Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice

The midwife national convention



It’s time for the
Midwife National Convention!

Publicity for the upcoming annual conference of the Midwives Alliance of North America, combined with this summer’s Republican and Democratic national conventions, were the twin inspirations for this cartoon.  It seems unlikely that we will elect a midwife-in-chief anytime soon, but cherishing midwives’ skills and experience under the cover of political maneuvering seems like an end in itself.

References and Explanations

Frame 1. The background photo is from one of this summer’s conventions. Does it matter which? The MNC logo is based on a graphic by Sam Taeguk, shared under a Creative Commons license.

Frame 2. Every gathering needs a quilt exhibit! This quilt is intended to convey – by the variety of fabrics in the baby blocks – the diversity of North American midwifery. Every midwife has been caught out at least once wearing good clothes when the urgent summons to a birth arrives. What to do with those stubborn stains? When Spray N Wash fails, cut up that fabric for a quilt! Many thanks to Kathy Peters for her quilt design skills. The person gazing at the quilt is taken from a photo by Phil Roeder, shared under a Creative Commons license.

Frame 3. The photo by Pete Souza shows a 2009 meeting of President Obama’s cabinet, shared under a Creative Commons license. We’ve taken the liberty of cropping out the President, but perceptive readers will recognize individual cabinet members.

Frame 4. This frame shows the White House Situation Room, as portrayed in The West Wing.

Frame 5. This song, published in 1980 by Molly Scott of Sumitra, is sung here in the U.S. House of Representatives.

Frame 6.  Anyone with knowledge of the midwifery model of care will recognize the original context for the words MANA president Marinah Farrell is speaking to Vladimir Putin against the background of the Oval Office:

Laboring person: I can't do it!!!
Midwife: You're doing it!

The Midwifey Face is an invention of your cartoonist, who theorizes that midwives are endowed with special facial features or expressions that allow them to persuade anyone to do anything, no matter how difficult.



The right to refuse medical care

right to refuse, slide 1


The Law Giveth and Taketh Away:
Religion, Science, and the Right to Refuse Care

This cartoon grew out of our astonishment that, particularly in the context of childbirth, U.S. law seemed to most strongly approve the right to refuse care when the refusal was based on irrational grounds. Evidence-based refusals both in law and in fact seemed to meet with much stronger resistance.

Legal Basis for the Right to Refuse Care

The right to refuse care is itself based on the overarching ethical principle of informed consent. While common understanding of informed consent is that a patient has signed a consent form that allows a provider to continue with a suggested treatment or procedure, in reality informed consent is – or should be – a repeated process, in which the following actions take place:

  • The provider explains the suggested treatment or procedure. The explanation sets forth the risks and benefits of the treatment as well as the risks and benefits of any alternatives, including doing nothing. The provider must ensure the patient understands what they have been told.
  • The patient makes a decision based on the information received, as well as on their own values and circumstances.

Case Law

Although informed consent requirements are now incorporated into patients’ rights acts in some states, informed consent doctrine has traditionally evolved as interpreted through a line of court cases, as shown in this cartoon in dark red text.

