Tuesday, May 16, 2017

Now, it’s the “Undeserving Sick” who don’t deserve health care

It’s been a long-held truism among conservatives that many of those who live in poverty in the United States are undeserving of help, because, well, it’s their own fault.  If they lived more virtuous lifestyles, studied and worked harder, and of course got a good paying job, they wouldn’t be poor. And if they don’t do these things, the thinking goes, then there is no obligation for “virtuous” taxpayers (well-off people with good jobs) to help support them through publicly funded poverty and income-transfer programs. 

(Never mind that people can be poor because there aren’t good schools where they live, or that well-paying factory and other semi-skilled jobs are a thing of the past, or that there isn’t accessible and affordable transportation to where the jobs are located, or that we’ve had decades of income stagnation, or that minimum wages have not kept pace with costs, or that their housing is substandard and their drinking water unsafe, or that labor unions are no longer around to negotiate for better wages and benefits, or that their parents and their parents before them were poor, so they likely will be as well—it’s all their fault, tough luck.   Or that the so-called virtuous and well-off people with good jobs and incomes have benefited from decades of income transfers from the poor to the rich, from living in good and safe communities with good schools and good jobs, from having nice cars to get them around  from their very nice houses to their very nice offices, even if it means sitting in traffic for 45 minutes, or that their parents were well-off people who gave them every advantage to get ahead—it’s all because of their virtue and hard-work, no luck involved). 

As offensive and factually wrong the “undeserving poor” narrative is, there is a variation of it that is now coming to the fore in the health care debate that may be even more offensive and wrong-headed, if that’s even possible, which is that people are sick because of their own bad choices and shouldn’t expect to get taxpayer-funded health care.  This undeserving sick narrative was used by President Trump’s budget director, Mick Mulvaney, to defend the American Health Care Act (AHCA) against late night TV host Jimmy Kimmel’s charge that the AHCA would deny care to children, like his own newborn, born with a congenital heart defect:

“The phrase ‘Jimmy Kimmel test’ was coined by Sen. Bill Cassidy, R-La., after Kimmel delivered a monologue last week in which he shared difficult circumstances about his son's birth and pleaded for politicians to keep Obamacare's guarantee for coverage of people with pre-existing illnesses. Cassidy said he would vote for a healthcare bill only if it met that test, and Mulvaney was asked by a member of the audience at the Light Forum at Stanford University in Palo Alto, Calif., if he agreed with that standard.

"‘I do think it should meet that test,’ Mulvaney said. ‘We have plenty of money to deal with that. We have plenty of money to provide that safety net so that if you get cancer you don't end up broke…that is not the question. The question is, who is responsible for your ordinary healthcare? You or somebody else?’

He said the debate centered on whether others should pay the burden of paying for someone's healthcare.  "That doesn't mean we should take care of the person who sits at home, eats poorly and gets diabetes. Is that the same thing as Jimmy Kimmel's kid? I don't think that it is.’" [Emphasis added in italics].

Then there is Alabama Republican Rep. Mo Brooks, who justified segregating people with preexisting conditions into underfunded “high risk” pools (where they would likely be faced with staggeringly high premiums, deductible and coverage limits) because, well, it’s the not the responsibility of virtuous people to pay for the health care of people with preexisting conditions who brought it on themselves:

“‘My understanding is that it will allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool,’ said Brooks. ‘That helps offset all these costs, thereby reducing the cost to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy. And right now those are the people—who’ve done things the right way—that are seeing their costs skyrocketing.’”

“I cannot adequately describe how much this enraged me” was physician Aaron Carroll’s poignant response to the “blame-the sick-for-being sick” meme, in an essay I'm sick. It's not my fault. And I shouldn't have to pay more for my health insurance he wrote for Vox.com.   Dr. Carroll recounts his own personal experience with ulcerative colitis, a chronic condition he acquired through no fault of his own, and raises important questions about the whole idea of blaming people for being sick:

There is certainly a case to be made that people have some responsibility for their health. But the lines aren’t clear at all. It’s easy to point at smokers and say they’re doing something harmful and are raising costs for all of us. That’s why we can charge smokers more under the ACA. After that…it gets dicey.

Do you start regulating what people eat? What they drink? If you eat dessert and I don’t, why should I have to pay for your health care? Should we charge people more if they drive cars, which is the number one killer of children? I like to ski. That has risks. So does rock climbing. Or playing contact sports. Should we make them stop, or charge them more? What about people who scuba dive?

Should we start charging more or less to people who have different organs, whether that be male and female reproductive organs or a spectrum of other differences in between?

Maybe the Congress member misspoke and my interpretation of his words is off. But maybe not. Maybe he does believe what he said, that people who did things the right way are the ones who are healthy. If that’s the case, then I have a few questions for him.

What did the baby born prematurely, the one with congenital heart disease, or the toddler with sickle cell disease, or the child with autism, or the little girl with leukemia, or the boy with asthma, or the adolescent with juvenile arthritis, or the young woman with lupus, or the young man with testicular cancer, or the new mother with breast cancer, or the new father with inflammatory bowel disease, or the woman with familial heart disease, or the man with early onset Parkinson’s disease, or the retiring woman with Alzheimer’s disease, or the elderly man with lymphoma — what did they do wrong?

Did they lead bad lives?

Take your time answering. I’ll wait.”

