Cost of Living
In 2008, the hospital where I worked—a Level II trauma center just outside Chicago—was $54 million in debt. Everyone seemed to be aware of this fact; the figure floated beneath the surface of all our conversations, an unspoken rigidity we seemed to bump up against everywhere we turned. We were to be careful when we distributed small stuffed animals to unhappy children in the ER, were told to dispense fewer scrub tops to adolescents with dislocated shoulders and bloodied shirts, to pay attention to the way that canes seemed to walk off as if under their own power. Everything cost money, Helene, our nursing manager, reminded us, even if the kid was screaming and had to get staples in his scalp. I was an ER tech then, someone who drew blood, performed EKGs, and set up suture trays. Most of my knowledge of the world of the ER came through direct patient care. If a nurse or a doctor needed something for a patient, I’d get it for them. I’d run into the stockroom, sort through yards of plastic tubing, through dozens of disposable plastic pieces, acres of gauze. We—the techs—were expected to guard against the depletion of resources. Helene seemed to remind us at every available opportunity by tacking notes up on the bulletin board in the staff break room. PLEASE CONSERVE YOUR RESOURCES. ONLY USE WHAT IS NECESSARY. These notes were pinned next to our Press Ganey survey results, a form sent to patients upon discharge. Helene blacked out staff names if the feedback wasn’t positive. But the question of resources seemed like the kind of problem that couldn’t be solved through gauze or surveys or suture trays.
When it was quiet—a forbidden word in the emergency department—I’d help with the billing. We’d break down charts as fast as possible: scan them, assign codes, and decide what to charge. Names I vaguely recognized flew by on the PDF reader. I studied my handwriting on their medication lists, a form techs weren’t supposed to fill out but did anyway. (Nurses were supposed to keep up with the medication lists, but there was never enough time for them to actually do it.) Because there were only twenty slots on these forms, I sometimes had to use two pages.
I was twenty-three at the time, still paying off the cost of the mental-health-care debt I took on at nineteen, a cost I believed I would shoulder well into my thirties, a figure that felt more like a student loan than an appropriate cost for medical care. I didn’t understand the nature of my mistake at the time, that I should have gone somewhere else for treatment—maybe the university hospital, where the state might pick up your bill if you were declared indigent, or nowhere at all. Sitting on a cot in the emergency room, I filled out paperwork certifying myself as the responsible party for my own medical care—signed it without looking, anchoring myself to this debt, a stone dropped in the middle of a stream. This debt was the cost of living, and I accumulated it in the telemetry unit, fifth floor, at a community hospital in Iowa City, hundreds of miles from home. There, I spent too much time playing with the plastic shapes that dangled from my IV line, which dripped potassium ions in carefully meted doses, like dimes from my future life funneled into a change-counting machine. I couldn’t imagine the amount of money I’d spent—the debt I’d incurred—in attempting to end my life. Suicide should be cheaper, I remembered thinking. Probably half the costs were for psychiatry, for an illness it turned out I never really had. I was depressed, but a lot of people were depressed in college, it seemed. I only tried to kill myself after I began taking—and then stopped taking—all the medications I’d been prescribed, twenty-six in all. All for what turned out to be a vitamin deficiency, combined with hypothyroidism and a neurologically based developmental disorder.
And then there were the unintentional costs, those involving loss of work, lost friends, having to ask my father if he would drive to Iowa City and help me pack up all my belongings and move into a new apartment, since my roommate, who had also been diagnosed with mental illness, had developed a profound depression and moved out. He wanted to drive to Mexico on a motorcycle. My life did not have space for motorcycles.
When my bill finally reached me, it wasn’t itemized, just “balance forwarded” from the hospital to the collection agency, after my paltry insurance covered the initial cost. From then on, I’d get calls requesting that I boost my payments, or I’d call them to switch bank accounts and they’d harass me on the phone. They would call me on my cell phone while I was at work, in the car, at home, in between shifts at the hospital, which I sometimes worked back-to-back if I could. For a long while I ignored them. I blocked their number, refused to answer when they dialed. My debt was five figures, an immense sum for someone making only $12.50 an hour. My coworkers in the ER were largely sons and daughters of first-generation immigrants. Most of them lived with their parents, and made up for it by driving nice cars. I lived in a third-floor walk-up almost far enough away from Iowa City to forget how much money I owed and to whom.
At the hospital where I worked, patients returned again and again, a kind of catch-and-release program, we joked, so nobody would pay for these stays. Some insurance plans prevented payment—as a kind of penalty—to hospitals that readmitted patients who’d been discharged inside thirty days. No payment to the hospital to disimpact a cognitively disabled ninety-eight-year-old woman, or to start two IVs and admit a woman who, at 108, had explained to the techs in providing her medical history that she had lost one of her older brothers in “the War,” in a trench in France in 1917. The government thought that these people should have been cured, explained in hundreds of pages on the Centers for Medicare & Medicaid Services website, then later in the documents that made their way across Helene’s desk. How do you explain the cost of a perennially septic patient whose nursing-home status and inconsistent care meant we’d see her again next month?
The patients who appeared on my screen flashed in bits and pieces, their visits reduced to minor explanations, to ICD-9 codes used to categorize their illnesses or injuries. I’d use their chart to determine what they should pay. If we were in doubt, we were expected to bill up (though this was never explicitly discussed)—that is, if someone received medical care from a physician assistant or other “midlevel” provider, the patient’s care might cost less; but if the physician assistant or a nurse practitioner did more work (sutures, for example), the care could still get bumped up a level.
Copyright © 2022 by Emily Maloney
