Reflections from Liberia: Considering Costs of Care, a Poor Problem

“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 eyes pointed down; clearly he was in agony.

He had been admitted to the hospital two weeks earlier with difficulty breathing. He was found to have a lung infection with likely empyema (pus adjacent to his lungs but inside his chest). He already had one procedure that drained 1.5 liters of pus from his left chest. And upon listening to his lungs, we could tell he likely had more fluid or pus in that left side.

We suggested repeating a thoracentesis to drain fluid from the left side of his chest and as we were prepping 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 one should not be asked by the staff for money for services), it was still surprising to hear that question…at that time. The reality is that cost, even for a patient who is dying, is a real concern.

It should have been no surprise that it was this 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 have to think first and foremost about costs of care. They are the ones who have to make such calculations, questioning: should I seek care or risk not paying rent or not having enough to eat? They are the ones who are literally one malady from bankruptcy.

I witnessed this when training at county hospitals in Los Angeles that catered largely to the poor, uninsured or underinsured. There were many patients who delayed care, even allowing tumors to grow from their necks to the size of grapefruits before going to a clinic or the hospital.

For physicians trained in the United States, costs are generally one of the last things to be considered. Throughout training in medical school and residency, we often do not learn about the direct costs of health care for patients. We order tests and perform procedures we believe are best for our patients, often without much regard for the bill that is generated. That would be fine in a system with limitless resources. However those bills, if unpaid, are passed along as higher provider fees and as increased premiums for health insurance. Ultimately, this makes health insurance unaffordable and decrease access to care.

Examples of community-based health insurance plans in Rwanda[i] and studies of Medicaid expansion in Oregon[ii] demonstrate the value of health insurance in lowering the barriers 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.

~E. John Ly, MD

   2012 UCSF Global Health Hospital Medicine Fellow


[i] Rosenberg T. “In Rwanda, Health Care Coverage That Eludes the U.S.” New York Times. July 3, 2012. http://opinionator.blogs.nytimes.com/2012/07/03/rwandas-health-care-miracle/

[ii] Baicker K and Finkelstein A. “The Effects of Medicaid Coverage — Learning from the Oregon Experiment” NEJM 2011; 365:683-685

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