Why are unmarried patients less likely to receive life-saving medical treatments? Peter McGraw talks to professor and author Joan DelFattore about how America’s healthcare system disadvantages those who are single or outside the nuclear family model. From TEDx talks to the New England Journal of Medicine, she’s sounding the alarm on a silent crisis. If you’re Solo—and especially if you live alone—you need to hear this episode.
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Listen to Episode #258 here
Sick while Solo
Welcome back. My guest’s work came up in a show showcasing the Singles Bill of Rights about how singles are routinely overlooked and sometimes outright disadvantaged by institutions built for couples. She writes about improving access to American healthcare for adults who are unmarried, who do not live in traditional nuclear families, or whose families cannot provide all of the expected support. Her publications include an article in the New England Journal of Medicine showing that compared with a married cancer patient, an otherwise similar unmarried patient is significantly less likely to receive surgery or radiotherapy, although more than 98% of unmarried patients accept those interventions when offered.
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Looking Back To Joan DelFattore’s Solo Story
Welcome, Joan DelFattore. I’m so thrilled you’re here in part because the work that you’ve done is incredibly important. There’s a lot of anecdotal evidence and a lot of stories that people tell about discrimination against single people, and not enough of it has data, and none of it typically ends up in the New England Journal of Medicine. We’re here to talk about being sick while solo. Since you are solo, I thought we’d start with your story, if that’s okay.
That is fine. Thank you very much for what you were saying about that work. I’m 79 years old. I have never been married. Staying unmarried in a traditional, conservative Italian Catholic family in the 1950s required a certain amount of determination. From the time I can remember, I did not want to be a wife and mother, and there were no models for that except my aunt, who was a nun. There simply weren’t women in our environment who went out to work and earned their own money. There were women in the larger culture who did that, but not where I was growing up.
I truly did not want to be a wife or mother. At first, I was thinking there must be something wrong with me because I had no models to show that this is normal. Women at that time, at least in the subculture I belonged to, were brought up to believe that we had to have either a man or an institution to take care of us. We were not encouraged to think that we could manage on our own. We were actively discouraged from having any such idea. Singlism, sexism, and misogyny were very intertwined when we’re talking about the 1940s, ‘50s, and ‘60s.
For example, I was 29 years old when I was able to, for the first time, have a credit card in my own name as a single woman when the US Congress changed the law. I’m sorry. This is slightly immodest, but it’s necessary to the story. I realized that the fact that I did pretty well academically was the way out, because being a teacher was an acceptable thing for a woman to do. I went through undergraduate school, taught for a while in high school, then went to graduate school, and then got a job at the University of Delaware.
At that point, I thought, “Now I need to get married,” because along the way, I could say to myself, “I should wait until I finish my education. It’s hard to get two jobs for a couple and so on. I’d better get married.” Bella DePaulo wrote something relevant to this. She said that at one point, she realized that finding a partner ranked somewhere around cleaning out her old emails and cleaning herself. Email had not been invented yet, but that was the case. I thought, “Obviously, something is wrong with me.” I went to a psychologist. This was a married woman, a few years older than I. I was in my early 30s.
The topic was, what’s wrong with me that I don’t want to be married? We talked about a number of things. She was very open-minded, which was fortunate, because at the time, many psychologists would have seen ‘the problem’ as getting me to want to be married. One day, the breakthrough came, because she said to me, “If you were to marry, what kind of a man would you marry?” We had already established I’m cis straight, so it would have been a man. I said, “I would like a man who is involved in his job. He loves sports. He does a lot of community service.” She said, “So you want a man who is intellectually stimulating and interesting?” I said, “No, I want a man who is never home.”
“I want a man who likes to go on long hunting trips.”
Exactly. We came to the conclusion. It’s one that I have found to have been absolutely the right conclusion. I wasn’t avoiding marriage. So often, it’s worded as, “Why are you not married?” For me, it was, “Why are you single?” I loved the life that I had. I didn’t want to change it. Once we had done that, I said, “Okay.” I bought a house, which is what a lot of people do when they are sure that they want to stay single. I traveled all over the world by myself. I have wonderful friends.
I’m very close with my cousins, who are my closest living relatives at this point. I’ve had a much better life as a single woman than I would ever have had as a wife and mother, not because anything is wrong with being a wife or mother, but because it wasn’t a good match for me. I didn’t want to be a surgeon. I didn’t want to be a pilot. It doesn’t mean there’s something wrong with being a surgeon or a pilot. The assumption that wife and mother are automatic for a woman is completely unrealistic, unless you want to believe that half the human race is all the same.
What a story. I have to ask. First of all, a lot of singles feel like there’s something wrong with them. That’s a common story I hear. It was my story. It took me a long time to realize that while there are plenty of things wrong with me, my desire to remain single is not one of them. There’s also a heavy lift that singles often have to do, which is educating and assuaging the people in their lives, often their loved ones, that everything is okay.
Everything is going to be okay. I don’t need someone to take care of me in the way that a spouse is tasked with that. We were joking offline that I was watching The Godfather and The Godfather 2, and the importance of family to these Italian families, both in Italy and in America, that there was a lot of pressure. What were the conversations like with you and your mother, with you and your father, and with siblings who were riding the relationship escalator?
I am an only child, so siblings did not get into it. My mother was completely supportive from day one. She deserves all the credit in the world for that. This was true of many women of her generation. She was the World War Two generation. When she was growing up, she had no choices. There was no viable way for a woman to have her own apartment, to be a separate person. She was determined that I was going to have the choice to do whatever would make me happy.
One thing I remember from quite early childhood, I couldn’t have been more than maybe eight or nine. My cousin, who I’m very close to, is a year and a half older than I am. We were at our grandparents’ house. He was talking about what he wanted to be when he grew up. I said that I wanted to be a writer. They laughed at me and said, “No, you’re a girl. You’re going to be a wife and mother.” My mother, who never challenged them, was low-key. She was like a little tigress. She said, “Don’t tell her that. She can do whatever she wants to do.” They looked at her as if a kitten had suddenly bitten them.
It turned her into a lion.
You know what she reminded me of? I worked with some women college students from Afghanistan who had to flee Afghanistan when the Taliban took over. I heard one of them tell the story about how her mother was hesitant about whether to leave. They had to decide very fast whether to get on the bus and go to the US. There was an army plane that was leaving. They either were on it or they were staying there.
