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Comment by shakezula | Hacker News Reader

And even if you can contest the denial, it can take days to months to get it back, meanwhile you’re shouldered with the burden of paying full price for your treatment with the _hope_ that they’ll reimburse you later.

My fiancée has cancer, and we regularly joke that dealing with insurance companies is worse than the actual stage 3 cancer she has. They constantly deny her coverage for medications she’s been on for years, they will randomly require new tests to make sure she still has cancer (megalolz), they’ll decide they don’t want to cover procedures just for fun until we call and argue with a representative for a few hours and then all of a sudden it’s a “billing mistake” that can be reversed.

It’s a racket, plain and simple. Medical care should never be tied to personal wealth, period.

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>My fiancée has cancer, and we regularly joke that dealing with insurance companies is worse than the actual stage 3 cancer she has.

You know what's crazy? This isn't even the first time I've heard this. Literally had the same conversation with a close friend last year. Thankfully it wasn't Stage Three and their spouse is in remission, but the financial ordeal was more stressful than the diagnosis.

It's so heartbreaking to see people who are very sick or even dying have to stress about bills. It's just not something a moral society does. It's not just mental, cortisol really knocks down your immune system.

Treatment and part of my income was insured by public actors (not US). No issue, everything is automatic, didn't had to pay a single thing and it would even be possible to get unlimited free taxi rides from home to hospital, free public transport, wig, sport... even a tax cut. I'm really thankful for this.

Other part of my income was insured by a private company. They lost my files, claimed I didn't fill the forms and after months of fight and involving my employer, they magically found papers I previously sent and paid.

Private companies seek profit and would basically do anything to keep your money. You cannot build a good (fair) insurance company with this logic.

What's the name of that insurer?

Not OP, but when my dad had cancer in Poland, the national health fund covered his entire treatment over 8 years. Few operations, monthly dose of Glivec(google the cost of Glivec treatment in the US to see how insane that is), hospital stays, and like OP said - he would get reimbursed for travelling to the hospital and back. And this treatment was never tied to his employment, he never had to prove to anyone that he definitely has cancer still, we've never seen a single bill for any of it, I simply have no idea how much this treatment has cost over the years. Which is the point of it all I think - if you need treatment, you simply get it, a regular person never has to worry about billing, dealing with insurers or anything like that. The only interactions you need to have are the doctors telling you when to appear for the operation, and the pharmacy calling you to let you know your drugs are ready to pick up. That's about it. I know there are outliers in that system, but for my dad's entire 8-year long treatment I'd consider the way this all works as 10/10.

The Gleevec was probably an order of magnitude cheaper or more for the Polish government than in the US:

https://www.statista.com/statistics/312011/prices-of-gleevec...

And doctors in Poland are probably not earning a few hundred thousand USD per year, and similar for nurses wages and all the other people in the healthcare chain. Quick googling shows wages might be an order of magnitude cheaper also.

I assume healthcare providers in Poland are also not subject to the legal liability they would be in the US.

Yes, the US has some extra administrative costs due to the billing nonsense of non taxpayer funded healthcare and overhead of health insurance companies, but bottom line is healthcare costs more in the US because everyone earns more top to bottom in the US, and supply of healthcare and medicine is constrained.

American exceptionalism at its finest

>>Yes, the US has some extra administrative costs due to the billing nonsense of non taxpayer funded healthcare and overhead of health insurance companies, but bottom line is healthcare costs more in the US because everyone earns more top to bottom in the US, and supply of healthcare and medicine is constrained.

Right, but just like your healthcare professionals are paid an order of magnitude more than ours, you guys will be paying an order of magnitude more in taxes and healthcare costs. So I don't think it's an excuse for the level of care provided in the US - yes, it's more expensive, but you also pay more for it, so.....why is the experience worse?

And I mean, Polish supply of doctors and medicine is massively constrained too, that's by no means a uniquely American problem to have.

>>I assume healthcare providers in Poland are also not subject to the legal liability they would be in the US.

I'm sure the deeper legal nouances of legal liabilities are of course not the same, but at least on the surface level it's similar - of course you can sue a hospital for malpractice if it occurs, and you will be awarded damages.

> Right, but just like your healthcare professionals are paid an order of magnitude more than ours, you guys will be paying an order of magnitude more in taxes and healthcare costs. So I don't think it's an excuse for the level of care provided in the US - yes, it's more expensive, but you also pay more for it, so.....why is the experience worse?

I believe the nuance is in who is paying more in taxes and who is receiving the benefits. This is the distribution of taxes paid by quintile:

https://itep.org/who-pays-taxes-in-america-in-2019/

The over-arching theme in the US is the lack of political will in voters to enact policies that benefit everyone. And I believe that manifests itself in the messed up systems that we get, which are half assed measures to “help” people, but not really help people. So you end up with a much worse experience in healthcare for half or more of the population, since the goal never was to actually provide them with healthcare, but to give the appearance of it while also minimizing the amount of wealth transfer that happens.

> And I mean, Polish supply of doctors and medicine is massively constrained too, that's by no means a uniquely American problem to have.

I presumed it is less supply constrained due to the lower price point. I know it’s quicker and easier to become a doctor in the UK than the US, but potential doctors in the US may also have better career alternatives.

> I'm sure the deeper legal nouances of legal liabilities are of course not the same, but at least on the surface level it's similar - of course you can sue a hospital for malpractice if it occurs, and you will be awarded damages.

I don’t know enough about this to make any solid claims, but I was just going off the worldwide reputation of the US being more litigious than anywhere else. Also, the healthcare providers’ higher incomes in the US also probably result in bigger liabilities since there is more to gain in a lawsuit.

> but bottom line is healthcare costs more in the US because everyone earns more top to bottom in the US

So there's more taxes available to absorb this cost. It's a self solving problem, in countries that have their shit together.

Depends how much tax the government collects and what the government spends it on. Obviously, the problem can be solved in a nation as wealthy as the US, it just depends what they want to give up to obtain it.

Right on schedule, here comes someone to parrot all the debunked reasons the US can't do stuff everyone else in the world can do.

I offered an explanation for how one can get that kind of treatment in Poland and not in the US in its current state, not as a permanent dynamic. Obviously, if the US focused its resources on providing healthcare to its people in a similar manner that other nations have, they could achieve it.

Axa, about 10 years ago. Forums are full of similar stories for almost any private insurer.

“Other part of my income was insured by a private company. They lost my files, claimed I didn't fill the forms and after months of fight and involving my employer, they magically found papers I previously sent and paid.”

That’s the same insane situation like during the mortgage crisis where banks constantly lost papers or made wrong claims and got away with that. It’s hard to understand that insurers and hospitals constantly get away with forgetting or misrepresenting things. I can’t imagine any other business being allowed to do that.

It’s intentional. They save billions using this practice because some people don’t have the time, knowledge or resources to dispute.

Are there services that will handle this nonsense for you?

In rich countries outside of the US it’s called “the government”

Other countries are slipping, though. For example, Germany does not actually have a single-payer system, but instead a "system" of public and private health insurance companies. As an employee you`re usually in the public system, which can be more expensive for higher-earners because the fees are based on your income (although the health taxes are regressive, capped above like 65K income per year). Self-employed people are often in the private system, and higher income earners can also opt into the private system.

The problem is you can´t easily opt back into the public system once you´re out (especially once you´re old), so there are tens of thousands (if not hundreds), that get stuck in the private system without being able to pay the fees because they´ve become poor (possibly because of health reasons), and then they get denied coverage and thus access to medical services.

Immigrants can fall through the cracks in the over-complicated system as well.

The problem is not as insane as in the US, happens "at the fringes", but it still affects thousands and is mostly outside of the perception of society, since everybody just assumes they got the best system in the world.

Please. Let’s not turn this into whataboutery. This isn’t about other countries doing things poorly, and more specifically Germany was not named by the parent commenter. This is about the US doing things significantly worse than basically any other developed country. I live in Germany, and know that the German healthcare system is not perfect, but I also know, as an American, that it is significantly better by essentially any metric than the US, and it’s unfair to pretend otherwise. I’m glad I don’t live in a society anymore in which I have to worry about taking an ambulance for an emergency because I can’t afford the fucking $500 price.

I think all systems have their downsides. In the UK for example, we've started doing citizenship checks for anyone who looks remotely like a foreigner, which to my mind is perverse and unnecessary, and part of a governmental preoccupation with trying to become as racist as possible via the back-door. (essentially, if we can blame the foreigners, we can absolve the government)

However, I think we can still say "America's system is totally screwy" and also say "and btw, as a warning, X country seems to be heading down that route too" - I don't think, phrased the way ant6n's post was, it takes away from criticism of America.

