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INEFFICIENCY INSIGHTS
When Patients Can't Afford Life-Saving Medications
The U.S. healthcare system has much to love and hate—but what I hate most is when patients can't access the care and medications they need. As a physician, I feel truly hopeless when a patient needs a medication or follow-up appointment but can't afford it or access it because of their insurance status. It's terrible.
Recently, I cared for a patient who made me feel exactly this way: uninsured, no access to care. His hospitalization was the first time he'd interacted with the healthcare system in decades. He came in with worsening shortness of breath. We found a massive clot in his lungs, plus uncontrolled type 2 diabetes, plus high blood pressure, plus high cholesterol. In the hospital, treatment was straightforward: apixaban for the lung clot, insulin for diabetes, olmesartan for blood pressure, and a statin for cholesterol.
But discharge planning became a nightmare. As I've said countless times, discharging a patient from the hospital is the most dangerous thing we do as physicians—and this patient is the perfect example why. How would we get him apixaban (very expensive without insurance), insulin (also expensive!), and his other medications? How would we ensure quick follow-up?
I'll explain how we navigated this in the Solutions section. But after we sent this patient on his way, I took time to reflect on the situation—root cause analysis and all.
Insights
Root Cause Analysis: 5 Whys
The 5 Whys process in root cause analysis involves repeatedly asking "Why?" five times to drill down into the root cause of a problem by exploring the cause-and-effect relationships underlying the issue.
The problem: A patient with a pulmonary embolism and multiple chronic conditions cannot access necessary medications or follow-up care after hospital discharge.
Why?: The patient couldn't afford the medications (apixaban, insulin) or secure timely follow-up appointments.
Why?: He had no health insurance coverage to help pay for these medications or services.
Why?: He likely couldn't afford insurance premiums, didn't have employer-sponsored coverage, and didn't qualify for or wasn't enrolled in Medicaid or Medicare.
Why?: The U.S. healthcare system relies on a patchwork of coverage options—employer-based insurance, individual market plans, and safety-net programs—that leave millions uninsured due to cost, employment status, or eligibility gaps.
Why (root cause)?: The U.S. lacks universal health coverage, creating structural barriers where access to essential medications and care is contingent on insurance status rather than medical need. This leaves physicians to improvise workarounds for patients who fall through the cracks—a system design problem, not a clinical one.
Impact Analysis
Impact analysis is the assessment of the potential consequences and effects that changes in one part of a system may have on other parts of the system or the whole.
Patient: Cannot afford life-saving anticoagulation or essential medications for newly diagnosed chronic conditions, dramatically increasing the risk of recurrent pulmonary embolism, uncontrolled diabetes complications, cardiovascular events, and preventable death. The patient faces an impossible choice between financial survival and medical survival. Without access to follow-up care, they have no monitoring, no medication adjustments, and no safety net—leaving them to navigate complex chronic disease management entirely alone. This information and access gap breeds anxiety, reduces any chance of treatment adherence, and forces them back into emergency-only healthcare utilization.
Clinician or Provider: We feel professionally and morally helpless when insurance status—not clinical need—determines whether a patient can access treatment. Discharge planning for uninsured patients requires hours of additional work navigating patient assistance programs, hunting for samples, coordinating with social workers and pharmacists, and piecing together makeshift solutions that we know are inadequate. We write prescriptions knowing they likely won't be filled. We document discharge plans knowing they won't be followed. We operate with the persistent, demoralizing awareness that we're sending patients into dangerous transitions of care without the resources they need to survive. The cognitive and emotional burden of improvising workarounds for systemic failures contributes directly to burnout and moral injury.
System: Uninsured patients generate significant uncompensated care costs. But the downstream costs are even more staggering. When patients can't afford medications or follow-up care, they return sicker—often via the emergency department or readmission within 30 days. Preventable readmissions alone cost Medicare billions annually, and hospitals face financial penalties for excess readmissions. Medication non-adherence driven by cost imposes an estimated $100 billion burden annually on the healthcare system through preventable complications, hospitalizations, and emergency visits. These patients cycle through the most expensive care settings (ED, inpatient) while being systematically blocked from the most cost-effective interventions (primary care, chronic disease management, preventive medications). The result is a system that spends more money achieving worse outcomes—a textbook example of penny-wise, pound-foolish policy translated into human suffering.
Solution
Here's what my team and I did—so when you face a similar situation, you'll have a framework to follow.
First: involve social workers. They're experts at navigating these challenges. Our social worker helped us obtain 30-day supplies of all medications. But that's it—30 days. Clot treatment requires a minimum of three months. Diabetes, blood pressure, and cholesterol management are lifelong. The clock was ticking. He needed a follow-up appointment within 30 days at the latest.
Second: secure that follow-up appointment. Anyone discharged should have a post-discharge appointment within two weeks—this is linked to better outcomes. But getting an uninsured patient into even my own health system proved nearly impossible. Fortunately, NYC Health + Hospitals has extensive resources for patients like this. After some calls and coordination, we got him a primary care follow-up within a week, plus financial assistance. Once connected to care, the NYC H+H social worker would help navigate Medicaid enrollment.
Third: have backup plans. We criticize redundancy in healthcare, but sometimes it prevents errors and inefficiencies. I used GoodRx to get coupons for his generic medications—olmesartan, atorvastatin, and insulin lispro—just in case he missed that follow-up and would otherwise pay for his meds out of pocket. The challenge was anticoagulation, as both apixaban and rivaroxaban cost hundreds of dollars for a month's supply. The alternative was warfarin, but for someone without reliable access to care, a medication requiring frequent monitoring and titration would be unworkable.
This was our solution. It worked. We played the best game we could with the cards we were dealt. Shout out to NYC Health + Hospitals.
Now—what's the actual solution to prevent this from ever happening again? Universal healthcare.
But that's an idealistic expectation.
So, assuming complete healthcare system reform is off the table, the next best solution is optimizing what we currently have:
Medicaid: Make the program more robust. Actively find and enroll at-risk people—which would improve individual care and prevent downstream costs (ED visits for primary care issues, missed preventive screenings, etc.). Unfortunately, the current administration is working against this.
Lower Drug Prices: I've discussed this at length before. The Inflation Reduction Act includes apixaban and rivaroxaban on its list of drugs to be negotiated. The Trump Administration is encouraging drugmakers to lower prices. Cost Plus Drugs provides cheap generic alternatives to brand names. GoodRx has offered coupons for years. Any solution like these would help.
Increased funding for public hospitals like NYC Health + Hospitals so they can continue being a critical resource for patients like this.
These solutions won't fix the system's fundamental issues, but they'll make them less burdensome to manage.
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