Bipolar Bear’s Misadventures

Book Review by Kevin Wolf

I haven’t read Judith Viorst’s Alexander and the Terrible, Horrible, No Good, Very Bad Day (September 2009, Atheneum Books) which is illustrated by Ray Cruz, so I don’t know if the book under review is also a spoof of Viorst’s work or only borrowing some of its title, but I’m ok with that; because, Kathleen Founds in Bipolar Bear and the Terrible, Horrible, No Good, Very Bad Health Insurance: A Fable for Grownups is venting her own frustrations in an allegory about struggling with a chronic mental health issue (bipolar disorder) which is exacerbated from health insurance claim denial  and mounting out of pocket costs. According to the afterword, Bipolar Bear is loosely based on Founds’ own experience. Founds dedicates Bipolar Bear to “All who brave the slough of despond, wander the labyrinth of health insurance claims, & endure the shackles of crushing debt”—all scenes shown in this graphic medicine work. This is a story of Theodore, who usually did bear-like things (eating, hibernating) until he had a problem with his health; namely, bipolar disorder with extreme mood swings of highs (euphoric, very busy with activities, performing for trees) and lows (slowed, depressed, “drew sad faces on rocks and turtle shells” (page 9)) and his process for seeking psychiatric help while being slowed by the insurance company (literal) fat cats not paying his health care costs. There are many anthropomorphic characters, scenes that almost aren’t allegory after waking following blackouts, pun-filled (starting with the title) words, and humorous scenes sprinkled throughout. I recommend this allegory, not so much for the medical aspects which have some depth, but for the secondary encounters that often happen in the United States’ healthcare system of arguing with insurance companies to get claims paid.

Imagery is often soft secondary colors primarily peopled with non-humans and infrequent appearances of humans. Animals include the protagonist Theodore struggling with bipolar disorder, with the forces against him including an insurance company made up of customer ssservice snakes, gun-toting raccoon enforcers and rich executive fat cats, bureaucratic mazes, phone hold hell, long lines, and even an attempt at paying him off by suggesting he become the insurance company spokesbear. On the other side are animal debtors (discussed later). Humans only appear as disembodied legs waiting in long lines, as police to jail Theodore for non-payment of debts, and a few other minor roles.

Theodore’s appearance is an oversized Teddy bear, unless he becomes really angry. We see his mood chart (12); “He felt wild and nervous euphoria, or utter sorrow and devastation. He burst with exuberance or collapsed inward like a dying star.” He learns from a friend Chachalaca, which I thought was a made-up bird but is real, that maybe Theodore has a chemical imbalance. Chachalaca takes meds (from a pharmacy) to reduce their anxiety and results in growing colorful plumage. Theodore seeks out the pharmacy, which begins his travels into the how-do-I-get-healthcare-paid-for maze: getting a job—moving from part-time to full-time over a year—to get insurance benefits, seeing a doctor to get medications, finding the doctor is out-of-network (OON), and all his healthcare claims have to be paid out of his own pocket (OOP) because of a large OON deductible. But his maze is more entertaining than my words here, because they become a literal maze of contacts with those working at the insurance company (snakes, chasms, skeletons of those who didn’t make it), claim forms, passwords, and so on.

Bipolar Bear is more enjoyable with a careful reading where one can find punny book titles (Pharm to Stable: organic sedatives, Schitzofriends, and more), medications (Nopamine, Piquemeup), side effects (ultimate frisbee face, murderous intent), getting tangled in phone cord (symbol of tangled mess of trying to make headway with insurance company customer service), insurance company website called WeCare.con, M. C. Escher’s classic Relativity image of every-which-way stairs to get to just closed claims window, to working in a debtors’ prison by burning banned books (graphic novels included Fun Home by Allison Bechdel, Maus: a survivor’s tale by Art Spiegelman), to escape, and … more. We even get a bit of Ayn Rand philosophy from fat-cat leader, Baroness Von Stinkleshanks, of the insurance company; she says “The achievement of your own happiness is the only moral purpose of life. … Are we Barons of Industry to reward your pathetic need for medicine and therapy? If we reimburse your claims, we encourage your weakness [61].”

In debtor’s prison Theodore meets other inmates including a foreclosed (homeless)shell-less turtle (with army helmet home); old dog fired because he couldn’t learn new tricks; owl with unpaid student loans; possum (playing dead is solution to everything) fired for sleeping on the job; mouse with massive credit card debt; snake who couldn’t afford a lawyer and had to plead guilty of armed robbery, though armless; a bomb-sniffing German shepherd puppy who lost job due to PTSD; and mother bunny with health insurance not covering dependents … “or birth control. [79]”

Much later, there’s somewhat of a change-of-heart by the Baroness, but only when forced. Theodore and the Baroness even seek out Congress to propose a single payer healthcare for all but are ignored. In conclusion, like the U.S. healthcare system, there’s no satisfying resolution provided or found, but isn’t that where we are today? At the back of Bipolar Bear are a few U.S. resources, including for activism (Healthcare-Now), and seeking help from National Alliance on Mental Illness Helpline (800-950-6264), and National Suicide Prevention Lifeline (988).

Kathleen Rounds won the 2014 John Simmons Short Fiction for When Mystical Creatures Attack! (University of Iowa Press, 2014) from the renowned Iowa Writers’ Workshop!

Skip these paragraphs if you’re not interested in fairly boring (but important) topics; and I know it’s often misplaced to take allegories or satire seriously, but I can’t help it. Officially debtor prisons (housing borrowers who didn’t pay their debts) ended by the U.S. Congress in 1833 and in 1983 “the Supreme Court affirmed that incarcerating indigent debtors was unconstitutional under the Fourteenth Amendment’s Equal Protection clause” (Bearden v. Georgia); though imprisoned debtors still exist today in a different form. More typically U.S. bankruptcy rules might lead to wage garnishments, credit deprivation, housing eviction, and so on. Or it could be real jail time for not being able to pay court-ordered bail. To bring it back to the Bipolar Bear, even after the implementation of the Affordable Care Act in the United States, the National Institute of Health found nearly 60% of all bankruptcies involve health care issues, whether not being able to work or not being able to pay out-of-pocket (OOP; i.e., what an insurer doesn’t pay) costs. Two sources of costs occur from health care. One is from insurance coverage (e.g., a deductible) and the other is from a non-covered service (including those without insurance) or non-covered OON healthcare provider with higher OOP costs. Bipolar Bear mentions claim denial from pre-existing conditions, but this ended in 2006 after passage of the Patient Protection and Affordable Care Act (aka, Affordable Care Act, Obamacare or ACA).

At an earlier point (27), Theodore receives an explanation of benefits (EOB, that is, the document an insurance company sends to explain what it’s paying or not paying) about a healthcare bill. The EOB show 5-digit codes which I presume are Current Procedural Terminology (CPT) codes 90846 [family psychotherapy without patient present], 90847 [same but with patient present], 90849 [multiple-family group psychotherapy], 90875 [individual psychophysiological therapy with biofeedback training] … since Theodore isn’t being treated with other family members the individual codes should’ve been used (such as any of 90804-90829) or been non-existing, nonsense codes altogether. The bill also repeats some of the same psychotherapy services as being done on the same day. Insurance companies, if they pay anything, would likely only pay for the first occurrence for any given day.  In this case the insurance company paid nothing because Theodore unknowingly used an out-of-network provider and had a large deductible to pay before anything would be covered.