In a week where we’ve seen the bungled Afghan withdrawal, had Texas show us its contempt for all sorts of rights, watched wildfires ravage the west and Ida wreak havoc on a third of the country, and, of course, witnessed COVID-19 continue its resurgence, I managed to find an article that depressed me further. Thank you, Aaron Carroll.
Dr. Carroll — pediatrician, long-time contributor to The New York Times, and now Chief Health Officer of I.U. Health — wrote a startling piece in The Atlantic: We’ve Never Protected the Vulnerable. He looks at the resistance to public health measures like masking and wonders: why is anyone surprised?
Some of his pithier observations:
· “Much of the public is refusing. That’s not new, though. In America, it’s always been like this.”
· “COVID-19 has exposed these gaps in our public solidarity, not caused them.”
· “America has never cared enough. People just didn’t notice before.”
Wow. What was that about Texas again?
Some of Dr. Carroll’s examples include our normally lackadaisical approach to influenza, our failure to recognize the dangers we often pose to immunocompromised people, our paltry family and sick leave policies, and our vast unpaid care economy. He could have just as well pointed to our (purposefully) broken unemployment system or the stubborn resistance to Medicaid expansion in 12 states (Texas again!), but you probably get the point.
Everyone likes to complain about our healthcare system — and with good reason — but it is not an abyss we somehow stumbled into. It’s a hole we’ve dug for ourselves, over time. We may not like our healthcare system but it is the system we’ve created, or, perhaps, allowed.
Health insurance was once largely community-rated, spreading the risk equally across everyone to protect the burden on the sickest, until some insurers (and some groups) figured out that premiums could be cheaper without it. Use of preexisting conditions and medical underwriting also served to protect the less vulnerable, until ACA outlawed those practices.
Fee-for-service wasn’t really an issue until Medicare came along and pumped billions, then hundreds of billions, into the medical-industrial complex. Healthcare professionals and organizations soon realized there was real money to be made in healthcare. Some physicians make millions annually from Medicare and/or pharma, and some hospitals sit on billion dollar endowments, but the problem is less that a few are making so much money than that so many make a lot money. That money comes from the rest of us.
The same business leaders who sit on hospital boards and/or make big contributions to those hospitals also complain about the impact of their employee healthcare costs on their bottom lines. The same physician leaders who have allowed our medical schools to become the longest and most expensive in the world warn about medical school debt and impending physician shortages. Neither connect the dots.
Public health was once a valued public calling, with public health measures making huge strides in protecting the public during the first half of the 20th century, such as through reducing infectious diseases, fluoridating water, and improving food safety. The 21st century, on the other hand, saw alarming declines in funding for public health, creating a “hollowed-out” public health system at the time we needed it most. The pandemic has seen public health officials ignored, ridiculed, even threatened — causing “mass exoduses” of them. We’re the ones really harmed.
The polio vaccine was a tremendous public health success, with near universal compliance, but the anti-vaxx movement was gaining strength before COVID-19 ever appeared. A COVID-19 vaccine was developed and rolled out in record time, and we wouldn’t be dealing with Delta’s surge right now if most of us had gotten vaccinated, but we still have a fifth of the population who still say they won’t get vaccinated. Their “rights” run directly into our well-being.
Health care professionals, particularly those working in hospitals, have been true heroes over the course of the pandemic, especially as they battled the surges last year and, unfortunately, are having to do so again now. Despite the fact that required vaccinations are nothing new for healthcare workers, many are now resisting getting the COVID-19 vaccine — protesting or quitting/being fired instead. They’ve risked their lives taking care of patients, but now are putting vulnerable patients at risk.
We love the jobs that healthcare creates, but complain about how expensive healthcare is. We hate health insurance companies but realize that we could never afford the most expensive care without some kind of insurance. Money spent on healthcare is money not spend on other needs.
We are frustrated with the waiting, paperwork, delays, and lack of transparency associated with our healthcare providers, but we not only put up with it but we don’t even demand evidence of excellence, or even competency. We enable all the flaws.
Most of us have had a family member who needed some kind of (custodial) long-term care, but it’s not covered by Medicare or private health insurance. Most such care is paid by Medicaid — after spending virtually all assets — or out-of-pocket, and that ignores all the unpaid care provided by family or friends. Talk about vulnerable populations…
Our politicians brag about the U.S. having the best healthcare in the world, but it compares very poorly to other wealthy countries, with some of our results, such as maternal health, positively third world. The racial disparities in our healthcare system are further proof that, when it comes to protecting vulnerable populations, we’d rather not.
So, yes, Dr. Carroll is right. In America, we’ve always looked after ourselves more than the vulnerable. The gaps in our public solidarity have long been with us. As much as we like to think of ourselves as caring people in a caring nation, the sad truth is that we’ve never cared enough.
As a result, we now have a healthcare crisis that didn’t have to be this bad, and are being ill-served in a dysfunctional healthcare system that we probably deserve. At this point, about all I can do is hope that Dr. Carroll is also right that people just didn’t notice how selfish we can be, much less realize the consequences for more vulnerable populations — and that it will spur us to doing better.
Is that being selfish of me?