Hospitalizations hit 100k in United States for first time since January | Hacker News Reader

Hospitalizations hit 100k in United States for first time since January

washingtonpost.com

79 pointsjustin66159 comments

according to Our World in Data they hit 133k in January and are only 89k right now, and approx flat for the last 5 days:

https://ourworldindata.org/explorers/coronavirus-data-explor...

Will these hospitalized people be also financially ruined? Or is emergency COVID care free of charge?

You can be ensured or not, it depends. Honestly it’s pretty stupid to end up in ICU when something free has been offered to you in order to avoid just that, so people should just take their responsibility.

> so people should just take their responsibility.

if you get a serious adverse event following a vaccination, however unlikely, who pays for your medical expenses since the link with vaccines is always denied?

One of the specific government programs set up for that purpose. https://www.hrsa.gov/cicp

thanks. this is a clear answer.

It may also interest you to know that, despite claiming "the link with vaccines is always denied", the https://en.wikipedia.org/wiki/National_Vaccine_Injury_Compen... awarded compensation in 42% of resolved claims, and has paid out multiple billions.

Everyone, including the vaccine manufacturers, is aware of the possibility of rare reactions. This system exists because "no one will make vaccines because a jury of twelve lay people may award a $500M penalty because little Timmy got autism despite there being no link" is a national security threat.

Why are you emotionally invested in trying to bump up COVID’s kill count? If you can explain the motive, maybe we can find an alternate way for you to work towards that goal with fewer casualties.

Are you answering to a different message ?

Do you also avoid seat belts because there are unlikely accident scenarios where they do harm?

Nope I am asking a simple question of who pays in this kind of situation.

Your health insurance, presumably. It's another argument for public health insurance.

Understand that the expected benefit of getting COVID vaccines should be positive for everyone -- the expected harm from side effects should be less (often much less) than the expected harm from COVID infection.

There could be public policy reasons for being generous with compensation for side effects, just to increase the vaccination rate, but I think that's a separate issue, and has more to do with the unequal distribution of benefit in a vaccinated population. It could make sense for the old to compensate the young, as the old get more benefit out of others being vaccinated.

Delta Air Lines is imposing a $200 monthly healthcare surcharge on unvaccinated employees, citing an average cost of $50k for a COVID-related hospital stay, which were appreciably affecting company health care policy expenses [0].

I wonder when insurers will follow suit. All these totally preventable hospital stays aren’t cheap, and insurers aren’t charities.

[0] https://www.wsj.com/articles/delta-air-lines-to-impose-200-m...

is that legal, or is that like charging for a preexisting condition?

It is a preventable condition or choice - if you smoke they charge you more.

Tobacco use is actually written into the ACA as an acceptable thing for insurers to discriminate on (there’s even a cap to how much they can add on for it — 50% of the total premium IIRC).

I assume Delta’s lawyers know better than I (who am not a lawyer), but I’d be curious to know how this squares with the ACA.

You can argue smoking/addiction is a disease, possibly genetic which reduces the element of choice involved, potentially creating a problem. Vaccination status wouldn't have any such issues.

Wait... your employer charges you money if you smoke? How the hell is that legal? What if you're fat? Or drink alcohol (but still sober at work)?

I mean.. our european worker protections are overkill.. but compared to this, they still seem as a better option.

It sounds like you're not familiar with the US system. The employer isn't charging for smoking, the health insurance, which is mostly provided through employers in America, is charging a higher premium for smoking since you will cost much more in future payouts.

technically the insurer charges you more. And often they just give you credits towards healthcare costs if you don't smoke, instead of charging you more if you do. As to why this is acceptable, cultural views on smoking tobacco in the US hover just this side of pedophilia it seems like. I don't know a single person who smokes and has a professional career.

What if you're overweight?

ACA does not allow for that to be a factor in pricing an individual’s premiums.

https://www.healthcare.gov/how-plans-set-your-premiums/

Seems hypocritical and inconsistent.

Why are harmful drug addictions a choice acceptable to discriminate against, but not a harmful food addiction I wonder? Probably because of the huge number of overweight making it socially and politically expedient to have their costs subsidized by others, whereas smokers are a much smaller minority so it's easy to discriminate against them.

