It was an unfamiliar pain, sharp and persistent, as if a rag were being twisted inside his abdomen. Tighter and tighter, crunching in on his organs, enough to wake Andrew Ondrejcak one morning in 2004 before his alarm went off. Indigestion? No, probably it was a return of the stomach ulcers that had plagued him as an undergrad a few years back. Ulcers felt somewhat different, it’s true, more an isolated stabbing compared with the lateral serrations currently tormenting him. But it had been a while; you forget the specifics of pain. Whatever it was, Ondrejcak, who was 24, worried he might have to see a doctor, something he made a point to avoid. Like 47 million other Americans, including most everyone he knew, Ondrejcak did not have health insurance.
Telling himself the pain was nothing, he walked to Sweet Melissa, a bakery on Court Street, where he made $6 an hour plus tips. He had come to New York from Mississippi, hoping to become a designer—maybe in theater, maybe fashion—but for the time being, he paid his rent (barely) by serving pastries. “Health insurance wasn’t even an option,” Ondrejcak told me recently. “I was flying through my savings, trying to get a career started. I was doing a lot of assisting designers who were doing great work, but I wasn’t making anything. The last thing I’m going to do is spend $300 or whatever on insurance, you know?” He paused before adding, “I’m a healthy person, I rarely get sick. I run, I do yoga. I take all the vitamins. Honestly, I never thought about it.”
At Sweet Melissa, the pain only worsened. But what to do? How to even find a doctor? Only one-third of the uninsured have a regular physician, and he was not among them. He searched the Yellow Pages for doctors in Brooklyn with the prefix gastro near their names; most wouldn’t take him. Eventually, he found a public clinic—a friend had been there—that recommended a specialist in Bay Ridge. “It’s probably ulcers,” the doctor said, after Ondrejcak said he suspected ulcers. He was given a prescription for Nexium ($73) along with a depressing bill of $200 for the visit. “Basically all the money I’d made that week. I left keeling over in pain but took the bus home because I was so broke,” he told me. He swallowed the Nexium with a swig of Maalox and went to bed, hoping the pill would rewire whatever was wrong.
Just before midnight, Ondrejcak woke in distress. Needling, jabbing, the pain was corrosive. “I crawled to my bathroom and tried to throw up because it hurt so bad,” he recalled. “I was in my underwear on my bathroom floor calling my neighbor who had keys to my apartment.” The neighbor phoned for a livery cab, asking the driver to take them to a hospital, any hospital, whichever was closest. Ten minutes later, Ondrejcak staggered into Long Island College Hospital in Brooklyn Heights. The desk attendant was blunt: No insurance? Wait in the emergency room. Ondrejcak had wondered about such a scenario—a sudden emergency, no safety net, the classic nightmare among the uninsured—but until now the thoughts were fleeting, theoretical. No way it would actually happen.
It’s tempting to view a mind-set like Ondrejcak’s as purely a symptom of youth. The young are naturally resilient and among the least likely to have a serious medical condition—as far as priorities go, health insurance tends to reside in a muddled region of the mind along with other abstract concepts: retirement savings, mortgage payments, marriage, death. But this is only part of the story. Those coming of age today are entering an economy where many of the old rules no longer apply. The paternalistic corporate culture of the past (full-time staff members supported for the long haul) has been largely replaced by a frenetic “permalance” model, the strivers and thrivers encouraged to jump from one company to the next as needed. There was a time when a health plan symbolized something—you were making it—but now benefits are scarce at many levels. For the young who don’t luck into a job that offers coverage, a certain outlook becomes inevitable: Premiums are a fortune, you can barely pay your rent, you rarely need a doctor, you decide to gamble. It’s a state of mind so common, in fact, that the insurance industry has a name for it: Ondrejcak is one of the “young invincibles,” those who, betting they can get through their twenties relatively unscathed, “choose” to go without insurance. They are the fastest-growing segment of America’s uninsured population.
There is, of course, a great deal of talk these days about health care. Open a newspaper and you’ll find op-eds sermonizing about the coverage crisis, a poll dissecting public dissatisfaction, a study offering grim statistics (“Since 2000, the ranks of the uninsured have grown by 6.8 million …”), and yet another politician laying out a plan for universal care. Compared with small children, uninsured young workers are generally ineffective as political sympathy-generators and are therefore typically viewed as a footnote to the debate. But health-care analysts will tell you that insuring children, while certainly noble, is a relatively easy goal. “What a lot of people don’t realize,” says Peter Cunningham, a researcher at the Washington, D.C.–based Center for Studying Health System Change, “is that most children are already eligible for some form of care. They either qualify for Medicaid or can be insured under their parents’ plan. So in many respects, it’s a matter of making the paperwork clearer, not overhauling the system.” The young invincibles, on the other hand, are an example of how the system bypasses some groups altogether. In this they are not alone—the poor have a long history of inadequate care, and increasingly, middle-class families are finding themselves priced out—though to understand their bind is to see just how ineffective the current system has become.