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Comment by josho | Hacker News Reader

> people don't go to a doctor when they should or too late

I saw this when travelling in the US for work. (I am Canadian). Striking up conversations in restaurants I met staff that worked while sick because they couldn't afford to take sick days, or worked with chronic conditions because they couldn't afford a visit to a doctor.

Even worse are the major chronic diseases from our lifestyle (hypertension, diabetes, etc). These are largely preventable or manageable with early care. But, if folks don't see their doctor then the severity of the disease grows until treatment becomes something major like surgery or an ER trip (both much more expensive than preventive care).

In short. Yes, the US healthcare system is broken. Interestingly one political party's solution is to blame a past president and continue to undermine what you have, while the other party is content with the existing for profit model.

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> the US healthcare system is broken.

s/healthcare//

Yeah it's not just the healthcare system as that example shows. Imagine GP visits were free for that service worker. They still wouldn't go, because paid sick leave isn't mandated by law, so going still costs them money. And even if they do go, unpaid, they have no security in their employment as they can be terminated for any reason at all with no notice.

Many people are just too stubborn to go to the doctor. And many people go, knowing they can’t pay, because they’ll just never pay the bill and will dodge the bill collectors. Plenty of people receive free healthcare in the USA by virtue of never paying, but getting treated.

It’s the middle class who pays their huge bills. Insurance doesn’t cover why these days and deductibles are insanely high. The poor get treated and just skip out on the bill.

They never pay the bill, because they can't.

Do you understand how insanely expensive healthcare in this country is, especially if you're making minimum wage and have dependents?

What do you suggest they do instead? Die? Let their kids die?

It's not clear to me that @bluedino was arguing that people who can't pay for health care should go without. Instead, to me, the comments merely stated that such people can get access to health care. They can do this either by subsidized treatment, or by not paying the bill. We probably all agree that the US system has many flaws, but it is worthwhile to recognize the various routes to getting treatment.

First, if you're making miniumum wage, don't have kids.

If you do, you (or at least your kids) likely qualify for Medicaid, so you do get treatment. Often preferentially. I have been to providers who have a 6-8 week lead time on appointments for new private insurance patients, but Medicaid patients get in almost immediately.

Making minimum wage can happen years after having kids. I know a guy with two young kids who lost his job and is now making ~35% less. That’s not the kind of thing you can know ahead of time.

So part of your solution to healthcare is poor people not having kids? How do intend we accomplish that?

Not GP, but I read that more as "if you can't afford something, don't do that thing" coupled with "kids are not an exception to the previous recommendation".

It's not a matter of forcing that decision on people, but rather having the same expectation of personal choice and responsibility for that choice that we have for other health matters (exercise, diet, smoking, alcohol use).

Yes, well stated.

Yes. I think we need stronger education in middle school and high school as to what kids cost, and what they deserve in terms of a stable home and parenting, education, etc. And to not have kids until you are in a position to provide those things.

It's a biological drive so it's tough. But I think we could do better. We're too sensitve that we might be "poor shaming" or such nonsense to even discuss it these days.

> I think we need stronger education in middle school and high school as to what kids cost, and what they deserve in terms of a stable home and parenting, education, etc. And to not have kids until you are in a position to provide those things.

That's mostly value indoctrination (both the what they deserve part and the “do not do X if you cannot do Y” part fairly directly,and also the “what they cost” if it focuses on what a preferred approach costs rather than the costs of a spectrum of choices), not education.

> It's a biological drive so it's tough

It's also an economic choice, which is why birthrate declines with strength of social safety nets.

(Which is also why strengthening the social safety net is probably a better approach than trying to shame people into not reproducing.)

There's another group of people like me. I have a good job, with good health benefits. I haven't been to the doctor for myself in probably a decade. I just don't like doctors.

> I just don't like doctors.

Why? They're there to keep you healthy. Yeah, sure it can be uncomfortable talking to a doctor about personal health issues, but it's better than waiting until it's too late and finding out that "if only you'd come sooner, we could have helped".

They can do harm too. In my personal experience, they have caused much more harm than good. Not saying that for everyone, but ymmv with doctors.

Our understanding of the human body is very rudimentary. Basically doctors are people who memorized a bunch of questionable info and try to guess what to do. Give people in that situation access to highly concentrated chemicals and extremely sharp objects (eg scalpels and syringes) and you really shouldn't expect much.

Like Feynman said though, if you are deathly ill in the jungle you would rather go see a witchdoctor than some random person. At least they will have some experience caring for the sick.

So do you stand by your words? Do you have a a Do Not Resuscitate order? Would you reject emergency surgery after being shot?

>"So do you stand by your words?" - Yes

>"Do you have a a Do Not Resuscitate order?" - No

>"Would you reject emergency surgery after being shot?" - No

I suspect the real problem here is with your reading comprehension though.

