The April 28th issue of the Wall Street Journal carried an article that would have been considered science fiction some thirty years ago — and James Gunn was one of the writers who addressed it then. Now it’s reality. Major non-profit hospitals are demanding payment up-front for expensive treatments when significant portions of the cost of treatment aren’t covered by insurance.

I suspect that the initial reaction of most people will be along the line of “that’s uncaring and cruel.” The problem isn’t uncaring health professionals or even heartless insurance companies, although I have my doubts that the accountants and actuaries operating most insurance operations have anything remotely resembling heart or compassion. The problem is that to deal with life-threatening diseases and conditions that were an automatic death sentence fifty years ago, medicine has become high-tech and expensive, even when pared down to cut-rate costs. Another problem is the cost of malpractice insurance, because in some specialties, malpractice insurance is the largest single expense for a physician, sometimes costing more than the doctor takes home for himself or herself.

Several years ago, my wife shattered her leg and ankle in a freak hiking accident on a very moderate trail. For a complicated, but relatively common surgery and a plate and screws in her leg, the total cost was almost as much as the average annual American worker’s yearly income. That was for something that is comparatively simple in medical terms. Other medical procedures that deal with life-threatening conditions are far more expensive. Cancer surgery and treatments appear to start at over $100,000 and climb rapidly. When somewhere over 40 million Americans don’t have any form of health insurance, wide-spread use of “pay-before-treatment” is effectively a death sentence for those who cannot find a hospital willing to treat them without a healthy deposit, and the numbers of hospitals who will do so — or that can afford to — is rapidly shrinking.

Non-profit hospitals have seen their unpaid bills pile up. Some have unpaid bills totaling $30 million to $50 million annually, up from a tenth of that two or three years ago. They’ve also discovered that collecting on such bills is often impossible. After all, if you don’t make the house payment or the car payment, the lender can foreclose and take them back. What sort of threat can a hospital make? They can refuse future treatment, but they can’t take back their treatment.

If they don’t collect on these bills, then people who can pay their bills — and their insurance companies — will pay more. That has already raised insurance costs and out-of-pocket costs for the financially able, and is likely to fuel future cost increases as well as make health insurance more expensive and less affordable for working Americans. If the government ends up picking up the losses, taxpayers end up paying the bill. All of the increased costs aren’t going to the doctors, nurses, and technicians, but also fund research, more and more elaborate equipment, and insurance.

There’s another fact that complicates matters more. Statistics released last week show that, for the first time, life expectancies are declining in the poorer U.S. counties. While statistics are not readily available, I suspect that in metropolitan areas, the group that may suffer the most is not necessarily those labeled as poor who receive government assistance and Medicaid, but those who earn just enough not to receive health care. For the past half-century, most Americans have taken health care as fairly much a given, but now, for a growing number, it’s not a given, and, equally to the point, regardless of all the political rhetoric, there not only isn’t a simple solution, there may not be one that allows more than basic health care for most Americans — and that may well result in the kind of future that Joe Haldeman suggested in one version of The Forever War — where virtually no medical care was available for the extreme elderly. Given the nature of advanced medical treatments and the resources required, it appears more and more likely that the most advanced medical care will only be universally available to the affluent, just as Gunn forecast over forty years ago… unthinkable as that was then, and certainly still is.