Full Disclosure: Out of pocket costs as side effects

This article, in the New England Journal of Medicine, offers a useful perspective related to the costs of medical treatments, especially for patients that have limited income, as many torture survivors do after arriving in the U.S.  Many torture survivors arrive in the U.S. with injuries they incurred during torture and were unable to obtain medical care for in their home countries.  Most torture survivors who are seeking asylum in the U.S. are not eligible for health insurance as they go through the asylum process in an attempt to obtain legal immigration status and safety.  Some may become eligible for health insurance once they obtain a work permit and find full-time employment.  Some torture survivors are able to access health insurance through state or local programs.  Others arrive with refugee status and obtain asylum status here and are eligible for federal health insurance programs.  Those that are not eligible for health insurance often access medical and dental services through free or low-cost clinics or emergency rooms. 

Many countries and cultures have very different medical systems than the U.S.  In many countries, when medical care is available, patients need to pay for the treatment upfront, before any care or treatment is received.  An inability to pay equals an inability to obtain needed medical care.  The U.S. system, in which people can access care without upfront payment can be a welcome surprise to someone in need of care, though survivors are often unaware of the costs that will be incurred or the repercussions for the inability to pay medical bills after care is received. 

Another difference of note is that in many cultures it is considered disrespectful to ask questions of someone in a powerful position, such as a physician or a lawyer.  This is true even if the questions are related to medical care or treatment.  Providers within torture survivor programs often provide education and support to survivors about their rights and responsibilities related to understanding their medical conditions, treatments, and options and the importance of asking their medical providers questions.  One can imagine that if it’s difficult to ask a physician a question about a medical condition, it may be much more difficult to ask about the cost of treatment and care, especially if one has little or no income.  Even when a survivor has medical insurance, he or she may have difficulty understanding how it works (as it may be the first experience with it) and may not understand or appreciate how, when, and why certain services are covered and when they’re not.  The cost of medical care in the U.S. may also be much more expensive than in their home countries which may be something survivors are not expecting.

Although it is not expected that physicians can provide thorough education about the differences between the U.S. medical system and that of a survivor’s home country, it’s important to be aware of these differences and how they may impact the care provided and received.  It would be useful for all staff of medical clinics working with survivors to be aware of this to help educate and support patients as they learn to navigate the U.S. medical system.  Obtaining safe and appropriate medical and dental services is essential to the healing process of torture survivors.  Physicians being aware of costs and willing to have conversations about this may help empower survivors in their healing process.

Peter A. Ubel, M.D., Amy P. Abernethy, M.D., Ph.D., and S. Yousuf Zafar, M.D., M.H.S.; N Engl J Med 2013; 369:1484-1486; October 17, 2013; DOI: 10.1056/NEJMp1306826

Related webinars

These two webinars discuss medications and torture survivors:


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