I share Dr. Carroll’s outrage, but would take it a step further.  Most of the examples he cites above are people who are born with a disease, or acquire one through their lifetimes that aren’t necessarily associated with any choices they made, like breast cancer or Alzheimer’s.  Or voluntary choices, like playing a contact sport or skiing.  While I agree with him that they should not be charged more for their health care as a result, I am as concerned about people who are sick with conditions that are associated with things they may or may not have done to stay healthy, like having a poor diet that leads to diabetes, or abusing drugs or alcohol (although I am sure that Dr. Carroll too shares this broader concern).

For one thing, the idea that these are “lifestyle choices”, freely made, is not correct; rather, the evidence suggests that they are due to a confluence of hereditary and environmental factors, trauma, poor education, income inequality and poverty, and other social determinants of health, especially for the poor.  As ACP argues in a new position paper, Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs,  “Substance use disorders have been regarded as a moral failing for centuries, a mindset that has helped establish a harmful and persistent stigma affecting how the medical community confronts addiction. We now know more about the nature of addiction and how it affects brain function, which has led to broader acceptance of the concept that substance use disorder is a disease, like diabetes, that can be treated.”  Many people in poorer communities live in “food deserts” where access to healthful diets is simply not available. 

Of course, many well-off people also engage in activities that may contribute to poor health—they may smoke, drive too fast, drink too much, abuse other prescription and illicit drugs, not exercise regularly,  and favor fast food over healthful diets.  The difference is that they can usually afford good health care insurance and access to the best physicians and hospitals when things go south.  Not so with the poor.

So the narrative that the undeserving sick don’t merit our help is really cut from the same cloth as the undeserving poor narrative: that some people, because they are sick and they are poor (which often go hand-in-hand), don’t deserve compassion, and certainly don’t merit financial help from those who are better off, money- or health-wise.  

Growing up, I was taught that “There but for the grace of God go I.”   We should approach health care policy in the same spirit, with the understanding that any one of us could  be poor or sick or both.  We don’t have the  right to selectively judge who “deserves” health care, and to suggest otherwise is an outrage.

Today's question: what is your reaction to the undeserving sick narrative? 


TakeOurCountryBack said...

As expected, I have some reservations about your piece Bob.

You begin with a highly-charged partisan generalization. As one who has spent his entire professional career caring for patients in an urban safety net hospital, I certainly do not believe that the poor health of all of my patients is of their own doing.

Next, you assail the "virtuous" taxpayers as them when in fact, each of us reading this post fits into that category. I suspect that each of us attempts to intervene in different ways. We volunteer with community organizations, make charitable donations, and employ people, as examples. What is most fascinating is the parenthetical diatribe - those well-paying factory jobs are gone because we no longer buy American, mostly as a result of those 'savior' labor unions who drove up the cost of goods to the point that we now import the very items we had exported two generations ago., resulting in tens of thousands being laid off, and entire towns becoming extinct.

While I disagree with the general notion that the patients are to blame, you rightly point out that smokers are charged a premium specifically because that is a behavior that increases health care costs. You mention skiing and rock climbing. While their health insurance premiums may not be an issue, their life insurance policies most certainly are. See how much a policy costs if you are a freehand rock climber (without safety harnesses and ropes) compared to if you do not rock climb at all. And, let's not forget that it is the Democratic party that touts value added taxes, so taxing sodas and juices, and fast food joints, all essentially do regulate what people eat and drink. All of this, of course, is in an effort to curb obesity and diabetes, but it is making those folks pay for their behaviors nonetheless.

I do agree that social determinants of health are rampant in some patient populations. Dealing with them is a societal benefit, good for those who live in such neighborhoods, good for the overall health of that population, and good for healthcare economics.

Socioeconomic class absolutely affects one's health, and the poor are definitely on the short end of that stick. But, rather than throw money at them thinking that they'll magically improve their lot in life and get better, they need the chance to be given employment. In my mind, that is the only factor that will break the cycle for them, and the generation that follows.

bruce said...

One of the oldest questions of mankind: "Why is there suffering in the world?" The Book of Job is all about this question. Jesus faced it when one of his disciples asked "Rabbi, who sinned, this man or his parents, that he was born blind?" Even in the realm of apparently volitional behaviors (smoking, opiate addiction, eating disorders, violence and suicide) most of us intuitively understand the complexity of human thought and behavior and extend some sympathy. In medicine, I don't think you can go to work every day believing many of your patients are willfully and clear-sightedly self-destructive or some are less deserving of health than others. Jesus answered the question by turning it around and saying it is not "Why did this happen?", but "What are you going to do about it?" The fundamental ethical choice is to walk away or stay engaged. The ACA says as a society we will engage with every American for healthcare. The AHCA is about the Federal Government walking away (I suppose some AHCA supporters believe charities will pick up those falling past the safety net. I personally don't believe this is true or reliable public policy.) The distinction is a fundamental ethical with a profound impact on society.

mike3 said...

@TakeOurCountryBack : There's a strong difference between taxing "bad behavior" by taxing the actual tools and encouragers of the behavior like sugary drinks and treats, and taxing it by denying medical care. Because in the second case, if you're already sick or you get so later, it will make you DIE, while in the first case it will at worst simply mean you pay the tax, but ideally will nudge some to a healthier mode.

mike3 said...

@TakeOurCountryBack: Secondly, if you want poor people to get employment, then you should be up for increased spending on education to make quality education available to those who cannot afford to pay for it out of pocket. You're gonna have to pay for other people however you slice it, period.