It was a relatively small abscess at the base of Angel’s wrist. Angel lived in an abandoned building in Southwest Detroit. Angel was a long-term drug user.  Angel was a citizen, but had little schooling and was predominately non-English speaking. She was born in and grew up in Chicago. Angel came to the syringe exchange program where I was working, and presented with the abscess. We referred her to the nearest clinic, which in this impoverished neighborhood was almost an hour’s walk. Such abscesses are common in drug injectors and can generally be treated easily and inexpensively as an outpatient.  Angel did not have a car, and did not have bus fare. She did walk to the clinic, only to be turned away. While Angel had Illinois Medicaid, the clinic would not see her because they saw patients only with Michigan Medicaid. She had previous bad experiences with perceived discrimination and stigmatization in other care settings, and being turned away felt normal. She did not know she had other options. Angel was soon admitted to the hospital and was found to have an infection that had spread to her blood (she had “sepsis”). She required a month long hospitalization, and two surgeries on her arm before she was eventually released alive but with enormous permanent scars on her arm. Angel had health insurance and would be considered by many to have “health care access,” however due to multi-level barriers including stigmatization, lack of transportation, arcane insurance restrictions and regulations, to her own learned fatalism, Angel’s inexpensively and easily treatable abscess came to require a month-long hospital stay with both worse clinical outcomes and vastly greater societal expense.

It was a relatively small abscess at the base of Angel’s wrist. Angel lived in an abandoned building in Southwest Detroit. Angel was a long-term drug user.  Angel was a citizen, but had little schooling and was predominately non-English speaking. She was born in and grew up in Chicago. Angel came to the syringe exchange program where I was working, and presented with the abscess. We referred her to the nearest clinic, which in this impoverished neighborhood was almost an hour’s walk. Such abscesses are common in drug injectors and can generally be treated easily and inexpensively as an outpatient.  Angel did not have a car, and did not have bus fare. She did walk to the clinic, only to be turned away. While Angel had Illinois Medicaid, the clinic would not see her because they saw patients only with Michigan Medicaid. She had previous bad experiences with perceived discrimination and stigmatization in other care settings, and being turned away felt normal. She did not know she had other options. Angel was soon admitted to the hospital and was found to have an infection that had spread to her blood (she had “sepsis”). She required a month long hospitalization, and two surgeries on her arm before she was eventually released alive but with enormous permanent scars on her arm. Angel had health insurance and would be considered by many to have “health care access,” however due to multi-level barriers including stigmatization, lack of transportation, arcane insurance restrictions and regulations, to her own learned fatalism, Angel’s inexpensively and easily treatable abscess came to require a month-long hospital stay with both worse clinical outcomes and vastly greater societal expense.