I think its a bit apples and oranges. Smoking is a choice, and obesity is (quite often at least) the outcome or symptom of choices. It should be even easier to charge more for obese insured, they already have the symptoms! But that symptom is a preexisting condition which can't be considered. Also, thyroid disorders (1 in 5 women) can also cause obesity with otherwise healthy diets by dramatically lowering metabolism. So can some gut disorders. I think a way around that would be to self certify that I haven't used tobacco, alcohol, or non whole foods in the last 24 months to get my healthcare credits for each. Of have had no added augar (that gets tricky) or haven't eaten in excess of some number of calories based on my height and age.

No I think it's still hypocritical and inconsistent in spirit.

There are reasons why a smoking addiction is not a simple choice in all cases, and conversely if smoking is a choice then obesity is also a choice in most cases being caused by food addiction.

But isn't overeating the choice, not obesity? That is like saying decreased lung capacity, low blood oxygen or lung cancer are choices. Those are symptoms of choosing bto smoke, and insurers absolutely cannot discriminate based on them or emphysema. They discriminate based on the choice, and I agree it is hypocritical that they only ask if I have used tobacco and not high fructose corn syrup, but that is the question they should ask, not my bmi if they want to be consistent.

Employers have indirect ways of approaching that, like giving discounts on health insurance to employees who track how often they work out, eat healthy, and get regular physicals.

They can incentivize healthy behaviors.

The effect of this has been more smokers go without insurance, not fewer smokers

I presume they are reducing the employer contribution towards premiums instead of raising premiums (which they can’t do).

I am wondering how this would affect their non discrimination testing (for tax purposes).

“Refusing to get a vaccine” is not a protected class.

I specified for tax purposes because I was not referring to that kind of discrimination, but rather where employer paid benefits to employees have to be offered in a manner that does not discriminate against lower paid employees otherwise they become taxable.

Why would that apply here, then? The premiums are the same. The fine is the same. Access to vaccines is the same.

The employer paid portion of the premium is reduced, which is what the non discrimination testing is looking at to make sure employer benefits are not disproportionately going to higher paid employees.

Again, premiums are the same, the fine is the same, the vaccination is available to all. How does the discrimination provision apply?

The non discrimination testing is to prevent companies from giving out benefits to higher paid employees disproportion to benefits given to lower paid benefits, in exchange for those benefits being able to be paid with pre tax dollars.

The benefit is the portion of the health insurance premium that the employer pays. For example, if an employee's health insurance premium is $500 per month, and the employer pays 60% of everyone's health insurance premium, then that leaves $200 left for the employee to pay. However, if the employee has to pay another $200, then they are now paying $400 and getting a benefit of $100.

I am not an expert in how the testing is done, but I was just wondering how Delta would get around any issues if many lower paid employees opted out of the vaccine and had to pay $200 disproportionate to the higher paid employees.

I imagine tax law does not have a carve out for pandemics and lower paid employees having to pay extra for not getting vaccinated, so it would not matter what the reason is that the benefit is being given disproportionately to higher paid employees, just that it is.

"We are paying $500 for premiums for all vaccinated employees, and $300 for all non-vaccinated employees, regardless of compensation level."

I think the point being made is that if instead at looking at the wording of the rules, they look only at employee pay and employee premiums, it could be that fewer of the lower paid employees got vaccinations, and thus paid more on average. That might make them culpable even if the rule wasn't inherently biased. They have made a lot of rules like this recently, such that an uneven outcome puts you in breach of the law regardless of the fairness of the policies.

Yes, non discrimination testing for benefits does not care about the intent or design, just the outcome.

At one point in 2020 a majority of insured Americans treated for COVID (>80%) had the majority of their COVID-related treatment waived by the insurer. However, most insurers have been terminating these waivers since January.

Also, to any non-Americans its always important to put this in the context that "waiving" here means you're still paying thousands per month (between employer and individual) in premiums and likely hundreds in various flavors of co-jargons anytime you step the foot in the door of a care provider even for "covered" care. Insurers always like to portray just providing the service you pay more for than you would in most of the rest of the world as altruism on their part. The major insurance companies providing these waivers (Anthem, UnitedHealth, etc.) all saw order $B profit increases over the pandemic.

