Gouging the Poor

    By Barbara Ehrenreich

    The Progressive

    February 2004 Issue

 

 

     There's been a lot of whining about health care recently: the shocking cost of insurance, the mounting reluctance of employers to share that cost, the challenge--should you be so lucky as to have insurance--of finding a doctor your insurance company will deign to reimburse, and so forth. But let's look at the glass half full for a change. Despite the growing misfit between health care costs and personal incomes, it is not yet illegal to be sick.

     Not quite yet, anyway, though the trend is clear: Hospitals are increasingly resorting to brass knuckle tactics to collect overdue bills from indigent patients. Take the case of Martin Bushman, an intermittently insured mechanic with diabetes who, as reported in The Wall Street Journal, had run up a $579 debt to Carle Hospital in Champaign-Urbana. When he failed to appear for a court hearing on his debt rather than miss a day of work, he was arrested and hit with $2,500 bail. Arrests for missed court dates, which the hospitals whimsically refer to as "body attachments," are on the rise throughout the country. Again, on the half full side, we should be thankful that the bodies attached by hospitals cannot yet be used as sources of organs for transplants.

     Mindful of their status as nonprofit charitable institutions, hospitals used to be relatively congenial creditors. My uninsured companion of several years would simply work out a payment arrangement--on the scale of about $25 a month for life--and go on consuming medical care without the least concern for his freedom. No longer, and it's not just the dodgier, second-rate hospitals that are relying on the police as collection agents. Yale-New Haven Hospital, for example, has obtained sixty-five arrest warrants for delinquent debtors in the last three years.

     Of course, if you work for Yale-New Haven, it's not your body that gets "attached." On a recent visit to Yale hospital workers, I met Tawana Marks, a registrar at the hospital, who had the misfortune to also be admitted as a patient. Unsurprisingly, her hospital-supplied health insurance failed to cover her hospital-incurred bill, so Marks now has her paycheck garnished by her own employer--a condition of debt servitude reminiscent of early twentieth century company towns.

     To compound the sufferings of the sick and sub-affluent, hospitals now routinely charge uninsured people several times more than the insured. The Fort Lauderdale Sun-Sentinel reports that one local hospital charged an uninsured patient $29,000 for an appendectomy that would have cost an insured patient $6,783. According to the Los Angeles Times, in one, albeit for-profit, California hospital chain, the uninsured account for only 2 percent of its patients, but 35 percent of its profits. The explanation for such shameless gouging of the poor? Big insurance companies and HMOs are able to negotiate "discounts" for their members, leaving the uninsured to pay whatever fanciful amounts the hospital cares to charge, such as, in one reported case, $50 for the use of a hospital gown.

     Back in 1961, psychiatrist Thomas Szasz noted the "medicalization" of behavior formerly classified as crime or sin, such as drug addiction or what was defined as sexual deviance. Rather than seeing this as a benign and potentially merciful trend, the crotchety Szasz complained about the growing concentration of power in the hands of a "therapeutic state." How quaint his concern sounds today, when instead of the medicalization of crime, we are faced with the criminalization of illness.

     Because almost everyone, no matter how initially healthy and prosperous, is now in danger of falling into the clutches of the medical/penitentiary system. It could start with a condition--say, high blood pressure or diabetes--serious enough to be entered into your medical record. Next you lose your job, and with it your health insurance--or, as in the case of 1,000 or so freelance writers (including myself) once insured through the National Writers Union, the insurance company simply decides it no longer wants your business. You go to get new insurance, but no one wants you because you now have a "pre-existing condition." So when that condition flairs up or is joined by a new one, you enter the hospital as a "self-pay" patient, incur bills four times higher than an insured patient would, fall behind in paying them, and, given the hospitals' predatory collection tactics, wind up in jail.

     Sociologists have long seen a connection between sickness and criminality, classifying both as forms of deviance. Certainly, the relevant vocabularies have been converging: Note the similarity between the phrases "pre-existing condition" and "prior conviction," as well as the use of the terms "record" and "case." A doctor once told me that, although he had detected a new and potentially life-threatening condition, he would refrain from prescribing anything to correct it, lest my record be marred by yet another pre-existing condition.

     The day will come when we look back on such small acts of kindness with nostalgia. Even as I write this, some bright young MBA at Aetna or Prudential is no doubt coming to the conclusion that a great deal of money and valuable medical resources could be saved through the simple expedient of arresting people at the first sign of illness. Skip the intermediate stages of diagnostic testing, hospitalization, and attempted debt collection, and proceed directly to incarceration. The end result will be the same, unless you succeed in concealing that cough or unsightly swelling from the cop on his or her beat.

     I'm prepared for this eventuality, having been raised by a mother who was in turn raised by her Christian Scientist grandparents, and had thus been trained to greet her children's symptoms with contempt and derision. I was conditioned, in other words, to conflate physical illness with moral failure. Should a rash or sore throat arrive, I stand ready, at some deep psychic level, to serve my time.

     But for those of you who still imagine that illness and pain should elicit kindly responses from one's fellow humans, I have one last half full observation: Our prisons do offer health care--grossly inadequate care to be sure--but at least it's free, even for child molesters, ax murderers, and those miscreants who have the gall to be both sick and uninsured.