  • Schloendorff v. Soc’y of NY Hosp., 105 N.E. 92 (N.Y. 1914). Patients who do not consent to treatment that is carried out on their bodies can sue the provider for battery, with exceptions for emergencies and unconscious patients.
  • Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972). Physicians bear a responsibility to explain the risks of a procedure to the patient before proceeding with treatment.
  • In re Quinlan, 70 N.J. 10, 355 A.2d 647 (NJ 1976). Patients may refuse care, even if not receiving the care might result in their death.
  • Stamford Hosp. v. Vega, 236 Conn. 646 (1996). The court ruled that the hospital had violated the rights of the plaintiff, a Jehovah’s Witness who refused a blood transfusion. The hospital had obtained a court order that allowed it to administer transfusions or blood products to the plaintiff for a postpartum hemorrhage. This case supports the right of a mother to refuse care, notwithstanding the contention that the loss of the mother would cause harm to the child.
  • McFall v. Shrimp, 10 Pa. D. & C. 3d 90 (July 26, 1978). A person cannot be forced to donate body tissue (here, bone marrow), even if not to do so would cause death in the person needing the donation, and even if the potential donor is a close relative (here, a first cousin).
  • Tamesha Means v. United State Conference of Catholic Bishops (appeal in progress). Tamesha Means, a Michigan woman experiencing a miscarriage at 18 weeks, was denied care at a Catholic hospital because her fetus still had a heartbeat. The hospital’s actions were a result of a directive of the U.S. Conference of Catholic Bishops that prohibits abortion under all circumstances. Rather than intervening when Means developed an infection, the hospital turned her away without disclosing that the refusal to treat her was based in religious belief rather than in the standard of care. The case was dismissed at the trial court, but Means appealed to the Sixth Circuit Court of Appeals, where it now awaits a decision.


Some provisions in state statute allow providers to refuse to offer care and require that parents accept care for their minor children.

  • Provider “Conscience Clause” statutes. Many states have enacted legislation to permit various health care providers to file a professional, ethical, moral, or religious objection to any procedure without any consequences for the individual provider or institution. Michigan’s law, Mich. Comp. Laws §§ 20182-4 concern abortion, but other states have enacted broader provisions for refusing to provide other services, such as filling contraceptive prescriptions.
  • Required newborn procedures. State public health code usually specifies mandated procedures to be performed on newborns. As a rule, the parents have the right to opt out of most or all procedures. In Michigan, for example, only newborn screening and prophylactic eyedrops are mandated by statute. The legal duty to perform the procedures tends to attach to the provider, which is perhaps why parents are discouraged from opting out, often to the extent of simply being told, “it’s the law” that their child receive these procedures. Other procedures, such as Vitamin K and Hepatitis B vaccine administration, are also often characterized by providers as being legally required. Enforcement varies by state; New York is usually held out as the strictest state in requiring parents to accept the procedures for their child. Regardless, parents are increasingly sharing anecdotes of being threatened with reporting to Child Protective Services if they refuse this care.

References and Explanations

Frame 1. The building in the background is, of course, the U.S. Supreme Court building.

Frame 2. Count Dracula is refusing a transfusion because he is a practicing Jehovah’s Witness, as signified by the copy of The Watchtower tucked under his arm.

Frame 3. Parents do have to put their foot down on serious matters like broken legs and Sunday School attendance. Parents are empowered by law to make medical decisions for their minor children. Children cannot give informed consent, although they are – ideally – consulted to see whether they assent to care. Little Jimmy apparently does not.

Frame 4. Thanksgiving dinner, when the family is all present and dismantling a large bird, seems the ideal time to talk about donating body parts. It’s either that or politics, right?

Frame 5. The nurse in this illustration is invoking a conscience clause right to refuse to assist with an abortion. If the refusal seems sudden, that is because state law does not require providers to register their refusal at any given time – or indeed, forbid them from changing their stance at any time.

Frame 6. Tamesha Means’s less than forthright provider (see Tamesha Means v. United State Conference of Catholic Bishops, above) did not inform her that she was suffering from an infection that could ultimately prove life-threatening. Means was fortunate not to be permanently injured, unlike a case in Ireland that ended tragically. See the story of Savita Halappanavar.

Frame 7. Many providers believe that a signed informed consent form of the kind that is often required when a patient is admitted to a maternity care unit constitutes a contract that cannot be changed. Nothing could be farther from the truth. Consent can be revoked vocally at any time.

Frame 8. The topic of who decides for the fetus is a rich one – and much too complex to include in this cartoon. Move along now!

Frame 9. Medical malpractice liability is often held up as an excuse for ignoring informed consent requirements – or as an opportunity to blame lawyers. (Health care providers tend to forget that lawyers defend them too!) This frame seeks to make the point that there is no corresponding liability avoidance right for the provider that would trump the patient’s right to refuse care.