Anthem profit margin is down:

https://www.macrotrends.net/stocks/charts/ANTM/anthem/profit...

UHC margins also do not indicate profiteering:

https://www.macrotrends.net/stocks/charts/UNH/unitedhealth-g...

Same with CVS/Humana/Cigna:

https://www.macrotrends.net/stocks/charts/CVS/cvs-health/pro...

https://www.macrotrends.net/stocks/charts/HUM/humana/profit-...

https://www.macrotrends.net/stocks/charts/CI/cigna/profit-ma...

It is always interesting to me when people claim insurance companies earn a ton of profit when their profit margins are always in the 5% or lower range. How much smaller should their margins be? Even retail businesses like Walmart need a couple percent of profit margin to survive.

I didn't say margin, I said profit, and you can click a tab over on any of those pages and see overall gross profit is up in 2020. What kind of rational baseline is assuming that increasing margin is the default neutral state? How is that a stable dynamic for any system?

I have never heard of a business that reaches $x of profit and then switches to pricing everything so that they get $0 of profit.

And why would I be concerned with gross margin? If insurance companies were profiting more than normal from COVID, then it would show up in the profit margin figure.

> I have never heard of a business that reaches $x of profit and then switches to pricing everything so that they get $0 of profit.

Isn't this the business model of tons of huge companies? Amazon famously ran at very deliberately low profits for years. Uber and Lyft have margins so low they're losing tons of money in an attempt to get market share.

Eschewing profits now to fuel growth with the intention of making large profits later is the exact opposite of that.

>Isn't this the business model of tons of huge companies? Amazon famously ran at very deliberately low profits for years.

No. Operating at low profit margins is not the same as reaching $x of profit and then selling everything at cost.

>Uber and Lyft have margins so low they're losing tons of money in an attempt to get market share.

These do not seem relevant, as most businesses, by and large, year after year, are not giving away products or services to try and gain marketshare.

Insurance companies have a vested interest in making sure that healthcare costs keep going up. It’s a counterintuitive notion because you would think they want healthcare cost to go down. The reason they want high cost it’s because they’ll be making that small margin on the higher revenue

So does every business. But just like every other business, they have competitors too, so they cannot expect their profits to rise simply because they keep increasing their cost of goods sold.

Either way, that is not relevant to the claim that was being contested, which was “insurance companies are profiting extra from covid than they normally would”.

Interesting point. I read the original point as contesting the idea that insurers are going to have to eat a loss.

In the end I think both perspectives are insightful: insurers aren’t in the red for 2020, but they’re also profiting from COVID less than they “normally would”

Incidentally, this is also why tobacco manufacturers don't really mind high cigarette taxes: it puts a higher floor on the cost of a pack of cigarettes, which means the overall profit is larger.

Only if the higher profit from higher sales price makes up for the possible decrease in sales from higher price.

Why does it set a higher floor? The tax goes to the government, the tobacco company doesn't get to keep it.

I don't understand your objection. The cost includes all tax.

Suppose the following price breakdown for a pack of cigarettes:

    cost: $3
    profit: $1
    tax: $1
    total price: $5

The government decides to increase the tax by $1, now it's

    cost: $3
    profit: $1
    tax: $2
    total price: $6

As you can see, the total price went up $1, but the tobacco company's per-unit profit is the same. They can increase the price by more than the tax (eg. hiking the price by $1.5 rather than $1), but that's equivalent to hiking the price $0.5 without an associated tax increase, which they can do at any time.

Let's say a competitor shows up who manufactures cigarettes at $1.

At a lower tax rate of $1 his cigarette is $3 vs $5.

But at a higher tax rate of $3, it is a $5 vs $7 customer price.

In absolute terms the price difference is the same. However, consumers think in terms of percentages for cheaper items.

Any added margin that makes your product more expensive, that does not go into your pocket, is bad for business.

It's basically a form of someone stealing from you.

The user was willing to pay $4.50, all of which you could have had, but $0.50 went to a parasitic third party.

We can look at it from the point of view of the transaction between the buyer and seller being arbitrarily robbed of $0.50.

We can also look at it from the POV of the supply-demand curve: fewer units are sold of the more expensive product.

Both these effects hit you: you're selling less because it's more expensive, without you getting any more of the extra per-unit revenue.

