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.
“People tend to trivialize the issue,” says Karen Davis, president of the Commonwealth Fund, a research foundation that recently published a comprehensive report on uninsured young adults. “The most common misperception is that they’re pretty healthy all in all and end up getting decent care without insurance. Yes, when you’re injured in an accident, you won’t be left in the street. But getting good rehab? That may not be an option. Most of the uninsured aren’t getting regular Pap smears, they skip tests and treatments, they tend to end up in the emergency room because they wait until the last possible minute—they are developing unhealthy habits that are likely to stick with them as they grow up and start having more-serious health problems.”
New York, unsurprisingly, is an especially fertile breeding ground for the uninsured young. “A lot of the professions that draw young people to New York—everything from retail to the arts to restaurants to software development—tend to have spottier coverage,” says James R. Tallon, the president of the United Hospital Fund, a health-care think tank. Even large corporations are increasingly reluctant to offer coverage. (At a company like MTV, for instance, many full-time employees work in a nebulous state of hourly wages and no benefits, an arrangement that can last years.) Those without employer-sponsored coverage are thrown into a market where individual premiums can cost anywhere from $250 (for a bare-bones catastrophic policy) to $900 a month, among the highest rates in the nation, and likely out of reach for someone just starting out. And so going without health coverage becomes one of those casual sacrifices that come with being young in New York—on par with funneling half your income into a 400-square-foot apartment.
As an informal litmus test, I recently sent an e-mail to a handful of people in their twenties asking three vague questions: Are you uninsured? Know someone who is? How has it affected your life? Forward it to anyone, I encouraged. I imagined I would get a fair number of replies—one in four New Yorkers is uninsured, so I wasn’t exactly shooting in the dark, and as a 27-year-old former young invincible myself, I had an undoubtedly skewed sample—but I was unprepared for the sheer volume of response: more than 100 replies within a couple of days, mostly from people I had never met. There were complaints, conspiracy theories, details of unpaid debts, stories of untreated injuries, shoddy care, one insurance-inspired marriage (he needed surgery), and, in the case of a musician friend, wisdom teeth that should have been pulled years ago. The messages led to interviews with more than 50 uninsured New Yorkers. If there was a dominant theme to these conversations, it was that being uninsured has a distinct way of tweaking one’s perception of the city: New York becomes a kind of phobia-forming obstacle course, one navigated with the goal of keeping doctors at bay.
Nichole Schulze, a 31-year-old former publicist and current student at the Fashion Institute of Technology, was quick to rattle off a battery of quasi-logical preventive measures: “You won’t see me snowboarding or mountain biking or even jaywalking. My friends think I’m a freak because I’m the only person in New York who actually waits until the light changes to cross the street. Oh, and I eat a kiwi every morning because I read somewhere that they contain twice the vitamin C of oranges. And if it’s snowing? I’m the one walking on the inside of the sidewalk, just in case a cab decides to swerve and hop the curb.” Should any of these methods fail? “I carry an expired Blue Cross card in my wallet. You never know, maybe they’ll think I have insurance and I’ll get better care.”
Andrew Kuo, a 29-year-old painter, told me he made a vow to be insured by the time he turned 30. “But that was when 30 seemed like a ways away,” he added. “Now I find myself making all these stupid calculations. Like, it would cost me around $3,000 a year to have insurance, right? Okay, isn’t that about what it would cost out of pocket if I broke my wrist? Chances are I’m not going to break my wrist once a year, so why not save the money for that onetime emergency?” Like many I spoke with, Kuo said he’d happily pay for insurance, if only the cost-benefit analysis tilted more in its favor. “What’s ironic is that I would never live without my cell phone, but I won’t consider buying health insurance. It sounds ridiculous to say that out loud, but the fact is insurance is just too expensive. If it was the same price as my phone”—$150 a month sounded reasonable to him—“I’d buy it in a second.”
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.
At the emergency room of Long Island College Hospital, Andrew Ondrejcak explained the nature of his stomach pain to an intern. Notes were taken. The intern vanished. This happened three times in five hours. At 7 a.m., nearly seven hours after he arrived, Ondrejcak was given a CT scan. “Within fifteen minutes of getting the results back, I was on the operating table, opened up,” he said. “Apparently, my appendix was about to rupture.”
What took so long? Appendicitis is among the easiest conditions to diagnose: A CT scan will detect it 90 percent of the time, and appendectomies are among the most common surgeries performed. But CT scans are expensive, and doctors, when dealing with the uninsured, are hyperconscious of burdening both patient and hospital with undue expenses. According to a report by the Institute of Medicine, the uninsured are far more likely to receive inadequate care in hospitals: Conditions are improperly managed; most bleakly, the uninsured are more likely to die in hospitals than the insured. “It’s those catastrophe situations where insurance really proves invaluable,” says the United Hospital Fund’s James Tallon. “Without insurance, you’re likely going to run into a roadblock at every stage of the process. Will you get a referral? Will you get the right tests? What kind of care are you going to get?”