Frame 10. Continuous electronic fetal monitoring (EFM) for all pregnancies is the standard of care in the United States, even though it has not been shown to improve outcomes in low-risk pregnancies. (It does reduce the number of seizures suffered by newborns, but not to the extent that final outcomes are affected.) Furthermore, EFM has been shown to lead to an increase in cesarean sections. Maternity care patients in particular have been heard to remark with surprise that they seem to be responsible for upholding their right to consented-to care that is also evidence-based. One would think that it would be the provider’s responsibility to offer this care, but … blame the lawyers! In truth, the provider’s hands often are tied – usually by their own institution’s policies or their malpractice liability insurer’s rates.

Frame 11. See Required newborn procedures, above. The mother in this frame is musing on the likelihood of her one-day-old baby being exposed to Hep B by sharing needles with a cribmate.

pastafarian-800Frame 12. If you have not yet become acquainted with the Church of the Flying Spaghetti Monster, you can remedy that omission here. Perhaps the strategy suggested in this frame is inadvisable, since a Nebraska Federal District Court declined to recognize FSM as a religion. You can find a lovely stained glass panel representing the FSM here. The story behind an adherent of FSM (a “Pastafarian”) and her successful struggle to be permitted to wear her religious head covering in a state ID photo is documented here.


[Updated July 16, 2016, to add copyright designation.]


My children on MIChild … and meditations on the purpose of government

I did not need to apply for marketplace health insurance for my children, because they already receive coverage through the federal Children’s Health Insurance Program (CHIP), know in Michigan as MIChild.

Before MIChild, my children were covered for a short time under Medicaid, implemented in Michigan as the “Healthy Kids” program. What’s the difference? Medicaid is the public health insurance program for low-income people, run under a state-federal partnership. In Michigan, children are eligible to receive coverage under Medicaid if their family income is under 150% of the federal poverty line. New figures should be out soon for 2014, but under last year’s guidelines, the poverty line for a family of four in most states was $23,550. MIChild/CHIP, on the other hand, is a program funded entirely by the federal government, available to children whose family incomes fall between 150-200% of the poverty line.

Is it too embarrassing to talk about?

Considerable stigma attaches to receiving direct assistance from government programs, especially when it’s in the form of health insurance. This piece by an anonymous writer provides an excellent portrayal of the stigma, including its racial dimensions. Besides indignation surrounding “socialized medicine” – that don’t seem to apply to politicians, other government employees, armed services members, or senior citizens, by the way – many of our fellow citizens seem to feel that it’s shameful to be the recipient of this or other forms of assistance.

I disagree about the need for shame, based both on policy considerations and on our family’s experience. For us, having the children receive public health insurance was beneficial and sensible because it removed the need to worry whether the children were sick enough to warrant care. At that time, on our very minimal insurance plan, we paid out-of-pocket for all care aside from two doctors’ visits a year. So if, for example, a child ran a fever for five days (not unheard of for small children), we had to decide whether it could possibly be the sign of something much more serious that would warrant the $100 doctor’s visit – or wait and see. To pay $100 to be told the fever was the result of a common virus, and that the child should be given OTC painkillers and kept hydrated, was a disaster. But waiting to see whether something worse developed was equally dreadful. Once the children were on Medicaid and then later on MIChild, this scenario never arose. If we were worried about the children’s condition, they got evaluated. The shame, to my mind, attached to the earlier need to delay the care.

From a public policy perspective, public health insurance for children is a reasonable trade-off: the government pays money up front for children to receive care so their illnesses don’t become more serious. It’s bad policy to create incentives for parents to wait for illness to progress until their children get care – not least of all when we remember the traditional public health rationale of protecting society against the spread of contagious disease. Frankly, I think we should extend public health care to all inhabitants of our country, not just children, for that reason alone.