Ask any industry if they want a fat tax on their products to take advantage of the effect you describe.

Don't tax you, don't tax me — tax that fellow behind the tree. --- Sen. Russell B. Long (among others) [0]

[0] https://quoteinvestigator.com/2014/04/04/tax-tree/

Insurance companies also have a particular interest in making sure that uninsured healthcare costs are sky-high, while they negotiate better insured costs.

Generally speaking the adage is “profit is an opinion, cash flow is a fact”

That adage is more useful when looking at individual companies, or maybe new businesses.

For long established, highly regulated operations, I would expect consistent profit margin figures across pretty much all companies in the business to represent a pretty accurate view of the situation, and to show if they are earning extra profit due to COVID.

That's my big problem with the healthcare debate. People think that its because of "profit", but if you look at the profit margins of all participants, they're all reasonable. Even if you could shift that profit over to consumer surplus, you're still looking at crazy high health care spending.

Something deeper is wrong with America's healthcare system. I think the third-party payer system and onerous regulations distort the market in costly ways. Just as the simplest example, if you want to open up a health care provider you need a "certificate of need" in most states. This means a board of current health care providers in the are determine whether there is a real "need" in the neighborhood for a competitor.

> Certificate of Need (CON) laws are state regulatory mechanisms for establishing or expanding health care facilities and services in a given area. In a state with a CON program, a state health planning agency must approve major capital expenditures for certain health care facilities. CON programs aim to control health care costs by restricting duplicative services and determining whether new capital expenditures meet a community need.

Ah yeah, lets reduce costs by restricting "duplicative services"

https://www.ncsl.org/research/health/con-certificate-of-need...

A great deal of service provision in many countries' systems is private. Even here in Canada, "socialist" medicine often boils down to a private clinic billing the public insurer. Though the major hospitals are usually owned and operated by non-profit corporations, or the local government.

The US wastes $150,000,000,000 a year (the most per capita in the world) in pushing paperwork directly because of our “competing” individual insurance provider model [1]. The US spends the most overall per capita by far on healthcare, while also not even covering all residents. Despite having poor health outcomes and lower life expectancy, the US is the leader in expensive diagnostic imaging and prescription drugs [2]. Its almost like the “competing” private insurance model creates large amounts of wasted effort in trying to extract profit, as well as perverse incentives to push high profit interventions while ignoring actual health outcomes.

> In countries where hospitals receive global, lump-sum budgets, garnering operating funds requires little administrative work. Per-patient billing, on the other hand, requires additional clerical and management staff and special information technology systems. In countries where there are multiple payers, as in the United States, billing is even more complex, since each hospital must negotiate payment rates separately with each payer and conform with a variety of requirements and billing procedures.

> Higher spending appeared to be largely driven by greater use of medical technology and higher health care prices, rather than more frequent doctor visits or hospital admissions…Despite spending more on health care, Americans had poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions… Even though the U.S. is the only country without a publicly financed universal health system, it still spends more public dollars on health care than all but two of the other countries…

[1] https://www.commonwealthfund.org/publications/journal-articl...

[2] https://www.commonwealthfund.org/publications/issue-briefs/2...

Ah yes, competition is what causes higher prices. We just need one organization creating the products and services for a given industry and setting prices.

I wonder why no one else thought of this and why we don't apply it to everything we produce

>Ah yes, competition is what causes higher prices.

Since no one said that, I don't know what you are talking about. This has nothing to do with competition being bad or good. The US isn’t the only country with private insurance. The US model competes in a fee-for-service model, instead of based on things like positive health outcomes through global budgeting, like Germany or Canada. The US model has providers negotiate prices which each individual insurer, with the actual costs being hidden and complex, instead of a transparent “all-payer reimbursement rate” for each provider[1]. Maryland, the only state to use global budgeting and all-payer reimbursement, is saving over $100,000,000 per year on healthcare spending compared to the national average[2].

I really do not understand how people can act like quality healthcare at lower prices is some utopian dream, and not the reality in every single high-income country except the US. That people can look at the US spending 3 times more money on paper pushing as the next highest country, while not even cracking the top 10 in spending on preventive or long-term healthcare, and throw their hands up and say “its unsolvable!” [3] How people can look at the American’s barely middle of the road health outcomes and think the out of control spending is somehow actually leading to quality care. The condescending dismissive attitude in the face of mountains of data from working healthcare systems around the world is truly stunning.

