The Cost of Not Getting Tested for Coronavirus: A $10K ER Bill | Hacker News Reader

The Cost of Not Getting Tested for Coronavirus: A $10K ER Bill

thecity.nyc

103 pointssmacktoward165 comments

We decided (slash "made the mistake") of going to the emergency room last summer. Spent less than two hours in an exam room before being dismissed with no conclusion and referral to another doctor. Got a $9500 bill about six months later and have been billed a 10% copay on that (insurance paid $5500 already at their negotiated rate). Still fighting it as absolutely absurd, but there's really no hope. This country is fucked. It's an embarrassment.

Meanwhile, I went to the emergency room in a hospital with my girlfriend in London two years ago and it was free for her. We're Americans.

Guess which country has better health outcomes.

Yeah, here in the UK she could've been told that she wasn't going to get tested for coronavirus over the phone for free. It's a much more civilized system. (Though to be fair, we did a little better at adding Italy to the list of qualifying countries promptly than the USA.)

UK tests per million: 387

USA tests per million: 26

Not really the same.

There should be some adjustment for expected exposures, no?

If you believe the numbers, the UK has 6.9 per million infected, and the USA has 4.1, so they're pretty similar.

You shouldn't believe the numbers, though, because the USA is barely testing people—and not because they aren't sick; testing in the US is often expensive, as obviously idiotic as that is. I'd expect the USA to have a higher number of infected per capita in actuality.

>Guess which country has better health outcomes.

The US, by all objective measures.

https://en.wikipedia.org/wiki/List_of_countries_by_quality_o...

It's actually not uncommon for Brits to travel to America to pay for treatments not available on the national health or to avoid the often years-long waiting lists.

Mmm yeah I wonder.

UK: someone dies of cancer or whatever. Enters the statistics as cancer death. Drags down outcome.

USA: someone dies of cancer or whatever. Was poor. Gets buried. Cancer statistics unharmed.

You still have to report some cause of death.

And how well does that work do you think? Given how many are misdiagnosed or undiagnosed before death, how much money and effort do you think is spent on the cause of death for some random, (literally) poor corpse?

Of course "some" reason will be logged.

You were implying, that sloppiness leads to reduced cancer statistics, painting a better picture for the US. Well, if another cause of death is used instead, the picture will look worse for it. There is no escape.

I think it might actually!

(Like obesity, heart failure, complex some-or-other, "natural causes", take your pick.)

On the other hand, https://www.salon.com/2018/03/05/americans-still-have-to-go-...

Here "Not uncommon" means "Very uncommon" because of course as this story illustrates US medicine is _ludicrously_ expensive and so the only reason you'd _travel_ there to get medical treatment is because that's the only place offering some obscure treatment you want.

Also is that list of really weird stats "all objective measures" ? No. It's just "Here are some numbers somebody seemingly randomly picked from a _vast_ array of statistics kept for the OECD".

>... so the only reason you'd _travel_ there to get medical treatment is because that's the only place offering some obscure treatment you want. <

When is this not true though? Of course traveling farther would be less desirable when moving between developed countries, it adds burden and costs on top of whatever you were already going to have to pay without offering much opportunity for recouping costs. The only exception might be traversing the EU but that's because of geographical convenience more than anything else. America is literally across the sea, if we're cheaper for someone in the UK then someone fucked up somewhere at the NHS.

My point is, if you're sat in say, Liverpool, and you see the elective surgery you want is six to nine months out but that seems forever, you don't go "Oh, let's fly to San Francisco and get it done privately there, we can spend the kids inheritance" you start looking at private providers in Liverpool (there are several) or maybe Switzerland. You are attracted by a good price in say, India, or a friend recommends somewhere in Eastern Europe.

The US is very expensive compared to other private options is my point.

40 million Americans don't have healthcare[1], and another 38 million have "inadequate" health care[2]. Together that's more than the entire population of the UK.

It's not so impressive that if you only treat the richest with the best jobs who can afford the best treatments, you get better outcomes than systems which treat everyone.

[1] https://www.cnbc.com/2018/01/16/americans-without-health-ins...

[2] https://www.pbs.org/healthcarecrisis/uninsured.html

I’m one of the people without healthcare and everyday I pray for my family, “I hope we stay in good health and don’t have to see a doctor or the hospital, one small thing and we’re likely to be bankrupt”

People take UBER to the hospital now instead of an ambulance. #Merica

IMHO, you're mis-stating the problem. One should take an uber/friend to the hospital if the ailment is not time-sensitive or in need of ongoing treatment so that the ambulances are freed up for more critical patients. Ambulances should have some level of cost associated with them to dissuade using them for minor ailments. Should that level of cost be thousands and thousands of dollars? Probably not.

Shouldn’t dispatch triage if you need an ambulance or not?

In other countries they do that so aggressively that we have stroke victims dying, which an ambulance being dispatched.

On the other hand, given that triage failures are rare -- cost/benfit wise it's probably better.

In countries where you can call an ambulance like a taxi, won't that lead to ambulances not being available to people who actually need them?

GP was making the argument that high costs of an ambulance is necessary.

Don't need to be a cost... We could just have 911 send a taxi instead.

I know in other countries ambulances are not always dispatched, because 911 operators decide it's not critical.

Mostly this decision is correct, but from time to time a heart patient dies. (Maybe the alternative should be to send a taxi)

Is that a thing in other countries? Sounds like an excellent idea for a bill here.

In Denmark we have cases where ambulances are not dispatched because operators don't think it necessary..

But I don't think the dispatch taxis instead -- besides our taxi availability is highly limited and extremely expensive (Uber being prohibited). To be fair taxi drivers are certified, and service is IMO high quality.

For example, some years ago on holiday to Edinburgh I had terrible diarrhoea. Probably norovirus infection. Fine, holiday spoiled but I can sit in a hotel room, stay hydrated and watch Netflix in the calmer moments. Then I began shitting blood. OK, that definitely might /not/ be fine, need somebody to check.