Health policy rationale and the means of delivery

That dream aside, I find that the real policy rationale for providing insurance – and consequently, one hopes, health care – to those who cannot afford it lies in the responsibility we have to each other. Noam Chomsky spoke eloquently on this topic when opposing the political push to dismantle Social Security through privatization, but his answer works just as well as a rebuttal to those questioning the need for public health insurance. This passage is taken from a transcript of a 2011 interview on Democracy Now!:

Social Security is based on a principle. It’s based on the principle that you care about other people. You care whether the widow across town, a disabled widow, is going to be able to have food to eat. And that’s a notion you have to drive out of people’s heads. The idea of solidarity, sympathy, mutual support, that’s doctrinally dangerous. The preferred doctrines are just care about yourself, don’t care about anyone else. That’s a very good way to trap and control people. And the very idea that we’re in it together, that we care about each other, that we have responsibility for one another, that’s sort of frightening to those who want a society which is dominated by power, authority, wealth, in which people are passive and obedient. (Emphasis added.)

I would like to think that it matters to others whether my children are healthy, and vice versa. In smaller civic organizations, we show this concern by bringing meals to parents of sick children, donating our time – if we’re health care professionals – to work at free clinics, holding fund drives through our houses of worship for children’s special medical needs, and much more. While these attempts are laudable, by their very nature they are limited to certain families, clinics, and congregations. We have a way to make these changes systematically and on a larger scale: that method is called government. We can embody the virtues of charity, kindness, generosity, fairness, and social justice through the use of our shared resources (yes, through taxation!) to make sure all children get the care they need.

Takeaways from my experience

Enough with the pronouncements! What useful tips can I supply regarding  MIChild/CHIP and Medicaid/Healthy Kids? These will be most helpful to Michigan parents, but parts may also be applicable to other states.

  1. Billing. My experience with Medicaid billing was delightful – there was none! MIChild was a little more complicated, but not much.
  2. Dental care. During our experience on Medicaid, dental care was effectively unavailable – no private dentist in the entire state accepted Medicaid, as far as I could make out. Since I have children with mercifully few medical needs, but who have inherited my fragile teeth (sorry, kids!), this was a hardship. Since then, Medicaid has improved its dental program for several counties. However, a look at this map shows that the counties containing and surrounding Detroit still lack coverage.
  3. Choice of providers. Another reason I wanted to get the children on MIChild was its broader choice of physicians. My children’s long-standing doctor does not take Medicaid patients – presumably because of its low reimbursement rate and high paperwork burden, particularly for a solo practitioner. I was thrilled to return to him on MIChild, but am now less thrilled; seven months in, MIChild has changed its plan and we must look for a new doctor.
  4. Surveillance. The sense of surveillance while on Medicaid was not overwhelming, but it was palpable. In the presence of health care providers and program administrators, I felt a presumption that because we qualified for Medicaid, our ability to parent could be called into question. I was able to combat this impression with my professional, class, and race privilege, but of course that’s not a satisfactory answer to the problem. For a scholarly examination of this kind of surveillance in the context of maternity care, I highly recommend The Reproduction of Race: An Ethnography of Pregnancy as a Site of Racialization, by Khiara M. Bridges. reproduction of race
  5. Funding. While this has little to do with our health care delivery experience, I must say I was happy to know that receiving MIChild coverage meant my children were pulling much-needed federal dollars into our state.
  6. Application tip! Finally, this one very useful hint: If you have determined you meet the income eligibility requirements for MIChild, do NOT fill out a paper application. These seem to get funneled automatically into Medicaid. Instead, fill out the online application. I wish I had known this before applying; our income seemed to fall in the MIChild range, but we were twice assigned to Medicaid.

What’s new with the ACA?

With regard to MIChild and Medicaid – not much. Michigan residents use the federal marketplace to apply for insurance, since our state declined to establish its own exchange. The marketplace should currently advise applicants whether their children are eligible for Medicaid or MIChild, but according to federal Medicaid documentation, will continue to refer qualified applicants to the state application process.

