Even after Obamacare—the core provisions of which are possibly about to be ruled unconstitutional by the Supreme Court—the U.S. health care system is based on the premise that open-market competition is the best way to deliver health care. It’s been pointed out elsewhere that this is both theoretically absurd (one doesn’t buy health care at one’s leisure, like choosing a toaster) and factually inaccurate (the U.S. system is only very partially an open market, but because we’re pretending it is, the non-market components of the system are haphazard and inefficient). I’m not out to draft a complete thesis on the failures of the American health care system, just to illustrate them with my own recent experience.
I’m 36 years old, and in good health. For now, at least, I have the luxury of rarely requiring health care—which is a good thing, since my job does not provide it for me. I went completely without health insurance for my first couple of years in this job, because I could get away with it: I knew that if something dire happened to me, Hennepin County Medical Center would take me in and stick the taxpayers with my expenses. (This being the free market and all.) But eventually I decided to do the prudent thing and buy health insurance—thinking that, well, if my appendix suddenly ruptures, it would be convenient not to have to declare bankruptcy.
So where do you go to buy health insurance? They don’t sell it at Target (I don’t think). I asked around, and was pointed to Assurant. After asking me a long series of questions about my physical fitness—this was circa 2009 in Minnesota, when it would still have been perfectly legal to leave me in the lurch if I had any potentially expensive condition—Assurant agreed to hook me up with coverage. For $88.97 a month, I’d have a $5,000 deductible.
I did the math, and that actually seemed fair. If I stay basically healthy and then, like most Americans, die around age 70 in a fantastically expensive manner, Assurant will probably about break even. I have to say that it’s been a little troubling that my premium has since risen at a rate that, if it continues, will make my monthly payment over $4,000 a month by the time I’m 55—but we’ll cross that bridge when we come to it. I did contact Assurant last year to inquire about raising my premium to reduce my deductible, and was told that so few people requested those plans, they’d been discontinued.
Well, there’s the free market for you: unless I find a job that provides health care, I have little choice but to pay out of pocket for anything short of a major medical procedure. Obviously this reduces my incentive to go in for check-ups or preventative care, but what the hell. Who has time for that stuff anyway? I figured I’d deal with any troubling health incidents if and when they occurred.
When turned out to be last fall. I woke up one night with a pounding heart and a strangely tight chest, which seemed very strange since I knew I was in good shape and don’t have a family history of early heart disease. Still, enough of the Google results told me that I was in mortal danger that I went in to the doctor. By “the doctor,” I mean my childhood doctor—or at least to the clinic I’d used as a child, which turned out to still have the records of all the physicals and vaccinations I’d enjoyed back when I was on my parents’ health insurance.
Where else was I supposed to go? I needed an appointment on the quick, and not only was it impractical to compare and contrast prices and services, it might have been impossible. Here’s the conversation I had with the scheduling nurse when making my appointment:
“How much will this cost?”
“You have insurance, right? It will go on your insurance.”
“Yes, but I have a high deductible, so I’m expecting to essentially be paying cash for this.”
“Your insurance will bill you.”
“Right, but how much will they bill me? How much does a physical cost?”
“Oh, God, I have no idea. You’re paying for the whole thing? I mean, maybe several hundred dollars? I really don’t know.”
Okay then. Well, I had to get checked out, so I went in. The doctor sent me for an EKG, gave me a clean bill of health, and told me to drink less coffee and alcohol. At no point was I told how much anything would cost, or asked whether I wanted to pay. They just did what they did, and I went along via not wanting to die or whatever. I actually went in once more, to urgent care, about a month later after being freaked out by some tingling in my fingers. The bottom line basically seemed to be that it was the effects of anxiety—which I do have a family history of—probably coupled with some overdoing it in the booze ‘n’ caffeine departments. Good to know: I’m not dying, and I’ve been fine ever since. Now, back to our story.
It was December, I’d been to the doctor twice in the last month, and I hadn’t been billed one single penny. They just knew where I lived—and who my health insurance provider was. How much health care had I just purchased? I had absolutely zero idea other than the very rough estimate the nurse had given me on the phone. I tucked a thousand dollars away in savings—fortunately, I was in a position to do so—and braced myself for the bills to come.
2011 ended. No bills.
January came and went. No bills.
Feburary came and went. No bills. I started to feel better about the American health care system, but I didn’t yield to the temptation to blow that grand on a new lens for my camera.
Then, in March, I opened my mailbox to find the Envelope of Destiny from HealthPartners. Here it is, I thought…here’s my bill! I took a deep breath and opened the envelope.
Two surprises: (1) The bill was only for about $50. (2) It wasn’t a bill. In fact, it was clearly marked: THIS IS NOT A BILL. The real bill would be coming from Assurant, as the nurse had told me.
So I tossed the envelope in my drawer and waited. It was followed over succeeding days by several more non-bills, totaling—yep—about $800. But none of them were actually bills. I was told to wait until my insurance provider billed me. The actual bills did finally arrive, in April—five months after I’d received the health care. I paid the bills, and we all seem to be cool. I expect my premiums will rise…but then, they were going to rise anyway.
This, then, was my experience with purchasing health care on our supposed free market. I bought the only plan available to me (from Assurant, anyway), paid the only price I was allowed to pay, and was given the only protection corresponding to that plan. Then, when I actually did need health care, I wasn’t told what it would cost until months after I actually received the care.
The good news, I guess, is that I can apparently walk into one of the best local health clinics and request top-notch care, which will be provided promptly and without question or downpayment. The bad news is that I won’t know what that care is going to cost me until months later.
I accept the need for personal responsibility, in health care as in other things. I get that high-quality health care relies on well-trained professionals and expensive equipment operated in safe and secure working conditions, and someone has to pay for that. That someone should probably be me. My experience, though, is just one small illustration of the two-fold absurdity of:
1. Providing health care through an open market. As health scares go, mine was extremely mild—but even so, I didn’t want to shop around, I wanted to get checked out. If there was ever a situation in which I’d be inclined to take my time and comparison-shop, the morning after weird chest pains kept me up all night was not it. We can give people responsibility for their health costs while acknowledging the reality that buying health care is qualitatively different than buying most consumer goods.
2. Pretending that our health care market is, in fact, open. I’m not saying I couldn’t have done more to compare different health insurance options or different clinics, or to have pressed my clinic harder on the specific costs associated with the procedures being done. But it is, nonetheless, true, that my health care story was a lot different than my car-buying story. My options for purchasing health care are very limited and very mysterious, and the connection between service and cost is more tenuous than in anything else I’ve ever bought. Further, because we’re not (yet) willing in this country to just have people be left on hospital steps to die with empty wallets, we all know that if push comes to shove, emergency care eventually will be provided—typically at greater expense and with less effectiveness than if we’d all planned to insure that care would be provided when it was inevitably needed.
America’s stubborn failure to guarantee universal health care, and to spread the costs equitably, is a profoundly troubling symptom of our failing democracy. I’m not given to apocalyptic pronouncements, but if the Supreme Court hands down an insistence that even the half-ass health care plan enacted by Congress is unconstitutional, one really has to wonder what hope is left that we’ll see, in our lifetimes, an obviously necessary overhaul of the patchwork system that’s sucking our resources, slowing our progress, and shortening our lives. If the United States can’t change course now, we’re in critical condition indeed.