Aside from a brief stint as a writing tutor during graduate school, I have managed to avoid respectable employment all my adult life. There was a time, after I earned my graduate degree and before I sold my first novel, when it looked like I might have to get an office job. I remember one interview with one stultifying prospective boss; it took him a half hour to describe the important tasks I would be called upon to perform, such as licking envelopes—a half hour I spent steadily withdrawing into a cocoon of self-pity, so that when he finally paused to ask if I was up for the challenge, I said, “Huh?” and wasn’t called back.

I don’t take my self-employment for granted. I commute 30 feet. I have the privilege to spend a great amount of time watching my son grow up. I have access to a supply of snacks rivaling that of a Silicon Valley start-up circa 1997. Still, there are drawbacks, most of them courtesy of the federal government. Some are minor, like having to pay estimated quarterly taxes, which for a writer with multiple contracts coming due at unpredictable times is a bewildering process akin to picking the next eight winners of the Kentucky Derby. More painfully, I am subject to the full amount of Medicare and Social Security tax, a burden more often shared with one’s employer.

Until recently, though, I had never given much thought to one of the clearest benefits forfeited by the self-employed: simplified access to health insurance. I’d never given it much thought because for years I’d been covered by my wife’s policy. Then she left her hospital job to work at home, and both of us were self-employed. The law entitled us to extend her coverage for an additional 18 months at the same rate paid by her former employer. After that, we knew, we were on our own. As a deadline, it seemed very abstract, and very far away. I don’t remember hearing a ticking clock, anyway. Today I look back and speculate that its sound was smothered by red tape. With our extension used up, we sat down to begin the paperwork. By we, I mean my wife, who took it upon herself to price out every plan under the California sun. Numbers were crunched, contingencies planned for. In the end we decided to reapply for coverage with the same provider. On some level, we had the idea that this would simplify things.

All was in Ordnung, or so it seemed, until the day we opened the mailbox to find a big fat envelope waiting for us. We tore it open like excited high schoolers awaiting SAT scores and unfolded the pages in search of our little plastic cards, the ones that would entitle us to stand before the gum-chewing receptionists at our local internal-medicine clinic and declare, “Behold, I am a member of the working world, gainfully self-employed and nominally self-sufficient, evinced by the way I wield this card plus a $40 office visit co-pay.”

There weren’t any cards.

There was, rather, a lot of tiny black type.

“I’m approved,” my wife said, squinting to read. “The baby’s approved.”

She frowned.

“You’ve been declined,” she said.

I chuckled, mentally. Declined? Impossible. I was a healthy 33-year-old man with an unremarkable medical history. I took no medications other than the odd Claritin or Advil. I’d never broken a bone. I’d never had a hospital stay. At 17 I’d had my one and only surgery, performed under local anaesthetic, to remove a benign bone spur in my toe. I ate well. I exercised daily. And talk about blood work—oh, my blood work! It runs in the family. Many of my forebears on both sides lived well into their 90s. My 89-year-old grandmother recently complained to me that she can no longer play mah-jongg because “all my girls are dead.” My 92-year-old grandmother does Israeli dance with a group of women half her age. Like my mother, who has a rare and beneficent gene variant, I have more good cholesterol than bad. A high triglyceride level is 200; 150–199 is borderline; lower than 150 is considered normal. Mine: 15.

“It’s about your nose,” my wife said, turning pages.

I instantly suspected anti-Semitism. “What about it?”

She showed me the page. In the interest of full disclosure, I suppose I ought to revise the rosy medical self-portrait a tad. One thing I have endured, from about fourth grade on, is insomnia. It gets better or worse depending on my stress level, and even when I do manage to fall asleep, I tend to wake up every three hours. The year that I spent abroad prior to college, learning in an Israeli yeshiva, was probably the roughest I ever had, sleepwise. At least once a week I was up all night, with the result that I rarely attended the regular 7 a.m. prayer service. Either I waited for the sunrise minyan, or I skipped services entirely and slept in. When I started writing full time, I embraced my inner night owl, often working until two or three in the morning and sleeping until nine.

The arrival of my son forced me to get on his schedule. I could never quite manage it, though, and long after he had learned to sleep through the night, I would still spend hours at a stretch tossing and turning. Concerned that I might have apnea, I made an appointment with an ear-nose-and-throat man, whom I’ll call Dr. K. I chose him because the practice he belonged to told me he had the first available opening. I’ve since learned that the person with the first available opening is seldom the person you want to see.

A sour man with a badly patterned necktie, he regarded me distastefully from behind thick aviator glasses. He asked me what I did. I told him I wrote novels. He asked if he had heard of any of them. I told him probably not. Then he shoved a wad of cotton soaked in topical anaesthetic up my nose. There was nothing gentle about the way he did this. Indeed, it seemed to be something of a game to him: How much can I cram in there? I shudder to imagine what the inside of his garage looks like. The anaesthetic still hadn’t taken effect when he yanked the cotton out and impaled my face on a plastic scope. I gagged and choked. “Sorry,” he said, smiling faintly. I tried to hold still while he rooted around up there, sighing and saying things like “hmm” and “yup.” Finally he pointed to the live feed of my sinuses on the screen and turned to the terrified medical student standing in the corner, her notebook at the ready.

