“What About Health Insurance?”

Nearly anyone who’s needed more than basic medical care—and especially people who take some kind of medication regularly—seems to get around to asking me this question eventually. If I’m moving off-grid, what am I going to do about health insurance?

I know that the question comes from a good place—whoever’s asking me is concerned with knowing I’ll be safe, come what may. But I often suspect that the question serves another purpose: adding a clincher to the person’s own internal debate. The subject of the debate is “Should I live off the grid too?” and it involves weighing the fraught morality of living on the grid against the infeasibility of living off it. Sure, living off the grid sounds great, but it’s not really practical in the real world. I’ve got medical problems and you will too sometime, and that first moment of mortal danger is when you’ll finally discover why people participate in the system.

Either way, I’ve been meaning for a while now to figure out my own thoughts on the whole health insurance question and address it here.

The question arises at least partly because of how sloppily I’ve used the phrase off the grid. I’ve never really defined what it means to me. So I’m going to try to do that now. Of course I first need to define what the grid is. When I use that phrase, what I’m usually thinking of is: all the connected national and global distribution networks for stuff, plus their flip side: national and global tax systems.

Going off the grid is a little more subtle than just “living without all that”, though. A simple way to define it is: declining to participate in “the grid” to some extent. It’s important to put to some extent in there, because at this point in history, the grid is so omnipresent that it’s just about impossible to live completely free of it. There turns out to be a spectrum of things you can do without relying on the grid: everything from growing a few cabbages each year to make a batch of sauerkraut, up to Dick Proenneke, who had himself airdropped in a remote Alaskan wilderness with nothing but some ax and adz heads, fashioned his own handles for them, built himself an entire log cabin before winter came, and lived there for about thirty years.

The grid doesn’t always give you much of a choice in the matter, and this is an important point. It’s pretty easy to grow a few cabbages instead of buying them from the grid. It’s a lot harder to make your own computer. And then there are some parts of life that the grid has explicitly claimed a monopoly on, and you’re not even allowed to provide them for yourself (unless you own a company big enough to get a license). Things like: Roads. Gasoline. Phone lines. Internet cabling. And: healthcare.

It’s true that you can get a little healthcare from some friend of yours who studies Chinese healing, and even give yourself some healthcare from a first-aid kit. But go much beyond that into, for example, bonesetting or prescriptions, and people either won’t give you help because they’d be charged with operating without a license, or can’t because the pharmacy wouldn’t honor the prescriptions they’d write. Which on the whole is actually a decent idea—keeping bad healers from practicing is common sense and I’d venture to say that every culture has some practice to try to achieve that goal. But in our culture the knock-on effects have landed us with a system that’s gotten horrifically warped. I’ll touch on that later, though.

When it comes to these things that the grid has monopolized, I don’t feel the need to refuse them just because they’re provided by the grid. I do want to minimize my use of them and maximize my use of alternatives. I’d like to speak more face-to-face and less through the internet, for example. But when it comes right down to it, I’ll bike on a public road rather than clear my own path alongside it, and I’ll go to a hospital to get my broken arm set rather than get Misty to set it with a sturdy stick and some homemade basswood cordage.

Here we come to another sticky question, though. Because if I’ve decided I’m going to use the grid’s hospitals, doesn’t that mean I have an obligation to pay my part toward keeping those hospitals running? If not, I’m just draining from the system, aren’t I? And is that not an immoral act—expecting my fellow humans to support me without doing my part in return?

That question rests on an interesting assumption: that the healthcare industry itself is just. If it’s responsible with its money and operates with the goal of making the public’s insurance premiums achieve the maximum amount of health in the whole population, then yes, I have a moral duty to support it to a fair extent.

But I think the opposite is true: I think we have a healthcare system that works to a goal completely unconnected to the public’s health, and achieves that goal in spite of the public’s health. And a system like that is one that I feel no moral obligation to preserve. To be explicit: I think the U.S. healthcare system is damn near the worst possible way to get healthcare to people who need it. In this country we’ve created a system that makes doctors miserable by forcing long hours and hundreds of grand of debt on them, makes nurses miserable by giving them even longer hours than the doctors yet busting their unions and skimping on their pay and benefits, and makes patients miserable by sending them to doctors and nurses who don’t have time for them, then charging them prices that are unarguably unjustifiable and would bankrupt them if not for insurance. The only party not miserable here is the insurance company. Which is laughing all the way to the bank. There’s the goal of our healthcare system: not to make people healthy, but to line the coffers of healthcare companies.

When a coyote kills a sheep on land that used to be prairie but is now rangeland, do you condemn the coyote for sucking off the teat of the system, or do you understand that it’s doing what it has to to survive in a world where its options have been curtailed?

