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BY: JEFF TIEMAN

Mr. Tieman is communications director, Covering a Nation, Catholic Health Association, St. Louis.

"Health care reform" is hardly a phrase that gets people excited. Although there can be no doubt that our health care system leaves many outside its boundaries and is in dire need of repair, the topic is just not as sensational as many we see on TV. In a media-saturated world, distractions are close and constant. Even people with a strong sense of social conscience can easily fall victim to the 24-hour news cycle and its tendency to skim over complexities and nuances.

When television producers and news directors decide what is important, even stories as serious as increasing poverty and diminishing access to health care are often ignored on the page and screen. With the war in Iraq, the journalism motto "If it bleeds, it leads" is employed on a daily basis. Other important topics often take a back seat to the story that sells.

This phenomenon, of course, is nothing new. But when we ask ourselves why there is no national movement to reform the broken health care system, no concerted cry for action—despite the evidence that people are marginalized and even harmed by the current system—we must also ask how to engage people on the issues within a broader context than is allowed by a brief newspaper account or MSNBC report.

Quite simply, health care is not a topic of community conversation, particularly as it relates to the poor and vulnerable. No one has made the issues compelling or personal enough to get people talking or to help them make important connections with related social problems that conflict with our moral and democratic values. No one has created the language and the images that will resonate with the public and prompt a call for change. The health care system is profoundly important to us all, even to the healthy and wealthy, but that message has not been effectively broadcast.

As members of a ministry long committed to promoting social justice and defending human dignity, Catholic health care providers can create the images and the words that will be needed. Those working on the front lines of health care are in a uniquely powerful position to spark the conversation and humanize the problem.

Describe the Connections
One way to accomplish that is to embrace complexity rather than hide behind it. We need to describe important connections between related issues and how those connections affect real people in real ways. The problems with access to health care and the growing poverty ranks are two excellent examples. These two social dilemmas are clearly related, but not everyone will think about how or why, and what that means.

Last August the U.S. Census Bureau announced that the number of people without health insurance grew to nearly 45 million in 2003, representing an increase to 15.6 percent of the population. The bureau also reported that between 2001 and 2004 some 4.3 million people fell into poverty. Although these statistics came out at the same time—and from the same source—they were not always conveyed together, or in a way that advanced the public's understanding of the related issues.

It is easy to see how news outlets might cover the poverty and uninsured stories separately or incompletely. Take the example of a daily city newspaper processing the census figures. If an editor decides to run one story addressing both poverty and the uninsured, the article is likely to use up most of its space listing the facts but without exploring in any depth how they are provocative and interrelated. Alternatively, the editor assigns the poverty and health care stories to two reporters who cover these issues under their pre-ordained beats. The reader may not even see both stories in the first place; but even if he does, he's unlikely to find in either story an explanation of how medical problems can lead to poverty and how poverty can exacerbate medical problems.

In a cursory review I did of recent news stories that mention both poverty and the uninsured, I found poverty mentioned only in the context of explaining eligibility thresholds for Medicaid and other public assistance programs. Except for an op-ed piece here and there, most newspapers do not examine the degree to which someone's health and access to care can threaten his or her economic viability.

Whether or not the media make clear and useful connections between the two problems, they are related. A recent Harvard University study offers direct evidence. As many as 2.2 million Americans who filed for personal bankruptcy in 2001 cited medical causes for their financial trouble.¹ More than one quarter of bankruptcy filers cited illness or injury as the specific reason for bankruptcy.

At least one critic has argued that the Harvard researchers must have surveyed only the lowest income earners, whose employers did not provide long-term disability insurance as a safety net. Another claimed that the study authors exaggerated their findings or used nonrepresentative sample populations to bolster their own agendas for a single-payer health care system.

Even if those arguments have any degree of validity, the study still highlights a problem that should be considered and discussed. Even considering the possibility that only half of the 2.2 million cases cited in the study actually filed for bankruptcy because of medical expenses, that still leaves more than one million people who saw their financial and personal stability collapse because they could not afford health care. As Martin Luther King aptly observed, "Injustice anywhere threatens justice everywhere."²

Many of the news stories generated by the Harvard study did not cite its possible limitations or biases, which in this case may not be so bad. If all the study did was teach us how easy it is for a person to lose his or her financial footing because of medical problems, it accomplished something important.

Reaching the Middle Class
The Harvard study is not alone in identifying links between access to health care and economic viability. According to the Commonwealth Fund's 2003 Biennial Health Insurance Survey, two out of five adults—including both people with and without coverage—said they either had problems paying their medical bills or were paying off medical debt.³ Sixty percent of the uninsured reported similar problems, and more than one-quarter of those struggling with medical bills said that they had been unable to afford such basic necessities as food, heat, or rent.

Of course, it stands to reason that poor people would find it more difficult than others to afford health care and that medical expenses can drive even middle class people into poverty. Fr. Robert J. Vitillo, the former executive director of the Catholic Campaign for Human Development (CCHD), recently said, "It does not take a great leap of logic to understand that poor and low-income people are heavily represented among the uninsured in our country and the situation with poor children is especially tragic."⁴ Logical as it may be, the connection is still not clear to many people.

