In the fourth episode of the second season of The Pitt, HBO’s smash-hit medical drama set in a Pittsburgh emergency room, we see an otherwise highly educated doctor learn for the first time about one of the most basic—and to many, familiar—gaps in the American public health system. Dr. Samira Mohan (Supriya Ganesh), a third-year medical resident whose empathy for her patients is matched only by her workaholism, is treating a patient who earns too much to be eligible for Medicaid yet does not receive health care through his employment.
Dr. Mohan’s patient is a construction worker, Orlando Diaz (William Guirola), who collapsed at work due to low blood sugar. He has diabetes but is unable to afford the amount of insulin necessary to keep it in check; he and his wife work multiple part-time jobs, none of which offer health insurance. In a classic television walk-and-talk with case manager Noelle Hastings (Meta Golding), Dr. Mohan asks how Orlando might be able to receive coverage.
“Can they qualify for Medicaid?” Dr. Mohan asks, brow furrowed, referring to the public health care program for low-income Americans.
“Unfortunately, no, because their combined annual income is over the Medicaid threshold for a family of five,” the case manager responds.
“So they make too much money?” Dr. Mohan shakes her head in disbelief. How could this possibly be?
“And not enough at the same time. They live over the poverty line, and yet are still living paycheck to paycheck,” Noelle finishes the thought.
Orlando’s on-screen travails are far from unusual in the real world. Eight percent of Americans—more than 25 million people—are uninsured. Eighty percent of uninsured people are in families earning below 400 percent of the federal poverty line. And in 2024, roughly 57 percent of Americans lived below that 400 percent threshold. In 40 states, eligibility for Medicaid is capped at only 138 percent of the federal poverty level; in the 10 that have not expanded Medicaid under the Affordable Care Act, the threshold is exactly 100 percent.
That this information is somehow new to Dr. Mohan, despite the relative commonality of her patient’s situation, seems odd. After all, this is an intelligent, industrious physician who cares deeply about her patients—one would think that she would be armed with this basic knowledge. I’m not a doctor, so maybe I’m assuming too much about the level of understanding rank-and-file emergency physicians have regarding the basics of the public health system.
But, of course, the idea here is not that Dr. Mohan would be ignorant of the trials of low-income Americans. It’s that The Pitt’s audience is. In this particular scene, Dr. Mohan is not just a character. She is an avatar, an empty vessel to be filled with knowledge that may be completely alien to viewers. Millions of Americans might know about the difficulties of obtaining Medicaid from personal experience, but the writers of The Pitt are assuming that their core audience are not among those with firsthand knowledge. They may be correct. The basic subscription for HBO Max with ads is $10.99 per month, and the “premium” subscription has a monthly cost of $22.99—a financial commitment requiring sufficient disposable income.
Without the possibility of obtaining Medicaid coverage, Noelle concludes that Orlando’s best option is to buy private insurance through the Affordable Care Act. As I was watching this scene, I was struck by Noelle’s use of the full title of the landmark health law, instead of referring to its acronym. But if you only know the ACA as Obamacare, it might be necessary to literally spell it out. On a meta level, the entire scene is a neon sign shrieking, This is important, viewers. Pay attention! Your health care system is leaving people behind!
The complications for the Diazes are layered. As a plot device, this makes them sympathetic characters. But it’s also a chance for The Pitt’s creators to show that they’ve done their health care policy homework. Orlando and his wife, Lorrie (Loren Escandon), are Spanish-speaking, implying that they may be immigrants. Filming for The Pitt began in June and ended in January, meaning that the writers had plenty of time to incorporate some of the changes to the health care system made by the One Big Beautiful Bill Act, the Republican law approved in July that dramatically slashed the social safety net. Executive producer John Wells told Variety last year that the second season would address some of the new law’s changes to Medicaid. (Noah Wyle, who plays senior resident Dr. Michael “Robby” Robinavitch, has a history of protesting cuts to Medicaid.)
But since their household wouldn’t qualify for Medicaid, using the ACA to purchase health care is far from an obvious fix for the Diazes—particularly given the expiration of premium tax credits in the beginning of January. The health research organization KFF has estimated that ACA marketplace premium costs would more than double on average with the expiration of the enhanced credits. For a household earning 288 percent of the federal poverty level, for example, that would be an average increase of more than $1,800 per year. The end result may be a “death spiral” effect, where people choose plans with lower premiums but higher deductible costs, or drop coverage altogether. (With only five episodes out, it’s unclear whether this season of The Pitt will go into that much detail.)
When insurance coverage isn’t possible, the options can be as drastic as medical debt or death. According to KFF, more than 40 percent of American adults reported having debt due to medical or dental bills in 2022. Those adults were disproportionately Black and Hispanic, low-income, women, parents, and uninsured.
“It’s unfortunately very common for people to fall between the cracks. It’s an imperfect system,” Noelle says in the fifth episode. Many medical dramas just tell you that a patient needs 10cc’s of whatever—The Pitt identifies, with perhaps off-putting bluntness, the sickness within the heart of the American medical system.
