Working for a Failing System

In this special issue of AFT Health Care, several economists and researchers answer a fundamental question: Why is it so hard to make ends meet? While the full story is complex, there are two simple truths we should all keep in mind. First, wages haven’t risen as quickly as they could or should have since the late 1970s; instead, as productivity rose, the gains went primarily to the people who were already ultra-wealthy. Second, a variety of policy choices (like cutting taxes for wealthy people while eliminating insurance subsidies) are forcing working people into debt for basic necessities like healthcare, utilities, medications, and groceries.

The scholars’ explanations offer critical insights, but we wanted to call attention to our members and the people they care for: What does our inequitable economy—and the resulting affordability crisis—mean for them? Few people want to talk about being in debt; even though our society is structured to make debt all but impossible to avoid, it seems like anything beyond a mortgage is taboo. We’re grateful to the three members featured here for sharing their stories.

–EDITORS

I’m an oncology infusion nurse in a 25-bed critical access hospital in Southeast Alaska. My four-year-old son has a cleft lip and palate, and he needs specialized care that isn’t available at my hospital. We do as many telehealth visits as we can with the craniofacial and ear, nose, and throat specialists at Seattle Children’s Hospital, but we still have to travel to Seattle sometimes, including for two separate surgeries so far. My son’s care team is great and does its best to cluster the in-person appointments, but we still can’t avoid staying at least one night in Seattle—and that’s the best-case scenario. It doesn’t leave a lot of leeway for clinicians who run late, for Seattle traffic, or for any of the challenges of traveling with a young child.

In addition to the few hundred dollars in coinsurance for clinician visits, I spend about $2,000 for flights, transportation, hotel, and meals each time we travel to Seattle. My health insurance covers two flights a year to Seattle for my son and me, but it doesn’t cover any other travel expenses—or airfare for my son’s father. Even worse, it can take several months to get reimbursed for the flights. In the meantime, I’ve got the cost of that airfare sitting on a credit card and drawing interest, unless I can afford to pay it out of pocket.

My son will need additional surgeries as he gets older, so I know that during the years he’s going to have surgery I’ll need to set a few thousand dollars aside to pay the deductible, in addition to the travel costs. But that’s money that I can’t spend on other necessities or save against future emergencies.

I see the financial challenges I deal with magnified in my patients’ lives. We’re in a rural part of Alaska where many patients are insured by some combination of Medicare and Medicaid. My colleagues and I often help patients apply for financial assistance through the hospital and get treatment-related expenses reimbursed by local cancer charities.

Recently, a newer patient brought in a stack of receipts to work on the reimbursement paperwork during her chemotherapy infusion appointment. When I asked if there were other expenses she was struggling with, she told me she couldn’t really afford her utilities. Housing and other expenses aren’t reimbursable by the cancer charities, so her options were limited. She was paying utilities by credit card, accumulating more debt with every month she couldn’t pay the balance. Although charities were filling in some gaps, it wasn’t enough. It’s extremely disheartening to see her struggle financially, all while dealing with all the fatigue and nausea and vomiting that come with chemotherapy.

–Caitlin, RN 
AFT member in Alaska

I’m an ED nurse, and I’ve worked for the same Connecticut health system for eight years. Three years ago, my husband and I used IVF treatment to get pregnant. We were on a high-deductible health insurance plan that covered most of the costs, but we still had to put $12,000 in out-of-pocket costs on a credit card, which we’re still paying. My husband had just paid off dental care from six years ago, and immediately we were in debt again.

Meanwhile, my health insurance premiums have increased significantly and are now up to about $1,000 a month for my husband, my daughter, and me. But the policies cover less and less, especially since my employer switched providers. We want to expand our family, but with the new insurance, I have only $10,000 in lifetime IVF coverage for my care team, which is in-network but not in the new policy’s “preferred” tier of providers. After two unsuccessful embryo transfers, we put another $6,000 on my credit card for a third transfer attempt, plus the cost of IVF medications, which aren’t covered. We were devastated when that attempt ended with a miscarriage and D&C at nine weeks. Now we’re worrying about those bills and whether we can afford to take on even more credit card debt to try with the two embryos we have left. It’s all more stress on my health and on our family.

At my hospital, many patients are uninsured because they make too much money for Medicaid but not enough to afford Marketplace insurance—especially now that the Trump administration and Republicans in Congress refused to extend the subsidies for Marketplace insurance. One patient, a type 2 diabetic in his 50s, has been trying to string out his insulin because he can’t afford it. He also can’t afford the healthier groceries that would help him manage his blood glucose. He recently came to the ED with blood glucose in the 1,000s and needed to be admitted—but when the registrar came to do the paperwork and the patient found out the ED visit alone was going to cost him at least $3,000, he decided to leave against medical advice. He didn’t have the money, and he didn’t want to miss work. I told him that if he went home, he’d probably be too sick to work, but he insisted.

Trying to convince people to stay has become a big part of my job. Our hospital offers payment plans, but sometimes patients can’t afford those either. We don’t have enough social workers at our hospital to connect patients with assistance or case management. With the increase in demand and limited resources, it’s been challenging to help all our patients get the help they need.

–Kate, RN
AFT member in Connecticut

I am a critical care nurse at a large academic medical center in central Ohio. I’ve seen over and over how inadequate insurance coverage and medical debt impact patients’ ability to receive care with dignity in their own homes. One patient was required to receive an IV infusion because her insurance wouldn’t pay for a daily oral antibiotic that would have cost thousands of dollars. Instead, she had to have an invasive line placed in her body for several weeks, increasing her risk of infection. And because of the high cost of infusion supplies, she had to be treated at an extended care facility instead of in her home.

Unfortunately, I’m used to caring for patients who have ended up in critical condition because they can’t afford care for issues that could have been managed or treated. I know it’s not just part of the job. It’s the result of a system that’s failing—and it doesn’t have to be this way.

Lately, it’s been hitting closer to home. Because of a bill that President Trump signed into law in July 2025, my retired parents saw their insurance premiums increase by over $1,000 per month. They couldn’t afford that on their fixed income. They still have Medicare, but dropping their secondary insurance coverage has significantly increased their out-of-pocket expenses for prescriptions and other medical services. It has also affected the decisions they make about their care. Now, they bundle their preventive care services to avoid paying egregious fees, or they delay care altogether. My mom told me she’s scared that if something happens, the bills will just pile up, and they could lose their house—so she just doesn’t go to the doctor unless she absolutely has to. My dad, who suffers from chronic nosebleeds, is attempting to manage his health at home instead of making an appointment with an otolaryngologist.

I worry about the financial fallout if either of my parents has a serious health issue. They already have to live very frugally, only buying gas to get around and the groceries they need to survive. It’s disgusting and really frightening the way things are headed.

–Rick, RN
AFT member in Ohio

[Illustrations By Nicole Xu]