Several years ago, while working in the safety net system for Louisiana, I received a call from the medical director at a small rural safety net hospital, who needed help to urgently transfer a patient for life-saving treatment. 

The patient was a 45-year-old man who worked in construction for a small firm that did not offer health insurance. He was being treated for an infected heart valve when he suddenly developed altered mental status. A CT scan showed a subdural hematoma, a condition that is treatable with prompt neurosurgical attention. Regional hospitals, including some with available operating rooms and willing neurosurgeons, refused the transfer because the patient was uninsured. The medical director called 17 hospitals that day in a desperate attempt to transfer the patient without success. The patient died later that evening. 

This occurred during the national debate about the passage of the Affordable Care Act (ACA). Several months after the patient’s death, I called his mother to ask if I could tell his story to demonstrate the hard consequence of being uninsured. She agreed (and subsequently testified at a state legislative hearing) but quickly became hesitant. “This is not about Obamacare is it?” she asked. “Because we’re against that.” The abhorrent performance of the health system earned her mistrust that day and that mistrust extended to the federal program that would have literally saved her son’s life. 

While the number of similar cases is no doubt lower in the decade since the passage of the ACA (and the expansion of Medicaid by 38 states and the District of Columbia), 30 million people in the U.S. remain uninsured. Access to health care remains largely a factor of geography for many of them. In Texas, nearly one in four nonelderly adults is uninsured. A few large counties like Dallas support a robust safety net, while many smaller counties provide much less assistance. 

Access to health care that varies by county highlights just how far we still must go to achieve equitable health care coverage in the U.S. A few weeks ago, I rounded with our gynecologic oncology team. I heard stories of uninsured women presenting with late stage cancer – the disease progressing while they attempted to find a provider willing to take on their care. They did not have access to services in their counties of residence outside of Dallas, and found care eventually through the Parkland emergency department.

This “out-of-county care” creates competing tension as the local newspaper attempts to quantify the costs and citizens’ groups question why Parkland provides unreimbursed care to residents of counties that do not contribute to that care. Still, in the absence of comprehensive federal or state policies, the solutions often fall to local providers to make it a priority to create more equitable systems of care so people with treatable conditions do not unnecessarily suffer for lack of access in the shadows of some of the most advanced health care in the world.    


Fred Cerise served as the Vice President for Health Affairs at Louisiana State University and is currently the Chief Executive Officer at Parkland Health and Hospital System.