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Healthcare is for fuck-ups, too
Insurance shouldn't depend on keeping up with mail.
I am not what I would call a “put-together” person. I have to set reminders so that I don’t forget to take my meds, or that I promised to feed my neighbor’s cat. I let vegetables rot. I lost my new wedding ring three days after it arrived. And I forget to check the mailbox for two or three days at a time—so when I do open it, it’s absolutely stuffed with junk mail.
I sort of can’t believe how big a problem junk mail still is. Junk mail has existed since long before we had email, yet it persists; a whole new medium for sending unwanted advertisements was created and overtook physical mail, and we still haven’t fixed the original problem. (The incentives are low to fix it, since the postal service would lose a lot of revenue without it.) Whenever I open my mailbox, I carry a huge stack of total bullshit over to the recycling and drop it straight in. We get multiple catalogs from various Millennial Clothing and Millennial Home companies each week, some of them hilariously out of our price range; infuriating advertisements from Comcast that pose as handwritten letters; EXCLUSIVE OPEN NOW IMMEDIATE ACTION REQUIRED offers from credit cards. The only thing I might ever keep is the King Arthur Baking Company’s catalog. Otherwise, straight into the recycling it goes. A complete waste of time, money, and paper.
Each time, I do a quick check to make sure that an important letter hasn’t nestled inside a catalog from Marine Layer. But I still worry that I’m throwing away something important. (I sometimes throw out medical bills on purpose—not because I don’t intend to pay them, but because I know I’m going to do that online anyway, and also fuck you, bill, you shouldn’t exist.) What if there’s a letter from USCIS telling me I’m being deported if I don’t call them right now, and I just threw it in the trash?
Of course, keeping up with your mail is a part of being an adult in the world, just like changing your HVAC filter and paying your taxes on time. But should you have to be competent at what annoying people would call ‘adulting’ to have health insurance? Should you have to do this stuff right, every single time, to be allowed medical care? Should your access to the healthcare system, and therefore your ability to stay healthy and alive, depend on your organizational skills? No, it should not. Healthcare is for everyone, including fools, scatterbrains, losers, and total fuck-ups.
Last week, the Daily Poster published my story about the wave of Medicaid coverage losses that will likely begin this year. Since the start of the pandemic, state Medicaid programs have received an extra 6.2% in federal funding in exchange for not terminating anyone’s Medicaid coverage—a process that would normally be conducted all the time—even if they no longer qualify. But once the official public health emergency ends, states will not only be allowed to do this, but also have a huge financial incentive to do it as quickly as possible, since the additional funding that had been paying for all these enrollees will disappear just 60 days later. This “redetermination” process often involves sending mail to Medicaid recipients asking them to prove their income is still low enough to qualify; in many states, if a piece of mail to a recipient is returned as undeliverable, the state will cut them off. Even in normal times, people lose Medicaid for avoidable administrative reasons. They move and don’t get the mail, or the mail is simply lost.
Or maybe they get the mail, but they just don’t respond to it. In some states, Medicaid recipients have just 10 days to respond to a letter from the state requesting documentation of their incomes. I know I would struggle to get my shit together that fast, and I have an entirely flexible job, a printer, and a basic understanding of these things. What if you don’t have internet access to get your documents? What if your eyesight is failing and you don’t have someone to help you? What if you need to go to the bank to print statements saying you don’t have more than $2000 in assets, but the bank wants to charge over a hundred dollars to print it all out? (This is a real situation that I heard about from a nonprofit worker in Pennsylvania.) What if you’re homeless and have nowhere to receive mail? There’s an endless number of very good reasons why people miss mail, or why even if they receive the mail, they might not be able to respond to it in time.
But if you believe healthcare is a right, as I do, then it doesn’t really matter how good the reason is. I want people who just put the letter under a magazine and forgot about it to have free healthcare. I want people who read the letter, got kind of overwhelmed by it, and ignored it until it was too late to have healthcare. I want people who threw it straight in the trash because it looked like a bill to have healthcare.
