The following blog post is from Kreena Patel, MD, MPH who is a full-time primary care physician with experience serving a diverse patient population, including patients in metro Atlanta. Her perspective as a practicing physician can help inform the ongoing discussion around health care access and affordability, particularly for Georgians with low incomes.
“I can’t afford to see you anymore.”
As a primary care physician practicing in the metro Atlanta area, I have heard this statement from my patients far too many times. When the ACA marketplace tax credits expired at the end of 2025, a patient told me “I can’t afford to keep my health insurance for next year so this is probably the last time I’ll see you for a while. Can you fill my medications for six months?”
Patients with high deductible plans, which require them to pay for the full cost of care until they meet their deductible amount, ask me, “Can I come back in six months instead of three? I can’t afford the office visits.”
Every time a patient says something like this to me, it crushes me. I spent over a decade training to become a physician, learning the best practices and guidelines for how to care for a wide variety of conditions as a primary care physician. And yet, none of that education and hard work ends up mattering when a patient cannot afford their care. For me, this is one of the harshest realities of the American healthcare system and one that I hope to see fixed in my lifetime.
I entered into medicine knowing the patient population I wanted to care for - the underserved, those patients who fall through the cracks and are often forgotten. My first job in Phoenix, Arizona was my ideal job at a Federally Qualified Health Center (FQHC), which is a type of clinic that receives federal funding to help care for patients with Medicaid and without insurance. The work was hard, often seeing over 20 patients a day with complicated medical issues and significant social barriers to care, from lack of transportation to lack of insurance. However, we had a robust support infrastructure of dietitians, social workers, behavioral health techs and a nurse who helped me address these issues for patients while I focused on the medicine. When a patient lacked insurance, my social worker team helped them sign up for our discounted sliding fee program or set them up with the process to apply for Medicaid.
When I moved to Atlanta in 2024, I started working at an FQHC here. I thought I knew what I was getting into based on my previous experiences at the FQHC in Arizona. I quickly learned that reality was very different. In Georgia, I had none of the support staff I was accustomed to having. When a patient had questions about insurance, or how to apply for our sliding fee program, I was the one explaining to them how to enroll in ACA Marketplace insurance or apply for sliding fee. My patients struggled with the complex generational traumas of structural racism and poverty, and it was not uncommon for patients to tell me that a loved one had been shot and killed or that they were unable to afford stable housing. Where in Arizona I could have a behavioral health specialist spend 30 minutes processing this huge grief with a patient, I found myself spending that time with them. To me, there was no alternative option. My job is to help patients be healthy and if that required helping them get insurance or being their therapist, that’s what I did. But wearing all these different hats took its toll on me and stretched me thin.
I often wondered why, despite working at the same type of clinic, my experience was so different in Arizona versus Georgia. It didn’t take long to figure out the answer. Arizona had expanded Medicaid, and Georgia had not.
I felt this difference in funding in my day-to-day life, not only in the lack of support and resources for my patients, but also in the affordability of care. In Arizona many more people were insured via Medicaid expansion, giving them very affordable access to care. They had no co-pay or a very minimal one for their visits with me, which was incredible. I would see my most complicated patients monthly, or sometimes more, until we got their medical issues under control.
In Georgia, without Medicaid expansion, many of my patients purchased insurance through the ACA marketplace. These plans still required patients to pay a variety of costs, including a co-pay every time they saw me. I had a patient with uncontrolled high blood pressure who I saw once a month, taking the same approach that had worked so well for me previously. After three months her blood pressure was improving but still high. She told me she couldn’t afford to keep seeing me monthly because the co-pays were adding up. Another patient with multiple chronic medical issues, requiring frequent visits with me and specialists, informed me that she could not follow up in one month to adjust her blood pressure medications because her Medicaid only allowed 12 visits per year without prior authorization.[1]
There are few things more disheartening than having to choose between what I know is medically right for my patients and what they can afford. The cumulative burden of making this choice multiple times a day with my patients, combined with exhaustion of being not just the doctor, but the social worker, dietitian, and so much more, wore me down. After one year working at the FQHC, I left. It was a hard decision, but I knew the immense burn out I was feeling would only get worse if I stayed.
