Mapping the Lack of Access to Affordable Healthcare in Pittsburgh
Assignment #1: Mapping Wicked Problems
Carnegie Mellon, Transition Design Seminar 2023
Team Diversity: Luis Garcia, Parrish Andre, Ariba Asad, Mary Priyanka Jacob, Emilie Zhou
Pittsburgh’s healthcare system has a unique set of issues within the national healthcare crisis that limit citizens’ access to medical services. This wicked problem demands the commitment and cooperation of various stakeholders to create a revolutionary ecosystem of solutions.
In this first stage of research and analysis, it became clear that the turbulent relationship between Allegheny Health Network (AHN) and the University of Pittsburgh Medical Center (UPMC) is a defining factor in the healthcare landscape of Pittsburgh. UPMC was founded in the late 1800s and began acquiring other hospitals in the late 1980s. Growth since then has been nearly exponential, and the system is now the largest non-governmental employer in Pennsylvania and operates over half the hospitals in the state. On the other side of the battle stands AHN, a 14-hospital conglomerate founded in 2013 by Highmark Insurance, that, upon its founding, requested a large-scale contract with UPMC. This contract would have deflated AHN prices, steering patients away from UPMC. The contract was denied, and since then, the two systems have been in direct competition in service, technology, pricing, and especially advertising. The effects of this institutional dispute are hard to track. Such high-level conflict trickles down to patient care through a multitude of convoluted paths. Our mapping has helped us connect this issue to others, but it will be one of the more straining sections of our research.
Another critical issue is Pittsburgh’s environmental risk factors for health. As a recent industrial manufacturing city, air and water quality are a huge concern. Over 50 years after the U.S. clean air act, Pittsburgh is still in the top 1 percent of U.S. counties for cancer risk from toxic air pollutants released from stationary sources, according to the U.S. Environmental Protection Agency (EPA). We have some of the highest national asthma, cardiovascular disease, and COPD rates. This disproportionately affects low-income brown and black communities like Mt. Oliver and Clairton. The perpetrators of the pollution are largely big oil companies like Shell that are frequently sued, to little avail or media coverage (see this instance unfolding now in Beaver County). The water quality in Pittsburgh has complementary issues. Since the problematic hire of water consultant Veolia in 2012, more attention has been paid to the Pittsburgh Water and Sewer Authority (PWSA). In 2014, an unauthorized switch in anti-erosion chemicals was discovered in the water, and contamination tests have failed since 2014. Efforts to replace lead piping have been made, but the complexities of the hilly terrain and outdated infrastructure make progress costly and slow. Track the progress of lead pipe replacement here. Specific environmental factors like these are not unique to Pittsburgh, but how they interact with our healthcare providers, personal wealth and insurance management, and transit systems is unique.
Pittsburgh’s wicked problems are interconnected and steeped in a complex history of industry and monopolization. Our efforts to map this issue have been a lesson in patience. Many factors are difficult to track and deserve a map of their own.
Mapping Process
Our mapping puts the lack of access to affordable healthcare in Pittsburgh at the very center of the question and unfolds the reasons behind it through various attributes. These attributes include Social, Environment, Infrastructure/ Technology, Political, and Economic (STEEP) issues. The issues project out from the center and create their own circles where each is explored in more detail, focusing on their root causes. The color associated with each enhances the map’s legibility, where each point at issue/root cause is placed in a solid square. Another level of detail is added to provide more particulars regarding that specific point inside outlined boxes using the same color. This elaborates on the cause and provides secondary information.
As any wicked problem cannot exist in isolation, the issues indirectly linked to another attribute are placed at the edge of each circle, and solid gray arrows represent that connection. These connections expose the complexity of the problem at hand and demonstrate the impact of one decision, policy change, infrastructural change, or race on a broader network.
Drawing Connections and Organizing Relations
Our initial mapping allowed us to identify various interconnected themes between the STEEP sections. For example, we found that disparities in access to healthcare based on gender, race, income, and level of education (social) were connected to environmental issues. Or, we found multiple interconnections between the healthcare for-profit model and our map's political and legal implications.
In order to maintain a clear hierarchy in our map while still showing the complexity of the problem’s connections, we located the interconnected ideas in the outer area of each STEEP section. Additionally, we used a grey line when drawing a connection between STEEP categories and a colored line when connections were inside a specific category. Finally, although our wicked problem mainly focused on the lack of affordable healthcare in Pittsburgh, we also included connections to other wicked problems such as racial discrimination, adverse effects of climate change, and lack of access to public transportation. This shows the complexity of the problem space and how it relates to equally complex issues, some of which are mapped by the rest of the groups in our class.
Our findings
Social issues
The cultural norms, attitudes, behaviors, beliefs, and practices of a society define its social construct, and that impacts each institution one way or the other. Access to healthcare is deeply impacted by the social issues prevalent in Pittsburgh. Racism against African American communities and redlining of US cities has put Pittsburgh’s underserved communities in neighborhoods that are closer to steel mills and river edges where harmful waste from the mills is disposed of. With no interest from private developers and grocery stores, these neighborhoods continue to move towards becoming food deserts. Lack of access to a nutritional diet and an efficient transport system has disadvantaged their health. At the same time, healthcare institutions like UPMC and Highmark continue to close their hospitals as they have monetary interests, and many of these communities cannot afford health insurance. Braddock Hospital's closing in 2010 is one of the examples of such a scenario and can be well-understood by Braddock’s Mayor John Fetterman’s comment, “Everyone knows you go broke providing health care to broke people.”
