Health Care Roulette: What Is Likely to Kill Me First? - Annals of Internal Medicine: Fresh Look Blog


Wednesday, October 28, 2020

Health Care Roulette: What Is Likely to Kill Me First?

"I’m just worried that if I keep coming to work this tired, I’ll lose my job," our patient sheepishly explained. She had a STOP-BANG score of 7, hypoxia, and chronic hypercarbia. Everything pointed to obstructive sleep apnea and obesity hypoventilation syndrome as the cause of her daytime somnolence. Because she did not have health insurance, she could not afford the $200 sleep study to confirm the diagnosis or the $400 continuous positive airway pressure (CPAP) machine it would likely recommend. She was technically homeless—living in motels and on friends’ couches—and trying to save up for an apartment but finding it difficult on her minimum wage salary. Her concern for her health was buried under a mountain of more pressing problems.

As we talked with our patient, we thought about a groundbreaking set of policy papers that were published by the American College of Physicians (ACP). One in particular—“Envisioning a Better U.S. Health Care System for All: Coverage and Cost of Care"—proclaims unequivocal support for universal health care and specifically highlights the barriers that cost sharing creates to providing evidence-based, high-value, essential care (1). This situation was unfolding in front of us in the clinic.

Limited by the constraints of the health care system, we were unable to offer anything to address either her symptoms or her underlying medical conditions. We placed a referral for the sleep study she could not afford, called a medical equipment representative who said she could not help uninsured patients, and scheduled follow-up in a few months.

Two weeks later, I was back on the inpatient wards when a coresident mentioned that he admitted one of my patients overnight. I pulled up the chart and, sure enough, there she was: "acute on chronic hypercarbic/hypoxic respiratory failure and new acute decompensated heart failure in the setting of CPAP nonadherence."

Our continuity clinic cares for a predominantly uninsured population with extensive medical and social comorbidities. Our safety-net workforce is phenomenal; many bend over backward repeatedly to creatively cobble together solutions for our patients. Despite seeing preventable illness ravage our patients every day and usually knowing the appropriate management, we are often unable to help because our patients can’t afford the interventions they need to stay alive. We frequently play a game of "What is likely to kill me first?" where we review the recommended tests and try to decide which is most urgent and which to defer because of expense. In this patient’s case, even that prioritization did not matter because she still could not afford to treat her top-priority medical issue. This leads to an overwhelming sense of futility as we attempt to provide care with our hands tied behind our backs. We know it is exceedingly worse for the patients themselves who live this reality daily.

In the United States, our effective health care policy for our 30 million uninsured is to deny recommended medical care until they are so ill that they either die or are hospitalized. At this point, the damage is done, and the cost to the health care system is astronomical. After their hospitalization, they frequently join the millions of Americans bankrupted by medical bills. This is abhorrent, particularly in one of the wealthiest countries in the world.

I cannot overstate how important is has been for me, as a doctor in training, to see ACP proudly state that universal health care (via a single payer system or public option), reducing barriers to care, and fighting the social determinants of health are essential aspects of our health care system. A single payer system would change the way we approach medical care with our patients. Rather than betting—with their lives—about which medical conditions to address, we could simply provide the standard of care. I have supported single payer health care since medical school but was frequently met with "that's a great idea that will never happen" from colleagues. They cited physician complacency and reluctance to act as advocates for systems-level change as barriers.

Seeing this conviction from ACP makes me feel like, despite the demoralization and burnout we
feel from failing to provide equal care for our individual patients, a better future is possible if we join together to fight the root causes of inequality. I joined ACP because I want to be a part of this fight. It gives me hope for my patients, the health of this country, and the career I have chosen.


  1. Crowley R, Daniel H, Cooney TG, et al; Health and Public Policy Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: coverage and cost of care. Ann Intern Med. 2020;172:S7-S32. [PMID: 31958805] doi:10.7326/M19-2415

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