In an address to the nation earlier this month, President Joe Biden marked the one-year anniversary of the coronavirus pandemic by announcing that all American adults would be eligible for the COVID vaccine by May 1. If we all get vaccinated, he said, “there’s a good chance you, your families, and friends will be able to get together” on the Fourth of July “and have a cookout.” The implication was that we will finally have passed the apex of the virus, and that, slowly but surely, things will once again begin to feel normal again.
Except that’s not how things work, really. We have spent the past year in the throes of a public health crisis which quickly brought with it an economic one to match. Nearly a year after the initial shock of 22 million Americans losing their jobs at the onset of the pandemic, 18.7 million people are still filing for unemployment. This is to say nothing of those who have been without a job for so long that they are no longer technically counted as members of the workforce. While plenty of people are going to emerge from the pandemic in better financial shape than ever, many others have felt the sting of financial precarity in ways that affect their ability to pay for their housing or food. We will be dealing with the economic consequences of the pandemic for years.
To Dr. Michael Stein, a Boston University professor and chair of the school’s Health Law, Policy, and Management department—and who also works as a primary care doctor to low-income patients—America’s issues with physical and financial health are inextricable. “Perhaps poverty should be approached from a public health perspective, as the moral perspective alone has failed us,” he writes in the introduction of his recent book Broke: Patients Talk about Money with Their Doctor. On the surface, Broke is exactly what it sounds like it would be—a book full of anecdotes, narrated by Stein but told mostly without commentary, about how his patients deal with money. But the format is just a narrative device, really, meant to illustrate Stein’s larger point, which is that when people are poor, their lives are hard in ways that are always unique and frequently unmanageable—to the point where day-to-day survival must take precedent over their long-term goals. It’s his professional obligation, he believes, to talk to his patients about money, help them deal with their financial problems as best he can. “Feeling a bit more in control of their finances, or less out of control," he writes, "allows patients the mental space to make clearer decisions, health decisions included."
Stein says he decided to start the book when a patient told him, “I’m so broke I have to rinse off paper plates.” The image is indelible, and in Broke it is the first thing we hear from his patients, who throughout the pages tell stories of hustling black-market watches to make ends meet, altercations with rapacious landlords, being swindled out of money by their loved ones, and falling through bureaucratic holes in America’s ragged, underfunded, and uncaring social safety net. Together, the vignettes of Broke describe a dizzying array of symptoms to the same sickness whose cure, however simple, is nevertheless out of reach. With more Americans hanging on by a thread than ever before, this is a book worth reading.
Stein spoke with GQ about the intense mental calculus that poverty requires on a day-to-day basis, why America will need a mental-health task force after COVID subsides, and why the American medical system is too focused on money to keep people truly healthy.
GQ: The people whose stories you relay are incredibly conscious about money. They know how much is coming in and going out every month down to the cent.
Dr. Michael Stein: It’s not only that they have it to the cent, it’s that they talk about it, right? There’s an American myth about the distaste we have for talking about money. People who seem to have enough of it, they’ll talk about addiction, politics, problems with their families, but they won’t talk about money. But what I find is that when you don’t have a lot of money, you’re thinking about it all the time, and you’re also talking about it with everybody around you. Maybe it’s that people who have a lot of money feel bad about talking about it and they imagine their silence makes that bad feeling go away. But when money is tight for someone and you’re open to hearing about it, they’ll ask your opinion. As a primary care doctor, my job is [mostly] talking and listening. I build in time for these things with people, particularly who don’t have an acute complaint that dominates a visit. I recognize that 99.9 percent of my patients’ lives take place outside my office. So anything they can tell me about that, and the conditions of their lives outside of my office, are going to be helpful to me.
As someone who works in healthcare policy, can you talk a bit about the relationship between money and health?
They are extremely closely related in this country, more so than any other. My favorite statistic on this is that if you live in the poorest counties in the United States, your life expectancy is about 68. And in one of the richest counties in America, your life expectancy is about 84. So by the luck of your birthplace, you have 16 years’ difference in your life expectancy. I mean, that’s outrageous. It’s sort of stunning. So that’s the connection between money and survival, which I would call the bottom line of health in the United States. It’s stark.
