Contemporary Concerns in Medicine

The deteriorating health of the Rio Grande Valley

This wasn’t until my grandfather was diagnosed with Stage 3 Hodgkins-Lymphoma disease and my family had to make the difficult decision to move to Houston, Texas—about 7 hours away from the Rio Grande Valley—just so that my grandfather would have the best opportunity to beat his cancer. There were hospitals in the Rio Grande Valley, but I did not realize they were unable to provide the accurate care my grandfather needed. I started to question why this was.

2 years later, my 9th grade English teacher suffered from a massive stroke during class. Thankfully, after a couple of months, she made a miraculous full recovery and was back in the classroom. During this time, however, I was researching “What causes a stroke?” “What is high blood pressure?” “What is diabetes?” “What causes obesity?” I was asking so many questions and I was making connections between these phenomenons happening before my eyes. After the premature research I was able to conduct, I came to the realization that my hometown was in a crisis. A severe public health crisis.

Social Determinants of Health

This region also boasts high rates of poverty, where 29.5% of residents live in poverty. With that, 34.1% of the population lack health insurance coverage. Not to mention, the Rio Grande Valley has a population of approximately 1.3 million people, and 200 to 250 thousand are undocumented individuals. It is also known that undocumented immigrants have significantly lower rates of health coverage. These demographics are an unfortunate medley that allow for social determinants of health to take over and deteriorate the health of my hometown. It it as if the already-broken health care system’s flaws are further amplified in the Rio Grande Valley, as the region suffers from high levels of obesity and diabetes. Not to mention, because of the higher immigrant population, there are higher barriers to the access of health care as well. Not only do individuals visit the doctor to address their intoxication from pesticides from their crop-picking job, but they will also attend that doctor’s visit with the fears of potentially being deported. Fragmented care also plays a major role in the declining health care within the Rio Grande Valley as individuals are forced to switch in and out of primary care physicians as an attempt to deflect any immigration-related accusations. Undoubtedly, there is a constant fear within immigrant communities of deportation, and because the Rio Grande Valley’s close proximity to the U.S-Mexico border, this fear is heightened since there is a stronger presence of United States border patrol agents. Not to mention, the Affordable Care Act (ACA) explicitly excluded undocumented immigrants from accessing health care—further pushing undocumented immigrants from obtaining the care they so desperately need.

But we’re not just about the border wall or the river…We’re about being fat, we’re about being poor, we’re about being illiterate.

Rose Timmer, long-time resident of Brownsville, TX

Food Insecurity to COVID-19

Another important and crucial crisis within the Rio Grande Valley’s health is food insecurity. Although this region lacks food access, it also has one of the highest rates of obesity in the United States. This is primarily due to this being a food desert, where fresh food options are scarce, but fast food options are excessive. It seems as if everywhere you go, you will not be more than a mile away from a McDonald’s, Whataburger, or a local taco stand. You will, however, struggle to find a grocery store near you that carries fresh fruits and vegetables that are not deep-fried. Even if individuals are lucky enough to access fresh fruits and vegetables, many will be unable to afford them as poverty levels remain high. The low socioeconomic status that impedes individuals from accessing the appropriate ingredients to supply a healthy and nutritious meal are rare, yet fast food is everywhere.

They are more at risk because of where they work and where they live, and because of limited access to health care

Carlos Rodríguez-Díaz, professor at George Washington University’s Milken Institute School of Public Health

The higher rates of obesity and diabetes put the community at a higher risk and was evident as Rio Grande Valley hospitals were at maximum capacity. Even when hospitals were overflowing with COVID-19 patients, Texas governor, Greg Abbott only lifted social distancing and opened Texas back up.

The Future of the Rio Grande Valley

In 2016, the Rio Grande Valley welcomed its inaugural University of Texas-Rio Grande Valley School of Medicine class, and graduated its first doctors in 2020 with the hopes of bringing a new generation of doctors who are properly equipped to serve a community who is in dire need of empathetic doctors who understand that their situation is a systemic issue, not a personal issue.

