Posted by: bkivey | 3 May 2017

Rx: Cash

I’m of an age where personal medical expenses are a budget line-item, and visiting health professionals is a regular occurrence. I take pills. So having a primary care physician is nearly as important as a good barber. I’ve been searching for a physician for a couple of years, and have seen the new American health care landscape.

My medical history is heavily weighted toward severe pain and disfigurement in my 20’s and 30’s; sometimes I had insurance, most of the time not. Everyone got paid. I learned that there are significant advantages to paying for your own medical care. And short of extreme cases like cancer treatment or organ replacement, not unaffordable. My current health coverage provider is Benjamin Franklin.

While looking for a physician, I found there were two types of practices: those that were closed or closing, and those accepting cash patients. Every conversation I had went thusly:

“Hi, my name is Blair Ivey. Are you accepting new patients?”

“That depends on what insurance you have.”


“Yes, we’re accepting cash patients.”

I’d read articles for the last several years about medical practices going to all-cash businesses. My last physician started his practice on that model, and my current physician has oriented his practice toward cash, and is considering ditching insurance patients entirely. America now has a functional two-tier medical system: insurance patients will get care; cash patients will get care on a more convenient schedule.

While I applaud the free market’s emergence in this most regulated of industries, the current situation takes some getting used to. When I was memorizing the route to the ER, insurance was king, and having it got you care noticeably faster. On the other hand, for routine visits cash patients were routinely offered discounts, and significant reductions could be negotiated for large bills. That world is upside-down. Now cash is expected and no discounts are offered. Practices don’t want to know from insurance. The same insurance everyone is required to have by Federal law. God will have His little joke.

For all that, it still feels like being grateful for maintaining something of the status quo, rather than any real gain in services. Prior to ACA, regulatory burdens put downward pressure on cash medical prices. Post-ACA, the regulatory burden is so great that practices are opting out of the government-medical complex and choosing their patients, with the attendant upward pressure on prices. Practices can choose their patients because ACA is a hassle for the individual, too. Even if you’re not philosophically opposed to the law, you still have to deal with the paperwork and the monthly insurance premium. And while it may be nice to have medical insurance, now you have fewer places to use it.

Around Town

Run out of B’s?

One of the many recent apartment/condo developments in Portland. Broadway Bridge in the background. It will probably look better in 20 years when the trees grow in, but right now it’s all glass and steel and concrete and not particularly inviting. The towers block the sun, which is not ideal most of the year.

Bang & Olufson’s Portland outpost.

Rain and hail. We’ve seen far too much of both this year.


A Spotted Owl in the back yard. We didn’t tell anyone lest we be ‘relocated’.

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