Michael Stein is the author of the new book Broke: Patients Talk about Money with Their Doctor. A primary care doctor, he also is Professor and Chair of Health Law, Policy and Management of the School of Public Health at Boston University.
Q: Why did you decide to write this book?
A: Broke is my tenth book—in addition to six novels, I’ve written three books of nonfiction that have been about the patients I’ve cared for as a primary care doctor working in a small city for decades.
My patients, who are mostly low income, have always talked to me about their money concerns—alimony payments, funeral costs, car bills—and in this Covid moment, these financial conversations have increased in the face of layoffs, either temporary or permanent.
I thought it was the right time to put my patients’ voices on the page to give readers a look into the wide assortment of lives of those without much money.
Each story is less than a page long. In Broke, I hope I’ve captured my patients’ many emotions: stoic nonchalance about hardships, laughter at the world. In just a few lines, you can learn the day-to-day effects of poverty.
Readers have told me that Broke reminds them of Barbara Ehrenreich’s Nickel and Dimed, in that both are frank, entirely unsentimental depictions of persons struggling financially. But unlike the narrator of Nickel and Dimed, I am a small voice here. My patients’ words are the ones that matter. I love talking to patients.
Q: In the book, you write, "I have come to think of these conversations about money with patients—which certainly don’t occur at every visit, but only when pertinent, and only with patients I’ve come to know—as a form of preventive care." Can you say more about that?
A: Most adult primary care visits are for chronic medical problems—high blood pressure, low back pain. When you care for people over months and years, they let you into their private lives.
Health is the state of not being sick, so doctors don’t see much of their patients’ healthy lives, which take place outside of our offices. But we all know that health is determined by the conditions in which one lives, and is shaped by environmental, social, and economic forces.
Poverty is one of those forces that drives and determines health, so if, as a doctor, I am interested in preventive care—the care that will keep a person out of my office—I need to have a sense of what can make them ill.
The lack of time to care for oneself because you’re working three jobs, the lack of sleep because you share a crowded apartment, the chronic stress of living without much money, can all make you sick.
Q: What impact has the pandemic had on you and on your patients, and what do you see looking ahead?
A: Even before the pandemic, the statistics were clear that half of Americans, half, will live in poverty by the time they are 65 years old. One in six children is living in poverty. These numbers are astounding and miserable, unmatched among our peer, high-income nations, and a disgrace.
Covid-19 has only made things worse, and there is likely to be even worse coming.
Poverty has unfortunately become a technocratic word—a dollar threshold, a means test—when it is really a massive moral conundrum. My patients are barely hanging on, and the future is nebulous. But if you don’t have much money, it is the present, not the future, that dominates.
Q: What do you hope readers take away from the book?
A: I like the idea that a nonfiction writer’s work should serve as a kind of optical instrument that allows the reader to see something she would perhaps never have discerned herself if she hadn’t picked up this book.
Many people who buy books have never experienced a life without enough money to make ends meet. In Broke I do not mean to moralize, but I would like to change my readers’ awareness, or better yet the country’s, one heart at a time.
I write as a primary care doctor who hears stories all day, and can address poverty in only small ways. Health is a matter of politics, and our stunning level of poverty a direct result of decisions by our political leaders, who are endorsed by us, the voters.
Maybe this small book of stories can make us all a little more compassionate and a little more alert to the policies and programs that can help our neighbors.
Q: What are you working on now?
A: After the patient-by-patient intimacy of Broke, I’m working on a new book about our national confusion about the difference between health and health care.
As a country, we invest trillions of dollars in healthcare—the system that we turn to when we are sick, that pays me as a doctor--but comparatively little in health, the infrastructure or policies and resources that form the conditions in which we live—whether there are parks nearby, or grocery stores, whether the air we breathe and water we drink sicken us.
Covid-19 emerged in a context where we were still broadly conflating health with healthcare and neglecting the true causes of health that have driven the worst outcomes of Covid-19, the chronic underlying illnesses, obesity, who goes to prison, who can afford masks.
Health follows wealth in the United States. We spend a lot of money for healthcare (even though 20 million Americans are still uninsured due to our cockamamie non-system of health care financing), and it’s time to change the conversation to discuss spending some of those dollars on keeping us well instead.
Q: Anything else we should know?
A: Maybe that my last book, Pained: Uncomfortable Conversations about the Public’s Health, is a great way to jump-start discussion about the 50 top issues in public health, again, so we can stop talking about doctors and nurses and hospitals and insurance companies, and start talking about the foundational forces, like poverty, that we need to address to get to a healthier world.
--Interview with Deborah Kalb