• Fresh Perspectives

    Do No (Financial) Harm

    In getting to know my patients better, I often ask them, "What is your dream job?"

    women with future career titles in clinic waiting room

    This was especially true at PurpLE Clinic, a program I piloted for four years in a New York City community health center that was designed to provide family medicine care for survivors of trauma, particularly human trafficking and domestic violence.

    My question has been met with declarations of "Doctor!" "Food truck owner!" "Social Worker!" "Teacher!" "Actress!" "Farmer!" and more.

    But patients also have shared struggles that prevented them from achieving these dreams: domestic violence that destroyed credit histories, intermittent incarceration that resulted in large resume gaps, severe debt that led to homelessness and exploitation, and physical and mental health diagnoses that persistently hindered their ability to thrive in school or keep a job.

    Many patients are caught in the health-poverty trap: a cycle of poor health that leads to loss of economic and educational opportunity, which, in turns, results in worsening health and health care access. The health-poverty trap disproportionately impacts women, people of color, and trauma survivors -- a reality that was reflected in my clinic.

    glad you came in for testing

    Understanding and addressing financial health is just as important for our patients as caring for their physical and mental health -- especially in the midst of a pandemic and economic crisis. Here's what I've learned from my patients: Key to understanding financial health is understanding financial trauma. And key to understanding financial trauma is understanding the diagnostic utility of a disconnected phone.

    In the early days of my clinic, I found myself sitting with critical results – a positive sexually transmitted infection screen, a CBC showing severe anemia, a creatinine level indicating renal failure -- and no effective way to convey them to patients. Each time, the dispassionate voice alerting me that a number was no longer in service triggered a production of "I Hope You Get Care: A Soliloquy in Three Acts":

    • Hopefully, they'll receive the letter I send alerting them to their results.
    • Hopefully, they'll walk into the clinic for follow-up.
    • Hopefully, even if they don't come back, they'll still seek care somewhere else.
    disconnected phone

    On the other end of a disconnected phone and an unshared diagnosis lies the rest of the story: The symptoms that lead patients to seek medical care call for appropriate -- but often costly -- lab testing that results in unaffordable bills that lead to debts being sent to collections, resulting in constant calls from collectors that exacerbate the need to screen phone calls from unfamiliar numbers (a practice already in place to avoid harassment from abusive ex-partners), all of which ultimately lead to disconnected phone numbers.

    Either the phone bills are unaffordable, or the phone numbers are untenable. Either way, health care is compromised. And in a world that hurtles toward telemedicine expansion, recognizing that both stable phone access and stable phone number access are luxury goods is essential in designing health care delivery options that ensure all patients have access to care. This is how a disconnected phone can diagnose financial trauma. And why it matters.

    past due bills

    For patients living paycheck to paycheck -- the working poor -- unpaid bills can become an entry into the health-poverty cycle through a mechanism known as fringe banking (i.e., utilizing cash-advance businesses, high-interest payday lending establishments and pawn shops). In some communities, fringe banking entities are more common than conventional banks. For example, paying a $25 Pap smear bill may involve paying a $15 fee to a payday lending company to borrow a $100 cash advance (to meet a minimum amount that a company sets for lending), with the total $115 to be paid back by the next payday (typically two weeks). If the payment cannot be made on time, then interest and fees can accrue on the original amount, potentially multiplying a $25 bill into a four-figure expense.

    payday loan business

    The Pew Charitable Trusts reports that 12 million Americans use payday loans each year. Those individuals spend more than $500 a year in interest to pay back an average of eight loans of $375. These expenses can trap patients in chronic debt.

    And when private debts, including medical bills, can't be paid, wages can be garnished. Several of my patients shared the stress and shame of employers garnishing their wages. Federal law protects employees from losing their jobs for any one debt resulting in wage garnishment, but they can be fired if there is more than one, because wage garnishment places liability on employers for properly implementing the terms of garnishment. This can lead to a cycle of unemployment, increased debt and delays in accessing essential medical care. Early experiences with debt and wage garnishment can impact the interplay between physical, mental and financial health for the rest of a person's life.

    wage garnishment

    According to the Federal Deposit Insurance Corporation, one in four U.S. households is unbanked or underbanked. Being unbanked means not having any savings or checking accounts, and being underbanked means having a traditional bank account, but still using alternative financial services (such as the fringe banking resources described above). The U.S. Department of the Treasury recognized the need to address this reality when issuing stimulus payments for households during the pandemic by providing prepaid debit cards to the unbanked. Notably, the disproportionate impact of the COVID-19 pandemic on communities of color is mirrored in the public health crisis of being unbanked.

    A 2017 survey conducted by the FDIC (the most recent version available) showed that the most common reason for being unbanked is that people did not have enough money to keep a bank account open. The second-most common reason was that they did not trust banks. Learning this matched offhand remarks I would hear in clinic about bills patients couldn't pay. They shared fears that using banks would allow the government or collection agencies to strip them of their savings -- post-traumatic stress from their experiences with wage garnishment, in some cases.

    cash under couch

    For them, personal banking meant keeping their cash hidden in their mattresses, walls, floors and safes at home. But it also meant never having savings, a retirement account, or a safety net during a pandemic. And being without a financial safety net can mean ever-teetering on the edge of homelessness.

    woman with bags outside bank

    For some patients, the only relationship they have with banks is as a form of temporary housing -- ATM spaces they sleep in overnight -- when the threat of eviction becomes a reality.

