Dreamkiller

Health insurance in the US is linked to being employed — but employed by a large business or the government. If one is a farmer, taxi driver, independent consultant, or a self-employed owner of almost any business in the ubiquitous strip malls, then one is very unlikely to have insurance. Either one's spouse works for a large employer with a family plan or one joins the growing ranks of uninsured who walk the daily tightrope, hoping not to slip on the ice, have crushing chest pain, or simply be at the wrong place at the wrong time.

A colleague told me about her younger brother who is an engineering student but really wanted to work for himself as a heavy machine operator, but would have to buy health insurance to do it. He is 25 and, like many other 25 year olds in America, feels impervious to risk. But he is smart enough to know that heavy machine operators injure themselves a lot. He will have to limit himself to reading through magazines about road graders and front end loaders rather than driving them.

Tom is a patient of mine in his late 30s. I don't see him very often for at least two reasons. First, he is a man who, like other men, believes things always happen to the other guy and so why risk the doctor finding something bad when you can just ignore it. Second, he was an athlete when younger and has, unlike many who were once in good shape, kept up and stayed in good shape. But his blood pressure has been creeping up over the past few years as has his weight. He had an episode with an intervertebral disc that healed slowly and which has worried him every time he gets a twinge. He came in for a variety of small problems last month, which is quite curious since most of the time he writes them off as nagging self-limited irritants, which they usually are.

He apologises for bringing things up that seemed so trivial but he still was concerned about them. All this was understandable when you realise that Tom's wife in her mid-30s was diagnosed with a rare form of appendiceal cancer after the birth of their third child and went through 2 years of chemotherapy and surveillance. They live, as one of my friends, Jenny Allen, writes about having ‘a spooked lifetime vigil against the return of the disease.’1

Each time I see him, he mentions that he and his wife talk about what they would do if the other dies. It is not morbid talk but practical. So far, he is doing fine. He is successful in his work and a highly valued employee, but the work is feeling stale. He loves to putter in his garage in his woodworking shop. He talks with more emotion about his shop than most other things in his life. Then he looked at me and said, ‘I have always dreamed of having my own business fixing up houses and doing remodelling. There are a lot of old houses in this town. I am really good with my hands.’ But then he sagged back into the reality that, with a wife with cancer and him with borderline hypertension, as an independent contractor with his own business, he could never afford even minimal health insurance to protect his family. Basic care for a healthy family runs about $1200 per month. His would be impossible. Tom's choices in life are restricted by the realities of health care in America. How we pay for health care in this country has killed his dream. It kills lots of dreams.

A characteristic of poverty is a lack of possibilities. But while people may be restricted by their circumstances, they all have dreams. Just ask them. In the UK, dreams may be hampered by many things, but affordable health care is not one of them. In the US, despite the possibility of economic ruin, thousands of restaurants, bed and breakfast places, repair shops and other small businesses start up each year. We are a country of eternally optimistic small business owners. Statistically, though, most of them fail. Many more, like my patient Tom, don't even try because doing so in the US would place their families in jeopardy from economic ruin brought about by unanticipated healthcare costs. In the US, healthcare cost is the single largest reason for personal bankruptcy. Of those surveyed, 54% mention medical bills as the leading cause.2 More people are retiring or leaving the workforce early but to do so before they have Medicare at 64.5 years is like walking one of those rickety bridges across the gorge in the old movies. The plunge to the bottom is a misstep away.

A few months ago I asked a husband and wife who come from the political crowd that has impeded any serious work toward universal coverage in the US whether they ever thought about doing something else. They excitedly began to talk about the craft shop they wanted to open, the freelance consultant they wanted to become and smiled at the thought. I asked them why they didn't do it and they said that one of them would have to keep their job because of health insurance. One of them would have to keep dreaming rather than acting. It made them angry. My point was made. Even market-force reactionaries have dreams.

James Thurber famously wrote about The Secret Life of Walter Mitty where the nebbishy figure of Mitty would daydream about being a World War I fighter pilot, a surgeon, or a Bogart-like private eye. While Mitty never did become any of his daydreams, it was his lack of courage that trapped him, not a lack of health insurance.

• © British Journal of General Practice, 2007.