Among those Terkel spoke to was Lilith Reynolds, a project coordinator for the federal government’s War on Poverty-era Office of Economy Opportunity (OEO). As a government employee, she explained, she used to believe that “[all of the rules and regulations] were correct and it was my job to carry out these rules. After I got to OEO it became more and more obvious to me that a lot of these rules were wrong, that rules were not sacrosanct.”
An active member of her union, Lilith believed that the office could be more effective if the employees doing the work were also in charge of policy. When she spoke to Terkel, she was in the midst of pursuing a project of her own rather than her assigned work, collecting statistics on sex discrimination and educating women of their rights. “Officially I’m loafing,” she said. “But, ironically, I’ve felt more productive in the last few weeks doing what I’ve wanted to do than I have in the last year doing what I was officially supposed to be doing.”
Greg Chern (a pseudonym), a certified application counselor at a non-profit healthcare clinic, feels similarly stymied when he helps patients sign up for health insurance through the Affordable Care Act. Though many patients come in with urgent medical issues, he says, “Most of the time a sheepish smile is all I can offer that person. It makes me sad when people are satisfied with what I’ve done, because it’s so limited. I can help direct their concern to the right office, but they still have to navigate several different offices. But people are still appreciative—which makes me even more upset, because the bar of what people expect is so low.”
I talk to people about Obamacare. My job is to help people buy insurance if they’re making above a certain income level. So I’m basically an insurance broker, except I’m paid by the government instead of an insurance company. And I’m making a crappy non-profit wage.
When I initially trained for the job, they couldn’t actually show us what the Marketplace was going to look like—it wasn’t up and running yet—so the training was more like, “Here’s how you greet a client.” It went over how to how to ask them questions about their situation, things like that.
By the time we started signing people up for the actual Marketplace, sometimes I would be discovering along with the patient what the next steps were, sitting and reading it along with them and figuring it out as I went. My job is to help people navigate complex websites. For a lot of people, the process is inherently alienating. The ACA took the healthcare system, which is messed up already, and then it added an application and an online shopping system on top of it, and then more layers of tax law and immigration law on top of that. It didn’t actually make the health system itself better.
A lot of people I see struggle with literacy, and I feel good when I can help them get through this process. But sometimes I’m basically a screen-reader, asking questions which are sometimes awkward to ask: “Hey, are you or your 17-year-old daughter pregnant?”
When someone walks in and they haven’t gone to the doctor in a decade, they have to do a whole series of steps—A, B, C, all the way through G—to get healthcare that’s covered. My job is really just to do A through the first half of B—help them fill out an application and then send it somewhere else.
Some people tell me information about their health problems. Part of the reason is that they see I’m a human face, and they want to impress upon me that they need that coverage. But I’m only doing A through B, so all I can say is, “Yeah, that sounds like you really do need coverage, and I’m glad that you’re here.”
I hear that there are people designing user interfaces to replace me. Basically, I’m just a very nice user interface, with a winsome smile (laughs).
Before this job, I knew that Obamacare wasn’t a national health program, and I knew that it wasn’t the end goal. I knew the general critiques of Obamacare, but I’d heard that it’s a step in the right direction. Since working on this stuff, I’ve realized that it’s more a step in the wrong direction.
A lot of what I’m doing is figuring out what’s going on, and then telling people I can’t help them. When I see patients who are undocumented, for example, there’s nothing in the ACA for them, so all I can do is direct them to discount programs.
There are some aspects that are worthwhile, like the expansion of Medicaid. But generally, it seems like we’re moving things away from what a lot of people need. Many who are above the Medicaid limit don’t agree with the government’s estimate of what “affordable” means, and they don’t think the options on the Marketplace make sense for their budget. There are people who don’t like the insurance they have at their job and thought they’d be able to buy something better on the Marketplace. Those people are kind of between a rock and a hard place.
I’m an insurance broker, but in another way I’m actually an outsourced Department of Human Services office. People can come to me to fill out the first part of a Medicaid application instead of going to the DHS office. So it’s a way of undermining the public sector.
I find myself wondering what’s happened to some people after I see them. There are some patients who I know needed some immediate help. In the cases of medical emergency, I can request to expedite things. The Medicaid office initially said it was going to take 45 days to turn around an application. I was trying to get somebody’s application expedited because of a medical emergency, and the patient told me they were rejected [for the expedition] because it wasn’t deemed a medical emergency, which was B.S. I asked if I could appeal the decision, or if the patient could, and DHS said they could appeal the fact that it took more than 45 days, but the appeal process would take more than 60 days.
As part of my ethics training, I’m not supposed to privilege one insurance company over another. I’m not allowed to say, based on my expertise, what I think about different plans. Which is kind of good, because I don’t really have any expertise. But do I know that BlueCross BlueShield got more than 90 percent of sign-ups in the Illinois health insurance exchange, and I’m not able to say anything about it. All the “ethical” requirements are just as much to protect the insurance companies as the patients.
When I explain that I talk to people about Obamacare, often people who are my age, in their 20s, are like, “Oh, I have to talk to you!” I was just at a party where someone cornered me. It was a Saturday night, and I was already kind of tired, and I didn’t want to talk about insurance with this person. I can’t recommend one plan or another to them anyway, so I say, “Sorry, I can’t give you advice about that.”
Then they say, “No, I know, but what do you think?”
There are so many variables that I can’t speak to, even if I were allowed to. I can define terms for people, but I can’t predict. There are now 143 plans in the Marketplace in my area, each with details to consider on things like deductibles, premiums and so on. These figures are probably set by actuaries figuring out what exactly the numbers should be to make money, but still have people buy the plans.
Individuals don’t have an actuary to help figure this out. So sometimes I try to make actuarial tables with them on the fly, and bring up spreadsheets to show them, “OK, this is you using your insurance in a really bad year. This is you using your insurance in a year where you’ll be healthy.”
It’s a complete farce. On the surface, individuals have all these choices, but I can’t really predict what will be best, and the patient can’t either. That’s one of the problems with the fact that all this is privatized. The people who actually have the useful information aren’t in the room.
Some patients are frustrated at me, which I understand because I’m the nearest target. Some patients don’t think it’s my fault, but they’re like, “This is what everyone’s talking about?” Some patients are just disgusted at that moment.
Some people I talk to about my job have heard about navigators on the news, and if they’re Democrats who buy into the message that this is a first step towards an improved system, they say, “Oh, that’s so great.” A lot of people assume I’m doing really good work, and I say, “No, I’m basically selling insurance, but not getting a commission.”
And then they try to argue with me that I’m “helping the uninsured,” as if I’m going out and curing lepers. This is not a disease; it’s a social problem. I try to walk them through why it’s not fixing the problems, and why it’s actually even making things worse.
And then I’ve ruined Thanksgiving.