Better Medical Resources ≠ Better Medical Care

Over the past century, humans have made incredible progress in our understanding of medical ailments and how to properly provide treatment to those affected by them. Major advancements in the development of technology and different medications have played a significant role in this growth of the medical field. With instruments that allow us to better study human pathogens, screen for various diseases, provide extremely precise care, and much more, we are living in a world in which people of the past never would have thought could exist. Within about 120 years, we have progressed from a nation where an average of one in every 40 Americans die annually to a significantly lower rate of about one in every 120 Americans and, although this average rate is affected by numerous factors, discoveries and advancements in the medical field have played a tremendous role in its steady improvement (Penn Wharton, 1). One cannot deny the benefits technology has provided us in our quality and duration of life, however, technology has also been a driving force of widening disparity within our healthcare system. Despite continuous breakthroughs in medical care through the use of technology, many of these new forms of care remain inaccessible to a majority of the population and distort our views of the medical world. The diabetic population clearly illustrates this growing disparity within the healthcare system and demonstrates our need to improve current policies to better utilize the incredible achievements we have made as a species.

 “Living with diabetes means people usually don’t realize or understand what you’re living with”

Nick Jonas

What is Diabetes and How Does Technology/Medication Play a Role?

Type 1 diabetes is an autoimmune disease in which the immune system irreversibly destroys the insulin-producing beta cells of the pancreas. Insulin is the hormone released by our body in response to the consumption of food as it allows glucose within the bloodstream to be taken up by cells for the production of ATP. For a diabetic that has lost the ability to produce insulin, that glucose will remain in the bloodstream and prevent cells from producing energy for the body while leading to many negative effects, such as the blood becoming acidic, loss of vision, damaged nerves, kidney failure, amputation of limbs, and much more. Type 1 diabetes is a chronic condition, meaning once a person is diagnosed, they will live with the disease for the rest of their life. Furthermore, it is a condition that requires 24/7 monitoring and care, often leading to drastic changes within a person’s everyday life and causing their whole world to revolve around this medical condition. Just over 100 years ago, a diagnosis of diabetes was a death sentence in which a child, as type 1 diabetes is primarily diagnosed in early childhood, would not be expected to live more than 3 years (Distiller, 3). However, medical discoveries and major advancements in technology have provided patients with the ability to live full and high quality lives as we now have access to synthetic insulin, insulin pumps, continuous glucose monitors (CGMs), improved education, and more. It is impossible to deny the tremendous amount of good these technological and medical achievements have made in the lives of people living with such a life-altering condition, however, this also begs the question of how there can be such large disparities in the quality of life for a disease we now know so much about and have incredible resources for managing. 

“We have the greatest hospitals, doctors, and medical technology in the world – we need to make them accessible to every American.”

Barbara Boxer

Barriers to Medical Care and our Misconceptions of Diabetes Management 

In today’s world, we have access to insulin pumps that will automatically deliver precise amounts of insulin, CGMs that allow a person to know their exact blood sugar at any given moment without the need for finger pricks, inhalable glucagon that saves lives when used during hypoglycemic emergencies, and so much more. So why is diabetes still such a hard disease to manage? Aside from the fact that diabetes is an irregular disorder that may still have complications regardless of near-perfect management, the primary barrier to effective diabetes management remains access to supplies. A majority of diabetics struggle to access the life-saving medical supplies we have available that transform a burdensome and debilitating condition into one that is manageable. This disparity in access is due to a number of factors, however, the main barrier remains the cost of insulin and diabetes technology. While various technologies such as insulin pumps and CGMs greatly improve a person’s ability to manage diabetes and can have life-changing results, it is still possible to manage one’s condition without these technologies through the use of traditional insulin syringes and finger pricks. Insulin, however, is required for a person with diabetes as they cannot survive without it. As previously mentioned in this discussion, insulin is needed to take up glucose from the blood for energy production and when insulin is not present, the body will turn to other sources for energy. The method for providing energy that the body primarily turns to is a process in which fat is converted into energy, however, unlike the regular process involving glucose, this secondary process produces ketones as a byproduct. This results in the buildup of ketones within the blood, turning it acidic and leading to a life threatening condition called diabetic ketoacidosis (DKA). Aside from this dangerous condition, sustained levels of elevated blood sugar can also lead to the many debilitating long term consequences that were mentioned earlier, such as loss of vision, kidney function, feeling in extremities, and limbs. This is why insulin is essential for not only living a high quality life, but for survival itself. With over 1 million diabetics having to ration their life saving insulin everyday, our healthcare system needs a dramatic change (Norton, 1). 

Why is Insulin so Expensive?

