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Comment by nimbius | Hacker News Reader

Whenever I see these outbreak stories (sars, mers, etc..) and it affects a US citizen, I always wonder who actually pays for this level of intensive care.

Ambulance trips in the states are routinely $3,000. my trip to the ER after a wreck was $3800. If you dont have insurance, how do you pay for an "isopod" and a quarantine with a medical robot? What reasonable insurance company would ever cover these expenses? (mine hardly covers birth control.)

Healthcare is private here. When i go to the hospital they ask if "i am a member." Do these treatments take place at in-network facilities? is there such a thing as an in-network facility for being quarantined with an incurable new disease? Can I be compelled to pay for health services in this case if i DO NOT want them?

Its at least reassuring to see CNN is dancing around the HIPAA implicationf of misidentifying or identifying the patient...although I wonder if its only because they recently emerged from a slander/libel lawsuit for painting a highschool kid from kentucky as a racist during a rally.

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> who actually pays for this level of intensive care

If you have decent insurance, you pay your maximum out of pocket and insurance pays the rest (at negotiated rates).

If you don't have decent insurance, you declare bankruptcy and the hospital ends up paying for all except the few dollars they are able to get out of you. This is pretty much the same situation as when homeless people show up at an ER, which is legally obligated to help them regardless of ability to pay.

I think it is VERY hard to tell what is "decent insurance" anymore.

It might say that your hospital stay is covered on paper ... but then at the hospital the robot (or another doctor) might not be billed through the hospital and some outside group that is suddenly out of network.... there's no way to know.

The ACA mandates the maximum [maximum out-of-pocket] that an insurance plan can require. There's no such thing as good or bad insurance when it comes to extreme medical events. "Good" or "bad" depends on how much of your premium your employer covers and how expensive it is when you only use a little bit of medical services.

The worst-case max out of pocket for any insurance plan in 2020 is:

$8,150 for self-only coverage

$16,300 for family coverage

In America, it is important to have liquid savings to handle life events like losing a job or a serious health issue. We get taxed less, have fewer safety nets, so we need to build our own safety net. You can argue that one way is better than another way as a big picture, but many people misconstrue the individualist vs. collectivist societies as a serious moral issue instead of a choice. Some of the details of each can be serious moral issues, but the big picture is simply a difference in priorities.

Bottom line: If you can come up with $16k/year to cover medical expenses for a serious issue, you won't go bankrupt.

> If you can come up with $16k/year to cover medical expenses for a serious issue, you won't go bankrupt.

The US median income is $63k... $16k would be 25% of that.

Now consider the percentage of income that is claimed in European countries with free healthcare. Hint, it's higher.

The difference is for people with no or low incomes as the tax is used to pay for these. Social security.

If you put away 10% of your income for retirement and emergencies, a $16k safety net would only take a few years to build with an income of $63k.

Indeed, and do you know what kills you faster and more reliably than lack of free/subsidized medical care?

Lack of food (9 days), and lack of potable water (72 hours). Since we seem to be leaning towards the opinion that the gov't needs to provide everything for us and we should have minimal/no responsiblity for our own sustenance, repair, or longevity, where's the Free Sh*t Army slogans for no-cost food and water?

The US had a pretty extensive foodstamps program. It still exists but is slowly getting killed off. Even so there are multiple states in which 20% of the population has their food paid for by the government.

That's a rather polemic way of talking about this topic. No one but a strawman actually talks about "free shit" or "no-cost", it is about social distribution of burdens for these extreme cases. Paying a reasonable price for drinkable water through i.e municipal water companies seems to fit your "responsibility" requirement. Paying 25% or more of your _yearly_ income for a medical bill because you had bad luck...not so reasonable in my opinion and has nothing much to do with "responsibility". And let's not pretend it is about no costs or free things, everyone is paying for it through taxes according to their means. Are you seriously suggesting to let someone on disabilities or social security starve to death cause those are essentially your "no-cost food and water" slogans. This notion of "having the government provide" shows the twisted view on government, it's not a separate entity the money comes from society, society is providing, is that such a bad thing for a society?

