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'Cost of Living' considers the real price of the U.S. health care system

Henry Holt & Co.

In her 2016 essay "Cost of Living" for the Virginia Quarterly Review — later anthologized in The Best American Essays — Emily Maloney unravels the juxtaposition of working to pay down her medical debt at a job where she assigns medical costs to treatments — costs that may, in turn, create the same kind of debt for others.

She writes of being 23 and working as an emergency room technician at a Chicagoland hospital, coding charts into bills, determining what to charge for the level of care each patient received: "Each level had its own exacting specifications, a way of making sense — at least financial sense — of the labyrinthine mess of billing."

But Maloney knew from her own experience that medical billing didn't actually compute in a financial sense. Four years earlier, she had been an ER patient at a hospital in Iowa City after a suicide attempt. That hospital stay resulted in a five-figure bill, one she could scarcely have imagined as a 19-year-old college student. "Sitting on a cot in the emergency room, I filled out paperwork certifying myself the responsible party for my own medical care — signed it without looking, anchoring myself to this debt, a stone dropped in the middle of a stream," Maloney writes.

"Cost of Living" — an indictment of the exorbitant costs of staying alive in America, and the weight of being hounded by a debt that reduces your life to dollars and cents — opens Maloney's debut essay collection of the same name. It's a powerful opening shot, but in the essays that follow, which recount Maloney's experiences as patient, caregiver, observer, and pharmaceutical industry worker, she stumbles before regaining the clarity of purpose and rigor of probing that "Cost of Living" promises.

There are 15 essays in Cost of Living, and the six that follow the titular piece feel as though they are narrated from underwater. Perhaps that is because they trace years in which Maloney herself felt that she had "not gotten the memo regarding how to be a person." She writes of being "too odd for elementary school, then secondary school," of attending seven schools in ten years, of difficulty conversing and maintaining eye contact, of seeing multiple psychologists at once.

Among the murkiest essays is "Clipped," which is at once about working as a dog groomer, deciding whether or not to apply to college, and feeling a need to escape her family. Maloney writes of her home life, "I knew something was wrong, that maybe there was a fire and everyone was inside the house." Something is wrong here, but that something is never clearly identified; I found myself waiting for retrospection that never came. "Clipped" feels, itself, clipped — an issue I had with several other essays, which put too much faith in the power of showing, not telling. "Some Therapy," for instance, is a list of 12 therapists, social workers, psychologists, and psychiatrists that Maloney saw, the reasons she was sent to them, and approximately how much they cost. "A Brief Inventory of My Drugs and Their Retail Price" is, well, what it sounds like. In these instances, I didn't know what to make of the litany: It is clear that both the therapy and the drugs weren't the treatment that Maloney actually needed, but unclear where she places the blame.

That Maloney does not even engage in any kind of questioning in these pieces is what makes them lack tension, fall flat. Later essays, where she takes up the same sort of thinking on the page that gives "Cost of Living" its verve, are far more compelling.

Among the best essays in the collection is "Soft Restraints," where Maloney finds a mirror in a woman she calls Elizabeth, who kept thrashing in her ER bed — and digs into the problem of female patients not being taken seriously. Elizabeth's chart labeled her as having borderline personality disorder and fibromyalgia, "a made-up diagnosis for us then, a kind of early aughts placeholder for female hysteria." In contrast is another woman who presents with "the worst headache of her life" and cannot stop crying. "Usually things like this were some kind of conversion disorder, or maybe psychosis," Maloney writes, but instead of resting in that assumption, this patient is sent for a CT scan that reveals a brain tumor the size of a small orange. Maloney herself ended up more like the "orange woman": she was eventually diagnosed correctly with a developmental disorder, hypothyroidism, and a vitamin deficiency, but realizes how she could have become Elizabeth: "It doesn't take much to get addicted to someone taking an interest in who you are, that sometimes all you are looking for is an answer, an explanation for why you feel this way, maybe a box to check or a space to occupy." This kind of zoom out and sustained inquiry is what I longed for in earlier pieces.

The essay that I cannot stop thinking about, though, is "Failures in Communication," where Maloney digs into the ethics of how physicians talk to patients about what is happening inside their bodies. Here, Maloney is no longer an ER tech but a pure observer in a teaching hospital in Pittsburgh, shadowing in an ICU step-down unit for a bioethics course she took while completing her MFA. This unit is where people go after they have survived intensive care, where "patients are responsive, awake, alert...but nevertheless very sick. This is the hardest part of patients and families to understand: that their loved one may still die, even though he seems fine."

In this liminal space between the worst of sickness and the beginning of what may be recovery or relapse, patients listen as medical students present their cases—explain what is keeping them in a hospital bed—to a group of residents, interns, attending physicians, and nurses during rounds. Medical students must "learn two languages, one for the patients and one for medicine." The language for patients isn't just medical jargon translated into what a layperson may understand, but a language with carefully regulated "nuance, tone, meter, facial expression," one that may include more or less information in order to manage the anxiety of patients and their family members. Writing of the case of woman whose husband always "assumes the worst," Maloney locates the conundrum that comes when translating from one language to another: "The information is incomplete, or they wait to tell the husband until they are sure they are going to do this procedure or that...Is making [patients] the last to know helping or hurting them? Where is the line?"

We will all someday land on the wrong side of the hospital bed, be at the mercy of caregivers who must determine how to treat us, how to talk to us, how to charge us. In the era of COVID — which Maloney touches on only briefly in the last essay — the precarity of health is all the more real. At its best, Cost of Living offers insight into the subculture of medicine and incites the reader to think more deeply about what our health care system is costing us all.

Kristen Martin's writing has also appeared in The New York Times Magazine, The Believer, The Baffler, and elsewhere. She tweets at @kwistent.

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Kristen Martin