Pharmaceutical companies have programs for poor patients, but they are usually Band-Aid approaches, rife with restrictions, rules, paperwork and bureaucracy, and are available only if a doctor takes the time to apply and then reapply for the program for each patient. Some of these programs are generous, but with so many pills and so many policies, hunting for discounts often overwhelms harried doctors and pharmacists.

Grady Memorial Hospital was established 107 years ago by wealthy citizens who wanted to live in a city where the less fortunate could receive healthcare. Eventually, the two Atlanta county governments--Fulton and DeKalb--levied a property tax to support the mission of the hospital. Between 1891 and 1999, the metro Atlanta population has grown from 65,000 to 3.5 million, and the metropolis has spread over thirteen counties. These counties have never contributed comparable tax dollars to assist with the healthcare for their poor populations. Approximately 5,000 doctors, hundreds of private clinics and dozens of hospitals are now in the business of providing medical care in the Atlanta area, but they want customers who can pay their bills, ideally those with health insurance.

Grady is a magnet for the medically indigent. As a public hospital with a sliding-fee scale, it serves people who have no health insurance or have lost it, as well as former welfare recipients who are now working and thus no longer qualify for Medicaid. In a sense, it is not only a charity for poor people but also for private hospitals. Those hospitals make a profit off patients while their insurance lasts; then Grady takes up the slack so those hospitals don't have to. Grady also ends up underwriting healthcare services for companies that provide inadequate or no health coverage for minimal-wage employees. Wal-Mart's health plan, for instance, does not cover medicines for the first fifteen months of employment, so those workers might go to Grady for prescriptions they can afford. Meanwhile, Grady has been steadily losing financial support from the county governments.

Similar factors threaten the financial viability of public hospitals across the country. And, similarly, many of these institutions are trying to solve their financial woes by cutting pharmaceutical services. Charity Hospital in New Orleans gives indigent inpatients a three-day supply of medications when they are discharged; after that there are only minimal discounts, if any, and you have to pay up front. The Medical College of Georgia Hospital in Augusta attempted to close its pharmacy completely; it retreated under pressure from the state. The University of Texas hospital in Galveston substantially raised its co-pay, to $10 to $45 per drug, and in Brooklyn, Kings County Hospital charges its indigent patients $10 per drug per month.

The medication crisis manifests itself differently in communities that cannot support public hospitals. There the problem appears in clinics and doctors' offices. In a small rural community clinic in South Georgia near Albany, one nurse reports spending 25 percent of her day searching for, applying for or reviewing applicable programs funded by pharmaceutical companies. Dr. Jack Birge, a private practitioner in Carrollton, Georgia, has been so frustrated by the paperwork, rules and bureaucracy that he's given up applying for these programs. A family physician in rural California has bypassed the system altogether by asking family members of dead patients to bring in their unused medicines so he can keep his living patients alive.

Patients develop their own dangerous innovations. They might take their medications every two or three days instead of daily as directed. A physician assistant in rural Pennsylvania reported that a mother came into the office with one child suffering from pneumonia, planning to get a prescription for him and then split the drugs among her four other children who were sick. In North Dakota, physician assistant Jackie Hollevoet stated that many of her elderly patients who have multiple diseases, such as diabetes, high blood pressure and arthritis, roll the dice and buy the medication for the one disease they perceive to be the most serious. Health provider Daniel Lynam in Elizabeth City, North Carolina, says that his patients often just do not show up for appointments when they can't afford medications. He visited one patient at home and gave him the money for his medicines. The patient was so thankful that he offered Lynam two live chickens.

Another patient, a 55-year-old woman in Hamilton, Georgia, who was applying for a job as a nanny, had a stroke, and now half her body is paralyzed because she could not afford her blood pressure medicine. A 67-year-old retired lumber worker was found dead in his house in the woods outside Morristown, Tennessee, because he could not afford his insulin. Nor is it necessarily the case that the injuries of missed medication will always be confined to an ailing individual. A school bus driver in North Carolina who could not afford insulin had such high blood sugar levels that she was driving the bus while dizzy.

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