The appointment you did not make

One · What happened

The 2027 numbers are in, and they are going up again

Insurers selling on the health insurance marketplaces have to file next year’s proposed rates in public. KFF read 276 of those filings, covering every state and the District of Columbia, and published its analysis on 8 July with an update on 3 August. The median requested increase for 2027 is 15%. Last year the median request was 18% and the final figure came in at 20%, so last year the final number landed above what was asked for. 63% of insurers asked for somewhere between 10% and 25%, and 51 of them asked for more than 25%.

The reason they put first in their own paperwork is that care just costs more. The median underlying medical trend the insurers report is 10%, against roughly 8% in recent years, and it comes from hospital contracts and wages and what the drugs cost.

There is also a policy fight buried in those documents. Insurers attribute about 4 points of next year’s increase to a change in who is left buying coverage, and everybody at your table already has a side on that.

Most Americans are insured through an employer and have been reading these headlines like they were about somebody else. They’re about them too. On 25 August the Business Group on Health released its annual survey of large employers, 127 companies covering 8.7 million people in this country, and their projection for 2027 is a 9.2% cost increase, which they hope to hold to 8% by changing what the plans cover. Run their own arithmetic out 10 years and health costs rise about 76%, roughly double general inflation. Some of that shows up in your paycheck and some of it shows up as a deductible that’s bigger than it was.

Enrollment opens on 1 November. About 23 million people bought individual coverage in the last one, according to the federal figures. Whatever you’re covered by, a number is coming on a date you already know.

The more interesting research is about what people have already done ahead of those numbers. West Health and Gallup asked 5,660 adults at the end of last year what they had put off because of what health care costs, and published the answers in March. Vacations came first, and anybody would have guessed that. Second was surgical or medical treatment.

Two · What it is doing

A postponement is a decision

To postpone something implies a later date, and most postponed appointments don’t have one, there’s no calendar entry anywhere. What there is, is a vague intention that keeps getting renewed and pushed back, and that is not a plan, whatever it feels like.

The cost of a scan stays right where it was when you decline the scan, and usually it grows, and the thing that needed scanning grows along with it. Nobody who has ever cancelled an appointment saved a dollar by doing it. They moved it down the road, and it got bigger while it sat there.

A test has 2 prices. There’s the invoice, which you can at least argue with, and there’s the answer, and you can’t argue with that one. Most people who tell themselves they can’t afford the first are also unsure they could survive the second, and the money gives that fear a respectable place to live. Nobody has to admit they’re frightened. They can say the deductible is $4,000, which is true, and everybody at the table will nod.

Avoidance also spreads, because a household that has learned not to look at one thing gets good at not looking in general. The envelope stays on the counter face down. Then there are 3 envelopes and a drawer, and before long the symptom goes unmentioned at dinner, and that is technically different from lying about it, though I don’t think the difference survives much examination. A person never sits down and decides to become somebody who doesn’t want to know what’s happening to him. He just declines one specific thing on one specific day, for a reason that would sound sensible if he had to explain it.

You can’t talk yourself down from this one by pointing out that it’s unlikely, because it isn’t unlikely at all. The first of November is going to happen. The premium is going to be a number, and it’s going to be larger, and there is no version of the next 8 weeks in which your paying attention prevents that. Anybody who tells you you’re overreacting about this hasn’t looked at the filings. You are forecasting correctly, and the forecasting is still doing you real harm, and you have to hold both of those at once.

Three · Where the ground is

What the premium was ever able to buy

A premium buys you a way to pay for your body when it breaks. It has never bought anybody a guarantee that it won’t, and most of the fear in a renewal notice comes from forgetting the difference.

Insurance is a prudent thing to have. Shop the plans when enrollment opens, take whatever assistance you qualify for, and read the deductible all the way through, including the part about what counts toward it. Proverbs 22:3 says the prudent man sees danger and hides himself, and the simple keep going and pay for it, and nobody in that verse gets credit for trusting God by walking into the danger.

What no premium ever bought anybody is a guarantee that the bodies they love will keep working. Somewhere in the last few decades most of us started treating the one as if it were the other, and in my opinion that substitution is why the renewal notice frightens people so far out of proportion to the dollars on it. The dollars had been carrying a promise they were never able to keep.

“You do not know what tomorrow will bring,” James writes in chapter 4, and then with no softening at all he adds that you are a mist that appears for a little while and then vanishes. He says it so that people quit resting their weight on something that can’t hold it, before the day it gets tested.

Why the appointment doesn’t get made

The copay is rarely the real reason. Usually there’s a conviction behind it, one you’ve never examined, that if the news turns out to be bad you’ll be alone with it, and that it will be more than you can carry. This may be an unpopular take, but I think that kind of avoidance is really unbelief, and it just happens to look, from the outside, like a person being calm and sensible about money.

The answer Scripture gives is narrower than people expect. Plenty of faithful people have opened that envelope and found the worst thing in it. Psalm 23, the one everybody can half-recite, says though I walk through the valley of the shadow of death, I will fear no evil, for you are with me. David says through, and he doesn’t say anything about going around the valley. What he was promised was company, in the one room a person most expects to be alone in.

A man who is certain he’ll be alone with the result has every reason to avoid it. If you know you won’t be alone in that room, you can stand to find out.

The bill is still the bill

None of this makes anything cheaper, and it would be cruel to imply that it does. Christians get sick, and some of them go bankrupt from it. Anybody selling faith as a hedge against medical debt is selling something, and the people in your congregation who have been through it will tell you that plainly if you ask them, and you should ask them. The number stays the same size. What changes is who is in the room with you when it gets read out.

Four · Today

Five things, and none of them are “stay informed”

People avoid things when looking seems to cost more than not looking. So make one act of looking small enough that you can actually do it this week.

1. 01

   Make the call you’ve been not making.

   The actual telephone call, during business hours, tomorrow. A message through the portal doesn’t count and neither does adding it to a list. You know exactly which call it is, the one you’ve been getting around to since spring.

2. 02

   Open everything on the counter, in one sitting.

   All of it, tonight, and write the real total on one sheet of paper. It’s going to be an unpleasant 20 minutes and then it will be over. The number you’ve been avoiding is almost always smaller than the number you’ve been carrying around in your head, and it’s the vagueness that has been keeping you up.

3. 03

   Put 1 November in the calendar now, with 2 questions attached to it.

   What will we actually pay across a year, premium and deductible together, and what happens to us if we have one bad year. Decide those in September while you’re calm, because a decision made in the last week of enrollment gets made by whoever in the house is most tired.

4. 04

   Ask for the financial assistance policy by name.

   Every nonprofit hospital in the country is required to have one in writing, to publish it, and to hand you a plain-language summary for free if you ask. Community health centers charge on a sliding scale. Almost nobody asks, because asking feels like begging, and it really isn’t, you’re requesting a document that was written for you and is sitting there unread.

5. 05

   Pray about the specific thing, using its name.

   Skip “our health” and “provision.” Pray about the diagnosis you looked up late one night and closed the tab on, or the person you can’t imagine outliving, or the actual figure in the account. Praying in generalities lets you keep your eyes shut and never look at anything. Pray it once, about the actual thing.