Header illustration by Tom Humberstone.
Sam Coster never worried about his health. About to finish college, the young and athletic 20-year-old had no reason to consider insurance plans and market exchanges. Thanks to the Affordable Care Act (more commonly referred to as "Obamacare," in both negative and positive lights), health insurance concerns remained sidelined, the law allowing him to stay on his parent's insurance plan until the age of 26.
At the age of 23, after founding his own game development studio, Butterscotch Shenanigans, with his two brothers, Coster was diagnosed with Stage Four B Lymphoma, an advanced strain of cancer that begins in a single lymph node and eventually extends to other organs.
"They didn't actually know how I was still alive when I got into the hospital," Coster says. "They thought I was going to be dead within two weeks if I didn't start getting treatment."
For several years, Coster was able to curtail the nearly insurmountable costs of his medical treatments through his parent's insurance, and then later a plan acquired through the ACA's health insurance exchange portal. Six rounds of chemo appeared to eradicate the cancer by the summer of 2014.
Six months later, Coster discovered a tumor in his left chest wall while showering and was re-diagnosed. Forced to enter multiple intensive rounds of "salvage chemotherapy," BEAM chemotherapy, a stem cell transplant, and four weeks of being quarantined inside a hospital with skyrocketing fevers and no immune system, Coster finally found some semblance of resolution.
Altogether, Coster's bill cost over $1,500,000. But through the ACA, Coster paid roughly $96 a month, with just a $2,500 out of pocket maximum.
Coster's story is far from the only one that illustrates the impact the Affordable Care Act has made on the game development community. Over a quarter of all games industry employees are not provided with health insurance by their employers, according to the International Game Developers Association's (IGDA) 2015 Developer Satisfaction Survey. While certain companies like Ubisoft and Electronic Arts provide their employees with traditional benefits packages, indie developers, contract workers, and freelancers are often left in the cold with little in the way of support for their own employees.
It's not farfetched to suggest that the implementation of the ACA in 2010 played a large role in the "boom" of independent game studios either. After the success of Jonathan Blow's Braid in 2008, subsequent indie hits like Fez or Minecraft, a studio culture that saw larger developers focus on fewer projects of mid-level cost, and the rise of ubiquitous tools like Unity, more independent developers (of all ages) were able to find success on platforms long-dominated by more established and marketable teams.
"Frankly, you're already going through enough shit when you're dealing with cancer that having to look at your future and say 'OK, if I live, I will basically be rendered financially broken.'" - Sam Coster, Butterscotch Shenanigans
In an industry where most salaries fall between $50,000 and $75,000 for larger studios (often based in urban locales with high cost-of-living) and in which only 24 percent of freelance developers make more than $50,000 a year, increased access to affordable healthcare is seen as a huge factor in the increased diversity the game development community has seen over the past seven years. "The rise of the availability of healthcare certainly is something that has helped people make the decision to branch out on their own and pursue self-employment because it is something they can actually do," says IGDA Executive Director Kate Edwards.
Now, with a newly elected Republican Congress that has made the repeal of the ACA it's number one priority , and seemingly little in the way of a tangible alternative, game developers of all stripes have taken to social media to express their mortal fears.
For creators like Coster, who was the only paid member of Butterscotch Shenanigans until the team's first commercial success with the D.I.C.E. Award-nominated Crashlands, the stress of medical treatment and the ensuing costs can potentially cripple not only the body, but also the will to pursue such endeavours in the first place.
"Frankly, you're already going through enough shit when you're dealing with cancer that having to look at your future and say 'OK, if I live, I will basically be rendered financially broken.' You're already not sure if you're going to be alive at the end of the whole thing," Coster says. "So part of you is owned by the hospital."
Despite a health insurance system that's often regarded as exhaustingly confusing to navigate, many game developers still regard it as a better option than what they had before or going without. Chris Stallman, art director on Octodad: Dadliest Catch, had perhaps the closest shave of them all.
After his mother's job left her with too few hours to qualify for coverage, Stallman found himself curiously browsing Healthcare.gov for a replacement. Much like Coster, Stallman had never had a serious medical episode in his life, much less visited a hospital for anything more serious than a checkup, but he signed up for an ACA-approved plan nonetheless.
