An Essayist Navigates the Labyrinth of American Health Care. Barely. – The New York Times


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COST OF LIVING
Essays
By Emily Maloney
The illness narrative, ending in financial ruin and decreased quality of life, has become one of the classic 21st-century American stories. In her debut essay collection, Emily Maloney documents the complex intersections of money, illness and medicine. For Maloney, the primary experience of receiving health care is not merely a bodily or spiritual event but always, also, a financial one. She understands on a granular level the relationship of money to being ill, to developing a drug, to housing and caring for patients and, of course, to managing an unfathomable amount of debt. Her broad perspective is hard won; at different times she has been a multiply diagnosed chronically ill patient, an E.M.T., an emergency room medical technician, a drug rep, a data analyst, a medical writer, a medical debtor and an American citizen who has — so far — survived the ongoing catastrophe of for-profit medical care.
The precipitating event in “Cost of Living” is the author’s psychiatric hospitalization at 19: “It wasn’t that I had wanted to die, exactly. It was more that I just couldn’t keep living.” Maloney’s choice of a nearby, independent hospital’s emergency room over the bigger university hospital “where the state might pick up your bill if you were declared indigent” leads to the crushing debt at the heart of the book. “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.”
As Maloney pries deeper into the machine of American health care, she finds no central mechanism other than that of the eternal money-go-round. By the time she gets to the conference at which doctors are painstakingly comped for their attendance at brunches with “soggy pastries” amid “transfer of value” concerns, I had lost all hope for a ready solution to the problem — which, Maloney implies, is inseparable from the very structures of capitalism.
Each essay documents a different kind of structural failure, caused or complicated by capital and inevitably ending in harm to patients. In one, Maloney is prescribed 26 psychiatric medications for what turns out to be a vitamin D deficiency, hypothyroidism and a neurologically based developmental disorder. In another, as an E.R. tech she is trained to “bill up” — increasing charges if at all possible — but she secretly perfects the occult art of minimizing patient cost without tripping any corporate alarms.
Embedding herself into various corners of the bureaucratic medical machine, Maloney describes everyone she encounters with the same perspicacity. “There’s a fine line between a pain patient and a drug addict,” she writes, “and sometimes patients go back and forth across it.” “Elizabeth … was what we called a frequent flier, someone who was unable to make sense of the world she lived in and so she came to us instead, a kind of tent revival in our suburban hospital, for healing.” A medical student, meanwhile, is “a strange mix of sweaty and cavalier.”
Thanks to her experiences, Maloney is able to see the cracks in what a less informed patient might experience, simply, as care: “At my doctor’s office for a masked annual physical, my internist depression screens me. I know it’s because Epic, the online medical record system he uses, prompts him to do so. Northwestern Medicine is part of a program that uses an installation of Epic that depression screens everyone.”
While working as a medical publications manager at a pharmaceutical company, where she becomes a part of the conference circuit for the first time, she is struck by the sheer scale of the apparatus. “Yes, the research everyone does is important. Yes, the work to take a drug from preclinical stages to the market is huge and hugely expensive. But the rest — the advertising, the television commercials, the hamburger sliders, the endless catered lunches, the agency money, the plane tickets to Europe — are all, directly or not, contributing to this enormous cost.”
Maloney’s essays read as if they were begun in low light, with little sense of where they were going or how far. They start with a question and work things out on the page. They don’t seem concerned about arriving at a grand unified theory of anything. They notice everything and have nothing to prove. They don’t prematurely grasp at an ending. These qualities combine to elevate this collection far above the usual first-person essayistic fare. The challenges of Maloney’s background — familial trauma, poor medical care, occasional indigence — form part of the back story, but they are ultimately beside the point of this book. Her broad authority and the quality of the prose — astute, compassionate and lethally funny — are what make these essays remarkable. Maloney is an exceptionally alert writer on whom nothing is lost, who sees everything with excruciating clarity, including the unassailable fact that in this country, there is currently no tidy passage through the interconnected quagmires of illness, money and care.
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