So I call NHS Direct, they agree that unexpected blood is potentially urgent and I arrange a taxi in the middle of the night to go to the closest Urgent Care clinic. Taxi driver did completely fail to find the right entrance to the hospital, but I was just sick not stupid so I followed the signs he'd ignored and went to Urgent Care. I was the only adult, every other patient was a sick child whose parents were probably worrying too much. A doctor takes a look, goes yup, just what you'd expect, not serious but thanks for checking, disapproves of my "Crisps and full fat Coke = Salt + Sugar + Water = acceptable rehydration" approach and hands me nasty tasting rehydration powder. Boo but since I'm the one who just dyed a toilet bowl red with their own blood I vow to follow their instructions. Taxi back to the hotel. All better in time for the trip home. Still have the last sachet of rehydration powder somewhere actually, it's probably expired but can't taste worse now than it did then.

NHS Direct is really handy, because it's often tricky to judge the correct amount of urgency or know how best to access the service you need, especially when far from home. But I don't see how you could build a trustworthy service like that under the US system.

one can wonder when Uber would get into the ambulance market.

I paid something like $800 for one crutch when I sprained my ankle once. Think another $300 for ibuprofen. Now I know why there's a crutch market on craigslist/thrift stores. Not sure what my insurance paid for xrays, etc, but my tab was something like $1100 for that ER rendezvous. Thought I broke my leg.

I had a laparoscopic surgery a few years ago that was $35k.

to be fair, you paid a doctor to administer you a crutch and ibuprofen, I'm certain that's not the raw material cost.

That's not fair, because the doctor no-doubt billed separately.

separate line items, typically

Do you really think current health care is giving accurate line items on your bill?

Accurate or not clinician time is typically billed separately, as are drugs, individual procedures, equipment, etc. Some stuff is rolled up but not that much; hospital accounting systems are quite comprehensive and structured in such a way to help them argue with insurance companies.

So the argument that the crutch is expensive because an MD handed it to you probably doesn't hold, the clinician files something, probably under a CPT code, and you were billed for that separately.

This depends on the service of course, you may see say a CT scan where the room time & tech etc. are rolled into one item, but the radiologist review is separate. So it isn't just people vs. equipment, etc.

I never said it was the only reason. The reason it costs so much is because you aren't paying for the raw material. You're paying for a service. That service happens to be laughably bad and expensive, but that's what you're paying for.

I don't understand your contention then, as this was a response to a very specific scenario that does not happen in practice.

I wish that was the case. If you sort the line items by cost, I would be surprised if labor was on top. Maybe for surgeries, but I doubt that.

My insurance got billed 6k for a chest ultra-sound. They paid 4k. Hospital still wanted around 2k, had to negotiate and pay a little over 1k at the end.

The line item for physician cost (billed separately) had 2 digits.

>If you sort the line items by cost..

Do you really think current health care is giving accurate line items on your bill?

Wouldn't a bill with inaccurate line items amount to a form of fraud?

Meanwhile, I got a doctor consultation and referral, X-rays, a temporary ankle brace, and two crutches, all for $240 from an urgent care clinic (no insurance help). That's an actually fair cost. Hospitals tend to be huge ripoffs but maybe not urgent care clinics.

there's a line item in the bill of $750 for "1mL iodine"

My wife just got a replacement mask for her CPAP (that would run 120$ up here in Canada) for 10$ on wish - except for the packaging it appears to be absolutely identical.

$800 for a crutch is insane. especially considering that one could do with some handy woodwork and some sticks if it was truly necessary.

To put it in perspective, I broke my ankle 3 years ago, and in the end, I paid, from my own pocket, 45EUR. For 1 ER visit, x-rays, cast, a few follow-up consultations and renting crutches for a few weeks.

An opposite example, went to the ER last year and spent a couple hours there. Paid a $100 copay. Haven’t seen any other bills.

Gonna go out on a limb and assume you have good health insurance. Many (most?) Americans do not. I'm on an HDHP for example, so the first several thousand dollars in medical expenses per year come directly out of my pocket before insurance starts helping at all.

i work for a tech company in the fortune 500 top 25... i would assume the best insurance possible, still killing us (paid nearly $7000 out of pocket last year + the actual premium costs of several thousand more). i've got three small kids including one with a heart condition, so it's particularly bad right now.

For insurance, I have found it's difficult to beat the negotiating power of the multiple large Federal Government offerings - and you can shop before you decide to join:

https://www.opm.gov/healthcare-insurance/healthcare/plan-inf...

> i would assume the best insurance possible

That's usually not a good assumption to make, not even among the FANG. There is extreme variability even with the same insurance company, depending on the negotiation between the company and the provider. And very few companies actually have any incentive to even provide the best 'possible' coverage.

Just looked it up and we're only in the top 50 (insert crying smiley).

And I got downvoted here for saying that I would require a LOT higher salary to move from Sweden to the US. Your example is why.

A $5k bump in salary should probably make up the difference in the average year. That's not a "LOT higher salary" by my reckoning. Hell, the difference in tax rate alone would easily make up for that, even if the US salary is lower (which seems likely to be opposite of what would actually happen).

Or the debt collectors haven't caught up yet. That happened to me around 2012 in the US. Went to the emergency room, had some tests done, got the hospital bill and paid a few hundred bucks. Then like 9 months later I get calls from a debt collector saying I owed $1,500 to a separate medical testing company that apparently provided the test I was given at the ER. I had never received that bill and it just took a while for them to send it to collection apparently.

Right, but you also benefit from the fact that it's an HDHP, right? Must you be on an HDHP (because the other plan is too expensive, or because another plan is not offered) or did you choose the HDHP even when presented with the options?

The big up-front deductible and an HSA is pretty much the point of the plan, and it's mostly advantageous to those that are young and/or don't have to go to the doctor that often, with a max downside of their deductible + catastrophic.