Racism is a public health crisis that impacts people regardless of their socioeconomic status and education. The stereotypes associated with black women among healthcare providers impact the maternal mortality rate of black women. Despite all these social issues emerging due to the insensitive attitude of healthcare providers, UPMC continues to advertise its facility as an institution that promotes health equity.
Technology and Infrastructure issues
Cities across the country struggle to provide citizens with reliable public transit, and Pittsburgh is no different. It is a wicked problem in itself, but the way it prevents access to healthcare is a particularly insipid symptom. Riding the Port Authority to the doctor can take an hour or two. That commute is impossible for most people, especially caregivers or hourly-wage workers.
Infrastructural problems extend to hospital-specific issues as well. Short staffing causes a variety of problems. Distrust in healthcare increases as staffing becomes more scarce. This causes more difficult caregiver-patient interactions, straining the already strained staff. Many of these issues were catalyzed during the pandemic when medical disinformation and politicization of medical practices were rising.
There are still more infrastructural issues. Lack of interpreters, loss of local pharmacies, and exhaustive amounts of healthcare advertisements all play roles in the Pittsburgh medical landscape. These factors are long-running issues that are cemented in interconnection, history, and economic intricacy. Attacking them will be difficult.
Environmental issues
Our research revealed several ways the environment affects people’s access to affordable healthcare in Pittsburgh. One issue that may be overlooked is that the city was built around steel and manufacturing industries, which have been, and currently still are, primary sources of pollution in Pittsburgh. From unhealthy air conditions to contaminated water sources, these industries have created an environment that negatively affects the health of Pittsburgh’s residents.
In addition, Pittsburgh’s topographic makeup, coupled with the impacts of climate change, makes people more susceptible to illnesses influenced by the environment and determines how much the city spends on repairing the city instead of on other areas, like healthcare. The healthcare industry's growth also contributes to the environmental crisis as healthcare-related products are global polluters that contain harmful chemicals that hurt the environment. Lastly, the environment impacts Pittsburgh residents’ access to healthcare since the treatment available to people is greatly affected by the hygiene, cleanliness, and racial and socioeconomic makeup of their area.
Economic issues
A region's economy impacts every aspect of the place, and access to healthcare is no exception. In our map, we lay out the different underlying economic factors focusing a lot on the consolidation of hospitals and healthcare clinics, and research centers by UPMC and bringing their profit-making model into play in most healthcare institutions in the city due to the pseudo-monopoly that is being created. The UPMC-Highmark rift in the early 2000s did throw light on the very firm control that UPMC has gained over the years on Pittsburgh healthcare. This brings with it very expensive healthcare, underpaid workers, and still insufficient infrastructure for a growing city with a young population of students and professionals.
Branching off the mention of expensive healthcare, the for-profit healthcare model is a counterintuitive approach to such a topic, where there is no incentive to cure patients and maintain good health. It is very alarming that cancer research and care is one of the biggest money-makers in the global economy. Pittsburgh’s lagging economy is another reason for the unequal access to healthcare, where the rich have access to proper nutrition and healthcare. In contrast, the lower economic strata fall into the vicious cycle of cheaply priced unhealthy food, health problems, and lack of access to proper care.
Political and Legal issues
Our research showed several political and legal implications connected to Pittsburgh's lack of affordable healthcare. First, there is a mechanism of healthcare price inflation that keeps healthcare out of reach of most Pittsburgh residents. Although this issue seems more connected to an economic aspect of the problem space, we discovered that this became a political problem because the federal government was paying for considerable amounts of the services provided to citizens. Up until 1983, medicare reimbursed hospitals retrospectively, which meant that a doctor in a hospital did a procedure, a patient stayed for some amount of time, and then the provider sent medicare a bill. The bills were asking for about 102 percent of the actual cost — that cost-plus formula meant that healthcare providers were writing themselves blank checks.
Another issue that repeatedly appeared when researching the political and legal implications is Pennsylvania's lack of regulation for hospital acquisitions. Pennsylvania is one of just a little more than a dozen states nationwide that does not have a certificate of need regulations for handling hospital acquisitions and closures. Such a situation makes it even easier for powerful groups, such as UPMC, to continue acquiring healthcare institutions and contributes to the decline of hospitals that are doing more labor-intensive, longer-term care, which is more community, or even neighborhood, rooted.
Reflections and next steps
Going through our first mapping exercise of a wicked problem as a team, we had to put a lot of effort into “not de-contextualizing” when trying to find the causes for the “lack of access to affordable healthcare in Pittsburgh” in the STEEP framework. In our first dig at the problem, we understood that it’s very easy to find causes in particular areas such as infrastructure, economics, and even politics, but it is very hard to find the links in the social and primarily environmental sphere; however after much brainstorming and deep thought, as a team, we were able to find the causes in these areas that are not as evident in plain sight.
Following this, we discussed how we wanted to map our wicked problem in the most understandable and user-friendly way possible. We achieved this by color-coding the different sections of STEEP, drawing intra-sector lines with the same colors, making inter-sector connections with gray lines, giving the problem definition on the post-its with sources, and giving more explanation in the hollow boxes. Graphics helped us to liven up our mapping.
Lastly, our toughest problem was in segregating causes into the right sectors and breaking down these problems to find the root causes in each sector (which requires multi-sectoral solutions to be in place to solve wicked problems). In our case, we feel the lack of access to healthcare in Pittsburgh is a mix of the improper infrastructure in terms of transportation, clinics, and neighborhood pharmacies; the economic and political implications of UPMC’s ever-growing power in the Pittsburgh healthcare network, the quite apparent social stratification in access to healthcare and lack of healthcare professionals and finally the overarching effects of climate change and pollution on the health of Pittsburgh residents.
A copy of our mapping exercise can be accessed here.
