HJNO Nov/Dec 2020

DIALOGUE 12 NOV / DEC 2020 I  HEALTHCARE JOURNAL OF NEW ORLEANS   population is not things that happened in the healthcare system. It’s things that hap- pen in people’s daily lives. Most people have maybe one medical encounter per year if they have an annual physical. The interaction with healthcare is minimal, so it’s what’s happening in every- day existence that’s impacting them. It’s the pressure of: your paycheck doesn’t make it to the end of the month, and you have to fig- ure out how to make it the last few days until [your] next check comes. It’s the pressure of: is my child going to be unjustly harmed or killed by the police or even community violence impacting my child?These are the daily worries. It’s just the everyday living and the stress that people live under that impacts people. It’s the economic circumstances and the ability to afford to avail yourself of all of the potentially helpful things that society has to offer and also your exposure to things that are harmful that is also offered in spades in this society. It’s all of these factors—the envi- ronment, the social interactions between people—that affect the health disparities issue, and some of those are not things that healthcare systems have resources to affect. But, there are also issues in the health- care system, because we also know that it’s more likely that you will be treated in a discourteous way if you’re African-Ameri- can, Hispanic or NativeAmerican. It’s more likely that you won’t get the same level of intensity or quality of care if you’re in one of those ethnic groups; those things have an impact, too. But it’s this very complex problem, because it is amorphous, and it cuts across all sectors of society. Editor Many of us are just stressed out. The long-term effects of elevated cortisol levels wreak havoc on our bodies and unfortunately sometimes lead to hurt, injury and violence to others. I personally hoped our generation would be doing better, that kindness to ourselves and others would be much more the norm than what is felt at this moment. From a public health perspective, do you know of a way we as individuals and a society can make unnecessary stress go away? LaVeist I do. I think that there are ways. Sorry to get political, but I don’t know how else to address this issue. One of the things that we’ve done as a society over the last 30 to 40 years that’s really ratcheted up the stress level for a lot of people is that we have had some policy makers who’ve come along and enacted policies that have reduced taxes on the very rich. Back in the 1960s, the income tax rate for the highest income was 90 percent. It’s now down to something around the 30s. At the same time, we have not had that same kind of economic relief for people in lower income catego- ries, which is the vast majority of people. Let’s look to income inequality, which we all know about in that more and more in society, resources are going to people at the top of the economic spectrum. This has further placed pressure on people in the middle- and lower-income categories. That is something that is fixable, at least in theory, if we have policy makers who pri- oritized reducing the economic stress on middle- and lower-income people at the [expense] of people like me who are in an income category where they’re not under as much duress. The structure of the economy has totally changed. It used to be that you could make a good, decent income right out of high school by going to work inmanufacturing. But with automation and many of those manufac- turing jobs leaving the country, it’s very, very difficult to make a living wage without a college education. At the same time, the cost of college has gone up so much over the last 40 or 50 years. It used to be that you could work your way through college doing odd jobs and paying your tuition that way. That is absolutely not possible at this point. These are all things that were deci- sions of policy makers. It has just placed a dramatic amount of stress and duress on the majority of the population and reduced the amount of stress for the people with the highest income levels. We’ve also decided as a society to make healthcare a commodity. We attach health- care to employment. So, you get a job, and as part of getting a job, your employer pro- vides health insurance—pays for, typically, about 2/3 of your health insurance premi- ums; you pay the other third. That’s typically the way it works. Have we ever stopped and really thought about the logic of why your access to health- care should be linked to your employment? Think about that for a moment. Why should that be? Does it seem rational?We don’t tie auto insurance to your employment. We don’t tie homeowner’s insurance to your employment. We don’t tie life insurance to your employment. But your ability to get healthcare is tied to having a job, if you happen to have a job where an employer is benevolent enough to provide you with health insurance. These are decisions that are made by humans. We could certainly make different decisions, make different choices. What can people do? People can vote for policy makers who will enact policy that would reduce some of the pressure that’s been placed on middle income and lower income people. But, that’s not what we do. We don’t vote for policy makers who do that. We tend to vote for policy makers who maintain the status quo. I was giving a lecture in Spain, and it was a basic intro to the U.S. healthcare system lecture, describing to people how healthcare is managed in the United States. I started talking employment, and people’s mouths were just dropping. They could not believe what I was saying—that your ability to go to the doctor is linked to whether or not you have a job. This is a foreign concept outside of this country, but most Americans would fight to maintain this system, even though the system fails so many of us. Editor Do you think climate change is real? LaVeist Absolutely. Editor Much has been said about Louisiana’s lax environmental laws and the additional pollution allowed by them, which may lead to negative health effects for our citizens. Others say this industrialism has to happen somewhere, and those industries provide jobs in the community. You have been in Louisiana for a while: what is your opinion?