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A friend is a freelance chef and caterer who clears about $50,000 after expenses–food, hired help, rent of half an apartment with a suitable kitchen. When I arrived to celebrate her birthday Saturday, she told me she was ill with a mystery malady. When discussing when she might go to a doctor to have some lab tests run, she told she doesn’t have health insurance. So I urged her to investigate coverage this week, during the open enrollment for Affordable Care Act (aka “Obamacare”). On the ACA website for our state, CoveredCA.com, we saw premiums starting at $630+ per month for coverage with a $6,000+ deductible. Yikes. “I imagine you qualify for some kind of subsidy,” I told her. “Find out.” She went to an agent and got the verdict: $524 per month with a $6,650 deductible for the least-cost coverage.

This reminded me of the first time I subscribed to Kaiser Permanente, before the ACA, starting in 2010. I paid $140 monthly with a $10,000 deductible. I was happy with that plan–a plan that was discontinued when ACA was implemented in 2014 and my monthly premium shot up $400 with the $6,650 deductible, the system’s least-cost “Bronze” plan. Facing the prospect of surgery on a pinched nerve in my arm at the time, I got a permanent job that offered full coverage and considered myself fortunate.

Should health-care coverage costs go up with ACA and its removal of the preexisting-condition limitation? I don’t think so. Here’s why: I used to live in Massachusetts, which removed the preexisting condition limit in 2001 or so. Did health-care costs shoot up? No. I think I heard that some providers left the state (or left the “commonwealth”). A few years later, during Mitt Romney’s tenure as governor, Massachusetts implemented its own affordable health-care system. Neighborhood Health Plan was the state’s health plan (not to be confused with MassHealth, the coverage for the impoverished). The state health plan offered low-cost coverage to those making $35,000 or less annually. This was great for my self-employed friends and my farmer friend, who couldn’t afford to cover her farm workers whom she paid $11 per hour.

I haven’t seen the health-care providers show actuarial figures that show they lose money on ACA and the lifting of the preexisting condition limit. I suspect they hiked their rates knowing that a lot of people receiving subsidies would not have reason to complain about rising premium costs.

Health care is expensive, especially the way we the United States does it. When I went to the urgent-care department with an appendicitis-like pain a few months ago, the doctor could not tell me how much the CAT scan he recommended would cost. I knew from the past it was likely $1,000 and possibly much, much more. We compromised, and he ran some blood tests. They indicated it was unlikely I had appendicitis. The bill for all of this was $1,100.

My recommendations for reform of our health-care system:

1. Pricing must be transparent.
   The doctor or facility should be able to pull up pricing while the patient is present. And variables like charging for testing colonoscopy-derived specimens should be flat fees. No vague cost additions.
   I recall seeing a bill for a colonscopy (my mom died of colon cancer, so I am considered high risk). Some cells scooped out of me (by the way, stay awake for your colonoscopies; I’ll explain later) were sent for testing. I was charged $1,100 for the specimen to be checked into the lab, then another $1,000 or so to test it. When I questioned these weird numbers on the bill, Kaiser Permanente just reminded me I had to pay out of pocket for this. No explanation for this odd billing. Even my doctor shook his head. They didn’t know how to deal with a question about costs.
2. Some common procedures should have set costs. Such as simple mammograms, etc.
3. There should be more market-based offerings for the procedures and tests we all take before we hit our premium threshold. Blood tests, even cardiograms, etc. should be competitively priced.
4. Low-premium/high-deductible plans should be offered. I miss my affordable $10,000-deductible plan.
5. Health care shouldn’t be an employer perk. Making health-care costs invisible to most users ultimately raises rates.
6. Let’s emphasize wellness and health-care management. As a medical researcher once said to me: “So many doctors but so few healers.” A friend calls doctors “technicians.” It’s actually helpful for me to think that way. How much can a doctor do?

Sadly, my chef friend is electing to go without health insurance. She says she’s barely putting anything away for her elderly living and Medicare years, should she get there. So the prospect of paying $7,500 per year for care she hopes she doesn’t need seems onerous to her.

I do think we underestimate the cost of health-care provision. Providing surgery and meeting modern expectations of surviving surgery, childbirth, etc. isn’t cheap. But we need to look to other countries that provide more reasonable and higher-quality care and take up this issue as a country. We also need to remove the big profits from health care. And make the pricing of procedures more transparent and the medical business more accountable and competitive.