Essentially, in a perfect world, nobody would be made bankrupt because they got ill, and it seems right that governments should do everything they can to prevent that. If there is a class of people who get forced into that position because of something they cannot change, then that system is broken - whether or not that broken system adversely affects you personally. For example, the American system is not broken for rich people, and especially those in perfect health. For those people, it works just right.

And even if you are the only person in a country that is given the choice between feeding their family or investigating an abnormal lump, it doesn't matter how many people benefit from the upsides of that system, it doesn't matter if all your neighbours can visit their GP for a weekly checkup without penalty - without a doubt that system is broken and unjust and needs fixing.

But yes, I think most developed-country-based non-Americans would rate America's system as somewhere between "more broken than mine" and "perverse and cruel". The fact that we all use America's system as the yardstick for what a bad system looks like says it all.

The rest of the developed world, especially Switzerland, also has to thank the US for single-handedly ensuring the profits for its pharmaceutical industry.

Downvoters might read up on which country those pharma profits overwhelmingly come from and why companies like Novartis or Roche are worth what they are worth. As a European the US healthcare system gives me a failed-state vibe, but there are people close to me profiting directly from the absurd prices it pays for drugs.

> The problem is you can´t easily opt back into the public system once you´re out (especially once you´re old), so there are tens of thousands (if not hundreds), that get stuck in the private system without being able to pay the fees because they´ve become poor (possibly because of health reasons), and then they get denied coverage and thus access to medical services.

Although I recognize the personal hardship this can cause, I fail to accept this as a general injustice. In the German healthcare system nobody is forced to choose a private insurance instead of the public one. Choosing a private insurance when you're allowed to (which often means because you're in a higher income bracket) is usually only cheaper if you're young and healthy. It's basically a gamble on your own health for wealthy people.

And if the wealthy young and healthy population don't contribute to the public health insurance system which also pays for the not-so-wealthy and not-so-healthy (older) population, the public insurance system isn't sustainable.

The real problem with this system is its division in public and private insurance. Mandatory public insurance would mean lower insurance fees for public insurance and the problem of being stuck in private insurance would no longer exist.

The point is that there exist cracks in that many people will fall through and society at large doesn't even know that they are there; society as a whole is in denial about the problem because they can look at utterly dysfunctional systems like the US and and say "we're so much better here". Part of the problem is that many of those who are aware of the problem blame the individuals themselves for falling through the cracks in the system (like you do, based on some notion of 'choice'). One possible solution (it seems you agree with me here), is to remove the division between public and private systems. The first step ist to accept the existence of a problem instead of denying it (blaming individuals is a form of denying systemic issues).

I was commenting on a specific point made by the parent comment. It's pretty far fetched I'm in denial of the root issue when I even mentioned the real solution which you're agreeing with.

So while I get your sentiment you're really arguing against the wrong person here.

Besides that in my opinion there is a significant difference between "falling through the cracks" and making wrong decisions poorer people aren't even allowed to make - and then wanting those poorer people pay for your errors.

There’s a whole industry segment of attorneys specializing in denied medical claims.

I want a cheap mostly automated service that monitors medical expenses looking for irregularities etc.

It’s not intentional. Insurance companies are better labeled “managed care organizations” (MCO).

They offer services for adjudicating services and prices for self insured and non self insured clients.

Self insured clients would be governments (Medicaid, Medicare, large corporations that can afford to pay for all of the healthcare). Non self insured are clients like smaller companies and people on healthcare.gov that pay insurance premiums, but are not liable for the entire amount of healthcare.

In the event the MCO is administered a self funded plan, they are simply following rules laid out by the payer. The payer (usually government) can come in and audit the MCO anytime and penalize them for approving healthcare that the payer deemed outside the scope of the rules. This works out quite well for the payer, as the MCO serves as the fall guy and takes the heat of being a “bad actor” and denying people healthcare.

The reality is that healthcare in the US is rationed, and MCOs are tasked with rationing it. The government gets to avoid being blamed for denying care.

I don't even understand how the "health care" system and the insurance industry can be both so messed up in the US.

It may be just anecdata, but In Hong Kong, my family has an insurance agent whom we work very close with. We're just middle class. E.g. only my dad has a car; my sister is 42 and I'm 38, and we still don't have our own car. Whenever something related to making use of the insurance plan comes up, the insurance agent would be very helpful and ensure we get our money's worth. She would teach us what to do in order to not miss out on benefits. The claims process is also easy. We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute.

> We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute.

It’s also not the case in 99% of US claims. The ones you hear about are typically due to healthcare providers not providing sufficient justification for the healthcare or medications they are prescribing, which can easily cost tens of thousands, if not hundreds of thousands of dollars.

The “insurers” are many times not even the payer. In many cases, the government hires insurers to adjudicate healthcare according to the government’s rules, which will specify under what scenario and documentation they will pay for certain treatments.

Surely, there are mistakes made, but there is no standard operating procedure at insurance companies to deny healthcare. They employ teams of doctors and pharmacists to review cases and determine what is evidence based medicine and what conforms to the payers’ guidelines.

> It’s also not the case in 99% of US claims.

So is it just sampling bias that we hear constant stories outside the US of everything from broken legs to cancer patients being denied coverage or being covered but having life destroying out of pocket costs? Because it really is constant.

There’s 330M people in the US and 365 days in a year, so you can hear about one mistake every day and it’s still an extremely minute error rate.

It would be nice if someone brought data to the discussion.

And specifically about health insurers erroneously denying coverage. I have first hand knowledge from a doctor at an insurance company that audits other doctors’ work at the same insurance company to ensure they are not erroneously denying claims, as there are heavy penalties from state governments and CMS.

That is a separate conversation from out of pocket costs destroying someone’s life that has nothing to do with health insurers and everything to do with how much US voters are willing to have their taxes go to those with less.

There is some information in this link:

https://www.kff.org/private-insurance/issue-brief/claims-den...

> The ACA guarantees external appeal rights to enrollees in all non-grandfathered private health plans. When issuers uphold denials at the internal appeal level, consumers have the option of requesting an independent review by an outside entity, whose decision is binding. Consumers also can bypass internal appeal and go directly to external review in emergencies and certain other circumstances. Consumers seldom avail themselves of external review.

There aren't 330M insured people, and many people don't need visit a doctor in a year. (Also, there are ~740M people in Europe, and yet...)

Even that link you provided doesn't really back up what you said: "denial rates ranged from 1% to more than 40% across insurers"

The point was there’s a lot of people with a lot of transactions in healthcare happening, so “hearing” about it constantly doesn’t mean anything.

And yes, I know the link doesn’t have statistics in erroneous denials of coverage (I couldn’t find it anywhere quickly), but it did note that the law requires insurers to abide by an external reviewer’s decision.

Surely if there were that many erroneous denials of coverage, there would be lots of people clamoring to get it overturned via the external reviews.

It’s probably just the case that most denials are justified (in the legal sense) that the requested healthcare lacked sufficient documentation, did not have efficacy data, was using brand name medicine instead of generic, etc.

I agree that there would be plenty of horror stories to fill the news, even if such events were extremely rare, but multiplied by 300 million.

However, many people's "hearing" is a slightly less biased sample than that. It's that every American they have personally talked to about any visit to a hospital seems to have a horror story about (at very least) crazy bills, hours on the phone with insurers for months to years afterwards, etc. That's also not unbiased since people like telling these stories, but at least the denominator is two digits not seven. (The stories may also not reflect the latest reality, as you say.)

Just to re-iterate, my original comment scrolling up was specifically responding to this claim:

> We don't get this nonsense where the insurer tries to deny us and hope that we don't dispute.

Restated, this is claiming that health insurers in the US erroneously deny coverage as a policy. And that is the specific statement I am saying is untrue.

The crazy bills are true, you should of course budget to be able to afford the out of pocket maximum for healthcare costs in any given year. The hours on the phone might also be true, but I know how complicated of a topic US healthcare is (perhaps needlessly, but it is what it is).

Personally, I have more issues with the healthcare providers than with the insurance companies. The insurance company has picked the phone pretty quickly when I call, and tell me the price of a procedure they have negotiated with the provider if I give them the code for it. You can even search it online on a map to shop around the prices.

The problem that I have in US healthcare is that no healthcare provider is willing to give me a code, even for simple checkups or X-rays or what have you, where everything is known in advance. The healthcare providers don't want to risk

And to finish, I'll provide with an anecdote about one of my experiences with healthcare:

My wife gets an ultrasound. The healthcare provider charges $15 for "towels" used to clean up the gel they put on my wife for the ultrasound. In reality, it was a few pieces of paper towel. The insurance company denies to pay for the towels, so we get a bill for $15. I call the healthcare provider and asked why I'm being charged $15 for a few pieces of paper towels. The person in the billing department says to ignore the bill and not pay it.

