The Great Divide: The Haves and Have Nots

(Originally posted June 2011. Updated June 2019)

The health and patient advocates who are listed at AdvoConnection are all private practice advocates; that is, they work directly for patients and the patients pay them. Their services are not covered by insurance, their services aren’t donated or free. This is how these advocates make a living – they are paid by patients or caregivers.

That seems to upset some people, and lately, it seems like a number of people have taken some sort of offense at that idea – as if patients or caregivers should not have the right to seek private help for their navigation through the healthcare system, or should not be able to call on someone to help them organize, or decrease their medical bills…. or that the very talented group of APHA members should not have the right to start a business offering the services they want to offer.


Here are the reasons I believe that attitude is so misguided:

First, in the US, most of our healthcare is private, or is a private – public combination. Although I’ve met many Medicare and Medicaid recipients over the years who believe their healthcare is “free” – they are mistaken. Those who worked for a paycheck in their lifetimes before retiring and are now eligible for Medicare, paid a good portion of their income to Uncle Sam over the years to pay for healthcare in retirement, and now, finally, in their senior years, they get what they already paid for.

And Medicaid is far from free. Our taxes pay for that. A Medicaid recipient may think it’s free, but many of us use our blood, sweat and tears to pay for their healthcare in addition to our own.

Individuals choose to pay health insurance premiums. Knowing the shortcomings of the healthcare system, they certainly do have the right to pay for a private advocate, too.

Second, this aspect of healthcare actually works similarly to school systems. Public schools are available to all children to attend. But some parents want more for their children – private schools or private tutors. So they pay for those additional private services.

When children go to private schools or work with private tutors, that actually benefits all the other kids, too. Because those kids aren’t using the resources of the public system, but their parents are still paying into the system, all the other children who continue to attend and make use of the public school system get more benefit from it because those unused resources are now available to them.

And so it is true for all patients. When some can afford the services of private advocates, then everyone else may benefit because those patients may not use the resources of the healthcare system.

This objection that somehow affording the services of a private patient advocate separates the haves from have-nots reminds me of the objections I heard a decade ago about whether the internet should be available to anyone because not everyone could afford the service. Eventually the public sector made the internet available, through schools, libraries, and in other ways.

Further – no one suggests that lawyers shouldn’t do their work just because not everyone can afford one, or that hairdressers shouldn’t do their work just because some people prefer to cut their hair at home…

Private patient advocacy is alive and well, fair and needed, and fully available in many parts of the country. The only real problem is that there aren’t nearly enough advocates for everyone who needs or wishes to hire one, or there aren’t advocates available in every location.

But it’s a bogus argument that private advocacy represents a division between haves and have-nots. So let’s put that argument away.

? ? ? ? ? ? LEARN MORE ? ? ? ? ? ?

6 thoughts on “The Great Divide: The Haves and Have Nots”

  1. Bravo! What a clear and powerful statement of reality Trisha. And one of the reasons that I had chosen more 11 years ago to define the services I provide as “Care Navigation” and not patient advocacy. That I am a “Healthcare Navigation Specialist” who provides many things, one being advocacy. Its been my experience that the use of the word advocate or advocacy somehow means “free of charge” or non-profit. And there is no such assumption with Care Navigation.

  2. Most of the advocates I know and train have done “set-asides” of slots for people they work with that are “low-fee/no-fee” to address this issue. Yes, we need to make a living, but that doesn’t mean we can’t thoughtfully look at allocation of our services and skills. Healthcare Liaison is a social entrepreneurship, so a percentage of the profits goes to the Grameen Foundation ( for micro-loans in developing countries. That’s only one way to address this situation–I”m sure people have developed many more. Ideas out there>

  3. Dwight K. Hamborsky Jr.

    As a former Psychologist I can tell you most people expect to pay for a service provided by a trained professional. Since developing my new career as a Patient Advocate I do not expect to charge what I did in practice but a reasonable fee for service should be expected by the public. The State has many Social Workers that can provide advice if the patient has the time and patience to leave voice mail messages that may or may not be returned, but for the person that wants personal service ASAP a professional Patient Advocate is the first choice. I also have found that many Sons and Daughters of patients will need the services of an advocate in there absence to report on the care being recieved at Assisted Living facilities and Hospitals. They welcome the chance to pay some one to be their for them to assist .
    Dwight K. Hamborsky Jr.

  4. Whether an individual can afford to retain the services of an advocate on their behalf or not, is a diversionary tactic being used by those who are being held accountable by the advocate, who is looking out for the health and welfare of the patient.

    We are a service society, yet many people who are providing the service forget that they are being employed by those whom they serve. The advocate is not only looking out for the patient, he/she is also protecting the provider from negligence.

    Retaining the services of an advocate is making a statement the medical community does not want to hear: ?I don’t trust you doctor,? therefore I have a second set of eyes double checking.

  5. The reason to hire an advocate is because medicine has become too complex with choices people simply don’t have the tools to understand. If someone comes to me who really doesn’t trust their doctor(s), then I would say one of my first tasks is to help them get to an physician or healthcare system that they do trust. And I would move heaven and earth to make that happen. …..

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