On Being

Health Care
In 1999, 43 million Americans—most of them poor—do not have health insurance. We tend to assume that if people are poor enough, they are eligible for some kind of governmental health coverage. Our assumption is wrong. Less than one-third of people living in poverty are eligible for Medicaid, the primary form of health insurance available to the poor. The low-paying jobs available to poor people rarely pay for health insurance. A family policy currently costs more than $500 a month or half the total income of a family of three living at the poverty level. Poor people, therefore, cannot afford to purchase insurance on their own, so they remain uncovered, spending significant percentages of their income on doctor or emergency room visits, especially if they have young children.

Even those few who do qualify for Medicaid can find themselves in trouble. Although patterns vary from state to state, fewer and fewer doctors and hospitals accept Medicaid, so poor people must usually go to hospital emergency rooms or public clinics for their care. Emergency rooms handle emergencies well (even for the poor), but they cannot offer much in the way of continuing care, preventive medicine, or help in routine medical problems. In fact, patients with routine problems are increasingly triaged out of emergency rooms. Public clinics can be good, but they rarely have the staff or other resources to provide good care to all who need it. Waits are usually long, one usually sees a different doctor each time, charges are made and bills are sent anyway, and there is usually no special provision for paying for other needed services—x-ray, special lab, hospitalization-which can be enormously expensive.

So, cost prevents the appropriate use of health care and drives the poor further into poverty.

We sometimes forget the other side of the equation: poor health is not only a complication of poverty but also among its causes. The health of poor people is measurably worse than average, which in turn aggravates their poverty. Poor prenatal care, inappropriate maternal drug use, and maternal malnutrition, for example, can all lead to significant learning disabilities and decreased cognitive abilities (which can lead to poor educational achievement, which further complicates poverty). Congenital disease and infant AIDS are far more common among the poor.

The chronic diseases of childhood are far more common among the poor. Asthma, lead poisoning, various anemias, malnutrition, chronic middle-ear infections are not only expensive to diagnose and treat, they can also lead to adult impairment, sometimes in surprising ways. Consider chronic middle-ear infections (otitis media). The usual acute ear infections cause pain and lead to emergency doctor visits. If these infections are (as often happens) insufficiently treated, chronic otitis media can develop which may have few noticeable symptoms. For financial reasons, a poor child is less likely to return to the doctor after her acute ear infection seems to have gotten better, so chronic otitis media remains often undiagnosed. Otitis media causes a temporary loss of hearing, which often persists through early childhood. Undiagnosed hearing loss can lead to poor school performance and permanent educational deficiencies, making it that much harder to escape poverty as an adult.

Similar stories can be told about lead poisoning, malnutrition, and many other childhood health problems. The "surround of force" seems inescapable.

The poor are much more likely to live in environmental conditions and work in conditions that are detrimental to health. A friend of mine cannot afford to move out of her damp basement apartment although the mold spores severely aggravate her daughter's asthma.

Finally, the stress of simply being poor has been documented to be a real health risk. The poor get it coming and going.