EDITL To be clear, I also believe significant reform is required, but there is also a lot of misunderstanding about how plans work which is not helping. The whole industry is extremely opaque.

The HDHP works out in years in which you need no medical treatment beyond the covered annual physical. Once you start needing anything, it ends up being a worse option. I discovered this a few years ago when I broke my ankle.

The big upfront deductible seems like exactly the wrong way to structure a healthcare plan, as it disincentives getting treatment until things get really bad.

True, but if you can offset that with an HSA to cover your entire deductible and sweep the rest into a qualifying retirement plan it makes a lot of sense _and_ you don't have to worry as much about the deductible. Note: I am on a typical PPO and optimizing for minimum catastrophic amounts, generally so this is not the way I usually go but many colleagues seem to like these plans

When I lived in the states I was on a medication I needed to get filled every month (Methylphenidate for the curious) due to life situation my cost to do so varied in this manner over the span of half a year:

30$ (1$/pill) while on uni insurance

0$ on state healthcare while unemployed (Green Mountain Care)

270$ (9$/pill) while employed and not qualifying for employer healthcare

120$ (4$/pill) while employed with my brand name uncovered (but discounted due to an Aetna preferred rate)

3$ (10c/pill) while employed after switching to the generic

Healthcare costs in the US are unpredictable, arbitrary and cruel.

It's pretty crazy how this works. Despite having pretty good coverage, I often use GoodRx because the prices are so much cheaper than using my insurance...

Ha! So I work adjacent to the insurance industry and, hilariously, sometimes tier based copays on medication fills can exceed the pharmacy's price - usually pharmacists will catch this and just never bill the insurer, but sometimes patients can end up paying more for a drug because of their insurance.

Healthcare is all kinds of insane at every level.

Yeah. A lot of people focus on the insured vs uninsured gap - if you're uninsured you're fucked. But the reality is that, even with insurance, medical care is a disaster. Finding a doctor in your network, waiting months to see them, completely unpredictable costs that, to me, borders on fraud, etc.

I've recently started a company, and at the same time a friend was laid off, and over the last 6 or so months I've gotten to experience the absurdity of this system from a few angles. It has been eye opening.

The whole waiting months thing is so shameful, since it is a major talking point from people arguing in favor of the status quo. They point to wait times in Canada, which are entirely misinterpreted and never point to the fact that it can take months to see a specialist in your network in the US. Heck, the number of times I've been told "this Dr. is not taking any new patients" or some version of that, is astronomical.

I'm up here in Canada - my wife's uncle had to wait three months for cataracts surgery, cataracts surgery is good in the long run and extremely non-urgent. He also had to have a rotoplasty in his heart to clear out plaque, he was booked into surgery within a week - my wife's aunt fell off a cliff (a small one) and got a concussion, she had excellent care.

In Canada non-urgent procedures have moderate wait lists, and urgent procedures get immediate attention. In the US monied patients get immediate attention and poor patients get long wait lines.

Honestly, this rationing BS needs to stop, the people spreading it are either maliciously disingenuous or misinformed and I'd bet quite a few are acting maliciously.

Went to the ER last year with fever because the insurance told me to go to an ER. Saw the doctor for five minutes and was sent home. Still calling the insurance and the hospital over a $500 bill that was supposed to be covered but somehow they keep sending it. My girlfriend once got a $300000 after a surgery that required a five hour stay at the hospital. It took her two years to clear that up.

My daughter had an allergic reaction to food last year, which required us to give an epipen. We were told when this happened that we needed to call 911 and have her taken to the emergency room for observation and potentially for further treatment. We did, the ambulance came and took her to the hospital, which is under a mile away. We then had a similar experience to yours - spent about 2 hours in the hospital being observed, then were dismissed. We eventually got a $2k bill from the ER, which our insurance paid, and a $4k bill from the ambulance company, which our insurance didn't pay.

That ambulance bill is insane. Up here in Canada ambulance charges are paid out of pocket but my wife had a low blood pressure emergency and got an ambulance called and was only out 300$ for a three mile drive (through dense city streets even).

I'm even of the opinion that that bill was a bit excessive.

$300 seems low.

'The distance' is basically irrelevant.

You're paying for a highly available, rapid response team to be prepared for almost any medical emergency, 24/7, literally almost at the press of a button.

'Preparedness' is expensive. What happened if the Ambulance broke down? Or a medic decided to say f-it and skipped a day. Or the phone didn't work. Or the critical piece of gear didn't work. Or ooops ran out of gas (hey doesn't happen often, but it happens!)

To get all of those things to 99.999% is quite a bit expensive. Constant vehicle checks/repairs/updates. Backups. Process, procedure.

The amount of training required for Medics should be quite a lot, considering the first few minutes of any problem are usually the most critical, and it can be 'anything'.

My unscientific 'instinct' is that $1K per call seems to be more or less in the right ballpark.

There should be some kind of insurance for this, one way to make it more palatable would be to have it subsidized. People who call more often I think can be expected to pay a little more but we can't be breaking the bank on folks.

Given that healthcare is a skyrocketing part of the economy, I wonder if we're going to end up with a kind of triage in Ambulances as well - i.e. ambulances for crazy life-threatening things, and ambulances for more common things which mostly require 'getting to a doctor quite soon, please' i.e. this is important, I need to go to the front-of-the-line'.

Edit: actually, $300 is definitely 'too low', there probably is some kind of subsidy.

Very crudely suppose an average call may last 1 hour. Suppose due to scheduling, that an ambulance may be idle for 1 hour in between calls. So the 'average call' would be 1 driver, 2x medics, for 2 'man-hours' each. Of course, there's other labor overhead: for each ambulance, there might be 0.3 mechanics, 0.3 dispatchers, this before we get into all the other unit an ancillary costs. $100K/year for any kind of professional in the medical field is ballpark reasonable, that's $50/hour - so we're looking at roughly $300 just for the immediate staffing - not including the mechanic, dispatch, op staff, gas, insurance, training, facilities, advanced equipment etc.. So very crudely ... ambulances are expensive.