[1] https://www.americanprogress.org/issues/healthcare/reports/2...

[2]https://www.healthaffairs.org/do/10.1377/hblog20170131.05855...

[3] https://www.pgpf.org/blog/2020/07/how-does-the-us-healthcare...

>> Since no one said that, I don't know what you are talking about.

> The US wastes $150,000,000,000 a year (the most per capita in the world) in pushing paperwork directly because of our “competing” individual insurance provider model

When you have real competition and the final user pays, as opposed to a third party, you'll naturally have a model in which people pay for outcome as opposed to fee for service. If I take my car to be repaired, I just want the mechanic to fix it at the lowest cost possible. I don't care how many services they have to run. It works in every other aspect of our economy, including safety critical sectors. For instance, I may pay for a safer car as opposed to a cheaper less safe car.

I just want a system in which I can make my own decisions regarding my health.

I don't know why people argue that the US has a free market in health care. It does not, as you have plainly stated. There's a lot of intermediaries and parties involved that are highly regulated and influenced by the state. US spends as much in public spending in health care as other countries. I would prefer to remove the complexity, allow actual competition and remove third party payer as much as possible. Your solution sounds like more of the same but better, which doesn't make sense

My solution: use any tried and tested model from other countries that have better, cheaper healthcare.

Your solution: a free market where you as the consumer can make your own health choices, of which you are not qualified to understand unless you went to medical school, and expect to pay the lowest cost for things you may need to prevent your own death (we all know price gouging in life or death situations is never a thing). Good luck with that.

Just so you know, unlike your car, you can’t just go buy a new life when you can’t afford to put in a new transmission.

> Just so you know, unlike your car, you can’t just go buy a new life when you can’t afford to put in a new transmission.

Exactly why I want to make my own healthcare decisions rather than some faceless appointed regulatory body

Maybe you have more faith in politicians to do the right thing on your behalf. I'm sure these systems will still exist and you could follow their guidance (e.g. the food pyramid). I just want more choice

From personal experience between USA and Germany, I can say quality of health care in US is many many times better than in DE.

> any non-Americans its always important to put this in the context that "waiving" here means you're still paying thousands per month (between employer and individual) in premiums and likely hundreds in various flavors of co-jargons anytime you step the foot in the door of a care provider even for "covered" care.

Where did you come up with “thousands” and “likely hundreds”?

Just so the non-Americans reading this have a data point, I’m a single person with Type 1 diabetes who pays $200 a month for my insurance premium (my employer also pays $200 a month). I also pay about $110 a month out of pocket for insulin, $1500ish a year for my glucose monitor, and pay about $250 total a year in various co-pays to see a primary care physician, endocrinologist, and ophthalmologist (maybe 6-7 visits total. This is on a “Gold” plan (the best offered by my employer).

Your employer is paying the difference for you. As part of their health plan setup, they select what percentage of the plan to cover for their employees and their dependents.

No. I oversee our HR/benefits. Company pays 50% of premium, employee covers other 50%.

The average gold plan in the US is $575 premium per person per month. For the average household that would be thousands. The average monthly healthcare cost across all "levels" is about $975 per person.

So just to be clear this was pretty exaggerated right?

> "waiving" here means you're still paying thousands per month (between employer and individual) in premiums

I get it that American healthcare sucks but let’s at least try to be accurate about how much it sucks.

If anyone wants a more useful comprehensive data point. Between Insurance premiums and out of pocket spending for services, the average American spends $4,516 a year. Oddly enough, the US also spends $4,197 a year in public spending, the third highest in the world, without the “costly” universal healthcare. Combined, the US outspends all other countries by a large margin. But with that spending we have less doctors, less doctor visits, poorer health outcomes, and lower life expectancy. But we do lead the world in prescription drugs and expensive diagnostic imaging.[1] We also waste $150,000,000,000 a year on paperwork (highest per capita in the world) because hospitals have to haggle with a bunch of different insures for every single thing.[2]

