Two Americas

Health care for rich people.

Health care for poor people.

This Monday, the New York Times decides to run two stories on health care.  First, and not too surprisingly, we find out that it's hazardous to your health to be poor:

A nationwide study has found that the uninsured and those covered by Medicaid are more likely than those with private insurance to receive a diagnosis of cancer in late stages, often diminishing their chances of survival.

The study by researchers with the American Cancer Society also found that blacks had a higher risk of late diagnosis, even after accounting for their disproportionately high rates of being uninsured and underinsured. The study’s authors speculated that the disparity might be caused by a lack of health literacy and an inadequate supply of providers in minority communities. The study is to be published online Monday in The Lancet Oncology.

Previous studies have shown a correlation between insurance status and the stage of diagnosis for particular cancers. The new research is the first to examine a dozen major cancer types and to do so nationally with the most current data.  It mined the National Cancer Data Base, which began collecting information about insurance in the late 1990s, to analyze 3.7 million patients who received diagnoses from 1998 to 2004.

The widest disparities were noted in cancers that could be detected early through standard screening or assessment of symptoms, like breast cancer, lung cancer, colon cancer and melanoma. For each, uninsured patients were two to three times more likely to be diagnosed in Stage III or Stage IV rather than Stage I. Smaller disparities were found for non-Hodgkins lymphoma and cancers of the bladder, kidney, prostate, thyroid, uterus, ovary and pancreas.

--snip--

The study’s authors concluded that “individuals without private insurance are not receiving optimum care in terms of cancer screening or timely diagnosis and follow-up with health care providers.”  Advanced-stage diagnosis, they wrote, “leads to increased morbidity, decreased quality of life and survival and, often, increased costs.”

The study cites previous research that shows patients receiving a diagnosis of colon cancer in Stage I have a five-year survival rate of 93 percent, compared with 44 percent at Stage III and 8 percent at Stage IV.

“There’s evidence that not having insurance increases suffering,” said Dr. Otis W. Brawley, the American Cancer Society’s chief medical officer.

Yeah.  There's a little more.  Now, this might not be the biggest revelation ever, but it seems that people who don't pay a lot for their health care get lesser-quality care.  I can hear the wingers already screaming that this is obviously a failure of public insurance, as private insurance leads to better care.  Well ha ha, fuck you very much, assholes.  If you cover everyone publicly, there's no two-tiered system of payments, and no incentive for doctors and hospitals to cater to the privately insured.  Check out, oh, the rest of the industrialized world for examples.  Take that tired-ass "argument" somewhere else.  What stories like this one say is that we are depriving some citizens of those inalienable rights we're supposed to learn about in grade school--that is, you can't have liberty and the pursuit of happiness if you're not alive.   Oh, and if you're a hard-nosed, all-dollars-and-cents type, our "system" is more expensive, too.

I am still amazed that anyone can defend the health care "system" of the US.  Alright, let me back up.  I am still amazed that anyone who isn't a paid shill for the insurance companies can defend the health care "system" of the US.  There.  That's better.

The other story today revolves around sports injuries in children.  It turns out that anterior cruciate ligament tears are becoming more common in children involved in sports.  Why?  Good question, and there's no one reason.  Partly, doctors are more aware of the injury.  Partly, increased use of magnetic resonance imaging (among those who can pay for it, that is) makes the diagnosis easier.  And, finally, (some) children are increasingly involved in sporting events year-round, with more intensive training, thus increasing the probability of injury.

Now, I tend to shy away from blaming individuals for larger social trends.  But, in this case, I think the parents of these (mostly privileged) children need to step back and evaluate what they're doing to their offspring.  The parents of the boy profiled in this article (why the author chose a boy, when the injuries are more common in girls, I don't know) live in an extremely wealthy suburb of Houston, TX, known as, and I am not making this up, The Woodlands.  The name is written with the definite article, always.  The child's parents took the boy to a doctor in Houston, and didn't get the answer they wanted.  So they took him to one in Dallas.  Finally, they took him to Boston, Massachusetts to get surgery.  Here's his mother, in the final sentences of the article:

Having the operation “was a difficult decision to make,” Mrs. Link said. “But if they can play sports, it’s the only option.”

