Reflections from Liberia: Considering Costs of Care Should Be a Problem For More Than Just the Poor

By John Ly, MD

“Will you charge me?” he asked quietly, between labored breaths. He sat in the hospital bed with his legs over the side in what is known as a “tripod” position—his elbows resting on a nearby stool to prop his chest up as much as possible. His head was hunched over, with his eyes pointed down; clearly he was in agony.

He had been admitted to the hospital two weeks earlier with difficulty breathing and was found to have a lung infection with empyema (pus filling the space between his lung and the inner surface of his chest wall). He initially had a procedure that drained pus-filled fluid from his chest. After listening to his lungs, we could tell he likely had more fluid. We suggested repeating the thoracentesis, and as we were preparing for the procedure, the first and only question he had for us was if he would have to pay.

Even though we were in a government hospital where care is free and there are signs throughout the building imploring “no money business”—meaning no one should be asked by the staff to pay for services—it was still surprising to hear that question…at that time. However, the reality was that cost, even for this dying patient, was a real concern.

It should have been no surprise that it was a poor patient, in rural Liberia, who was concerned about the costs of his care.

In the United States, it is often the poor and uninsured who think first and foremost about costs of healthcare. They have to make difficult calculations, questioning: should I seek care and risk not paying the rent or not having enough to eat? Many are literally one malady from bankruptcy.

I witnessed this when training at county hospitals in Los Angeles that catered largely to the underserved. There were many patients who delayed seeking care. One such patient, whom I will never forget, had a tumor growing from her neck the size of a grapefruit. She did not have insurance and was fearful of the costs she would face. By the time she had presented, she already had metastases to her brain and the best we could offer was palliation.

For many physicians trained in the United States, costs are generally one of the last things considered in medical decision-making. Throughout medical school and residency, we often do not learn about the direct costs of health care for patients. Tests are ordered and procedures performed, many times without much regard for the bill that is generated. However those bills, if unpaid, are passed along as higher fees that providers charge and as increased premiums for health insurance. Ultimately, higher costs contribute to making health insurance unaffordable and decreasing access to care.

Patients such as the one who asked, “Will you charge me?” are a continual reminder of how important it is to lower barriers to care for poor people in the developing world as well as the developed world.

The Affordable Care Act, which has survived a Supreme Court decision and a presidential campaign, will do a lot to minimize the number of people who are uninsured in this country. For many, it will eliminate the anxiousness that comes from being uninsured and lead to improved primary care and prevention.

However, if we are to ensure we have enough healthcare resources to cover everyone while not bankrupting individuals or the government, the next critical step will be addressing the growing cost of healthcare. It will be about everyone—not just poor patients—considering costs. It will involve moving beyond one patient asking, “will you charge me?” to all patients and providers asking, “Is this really necessary?” and “Is it worth it?”

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John Ly is a Fellow in Global Health and Hospital Medicine at UCSF and a contestant in the 2012 Costs of Care Essay Contest.