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Sorry, but you're not sick enough yet... [1]

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Date: 2023-06-10

Please bear with me on a meditation that starts with a mysterious $150 overcharge, and ends with matters of good and evil, and life and death.

I recently completed cataract surgery. I’m still on the post-op protocol for the second eye (they don’t do both at once in the USA) and I’m not supposed to lift heavy things, bend over forward, do aerobics, or get soap in my eye. I have to do a course of three eyedrops four times a day for a week, with tapering off after that for some of them.

But I can see clearly. I am a miracle of modern technology. My doctor made a very small incision, used an ultrasound machine to break up and suck out the remains of the natural protein lens my body made which was rotting, and used an injector to put in a spiffy modern artificial lens that will never rot the same way. The procedure was painless and even fun. They put me on an IV and pumped me up with a benzo called Versed, and there was no pain as the process of fixing my eyeball created quite a little light show. Rock artists should take notes for their next concert.

There was one little bit of weirdness though. A few days before each procedure I got a text asking to confirm my appointment, then a few minutes after I hit C-send a phone call letting me know that the insurance had approved and what my share was. I had to pay $200 for the first eye, but for the second eye I was asked to pay $350.

Whatever. I gave them my credit card info and let it go. I’m not rich, but I’m not that poor that it’s that important.

It was kind of mysterious though. Same procedure, same doctor, same everything except left eye instead of right, two weeks out what changed? My service manager (who is known to be a bit combative) lit up. “I’d have challenged them about that,” he insisted. “Something’s up.”

I told him rule #1 for localroger is that when someone is about to use a high-tech machine to poke a hole in your eye, you don’t start an argument with them over $150. But I did tell other people about it.

About a week later one of my customers explained it to me. “Let me guess, your right eye was worse than your left?”

It was. When I was tested my right eye was 20/70, fully legally blind, and my left was 20/40, technically allowed for driving.

It turns out the insurance company pro-rates your share of the payment based on how blind you are. For my fully legally blind right eye they covered the max. For my left eye, still capable of legal driving, they covered less.

The fellow who told me this followed that he had been diagnosed three years previously and while he could tell his vision had deteriorated, his optometrist had told him that he would save thousands of dollars if he waited for it to get worse so his insurance would cover the surgery. His vision wasn’t bad enough to make him eligible for coverage yet.

Most cataracts grow slowly. They crawl, slowly but inexorably. When you have cataracts there is only one possible and inevitable endgame: You will go blind. They don’t ever get better. They don’t stop. It’s just a matter of watching the world get less and less distinct, more and more blurry, until the insurance will finally admit that you are in bad enough shape to need their help.

My cataracts were a more rare form though. They sprinted. I went from barely noticing that things were a little weird in December to realizing I needed weak readers to use the computer monitor in February to doing a mad dance between the weak readers for the computer and the strong ones for printed matter in March to realizing something was terribly wrong in April, when I finally scheduled an eye exam. That was when I found out about the cataracts. And they were getting worse week by week. Fortunately (?) they were already bad enough to justify surgical correction.

My surgical dates were three and five weeks out at the point my opthalmologist verified the diagnosis for herself. About a week after that consultation I was driving myself home from a nice lunch at a local restaurant when I realized I had no business trying to drive a car. I couldn’t read signs, I couldn’t read license plates, I couldn’t reliably judge distance or speed of the other vehicles. Sure I could muddle through on familiar roads but it would only take one child running out into the roadway, one bicyclist where I didn’t expect him, one unsignaled lane change on the part of another driver to create a lifetime of regret. I called my boss and told him I couldn’t come in to work.

Then I cried for two days. I am 59 years old and I have never felt the sense of existential despair that I felt when I realized that I was actually going blind. Even though I knew it could be fixed, everyone reassured me that it could be fixed, just opening my eyes and not being able to make out what the alarm clock said was enough to make me want to die instead.

(I know it is possible to have a fulfilling life if you are blind, and I suppose I could have learned to do that, but it’s very late for me and reading is at the core of everything I do. I would literally have to become a different person to deal with that.)

But now both surgeries are done and the results were excellent. My surgeon and optometrist are both very pleased. I was able to start driving again after the first eye was fixed three weeks ago. I’m back at work. Modern technology For The Win.

Except for that weird $150 thing. I remembered the customer telling me that he was still waiting, while his more conventional slow-growing cataracts got bad enough for his insurer to consider them worth notice.

He wasn’t sick enough yet.

And with all that , I heard a dark echo.

