ACA was designed to protect patients, not support insurance companies

I always looked forward to seeing David* in the office. He was a great young man — witty, polite, engaging. We talked about his job at a bank, his love of Ultimate Frisbee, his new apartment. I became his physician when he was in his early twenties and needed a primary care doctor to complete a medical form for work. For the next couple years, he saw me just occasionally: for a sprained ankle or a sinus infection.

David was really healthy, until he wasn’t. One day he came into the office and before we even started talking, I noticed how pale he was. He told me he had had no energy for a few weeks — first he had thought he’d just had the flu, but the symptoms didn’t go away.

{mosads}It didn’t take long for us to diagnose leukemia. Overnight, David’s life was upended. In the next year he underwent intensive treatment for his cancer, which included chemotherapy and multiple hospitalizations for the illness and complications of the therapy. The bill for his care after one year was hundreds of thousands of dollars.

Healthy young people who get their insurance from an employer usually don’t give much thought to the premiums. They may think that there is much better use for the hundreds of dollars that is taken monthly for services they rarely use. It can seem excessive when it’s used for only minor illnesses. But when health insurance is a mandatory as part of employment, an individual has no choice about the monthly paycheck deductions.

Everyone who has ever owned a house or a car realizes the paradox of insurance. Insurance feels unfair when you pay the premiums every month. It seems like money for which you get nothing. But the irony is that the ideal situation is to pay insurance premiums your entire life without ever needing the insurance. It’s much better if your house never burns down or your car is never damaged, even though that means you’ll never “get back” any of the money you’ve paid to the insurance company.

This is never truer than with health insurance. Paying monthly for insurance but never getting to “use” it — that is, you don’t get sick — is the ideal situation.

And health insurance is fundamentally different from any other insurance. The loss of a car or a house can feel devastating, and deciding how and if they should be replaced can be difficult. But when faced with a life-threatening illness, no one ever wants to make the choice to defer care.

That is why President Obama insisted that the Affordable Care Act (ACA) contain policies that were comprehensive, without a lifetime cap on benefits. These policies are more expensive because of this stipulation. But recently President Trump signed an executive order allowing for policies that cost much less, but provide many fewer benefits — commonly and accurately known as “junk” policies because they don’t cover people when they actually get sick.  

Such a “cheaper” policy proposed by President Trump is woefully inadequate in the face of a catastrophic illness. Older people need medical care much more often than younger individuals but all of us are vulnerable to unpredictable illness at any age.   

Modern medical care is nothing short of miraculous. Individuals injured in serious motor vehicle collisions are saved daily by trauma surgeons and can return to full lives, although it may take multiple surgeries, long hospitalizations, and months of rehabilitation. Infections and cancers that would kill people in the past are now curable.

But none of this technologically and scientifically advanced care is inexpensive; it’s costly at every stage.  We all know someone, or are someone, who survives today in a way that that would have been impossible 40 years ago. And when you walk in a hospital you feel overwhelmingly grateful that the doctor, nurse, radiologist, and pharmacist are the best ever available in the world and throughout human history. But all of this comes at a high price.

If his insurance had been one of Trump’s less expensive policies, David still would have pursued the most aggressive treatment for his leukemia, and the doctors and hospital would not have withheld that care. But even by attempting to pay, he would never be able to afford the full cost. In this case, others who do have comprehensive plans end up subsidizing the care of others, either when the hospital charges higher prices to cover the underinsured or society pays when a patient files for bankruptcy.

The ACA was not designed to be punitive nor was it written to support insurance companies. The rules requiring comprehensive care for catastrophic illness were put in place to protect patients who are faced with high priced care and to protect others in society from having to subsidize those who have not paid their fair share of insurance when they become ill. If someone needs prolonged health care, it is the rare person who can actually afford to pay for it out of pocket. But, one way or another, the bills do get paid.

No one ever wants to be ill, and as much as we complain about premiums, no one ever wants to have to use their health benefits. But overwhelming illness or injury can happen to anyone at any time, even the most healthy among us.

The outstanding medical care we have in this country should be available to all when they need it, but it comes at a cost. There is never a time in a person’s life when they can legitimately say that they don’t need health insurance. As with other insurance, we must all share the risk and hope we never need it.

*Name changed to protect the privacy of the patient

Katherine C. McKenzie, MD, is an internist with over 25 years of experience treating patients, and the director of the Yale Center for Asylum Medicine.