As a consumer, what am I to understand here? That healthcare providers are overcharging? Or maybe insurers are underpaying (or paying late, or causing too much paperwork) so that healthcare providers are overcharging to make up for some of that? Or healthcare provider is just charging and collecting payment from anyone who doesn't contest, and letting it go for anyone who does?

I inquired multiple times as to all the charges that will be had during the ultrasound. It's a completely routine procedure with no unexpected costs, but the healthcare provider told me they can't give me the codes they will bill. Had I been provided the codes beforehand, I would have brought my own paper towels to wipe the gel off. So I can conclude that the healthcare provider was not really trying to recoup paper towel costs.

"Restated, this is claiming that health insurers in the US erroneously deny coverage as a policy. And that is the specific statement I am saying is untrue."

The policy may not be explicitly stated, but having dealt ( and likely having have to deal with both this year ) with medical issues ( and related bills ) in US, to me it is clear that everything is stacked against the recipient of healthcare benefits. In other words, actions speak louder than words. The moment I have to spend multiple hours a day, faxing stuff, confirming receipt, complaining, contacting various overseeing bodies, I think the unstated policy is pretty simple. Deny and delay is a tactic. And it works. Not everyone can devote time and energy to this. It is exhausting.

"The problem that I have in US healthcare is that no healthcare provider is willing to give me a code, even for simple checkups or X-rays or what have you, where everything is known in advance. The healthcare providers don't want to risk"

I am willing to agree here. There is a fair amount of issues that are created for a patient by the providers ( coding, communication with insurer or lack thereof, now standard 'you are responsible for everything insurance doesn't pay' clause and my current favorite 'some of the providers in our hospital may bill you separately' ). It usually takes some yelling to get some of the charges to 'reasonable' level and I have the feeling the only reason I got away with it is, because the election was in full swing and no one wanted another crazy hospital story.

I agree with all of your comment.

> It’s also not the case in 99% of US claims. [...] Surely, there are mistakes made, but there is no standard operating procedure at insurance companies to deny healthcare.

This is so out of sync with the experience of everyone i know that i wonder if you've interacted with the healthcare system at all beyond checkups and occasional antibiotics.

If it was true that insurers are routinely erroneously denying care, then people would be taking advantage of the ACA law that mandates external review of all claims and subjects insurers to the external’s reviewers’ decision.

You seriously over-estimate how much people know about their rights and the time they are willing to spend exercising them. But you are right that they should.

https://www.npr.org/sections/health-shots/2014/04/14/3025478...

That's actually very interesting. Although the article is from Apr 2014, it has some statistics that may be relevant to insurers erroneously denying coverage:

https://www.capradio.org/articles/2014/04/01/patients-win-ab...

>Insurers say only about three percent of claims are denied.

>California data show about half the time a patient challenges a denied health care service through a third party, the patient wins and gets the health service.

If we assume that denied claims that were overturned were erroneously denied coverage by the insurance company, then half is a huge error proportion, one that would make me think the insurance company is doing it intentionally, or at least intentionally not doing it right.

But maybe the ones that got appealed are closer to being decisions that could go either way and the ones that don't get appealed are black and white cases that were clearly covered or not covered.

It’s easy to lie with statistics. I’d be willing to bet lots of money that it’s 1% because the vast majority of claims are doctors appointments and other very routine things and that major medical procedures, that are less common though more impactful, make up a disproportionate number of denials.

I’m bipolar and every month I’m dealing with insurance medication denying extreme common, proven, and relatively cheap first-line medications. My insurance constantly requires exemptions and referrals for every step of my treatment. Even for things that have already been approved.

At this point, it would be cheaper and easier to manage everything myself. The only problem is, if I don’t use my insurance, the out of pocket maximum for inpatient treatment would be so expensive I’d refuse treatment and risk killing myself or harming other people. (Which is very much non-zero.)

As a child, my parents constantly fought insurance to get life-threatening allergies treated.

I'll chime in with an opposing anecdote about managing the healthcare for my father with cancer. Dealing with a large insurer, we have no problems with being denied coverage, timely prior approvals, and while some of the copays are high, they are not unreasonable for the plan he chose. Whenever I call, the agents are pleasantly helpful. My main complaint is with providers' fraudulent billing ("cost": $500, "adjustment": $390, insurance: $65, copay: $45), and the worst thing I've had to do was sometimes wait after receiving a billing nastygram, for the claims to settle out.

Of course he is of Medicare age, so this is a Medicare Advantage plan that is still bound by many of the Medicare rules and copay schedules. I can't imagine going through the same thing with my own insurance.

Where is your data to backup this claim? Maybe you are right that claims are approved most of the time but in my experience the problem with our health care system is not just denial of claims, but about the cost of medical services and medicine.

In my anecdotal experience I have had insurance deny claims on medicine prescribed by my doctors frequently, in one case they would not cover a medicine costing $50 over the counter, but instead had me switch to an alternative with a $10 copay which turned out to be billed at $170 to the insurance company once i got the detailed statement!! how does that even make sense?

It makes sense to them because the insurance company benefits from higher cost of delivering health benefits as it justifies higher premiums. Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state), the only way they can deliver increased returns to shareholders is by increasing our costs and hence our premiums.

> Where is your data to backup this claim?

I’m claiming that insurers do not erroneously deny claims in the hopes that people give up. I don’t have data for it, but I’ve also never seen data that shows insurers deny coverage just to dissuade people (post ACA).

> experience the problem with our health care system is not just denial of claims, but about the cost of medical services and medicine.

Yes, I agree here about the cost of healthcare, but that is a separate issue from insurance companies erroneously denying coverage.

> how does that even make sense?

Prices for medications are extremely obfuscated, and you will never know the true price paid due to various rebates and fees on the backend between manufacturers, insurance companies, and retailers. There are various reimbursement rules from CMS (centers for Medicare and Medicare services), state Medicaid, various employers, and it’s a very, very inefficient method of price discrimination.

> Since they are by law limited to earn a capped percentage on premiums minus costs (at least in my state),

ACA caps health insurer profit margins federally, so it applies to all states. Assuming there are multiple competing health insurers, then unless they collided, they would not be able to arbitrarily raise prices to increase the absolute value of their profit margin.

The problem was the political compromise that had to be made in order to pass ACA, which is that it allowed employers to maintain their silo’d group of employees. So you have a whole bunch of healthy white collar lives taken out of the healthcare.gov market, which leaves it with all the sick and poorer lives, making it less viable for multiple health insurers to exist. If everyone had been forced onto healthcare.gov, then it’s feasible for multiple health insurance companies to exist and compete. Also, there should be no state boundaries, since some states’ populations are so small that they can’t afford to spread around the healthcare costs.

Regardless of any progress that has been made, I think anecdotal evidence is important here, and pretty much anybody who has actually used the system knows that it sucks. Nobody knows what to pay and what not to pay, for one thing. There isn't any trust - as many posters here describe, paying medical bills in the US is (feels like?) a constant struggle against being defrauded by both your insurance company and your doctor.

I always tell the same story in opposition to our current capitalist healthcare model:

1. When my oldest daughter was born 10 years ago with Spina Bifida we had private insurance through my employer. The premiums for this were something like $15,000/yr. At the time this was probably 1/3 of my total income.

2. Despite that, we continue to receive bills that we couldn't possibly pay for years after that.

3. Since my third child was born, the children have been covered by a state program (Georgia), and pretty much everything has been covered, no questions asked. As a consumer, this is pretty much all I care about.

I recognize that the current system is bad for the service providers as well, as evidenced by this article. The doctor in question gotten all he's gonna get from insurance companies. He has no hope of collecting this money, so he may as well turn it into good PR (cynical perspective, I guess, but that's me).

While the system may suck, it's leagues better than it was before ACA for most people. Even your example shows it, since before ACA, there was no out of pocket maximums, and hence you continued to receive bills. In fact, before ACA, there was a maximum benefit amount the insurers would pay up to, and then after that, the costs would fall on you.

And your GA state program is most certainly made possibly by the expanded Medicaid funding due to ACA.

>There isn't any trust - as many posters here describe, paying medical bills in the US is (feels like?) a constant struggle against being defrauded by both your insurance company and your doctor.

This is true, but it would help if healthcare providers would list the codes they will charge so that people can look up the cost with their insurer and aren't signing blank checks every time they enter a medical office.

I’m claiming that insurers do not erroneously deny claims in the hopes that people give up.

You keep saying "erroneously" but I'm not sure what you mean by that.

My experience is that for any major change in medication (either dosage or brand, but for the same chronic condition) the insurance will initially deny the claim. This kicks off many hours of phone tag between my family, the insurance, and the doctor. Eventually the insurance company will pay up, but usually well after we've already paid out-of-pocket for the first month, which then requires another few hours on the phone to get reimbursed.

