• Rosalind Kaplan, M.D.

Before I Shut Up and Listen

The last couple of weeks has rendered me almost speechless. Almost, because I always seem to have something to say. But this post is going to get right to the point, because I've got a lot of reading and listening and thinking to do. After George Floyd's murder, and in the midst of the massive nationwide and worldwide protests over police brutality and racial injustice, I, like many people I have talked to, must really come to terms with how much I've stuck my head in the sand on this issue, and try to do better. I need to relearn history. I need to really pay attention to what black writers have to say. I need to listen to what my black friends and colleagues are saying. There is so much I don't know; I need to shut up and listen. But first I have to get this one thing out.

What I do know is that, to be part of a just society, health care needs to change. None of this is new, but the coronavirus epidemic overshadowed everything else in medicine for the last few months. Now, the dialogue around social justice has opened up, and we might have a chance for some real, positive change in our nation. And healthcare needs to part of that change.

I may not have paid enough attention to some aspects of social injustice, but as a physician, certain facets have been right in front of me. Health disparities reach far and wide, and to improve the health of the population, many areas of injustice need to be addressed. Socioeconomic disparities, such as lack of affordable and safe housing and lack of access to healthy food all over the country, are enormous drivers of disease, and the cycle of poverty, disease and disability leading to more poverty, disease and disability is one of our country's huge shortcomings. Treating drug abuse as a criminal issue rather than a health and safety issue is another- and the cycle of poverty and incarceration repeating itself over and over has tremendous human costs as well as financial consequences. Money frequently takes wrong turns in its travels through this country. Too much for police and imprisonment, not enough to address hunger and homelessness. The response to the pandemic has been yet another example of less-than-optimal use of taxpayer dollars, and has again contributed to disproportionate suffering in people of color and all those in low income areas. Then, to add more misery, there is tremendous disparity in access to the medical care needed to address the results of all the gaping holes.

I have been watching, and participating in, our fractured health system for decades. In theory, we have everything we need in this country to ensure the best medical care to the population. We have incredible research, great teaching institutions, massive brain power, and all the skill and knowledge and innovation we could ask for. The problem is that so many people can't get near any of it. As millions lost employment during the pandemic, they also lost health insurance. That's if they had it in the first place. Not only that, but many people WITH health insurance can't afford the deductibles and copays for the care they need. Care is delayed and deferred because of prior authorizations and precertifications for medications and tests, which have not, in practice, lowered costs. They've just shifted the money from the patients and caregivers to the insurance companies and administrators.

There's more. Hospitals are closing in financial ruin in underserved areas. In the midst of a pandemic, doctors and nurses are being furloughed because of health system costs. Primary care, the specialty that is uniquely positioned to help people maintain their health, keeping them out of hospitals, is so underfunded that it risks extinction, leaving more expensive, fragmented specialty care as an alternative rather than an adjunct. And access to mental health care? Well, ask anyone who can't pay for it out of pocket how difficult it is to see a psychiatrist regularly and to get quality psychotherapy. That's a huge problem, given the fact that depression and anxiety alone are rampant illnesses, contributing to a great deal of suffering and disability.

Overall, to the dismay of patients and caregivers alike, the process of obtaining and providing medical care has become so convoluted that we are all exhausted by it. That wasted energy could be much better used to care for others, ourselves and our environment.

We MUST prioritize universal health coverage in which money goes to the care of patients rather than to administrative costs. Everyone must be covered; access and quality must not discriminate based on race or on wealth. I don't believe that can happen as long as commercial insurance companies and profit-driven health systems are driving the train. The corporatization of medicine has not resulted in better health or lower costs. We MUST disconnect health coverage from employment, so that loss of a job does not mean loss of coverage and change of jobs does not mean loss of continuity.

We also must invest in primary care and in mental health care. It may not be glamorous or profitable, but the prevention and early treatment offered by primary care is the first line to improving the well-being of patients, the health care system and society.

Advocate, protest, and VOTE for the changes we need in healthcare! An unhealthy society can't be a just society. And an unjust society can't be a healthy one.

(Okay, now I'll shut up and listen)

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© 2017 Rosalind Kaplan