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Comment by treyfitty | Hacker News Reader

Anecdotal: my dad had a heart attack and was in the hospital for 6 months due to complications. After a certain amount of time, the bills started to rack up and we were being charged for services that we thought would be covered under “health insurance coverage.” Instead of being covered, the health insurance provided coverage for standard hospital care, but we were charged every time a non network doctor stepped into his room. Then, the non-covered machines that were used. Then, stupid things like “staying in an ICU longer than allowed by coverage.”

My father passed away before making it home, but when all was said and done, insurance was billed $10 million in total, of which the various doctors and hospitals billed the estate $2 million. My dad didn’t have an estate because he had no assets. But imagine your life + childrens’ lives being ruined for having insurance yet filled with invisible asterisks.

At the time, NJ laws were onerous in this regard and favored insurance companies so we had no recourse. The state had a process for dealing with issues like this, but it was more of a cursory “jobs done here boss” type process and didn’t provide consumers with relief. Because of that, I moved my family out of NJ. When all contingency plans are filled with asterisks, do you really have insurance/protection?

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> having insurance yet filled with invisible asterisks.

"Invisible asterisks" captures the reality perfectly. The asterisks are invisible and infinite. I think even Kafka would be horrified.

We've turned medical billing into an impenetrable Byzantine hellscape, and I fear that the only way to fix it would be to nuke it from orbit and start over.

Medicare For All is the single most important policy in American politics right now, IMO, for this exact reason.

People complain that all the people in private insurance will be put out of their jobs - I view that as a feature, not a bug.

This needs to happen. The medical billing industry is literal cancer.

They sent me a bill for $350 then I called up to complain and suddenly the bill goes away because it’s billed to my other insurance that I didn’t even think I had anymore.

If I sent a client a random bill for $$$ things would not go nearly as nicely, but they have so captured the regulators and politicians that this is the world we live in now.

I want nothing to do with many of the policies of the left, but this would make things so much easier for small businesses and people Changing jobs in the labor market.

It's important to know some assets avoid probate and go directly to the beneficiary. These include things like a life insurance policy, or a 401(k) with a beneficiary information you can input, and possibly even update online (low friction). The health bill can go to the estate, but the estate also isn't comprised of the retirement account.

This should be common knowledge (but, unfortunately, isn't.)

A primary breadwinner should carry at least 10x his family's annual living expenses in term life insurance coverage.

Once the size of his retirement accounts exceeds this, he can start thinking about reducing the insurance.

Both will pay directly to beneficiaries in the event of his death.

You can setup a simple trust with the right form/software, and a visit to your bank for notarization. I don't know if a revocable living trust would protect your heirs against healthcare shakedowns, and it would likely depend on the state. But if the current corrupt system continues much longer, I can see irrevocable trusts becoming popular to protect yourself even while alive.

Sorry for your loss. This is one of the things that tends to get overlooked when discussing how awful the US health care industry is. You always hear: "US health care is terrible unless you have insurance!" But, it's also terrible when you have insurance! There are all kinds of ways doctors, hospitals, and insurance companies conspire to drain your pockets or your loved ones' estate's pockets, and they're all likely documented somewhere in a 100 page policy. The system is irredeemably beyond repair.

It more and more feels like the difference between not having insurance, and having insurance when something bad actually happens is "do I get a massive bill that I can't afford now, or do I get a massive bill that I can't afford later?".

The only real benefit of having "insurance" in the US is having reasonable access to basic preventative care. Don't get me wrong, it is a massive advantage to have default access to basic preventative care (without it being a cost-benefit tradeoff each time), but that is in no way/shape/form "insurance" in the typical meaning of the term.

Most of the time the system works for people who have good coverage. The tragedy is that "having good coverage" is a hard-to-control combination of luck in employer and/or wealth.

