Essay: Colorado’s healthcare depends on invisible labor. What happens when no one is there?
A few months ago, I missed a few stairs. What followed was orthopedic surgery and several weeks of navigating my Denver apartment on crutches.
I am 34, single and live alone — unless you count the dog, which, despite his many fine qualities, is useless at carrying things.
Recovery was going well when I encountered an absurdly mundane problem: How do I get my dinner from the kitchen to the table when both hands are occupied by crutches?
Medically, I was doing great. I could get around independently and manage my medications. But there was my dinner, sitting on the kitchen counter, while I stood several feet away trying to work out the physics of transporting a plate without dropping either it or myself.
If another person had been there, the problem would have been trivial.
I had prepared for surgery. I had figured out groceries, the dog and how I would get around. What I hadn’t anticipated were all the tiny, ordinary things that become surprisingly difficult when you live alone.
None seemed significant enough to appear in my medical plan. Yet the plan quietly assumed someone would be there to help with them.
As a clinical ethicist in Colorado, I see much higher-stakes versions of the same problem. Healthcare is full of plans that work perfectly well — as long as there is another person around to help carry them out.
We tend to call that “support,” which makes it sound almost incidental. It isn’t. It’s work.
The way Americans live has changed, but many of our assumptions about caregiving haven’t. More people live alone, and fewer households are married couples. And Americans are having fewer children.
Much of our healthcare, however, still depends on family and friends stepping in when help is needed. Nearly a million Coloradans already care for another adult, most of them without pay. If we put a price on all those unpaid hours, the bill would be an estimated $16 billion a year.
That’s not a small supplement to our healthcare system. It’s part of what keeps it functioning.
The answer isn’t that everyone should live near family, get married or have children. Nor can every ordinary need become a publicly funded service. But we do need to stop making medical plans around caregivers who may not exist or may not be available.
We have confused having people who care about us with having people who can care for us.
That distinction matters across a lifetime, from a temporary injury like mine to the question of how people can remain at home as they age. Staying home is an understandable goal, but for many people, making it possible will eventually require someone else’s labor.
Sometimes that person will be a loved one. Sometimes it will need to be someone who’s paid to be there.
Colorado has taken steps to strengthen the workforce that provides care in homes and communities. Doing more will cost money at a time when the state is under real pressure to control Medicaid spending. But the other side of that calculation is harder to see because it doesn’t necessarily appear in a state budget.
When paid care isn’t available, the work doesn’t disappear. A daughter may cut back her hours. A sibling may buy a plane ticket. A friend may take on more than they realistically can. Or the person who needs help may simply go without it. And when no one is available, the person who goes without needed help may pay the highest price.
I am not suggesting that Colorado can or should pay for every hour of help someone might need. But as we decide what care we can’t afford, we should also ask: At what expense?
Answering that question honestly requires us to stop assuming unpaid care will simply materialize. Healthcare systems should make actual caregiving capacity part of care planning: Is there someone available to help? If so, what are we asking of them, and can they realistically do it? If not, what needs to change about the plan? And Colorado should invest in recruiting and retaining enough paid caregivers to fill the gaps that family and friends cannot.
We can debate what care we can afford, but we cannot budget away the fact that eventually, care requires a person.
My dinner problem was temporary and almost comically small. I figured it out.
But the question it exposed isn’t small at all.
Who will pick up your prescription? Who will help you with the stairs? Who will make your meal?
Someone, eventually, has to get dinner to the table.
Chelsey Patten, of Denver, is a clinical ethicist and assistant professor at the University of Colorado School of Medicine whose work and research focus on culturally informed, patient-centered care and how patients’ lives outside the healthcare system shape their care within it.
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