New York State of Health, the official New York health insurance marketplace, mainly wants to know how much money you make. The application for a health-care subsidy asks you to list all your employers, along with how much each one pays you, and how often. If you’re a freelancer, as I am, this part can take a while. It’s helpful to have a copy of last year’s tax return nearby. If your annual income is less than $40,000 a year, you’re eligible for a subsidy to help you pay the monthly premium on some health plans—which plans will depend on exactly how much you make and how many people you’re looking to cover. The size of the subsidy varies in inverse proportion to your income. Depending on your income, you can apply for a tax credit, too. About a week after I finished my online application, I received a thick envelope in the mail telling me that I had qualified. “Congratulations,” began the letter informing me that the state had determined I was broke.
While most of the online application questions were about money, others were more personal—about family, history, and habits. This made sense, for a health-care website: they were the kind of questions your doctor would ask you. But in the densely bureaucratic context of the state exchange, these prompts seemed uncanny, bizarrely tender. One section, under the heading “Absent Parent,” contained the instruction, “If you fear physical or emotional harm as a result of providing information about the absent parent, click the box here.” One of the security questions I was asked to pick from a drop-down menu was, “What band poster did you have on your wall in high school?” The effect was exaggerated by the site’s tendency to refer to the applicant in the third person, like a chipper guidance counselor. “Tell us about Moira,” one page implored me. “Was Moira ever in foster care? Is Moira pregnant?”
Once you’ve been accepted, you’re able to access the part of the site that lists and compares the plans you’re eligible to purchase. A tool at the top allows you to sort by plan type, cost, and services offered: the matching plans appear below, sorted from lowest price to highest. For New Yorkers, Oscar plans are reliably the cheapest; marquee names like Blue Cross Blue Shield are the most expensive, at the bottom of the list. Click on a plan and you can see the prices for an array of services you hope never to need. The plan I eventually bought would charge me a $1,600 copay to give birth, the same amount that it would cost me to receive an organ transplant—things I had never been so precisely aware of being unable to afford. Well-baby pediatric visits are free, as is contraception and sterilization. Specialist visits cost $50 unless I am visiting a psychiatrist for the treatment of an autism spectrum disorder, in which case it’s only $30. If I have to go to an inpatient rehab clinic for a drug addiction, it will be $1,500. If I need chemotherapy, it will be $30 per session. Because my income level is low enough to qualify me for subsidies on some plans, but not low enough to qualify me for subsidies on all of them, I was “incentivized” to buy a plan that included some services I won’t use. I will not have a baby while I am enrolled, for instance, but if I did, her glasses would be free.
Besides the sheer experiential weirdness of being encouraged, as a consumer, to plan ahead, one of the stranger things about buying health insurance is that it requires you to consider the future as something more than merely rhetorical. What is especially strange about buying health insurance on the public exchange is that it requires foresight from people whose lives are necessarily preoccupied with the present. Obamacare’s subsidies, after all, are useful mostly to people who do not receive insurance from their jobs—people who are part-time employees, who are unemployed, or who work in an irregular or nontraditional enough way that they are classified as independent contractors. There’s some evidence that even with the subsidies, many people still can’t afford to go to the doctor: a recent Gallup poll found that 31 percent of Americans had delayed seeking medical treatment because of the cost, even though the number of insured people has increased since the passing of the health-care law. Ours is a system that demands long-term planning almost exclusively from people whose work is scarce enough and precarious enough to preclude even short-term security.
My new insurance will take effect on January 1, just as my old insurance expires. For the past three years I’ve been covered by a graduate school catastrophic plan, which I used for one clinic visit to cure an ear infection and not much else. The stinginess of my coverage wasn’t a problem, because I was healthy. But signing up for the new, more extensive coverage has made me more critical of my body, snobbier and more entitled about the levels of health and efficiency that I can expect from it. For years, not having dental coverage seemed fine, as long as I remembered to floss. Now that I have the promise of going in for a cleaning, my mouth seems gross. It occurs to me that my $45 Lenscrafters glasses might not have a strong enough prescription. Friends with more stable jobs have been speaking to me in hushed tones for years about how much they love their therapists, and now that I can afford one of my own, I wonder if I’m satisfied with my emotional life. Does that seem crazy? Well, maybe it’s something I can talk to someone about.
A few days after submitting my application for a subsidy, I fell down the stairs of the West 4th Street subway station. For the same reasons I qualified for the insurance subsidy, I always buy cheap shoes; running to catch a train, one of them broke under me, and I hit my head on the grimy handrail. Later that day, feeling spacey and confused, I left my freelance job to go to one of those walk–in clinics in the back of a chain pharmacy, where a dour Jamaican nurse shined a light in my eyes and asked me a series of questions to make sure I wasn’t concussed. (I wasn’t.) Walking back to the office, it occurred to me that one of the calculations you have to make when you buy insurance is how your own relative wealth or poverty is likely to contribute in large and small ways to your health. Another is how much confidence you feel in your own continued carelessness, bad luck, and bad judgment. Passing a mass-market clothing store, I walked in to buy another pair of cheap shoes.