Her mother actually shoved her onto the bus and said, “Go, you’ll have no life here.” It was not as dramatic, but it was somewhat the same instinct in the mother that I didn’t have choices, but I want you to. As is not at all uncommon, my father was much more traditional, much more inclined to think that women had to be wives and mothers. He had gone to all-male Catholic schools. He was born in 1920. He went to all-male Catholic schools in the late ‘20s or ‘30s.
He was then in the Navy in World War Two. He was then an engineer at Bell Laboratories, where the only women were secretaries. That was very much his worldview. He genuinely believed that a woman isn’t going to make it on her own. There was a nice moment. I was probably in my 40s. I was in the first detached house that I owned. I had owned a townhouse. This was a detached house. My parents were visiting. My father was standing in the living room and looking around. He said to me, “I hadn’t realized a woman could do this,” which I thought was sweet.
You taught him through your actions.
When my first book, What Johnny Shouldn’t Read, was published, it got quite a bit of attention. I got a review on the front page of The New York Times. He was thrilled. My mother said he went out to all the stores. It was 1992, so there were still hard-copy newspapers. He went around and bought all the newspapers and sent them to everybody. I am very happy that it ended up that way. The people I cared most about did eventually come around.
I see some people who talk about hating to go home or visit their family for the holidays. I am so happy to say I did not have that experience. The initial push took a lot of determination on my part, but once I did it, and I had the PhD, the book, and the house, then I had established a single life. I give them credit, given the way they were brought up, that they could accept that.
Was it an aunt who was a nun?
Yes, my father’s sister.
Did she play a role in any of this?
She was one of the sweetest people I knew. She was also my godmother. She entered the continent when I was about five years old. She was somebody who would have wanted to be single, but she was a generation ahead of me. The options were not there. She was very supportive. She never gave the slightest indication of being uncomfortable with anything that I was doing. When the rules relaxed, and she and her companion nun were allowed to come and visit me, she asked me, “What time is mass on Sunday?” I said, truthfully, “I have no idea. I haven’t gone to church in years.” She was even okay with that. I feel blessed because I know that’s not a lot of people’s story.
You named four people in your life, the psychologist, your aunt, your mother, and your father, who ultimately were supportive. They saw that you were living your best life. You were living a remarkable life.
My mother from the beginning.
It was probably quite important. It is funny. Sometimes, there are two sides that come out of married people. I travel a lot. I’m often in Ubers in various places, cities around the world, etc. My bachelorhood will come up. It’s almost always a male driver, especially if it’s late in the evening. I get, “No, it’s great. You should do it. There’s nothing like being a husband and father.” The other one is, “Good for you, man. It’s rough out there.”
There are plenty of married people who are happy and blissful and living their best lives, and there are a lot who are struggling. The grass is equally hard to cut, depending on which side of the fence you are on. These therapists are critical to this movement because a lot of them don’t get it. They’re part of the culture. They believe that getting married and staying married make you happy because that’s what they’ve been told.
That’s part of the media diet. It’s part of the narrative that Bella DePaulo has been attacking. The data don’t actually bear this out in the way that we like to think that it does. Sometimes, you’re going to have to even educate your therapist. I had a therapist for many years. He was a bright guy. He was a great therapist. He figured it out. It took a little while. He let that go. He let me be me and helped me be the best version of me, which was a bachelor, even through the ups and downs of various relationships, while he and I were together for ten years.
You were talking about some marriages that work better than others. For me, though, being single is what I would rather do even than a good marriage.
That’s good. That’s very single at heart, to use Bella’s term for you. If you had to rank your life, it would be single, then a happy marriage, then an unhappy marriage. It’s not a matter of whether you didn’t find it or whatnot. That’s there. I’ve never considered that question. In the simulation, there are worlds where I’m married. I’m happily and healthfully married. There’s some, not so much. I do think that a lot of them, I remain single. I’m a little bit like you. It is a better fit.
That’s an excellent word. In the book that I’m working on now, I keep saying it’s not a zero-sum game, where any credit given to marriage detracts from singlehood, and any credit given to singlehood detracts from marriage. It is an individual choice. It’s a matter of the match between the individual and what is available to them. For example, when I say I’m very happy being single, I was fortunate enough to get a good education and have a good job. I have not had an issue with not being able to afford housing.
That’s going to make a difference in how you feel about being single. Quite a bit of work has been done. It illustrates what seems to be an obvious point that people who want a partner are less happy being single than people who are either indifferent or don’t want a partner. It’s groundbreaking in the sense that growing up, there was simply no conception that there was such an animal as a person who didn’t want a partner. At least this shows, yes, there are some people who don’t want partners. However few they may be, they are happy being single.
Writing About Healthcare Discrimination Against Unmarried Adults
This is a perfect segue into the topic of this episode, talking about this notion of having someone to take care of you. You’re a retired English professor.
That is correct.
How did you come to write about discrimination against unmarried adults in healthcare? Are you allowed to talk about this new book?
I am going to tell the story briefly in the book because it’s so relevant to what I’m writing about. As happens with many writers, it was a matter of personal experience. In 2011, I was diagnosed with stage four gallbladder cancer, which is extremely rare. There are something like 3,000 cases in the whole country. The life expectancy is less than a year. The survival rate is less than 2%. I am fortunate to live on the East Coast. I live halfway between New York and Washington, and Philadelphia and Baltimore are in between the two.
I also had excellent health insurance with my job. I was able to consult a number of physicians. I found a physician who was a surgeon who was then at Sloan Kettering. He is now the chair of the Department of Surgery at Penn Medicine, Ronald DeMatteo. He agreed to do surgery, which other people said was not doable or not worth doing. That changed the game. I became one of the 2% who survived. I then went to a medical oncologist at Sloan Kettering because, since it was diagnosed as stage four, the assumption was that even though the surgery had removed all of the visible tumors, there were still cancer cells circulating.
I went to the top person at Sloan Kettering for this field. When you’re the top person at Sloan Kettering in a field, you’re pretty good. She told me about an article that had been published in the New England Journal of Medicine, which was a gold standard study showing that the best chemo to date was a combination of a drug called gemcitabine and a platinum drug. She said, since I live in Delaware, it’s a couple of hours to get to Sloan Kettering. Why didn’t I get treated closer to home, since she was assuming that’s what anyone would use?