According to Ashley Driesbach’s research, a study conducted in 2018 found that on average it costs about $2.28-$3.42 to produce a single vial of human insulin and a year’s worth of insulin only costs $48-$71 per diabetic patient (Driesbach, 8). So how can so many people still be struggling to afford their life saving medication? The answer comes down to the lack of regulations surrounding the major insulin-producing companies. Insulin is manufactured by just three major companies: Eli Lilly, Novo Nordisk, and Sanofi (Martínez, 1). These companies face very few regulations in how they manufacture and sell their product, which is what allows them to increase the selling price of insulin to about $25-$100 per vial for older insulins and $174-$300 per vial for newer insulins merely for the sake of profits. Although insurance may help with some of the cost, many people with insurance are still forced to pay a hefty amount out of pocket and those without insurance are often left helpless (SingleCare, 6). A study from 2019 and 2020 found that insured diabetics were still forced to pay an average of $35 for a 30-day supply of insulin while many others are forced to pay more (Lovelace, 11). Recent studies have also shown that this inflation crisis is only getting worse as insulin prices have increased by about 600% over the last 20 years (Inskeep, 1). The cost of insulin has proven to be a major barrier to diabetics living a full and healthy life and as this crisis continues to worsen, leading to the deaths of people around the globe that could have been prevented with access to insulin, many are wondering what can we do as a society to solve this problem.

“Universal coverage, not medical technology, is the foundation of any caring health care system.”

Richard Lamm

What needs to be done

Reducing the growing disparity diabetic patients face in accessing their medical supplies and technology is something that needs to happen, but there is no clear and simple solution for achieving this. From reading the current research and hearing the life experiences of diabetics around the world, I believe our best chance at reducing this disparity is reducing the cost of diabetes supplies. Although there may be other factors that make accessing medical supplies difficult for a diabetic, cost of insulin and other diabetes supplies remains the most significant barrier as insulin pumps themselves cost an average of $4,500-$6,500 (Vaida, 16). To help alleviate some of the financial burden faced by millions of Americans living with diabetes, we must form new policies that regulate these costs, whether that be introducing policies to provide greater healthcare coverage for uninsured patients, policies that require insurance companies to cover more of the costs for things like insulin and insulin pumps, or policies that regulate the major insulin-producing companies and how much they can sell their product for. It is difficult to say when policies such as these may become possible or if they will ever become possible, as the US is still a long way away from adopting universal healthcare and pharmaceutical companies and insurance companies have remained relatively free to make decisions that directly benefit them at the expense of their “customers” for decades. Whether or not policies such as these are achieved in the US someday, we must continue to raise awareness of the issue as healthcare costs continue to be a widespread epidemic that plagues non only diabetics, but millions of Americans affected by other conditions as well.

Works Cited

Catastrophic spending on insulin in the United States, 2017–18. (n.d.). Retrieved February 21, 2023, from https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01788

Centers for Disease Control and Prevention. (2022, December 30). Types of insulin. Centers for Disease Control and Prevention. Retrieved February 20, 2023, from https://www.cdc.gov/diabetes/basics/type-1-types-of-insulin.html

Distiller L. A. (2014). Why do some patients with type 1 diabetes live so long?. World journal of diabetes, 5(3), 282–287. https://doi.org/10.4239/wjd.v5.i3.282

Drugmakers that dominate the world’s insulin market must scale up access efforts globally. Access to Medicine Foundation. (n.d.). Retrieved February 20, 2023, from https://accesstomedicinefoundation.org/news/how-the-dominant-global-insulin-producers-must-scale-up-access-efforts-to-reach-people-with-diabetes-worldwide#:~:text=The%20three%20companies%20that%20dominate,%2Dincome%20countries%20(LMICs).

Facts. JDRF. (n.d.). Retrieved February 20, 2023, from https://www.jdrf.org/t1d-resources/about/facts/#:~:text=Some%201.45%20million%20Americans%20are%20living%20with%20T1D.&text=64%2C000%20people%20are%20diagnosed%20each%20year%20in%20the%20U.S.&text=2.1%20million%20people%20in%20the,to%20have%20T1D%20by%202040.

Inskeep, S., & Aubrey, A. (2022, September 12). Insulin costs increased 600% over the last 20 years. states aim to curb the price. NPR. Retrieved February 20, 2023, from https://www.npr.org/2022/09/12/1122311443/insulin-costs-increased-600-over-the-last-20-years-states-aim-to-curb-the-price#:~:text=The%20price%20of%20insulin%20remains,patients%20ration%20this%20lifesaving%20drug.