My current practice sees primarily patients who have health insurance through their employer or elderly patients with Medicare. But still, the same challenges with affordability exist. A few months ago, I saw a patient who worked as a manager in the service industry with very uncontrolled high blood pressure for the first time. She had been to the emergency room several times for chest pain and high blood pressure and was feeling frustrated and distrusting of the medical system because her numbers were still high. Thankfully, we established a trusting relationship and I saw her every two to four weeks to work on adjusting her blood pressure medications. She had a high-deductible plan and each visit cost her around $300. These visits added up but it was worth it to her because we were finally making progress on her blood pressure.
I last saw her about two months ago. We had been working on a temporary reduced work schedule while we were getting her blood pressure under control but her employer was not willing to accommodate it. She lost her job. She saw me for one last visit before her employee sponsored insurance was cancelled, worried about what was going to happen to her health without insurance. She can’t afford COBRA and cannot afford a plan on the Marketplace either with the premiums having gone up so high. She looked at me and said “This is probably the last time I’ll see a doctor until I get a new job with insurance. Can you fill my medications for six months?”
This is the reality of the American health care system. It doesn’t matter who you are, your background or your socioeconomic status. Health care is unaffordable. Every day, patients and providers are forced to decide between what is medically right for a patient, and what they can afford.
For patients insured through the ACA or employer plans, high cost-sharing presents a huge barrier to care. Cost-sharing through co-pays or deductibles has often been used to reduce health care spending. When patients must pay for their care they are less likely to seek care, which saves money. However, high cost-sharing also means that patients are less likely to seek out necessary medical care. When this happens patients often progress to having preventable complications that are expensive to treat. I have seen this scenario play out all too often: a patient with uncontrolled high blood pressure ends up in the hospital with a heart attack or a stroke, a diabetic patient has a toe amputation because of uncontrolled diabetes and so on. We need to cap cost-sharing and ban high-deductible plans so that patients don’t have to pay exorbitant amounts just to access care. This would require both state and federal level policy changes, such as replacing high-deductible plans on the ACA marketplace with co-pay based plans.
While tackling the high-cost of health care seems like a daunting task there are concrete steps that can be taken to reduce costs and improve accessibility. In Georgia, one of the simplest options is to expand Medicaid. Currently, most low-income adults aged 19-64 without children are ineligible for Medicaid. They may be eligible for Georgia Pathways to Coverage, but only if they meet certain work requirements and make less than 100% of the federal poverty line, which is an annual income of $15,960 per year.
Expanding Medicaid would unlock a new, affordable insurance option for over 300,000 uninsured Georgians with household incomes less than 138% of the federal poverty line, which equates to an annual income of $22,025 for one person. Currently, some of these patients are eligible for ACA marketplace plans for insurance (known in Georgia as Georgia Access). However, because Congress failed to extend the enhanced premium tax credits at the end of 2025, premiums have skyrocketed. Already more than half a million Georgians have lost health insurance because they are unable to afford the premiums for ACA marketplace plans. Medicaid expansion would be a lifeline for some of these patients.
In addition to improving access to health care for Georgians, Medicaid expansion is also a smart financial choice for Georgia. With Medicaid expansion, Georgia would receive federal funding for Medicaid to pay for 90% of the cost of care for expansion enrollees compared to just 66% federal funding Georgia receives for enrollees in Georgia Pathways. Medicaid expansion would allow more Georgians to have access to health care while also bringing new money into the state. To me, this is a no-brainer. Medicaid expansion is a moral and financial necessity for Georgia.
I am not sure which path Georgia, and the US will take towards improving affordability and access to health care, but I know that change is necessary. Too many people live without health insurance and even those with insurance still struggle to pay for it. As their doctor, I am stretched thin, worn down by the weight of having to navigate this broken system. Without meaningful health care reform, I fear that many doctors will leave the field of medicine altogether. Every time a patient tells me, “I can’t afford to see you anymore,” I jump into problem solving mode and help figure out how to get them the care they need. But when I leave the exam room, I think to myself, “I can’t do this anymore.”
[1] Medicaid State Plan, https://medicaid.georgia.gov/organization/about-georgia-medicaid/medicaid-state-plan