Food-stamp recipients and folks on social security are completely different classes of citizen. Firstly, we expect the food-stamp recipient to eventually get off of them and start providing for themselves. The social security recipient has paid into the system their entire life, and they are now entitled - by virtue of having lived long enough and paid enough in - to start withdrawing the money they've been coerced into depositing.

Interestingly enough, most economic studies of social security show that putting the same money into a low-risk index fund would've netted more gains, plus that money would've been available to the person with far fewer 'strings attached' (vis a vis able to be withdrawn earlier if desired, descendants/spouses able to withdraw in case of untimely demise, etc). Coerced gov't meddling, again, has proven to be the more-painful economic road to go down, as opposed to letting individuals choose what to do with what they've earned.

>food stamp receipients

>folks on social security

I notice that you call some people "folks" while others are simply "receipients". Do you think poor people are human?

Certainly. But humans are supposed to be responsible for their own outcome, more often than not. America is the land of opportunity. Many people who are otherwise more than able to work, choose to Trustifarian it up and be a pimple on the backside of society when they COULD choose to be productive members. I am perfectly happy to pay taxes and lend a hand up. It's when I'm obligated to give a hand-out that I get cranky.

So you don't actually know of anyone who is abusing the system in the way that you claim? You're... just making stuff up?

I thought this "argument" around welfare queens had its day in the 90s...not the 2020s

Does that continue to year 2 after a huge claim or would the insurance price increase in year 2 to make up the expected gap the 16k limit might suggest to the prospective insurer?

No, premiums don’t increase. The ACA prevents insurance companies from considering medical history when pricing insurance.

Most people who can't come up with $16k/year in rainy day money don't actually benefit from lower taxes on the rich, because they are in the lower income brackets.

It isn't lower taxes on the rich, its lower taxes on the middle income.

For example, the French tax bracket for income between $28k and $81k* is 30%

In the US the rate in that bracket is 12% up to $39k and 20% after. If I did my math right that averages to 18%.

That isn't high income earners saving on taxes, that's a 40% lower marginal income tax rate for the middle class in the US vs. France. There are also many other sources of tax outside income which are different and higher in countries with social medicine.

* converted from EUR to USD

(taxation is complicated and making apples-to-apples comparisons is hard. it is easy to argue about fiddly details and hard to avoid a long list of caveats)

That net difference of 12% of your income will be completely eaten by the premiums of the cheapest, crappiest insurance plan you can buy in the US. Just the premiums - I'm not even talking about the co-pays for actually getting care (which are quite high on those plans.)

The poor and lower middle class aren't in any better position to save tens of thousands of dollars for medical emergencies, despite the lower taxes. Lower rates don't help, when your income is low.

And in California, that difference is a lot less than 12%.

The maximum limit is just ... the maximum limit.

How / when you might hit it is an unknown from plan to plan for the reasons I noted.

In / out of network is not relevant to max out of pocket.

In / out of network can dramatically impact what you pay out of pocket.

Not if you hit the max.

If you hit the max it is irrelevant, I am talking about hitting the max and going bankrupt.

At this point I'm not at all sure what this concept of hitting the max means as far as your response to my comment.

The costs of a given hospital visit is still an unknown leading up to the max... and how quickly you hit it is an unknown... and thus actually finding "descent insurance" is not easy.

As far as I can tell you seem to just be hooked on this concept that after you hit the max you're not paying and that somehow means something. Perhaps you feel that hitting the max is a trivial thing?

This thread is discussing the astronomical costs you would expect from robot-assisted quarantine procedures for infectious disease. That would be a case where the max out of pocket is what is relevant to consider.

If you hit the max, you can still be billed over the max.

https://time.com/5555988/medical-bills-out-of-network/

This lady had insurance, and yet was stuck with a $227,000 'balance bill'.

I'm no mathematician, but $227,000 seems to be a bit higher than the 8.5k max that this thread keeps citing.