It's terrible that these things happen at all, and we CERTAINLY need to improve the US healthcare system, but exaggerations like "the only benefit of insurance in the US is access to preventative care" doesn't help. If people were regularly getting fucked like that the system wouldn't have the entrenched support it does from the "but I want to keep my insurance" camp, and so speaking in generalities like that just makes you appear uninformed to the millions who regularly see doctors, get treatment, have surgery, etc, without these problems.

It also cheapens the inequality problem: the gap isn't just "has access to preventive care" vs "doesn't have that access." The gap is "has hundreds of thousands of dollars, or even millions, of bills turn into nothing" vs "bankrupt if they seek treatment for any serious problem."

> Most of the time the system works for people who have good coverage.

I'm sorry, but I just can't see how this is true. Do you only go to the doctor for a yearly checkup, or something?

I've had "good" coverage (paid for by big employers with cushy all inclusive packages), and I've also had the cheapest option on CA’s exchange, and the only difference was whether I had to pay the receptionist $25 or $150.

The "we won't cover this" and the "surprise, this costs 50x what you were told!" billing nightmare comes six months later. This has happened with every insurer I've ever had.

It really does vary by individual. My mom is going through cancer treatment right now. 35K/month in medication and she pays $250. I don't expect surprise bills later. She had surgery 8 years ago for the same cancer and that was also $250, for a week-long hospital stay.

In my experience it does help to have an HMO. My mom uses Kaiser. So there's none of this in- vs out-of-network. One billing system, one insurance, etc. She has nothing but positive things to say about them. My dad had a similar experience towards the end of his life. He loved 'em. And nobody was left destitute as the result of his medical care.

One of the problems with the how the US medical system works is that "35K/month in medication" is only "35k/month" because of some expectation that insurance is going to pay whatever the negotiated rate it (and I seriously doubt that it's 35k/month).

Lets look at it this way: If that was the true price, what percentage of the US population do you think has the funds to actually pay $420k/year in for medication?

In this case the insurance is paying $25K/month for the medication, so they definitely did negotiate it down somewhat.

> what percentage of the US population do you think has the funds to actually pay $420k/year in for medication?

Zero, plus or minus. That's why the manufacturers basically give it away to people who can't afford it. Because they can, and it helps them somewhat mitigate the bad PR.

That shouldn't be the exception, that should be the rule.

I've had "good" coverage for my 15 year career and it does not work most of the time, or even half of the time. I've paid bills out of pocket because I didn't have time to untangle payer/insurance situations. I was taken to the ER unconscious once after a freak accident and ended up paying thousands for the ambulance. I've had to do provider paperwork myself and submit it to insurers myself because they refused to help me help them get paid. The system is simply not functional for people who don't have huge amounts of free time, patience, and money.

That is why I like the Kaiser HMO system. Most of the rates are pre-negotiated since the hospital and insurance are under the same company. Its typically $20/40 copay for a doctor visit. Even for me with my kidney failure and health issues, the OOP is minimal.

> “If people were regularly getting fucked like that the system wouldn't have the entrenched support it does from the "but I want to keep my insurance" camp”

I don’t see how that follows.

The “I’ve got mine” camp doesn’t care that it happens to those other people, and also doesn’t understand that it could happen to them in their old age (or simply after bad luck) because they’ve only made short visits into the system.

After serving 3 large employers and reading through all the fine print attached to each health insurance policy, I can wholeheartedly say most companies do not offer "good coverage." After experiencing the fallout from my father's heart attack, I scoured through every health document I received afterwards, including but not limited to health insurance policies.

Of my different health insurance policies, the longest duration in an ICU that was covered by any of those insurance policies was 60 days. My father was "lucky" in that he was on a subsidized Obamacare policy that "only" charged $350 per month (which was cheaper than my employer's policy) but was FAR superior to any of my employers' health insurance in every aspect.

> If people were regularly getting fucked like that

I'm not sure what point you're trying to make, but it sounds like you're making the claim that people in the US don't regularly end up with massive surprise medical bills? This entire conversation is about action the government is taking because it happens so often.

