When my grandson was three, he picked up a raisin that someone had stepped on. It was flat and round. He held it by the edges with the tips of his fingers, turned it like a steering wheel, and said, “Dwive, dwive, dwive. Dwive, dwive, dwive.” He was annoyed at how long he was going to have to wait to be old enough to get his license. I was sympathetic, because I’d been waiting much longer to be old enough for something that I wanted even more: Medicare.
For more than forty years, I struggled to get decent health insurance. My first grown-up job, as a fact checker at a weekly magazine, came with a medical plan, but my wife and I were in our early twenties and therefore didn’t think of that as a benefit. My take-home pay was less than the rent on our apartment, so I quit to become a freelance writer, and for months after that we had no insurance at all. Then my wife, Ann Hodgman, got a job at a book publisher. When our daughter, Laura, was born, in 1984, Ann’s policy covered most of the cost of the delivery.
We moved out of the city when Laura was one, and Ann became a freelance writer, too. A magazine that I regularly wrote for put me on its health plan, but some time later the magazine’s insurance company discovered that I wasn’t an employee and threatened to drop the entire staff. I switched to an individual policy from the same insurer, at a premium I remember as about a hundred and fifty dollars a month. The magazine reimbursed me (until I stopped writing for it).
In 1990, I wrote the script for a single episode of a network television show, and, as a result, got a year of health insurance through the Writers Guild of America. The policy was so comprehensive that it practically covered toothpaste and deodorant. That year, Ann, Laura, our son, John, and I addressed every health issue we could think of. A surgeon removed a small cyst from my scalp, and, while he was at it, I had him slice off a couple of moles, what the heck. We also filled and refilled as many prescriptions as we could. We didn’t have another bonanza like that until sixteen or seventeen years later, when John and two college friends were planning a trip to India. Before he left, he needed several vaccinations, including a three-shot rabies series for what I was told could be as much as a couple of thousand dollars. I gulped, and asked our veterinarian if there was a less expensive option—but went ahead, of course, after finding a doctor on Martha’s Vineyard who could administer the third shot while we were on vacation. Miraculously, though, John’s college health plan covered all but a fifteen-dollar co-pay.
When my Writers Guild year ended, I could have kept the coverage going for another eighteen months by paying for it myself, under the terms of the federal COBRA law, but the premiums were higher than we could afford, so we went back to the policy we’d had before—which I’d actually kept paying for, because I was afraid of losing it. A couple of years later, I did lose it: the insurer stopped offering individual plans to anyone, and we were on our own.
People who have jobs with decent benefits may not realize how tricky life in the United States is for people who don’t. Ann and I went to see a local insurance agent, who described the individual medical policies offered by a couple of big insurers. But he told us that, when we filled out our application forms, we would need to lie: Ann was seeing a therapist and taking Prozac, and, he said, no insurance company would agree to write an individual policy for someone like that. Lying to an insurance company carries a risk, because if you get sick and the company finds out that you deceived them, your coverage could disappear and they could sue you to recover claims they’ve already paid. The issue was moot, however, because both companies we applied to turned us down. (Individuals are riskier than groups.) As it happened, a college classmate of ours had (reluctantly) ended up in the insurance business. He recommended a policy from a company we hadn’t heard of: American Republic. It had a reasonable premium and a relatively high lifetime payout limit—enough to cover at least a car accident or two—and, significantly, it agreed to insure us. Several years later, the guy who pumped our septic tank (his business card read “It May Be Sewage to You, but It’s Our Bread and Butter”) mentioned that diabetes and a heart condition made it impossible for him to get health insurance. I put him in touch with our old classmate, and American Republic insured him, too.