One month later, deep into an April night, he awoke with the worst chest pain he had ever experienced in his life.
Stallman ended up experiencing two gallbladder attacks before his medical needs were properly addressed, the staff at his local hospital sending him home during the first night once the pain subsided. It wasn't until two weeks later that Stallman's second attack set off the necessary alarms for treatment.
The first emergency room visit alone, in which they turned him away, would have cost him almost $4,000, and in full Stallman's bill ended up costing $43,585, a little less than the average American yearly salary in 2013. With his insurance policy, he ended up only paying his $6,000 deductible.
"Something that was bad could have been so much worse," Stallman says, describing the relative ease with which he acquired his insurance, something he feels may not be possible in the near future thanks to potentially destructive politics and business. "It's weird, because I feel like I have someone in the fight for me, even though they're against people who don't exactly play fair. I don't feel like I'm completely alone."
And while some game developers may find themselves saved just in the knick of time, for many immigrants in the industry, the looming threat of ACA repeal is a tortuously contemplative road.
Fernando Ramallo came to the United States near the end of 2015, after having grown up in Argentina, then later spending some time in Europe. Now settled with his partner in New York, Ramallo's work has gone onto be featured in over 20 museums and festivals around the world, including nominations for "Excellence in Visual Arts" and a Nuovo Award from the Independent Games Festival.
Ramallo, who must take a pill every day for a pre-existing medical condition, currently pays $600 a month for a plan that only covers roughly half of his needs. By itself, and without the ACA, Ramallo's medication would cost him $3,000 a month, on top of his copays, premiums, and regular lab checkups. Having come from the European Union, where many countries offer universal healthcare, the shock of the American healthcare system (and the looming repeal) has begun to unravel the life Ramallo and many other immigrants have built up for themselves.
"I'm terrified by what's going on," Ramallo says. "If they gut Obamacare and the protections on people with pre-existing conditions, I'm scared that my insurance will decide to not cover my pills, or charge me three, maybe four times as much for my premiums and I'll just not be able to make games living here anymore."
"It's kind of a culture shock for me," Ramallo says. "I didn't even know it was so complicated to get healthcare coverage here. I like it here and want to stay, but this is all making me want to go back to Europe where I have citizenship, and all of my healthcare issues would be gone. Coming to America [included] the realization that if you don't have money, you're through."
Ramallo, whose partner is originally from the United States, feels the pull between both sides of the Atlantic. While healthcare is a guarantee in many European Union countries, the United States (particularly its more expensive coastal regions) is still a powerhouse in terms of having strong, centralized development communities. Access to other game makers is a real boon for indie developers like Ramallo, but only if they have the means to stay.
"If I leave, I'd have to renounce my green card, and no immigration lawyer has been able to assure me that that's an OK thing to do," Ramallo says. "A few have said that'd be unprecedented and I'd have complications coming back to visit my partner's family in the United States. So because of that, I'm waiting, but all the signs saying that I'll have to leave are there. I feel incredibly lucky to have that option, but this is still gut-wrenching. I have so much to give people here."
"Coming to America [included] the realization that if you don't have money, you're through." - Fernando Ramallo, Independent Game Designer
Ramallo's struggles underline a much graver one for the game development community. For some studio leads, a repeal of the ACA means having tougher conversations at the end of the fiscal year to determine how much support they'll offer potential employees. For others, including solo developers, it may mean getting out of the business altogether, shifting all advantages back to larger studios.
A Shrinking Sense of Diversity
"If the ACA is repealed, we are going to go back to those days prior to the ACA where companies can't just shove them off to a health exchange and say 'Well, yeah, we're going to give you a stipend. We're going to give you some bonus to your salary that' going to help you pay for your own healthcare but it's up to you to go to the health exchange and do it yourself.' That's not going to be an option," Edwards says.
Edwards estimates that companies like Sony, Microsoft, Ubisoft, or Electronic Arts will see little change in the way they provide employee benefits since their policies have always been supported by funding no smaller company could ever hope to receive. Over recent years, multiple members of larger studios have departed to pursue their own passion projects (Firewatch, The Flame in the Flood, and Gone Home to name a few). Without an option of affordable health care, it's increasingly likely that industry vets may choose to remain with their original employers for fear of losing coverage.