> "has hundreds of thousands of dollars, or even millions, of bills turn into nothing"

That's not really how that works. It's not like your insurance company is actually paying "millions of dollars", they're paying some level of reasonable negotiated rate. If they actually had to pay "millions of dollars", that's when they claim something is not covered and you get stuck with a bill anyways.

Edit: First quote was just wrong from a bad copy/paste

When you have insurance, a claim should become purely a discussion between your insurance company and the health providers. It seems the current system needlessly inserts the patient into the middle, for the purpose of torturing him/her with paperwork, threats, bills, threats of bills, and the need to learn the intricacies of in-network, deductibles and co-pays, lifetime maximums, covered vs. uncovered procedures, etc. Instead of the insurance and health companies privately fighting it out between each other, they stick you in the middle, fighting through you as the proxy/punchingbag.

Wouldn't it be better if you went to the hospital, gave them your insurance information, and that's the last you ever were involved with anything regarding payment? Isn't that one of the reasons we have insurance?

> The only real benefit of having "insurance" in the US is having reasonable access to basic preventative care

What insurance do you have where the cost of the annual premium is less than what the out of pocket costs would be for annual checkups for the covered individuals?

I have the cheapest insurance I can get. Yes, it pays for basic preventative care (basically a checkup per person per year), and it also costs more than my mortgage.

My wife is a primary care doctor in the United States. Saying that disqualifies me in some people's minds from having an opinion about the quality and cost of health care in this country. But I am willing to give an opinion regardless.

There are plenty of medical practices and institutions that function well and deliver good value to the patient. But there are many that do not.

As someone who doesn't have friends inside the health care industry, it can be extremely difficult to figure out what to do in an emergency. Quite often your options are limited especially if you are caring for a loved one rather than yourself.

The best advice I can give is to find good doctors before you need them, and when conversations come up about someone else's medical care, be willing to ask, who is your doctor and how good are they? Or, which hospital did you go to, and do you feel you had a good experience?

Often there is little out-of-pocket difference between the cost of excellent medical care and lower quality care, if you have good insurance.

If you don't have good insurance and you are looking at a potentially significant medical procedure, ask to speak to someone about financial assistance. Good practices and good hospital systems are not looking to bankrupt their patients.

am hàppy to see HHS moving forward, long overdue!

most US doctors are part of a bigger group in order to provide more comprehensive coverage (and due to systematic buyouts), which in turn have preferred insurance providers and additional out-of-network providers, and emergency services are generally for wherever an ambulance takes you. your physician may be great, but they are just a tiny cog in a broken machine

one of the only outs, afaict, is something like working & living near a big & strong HMO like kaiser. but that comes at the cost of pretty firm boundaries on what services they allow: capped care

(my SO is also a physician at one of the nation's best hospitals, and despite that, patients struggle w the broader system outside of her practical daily control)

>There are all kinds of ways doctors, hospitals, and insurance companies conspire to drain your pockets

People also want cutting edge care from some of the smartest and most highly educated people in the world (which is in short supply) for cheap.

People also want cutting edge care from some of the smartest and most highly educated people in the world (which is in short supply) for cheap.

Actually, people just want someone to help them with their health issues and not treat them like shit.

Sure, I guess you could find people with the above attitude, but it's mostly a straw man you are using to deflect responsibility from the health industry.

There are HMOs, like Kaiser, that solve most of these problems. Unless I'm traveling, I would never have to worry about such extraneous bills. However, for any particular serious condition a particular HMO might not have the top-rated team in the country. This unreasonable fear is used by non-HMO insurance networks to draw customers.

Perhaps what we need is something like the WTO's most-favored-nation rule for domestic insurers, but imposed statutorily. If you're treating an out-of-network patient extemporaneously, you can only charge that person's insurer at the lowest rate you'd charge an in-network provider.

