Waking Up to the Quiet Injustice of Underinsurance

By Safia S. Khan, MD
July 8, 2025 | VOLUME 3, ISSUE 2

“I have a dream.”

These words, immortalized by Dr. Martin Luther King Jr, have long stood as a call to action against injustice. Today, I invoke them to speak about another quiet but pervasive injustice in our nation: the way we allow access to health care—particularly sleep care—to be dictated by income and insurance status.

I am a sleep specialist. I treat people with conditions like OSA, insomnia, restless legs syndrome, and circadian rhythm disorders. Sleep disorders are not just minor inconveniences; they are linked to heart disease, stroke, diabetes, depression, workplace accidents, and premature death. And yet, for many underinsured Americans, treatment remains out of reach.

In one of the wealthiest countries in the world, patients are still being turned away from sleep studies because they can’t afford the test. CPAP machines—the first-line therapy for OSA—can cost hundreds to thousands of dollars up front and are often not covered fully by insurance, especially for people with high-deductible plans. Home sleep tests have improved access for some, but they’re not available to all and still require follow-up care that can be prohibitively expensive.

I have cared for patients who ration electricity to power their CPAP machines, truck drivers who risk losing their licenses because they can’t afford the sleep study required for diagnosis, and single parents who fall asleep at red lights from chronic fatigue while waiting months for care. These stories aren’t rare. They are the reality of life on the margins of our broken health care system.

These patients are the underinsured—a rapidly growing group who technically have health insurance but whose out-of-pocket costs and limited coverage make it nearly impossible to get the care they need. They live in every state, in urban and rural communities alike. And they are often invisible in policy conversations because they don’t fit neatly into the category of “uninsured.”

I have a dream that, one day, we will stop treating sleep as a luxury and start recognizing it as a fundamental part of public health. I have a dream that access to diagnosis and treatment will not depend on your ZIP code, job, or insurance card. I have a dream that every person with sleep apnea—rich or poor, documented or undocumented, rural or urban—can sleep safely through the night and wake up ready to live fully the next day.

This dream is not radical. It’s rational. We know that untreated sleep apnea increases the risk of heart attacks, car accidents, and lost productivity. The costs to the health care system and the economy are staggering; 50 million to 70 million Americans live with sleep disorders, with sleep apnea affecting approximately 30 million people.^1,2 Yet, this represents only the diagnosed cases.

Research consistently shows that 80% to 90% of sleep apnea cases remain undiagnosed, creating a silent epidemic of untreated disease that costs our health care system upward of $149.6 billion annually in workplace accidents, motor vehicle crashes, and increased health care utilization.^2,3 Providing timely sleep care isn’t just compassionate—it’s cost-effective. It prevents downstream complications and keeps people working, parenting, and thriving.

As physicians, we are taught to diagnose and treat disease—but we must also recognize when the disease is systemic. Our duty does not end with writing a prescription; it includes asking whether our patients can afford to fill it, whether they can get time off work for appointments, and whether they have a bed to sleep in or a machine to breathe through.

Health care advocacy should not be considered extracurricular. It should be woven into the fabric of our clinical practice, medical education, and institutional priorities. As a sleep specialist, I’ve learned to push back on denials, seek out community resources, and speak about the barriers my patients face. But this work shouldn’t be done in isolation—it needs collective voice and systemic action.

What can we do?

We can support legislation that mandates insurance coverage for sleep diagnostics and durable medical equipment without punitive copays. We can build partnerships between sleep centers and community health clinics. We can create national CPAP donation programs, telehealth sleep consults for underserved areas, and public education campaigns on sleep health. And we can train the next generation of clinicians to see advocacy not as activism but as standard of care.

The underinsured are not a special interest group—they are our neighbors, our coworkers, and our patients. And they deserve to be seen, heard, and cared for.

When we allow 80% of sleep apnea to go undiagnosed… when we force patients to travel hundreds of miles for basic care… when we create insurance obstacles that delay treatment for months or years… we abandon our fundamental obligation as a health care system.

The solutions exist. The evidence is clear. What we lack is not knowledge but will—the political and social will to transform a health care system that works for some into one that works for all. Sleep disorders have shown us the way. Now we must choose to follow.

It’s time to wake up to the quiet injustice of underinsurance—and to dream of something better, together.