Health and health care services in the poorest US city
30 March 2010
The following report on health and health care in Detroit has been submitted to the Citizen’s Inquiry into the Dexter Avenue Fire. It documents the impact of pervasive poverty on the health of the population of Detroit and the availability of health services for them.
Detroit’s official poverty rate is 33.8 percent, the highest of any city in the US. This has direct consequences for the health of the population. In January 2010, for instance, 23 percent of Detroit residents said they have had problems paying medical bills in the last 12 months.
The following table shows data from 2001, when the poverty rate was 28.3 percent. The poverty level has increased by another 5.5 percent since that time.
At or below poverty
Age adjusted mortality rates per 100,000
Cancer (all types)
Infant mortality (per 1,000 live births)
As the table shows, comparing Detroit to the national average:
• The rate of heart disease is twice as high
• The rate of HIV/AIDS is nearly three times as high
• The cancer rate is 20 percent higher
• The diabetes rate is 35 percent higher
• The infant mortality rate is more than double
In 2008, the Michigan Department of Community Health estimated there were 11,560 people with HIV/AIDS in the Metro Detroit area (Lapeer, Oakland, Macomb, Monroe, St. Clair and Wayne counties). The city of Detroit has 60 percent of the cases.
On the east side and in southwest Detroit, 68.8 percent of African-Americans and 73.8 percent of Latinos are overweight or obese.
In Detroit, over 28.3 percent of residents have some type of disability.
Two federally funded health clinics and about 20 dentists provide dental services in Detroit. Oral cancer is the fourth most common cancer among African-American men in Detroit, after prostate, lung and bronchial, and colon cancer. With a lack of dental care providers and coverage for dental services, 27 percent of the state’s oral cancer occurs in Detroit and Wayne County. The city also has a higher mortality rate than the state.
Even before the recession, Detroit’s child health indicators were among the worst in the US. Some 39.6 percent of the city’s children live below the official poverty level. Poverty is the main reason people live in poor-quality housing, which in turn has many negative effects on the health of their children.
Lead poisoning can affect vision, hearing, growth, educability, employability and socialization skills.
In Michigan, children with elevated blood lead levels are mostly in urban areas, such as Detroit, Flint, Saginaw, Pontiac, Grand Rapids, Muskegon, and Benton Harbor.
In Detroit, more than half of the housing was built before 1950, when lead-based paint was normally used. Other sources of lead are water running through lead pipes, industrial pollution by smelters and metal works, and lead put into the environment from burning leaded gasoline. In 2004, 6 percent of all Detroit children 6 years old and younger were shown to have lead poisoning. In some neighborhoods, 25-30 percent of children tested had blood levels above the threshold of concern.
Twenty-seven percent of preschool children in Detroit have asthma, compared to about 7 percent of children nationally. The American Lung Association calls asthma the leading serious disease among US children. Low-income groups, minorities and children living in inner cities have higher illness and death due to asthma.
More than half of the state’s asthma deaths between 2004 and 2006 were Detroit children. Six out of 10 children with asthma covered by Medicaid did not see a doctor at an office or clinic, but instead visited a hospital ER. Detroit’s pediatric hospitalization rate is three times that of Michigan.
Prenatal care and infant death rate
Michigan’s rate of infant death is higher than the US rate. One of the main risk factors is inadequate prenatal care. More than 40 percent of Detroit mothers did not receive prenatal care in 2007. Detroit’s low birth weight rate in 2008 was 14 percent compared to 8.3 percent for the US as a whole.
National Institutes of Health data consistently show lower immunization rates for children aged 19 to 35 months in Detroit: the rates are 19 percent lower than the rest of the state for DTaP, Polio, MMR, Hib, Hep B. Nearly 4 out of 10 young children in Detroit are under-immunized.
In communities such as Detroit, there are many obstacles to staying healthy. Ranking counties in Michigan for social and economic factors that influence health, the Robert Wood Johnson Foundation ranked Wayne County last.
State governments have reduced investment in public health by nearly $392 million, and federal funding (excluding emergency and stimulus funds) has gone down in recent years (when adjusted for inflation). In 2009, Michigan ranked 45th in how many dollars per capita the federal Centers for Disease Control spent.
Diet is a major risk factor for chronic diseases. If there are no supermarkets within neighborhoods, it becomes very difficult for residents to buy healthy food.
In 2007, Detroit became the most expensive city to own a car, and one fifth of the residents don’t own one, making it harder to get to supermarkets. More than half a million Detroit residents live in an area where it is difficult to get healthy food. Statistics show that this makes it more likely for residents to die prematurely from a diet-related disease (diabetes, heart disease, high blood pressure, cancer, obesity).
More than half of all USDA food stamp retailers in Detroit are liquor stores, party stores, gas stations, or bakeries. These venues are closer than full-service grocers.
Medicaid and the uninsured
The main US program paying for health care for the poor is Medicaid. In the Detroit metropolitan area, some 828,382 residents—15 percent—were Medicaid beneficiaries in 2009, including 55.5 percent of the children in the city of Detroit. As of July 1, 2008, 533,935 Detroit metro-area residents—10 percent—were uninsured.