This would remove the incentive for out-of-network providers to eagerly provide many services. That has its own downsides, of course, but it might help to resolve many of these billing nightmares.

But, heck, maybe something like that already exists. Obamacare (aka ACA) comprehensively thought through many of these dilemmas. But enforcement has been gutted by the GOP.

In 99% of cases, you don't need or want cutting edge care— you need basic, efficient, timely care. The rest of the world manages to deliver that as a basic human right.

Yes .. but. Canada is often pointed at by Americans as an example of a functioning healthcare system. I can tell you we have many problems, but they are different. It might mean long queues for basic diagnostics/assessments/procedures, facilities that look ugly, excessive waits in the ER, and still paying an arm and a leg for medication. I have heard of great experiences in Canada but also pretty terrible ones.

I'm a Canadian too. Maybe I've just been lucky, but when I or anyone in my family has needed urgent care, I've never felt like I had to wait excessive amounts of time for it.

As far as whether facilities could be "nicer", I mean... maybe? I actually kind of prefer healthcare to be like schools in this way— if I don't think it's nice enough for me, then I need to lobby the province to collect more taxes and make it nicer for everyone rather than just taking my dollars elsewhere.

And that doesn't even address the whole billing-surprise angle. I would happily wait forever if the alternative was not knowing if I was going to randomly be stuck with a $10M bill.

> Canada is often pointed at by Americans as an example of a functioning healthcare system.

To be fair, Americans have a very low standard for “functioning healthcare system” due to the American healthcare system.

Wrong. YOU might want cutting edge care from the smartest and most highly educated people in the world (not sure where you get this from however, healthcare in most of the developed world is equally good). Most people want decent care that does not involve them worrying that the next healthcare bill will bankrupt them. I highly doubt ludicrous hospital bills are a necessity to getting "cutting edge care", if so something is definitely broken (and is).

When I lived in Manhattan and worked with some really wealthy clients, they'd fly to France, Israel and elsewhere for care when they could have easily gotten the best care the US has to offer right down the street.

Personally, I just want to know the cost of services before committing to pay. I have been unable to get that in many situations, even for non-emergency care.

I do too. A doctor should be able to give you the codes for whatever routine or preventative procedure you’re interested in paying for, and you should be able to look up the price on your insurance company’s website.

It's not that simple. Doctors themselves often don't even know which billing codes will be used; coding is done by other office staff. And insurers don't have a single set price list. The patient's out of pocket expense will depend on a medical necessity determination and whether they have reached their annual maximum.

That is why I specified for routine or preventative procedures, where everything is known beforehand.

I also do not buy that doctors do not know which code will be used. I don’t care if the doctor themself does not know, surely someone that works with them knows and can provide it.

It should be dead simple to go to a doctor’s website and find the codes for routine procedure that they will bill. If something in the visit happens outside of that, the doctor can feel free to say that is outside of the scope of the visit, just like a mechanic can tell me he will not fix the transmission if I am in for a brake job.

There is a pretty large continuum of potential value between the 'cheap' care that people want, and the ruinous bills that get charged.

Ruinous bills are frequently used to cover the costs of routine procedures. It’s another situation where 10% of the healthcare consumes 90% of the resources. It’s the person who needs 6 months in the hospital, the 2 month premature baby in NICU, the hemophiliac that needs $1M medication that balloon all the costs.

And no one can really afford that, but instead of spreading the costs around to all taxpayers, we were spreading it around by inflating everything else. ACA helps with this, but today’s announcement about out of network care will help more too.

There is a pretty large continuum of potential value between the 'cheap' care that people want, and the ruinous bills that get charged.

That can't be true, everyone knows that people are only greedy and stupid, and it's really the citizens' fault for the prices of the current healthcare setup. The industry itself is all made up of kind-hearted super heroes who would never think of manipulating prices to syphon more money from patients.

Are American doctors really smarter than Dutch or Swedish doctors?