>In 2013, the average U.S. resident spent $1,074 out-of-pocket on health care, for things like copayments for doctor’s office visits and prescription drugs and health insurance deductibles. Only the Swiss spent more…As for other private health spending, including on private insurance premiums, U.S. spending towered over that of the other countries at $3,442 per capita—more than five times what was spent in Canada ($654), the second-highest spending country…Even though the U.S. is the only country without a publicly financed universal health system, it still spends more public dollars on health care than all but two of the other countries…Higher spending appeared to be largely driven by greater use of medical technology and higher health care prices, rather than more frequent doctor visits or hospital admissions…Despite spending more on health care, Americans had poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions [1]

[1] https://www.commonwealthfund.org/publications/issue-briefs/2...

[2] https://www.commonwealthfund.org/publications/journal-articl...

Wow, I'm more average than I suspected. My total is ~5400 give or take a bit.

>Wow, I'm more average than I suspected.

Story of my life.

> Also, to any non-Americans its always important to put this in the context that "waiving" here means you're still paying thousands per month

Also important to remember the "take home" pay in the USA vs other countries. For many software engineers from the USA it would be significantly more than in other countries, for example due to the fact that there are a number of opportunities to earn good 6 figure salaries

My understanding is that it's mainly only software development that has such a disparity though. Doesn't help much if you're not a software dev (or you lose you job due to ill health).

Yeah, I think another field(though I could be wrong on this one) that pays much better in the USA VS other countries is finance. Outside of these field the situation is very different

Most people in the US aren’t tech workers though. And the pay disparity for many other roles, especially in the middle-low ends of the spectrum, are not very competitive compared to other countries with nationalised healthcare.

Absolutely, no dispute there. I thought it might be worth pointing that out, since Ycombinator has a lot of IT visitors.

Do also take into account that the median wage in the US is only around 35K per year. Clearly most americans are not in line for a 6 figure salary, nor will they ever be.

No dispute there, please see my comment below to "glenngillen"

That's one of my biggest arguments (see my post history). I am super fortunate I am a software developer and earn a decent salary in the US. I pay $700/m for the highest plan my employer offer.

I know I am lucky. I've met many, many people who aren't as fortunate. I worked for 204 days from my little girl's ICU room. I was able to make ends meet. My fight is for the average American, the $30-45k earners, who don't WFH, and have sick kids in hospitals - and are forced to work to keep their benefits, while their kid is alone in the ICU.

I am really sorry to hear about your personal loss, by no means my goal was to create negative reaction.

Based on how much my little girl’s ICU admission cost,

https://kingsley.sh/posts/2021/two-weeks-in-the-icu-as-a-bab...

there is no way (in my mind) that their ICU admission will be free.

Sorry for your loss, nobody should have to go through that.

How do people in the US who don’t have insurance get treatment for themselves or their family members in situations like this? It seems inconceivable to me that they or their kids are just expected to die?

They will get treatment, assuming the hospital has capacity:

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

And generally, if you have nothing, the government will pay for you. However, quality and quantity of healthcare will likely not be as high.

The rough spot is in the middle when you have some assets, but not enough for a secure life, but do not have insurance, then you will have to forfeit your assets in order for the government aid to kick in, and then you are poor.

The interesting concern for me is always "i won't go see anyone about medical issue X because the copay/deductible structure dissuades me from checking". Even if you have a spare $800 for [insert tests here] you're going to be reluctant to spend it unless you're pretty confident it's necessary.

Is this the source of significant delay in diagnosis? Does it increase or decrease overall costs of treatment? Does it meaningfully alter expected prognosis of the middle income US patients etc

Depends on the individual’s finances. Preventative care such as annual wellness exams are mandated to be covered (i.e. free for insured) and you get a blood test with that. So presumably, you are catching most lifestyle or inherited or long term ailments there.

By law, annual out of of pocket expenses are capped:

https://www.healthcare.gov/glossary/out-of-pocket-maximum-li...

However, based on the median income in the US, many Americans would have to think twice about scheduling a doctor’s appointment and being on the hook for an unexpected hundreds or thousands of dollars.

It is all a form of rationing healthcare, so having people think twice about going to the doctor at the expense of some people’s health is part of the system.

