Being Thankful for the Uninsured

DrRich | November 23rd, 2011 - 8:15 am



(In what has become a tradition over the past few years, DrRich proudly reprises his annual Thanksgiving message to his beloved readers.)


Gathered around the Thanksgiving table, DrRich’s large extended family, carrying out a longstanding tradition, each offered in their turn one reason for being thankful on this most reflective of American holidays. DrRich listened respectfully as each of his loved ones, and each of the ones he was obligated to tolerate benignly because they had married (or in some other manner had committed to) one of his loved ones, recounted a cause for thanks. There is no need for DrRich to recite their utterances here, because they were all perfectly predictable and fairly mundane, having mostly to do with items such as maintaining good health, finding a job, being able to afford one’s mortgage payments, getting a passing grade in French, receiving a new puppy, Mr. Obama’s remarkable Presidency, the apparent continued structural integrity of the Universe despite Mr. Obama’s Presidency, &c., &c.

When it was at last DrRich’s turn, he, in retrospect perhaps somewhat inadvisedly, was unable to refrain from displaying his keen insight and superior analytical abilities on matters related to healthcare (a topic, anyone would have to admit, about which most of us would very much like to feel thankful). Lifting his glass, DrRich pronounced that he was most deeply and humbly thankful for the 47 million Americans without health insurance; and further, especially thankful that their ranks  must surely be growing, given the recession, advancing unemployment, imminent collapses of businesses and indeed entire industries, &c. And even though Obamacare promises to significantly reduce that number, DrRich went on to express his fervent wish that large numbers of the uninsured might still be with us a year and two years and even ten years hence, for the great and good benefit of us all.

Enjoying the remainder of his Thanksgiving meal out on the back porch with the new puppy, DrRich composed in his mind this explanation which you now behold for the keen appreciation he has developed for the uninsured. He now offers this explanation both to his readers, and to the few members of his extended family who, he believes, might have been inclined to hear him out, had Mrs. DrRich not offered at that moment to consider remaining married to him only if he would retire from the table immediately. (Believing his marriage to be a union sanctified in heaven, he did so.)

In any case, for those who have an open mind, there are two compelling reasons we should be thankful for the uninsured, and should be particularly loath to allow them to disappear.

The first reason is that it is largely thanks to the uninsured that we are able to maintain the fundamental and dearly-held American fiction that there need be no limits on healthcare. (The image DrRich conjures up when he says “dearly held” is that of Gollum caressing the Ring.) Simply put, when we have tens of millions of uninsured Americans who don’t have ready access to regular and routine healthcare, then it’s relatively easy to pretend that “healthcare” should include everything we might want it to include.

Our current healthcare system relies heavily on using the uninsured as a huge fiscal safety valve. That is, in lean times (such as now), we open up the valve, increasing the number of people who are ineligible to consume routine healthcare. Increasing the number of uninsured Americans has become perhaps our most effective mechanism of covert healthcare rationing.

This simple expediency alone goes a long way toward enabling us to avoid having to consider or discuss limits. Openly recognizing the unavoidable limits to healthcare, much less having to figure out how to implement such limits fairly and rationally, would be exquisitely painful and disruptive. (Just ask Gollum how unpleasant it is to be forcibly separated from that which we love and deeply value.) For helping us to avoid such pain and societal disruption, we clearly owe a great debt of thanks to our uninsured brethren.

The second reason came to light recently in an article in the Journal of the American Medical Association.* This article showed that – contrary to both popular lore and to stern pronouncements by policy experts bent on convincing us that (next to global warming) reducing the number of uninsured Americans is the most important task of mankind – the overcrowding in American emergency rooms is NOT due to the uninsured. Rather, it is due to insured Americans who cannot get in to see their primary care physicians.

DrRich has discussed at some length the primary care crisis and its causes. That is a very important topic, but it’s not the topic of this particular posting. This posting is about the great and abiding value of the uninsured.

It really should not be a great surprise that emergency room overcrowding doesn’t have all that much to do with the uninsured. While it is difficult to generalize about such things, a large proportion of the uninsured are people who have assets. (If they had no assets they likely would be eligible for Medicaid.) That is, they are people who have jobs, homes, cars, &c., but their employers (who, in many cases, are themselves) cannot afford to provide them with health insurance. The chief point being, of course, that these individuals have something to lose.

These are not the people who will voluntarily enter an emergency room for their healthcare, at least, not for a medical problem that they can somehow convince themselves might go away on its own if they give it a chance (such as, perhaps, crushing chest pain, or paralysis of the left side, or some other such eventuality which might cause some of us less circumspect, more insured people to just go ahead and dial 911, all willy-nilly). They realize that the moment they set foot into an emergency room they will generate a bill of at least several thousand dollars, which they will either have to pay, or spend months or years fighting off the increasingly aggressive bill collection professionals being dispatched these days by their local hospitals. They are putting their assets and their futures at risk if they come to the emergency room.

Rather, the overcrowding is due to people who have insurance – whether it’s Medicare, Medicaid or private insurance – and who are therefore entitled to their healthcare by whatever means they calculate is the most convenient for them. Increasingly, because primary care practices are hard to find, are booked for weeks in advance, and are less and less user-friendly by the day, the convenience calculation tends to default (incredibly) to the emergency room. (That insured people are choosing emergency rooms – notoriously one of the most unpleasant experiences American citizens can encounter in peacetime – instead of the offices of their primary care physicians should itself set off major alarms about the state of American primary care.)

