healthcare in America: a returned expat fulminates


A subconscious habit afflicting me recently is the compulsion to flip my tongue over to the right-side of my mouth and press it against the smooth porcelain of my new crown. It’s my first dental intervention of this sort, and I’m amazed at how real it feels: better than the original tooth. By far. Oh–and it cost me around $1,400.00.

Who would of thought a tooth could break the bank?, I wrote as the first line of a poem at a workshop about a week after the implant. That sentence was all I could muster, consumed as I was by the fury and weariness of that simple fact, knowing how shriekingly unjust it is.

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Eight years ago I went to a doctor in a socialized healthcare system for the first time in my life. I was living in Belfast, Ireland, a member state of the United Kingdom with access to the National Healthcare Service (NHS). Before going to my appointment I called my health insurance provider (Blue Cross/Blue Shield) to double-check that my healthcare would be covered. They told me that 80% expenses were covered and I just needed to email or fax them documentation. Later, I looked like an absolute idiot when I approached reception after the appointment and tried to pay my co-pay. Healthcare in the UK is free. You just register and go.

I had made that appointment because I had a slight and infrequent pang in my lower stomach. I was convinced it was either giardia, an ectopic pregnancy, or an ovarian cyst (the latter I had had before). This hypochondriac mindset, I would later realize, is a symptom of being able to afford healthcare in one of most exorbitant markets on the planet.

The doctor asked me a couple of questions and once we established that all the symptoms pointed to an ovarian cyst he said not to worry about it and come back only if the pain becomes constant and intense. I was very, very confused. A year earlier, I was working in the theater at my college when I collapsed in total agony. I was ambulanced to the hospital ($300+) where a bunch of tests, including a cat-scan ($1,000+), determined that a small cyst, about the size of a grape, had ruptured. It was extremely painful at the time, but ultimately entirely harmless. Nonetheless, I made an appointment with my primary care physician (PCP) and was advised to see a gynaecologist, who in turn recommended that I come in for monitoring every 5-6 months.  It must be serious, I thought.

In the spirit of this thought, I relayed the episode to the NHS doctor and asked when I should come back to have the cyst monitored. The doctor explained–very patiently–that even if they found a cyst, unless it was the size of a orange they would not be able to do anything about it. There was no need to. Cysts happen, then they go away. It’s fine.

That day I learned about more than just the medical contingencies of ovarian cysts; I learned that as a consumer of American healthcare, at least some of the healthcare I receive is a waste of precious resources. In healthcare terms, I was equivalent to royalty. My parents work for Mass General Hospital, one of the top hospitals in the world. We paid for the most exclusive healthcare package available under Blue Cross, and MGH footed a huge portion of that monthly bill. This all went to my head. Me, my mother, my family, we all believed that recommended treatment is a necessary treatment, and that since it was important and necessary we were fully entitled to it. Doctors help propagate this disposition, which is not to say doctors are nefarious, greedy individuals. They work in system that relies on healthcare being purchased, and this fundamental impetus of capital is of course dressed-up in their minds (and ours) as benevolent “care”. And “care” is what we consumers of healthcare expect, what we feel entitled to. Happily or not, the proponents of the system usually oblige. They need our business and they want to think of themselves as custodians of a system that ultimately does good in the world.

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This morass of expectations is toxic to one’s relationship to healthcare. Among those who can access healthcare (and even those who cannot), it breeds a trenchant privilege that spirals into unbridled hypochondria. When my step-mother, a self-employed real-estate agent, married my father over a decade ago, she had steady health insurance for the first time in her life. Since that time, she has gotten multiple elective surgeries and treatments, from the removal of benign moles, to something done on her elbow, to the most advanced pre-emptive bunion surgery possible, among others. These interventions are always elective, and there have been times when his insurance refused to pay for them. When my grandmother, who by contrast has had insurance her whole life, visited me in Belfast one summer, my friends were astonished by the arsenal of medications and vitamins she carried around in her bag and popped throughout the day.

An outcome of this wasteful and neurotic orientation towards our health is that quick-fixes are often offered over more tried-and-true solutions to health problems. This propensity makes us vulnerable to the more pernicious elements of the system.