This isn't a single insurance provider. This has spanned decades, 4 employers, 5 insurance companies, and at least 3 medical providers.

>You keep saying "erroneously" but I'm not sure what you mean by that.

"Erroneously" as in denying coverage for something that should be covered (per the terms of the contracts).

It's unfortunate that you have to go through all of that when changing medications. I don't know the reason for it in your specific case, but I would hope it's not widespread fraud across all of those companies.

“I would hope it's not widespread fraud across all of those companies.”

Assume it is. It’s the normal way of doing business. Deny things and hope that most people will give up.

If it is fraud, then it's not manifesting in outsize profits for insurance company. Almost all premiums go towards paying for benefits, and they are left with ~5% or less in profit. The executives are not earning outsized compensation compared to executives at other large companies, there is no army of people with FAANG salaries, so who is the fraud benefiting?

This is all public information per their SEC filings. You can drop the compensation for all the bosses down to zero and it wouldn't move the needle on how much more healthcare they could be providing the insureds.

5% or less is still a massive amount of money.

Cigna alone posted annual profits of $122 billion in the same year that General Motors and Ford combined made less than $7 billion.

Sure, I won't go as far as calling it outright fraud. But, it certainly is part of the business. And as the consumer, at the time of service, I really don't care why it happens, only that it does and that it costs me time and money and delays treatment.

As far as I can tell, it's a byproduct of an adversarial relationship between the 3 parties (consumer, doctor, insurer). Insurance doesn't trust the MD to do his job, so hires their own MDs to second guess. And on anything that costs more than $100, that second guessing is the default action - the insurance company's own MDs are only there to provide legitimacy to the initial denial. I say this because in ALL cases, my medical needs have eventually been covered, but not before committing more time and energy than should be necessary.

At the end of the day, we pay more money (and time) for worse outcomes than most of Western Europe and the wealthier nations in Asia.

>the insurance company's own MDs are only there to provide legitimacy to the initial denial.

I have first hand knowledge that this is false. Especially if the insurer is just acting as an administrator for a state Medicaid or federal Medicare or other payer, since there are big penalties for denying coverage just to save money. The insurers even have MDs and PharmDs to audit their own MDs and PharmDs to see if they are appropriately approving or denying treatment.

A lot of the problem is probably coming from lack of proper EMR and supporting documentation justifying treatment, and subjectivity in justifying treatment because there are many gray areas.

This same approval denial situation happens under taxpayer funded healthcare also, since no one has unlimited resources. But yes, the US implementation of it with myriad payers and rules certainly makes for an unpleasant experience and results in subpar healthcare.

I guess, but if so, that's a massive amount of cost to the insurer (and eventually falls back on the consumer) around paperwork/review/approval for something they're going to approve eventually. I really don't understand it. Certainly in my experience, the insurer could get rid of their internal review process and people, just rubber-stamp whatever our MDs are prescribing, and save us all a lot of money and headache.

>the insurer could get rid of their internal review process and people, just rubber-stamp whatever our MDs are prescribing, and save us all a lot of money and headache.

If that was true, there would be an insurer doing that and offering lower premiums on healthcare.gov

But it's not true, and the review processes do control costs (even if wrongly at times). I think the government farms this task out to insurers specifically so the insurer can take the heat for the denials, when it's actually the government's rules and standards for the requested therapies that is resulting in denial of coverage.

I've personally seen this with Medicaid or CMS penalizing for erroneously approving payment for treatments and also erroneously denying payment for treatments. And it gets very fun when the rules are not clear and there is a lot of gray area.

I have some exposure to the claim adjudication space, and I can say that there are undeniably people who see it as a fiduciary duty to make people jump through hoops before paying out a claim. This is a large part of why so many prior authorization proccesses suck royally.

However, w.r.t. long term medications getting denied, keep in mind that every claim starts denied until a path through to an approval can be traversed. This is a fundamental starting pount for any insurance related system. It is fundamentally a filter.

You as the customer do not have readily available access to many of the clinical programs going on in the background. Opting in and out by a plan sponsor can substantially change the footprint or character of approvable claims. Especially if paired with formulary changes.

If you happen to be on any type of high cost or specialty treatment, you're on course to misery-town, because you just popped up on the radar for entire divisions worth of second guessing justified by fiduciary duty, but often implemented in ways that leaves the patient both helpless to know what is going on, and holding the bag.

I agree. I think if the US is going to stick with this insurance as an agent for the patient system, then the federal government should standardize the prior authorization process, as well as EMRs and do whatever it takes to make the communications quicker and easier for the patient. I would also recommend dropping the state boundaries when it comes to healthcare, it makes everything literally 50x more complicated for no reason.

There's no reason why all these billing codes and coverage conditions should be shrouded in mystery.

When my wife had surgery and insurance denied part of our claim, hospital billing said it was normal, and it usually doesn't get resolved until one of their lawyers sends a strongly worded letter.

Is it possible the hospital also has a tendency to over charge? For example, the data for Synagis indicates it only works to prevent RSV in a very narrow set of cases. It's a very expensive medicine. And it's vastly over prescribed based on the efficacy data, so a parent who is already emotional over their premature baby is going to be frustrated if/when the insurance company denies it. The doctor isn't going to into detail and explain that the data doesn't support its use. They're incentivized to "do something", even if it's a shot in the dark.

For my wife's surgery (gall bladder removal - supposedly one of the most common in the country) insurance paid the surgeon, and initially denied the hospital bill and anesthesiologist bill as medically unnecessary. After 8 months of back and forth and dozens of multi-hour-long phone calls insurance finally covered it all.

I don't really care whose fault it is, I shouldn't have to play phone tag with two powerful entities over the course of 8 months as they try to figure out if they're going to fuck me over or not. It's a huge waste of time.

Yes, that’s why Kaiser is a nice model if we can’t get to taxpayer funded healthcare. It’s vertically integrated insurers and provider so there’s no in network and out of network and covered or not covered BS.

“It’s also not the case in 99% of US claims.”

From what I observe with people I know the number is way higher. If you have a serious disease like cancer you there is a very good chance that you will spend a lot of time fighting providers and insurance. It can turn into a full time job.

Or they simply die in the process.

Presumably also if they can drive up stress of patients more of them will die more quickly and they will have to pay less.

Exactly. Dealing with the back and forth between the insurance company and the provider today, actually. What a hassle. Only over $150 for charging me for an annual preventative care visit which should be covered by insurance. Normally I would just pay to avoid the hassle, but this I will try to fight it.

I've dealt with the same nonsense. Is this your first time with that specific doctor? The doctor has to use one of the annual wellness visit codes, so if it's your first time, the doctor will charge you a new patient charge code, which is higher reimbursement than a wellness visit code, so insurers will deny it.

However, I was able to tell my doctor's office that I want the wellness visit charge code only, and they did that. I don't even see a reason for the new patient visit code to exist, since they are allotted the same time and subject matter.

For example:

https://content.highmarkprc.com/Files/EducationManuals/Geria...

If a doctor bills for code 99387, that might not covered under "annual wellness visit" or "annual physical" by the insurer, so you end up having to pay the whole amount if you haven't met your deductible. If the doctor bills code 99397, then it would be.

But it shouldn't be this hard. The insurer should be forced to show the codes that qualify for the free annual wellness visit, and you should be able to inform the doctor's office that you want to purchase services for that code and that code only.

A woman got her face bit off by a wild animal (bear I think) and did an AMA a while back; she said that the worst part of the experience was dealing with Blue Cross.

I'm so sorry to hear about your fiancee. We don't know each other, but I can only imagine what that'd be like. Wishing you both a good 2021!

my god, that sounds horrible

>"It’s a racket, plain and simple. Medical care should never be tied to personal wealth, period."

In agreement. Still Government covered medical care has their own methods of avoiding / delaying procedures. In the end it all comes down to money.

You may not have meant it to come across this way, but "The alternative isn't absolutely perfect in every way, therefore both options are equivalent" isn't a useful contribution.

I meant exactly what I said. Basically nothing is perfect. And while I completely support the idea of free universal healthcare I know on my own experience that Government is on a constant lookout to cut those expenses and does it at the first opportunity.

Bunch of warriors with the downvoting clubs is not going to change anything. Frankly I do not give a s..t about being downvoted. I am not here to accumulate karma. Just for the record: personally I have never downvoted even single post. I believe that all this voting system is very unhealthy.

Nobody is trying to change your mind, it's just that most people disagree with you.

Disagreement and karma are two different things.

> Medical care should never be tied to personal wealth, period.

