The rot of privatized healthcare

Letting the rich buy better healthcare cannot be justified

This week, Strikewave reported on a very interesting union effort: Hourly workers at One Medical, a membership-based primary care service for the semi-wealthy, are unionizing. The company’s CEO has not recognized the union, trotting out the same bullshit excuses that I won’t even repeat here. Covered workers would include administrative assistants and phlebotomists (the nice people who draw your blood). The workers’ grievances are those shared by many hourly workers in the US— low wages, a lack of hazard pay, and the expectation of long hours—but their troubles are made even more striking by the contrast with the wealthy people they serve, and the healthcare system that underpins it. One worker told Strikewave that, far from One Medical’s lofty rhetoric about changing healthcare for the better, “you’re not transforming shit if it’s not accessible to everyone.”

One Medical is not exactly a concierge medicine operation, but it’s a similar model. Like concierge medicine, One Medical customers pay a fee for better, faster access to doctors. True concierge medicine doesn’t even accept insurance, private or government; the costs are entirely covered by the monthly fees, which are far higher than One Medical’s $200-a-year charge. One Medical strikes a balance between the two, promising better than your standard primary care experience without country club membership-level costs, relying on private insurance payments to bridge the gap. (As Strikewave noted, One Medical categorically does not accept Medicaid.) It’s also worth noting that it’s backed by huge investors like Google’s parent company and the Carlyle Group.

It’s not quite concierge care for the one percent; it’s more like concierge care for the five percent. Places like One Medical, and similar ventures like Forward, are aimed at the young-ish with disposable income in big cities. They can afford a little bit extra to guarantee a decent healthcare experience and who value things like emailing doctors and telemedicine appointments highly, perhaps because of their busy professional lifestyles (and they’re glued to their damn phones anyway). They might be in double-income-no-kids households; in DC, for example, One Medical doesn’t even do pediatric care, as of March 2020. They’re not super rich by any means—they may not be buying something as decadent as a house, at least not yet—but they aren’t living paycheck to paycheck. They’re much more likely to order Seamless than deliver for it. The branding screams Instagram Aesthetic, if you get as many medical startup ads on there as I seem to; it’s all about medicine “designed around you.”

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One Medical is not the only company like this. Forward advertises a complete testing panel for new members, including genetic testing, skin cancer exams, biometric scanning, and blood work; they’ll even send a lab specialist to your house to take your blood. Imagine getting a damn house call, in the United States! This sort of pitch reminds me of what Larry Sanders said to me in our recent interview, that America spends so much more on healthcare because it provides too much healthcare for the rich, while not providing enough for the poor (which also creates further costs down the road, if we’re counting). Wealthier people with good insurance are more likely to be the beneficiaries, or the victims, of plentiful care. Unnecessary tests, procedures, even surgeries are performed because they earn the hospital more money, and because patients don’t know which tests and procedures they really need. After all, isn’t that what the doctor is for? Insurance pays up, and the cost of American healthcare continues to soar. There are few winners, but they win big.

I always think back to the time I first saw a neurologist for my chronic migraines, in England, just before I went to university. She took a detailed history, with great sympathy and insight, and after a brief neurological exam—following a pen with my eyes, touching my nose—the neurologist said she could order an MRI if I liked, but she didn’t think I needed one. The humiliating neurological exams were all completely fine, and I’d had gradually worsening migraines for 10 years, so I probably didn’t have a brain tumor. A few years later, as a grad student in DC, I saw a neurologist again at George Washington University hospital—except I mostly saw her medical student, who took my history and asked all the important questions. The neurologist herself came in for five minutes, did the same neurological function tests, and said I should get an MRI anyway. Not knowing much better, I got the MRI, which was all clear—and cost me $300, out of a total bill of something like $2000. If I had known the cost, I might not have gotten it—people make that choice every day—but who was I to say the doctor was wrong? I certainly had never had to think about a doctor’s profit motive before.

Years later, and with better insurance, I had a One Medical membership. It was free, because my employer’s insurance provider sponsored it (and I’d love to know how that deal was funded, knowing that people like to keep their doctors and they switch insurance providers all the time). It was fine, medically speaking. I liked the nurse practitioners I saw there, and it was easy to make appointments. I used the email service a couple times. They had lemon water in the lobby. The bathrooms were nice. It looked more like an Outdoor Voices store than the NHS offices I used to go to back home—and I hated that. I hated the feeling that I was both being pampered and being told that I was worth pampering, because I knew that the same system has decaying facilities for the poor and shuttered rural hospitals. This doesn’t make me especially noble—I still went, and I’m still going to be executed in the revolution, as I should be—but the experience of care that is definitionally for an elite was quite jarring, having grown up with the NHS. The care I’d experienced up in the United States until then, even with private insurance, was no better than the NHS, if not worse. I had leveled up to another strata of wealth-dependent care; I had peeked behind the curtain of the five percent. When I switched insurance, I was allowed to keep seeing my doctor without paying the fee (though not to use the telemedicine services), but I ended up going back to a normal primary care doctor.

