I wrote “Not What the Doctor Ordered” in 1995, which seems a lifetime ago by any standard, but especially when it comes to the world of medicine. The story predated not only the Affordable Care Act, a.k.a. Obamacare, but also the wrangling over health care that happened in between then and now. (In the article, I mention “the failure of the Clinton plan,” and it took me a few minutes just now to recall Hillary’s doomed attempt at revamping the medical landscape in that era.) It was inspired by a much-beloved, old-fashioned neighborhood doc in Houston, the kind who knew not only his patients but also his patients’ kids and most of his patients’ friends, who were also his patients and, often, his friends. His waiting room could sometimes seem like another familiar stop in a Montrose neighborhood full of familiar stops.
And then, suddenly, it didn’t. A chance encounter with Dr. B. could turn into a monologue about the insurance companies invading his practice, telling him how to treat his patients, and drowning him in paperwork. “He felt himself becoming a medical Cassandra,” was how I described him, as he became trapped evermore in a world in which his decisions about what his patients needed became tinted, and eventually tainted, by what insurance companies would pay for. If that statement elicits little more than a shrug now, it was a rarity 27 years ago, when being a solo practitioner also meant being pretty much the solo decider—along with the patient, of course.
In retrospect, then, “Not What the Doctor Ordered” serves as an inflection point, though I didn’t realize it back then. As the costs of medical care exploded, the problems with the conventional model became obvious: greedy docs could order tests ad infinitum, and insurance companies paid up and raised their rates in response, which in turn raised the expense for businesses. “Managed care” was supposed to bring down costs by limiting patients’ choices and limiting insurance reimbursements. But that created a different set of problems, which were novel then and not at all novel now.
“Maybe you noticed the problem during a pregnancy,” I wrote, “[when] you had to call the insurance company for approval before leaving for the hospital to deliver your baby. Maybe you noticed it the day your pediatrician ordered a chest x-ray for a sick child, and you had to wait, while his fever raged, for approval of the procedure. Maybe, new on a job, you felt a twinge of anxiety before you found your longtime doctor’s name in the booklet of approved physicians provided by your employer’s insurance company.”
The story won a National Magazine Award, I’m proud to say, but medical costs did not go down, and medical care became more complicated than ever. I’m happy that Americans now have access to health insurance, but I’m sorry that they will never again have access to the likes of Dr. B.
