Thanks to the US healthcare system, I have more time to bake cookies.

Unintended consequences in a broken system

Today, I was supposed to get an echocardiogram. My doctor wanted to follow up on a screening I did 10 years ago for a heart condition that runs in my family. The last screen was negative, but the doctor thought it was a good idea to check again. I thought it was overkill, but I figured that it would cost about $500 and that we were going to hit our deductible, so why not?

Turns out it was going to cost almost $2000 after the insurance company paid $800, payment in advance required, and I had a personal deductible to hit before the family deductible kicked in.

My non-US readers are probably shaking their heads, while my US readers are nodding along. I cancelled the appointment.

Early in my career, I followed the health care industry. People talked about health care reform then. Richard Nixon pushed for Medicare for All in 1974, making it an ongoing topic of conversation. Also, many of Richard Nixon’s policy proposals would be too liberal for the modern Democratic party. At work, I was steeped in the data. I regularly talked to startups that wanted to go public with a sure-fire way to make money by reducing health care costs. None of them succeeded. It was so clear that the only solution was universal health care.

Every single industrial economy in the world has universal health care except the United States and the Republic of South Africa. The US has a single-payer system that works well, but you can’t access it until you turn 65. Our system gives us extraordinary treatments for serious conditions—the best hospital in the world is in Cleveland—but we have a lower life expectancy that most wealthy industrialized countries, in part because of shameful infant and maternal mortality rates. We can’t do the basics right.

I was so deep in the numbers that I considered going back to school for a Ph.D. in healthcare economics, but then I thought about the academic job market and decided that it wasn’t for me.

During this era, Bill Clinton was elected president and Hillary Clinton decided to take on health care reform. Health care stocks were tanking, and clients were panicking. Every day was super stressful, in part because of the secrecy surrounding her process. The politics were awful, and of course, it never happened. While universal health care was necessary in the United States, the debacle showed how extraordinarily difficult it would be to get it enacted. It wasn’t only the economic interests of pharmaceutical companies, hospitals, and insurance companies that came into play. It was the nature of our political system and the very real fear that surrounds the most expensive medical conditions.

These conditions include certain premature births, catastrophic cancers, major cardiac events, serious congenital conditions, and major accidents. Diet and exercise are of no use against familial glioblastoma, a collision between a car and a pedestrian, or conjoined twins. Preventative health care can lead to a better quality of life, but it does not save money over a lifetime.

So, what do we do about this? First, we need to accept that health care costs money, just like housing, education, and transportation. Health care coverage is technically welfare, not insurance; the risks cannot be managed and priced like property-casualty coverage. You will be better off if you eat more vegetables and get more exercise, but it’s not going to pay off for you financially. The second thing we need to accept is that giving more money to the CEO of United Healthcare is different from spending money on health care. Did he add $21 million in value to the health care system last year? I don’t think so.

I don’t think my doctor ordered the echocardiogram out of concern for malpractice. Yes, that’s an issue in the US, but it’s not as big a concern as people think. She was probably thinking that it was a good idea to track what was happening with my heart, and that it might prevent an ugly surprise down the line. She probably had no idea what it would cost me, in large part because our insurance system makes pricing opaque. Sure, there’s a list price that’s publicly available, but then there’s all the goofiness with copays and deductibles and out of pocket maximums. She can’t be expected to keep track of all that.

Was the echocardiogram strictly necessary? No, which is why I cancelled the appointment. In the meantime, the hospital incurred the costs of dealing with the insurance company, and the insurance company incurred the costs of its response. An imaging technician, who is probably on salary or paid hourly, now has an unfilled half-hour appointment. Even my cancelled appointment costs the health care system money.

Obamacare was a stopgap. The idea was that it was a first step to universal coverage, and it is better than what we had before (which isn’t saying much). Opponents talk a good game about repeal and replace, but they haven’t come up with something better because the thing that’s better is universal coverage. Meanwhile, our infant mortality rate is appalling.

Way back in the day, I went to a presentation by a health care expert who said that reform was inevitable. “We aren’t going to be schlepping though the ‘90s with piecemeal changes,” she said (at least in my memory). And here we are, in the 2020s, shlepping through the health care system.

I’m taking next week off, so no newsletter. See you Tuesday, January 2!