As Larry Sanders told me, there is something very wonderful about going to an NHS doctor and seeing “all sorts of people,” and knowing it is for everyone. (Private doctors very much exist in the UK, and are growing as the NHS gets hacked apart, but it is still tiny compared to the US, where it is almost the only way to get care. It’s also plagued by some of the same problems as American health insurance; I talked to some workers at Mum’s hospice about their experience with it, and they told me about being denied coverage for pre-existing conditions. Even America got rid of that!) I would take the dingy waiting room of my GP’s surgery in Banbury, with its sticky abacuses for the children and old copies of Glamour for the adults, over the manicured Airbnb aesthetic of One Medical any day—if it meant that it was for everyone, that the money was being allocated equitably and was being spent on healthcare and not on succulents.

But that’s not America, and here, it’s very easy to see why these places might be an easy sell, especially for urban millennials who are health-conscious and have the cash. Though I’ve never personally experienced any difficulty getting appointments with a regular primary care provider in DC—I go to Comprehensive Primary Care, who saw me the same day when I got pneumonia and whose doctors have always answered my emails—such appointments can absolutely be hard to find, even with good private insurance. If your care needs are any more complicated than the annual physical or occasional rash, like seeing specialists or needing tests, anything that removes the friction, hassle, and delays could be appealing. I waited six months for my first appointment with a neurologist at Medstar, for example, and in the meantime suffered greatly. (Luckily for One Medical customers, the company is partnering with MedStar for access to their specialists.) I would note that it took far less time to see a neurologist in the UK, whose wait times are supposed to be an argument against single-payer.

And why wouldn’t better-off Americans expect to be able to use their wealth to skip the hassles that affect everyone else? That’s what wealth means; the more you have, the less the crumbling foundation of this country affects you. Public transit in your city sucks because of years of neglect and defunding? Just take an Uber. Underfunded public schools? Send your kids to private school. Having trouble making an appointment with a doctor because we don’t have enough doctors or, like, a healthcare system? Just go to One Medical—it’s not much more than you’d spend on Netflix a year anyway.

Of course, not everyone who uses One Medical is rich. Some of them are absolutely not rich, but spend the money anyway because American healthcare is so broken that they had no alternative. Last year, Washington City Paper spoke to some of DC’s One Medical patients; one of them, a bartender, used his tip money to book an appointment because “it was the only provider where he could book an appointment within a month’s time.” This is the perniciousness of this model; it doesn’t do anything to make healthcare more equitable, but does offer people with a bit more than nothing a way out, further widening the gap between the very poor and everyone else (which I think is a vastly more important gap than that between multimillionaires and everyone else).

Here is where having a healthcare system would really come in handy. Without it, there is no way other than the market to reallocate the clearly abundant time of these doctors to the needy, regardless of how profitable that would be. Far from any sort of central planning of healthcare, there’s nothing but a shrug from the government at these problems. You need a doctor? Go to the ER, I guess. Otherwise, it’s the Wild West. If a doctor wants to charge an entry fee to keep their days clear, while other doctors struggle with full calendars and wasting time on insurance reimbursements, they’re free to do so.

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It was never a surprise that this inequality would hamper our coronavirus response and lead to needless death. One Medical was the subject of an investigation into its coronavirus vaccine practices in March, after reports emerged that it was vaccinating ineligible people and those with connections to leadership. Around the same time, a true concierge doctor gave a chest-thumping interview to Washingtonian about the rich patients badgering him for early access to the vaccine:

“I get easily 50 to 100 calls a day—even from people who’ve never used our service—asking about [vaccines], and I’ve just got to tell them the cold hard facts: I am abiding to what the requirements are. It doesn’t really matter what you might offer me. And once I’ve done my triage and determined you don’t qualify for this initial vaccination round, then you’re not going to buy me. There are some people who say, well, I thought you could do everything, and I’m like, well, yeah, I can do what’s appropriate. I don’t mind saying no to a billionaire. I’ve done it before, I’ll do it again.”

Damn, dude, that’s so cool, that you said no to a billionaire—are you even allowed to do that? How impressive and noble—except that this guy’s entire business model is giving rich people better healthcare in exchange for money. His house calls start at $600 per visit, let alone whatever sort of higher fees he takes for more complicated medicine. Why draw the line at the coronavirus vaccine? (It certainly feels a little silly in hindsight; all those clamoring millionaires would have become eligible for that vaccine within a few weeks of that article being published anyway.) Why is it fine to be bought—in his terms—for other kinds of healthcare? To practice the sort of medicine a concierge doctor practices is to accept the premise that a doctor should be able to sell his services to the highest bidder.

But then this is the premise of American healthcare, period; that money should be able to buy you health, happiness, a longer life. The person with an employer-sponsored insurance plan gets better care and more doctors than the person with Medicaid; the person with a really good employer-sponsored plan gets even better care, more frequently and more easily. The person with millions gets whichever doctor he wants, and so on. It’s not just The People versus millionaires; every rung on the class ladder gets you better care compared to the one beneath.

So I can’t really blame the individual who pays One Medical to skip the hassles and indignities of American healthcare; those hassles can absolutely be harmful to your health, even deadly. But that option should not exist, nor should it need to exist. There should be no One Medicals offering a premium service for the better off while everyone else still suffers, because we won’t fix health injustice for the poor until the rich can stop buying their way out. It’s got to be everybody in, nobody out.

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