Another vulnerable population that is improperly treated by both health care providers and the health care system is those who are severely low income. By low-income people, I mean both people that qualify for OW, Trillium, or ODSP (Ontario’s social assistance programs), as well as people who make just more than is required to qualify for social programs, but don't make enough money to afford to live (Candib, 2007).
My #MHST601 colleagues and I have learned throughout our careers, and most recently in the determinants of health unit, that people of low socioeconomic status are disproportionately burdened by chronic disease (Candib, 2007). Today, I want to examine how low-income diabetics are treated by our health care system and share both positive and negative personal accounts. It is estimated that diabetes can cost up to $6,800 annually (Goldman, 2019). Candib (2007) examines how proximal and distal factors such as genotype, maternal and fetal considerations, urbanization, and eating behaviours determine diabetic incidence in low-income individuals. Curtis & Lee (2010) review how low-income diabetes are more likely to use the emergency department for diabetic concerns, a more costly way to treat than those of higher socioeconomic status. Pesantes et al. (2015) explore teaching resilience and improved outcomes among vulnerable populations with type 2 diabetes.
Price of insulin
1 in 4 insulin-dependent Canadians misuse their insulin to save money (Goldman, 2019). I cannot count the frequency in which a health care provider comments that if x person just used their insulin as prescribed, they would not have severe complications associated with their diabetes. As if it were a choice, and they were just too lazy to buy and use their insulin
Other considerations in pricing diabetes care
Insulin is not the overpriced product required by many diabetics. Testing supplies, injecting supplies, oral hypoglycemic agents, foot care, and medications required for comorbid conditions are among the drivers associated with the high cost of a diabetes diagnosis. 57% of Canadians cannot comply with their suggested treatment plans because of the costs associated with the required products (Goldman, 2019; Pesantes et al., 2015). If over half of diabetic Canadians cannot afford Diabetic care, how unaffordable is it for those in the lowest income bracket? Health care providers must consider this before we label our diabetic patients non-compliant or poorly self-managed and put the honus on them in regards to their A1C to the incidence of DKA.
I live in a town that borders Minnesota. It is ubiquitous to see low-income Americans coming to our pharmacies because a medication is more affordable here than in Minnesota. I cannot begin to understand how impactful border closures have been on these low-income medical tourists. Medical tourism of Americans can drive up the costs of insulin and other diabetic medications in Canada due to supply and demand, something I believe we might see as COVID enters endemic status and travel restrictions cease. Again, this does impairs and magnifies the ability of very low-income persons to afford to be diagnosed with the disease.
To get the full picture of financial barriers to optimal diabetes care, we must also consider the price of transportation to obtain care, the ability to take time away from work to access care, the distance associated with care centres from the person’s home, and the attitude of a person who is constantly stigmatized and marginalized for being diabetic, for being uncontrolled, or for poor to want to access care from people who contribute to that stigmatization. I would also like to note the incidence of depression as a comorbidity to diabetes could factor in the ability of a low-income person to manage this chronic condition.
Dietetics
The first point of intervention for type 2 diabetes mellitus is often dietary changes. With the increasing price of food, especially in rural and remote locations where socioeconomic status is typically below the national average and diabetic prevalence is above the national average (Kulig & Williams, 2012). In many health care settings, diabetic patients are told to focus on eating better, more healthful foods; in my experience, some providers do not understand the inability to change for those who are low income. IN MY OPINION, the RD that I work with is amazing when it comes to setting reasonable goals for low-income diabetics and has many low-cost nutritive recommendations for those clients.
Tobacco and alcohol use
It is well known that the lowest income people are also affected by other health determinants, namely, those perceived to be “choices” such as tobacco use, alcohol, or other substance use. In my experience, care providers often treat those who use tobacco products or consume excessive alcohol to prioritize this over their health. To illustrate my point, I would like to share a conversation with a coworker the other day about a client of our DEP who cannot afford insulin. The care provider made a “Yeah, but somehow he can afford cigarettes” comment, which led to a discussion about why some low-income people “choose” to use cigarettes. Cigarettes are often perceived as a stress reduction or coping mechanism by users (Raphael, 2012). Sometimes, they are a person’s ‘five minutes of peace’, escaping a stressful home or workplace. Some people continue to smoke as an appetite suppressant, and we haven’t yet mentioned the physical addiction to nicotine. The desperation that is perceptible in this man’s voice when he calls because he needs more testing strips and cannot afford them, or is looking for help in purchasing his insulin tells me that he probably does not wish to be in a situation where he is buying cigarettes and rationing insulin. I feel as though the CDEs at my workplace treat all of our clients with fairness and respect and tailor their diabetes education programs in an equitable patient-centred way. They follow Candib’s recommendations to employ strategies that foster healthy eating and activity levels without stigmatizing and marginalizing at-risk populations (Candib, 2007).
References
Candib, L. M. (2007). Obesity and diabetes in vulnerable populations: Reflection on proximal and distal causes. The Annals of Family Medicine, 5(6), 547–556. https://doi.org/10.1370/afm.754
Curtis, A. J., & Lee, W.-A. A. (2010). Spatial patterns of diabetes-related health problems for vulnerable populations in Los Angeles. International Journal of Health Geographics, 9(1), 43. https://doi.org/10.1186/1476-072x-9-43
Goldman, B. (2019, January 28). The soaring cost of insulin. Dr. Brian's Blog - CBC. Retrieved March 18, 2022, from https://www.cbc.ca/radio/whitecoat/blog/the-soaring-cost-of-insulin-1.4995290
Kulig, J. C., & Williams, A. M. (2012). Health in rural Canada. UBC Press.
Pesantes, M. A., Lazo-Porras, M., Abu Dabrh, A. M., Ávila-Ramírez, J. R., Caycho, M., Villamonte, G. Y., Sánchez-Pérez, G. P., Málaga, G., Bernabé-Ortiz, A., & Miranda, J. J. (2015). Resilience in vulnerable populations with type 2 diabetes mellitus and hypertension: A systematic review and meta-analysis. Canadian Journal of Cardiology, 31(9), 1180–1188. https://doi.org/10.1016/j.cjca.2015.06.003
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