U.S. Healthcare Is a Pyramid Scheme

Two months ago, I had my third-scariest experience ever. Among terrifying moments where my life or someone else’s flashed before my eyes, what happened that Thursday morning is topped only by what happened the Sunday morning I was attacked by burglars in my apartment in Buenos Aires and what happened the Tuesday morning I watched the second tower of the World Trade Center crumble to the ground in slow motion while walking down Avenue of the Americas in New York City. (Mornings can be rough in my world.)

As with 9/11, I didn’t fear for myself during the latest frightful episode. Unlike 9/11, though, it wasn’t about countless strangers perishing in real time several miles away but the person I’m closest to, the man I go to bed with every night, fainting right in front of me.

My husband has suffered from recurring lower back pain for most of his adult life. Over the last three years, it’s tended to recur like clockwork every six months, leaving him mostly bedridden for no more than a week each time. On January 20, however, the agony was worse than usual. It became so excruciating that my husband passed out with his eyes open — at least that’s what the EMT told us later. It looked like he was having a seizure.

I called 911 and two EMTs arrived, checked his vitals, hooked him up to an IV drip, put him on a stretcher, carried him downstairs, loaded him into an ambulance, and rushed him to the emergency room at Lenox Hill Hospital. Aside from routine blood work and an EKG, no tests were taken, and no diagnosis was made. The ER doctor prescribed him three different painkillers and recommended several days of bed rest. About a week and a half passed before my husband started to walk like his old self again. He continued to improve until February 15, when a relapse during our belated Valentine’s Day dinner sent him back to bed.

This time, we decided it was best for him to see an orthopedic surgeon who would hopefully pinpoint the source of his recurring back issues rather than just treat the symptoms. Two X-rays later, we had a name for what has supposedly been ailing him for years: spondylolisthesis. The doctor prescribed three different medications for the pain and referred him to a physical therapist to help strengthen his core and control the condition.

And thus began our descent into a hellish vortex of bad medicine that has included a careless physical therapist who ended up injuring my husband and setting back his recovery and an orthopedic surgeon who excels at spouting medical jargon and writing prescriptions but is less skilled at offering medical care — as in, he has yet to convince me that he actually cares about how my husband is feeling.

With people like this in his corner, it’s no wonder my husband’s situation has improved only incrementally through several further relapses. At his follow-up with the orthopedic surgeon two weeks after the first appointment, the doctor ordered an MRI, shoving us further into the legal pyramid scheme — US healthcare — that, for decades, has been making insurance companies and the medical community rich while sending many of the rest of us to early graves.

Throughout the bureaucratic nightmare, I’ve been thinking a lot about Beverly Hills 90210 actress Shannen Doherty, who is currently living with stage 4 breast cancer. She has talked about how she initially put off getting herself checked out due to a management snafu that, for a time, left her uninsured. According to a 2015 suit filed by Doherty against her former management company Tanner Mainstain, “had she been insured and able to visit her doctor, the cancer could potentially have been stopped, thus obviating the need for the future treatment (including mastectomy and chemotherapy).” If a big Hollywood star can’t get access to timely health care in the US when she needs it most, what hope do the rest of us have?

On March 10, eight days after we scheduled the MRI for March 21, eviCore healthcare, which had been authorized by our insurance company, Aetna, to review our request for pre-certification, sent us a letter denying coverage. According to eviCore healthcare:

This request cannot be approved because: Imaging requires six weeks of provider directed treatment to be completed. Supported treatments include (but are not limited to) drugs for swelling or pain, an in office workout (physical therapy), and/or oral or injected steroids. This must have been completed in the past three months without improved symptoms.

Basically, we had two choices: 1) We could pay for the full cost of the MRI and get a precise and complete diagnosis that possibly might lead to more effective treatment and help us sidestep the expense of physical therapy. The MRI could also spot any other issues that the initial X-rays didn’t pick up, preventing further complications down the road. 2) We could pay for two PT sessions a week for six weeks, at $142.74 a pop, since Aetna pays only a small fraction of our medical expenses until we reach the $4,000 deductible. Then we’d get our pre-certification, which still wouldn’t necessarily protect us from a hefty MRI bill. Either option would require us to spend well over $1,000. Incidentally, we received the denial notice from eviCore on the same day that we received a $508.78 bill for the first appointment with the orthopedic surgeon.

I haven’t felt so powerless against the system since my return to the US three years ago after 13 years of living abroad. I’m back in the supposed land of the free, yet Americans who can’t afford to pay the full cost of medical care — a group that apparently includes rich Hollywood stars like Shannen Doherty — aren’t really free at all. In order for most of us to have affordable access to health insurance, most of us have to tie ourselves to an employer, a guild, or a management company, and even then, we are left with massive medical bills. The US healthcare system has been designed so that those at the top of the pyramid, insurance companies and healthcare providers, get richer, while at the bottom, the sick get sicker.

I should have been more appreciative of the affordable healthcare everyone had access to during my 13 years living in various countries outside the US. I saw a heart specialist and a psychiatrist at a private practice in Serbia who treated my panic disorder for less than the cost of that first appointment with the orthopedic surgeon. They were also able to do what no expensive doctor in the US had been able to do: They got my anxiety under control.

In Ukraine, I had my first colonoscopy and an endoscopy, and I was treated for the gastritis they diagnosed afterward, all for less than $1,000. In Romania, I spent several hours in the ER of a public hospital where blood work was taken and I was connected to an IV drip of alprazolam. Total cost: $0.

While living abroad, I was impressed by both the low cost and the high efficacy of the medical treatment I generally received. In Sydney, my primary care physician ordered an MRI because of my chronic migraines, and pre-certification was nearly instant. My out-of-pocket cost: $0.

In Prague, a doctor gave me an injection for excruciating back pain. I walked out of the hospital pain free after paying a bill that was around $30. In Postonja, Slovenia, I went to see a doctor across the street from my hotel in the middle of the night because of a sore throat. He examined me and assured me it was just a minor malady that would go away on its own (which it did by the next morning). When I offered to pay, he smiled and said, “It’s on me.”

That would never happen in the United States, a place where being rushed to the hospital in an ambulance after passing out at home with your eyes open doesn’t guarantee coverage for an MRI because you haven’t spent enough money yet. I’m not sure there’s any place on earth that feels safe and un-scary right now, but if we survive global warming and the latest threat of World War III, most Americans still will be at the mercy of a healthcare system that doesn’t care if we live or die, as long as someone gets paid.

This post originally appeared on Medium and is edited and republished with author's permission. Read more of Jeremy Heligar's work on Medium.

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