25 of 50 states ban the practice, in the rest you are responsible for negotiating and fixing the billing discrepancy.

This kind of issue should be taken into account when choosing an insurance plan. If you choose one which has a restricted network, you have to be more diligent about where you get your care in emergencies.

Medical billing is nonsense though. Just because someone sends you a bill does not mean you owe it or will ever have to pay it. This is one of those details and rare occurrences which get way out into the weeds and doesn't really support the argument of which type of health care your country should provide. There are similar edge cases in social medicine where some situation or another is appalling. Extreme cases need to be handled, but unless they are common, they shouldn't drive the debate.

1. Those 25 states ban this practice, and yet this practice happens in them... As well as the 25 others.

2. Did you notice the anecdote in another part of this thread where an approved, in-network procedure at an in-network hospital had an out-of-network anesthesiologist, because every single practicing anesthesiologist in the region is out-of-network?

3. As a buyer of health insurance, how can I even know, ahead of time, that there's a problem, like what was listed in #2?

4. As a non-buyer of health insurance (Because my employer chose which one to buy), even if I knew about #2, I don't even have any choice in the matter!

It's ludicrous to expect people to do all the research they need to do, to avoid getting bitten, in an industry that is as hostile to transparency as the medical billing industry. Where do you even start? [1]

> Medical billing is nonsense though. Just because someone sends you a bill does not mean you owe it or will ever have to pay it.

Is this legal advice? Because as I understand it, there are plenty of places which will happily garnish your wages over medical debt, and there are plenty of hospitals who won't write off outrageous balance bills if they discover that you actually have savings in the bank. (Oh, and the ones that will forgive it... Are robbing the public, because they get to claim that write-off on their taxes. As a taxpayer, that's my favorite part of 'charitable debt forgiveness'.)

[1] And even if you could do that research, the problem of balance billing comes from your insurer, and the hospital not agreeing on which services should have been paid for, and sticking you with the problem. You cannot predict that, at all, because it is always an after-the-fact case-by-case scenario.

> We get taxed less

My friends from other countries say, not really when you add everything. Then add the US's system of 'private taxes' which drive up the cost of things like health insurance, schools, etc.

Even when you do have 'good' insurance...

When I had severe hypokalemia and was effectively paralyzed several years ago [1] (sorta comical read) they never once asked me about my dietary intake, instead they assumed I had some rare genetic disorder (in the ER the doctor literally told me "we're googling your symptoms") and once I was admitted they paraded 3 doctors through my room and billed me for 5 or 6 'consults'.

While I considered my insurance to be 'good' getting dinged for each of those 'consults', 2 times each, despite only ever having seen 4 doctors total (one an ER doc that was probably a year or two into his medical career) face to face once each I ended up paying 10-12 different 'consul' fees, then a portion of the ambulance, then a portion of the room, the two different physical therapists they sent by after declaring me a 'fall risk' since I came in functionally paralyzed, then a portion of all the tests. From the time I set foot in the ER until I left I was there about 37 hours.

All they had to do was give me some oral and IV potassium and I was fine. I actually diagnosed it myself, with no medical training whatsoever, in the ER unable to move 45 minutes before they did. My mother was there and after I'd somewhat calmed myself (I could not move, I could barely move my fingers) I told her it was probably a sodium potassium imbalance and I could probably still make it to work for overtime that morning. I ended up paying a little bit under 7k$, 1/4 of my gross income at the time, with my 'good insurance'. Took me 4~ years to pay it all off.

[1] https://www.ryanmercer.com/ryansthoughts/2013/2/19/flashback...

I had a minor procedure a few months ago. Hospital, surgeon, etc, are all 'in-network' the anesthesiologist, however, is not. And there is only one 'group' for anesthesiologists in our town.