"That's going to be a competitive advantage that goes back to larger companies, which has been the antithesis of what we've been seeing in the games industry for the past several years," Edwards says. "I would argue the creative advantage has been with independent developers because they're able to leave the companies and pursue their dreams and make the games they want to make."
Smaller studios that toe the line between pure "indie" and simply modest budgets will also be affected in the wake of ACA repeal, Edwards suggests. Studios of 20 or fewer people may find themselves having to scale back their budgets and employee count, or at best hire freelancers or contract workers to fill in the gaps without any of the benefits full-time employment requires.
"It's just one more thing that is going to make our environment that much less hospitable to people who are underrepresented." - Kate Edwards, IGDA Executive Director
"I don't necessarily think that's a good thing for the industry in general," Edwards says. "It depends on the job type and personality, but you want to see developers having stable jobs, predictable workloads, and benefits and all those things that tend to happen in the context of a larger company. So without the ACA, that could be one factor that encourages larger companies to hire more contractors."
While providing healthcare coverage can still be a burden on financially strapped studios, some have embraced the legislation as an opportunity to find new workarounds that fit for them. Studio directors like Philip Tibitoski of the Young Horses (creators of Octodad) have had to find whatever workaround protects their bottom line, while also protecting the supportive culture they've cultivated. To that end, Tibitoski and his Chief Financial Officer worked to provide each of the Young Horses' eight full-time employees with a $400 stipend on top of their normal salary, all based on the highest premium within the team.
"Doing everything we can to make sure our team members come into work every day knowing they're taken care of seemed like a no-brainer," Tibitoski said. "I can only speak to our own experiences, and without the ACA we would have had a much harder time being able to take the risks we did in order to start and successfully bootstrap our business."
For developers already or soon-to-be in their 30's, the prospect of having children while working in the games industry without the ACA looks frightening. According to the IGDA, only 22 percent of industry workers currently have children, but age demographics are nearly tied (26 percent ages 25 to 29, 25 percent ages 30 to 34), suggesting that a new generation of developers will soon be entering both the first and final stages of adulthood where childbirth is most common.
Women in the industry may yet be hit the hardest. Before the ACA was signed into law, it was unusual for individual plans to include coverage for prenatal care and childbirth. The ACA now requires such coverage as part of its "essential health benefits." This is in addition to maternity leave, which prior to 2009, was covered by only about 13 percent of individual plans according to a study by the National Women's Law Center. According to the IGDA, only 31 percent of industry employees receive parental leave from their company, though 37 percent claimed to not know what their company's policy on this was.
"I think that's something that could contribute to a decrease in diversity, which we're obviously already very challenged in that regard" Edwards says. "It's just one more thing that is going to make our environment that much less hospitable to people who are underrepresented."
And all of this is to say nothing of the medical challenges older adults face.
"Honestly, I think it's going to make more of an impact for those in their 30's, 40's, and older mainly because those of us who get into these age groups are feeling the realistic effects of physical health, then you realize it's very important," Edwards said.
Another factor, Edwards adds, is that many industry veterans end up surviving off of their spouse's non-games industry job's insurance plan, acting as a safeguard against whatever shortcomings the other's position may have.
"If someone works at a bigger studio, but they're like 'I want to go indie, be on a small team, be a part of your culture,' but we can't offer health insurance—if we really want them, we have to ask them to take that risk," Coster said. "That feels terrible from our perspective, because we've essentially been a case study in not expecting the worst thing to happen and having it happen."
Laralyn McWilliams is a woman with her eye on the future, and whatever she may have left of it.
As the lead designer on 2004's Full Spectrum Warrior, then later creative director on the well-received online role-playing game Free Realms, McWilliams has seen everything the industry could possibly throw at her. She was even listed as one of Gamasutra's "Top Developers of 2014," a spot earned through tireless dedication to industry diversity and equality in the wake of coordinated harassment campaigns.
In 2012, McWilliams was diagnosed with cancer. While it and the ensuing bills were still egregiously expensive, McWilliams' doctors told her she'd make a full recovery and likely live cancer free. Then in 2016, after a bout with pneumonia, a scan showed her cancer had actually spread to her lungs. More chemotherapy ensued, and eventually McWilliams was cleared again. Six months after that, another scan showed the cancer had in fact spread to both lungs.
