In a recent piece in the New York Times (“Can You Afford Your Medicine? Doctors Don’t Ask”), Allison Bond – a medical student in Boston – poignantly tells the heartbreaking stories of patients who lack the money to afford copayments for prescriptions or doctors visits.  She describes, for instance, a mother and two daughters – recent immigrants from East Asia – who she meets at an appointment with their pediatrician.  The children have signs of growth retardation from malnutrition, evidence of the family’s poverty.  When the mother is told of the $20 copayment, she breaks into tears, knowing she will be unable to afford a return visit.

Bond explores the various reasons why doctors fail to inquire about their patients’ ability to afford health care, and cites evidence demonstrating that out-of-pocket expenses cause patients to avoid care.  I agree entirely that we must be attentive to the reality of rapidly rising out-of-pocket health care costs when prescribing care for our patients, and do what we can to minimize it.

But there is much more to be said of this issue.  First, we have to recognize that the sole justification for copayments (and out-of-pocket medical expenses generally) is in fact to discourage patients from seeking health care, by giving them “skin in the game.”  More precisely, defenders of cost sharing will say that the aim is to deter individuals from seeking unnecessary care, but insofar as most of us are unable to perfectly distinguish unnecessary from necessary care until we’ve been evaluated, the overall effect of cost sharing has always been to reduce care across the board.

No doubt, as Bond emphasizes, physicians – myself included – must be more aware of the financial implications of their recommendations for patients.  Perhaps this is the most the individual physician – in some circumstances – can do.  But left unsaid is whether this is a desirable – or just – state of affairs.

Making medical decisions based on a patient’s financial resources – even if done for the patient’s benefit – will lead inevitably to a system of “class-based medicine,” in which health care decisions are based on a patient’s means instead of the best medical evidence.  Bond is right that physicians must ask patients if they can afford their medicine, but that’s a weak remedy for a grave illness.  Cost sharing is entirely unnecessary; other industrialized countries have little or none of it.  By talking about costs but not changing the system, we tacitly legitimize the status quo, in which poor families have to choose between copayments and groceries.