welcome to the Ambassador Suite, sir

I’ve been wondering for some time now how much our insurance company would ultimately end up paying for our amazingly expensive birth. One of the weird things about the American insurance model is that nobody knows how much anything costs. When you go into a bookstore to buy a book — I mean, to the extent that people still do that — the price of the book is written on the cover. You look at the price, you agonize over it for a while, and if it’s an expensive book you look around to see if there are other, cheaper books you’d be just as happy with. But with health care, it’s not that way. You go to the doctor and you say, “How much for a check-up?” and they say, “Who’s your insurer?” Right away, you know something is wrong with a system like that.

Immigrants don’t screw around with this insurance crap. Elana had a minor dental emergency while we were traveling. Since we don’t have dental through Tricare, we had to find a cheap dentist we could pay out of pocket. Elana was casting around for ideas on how to find the least expensive dentist possible, and something from deep inside me — some source of wisdom to which I had not, hitherto, had conscious access — said, “Look for a Vietnamese dentist.”

And sure enough, we were able to find a Vietnamese dentist with a degree from a very respectable school who nonetheless catered to hardscrabble, uninsured immigrants. She understood our approach to dental care — seek it only in emergencies, and pay cash to fix only the immediate problem — perfectly. She did not try to upsell Elana on additional procedures. She did not try to make my wife feel bad for not seeking care sooner. She was willing to see us on short notice. And she had a set price list, which she knew by heart. Elana enjoyed this experience greatly — as much as anyone enjoys dental work — because it was clear, customer-oriented, and anxiety-reducing.

That’s the purely capitalist side of medical care. We also experienced the flip side while traveling. I was on active duty orders for a while, and so I was taken off of Tricare Reserve Select and put on what’s known as “Direct Care,” which means you’re required to seek care directly from the military health care system unless you’re too far from a Military Treatment Facility or you’re in danger of losing “life, limb, or eye.” I was never in danger of losing any of those things, but I did strain something while running, and while I thought it probably wasn’t a big deal, I wanted to get it checked out. When you’re in the Regular Army, you do this by visiting your unit’s aid station, but when I asked my First Sergeant what Reservists do, he was puzzled for a second and then said, “Go to the emergency room.”

This turned out be exactly right. The emergency room at the Madigan Army Medical Center also has an urgent care section which is open from 0500 to midnight, and they don’t really mind if your problem isn’t that urgent. If you’re willing to hang out for a couple of hours, a gruff but reassuring P.A. will examine you, explain that you don’t have a hernia and you just need to lay off it for a couple of weeks, and send you home with some overly effective painkillers. And that’s it. There’s no charge. It’s like Michael Moore and the Queen of England dreamed it up together:

You may not like socialized medicine — you may think it results in less innovation in the really important fields, like boner repair and mild sneeze reduction — but it shares one important attribute with the purely capitalist immigrant medical economy: when you go to the doctor, you know how much it costs.

Sadly, when I’m not on active duty orders, my wife and I use an insurance company like everybody else. Because our insurer, HealthNet Federal Services (aka Tricare), is carefully regulated (and heavily subsidized) by the government, it’s a sterling company that charges reasonable rates, does not ask you about your medical history before enrolling you, and actually pays out claims when you get sick. For all these reasons, I adore Tricare and would not change it for any other insurance plan. Nonetheless, like any insurer, it contributes to exactly the weird disconnect between consumer and price that causes market economics to fail in the health care system.

Consider Elana’s emergency room care and C-section. When we arrived at the emergency room, I was taken away from my seizing wife and led off to a little room to be interviewed about my health plan. The interviewer was very nice, though I can’t help thinking that having an RN ask me about my wife’s recent health might have been more useful at that point. But no, we talked about health plans and how difficult it was to do Tricare paperwork and where everybody’s insurance card was at the moment. They were, as I said, very nice. At no time did anyone actually mention money.

Elana and Henry were both in the hospital for many days after that. We concentrated on their care and recovery. At no time did anyone actually mention money.

Eventually Elana was well enough to check out, and I brought her home. At no time did anyone actually mention money.

Five days later, we got the thumbs-up from the neonatologist to bring H. home. It was a scary and momentous day. It was also the last time anyone at St. Joseph’s would have an opportunity to discuss the cost of care with us in person. They were very nice. At no time did anyone actually mention money.

The reason for this, I believe, is that they had no idea how much Elana’s care, or Henry’s care, actually cost. What happened next was this: the hospital submitted bills to Tricare for payment. But the amounts demanded on these bills bore no realistic resemblance to what Tricare is willing to pay for those services. The amounts are purely notional. They exist to satisfy some bookkeeping need, to fill a box on a spreadsheet somewhere. These amounts are not the amount anyone will actually pay.

