The State of Affairs: Disparities in Healthcare
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” –Dr. Martin Luther King Jr.
Medicine has a problem and it goes along with social inequality. As I write this blog, I find myself in distraught at the thought that at this very moment an individual is fighting a treatable condition alone, without appropriate medical care. Some months ago I read an article published in The Guardian titled “America’s poorest border town: no immigration papers no American Dream.” In short, the article discusses the hardships endured by the residents of one of many small communities known as las colonias near the border town of McAllen, Texas. McAllen calls itself the Square Dance Capital of the World, the streets are adorned with majestic palm trees magnified in grace by the beautiful south Texas sunset, but just seven miles east from McAllen along the interstate off ramp one can start seeing traces of these ramshackle and impoverished communities as they are accentuated by the beautiful vivid green fields of cilantro. Las colonias are primarily occupied by Hispanic families. The vast majority are undocumented Mexican farmworkers who earn sustenance laboring the fields. Many of these workers and their families have less than enough for food and other essentials. In fact, most colonias have no paved roads, streetlights, or potable water. The residents of las colonias, despite their large numbers, have been marginalized “…to the point of near invisibility” and with no state or federal healthcare programs available for the undocumented there is no doubt the majority fall through the cracks of a system that has inefficiencies of its own, the medical system.
But the undocumented are not alone in this ongoing crisis. The poor received less than adequate care, according to Paul Ruggieri. In his 2014 The Cost of Cutting he reports a plethora of studies correlating the status of a patient’s insurance with the quality of care received.
In 2010 a study in the journal Cancer “…showed the outcomes of 1,200 patients treated for throat cancer. The study found that Medicaid and uninsured patients were 50 percent more likely to die than those with private insurance. This number has held steady even after adjusting the data for other factors related to patient demographics.”
Again in 2010 a study published in the Annals of Surgery, concluded “Medicaid patients had the longest length of stay in the hospital, higher costs, and a higher risk of dying after surgery when compared to the privately insured.”
In 2011 a study published in the Journal of the American College of Surgeons, stated the following “…Medicaid and uninsured patient status conveyed an increased risk of dying in the hospital when compared to private insurance.”
In 2012 JAMA Surgery, in a study analyzing national data of patients that underwent brain surgery concluded, “In this study, Medicaid insurance also correlated with a higher risk of dying after brain surgery.”
These are just a handful, but more and more studies are finding that uninsured and Medicaid status increases the risk of poor outcomes post-surgically. Why? One possible answer, at least for those such as the people of las colonias, is that the uninsured and the poor seek medical care in emergency departments when their condition is already too advanced, a very inefficient way to go about the system but for many there is no other alternative. Current presidential candidate Ted Cruz has argued that it is “much cheaper to provide emergency care than it is to expand Medicaid,” and Rick Perry has claimed that Texans prefer the ER system, according to Rachel Pearson MD/PhD candidate at UTMB. It is true that emergency departments must see every person that comes through the doors, but here we must get technical. In 1986 the federal government enacted the Emergency Medical Treatment and Labor Act (EMTALA), which states, “Hospitals with emergency rooms have to accept and stabilize patients who are in labor or who have an acute medical condition that threatens life or limb.” The word “stabilize” simply put means that they have to get you to be well enough to follow up with your own providers as an out-patient, in other words, have you, the patient, figure out the details to continue your own medical care with your own private doctor, which for many it is not possible. But the insurance status is just part of the whole picture.
Last November I read a small article for an upcoming book in the magazine Scientific American by Rachel Pearson MD/PhD candidate at UTMB and author of the forthcoming No Apparent Distress. The article begins,
Medicine has a race problem. Doctors consistently provide worse care to people of color, particularly African-Americans and Latinos. In studies that control for socioeconomic status and access to care, researchers have found racial disparities in the quality of care across a wide range of diseases: asthma, heart attack, diabetes and prenatal care, to name a few.
So even after overcoming the insurance barrier an individual of color must go through other hurdles such as racial bias and other healthcare disparities, perhaps even social class discrimination. In 2002 the Institute of Medicine published a book called Unequal Treatment which concluded “…Although myriad sources contribute to [health] disparities, some evidence suggests that bias, prejudice, and stereotyping on the part of the healthcare providers may contribute to differences in care.”
Just last night I watched a two-hour long documentary by FRONTLINE. The documentary takes place primarily in Seattle, Washington but the message is to resonate across the nation, heroin addiction. Professionals from the FDA, CDC, NIH and other institutions are in accordance that the heroin addiction in America has escalated over the last 20 to 30 yeas to the epidemic it is today. The documentary attributes the onset to opioid abuse secondary to bad prescription habits of physicians secondary to Purdue’s OxyContin. The most interesting findings are in relation to the heroin consumers themselves, which are about 90 percent middle class White Americans, in large teenagers. According to authorities, the use and abuse of heroin was well known for years, but it was confined to minority groups in the lower class, it was not until cases were reported among middle class white suburbia that action took place to safeguard the public. For many years Hispanic and African American drug consumers have been incriminated and sentenced to years in prison, it is until now that programs such as drug courts and LEAD are surfacing. The documentary describes the efforts of LEAD, in essence the program is intended to keep addicts from serving prison time, for as long as the addict is enrolled in the program he or she would not go to prison, even if the individual is found shooting heroin on the street, the Seattle police department is to confiscate the drugs but not apprehend the individual. Drug courts provide a way to forgive non-violent drug offenders who under certain conditions, like completing a rehabilitation program, can bypass prison time.
These are all great innovations, they show deliberate and progress, but what I am left to wonder is why did these programs start after the problem with heroin perpetrated middle class White suburbia? Could there be a correlation with the way drug usage is switching between a crime and a health condition and the chronology of events? Could there be social class discrimination all around? I personally believe there is and those who deny it are oblivious to it. These are all problems that have been stacking one on top of the other for years and they certainly won’t be solved overnight.
In a way, I know how and what it is to live in America as an undocumented immigrant as I have spent the last decade or so living in the shadows among other silent voices. In my particular case, the lack of opportunity was a partial deterrent in my quest to obtain an education and better myself in a foreign country where I had little to offer and much to prove. I had no guidance or means to better myself, but I attempted to keep busy at all times working as a dishwasher, waiting tables, cleaning carpets, mowing lawns and more, I waited for the right time to open my own doors to opportunity. It was at this time that I realized the clear fact that in life hardships will always present themselves, it is our responsibility to overcome them. I plan to attend medical school in the coming years, I have a special interest in border health and migrant health as my particular background has given me the desire to dedicate time to caring for those who otherwise could not afford to see a physician. It is my intent to reach out to those who find themselves where I once were and give them what I wish I would have been given at the time, after all medicine is about service and though there is so much a single physician is able to do my share and echoed the words of Dr. Damon Tweedy, “But as doctors, we can do one simple thing for our patients: We can make our very best effort to treat everyone fairly.”
MC