The main problem with American Republic was that I wasn’t the only one who hadn’t heard of it. Some of the doctors we used wouldn’t deal with it; they classified us as “self-pay” and charged us more than the fees they accepted from companies that regularly reimbursed them—big corporations like Aetna, Blue Cross Blue Shield, and UnitedHealthcare, which negotiate prices with medical providers. (Negotiated prices also vary significantly from insurer to insurer.) Occasionally, I was able to negotiate on my own. When John was ten, he broke his wrist after a soccer game by falling off the roof of a baseball dugout. The office of the orthopedist who put the cast on his arm looked as much like an accounting firm as a medical practice: there was a huge open workspace filled with desks covered by piles of insurance forms (plus a few small examination rooms, way in the back). I asked the receptionist if she would give me a discount if I paid right then, with a check, thereby sparing the clerks behind her the nuisance of having to find out that I hadn’t met my deductible. She knocked a couple of hundred dollars off the bill.
Not long afterward, I learned that negotiation has its limits. Ann had hand surgery, performed by a doctor who, amazingly, either had an agreement with American Republic or was willing to operate for what it was willing to pay. A few weeks later, though, the doctor’s office manager called to say that, because we hadn’t met our deductible, he was going to ignore the negotiated fee and charge us full retail. In addition, he said, there was the matter of certain “operating room” charges, even though the surgery hadn’t been performed in a hospital. I already didn’t like this weasel; now, I thought, Aha! I’ve got you! But, when I called American Republic to report what I assumed was insurance fraud, the customer-service agent said I was wrong and that the doctor could charge whatever.
American Republic’s premiums eventually rose so high that I decided we might as well try to sign up with an insurance company that we (and our doctors) had heard of. One turned us down because I’d had Lyme disease a year or two before. (We live in Connecticut, where ticks bite even people who never go outside.) Another agreed to insure me but not Ann—Prozac again. She ended up in the state’s “high-risk pool,” for people who were otherwise uninsurable as individuals. Her premiums, from a company I’d also never heard of, were double mine.
If you have bad insurance or a high deductible—and we had both—you don’t necessarily seek all the medical care you should. Contemporaries spoke of their colonoscopies mainly as nostalgia-inducing drug experiences that they were eager to repeat. When Ann called our local hospital to inquire about costs, though, the person she spoke to was vague: probably something like four thousand dollars, but more if they found polyps. John was born in the same hospital in 1988, in its brand-new “birthing center,” which had soft lighting, comfortable furniture, and a nice big private bathroom. But the birthing center was a money loser. The hospital’s owners closed it in 2013 and later turned the space into administrative offices. They still do colonoscopies, though (“It May Be Sewage to You . . . ”).
The passage of the Affordable Care Act was huge for us. In 2014, for the first time, we were able to sign up, together, for a normal medical policy, from a major company, without fear of being turned down because of the possibility that someday one of us might get sick. The annual deductibles were so high that we never met them: six thousand dollars each. But now, at least, we were only charged whatever our insurer’s negotiated prices were. Before Obamacare, Lyme-disease tests had cost several hundred dollars; now they were more like a hundred. In 2019, I had Mohs surgery to remove a basal-cell carcinoma from my nose. All in all, I paid about fifteen hundred dollars. That was an annoying, unexpected expense, but before Obamacare the bill would have been higher—and the fact that I’d had skin cancer might have bumped me forever into the high-risk pool.
Republicans’ many efforts to undermine the Affordable Care Act have been depressingly effective, and I assume that those efforts were at least partly responsible for the premium increases that Ann and I received during the next few years. Our combined monthly Obamacare premium in 2014, for a Bronze policy, was a little less than a thousand dollars; by 2020, it had doubled. That meant that our annual health-insurance outlay, plus our combined deductible and miscellaneous out-of-pocket medical expenses that wouldn’t have been covered anyway, added up to more than thirty-seven thousand dollars—a big yearly nut for a couple of self-employed senior citizens. To make matters worse, the doctors we’d both been using for years became “concierges,” with high fees that not even the Writers Guild would have reduced. So they became our former doctors.
I turned sixty-five on Valentine’s Day, 2020. Two months before my birthday, I called a local insurance agent to schedule a Medicare consultation. The agent told me that, before I came in, I needed to create my Social Security account.