Instead the way it works is this. The hospital says, “For an emergency room visit, a C-section and eleven days in the hospital, we charge, mmm, forty-five thousand dollars.” And the insurer says, “We’ll give you nine grand and this packet of circus peanuts.” And because the hospital wants the business of all the people who hold Tricare insurance, they agree to it.

But please keep in mind — $45,000 is a fictional number. It’s not even their retail price. It’s not like you can call up a hospital and say, “My wife would like to have the following procedures at your hospital — how much would it cost?” The answer, as always, will be “Who’s your insurer?” (And please don’t say you’re uninsured. That’s only going to make them feel embarrassed at having taken your call in the first place.)

After I convinced my wife to fly 3,000 miles with a three-month-old to come see me in Washington, she was adamant that we fly back on the same flight. Which turned out to be prescient, because mild fog and rain for some reason threw the Chicago-O’Hare Airport into complete freak-out mode, delaying every flight into the Windy City for at least 2-1/2 hours and causing us to miss our connecting flight, and as hard as that was, I think if either of us had had to make the trek alone with the baby it would have ended in tears and babbling.

If you were to guess that there aren’t that many flights from Chicago to Syracuse in the middle of the night on a Saturday, you’d be right, but we hustled down the concourse to the last one anyway, hoping to be put on standby. We looked up at the standby notices on the monitors. It was a grim picture — there were already 25 people on the list. But the gate agent refused to admit that we would never get on the flight because, he said, “It’s not first-come, first-served.”

“Oh,” I said. “What’s it based on?”

“It’s based on the price of your ticket and how many Frequent Flier Miles you have.”

My wife and I looked at him in Marxist disgust and stalked away in protest immediately after adding our names to the list. (Hey, you never know — the Army might have some massive bank of Frequent Flier Miles somewhere.)

We moved quickly back to the customer service counter, which was already swamped, though we would later turn around to see that we had just beaten the massive crush of grouchy, stranded travelers. After waiting in line for quite a while and displaying our beatific former lama of a son to a delighted Buddhist nun, we finally made it up to the counter, where a young lady whose last nerve had not yet been frayed endeavored mightily to help us.

“I’m sorry,” she said, looking sorry. “All the flights for tomorrow are booked up already. Is there anywhere else you can fly into? Maybe LaGuardia?”

LaGuardia is about five hours away from Syracuse.

She had a few other plans involving rental cars and trains and also one where we would just give up and rent an apartment in Wicker Park.

I was ready to buy into these elaborate schemes. But Elana kept politely insisting that we’d like to go home tomorrow. Eventually, backed into a corner, the ticket agent picked up a phone and called someone and supplicated for help and, magically, two tickets for a flight to Syracuse the next evening were made manifest. She thanked the person on the other end of the line, printed out boarding passes, and voila! problem solved. We praised her for her diligence and resourcefulness and went off to find a hotel.

As we were walking away, I expressed skeptical amazement that two seats had “suddenly” become available. Elana, who worked for several years as an assistant to various high-powered executives, rolled her eyes. “They always have seats available. They save them for when George Clooney from Up In The Air suddenly changes flights.”

That’s just how it is, man. There’s a club, and you’re not in it. That’s what makes this America.

I happen to think that’s fine, most of the time. Even when it’s causing me and my little family no end of hassle and exhaustion and non-frequent-flying airport shame, I don’t discount the value of a little class-based elitism. There are nice things in the world, and wanting to have them is a good goad to achievement.

But health care is different. It’s stupid and counterproductive to insist on people applying for elite club status in order to stay alive and healthy. Health is the real engine of a country’s economic growth, and it’s ridiculous to try to use it as an incentive to hard work, especially when it’s poor health that’s keeping someone from working hard. Yet health insurance in our country is the Frequent Flier club of social achievement. When you have it, doors open to you; a mysterious system of discounts and advocacy and personal care is made available to you; emergencies affect you less. Also, there’s a cocktail lounge.

I find this morally repugnant. But unfortunately, it’s more than that. This preposterous club system has taken over the economics of health care, corrupting it and leaching out of it all the vitality of capitalist endeavor without giving any of the security and stability of socialism. It’s a farce, and from now on I’m going to do my damnedest to stick to Vietnamese dentists and whatever “government takeover of health care” I can find.

One response to “welcome to the Ambassador Suite, sir

  1. Is there some way this essay can make it to Pelosi’s desk to be read to congress? or at least to some .gov websites?

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