Last week, I wrote about the strong correlation between lower socioeconomic status and the experience of higher pain levels. Particularly, that those who live in poverty are exposed to higher incidences and a greater degree of chronic pain than their more affluent counterparts for a variety of reasons including occupational hazards, less access to interdisciplinary treatment, and less social support. This week, I wanted to take a deeper look at the financial toll of chronic pain; principally, how having a diagnosis leads to exorbitant financial burden, as well as, look at the social stigma of poverty and how that can influence proper treatment.
My post entitled: “You are not Alone: My Interview with a Patient with Chronic Pain” featured an interview with an individual that has been living with chronic pain for more than seven years. In that interview, I asked this individual about the financial impact of chronic pain. The response I received was: “[t]he cost of my pain medicines has taken a huge toll on my finances. I put the need for medication ahead of my need for groceries, so as a result, I don’t eat as well as I probably should be.” According to a report that was published in the summer of 2013, bankruptcies due to the cost of medical expenses affects 2 million Americans and is the number one reason for filing bankruptcy, more than credit card or mortgage debt. The report that examined data from the Center for Disease Control, U.S. Census Bureau, the federal court system, and the Commonwealth Fund, estimated that roughly 56 million adults (20 percent of the population) grapple with health-care related costs and 10 million Americans with insurance coverage have medical payments they cannot meet. The U.S. spends the highest percentage of its gross domestic product on health care (17.7 percent of gross domestic product (GDP) in 2011) more than any other developed nation, while performing poorly on measures of health quality and equity. The Organization for Economic Cooperation and Development (OECD) compared the U.S. with 34 other member countries and found the U.S. ranked number 26 in life expectancy, had fewer doctors per capita, had higher incidences of asthma, diabetes, and heart disease but paid more for the healthcare they received. In no way can illness, health, and wealth be separated from each other. An article published in the Journal of Health and Social Behavior entitled “Debt and Forgone Medical Care” (2013) authored by Lucie Kalousova and Sarah A Burgard found that, in a sample of 914 Southeastern Michigan residents surveyed during the recession in the late 2000s, respondents abstaining from medical care for financial reasons had poorer health than those who did not forego care. The authors state that the results of their study were extraordinarily clear: the amount of income and assets or lack thereof, credit card debt, and medical bills were strongly and positively correlated with abstaining from medical care in the 12 months prior to completing the survey. Pertaining to chronic pain, a feedback loop is thus created where the diagnostic, treatment of, and loss of wages due to disabling pain positions individuals at an exceedingly high risk of falling into poverty and poverty places people at a greater risk of experiencing more and higher levels of pain.
We live in a work culture. Sociologists have long talked about Max Weber’s writing on the protestant work ethic and have drawn correlations to American society where a moral value is placed on productive work and health. So, what does it mean for quality treatment if you’ve been priced out of a system or the stigma of receiving care, such as Medicaid, has a great price as well? An extremely disturbing report came out in August of 2013 from the Philadelphia Inquirer. Susan Fiske, a Princeton University psychologist has been running a study for 12 years in which she places people in a neuroimaging machine and showed them pictures of the poor and homeless. The results showed that when people viewed these images their brains responded as viewing something unhuman and exhibited signs of revulsion. The article goes on to say that dehumanization allows for societal neglect and points out that prejudice against the poor increases during times of economic downturn. However, according to John Dovidio, a Yale University psychologist, key to understanding discrimination against the poor is the idea that if you work hard you succeed and if you fail it reflects on your work ethic not on circumstances outside of your control. Perhaps, these views just remain in the dark recesses of the mind and do not influence medical treatment in any form? In my interviews with patients for this blog, I spoke with one woman who had been receiving care for the painful disorder, Psoriatic Arthritis, characterized by pain, swelling, heat, and redness of the skin and extreme pain and swelling in the joints. She had been receiving care under Medicaid due to earned income and assets assessment and it had come time for her annual renewal paperwork. She had taken the paperwork into her specialist and this is what she had to say:
The appointment was ending and I brought out the paperwork. He looked at it and said ‘this is for patients who have given up. You haven’t given up have you?’ I said no. He said: ‘Well then, I am not going to sign it then because this is for people who have given up and clearly that isn’t you.’ The thing is I was seeing him because he took Medicaid patients. My symptoms were unexpected and dramatic. I had grown up poor and had no family to depend on. I was referred to the Medicaid program by a social worker in that same hospital after diagnosis. I left in tears feeling that I had experienced a type of natural selection. Don’t get sick if you are poor in America.
Maybe this is merely an anecdote. Is there any available research that reveals that groups that have more negative stereotypes associated with them have worse outcomes of treatment of pain? In a 2011 article entitled “Corporatization of Pain Medicine: Implications for Widening Pain Care Disparities” published in the journal, Pain Medicine, Salimah H. Meghani details how the poor, people of color, and the uninsured and underinsured are not mutually exclusive and suffer the most when it comes to disparities in treatment particularly are less likely to receive opioid, epidural, and patient-controlled analgesics, as well as, nonsteriodal anti-inflammatory drugs. The author argues that treatment of pain falls so easily pray to stereotypes because it is a subjective state for patients, historically pain has been associated with negative labels, and opioids are the most commonly used in treatment of pain and have negative social associations with their use. Bolstering the argument that discrimination or perceived discrimination can have a deleterious effect on care is a study that came out in 2012 from Cornell University that showed adolescents who live in poverty and face discrimination have worse health outcomes. What is remarkable about this study is just the act of discrimination alone can cause an increase in body mass index, blood pressure, and higher levels of stress in young healthy individuals. It leads one to question how this may compound an individual’s health that is already coping with bodily pain and inflammation.
For Those Interested
Read my full interview with a patient with chronic pain:
Read part one of series:
Philadelphia Inquirer’s article “Reacting to the Poor–Negatively”:
Kalousova and Burgard’s Michigan Study:
Medical Bills are the Biggest Cause of Bankruptcy Report:
Report on where U.S. ranks in healthcare in comparison to other OECD nations:
Cornell Study Negative Stereotypes Influence Health: