The Health Insurance Plot Is the New American Happy Ending

In Raven Leilani’s Luster, Edie is a 23-year old Black woman who, amongst other problems, has irritable bowel syndrome. “I can’t shit,” she explains, describing her bowels at various points as “dysfunctional,” “inaccessible,” and “shy.”

She goes to see a doctor; the doctor suggests further tests. But with Edie’s insurance expiring in four days, she’s ultimately only prescribed an over-the-counter laxative. The doctor asks her to return once she has insurance. “The plea is so sincere,” Edie observes, “that when I visit the pharmacy to pick up my prescription, I wander the vitamin aisle and cry.”

Welcome to the Health Insurance Plot. 

The Health Insurance Plot is a cousin to the Marriage Plot, which refers to a story that concludes in a marriage. The Marriage Plot is still prevalent today, but in 19th-century England it was especially popular. All of Jane Austen’s novels, for example, end with weddings. At the time, marriage was essentially permanent and offered Austenian heroines domestic and financial security—a kind of happy ending.

Today this happy ending is instead achieved by acquiring a job, one with great health benefits. The Health Insurance Plot may have a deadline, as in Kiley Reid’s Such a Fun Age, in which the protagonist anxiously seeks a job with insurance before her 26th birthday. Or the plot can follow a character through her uneven access to health care and into how this uncertainty feels. 

The characters embroiled in a Health Insurance Plot may have a specific ailment. Edie has her irritable bowels. In Lily King’s Writers & Lovers, Casey has a questionable lump. These health issues amplify the stakes of needing insurance, but they are rarely the primary plot. Sometimes the character is perfectly healthy, like Emira in Such a Fun Age. 

But Emira still needs a job with health benefits; insurance is an issue independent of illness. It’s worth noting these characters are usually millennial women, struggling with life things: love, sex, the gig “economy,” racism, having a body, making art. These novels aren’t stories about women with diseases. They’re stories about women who—much like their Austenian predecessors—are seeking security.

The American health system, Beatrix Hoffman argues, has always been characterized by two things. The first is a refusal to adopt a right to care– the closest thing the U.S. system has to a right to health care is EMTALA, an act passed in 1986 that requires the provision of emergency care for the indigent and uninsured. The second is the unequal and ineffective rationing of medical services by income, immigration status, race, region, and insurance coverage.

This rationing is reflected in recent American media and fiction. Consider a scene from Writers & Lovers by Lily King. Casey, a 31-year old white woman, is riding her bike. A car hits her. The woman in the car offers to take Casey to the hospital. Casey explains that she can’t afford that, leading the woman to exclaim, “I will pay! Of course I will pay!”

“When I tell her that without insurance X-rays will cost hundreds of dollars,” Casey notes, “she grows frightened and gets back in the car.” Afterwards, Casey feels relieved. She notes that her leg doesn’t “feel” broken. “I got lucky,” she thinks. “If the accident had been any worse, the cost would have sunk me.” (Lucky! She was hit by a car!)

Beyond cost, America also rations health care by employment status. So the Health Plot is also about work. (Luster, Such a Fun Age, and Writers & Lovers are great work novels.) The work-health link can manifest as a persistent anxiety. What kind of work provides insurance? How do I get a full-time job with benefits? Is this a job I want? Does that matter?

In Such a Fun Age, Emira does not have a particular physical ailment; she’s a young Black woman who’s just trying to figure life out. We’re introduced to Emira on the cusp of her 26th birthday, when she’ll be booted off her parents’ health plan. (“Should we get you a helmet for while you’re uninsured?” her boyfriend jokes.) 

 Emira loves Briar, the white child who she babysits part-time. But when Emira is racially profiled in a grocery store — accused of kidnapping Briar — she tells herself:

This wouldn’t have happened if you had a real fucking job…You wouldn’t leave a party to babysit. You’d have your own health insurance. You wouldn’t be paid in cash. You’d be a real fucking person. Taking care of Briar was Emira’s favorite position so far, but…part-time babysitting could never provide health insurance.

You’d be a real fucking person. Beyond the actual health inequity, what makes me so angry for Emira (and for myself) is that a “real job” becomes equal to “a nine-to-five position with benefits” becomes equal to “adulthood.” If Emira loves her babysitting position, why should she have to leave it?