I went to a medical oncologist at a major medical center. He got very hung up on, “You have no husband? You have no sons? You have no daughters?” I’m not parodying him. That’s actually what he said. “Are your parents living? Do you have any brothers? Do you have any sisters?” When he finished that family tree, he said, “Then how will you manage?” I started to tell him about my cousins and my friends who had been helpful when I was recovering from the surgery. Surgery involved removing most of my liver, and you’re going to be a sick puppy after that.
I definitely had plenty of social support. This particular medical oncologist said to me, “We’ll start gemcitabine on Tuesday.” He didn’t even let me finish the sentence about my cousins and my friends. He interrupted and said, “We’ll start gemcitabine on Tuesday.” Having already spoken about this with the oncologist at Sloan Kettering, I said, “What about a platinum drug?” He did not like the question. He did not disagree that that was the more promising therapy, but he absolutely would not do it. He said, “I would not risk those side effects with someone in your situation.”
He simply couldn’t get his mind around the fact that my marital status and family status were not coextensive with social support. Dr. Sloan Kettering and Dr. Eileen O’Reilly oversaw the ‘good chemotherapy.’ She and Dr. DeMatteo both asked the right questions about social support. It is perfectly true that social support is a legitimate concern. If a doctor is going to do something that’s going to cause you to be flat out and you can’t take care of yourself, they do need to make sure ahead of time that you have the support system you need.
Those two asked questions like, “Who would give you rides?” Dr. O’Reilly, because she knew that chemo would cause you to get quite debilitated, wanted to know how physically close people I could call on. In other words, is there a next-door neighbor, because you might need somebody in a hurry? Those are legitimate questions. That makes sense as opposed to that other oncologist whose questions were, “Do you have a husband? Do you have children?” I emphasize this because I don’t want to give the impression that all oncologists undertreat single patients.
After I had recovered, I thought, “I need to look into this.” You were asking how I got into writing about this. I could not get that scene out of my head, particularly the oncologist saying so flatly and definitively, “We’ll start gemcitabine on Tuesday.” If I hadn’t known, I would have gone along with it. There was actually a wrinkle later on. The oncologist at Sloan Kettering became the lead author on a study that was published in the New England Journal of Medicine, which showed that certain genetic mutations make platinum drugs much more effective.
The prediction of whether the platinum drug will work depends on your genes. I wasn’t in the study, but out of curiosity, she checked my genetic makeup. I do have the mutation. If he had left that drug off, it was the surgery that gave me a chance. It knocked out most of the cancer. It reduced the burden to what the chemo could handle. Without the edge that I got from the stronger treatment, and perhaps from my own genetic disposition to respond well to it, we might not be having this conversation. I thought even before I knew about that part, “I need to use my skill set to try to do something about this.”
What I could do was write about it. I realized that I am not going to be convincing unless I have the validation of a solid major publication. I realized I have to prove two things. I have to nail it down solid. One of them is looking at the medical literature. At the time I did that article, there were 84 articles indexed on MEDLINE on this topic. There are now over 200. First, I had to show that unmarried adults are undertreated. That’s what I first set out to find out. I thought, “Is that when I saw an outlier, or is this a thing?”
I checked the medical literature and found 84 articles. There is no difference of opinion about the fact that unmarried patients are undertreated relative to married patients. The way they know that, there’s a database that’s maintained by the National Cancer Institute. It has the records of more than ten million people who were treated for cancer in the US. It can be searched by marital status, and then cross-referenced with things like age, type of cancer, stage of cancer, and so on.
Starting in 1987, these medical authors had used this database to prove that, first of all, unmarried patients are less likely to survive cancer. They don’t get the same treatment. Until I published my own article in 2019, there was not a single article that suggested that there was any reason for the undertreatment of unmarried patients other than what was attributable to the shortcomings of the unmarried state. All of these articles were saying it’s because unmarried people are depressed and they have no social support.
A lot of it was the social support. Without a spouse, they don’t have anybody to encourage them. They don’t have the will to live. Some of the articles use the expression, “They don’t have a fighting spirit.” They have never encountered some of the single study scholars who have the fighting spirit. I thought, “I need to do two things. First, I need to show clearly that single people are undertreated, that the medical establishment is aware that single people are being undertreated. I have to show that the reasons they’re giving are not true.”
What you were talking about before, the data is not showing it. Systematically in the New England Journal of Medicine article, and now in the book that I’m writing, I’m taking each statement that they make about this is why single patients are undertreated relative to married patients and doing a deep dive to show that’s not the case. I’ll give you one specific example. Quite often, these medical articles say that, without any kind of basis, single people are less likely to survive because they don’t follow medical instructions. They don’t comply. One article said something to the effect, “You have to be careful about how you treat single patients because research shows they don’t show up for appointments.”
They cited a study that was done on patients who had had bariatric surgery and needed to come for follow-up appointments after the bariatric surgery. I read that article, which apparently the peer reviewers and the editors did not, because what it said was that unmarried patients were 2.7 times more likely to show up for appointments. That article was used as the only source to support the statement that they’re less likely. One of the arguments I made in the New England Journal of Medicine article, and I’m also making it in the book, is that peer reviewers and editors need to wake up because that shouldn’t have gotten through.
It’s so interesting hearing an English professor talk like a scientist.
I should mention I may be a D in Clinical Psychology. I never finished the dissertation. I had had statistics courses and so on. I wouldn’t try to do the kind of quantitative research some people do, but I understand what it means.
I love it. It’s not a critique. It’s fantastic to be able to think through it. I’m highly critical of academic research, of peer review. I joke about it on the show and certainly at length with my peers, especially because so much of this work is an academic exercise. It doesn’t have much effect in the real world. Your research does. The actual cost of this bias that you’ve revealed, and bias is the right word, because it’s one of the things that Bella documents very well, that it gels with your own personal experience, my own personal experience, and lots of the audience’s personal experience, is that the solo is not this isolated, lonely person necessarily.
