John Q.: How Real Is This Horror Story?

As a rule, it’s not a good idea to pick up a gun, take over the emergency room of a hospital and threaten to kill your family’s cardiac surgeon. But that’s what Denzel Washington’s character does in the film John Q. when his son is denied the heart transplant he needs to survive. And if box-office reaction is any indication, plenty of frustrated health-care consumers have at least fantasized about doing the same thing: John Q., released in late February, hit No. 1 in its first week and stayed near the top. But does HMO hell really get this bad?

The good news is that most of us will never find ourselves in quite the medical crisis the John Q. family does. In the movie, which was written in 1993, during the Clinton health-care-reform battle, the parents are told that a heart transplant costs $250,000, that their insurance doesn’t cover it and that they’re required to post a $75,000 deposit or their sick son will be sent packing. While it’s true that hospitals expect to be reimbursed for services provided to even the neediest and most grievously ill patients, it’s not true that they handle things in so mercenary a manner. “That’s Hollywood,” says Anne Paschke, spokeswoman for the United Network for Organ Sharing. “The fact is, there are a lot of things that would prevent that from happening in the real world.”

First of all, with 2,200 heart transplants performed in the U.S. each year, the procedure is no longer considered experimental; most policies today cover it. More important, those patients whose policies place restrictions on their transplant coverage and those who have no insurance at all are not simply turned away. (Even prisoners are entitled; in January a 31-year-old felon serving time in a California prison received a heart transplant that it is estimated could cost that state’s taxpayers some $400,000, if not more.) Transplant hospitals keep on staff financial advisers who work with insurance companies, federal and state governments, and even private foundations–which often provide funds for poor patients, especially children. “Transplantation hospitals must and do have this in place,” says Paschke.

The problem is that other pricey medical procedures that are also matters of life and death do not come with the same financial safeguards. And like the family in John Q., millions of Americans live in a sort of insurance netherworld–too poor for the procedure they need but not so poor that they can rely on the government to step in and pay. “There are about 84 million Americans who are covered by either Medicaid or Medicare,” says Kristina Newman of the Kaiser Family Foundation. “But there are about 40 million uninsured people who are not quite old enough or poor enough to qualify. If they have a serious accident, they’re really up a creek.”

Perhaps an additional 10 million to 15 million people have some coverage but not enough–belonging to plans that offer not much more than the basics. For them, a little insurance can be almost as bad as none at all. “Sometimes we tell people simply to stop working and spend all their money,” says Mehmet Oz, the director of the Cardiovascular Assist Device Program at Columbia University’s College of Physicians and Surgeons in New York City and a technical adviser for John Q. “Then at least they qualify for Medicaid.”

For the majority of even minimally insured people, things will never come to that. Coverage caps–which in John Q. limit the family’s reimbursement to just $20,000–do exist, but they’re typically lifetime maximums rather than annual caps, and the majority of them are $1 million or more. Such a payout is usually more than adequate, though a catastrophic injury like paralysis can blow through the whole reserve in just a few years. Similarly, surreptitious policy switching–which in John Q. causes the family’s coverage to shrink as the lead character’s work hours are cut–is not as much of a danger as the movie would suggest. Even barebones policies ought to cover “medically necessary” procedures (a term that can be slippery), and in many cases, coverage doesn’t dwindle as hours do, though such workers may be required to pay more to maintain the policies they have. Yet no one disputes that the health-insurance safety net remains badly frayed. “There are many people who still fall through the cracks,” says Ray Werntz, of the Employee Benefits Research Institute, “but in some cases, that’s because they don’t know what their options are.” Learning and acting on those options may be the best thing people can do to avoid a John Q. scenario. It’s not always pretty when life imitates movie art, particularly when it’s this movie–and your life.

–By Jeffrey Kluger. With reporting by David Bjerklie/New York