The context is Americans getting healthcare, so Americans would be choosing from people in America.

I would also point to the unnecessarily arduous and lengthy process of becoming a doctor in the US as one of the US system’s problems.

If I’m going to be asked to sacrifice all of my 20s and maybe early 30s and worked on 24 hour shifts during the prime of my life, I am also going to be making sure I get paid a ton for it. Otherwise, I would choose a different career.

I know a lot of doctors that advise their kids to not pursue medicine even if they want to do it, simply because the cost benefit is not worth it anymore (if you have other options).

They’re probably comparable, but one advantage, no doubt due to our high costs, is that US hospitals tend to have a ton of resources and the latest equipment. This does make a difference if you have a condition that benefits from cutting edge treatments.

I recently had a family member get surgery for a life threatening condition where a cutting edge treatment greatly reduces complications. The equipment only exists in a small number of hospitals on the planet and their normal hospital, which wasn’t even a particularly fancy US hospital, had one. It's probably not an issue for small and rich countries though. Probably more-so for medium income countries.

Do the children have to pay off the bills of the parent? That doesn’t seem reasonable to me. It sounds like the best thing to do before getting too old is to transfer all your assets out so that if you die you won’t have it robbed by hospitals, etc.

It depends on the state. Some states have filial responsibility laws which require adult children to support indigent parents.

https://en.wikipedia.org/wiki/Filial_responsibility_laws?wpr...

This is jaw dropping. How is this legal at all?

It sounds like a good startup. Do background checks on homeless people, see if they have any living relatives, and if so you can house them in a nursing home and charge the relatives.

They're legal because they're laws. I think you might be asking how they're constitutional? They're constitutional because there's nothing in the constitution that prevents such laws.

Are they fair? I mean ... sometimes? These laws (supposedly) solved a problem where parents would bequeath their estate to their children prior the parents' death and, then, the children would leave their parents destitute. It's not clear how much of a problem this really was (think "19th century); it was probably just a popular image that politicians used as a talking point?

My suspicion is you'd need to use jury nullification to make the law "go away".

>In 2012, the media reported the case of John Pittas, whose mother had received care in a skilled nursing facility in Pennsylvania after an accident and then moved to Greece. The nursing home sued her son directly, before even trying to collect from Medicaid. A court in Pennsylvania ruled that the son must pay, according to the Pennsylvania filial responsibility law

That is literally inheriting debt. That should be illegal, yet almost half the country allows this.

It's mostly just Pennsylvania. There are something like 29 different states with some kind of filial support laws on the books, but Pennsylvania is the crazy one.

Woah. And what if you had a terrible relationship with these people? What if you worked your whole life to get the fuck away from them?

This reminds me of tobacco tax to pay for children’s healthcare initiative. As if the responsibility sits directly with cigarette smokers. It sits on all of us, not one person. Impoverished elderly people that need medical care should receive aid from the state indiscriminately where we all foot the bill.

No, they do not. However, the companies in question still might try to get the children to pay up in the hopes the children are ignorant that they are not responsible for their parent’s debts.

It depends on the bill and the state laws. E.g. debt collectors will use misleading and predatory tactics to get the children to pay "a token sum" that then makes the children liable for an entire debt.

While this strategy helps spend down to qualify for assistance near the end, all states have a lookback period that can disqualify you for state aide, and most look back periods are 60 months.

https://www.medicaidplanningassistance.org/medicaid-look-bac...

No, children aren't responsible for bills. It can only come from your estate.

Transferring assets isn't crazy but you do need to be careful if you want to do it in a non-taxable manner (you can't just give your kid $500k cash without them counting it as income).

> No, children aren't responsible for bills. It can only come from your estate.

I think it's worth noting that while this may be true if you're dead, it's not the case when you're still alive.[1]

Filial responsibility laws mean that adult children can be legally required to pay their impoverished parents' medical bills. The above cites a case where a man was required by the courts to pay $93,000 for his mother's rehabilitation.[2] From what I've read, Pennsylvania may be particularly onerous compared to other states, but it's not a slam dunk kids won't be on the hook.