It’s often someone who has very rich connections, is involved in the community, and could put out the call. Not just two people show up, but dozens show up, in part because we don’t isolate ourselves. We are often the ones who are reaching out. We’re not in this little nuclear family out in the suburbs without any connections beyond our spouse and children, and maybe some parents, if they’re still around.
I invited a group of guys to meet for Sunday morning coffee. It’s the single guy who does that. The married guys never do that because they’re going to brunch with their spouse, oftentimes. This is a very real bias, which both anecdotal and the data support. One of the major things about this is that the costs of these are enormous. You’re denying people potentially life-saving or life-extending therapies as a result of an assumption that your father had, which is, “How are you to be happy?” They have these assumptions that are not supported by fact and reality.
Unquestionably, a given cancer patient is more likely to die sooner unmarried than married. The same patient has a better life expectancy if they are married. There’s definitely that cost. There’s also the cost of a sense of self-worth. There’s a suggestion to the single person that you’re somehow not part of this. Even apart from what treatment an individual patient gets, there’s also treatment in the broader sense, how you’re treated in the medical institution.
As an example, there’s a law in HIPAA, the Health Insurance Portability and Accountability Act. That’s the one that says that doctors can’t reveal your medical secrets, and you have to sign for them to share your medical information with certain other people. Under HIPAA, a competent adult patient is entitled to say who they want to get their medical information. When I was going in for the surgery at Sloan Kettering, I was actually on the gurney in a gown with a hairnet on, the whole thing, and little booties on, when the nurse came in with a form and said, “We need to fill out this form to say who we can share information with about your progress in surgery.”
I had two cousins and a friend who were with me that day. If you think about it, these people cared enough about me to get up at the crack of dawn, first of all, to go from where they lived to New York City, in the case of my friend, to stay overnight the night before, and to pace around that hospital for six solid hours while I was in surgery. I put their names down. It asked relationship, which you probably shouldn’t have because it’s irrelevant.
The nurse looked at it. I put cousin, cousin, friend, and the nurse said, “No, it has to be immediate family.” I said, “No, it doesn’t. I don’t have any.” She said, “I don’t know about this.” I found out later that my cousins and my friend could not find out anything the whole time I was in surgery. They said that the woman in the surgical waiting room kept making a zipping motion across her mouth and saying, “You’re not immediate family. I can’t tell you anything.” I don’t know whether she made that decision herself or whether the nurse never sent the form.
That happens enough that it’s an issue, even when you have rights. You know where this shows up the most because of the extent to which it’s vocal? Before same-sex marriage was legalized, even today, with some same-sex couples or some couples choosing not to marry, it comes up with them where the unmarried partner can’t see the other one in situations where they have every right to. I’m sure Sloan Kettering’s lawyers knew that they had to honor my wishes, but they weren’t in the surgical waiting room.
Why Singles May Have Better Support Systems
There are two things going on here right now that I want us to address. The first one is that some of these healthcare providers don’t understand. They’re running an old operating system that’s there. You, as the patient, and it is unfortunate because you’re not always at your best, have to advocate for yourself in this way. What do you tell people to do when they’re faced with someone who is not getting it?
They don’t realize that your support system is way better than that person down the hallway who has one spouse who is a bit of a ding-dong anyway. That’s the first question. The second one has come up on the show before. How do you advocate for the fact that you have these other people? They need to be informed. They need to be let into the room. They need to be talked to like a spouse ought to be talked to.
In answer to the first one, before I wrote the New England Journal of Medicine article, I wrote a few articles to get started. I published a couple of them in The Washington Post. When I was working on one of The Washington Post’s articles, I interviewed three social workers who work at hospitals in medical centers. It was the Mayo Clinic, Sloan Kettering, and then my local hospital for an example of that. I asked them that question. What would you advise a patient to do? They were thinking in terms of inpatients.
They said, “Before you’re even admitted, get in touch with a patient representative because any medical institution will have patient advocates. Get in touch with a patient advocate, especially if it’s for something serious and you’re going to be there a while. Tell them that you have reason to believe that the fact that you’re single may be an issue. Tell them what your support system is. Tell them who the people are who are supposed to be admitted, and ask them because they’re in that environment. Ask them what they would advise you to do to make sure that your rights are respected, including visitation rights.” President Obama signed an executive order, which resulted in a change in the Center for Medicare and Medicaid rules.
The hospitals have to allow a patient to see any visitors they want. They can’t say it’s immediate family only, but that’s what it says on the books. It may or may not be what they actually do. That was one suggestion. Other things that I was thinking about, I would not wait. In fact, I never do. If I see a new physician, and social support could be relevant, I don’t wait until they start asking me whether I have a husband. Do I have children? I start with, “By the way, in case I’m going to need help with rides or something, I’m happy to say I have plenty of help.” You might want to bring someone with you if you’re comfortable doing that, almost as a visual aid. There’s another person in the room. I have also, on some occasions, handed the physician the article I published.
I was going to make that as a joke.
I’m not going to argue with that, particularly. I actually did that at Penn. The next time I came in, they said they had been passing it all around the department. Some of it is a matter of education. Before you let them go down the well-traveled route that they’re on, take them off it before they even get on it.
This idea of getting ahead of it, too, I wanted to ask, it sounds like you often want to have a plan before you’re even sick or injured. You want to have conversations with those loved ones, friends, neighbors, and cousins to say, “Can I rely on you? What can I expect?” Also, oftentimes, offer it yourself. I have Julie, whom people know, my soul sister. She’s here in town.
She has gone to appointments with me and hung out in the waiting room, or just dropped me off and then picked me up. I had a cancer scare. I’m having that support, having someone to talk to on the way to the hospital and on the way home. With her, I didn’t have to do this. All I had to do was call her. It seems like getting ahead of it and talking to people about this might be a need. It’s good.
That may very well be what some people would need to do. For me, it was more integral. The question is not who would drive you if you were sick. These are people who are in my life all the time. They’re people I do things with. They’re people we do things back and forth for each other. It’s reciprocal. If I asked my cousins whether they would be there for me, they would be highly offended because that’s part of the deal.
They do not need me in the same way because this cousin I mentioned that I’m very close to has a wife, three kids, in-laws, grandchildren, and so on, which actually brings up another point. When some of these programs talk about allowing the next of kin, you have to be careful that you are talking about the patient’s next of kin, not the person who is next of kin, you are. My cousin is my next of kin, but I’m not his. The point you were making before is absolutely right on. People need to have the answer to that question. What would I do if I were sick?