OK, The Pitt is also a fun and fast-paced medical drama with engaging characters and a level of accuracy that has earned it plaudits from physicians. (If you’re anything like me, you just allow the medical jargon to wash over you like a gentle tide, without ever attempting to actually grasp the wave.) The show could also be viewed as an extended public service announcement; one in which every installment is a Very Special Episode. And since each episode of the show is one real-time hour of a 15-hour work shift at the fictional Pittsburgh Trauma Medical Center, it suggests that health care professionals spend as much of their day navigating the vicissitudes of the health care system itself as they do healing patients. The Pitt wants you to know that we live in a society, and one that often fails its most vulnerable.
I’ve covered poverty policy for several years, including Medicaid; like many professionals with a level of knowledge in a certain field, I tend to overestimate the average person’s understanding of the social safety net; what may be obvious to me could be brand new information to you. (Although hopefully not, if you’ve read my articles about Medicaid and the ACA before.) If you have the money to afford the HBO streaming service without a second thought, you may not realize a family of five, like Orlando’s fictional household, would need to earn less than $38,680 a year to receive Medicaid.
Throughout its inaugural season and the first third of its second, The Pitt has, with varying degrees of subtlety, expounded upon the difficulties that patients face in obtaining adequate care. The first season covered such issues as—deep breath—abortion access, vaccine skepticism, opioid addiction, the coronavirus pandemic, unconscious bias in the medical industry, young men’s mental health, sex trafficking, the safety of health care workers, and gun violence, specifically through the lens of a fictional mass shooting. (And these are only the topics I can remember off the top of my head.) Every episode is peppered with new lessons about how the medical system works and how patients are treated. One installment depicts a Black woman experiencing severe complications after giving birth, highlighting that Black women face disproportionately high rates of maternal mortality and morbidity. In another, a doctor gently chides another for her unconscious bias against an overweight patient.
The second season, taking place over 15 hours during the Fourth of July, has similarly incorporated stories of societal struggles. The pandemic is not the only real-life event that casts a large shadow over the daily lives of The Pitt’s medical professionals. The second episode features a patient who survived the mass shooting at the Tree of Life Synagogue in 2018. The patient tells a Muslim nurse that in the wake of the tragedy, the Muslim faith community had offered particular support to worshippers at Tree of Life. Whether this scene is a gentle renunciation of Islamophobia or a jarring moment of pedantic over-explanation, or somewhere in between, depends on the viewer.
Dr. Mohan’s subplot treating Orlando is only a small portion of the fourth episode, but it addresses a wide range of social issues in just a handful of minutes. Despite being literally necessary for survival for diabetics, insulin without insurance can be exorbitantly expensive; Orlando thus takes a smaller dose than he should, in order to make the medicine stretch. His wife arrives at the hospital hours after he was admitted because she needed to use unreliable public transit to get there, an issue for many low-income individuals without a car. His daughter, Ana (Savannah Ruiz), tries to set up a GoFundMe to help cover his medical costs, demonstrating how often individuals are reliant on charity to help pay their bills—something Orlando heartily resists.
The fifth episode offers some resolution to Orlando’s woes. Noelle tells the Diaz family that they earn too much to qualify for the state-run health exchange or the hospital’s charity program. She offers a payment plan, where the hospital will cover 40 percent of Orlando’s bill. But with costs racking up to $100,000 or more, paying $60,000 presents an incredible burden.
Student Dr. Joy Kwon (Irene Choi)—who before now has been a laconic but unimpressive presence, offering quips and not much else—provides a solution. If they move Orlando to medical-surgical nursing, rather than keeping him in the emergency room, the cost will be lower. With some maneuvering to ensure “med-surg” will take Orlando—it involves switching from an insulin drip to something called a SQuID protocol, and don’t you dare ask me what that means—now the Diaz family is looking at a bill closer to $20,000. Orlando doesn’t love the idea, but his family encourages him to take the deal.
“If the system doesn’t work for you, you’ve got to work the system,” Joy says, revealing that her family pulled a similar trick to care for her dying grandmother. Another win for the good guys! But in The Pitt’s America, as in the real one, victories are always qualified.
Watching the Diazes’ story unfurl, one gets the sense that the creatives involved with The Pitt see it as their moral imperative to educate, as well as entertain (or, frequently, gross out). Perhaps this stems from an assumption that their viewers are disconnected from such struggles. Naturally, many issues are universal and cross racial, gender, and class boundaries; wealthier people will lose parents just as surely as poor people.
But the consistency, and earnestness, of its lessons suggests an even deeper motivation. Television has always had the power to connect viewers with stories that they might not otherwise appreciate; think of how cultural juggernauts like Will & Grace, Modern Family, and Glee encouraged acceptance of gay people in the 1990s, 2000s, and 2010s. It’s not enough for The Pitt’s audience to just learn about the ways in which people struggle. No, they need to have empathy—not just sympathy. And empathy requires information, the knowledge necessary to put yourself into the shoes of another.
In a time when apathy and nihilism are societally ascendant, The Pitt argues, emotions can be extraordinarily powerful. Maybe, if enough people know about plights like that of the Diazes—interspersed between gross-out depictions of necrotizing fasciitis treatments, of course—they can be stirred to feel, and then to act. And if that requires suspending disbelief not in terms of medical accuracy but to accept that a doctor might not know about Medicaid, well. That’s a cost The Pitt is willing to pay.