What the hell?  The only option?  Why don't you tell your child that, you're sorry, but he won't be able to play sports anymore.  There are lots of other ways to live a fulfilling life--and, for the hyper-competitive types, there are other arenas in which to compete.  Here you have people who are hardly powerless in the world who refuse to exercise their considerable influence to keep their (and other people's) children healthy.  Start an organization, raise awareness, get people to understand that they don't need to have their children in thirty hours of extracurricular activities per week.  That shit is optional.  Walking, on the other hand, tends to be more necessary.

I can understand parents wanting to get the best possible care for their children.  But the juxtaposition of these stories does a good job of illustrating those "Two Americas" that John Edwards talks about.  On the one hand, you have people dying because they can't afford to get routine checkups and catch cancers in their early stages.  On the other, you have people crisscrossing the continent to get extremely expensive operations so that their children can continue to engage in after-school sports.  It just doesn't seem right to me.

Comments

[spocko]

Oh there are people who are in favor of the current system, because they get THEIR care. I can understand that. I also understand the mind set of scaricity that they don't want to talk about. "If everyone gets good health care will that dimish MY health care?" And that is what the insurance companies will pick up on and exploit.

As someone said to me years ago, you might abstactly say let's spread out the health care to all, but when it is YOUR relatives you suddenly focus on your issues and ignore the rest of the world.

[coldspaghetti]

"The study’s authors speculated that the disparity might be caused by a lack of health literacy... "

Yup. The fact that blacks have a higher rate of diagnosis is totally all about them just not being as smart as other folks. Right. That's fabulous science, folks, really fabulous. You definitely uncovered every stone with that one. Because the experience of being something other than white, male, wealthy, heterosexual, and English-speaking has nothing to do with the care that you seek and receive. Enough "health education" and everyone would have completely equal levels of health.

What a crock. This sort of stuff is everywhere in public health literature whenever and wherever health disparities are mentioned, at least since blaming disparities on some sort of genetic difference became out of vogue (darn that genome project!)

What is frustrating about reading passages like the above is that good science exists that clearly points to racism -- the experience of race within health care -- as being a primary (if not the primary) factor in health outcomes. Yet it is categorically ignored by these larger studies. Forget what is scientifically sound -- if you want coverage in National Press, you gotta toe the popular line.

Good post and great comments.

[Dorothy]

Maybe a good way to reach those people who want to focus on their own health is to point out how universal health care is in their self interests:
-- If poor people can afford to go to a doctor with non-emergency issues, they won't be crowding the ER when you have a car accident.

-- If poor people can afford to go the doctor on their own, they doctors and hospitals won't have to inflate their prices to cover pro-bono cases, and that should save you money in the long run.

-- If everyone can afford a flu vaccine, the chances of a flu outbreak are greatly reduced.

-- If poor people can't afford to get their kids vaccinated or treated for minor infections, it increases the chances that YOUR kid will get infected by the same bug.

Even people who choose not to vaccinate because of perceived risks still depend on "herd immunity": if everyone stops taking the polio vaccine, a polio epidemic becomes likely. If 5% of the people refuse polio vaccines, they are actually counting on the 95% who didn't to keep the desease in check.

And, yes, I realize that means these people must be willing to sell poor kids down the river to reduce the risks for their own precious offspring, but based on Athenae's points here, I think that's completely in character.

(Sure, it would be nice if people like that got on board with the idea that health care is a basic human right instead of a status symbol, but I'm a cynic...)

[pansypoo]

luckily i live in milwaukee. we had a LOT of socialist mayors. and mayor zeidler instituted health 'coverage' for indigent people. as i am indigent, i have gotten MRI's. so, so far, socialism ROCKS.

[MapleStreet]

Dorothy, as an additional point, if they can go for health care at a clinic, it is much more cost effective than going to an ER for the same problem.

