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March 10, 1989

The Torturer's Horse

JAMA. 1989;261(10):1481-1482. doi:10.1001/jama.1989.03420100117035

WHEN people have no coverage for health care costs and cannot afford to pay for care themselves, the inevitable happens. Health care becomes charity doled out sporadically by those providers who are moved to do so—and not all providers are so moved. However, the lack of access of the medically indigent is not absolute; they usually receive last-minute interventions in emergency departments and delivery rooms. Beyond that, pickings are slim; the eroding availability of nonemergency care in most urban public hospitals has erased even this haven of last resort. These institutions have been overwhelmed by the needs of critically ill and injured patients and pregnant women.

But I do not believe that payment problems are the only barriers that separate the uninsured poor from providers. The gulf that has opened between physicians and hospitals on one side, and vulnerable would-be patients on the other, has darker origins.

For one thing,