How A Solo’s Autonomy Can Backfire
I’m speaking directly to the audience right now. One of the things that Solos often do well is autonomy. We’re very good parents to ourselves. I don’t need anyone for me to exist. I can clean my house. I can cook my food. I can change my oil. I can do all those things. I don’t need a wife or a husband to do any of the basic things in life, but sometimes, that backfires on us because you’re like, “I’ll do it alone. I’ve had the flu and managed.” It is this trope of the man cold, the man who gets a cold, and then he turns into a little baby.
I’ve always chafed at that because I’m like, “What are you talking about? I’ve been bedridden with the flu and managed to go it alone without turning into a baby, in that sense.” That can backfire. I’ve had that backfire on me. “I’ll be fine. I’ll take an Uber home.” Having that person in the waiting room, they can go pick something up for you to eat or drink. You don’t have to call Uber. They pull the car up. They see that you get home. Sometimes, our autonomy can backfire. It’s important to recognize that you often don’t know how it’ll all play out. Don’t be too proud.
That also brings up another point that I’m making in the book, one of the problems for people who are single or who are essentially in charge of their own healthcare. There are some whose spouse may have a disability or dementia, or the spouse may simply be of no use in this kind of thing.
I use the term ding dong.
They’re effectively in charge of their own healthcare. One of the characteristics of the healthcare system is that it tends to wait until the screaming last minute to tell you anything. For instance, you have an outpatient surgical procedure. You’re ready to go home, and they hand you a piece of paper that tells you you need certain things from the pharmacy. Why didn’t you tell me that last week, when I could have gone to get it from the pharmacy?
For me, the key to what you were talking about before is reciprocity. For instance, I had my aortic valve replaced, which was an amazing thing. I was in the hospital only one night. They do absolute miracles. A friend of mine came to Philadelphia to stay overnight with me. She and I used to team-teach at the University of Delaware, so I can teach her courses. When her mother was dying, and she needed to leave suddenly to be with her mother, I took over her courses.
Another friend brought me for the procedure, stayed with me, and came and got me the next day. I have a membership at the Met Opera because I love opera. When I got invited to a rehearsal, I knew this friend loves opera as well, so I invited her to come with me to the rehearsal. We do things for each other. To me, that makes a huge difference. It’s not who I impose on or even a sense of imposing. I would not be comfortable if someone else were always doing things for me and I never did anything for them.
Sometimes, when we make it possible for a friend to reciprocate to us something, things that we did for them, it actually makes a more comfortable relationship both ways. The problem is assuming that that always happens inside families. We need to open our minds to the reality that that kind of a social support network may be partially or entirely non-kin.
Friend relationships are often much more reciprocal than familial ones, too. In general, what you’re highlighting is a good orientation for life, which is give as you can, take as you need. The idea is that people are going to need you at times and be generous with your time, attention, and energy, because not just from a selfish standpoint that you might need it back, but that makes the world a better place. Giving feels a lot better than receiving. It’s one of those things that ends up mattering.
Helping someone else feels so good to be able to give whatever it is, even if it’s that ride to the hospital for someone. Probably the better conversation to have, hearing you talk, is to go to the people in your life and say, “I want you to know I’m here for you. If you need something, don’t hesitate. I’m here for you.” I like to ask this question. This came up in the Singles Bill of Rights episode. If you had a magic wand and you were able to change one policy to make healthcare more fair for unmarried adults, what would that be?
Allowing Caregivers To Take Paid Leaves
It would be a caregiver’s leave from work because the Federal Family Medical Leave Act provides for job-protected leave from work, only to take care of a spouse, a parent, or a child. A number of state laws that provide paid leave also cover either only those categories or very close family relationships, such as grandparents or an unmarried partner. For example, there’s a widow up the street who is in her 80s. Her kids live all over the country, nowhere near here. Nobody can take time off to take care of her.
Nobody could take time off to take care of me. What makes it especially unfair, the policies in the states work in one of two ways. Many jobs include paid leave from work if you are sick. Can you take paid leave from work if someone in your life is sick, so you can take care of them? Under the federal law, it’s unpaid leave. A number of states have passed laws to provide for paid leave, and they work in one of two ways. Either it is a payroll deduction, or it’s an insurance policy.
Either way, the unmarried person with no parents and no children is paying the same amount. With the payroll deduction, it’s worse because that’s not voluntary. I’ll use my own state as an example. In the state of Delaware, every employee has to contribute without any choice. It’s 0.4% is the total. The employee contributes 0.2%, and then the employer contributes the rest. You have to contribute to that. You can take time off only for a spouse, parent, or child.
When I spoke with the sponsor of that bill, the response was that it would be too expensive to allow people to take time off for other people. Bella DePaulo and Christina Campbell, whom I know you were talking to in earlier episodes, have made the point very clearly. In many cases, the financial model is based on the assumption that it’s perfectly okay to force single people who don’t have kids to subsidize others by paying into something that they themselves can’t use.
Bella and Christina have both done very good work on Social Security, for example, and other kinds of plans like that, employer healthcare plans, where single people are exploited to subsidize others. Going back to 1913, this is not a new thing. When they were putting in the federal income tax for the first time, Teddy Roosevelt actually said in so many words, “Single people should pay more to subsidize married people, and that’ll get them to get married.”
I had an episode on bachelor taxes throughout history, both in America and beyond. How do we get these untamed men settled down? Let’s tax them until they marry.
Emperor Augustus did that.
The Impact Of The Striking Rise Of Singles
It shows up time and time again. It has been proposed. You were talking about how your own personal experience leads you to dive into ideas and to write about things. I’ve been talking and writing about the solo economy, as I call it. How will the world change with this striking rise of singles? In the United States, at the moment, married and unmarried adults are about 50/50. What if it goes 30/70? How will the institutions change? How will religious organizations change? How will a government change? How will businesses change as a result of recognizing this impossible-to-ignore demographic?