One of the frustrations of getting older is that government services aimed at older people often seem to have been designed to make it difficult for older people to use them. There is a Medicare Web site—medicare.gov—but that’s not where you sign up for Medicare. Instead, you go to the Social Security Web site, ssa.gov. In order to create your online account, you have to answer a few questions about yourself, to prove that you’re you. My questions were weird: one concerned a car loan I hadn’t taken out; another was about a credit card I’d never had. I did my best, but I must have answered at least one of the questions wrong, because the site locked me out for twenty-four hours.
My identity questions, I figured, must have been based on information from one of my credit reports, which I’d never looked at. I was easily able to download two of the three, from Experian and TransUnion. But I couldn’t download the third, from Equifax, because its Web site wouldn’t let me in unless I correctly answered questions that were eerily similar to the ones I’d got wrong at ssa.gov—proving, I guess, that Equifax was the government’s data source. (A Catch-22: in order to find out what’s in your credit report, you need to know what’s in your credit report.) Twenty-four hours later, during Thursday Night Football, I tried ssa.gov a second time, and was locked out again.
In the morning, I called the Social Security Administration’s hotline, and, after waiting on hold for forty-five minutes, spoke with a surprisingly pleasant man, who assured me that he was a pro at guiding Medicare applicants past security questions. He unlocked the site and gave me some tips: if it asks about an old street address, the correct answer might be a street that was a block away from the one I used to live on; if it asks about an old phone number, the correct answer might be off by a digit or two. With his help, I answered “none of the above” to the first three questions, guessed right on the fourth, and, boom, I was in.
I knew—because Ann and I receive both the A.A.R.P. Bulletin and A.A.R.P. the Magazine—that Medicare isn’t just one easy-to-understand thing. Everyone who signs up has to get Part A, which helps cover things like hospital stays and, for most people, doesn’t have a premium. Part B, which helps cover things like doctors’ visits and lab fees, is optional and does have a premium. (The standard Part B premium for 2022 is a hundred and seventy dollars and ten cents a month—an increase of almost fifteen per cent from 2021—with an annual deductible of two hundred and thirty-three dollars. People with incomes above a certain level pay more.) Parts A and B are known as Original Medicare. You can also get Part D, which covers many prescriptions, also with a deductible, and you can get Medicare Supplement Insurance, known as Medigap, which pays for some things that aren’t paid for by Parts A and B. Part D and Medigap are both provided not by Medicare but by private insurance companies, which have to meet certain government requirements; they come in multiple versions, at multiple prices, and they differ from state to state. The Medigap policy I signed up for, from Anthem, is two hundred and eleven dollars and ten cents a month; my ninety-two-year-old mother’s policy, in Missouri, is four hundred and fifty-three dollars. If you have Medicare, you can no longer contribute to a Health Savings Account, but you can spend down your existing balance.
Part C, usually called Medicare Advantage, is an alternative to Original Medicare and is also provided by private insurance companies. It usually has lower out-of-pocket costs and often covers things that Original Medicare doesn’t, including some visits to dentists and eye doctors. But most versions work in only a limited geographic area, and they generally cover you only if you use your policy’s network of providers, as with an H.M.O. (With Original Medicare, you can go to any doctor who accepts Medicare—not all of them do, by any means—and you seldom need a referral.) You can switch plans during an annual open-enrollment period, but things get complicated if you want to switch from Medicare Advantage to Original Medicare because you’ve just received a grim diagnosis and would prefer to be treated by a specialist who is outside of your Part C network. The problem is that if you have Part C you can’t get Medigap, and, except in certain situations, if you apply for Medigap when you switch to Original Medicare, the provider can employ what medicare.gov refers to as “medical underwriting” in evaluating your application. “Medical underwriting” is a euphemism for “preëxisting conditions.” If you have one, the Medigap provider can turn you down—or, if it agrees to insure you, it can charge you more than it charges other people. The safest thing to do, I decided, was to ignore Medicare Advantage and choose a Medigap plan immediately, during the so-called Medigap Open Enrollment Period, which begins when you sign up for Part B and lasts for six months. During that period—which “can’t be changed or repeated,” according to medicare.gov—insurers cannot reject you, no matter what.