I didn't even know that an out-of-network provider was involved in my surgery until after it was over. A couple of weeks after the surgery, my insurance company sent me an unexpected check for $3,000. I called and asked them about it. They said, "It's to pay the surgical assistant. They're out of network, so we can't pay them directly." I had no idea that a surgical assistant was even there. (I hadn't yet received the bill.) The insurance company told me that since I had already been anesthetized and couldn't ask the surgical assistant if they were in-network, I didn't have to pay anything out of pocket for the surgical assistant.

Anesthesiologists are never in-network, it's usually the most expensive part of having surgery in the US.

Another major annoyance -- if you have surgery, the hospital usually gets their money from you right away. However, you're going to spend the next 18 months receiving random bills from various different firms representing nurses, doctors, lab technicians, etc. related to your procedure, many of which come down to "stuff we decided to do while you were unconscious."

That has been exactly my experience with a very minor event a few years ago. The bills kept coming at random intervals for about 18 months, some for a few tens of dollars, one or two for hundreds, others for literally $0. I just had no visibility into it and honestly would only be half surprised if now, 8 years later, I received a bill for $17 for procedure AU8-QB-12 from department CO9-s4 (and the bill would mention that my insurance paid the other $872)

Most plans have clearly stated out of pocket maximums. That is the most you are going to pay in a given year.

That doesn't really provide you much information as to coverage and how likely you are to hit those maximums.

Carpooled with a friend to the pharmacy. His family and I were all exposed to influenza A, and for different reasons all decided to take Tamiflu.

My cost was 10 times his. His whole family for less than half the cost of just myself. My initial suspicion was he got generic and I didn't. Nope, same box. He's said before he has 'good insurance' but it's almost always just talk. Guess it wasn't in this case.

> you declare bankruptcy and the hospital ends up paying for all except the few dollars they are able to get out of you.

Does that mean the entirety of your life savings and any liquidatable assets?

401Ks, IRAs and other retirement plans are usually protected unless the creditor is the Federal government, e.g. the IRS or the Department of Education.

> 401Ks, IRAs and other retirement plans

What about non-retirement investments? Aren't you only allowed to put so much into a retirement plan per year?

Non-retirement investments are subject to seizure to pay creditors.

Yes, retirement accounts are limited in terms of annual contributions. But bankruptcy protection is one factor to consider in whether to max your contributions and/or to pay ahead on the mortgage on your primary residence.

That's incredibly depressing that there is a whole class of people who are doing perfectly fine, can even afford to pay ahead their mortgage or their retirement plans if they want, that are one illness, with all it's impossibly insurmountable debt, away from bankruptcy.

Combined with state bankruptcy protections practice this means that most middle class people who don't have tons of money in a bank account, a home that is not their primary residence (or in their primary residence above whatever value their state protects) are decently protected but the upper middle class who often does have those things loses them in bankruptcy.

Its complicated, there are usually certain assets you can keep in bankruptcy in the US like your primary residence

You don't always declare bankruptcy. Medical debt can't be deducted from your wages and is usually negotiable with zero interest payments and for massive reductions in amounts. And after enough time, most hospitals will just write it off. And in exchange you can walk into any hospital in the country and they have to provide you emergency services.

If the healthcare providers are in network, i.e. the insurance company and the providers have reached a pricing agreement. Otherwise the providers can bill you whatever they want.

Or option 3: they don't go to real hospitals, use perscription medicine, or see real doctors.

> which is legally obligated to help them regardless of ability to pay.

Which tangentially makes all the Rand Paul bullshit about doctors being slaves under a universal healthcare system kinda moot.

I know intelligent people aren't making that argument but it's a reasonable counterpoint in case you come across one of them

Your argument is inconsistent.

If we accept the premise that being legally compelled to treat a patient makes a doctor a slave, it is perfectly reasonable for Rand Paul to argue against the expansion of such a law. Similarly, the current existence of such a law does not contradict his moral stance unless he advocates or supports the current system, which he does not.

I don't believe it is. Rand Paul's entire platform on the issue is based on a false premise. Nobody is putting guns to doctors heads, there is just a legal impetus for hospitals to treat sick people, rather than sitting around demanding payment while the house burns.