> The rough spot is in the middle when you have some assets, but not enough for a secure life, but do not have insurance, then you will have to forfeit your assets in order for the government aid to kick in, and then you are poor.

Which is where a lot of elderly people who need long term care end up.

> It seems inconceivable to me that they or their kids are just expected to die?

Basically, yes. Hospitals are required by law to treat anyone who presents themselves to the emergency room (thus the ER is the primary entry point for many people, regardless of symptom) but they get triaged to the bottom of the queue. Hospital insurance administrators can and do intervene in doctor decisions on care.

Medical debt in the US was already a crisis before the pandemic. It can push people out of their homes and pretty much destroy them. Even some with insurance make gofundme pleas to try to cover their medical bills.

> ...they get triaged to the bottom of the queue.

I can't find any evidence of this happening using Google. Do you have any?

Just talk to anyone who works in an ER. Or read the first link returned by DDG: https://www.kff.org/uninsured/issue-brief/key-facts-about-th... which looks at the more general case. Key paragraphs to read (in this regard) are “ How does not having coverage affect health care access?” and the immediately following “ What are the financial implications of being uninsured?”

Worse is the hospital revenue people intervening in care decisions. There was an expose about this in the NYT a few years ago; as far as I can tell nothing has since changed.

Those two sections say nothing about getting "triaged to the bottom of the queue."

As far as "hospital revenue people intervening in care decisions," that doesn't mean people don't get care. It means they may not get super expensive treatments. That certainly may not be the best care, because, all the ER needs to do, legally, is ensure that the patient's condition is non-emergent before they discharge them, but it's completely unrelated to triage. It is, however, a predictable result of hospitals needing to make a profit.

Do you have any hints or keywords I could search to find the NYT article?

I can’t find it either because all the links these days are full of COVID discussion. I originally read it because one of my neighbors (a surgeon) mentioned it. It was a few years ago, I think during the Obama administration (when health care system was a hot topic of conversation). I remember being surprised because it mentioned hospitals and interviewed doctors by name.

But everybody working in an ER knows this so surely you know someone you can ask who will be more authoritative than some rando like me on the net.

Ok, that's fair. Thanks for the discussion.

But are they only required to get you stabilized and send you home? Or are they going to provide your cancer treatment, diabetes supplies, etc?

This must have been tough, I can't imagine going through it.

The bill is eye-opening, thank you for sharing. I have no hard data, but I believe private medical care in the UK is so much cheaper, simply because there is the alternative of totally free health care from the state. It's not perfect, but any condition you have, they (eventually) do, and to a high level of professionalism (exceptions notwithstanding).

I know treating people requires highly trained, dedicated stuff, advanced technology and medication, and those aren't cheap, but I can't help but feel that something is broken in the US. One of the few things putting me off jumping across the pond.

It was rougher/tougher than I ever thought it would be, not for me/my family, but the pain and suffering my little girl endured - to then receive a bill at the end of the day, is just insulting, imo.

I'm actually British, I moved to the US in 2016. Me/my family have used our fair share of the NHS - my mom suddenly died when I was 12, my dad is in remission from prostate cancer after treatment, I've had kidney stone surgeries, 8 years of orthodontics, major jaw surgery, broken bones, bad childhood asthma, etc. https://kingsley.sh/posts/2021/staggering-cost-of-surviving-...

I agree, I got world-class care, by world-class medical professionals, but, I also earn 2x than the average worker, I can afford to pay $700/m, the highest plan my employer offers. We still got a mistake $2.5 million dollar bill, we went to collections 3 times for less than $50, etc, etc.

The icing on the cake was my daughter being denied Medicaid because I earn too much. They skipped over HER 1-in-700m to 1-in-2b diagnosis, and her many disabilities, to deny me because I earned too much. I was told I'd need to spend the GoFundMe money (which ultimately paid for my baby's funeral), my 401k, any/all savings, and maybe even consider getting divorced (I'm here on a marriage green card). I like the good, but despise the bad.

Good God man, I'm sorry. We lost a baby early on too and would never wish that on my first enemy. And yes, the financial aspects are just a slap in the face.

You've had the vaccine for longer then almost anyone, what's happening?

The states with the low vaccination rates are now paying the price of their politics.

