Walking Around, Uninsured

Let's talk about health insurance. I don't have it. This feels like such a flagrantly transgressive thing to confess, even though the decision was the product of intense rumination. My public defense practice is a one-man operation, which means I have to purchase my own health insurance. I make too much money to qualify for any premium subsidies so I have to pay the full amount (although the field is known as “Public Defen$e” for a reason, realize that the cut-off income for losing premium subsidies is around $53k/year). Most of the plans available on the low-end cost about $400 a month, and come with a deductible of around $8,000. Those plans cover only a narrow sliver of medical services, with the rest paid out of pocket until you hit the deductible. I can, of course, lower my deductible and increase my coverage, if I was willing to accept a bigger monthly chomp.

I thought about my options. I'm in my 30s and reasonably healthy, but my default socially-conscious assumption is heavily leaning towards having insurance of some kind, because going without seems wildly irresponsible. As they say: What if something happened? But I ran the math, accounting for the benefits and coverage, and concluded I would need to expect to incur at least $10k of medical expenses in a given year just to break even. My other option was to just forgo insurance coverage and bank the money that would otherwise have vanished into monthly health premiums. Obamacare used to have a tax penalty to discourage people from doing exactly this, but it was since eliminated in 2019. Going naked is free now.

I should note that I am very comfortable financially, and I am lucky to not have any chronic health issues. Almost all the healthcare expenses I've incurred have been physical injuries stemming from weightlifting, bicycling, and giving people lapdances at parties. I am not at all living on the brink by any measure. But still, this shit is so goddamn annoying to deal with.

The fact that I have to be completely financially responsible for all my medical expenses is very much impressed upon my psyche, especially as I gained further familiarity with just how eye-poppingly expensive services are. Beyond just the absurd cost, providers are so confused with how to deal with me. I recently fucked up my back doing barbell squats, so I called up a physical therapist I had been going to for years to see if they could see me immediately. No dice, they said I first needed a referral from a primary care physician (PCP). I know that almost every insurance provider uses PCPs to determine whether you really need to be seen by a specialist, so I assumed the physical therapist was looking out for my own interests to make sure I wasn't running afoul of my insurer's requirements. So I politely explained to them that I'm fortunate enough not to have insurance, and so I don't need a referral! They had no idea what the fuck I was talking about, and just kept saying that their policy is to require a referral from a physician. It's perfectly legal for people to self-refer themselves to physical therapy, but I had to call around a few places before one would see me. It was $150 for each 45 min appointment, but well worth the money given its specialized efficacy.

I also thought that the “minute clinic” model would be my savior. The intent behind these type of retail clinics is to staff them with nurse practitioners or physician assistants, and offer a way to address common health issues that don't really need to take up an hour from a fully licensed physician. Based on how often locations around me shutter, I have to conclude they experience some degree of financial insolvency. I had some foot pain, but it was puzzling enough that I didn't know if a physical therapist was the right call. So I went to a retail clinic first. The doctor looked at my foot, shrugged, and suggested I take ibuprofen and go see a physical therapist. She then started writing me a referral to a podiatrist, and I told her I didn't need one because I didn't have insurance. She paused, confused, looked at me and said “but I'm writing you a referral”, apparently having no comprehension of what I said. The ten minutes I was there cost me $200.

I never had to navigate the health insurance field on my own before the ACA passed in 2010, thanks to being either a student or salaried like a normal person. But companies used to offer what is known as “catastrophic coverage” which had low premiums but very high deductibles. The ACA has significantly restricted who can qualify for those plans to the point that they're functionally unavailable for most. The only remaining option are the “metal plans” that combine high deductibles with high premiums because of all the services they're legally mandated to cover.

What irks me is that the American healthcare system manages to needlessly integrate some of the worst bureaucratic impulses known to man. Thanks to medical licensing laws, a lot of otherwise highly trained medical professionals are forbidden from saying the d-word: diagnosis. So you're generally required to make a separate appointment with a doctor who then scribbles out a scrip after seeing you for 5 minutes, which you then have to go to a separate place to fill. Compare to places like France, where pharmacists can diagnose. Pharmacist prescription powers are still limited, but my experience with pharmacies in both France and Morocco was so damn effortless in comparison to the US. I just walked in, told them what I was experiencing, and walked out with medication.

I have no idea how the healthcare system here works, apparently nobody does. But for the vast majority of people, they're insulated from really thinking about it. If you're poor enough or old enough, you qualify for one of the few oases of universal healthcare coverage available in the United States where the cost is somebody else's problem. Similarly if you get your coverage through your employer, where some insurance company in the ether pays your bills. The system is obviously ripe for abuse and fraud when a distant third party has to pay for services rendered to a patient who could care less what the bill was. I noticed this with a dentist I went to years ago, where I noticed they were billing my insurance provider for things that never happened. But after all, why wouldn't they? The patient isn't going to pay attention to the bill, and the insurer isn't there to double-check what actually was provided, so any provider has wide leeway to phantom bill and has to fuck up badly to get caught.

But health insurance companies, for whatever reason, don't seem to care all that much. I don't get it! Either way, the only people that get to peek behind the curtain and experience the US healthcare system in all its raw glory are folks like me who have to operate outside the traditional system. Again, I'm in a highly privileged position in many respects, so this is by any measure primarily an annoyance and inconvenience for me. Not everyone is as lucky. Sometimes the nukage leaks through, and we get fun headlines about someone getting billed $324,000 or whatever for a broken arm or some shit. The only result of consequence from stories like those are a chuckle from the crowd at how crazy the wasteland behind the walls of insurance are.

Although I don't have coverage now, I can change my mind at the end of every year during the Open Enrollment Period. There are also numerous exceptions that could qualify me for a special enrollment, and this might include the scenario where I suddenly qualify for a fully-subsidized health insurance plan if I suffer a debilitating condition. Ever heard of the health insurance “death spiral”?

None of this seems very sustainable in the long-run.