I’m actually working on an essay right now. We’re taping this around the holidays. Singles work the holidays because their managers give the married people time off. In 1960, peak marriage, when almost everyone got married eventually, that was fine. It evened out. “I was single. I’ll work the holidays. When I’m married, the other singles will.” It balances out. For people like you and me, it’ll never balance out because we’re never going to marry.
We need to have different models by which to make these decisions. Sometimes, the best models remove the judgment of individuals because the judgment of individuals, as you have well documented, can be fallible based on faulty assumptions or an old way of thinking, let’s just say. Where is healthcare changing? How is healthcare improving along these lines in terms of helping singles get the same treatment, have better outcomes, and have better experiences?
I would divide that question into two. Before I do that, let me throw another statistic at you that may be relevant for what you’re writing. You were talking about the number of singles versus the number of married people. I wrote this, so it’s stuck in my mind. According to the US Census Bureau, between 2020 and 2024, the population of adults over age 65 increased by 13%. The percentage of adults between ages 18 and 64 increased by 1.4%. The percentage of children decreased by 1.7%. The title of that chapter is Do the Math. It’s not only that people are single and we need to deal with the fact that their support system is different, but we also need to deal with the implications.
Some single people have children, but clearly, as those statistics indicate, the birth rate is declining. Families are smaller. Compared with the 1970s, women today are more than twice as likely, if they have children, to have only one, which means those adults, as they age, are not going to have siblings. They’re not going to have nieces and nephews. In healthcare, to me, the first thing that needs to happen, and the proposal I’m making in the book, is that in medical schools where they talk about implicit bias and racism and implicit bias and gender, they need to talk about implicit bias with respect to social support systems.
It’s relatively easy to do because the statistics are so clear. Bell has done a lot. Other people have also done a lot. They need a crash course in a support system that doesn’t have to be family-based. One thing that is going to make a difference is simply generational. Some people have done good research using the NHATS program, the National Health and Aging Trends Study, which has shown that some of it is generational.
The people who grew up in the ‘50s and ‘60s in enclosed nuclear families are much more resistant to non-family caregivers, whereas in the younger cohorts of aging adults, they grew up with more varied family structures, with more divorce, and with more acceptance of feeling solidarity with a community that is not necessarily their family. The LGBTQ+ community is known for that. Other communities are doing that as well.
Some of the solutions to this may be the attitudes catching up in the natural course of events with the demographic changes, but also, especially for the doctors who are still practicing and will be for another ten or fifteen years. I’m suggesting not only medical school but continuing medical education. There should be education on the kinds of questions you need to ask if you’re trying to figure out social support.
Before you get to answering the second part of that question of where healthcare is doing better, you’re spot on with your observation. I’m a business school professor, so I think a lot about the marketplace, how singles are underrepresented in marketing communications, and how there are not enough products and services being made for singles. I think some of the reasons for this are that the people who run businesses in the C-suite, the presidents, and the vice presidents are normies. They’re married. They have kids. They live in the suburbs. They are more like the 1950s executives than they ought to be. This is not even on their radar.
If you’re a CEO of a company, you might not know anyone like you or me. All your friends are married. Maybe you have one kid. Maybe you had a sister. For the most part, your world is a 1950s or 1960s-style world in that sense. What you’re highlighting is what Max Planck is saying about. “Progress in science happens one funeral at a time.” There’s a similar thing. If you think about doctors, they are very traditional people. They play by the rules. They go to good schools. They’re not typically avant-garde thinkers. Some of it is the progression of who is moving through the system and their own culture and values. That’s a good point.
Rather than one funeral at a time, I prefer to think of it as one retirement at a time.
That’s fine.
Go play golf. That’s fine. Just get out of my hair. When I was writing one of the articles for the Washington Post, I interviewed some of the medical authors who had written those articles I was talking about. What was interesting, three of them, with no prompting from me, volunteered the information, and these were all men, that they would never go to the doctor themselves if their wife didn’t make them. I had not asked anything that would have prompted that.
What happened was that the general topic of social support in medicine, the availability heuristic, made it come to the top of their mind. I would never write about that because I would never psychoanalyze somebody by name, but I did say it as a hypothetical. Cass Sunstein and Richard Thaler wrote a book called Nudge. They said in that book that they thought that certain behaviors were caused by women being more responsible than men.
They said, “We admit that it could be the availability heuristic because our wives fill that role for us.” I did put that in my book and said that they, as experts in human decision-making, realized that that happens. You’re absolutely right. The oncologist who could not believe that an unmarried woman who lived alone could have social support, I have absolutely no doubt he was coming out of his marriage, his life, the people he had dinner with, and the people he went to events with, who all fit that model.
Improving Home-Based Care For Singles
You asked about how the medical community is improving. There are a couple of very notable improvements. One of them is a program called Hospital at Home. Johns Hopkins pioneered it in the US. Its main purpose is to save money by having especially older people who have an acute need, say a broken leg, but they also have chronic conditions, to be able to keep them at home rather than in the hospital.
Even if the motivation for the institution is financial, most people would rather have their loved one at home and stay at home themselves. Unfortunately, they’re not available everywhere, but what these models do is they train the informal caregivers. They have telemedicine. They carefully select the patients so that, as the name suggests, Hospital at Home, you can get meaningful care at home.
Another helpful thing is that they’re finally beginning to realize that transportation sometimes is the reason people don’t come in for a colonoscopy or something like that. Veterans’ hospitals, in some instances, have what you might call a halfway house. I personally would be able to get someone to give me a ride if I needed a colonoscopy. I’m going to be under and then have to be driven home. For somebody who can’t, they could drive themselves to the veterans’ hospital, have their procedure, and then stay overnight in this building across the street. It is not a medical facility, but you’re right there, and then you drive home when you’re able to drive the next day.
Sloan Kettering, Weill Cornell, and New York-Presbyterian in New York have something like that. They’re all on the same block of York Avenue. The Helmsley hotel chain actually built a hotel specifically for the staff, the patients, and the caregivers in those institutions. When you make a reservation there, they’re very flexible because you may not know exactly what day you’ll be released and so on, but the purpose is the same. Both times I had surgery at Sloan Kettering, the surgeon said, “You don’t need to be in the hospital, but I don’t want you going back to Delaware yet.” That facility was right there. That is a case where it was a private, not done by the medical facilities, but they are improving in that sense.