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

[2]: https://abcnews.go.com/Business/pennsylvania-son-stuck-moms-...

It's not cut and dry and it requires the company or state to sue. So 'can be' is very unlikely because the laws are not typically enforced. Federal law can also prohibit companies from collecting.

More info is here:

https://www.nolo.com/legal-encyclopedia/your-obligation-pay-...

Because Wikipedia only talks about their existence, not a discussion of them.

> It's not cut and dry and it requires the company or state to sue.

I have to imagine that it's pretty rare, and I don't think it's appropriate to generalize from what appears to be a pretty sensationalist case. I expect the laws are usually structured to ensure that children don't fleece their parents out of money and turn them effectively into wards of the state, etc. It doesn't seem unreasonable to me that states would encourage families to take care of each other, though PA seems a bit of an outlier in this regard.

It's incredibly rare and PA is absolutely an outlier. That's why the case that is mentioned was newsworthy.

Typically when it's used it's to recover money in cases of fraud. For example, where the parent or child conspires to hide money from the state to avoid paying for care. To the best of my knowledge, PA is one of the only states that allows private entities to sue. Some states are like Ohio where it's a criminal statute, so only the state has standing to bring charges. All said, don't get legal advice on the internet, this is an armchair discussion by laypeople.

As an aside, I don't see why the children should have any specific burden to take care of their parents medical expenses now that we have Medicare and Social Security. We've decided it's better to have all of society to take care of our elderly rather than tie it to their children's ability to pay.

I could be wrong, but I thought that the $500K would not count as income for them, but would deduct from your lifetime estate tax exclusion. See https://www.nerdwallet.com/article/taxes/gift-tax-rate

This depends on jurisdiction and the nature of the bills.

Pennsylvania has filial support laws which mean that children can be held directly responsible for the medical expenses of their parents. This requires that Pennsylvania have jurisdiction over the children, of course.

Is this really true? American health care is a horror show but this is possibly the most messed up thing I’ve heard.

Filial support laws are not even remotely unique to the US, and it's only true in certain states. Pennsylvania is the most notorious.

France: https://fr.wikipedia.org/wiki/Obligation_alimentaire_en_Fran...

Germany: https://de.wikipedia.org/wiki/Elternunterhalt

Asia has a ton, I'm sure.

It’s the combination of filial support and the expensive US health care system that I’m shocked by, not filial support as a concept.

Like other filial / familial support laws, there are limits based on the ability to pay.

True in some states. Also not just the US. Germany also seems to have some version of filial responsibility.

I've heard that only the parent needs to live in PA.

This is incorrect.

The parent does not need to live in PA at all, but a suit needs to be brought against the defendant to make them pay, and therefore the court needs to have jurisdiction over that person in order for the lawsuit to succeed.

No, they're not. But hospitals, many times, will absolutely imply that they are when a parent dies in hospital.

And if they do that well enough to have you make a payment, most legal systems will consider that acceptance of full financial responsibility on your part.

My Mom died in 2014, in a local hospital. Several years after her death, I received a bill from that same hospital, addressed to her but sent to my address, for $9K. The kicker is, the "service date" on the bill was 1996! I ignored it since a) she had died; b) she had died in their hospital, so they obviously knew; c) her estate had settled years ago; d) she never received this bill while she was alive.

Hospital billing practice are pretty horrible. If a more compliant person had received this bill, they might have paid it, even though there is no way it was legit.

Yes you can. It just come from your lifetime gift tax exemption.

https://smartasset.com/retirement/gift-tax-limits

I believe the gift giver is the one who is responsible for any taxes (beyond the $11m threshold). Although if you give gifts as a way to get around debts it might cause issues

Not directly. But if the hospital takes money out of the estate directly, this is in effect taking away from a child's inheritance. Thus, one could interpret this to be "the children paying for the bills"

> imagine your life + childrens’ lives being ruined

A parent’s debts cannot be put on to their children. Once your father died, anything not covered by his estate had to be written off by everyone.

