My 79-year-old neighbor is a month into her third attempt to quit smoking. Retired for 15 years, she survives on her monthly Social Security check by shopping at deep-discount stores and keeping the furnace turned low in the winter. The nicotine patches she uses cost far less than cigarettes, but she still can’t afford to get the zipper on her winter coat fixed. For now, she’s making do with a light jacket and layers.

She has no living family members. When we met 10 years ago, she told me she was prepaying her burial and had just paid off the engraving of her birth year on her headstone. She has had both knees replaced in the last few years, and she uses a cane for her daily walks around the block with her little dog. Lately, she’s been wearing a disposable dust mask over her nose and mouth to keep cold air out of her lungs. Never shy about airing personal details, she says she hopes the mask will speed up her recovery from the debilitating chest cold that has had her coughing up blood for more than a month.

Her criteria for what warrants a call to the doctor narrow every year. She sees unexplained swelling in her legs, a week-long inability to keep solid food down or her recent cough as inevitable, yet routine inconveniences that aren’t worth the fuss of trying to get a message to her physician or bundling up and driving to an appointment. “Lonely” isn’t in her vocabulary, but it’s in the way her shoulders droop as she walks away.

When we talk about the transformation underway in health care and the potential of population health, this is where I want to see the change. I want an elderly woman to get care when she needs it, not just when the streets aren’t slick and she has the energy to drive; not just when she needs a joint replaced; and not just when a catastrophe happens. The field is full of innovative, life-changing ideas, and I just hope that they are adopted soon enough to make a difference in hers.