Globe Spotlight journalist reports on the link between economic inequality and financial toxicity in health care


Image by Colin Dunn via Flickr

Two of the biggest issues the Democratic candidates are addressing in the presidential race are economic inequality and the need to reform the health insurance system.

In 2016, Liz Kowalczyk, a health care and medical writer for The Boston Globe, rotated onto the paper’s Spotlight team for a project about race to document segregation in the city’s health care system. Soon after beginning that assignment she found an almost ideal source for one of her first articles, a nursing home worker who was diagnosed with stage three breast cancer.

In a new “How I Did It” piece, Kowalczyk, an award-winning journalist, explains how people with serious illnesses who have insurance through their employers end up “buried under back-breaking medical bills for deductibles and copayments.” Those who are on Medicaid also struggle financially because if they are too sick to work, they often don’t have savings to cover the costs of housing and food. The result is they become homeless, which happened to Kowalczyk’s nursing home worker, a woman named Marie Cajuste who was uninsured when she was diagnosed in 2016.

For health care journalists, Kowalczyk’s work can serve as a tutorial on how to cover financial toxicity for several reasons. How she found the woman with breast cancer and then negotiated with her physician about how she wanted to cover the story offer insights into reporting on such a sensitive and personal subject. She asked a photographer, Craig Walker, to accompany her on some of her visits with the patient and she pushed back when the hospital wanted to send a member of the media relations staff to Cajuste’s home when Kowalczyk was there.

The director of the nursing home where Cajuste worked refused to let Kowalczyk and Walker visit Cajuste on the job, afraid that the media attention would reflect poorly on the business.

After Cajuste could no longer work, she and her family members (three grown children and two grandchildren) were evicted from their apartment. When the landlord didn’t agree to an interview, Cajuste offered text messages she had with her landlord that documented the struggle she faced to keep her family there.

Those communications were important to Kowalczyk’s story because they showed how the landlord knew about her diagnosis and still forced Cajuste out.

The Cajuste story and photos are part of a series that Kowalczyk did. In other articles, she reported on how the mentally ill struggle financially when seeking costly inpatient mental health or substance abuse treatments.

Poor and middle-class patients in Massachusetts often can’t find affordable providers, despite that fact that the state has more mental health care providers per capita than any other state and more psychiatrists than all but one state, she wrote. The result: many mental health patients suffer longer than necessary or settle for care by an inexperienced or less-credentialed practitioner, she wrote.

The Globe packaged all of Kowalczyk’s stories in the series under the heading, “Unhealthy Divide.”

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