NBCUniversal News Group. (2022, July 24). Why is insulin still so expensive for diabetes patients in the U.S.? NBCNews.com. Retrieved February 20, 2023, from https://www.nbcnews.com/health/health-news/why-insulin-so-expensive-diabetes-united-states-rcna39295

NBCUniversal News Group. (n.d.). Insulin costs will be capped in 2023, but most people with diabetes won’t benefit. NBCNews.com. Retrieved February 20, 2023, from https://www.nbcnews.com/health/health-news/insulin-cost-cap-people-diabetes-no-benefit-rcna58165

Over a million Americans are rationing insulin due to high cost. (n.d.). Retrieved February 21, 2023, from https://www.usnews.com/news/health-news/articles/2022-10-18/over-a-million-americans-are-rationing-insulin-due-to-high-cost

PPI, W. (2018, December 19). Mortality in the United States: Past, present, and future. Penn Wharton Budget Model. Retrieved February 20, 2023, from https://budgetmodel.wharton.upenn.edu/issues/2016/1/25/mortality-in-the-united-states-past-present-and-future#:~:text=The%20United%20States%20has%20enjoyed,of%20more%20than%20two%20thirds.

Team, S. C. (2023, February 8). How much does insulin cost? The Checkup. Retrieved February 20, 2023, from https://www.singlecare.com/blog/insulin-prices/#:~:text=A%202018%20study%20estimated%20that,133%20per%20patient%20per%20year.

Vaida, B. (n.d.). What diabetic supplies do I need, and what are the costs? – goodrx. Retrieved February 21, 2023, from https://www.goodrx.com/conditions/diabetes/supplies-for-diabetics

Xplore. (n.d.). Medical Technology quotes. BrainyQuote. Retrieved February 20, 2023, from https://www.brainyquote.com/topics/medical-technology-quotes

Through the Contemporary Concerns in Medicine course, we have learned about flaws in the United States healthcare system and have determined that current policies do not provide high quality care for all people.  One particular group that receives inadequate healthcare is Americans living in rural regions of the country.  Among the worst off are Native Americans living on reservations.  

In high school, I traveled to Pine Ridge, South Dakota, one of the largest of the 326 Native American reservations on US territory (Indian Affairs (IA)).  This was an immersive trip and part of my high school’s effort to educate students on disadvantaged communities within the United States.  In learning about the conditions on the reservation, I was most surprised to learn about the poor healthcare available on the reservation and the diminished healthcare outcomes for Native Americans living on the reservation.  Taking both the knowledge I learned from my travels to Pine Ridge, and our discussions on disparities in the U.S. healthcare system in this class, it is clear that the Pine Ridge reservation is an example of how the US healthcare system does not support all people living in this country.  

The Pine Ridge Reservation was established in 1889, encompasses 2.1 million acres of southwest South Dakota, and is located near Rapid City, South Dakota and Badlands National Park (Strickland).  Roughly 18,000 people live on the reservation with the majority of residents identifying as part of the Oglala Lakota Native American tribe who consider the Black Hills of South Dakota their ancestral lands (Pine Ridge Indian Reservation Facts | Re-Member).  People living on Pine Ridge have some of the worst health and are among America’s poorest with a per capita income of $8,768.  Life expectancy on the reservation is the lowest in the entire U.S. with women having a life expectancy of 52 years and men having a life expectancy of 48 years (Shift).  89% of people on the reservation are unemployed, and a reported 53.75% live in poverty, and some estimate the poverty rate to exceed 80% (Pine Ridge Indian Reservation Facts | Re-Member).  Additionally, Native Americans on Pine Ridge see an excess of tuberculosis, infant mortality, suicide, alcoholism, cervical cancer, diabetes, car crashes, and unintended injuries (Shift).  Further, very few hospitals exist on the reservation and within the surrounding area, meaning residents have to travel great distances for care.  Only one true hospital exists on the entire 2.1 million acre reservation which is the Pine Ridge Hospital.  Despite being responsible for a population of 18,000 people, this hospital has only 45 beds and 16 physicians (Pine Ridge Service Unit | Healthcare Facilities).  The available care is still significantly worse than care received at other hospitals.  In 2017, the Centers for Medicare and Medicaid Services ended the provider agreement with Pine Ridge Hospital, preventing the hospital from being able to bill Medicare for services.  This decision was made due to reports of misdiagnoses and inadequate care that put patients at risk for “imminent injury, serious harm, death or impairment” (Abourezk).  The combined effects of extreme poverty and limited access to adequate care causes Native Americans on Pine Ridge experience extremely poor health.

