My last post didn’t really go into why I dislike the way we do health insurance so much.

Of course, there are the usual criticisms based on compassion and efficiency. Compassion because poor people can’t get access to life-saving medical care. Efficiency because it’s ruinously expensive compared to every other system around. I agree with these arguments. And they’re strong enough that asking whether there are any other reasons is kind of like the proverbial “But besides that, Mrs. Lincoln, how did you like the play?”

But I had already internalized the compassion and efficiency critiques before becoming a doctor. After starting work, I encountered new problems I never would have expected, ones which have yet to fade into the amorphous cloud of injustices we all know about and mostly ignore. Most of my patients have insurance; most of them are well-off; most of them are intelligent enough that they should be able to navigate the bureaucracy. Listen to the usual debate around insurance, and you would expect them to be the winners of our system; the rich people who can turn their financial advantage into better care. And yet barely a day goes by without a reminder that it doesn’t work this way.

Here are some people I have encountered – some of them patients, some of them friends – who have made me skeptical that our system works for anyone at all:

— The elderly man who had a great relationship with his last psychiatrist, who saw him for twenty years, and who knew every detail of his issues. He switched jobs, got a new insurance, the old psychiatrist was no longer in network, and so he had to see me instead. I know nothing about him and it will take several evaluation sessions before I can even consistently remember who he is and what he needs from me.

— The businesswoman who was seeing me and doing well until the HR person at her job told her that she didn’t need to submit any forms to renew her insurance that year. That turned out to be wrong, and she missed The One Month Of The Year When You Are Allowed To Renew Insurance. She lost her insurance and can’t afford to keep seeing me.

— The bipolar man on a very important daily medication. He changed insurance plans. The new insurance refused to pay for his drugs until they got a form explaining why he needed the medication. I sent in the form. They said they couldn’t find the patient in their system and so couldn’t process the form. We argued about this for several days, during which he ran out of medication and decompensated.

— The would-be entrepreneur who wanted to save up enough money to live on for a year or two, quit her dead-end job, and start a startup – but who wouldn’t be able to afford health insurance outside of her dead-end job’s plan. She is still at her dead-end job.

— The young gay man with conservative religious parents. He had a supportive friend group and should have been able to come out to his parents without caring what they thought – except that he’s on his parents’ insurance and has no good alternative. He remains in the closet.

— The young woman in a not-quite-abusive but far-from-acceptable marriage, who stays in it because she’s on her husband’s insurance and has no good alternative.

— The depressed guy who was doing well on a complicated antidepressant regimen for a while, changed insurances, and was too depressed to do the work of finding a new psychiatrist. Now he comes to me saying it’s been five years, he’s been depressed all that time, and he would like to get back on the medications that he knows work well for him.

— The endless train of patients I saw when I worked in a hospital emergency room, whose stories started with “So I lost my insurance, but I figured I could get along fine without the medication…”

— The other endless train of patients I saw when I worked in a hospital emergency room, whose stories started with “So I lost my insurance, but I was smart, and I had saved up a stockpile of my medication, and I figured, how hard could it be to manage it myself without a doctor’s advice…”

— The other endless train of patients I saw when I worked in a hospital emergency room, whose stories started with “So I changed insurance, and I got a new doctor, and he said he didn’t see a good reason why I had to be on this medication…”

— The Oklahoman who wants to move to California where he has more friends and better job prospects, but he’s on Oklahoma state insurance for the needy. Although California also has a state insurance for the needy, there is no way to figure out whether it will accept him or cover the care he needs other than by moving to California, applying, and seeing what happens. Also, the application process takes weeks to months, during which time he will not have either state’s insurance (though California promises he will get reimbursed for care he gets during this period later). He decides to stay in Oklahoma.

— The well-off Oklahoman with good private insurance who visits California on a business trip, gets sick, and finds that surprise! his Oklahoman insurance doesn’t have any in-network providers in California and he has to pay $20,000 out-of-pocket for care.

— The depressed guy who was in remission for years and had a great job with great insurance. Then he had a relapse, became too depressed to go to work, got fired, and lost his insurance right at the moment when it finally could have been useful for him.

— The woman who had a minor breakdown and was brought to the hospital by police. The hospital admitted her against her will, on the grounds that her minor breakdown sounded potentially dangerous, treated her, and released her. Her insurance refused to pay, on the grounds that it was just a minor breakdown and didn’t really require hospitalization, by the standards of This Particular Insurance Company. She is on the hook for the entire cost of the involuntary hospitalization.

— Anything involving Kaiser [EDIT: I’m getting some pushback on this who say Kaiser is good at everything except mental health; I only deal with them in a mental health capacity so I can’t speak to this]

— The trauma victim who needs trauma therapy – which means reliving all your traumas in order to come to terms with them – but is reluctant to start because her work situation is unstable. She knows that if she changes insurance, she’ll have to restart the therapy from the beginning and relive all her traumas all over again.

— The young schizophrenic man who is on his parents’ insurance. Because so many schizophrenics are poor, all of the expertise in treating schizophrenia is concentrated in Medicaid clinics. But a rich kid on his parents’ excellent insurance can’t access Medicaid, he can’t go off his parents’ insurance for other reasons, and he can’t find any private psychiatrists who know how to treat his particular schizophrenia-related complications. I am sure there is some good solution to this which I am missing, but I haven’t been able to find it and his family hasn’t either.

— The anorexic woman who has Blue Cross, and the only good anorexia therapist in town only takes Aetna. The sex-addicted man who has Aetna, and the only good sex addiction therapist in town only takes Blue Cross.

Any other system would fix these problems. A public system like Medicare For All would fix them. A communal system like the Amish have would fix them. A free market system like our grandparents had would fix them. The prepaid doctor cooperatives Reason talks about would fix them. A half-assed compromise like Joe Biden’s Medicare For All Who Want It would fix them. But here we are, stuck with a system that somehow manages to fail everybody for different reasons.