Bleeding-Edge Benefits

Jay Himmelstein


Health Affairs. 2006;25(6):1656-1663. 

In This Article

Preface and Introduction

The sentiment "if it ain't broke, don't fix it" has a strong foothold in the United States, as does the thought that it takes a whole lot to prove that something's "broke." Nonetheless, Americans are increasingly declaring that health insurance in this country is very badly broken.The reality, many say, is that insurance coverage often is nonexistent for preventive care, is slight for regular office visits, and peters out during catastrophic situations and hospitalizations. Additionally, because there is no organized health care system in the United States, there are always complicated questions about the specifics of insurance benefits. Jay Himmelstein, a professor and a director of a health policy center at a medical school, discovers this first-hand when his graduate student niece, Emily, is diagnosed with an aggressive form of cancer. Worried about her health, her mounting treatment bills, and the limitations of her school insurance policy, Emily wonders whether declaring bankruptcy might be the only solution. Next, health economist Phil Musgrove gets an up-close-and-personal view of American health care and its emphasis on insurance when he rushes a stranger to an emergency room and gets a "paper first, people second" reception.

Hiking in the foothills of the Rockies in late summer 2004, I found it a challenge to keep up with my two fit and energetic twenty-four-year-old companions—my son Jesse and niece Emily—on a warm, cloudless Colorado afternoon. At one point, we stopped on a cliff top to rest, snack, and watch kayakers paddle the rapids below and rock climbers scale the canyon walls across from us.

"Uncle Jay, what do you think of this bump on my thigh?" Emily asked while we were sitting there. "The doctor at student health services thinks it's probably just a fatty tumor, but she's referred me to a surgeon to have it cut out—do I need to worry about this?" The doctor had also suggested that she get an MRI before the surgery. "But," Emily continued, "our student insurance only covers $1,000 in x-rays a year, so the MRI would cost me about $2,000 out-of-pocket. The surgery itself will cost me only $200 after insurance. Do I really need the MRI?"

When you're the doctor in the family, you get asked questions like this. I took a quick look at Emily's leg as we finished our trail mix. Her skin looked normal, and the one-inch "bump" on Emily's left inner thigh was soft and freely movable; it did, indeed, feel like a benign lipoma.

"I wouldn't worry too much about it," I said. "But you should follow up with the surgeon just to make sure."

Emily smiled and seemed reassured, and I was pleased to help. After several more hours of hiking, we all went our separate ways, Emily to her graduate program at a state school in Colorado, Jesse to his graduate studies in France, and me to my work as a director of health policy at a medical school in Massachusetts.


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