The common assumption is that the exorbitant rates are schemed up by the politically influential executives governing the trillion-dollar insurance industry. But if insurers could target cheaper plans at younger New Yorkers, they would: Every business thrives by exploiting untapped markets. State law, however, requires insurers to follow a “community rating” system that throws everyone—young, old, sick, healthy—into one risk pool. “The whole point of insurance is that you’re pooling the risk to spread out the costs for everyone,” explains Cunningham. “If you target healthier groups with favorable policies, you’re likely going to make it more expensive for the older, less-healthy populations who need regular care.” Of course, if the young and healthy don’t buy policies at all, who’s balancing the costs? Recognizing this Catch-22, some states have adopted a more flexible “age banding” system, allowing insurers to customize packages based on age. WellPoint recently created a youth-centric program called Tonik, with plans as low as $67 a month, but it’s currently only available in eight states.
According to the Commonwealth Fund report, nearly 60 percent of uninsured young adults (ages 19 to 29) say they have gone without health care because of the cost. Deny the symptoms until they vanish: Such becomes the standard protocol, supplemented by a regimen of self-diagnosis and self-treatment. Trent MacNamara, a 27-year-old fact-checker at GQ, was riding his bike down lower Fifth Avenue last year when the door of a garbage truck opened in his path, knocking him off his bike and into the middle of the road, where the Jeep Cherokee behind him ran over his forearm. MacNamara was wearing a helmet and remained conscious; remarkably, no bones were broken. “Once I realized I was more or less all right, the first thing that went through my head was that I didn’t have insurance,” he told me. “When the paramedics arrived, I pleaded with them to let me go. I kept asking if they thought I had broken ribs, and they kept saying they weren’t qualified. Finally, they told me that if I could breathe without pain, they probably weren’t broken. I promised them I would walk to the hospital. I just limped to the subway and went home.”
And when forgoing treatment isn’t an option? The term medical clinic doesn’t evoke much comfort, but when it comes to affordable care, New York has more options than most cities. A few weeks ago, I spent an afternoon at the Ryan Chelsea-Clinton Community Health Center, a public clinic in Hell’s Kitchen where about half the patients are uninsured. While giving a tour of the facility (pastel décor, patient-made art, multilingual signage), Dr. Andrew Gotlin, the chief physician, told me that the 50 or so walk-ins who pass through the waiting area daily tend to be under 35 and “often not what people picture when they think of the uninsured”: waiter-photographers, bartender-playwrights, aspiring graphic artists, and “a lot of actors who’ve had small roles on Law & Order.” Most come in for “episodic care,” he told me, a delicate way of saying the center is a last resort. “That’s one of the biggest problems for the uninsured—they don’t get any preventive care,” Gotlin said. “We try to encourage it, but even at our rates”—$32 to $92 a visit, depending on income—“it becomes a pretty hard sell. I would say the majority of patients don’t come back for needed follow-ups.”
One of the staff physicians, a mellow, well-dressed man named Aashish Dadarwala, told me a chilling story to underscore the public-health ramifications of Gotlin’s point. “I had someone come in six months ago, a young, healthy-looking woman,” he said. “She was 28, I think. She had had a nasty cough for a while but didn’t want to get it checked out because of the costs. When it didn’t go away, she decided to come in. I gave her all the tests—one of the great things about this place is that none of that costs extra—just to rule out anything serious. Well, it turned out she had tuberculosis.” The woman was immediately masked and sent to the hospital to be quarantined until she was no longer contagious. “Here she had been getting on buses, on the subway, potentially infecting who knows how many New Yorkers,” Dadarwala said, shaking his head. “If she had come in earlier, chances are we could’ve done something before it developed into something so serious.”
In other instances, of course, something serious happens with no warning, no prelude, just a sudden paralyzing jolt to the equilibrium. Even the youngest, healthiest, most resilient bodies can malfunction in mysterious ways. One morning you wake up with a minor stomachache, and before you know it, you’re in the hospital, delirious with pain, waiting to see the doctor.