> They're there to keep you healthy.

This is probably the issue under contention. I don't like doctors either (or really the entire medical establishment). Some part of that is a belief that they aren't in fact there to keep you healthy. No I'm not trying to argue something like profit motives or whatever driving an unethical effort to make you dependent instead of healthy, or say doctors shouldn't exist, or that I wouldn't go to one if I thought I needed medical care, just that I don't like doctors or the systems and methods they operate under (some by force). nonbel unpacks one aspect of the dislike, The Elephant in the Brain unpacks another aspect (e.g. by the finding that people who receive free healthcare consume a lot more medicine but aren't any healthier, which wasn't actually surprising for me to hear!), and there are other aspects for my dislike too.

Mostly this. I think most doctors mean well but but when you go looking for problems that you are trained to find you usually find something, and medicine is so defensive these days due to malpractice litigation that nothing even slightly anomalous is ever ignored.

> medicine is so defensive these days due to malpractice litigation

Is there any evidence of this? I've seen malpractice litigation similarly cited as one of the reasons behind the the high cost of health care in the US (which is also frequently disputed [1])

[1] https://www.nytimes.com/2014/11/04/upshot/malpractice-reform...

My dad is dying from a 20 cm tumour right now. He has insurance but put up with the pain of a growing mass in his pancreas and stomach for months because he didn't like going to the doctor. Had we picked it up early, they could have operated and put him on immunotherapy.

Please, go to the doctor early and regularly. It's not worth it, trust me.

> "Had we picked it up early, they could have operated and put him on immunotherapy."

Your story could be helpful to others. According to the doctors:

1) What is the years survived estimate of this vs doing nothing in your fathers situation (age, stage, etc)?

2) What are the side effects (and in general the quality of life) after/during this treatment vs doing nothing?

Also, these should both be some sort of histograms or at least ranges.

My grandfather was born in the 1890's in what was then called Indian Territory (aka Oklahoma). He refused to go to the doctor for his entire life. He had a heart attack at ~70 and died a week later in the hospital. No procedures, drugs, waiting rooms, or paper work. I really admire that approach.

The "middle class" you're referring to is literally everyone who has insurance. This has nothing to do with income. Non-payment is not the cause of the high prices. The system is broken in a number of ways. Premiums are a crazy percent of income, putting them out of reach for people who don't have employer subsidized plans. Even then, those employer subsidized plans get more expensive and provide less with each re-enrollment. Here is a small personal example of someone who works in tech for a very large enterprise and is lucky to have the means to handle it: I went to the ER for an issue, admitted for 6 days with a myriad of tests to diagnose. The total bill for that was over $100k. Even though I went to one hospital nearly, $40k of those billings were "out of network" and I had no choice in the matter. I easily met my high deductible but, there were still random bills "not covered". That made my part nearly 10k. This open enrollment period, my employer has decided to drop all "out of network" support because only 10% of the workforce used it in the past. So, if I were to have an issue like this again, my part would be in the neighborhood of $50k for a few test and few days in a bed. That's a scary prospect for a lot of people. For some, letting a bill like that go to collections may be their only option.

Uh, despite what you have heard about the ACA (obamacare) it actually did do a number of good things. One of which is limit total yearly out of pocket. So if you have insurance (no matter how bad) your max out of pocket is capped.

For 2018 the individual limit was $7350,

https://obamacarefacts.com/health-insurance/out-of-pocket-ma...

Which granted is a _LOT_ if your making $30k a year, but its not the instant bankruptcy many people discovered themselves in after situations like yours where the out of pocket for "good insurance" could easily go over $100k for fairly limited hospital says.

> And many people go, knowing they can’t pay, because they’ll just never pay the bill and will dodge the bill collectors.

Most providers (outside of ERs and the mandate for emergency stabilization therein, and some free clinics operated as charities) won't provide treatment without proof of insurance and any required co-payment upfront, or, for private pay clients upfront payment or fairly strong proof that payment will be collectible.

I think that's what he's saying - they go to the ER.

Yesh, but ERs are limited in services provided. The mandate they face with regard to service independent of payment is stabilization, not full-scope general medical service.

Going to the ER is a very common thing for many people. Even for cold and flu. So yes, they aren't getting general exams or long term care. They are getting immediate symptom based care in the most expensive way possible. This goes back to the issue mentioned above. People wait too long, go to the ER when it hurts but, it's too late.

https://boingboing.net/2014/04/23/tom-the-dancing-bug-lucky-...

Yeah, you're right, goddamn poor trying to be healthy when they can't afford it. Only people with money deserve health!

What's your proposed solution? Just murder the poor to balance the system? Which is, after all, what we already do, we just disguise it as "choice".

One of the problems is that it is expensive. More expensive than it has to be.

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