The PICU — canary in the healthcare coal mine
We have known for a long time poverty is associated with illness. Tiny Tim did not die at the end of Dickens’ Christmas Carol. The reason he lived was because, just in time, Scrooge had an epiphany and raised the Cratchit family’s standard of living. That Christmas goose brought more than good cheer to the Cratchits — it brought good health, too. Some historical studies, such as those of Thomas McKeown, have linked the long population rise of the past century to improved nutrition. Experts still debate if this is true or not, but either way it is old news.
It may be old news, but for today’s Tiny Tims it is very much still current news. The furious debates over what to do about health care reform are often about choice — what choices Americans should have selecting their health care, what choices doctors should have in providing it, and what choices society has in paying for it. I take care of children, so that is the lens through which I see the issue. And children have no choice at all in this matter, because the family they are randomly born into determines everything, even if they will live or die. Across America we have constructed what are, in effect, a series of laboratories to test the results of what happens when different sorts of children get severely ill. These laboratories are pediatric intensive care units.
Poor children are far more likely than affluent children to end up in a PICU. The simplest indication of this is to look at the proportion of children in PICUs who are on Medicaid: it is generally at least half, often more. Yet the proportion of children in the general population who are on Medicaid is roughly a third. Why is this? Why are poorer children more likely to become critically ill or injured?
One reason is that pregnant woman who are poor are more likely to deliver prematurely, and former premature infants have a high prevalence of residual medical problems, things which often lead to future PICU admissions. Thus more premature births equals more PICU admissions. Another reason is that, because of low reimbursement rates for providers, it is often hard for a child on Medicaid even to find a doctor. So children with chronic problems, such as asthma or diabetes, often cannot get the kind of good routine care that would keep them out of the PICU. These reasons are straightforward, ho-hum, so obvious we have become inured to their implications. (Though we should not be.)
If we dig deeper, though, we find other disturbing possibilities. For example, a study by Evans and Kim on the physiological effects of poverty found that poor children have chronically high levels of stress hormones that correlated with the length of time they were in poverty. Adolescents who were recently poor did not show these findings; what mattered most was the duration of poverty. We know childhood poverty is strongly associated with poor health as an adult, and this may be one of the reasons. Even if a poor child somehow later breaks through to affluence, the health effects linger on.
Thankfully, evidence shows that once children on Medicaid who need a PICU get there, they get the same level of care and have the same outcomes as children with private insurance. That is reassuring; poor kids on Medicaid do not get second-class care and have the same risk of mortality as the affluent ones. However, the research uncovered a very disturbing finding — children without any insurance at all were more likely to die. Why? Because they were sicker when they first arrived in the PICU, undoubtedly because their parents feared to bring them to the doctor. Because of our current dysfunctional non-system, the parents waited, and their children died as a result. Personal anecdotes are not research, but I have thirty years of them saying the same thing — uninsured kids are sicker when they get to the PICU. This is entirely predictable. Of course the prospect of a massive, bankruptcy-inducing medical bill makes even the best of parents equivocate and delay why they should not.
It is fair to debate how many adults without health insurance are in that situation owing to their own choices, although I think that argument is a straw man, as is the notion that many homeless adults choose to live in boxes under bridges. But it is not fair to inflict this debate on children, who are stuck with their birth situation. Childhood poverty carries life-long health care risks, but at least Medicaid generally gets the poorest children the care they need. Denying children health care insurance, however, kills them. I find this to be obscene.