Michigan’s Medicaid expansion, planned to take effect in April 2014, changes the eligibility requirements only for adults: those whose income is under 133% of federal poverty guidelines will be eligible. However, the federal government recently granted Michigan a waiver to include previously prohibited conditions for Medicaid coverage, including limited premiums and co-pays as well as “Healthy Behavior Incentives.” Until I can locate waiver details on the CMS website, you can read about them as described by this management and communications firm.


Success! I greet the new year with new health insurance ID cards in hand. Many of them, in fact. How did that happen?

Pre-Affordable Care Act

Until December 1, I was covered by an insurance plan purchased on the individual market. This fall, I received notice that the plan would be discontinued because it did not comply with the ACA. I did not mourn this plan. As mentioned in an earlier post, the only thing going for it was its merely moderately high premiums.

My insurance carrier repeatedly urged me to buy an alternate “Keep Fit” plan. However, I knew  that my federal tax credit would almost certainly make a plan purchased through the Marketplace a better bargain. The Keep Fit plan’s other disadvantage was its notice of “lower deductible and fitness reward if you meet certain health standards.” Translation: your fitness activities and health standards count for nothing if you’re fat. Much has been written about the discriminatory nature and lack of evidence basis of such a restriction, both by the Health at Every Size and Size Acceptance communities as well as those critical of the Workplace Wellness provisions included in the ACA. I hope to return to this topic in a future post; for now, let me simply say that I knew the “Keep Fit” plan was not for me.

Temporary Insurance

To cover the gap from December 1 to January 1, when I expected to obtain Marketplace coverage, I purchased temporary insurance. This is a tactic I’ve used in the past; I mention it here because it can be a useful stop-gap. I did not expect to need any medical care in December, and I made sure to take care of any existing dental problems beforehand. The temporary insurance, which I obtained from the agency that provides our car and property insurance, was simply a hedge against catastrophe. If, for example, I slipped down the stairs and needed brain surgery, the insurance would kick in after a certain amount to ensure that our family did not lose all assets in a medical emergency – a reasonable fear, given that a majority of U.S. personal bankruptcies are precipitated by a medical emergency. The temporary insurance doesn’t pay for any routine care, so it is not suitable for everyone. But it bought me peace of mind for a month.

Enrollment – check! Payment – uh…

As reported before, through the federal Marketplace I successfully enrolled in a new plan from my earlier insurer and was told to expect a bill within a week. But when I opened the bill that arrived several days later, I was surprised to see a premium 50% higher than the one I had been quoted. Some small portion of this was due to federal and state taxes, but the remainder still constituted quite a large difference. I immediately got in touch with by online chat, was referred to the special hotline – only to learn that once I purchased a plan from the Marketplace, I was essentially on my own. I tried to imagine what it would be like if I bought a plane ticket from Orbitz, for example, and then found that the airline had raised the price of my ticket 50%.

Next stop: the insurance company. After I waited a very long time on hold, the customer service representative easily explained the problem. I had missed the reference to “Keep Fit” on my bill. Remember Keep Fit? The plan I did not purchase? Apparently the insurer decided to enroll me without my permission and then billed me for it.

The problem was easily remedied: I was instructed to simply ignore the bill. Imagine, however, that I had dutifully paid it. Now multiply this error by however many former customers the insurer mistakenly enrolled in this plan. I’m sure reimbursement would have been possible after considerable time and effort, but the insurer would have had the use of money not its own for some time – and presumably reaped the benefit in interest.

My many cards

The problem is solved. I eventually received a bill for the plan I actually selected, and I set up monthly payments through my bank account. My premiums are considerably lower now than they were for my pre-December high-deductible plan. With the money I’m saving in premium payments, I plan to pay off debts to various health care providers, all of whom have been remarkably patient. I look forward to scheduling an appointment with my doctor – the first in over a year. For the moment, life is good.

The insurer sent me four different sets of ID cards, including ones for the mistakenly-assigned “Keep Fit” policy. The cards have now been dealt; I look forward to seeing how the game plays out.

