire ethos of the profession from a calling to just another job.

Never believe anyone that says the solution is a simple one. There are always new problems that will spring up from our solutions, and sometimes they may be even more devastating. The issue of healthcare in particular is extremely complex, even without considering the specifics of the byzantine system we have in place, healthcare involves some 17% of our GDP (the size of the entire GDP of France) and nearly 320 million people.

That being said, I would have liked for the author to have been more aggressive in advocating a particular solution for the problem, whether it be single-payer or some other plan. It would definitely have made things more interesting. Instead he just peppers the whole book with passive aggressive statements like “this is a story of ambivalence, for no other word better describes efforts at charity medical care in the US.”

It should be noted that the book covers up to the end of GW Bush’s presidency, and hence leaves out the ACA and its 6-7 years of implementation.