Introduction
Americans who are in the lower tax bracket are twice as likely to suffer from chronic illnesses such as hypertension or diabetes. Still, according to the Centers for Disease Control and Prevention (CDC), they are less likely to receive regular preventive care.[1] In the most recent years, the growing divide in assessing healthcare has underscored how deeply a variety of barriers, such as socioeconomic, cultural misunderstandings, and racial biases, are weakening the doctor-patient relationship and significantly worsening health outcomes for many individuals. What once may have seemed like many isolated issues concerning affordability have now become compounding obstacles for millions of individuals. Particularly in rural or underserved areas, this trend highlights stagnant matters and rapidly worsening issues. These systemic limitations will leave many patients feeling dismissed, neglected, and unworthy of medical attention, along with delaying many treatment options. Those who have shared their stories regarding substandard treatments, lost insurance, and insufficient visits with physicians prove that these disparities aren’t abstract–they are real, and daily realities.
Lived Experiences of Disparity: Patient Perspectives on Neglect
A core challenge that individuals face with lower incomes is the absence of stable and consistent health insurance coverage, which is also known as the primary way to access quality healthcare. Without insurance, many patients are usually forced to relinquish preventive care and/or delay necessary treatments until their conditions reach a severity that will demand treatment. The instability within these challenges will discourage individuals from seeking help in the first place, mainly with expensive out-of-pocket procedure costs. This theme is powerfully echoed in Tiffanie’s oral history, who was a Substance Abuse Counselor born and raised in Raleigh, NC. She highlighted the emotional and administrative ramifications of what one experiences with losing their insurance. She questions herself why patients should have to struggle so hard to get the care that they need, and why exactly those services are taken away. Tiffanie reflects on the broader implications of losing healthcare insurance, stating, “But then you have people right now who qualify for it who’ll be losing it, and that means children may be losing healthcare. Everybody can’t afford Obamacare.”[2] Her words highlighted the unsettling consequences of a vulnerable family losing their health coverage, and how anxiety is increased within individuals who experience health issues that could escalate without proper coverage.
The next oral history that I observed was Janette’s, who was born in Raleigh North Carolina, after analyzing Janette from Raleigh, NC, in 1989. She shed light on how some healthcare environments are structured, related to nursing homes and rehabilitation centers often failing to prioritize the well-being of patients. Her experience placed a troubling dynamic where financial aspects took priority over compassionate care. She put it as, “I just didn’t like that environment, either, because it wasn’t about the wellbeing of the person, it was about the insurance reimbursement, and that’s not the side of healthcare I wanted to be on.”[3] Janette’s story illustrates the quality of care that low-income individuals receive in institutional settings, and what kind of implications are taken from these actions. Ultimately, her reflections suggested that even if access to healthcare is technically granted, the superiority and consideration of care are compromised based on one’s economic status.
Neglect in healthcare can be taken in both physical and emotional forms, especially when low-income individuals, whose ability to access healthcare is often deprioritized. These delays can lead to a deep sense of being forgotten or unworthy of care, which is one of the factors that weaken the doctor-patient relationship. This form of emotional neglect is frequently linked to the way providers (consciously or unconsciously) disregard their patients based on their ability to pay the perceived value within the system. According to researchers Fiscella, K., Franks, P., Gold, M. R., & Clancy, C., their research showed that low-income patients are more likely to receive shorter consultations, less follow-up care, and fewer diagnostic tests than their counterparts who have higher incomes, even when they both experience similar symptoms.[4] This intertwines with Dr. Carl Henley’s oral history, who was a professor at the School of Social Work, after receiving his master’s and doctorate in biostatistics at the School of Public Health at UNC. Carl’s story demonstrated this kind of systemic neglect, describing the enduring long wait times and feelings of avoidance of even wanting to seek care. His experience highlights the reality that minimal communication and prolonged delays can erode a patient’s motivation to want to engage with the healthcare system as a whole. This ultimately boils down to the conversation of insurance, as it acts as the gatekeeper that determines who receives timely and high-quality treatment and who must settle for limited, inadequate care. As stated by researchers Paez, K. A., Mallery, C. J., Noel, H., Pugliese, C., McSorley, V. E., Lucado, J. L., & Ganachari, D, “Differences in health insurance literacy may be a previously underrecognized source of healthcare disparities because even minor errors can result in delayed care or unanticipated medical bills.”[5] On the other hand, institutional practices that are rooted in profit and effectiveness place additional pressures on providers, minimizing time and resources spent on patients that have the appearance of being less “cost-effective.”
The Institutional Logic of Unequal Healthcare, Neglected by Design
Disparities that appear in healthcare are not at all random or accidental, these are symptoms of a larger institutional and cultural dynamic that continually diminishes low-income communities. Healthcare institutions unintentionally reinforce economic and racial disparities through biased resource allocations, protocols, and many other aspects that overlook the unique needs of diverse populations. Van Ryn, M., & Burke, J. published the article “The effect of patient race and socioeconomic status on physician perceptions of patients” which studied the amount of time providers spend with patients from minorities or lower socioeconomic backgrounds.[6] This could also lead to them unintentionally disregarding the symptoms of the patients due to possible cultural or communication barriers. Cultural misunderstanding only intensifies the emotional toll of neglect. These low-income patients are perceived as uninformed when in reality, they are struggling with systemic obstacles like transportation or financial strain. This builds on Carl, Janette, and Tiffanie’s stories by presenting how neglect does not only pertain to insurance –it is primarily about the failure to consider and recognize the dignity of patients whose voices are often overlooked. Socioeconomic disparities are the central focal point in understanding why individuals experience lower quality of care. The several oral histories and scholarly articles within this writing illustrate how systemic issues have deeply eroded the doctor-patient relationship. The very population that is most at-risk needs are not met due to these inequities intensifying in institutional structures and cultural blind spots. Moving toward a more equitable healthcare system is going to require changes on many different levels within the system: advocating for subsidized insurance models that will remove financial barriers for individuals, providing more access to community-based clinics, and considering cultural competency training for healthcare professionals. That change has to stem from awareness by rebuilding trust and restoring dignity in healthcare.
Works Cited
[1] Susan Levine,” Health Care Industry Insights: Why the Use of Preventive Services Is Still Low” (Centers for Disease Control and Prevention, 14 Mar. 2019) www.cdc.gov/pcd/issues/2019/18_0625.htm.
[2] Tiffanie Cotton, Oral History Interview, Interviewed by Joanna Ramierez, Southern Oral History Program, June 29, 2018. Y-0016 :: Southern Oral History Program Interview Database
[3] Janette Godwin, Oral History Interview, Interviewed by Maddy Kameny, Southern Oral History Program, June 26, 2018. Y-0025 :: Southern Oral History Program Interview Database
[4] Fiscella, K., Inequality in quality: Addressing socioeconomic, racial, and ethnic disparities in health care. JAMA, 283(19), May 17, 2000. https://doi.org/10.1001/jama.283.19.2579
[5] Paez, K. A., Mallery, C. J., Noel, H., Pugliese, C., McSorley, V. E., Lucado, J. L., & Ganachari, D. Development of the Health Insurance Literacy Measure (HILM) Journal of Health Disparities Research and Practice (2014). https://www.tandfonline.com/doi/full/10.1080/10810730.2014.936568
[6] Van Ryn, M., & Burke, J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Social Science & Medicine, 50(6), March 2000. https://doi.org/10.1016/S0277-9536(99)00338-X