Since the Dobbs decision that erased Roe v Wade, there has been a succession of horror stories about women who had tragically flawed pregnancies that needed immediate care but could not be treated because they weren’t sick enough. Like the cataracts these pregnancies have only one possible outcome if not treated, but it is not blindness. The end game of an untreated ectopic pregnancy is death. There is no other possible outcome. There is no sensible reason not to take care of the situation while it is still in a relatively stable state.

But in many states today a woman with an ectopic pregnancy or tragically malformed fetus cannot get the care she needs until she is sick enough to make it obviously necessary. There has been at least one story about a woman who was rendered unnecessarily infertile because of this, because when the doctors finally decided it was necessary to save her life they had to do a hysterectomy to do that.

What the fuck is wrong with us?

There is actually an answer, although not a pretty one, to the reason that cataracts are treated the way they are. I said a few paragraphs ago that there is only one possible outcome for cataracts, but that’s not completely true. Cataracts mostly affect older people and they mostly grow slowly, and the chances that you will die of some other completely unrelated problem before they reach the threshold for oh gee we have to actually take care of this are nontrivially nonzero. By making you wait the insurance company gets a significant bet in that you will die before they have to pay for the procedure.

Normal people, by which I mean human beings rather than corporate entities, tend to be a bit miffed when they realize this kind of logic is being applied. This is what happened with the infamous McDonald’s hot coffee lawsuit, which wasn’t frivolous at all. McDonald’s had settled hundreds of such suits before over their coffee being too hot and causing injury, but the lawyer in that case made the judgement that if they stretched the case out with delays the old woman would probably die before she could collect a judgement. When that became apparent to the jury they whacked the company hard for its inhumanity.

But that’s actually unusual. Largely we are numb to this inhumanity. So your eyes are becoming blocked, but you’re a bird watcher or machinist for whom fine vision is critical to your hobby or job? Tough shit. Of course you can always just pay for it yourself; worst case considering treatment options it’s only a few thousand dollars an eye. You can afford that if it’s really important, right? And if not fuck you.

Not so much though if you’re a woman with an ectopic pregnancy and it’s the law standing between you and lifesaving treatment, a law written by people who don’t know what an ectopic pregnancy is or what it implies. But a law with real penalties that could send doctors to jail for doing their job. Hey, if you’re sick enough those lawmakers will admit that maybe you should be saved, but only if you’re sick enough. The fact that you will inevitably get that sick if you wait isn’t good enough. You have to wait.

Lots of critics like to bring up Viagra but men get screwed by this too. When Pfizer invented Viagra they hired an army of actuaries to ask the question, what is the optimum price? It’s kind of like the Laffer curve, if you give it away you don’t make any money but if you charge infinity for it you don’t make any money because nobody can afford it. They arrived at a price of $25 per boner. This is, of course, suspiciously close to the price a working class prostitute might have charged in the day. And it was literally per boner. They had different doses depending on what you might need to get that boner, and they all cost the same. Of course they were doing this to middle-class educated men who weren’t stupid, and all of them told their doctors to say they needed 100 mg even if they only needed 50 mg and they all bought pill cutters.

As far as people who couldn’t pay $25 to have sex again well, fuck those guys. Or not, since they can’t get it up. Not Pfizer’s problem.

All of this brings me up to a comment Terry Gilliam made about his movie Brazil, a nightmare hellscape of bureaucracy run amok. “These people are probably quite proud of the world they’ve made,” he once told an interviewer, and we’re of course very proud of the world we’ve made. We can roto-rooter our arteries and replace the lenses in our eyes. But somewhere in the process of making that possible we seem to have traded in our humanity.

And it contrasts with a story I think I read here, although I can’t find it in the diary search, of an American woman in Iceland who found a lump in her breast and went to the clinic. After the clinician verified the lump she brought the woman across the hallway to do a mammogram. Right then and with no further appointment — “You have a lump honey, we have to see whether it’s serious.” There was an implication that if it had been serious the next step would have been similarly automatic. No transfer, insurance weirdness, future appointments. Let’s just take care of it. Once it was verified safe, the clinician chided that she’d have to pay, since she wasn’t a citizen. It came to like $15, for a process that would have taken weeks and cost hundreds if not thousands in the US.

Of course in Iceland citizens aren’t “free” as we are here, they’re wards of the King. Perhaps that’s why the country actually values its people, and gives them free college educations without any onerous loans or other obligations to repay. But the problem with that model is when you get a king like Henry VIII or Louis XVI, who doesn’t value certain of his people as much as others.

One thing is certain, though. Neither democracy nor the free hand of the capitalist market are consistently any better. And that’s what my cataracts have taught me this year.

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[1] Url: https://www.dailykos.com/story/2023/6/10/2174564/-Sorry-but-you-re-not-sick-enough-yet

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