He makes the argument entirely because he was searching for something to support his platform, not the other way around. He doesn't appear to even delve into the issue beyond healthcare == slavery but rather focuses on supporting his strange forever contradictory hyper-capitalistic vision. As such he waives any possibility to debate the issue from the position that he doesn't support the current solution because he doesn't support anything.

>If you have decent insurance, you pay your maximum out of pocket and insurance pays the rest (at negotiated rates).

I think the OP's question was more: who decides this person gets treated by a state-of-the-art robot, while this person gets a prescription and told to go home and rest?

If you can't pay, the hospital absorbs the cost to a degree. Hospitals are most likely also part of a larger "reinsurance" type pool to keep expenses manageable.

My mom worked in healthcare billing her whole career. My understanding is that half the reason medical bills are so high for normal people is they need to cover the costs for the people that need and have received care but were unable to pay.

In this particular case, it's a matter of national security, so I'm sure the needed funds would magically appear if needed.

Only if the hospital is state run. In WA the University of Washington hospital routinely runs losses because of this. Private hospitals can give you the bare minimum and kick you out the door.

The "bare minimum" required by law is still "doing whatever is required to save you life". They cannot legally kick you out if you are not stable.

Stable is subjective. It's also common for non-state hospitals to say "outside our expertise; transfer to state run-hospital".

Thing is the state hospitals will actually try to cure you; and they are fairly good at it. Harborview (part of University of Washington) is the only L1 trauma center in the region.

For-profit hospitals stick it to the taxpayers by doing this. It's a good argument for some form of universal healthcare, since we're paying one way or another.

except they (the doctors at the hospital doing whatever is required to save your life) get to decide what "stable" means. I imagine for many doctors that get into the profession because they care about their fellow humans, the answer is sane, but I imagine there are still plenty of for-profit hospitals/doctors whose idea of "stable" is much lower.

But stable doesn't mean (for instance) treating your very treatable brain cancer after discharge. They will remove the tumor causing falling and doziness, but won't provide radiation / chemo follow-up until its terminal and you have to be inpatient.

>half the reason medical bills are so high for normal people is they need to cover the costs for the people that need and have received care but were unable to pay

Sounds totally fair and reasonable to the people who get crazy high bills for the one thing a year that they need it for, despite paying hundreds a month in premiums for the "privilege" of also paying for people who can't. What a system.

Yea. It's a mess.

I don't see why the patient would pay for it. If the country / state wants him quarantined and treated by a robot then they are going to have to take that upon themselves.

Otherwise the person could just choose to freely infect as many people as they want because they can't pay for specialized treatment.

It would be nice if the real world was as rational as this. However, this is America. We always find someone to pay.

I'm more curious what happens if you try to refuse treatment. The legal basis for forced quarantine is shaky (The CDC tries to justify it on the Commerce Clause of the constitution), and trying to charge someone for a treatment they refused has some obvious issues.

I believe in extreme cases such as this the hospital considers it an academic/research/prestige/security cost and would essentially charge the patient nothing or standard daily rates. I know when the Ebola scare happened in the US the prestigious hospitals near me were throwing $1,000,000's into constructing state of the art rooms for preparedness and to impress the CDC and get federal approval and academic recognition.

Also the hospitals can write these costs off of their taxes in various ways. If outbreaks like this cost them millions in expenses they have tax loopholes and it ends up costing them nothing.

Im continually amazed at the way people think "write offs" work.

If a company spends X dollars on something, they don't pay X dollars less in taxes. They pay X dollars * their marginal tax rate less in taxes.

Now they may be able to apply for grants or other types of funding, but there is simply no way to "write things off" and then get them for free.

I agree, I oversimplified for the sake of brevity. I also don't know the details for hospital accounting, only the generals and that it is very complicated. In reality it would be they spend say $1 million on these cases. They could then say it was a public service and take it off their overall income. CDC or other grants might pay the rest depending on the severity of the outbreak. Whatever isn't covered would still be potatoes for most hospitals and worth more in prestige than the hospital could have bought with the cash. Again, I literally saw hospital executives fight over Ebola patients.

