In 2004, I got my first medical bill, for $300. I had just arrived in the United States after completing medical school in Pakistan and was making $8 an hour as a full-time medical assistant at a primary care clinic in Wichita, Kansas.
The bill was for a skin biopsy recommended by my doctor for a suspicious-looking spot, later found to be benign. My doctor assured me the procedure would be covered by my insurance. At the time, I thought having insurance meant I didn’t need to worry about getting medical services.
I was wrong.
When I got the bill, I called my doctor’s office in a panic. They told me they billed me because my insurance had applied it to my deductible.
“What is a deductible?” I asked.
I could not believe there was a predetermined amount of out-of-pocket money I had to spend before insurance would cover my healthcare needs.
I felt cheated. I lived paycheck to paycheck, and didn’t have $300. It took me several months to pay it off.
Much has changed in my life since I received that bill. I’m now a practicing community psychiatrist in Minneapolis. I provide outreach treatment to people with serious mental illnesses through a community-based team. While a bill for $300 is no longer a devastating blow to my finances, for most people in this country who struggle to make ends meet, a $300 bill can mean being late on paying rent or not having money for groceries.
I hear these stories every day. Patients canceling their appointments because their account was sent to collections. Patients refusing to get necessary care because they have to meet a “spend down” before Medicaid would cover them, and when spending down their income means deferring other basic needs. Many of my patients cannot get their prescriptions for antidepressant and antipsychotic medications filled because insurance companies would not approve them.
My patients depend on these medications to live and function in the community and, in many cases, to be alive. Not having access to medications can result in recurrence of symptoms including suicidal or delusional thoughts, which then feed into a spiral of several other losses: loss of work, relationships, housing, and self esteem.
When the end goal is making profit, regardless of whether we cure sickness, healthcare insurance feels like a mirage, visible from a distance and disappearing as you get closer.
Healthcare providers share the mental burden of bearing witness as the industry exploits patients for profit through our labor. The burnout from bearing witness and feeling complicit leads many healthcare providers to reduce their work hours, change jobs, or leave healthcare altogether.
Looking back, I can see how this played a role in my own career. Hoping to find value in my work, I moved from working for a large healthcare system in Minnesota to a smaller healthcare system, and then to academia, before finding work as a community psychiatrist. What I did not realize then was that a change of employment will not fix the for-profit healthcare ecosystem that we all exist in.
Behind the scenes, most healthcare-provider meetings are focused on generating revenue for our employers. We get reports showing us how financially productive we are as providers. We’re taught how to write progress notes in a way that allows our employers to get the maximum reimbursement from insurance companies, which often results in our progress notes being indecipherable to patients and our colleagues.
Our notes no longer tell the stories of our patients. They simply make it easy to commodify illness into revenue.
Ironically, we still teach medical students about the social determinants of health: circumstances like poverty, housing, racism, and unemployment. I’d argue the status-quo healthcare industry is also a social determinant of health. It makes patients poorer simply for seeking healthcare.
More and more people are coming to the realization that the current healthcare industry does not care about us. Medicare For All, which started out as this fantastical idea, has become a major deciding factor between the Democratic presidential candidates.
Medicare For All essentially means universal healthcare. It is an affirmation that your health is not a commodity subject to deductibles, prior authorization, or surprise bills. Keeping private insurance options or extending Medicare to “those who want it” is essentially a prescription to maintain health inequities as well as economic and racial disparities.
Out of all the Democratic candidates, U.S. Sens. Bernie Sanders (Vermont) and Elizabeth Warren (Massachusetts) support Medicare For All. Sanders, however, is the only candidate who wants to do away with private insurance completely, while Warren has proposed expanding public options. Preserving public options along with private insurance maintains structural inequities that are financially ruining the working class, which is why I prefer Bernie Sanders' plan.
Even though many healthcare providers are publicly advocating for Medicare For All, there are still not enough of us doing so. One reason for this could be that implementing Medicare For All will mean many structural changes for people in the healthcare industry, including changes in jobs and salaries. So even while Medicare For All might not make personal financial sense to those of us with means, the question we must ask ourselves is: Do we want to live in a society where some of us have so much while others struggle to survive?
Another thing we teach medical students is the principle “first, do no harm.” It translates to not intentionally harming our patients either through our actions or inaction. When our patients tell us that the healthcare system is harming them, are we not doing harm by looking the other way?
Dr. Adnan Ahmed, MBBS, is a community psychiatrist in Minneapolis.