Disparities in healthcare are caused and exacerbated by a variety of factors, including a lack of access to insurance, inability to afford medical care due to cost-sharing, geographic barriers, illness-based disparities, and institutional racism (Dickman et al).  All of these issues can be seen on the Pine Ridge reservation and contribute to the decreased health outcomes for Native Americans.  At present, the US has no national health care plan, and healthcare is primarily tied to employment  (Shmerling).  For the people in Pine Ridge, 89% of people are unemployed, meaning most do not have reliable health insurance or must rely on Medicaid for insurance.  Even for those who are insured or qualify for Medicaid, cost-sharing and out of pocket costs for specialty services can be expensive and not feasible for the many residents of Pine Ridge who live in poverty. As is common with healthcare in many rural regions, Pine Ridge has extremely few healthcare facilities, and aside from the Pine Ridge hospital, there are only two other facilities on the reservation with limited providers and services (Pine Ridge Service Unit | Healthcare Facilities).  

Roland left the reservation for the first time in his life in April, when he was airlifted to a hospital in Rapid City for an emergency surgery after he slipped in the snow and shattered his hip while chopping firewood. Only able to move with the help of a walker, Roland, who wears a dirt-covered jacket and repeatedly pulls up his oversized jeans as they sag from his waist, says he will never be able to pay the $2,000 in medical bills through the small amounts of cash he gets doing odd jobs for neighbors and ranchers.

Strickland

Additionally, several of the illnesses plaguing Pine Ridge residents such as substance abuse and mental health conditions are not adequately treated for and exhibit illness-based disparities.  With limited health centers and practicing physicians, treatment for psychiatric care is limited in Pine Ridge despite the widespread incidence of mental health conditions and substance abuse among residents.  Psychiatric care is oftentimes an out of pocket cost not covered by insurance plans, meaning low income families may not be able to afford these services (Dickman et al).  Systemic racism also affects Native Americans on reservations.  During the U.S. westward expansion, Native Americans were forcibly removed from their ancestral land and placed on reservations.  Beyond this, Native American communities have experienced massive injustice, including massacres such as the 1889 Wounded Knee massacre at Pine Ridge and placement in conversion schools.   For decades, the U.S. government did not provide healthcare to Native Americans despite stipulations in reservation treaties dictating the government must provide for these needs.  This history of oppression has placed them at an economic disadvantage, and to this day federal programs and infrastructure on reservations are underfunded and underdeveloped.  These systemic issues have direct effects on the health of Native American people (Ferguson and Solomon et al).

The present-day poverty gripping many indigenous communities – on and off reservations – is firmly rooted in the historical laundry list of massacres, ethnic cleansing, land theft and broken treaties endured by indigenous people in North America.

Strickland

Native Americans experience significant problems in accessing healthcare and experience worse health outcomes than the majority of people living in the United States.  This is a serious injustice that contributes to massive suffering among Native American communities and must be addressed.   Many initiatives from well-known organizations are in progress to address the social determinants of health that apply to rural communities such as efforts by the Association of American Medical Colleges to educate new physicians on healthcare in rural regions and how to treat patients in rural areas.  Additionally, the US Department of Health and Human Services included rurality as a social factor that affects health in its report to Congress to inform Medicare purchasing programs (Social Determinants of Health for Rural People Overview – Rural Health Information Hub).  However, in discussing the issue of health disparities in rural communities, the significant disadvantages that Native Americans face are lumped together with the larger issue of inadequate rural healthcare.  There is a lack of awareness and understanding of the considerations specific to Native American reservations, especially with respect to healthcare.  

The problem of healthcare on reservations is vastly complicated, involves the interplay of economic and social factors, and is rooted in historic mistreatment of the Native American community.  In my opinion, a critical first step in rectifying healthcare disparities is increasing the number of practicing physicians on reservations.  This could be accomplished by incentivizing physicians to work in Pine Ridge or by encouraging and providing access for community members to gain an education to become a physician.  Additional work could be done in expanding insurance coverage and in tackling extreme poverty occurring on the reservation.  

Severe mistreatment of Native Americans is a part of U.S. history that is not always acknowledged, but still impacts their community today.  Healthcare is a basic human right, and the fact that Native Americans experience barriers in accessing health care due to their initial displacement in the 1800s is disheartening and adequately addressed.  It is important to continue educating people about this issue to reach any progress and improve conditions for these communities who called U.S. territory home well before the majority of Americans.

