The Price of Being Well

You are standing outside the clinic with a phone in one hand and your work schedule in the other. The appointment is available. That is the good news. It is available at eleven on Thursday, when you are supposed to be earning the money that pays for everything else.

You can ask someone to cover you. You can move the appointment. You can try another office. Each option opens another small negotiation, and suddenly a simple visit has become a project with several people in it. Your body has made a request. Your life is determining whether you can answer.

We should begin here, before the national expenditure charts and the arguments about insurance. Being able to receive care means getting all the way into the room. A benefit listed in a document has to survive contact with a Tuesday afternoon. It has to pass through the price, the journey, the opening hours, the available appointment, and the consequences of being absent from work.

If any one of those doors remains shut, the promised access can disappear.

In the Federal Reserve’s survey of household well-being in 2025, 26 percent of adults reported going without some form of medical care because they could not afford it. That was an improvement from 28 percent the previous year. It still meant roughly one adult in four reported a cost barrier serious enough to forgo care. Among adults who had health insurance, the proportion was 24 percent.¹

Hold those two facts together. Improvement is possible. Coverage alone does not finish the job.

A country ought to be able to say both without turning either into a partisan loyalty test. We should welcome fewer people being priced out of care and then ask why so many remain outside. Nobody receives treatment from our satisfaction with an improving average.

The price before the price

Health insurance asks us to think about costs in several compartments. There is the payment for having the plan and there may be additional payments when care is used. HealthCare.gov explains that an out-of-pocket maximum applies to covered in-network services; the limit excludes premiums, services a plan does not cover, and out-of-network care.² Those distinctions matter. They are the difference between a protective ceiling and the total amount a household could actually spend.

But imagine explaining all of this to someone who has just been told they need a procedure. They want to know whether they will be all right. Their next question may be whether they can afford to find out.

We ought to regard that second question as an institutional problem worthy of our strongest attention. There is nothing unserious about wanting a predictable bill. There is nothing indulgent about wanting an answer that does not require becoming an amateur specialist in the financing of illness.

The money is only part of the difficulty. The uncertainty has a place in the household too. Put an unknown bill beside a known rent payment and the uncertainty starts making decisions. A course you were considering becomes something to revisit. A proposed move becomes too dangerous. You leave money untouched because you do not know how much of it has already been claimed by care you have received.

This is one of the ways the price of being well can enter a life before a payment is due. It can narrow the future in advance.

Suppose a worker wants to leave a job and open a repair shop. The tools are affordable, the plan is careful, and the first customers are plausible. But the family also needs continuing medical care. The worker is asked to compare a known arrangement with a new one whose costs and access are harder to predict. Even without assuming that every such worker abandons the idea, we can see the conflict. A nation that celebrates enterprise should want fewer essential protections riding on the decision to remain where you are.

The same reasoning applies to leaving a destructive workplace, reducing hours to care for someone, or studying for a different occupation. Here is a practical test of freedom: could a person make the change without placing necessary care in jeopardy? If our answer is uncertain, the freedom on offer is uncertain too.

Yet we must be careful about a temptation hidden inside this argument. We can become so eager to prove that healthcare makes workers productive that we forget the person who will never return to paid employment.

Their claim on care remains.

A retired cashier does not owe us another shift. A person with a disability does not have to promise future tax revenue. Someone receiving care at the end of life does not need a business case. Economic participation gives us one reason to build a capable health system. Human dignity gives us a reason that survives when economic participation is impossible.

I want us to build a country in which that is understood without the vulnerable person having to win the argument each time.

Your time is part of access

The National Center for Health Statistics examined five nonfinancial barriers in the 2022 National Health Interview Survey. It found that 12.5 percent of adults had delayed or gone without care because they were too busy with work or other commitments; 10.6 percent could not get an appointment when they needed one. Altogether, 21.7 percent reported at least one of the five barriers. These categories can overlap, so they must not be added together.³

That study describes a particular year. It does not tell us that every missed appointment was an employer’s fault, or that time and money can be neatly separated. It does something more useful than provide a villain. It makes visible the distance between a service existing and a person being able to use it.

Return to Thursday at eleven. If the worker loses pay to attend, time has become money. If a relative must leave work to drive them, the appointment has drawn another household into the cost. If the visit must be repeated because a needed service is offered elsewhere, the process starts again. The clinic may have recorded one appointment. The family has had to reorganize a day.

Consider the difference between an office worker who can move a meeting and a cleaner who must find someone to cover a shift. The unequal distribution of paid time away from work is measurable. In March 2025, the Bureau of Labor Statistics found that 58 percent of private-industry workers in the lowest wage quartile had access to paid sick leave, compared with 94 percent in the highest. The survey groups jobs by average occupational wage, rather than simply sorting every individual worker’s earnings.⁴

An ordinary phrase such as taking time off can therefore describe quite different events. For one person it means moving a task. For another it may mean a smaller paycheck. We cannot judge the practicality of a health system using only the schedule of the person who has the most control over their day.

The proposed remedy has to extend beyond a cheaper insurance card. I would make usable medical leave part of the design, alongside appointments at workable hours and assistance for people who need transport. These arrangements require staffing and money. Evening appointments cannot be provided by simply asking an already exhausted nurse to stay indefinitely. A humane system for patients must also be a humane workplace.

This is where slogans become inadequate. The relevant questions are wonderfully specific. How many appointments are available outside standard working hours? How long does someone wait for an answer? Can the person who answers the telephone actually resolve the problem? Who arranges the return journey? Is the promised accommodation real when a patient needs it?