Edit 2: yes, I'm talking costs here, obviously this is different than what people end up paying as a commenter has indicated.

As with so many things in healthcare, if it's such a great system, why isn't it used for the military? Medevac helicopters are really expensive, so why not make individual troops decide whether their case merits a few year's pay?

Misplaced sarcasm aside, the military makes very excessive use of basic triage.

Medevac is not called for 'asthma attacks' I can assure you.

$300 is a user fee, a fraction of the actual cost, which in Canada we do pay for through an insurance scheme called taxes. (Most other medical expenses are covered through our single payer insurance, funded though provincial income taxes, but ambulance service is paid for by property taxes, I think).

Different country, but pointing out some reported data on actual costs:

https://www.stjohn.org.nz/news--info/news-articles/st-john-a...

In New Zealand one of the major ambulance services reports costs of around $615 including taxes per callout.

However, the charge passed onto the customer is set at $98 for medical emergencies. This is waived for accidents (covered by the government).

A $4000 ambulance bill is offensive and I don't think justifiable in any way.

Hell, New Zealand only charge $800 (USD500) for non residents!

In New Zealand if you get tested (free) positive for Coronavirus they'll put you in hospital (free). Assuming you've collapsed and need to be taken there in an ambulance, you'll still have to pay the $98.

Hopefully, the hospital won't put a lien on your home. Some states allow them to do that.

As someone not from the EU, this is something totally insane and crazy. Once, after my country got out of the Soviet Union, the US was seen as the dreamland of everyone. Now.. I don't think so, when getting sick with something easily treatable will ruin your whole life. That's just not a place I'd like to live in.

Once I was on a date with a younger girl and she was going on about how she'd like to live in the US, and I, being kind of a nerd had a Sheldon type of moment told her how awful it is, and she said "thanks, you ruined my dream". And she was talking about how she spent a summer as a barmaid there, got tonsilitis, visited a doctor who made her take a test for tonsilitis and got billed for it. Here where I live.. you can see that when someone has 1) a high fever 2) inflammation in their tonsils 3) has a swollen throat and white stuff there because of it then they have tonsilitis and you don't need to make additional lab tests, because it's 100% obvious, you don't need to waste time and money on useless stuff.

It is not always obvious (e.g. strep throat is similar, but one or the other sicknesses may or may not need medicine) and doing things on a hunch is not how scientific fields should do things when there are simple tests.

Testing also provides safety for doctors against medical malpractice lawsuits.

What made you decide to go to the ER instead of scheduling an appointment with your GP out of curiosity?

it was acute gut-wreching pain that we weren't sure what to do about, didn't know if it was going to get worse... we should have gone to an "urgent care" clinic, which was our mistake.

The statement from the hospital management boggles my mind: "In addition, there are different parts to a patient bill. One part is what the hospital charges the insurance company, one part is what the insurance company eventually pays [...]"

I can't think of any other business transaction where someone just puts a giant number on a bill and then is happy if someone pays ~25% of it. Such companies would be shunned by their customers and they'd go bankrupt. Is there any economic theory which explains how such odd of an system can emerge/survive?

A lot of businesses work like that. There is a retail price and then a discount is applied depending on who you are. That's kind of how all retail works, really.

Even working with Amazon or Walmart is kind of like that. You invoice them for one amount, but you get paid much less based on different deductions for things like discounts, co-ops, damage allowance, etc.

Nothing about hospital billing would fly anywhere else. Bills just showing up after the fact with little ability to verify their accuracy, constant errors one can catch anyway (so how many are missed?), bills showing up months later from a half-dozen different sources when you only had one apparent "vendor", and so on.

I bet we received between 100 and 200 pieces of mail for each of our kids' births, including maternal care before the births. Probably averaged 40-60 hours dealing with billing and billing problems with each one, maybe more. And ours were all totally normal and about as easy as it gets, and we had insurance. I think we ended up missing some tiny bill we could easily have paid in each one (oh, yeah, they also like to give you very little time to pay) and had them go to collections.

I found a bill with a mistake on it, as one of my kids was charged twice for a single procedure. I called to get it fixed, but instead of dealing with it they just immediately sent it to collections.

My experience has been that no one at the insurers nor at medical providers’ billing departments give a shit until state regulators and/or legislators’ offices get involved. Which means yet more time on the phone.

The amount of time lost dealing with this system of ours is incredible. All else being equal it would be a win just to eliminate that, and there’s no reason to suppose that is the only improvement we could achieve.

Here is an overview of the economics of healthcare from a textbook: https://scholar.harvard.edu/files/mankiw/files/economics_of_...

Awesome read.

> Is there any economic theory which explains how such odd of an system can emerge/survive?

It has nothing to do with economics, but rather with law. My first reaction upon seeing figures like $300 for ibuprofen or $750 for iodine (both elsewhere in this thread) is imagining I'd tell the hospital to fuck right off (ie respond with written notice disputing the validity of such charges), but clearly there are other details that pressure people into actually paying the nonsensical bullshit.

Regardless of single payer, private insurance, subsidies, out of pocket, etc, I do think much of healthcare could be solved if providers had to charge/publish uniform prices and couldn't post-facto bill, you know, like every other business. Imagine going to the grocery store, paying at the register, and then two months later receiving a bill in the mail for the cashier's time!

Side note: if you suspect a COVID-19 infection, DO NOT GO TO THE ER. Contact a physician by phone, get instructions. By going to the ER you put a lot of people at risk.

This is the most important thing here. The testing should be done at home.

I'm pretty sure testing not available at home.

But you're right, testing should be available at home.

We're simply in a lot of trouble.