• References:
• Abourezk, Kevin. “Another Indian Health Service Hospital Placed in ‘immediate Jeopardy’ Status.” Indianz, 6 Nov. 2017, www.indianz.com/News/2017/11/06/another-indian-health-service-hospital-p.asp. 
• Dickman, Samuel, et al. “Inequality and the Health-care System in the USA.” The Lancet, vol. 389, no. 10077, Elsevier BV, Apr. 2017, pp. 1431–41. https://doi.org/10.1016/s0140-6736(17)30398-7. 
• Ferguson, Dana. “Violated: Inside South Dakota’s Native American Health Care Crisis.” Argus Leader, 5 Dec. 2018, www.argusleader.com/story/news/2018/12/05/south-dakota-ihs-indian-health-service-history-native-american-healthcare-crisis/2128151002. 
• ​​Indian Affairs (IA). “Frequently Asked Questions | Indian Affairs.” Indian Affairs (IA), www.bia.gov/frequently-asked-questions#:~:text=There%20are%20approximately%20326%20Indian,%2C%20communities%2C%20etc.
• “Pine Ridge Indian Reservation Facts | Re-Member.” Re-Member, www.re-member.org/pine-ridge-reservation. 
• “Pine Ridge Service Unit | Healthcare Facilities.” Great Plains Area, www.ihs.gov/greatplains/healthcarefacilities/pineridge. 
• Shift. “What Led to Health Disparities for Native Americans on the Pine Ridge Reservation — and What Can Nurses Do About Them? – SHIFT.” SHIFT, 10 Aug. 2022, www.shiftnursing.com/articles/pine-ridge-reservation. 
• Shmerling, Robert H., MD. “Is Our Healthcare System Broken?” Harvard Health, 13 July 2021, www.health.harvard.edu/blog/is-our-healthcare-system-broken-202107132542. 
• Social Determinants of Health for Rural People Overview – Rural Health Information Hub. www.ruralhealthinfo.org/topics/social-determinants-of-health#address-issues. 
• Solomon, Danyelle, et al. “Systemic Inequality: Displacement, Exclusion, and Segregation – Center for American Progress.” Center for American Progress, 14 Feb. 2023, www.americanprogress.org/article/systemic-inequality-displacement-exclusion-segregation. 
• Strickland, Patrick. “Life on the Pine Ridge Native American Reservation.” Human Rights | Al Jazeera, 2 Nov. 2016, www.aljazeera.com/features/2016/11/2/life-on-the-pine-ridge-native-american-reservation

I think that privilege can be one of the most difficult things to explain to someone who either a) doesn’t understand it, b) has it, or c) fails to acknowledge that it exists. Often when I hear the word privilege, like many people, I usually assume that the context around it is from a racial standpoint. However, privilege exists in so many different dimensions. Privilege exists not only racially, but also based on gender, ability, socioeconomic status, age, sexual orientation, religion, citizenship, education level, and most associated with this class–health. 

Understanding different forms of privilege is important to understanding how systems of inequality are perpetuated because privilege is one of the key mechanisms that perpetuates these systems. When certain individuals or groups have privilege based on certain identities that they possess, they have greater access to opportunities and resources that others (without those identities) do not. For example, studies have shown that prospective job employees with more ethnic-sounding names face hiring discrimination in comparison with their competitors with white-sounding names. This kind of discrimination leads to unequal variations in status, opportunity, and resources–that end up being key factors in the perpetuation of systemic inequality. However, learning about these inequalities and addressing them can help dismantle them to create a more equitable, just society.

Many of the inequalities that we have discussed in this class highlight an underlying trend of individuals with privilege–or lack thereof, and how this affects their lives. In the first week of class, we discussed the many pros and cons of the American healthcare system using readings from The Commonwealth Fund. Although there are pros–such as advanced care, technological innovation, and vast research–there are also many cons in the system that have detrimental effects to those that may not have some of the privileges that I listed above. Some of these cons include, but are not limited to, expensive costs of care, uneven investment in resources, lack of access, corruption, and disparities affecting marginalized groups. 

The film that we watched in class, Remote Area Medical, was a powerful visualization of what some of the healthcare inequalities look like in this country. The film followed the nonprofit group that stages free clinics in Bristol, Tennessee that lacks access to basic health care. The film explained that Bristol has a bad drug problem and many of its citizens have done/do drugs, leading to various conditions such as lung cancer, bronchitis, lung disease. Many of the people living in Bristol are also blue collar workers that have no jobs or have low paying jobs with no insurance coverage.