There is literally no limit to how much effort society can put into one person's healthcare. In the absurd extreme, we could reshape society into doctors, farmers and medical manufacturers in a mad quest for best possible medical care.

At some point we have to ration healthcare and decide when to put more resources towards something else. If not personal wealth, what do you want to use for the rationing process? Age? A lottery?

Unless there is some really amazing alternative, money is one of the best proxies available for for contribution to society. A bunch of edge cases exist, but they are edge cases. It is a fair way of rationing healthcare.

> Unless there is some really amazing alternative, money is one of the best proxies available for for contribution to society

This is an absolutely ridiculous assertion. Many people inherit, luck out, or get wealthy by other means. Personal wealth is a terrible way to determine "societal value". It is deeply disturbing to me that there are people with these types of views. I hate to assume but my impression is that you have not had to personally experience much hardship, would you say that is accurate?

> This is an absolutely ridiculous assertion.

What do you think is a better proxy?

You seem to be assuming that "contribution to society" should be the only factor when portioning out health care, and that there should be only one "best" proxy to measure such a factor. Why?

I'm assuming that while people don't like rationing things based on wealth, their objection is to the rationing more than the wealth.

There are alternatives to rationing things by wealth. All the ones I can think of are arbitrary, unfair, or unworkable (raising interesting and difficult questions too, eg, a fun example would be should highly contentious politicians be first in line for the best healthcare due to their mass popularity or last in line due to mass condemnation?).

I think that people are happy to call me ridiculous but not actually able to say how we should be deciding who gets time from a doctor. I'm very doubtful of the alternatives, I suspect that many of them involve magical thinking that wealthy people are somehow hiding hundreds of doctors in their cellars that will suddenly appear and literally cure everyone's ills if only the government mandates it.

There are a lot of problems with US healthcare. It costs too much, and there are too many restrictions that stop one person trying to help another. But the fundamental "pay money, get service" aspect isn't something that is as easy to improve on as people try to believe. It is reasonable for wealthy people to get a much better standard.

There is no need for magical thinking, but you do need to take a step back and look at the bigger picture.

Many countries view it as a much simpler problem of optimizing their society as a whole:

1. There are N doctors & medical supplies.

2. There are M people that have an illness.

3. How can we as a society make sure that these M people don't die?

Then, you (as a society) make up a set of rules and incentives and economic structures so that longterm you are able provide treatment to M people and define what "adequate" means based on your resources. If someone wants more than "adequate" treatment, you add some way to pay for things. Ideally in wealthy countries these are never actual medical necessities.

Once you're there, you just solved 80% of the problem and nobody dies just because they weren't rich.

Of course life is messy, so you need to have some resources to spare for edge cases and exceptions to the rules out of compassion, where there are e.g. experimental treatments, etc. It is true that there will be limits as to what you can provide, as treatments will cost money and disability-adjusted life years gained will go towards zero the older you are.

But that is also the case when you have a "pay money, get service" system, even if you are extremely rich you will not be able to extend your life forever.

The rationing happens either way, and in most countries you would need to be extremely rich to be able to come out on top. Actually you would need to already be born rich in order to be able to pay for anything that comes up in your childhood. That is extremely cruel, but unfortunately a reality in some places in the world.

You're avoiding the question of "how do we choose who doesn't get access to a scarce resource" there though.

It is all very well to say "we'll prioritise illnesses that kill people", but pretty much every death can be traced back to an illness. Even the ageing process could reasonably be defined as an illness, it probably will be one day if the world hasn't gotten there already. That leaves the unlimited nature of healthcare as an open problem. We all die, and arguably anything other than an accident death is people dying sick.

> Then, you (as a society) ... define what "adequate" means based on your resources.

Your country, and the US if if isn't your country, has already done that. The political process asked that question with Obamacare, for example. That is pretty recent accounting of what resources are available and what the people thought they could do with them.

And you've not grappled with the key question - we aren't going to use wealth to decide who gets healthcare. Ok, take that as a premise, we aren't using wealth to decide allocation questions. So someone comes up and says they need more healthcare. We don't have the resources to deal with them. What is the criteria where they get told no vs someone else loses treatment? You're not allowed to say "well, we're assuming there is enough for both" because there are finite resources and infinite demands. We aren't dealing with food here where everyone can reasonably be fed. Everyone suffers from diseases and could use healthcare.

For one, minimizing disability-adjusted life years lost. Of course it's not perfect and making this the the only criterium would be morally wrong, but it's definitely more fair than going by bank accounts.

Quote (https://en.wikipedia.org/wiki/Disability-adjusted_life_year):

>The methodology is not an economic measure. It measures how much healthy life is lost. It does not assign a monetary value to any person or condition, and it does not measure how much productive work or money is lost as a result of death and disease. However, HALYs, including DALYs and QALYs, are especially useful in guiding the allocation of health resources as they provide a common numerator, allowing for the expression of utility in terms of dollar/DALY, or dollar/QALY.

This is already widely in use btw, it's not exactly a new idea.

I see a decent argument that, but that is basically inverting someone's access to healthcare with the amount of time they've put into their community. It is much easier for old people to look back on a lifetime of doing good than young people, but prioritising healthcare to young people minimises DALY lost.

It also penalises people who are sick with serious diseases, as giving them more healthcare would have less impact than helping someone healthy.

I think it is easy to justify mathematically but in practice would be quite cruel. Plus it creates incentives for shenanigans as people desperately bribe doctors to lie about their potential futures.

I don't think lying has much of an effect, the main thing that counts for "potential future" is being alive / able to "live".

IIRC the metric is routinely used when evaluating new treatments, measuring their associated cost in $/DALY helps comparing and price negotiations.

If things are really tight (think war, poverty, pandemic, etc) I think at least it can be fair and effective. One can't live forever, and IMHO prioritizing younger people for medical care is widely accepted. Of course there needs to be a few humans in the loop as it's just a statistic and there are no guarantees.

And obviously a cold soulless robot AI optimizing for it would be insane, but that goes for most metrics.

> It is deeply disturbing to me that there are people with these types of views.

Just friendly advice: you're never going to have a meaningful discussion or a productive debate if that's how you treat a differing opinion.

Sometimes a differing opinion is disturbing enough that it should be called out as such.

All good questions, but irrelevant to the point you are refuting.

With a public health system, medical care is tied to the country's wealth - not to any individual.

In my country, a government body negotiates with the drug companies on behalf of the entire country.

That does indeed mean that some drugs are not funded - e.g new cancer drugs can take some time, or maybe never be publicly provided.

But what will (should) never happen under the public system is that a poor person is denied equivalent medical treatment to a wealthy person.

For people who want access to a higher level of care - there's private health insurance. Many have it, and use it, but anyone without it is provided the same base level of care, including free hospital treatment, available to everyone else.

> With a public health system, medical care is tied to the country's wealth

This is misleading. In a country with less wealth wages are usually lower, including those of health care provider and so on, making medical care cheaper.

Case in point: Cuba is pretty poor and have excellent medical care.

Look at the percentage of GDP that the US spends on healthcare.

Wealth is a terrible proxy for contribution to society.

It's inevitable that medical care in some way is tied to personal wealth. Some treatments are so expensive and/or niche that public programs likely wouldn't cover them. Such treatments will probably always exist. (And if they didn't, then that could he a problem by itself.)

But at least basic modern healthcare (things that existed ~20 years ago) should be provided as (mostly) free to the patient. We need people to not worry about going to the doctor - there should be minimal paperwork and cost. More people going to healthcare earlier would hopefully pay off through better preventative care.

> It's inevitable that medical care in some way is tied to personal wealth. Some treatments are so expensive and/or niche that public programs likely wouldn't cover them. Such treatments will probably always exist. (And if they didn't, then that could he a problem by itself.)

Not in a single-payer state, no.

It's also not really a problem in and of itself. You'll find that if cancer treatments are actually cheaper and more effective than the status quo as demonstrated by a study that a single payer state will quickly take them up.

[edit] Frequently you'll find these eccentric or fringe treatments that are incredibly expensive aren't actually better per se. There is a point of diminishing returns in everything. If you paid $200K for cancer treatment, would you get a better outcome? $1M? $10M? $1B? No. We know what we know, and we have the tools we have. Healthcare isn't a pay-to-win game. Generally if you find a way to pay more to get better care you're just bumping someone else down the priority list. That may be acceptable in America but it's not in much of the rest of the world.

Extremely rich people in non-USA countries can still travel elsewhere and pay exorbitant amounts for exotic treatment if they so desire. Some of those might be lifesaving.

Some (who don't understand the value of money) may even visit the US. My question is do you have some good examples of this, particularly where efficacy is disproportionately better?