    Banks recognize this, too, investing in policies and signs to rid themselves of this nuisance -- triggering an ongoing cycle of debt, homelessness, arrest, unaffordable bail, incarceration and poor health.

    officer at bank

    Working with patients who were newly experiencing homelessness taught me to expand the concept of a physical exam to include the physical objects a patient brings with them to an appointment. I used to naïvely think that patients with a suitcase had just returned from travel or those surrounded by shopping bags had just made a few purchases before an appointment. But as hospital discharge summaries were pulled out of suitcases and albums of certificates and awards were proudly pulled out of Ikea bags, I realized that the shopping bags were not filled with items that were new, but with moments from the past. My patients sometimes carried their whole lives with them to appointments because they had recently become homeless or were between shelters.

    doing fine, doc

    Accounting for financial pain expands the language of trauma, rendering a translation of "Everything's great" to "I don't want to bother you with my nonhealth problems." And because "nonhealth” problems are almost always miscategorized, I learned to be prepared to ask, "How are you really doing?" The answer to this vital follow-up question can lead to better medical diagnoses, care delivery and connection to services.

    eat healthy exam room

    Expanding the physical exam to consider objects patients bring into the exam room also helped me better understand how nonhealth policy issues are almost always miscategorized, as well. For example, observing the traitorous presence of fast food in the clinic used to lead me down a road of resigned frustration. But eventually, just like with any concerning physical exam finding, I worked on getting a better history.

    fast food in exam room

    This is how I learned about a new type of food desert in the United States: "credit card-only" food establishments.

    Many of my patients don't have access to credit or are deemed to have bad credit and are unable to qualify for credit cards. For those who rely on cash, the promise of organic, all-natural and fresh foods at restaurants is often merely a food desert mirage. This leaves cash-accepting fast food establishments the sole reliable, ever-accessible option and, for some, makes food banks the only accessible banking option.

    food desert

    The issue of credit card access and banking ability permeates other aspects of health, as well, impacting the ability to perform such tasks as paying a hospital bill online or by check, receiving prescriptions from an online pharmacy, and setting up grocery delivery during a pandemic. Some cities have pushed to ban cashless vendors, citing the harmful impact of financial exclusion of the unbanked. And in these efforts, it again becomes clear that financial policy can be health policy.

    In the age of COVID-19, when for both public health and financial purposes, stores are shifting away from cash to credit, the pain for those with poor credit is intensified.

    salad bar storefront

    Which means recognizing the shame that comes with financial trauma. The heat of shame can come when parents are counseled to make sure their children eat healthy, all the while knowing their food options are limited. It can appear when patients share the need for STI testing because their landlord is coercing them to exchange sex for rent to avoid eviction (which can be considered a form of sex trafficking). It can present when front desk staff divert a patient to see a case manager before seeing the doctor because they don't have insurance anymore. And it can come out when a patient shares that he is being bullied at school for wearing smelly clothes because his mother, who is awaiting asylum and her work permit, could only afford one school uniform on the income she makes braiding hair.

    no cash on premises

    These experiences pushed me to reflect on the health care system's role in the health-poverty trap. And my own role in perpetuating it. I began incorporating "do no financial harm" into routine care. I know now that a physical exam is not limited to the patient's body, that front desk staff should be trained to reassure patients that seeing a social worker first does not mean they will not see a doctor, that a "15-minute visit" needs to include time for having uncomfortable conversations about the eventual receipt of a medical bill so a patient is not caught by surprise (and making sure they know who to contact if they cannot pay) -- and being prepared for patients to decline essential care because of this -- that it's essential to know whether a patient has access to a stable phone and phone number before they leave to set up an appropriate plan for sharing results -- and letting them know the clinic phone number they should expect when I call with results so they feel safe answering the phone -- and that pre-employment physicals need to be scheduled as urgent care appointments so that patients are not delayed in starting their jobs. These are ways in which I have integrated patients' financial health into care delivery to mitigate my role in the health-poverty trap.

    women in clinic waiting room

    Despite these efforts, my frustration grew on seeing television commercials and billboards that advertise wealth management services, "smart" retirement planning, banks that "can do wonders" with your savings, and homeowner's insurance, and recognizing the elusiveness of their applicability to my patients. After years of meeting potential doctors, food truck owners, social workers, teachers, actresses and farmers stuck in the health-poverty trap, I was being confronted by the possibility that economic mobility is a myth instead of an aspiration of the American Dream. And that was unacceptable.

    So I decided to take a career leap in 2019 to work on transforming the health-poverty trap into a health-prosperity cycle for my patients -- one where they would be supported in not only realizing their dream jobs, but also their vision for themselves and their families. Together with a team of fellow family physicians and multidisciplinary collaborators, we founded a nonprofit and medical practice to improve the health of our communities by addressing the physical, mental and financial health of women and girls who experience gender-based violence. And when anyone asks, I tell them that this is my dream job.

    Anita Ravi, M.D., M.P.H., M.S.H.P., is a family physician in New York and the CEO and co-founder of the PurpLE Health Foundation. You can follow her on Twitter @AnitaDRawing.

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