Health care barriers impact doctors, too
During Texas’ three legislative sessions this year, our leaders have focused on restricting voting, health care services and free speech. Meanwhile, they have again failed to act to improve health care access for their constituents despite bipartisan support for the latest bill, Live Well Texas (HB 3871/SB 117). Their priorities are gravely misplaced. Lawmakers in opposition may not realize that barriers to health care access have negative impacts not only on low-income Texans, but also on the providers who struggle to serve them.
I know this from personal experience as an internist and pediatrician who has been providing primary care services for uninsured and underinsured adults and children for the last decade — notably, since just after the passage of the Affordable Care Act. I practiced in Florida — another state with extremely restricted Medicaid access — and Maryland before returning to my beloved Texas. It is difficult to overstate how much easier it was to do my job in a state like Maryland where people who are working hard but still cannot afford insurance had the option of enrolling in Medicaid. If a patient needed a life-sustaining medication or diagnostic referral, I placed an order, and it usually happened.
Practicing in Texas has been a different ball game. I think about my patient who might have blockages in his heart that could lead to a heart attack, but who is unable to get a stress test because it costs over $500 out-of-pocket. So, while I can try to reduce his cardiac risk through medications, we both must live with the knowledge that he may have a ticking time bomb in his chest that could devastate his life and the lives of his loved ones. I think about the woman with a rotator cuff injury that threatens her livelihood by preventing her from cleaning houses the way she used to. Evidence shows that physical therapy can result in significant improvement, but she has no access to those services, driving her and her family further into poverty. The examples are so many that it is almost banal; sometimes I must remind myself that this is not normal . Or rather, it is normal but should not be.
The stress of constantly fighting against a broken system to do one’s job takes a toll. We see this in the high rates of burnout and turnover among primary care providers who see unfunded patients. There is growing consensus that moral injury — defined as “the damage done to one’s conscience or moral compass when one perpetrates, witnesses or fails to prevent acts that transgress one’s own moral beliefs, values or ethical codes of conduct” — is impacting health care providers and reducing their effectiveness and job satisfaction. This creates a vicious cycle; the difficulty of caring for this population produces a fatigued and reduced primary care workforce that is stretched beyond reason.
The COVID-19 pandemic has compounded the sense of helplessness for providers. As the broader population has suffered unimaginable death and suffering, providers have had increased burnout and possibly even a spike in suicide rates that were already higher than in the general population. This is not a new problem, but, as with so many other longstanding issues, the pandemic has uniquely highlighted it.
I love my career in medicine because of the unique combination of scientific application and human interaction. But when my application of science is limited by patients’ lack of access to appropriate services, and my human interaction is limited by unreasonably short visits due to uncompensated care and low reimbursement rates, it becomes harder to love work and harder to impact health.
Of course, the suffering of patients is much more important than the comparatively minor tribulations of their clinicians. But if officials won’t listen to the stories of uninsured patients, maybe they will listen to the plaints of their often more privileged providers.
I write in full support of the U.S. Congress’ efforts to identify a health care solution for low-income Texans where our own state lawmakers have repeatedly failed. As Texas remains the most uninsured state in the nation, Congress must create opportunities for health care access for the least fortunate among us — for their sake and for those of us who care for them.