Bioethics Forum Essay
Being Poor Is a Full-Time Job
An article in the Hastings Center Report asks whether it is ethical to ration health care by inconvenience and red tape. In other words, given that all societies must ration health care in one way or another, is it ever ethical to push people away from an unpreferred health care option by making it more inconvenient? For example, what if physicians had to go through a very long process to prescribe a brand name drug, or if ERs had really onerous check-in procedures for patients without medical emergencies?
This article came at an interesting time for me, because I was recently asked to provide informal support for a woman I will call Millie, who is dependent on public assistance and was moving from her home in New York State to my community in Pennsylvania. Despite my fairly extensive reading on what it means to be poor in America today, I was blown away by the sheer inconvenience of Millie’s daily existence (and awed by the way she navigated bureaucracies that would have reduced me to gibbering idiocy).
Millie is in her 50s and with a number of health problems, including diabetes and hepatitis C. She had spent her last dollars to hire the truck to move her possessions to a new home; she had moved to Pennsylvania to live with relatives who had been persistent in inviting her, but turned out to be interested only in her disability paycheck. The household was chaotic and unsafe, and everyone smoked. Millie’s immediate problems were to find new Section 8 housing and a way to move her stuff, to get her many medical prescriptions transferred to her new state, and to find new doctors and get her medical care back on track. She had to do this with no car, no credit card, and no checking account.
In addition to the hours that Millie spent dealing with those problems, her daily life presented its own inconveniences. Living miles from a decent grocery store, she had to shop at the local bodega, whose meager offerings were not ideal for someone with diabetes. Without a car or the money to call an Uber, she would have had to use public transportation to shop at better grocery stores, but that would have eaten up a big chunk of her day. Picking up prescriptions presented similar problems.
In short, what I learned from Millie was how time-consuming and inconvenient it is to be poor. Being poor is virtually a full-time job. Being poor with chronic illness is two full-time jobs.
This is especially concerning because of a theory, promulgated by researchers at the Wharton School of Business, that poor people are often so preoccupied with the challenges of daily living that they have less “bandwidth” with which to make good choices. The authors of the Hastings Center Report article do not ignore this question. They are concerned that any rationing process not be regressive, that is, that it not disadvantage those who are poor. But they believe that rationing through inconvenience is less regressive than, for example, rationing through cost-sharing. “[All] people have twenty-four hours in a day, a limited attention span, and a body that can be in only one place at a time.” The authors do acknowledge that rationing through inconvenience must be used thoughtfully, but some of their solutions seem merely to generate more onerous paperwork: “In some instances, a hardship waiver would be feasible and appropriate.” Can you imagine how long it would take to fill out the application for that waiver? Rationing through cost-sharing or other financial means can more easily be made less regressive by exempting people who have already done the paperwork to be eligible for Medicaid, SSI, and so on, and already have the card to prove it.
The authors of the Hastings Center Report article are not targeting only patients in their paper; they propose “negative nudges” that operate on all players in the health care system. But since poor people already get poor health care and live in less healthy environments, and since their lives are already burdened by inconvenience, we need to be very sure not to increase that inequality.
Dena S. Davis, JD, PhD, Hastings Center Fellow, is the endowed presidential chair in health and a professor of bioethics and religion studies at Lehigh University. A version of this essay originally appeared on her blog, Bioethics and Other Stuff.