I could be wrong, but I believe one of the few metrics that the US outperforms in is cancer survival. I have heard that there are quite a few wealthy people (even from places like canada and the uk) that come here for cancer treatments that are not provided in their country because the public health system will not pay for them.

That's a funky one, and I'll be the first to say that America does have some very good cancer treatment clinics if you don't mind bankruptcy (although the same is true if you break your leg).

Part of that has to do with how cancer survival rates are measured and what role screening has in the various systems. This came up with Giuliani a while ago and is well described here [1]. tldr: The statistics are quite misleading as cancer survival is measured in 5-year survival rates, and the US has aggressive (sometimes medically unjustified) early screening programs. Early detection of some kinds of cancer, such as prostate cancer, doesn't change the mortality rate but it does change the 5-year survival rate as the disease is detected earlier.

If you have more data, or this isn't what you were referring to, I'd love to read it!

[1] https://www.factcheck.org/2007/10/a-bogus-cancer-statistic/

Here is a good example as to why you might want to go to the US for cancer care.

"It's crazy that I live in Canada, but now I'm looking at having to sell my house for coverage of my medication."

https://www.cbc.ca/news/canada/british-columbia/a-tale-of-2-...

That's one people out of 36 million, making national news. You'll trip over a stack of them on your way to the news stand in the US. "I'm looking at having to sell my house for coverage of my medication" is practically America's national anthem.

Failures happen from time to time but they are the exception and not the norm. Numbers available here: [1] for the most part Canadians getting medical care in the US are "snowbirds" who live in Florida or California for half the year. This is utterly logical as Canadians don't usually have $100,000 to pay for a new hip.

If you dig into that specific situation, the issue was that Health Canada only gave conditional approval for Ibrance in early 2016. Broader approval was granted in mid/late 2017. This article was written in January of 2018 - between when Health Canada had approved Ibrance and when the British Columbia Ministry of Health had added it to it's list of covered drugs. That happened just 3 months after the article was published, in April of 2018.

This particular lady chose to travel to the US to obtain a drug that was not approved for sale in Canada at the time. That has since changed.

I don't think it's fair to indict the health system over this especially when not all health Canada approved drugs are fda approved and vv.

[1] https://www.vox.com/2016/10/9/13222798/canadians-seeking-med...

[2] https://www.pfizer.ca/pfizer-receives-expanded-health-canada...

I'm just calling out that health care coverage in Canada isn't all peaches and cream. I've experienced both systems so I know what the pros/cons of each are.

Here is another examples: https://www.cbc.ca/news/canada/british-columbia/patients-liv...

People in pain (who can't work or even walk) waiting 2 or 3 years for hip replacement. A friend of my mom's in BC is 85, needs a new hip and the gov't said no. Not "no, maybe later" it was just "no, you're too old for it to be worthwhile".

Now don't get me wrong, this is why healthcare is Canada is way more affordable than the US. The Canadian system is just limited by budget - the provinces set the budget (based on support from the federal gov't) and then say "this is how many hip replacements we'll do this year". And if you're not a priority, you wait.

While in the US, if you're either poor (Medicaid), retired (Medicare) or have good insurance through your employer (majority), you'll get care pretty quickly. But that comes at a cost - a cost about double of healthcare costs in Canada.

Again, I'm not saying the US system is better. It's outrageously expensive system, leaves many without care and is unsustainable. But if you're a middle class person in the US, don't expect the Canadian system will give you the exact same care for free.

> I'm just calling out that health care coverage in Canada isn't all peaches and cream. I've experienced both systems so I know what the pros/cons of each are.

As have I.

The US system is also generally ranked below the Canadian system on every measure I've seen. That doesn't necessarily mean much, as being better than the worst isn't much to write home about.

One great example of this is the US is the only developed country in the world where mother's mortality rate is rising. It's 4X higher than any in Canada. There's real serious on-the-ground issues with US healthcare. [1]

[1] https://en.wikipedia.org/wiki/Maternal_mortality_in_the_Unit...

Sure. Again, if you are lower middle income you’re better off in Canada. If not, better off in the US.

Not if you’re giving birth apparently. People seem to say this as fact, because it’s a pay to play system (so if you pay more, you must get ... something; right) but I don’t think I’ve come across evidence to support your conclusions. Did you happen to have some data I could look at?

All the data I’ve seen ranks the Canadian system ahead of the American on outcomes.

This isn't correct in the UK under NHS. There's a set amount NHS is willing to pay for drugs and treatment, and beyond that, it's refused altogether. You'd have to go elsewhere and on your own dime for expensive treatments. Here's a link from the BBC I quickly found but it's widely documented: https://www.bbc.com/news/health-28983924

The QALY metric they mention is exactly what I had in mind, actually, very cool.

Wealth won't get you better care, or faster care, or different in the NHS. That's the point I was making, and your article supports that position.

> "You'd have to go elsewhere and on your own dime for expensive treatments."

[In a single payer system there's nowhere else to go.] (retracted)

The majority of single payer systems don't outlaw private care. There are private hospitals in the UK for example.

Single payer is about removing insurance companies from the process (saving money), standardising care (saving money, improving outcomes), collective bargaining for drugs (saving money), providing a base level of care to all (saving money and improving QOL). But it doesn't usually forbid spending money on private care.

As a result single payer results in similar outcomes for vastly less public money, and almost zero private money spent on healthcare.

Indeed, and I retract my final sentence.

Ideally though, all private healthcare would be banned.

Aside from ideological concerns about not giving the wealthy an unfair advantage, this has pragmatic benefit in ensuring that the public healthcare system is up to standard.

That is, if the wealthy and powerful are forced to use it too, it means they have skin in the game and won't just use their power to run it into the ground in pursuit of profit or from lack of concern for others.

Interestingly, private healthcare isn't banned in Canada but in in reality, there's virtually none of it. The system is designed so that the public sector doesn't subsidize a potential private sector, and without those subsidies, nobody's interested.

Personally, I agree with you. Private healthcare should be abolished entirely.

In the UK, about 10 percent has private insurance, but nearly all private plans are 'top up' type plans where the assumption is that you usually rely on the NHS first, but ask for a private referral if you need a specialist or procedure there's a wait for.

As a result they're generally pretty cheap.

In effect you're paying to jump queues for a limited resource.

I don't know if you live in the UK but I can share my 2 cents: UK NHS systems isn't exactly what many Americans picture it.

Thank you for the information - it is interesting to learn of a case where discouragement and disincentivisation, in lieu of abolishment, has turned out to be a reasonable and pragmatic secondary option.

Looks like I forgot to link you to the write-up (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC80881/) but I suspect you'll find it interesting!

> Private healthcare should be abolished entirely.

Wouldn't this mean using the police to arrest people if, e.g. a person got a doctor to look at them or suggest a treatment for a condition and it wasn't something that had gone through government channels?

Perhaps at an extreme point, but most white collar crime is dealt with by fines and licensing rather than arrests and jail. E.g minimum wage laws.

But if you refuse to pay the fine on the grounds that you consider it unethical to withhold medical care from someone who requests it, you’d still be subject to incarceration?

This situation exists today. Let's say I'm a physician, with experience from a foreign country and a years-long unimpeachable track record. What I don't have is a US degree or residency. I'm 100% going to prison if I perform a surgery in my van. Licensing and various other requirements are imposed on physicians in order to practice lawfully. One of those requirements would be not to accept direct payment for services outside the public system. If you do, then you are practicing without a license, and whatever comes of that comes of it. Likely a fine, or license suspension or if you continue to defy the law, prison.

Your argument that "you consider it unethical to withhold medical care from someone who requests it" is not a defense today for practicing medicine without a license, and in my scenario, that would not change.

> This situation exists today. If I'm an physician, with experience from a foreign country and a years-long unimpeachable track record. What I don't have is a US degree or residency. I'm 100% going to prison if I perform a surgery in my van.

I agree and this is terrible.

> Your argument that "you consider it unethical to withhold medical care from someone who requests it" is not a defense today for practicing medicine without a license,

it may not be a legal defense but it is absolutely a moral defense.

> in my scenario, that would not change.

I just want to make it explicit that you agree with the criminalization of healing people without permission.

Replying here because rate limiting, and I find this conversation interesting :)

> it may not be a legal defense but it is absolutely a moral defense.

I suppose that's so.

> I just want to make it explicit that you agree with the criminalization of healing people without permission.

By framing your reply as "criminalization of healing people without permission" you have baked in a lot of unstated assumptions:

1. The person doing the 'healing' has met your personal standard for a 'healer' - in this case foreign experience. Without licensing, I could, with no experience whatsoever, just cut you open and go to town. You would die, and then what? Who's liable? What if I get half way through and then realize that Milton Bradley's Operation is not a replacement for Grey's Anatomy and you are rushed to a real hospital?

