Healthcare Insights: "Without Health There Is No Person"

NOTE: The author is grateful to Josef, Maria, and Lucia who graciously met to share their experiences with work and health and healthcare in New York City.  Because of issues related to immigration status, this story will be shared without the true names of the workers or the nature or location of the business.

In last month’s article in Healthcare Insights, we explored the impact of recently passed legislation in Florida that requires hospitals to ask patients about their immigration status. We shared documentation of the harm and potential harm such inquiries have on the health of a large segment of the population and workforce of the state. We also illuminated the policies of the federal government that do not allow undocumented people access to Medicaid and Medicare, along with a host of other social benefits afforded citizens.

We also shined a light on another dimension: that though millions of undocumented people work hard every day and pay taxes, they are denied these important and in many cases life-saving services.

In this month’s Healthcare Insights, we want to share the story of a small business in New York City, one that is quite typical and well known to all New Yorkers: it is one of the thousands and thousands of small businesses that provide our needs, from small groceries and restaurants, to nail and hair salons, to shops of all types that are part of neighborhoods that define the unique culture of New York City. 

So many of these small businesses employ immigrant people, many hundreds of thousands of whom are undocumented or in varying states of immigration which make it difficult to obtain healthcare and other necessary services.

Before sharing this story though, I want to step back and remind ourselves that affordability and access to healthcare is a problem for most Americans under age 65, not just undocumented immigrants: According to KFF Health Care Debt Survey: Feb.-Mar. 2022, many U.S. adults have trouble affording healthcare costs. While lower income and uninsured adults are the most likely to report this, those with health insurance and those with higher incomes are not immune to the high cost of medical care.

About half (47%) of U.S. adults say that it is very or somewhat difficult for them to afford their healthcare costs. 

Among those under age 65, a vast majority (85%) of uninsured adults are much more likely to say affording healthcare costs is difficult compared to those with health insurance coverage (47%). Additionally, at least six in ten Black adults (60%) and Hispanic adults (65%) report difficulty affording healthcare costs compared to about four in ten (39%) White adults.

Adults in households with annual incomes under $40,000 are more than three times as likely as adults in households with incomes over $90,000 to say it is difficult to afford their health care costs (69% v. 21%)

The survey also found that debt due to medical and dental bills is a widespread issue in the United States, affecting both uninsured and insured adults. Healthcare related debt encompasses more than just unpaid or past due bills from providers. Substantial shares of adults carry debt from medical and dental bills that they have paid off by taking on other forms of debt, including credit cards, personal bank loans, or loans from family and friends. A key finding was that four in ten adults have some form of health care debt.

Difficulty in obtaining affordable, comprehensive, and high-quality healthcare is a challenge for most people who live in the U.S. It is a stressor that in and of itself contributes to ill-health. 

Back to our small business story…

While I was discussing healthcare issues with Josef, Maria, and Lucia, it came as a great surprise to them that all Americans did not have access to high quality healthcare. They thought that it was only people like themselves who had such a difficult time obtaining healthcare!

With that in mind, it is fair to say: In many ways we are all in this together.

I asked the owner of the business, Josef, who was born in the U.S. what his primary concern was about not being able to afford to provide healthcare for his employees. He said, “Without health, there is no person, without health there is a breakdown of the well-being of a person, and this affects me on a deep emotional level. Without them, I am nothing.”

They worked together all through the pandemic. Other employees moved on.

They are still there, together, re-building their clientele. 

Maria and Lucia have limited access to healthcare: Maria through Medicaid, Lucia through the NYC Cares program. They have no coverage for dental or vision care. They have access to medications, but pay deductibles and co-pays. While they are grateful for the care they receive and find it warm and friendly, any out of pocket costs are expensive for them.

Josef helped Maria and Lucia navigate the systems to obtain these coverages.

It was very clear that all during the interview, Maria and Lucia were quite guarded. Even though in New York City, healthcare and other services are more available than in many other places in the country, the rising tensions around immigration are evident in the eyes of these hard-working women.

They work 30-40 hours per week. Maria has worked for Josef for 12 years; Lucia for 8. They pay taxes.

Josef feels fortunate as his partner has family health insurance coverage through his work. Prior to this development, Josef paid as much as $1500/month for private insurance for himself which included co-pays and deductibles. And even though he now has good coverage, he is delaying having knee surgery, which he has needed for some time. He says: “I must keep working so that Maria and Lucia will be able to work and have an income. I don’t know what would happen to them if they missed even a few days of work because I had to take time off.” 

When Josef shared this part of the story, everything came into sharp relief for me. In addition to a generalized fear of living and working here, Maria and Lucia are wholly dependent on work provided by a kind and caring employer who sacrifices his own health to be able to provide for his workers. Josef must live with pain and a chance of a more complex injury so that he, his employees, and business can just get by.

Like the millions of immigrant people who came to the U.S. over the past 200 years, Maria and Lucia came here for a simple reason, “to look for a better life with opportunities for growth,” they told me.

They are doing what they can in that regard. They are hopeful.

It is a doctor colleague friend of mine who uses the phrase daily in her medical practice with her co-workers: “Do you know who you serve”? She explained to me that this question is the grounding she needs each and every day of her practice so as to listen, really listen to what her patients are telling her. If she does not listen to the whole of the person, it is quite possible she will not make the correct diagnosis, or a complete one. 

On an individual basis there are controls and context for getting it right. But as we read each day about doctor and health care worker burnout and moral injury, we must wonder if it is not a whole system that fails to ask the question, “Do you know who you serve?”

The fears of the hard-working immigrant people like Maria and Lucia and their caring boss, Josef are only a few steps of separation away from most Americans. The experience of sitting quietly with the people who work every day to provide an essential service to their neighborhood and listen to them speak about health and healthcare is a great privilege. 

It ought to be required “reading” for the work of healthcare improvement and healthcare transformation: knowing who we serve.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.