Arugula for Asphalt Crews
Unintended Elitism of Healthcare Wonks
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One of my favorite aspects of Substack is the high quality of the comments by readers. Earlier in the week, I posted “Doctors with Borders: The Divide between Physicians and Advanced Practice Registered Nurses.” This piece asked whether advanced practice registered nurses (i.e., nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists) should have broader scope of practice and greater practice autonomy—particular to increase healthcare in underserved areas (e.g., rural areas, inner cities). One reader offered a thoughtful question, and that reminded me of a piece I published in a different venue five years ago. Below is an edited version of that article, “The Unintended Elitism of Health Care Policy,” published August 7, 2018 by InsideSources.
The biggest problem with healthcare policy may be that those who design healthcare policy mostly design it for people who design healthcare policy.
We policy folk reside in a variety of institutions: medical facilities, corporations, universities, think tanks, legislative offices, regulatory agencies and advocacy groups. But we broadly share certain characteristics. We’re well educated. We possess deep knowledge of health-related matters. We’re analytical. Our thoughts and passion focus on health.
Our lives and careers follow similar patterns. We have white-collar jobs. We either pursue healthy lifestyles—exercise, diet, medical care—or at least feel guilty when we don’t. Our schedules theoretically leave us time to exercise or obtain healthy meals. Our friends, co-workers and families share many of these characteristics.
Most of our employers provide generous formal and informal health-related benefits. If we’re sick, they let us take time off to visit the doctor, usually with no loss of wages. Our employment is relatively stable and our hours regular and predictable.
While many of us, particularly in medical institutions, interact with those in less rarified circumstances, we have the luxury of retreating into our fortunate bubble when we leave the office.
This bright, monochromatic life skews our thinking about public policy. When we ask ourselves, “What can the government or employers do to improve people’s health?” we tend to conjure up solutions we imagine would work on ourselves or the half-marathon runner in the adjacent office or the overweight colleague across the hall.
For many years, I asked roomfuls of doctors and nurses how employers might help stanch Americans’ rapid increase in obesity. Their answers usually fit this cloistered stereotype:
“My office had a walkathon competition.”
“My company opened a gymnasium for employees.”
“My employer pays 50 percent of gym membership costs.”
“We have twice-weekly yoga classes in the boardroom.”
“Human Resources offers wellness classes.”
“Our cafeteria offers healthy options.”
Ask the same medical professionals what the government and other employers ought to do to fight obesity, and the answers reflexively veered toward “encourage or require employers to do all those things my employer does.”
The problem is that many of America’s most serious health problems reside in people whose lives and jobs do not remotely resemble those of healthcare professionals or policy-shapers.
7-11 isn’t going to build a gymnasium for the guy working the night shift. The long-haul trucker won’t be participating in an office walkathon. The fast-food restaurant can’t give a complimentary Planet Fitness membership to the burger flipper who only brings in a few hundred dollars in extra profits annually — and whose stay is likely short-term.
The single mother working three part-time jobs probably won’t fit the yoga class into her schedule. When she or her children are sick, a doctor’s visit likely means a difficult-to-afford loss of wages and perhaps a disgruntled boss. The dayworker waiting outside The Home Depot for a one-day construction gig won’t be taking HR’s wellness classes. And the road-construction company won’t be offering a “healthy options” menu to its asphalt pavers and flaggers.
In 2018, at Reason.com, Peter Suderman wrote about a Congressional proposal—popular with Republicans and Democrats alike—to create a medical tax deduction for gym memberships and fitness classes (“Republicans Want a Tax Break For Gym Memberships. That’s a Terrible Idea”). He astutely argued that the primary beneficiaries would be the fitness industry and people who already had gym memberships. Plus, it would only matter for people who itemize tax deductions, with the largest breaks accruing to those in the highest tax brackets.
Some years back, I had a heated discussion with a physician who thought the key to better health lay in more intimate involvement of doctors in the lives of their patients—the doctor as life guide. I argued that her aspiration was noble, but that in a country of 200,000 primary care doctors treating 320,000,000 patients—many transient and most outside the elite bubble—her idea, while great when it works, would mostly serve the fortunate few.
This bias—focusing on what motivates ourselves and our similar acquaintances—permeates healthcare policy with an unintended and sometimes destructive elitism. Psychologists call this the “false consensus effect”—assuming everyone else is like us. In rare acts of bipartisanship, we devise well-meaning policies that squander scarce resources on efforts that do relatively little for those who are most likely in need of assistance.
Anatole France, winner of the 1921 Nobel Prize in Literature, famously wrote, “The law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges, to beg in the streets, and to steal bread.” In our own time, public policy, in its majestic beneficence, offers Congressional staffers and asphalt-layers alike the ideas of walkathons, gymnasiums, yoga classes, and salad bars.
A Week for Remembrance
At some point, I will decide how to weigh in on the atrocities in Israel this past week. For now, I prefer to hold my thoughts. After a week of barbaric imagery, I’ll use this brief space for peace of mind. Two years ago, I wrote this quiet, pensive song in remembrance of a long-ago domestic tragedy. However, its mood, theme, and narrative description work for the events transpiring overseas as we speak. (As always, I recommend listening via headphones.)