After Ondrejcak came out of surgery, his mother arrived from Mississippi and noticed something the nurses had somehow overlooked: Her son was sweating profusely, yet his skin was cold to the touch, and a rash had broken out over most of his upper body. “My mom is typically this very sweet southern woman, but she was so pissed off,” he recalled. “She asked if I was getting negligent care because I didn’t have insurance. Later, the doctor made some remark about how the hospital is ‘careful’ with cases like mine because most people never pay.” It turned out that Ondrejcak was having an allergic reaction to the antibiotics, so he was taken off the medicine. The rash subsided, but the healing process was jeopardized. The following night he was discharged, only to find himself in serious pain again four days later—a condition the surgeon initially diagnosed as the result of an “idle mind.” “He said I’d been sitting around all day, and that sometimes your mind can believe things are happening that aren’t really happening,” remembered Ondrejcak. “I couldn’t believe it.”
When his test results came back, the doctor’s tone was more urgent. Ondrejcak’s white-blood-cell count was three times normal, his pain likely connected to an internal infection and not at all imagined. He was ordered to come to the hospital “immediately,” a term that has a different meaning to the uninsured. Once again, Ondrejcak had to be admitted via the emergency room, wait a few hours, then explain to the ER physician that his doctor had sent him, wait while they paged the doctor, and again before being admitted. He spent the next three days in the hospital, getting injections of intensive antibiotics every eight hours.
At last, he started to heal properly. Three weeks later, the only evidence of the ordeal was a two-inch-long burgundy-colored scar below his right hipbone.
“And then,” said Ondrejcak, “I got the bills.”
They came separately, over the course of a week. The most damaging expenses were for his overnight stays: $16,608.76 for his first, $16,223.61 for the second. Then came the surgeon’s bill ($1,665.50), the anesthesiologist’s ($1,014), the two ER physicians ($605), the blood clinic ($551), and the post-op clinic ($592.04). A staggering $37,259.91 in total, a sum far higher than the prenegotiated rates the hospital would have charged an insurer. “That’s one of the unfortunate ironies,” says Cunningham. “The same people who don’t have insurance because they can’t afford it are charged much higher rates than someone with insurance.”
Panicking, Ondrejcak called the hospital. “Look, I have no money,” he told the woman from billing. “What am I supposed to do?”
Debt is a condition that can plague the uninsured long after they’ve recovered from whatever brought it on in the first place. Nearly half of all uninsured young adults have problems trying to pay off bills—taking second and third jobs, being hounded by collection agencies. Some analysts have noted the oppressive effect this can have on the economy at large: Debt pigeonholes the young into unwanted jobs, slowing down the overall job market. “The debt itself is devastating,” says Commonwealth’s Karen Davis. “Credit histories are ruined—it takes years, sometimes lifetimes, to come out from under it.”
Giselle Reesey, a 20-year-old aspiring musician who works at a Williamsburg coffee shop called Verb, is still reeling financially from what she described to me as “a really, really bad year.” Last winter, she developed a rare blood infection that spread to her liver and kidneys and cost her $3,000 to treat. At the same time, her husband, Ryan, who is 24 and waits tables at Suba, an upscale downtown restaurant, needed to have his tonsils removed. The surgery cost close to $5,000. They set up an installment plan and are expected to pay about $60 a month, not always an easy sum to come up with. “A few months ago, we were living in this hellish pocket of Bushwick and our apartment was robbed,” Reesey told me. “I literally went to the doctor’s office and was like, ‘Here, I was just robbed, all I have is this $12. I’ll make it up next month.’ ” Most frustrating about the debt, she said, is that the payments make it that much more unlikely that she and her husband will ever be able to afford insurance.
Debt isn’t simply a problem for the uninsured who incur it; unpaid medical bills reverberate through the whole system. “It filters down to the rest of society,” explains Cunningham. “Either the hospitals or the physicians absorb the cost, making the funding streams less certain and their capacity to deliver services more constrained. And premiums for everyone else go up.” This point has become a favorite among those advocating a system overhaul. “We, in essence, have become the insurers of the uninsured,” Victor Campbell, then-chairman of the Federation of American Hospitals, said last month when unveiling a proposal for universal coverage. And in January, when Arnold Schwarzenegger announced that he would make insuring every Californian the cornerstone of his second term as governor, he sold the plan by stressing the “hidden tax” paid by the insured to offset the debt created by the uninsured. As a stopgap measure to prevent the cycle of debt and higher costs from spiraling even more out of control, a handful of states have proposed raising the age under which children remain eligible to receive care under their parents’ plans. (In New Jersey, those as old as 30 now qualify.) Massachusetts has gone the furthest, passing a landmark plan to make health insurance like car insurance: legally required and relatively affordable. Yet for all the reform on a state level, analysts note that states don’t have the revenue to sustain these programs for the long term. As Cunningham puts it: “Eventually, the federal government will have to step in and figure out a way to make it all work.”