All of this sounds insanely complicated. And it is insanely complicated. Some communications from Medicare come not from Medicare but from C.M.S., which stands for Centers for Medicare and Medicaid Services, which is part of the Department of Health and Human Services. If you sign up for Medicare Easy Pay, which withdraws your premium straight from your bank account, you may nevertheless receive mailings that say “MEDICARE PREMIUM BILL” in large bold type in the upper left-hand corner and “THIS IS NOT A BILL” in smaller, non-bold type in the upper right hand corner. In a sane country, bills that aren’t bills would not arrive in the mail, coverage would begin at conception, doctors wouldn’t be able to opt out of treatment, preëxisting conditions would never matter, and patients wouldn’t need expert help to figure out which diseases they can afford to have. Even so, when my Medicare card arrived in the mail, I celebrated. “At long last,” I told Ann, “I’ll be able to have that colonoscopy” (although I haven’t done it yet). Another plus: I can now read Lisa Sanders’s “Diagnosis” column in the Times without brooding about who’s paying for all those MRIs.
Ann turned sixty-five a year and a half after I did. By then, I knew how to sign her up without help from the surprisingly pleasant man. (I even got her security questions right, by myself, on the first try.) We enrolled her in Part D and Medigap plans that are different from mine, because we thought it would be interesting to compare them, but so far we haven’t studied them closely. We still have health costs. Our combined premiums for Part B, Part D, and Medigap add up to just under nine hundred dollars a month, plus various deductibles. That seems like an amazing bargain to us, because we used to pay so much more for so much less, but it’s still a significant cost. A study published by A.A.R.P. last year found that Americans covered by traditional Medicare, on average, spend more than a third of the median Social Security income on health care—including premiums, deductibles, co-pays, the cost of supplemental insurance, and other uncovered expenses.
Republicans seem to hate Medicare almost as much as they hate Obamacare. Recently, Congressman Thomas Massie, of Kentucky, tweeted, “Over 70% of Americans who died with COVID, died on Medicare, and some people want #MedicareForAll?” Republicans often seem to view Medicare in any form as socialism (while finding nothing objectionable about the oil-depletion allowance, the reduced tax rate on capital gains, the law that prevents the government from negotiating Medicare drug prices with pharmaceutical manufacturers, or the Trump Organization’s portfolio of tax-avoidance strategies). But, no matter what you think of socialism, Medicare recipients do pay for their coverage, and not only once they’ve got it. I’ve been paying for Medicare since the summer after ninth grade, more than half a century ago, when I angrily carried my first paycheck into my employer’s accounting office to ask why the amount was so much less than I knew I was supposed to be paid.
At any rate, when it comes to medical care, what’s wrong with socialism? The existing American system, with its dazzlingly inefficient mix of public and private insurers and its legions of redundant paper shufflers, is not a persuasive argument against it. Canada, which does have universal health care, spends roughly half as much per capita as we do, yet has better outcomes, including an average life expectancy that’s more than four years longer than ours. In fact, according to the World Health Organization, the U.S. ranks just fortieth, worldwide, in life expectancy at birth. That’s a little bit better than Ecuador and Poland but a little bit worse than Turkey and Croatia. Once the final COVID tally is in, we may fall even further.
Premature death isn’t the only negative consequence of the American approach to health care. Workers often keep jobs that they hate because they don’t want to risk ending up with a worse plan, or with no plan at all. Ann and I know a couple who split up years ago—and live hundreds of miles apart, with different partners—but remained married for ten years because the wife had good coverage, through her job, and the husband has a chronic illness that he couldn’t have afforded to treat if he’d had to deal with it on his own. There’s a lot I still don’t understand about Medicare, even though I’ve read the oversized hundred-and-thirty-page book that comes with it and dug fairly far into the Web site. I do know that it’s complicated and surprisingly expensive, and that Congress often seems to be on the lookout for new ways to screw it up. So maybe the strongest argument against the rest of the American health-care system is that, now that I’ve spent time in both, I think Medicare is almost miraculously great.
