A Framework for Understanding Poverty – no really

In 2016 J. D. Vance’s book, Hillbilly Elegy: A Memoir of a Family and Culture in Crisis was published to critical acclaim. Of the book, the Economist said, "You will not read a more important book about America this year." It the story of one family of the Appalachian diaspora that moved out eastern Kentucky and poverty after WW II, fell back into it in the 70’s and 80’s and how the author escaped but left behind the poverty that still haunts the Midwest.

This entry is not about Hillbilly Elegy. It is about a book that, in an organized and systematic way, explains every facet of the origins of poverty that J.D. Vance experienced, the patterns of culture and family structure that he experienced in poverty, and offers instruction in how to break those patterns and where Vance’s escape from poverty is a prime example.

The book is A Framework for Understanding Poverty by Ruby K. Payne.[1] Ms. Payne is a educator and she wrote this book as a workbook for teachers and guidance counselors to help them not merely deal with poor students but help them develop skill sets to get them out of poverty. More than 20% of children in this country live in poverty.[2] This is not only a disproportionate part of our population but we are 34^th out of 35 developed countries[3] with respect to the percent of children in poverty.

A patient of mine who is a retired police officer and runs a shelter for homeless women and children told me about the book and for me I did “not read a more important book about America” in 2016 and I read it on the heels of reading Hillbilly Elegy.

In the introduction she has “Key points about Poverty” and some statistics, about poverty.  Most important in this are the factor that get people out of poverty. These are that it is too painful to stay, a vision or a goal, a special talent or skill, a key relationship.

In chapter one she enumerates the factors that define poverty. Poverty is more than a lack of money. People who are poor also lack:

1.     Emotional resources, the ability to withstand hardship and persevere. She considers this the most important resource

2.     Mental resources, ability to process information

3.     Spiritual resources when present help the individual to not feel hopeless or useless.

4.     Physical resources, People with disabilities lack the ability to be self-sufficient

5.     Support systems, people or groups who provide physical, financial, or emotional support for the person in poverty

6.     Role model/mentor to model the hidden rules of the class (the middle class) to which you should be aspiring if you want to get out of poverty.

7.     Knowledge of the hidden rules of class

 

 

In chapter 3 she enumerates the hidden rules of poverty, middle class and the wealthy. People in these different classes have different relationships to very fundamental aspects of our life. The following are some examples:

	POVERTY	MIDDLE CLASS	WEALTHY
Money	To be used and spent	To be managed	To be conserved and invested
Education	Valued and revered as abstract but not as reality	Crucial for climbing success ladder and making money	Necessary tradition for making and maintaining connections
Time	Present most important. Decision made for moment on feelings and survival	Future most important. Decisions made for future ramifications	Traditions and history most important. Decisions made partially on basis of tradition and decorum

The point she makes here is that first people in poverty aren’t making “bad” choices because they are stupid; they are making the choices they make because that is what allows them to survive in poverty. Second, in poverty crises arise in the moment so time is compressed and everything is about the current moment so middle class skills like perseverance and delayed gratification are hard to master in this environment. Third the object of education (and perhaps by extension any anti-poverty program) is to educate the poor to the hidden rules of the middle class so that when they enter the middle class world (at work or school) and can find success there and hopefully find their way out of poverty.

In chapter four she delineates generational poverty, defined as two generations living in poverty.  Unlike situational poverty in which one has fallen out of the middle class into poverty, in generational poverty the hidden rules of the middle class are unknown and the hidden rules of poverty are more deeply ingrained. In addition, the family structure, discipline, and language (as presented in chapter 2) are such that they only reinforce the hidden rules of poverty.

The last half of the book consists of strategies for educators to use to address these issues. Furthermore, this book is a publication of an organization Aha Process that offers education of these strategies.

Virtually every aspect that Vance described about poverty from the multiple aspects of poverty, to the hidden rules, to the family trees. For me what was so important about this book was that while Vance's personal saga is about Appalachian poor, she make crystal clear, that poverty regardless of race color or creed regresses to the same mean and the path out is identical for all who are born or fall into poverty.

Vance suggestion that the government throwing money at poverty has largely been a waste may be because we are not focusing in on the other co-conspirators in the cause of poverty.

J. D. Vance credits his grandmother’s mentoring as his salvation from poverty and doesn’t think government can reproduce that. Of the factors that get people out of poverty (see above) the only one outside the individual is a mentor to lead them. Ms. Kane suggests that this is a piece of the puzzle that education might provide if the teaching community embraced it.

In my next blog I am going to give my thoughts on education and how to change it. Since this is something about which I know nothing there will probably be a lot of dogma. (Although I will try to reference my dogma as much as possible.) However, I would very much like to hear your thoughts (and corrections).

 

 

 

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[1] The version I read is the 2003 edition. This can be purchased used on Amazon for under $10. The version I bought is pictured above.

