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The conversation about healthcare in America often (correctly) focuses on how utterly insane it is that the United States doesn’t provide healthcare to every citizen, but it turns out the outcomes aren’t much better for people with insurance.

New research, highlighted by the New York Times today, underscores exactly how terrible it can be: for a “substantial fraction” of Americans, hospitalization leads to “a permanent reduction in income.” Permanent! Forever! Because you got sick once!

Insured, non-elderly adults (ages 50–59) in the study experienced a 20% drop in earnings compared to before their hospitalization. The researchers estimate that 4% of bankruptcies among insured people are due to hospitalization. Sixty percent of those whose income dropped after hospitalization never returned to work at all.

The reason that even those with good health insurance experience a financial hit after hospitalization is because America sucks at that whole social safety net thing. If your hospitalization renders you a person with disabilities, affects your productivity at work, or forces you to cut back on your hours, government support available in the U.S. simply isn’t as good as it is in other nations. As the Times points out, “similar reductions in income have been found after hospitalizations” in Denmark, but “government programs help replace some of the losses, lessening people’s financial burden.” Social security disability payments, for example, only kick in if you earn less than $1,180 a month, which is less than $15,000 a year. If you were earning $30,000 a year before—still a very low wage in much of the country—and your income is cut in half by your hospitalization, you’re still not eligible for disability coverage. Those payments also don’t kick in until you’ve met the government’s criteria for five full months. And getting those assistance payments, even when you should be eligible, isn’t always easy.

Long periods of missing work can mean debt piling up, too, making it harder to catch up afterwards; the lack of mandatory paid sick leave is yet another hole in the social insurance net. The researchers also looked at credit report data, which showed “people’s overall spending tended to go down and stay down for years after a hospitalization, suggesting a drop in income,” according to the Times.

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America: where getting sick is a rich man’s luxury.