An Uber Insight Into The Uninsured


  • Met an Uber driver who was uninsured and proud of it despite getting in a very expensive accident

Yep, this title was shamelessly click-bait (and thank you for clicking 😊), but it is also accurate. While it is not about Uber, it does involve an Uber driver.

Earlier this month I had the honour of being invited to speak and sit on a panel at the Manova Summit, in Minneapolis (thanks, Erika!) — it’s the second year this event was held, bringing together key stakeholders and innovators to inspire transformative change in the world’s largest and most expensive health system (and sometimes by looking outside).

My exposure to this reality came before the conference even started.

I had run into a fellow delegate from Hong Kong at the airport and opted to share an Uber to our conference venue. Our driver, a jovial and slightly rotund young fellow in his late 20s / early 30s welcomed us to Minneapolis and apologised for not being able to lift our luggage as he threw out his back.

Upon commencing our journey to downtown Minneapolis our driver continued to talk about his health, and that he was grateful he could drive an Uber given he could no longer work in construction due to a tragic past injury.

(Note — the details presented here-on have not been verified and are presented as recalled from the conversation — it serves more to illustrate key pain points rather than provide a clinically accurate assessment and outcome.)

During a prior winter he was walking outside and had slipped on some black ice, causing his ankle to hyper-extend, then shatter. This required joint reconstruction (possibly an ankle replacement — details were unclear), however prior stresses on his legs resulted in numerous microfractures that made anchoring in the conventional sense impossible. The options presented were 1) amputation at the knee; or 2) an experimental procedure that could reconstruct the joint with titanium implants.

He opted for the experimental surgery and was kept for observation and recovery for four days. On the third day they discovered a blood clot in his lung, which required removal and another week of hospital stay. Thankfully he was able to recover, get back to work, and live on to tell his story to us.

While the medical case was quite interesting, it’s not why I’m writing this article.

Our Uber driver was uninsured, and even after this episode, adamantly remained against health insurance. He cursed the annual US$1,400 ‘Obama tax’ and would rather pay it than get insured as it was cheaper to do so. He could just ‘work more’ if he had a big medical bill.

The bill for his surgery and recovery came out to around US$65,000, for which he was able to negotiate an instalment payment plan with the hospital. He was also told that if he were insured, he would have been denied reimbursement on the surgery as it was considered experimental and would have only been allowed to remain in observation for 48 hours. To add icing to the cake, they mentioned that they would have billed insurance around $360,000 for the amputation and shorter observation — nearly a 6-fold difference in price (and missing a leg!!). He’d also be dead in the unlikely case that the amputation would result in the same pulmonary blood clot on day 3.

He concluded the story by saying that he thought it was a pretty good deal for the care he received, and that he has some wealthy relatives who purchased a premium family subscription plan for ‘all you can eat healthcare’ with a private hospital system, rather than get insured (go figure).

We did not feel like really interjecting too much or speaking about our experiences in other health systems (public, hybrid, etc) as he still had the primary job of getting us to our hotel safely 😊, but it made me pause to think about some of the (many) structural challenges faced by the US healthcare system:

1) Hospitals and insurers are still in an ‘arms race’ of billing — with hospitals pressured to over-bill, expecting to get every line item negotiated down, instead of focusing on choosing procedures with the best likely outcomes and societal / lifetime cost saving

2) There are people who honestly believe that being uninsured is better than paying for any medical insurance (even with availability of high deductible plans, and the possibility of a catastrophic or terminal illness — like say… stage IV pancreatic cancer… not allowing you to ‘work more’)

3) Some Americans have accepted that healthcare is a premium product and should be expensive — to the point that our new friend considered US$65,000 and a financing plan for a joint replacement to be a good deal — in contrast, here in Singapore, the median cost of a total hip replacement, unsubsidized in a public hospital, is about US$5,900

When healthcare spend as a percentage of GDP is at 18% with every stakeholder in the health system driving for their share of profit, and 2/3rds of personal bankruptcies in the US resulting from medical bills, something has to change.

Having spent some time in a past life working within the US healthcare system, I’m not sure the answer will come from the large established health insurers, pharmaceutical benefit managers, TPAs and hospital systems — all of whom want to genuinely shift to value-based care, but only as long as they get to keep most of said value (hence the problem).

I am starting to think we’ll see a bifurcation of healthcare — another ‘collapse of the middle’ — into premium/legacy and no-frills offerings, where it becomes more and more difficult to afford/access the former.

One thing that supports this, and featured quite prominently at the Manova Summit, was Walmart Health. These are standalone centres, leveraging Walmart’s scale and supply chain to offer $20 consultations and $4 generic prescriptions. They also offer a suite of diagnostic, preventative and ancillary support services, all priced affordably. Insurance is also accepted, but the co-pays alone might exceed the cash price for the aforementioned reasons. This is not to dissimilar to the CVS HealthHUB project or even existing Minute Clinics, albeit the former being more comprehensive.

Could these efforts be the start of a lighter more agile health system, beginning with pharmacy and primary care? Would it be long before you saw a Walmart day surgery centre?

The next question is, with the severe cost constraints of catering to an out-of-pocket customer base, how would you be able to deliver on quality — could you get well-trained doctors to make it work on a $20 consult?

Could specialists be accessed and shared remotely across a wider catchment area?

Could new technologies and streamlining of operations drive efficiencies and consistency high enough to make this sustainable?

Hmm.. these questions start to sound like the questions we ask here in emerging markets and makes me wonder if some of our solutions might work just as well over there 😊.

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