You are correct about the debt and the parent post clearly knows that, having lived through it'l. However the further point being that any assets that had accumulated with the intention of leaving them to the family, and which they relied on, would have been in jeapordy if they hit probate. If he owned a businessnor a house I'm not sure of the rules, but definitely savings, other assets etc. would be up for grabs.

The rules vary by state and can change depending on if a written will exists.

Parents, talk to an attorney while you're healthy. Some of the states have rules that will surprise you.

I'm not sure how many people know that though, and the moment you make a payment towards that bill it's legally your debt.

Bear in mind, this can happen to people that have a spouse and underage children. Spouse is decimated, children no longer have any help with collage (assuming they did before that). The family can be left destitute.

true but what of inheritance? I suppose thats what life insurance policies are for.

OP said the father had no assets, so there was no inheritance forthcoming.

If that had happened to my parents, my sibling who lives with them would have lost their home and had to move in with me. Just because OP's situation was different doesn't make that good.

Without knowing anything, 10 million seems excessive, but 6 months in a hospital will no doubt be expensive. I don't want to stir up bad feelings, I'm just curious, was there a good chance that your dad was going to make it out of the hospital? What was EOL talks like with the doctors? This story brings back the article here not too long ago, regarding the average hospital stay of a doctor at EOL vs the general public. I'm not sure of all the influencing factors regarding EOL procedure, but it does seem like a huge amount of resources are used for the very short end of a large amount of people's lives. Once again, no offense intended, it just got me thinking.

Anecdata: I spent 5 days in ICU in 2018 and had a $350k bill from a California hospital, which my insurance company paid $200k for after adjustments and discounts. I wouldn’t say $10m for 6 months is far off.

Yea that sentence came off wrong. I don't doubt the OP's claim at all. I was trying to acknowledge that billing that amount to anyone isn't right and looking to make the point that healthcare is expensive and how "we" choose to allocate resources is an important discussion.

No offense taken. In hindsight, it should have been clear that every day spent in the ICU past 3 months was not a good sign of my dad ever making it out of there. However, we 100% believed he was going to get better all throughout the process. Idk what this assessment was based on, but reflecting back for the first time in a long time, I now realize just how much emotions cloud sensible outlook & probability assessment.

Where did you move to that has better protections for patients regarding health coverage?

10 million USD in 6 months? 10M?

So I immediately imagine an absurd nonsense like "liquid gold transfusion", then I realized it's 800g gold per day in the current gold price.

My pathetic mind can't even imagine the how absurd that is.

Was this before 2010?

We (society) cannot afford to pay for everyone's 10 million dollar hospital bills so how do we decide who gets their bills paid?

EDIT: Some argue here that it'll average out, however at what cost to others? [1]Here's article about African Americans getting limbs amputated as their treatment for diabetes.

[1]https://features.propublica.org/diabetes-amputations/black-a...

Most people don't have 10 million dollar hospital bills. That's how insurance works: everyone pays in case something happens to them, and the people who have expensive treatments are subsidized by those who don't.

Insurance is more effective at dispersing that cost when the pool is larger, so the most effective scenario would be for everyone to pay in via taxes and simply… be covered.

Edit: I don't understand the point you're trying to make with your edit.

Rather, were services purchased really worth 10 million dollars?

How much of that are salaries for underperforming, bloated structures in charge of "management" and billing?

Canadians spend 220k (in 2013) per person per lifetime. It's very unlikely you can shrink 10 million dollar bill to anywhere close to that.

[1]https://www.theglobeandmail.com/life/health-and-fitness/heal...

What makes Americans that much more expensive than Canadians?