At some point, the people who suspect COVID-19 infection are going to be people who have full-on pneumonia. They would need to go to ER under normal circumstance but indeed, that will have a bad result.

Basically, we desperately need a special COVID-19 program, not simply a person's regular physician giving instructions. How many physicians are going to be getting calls soon and how much time does that take important activity on their part? Etc.

Note that Korea has ER wards set-up with pre-entry tents allowing COVID patients to be routed elsewhere. Some multi-track system like this is going to be necessary or more desirable than Italy, which has shut down the part of its health care system not treating COVID patients and is still mostly watching them die.

> Some multi-track system like this is going to be necessary or more desirable than Italy, which has shut down the part of its health care system not treating COVID patients and is still mostly watching them die.

Please don't spread disinformation, this absolutely not what is happening in Italy.

ERs are working, hospitals are working.

Planned and elective procedures have been delayed, to spare personnel and rooms and to avoid creating new emergency cases in case the procedure goes wrong.

Italy has less than 7000 hospitalized COVID-19 patients. Dealing with those is not a problem. Even the 1000 people in ICU are not a problem themselves, the 600 in Lombardy are. Lombardy had around 900 ICU beds before the crisis (they now have more but the extra ones are makeshift); this means that 2/3rds of the bed are needed for COVID-19 patients only, which is obviously a huge problem. In Bergamo, the city with the worst situation, some people cannot be tubed because of lack of equipment will get will get a NIV instead, which is very very bad, but it's not "wathich people die".

BTW, Italy has enforced the dual track system for suspect COVID-19 cases since at least two weeks ago.

References? I'd love to believe this is the case but I haven't seen any mainstream news to this effect and I have indeed seen desperate shared tweet.

I mean, I'm happy if this is true but if you want to reassure people, give a reference.

Edit:

ERs are working, hospitals are working.

Press I read says: ER isn't working for non-COVID cases and isn't able to deal with a substantial number of COVID cases.

The term would be overwhelmed. And I know Italian hospitals are better than a lot of American hospitals, which certainly couldn't be called "top notch".

My direct source is Italian newspapers and personal conversation with ER doctors.

You can use google translate to read this local newspaper from Bergamo that quotes the Lombardy ministry of health about how this Monday they closed day hospitals (clinics? not sure how it translates) and scheduled surgeries are reduced to a minimum:

https://www.ecodibergamo.it/stories/bergamo-citta/gallera-st...

Don't get me wrong - the situation is bad, and it will get much worse. We can probably help Bergamo by shifting people around, if we reverse the trend and the rest of the country stays in a better situation, but if left unmanaged the epidemic would definitely bring the healthcare system to its knees. But we're not there yet and hopefully we'll be able to avoid it.

And again, because this is very important: COVID patients do not go through ER. Please tell everyone around you that if they suspect COVID they must NOT GO TO THE ER. In the beginning of the epidemic, before this information was understood by people, infections in the ER have been a major factor of the virus spread.

As a Canadian who has also lived in America, I am consistently mortified by the costs of health care in the states.

Are they intentionally designed to force the lower class into even more poverty (I’ve seen $50 being charged for a pill of Advil - first hand) - or is it just an unintended side effect?

I find it harder to believe it’s accidental than intentional.

EDIT: Due to jiveturkey’s pathetic and wholly inaccurate defense of this system, and my inability to post in this thread further, I need to specify I was changed $740 to see the doctor and identify the issue. The pill itself cost $50. Please don’t defend this pathetic slavery of the lower class, guys, unless you’re a part of it. I’ve actually got a photograph of this bill somewhere on my backup drive I’d love to share.

EDIT 2: And before any of you say this isn’t intentional, please look up Martin Shkreli. The only difference between him and the other guys at the top of the industry is that he got caught.

Get real, guys. Please. Most of the comments here are beyond sad - I’m glad this has so many upvotes from people who silently disagree.

I think they're doing it just because they can. there are some long winded explanations about this being about the negotation process between the hospitals and insurance companies but that's no exucuse. at the end of the day, it's just unmitigated greed on the part of the hospitals.

It's politics as well. The Democratic candidate campaigning on maintaining the status quo is leading against the candidate who is campaigning on single payer. There's not much left to do when larger cohorts of voters prefer an inefficient, wasteful system (or a candidate who supports such a system). What we currently have is what people are voting for.

I've tried to make everything stated above objective in keeping with forum guidelines. Personally, I find the situation incredibly demoralizing. Perhaps the outcome of COVID-19 is a demonstration as to why healthcare needs to be fixed.

The Overton Window has slid so far to the right that such remedies are considered to be radical. Sigh.

Single payer healthcare for all has always been radical in the US. The Overton Window shifting to the left over the last decade is what has allowed Bernie to have any relevance at all.

Has it been? Those 65 and older (Medicare), those on assistance (Medicaid), and current/past military service members (Tricare) all appear to be very satisfied with their single payer healthcare.

I genuinely don't understand why this is considered a radical idea when so many citizens are happy with this public benefit. This leads me to believe that the only cohort who believes it to be radical is that which is to be disrupted by such a policy.

https://news.gallup.com/poll/186527/americans-government-hea...

"Americans' satisfaction with the way the healthcare system works for them varies by the type of insurance they have. Satisfaction is highest among those with veterans or military health insurance, Medicare and Medicaid, and is lower among those with employer-paid and self-paid insurance. Americans with no health insurance are least satisfied of all."

Yes, they are happy with it just like they are happy with social security income. The radical part (in the US) is suggesting that it should be available to everyone regardless of age (or veteran/military status) without any concrete plans to pay for it.

> This leads me to believe that the only cohort who believes it to be radical is that which is to be disrupted by such a policy.

Then you are being willfully myopic if you can’t possibly envision people who don’t have faith in the government to not cause a meaningful regression in care by destroying the private market. You can both be unhappy with the current opaque healthcare market and not support Medicare for all.