Here in MO, the Missouri Hospital Association is floating a change to the medicare / medicaid to do just that. The basic idea is sound, but I've got to admit that I don't trust the association without seeing the details.

[The Other Sarah]

Paul Krugman, of all people, writes something salient about this situation -- poverty is literally a poison:

http://www.nytimes.com/2008/02/18/opinion/18krugman.html?em&ex=1203483600&en=aca7ab0dacd2e4d3&ei=5070

and since 1969 (gee, I wonder what might've turned national politics rightward in 1969, what with Nixon in the White House and all?) it's been steadily getting worse, not better.

John Edwards' message is not untimely, and his leadership is needed now more than ever, I think.

[Interrobang]

-- If poor people can afford to go the doctor on their own, they doctors and hospitals won't have to inflate their prices to cover pro-bono cases, and that should save you money in the long run.

If you have single-payer healthcare, "saving money in the long run" becomes irrelevant. (I ought to know; it's how it works here.) As far as I know, I probably pay a little more tax than someone of my income level would in the US, assuming I were not getting hit with the same kind of state/municipal taxes, but healthcare is more or less an invisible expense to me. I just had my head CAT scanned, too. (It was sort of fun.)

I can understand not wanting to have to tell your kid they can never play sports again, but isn't the solution really to stop pushing the kids to play so hard and so much? I work with a guy whose daughters are likely in the high-risk category for these sorts of injuries, and I sort of worry that he's trying to turn them into Olympic-calibre athletes at, like, age 14. (They play soccer, so that'd be a bit young.)

There's also the issue that, even if you have a sports injury, there are other sports you can do. I have a knee injury that doesn't let me cross-country ski, but it doesn't get in the way of aerobics, swimming, horseback riding, weight lifting, or any of the other things I like to do. (Despite being disabled, I can play about 20 sports; there are lots to choose from.) I also have a rotator cuff injury. I work around it.

Nothing about US politics would make me happier than if you folks managed to get a decent single-payer healthcare system (and kick the insurance companies out of the healthcare racket finally). Number two on the list would be if you folks actually finally adopted the metric system. :)

[Jude]

Interrobang--

The "stop pushing the kids" general solution was what I was trying to get at. Sorry if that was unclear. In this particular case, the parents need to a) stop pushing and b) stop using their enormous resources on something that will quite likely result in a re-injury. The kid's playing non-contact football. So? You can tear an ACL just making a cut. But, yeah. As a group, those middle- to upper-middle-class parents need to stop pushing their damn kids to do so much.

And we'll adopt the metric system when you people add a fourth down to your football game. Deal?

[MapleStreet]

I wouldn't be too quick to discount "low health literacy" as being a contributing factor (as much as I despise the tactic of blaming the victim and how low-literacy lends itself to racial and economic terms).

1) I say this because even though I am a medical librarian, **I PERSONALLY** have trouble negotiating the maze of protocols for coordinating my doctor with the insurance company. I don't see how a person without a sense of empowerment has a chance of negotiating variable copays and preferred formularies.

2) Modern healthcare is increasingly built on the model of the patient being the orchestrator of the medical professionals (as opposed to the old model of submissively listening to the doctor tell you what to do). A single person may very easily be seeing 3 or 4 different medical professionals for different problems. Again, how is a person supposed to make sure everyone is on the same page ?

[Alexandra]

I understand the point about the hypercompetitiveness of sports, but if a kid has an injury, , don't you think that's it's kind of a good thing to get it fixed? I mean, isn't that what parents are supposed to do? I can understand thinking that rhinoplasty could be a luxury, but I think fixing a ligament is hardly frivolous. Yes, jetting around the country is kind of ridiculous. But if parents have insurance and DON'T try to fix their children's injuries, they wouldn't be winning parent of the year prizes. Some busybody would be saying "How come they spend their money on a swimming pool instead of fixing their own kid."

[karen marie]

thank you first draft!