It's mostly end of life care (relative to other countries).

So during your life - broken bones etc - roughly equal.

But if you are stuck in ICU for a year when 75+ - that's uniquely American and incredibly expensive.

"Numerous articles on EOL costs show that a large proportion of Medicare expenditures occur during the last 6 months of life.1-9 This phenomenon has continued for many years as the number of Medicare decedents has increased with the aging American population. Medicare expenditures for EOL have increased dramatically from 1983 to 2016, primarily because of the increase in the number of decedents. Other articles compare EOL expenditures in the United States to other countries10,11 or focus on Medicare expenditures for specific diseases.12-14 A recent development in the literature challenges the idea that EOL costs are responsible for a high percentage of health-care costs.15

- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610551/

I am aware that EOL care is a large part of the costs of our system. However, one thing I have not heard is any definitive evidence that that is materially different in the US vs. e.g. Canada or the UK.

This study suggests that your interpretation is not correct: https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0174 Mean end of life spending is only marginally higher in the U.S. than in other countries.

I thought something like 25% of medicare spending was in last year of life spending.

I've also heard that something like 5% of folks generate 50% of costs.

So the argument has been that because in the US total expenditure can go so high (ie, we will easily spend $10M on one person where other countries won't) that you end up with a serious spike as a result of last year of life and extraordinary effort costs.

Other countries have less variance (including income inequality)

Yep, I'm aware of the argument, and I think you've stated it correctly. But the data I was able to find does not seem to support it.

From the study (~1980 data) [1]: Cost of care in the last year of life in USA varied from study to study, between US$40,000 to US$95,776.

Extrapolated cost for Canada: 6,758.2

[1]https://www.longwoods.com/content/20878/healthcare-quarterly...

That number is the total cost for all people who died in Canada, extrapolated from Saskatchewan data, in millions of dollars. 6.7B dollars, that is. Considering something like 300k people die in Canada each year, that's around 20k per capita. (This is seriously mixing units because the population of Canada has increased a lot since the study you cited.)

In any case, it's not the correct number. Quebec data from the study I cited showed 60k per capita on hospital alone, with incomplete data to characterize the remainder of the costs.

> At what cost to others?

Assuming nothing else changes, it'll about double the cost of what people pay now for private insurance (in terms of taxes).

However, there's no reason to assume nothing else changes. The US spends an atrocious amount on the overhead of bookkeeping our "free-market" semi-adversarial healthcare system. Estimates over the past 22 years range from 13 to 25% of the cost is raw administration. Assume most of that cost goes away (let's say 90%, which seems fair) and you're left with Americans paying about $250-400 a month more on average in taxes for healthcare than what is paid now.

Since it's taxes, the progressive tax rate would kick in and this would translate overall to most Americans paying almost nothing more, the middle class getting squeezed (this could be ameliorated with laws, but if nothing else changes the middle class gets squeezed), and the wealthy and super-wealthy shouldering the bulk of the cost.

I think a piece that you're missing here is that health problems get drastically worse, and more expensive to fix, when they're not addressed.

Problems are often not addressed in a reasonable time frame because many people don't have access to reasonable health care. Even they they do, they may be hesitate to use it. Anecdotally, last time I went for a preventative check, I was given an FAQ sheet when I signed in reminding me that if I ask about anything specific, or diagnostic, that is not preventative (as if I'm supposed to understand the difference), then it would have to be billed separately and may-or-may-not be covered by my insurance. That was almost enough for me to not ask my doctor questions while I was at the office.

I would imagine that more widely addressing issues early on before they become expensive would remove another large portion of overall US healthcare costs.

Not everyone is going to have a 10 million dollar hospital bill. That's the entire point of insurance, and also the point of having a national plan: you generally aren't going to know if you're going to have a lifetime expense of 10K or 10M. So you need to aggregate that across the entire population.

Other countries seem to manage it.

Why? Works ok in Australia.

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