Anjali Nirmalan
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My Moral Hazard

December 27, 2010 @ 3:37 PM | Permalink

"Your best bet may be to just go uninsured."

I sat in disbelief. Is this really what it had come to?

I thanked the insurance salesman and pressed “End” on the Skype call.  He had just informed me that it will take three months to get me onto Medicaid or another low-cost health insurance plan for low-income people.  But I don't have three months.  In one month I will leave Britain – where I am automatically covered under the National Health Service – and return to the U.S., uninsured for three months until my new job starts.

In previous decades, young Americans didn't think twice about going insured; they were healthy and careful, and emergency medical costs weren't too high.  Today, the scary truth is handed to us along with our diplomas: “Don't go uninsured.  It's not worth it.”  One accident, we are told, can screw up our lives; once hit with astronomical hospital bills, it can be near impossible to fight off debt – let alone find an insurance plan that will then take us on.

But without a source of income for the summer, I am finding it impossible to locate a healthcare plan with affordable premiums, even to just cover emergency costs.  Obama's new health reform would let me go back on my parents' plan – but not until next year.  I have tried different states, using the addresses of various family members resident there.  I called 1-800 number after 1-800 number from my London apartment, the last one resulting in this painfully honest advice: go uninsured.  Register at a free clinic, and be careful.

“Be careful”?  I didn't understand; how could something so natural in the UK – emergency medical coverage – be so difficult to attain in the U.S.?

While the British complain about NHS, they would never give it up.  Even with all its problems, it has become an accepted institution since its establishment post-World War II.  When covering the American healthcare debate over a public option, the British media outlets adopt a scornful tone.

“If a grandmother were to fall and break her hip on the floor of her home, the National Health Service would be there to offer immediate help...but in the US, it would be an entirely different story,” declared the Daily Mirror recently.  “Medical debt is the top cause of bankruptcy in the U.S...[Obama] wants to introduce a system more like our NHS, where treatment is free to all at the point of need.”

The British media, normally loud critics of the NHS, also leapt to its defense when it has been regularly smeared by U.S. Republicans as “evil” and “Orwellian.”  At the same time, they are extremely aware that NHS does come with its own host of problems.  A Spanish woman I sat next to at a concert cursed the system.  “It is far too difficult to get quick, high-quality treatment,” she told me.  “I am going back to Spain for it!”  Parliament recognizes this problem; in the latest round of reform, it has vowed to get the waiting period for specialist treatment down to a maximum of 18 weeks.  That's still more than four months.

But when it comes to access to medical care, the British trounce Americans.  When I contracted what may have been swine flu, I never had to leave my room.  I called an NHS hotline and they arranged for free antivirals to be waiting at a local pharmacy.  My American friend, Jade, went and picked it up.  No charge.  (In the U.S., it is $80 for the same ten-day course of drugs.)

When Jade recently broke out in a full-body rash, she walked down the road to the university hospital's emergency room.  She ended up spending the night in a ward as physicians tried different drugs on her.  Eventually they pinned it on the round of amoxicillin she'd taken a week ago for a throat infection and sent her home to wait it out.  No charge – and she had been able to get checked out in case it was something more serious.  In the U.S., a visit like that would have left her at least $4000 in debt – so she probably would not have gone at all.

However, at this top London hospital, Jade was also shocked by the confusion and ineptitude of those who treated her.  Baffled and outwardly horrified by her rash, they kept passing her on to the next senior person in the bureaucratic line-up.  It took four painful tries for an attending nurse to find a vein for the IV – and when she asked for food, no one seemed quite sure about where to find her some.

“Doctors here are not as well-trained as in the States,” a retired British physician recently told me. It takes nine years for a British student to attain General Practitioner status, versus at least eight years of schooling and a three-year residency for their American counterparts.   At my London university, I quickly became accustomed to meeting medical students as young as 18.  American medical students also pay a great deal more for their education, graduating on average with debts of more than $150,000 .  The investment of time and money can be justified, however, by eventual large salaries and often pursuit of profitable specialties; not so in Britain, where doctors are paid adequately by NHS and accessible primary care is a priority.

One reason why American insurance plans are rife with co-pays and deductibles is the “moral hazard” dilemma.  Moral hazard refers to the phenomenon when a person, insured against some of the effects of risk, changes their behavior from what they would have done had they been fully exposed to that risk.  If all hospital treatment is covered, won't people just run to the doctor with any common cold?  Shouldn't there be discouragement of burgeoning hypochondria?

While covered by NHS, I have caught myself succumbing to moral hazard.  Perturbed by a couple of itchy spots on my shoulder, I dropped into the university clinic to have it checked out – even though in the U.S., I would've ignored it.  The physician told me to put some hydrocortisone cream on it – probably what I would have done anyway – and sent me on my way.  No charge.  But if I had wanted to see dermatologist, I would have had to secure a recommendation from my assigned GP and then get onto the wait list; this is how the UK chooses to discourage moral hazard.

Now take birth control.  While marking the 50th anniversary of the invention of the birth control pill, a New York Times columnist speculated that should the U.S. government “announce tomorrow that all birth control would be free for every woman in America, I think the health care plan would gain 30 points in popularity overnight.”  By contrast, a British woman can always get the pill easily and without paying a penny.  While living in the UK, many American female students unrepentantly stock up on packs of oral contraceptives to take back with them to the U.S.  This may seem fairly harmless, but British politicians criticize this kind of “health tourism” at the expense of NHS; they cite stories of heavily pregnant women and immigrants with cancer who come to the UK on holiday visas, looking for free medical care.  However, these days the story seems to play in reverse; rather than wait six months to receive surgery, British patients are now flying as far as India to pay relatively inexpensive costs for immediate action.

Even with all the associated dilemmas, should the U.S. still implement some kind of public option?  Should healthcare be mandated, with affordable options within everyone's reach?  Sometimes, does a person just have to go uninsured?  As hard as I try to answer these questions logically and unemotionally, it's also hard not to think of my sister.

My youngest sister was born with an extremely severe peanut allergy.  Last year, when she was home in New York, she unknowingly took a bite of a pancake with peanut butter in it.  She immediately vomited it out – and so my mother, wary of the co-pays associated with a hospital visit, cautioned against us heading for the emergency room unless we needed to.  I will never forget sitting on the couch holding my sister, watching her skin break out in hives, and listening to the growing rattle in her lungs.   We ran for the car and spent the rest of the day in the hospital with her hooked up to an IV.

America is my home; it is also a global leader and industrialized nation.  But I know the healthcare system waiting for me there: no morals, just hazards.  There are patients with flu, infecting everyone in the clinic waiting room.  Jade covered with angry red welts, staying at home and desperately hoping it's nothing.  A sexually active woman forgoing birth control because her insurance won't cover it.  My little sister, fighting for every breath, who will spend her life bankrupting herself to try to stay insured.  Me this summer, bicycling to the grocery store, one drunk driver away from a lifetime of crushing debt and pain.

System?  The British have shown me that ours is no system at all.  

I am no longer disbelieving.  I am careful – and afraid.

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