During elementary, middle and high-school, my mother sent me and my siblings to the local chiropractor because she was worried about the effect of our school bags on our spinal health. He told my mother that I had a condition called a “sway back”, which is just a circuitous term for slouching. Instead of encouraging me to do a couple of sit-ups to strengthen my core, he recommended I come in each week for adjustments and electro-therapy. My mother, a full-time nurse, also attended the practice, sometimes multiple times a week for similar treatments (I don’t doubt her back was hurting, but as someone who underwent those electro-treatments I now wonder whether they did more harm than good). At one point in high-school, my right shoulder started hurting a bit. More electro-therapy.

Mine and my mother’s pathological need for healthcare set us up to become complete suckers. At some point in college I received word that that chiropractor had been investigated and convicted of insurance fraud. Apparently, we was selling droves of patients expensive treatments that they did not need so that he could charge insurance companies.

Years later, I started to develop serious knee, back, and shoulder pain. This was when I was living in England, and my GP referred me to a podiatrist, who laid me down on a table and told me within two seconds that one of my legs was shorter than the other, my feet were slightly flat, and my shoulder just needed to be exercised a certain way to build up muscle in a certain spot. Twenty minutes later, I left the office with new orthodontic insoles and within a couple of weeks of doing the stretches and exercises she taught me I was free of pain. Notably, my former chiropractor had laid me on the table and conducted the exact same examinations.

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In recent months, the Affordable Care Act has survived a failed assault by congress, and although I find this consoling,  I stand by the position that healthcare in America blows. Why we cannot see it as a fundamental right that provides more freedom than restriction is a myopia that I find hard to fathom now. It’s a injustice I bump up against constantly.

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As I sat in the dentist’s office waiting for the crown application a young woman dressed in sweats and carrying a skateboard was trying to check out. She had just had a tooth cleaning under the first-time customer discount plan: $57.00 for a cleaning and examination. The receptionist asked her for payment or her insurance card. She handed her a New Hampshire medicaid card. The receptionist looked it over and said there was nothing indicating dental coverage on it. The young woman looked at her with passive perplexity, insisting that it was covered. The receptionist humoured her for a few more minutes, offering to call the insurance provider to double-check, but I knew she knew that this would amount to nothing. I don’t know why that young woman was on medicaid, but I expect that even $57.00 was a lot of money to her.

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Later on that week I received an email from one of my students that she was withdrawing from my class and going on a leave of absence from the school. A few days earlier she had been sitting in my office, an exhausted heap, telling me that her insurance plan was refusing to pay for her medications. Her father had been laid off at the start of the year and she and her family just switched onto medicaid in their home state. She had to drive back every weekend to see her doctors for an incapacitating anxiety disorder. She also caught mono and someone rear-ended her a few weeks back, leading her neck to begin hurting. The college knows about her situation, but there is no hardship fund available. She was one of my brightest students and we had connected over the course of the year. Her email also mentioned that she would be transferring to a school in her home state.

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My brother was kicked out of my mom’s house a couple of months ago. He was stealing money from my younger brother, taking cash and forging checks to buy pills. He needs to go to detox. He is unemployed so he’s eligible for medicaid, but he’s living in a world where paper-work and ringing call-centers is difficult to carry out. If he could just walk in, like one does in the NHS, maybe things would be different. My father wants to section him through the courts in order to streamline him right into detox and rehab, but the risk is that if there are no beds available at the time of his sectioning–and the current statewide opioid epidemic is making that scenario likely–he would have to go to prison until a bed is open. I was sorting through some papers the other day and found a photograph of us siblings at my 11th birthday. He has missing teeth and the widest smile.

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In early March I noticed my urine smelled slightly rancid. This persisted for a few weeks until a minute burn became noticeable. I bought some cranberry juice and started to drink a lot of liquids. More weeks. The burn persisted. I finally made an appointment with my PCP, and when the nurse practitioner confirmed I had a minor urinary tract infection I beamed with relief. Thank god I didn’t pay a $20.00 co-pay for nothing.

I don’t think someone would think that anywhere but America.