How Single People Are Shortchanged in the Health Care System
Singlism is rampant in American health care.
Posted Mar 10, 2019
(This article is co-authored with Joan DelFattore.)
For decades, the prevailing narrative has been that getting married makes people healthier. Too often, though, the evidence has come from cross-sectional studies comparing currently married people to unmarried people. Those studies suffer from obvious flaws. For example, the married people might differ from the unmarried in countless ways, such as financial status, that could account for the differences in health. And, less often acknowledged, the currently married group leaves out a large number of people who did get married and then divorced—they are often less healthy than those who never married. Widows, too, have poorer health outcomes than the never-married, even when researchers control for age. Consistent with these findings is a 2016 report by the U.S. Preventive Services Task Force, which identifies being previously married, not being unmarried, as a risk factor for depression.
Results of the latest large-scale, more sophisticated studies upend the “get married, get healthy” storyline. Longitudinal research shows that people who marry experience no fewer illnesses than when they were single. On reports of their overall health, they are typically either no better off or even a bit worse.
What is especially remarkable, and rarely recognized, is that single people are doing so well despite the “singlism” in the health care system, as unmarried patients face pervasive stereotyping, stigmatization, marginalization, and discrimination.
One of the most common stereotypes is that just about all single people want to marry and will marry eventually. In fact, though, a recent survey showed that only 23 percent of people who had been previously married and 58 percent who had never been married said they wanted to marry. In the U.S. today, more than 110 million adults are not married, close to half of the adult population. And yet, the stereotype continues to hold sway when single people seek treatment. In Doing Harm, Maya Dusenbery writes of a woman with breast cancer "who wanted a mastectomy but whose doctor objected, saying, 'But you aren’t married.'" Abby Norman, author of Ask Me About My Uterus, had a similar experience when doctors limited her endometriosis treatment in accord with their belief, which she did not share, that protecting her (presumed) future marriage and motherhood were more important than relieving her pain and sexual dysfunction.
Another stereotype of single people, that they “don’t have anyone,” can be deadly. One of us (Joan DelFattore) learned that lesson when an oncologist, upon hearing that she has no immediate family, proposed to use only one mild drug instead of the more challenging combination therapy that offered the best hope of survival. In fact, Professor DelFattore has a robust social support network of friends and cousins—and contrary to the stereotype that misled the oncologist, that's not unusual. Studies show that single people have more friends than married people do, and they do more to stay in touch with, and to support, friends, neighbors, siblings, and parents. Longitudinal research reveals that when couples move in together or marry, they become more insular, paying less attention to friends and parents. It's therefore not surprising that simple binaries like married/unmarried are, according to multiple studies, the least effective way to measure the implications of social support for health outcomes.
Unfortunately, research shows that the oncologist DelFattore encountered was far from unique in undertreating patients without partners. In a Washington Post article, she examined 59 studies based on the National Cancer Institute's massive database, SEER, which show that unmarried patients are less likely to survive cancer and also less likely to receive surgery or radiotherapy when those are the treatments of choice. As is common in such comparisons, the medical authors hypothesize what they cannot establish: that married patients survive because they're married and that unmarried patients not only couldn't handle aggressive treatment but don't even want it. Nevertheless, evidence that unmarried patients rarely refuse treatment when it's offered, together with their unrelentingly negative portrayal in oncological studies, raises the chilling possibility that some may die not from lack of spousal support, but from discriminatory undertreatment.
Not only medical professionals but also the laws meant to protect our health, fail to recognize the important people in the lives of singles. Under the Family and Medical Leave Act, for example, employees in eligible workplaces can take unpaid leave to care for a child or parent. Married employees can also take time off to care for a spouse. But unmarried employees cannot take time off to care for someone who matters to them, such as a close friend or relative, and no employee can take time off to care for the single person in their life who needs help, except the single person's parent or child.
Consider, too, the fundamental issue of access to affordable healthcare. In some workplaces, employees can add their spouse to an employer-sponsored plan at a reduced rate. Unmarried workers, though, cannot add someone important to them, such as a close friend, sibling, or cousin. With few exceptions, such as parents of a young adult still in school, no one can add an unmarried adult to their plan. Even before same-sex marriage was legalized, there was some progress in accommodating domestic partners. With rare exceptions, though, non-romantic partners do not count, even if they are, for example, two close friends or two siblings who live together and have lives just as interdependent as those of conjugal couples in every way except for the sex.
In other instances, federal laws do acknowledge the people who matter most, regardless of their marital or family status. For example, patients have the right to decide who is to receive medical information. But medical staff do not always follow the law, insisting instead that only immediate family members can be informed.
The single patients most likely to be marginalized and pitied are those who live alone, as do more than 35 million adults in the U.S. To be sure, some solo dwellers really are struggling and deserve serious attention. Many others are doing just fine, though, except for problems arising from health care policies based on the outdated expectation that just about all adults have spouses or grown children who can be with them at every point of their medical care.
When Cathy Goodwin, a single woman living alone, needed a minor medical procedure involving anesthesia, the procedure worried her less than the logistics did, as she explained in this guest post for “Living Single.” Federal law requires, and common sense dictates, that patients who may be cognitively impaired after anesthesia must be discharged to a “responsible adult.” But many medical facilities have upped the ante by requiring such precautions even for patients who are not impaired, and by excluding paid drivers except for medical transport services which, if available, may be prohibitively expensive.
Since Goodwin had just moved, she had not yet made local friends and had no family nearby. As she noted, though, access to medical procedures should not be denied to people who, for whatever reason, have no companion available at a particular time. Even single people living near friends and relatives may hesitate to ask someone to take time off from work—or their chosen companions might be unable to help because of FMLA restrictions or employer-mandated rules limiting time off to the care of immediate family. The problem is exacerbated when medical facilities wait until the evening before a procedure to finalize the arrival time, thus forcing drivers to keep the whole day clear even if needed for only a couple of hours. The search for a personal driver may also compel reluctant single people to share sensitive information about the need for medical care solely on the basis of who might be available on a particular day.
Similar problems arise when hospitals require patients who stay overnight to have someone with them, and even when personal caregivers aren't mandated, they may be a practical necessity because of inadequate care by hospital staff. That, too, can be daunting to people who live alone, as can the lack of affordable home care after discharge.
It is not just single people or solo dwellers who are shortchanged by prevailing practices. A marriage license is no guarantee of a spouse who can easily take time off from work, or who is able and willing to act as a caregiver.
Without a doubt, many laws and health care policies reflect legitimate concerns about the well-being of patients, but such efforts need to recognize and accommodate the realities of how people live today. In the Community of Single People, we have discussed the challenges we face and the many approaches we’ve used to meet them (summarized here; some other relevant articles are here). But we need more systematic and affordable solutions.
There are some signs of progress. For example, in 2018, the New York Times published an article on the growing need for transportation relevant to nonemergency healthcare and mentioned some start-ups attempting to address that need. The services are not available everywhere, though. The two of us will be monitoring relevant developments, and we welcome your input if you know of services or solutions not already mentioned in this article or this one.
[A version of this article was originally published in the Fall 2018 issue of Health Psychologist, a publication of Division 38 of the American Psychological Association. This revised version is published with the Division’s permission.]
Joan DelFattore, Bella DePaulo’s co-author on this article, is the author of three books published by Yale University Press as well as dozens of articles. Since retiring from a professorship in English and legal studies at the University of Delaware, she has been writing about living single, especially with respect to health care.