In 1996, 1 million Michigan residents were covered by Medicaid. In 2010, 1.8 million, one in six people, are covered. Another 1.2 million people are uninsured. This means that 30 percent of the population in Michigan are either on Medicaid or uninsured. In families that are uninsured, over 80 percent have at least one family member working full or part time.
Medicaid eligibility is now limited to low-income disabled, parents, elderly and children. The state of Michigan currently covers adults up to 150 percent of the federal poverty level (FPL) and children up to 200 percent of the FPL. In 2008, 200 percent of the FPL amounted to about $34,340 for a family of three.
The Michigan state legislature has eliminated Medicaid coverage for adult dental care, chiropractic care, hearing aids, eyeglasses and podiatry. Medicaid no longer covers hospital treatment for dental, feet and hearing problems.
Medicaid reimburses doctors 50 cents on the dollar for services. Because of the low reimbursement, many doctors either do not practice in Detroit or do not accept patients with Medicaid. For an office visit, Medicaid may reimburse a family practice doctor about $19. Doctors cannot afford to maintain their practices with such a low amount and may stop seeing patients with Medicaid.
This year, Michigan cut Medicaid reimbursement by 8 percent. Before the cuts, Michigan had the sixth-lowest reimbursement rate in the US. Because of chronically low reimbursement rates, the percentage of doctors participating in Medicaid has gone from 88 percent in 1999 to 40 percent today.
A recent news story described how ill people covered by Medicaid in Flint suffer because of the lack of doctors and cutbacks in benefits. One woman has to drive more than 3 hours so a doctor who takes Medicaid can remove her son’s tonsils.
In addition, Medicaid plans on average have reduced access to prescription medicines. A 2008 review showed that Medicaid patients served by certain HMOs in the Detroit, Flint and Lansing areas saw their access to prescription medicine drop by between 15.7 and 31.9 percentage points. Higher co-pays and requirements for prior authorization made it harder to get the drugs. The review looked at medicines to treat cardiovascular disease, asthma, diabetes and mental heath problems such as depression.
Access to care: Doctors
Because of Detroit’s weak economy, hospitals and physician groups have had a harder time recruiting doctors, especially certain specialties, such as cardiologists, neurosurgeons and pediatric intensive care specialists.
According to Dr. Herb Smitherman, assistant dean of the Wayne State University School of Medicine, the city has only three or four ob-gyns in private practice outside of hospitals.
The federal Health Resources and Services Administration designates Health Professional Shortage Areas where there are shortages of primary medical care, dental or mental health providers.
The federal agency designates Medically Underserved Areas/Populations where there are too few primary care providers, high infant mortality, and/or a high elderly population.
Health Professional Shortage Areas in Detroit include:
• Primary Medical Care: Eastside, Tireman/Chadsey, Mackenzie/Brooks, North Central Detroit/Highland Park, Southwest, Brightmoor
• Dental Care: Northeast, Southeast, Southwest, River Rouge Park, Northwest, North Central
Medically Underserved Areas/Populations in Detroit include 73.8 percent of the city’s census tracts:
• Pershing/Nolan/State Fair/Davison
• Harmony Village/Grandmont/Cerveny
The lack of primary care physicians leads to overburdening hospital emergency rooms. Few private practices accept the uninsured, and there are long waits for appointments at health centers. Therefore, many people visit hospital ERs because they have nowhere else to go.
Patients seeking treatment at hospitals are unable to receive follow-up care from a doctor who can monitor their condition. So they are more likely to end up back in the ER.
Access to care: Hospitals and clinics
The percentage of Detroit residents who are uninsured is soaring, leading to increased visits to community health centers, federally qualified health centers and hospital emergency rooms.
Clinicians working in emergency rooms nationwide report that the ERs are operating at or over capacity; several were described as “overwhelmed” or “close to the breaking point.”
Hospitals have had a huge increase in uncompensated care. Uncompensated care in Michigan hospitals was over $2 billion in 2007. Charity care costs increased by 40 percent, mainly because uninsured patients were not able to pay for the care.
Medicaid reimburses hospitals 74 cents on the dollar for services. Medicaid underfunds hospitals by more than $1.1 billion compared to Medicare rates for the same health services. Between FY 1996 and FY 2010, Medicaid funding for Michigan hospitals and the patients they serve was reduced by more than $900 million.
Hospitals have reduced expenses by laying off employees, freezing wages and delaying construction.
The number of hospitals in Detroit has gone down from 42 in 1960 to 7 today.
The acute care hospitals today in Detroit are:
• St. John Hospital and Medical Center
• Detroit Medical Center, which includes five facilities: Harper University Hospital; Sinai-Grace Hospital, Detroit Receiving, Children’s Hospital of Michigan, Hutzel Women’s Hospital
• Henry Ford Hospital, main campus
On March 19, Detroit Medical Center, which accounts for five of the seven acute care hospitals, announced that it was being acquired by a for-profit corporation, Vanguard Health Services of Tennessee, which specializes in buying up distressed medical facilities and restructuring them.
In the early 1970s, Detroit had nine community health centers. Today, the Detroit Department of Health and Wellness Promotion has three: Herman Kiefer/Pathway, Grace Ross and Northeast. Other clinics are classified as federally qualified health clinics. CHASS clinic, in southwest Detroit, treats 14,000 Medicaid patients.
The wait for an appointment at a health clinic could be four to six weeks or four to six months in some areas.