"What kind of insurance does she have?" asked the orthopedist's office secretary. The question was both forthright and expected. "Does it matter?" I queried, as I struggled to get my patient a necessary consultation. But I knew the reality that Medicaid and uninsured patients go to clinics, not private offices to see residents (like myself). They wait in large, impersonal rooms for their name to be bellowed through the door or over a loudspeaker. Their referral delay is 2 to 3 months, not 2 to 3 weeks. When they have an acute problem, they may be put on hold unless they have the sacred "back" number. They get shuffled every year or few years from one resident to another and to a different attending physician each time they are hospitalized. They are admitted to wards rather than private floors. Perhaps most tragically, Medicaid recipients and the uninsured are stereotyped as being unemployed, on drugs, mentally ill, or just plain feeding off the system. This is the reality of our two-tiered, or two-class health care system.

Still, one argues, don't knock the care offered by residents. It is how we all were trained, and some care is better than none. But why should some members of society be training ground and others not? It is a disgrace to let health care be a commodity under the assumption "You get what you pay for, and if you can't pay for it, you get even less." It should be a right based on humanness, not income.

This is old news, I know, and maybe that is the problem. We have grown too accustomed to a two-tiered system of health care, to "the clinic" and "the wards," serving two different populations. We acknowledge matter-of-factly that new internists (my colleagues) in private practice cannot routinely accept Medicaid patients because of poor reimbursement. We are not surprised that poorer communities display higher acuity on presentation for care—"they don't have insurance, so they don't show up until they're really sick." We marvel that a Medicaid or uninsured patient can get intensive care, bypass surgery, or a liver transplant—only in America, right?—yet many frail and elderly go without a flu shot, and too many mothers get inadequate prenatal care.

I am not an economist or a politician, but a young physician who without much effort can see the unjust and unhealthy state of our health care system. We may have to make tough choices about rationing health care, but I would rather it be a debate over what is included rather than who is included. It is time we stood up for the powerless underinsured; our society will be judged by how we treat the materially poor, including the medically underserved.