> Then you are being willfully myopic if you can’t possibly envision people who don’t have faith in the government to not cause a meaningful regression in care by destroying the private market. You can both be unhappy with the current opaque healthcare market and not support Medicare for all.

I can't empathize with irrationality. We are at rock bottom. If you refuse the only life raft in sight in the ocean, you have only yourself to blame for the suffering you inflict on yourself and others.

National healthcare has been attempted for generations now: https://www.healthcare-now.org/legislation/national-timeline...

It's been vigorously opposed by the usual suspects, but it's not at all a new proposal.

IMHO it’s not so much that they prefer the existing system as it is that they fear the unknown. No matter how bad their existing coverage is, they worry that some replacement would be even worse. It’s a downstream consequence of the collapse of faith in our institutions - as bad as things are, nobody trusts Congress to be able to design anything better. So they cling fearfully to whatever they’ve got.

The Devil you know, etc.

I am unsure how you cultivate courage and compassion at scale, but we have never needed it more as a society. Somehow we must get from "I've got mine, f___ you" to "I've got mine, how can I help you?" Otherwise, ruin awaits us.

There's plenty of evidence that single payer polls better than Sanders. Maybe a candidate without his baggage can get it done.

No other such candidate exists at this time. EDIT: We're going to have to keep waiting for older politicians and voters to age out of the system before meaningful policy progress can be made. Sanders is the best candidate if you value single payer.

"You can always count on the Americans to do the right thing after exhausting all other options." -- Churchill

No such candidate could exist - Sanders' only baggage is being described as a socialist, they haven't dug up any moral failings or flip flopping or other BS rationales. Any candidate that embraces Medicare for All will instantly be branded a socialist by the MSM and be in exactly the same spot, but may lack the honesty and integrity that Sanders has cultivated.

What baggage? The label of 'democratic socialist'? No Presidential candidate in recent memory has been as devoid of scandal as Bernie Sanders.

What we currently have is what people are voting for

We have something similar with respect to climate change policy in Australia - most people in polls and surveys claim to want more aggressive mitigation policies, yet they will just not vote for it.

A complex web of fears and other factors seems to have caused a sclerosis in most of the liberal democracies, and any significant change from the clearly dysfunctional status quo is almost impossible to bring about. Polities that can't respond to changing circumstances are not going to fare well & we clearly have deep troubles in our very near futures.

I don't think it requires any more than an indifference towards the welfare of others from those who believe they can afford any kind of healthcare they would ever need while simultaneously pursuing a minimal tax bill.

They are not - the effect these prices have on the poor is an unintended[1] consequence of the true aim. Extracting the most money possible from insurance payors - honestly, if hospitals could bill "You owe us 50$ or as much of that that your insurance would cover" then they would. Nobody actively wants to impoverish the poor (except for a small number of utterly terrible people) but payors force cost pass on to their subscribers as a way to keep the costs from getting too crazy and and the uninsured get hit by the full bill that providers want to extract out of payors simply because it's impossible for them to under bill without getting hit by lawsuits.

That paragraph was an attempt to be really fairly voiced so just to follow up - this system is utterly rotten and terrible, the US has one of the worst health care systems in the world when it comes to the non-super rich - and even for them there are better options - and it needs to be fixed.

1. Edit note: Originally I used "unavoidable" here which was a poor word choice that's been pointed out below.

Also good to point out - payors actually benefit from crazy costs. Insurance companies had their profitability capped as a percentage of premiums collected[1][2]. The easiest path to profit growth is just to let claims balloon, then use that to justify premium increases.

[1] Technically it's a cap on all non-medical spending, rather than profit margin specifically. But in effect it's a cap on profits, as there's only so much overhead you can cut.

[2] https://www.aeaweb.org/research/regulating-health-insurers-a...

It isn't intentionally designed, just a side effect of the system as it exists today. There are two ways to bring healthcare costs down in America:

1. Insure everyone — no exceptions (by the government or through private insurance)

2. Let hospitals (and ERs) deny care to those that can't pay

Since neither of them is happening anytime soon, Advil is going to keep costing $50.

No. Cost per outcome is still higher. More is wrong.

I don't see how #1 solves anything. The biggest issue which leads to all the cascading effects is the hospitals can charge a ridiculous amount for goods and services, with some hospitals charging more than 1000% more than what the government thinks they should (https://www.theatlantic.com/health/archive/2015/06/hospitals...).

I had a colonoscopy done a year ago and the prices pre-insurance ranged anywhere from $7000-$16000 depending on the location, all within network. I ended up paying just $1300 because of my insurance with a couple hundred covered by my HSA account. Why is there such a drastic price difference between places? Why are hospitals and other care providers that have a monopoly over an area able to act like a monopoly and have complete control over pricing?

Everything else is just a 2nd order effect.

The reason hospitals charge more is (1) they need to recoup the cost of the services they are otherwise providing for free and (2) they have no leverage to negotiate with insurance companies and drug manufacturers. Having a national or privatized healthcare system that covers everyone will greatly help with both of them.

> I’ve seen $50 being charged for a pill of Advil - first hand

A paper plant was having a problem with their mill. They brought in a consulting engineer to help them with the problem. He took a look at the machine and after a few minutes, drew an X on it in chalk. "Hit it there with a hammer". It worked!

"How much do we owe you?"

"$10,000"

"That's absurd! I can't pay you that for literally 2 minutes of your time! I need a detailed invoice."

The engineer wrote up an invoice:

chalk mark $5 knowing where to put it $9995

=========

The patient in your example did not pay $50 for an Advil.

There is a lot wrong with US healthcare, but this isn't it. It's about misaligned incentives.

It’s pathetic you’re defending this, and terribly evident you have never had to live in poverty in the states.

It’s also patently, blatantly false. I paid $740 to see the doctor to identify I needed an Advil.

I paid $50 for the Advil!