Let’s look, for comparison, at Sally Rooney’s Conversations with Friends. The novel is set in Ireland, where there’s government-funded public health care. The protagonist, Frances, suffers from harsh period pain and is eventually diagnosed with endometriosis. 

But Frances is not worried about access to a doctor. She has a basic security where Emira, Casey, and Edie have only an abiding anxiety. She doesn’t have to apply to full-time jobs for insurance. Frances is a writer, and she’s able to pursue art while working part-time at a coffee shop.

Meanwhile, Casey is also a writer, and Edie a painter. When Casey and Edie make art in America, they experience not only the expected economic instability but an embodied insecurity: the threat of illness or even death, and an associated everyday anxiety. This in turn makes it more difficult to make art, or as Raven Leilani has put it: “There is also the fact of [Edie] trying to make art while she barely has enough money to eat or pay rent, and it is nearly impossible to produce anything when most of your bandwidth is spent trying to live.” 

So, suffering. One way health insurance is made urgent in these novels is by bringing up suffering. The stakes of insurance are made clear by the horror of physical and mental suffering, which occur seemingly at random to our protagonists. And in my experience, this is how sickness feels: challenging to ignore, and generative of a basic kind of nihilism:

Casey: “Then I remember the oncologist appointment tomorrow, and maybe none of it will matter because even if I get the job I’ll just be the teacher who has cancer and dies.” 

Edie: “God is not for women. He is for the fruit. He makes you want and he makes you wicked, and while you sleep, he plants a seed in your womb that will be born just to die.”

Frances: “A searing anxiety developed inside me…first the realisation that I would die, then that everyone else would die, and then that the universe itself would eventually experience heat death, a kind of thought sequence that expanded outward endlessly in forms too huge to be contained inside my body.”

Of course nihilism is not new, and fiction has always dealt with illness, and suffering. The nihilism is because of mortality, not insurance. Health benefits can’t remove this anxiety. But not having insurance, or having other barriers to care, can press this anxiety into every day, and we already live so precariously now. Health inequity is especially present for marginalized groups, like undocumented immigrants who face greater barriers to even obtaining insurance, and Black women, who are two and half times more likely to die of maternal causes than white women. 

Why wouldn’t fiction account for these anxieties around care? This is what life is like. With no right to health care in America, “real fucking jobs” with health benefits are a clear path to some security. As a reflection of this, insurance is functioning in recent fiction the way marriage did long ago: as a happy ending, as a relief. 

In the American novels I’ve brought up, our protagonists get lucky. Near the end of these novels, the characters are offered full-time jobs. Of course they accept the offers. In Luster, Edie takes an internal communications job, “a job I actively do not want but that offers paid sick leave, health insurance, and a free mattress.” 

Casey from Writers & Lovers is offered a full-time teaching job with Blue Cross Blue Shield health insurance. It’s a happy moment. “There’s a particular feeling in your body,” she thinks, “when something goes right after a long time of things going wrong. It feels warm and sweet and loose.”

And Emira, in Such a Fun Age, gets a job offer without benefits. But with a friend’s guidance, in what is a deeply satisfying scene, Emira negotiates the offer. She lowers her rate to secure health insurance. Emira hesitates to accept — she’s lowering her rate? — but her friend Zara intervenes. “Mira? It’s just for now,” Zara says. “This is a real-ass job.”

An ending does not necessarily provide closure. Both the Marriage Plot and the Health Plot offer happy endings. A partner, a real-ass job. But the Marriage Plot used to offer closure, the firm sense that insecurity would not return, even beyond a book’s pages. Since marriage was basically irreversible, its associated domestic and financial security was assured over time. In Austen’s Mansfield Park, when Fanny and Edmund marry, their happiness is “as secure as earthly happiness can be.” 

There was a finality to the Marriage Plot, but getting health insurance is no final thing. Health insurance is not wed to these characters by law. People lose their health insurance all the time. In the Health Insurance Plot, closure is untenable because insecurity is likely to return. 

Still, getting health insurance is a happy ending. In these novels, having insurance removes a latent anxiety. For Edie and Casey it opens up space to make art. And if either of them, or Emira, is hit by a car, she can now go to a hospital with a somewhat lessened fear of bankruptcy. Today this is a substantial, if tenuous, security. In America this is a lucky thing.

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