In a truly fantastic 2002 edition of MTV Cribs, Jackass performer Ryan Dunn (RIP) showed the audience his pool table, strewn with obviously important letters. This table, he said, is “where I stick all my bills, and they usually sit there until someone calls me and yells at me because I hate dealing with the paperwork, and licking the things.”
He goes on to address anyone he owes money: “You might as well call, because I’m never gonna touch that stuff again, unless I move it to play pool.” (Though he notes that their phone line was also disconnected—they didn’t pay the bill.)
I want guys like Ryan Dunn, who throw their important mail on the pool table and ignore it, to have healthcare. I want America’s biggest fuck-ups—guys who got kicked out of their parents’ house for not getting a job and playing video games all the time, guys who got fired from GameStop for selling weed to customers, guys who have really disgusting toilets and an inexplicably hot girlfriend—to have healthcare. I want anyone who lives in America, regardless of their organizational skills, moral character, employment status, immigration status, criminal status, or excessive fandom of Rick and Morty, to have healthcare.
You might think people who actively ignore mail are irresponsible, especially compared to the situations I outlined above, where a person’s disability or financial status makes it harder to deal with stuff like this. You might think they’re lazy, or that someone should be able to deal with a simple piece of mail. But do you think being a bit shit at dealing with adult stuff is enough of a crime that it should cut people off their healthcare? Because that is the reality of the system we live in, where insurance determines access to care. There’s a tendency in healthcare coverage to focus on people who did everything right and still got screwed, like people who get hit with surprise bills. It’s understandable—if you want to convey how arbitrary and stupid the system is, those cases are the most powerful examples—but I’m equally outraged on behalf of people who didn’t jump through the right hoops. The hoops are the problem.
I often think Americans have (completely understandable) trouble imagining how differently things could work, so to be clear: It would be very possible, and in fact much less complicated and expensive, to instead have a system where people simply go to the doctor and the government pays for it. We don’t have to turn people away from the doctor because they don’t have the right insurance; we don’t have to have insurance at all, if we don‘t want to. In the UK, where I grew up, I wasn’t ‘insured’ by the NHS. It was just… there. I was registered for a general practitioner’s office based on where I lived; when I needed an appointment, we would call for one, and go to the office, and get care, and get prescriptions (currently £9.35 each) in the same building, and go home. No one asks for your credit card. You don’t get a bill if you filled in a form incorrectly, or if someone else did.
You don’t even need an ID to register with a GP in the UK. Here’s the form you fill in; it’s simpler and shorter than any form I’ve had to fill in at an American doctor’s office. (As always, the caveat applies: Over the last 10 years Conservative governments have made the NHS much worse, for example by charging foreign patients, than when I lived there.) In the US, there’s at least three or four things to fill in, and you have to sign a whole separate contract saying you will be responsible for the cost if insurance doesn’t pay, no matter what it is. You get bills in the mail, and if you miss those, debt collectors can come for you. Crucially, you have no ‘right’ to any of this; you might qualify for insurance subsidies or Medicaid, but nothing is guaranteed.
This is not to say that it would be easy to have a society where throwing mail straight in the bin would ever be a good idea. Unmissable bits of administrative correspondence exist everywhere. But the point remains that the healthcare system shouldn’t become completely inaccessible if you miss one or two letters, which is the reality for tens of millions of poor people in this country. It shouldn’t be a normal feature of the ‘safety net’ healthcare program that people get kicked off because they missed a piece of mail, or didn’t know how to provide evidence of their income. Medicaid is meant to be there when you are too poor or disabled to get employer insurance; why would we make it so easy to lose it?
The best way to do this would be to decouple individual insurance from financing the healthcare system, either the way the NHS does it (by directly employing healthcare providers) or through single-payer. Get rid of the entire concept of insured and uninsured, the awful distinction underpinning this cruel system. But if we can’t have that, we should at least make it impossible for people to be kicked off Medicaid, regardless of how bad they are at keeping up with mail. If we are going to call it a safety net, it has to catch everyone—even someone who rode a skateboard directly off the cliff.