It is hardly a surprise that television cowboys bear little resemblance to the real thing, as the writer Maddy Butcher recently explained in the Washington Post. Unlike the modern-day characters in the Yellowstone series, Butcher informed us, today’s ranch hands are not all tall and brusque, or even male, and they certainly don’t engage in frequent gunplay. The intransigent cattle barons and the “simpletons kicking gravel in the road” are equally fictional, but some of the literary stereotypes do seem to have counterparts among today’s 600,000 or so working cowboys, as counted by the Working Ranch Cowboys Association. According to Butcher, cowboys often have leathered hands, and sometimes broken bodies, from years of hard living and dangerous work. They also tend to be solitary and independent, with an average income of under $30,000, and “few have health insurance,” which is the subject of our essay.
Most cowboys without medical insurance have opted to forgo it for some reason, despite the availability of nearly universal coverage under the Affordable Care Act (ACA). That choice fits the familiar image of rugged, government-disdaining individuals, suspicious of social welfare programs, especially in the deep Red western states. But even the toughest, most go-it-alone cowboy can still end up needing a doctor.
Butcher tells the story of a cowboy named Pete who works on the Crow Reservation in Montana. He suffered an accident while riding alone on the range, “but he managed to get to an emergency room, where he was treated for a broken nose, broken eye socket and broken cheekbone,” and had his eyelid “stitched back together.” Advised to take 12 weeks off, Pete was back riding the next day. “It could have been way worse,” he told Butcher.
Assuming that Pete matches Butcher’s profile of an uninsured loner, somebody still had to pay for all that repair work. The only emergency department on Montana’s Crow Reservation is at the Crow/Northern Cheyenne Hospital, which is operated by the federal government’s Indian Health Service. Like every hospital receiving government funds, the emergency department at Crow/Northern Cheyenne is required to treat everyone who presents with an injury, with or without insurance; it is even forbidden to ask about insurance during intake. So unless Pete had the money to cover the expenses himself — highly unlikely on a typical annual income of $30,000 — the chronically underfunded Indian Health Service was left eating the costs.
It didn’t have to be that way. A 33-year-old male in Montana (Pete’s actual age, as revealed in a Google search), with an income around $30,000, is eligible for a monthly ACA subsidy of $374. Although Montana does not have its own ACA exchange, policies from multiple companies are available for Montana residents at the federally operated Healthcare.gov, with monthly premiums of $83 or less (after the subsidy). If Pete had purchased such a policy, a private insurer could have picked up most of his hospital bill. Depending on the coverage and deductible, his nominal share could have been far less than the total tab, for which he is theoretically responsible without insurance. Most importantly, the Indian Health Service could have gotten substantial reimbursement from the insurance company, even without pursuing Pete for any of the balance.
The focus of the post Office story was on the realities of cowboy lives rather than the gaping flaws of the country’s healthcare system. But it nonetheless highlights how the ACA has fallen short in ensuring that everyone has coverage for basic medical care, including emergency services. Because of compromises needed to ensure passage of health insurance reform legislation, the ACA’s requirement that everyone obtain a coverage plan was never expected to lead to a fully insured population. It was always clear some or many people would decline to participate — the tax penalty for violating the ACA’s individual mandate was relatively modest, and Congress effectively eliminated it during the Trump administration.
There were then, and there still are, policy options that could prevent this situation from happening. Single-payer systems — as enacted in various forms in other industrialized countries across the globe — generally seek to cover everyone in the treatment pool. While they differ greatly in how they function, the systems share the understanding that leaving people outside the insurance structure ends up costing society a lot more in the end. It is unfortunate that US policy-makers and the public still do not accept this self-evident fact.
If Pete is one of the few ranch hands with health insurance, well, good for him. If not, he has learned by now that even the most self-reliant cowboy sometimes needs help from the federal government, at least when it comes to fixing broken bones. Happily for the uninsured, whether intentionally or not, Congress has decided that nobody should ever be turned away from emergency care, no matter what that does to the hospital’s budget. Individual responsibility, as it turns out, does not mean taking care of only yourself. It also means taking reasonable steps — including the purchase of medical insurance — that protect everyone, taxpayers included.
David Tuller, DrPH, is a public health researcher and journalist in the School of Public Health at the University of California, Berkeley. Steven Lubet, JD, is Williams Memorial Professor at the Northwestern University Pritzker School of Law.