I think one of the biggest eye-opening moments for me from the film really was the way that privilege, in many different areas, was displayed. Because so many people in rural areas like Bristol do not have the resources or education to obtain college degrees, they are often forced to work in jobs with dangerous health implications such as jobs in the painting industry, automotive industry, and mining industry. Many of these jobs do not have medical benefits, which highlights one of the flaws in the American healthcare system, that there is no universal coverage.“Compared with the insured, uninsured individuals have a higher prevalence of chronic medical illness, greater physical morbidity, and higher mortality” (Washington, 2001). This would be an example of individuals lacking privilege from a socioeconomic standpoint that then affects their lives in other areas, such as health and education. While all of the patients in the film were white and do obtain privilege in their lives from their whiteness, and some may have privilege as it pertains to their physical ability or sexual orientation, they are all disadvantaged socioeconomically in one way or another. This demonstrates a key idea around privilege–that it is not one-dimensional. 

For example, a white woman in America can experience sexism and not racism, while a Black woman can experience both. The white patients that were being treated in the film were disadvantaged academically and economically, but they were not discriminated against based on their race.

The socioeconomic statuses of the patients being treated by RAM significantly impacted their way of life and their access to quality medical care. Bristol, TN is over 90% white, so this racial makeup makes sense, however I could not help but wonder how the availability and accessibility of this free medical care could be different if Bristol was 90% Black. Would the clinic even exist? Would RAM try to make sure that the physicians that were volunteering represented the demographics of the people that they were serving? Would there have been racial bias within the diagnosis and treatment of certain conditions that are often racialized?

Understanding the intersectionality of privilege is critically important because it helps us to conceptualize that individual experiences that people have are constantly being shaped by their numerous identities, whether that be based on their race, gender, sexual orientation, socioeconomic status, or ability. These compounding identities intersect with one another that can either exacerbate or mitigate one’s privilege or lack thereof.

Sources

Blacksher, E. White Privilege, White Poverty: Reckoning with Class and Race in America. Moral and Social Challenges of Civic Learning. 25 February 2021. https://onlinelibrary.wiley.com/doi/full/10.1002/hast.1230.

University Libraries at Rider University. Privilege and Intersectionality. https://guides.rider.edu/privilege

United States Census Bureau. United States Census Bureau. 2022. https://www.census.gov/quickfacts/bristolcitytennessee

Bridges, K. Implicit Bias and Racial Disparities in Healthcare. American Bar Association. 2023. https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/the-state-of-healthcare-in-the-united-states/racial-disparities-in-health-care/

UK Research Integrity Office. Academic Wheel of Privilege. 2023. https://ukrio.org/research-integrity-resources/equality-diversity-and-inclusion/academic-wheel-of-privilege/

Washington, D. Charting the path from lack of insurance to poor health outcomes. West J Med. July 2001. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071459/#:~:text=Lack%20of%20health%20insurance%20is,it%20has%20significant%20health%20consequences.&text=Compared%20with%20the%20insured%2C%20uninsured,physical%20morbidity%2C%20and%20higher%20mortality.

Day, J. Rates of Uninsured Fall in Rural Counties, Remain Higher Than Urban Counties. United States Census Bureau. 9 April 2019. https://www.census.gov/library/stories/2019/04/health-insurance-rural-america.html

Roberts, N. Urbanization Leaves Rural America In A Health Care Crisis. Forbes. 25 October 2019. https://www.forbes.com/sites/nicolefisher/2019/10/25/urbanization-leaves-rural-america-in-a-health-care-crisis/?sh=36210e3d1b2a

Carlsson, M. Is It Your Foreign Name or Foreign Qualifications? An Experimental Study of Ethnic Discrimination in Hiring. ECONSTOR. November 2008. https://www.econstor.eu/bitstream/10419/35823/1/584702035.pdf

Monopoly on Knowledge

If I gave you two minutes to explain the basic details of your health insurance plan, could you do it? If not, you are far from alone. A recent survey has concluded that a majority of Americans feel “hopelessly confused” by health insurance (Bend, 2021). Coupled with the fact that Americans spend more on healthcare than any other country in the world while producing outcomes that are far from the best, the current state of affairs is aptly summarized as rife with market failures (Tikkanen, et al 2020). Wherefore art thou invisible hand?

Imagine I was something akin to Billy on the Street, and I brought with me a large poster of the image to the right. How likely is it that an interviewee would be able to provide a brief summary of our healthcare system? Even if I were incentivized with a $1, I may consider it not to be worth the mental effort. Overly complicated systems engender feelings of helplessness, and you don’t have to look far for another example. The US tax code has become so complicated that an entire industry has arisen to profit from the average American’s lack of understanding.