Given that COVID has presented us with these parallel economic and public health crises, do you see that difference growing even starker in the future?
Well, we’ve lost millions of jobs in the United States, but we happen to have a newly generous administration. Obviously, there are lots of reasons people want to be employed. But we have an inequality of jobs, and therefore a lot of money going to a particular group of people in the United States. So I think we’re going to see these dramatic health differences worsen over the next year or two as the long tail of COVID’s effect on people. We know that unemployment is associated with mental health problems, increased addiction, and suicide across a population. Those numbers have gone up and will go up in the next year. There’s going to be a reckoning on top of the rebound. I think we’re in for hard times.
I was laid off at the beginning of the pandemic. It felt like this crushing blow to both my finances and sense of self-worth. I ended up going to therapy over it.
You’re not alone, and you’re lucky to have found your way to a therapist. That’s a whole other issue in America, the lack of access to mental health services and the continued stigma about that. I do think that one of the silver linings of COVID may be the sort of attention to what it’s like to seek mental health care, what it’s like for a single parent to take care of kids who are stuck at home. I think there’s been a bit of an awakening for those who, even if they themselves have been untouched, see what’s happening around them. I think the next task force is going to have to deal with mental-health consequences. We had the COVID task force, now we need the COVID mental-health task force.
It also feels like this is all coinciding with doctors feeling increased financial pressure to move patients in and out of the office so they can see as many folks as possible in a day.
I wrote an essay about this and called it “the 15-minute visit.” It’s an utterly artificial, financially-driven notion. And there’s frankly no reason that patients should put up with it. If they need more time, they should ask for more time, and they should get more time. The 15-minute visit is an artifact of a fee-for-service system. As long as we have that, the doctors are paid to increase volume. You increase the volume by having limited time for each person. Doctors under this system, in most cases, are incentivized to see people. Until the financial incentives change, doctors won’t change. If you had a system that was not fee-for-service, it would change the complexion of visits—including no visits, and much more telephone work and other things to keep people out of your office.
How did you go about asking patients if you could relay their stories?
Most of my patients at this point know that I write books. I usually said to them, “I’m working on a project about money. Do you mind if I write down some of the things that we talked about?” Usually, I’d document it in their medical chart. I always said, “Listen, if I were to ever write about what you tell me, it’s not going to be ‘you.’ I’m not going to mention anything that’s identifying.” Most people were flattered. They like to be heard, especially if I’m not revealing deeply personal things about them.
Their stories are incredible. I was really struck by who worked on lobster boats and decided to go into a boiler system business with a partner, who then revealed that the partner swindled him out of their start-up costs, and that the partner was his dad. When someone says something like that—essentially, that they were deeply screwed by a person they love and trust—how as a doctor or even a person do you respond to that?
I didn’t see him acutely after his split with his father-partner. But he was still very sore about this when I heard about it, and it went on for a long time. He was angry. I’m interested in their health, so the question for me is always, what do these occasions or experiences mean for their decision-making around health? I often talk to people about how not having a lot of income both almost obliges you to make bad decisions, and yet you have no room to make bad decisions.
In the book’s conclusion, you write that talking to patients about money is “a form of preventative care.” It’s a moment that really hammers home the fact that things like diet, exercise, and sleep are economic privileges in many parts of America.
The question is, “What are the things that keep people healthy?” It's what and how much you eat, how much you exercise, and how much you sleep. But the notion that those three things, which have come to be seen as the holy trinity of self care, are completely under anyone’s control is illusory.
There are communities in this country that may or may not have a supermarket or running water, that may have so much noise outside their window that people can’t sleep. These drivers of health are structural—if you’re poor, more of these things are going to be outside of your control.
A conversation with neuroscientist Lisa Feldman Barrett on the counterintuitive ways your mind processes reality—and why understanding that might help you feel a little less anxious.
Originally Appeared on GQ