“Deviated septum,” he said to her. She wrote it down. Then he flashed me a Bond villain smile. “Severe.”

I had three options. The first was a course of nasal steroids to reduce the swelling, although Dr. K. made it clear that this was a giant waste of time, strictly a formality to secure permission from my insurance company to proceed to option two: corrective surgery.

“What’s option three?” I asked.

“You could try those little plastic thingies,” he said, stroking the bridge of his nose. I couldn’t afford to be laid out for a week or more. I had a novel to write and a toddler to manage. I said I’d give the plastic thingies a shot. I could tell he was disappointed. “Suit yourself,” he said, walking away to dictate his note into a pocket recorder.

My first few nights wearing Breathe Right Nasal Strips weren’t all that different. Then I discovered that I had accidentally purchased the wrong size, the large ones, “for adults with larger noses.” (Self-anti-Semitism?) Once I got hold of the small/mediums, my life literally changed overnight. For the first time in 20 years I slept seven straight hours. I called Dr. K.’s office and left a message saying I had the problem under control. And I did. The only apparent downside was that I developed, over the next few months, a semi-permanent red stripe across the bridge of my nose where the adhesive attached. It seemed a small price to pay. Every morning my wife would look at me and say, in the Jamaican accent of the guy from the beer commercials, “Reeeed Stripe.”

We laughed the laugh of the young and able-bodied.

Back to the letter. “‘Health history,’” my wife read. “‘Deviated septum, surgery recommended. Should Jesse Kellerman wish reconsideration of our underwriting decision, he must, one, be sign-, symptom-, and treatment-free from the deviated septum, not a surgical candidate and no symptoms documented by your physician and no further treatment needed, and, two, meet the Medical Underwriting Guidelines in effect at the time of application.’”

“It’s nice that they’re employing the illiterate,” I said.

“Here,” she said. “Call them.”

It took a hard charge through several layers of voicemail and an hour on hold, but at last I found myself talking to the underwriting department.

“You have failed to meet the underwriting criteria,” the underwriter said.

“I realize that,” I said. “My question is what I can do to qualify.”

“You must be sign-, symptom-, and treatment-free—”

“But I am sign- and symptom-free. I wear those little plastic thingies. I pay for them myself.”

“I understand, sir.”

“So what’s the problem, then?”

“You must be sign-, symptom-, and treatment-free, and not a surgical candidate, and if you meet the underwriting criteria at the time of application, you may qualify.”

“That’s what I’m trying to tell you. I feel fine.”

“I understand.”

“OK, so, just to be clear, here, if I get reevaluated and I’m OK, then I’ll qualify.”

“You must be—”

“Janet. Janet. Janet. May I call you Janet?”

“Sir.”

“Janet, I understand that you have a script to follow. I understand that. I’m just trying to get some information here, like a normal person. And what I’m trying to understand, Janet, is what else I have to do to qualify, because, Janet, I am sign- and symptom-free.”

“I understand that, sir, but until you are no longer a surgical candidate, and until you meet the underwriting criteria, we are declining to offer you coverage.”

“My nose is shaped in a certain way. It’s not going to change, magically.”

“Sir.”

“So as long as I have this nose, I’m always going to be a surgical candidate.”

“Sir.”

“The only way not to be a surgical candidate is to have surgery.”

“Sir.”

“But I don’t want surgery. I don’t need it. I’m fine. Janet, I promise you that I will not have surgery.”

“I’m sorry, sir, but we can’t offer you coverage based on your promises.”

“Okay, well, what can I do to convince you?”

“You must be sign-, symptom-, and treatment-free, and not a surgical candidate, and if you meet the underwriting criteria at the time of application, you may qualify.”

I paused. “Let’s try another approach here.”

“Sir?”

“Right now I’m covered by your company, right?”

“I don’t know, sir. Are you?”

“Yes. I am. And I’m reapplying to be covered by your company.”

“Sir.”

“So you’re telling me,” I said, “that the only way for me to get new coverage is to no longer be a surgical candidate.”

“If you meet the underwriting criteria at the time of application, you will qualify.”

“Fine. Got it. So. I have the surgery, and now I meet the underwriting criteria, right?”

“I can’t promise you that.”

“I’m not asking you to.”

“There’s no need to yell.”

“I’m not asking you to promise me that. I’m asking you, Janet, my love, to follow me, please, down this theoretical path. OK? Let’s say I get surgery. And I am no longer a surgical candidate. And I meet the underwriting criteria when I reapply. Then what happens?”

“Then you may be eligible for coverage.”

“‘May?’”

“Yes, sir, you may qualify.”