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Time served

Governments manage to build roads, regulate air quality, invade countries – however imperfectly and occasionally inappropriately. So I am moderately hopeful that my new health insurance plan, purchased through the marketplace set up by the Affordable Care Act, will be an improvement, even if only because of the generous tax credit that subsidizes my premiums.

That said, if time spent could be parlayed into dollars, I might be able to forgo the tax credit. Although my search for insurance for the adults in our family was neither quick nor easy, I can’t blame the ACA or even Much of the complexity was the result of my family’s economic circumstances and the structure of private health insurance.

Essential tool: crystal ball

I was surprised when asked me for proof of income for 2014 – frankly, I would like proof of income for 2014 too. Neither, the federal exchange, nor a local navigator were able to tell me what documentation I could reasonably provide for income not yet earned – or even conceptualized! [Time spent on phone calls and internet chats: approximately 2 hours.]

Out of necessity, I invented a solution: I will submit my final pay stub from this year, even though it is not a reflection of my income for next year, as evidenced by the fact that I will also submit a letter from my employer confirming that I am no longer receiving paychecks. My husband will submit a “self-employed ledger”; because no one is able to tell us exactly what that means, we will concoct a spreadsheet of business income and expenditures and hope that it suffices. I give credit for not requiring that documentation be uploaded before selecting a plan. [Time spent gathering documentation so far: 1 hour.]

What’s my point? The ostensible purpose of the ACA is to provide affordable care by means of health insurance to people who would otherwise lack access. It’s not a long shot to say that a large number of people in this situation are those whose employment is sporadic, variably paid, or simply unpredictable. Demanding proof of future income defeats the purpose of providing easier access to care for this population.

Dental …

Our family is blessed with relatively good health, with the notable exception of My Teeth. Thanks to genetics and my tendency to send stress directly to my jaw – and believe me, I’m grateful it doesn’t go to some other body parts – I am very familiar with dental care. Health insurance, on the other hand, has always considered dental care to be a separate, alien entity. When I searched for plans within my price range that also included dental care, I found one, for which our out-of-pocket cost for the premium would be higher than we’re currently paying, even taking the tax credit into account. Naturally, I wanted to be sure this costly plan was worth it, so I carefully examined the dental benefits. While I was on hold with the insurer, I also hopefully text-chatted with, to no avail. The insurer was finally able to clarify several of the “Benefit Explanations” regarding frequency of coverage of fillings. For anyone who’s wondering: “1x per 48 months for permanent teeth” means as many teeth as need to be filled in 48 months  (subject to plan maximums, of course), just not more than once in any given tooth during that time. Perhaps I was overly suspicious of that language; however, I have forked over plenty as a result of past misunderstandings of policy language. [Time spent on hold: 1 hour.]

After looking at the numbers again, I decided to investigate dental riders available directly through the insurer. I reasoned that if such a rider cost only about $50 a month, as it did in our pre-ACA individual plan, we could easily buy one of the more cost-effective health care plan without dental benefits. I had questions regarding:

  1. My dentist’s participation in a provider network, the meaning of which was far from clear on the insurer’s website;
  2. Whether as a result of my dentist’s possible participation, I would or would not be charged for the difference between the insurer’s approved amount and my dentist’s charges;
  3. Whether the deductible on the dental rider worked as a group or individual deductible.


After another long wait, I was connected with a customer service representative who was apparently puzzled by my questions. His answers included the word “probably” and once directly contradicted a benefits summary document, which itself was careful to state that it was not a contract – the legal equivalent of crossing your fingers behind your back. I was far from reassured. [Time spent on hold: 1 hour.]

However, I was gratified to discover that I could purchase the dental rider through I am almost certainly overestimating the scope of government oversight on private plans, but I felt that going through the exchange would provide me a layer of protection against the excesses or obfuscations of the insurer. We’ll see how that plays out when I deal with my first claim.

What’s my point? I am thrilled that it is possible to purchase a separate dental care rider through the exchange, but knowing that from the start would have saved me a number of steps. Better-informed customer service representatives staffing insurer phone lines would also be helpful, but I am under no illusion that this falls under government dominion.

