How the American Healthcare System Radicalized Me
For freelance and self-employed workers, this is personal
In 2001 I became unemployed when the medical book distributor I worked for was forced into bankruptcy. I was forty years old and like most Americans of my age, education, and background, I had only ever had health insurance through an employer. I had been unemployed before, though, so I knew all about COBRA. Unfortunately, also like many Americans who have been unemployed, I could not afford the monthly premiums on COBRA. I became uninsured.
This was the first time that I decided to go freelance and become self-employed. I needed to purchase health insurance. I called around, did some online research and came up with a few insurance companies I felt offered good plans. I filled out their applications and was denied coverage by all of them. I was stunned.
I talked to my doctor at the time, who was completely unsurprised. I remember sitting in the exam room, buttoning my shirt and looking at her as she said “Your chances of getting health insurance are vanishingly small.” Her exact words.
Why was this the case? As far as I was concerned I was a healthy enough forty-year-old. I didn’t smoke, I got some exercise, my weight wasn’t bad, my blood pressure under control. My blood work was normal. My family history wasn’t particularly ominous.
But I had come in contact with the medical world a few times. First of all I suffered from asthma, which I had had since childhood. It had never landed me in the emergency room but I was prescribed a preventative and a rescue inhaler. I also suffered from periodic bouts of kidney stones. The first time had been my sophomore year of college, while I was still covered by my parents' health plan. By this time in my life, I’d had a few attacks over the years, generally resulting in one ER visit for x-rays to ensure the stone was small enough to be passed and for pain killers to take while waiting for that to happen. But I had never been admitted to the hospital because of it nor had I required surgery.
There was one more thing. I had complained of abdominal pain and a sense of fullness even when eating little food. Medications and diet changes were tried for a month or two with little change. I was referred to a gastroenterologist who recommended endoscopy, which revealed an eroded area near the juncture of my esophagus and stomach. Biopsies revealed no cancer, so I was given stronger medication to take for two months in order to heal the erosion. This worked and I suffered no further symptoms, though I read that this might increase my risk of developing gastrointestinal cancer later.
My doctor revealed that these scenarios, in which I had complained to my doctor of a problem and been diagnosed and treated successfully, would be used to deny me health coverage because it made me appear risky. Any of these health issues, while not uncommon or costly in themselves, could develop into a major, costly health crisis.
“You’re being punished for seeking help and using the medical system as you should.”
My doctor’s words, depressing as they were, turned out to be entirely true. I was unable to secure any insurance from the companies I applied to. I wasn’t even offered a plan at a high cost. I had pre-existing conditions and I would not be covered.
One day I saw an advertisement online for insurance that might cover me. It stated that there were no pre-existing conditions and m the price seemed reasonable. Looking over the information I could find online, it looked like the plan they suggested didn’t cover a bunch of things, like regular exams, vaccines, prescriptions. Nonetheless, thinking that a company would have another plan that was good for me even if this one wasn’t, I booked an appointment for an agent to come and speak to me in my home.
What became apparent as we went over the plans together is that there was no coverage whatsoever for preventative care. In addition, the same pre-existing conditions (or imagined future conditions) would be outside the plan’s protection. Basically, if I was shot on the street or hit by a bus or fell victim to some terrible illness that wasn’t judged to be the result of a pre-existing condition I would probably be spared from having to declare bankruptcy due to medical bills.
Such a plan is known as short term health insurance and it was legislated away in 2009’s Affordable Care Act (AKA ‘Obamacare’), but it was brought back to life by President Trump’s executive order in 2018. These plans exist because they are cheap and people are rightfully frightened of being hit with catastrophic medical bills. But the only people for whom they could possibly be at all useful are really young and completely healthy, which means they have never been to the doctor for much more than an annual checkup and a flu vaccine. Regardless of your feelings about them, it was not going to provide me with adequate coverage so I moved on.
As a freelance writer, I came across the National Writers Union and the fact that they had, at the time, a group health plan available to members. Underwritten by United Healthcare, it was still expensive but it was a reasonable insurance plan in terms of covering preventative care, office visits, and prescriptions as well as emergency care.
I was able to obtain health services during the time I was covered with the NWU, and my problem was solved. There were two problems, however. First, the plan became ever more expensive — just as my old employer-based programs, only much worse as there was no longer any company that absorbed part of the increase. Second, the plan covered a large number of writers, many of whom were older than I was and who had more health problems than I did. So the group’s medical bills went up, the NWU was charged more and United Healthcare frequently threatened to discontinue the plan.
For me, the hammer finally came down when United Healthcare decided that it would no longer cover anyone outside of New York, the NWU’s home state. I already knew what the options were and that I would be charged exorbitantly for any kind of individual coverage or, more likely, denied outright.
I then became completely uninsured for a few years. During this time I came down with a mild infection and paid $100 out of pocket for some antibiotics and I had a kidney stone attack. I tried to wait out the kidney stone, but the pain only got worse over the course of a day. The ER insisted on doing a contrast CT to establish the size and location of the stone even though I mentioned that I had always been able to pass stones before and also that I was uninsured.
So I ended up with something like a $10,000 bill that, even with a reduction to around $8000 could not be paid. I filled out paperwork for financial help from the hospital but was denied because I had an IRA. Even though I couldn’t just withdraw those funds easily and would incur the double penalty of taxes and early withdrawal fine, the hospital considered the account to be liquid funds that were sufficient to satisfy the debt.
“Or” the hospital billing representative told me “you should probably just apply for one of those low-interest credit cards and use that to pay it off.”
That was their advice. No shit.
I refused to do so and was never sued. Eventually, the hospital ended up writing it off, as they do to countless other uncollectible bills which, of course, contributes to administrative costs and the overall rising cost of health care in America.
