The parable of the Chinese farmer is a story with many versions. In shorthand, it goes something like this: a farmer’s horse escapes – the neighbors say, “How terrible!” The farmer says, “Maybe.” The horse returns, bringing some wild horses with it. The neighbors say, “How wonderful!” The farmer says, “Maybe.” The farmer’s son falls off one of the wild horses while trying to tame it and breaks his leg. The neighbors say, “How terrible!” You can probably guess what the farmer says next. The broken leg prevents the son from being sent to war, and so on. I love the story.
I recently experienced my own version of this story, which I’m calling the parable of American health care. My version was prompted by an attempted medical encounter and illustrates some of the problems in our health care system. Sharing the details from the patient experience side of things may be useful.
I retired from medical practice but have remained employed part-time, providing coaching and support. How wonderful! However, since my level of employment is well below 50 percent, I lost my employer-covered medical plan. How terrible! I qualified for COBRA, and although it was expensive, I was able to continue my previous medical plan, which I knew how to navigate. How wonderful!
My COBRA expires before I will be eligible for Medicare. How terrible! But I have resources and a fairly robust level of education in health care, and there is a health care marketplace. How wonderful! I found the marketplace cluttered and confusing and ended up making a somewhat arbitrary decision – picking a plan that seemed robust. Terrible? Wonderful?
I received notice of a merit raise for my part-time work. How wonderful! Then, I discovered that the raise put me right above the threshold for a tax rebate on my medical insurance premiums. So, as a healthy single person without serious underlying conditions, I am paying a much higher price than I thought I would for a plan that I don’t fully understand. How terrible!
When I did a provider search on my new plan’s website, the name of the specialist I have been waiting to see came up as covered by my plan. How wonderful! When I went to my appointment, the sharp-eyed receptionist noticed what neither the plan’s computer nor I had noticed – very fine print on my new insurance card that said, “narrow network.” After verifying with her laminated cheat sheet, the nurse, and a management person, she very apologetically informed me that I could not be seen. How terrible! I had been waiting a long time for this appointment, so I offered to pay out of pocket but was told it was impossible. How terrible!
This blog post wrote itself in response. How wonderful! My medical issue is not life-threatening. The rest of my life is stable and satisfying. The gas I spent going across town was not a budgetary big deal. My sense of being rejected by the system was not part of a pattern of systematic exclusion. So, I can afford to have a sense of humor about this. Not everybody reliant on the system can.
The history of employer-based health insurance is complicated. The logic is flawed. I have had a patient with MS causing severe neuropathic pain in her feet and legs who had to keep working on her feet all day as a pharmacist because her employment carried the health insurance for the whole family. The Accountable Care Act, in creating the marketplace, made it possible to purchase insurance independent of employment status. However, the plans are private and expensive, not to mention difficult to compare. My own bias is that we should have universal basic health insurance at the least.
In Quebec, where I trained, it was delightful to provide care to everyone, knowing that no one would be sent to collections for backbreaking medical debt. However, that system is strained, there can be long waits, and there have been calls for privatization. I’m not sure what the real answer is. I am sure that it will be complicated. I am also sure that it is vital.
During COVID-19, it became impossible to ignore social determinants of health. In fact, as this very touching reflection lays out, there are now codes in the EMR to capture information related to social determinants. It seems that access to health care that is equitable and understandable is a vital foundation for improving our system. It is clear that we have a way to go.
Claudia Finkelstein is an internal medicine physician.