… and mental

Mental health care has traditionally been as alien to the average insurance plan as dental care. The Mental Health Parity Act of 1996 sought to address this problem, but in the end did little to require plans to offer routine mental health care.

My hope was that our new health care plan would pay the mental health care professional seen regularly by our family. I found, however, that our provider was out of network for all of the plans available to us. In order to receive any coverage at all for her services, we needed to buy a plan with premiums more expensive than our recently expired plan. When I did the math, the best of those plans would cost us $200 more a month than the less expensive plan we were considering, and due to deductibles, coinsurance, co-pays, and a maximum 50% reimbursement, would save us at most $400 a year. This was the final impetus for us to discard that plan. [Time spent examining provider networks and crunching numbers: 40 minutes.]

What’s my point? Plans continue to prioritize coverage for inpatient mental care over outpatient care, and reimburse providers accordingly, thus providing less incentive for providers to participate. While inpatient care is more expensive and thus especially deserving of coverage, it is a mistake to neglect coverage for outpatient care, for the simple reason that regular outpatient care can significantly reduce the possibility of needing inpatient care. When outpatient coverage requires substantial out-of-pocket expenditure, patients are less likely to continue that care.

Just the facts – but where are they?

I haven’t described the process of sorting through possible plans, seeing whether our providers participated in those plans, constructing a spreadsheet to compare the plans, running through various health care needs scenarios to test the numbers, or any of the other tasks required to make a decision of this importance.  [Time spent: 6 hours.]

What’s my point? I am struck again and again by how unlike other purchases it is to buy health insurance. Consumers must predict what they will need to spend, in a market where costs are for the most part indiscernible. Customers must predict what they can afford to spend. Customers must decide whose services they will need should some of their scenarios come to pass.

Time and again

I’m grateful for the ACA and the chance to buy health insurance that actually allows us to receive medical care. Under our old plan, the deductible was so high that it was hardly even worth getting an annual physical: had an exam unearthed issues that needed further study or treatment, it would have been too expensive to follow up. The only answer would have been to buy a lower deductible plan – one that charged unaffordable premiums. The ACA cut through that problem to some degree by aligning income eligibility with insurance costs through the tax credit.

But the problem it didn’t solve was the vast amount of time needed to organize insurance. I’m an educated, privileged person with a computer, a fast network, and enough free time to make endless phone calls and sift through the benefits – or lack thereof – of various plans. Even so, getting coverage has taken weeks and is not yet completely resolved.

What’s my point? If I were an economist assessing citizens’ productive labor capacity, it would concern me that so many of us are must use our time to get something that other developed nations take for granted: access to affordable health care. After watching several British TV medical dramas, I reported to my family that I couldn’t get over how every patient expected care – and got it! I hope the ACA will make a dent in our nation’s problems that are responsible for this sort of amazed perception on my part, for the obvious public health reason that populations are healthier when they can access quality health care. However, setting aside health outcomes, I can’t help imagining the things I might have accomplished in the time I spent identifying and purchasing a workable health insurance plan. Multiply that by everyone buying plans on the exchange, and we potentially have the 21st century equivalent of Sputnik – some giant leap we might have made as a nation, but didn’t.

Furthermore, I am under no illusion that my work is done; past experience tells me that each time I have contact with the health care system, six months of phone calls and paperwork with my insurer ensue. It is in the financial interest of insurers to avoid reimbursing care and they count on the inability of most of their customers to take the time to vigorously pursue claims. I do not relish the prospect of disproving their expectations, but I cannot afford not to. When I had employer-based health care, I could count on my H.R. department to wage some of these battles for me. Now it’s just me against the insurer.

All this time! In which, perhaps, I could have written another article, looked for a new doctor for my children (due to their change of health plan – more about that in another post), lobbied legislators, done more laundry – you name it. Let’s hope it will have been worth it.

With luck, my next post will mark the beginning of my new health insurance plan.