MILWAUKEE — Richard "Buz" Cooper of New York City has practiced medicine for five decades. Recently he had prostate surgery and reflected on the difference between a recovery in Manhattan, where he lives, and one in Queens.
"I had a catheter," said Cooper, 77. "I'm a doctor so I know about catheters."
He rearranged his bathroom to keep the supplies sterile.
"My bathroom window looks across at Queens," he said. "I was thinking there is some guy in Queens who had the same surgery, who lives in a fourth-floor walk-up that he shares with five unrelated people. They all share the bathroom. He's never used a catheter. He puts the stuff in the bathroom. Some other person pushes it out of the way. He doesn't bother changing his catheter bag. He winds up back at the hospital.
"I had an uneventful recovery. He was back at the hospital with complications."
Cooper has studied the connection between income and health, and like others has come to this conclusion: Poverty makes people sick.
"They are sicker and they stay sicker," he said, "despite the best efforts of physicians and hospitals."
Yet the economics of medical care in the United States has made poor patients the ones no one wants to treat.
They often are uninsured or on Medicaid, which doesn't reimburse the hospital or doctor as well as private insurers or Medicare. They are less likely to have a primary care provider and more likely to turn to emergency rooms for basic care. Or they delay treatment until they are very sick, requiring longer stays and more costly care. Then they are more likely to be readmitted because their follow-up care is not adequate.
In short, poor people are expensive to treat.
"Mainly the game is to keep the poor out," said Cooper, senior fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania. "It's a hot potato - you try to make them go somewhere else. Eventually they get in somewhere. So they get inefficient access, outpatient and inpatient both. Access improves when they're sicker, so as they go up the sickness ladder they do get access, but when everything else has failed."
This creates a predictable cycle. Health systems lose money on these patients, so hospitals are more likely to face financial problems in poor communities. That can lead to closures. And closures result in doctors moving to places where they can be affiliated with a hospital.
New hospitals are built in affluent areas, often suburbs and exurbs that already have excellent medical facilities. These centers compete not only on quality of care and technological heft but on increasingly luxurious settings and high-level amenities.
So despite the fact that the United States has a vast and sophisticated system of health care, the country is dotted with health deserts - not just in isolated rural areas but in the midst of large cities served by prosperous health care giants. These deserts are growing in a system that has shed the tethers of charitable care as it follows the money.
This cycle plays out for people like John Patton Jr., a 51-year-old who lives on Milwaukee's north side, had no health insurance until getting on Medicaid in April and has bounced from emergency rooms to clinics for decades. He was injured more than 20 years ago when a chain hoisting a dumpster-size container in the foundry where he worked broke free and struck him on the back. He copes with hypertension, depression, gout, a heart defect and chronic back problems. He is waiting on an appeal for disability benefits and waiting to find out if he qualifies for rehabilitative and job-placement help.
"See all these brick walls we be hitting?" he said.
The economic framework of the medical care system makes these patterns unlikely to change without new incentives to treat the poor and address overall health. As long as health care is viewed as a commodity and corporate providers see financial success as the main goal, poor neighborhoods will be underserved.
Ironically, most health care companies started as charities for the poor - and enjoy tax breaks as if they still are.
"Trying to find cost savings in the system without addressing the issues of poverty is very analogous to trying to find all the other causes of lung cancer in a smoker," Dr. Cooper said. "Smoking overwhelms the system."
The challenge, said Steven Galen, president and CEO of the Primary Care Coalition of Montgomery County, Md., is "how do you get the money out of the health care system and into the social service system?"
Around the country, a growing number of health care systems and local governments are beginning to work on that challenge.
Sometimes solutions to a stubbornly complex problem can be simple: Spend a few hundred dollars on an air conditioner for a frail man with heart disease living in a stifling walk-up rather than tens of thousands to repeatedly treat him in the hospital. Usually it's harder than that, but there is one thing in favor of the concept of addressing the conditions that make poor people sick rather than treating them afterward.
It can be cheaper.