We should ask these questions with the seriousness usually reserved for financial performance. A service that absorbs a patient’s entire day has used something valuable, even when it never sends an invoice for the hours.

And if the patient has the money and the time but the provider is too far away, another kind of access fails. In a study of service areas affected by 64 rural hospital closures during 2013–2017, the Government Accountability Office found that the median straight-line distance to general inpatient services rose from 3.4 miles in 2012 to 23.9 miles in 2018. Those are geographic estimates, not measured driving distances or a forecast for every rural community.⁵

You cannot insure a hospital back into existence. A financing promise and a local supply of care are related tasks, but each has to be accomplished.

Build the ability to care

The United States spent approximately $5.3 trillion on healthcare in 2024, according to the official national health expenditure accounts. That was 18 percent of the economy.⁶ The number establishes the scale of our commitment. By itself, it tells us neither which spending is valuable nor which reform would improve care.

Still, it should change the tone of the conversation. We are already making an enormous collective commitment, through many different payers and institutions. The serious question is how that commitment becomes reliable care in an ordinary life.

I would start with a clear public obligation: people should be able to obtain necessary care without being driven into financial insecurity, and they should retain that protection through ordinary changes in employment and family circumstances. Different financing structures can be judged against that obligation. Their labels deserve less loyalty than their performance.

Then I would insist that the money reach actual capacity. We need the trained people who can provide care, suitable facilities, and working arrangements that allow good people to remain in the profession. Funding a promise without planning how it will be delivered is an invitation to frustration. Offering a training place without thinking about where the graduate will work leaves another gap. A serious plan must connect those steps.

There are existing foundations to build upon. HRSA describes its Health Center Program award recipients as community-based providers delivering primary care in underserved areas, with requirements that include sliding fees based on ability to pay and governing boards that include patients.⁷ This does not prove that every health center has all the appointments a community needs. It shows that public support, local provision, and a formal role for patients can be part of the same institution.

We should evaluate and strengthen such arrangements according to what happens to people who seek care. An institution should not be able to satisfy us merely by possessing an inspiring mission statement. The person waiting for an appointment deserves evidence of delivery.

That evidence should include things a patient can recognize. Whether care was available. Whether the bill was manageable. Whether the explanation was comprehensible. Whether the treatment respected the person’s own goals and circumstances. A beautiful building is welcome, but the building cannot be the achievement we confuse with the work.

There is also a proper place for examining prices and the terms under which public money is spent. If a public purchaser commits substantial resources, it should be able to ask hard questions about what it is buying. We need the courage to distinguish compensation that sustains excellent care from expenditure that does not advance it. That requires evidence and competent oversight, rather than a fantasy that every difficult question can be solved by cutting a line from a budget.

The moral urgency is real. So is the operational work.

Stop making sickness an administrative occupation

Picture the patient who has written a name, a date, and a reference number on the back of an envelope. They have spoken to three people. The first referred them to the second. The second needed something from the third. They are now calling the first again.

Nobody in this scene has to be cruel for the process to become cruel. Each worker may be following the rules of their small part of it. The patient is the only person being asked to hold the entire process together, while also being the person who needs care.

A better system would assign responsibility for completing the handoff. It would give the patient a clear explanation and a person or office able to resolve errors. When additional review is genuinely needed, there should be a proportionate process and a meaningful way to challenge the result. The burden should not be allowed to grow without someone being responsible for it.

This is a proposal for institutional competence, not a demand that clinical or financial review cease to exist. Resources are finite. Errors occur. Treatments differ. Those facts make competent judgment necessary. They do not make avoidable confusion a virtue.

Imagine a very simple accountability rule: if an institution requires a patient to supply information it already has, the institution must explain why. If two organizations cannot communicate, the patient should not automatically become their unpaid courier. If a decision can be reviewed, the means of review should be understandable to someone who has never worked in insurance.

Now ask what kind of technology would serve that purpose. The useful machine would reduce repetition, surface a missing item early, and help a responsible human answer the question. We should judge it by how much unnecessary effort disappears from the patient’s life. A faster way to send an incomprehensible refusal is a technical achievement with a very small human ambition.

There will be tradeoffs, and we should explain them honestly. Money devoted to one service cannot be spent twice. If expanded access brings more people into care, staffing and facilities need to keep up. These are reasons to plan the transition carefully. They are poor reasons to accept an arrangement in which a sick person must be exceptionally energetic to get help.

What being well is for

Let us return to a life outside the clinic.

There is a class someone wants to take. A garden waiting to be planted. A grandparent hoping to sit through a school performance without worrying about a bill. There are people who want relief sufficient to have a conversation, or support that makes the day more manageable. A worthwhile health system must be large enough in its moral imagination to include all of them.

We should resist measuring success only by how quickly someone returns to work. Work may matter greatly to that person. So may the afternoon they spend with a friend. The life restored belongs to them.

This is why the price of being well reaches beyond healthcare policy. When necessary care consumes the resources needed to pursue the rest of life, it becomes a charge on possibility. When access is dependable, a person can make decisions with one fewer threat hanging over them. We should want that security to be ordinary.

It will not remove the uncertainty of being human. No public system can promise that we will never become ill, that every treatment will succeed, or that grief will be abolished. A mature social promise begins by recognizing those limits, then refusing to add avoidable financial and administrative punishment to them.

You should be able to seek help without apologizing for having a body. You should be able to receive care without proving that your future output will justify it. And when you stand outside that clinic with your schedule in your hand, the arrangements of your country should help you get through the door.

That is a practical ambition. We can build toward it, measure our progress, correct our mistakes, and keep going. The subject is too important for resignation. There is a whole life waiting on the other side of the appointment.

Sources and notes