Ninety percent of respondents to the CCHD's most recent Poverty Pulse survey said they are concerned about poverty as a problem in the United States.⁵ An equal number said they are very concerned about health care. In a separate question, however, respondents were asked to identify what they feel are the causes of poverty. Lack of education topped the list, with 27 percent of respondents citing it as the cause. Meanwhile, only three percent of the respondents identified illness or health problems as a cause for poverty.⁶ People who live comfortably tend to spend little time thinking about poverty and exorbitant health costs. Indeed, many of us never have to imagine being unable, because of poverty, to visit the doctor when we are sick.

The CCHD survey bears this out. Only 23 percent of non-low-income respondents said they were concerned they will become poor at some point in their life. It is easy to be complacent when one's own needs are met; people who struggle for basic necessities can be invisible to those of us who have adequate or plentiful resources. Although 97 percent of survey respondents said it is important to reduce or eliminate poverty in the United States, and more than 90 percent said the government should help low-income populations afford health coverage, poverty was not prominently debated or discussed in last fall's presidential and congressional elections.

Although health care reform was featured in the 2004 campaign, it was usually ranked below such issues as national security and the war in Iraq. Concerned as many of us are about our friends and family members fighting overseas and about the threat of terrorism at home, we find it easy to forget about those who are wondering how to meet their daily needs for housing, education, and health care.

"If we guaranteed health insurance for everyone under 200 percent of poverty, 45 million uninsured Americans would probably become five million," observes Tony Garr, director of the Tennessee Health Care Campaign, which works to expand affordable health care to residents of that state through education, outreach, and advocacy.⁷ As Garr and others point out, covering the poorest Americans would also help prevent them from getting sick or needing hospitalization in the first place—which would ultimately save money for the system and the taxpayers supporting it.

A New Rights Movement
How, then, do we summon the public will to acknowledge these facts? How do we create an environment wherein people not only view poverty and health care access as part of the same social problem but are persuaded to give them high priority on the nation's action agenda?

A large part of the answer, as envisioned by CHA's Covering a Nation initiative, involves exchanging ideas community by community and shaping a national dialogue. Until we Americans collectively see related social problems as urgent and begin to engage in a substantive, all-inclusive national discussion of them, true progress will not occur. In this discussion, everyone must be "at the table"—rich and poor, minorities and other ethnic groups, the employed and the unemployed, insurers and hospitals, physicians and lawyers—all the strange bedfellows.

The U.S. civil rights movement was successful because committed activists worked together to persuade local communities of the injustice of segregation, and eventually these local voices helped form a national consensus. Once that consensus was formed, the federal government had no choice but to take action. Something similar occurred with other movements, from women's suffrage to the elimination of apartheid in South Africa. We who serve the Catholic health ministry can help create the same sense of urgency when it comes to health care access, particularly that of the poor and vulnerable.

The challenge is twofold. First, we must help people understand that lack of access to health care touches every aspect of life, offends human dignity, and stifles progress. Second, we must catalyze public interest in the problem and get people everywhere talking about it in a serious and concerted way. Those who are on the front lines of the access issue can and should prompt dialogue in their communities, making it clear that when any person is unable to gain access to health care, it is not only that person who suffers—society as a whole suffers as well.

This work is not new to the Catholic health ministry. But we must now commit ourselves to doing it in a more focused way. In May, the ministry joined other health care providers and organizations nationwide to rally on behalf of health reform during the Robert Wood Johnson Foundation's Cover the Uninsured Week 2005. As was the case last year, ministry participation was substantial, and for at least a week there was an uptick in headlines covering the issue.

Now the challenge is to make Cover the Uninsured Week 2005 happen every week. A discussion among hospital employees would be a good place to start. What are their frustrations and hopes for the health care system? Having launched discussions among health care workers, we might initiate community discussions at local branches of the Rotary Club and Chamber of Commerce. We could organize town-hall meetings in local elementary school gyms. We could put up posters in local grocery stores, reminding shoppers that their neighbors may not be able to afford a visit to the doctor. The smallest steps can encourage conversation and enlightenment.

As we go about this work, we should remember always to put a human face on our message. Statistics, studies, and policy journal articles are all well and good. But one reason people are not attracted to news stories about health care and poverty is that these stories often lack the human touch. They provide little with which the average person might connect or sympathize.

The reason so few people imagine being poor is that they have not seen poverty up close. They have no frame of reference. Let us give it to them, and in the process help make connections that shed light on the series of problems we must face as a nation. If it is indeed easiest not to care, the least we can do is make it a little harder.

NOTES

1. David U. Himmelstein, et al., "MarketWatch: Illness and Injury as Contributors to Bankruptcy," Health Affairs, February 2, 2005.
2. Martin Luther King, Jr., "Letter from Birmingham Jail," April 1963, p. 1, available at www.stanford.edu/group/King/popular_requests/frequentdocs/birmingham.pdf.
3. Commonwealth Fund, 2003 Biennial Health Insurance Survey, chart 16, available at www.cmwf.org/usr_doc/Collins_biennial_hlt_ins_surveycharts.pdf.
4. Catholic Campaign for Human Development, news release of January 2005, available at www.usccb.org/comm/archives/2005/05-006.shtml. Fr. Vitilla is now special adviser to Caritas International, Rome.
5. Catholic Campaign for Human Development, Poverty Pulse Survey Low-Income Survey, January 2004, p. 5, available at www.usccb.org/cchd/LOWINFNL.PDF.
6. Catholic Campaign for Human Development, Poverty Pulse Survey, p. 10.
7. Tony Garr, telephone conversation of February 16, 2005.

Copyright © 2005 by the Catholic Health Association of the United States
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