This is all fairly intuitively obvious, and the JAMA article really should surprise only those who habitually believe all the prevarications being promulgated as Gospel today by politicians, media, and various authorities on healthcare.

It should be plain that suddenly providing tens of millions of Americans with health insurance will decidedly not relieve emergency room overcrowding, as the policy “experts” all promise us (the same experts, apparently, who promised us that the stimulus package would rescue the economy and prevent increased and prolonged unemployment, and who confidently spout a host of predictions which fly in the face of history, common sense, and laws of economics, physics, and human nature). On the contrary, creating tens of millions of newly insured individuals, without simultaneously revolutionizing our attitudes and policies toward primary care medicine, will quite obviously make our already overcrowded emergency rooms absolutely burst at the seams, and render even more hellish than it is today – even deeper down within “grief’s abysmal valley” – the prospect of entering such a place. Indeed, if we suddenly insure all these people, the rest of us who currently have insurance really won’t have anywhere to go to get our healthcare.

So. QED. As DrRich said at the Thanksgiving meal, thank God for the uninsured.

Clearly if DrRich had been permitted a mere five minutes to explain himself, not only might he have avoided eating runny mashed potatoes in a steady drizzle, but he also might have salvaged his reputation among some of the more remote members of his extended family, who really don’t know what a swell and reasonable guy he can be. Next year when his turn comes, DrRich will choose to be thankful for some more traditional value, in the hopes of being allowed to eat his meal in a warmer, drier, friendlier environment – perhaps he can be thankful for the growing number of obese Americans, and the great service being provided by these patriots-to-mankind as they reduce global warming.

* Newton MF, Keirns CC, Cunningham R, et al. Uninsured Adults Presenting to US Emergency Departments: Assumptions vs Data JAMA. 2008;300(16):1914-1924.

5 Responses to “Being Thankful for the Uninsured”

  1. Jupe says:

    This is such a wonderful line (and I’m delighted every year, 4 years now?) by the re-publication of this essay):

    “These are not the people who will voluntarily enter an emergency room for their healthcare, at least, not for a medical problem that they can somehow convince themselves might go away on its own if they give it a chance (such as, perhaps, crushing chest pain, or paralysis of the left side, or some other such eventuality which might cause some of us less circumspect, more insured people to just go ahead and dial 911, all willy-nilly)”

    Hilarious and true. But, it’s lacking the insight of the already medically bankrupt. No satire, many families end up wage garnished over medical bills in a way that precludes one parent from working in a time of high unemployment. Because bankruptcy is limited, one must avoid bankruptcy regarding the hospital for as long as possible after a first encounter. If you recently had assets, assets can be regained. There is no recovery from the deeper healthcare surfdom that exists.

    Once you’re a health care surf via medical bill wage garnishment, etc, you’re part of the permanent underclass. Thank god for Obama, huh? That reform sure fixed everything.

    • DrRich says:


      You won’t find me endorsing the current healthcare system, which is entirely dysfunctional in numerous ways. And in numerous ways (for instance, making people go bankrupt because of unavoidable medical costs) it is a complete travesty.

      But what we get with Obamacare is a travesty plus surrender of our individual autonomy (not only in healthcare but in all aspects of life). And you trade the prospect of bankruptcy for the prospect of not receiving healthcare services at all, if you don’t fit precisely into the “guidelines” put forth by the Central Authority’s experts.

      There are ways the system can be fixed that avoid these hazards, but it takes thinking outside of the box, and neither of our major political parties even come close to doing that.


  2. Bonnie says:

    Dr. Rich, I do have health insurance, and recently had to avail myself of emergency room services. I spent five minutes with a triage nurse, then twenty minutes going over all my billing information. Wisely, I keep a lot of that stuff on my iPhone, or it would have taken longer until I got the EKG done. Luckily for me, it was gastritis. My insurance got me prompt treatment and a private exam room. Other uninsured patients got to spend time in the hallways. There was a woman with a hamburger face (from being beaten?) waiting in a wheelchair, unattended, in front of the doors. Looks like they put a bandaid on her, and then kicked her out. Hospitals seem to me to be brutal, unkind, dirty, smelly places, and likely to make you want to say, please just put a bandaid on it and send me home. How anyone can cheerfully work at one is beyond me.

    That said, there is an article in the NYT today about how many billions of dollars could be saved by hospitals by ensuring that their employees WASH THEIR HANDS! How many other easy fixes could save billions of dollars? Would the money saved go to providing better, lower cost care? Or would it get siphoned off to plump up CEOs of healthcare corporations?

    I’m thankful for the internet, because I learned that gastritis can be helped by Ginger Ale. A glass of that would have saved my insurance company a few thousand dollars and left a room open for the lady with the hamburger face. I hope she had a nice Thanksgiving!

    • DrRich says:


      There’s one more thing the uninsured hamburger-face lady got that you didn’t get, besides the band-aid: A Huge Bill, one that she’s on the hook for herself. Next time she’ll know better than to show up in the ER for mere soft-tissue injuries.

      Also, major efforts to assure hand-washing in hospitals have been going on for 15 years, with frequent lectures, e-mails, signs all over the place, and dispensers with that germ-killing squirt-um every 5 feet. If doctors still aren’t washing their hands, the only other think I could think of that might change their behavior would be to publicly execute a few of them once a week. As a matter of fact, I think Obamacare has that in there, somewhere.


You can leave a response, or trackback from your own site.

Leave a Reply