Another statistic that is relevant and is motivating some of the change is that because people have smaller families to begin with, and because, as you said before, more people are not marrying and more people are not having children, demographers are predicting that the number of older people who have no living kin is going to skyrocket. If you start with fewer kin, the probability of outliving all of them becomes much higher. They are starting to zero in on specific things, like you need a ride, or you need a way for a caregiver to be able to take care of your broken leg at home.
I hope it’s coming because you’re right. Over time, attitudes may change. Enough retirements may make a difference. What’s missing is a clear sense that social support doesn’t have to mean family, because it’s not just the doctors. It’s the person at the front desk. It’s the nurse. It’s the nurse’s aide. There needs to be general education, just as there is with regard to race. There are clear expectations about what you can and can’t do with regard to race, not that it always prevents racism, but at least there’s a motion toward it.
There’s a conversation.
We need more awareness that lifestyle is an issue in medical care because it has not been recognized as such.
That’s well said. It’s why the book you’re writing is important. It’s one thing to write something for the New England Journal of Medicine, but that sits behind a paywall. You have something that’s going to be out there in the public. I talk about how Solos can engage in three forms of advocacy. The first one is to live your life the best that you can and be an example. Other people see you and go, “There is another way.”
The next one is a very micro, which is to talk to your doctor about it, to not let that slide with the nurse, to tell a friend about the Solo Movement, to tell them about Single at Heart, Bella’s work, et cetera. The last one is a more pure advocacy, which is writing a letter to your senator, publishing work, appearing on a podcast, and doing the things that actually spread the word broadly and can educate people and advocate for people in a sense. That’s why what you’re doing is incredibly important. When I came across your work, I wanted to have you on.
I’m glad to hear that. One quick thing to support what you said. I had an opportunity to interview Sarah McBride for my book. Sarah McBride is the first trans person elected to the US Congress. She is sponsoring some pieces of legislation that would fix the Family and Medical Leave Act to make it apply more broadly. I asked her with regard to the law in Delaware. She was in the Delaware State Senate at the time that the bill passed and was, in fact, the sponsor of it. I said to her, “Did you hear from anyone objecting to it being limited to family, spouses, children, and parents?”
She’s quick. She came back with, “Other than you, you mean?” I had been on her about it. I’m citing this up and down in the book because it’s important, especially coming from that source. She’s absolutely right. She said, “We’re not hearing from single people. We’re not hearing from people who don’t live in families.” She used an expression in another context, not to me, where she said, “If you don’t have a seat at the table, you’re on the menu.”
That’s well said. That’s right. Part of it is of the isms, singleism is the most acceptable one.
It is the most invisible.
Answering Questions From The Solo Community
A big part of this movement is raising awareness and letting people know there’s nothing wrong with you and that the world is built for two still. That’s why these kinds of conversations are important. If you do want to connect with like-minded people, I have a Solo community. You can sign up for it at PeterMcGraw.org/Solo. There’s an online message board. I posted that I was going to be talking to you and solicited some comments and questions.
I’d like to wrap up by hitting a few of these. The first one wrote, not a question, but a comment for consideration. “Two things. I’m a healthcare provider. I much prefer being a provider to a patient. Two, I also feel as though being Solo, a single mom, having raised myself and a lot of others around me, we are very independent and do not necessarily have a hard time asking for help when needed, like at the time of an illness, but it’s not our typical nature.”
That is very true, but I would add something else. There’s also good research that occurs in families. That’s absolutely true. It may be characteristic of those of us who pride ourselves on being independent or simply have learned to be independent because we have to be. There was a dead mouse in my garage. There’s nobody I can call. “Jim, take care of this mouse.” My garage, my mouse. I got to deal with it. Also, family members do that.
One of the research topics that’s now happening around the question of caregiving is that family-based primary caregivers may be very slow to ask for help for a different reason, because they’ve been brought up to believe it’s their job. It’s humiliating to the family if you’re bringing in people from outside. It’s an imposition. That reader was absolutely right. I would broaden it out to a human tendency, which may come from a number of different sources.
This is related. Another one wrote, “Personally, I can say that when I have had a serious health complication, it has not occurred to me until further down the line than it should have to ask for the help that I need. I also think it can be hard to receive help sometimes as very independent individuals.” It’s right on to what we were talking about.
It goes right into what we were talking about with reciprocity. It’s a whole different story when it’s your turn to be the receiver in a relationship where you are also the giver.
I guarantee you this person would run through fire to help someone they know. There’s an empathy gap that happens, which is like, “No, it’s not an inconvenience. Of course, I want to help. I’d be insulted if you didn’t ask me. What do you mean you went on your own? I can’t believe that.” I had a friend who was very angry with me for going and dealing with a bunch of medical stuff on my own when she found out what I went through. She was disappointed that I didn’t rely on her. Here’s another one. Another one wrote, “When I threw out my back, I had to rely on grocery delivery because every movement was extremely painful. Do you have any suggestions for services, tips, or strategies to help navigate living alone when health is compromised?” It’s a question for you.
I can only say some things that I’ve done myself. I’ve had to come to grips with the fact that even though right now I’m very independent and can manage just fine, you never know what’s going to happen. One thing that I did was get one of those services where you have a thing you can hang around your neck. You push a button, and people come. It includes a lockbox on the front door with a key in it. The medical guardian service has the code to the lockbox. If I ever push that button, they would tell the first responders the code to the lockbox so they could get in. That reader mentioned every movement was painful.
One question you have to consider is what if you can’t get to the door? That’s one way to do it. Put a lockbox on the door with a key in the lockbox. You can give the code to somebody you want to be able to get in. My neighbors have the code. My cousins have the code as well. Some friends have it. You can have a service where you push a button, and they immediately come. I don’t wear that thing all the time. I don’t have it on now. For instance, when I had the aortic valve replaced, for a couple of weeks after that, I wore it all the time just in case something had gone wrong.
I know some people don’t want to do that because they feel as if it’s a sign of aging or whatever. They don’t want to do it. To me, it’s freedom. It means I can continue to live alone with a layer of security, a layer of help. Also, there are both paid and unpaid services. If you check with the state agency, and I don’t know the age of that reader, but if you’re over 65, there are also services for older residents, for older citizens. Unfortunately, they tend to talk about it as services for families, but individuals can take advantage of it as well.