After three separate diagnoses, McWilliams' condition has been officially deemed "incurable" by modern approved medicine. Her only alternative has come in the form of special clinical trial medication, paid for in part by the drug company administering the medication and her company's health insurance. While her cancer isn't a massive threat at the moment, McWilliams will need to keep subjecting herself to her clinical trials for as long as it keeps working.
"Until there's some breakthrough, I'm not going on conventional treatment," McWilliams says. "If I go back on conventional treatment, it's because I'm dying. That's the only reason I would do that, and it would only buy me a couple of months. So I'm going to be in the land of clinical trials for the rest of whatever life I have left. Otherwise, I'm great."
Despite working for a company that provides her with competent health insurance, McWilliams has devoted recent months to openly defending the Affordable Care Act. Because the ACA stops insurance companies from setting lifetime or yearly limits on certain kinds of healthcare, McWilliams is able to continue her treatment without fear of losing it. She'll need it, considering a year's worth of just one of her medications cost roughly $1,000,000.
"The odds are I'm not in a situation where I'm going to bankrupt my family and die," McWilliams says. "I'm probably going to die before I bankrupt my family, which is a terrible thing to have to say, but it's the reality of the situation for most people."
McWilliams has tried to make the best of her situation, documenting her thoughts and experiences regularly on her blog. For her, speaking out is the least she can do, since many others seeking employment can't. While the Americans With Disabilities Act forbids employers from discriminating against applicants and employees with pre-existing conditions, applicants looking to ensure their conditions will be covered by a company's benefits package have to essentially out themselves in order to know.
"You're asking [applicants] to raise a red flag with them, especially if you're in a role where there are more candidates available, like a junior designer," McWilliams says. "When you have a chronic condition like this, you actually have to find a way to ask those questions with drawing attention to yourself, or in a way that doesn't make you look 'expensive.'"
The Death of Your Future
"'Tis impossible to be sure of anything but death and taxes." Though the famous phrase originated from the British Air Ministry's Christopher Bullock, perhaps it's appropriate that it's most commonly recited permutation is credited to Benjamin Franklin. In America, death and taxes are two subjects that feel more than certain to those suffering under the weight of illness.
In the games industry, the idea of a future free from such stresses is the only thing many developers can cling to, despite the threat of the ACA's repeal. To that end, Edwards and her associates on the board of the IGDA are currently discussing strategies, both on member support and activism.
"If it's the case where the ACA is completely repealed and we go back to the pre-ACA days, then it's very likely that we at the IGDA will step up again and work with an insurance company and broker to create a program that at least our members will have access to something," Edwards says. "Other than that, there's something we're discussing at the moment to make a decision on basically mobilizing our members to speak out and say something about this because now is the time to do it."
While American members of the IGDA and regional groups may heed a call to action, developers like Fernando Ramallo may try to convert their sorrows into modest deeds.
"I have a lot of mixed feelings about it. Yeah, it's something I should do, but I'm so new here, it's sort of not my fight," Ramallo says. "I also feel that it's kind of pointless. They got it. They won. I don't know. The most I can do is help out at the local level, try to navigate others, push back in practical terms."
For some like Sam Coster, developing a studio culture that's welcoming and understanding of medical conditions is made easier by the family he shares a creative space with."All of us [at Butterscotch Shenanigans] feel it's the case that when people are really in a good spot, they're happy, and they don't have to worry about such things, they're able to produce creative work that's above and beyond what they can produce if they're stressed out," Coster says. "It's not just limited to your health. The stress is going to spill into your relationships, spill into your work, and it will spill into your finances in a lot of ways. One of the linchpins of a successful creative life is having a modicum of safety to do your work in."
The future of health insurance in America may not be clear, but Coster's disappointment is. "That our government, our representatives are uninterested in protecting that, there's going to be damage from that. I think until people realize that we can take care of each other—maybe not the ACA—but [something like that] is frankly a necessity for society to produce ridiculously good works that aren't just produced by people laid destitute by the whims of the universe."
"It's horrifying that a random probabilistic event that you have no control over in an extremely affluent society can essentially be the death of your future, if not the death of you."