2. You assume the 'healing' is successful. Does it become butchering if I fail to do so?

So, to that end, while I may not agree with all aspects of licensing physicians (for instance, I'm with you on the foreign degree and experience limitations) I believe that on the whole it does more good than harm.

I will therefore be explicit and say, yes, I do "agree with the criminalization of healing people without permission [of competent authorities]," even if I do not today agree with all of their requirements, however I reject your framing.

> The person doing the 'healing' has met your personal standard for a 'healer' - in this case foreign experience.

I'm not imposing my standards for a healer on a sick person in his personal quest for a healer.

> Without licensing, I could, with no experience whatsoever, just cut you open and go to town.

Indeed, you could do the same thing absent a license in a regulated regime, and also you could get a license and kill me on purpose and say it was an accident or unfortunate outcome. What the requirement for a license does is create a class of people who are approved healers, and criminalize medicine outside of that state-sponsored context.

> You would die, and then what? Who's liable?

You'd be liable, just like you would if there were licenses and you either had one or did not. Or are you referring to the fact that physicians are shielded from liability if they meet industry accepted standards of care?

> You assume the 'healing' is successful. Does it become butchering if I fail to do so?

I don't assume that. I'm just referring to the telos of the act. You're allowed to give people free tattoos. You're not allowed to give them a tattoo if you claim it is medicine. It doesn't matter if its a drug or whatever. The intent to heal is what's criminalized here.

> So, to that end, while I may not agree with all aspects of licensing physicians (for instance, I'm with you on the foreign degree and experience limitations) I believe that on the whole it does more good than harm.

The problem arises when you enforce your values on other people who do not share those values because of your belief that "on the whole it does more good than harm."

> I will therefore be explicit and say, yes, I do "agree with the criminalization of healing people without permission [of competent authorities]," even if I do not today agree with all of their requirements, however I reject your framing.

Thanks for your reply and thanks for engaging my perspective directly :)

> Thanks for your reply and thanks for engaging my perspective directly :)

I think you have a totally reasonable and consistent position, it’s just not one I personally agree with. Thanks for sharing and have a great evening!

Disagree on private healthcare being abolished. If people want to spend their own money outside the single payer system, why not let them? It doesn't absolve them of contributing to the public system, so the public system benefits when they decide to go outside it.

And in Canada, there isn't much private healthcare because of the way Medicare is set up. A doctor has to choose - practice in the public system or the private system - they can't do both.

As a result, you have a handful of doctors who do private with the majority in the public system. For certain procedures there is actually a lot of private healthcare in Canada. Take a look at MRI's. Instead of waiting 2 or 3 months for an MRI you can pay $300 and get one this week and send the results to your doctor.

It varies from province to province [0]. What you're saying is true in some provinces but not all. However, even in the provinces without material barriers, no private sector exists. The article actually provides some solid theories.

Your information about MRI waiting times isn't accurate in general - or rather paints only part of the picture. Even with the COVID situation happening now, in Ontario... Patients who should be scanned immediately receive a scan, immediately. Patients who should be scanned within 2 days are in fact scanned within 2 days. Patients who have a target of 10 days for a scan wait closer to 18 (but 53% are scanned within the SLA). Patients who have a target of 28 days wait closer to 90. [1].

If you don't need one now, you're wasting capacity by getting one now. This capacity should be allocated 100% to the public sector on a need basis. That would reduce wait times for all priorities. This is in fact what the British Columbia government did [2] to excellent effect [3].

[0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC80881/

[1] https://www.hqontario.ca/System-Performance/Wait-Times-for-D...

[2] https://globalnews.ca/news/4481951/b-c-to-purchase-two-priva...

[3] https://globalnews.ca/news/5256655/wait-times-mri-procedures...

"For the 90th percentile wait times, the improvements are even more significant. Province-wide, wait times went from an average of 221 days to 161 days."

That's a success? Waiting half a year for an MRI?

Come on. I'm Canadian and know plenty of Canadians. Wait times are one of the major issues in Canada. Yes, if you don't need it right now, you wait - sometimes years. But sometimes you need it in the next few weeks and you wait months.

90th percentile wait times for the lowest priority class - anyone who needs an MRI badly gets one immediately - literally, immediately, you walk into the next room. I’ve seen it happen to family. Yes it could be better still, yes it was improved by having the province purchase private facilities, and yes an improvement is a win.

The challenge with transparency like this is you see a number like that and freak out. The reality is need based triage works and plays a huge role.

Their goals are likely a few months, due to low need. Not every MRI needs to happen right right now, and that attitude is part of why there are wait times and shortages in the US too. Still cold and should be better!

Canadian healthcare is horrible.

"Out of 11 countries, Canada was ranked ninth for health care, placing just above France and the United States."

https://www.kelownanow.com/news/news/National_News/Canada_ra...

"217,500 Canadians left the country for health care in 2017, according to Statistics Canada. If those travelling with the patients are included in the count, the total rises to 369,700 people."

https://torontosun.com/news/national/canadians-continue-to-l...

In this thread, someone said people travel to the US even from Norway. (!!!)

The US has the absolute best system money can buy, period.

It's just that most people don't have much money, and that is the problem that needs fixing.

In your link, US is even lower. So if someone praises Canadian system in comparison to US one, it is still correct.

It is absurd to show link that ranks Canada higher then US despite having problems and then proceed to ... call US the best. Also, Americans near border travel to Canada to buy drugs pretty routinely despite it being illegal.

Btw the majority of those who “left for healthcare” are the Canadian old folks who spend half the year in America and have insurance as a result.

source?

I know dozens that went to the US for treatments. Some even took out second mortgages because it was a choice between languishing on a waiting list with a heart condition that can kill you, or getting it fixed next week.

I suspect their new insolvency created a different kind of heart condition.

One way of deriving this is the cost of an average hip replacement in the US is $100,000 USD ($128K CAD) - how many Canadians have a spare house kicking around to finance a hip? Probably not that many.

Further, this paper, [1] and this write-up [2].

If you actually read the policy brief on which your article was based [3] you'll find a few interesting things. For one, they acknowledge that this travel includes traveling for non-covered procedures like cosmetic plastic surgery. It also implies snowbirds are not covered in this data, but then acknowledges in the next line that they probably are too but they don't have actual breakdowns other than their own "knowledge" that people are leaving due to wait times.

"The federal agency wasn’t able to provide a breakdown of patients seeking medically-necessary procedures and those leaving Canada for cosmetic surgery." This feels like important information to know.

I find this paper incomplete and un-compelling.

With that said I did find this statement in the second street brief pretty funny: "While health care debate in Canada often focuses on comparing our current system with the United States, readers should note that the Commonwealth Fund report ranked the United States 11th out of the 11 countries it examined."

[1] https://www.healthaffairs.org/doi/10.1377/hlthaff.21.3.19

[2] https://www.vox.com/2016/10/9/13222798/canadians-seeking-med...

[3] https://www.secondstreet.org/wp-content/uploads/2019/04/Poli...

Thing is a good public option decimates the market for advanced private care of the level you have in the US.

Here in Norway the private health providers that do exist mostly deal with low-investment, low-asset, high-return cases. They will look into your psoriasis but ain't going to treat your cancer.

Fortunately the advanced care in public system is great. Still it's not unheard for patients that can afford it to go to the USA for specific treatments.

> decimates the market for advanced private care of the level you have in the US.

> Still it's not unheard for patients that can afford it to go to the USA for specific treatments.

They're often getting very expensive, but not very good, treatment that do not lengthen life nor improve quality of life. Sometimes these treatments reduce length of life or quality of life.

No, I'm talking specifically about things like bleeding edge treatments for late cancer stages accessible only in top U.S. hospitals. Treatments that are still in trials or just approved and not available in Norway yet.

Sometimes they would work and sometimes they wouldn't, but in Norway your option then is basically arranging your own funerals.

https://www.aleris.no/en/cancer-center/cancer/

"Aleris’s Cancer Centre (Aleris Kreftsenter) provides a complete range of diagnostic tests and therapies for most types of cancer.

We offer the latest cancer drugs and innovative treatments, such as immunotherapy, before they are available in public hospitals."

In fact a single payer system alongside private insurance works really well to keep the private insurance providers honest. Up against a single payer one of their primary value add for most people isn't even better health care per se but better customer service, faster appointments, clear and helpful advice, etc. This is a good deal for the NHS as well because they still get your tax contributions but the private system takes some of the load off them.

In theory I'm mostly a Friedmanite. I think he has good reasons for preferring private enterprise for most thing. In theory private enterprise should be able to provide better health care than a public system as well. The problem is politics, lobbying and market distortions always introduce complications and obstacles. Health care is one of those markets where the resources and incentives on the provider side just overwhelm the ability for private individuals to get a fair deal.