Society as a whole benefits from an infected person being quarantined so therefore society should also pay for it.

Is that not the case?

I'd assume the US has programs/budgets for this sort of contingency funded at the federal level?

Until Obamacare, even flu vaccinations were not commonly covered. Your logic is sound but unable to cope with the insanity of the US healthcare system.

I recall an article a few years ago about the google founders (?) paying for kids in San Francisco to get vaccinated. The comments were split between Americans praising the act and Canadians that were confused.

Flu shots aren't necessarily free in Canada.

They were $20 or so in Quebec if you weren't in an at-risk group. https://www.quebec.ca/en/health/advice-and-prevention/vaccin...

Even in most of Europe you pay for the flu shots yourself or you can get it done cheaply at a free clinic with the downside of long waiting times or some companies will even bring in doctors to administer the vaccines to their employees for free on site.

just got a free flu shot last week in Finland when visiting a nurse.

If it's a serious outbreak I'd imagine the CDC would be footing the bill, considering they want as much information about the disease as possible.

HIPAA regulates healthcare entities/providers, e.g. what info they can give out about a patient. Not journalists themselves.

Insurance covers things to a point as others mentioned, but you may not know what tests or procedures they'll run. Will all the doctors you see be "in-network". Sometimes ambulance trips are not covered if you don't get admitted, so it's a gamble. It's exactly what we'd want a life critical service to be. (/s).

In addition to that, workplaces also give out limited number of sick days, so people don't go to the doctor and go to work instead. They ride in public transportation to get there, maybe stop at the store on the way back if symptoms haven't gotten too bad, handle some produce and so on. Well we see where this is headed. I think once something like this virus comes to a large city in US, it just has a pretty good chance of spreading and in large to our broken healthcare system.

I'm not a lawyer, but it looks like the CDC pays (or at least has rules allowing them to pay) for some stuff that insurance doesn't cover. But you may still have to pay deductibles.

This page has a lot of good info:

https://www.federalregister.gov/d/2017-00615

Particularly the "Payment for Care and Treatment" discussion here, which talks about public comments and even gets into the ethics of what you can make someone pay for compulsory treatment or isolation:

https://www.federalregister.gov/documents/2017/01/19/2017-00...

And the rules in 70.13 and 71.30 here and here:

https://www.federalregister.gov/documents/2017/01/19/2017-00...

Excerpt from the rules in 70.13 (which I think covers domestic stuff):

> Director may authorize payment ... Payment shall be secondary ... after all third-party payers have made payment in satisfaction of their obligations ... For quarantinable communicable diseases, payment shall be limited to costs for services and items reasonable and necessary for the care and treatment of the individual or group for the time period beginning when the Director refers the individual or group to the hospital or medical facility and ends when, as determined by the Director, the period of apprehension, quarantine, isolation, or conditional release expires.

I don’t think that CNN is a covered entity under HIPAA.

I'm not sure what you mean by "implication of [...] identifying the patient". Although I didn't see any personal information in the article, there isn't a law in the US that prevents a news agency like CNN from identifying hospital patients. HIPAA only covers entities like health insurance companies, care providers, and their business associates.

I think the summary answer to these kinds of questions is "if a pandemic gets loose in the present day USA, you're fucked".

In theory, preventative treatment for epidemics should be paid for by underwriters (the people who insure insurance companies).

In practice, that poor bastard is gonna get a huge bill for saving the rest of us from his illness. I hope at least his friends buy him free beers for a while.

I would imagine the cost of isolating patient zero like this is much lower than letting it spread.

Just say "We're still incubating here but I can pay you in exposure!" on the way in. That should get the message across :-)

And you could mention that you're pretty agile, so if they don't like your terms, you might move fast, break things, and make a disruptive exit that leads to an acquisition they won't like.

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