Facing nearly $40,000 in medical bills, Ondrejcak pleaded with the hospital. The only thing he could do, they told him, was apply for Medicaid assistance. He sorted through bank statements and pay stubs and submitted his claim: His documented income for the month of the surgery came to $507. (He didn’t include tips or off-the-books work.) A paltry sum, especially by New York standards. And yet a few weeks later he received a letter from Medicaid denying his request. The limit for assistance was an even paltrier $352.10. How was he expected to pay nearly $40,000 because he made $1,800 a year too much? File for an appeal, the hospital suggested. On October 13, 2004, Ondrejcak presented his case at the Medicaid Assistance Program on West 34th Street. “It was all very cut-and-dry,” he said. “Me, a woman representing Medicaid, and a judge-type guy. She was like, ‘I’m sorry, there’s nothing I can do,’ and the other guy gives me a look like, ‘Dude, you’re fucked.’ We all agreed in this itty-bitty room that there was nothing they could do to help me, but they all knew I was going to leave $40,000 in debt.”
Notes from creditors began appearing in his mailbox, and Ondrejcak grew desperate. “Here’s the deal,” he told the hospital. “I’m either going to file for bankruptcy, which will ruin my credit and ensure that you’ll never get any money, or I’m going to look into a malpractice lawsuit.” On March 20, 2005, almost exactly a year after the surgery, he received a letter stating that his hospital costs had been reduced—by 100 percent. The other doctors followed suit, offering substantial discounts, and in the end, Ondrejcak had to pay only $1,700. It was an extraordinary conclusion for him, but a common one for hospitals. When the sums are so high that a payment plan isn’t feasible, hospitals are often forced to simply write off the treatment as a loss. New York hospitals alone provide $1.8 billion in uncompensated care annually.
It has been just over a year since Ondrejcak paid his last medical bill. Now 27, he no longer works at Sweet Melissa, having established himself as a freelance set designer for fashion shows. He works in a studio near the Gowanus Canal that he shares with a client, the designers behind the trendy Vena Cava line. A sun-speckled loft with wide-plank flooring, white-brick walls, and exposed air shafts, it’s a space that epitomizes a kind of bohemian success: independent, informal, productive. During one of our meetings, he was in the process of conceptualizing Alice Roi’s Bryant Park show, one of a handful he was working on for Fashion Week, and had to excuse himself numerous times to give assistants direction or to answer calls from his agency. His circumstances are vastly different from the morning he woke up in pain—on the surface, at least. “My credit is basically destroyed,” he said. “It’s amazing how much it haunts you. The other day, I tried to apply for an extension on my credit limit and they rejected it, bringing all this up. I can’t even imagine what will happen if I ever, like, try to buy a house.”
Toward the end of one of our conversations, I asked Ondrejcak, the least invincible of young invincibles, how coming down with appendicitis changed his attitude toward health insurance. Did he now see it as essential? Given what he had been through, and that he was better off financially, I assumed the answer was obvious. I was wrong. “Oh, no, I still don’t have any insurance,” he told me, rolling his eyes to indicate that, yes, he knows how it sounds. “I think about it, but it’s not like I have a consistent income right now. I think about paying $300 a month on top of my other expenses, and it’s like, God, when’s it going to end?” He paused. “But, really, it’s more than that. I was just so disillusioned with the process. I wanted nothing to do with it, you know? And maybe because, in the end, I kind of managed to get away with it, I end up thinking …” He trailed off, not finishing the thought, but the sentiment was clear: He is still young, he runs, he does yoga, he takes all the vitamins. And it’s not like you can get appendicitis twice.
No insurance? Here’s where to go when…
You’ve got a toothache: The clinic at NYU’s College of Dentistry provides care for 30 percent to 50 percent less than what you would pay out of pocket:A checkup and cleaning is $50 to $90, a filling is $70 to $110.
You want drugs: Wal-Mart now offers 331 generic prescription drugs at the flat rate of $4—everything from antidepressants to prenatal vitamins. Worth buying a New Jersey Transit ticket to the big-box store in Secaucus.
You need birth control: Planned Parenthood is still the gold standard for inexpensive gynecological care. Patients are charged on a sliding scale at the Brooklyn clinic: An exam ranges from $39 to $116, birth-control pills from $5 to $15.
You have an emergency: Go to a city-owned hospital (for a list, go to nyc.gov/hhc), where, thanks to a sliding scale, single adults earning less than $38,280 pay $15 to $60 for ER services, and $5,000 max if they are hospitalized.
You decide you need insurance: If you freelance twenty hours a week, call the Freelancers Union (from $127 a month for catastrophic). If you make less than $25,000 a year, try the state-run Healthy NY program (from $145 a month).
SEE ALSO: No insurance? Here’s where to go when…