Your post literally incited a large amount of rage in me. Defending people like Martin Shkreli- which the pharma industry is full of - or the medical industry itself’s rape of the lower class - is pathetic, selfish and just straight up wrong.

EDIT: I’m unsure, as well - how I was unable to downvote this comment.

eh? I grew up in poverty on public assistance and didn't have a decent job until I was 25. I've been hungry. etc etc. I know about being poor, ok.

I also didn't defend the behavior. Get out of your personal shell and re-read it.

You paid 0.05 for the Advil. You paid $49.95 for everything else that goes along with it, when you get an advil at an advanced medical care facility. You would understand that if you comprehended my post.

Do you realize that when you go to any store and buy a coke for $1.50, you are only paying maybe .25 for the soda (incl. the bottle it comes in)? .75 or so is shipping and .50 is to the retailer. Every product has non-production costs associated with it, and that is what you pay for when you get a $50 advil at any kind of medical facility.

No. I paid $740 for the rest. I paid $50 for the pill.

You would understand if you could get beyond defending this pathetic system. Sad and shameful.

There is no excuse to mark up a pill $49.50 beyond raping the poor. That is all. Ten dollars? Sure. $49? No. Just no.

Disgusting, shameful and a horrible abuse of human life.

Almost not worth arguing here.

What Martin Shkrelli did was price gouging (qualitatively, not legally, and he went to jail for securities fraud, not price gouging). In those specific circumstances, that's evil.

A $50 Advil is not price gouging. That's the cost of getting a pill -- any pill -- at any kind of medical facility. The overhead costs are exceptional. Single payer healthcare alone would probably shed 50% of the cost, before price bargaining even comes into play, as the billing involved is insane. Inventory control, yes for an Advil, brings high costs. A nurse being paid $50/hr vs a store clerk at $5/hr (neither exact numbers; just making a point) also brings high cost.

There absolutely is a reason to charge $50/advil. And that reason boils down to misaligned incentives. I won't bother to go into detail because you aren't listening.

Definitely need to start cracking down on predatory hospital billing. 10K billed just for stepping into the ER Room without even getting tested is absolutely insane. AT point do we decide this is criminal and start taking actions against these guys? Normally, I would never be in favor of price ceilings but this is one industry that desperatly needs it.

I think once the dust has settled from COVID-19 the entire health system in America will be totally changed.

I remember studying political science as an undergrad two decades ago. My professors all said the same thing about the Electoral College: “it’s a relic that has long since stopped serving a practical purpose, but people live with it because it never rocks the boat. If there’s ever an election where the winner of the popular vote doesn’t actually win because they lost in the Electoral College, there will be a huge mass movement to finally get rid of it.”

Since then we’ve had two elections in twenty years where a candidate who lost the popular vote “won” thanks to the Electoral College. And the Electoral College is still there.

In politics, never underestimate the power of inertia.

It's not about inertia. Look at which party benefits from the electoral college, and then recognize their attempts at voter disenfranchisement.

Indeed, this was a key misconception my professors and I all shared: we thought there was a broad consensus in American society that democracy is a good thing. It turns out there are a lot of Americans, disproportionately gathered on one side of the ideological spectrum, who care less about democracy than they do about their team winning.

There's pros and cons to the electoral college. At the moment the states can award electors however they want, including deciding on their own to commit them to the winner of the popular vote, as some have done. The states legislatures can also choose electors - there's nothing in the 12th amendment saying it's a people's vote.

I think the bigger point that should be talked about is why everyone has invested so much power in the presidency, and argues that their candidate should have won by a 1% majority and is now entitled to implement their national agenda. That is not the way this country was meant to work. You eventually end up with a dictator.

My best guess at the reason why we do this: tribalism and mass media. Human nature. Gotta have a chief, one person to look to for answers.

On the other hand, the nature of "collapse" is the suddenness with which it takes place. There are all kinds of changes taking place right now, as a result of this crisis, that were previously dismissed as politically infeasible.

When the crisis is over there will definitely be some attempt to roll everything back to the "good old days", but not all of it will stick, and we'll have a different set of trends emerge - and trends in the political system may be among them. But maybe not the Electoral College. I don't see the federal system changing very quickly as a result of any current events.

Yeah, this what Rahm Emanuel was getting at with his infamous line “you never want a serious crisis to go to waste.” A crisis can break through the logjam of everyday interests that normally prevent action. It wakes people up and changes the way they look at things.

(Not always in a good way, of course. But still.)

More than that. Governments are going to collapse over this, capitalism as we know it is done. After the financial crisis we [in the US] put far more effort into share buybacks and the like than into infrastructure, housing, economic stability etc. There was a partial attempt to reform the appallingly bad healthcare system but it failed, partly from a lack of vision and partly from sabotage by economic rent-seekers. This is the hangover.

I am a pessimist - I think that once the dust has settled another Shkreli like ass-hat will be hung out to dry and everyone will decry how much they were charging for such-and-such component of the treatment while drawing attention away from the unreasonable prices in every other portion of the treatment.

Nothing will change or it will get even more expensive. There is way too much money to be made with the current situation so doctors and hospitals will fight tooth and nail.

ERs get to deal with the unwashed masses. Everything from gunshot wounds to stokes to stubbed toes to people looking for a cab ride.

You, and someone who isn't indigent, get to pay.

Price controls, de facto or de jure, seem to be one prominent, common factor in the health care systems of every other advanced economy. Even Singapore, practically the only "see, the market can work for health care!" example I see used, has them.

Where I'm from, in the EU, there is an organization that pays for procedures that people have in hospitals, and they have a price list that they agree on with the hostpitals in a contract. If a hospital wants to be paid for some kind of operation on patients or for "days in type x of hospital bed/care" then it's all in the price list they agree on. And the hospitals don't go bankrupt... or make a profit. They are basically non-profit organizations owned by the local government and the country. They were created with the goal of taking care of peoples health and doing the procedures that people need, not with the goal of making a profit or meeting some financial targets.