To this idea of the Solo economy, the robots are coming. As a single person, it’s exciting because it will provide the opportunity for you to stay more independent for longer. You’re going to have your little robot assistant, who will be monitoring how you’re doing and will be able to help out with some of the tasks around the house. I’m a big advocate. I love my apartment living.
I certainly appreciate having a concierge. You have someone who can let someone up. You can call them. They can drop off packages. They’re there for you in the way that the lockbox is there for you, in a sense. One of those in-between places could be a building that has a little bit of energy, has some young people, but then also has staff who can help out in terms of admitting, giving access, etc.
That is a good thought. One other thought that occurred to me, my friends are downsizing and moving into senior communities or whatever. One of the advantages of being single is that I have not faced that. I live in a house where I have very lovely neighbors all around me that I’m friendly with. I could get help quickly if I needed it. Sometimes, I’ll get a text. There’s an Amazon package. “Are you home? Do you want me to bring it in for you?” My friends who are downsizing, when they bought their ‘main house,’ had a spouse. They had three kids. They had a lot of people to help maintain the place. They needed a lot of space.
When I bought my house, I was a single woman, knowing I intended to stay single. My situation now, unlike theirs, is exactly the way it was when I was 40. When I bought this house, I budgeted for the fact that, from day one, I couldn’t, or at least I wasn’t going to try to mow the lawn or trim the bushes. I budgeted from day one what amounts to a condo with ad hoc services. I’ve had the same companies doing the landscaping, the lawn, the whole thing for years. It lessens my need to move somewhere else because it’s already set up for a single woman who’s not doing all that stuff herself to begin with.
That’s smart. I want to finish with this one. Another one writes, “I’m interested in practical advice for us single people.” As it was said before, as singles, we need to nurture our relationships, as we will need help in later years. This is related. Prevention is best for everyone. Build and keep muscle as we age, but also tend to our relationships and help others so they can help us in times of need. We can’t expect to be assisted if we live isolated lives.
That is beautifully said. That is absolutely true. You need to make the effort. People say, “I’m not meeting people.” What are you doing to meet people? Go out and do things. The last thing I wanted to say, apropos of something you said before about the advocacy, I think you’re familiar with what Donna Ward is doing. Donna Ward is the head of Singlehood Australia. She has a group now called ISAN, which is an international group. About every continent is represented, talking about how to translate research into political advocacy and real change. There does seem to be a real movement going on of single people suddenly waking up and saying, “We can’t just stay in our little box. We need to get out there and make a difference.”
Episode Wrap-up And Closing Words
First of all, I’m thrilled that we had a chance to talk. This is an incredibly important topic and also one in which there are very clear things that the individual can do to advocate for themselves and others and be better off than they would otherwise be without the information. I started this Solo project years ago. I’m coming up on my sixth anniversary of launching the show, so I started a little bit before that.
When I first started, and I can’t even imagine what Bella thought years ago, I thought, “Am I too early? Am I just going to be shouting into the wind, and no one’s going to hear me and pay attention?” I don’t believe that anymore. You look at the Singles Bill of Rights, the stuff that Donna is doing, and the book that you are writing. Bella DePaulo is still going strong. You have a TEDx Talk. I had a TEDx Talk that turned into a TED Talk.
It’s happening. People are starting to pay attention. They’re starting to recognize. They’re recognizing it because it’s an easy story. People want to be treated fairly. They want their choices to be honored. The singles are not saying, “We’re better than married people.” No single person says that. They just say, “I want my different path to be valued in the world.” It’s an exciting time. The question is, when does the hockey stick happen? It is like bankruptcy. It’s slow, and then all of a sudden, it does that. When does that happen?
You came in. I published my first thing on singlehood in 2014. It was on Bella’s blog in Psychology Today. I was very hesitant to approach her because she was the big shot in this field, but I dared to write to her and said that I had this article. It was what I was talking about with my cousins and my friend, not being able to get my information. She was a voice in the wilderness for a long time and stuck with it. There were other people who came in and out. She stuck with it.
Solo does not exist in this very well-thought-out, research-backed way if Bella hasn’t been doing her work, you haven’t been doing your work, and other people haven’t been doing their work, and so on. Joan, first of all, I’m so thrilled that you’re part of the 2% that made it through.
Thank you.
I want to thank you for your time and for the work that you’re doing. I look forward to reading your book.
Thank you. I do, too.
Cheers.
Important Links
- Joan DelFattore on LinkedIn
- What Johnny Shouldn’t Read
- Single at Heart, Singles Bill of Rights, and Singles’ Day
- The Bachelor In Colonial America And Beyond
- Nudge
- Single at Heart
- Welcome to the Solo Movement
- Singlehood Australia
- International Singlehood Advocates Network (ISAN)
- Sick While Single? Don’t Die of Discrimination | Dr. Joan DelFattore | TEDxWilmingtonWomen – on YouTube
- Peter McGraw: Stop Telling Single People to Get Married | TED Talk
- Joan DelFattore on Wikipedia
- Being Single With Cancer
About Joan DelFattore
Joan DelFattore writes about improving access to American healthcare for adults who are unmarried, who do not live in traditional nuclear families, or whose families cannot provide all of the expected support. Her publications include an article in the New England Journal of Medicine showing that compared with a married cancer patient, an otherwise similar unmarried patient is significantly less likely to receive surgery or radiotherapy, although more than 98% of unmarried patients accept those interventions when offered.
Research and personal essays have also appeared in the Washington Post, Herald Tribune, Psychology Today, Health Psychologist, and many more. She gave a TedX talk, “Sick While Single: Don’t Die of Discrimination,” as well as doing a podcast for Cure and an interview for All Things Considered. Her current project is a book under contract with Yale University Press.
Professor DelFattore’s earlier publications include three books with Yale University Press and dozens of articles, mostly about freedom of speech. Her work has won awards from the American Library Association, the American Educational Research Association, and the Spencer Foundation, among others. In addition to speaking at conferences and events throughout the country, she’s appeared on dozens of talk shows, notably 20/20, Radio Times, Fresh Air, Talk of the Nation, All Things Considered, and the Diane Rehm Show. She holds a Ph.D. in English and an M.S. in clinical psychology from Penn State University.