The healthcare industry naturally profits from consumer naïveté. A study from the American Economic Association suggests nearly 9 out of 10 Americans purchase the wrong prescription drug coverage plan for their needs, costing them 30% more than the ideal plan on average (Abaluck & Gruber, 2016). It begs the question, who is responsible for educating Americans on navigating our healthcare system? By the time Americans need to purchase health insurance for the first time, they are likely 26 years old. Many years removed from the education system, we are relying on Americans to figure it out for themselves, and it clearly isn’t working.

“Because people are so bad at choosing plans, the market often sends weird signals to insurance companies, encouraging them to offer more of the wrong plans instead of the right ones.”

Margot Sanger-Katz, “It’s Not Just You: Picking a Health Insurance Plan is Really Hard”

Inexplicable Inconsistencies

This past fall break, I road tripped to a close friend’s house outside of Charlotte, North Carolina. As usual, I forgot to pack an item, but unfortunately this time it was my thyroid medication—something I am supposed to take daily. Luckily, I was able to have the prescription filled at a Costco in Charlotte, where I was only charged $7. This was in stark contrast to the $27 I typically pay at the Costco in Mishawaka, Indiana. In the American health system, this isn’t remotely unusual! The varying costs of identical surgical procedures from hospital to hospital and city to city are well documented (Rosenthal, 2013).

Yet again, a lack of transparency and awareness leads to wasteful spending. In an ideal market, consumers and competitors would take advantage of mispricings and force the most efficient outcome. In a country that prides itself on free market capitalism, how is this allowed to persist? I believe two central issues perpetuate this broken system.

The first is the influence of the healthcare industry on regulation via political lobbying. Three of the top five largest political donors this past year were the Pharmaceutical Research and Manufacturers of America, the American Hospital Association, and Blue Cross Blue Shield—all donating in excess of $25 million (OpenSecrets, 2023). Uneven pricing allows some to inflate their margins. The desire to protect their profits is a rational, self-interested act.

The second is once again a lack of knowledge on behalf of the consumer. Once more, if you asked random individuals on the street to estimate the price of a common medical procedure, more likely than not you would get wildly different responses. Ask the same people the price of a gallon of milk and nearly every answer would be between $2-$4, depending on location. This is by no means the fault of the everyday American. Even at the same hospital with the same doctor, individuals may have wildly different out-of-pocket costs depending on their insurance plan. It is, however, a failure of broader American society.

A Simple Step Towards Better Healthcare

“There is rarely a single, immediate remedy […] Success would be incremental.”

Dr. Elizabeth Loder, The Heroism of Incremental Care

Much of the debate in U.S. politics over the healthcare industry surrounds controversial topics. Deadlock prevents radical change, and thus leaves us stuck with the issues of the present. In our obsessive debate over universal coverage or the sustainability of current public health programs, we forget about the uncontroversial. One of the few matters in existence not to exhibit diminishing marginal returns is that of useful knowledge. It is not controversial to suggest that Americans should have a better grasp of our healthcare system. The government has a long-held desire for an educated populace. More quickly than we can cut through red tape, more quickly than we can restrain the influence of lobbyists, more quickly than we can reign in pharmaceutical drug costs, politicians can help the everyday American by enacting programs that will help them to navigate the costs of care. The citizenry so often criticize the wasteful spending of government; how ironic it is that government now has the opportunity to eliminate the wasteful spending of its citizenry. Unsurprisingly, education can make our country stronger.

References

Abaluck, J., & Gruber, J. (2016, August 8). Evolving Choice Inconsistencies in Choice of Prescription Drug Insurance. American Economic Review. Retrieved February 20, 2023, from https://www.aeaweb.org/articles?id=10.1257%2Faer.20130778 

Bend. (2021, February 3). More than Half of Americans Confused by Health Insurance, including HSAs. Bend News. Retrieved February 20, 2023, from https://www.bendhsa.com/newsroom/more-than-half-of-americans-confused-by-health-insurance-including-hsas  

OpenSecrets. (2023). Top Spenders. OpenSecrets: Following the Money in Politics. Retrieved February 20, 2023, from https://www.opensecrets.org/federal-lobbying/top-spenders 

Rosenthal, E. (2013, June 1). The $2.7 Trillion Medical Bill. The New York Times. Retrieved February 20, 2023, from https://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html 

Sanger-Katz, M. (2020, December 11). It’s Not Just You: Picking a Health Insurance Plan is Really Hard. The New York Times. Retrieved February 20, 2023, from https://www.nytimes.com/2020/12/11/upshot/choosing-health-insurance-is-hard.html 

Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. (2020, June 5). United States. International Healthcare System Profiles . Retrieved February 20, 2023, from https://www.commonwealthfund.org/international-health-policy-center/countries/united-states