So when someone tells me it’s my duty to pay into this system, so as not to be a drain on my fellow humans—I tell them it’s their duty to refuse to give this system any more money than they can get away with, because if all of us do that, the system comes apart, or transforms. Something new arises from its ashes—very quickly (since the infrastructure is still in place), and with the intervening time made bearable by the well-documented tendency of humans to help each other out in tough times, like when the Haitian earthquakes resulted not in riots but in people helping each other on a tremendous scale. And whatever that is that comes from the remains of the dead insurance and drug companies is practically guaranteed to be better for everyone.

I say that not just because this system is so bad that nothing could be worse, but also because the system we have now is built on prosperity. We’ve had a lot of extra wealth in our country. Where there’s an excess of wealth, there are people in the business of figuring out how to get their hands on it. This is the principle that most of the fashion industry operates on (and the reason our landfills and Goodwills are choked with excess clothing). It’s also how our healthcare industry got so bad. Now, though, on the downslope, there’s less wealth to go around and that means less opportunity to make unforgivable waste the norm, and that in turn means it’s less likely, in the future, that everyone will be expected to pay a price that’s one part real-world operating costs and ten or a hundred parts bureaucratic pocket-lining.

With that sweeping condemnation of our current healthcare system, I suppose I also need to offer an idea of what a good system could look like.

If we assume the continued existence of the U.S. as a country, my preference is nothing special or radical: I just want single-payer. It works for loads of other countries. I pointed out earlier that we already treat healthcare as though it’s the same type of service as road-paving, except that we still allow rapacious private companies to have the ultimate say on it. I see no reason this should be allowed to continue.

I’d also submit a way to simplify it, inspired by Retrotopia: simplify becoming a general practitioner. Just do it by apprenticeships. There’s no reason a GP needs as intense a training as they’re required to get. Treat simple cases—the broken arms and flus and strep throats that make up most doctor visits—and if it’s not a simple case, refer it to a specialist. That doesn’t take a $200,000 education.

What about in the post-petroleum world? If the ideal green-anarchist future arrives and there are no governments to collect the taxes and finance single-payer and keep the quacks from killing people, what then?

In Original Wisdom Robert Wolff explains how “going to the doctor” works among the traditional Sng’oi of Malaysia (among whom he lived for decades). The elementary unit of society in the West, he explains, is the family, but for the Sng’oi it is the village, the kampong. And every kampong has a healer, a bomoh. The bomoh is just any other villager, except that they’ve learned healing—from, one surmises, some independent studying and some one-on-one learning with an elder, respected bomoh. If you’re sick, you go first to the bomoh, and together, in a personal conversation like you’d have with anyone in your family, the two of you figure out what’s going on with you and how to fix it.

The bomoh may give you advice, like “rest that arm”, or pop a joint back into place, or offer medicine: traditional herbs or Western pills. Wolff relates, “When I asked one bomoh why he used Western medicines, he looked quite surprised and said, ‘Why not? They work.’ […] Bomohs are intelligent people. Those I knew studied to keep up with what was going on in the world. […] Bomohs would carefully read the fine print on the inserts included in packages of medication to understand the possible side effects and drug interactions before they would hand them to a patient.”

For this you wouldn’t pay the bomoh, any more than you’d pay your mom. “When the child has recovered, the mother may bring him [the bomoh] a nice chicken, a piece of cloth, or some special fruit that is in season—but that is not considered payment.” It’s just part of the complex gift economy that weaves the whole kampong together: the way that everyone depends on everyone else, and will always help out when help is needed.

I’m not suggesting that this exact system is what everyone in the world should use in the post-oil future. But I do think we can learn some very useful lessons from it.

A bad doctor, in a Sng’oi kampong, wouldn’t remain the village bomoh for very long. People would just not go to them for treatment, and soon someone else would become recognized as the kampong’s healer. Similarly, you don’t need a government to keep quacks from practicing. Even now, the medical boards mostly take care of that. Depending on how many people are in some region, the authority for accrediting doctors could stay with a regional medical board, or devolve to a university, or a doctors’ guild, or even just popular sentiment.

As for payment, in a cash-free style of anarchist utopia, there might well be a gift economy functioning: a little give and take, from and to each person, with a mind not toward how you can accumulate savings (now a meaningless concept), but to how you can all keep your town functioning. If we’re looking at an anarchist utopia that’s not so cash-free, well, small decentralized clinics, not answerable to an insurance company and running a modest operation, would cost far less than they do now.

These are just vague suggestions of what the future could look like. In some way or other, though, I think a lot of the crucial knowledge we have now will be preserved, and a lot that’s of questionable usefulness—I’m looking at the manufacturers of Requip, the restless leg syndrome pill, and at whoever makes that pill you can take to make your eyelashes fuller—will be lost. And the people who inhabit the future will figure out something that works for them in the modest means now allowed to them.

