I was behind schedule (again). My next patient was Helen, a non-compliant diabetic that hadn’t been into my office in over two years. Her blood sugars weren’t controlled at her last visit when I’d tried to impress on her the serious health problems that could develop if she didn’t take better care of herself.

Clearly, I’d failed. Maybe I’d even chased her away? No pill I prescribed would help her diabetes if she didn’t refill the prescriptions.

I knew her insurance didn’t cover much. One of the reasons she didn’t take her pills faithfully was financial (although her pride wouldn’t let her admit this). I prescribed generic medications whenever possible and gave her coupons when I couldn’t. I also explained how to appeal directly to drug companies for patient assistance.

Helen always rebuffed my efforts claiming she and her husband made too much money to qualify. Like many of my patients, though, she seemed to be barely scraping by. “I can afford medicine,” she insisted. But who could afford drugs with co-pays of $50 to 200 a month, especially when taking a half dozen?

I believed my words fell on deaf ears. I was wrong. She wasn’t ignoring my advice. She just couldn’t follow it.

I took a deep breath before knocking on the exam room. I felt defeated already. There was no way I could fix her problems in 15 minutes. A direct approach would be quickest, but I knew it wouldn’t help to lecture her. She might not come back again.

I opened the door and saw her slumped over in the exam chair. She barely looked up. Sometimes my patients felt ashamed when they returned after a long absence, especially if they didn’t (or couldn’t) follow my suggestions.

But this was different. Helen didn’t look well.

I tried to be cheery to show her there were no hard feelings. We could just pick up where we’d left off. “Good morning, Helen!”

“I’m sorry I haven’t been in to see you,” she mumbled barely glancing up from her lap.

“Don’t worry, you’re here now. I hope you stayed away because you felt so good,” I said with more optimism than I felt.

Helen started to cry softly. I sat down next to her and cautiously reached for her hand. She wasn’t a particularly affectionate patient. In the years I’d known her she’d been through some difficult times, but she’d never asked for help. To my surprise, though, she didn’t push me away. I gave her hand a gentle squeeze of encouragement. After a brief silence she began to talk.

She explained that she hadn’t been into the office because she’d lost her health insurance after her husband got sick and lost his job. Sadly, this wasn’t the first time I’d heard this. I’ve seen many patients without health insurance stagger into my office when they could no longer ignore the need for a doctor. I recently saw a patient with pneumonia that had progressed to near respiratory failure. He was so sick that I sent him directly to the hospital by ambulance where he incurred outrageous medical bills.

My own mother continued to work as a nursing supervisor to keep her health insurance despite a steadily progressive shortness of breath (that we later discovered was due to serious heart issues). When she finally did leave her job, she was forced to pay an enormous monthly premium to keep her insurance until she qualified for Medicare.

I also knew personally what it was like to not have health insurance. I was kicked off my parents’ plan when I went to college and had no insurance in medical school. I avoided doctors, too.

Helen’s husband grew sicker. Much like his wife, though, he was stubborn. He didn’t want a handout, and he didn’t want to become a financial burden to his family by amassing huge medical bills. Helen pleaded with him to go see a doctor, but it was no use.

He died.

I gasped. “He died?” I whispered, pulling her closer to me.

“He died,” she choked through her tears.

I was shocked. I was sad. I was outraged! How could my country allow this to happen? I read recently that not having health insurance increased the risk of death by 40 percent. More than 45,000 people die every year in the United States from preventable causes because they don’t have insurance and are afraid to seek help. Who can blame them? Medical bankruptcy isn’t rare.

Even before she lost her insurance, though, Helen had suffered in our fragmented health care system. Like many Americans, she was under-insured. She had insurance that she was afraid to use because of high deductibles and copays. These expenses kept her from doing routine blood work to monitor her diabetes. She also skimped on her medications, taking her pills every other day, or cutting her pills in half to make them last longer. She was labeled a “non-compliant patient.” But whose fault was this?

Despite spending more than twice as much as the next highest-spending country on health care, Americans are not healthier. In 2014 the Commonwealth Fund ranked the United States 11th in health performance, trailing behind most of the developed world.

None of these cold numbers helped Helen, though. At 62, instead of enjoying her retired life with her husband she was a grieving widow in poor health herself.

I desperately wanted to address a few of her health issues in the minutes we had left together. I was afraid if she left now, I might lose her for another few years.

Helen wiped away her tears, pulled herself upright and spoke.

“I’ll do my blood work this week and make an appointment to see you next month,” she said standing to leave. She’d put her stoic mask back on to face the world.

“I haven’t been a good patient, but I’m going to be better,” she said as she left.

What more could I ask?

Jen Baker-Porazinski is a family physician who blogs at Pound of Prevention.

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