[2] http://www.nccp.org/topics/childpoverty.html

[3] https://www.unicef-irc.org/publications/pdf/rc10_eng.pdf

Fixing Healthcare Part 3C: Odds and Ends

Here are some other issues that would come up in a transition from our current health care system to a Guaranteed Healthcare Entitlement (GHE).

Where does the money come from? Well to begin with the money is already coming from somewhere so we could start by identifying the current sources and creating a system around that.  For instance, there could be corporate tax at approximately the rate they pay currently for health care which, from talking to at least one business owner, they would embrace in a heart beat knowing that that rate would be fixed for at least a decade.  However, it should be structured in a way that it is not based on the number of employees so as not to discourage hiring.  Medicare contributions from salaries could still be collected. A small 1 – 3 % tax on non-wage income again fixed for at least a decade could be created to cover any shortfall. 

Where does the money go? Of the $3.3 trillion we spend on health care 80 – 90% would go directly to ACO’s for patient care.   However, there would be additional cost outside of direct patient care. These would include . . .

There would be administrative cost. These would include computing the actuarial tables on which premium payments would be based.  The distribution of these payments to ACO’s would be an expense but much less than current Medicare costs because it would be a monthly lump sum payment for lives covered not a payment for each individual procedure.  Establishing what is covered and standards of care would be required and periodically updated. These would be covered.

The current bill for health care includes government agencies such as the National Institute of Health, the Food and Drug Administration, and the Center for Disease Control.  These would continue to be fully funded.

           

What to do about malpractice: If medical groups are to be open and transparent the malpractice system should be scrapped.

Malpractice is the system we have to identify medical errors and compensate people who are hurt by those errors.  The problem is that malpractice is not a system and it does a very poor job of identifying those errors and providing compensation for the errors. 

Malpractice grew organically out of the fact that there are doctors who make mistakes and there are lawyers to sue them so on a case-by-case basis we have a huge industry that awards payments to around 150,000 plaintiffs annually.[1] It is demonstrably true that there are many more medical errors than this.[2] It has been suggested that this is a reason for even more litigation[3] but the problem is that malpractice itself inhibits the investigative process that would identify individual and systemic problems, formulate corrections, and provide reasonable compensations to the injured.

Malpractice is litigation and to paraphrase Clausewitz litigation is dueling by other means. In addition, when one gets sued, their lawyer immediately advises them that they are only allowed to talk to their counsel, their spouse, or their clergy. In this secretive and adversarial atmosphere in which virtually every physician feels threatened[4] it is virtually impossible for an open and transparent dialogue to take place.

Furthermore, because especially those who, in the current system, are labeled plaintiff and defendant can’t have a dialogue a large part of the healing process is lost.

Finally every discipline has its own system for establishing truth. The legal and medical epistemologies are very different.  Medicine is disinterested, rational, and cooperative; litigation is partial[5], emotional, and adversarial.  In my limited experience legal judgments are hit or miss when they come to accurately reflecting the medical facts. 

This is not to say that medical errors don’t occur. They, of course, do but these errors would be far more likely to come to light in a system if malpractice were replaced with a no fault compensation system for medical errors.  Such a system could be run by the states by strengthening their board of medical licensure and discipline.

In summary the current malpractice system does not allow for the open investigation of medical errors, does not allow for reconciliation between the provider and the patient and family, and in general does not give justice a good name. Health professionals and patients need a better system.

There are of course a lot of other issues that I have not thought of which would effect the implementation and effectiveness of such a radical change in health care delivery.  I would certainly welcome any thoughts from readers on the matter.  If you don’t like this system you don’t have to worry because . . .

1.     I am not emperor.

2.     Most people don’t recognize the long-term deleterious effect the medical industrial complex has on the economy.

3.     Those who are concerned put the blame for health care problems on the insurers or government and not on providers.

4.     Currently, the federal government spends $1.2 trillion dollars on healthcare.[6] With the GHE that number would be 3 times that. Again We the People are already spending that on healthcare but there would still be a significant (I would say knee jerk) reaction to this “socialization” of medicine and corresponding increase in the federal budget.

5.     Since such a system threatens doctors, insurers, lawyers, and drug manufacturers it may be a good thing but the powers (read money) that would oppose it would be all but insurmountable. 

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[1] https://www.npdb.hrsa.gov/resources/npdbstats/npdbStatistics.jsp

[2]https://www.hcp.med.harvard.edu/sites/default/files/methodsmakarydaniel_2016_bmj%20%281%29.pdf

[3] https://centerjd.org/content/briefing-book-medical-malpractice-numbers

[4] 

 

http://www.nejm.org/doi/full/10.1056/NEJMsa1012370

[5] The fact that medical testimony for both litigants comes experts who are paid by those parties is the antithesis of disinterested and counter to the principles of best medical inquiry practices. 

[6] http://www.taxpolicycenter.org/briefing-book/how-much-does-federal-government-spend-health-care