Any of these possibilities—single-payer, a village with a healer, a network of villages with small clinics—is something that I would happily live in and pay toward. But I refuse to support our current system any more than I can avoid—not because I’m cheap and want a free ride, but because we should have something better. Meanwhile, if I’m in an accident, I’ll use the hospitals and the insurance that we’ve got, because I enjoy living and would like to continue doing so, even if I don’t get to choose exactly how.

File under: off-grid, civilization


Chuck

That’s what I’m trying to do by writing this… I guess I’ll find out soon enough whether “writing blog posts” is a good answer.

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Dave

Normally your arguments are well thought out. You’ve left the reservation on this one. Sweeping generalizations that all healthcare professionals are miserable, all patients are miserable, and all healthcare companies exist to ‘line their coffers’, smacks of intellectual rationalizing/laziness.

Chuck

I’m speaking from a lot from what I’ve heard from people who are involved with the medical industry, Dave. Some of what I argue is based on thought experiments, but this one happens to be based fairly substantially on real-world experience.

One person I know who’s training to be a doctor tells us the on-the-job training makes him pretty miserable most of the time. Another doctor in training I’ve met has intense moral ambivalence about everything she’s doing, and wishes the field were very different. I know a few people who’ve started getting into the medical field, as nurses or in similar work, and had to get out because they couldn’t stand it for quite a few reasons, like disagreeing with the industry’s direction or realizing how overworked they would always be (reasons that are consistent from person to person, not just each person’s individual excuses or whines).

Everyone I know who’s getting into healthcare is deeply alarmed by the amount of debt they’ve taken on, and one has told me she’s seriously looked at which countries she could move to that don’t extradite for debt. The nurses in Minneapolis were on strike for quite a while late last year because their benefits were being slashed.

A lot of my friends have chronic health problems, and all of them talk about the difficulty of finding doctors who will really listen and care. Most of them have found some, but it took them a lot of looking and advocating for themselves. There’s no doubt in my mind that someone without the time or energy (or acculturation) to do that advocating would have an even harder time finding good care.

What are you basing your alternative view on?

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Dave

A few of my observations:

  • you make a sweeping accusation that the whole medical system(healthcare insurance providers) exist only to line their own coffers. Historically, healthcare providers are average profit makers at best. 4% is the nominal number I’ve found. Their stock prices have soared since Obamacare, but this is purely speculative, and not indicative of massive profits. Big pharmaceutical makes an average of 20% profit so one might find some truth here. I’m tired of big pharma advertising. You can’t watch wheel of fortune without the continuous onslaught of ads.

  • everyone I know in healthcare is happy. My wife runs a clinic for under advantaged adults with severe mental health problems. She has concerns that these poor people aren’t represented, or properly advocated for in the system. They only have Medicaid, which pays next to nothing. But this isn’t a healthcare problem, it’s a money problem. This gets to the true heart of the issue. Healthcare is expensive. Very expensive. The politicians and constituency haven’t acknowledged the elephant in the room. If everyone is going to get A-1 care, it’s going to cost big. The single payer is coming, the next democrat will deliver it if Trump doesn’t do it preemptively. And like everything else, it won’t be properly paid for. It will go onto the list of unfunded entertainments, that stretch out into the future of insanity. As Greer has said, we are most likely on a 10-20 year timetable for a sovereign debt default. Just like Russia in 1998, the haircut is coming.

  • so the system is not really broken. It does very well under the massive strain it is under.

  • the debt burden people take on for elective education is beyond unsustainable. Just like healthcare, the system isn’t broken, it’s just much more expensive than we care to believe. Formal education is pricing itself out of the market in the long run. I believe most employers will continue to develop their own training, education, and development programs. It will be cheaper and more effective to screen for raw talent and do your own thing with them. Google and apple don’t care if you have a degree.

  • my healthcare providers are happy. My primary care physician is in my marathon running group and certainly is not miserable. My urologist is middle aged, young at heart and happy. He and his wife went to a 21 pilots concert. Not the actions at a miserable person. He and his group are giving me excellent care as we watch closely for prostate cancer.

  • I know a nurse who works in pediatric oncology at CCHMC. She watches kids die from cancer. When Kim worked at CCHMC, she regularly talked with the oncologists, they work very closely with the orthopedic surgeons. One of them told her he worked there several YEARS before he had a patient who actually survived. Kids who get cancer die. She does it because she is called to it. She has attended many funerals. Is she miserable? Perhaps she is much of the time, but she still does it, and thank God she does.

Chuck

Thanks for all this information. It’s interesting how different our experiences of the medical system are. I don’t have time to write the response all of this deserves, but I’ll keep it all in mind and think about it when I think about health insurance in the future.

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