On the day that the Affordable Care Act was passed, I posted this message to my Facebook page: YES WE DID. Because health care had become a battle cry both within the Democratic party and among their constituents. I have sometimes second-guessed, retroactively, President Obama’s decision to spend most of the massive political capital he had amassed on getting the ACA passed because after that it was an all-out war on his presidency from the right and beyond.
But if not for his focus, vision, and short term political sacrifice, no health care law would have come to pass. I had seen what happened to Bill Clinton’s best-laid plans to pass an overhaul of the U.S. healthcare system and how it had all come to naught. In the years after I became covered by a succession of ACA plans, I had more kidney stones, an asthma attack, and required total hip replacement surgery. My ACA plan, while not cheap, completely covered the costs of my surgery and rehabilitation after my deductible was met. Without it, I would not have been able to afford the surgery, which would have severely diminished my mobility (I was already using a cane prior to surgery) and my ability to earn a living as a veterinary technician.
So you can see that my feelings about Barack Obama and the Affordable Care Act are deeply personal. Despite the issues and increased costs over the first couple of years that the ACA was in effect, things had become more manageable by the time he left office.
When Donald Trump was elected I pretty much kissed my health insurance goodbye, because he had campaigned heavily on repealing the ACA, as had many GOP members of Congress. With majorities in both houses and control of the White House, there seemed to be no way that Obamacare would avoid being repealed. I watched as the Congress and Trump moved steadily towards a repeal vote with absolutely no hint of a replacement plan. They might as well have called me on the phone to personally deliver the message: “We really don’t want to have to give you access to healthcare. We’d rather you died or went bankrupt.”
On July 27, 2017, in the early hours of the morning, the Health Care Freedom Act, known as ‘skinny repeal’ and widely believed to be a horrid piece of legislation even by some Senators who agreed to vote for it, was defeated when Senator John McCain cast the deciding vote. McCain had been a troubling presence on the Senate floor because, although he complained loudly about some of the GOP bills that came up for a vote and was openly critical of President Trump, he often managed to vote with his party anyway. He had voted for repeal before, but not this time. When he marched up to stand within spitting distance of Majority Leader Mitch McConnell and cast his thumbs down vote, I feel as though he spoke, without words, for all Americans whose only hope of being covered by health insurance was the ACA.
But Trump has continued to cut into the ACA with a variety of tactics: drastically shortening the annual enrollment period as well as cutting funding dedicated to promoting open enrollment and providing assistance in signing up, providing Department of Justice support to lawsuits that claim the ACA is unconstitutional, and allowing the resurgence of short term plans.
I doubt that my experience is unique among the increasing number of self-employed and freelance workers engaged in the gig economy. The health insurance plan I had access to through the NWU was still very expensive and realistically not all freelancers or self-employed individuals could have afforded the monthly premiums much less the deductible — indeed there are many who cannot afford the cost of a plan on the ACA exchanges, presuming they live in a state with such an exchange.
I believe that the way for Americans to get better healthcare coverage and improve our overall healthcare system is to adopt a single-payer model as most developed countries have done in one form or another. There simply is no reason that one’s access to healthcare should be tied to one’s job, only to change, sometimes drastically, when there is a loss or change of employment.
I supported the public option that was discussed early on in the planning of the ACA, but unfortunately, Democrats gave that bargaining chip away much too early in the process in order to satisfy some members of their own party (Republicans were never going to go for the plan anyway). I think that the ACA, for all its flaws, has been a solid starting framework for reforming our healthcare system, and it would no doubt have been adjusted in a number of ways during a Democratic administration.
Instead, the Democratic party has moved towards the complete replacement of our current system and the ACA with a single-payer system that is commonly called Medicare for All (M4A). That approach was championed by Bernie Sanders in 2016 and it has only gained traction since. Sanders and Elizabeth Warren are the purest in their plans to institute M4A, with various other candidates floating plans that differ in some details as to how quickly and completely they approach the goal of universal healthcare access. Joe Biden has resurrected the public option, though his current plan is more robust than that which was abandoned in the runup to the ACA.
I support an incremental plan rather than a complete switch-over in healthcare plans because I am concerned that single-payer, while much more mainstream an idea than ever before, is still too radical a change too fast for many Americans. If Democrats ran the table and won the White House and control of the Senate in 2020 (retaining their current control of the House) the new President would still need to use an enormous amount of political capital in order to leverage such a change. Recent polls show that as many as 70% of Americans support M4A, though support drops quite a bit in the face of higher taxes to pay for the plan.
The experience of watching Donald Trump and his henchmen in the GOP wrench healthcare coverage away from millions woke a lot of Americans up to the need for protection and improvement of the ACA. When the repeal of Obamacare seemed almost certain they showed up at Town Hall meetings and the office of their representatives in Congress and let their feelings be known. That alone wouldn’t be enough to sway legislators but it definitely made enough of a difference to sway a few crucial votes. Now Americans identify healthcare as the number one issue going into 2020, but with all the different flavors of healthcare plans floated by presidential candidates, many are unsure of what idea seems best. Most Americans don’t want Congress to make another massive change in healthcare, preferring instead action that protects pre-existing conditions and brings down the cost of prescription medication.
The main thing to remember is that whatever we do, we can’t be allowed to return to the days of denial of coverage for pre-existing conditions, plans that cost more than the average worker can afford with no tax offset or other assistance, and the threat of bankruptcy for those who find themselves requiring medical care or hospitalization.
Today freelance and gig workers have more options for healthcare coverage, though for many the costs are still too high and the choice of doctors and hospitals may leave something to be desired. I don’t want to go back to being un-insurable, and if you are part of the rising tide of self-employed or contract workers, neither should you.