I'm very glad we have the NHS over here, yes it has inefficiencies and weaknesses but compared to the horror show in the US I think it's far preferable.

In a single payer system there's nowhere else to go.

We have private health care in the UK in addition to the national health service (eg https://www.bupa.co.uk/). It's insurance-based, and it pays for treatment in hospitals both inside and outside of the NHS. It's even offered as a perk by some employers. Specifically relevant to this HN story, there's access to cancer treatments before they're approved by the NHS and NICE (https://www.bupa.co.uk/health/health-insurance/bupa-cancer-p...).

I realise that some people are politically averse to single payer healthcare, but please read up a bit about how the UK's healthcare system works before posting about it. You're only spreading misinformation if you don't.

For clarity - the UK's NHS is a single payer taxation funded, free-at-the-point-of-use healthcare system, but we also have companies that offer parallel private health insurance funded healthcare for anyone who chooses to pay (and yes, that does mean they're paying for the government service and their own private service, but that's just how taxation works).

I wasn't commenting on the NHS there, I was making my comments with reference to the Canadian system. I retracted my comment because I made it overly board. If you'd like to learn more about the legality of private cover within the Canadian system you can do so here. [1]

In Canada, while in general private cover is not illegal, for covered health services, it roughly speaking does not exist and my statement that you "have nowhere else to go" holds.

I can see that my statement was unclear, hence my edit.

With respect to the other statement I made, that money won't buy you better care within the NHS is true to the best of my knowledge.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC80881/

> In Canada, while in general private cover is not illegal, for covered health services, it roughly speaking does not exist and my statement that you "have nowhere else to go" holds.

The key is “covered health services”. E.g. a friend who broke his arm in Israel (which has an NHS like medical system) needed to have it cast; a standard plaster cast was covered, but for an extra $150 or so, he was able to pay and get a super-lightweight composite cast material (which he had to buy at a pharmacy down the road himself, but the doctors at the public hospital happily applied).

This was about 20 years ago - I suspect the ultra lightweight cast is covered by now as well - but there will always be treatments which may make sense for an individual to pay for, but not for the system.

Similarly to the NHS, more money doesn’t buy you better care within the system in Israel; but there is a complementary private system which occasionally can get you better care (and can often get you the same non urgent care faster). The general rule for coverage inclusion in the Israeli system is: if it’s life saving, it is covered. If it’s life extending or quality improving, then a QALYs analysis and budget constraints set the priorities (most proven reasonable cost treatment are indeed covered)

> The key is “covered health services”.

Covered health services in Canada is substantially all health services.

This is addressed in the link I provided.

It is the same in Israel. And yet, there’s room for some private health services.

In the public system, you usually have a room mate after an operation.

If you use the private system, you get a private room and get to request specific food. You don’t get treatment that is any better from a health perspective. But you do get a nicer stay.

As somebody who paid significant fees out of pocket to see NHS physician in private capacity that is very, very false.

To clarify, the NHS evaluates the cost effectiveness of treatments. It does not set any kind of cap on expenditure per individual (nor is this number even tracked AFAIK).

I don't know of any healthcare system that doesn't make some kind of evaluation of cost effectiveness. Insurance companies do this too!

Your article mentions the cancer drugs fund.

In the US companies will happily exploit dying people to extract as much money from them, and their families, as possible.

In the UK we recognise that dying people are vulnerable to this form of harm and we put protections in place.

The cancer drugs fund was a way to allow the NHS to use newer cancer drugs by reducing the amount of testing needed, and by increasing the amount of money we were will to pay for these meds.

After several years we realised that these drugs, while being very expensive, provided no meaningful benefit and often caused harm. Sometimes they degraded quality of life and shortened length of life.

https://www.bmj.com/content/357/bmj.j2097

There are a few treatments that work well but are just to expensive to be viable. For instance a few decades there was a gene therapy developed for people with a gene deficiency that blocks them from digesting fats. If I remember correctly it was developed in Canada. Even though it cured the people, it was and is too expensive for it to be used at the moment.

>Not in a single-payer state, no.

You can always go to another country or just pay someone personally to hear out your problems and help fix them. You can't avoid that.

>It's also not really a problem in and of itself. You'll find that if cancer treatments are actually cheaper and more effective than the status quo as demonstrated by a study that a single payer state will quickly take them up.

Some people report that doing a ketogenic diet helps them control some diseases (eg diabetes). It's been a decade since its surge in popularity. Keto doesn't seem to always work, but it seems to work for some. Is it considered a treatment yet? Because doing a keto diet is likely to incur a higher cost - carbs are cheaper compared to protein and fats.

>Healthcare isn't a pay-to-win game. Generally if you find a way to pay more to get better care you're just bumping someone else down the priority list.

What do you mean? Healthcare is not a fixed pie. It's constantly expanding in what can be treated, you can train and hire more doctors and nurses, you can make more and better equipment. If people are willing to pay enough extra for some treatment, then this can directly lead to the capacity of that treatment increasing.

>That may be acceptable in America but it's not in much of the rest of the world.

This is exactly how it works in many countries. You have your public healthcare and then private healthcare, where you can skip queues.

I like our healthcare system here in Canada, but this is not fully true. There are often experimental or very expensive treatments that the provincial health care systems don't cover, and so every few months I hear about some medication for a rare disease or cancer that someone is struggling/lobbying to get covered.

One historical example is Herceptin, for treating breast cancer. It took six years to get the Ontario gov't to finally cave and cover it, meanwhile some people were traveling to Buffalo or other places in the US and paying out of pocket to get it. See this old article from 2005: https://www.theglobeandmail.com/life/ontario-makes-herceptin...

On average, yes, it is better to be a cancer patient here than in the US, especially if you're working class or poor. And I believe last time I looked the life expectancy and recovery rates statistics etc. bore that out.

But there are definitely medications and treatments not covered, still, and having extra insurance coverage is important enough that people I know have struggled to keep their jobs so they could continue to pay for their partner's treatments.

In general, in Canada, medical care is covered but prescription pharmaceuticals are not. Which needs to be remedied.

> In general, in Canada, medical care is covered but prescription pharmaceuticals are not. Which needs to be remedied.

Dental and vision too!

> Some treatments are so expensive and/or niche that public programs likely wouldn't cover them.

I have co-worker with a very unique disease with a very niche and very expensive treatment and here in Canada it's free. The whole point of public health care is that the cost is spread among everyone -- the young, the healthy, the old, the very sick.

This spreading of cost amongst the whole of society should really be the norm rather than the exception, particuarly for all the other essentials of human existence and dignity.

For example, here in the UK we have a growing network of food banks who have stepped in to fill the needs of the many people who are in dire financial straits (and not just because of the pandemic - their use has been rising rapidly for the past ten years, due to right-wing austerity policies that have decimated the welfare state).

These are almost all run by the third sector (charities, etc.) and they do excellent work in the circumstances. But coverage is patchy and uneven, and many families still suffer from food poverty.

How much better it would be for us to have a National Food Service, with country-wide service guarantees such that everyone's nutritional needs can be met.

No more wondering where your next meal is coming from, or starving yourself to feed your kids, or eating unhealthily because it's the cheapest option with the resources available. It's just provided as needed and the cost is shared. Indeed you may even have paid for it already with your taxes, or will do in the future.

And a similar sort of thing should be done for housing, water, etc.

I'm appalled that we have come to the point where we need food banks for people here in the UK - they were practically unheard of before 2008 and the subsequent "austerity".

You can sink virtually infinite resources into healthcare. There are always going to be more things to research and develop treatments for. At some point you have to draw a line, because the cost to the system can become enormous.

Take some of the gene therapies as an example.[0] Zolgensma costs over $2 million per treatment or Zynteglo[1] that costs $1.8 million per treatment. Maybe US healthcare can afford this, but poorer countries can't. The hope is that the existence of these treatments means that they will eventually come down in price. 20-50 years from now I expect these treatments to be part of basic healthcare in most countries. On the other hand, if we limit the existence of treatments like these right now, then maybe 20-50 years from now these treatments simply wouldn't exist.

Healthcare systems always play with limited resources. We should first start covering dental care, glasses and eyesight surgeries as an example of something that's missing in a lot of countries.

Furthermore, regardless whether the system had the money or not, some 'treatments' will still be niche and not considered 'healthcare'. Traditional medicine can help with some problems, but it might not fall under healthcare. Most things related to diet are basically a pseudo science, but some of them work for some people. You'll never cover all of this.

[0] https://www.reuters.com/article/us-novartis-genetherapy-idUS...

[1] https://www.wsj.com/articles/new-gene-therapy-priced-at-1-8-...

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