Wow, this brings home what a huge crisis this is for US health care system. It's not just the huge costs or huge administrative overhead as such. It's that the entire system is built as "we design a giant filter-rationing-marketizing system to dole out services and you pay for both the service and the rationing process". This stuff can't work for the Coronavirus at all. Testing needs to free and fast, not even "free eventually but there's bureaucracy first". Who knows when or if this paradigm will be abandoned but if it isn't, suffering will be tremendous.

But either way, the risks discrediting the filter-ration paradigm. If X can be provided for free to everyone, the question of why can't you will loom that much larger.

Lets not forget that the US could dodge a lot of these issues (and increase the chances of a good outcome) by simply putting out a few tens of millions for tests and distributing them to providers free-of-charge with an agreement that there be no administration fee.

That is, honestly, sorta what a government should do in a crisis, just eat the cost to make sure everyone is safe - instead the government is "letting the market decide" and continues to dump millions times the cost of resolving this crisis into boondoggle never-gonna-work F-35 fighter jets.

The US healthcare system is best described as a pack of wolves negotiating about whose going to eat the sheep.

I think that's close to accurate, but a better description would be "A pack of wolves fighting over who is going to eat the sheep".

The different market players here, PBMs, Payors, Manufacturers, Providers, Special Interest Groups, Advisory Boards and others - all are trying to bankrupt one another much harder than they're trying to bankrupt customers because customers have nearly no money to take - most of the inflow into this market isn't coming from the consumers but from the employers of the consumers (that are paying truly staggering amounts of money) and a lot of the damage you see to customers ends up being, essentially, collateral damage from one market player trying to stick it to another market player.

Just yesterday I was reading an interview with the CEO of a German company which produces coronavirus tests about how they charge 2.5EUR for a single testing kit and that reasonable cost for processing it should be around 10EUR. Where does the 1000x multiplier come from?

Huh? She wasn't tested. Whatever the ER charges, outrageous or not, why would you assume there's any correlation at all to the cost of a test that wasn't administered?

This is unfortunately why the US is going to fail miserably at containing SARS-CoV-2.

The reason we will fail to contain it is because we don't have any test kits. So we don't know the true rates of infection.

Policy: ignorance is bliss!

It looks better to have lower numbers.

Trump usually likes higher numbers

The American healthcare system is the main reason I'd not want to move there.

I live in the US, and the healthcare system is the primary reason I want to move to another country.

The US, judging from Italy, is about 4 weeks away from a complete collapse of its healthcare system due to corona virus.

With no serious attempts at mitigation or contact tracing or testing, that thing is going to spread like wildfire.

Is there anyone doing work on analyzing current legislation and providing alternate wording to fix the issue?

https://www.congress.gov/bill/116th-congress/senate-bill/112...

Sorry, that's just an impermeable wall of text to me. I'd love to know from someone who groks this, the specific wording in the bill that would address the ER costs issue, and where the current legislation fails.

Basically I'm looking for the bug fix, not the entire source code.. :)

Serious question, why can’t individual states rollout single payer healthcare ?

Nobody should worry about Covid in the USA, 1) Trumps dead Uncle went to MIT and 2) we have his hunches to keep us safe.

Further, as long as we don't test in mass, our case numbers will remain very low.

It is depressing that the hyperbole comment is just a list of easily confirmable statements by the administration.

This story is total fake news. The patient is a teacher with a Cadillac health insurance plan. She paid $75 co-pay. The $10,000 bill is an illusion printed by the insurance company to make her think that her insurance is actually valuable. No one was paid $10,000. The hospital was paid a secret negotiated rate much much much much lower than $10,000.

The provider was paid 3,000 by the payor - that's how insurance billing works. It absolutely is a rats nest when it comes to finding out pricing information but the number on the bill is what ended up changing hands (less, possibly, any amount not covered and defaulted on by the patient).

I believe you're thinking of the provider's chargemaster and the pricing discrepancies there - this procedure was billable as 10,000 to a patient without insurance with the 7,000 discount being the payor's preferred rate - that 10k is the BS number that (mostly[1]) no one ever pays, while this 3k is the actual amount changing hands - for the patient the out of pocket cost is the most visible portion, but that bill was fully paid.

1. Mostly everyone except for the uninsured or out of network - those folks will get stuck with that BS price 7k price, which is there since payors always want to feel like they're paying discount prices.

(edit - corrected numbers to be in line with the actual bill)

Insurance _never_ pays as much as they bill. This is one of the reasons to have it in the first place: each insurance company has negotiated rates with the hospitals. Even if you have high deductible, you'll still be getting negotiated rates, not the bullshit they (try to) charge people with no insurance at all. IMO, this is one thing that should be made totally illegal, no matter where one lands on the political spectrum: cash customers should be "favored", meaning cash price must match or be lower than the lowest insurance negotiated rate for each procedure. Anything else is just stupid and unfair. That way if the insurance pays five cents for the paper cup the pills come in, you can't charge fucking 13 dollars for the same thing if I pay cash.

I agree and find it utterly outrageous. I'm lucky enough to have avoided any hospitalizations in my adult life, but I am quite familiar with this BS on the pharmaceutical side, in another comment on this article[1] I broke down that "preferred partner" price difference as I experienced it personally and it is insane that these pricing differences are allowed to continue. Also, bear in mind it's not just patients paying in cash - all these rules also apply to anyone unlucky enough to be treated out of network, even if it's just because they were brought to the wrong hospital while unconscious.

1. https://news.ycombinator.com/item?id=22550564

The insurer paid about $3000 according to the screenshot. The $10,000 is an illusion but I believe it's for tax purposes. If someone gets a $10k bill and the hospital eventually writes it off, they can write off the whole 10k.

So it's basically fraud, then. OK, nice to have that clear.

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