“Okay. I ‘may’ qualify. Fine. Excellent. Super. Now answer me this. To not be a surgical candidate, I actually have to have this surgery. So let’s say I decide to go for it. I’m gonna have this surgery. All right? So. Riddle me this, Janet: Who’s going to pay for it?”

“I don’t know, sir.”

“You will. You will, Janet. You will pay for it, because you already are my insurance provider. Do you see what’s happening here? You’re incentivizing me to have an operation, which I neither need nor want, and which you will pay for, in order to avoid paying for that same operation in the future.” I paused. “Janet?”

“Yes, sir,” she said. “That sounds about right.”

“And that doesn’t strike you as odd?”

At last a hint of humanity crept into her voice. “I guess it does, a little.”

“Well,” I said. “As long as we’re clear on that.”

I had surgery. I had alternatives, of course. I could have bought into a pre-existing condition plan, or a HIPAA plan, either of which would have covered me and my bent septum. But these plans were extremely expensive, and when we amortized the cost of the operation over a year, it turned out to be cheaper to have it than not, even if I had to pay for it in full.

So, I had surgery.

I didn’t go back to Dr. K. First, he creeped me out, and moreover he was booked. Everyone in San Diego was. I had to drive two hours north to Los Angeles to find someone who could operate soon enough for me to recover (and thereby qualify for the underwriting criteria) before our coverage ran out. I chose my parents’ ENT. The walls of Dr. R.’s Beverly Hills practice were hung with the gold and platinum albums of pop stars whose nodules he had soothed. He booked me into a surgical center within 48 hours. My mother drove me over at five in the morning. I handed my credit card to a young woman who had no right to look that beautiful at that hour. She ran the card, and I signed for several thousand dollars.

“At least I’ll get miles,” I told my mother.

The surgery went well, and for the next few days I sat in bed and watched TV. When it came time to remove the packing from my nose, Dr. R. was good enough to come in on a Sunday morning.

“Don’t blow, don’t pick, don’t futz with it at all,” he said. I obeyed. Still, the incision kept on bleeding, so he had me return for a chemical cauterization. I drove back to San Diego with the smell of it in my nostrils. My wife met me at the door, scrutinizing me before she let me back in.

“I’m checking to see if you look different,” she said.

“Do I?”

“No.”

“Do I sound different?”

“You’re bleeding,” she said.

I ran to the bathroom. Sure enough, a little ruby droplet had formed near the inside corner of the left nostril—the one Dr. R. had just cauterized.

I called him.

“Don’t futz with it,” he said.

I didn’t futz. Three days later, it was still bleeding.

“Come back in.”

I drove to L.A. He cauterized the incision a second time.

“It has to scab and heal,” he said. “Don’t futz with it.”

I drove back to San Diego. I didn’t futz. It was hard not to; it itched like hell. And it was still bleeding.

“Come back in.”

I got into the car.

An ENT’s tools are either extremely sophisticated or else positively medieval, and I had discovered that Dr. R., for all his charm, shared Dr. K.’s enthusiasm for ramming larger-than-reasonable objects in my face. Before cauterizing the incision a third time, he pried the offending nostril open with pliers and gazed contemplatively into my sinuses.

“How’s your breathing been?” he said.

“Pretty good,” I said.

“Mm.” He reached for the cauterization stick. “It’s amazing, how the cartilage has a memory. It’s curving back a bit. You can breathe, though?”

“Pretty well.”

“Well, good enough.”

 The third cauterization took. The bleeding tapered off, and within a few weeks I was back to blowing my nose like normal. But in the interim, a new problem had arisen: The left nostril had turned shiny and crimson and tender to the touch.

“It looks infected,” my wife said.

I called my primary-care physician.

“He can see you in February.”

“It’s May.”

“Do you want to see someone else?”

I saw an intern, who looked at my nose and wrote me a prescription for an antibiotic. It didn’t work. I called the practice and spoke to a nurse, who told me I needed to come back in.

“I’m pretty sure it’s one of those drug-resistant strains,” I said. “You can’t have them just write me a new prescription?”

“Not without seeing you first.”

I went back in. A different intern looked at my nose.

“It’s one of those drug-resistant strains,” he said, writing me a new prescription.

Twice a day for the next seven days, I swallowed a pill the size of a ping-pong ball. The infection abated, and I stood victorious in front of the mirror, prodding my nose.

My wife entered with a torn envelope. “We’ve been approved.”

“Great,” I said. At that moment, it all seemed worth it. To celebrate, I reached for a tissue and blew my nose, expelling a massive quantity of bright red blood.

Eight months later, I’ve recovered, for the most part. The surgeon was right: Cartilage does have a memory. Every day I feel my septum curve a little bit more as it struggles to regain its original shape. After the surgery, flush with optimism, I threw away all my Breathe Right strips; I have since bought more, for use in the event of a cold or bad allergies, which render my nose just as obstructed as it ever was.

And so, some nights, I lie awake, gasping for air.