The vaccine does unfortunately not work as well as hoped for in the case of the delta variant + a lot of people are still unvaccinated and delta is much more infectious. Cases and hospitalisations are also up in Israel https://graphics.reuters.com/world-coronavirus-tracker-and-m.... Here is a corresponding news item in Science: https://www.sciencemag.org/news/2021/08/grim-warning-israel-.... It also suggests that the protection against hospitalisation of the vaccine is not as good as it was hoped for among older people. From the publicly available data for Israel you can estimate the vaccine efficacy against hospitalisations to be ~59% (relative risk reduction).

Statistics are hard to interpret correctly. See https://en.m.wikipedia.org/wiki/Simpson%27s_paradox

Well it is easy to work it out yourself. Israelis >12 years are 78/22 vaccinated/not vaccinated. Among the hospitalised 59/41 are vaccinated/not vaccinated. So you have 59/78 = 0.756 and 41/22 = 1.864. Therefore the ratio of risks is 0.756/1.864 = 0.41. Which gives you 0.59 as I mentioned. I believe that is the same way the original efficacy of the vaccine was calculated in the first place. Admittedly I have a PhD in Physics not statistics, so I might be missing something :).

It seems like lately there's been a big push for people to respond to the disappointing outcomes for the vaccines in places like Israel and Iceland with "Simpson's paradox!" or "base rate fallacy!" as a way of ignoring what the actual data is saying. The other day NPR had a segment about Iceland where they said "67% of cases being in vaccinated people might sound like a disappointing number, but you have to remember that 71% of the country is vaccinated" which still seems pretty underwhelming?

What ultimately matters is if the hospitals can handle the load, delta is problematic because it produces new cases more quickly even among vaccinated and a sufficiently large number ends up in the hospital for it to become problematic. Both of these are demonstrated in Israel without invoking any kind of statistical analysis. Qualitatively the vaccine alone does not work well enough to lead to an R0 < 1, even when the most susceptible people are almost all vaccinated. I think that is super disappointing and at the same time I think it is really worrying that some politicians have not got that message in Germany / other places.

Good thing we've had over 18 months since the start of this pandemic to add a significant number of hospital beds and nursing staff to help handle these spikes ...

They've been firing staff and closing beds.

I think beds and staff are repurposed when demand wanes? Closing beds and firing staff could be the interpretation of this but I don't think it shows the whole story.

> Qualitatively the vaccine alone does not work well enough to lead to an R0 < 1

I honestly haven't seen any evidence of this.

With Alpha the attack rate for 80% of breakthrough infections was zero and the other 20% were only 1-3 cases. That's enough to drive the r0 down below 1.0 in a 100% vaccinated population. Nobody has done similar studies against delta breakthroughs.

These calculations aren’t stratified by age / prior risk, so you can’t really infer the efficacy this simply.

The original statements of vaccine efficacy were also not stratified in that way, were they? With delta you arrive at ~39% relative risk reduction of preventing a positive PCR (instead of >95%) and ~59% relative risk reduction of preventing hospitalisation. That would also be true if you randomly drew people from the population and conducted a study, no? Of course it still can mean that your individual benefit is much higher.

> so I might be missing something

You're surely calculating a useful number, but it's not the "vaccine efficacy". Definition from the CDC website:

    Vaccine efficacy/effectiveness is interpreted as the proportionate reduction in disease among the vaccinated group. So a VE of 90% indicates a 90% reduction in disease occurrence among the vaccinated group, or a 90% reduction from the number of cases you would expect if they have not been vaccinated.

Your calculation looks at the number of hospitalised people not in the people who got the disease.

So, on a first glance it seems you're computing a useful number: how effective is the vaccine from preventing your to get hospitalised assuming that you would have been hospitalised if you caught covid. Surely that's a useful number, it just shouldn't be confused with the >90% vaccine efficacy number, which measures a different thing.

Now, I do also have some qualms with your calculation of the "hospitalisation prevention efficacy" rate.

Let me rewrite your calculation symbolically:

    "Israelis >12 years are v/(100-v) vaccinated/not vaccinated. Among the hospitalised h/(100-h) are vaccinated/not vaccinated. So you have h/v = x and (100-h)/(100-v) = y Therefore the ratio of risks is x/y = z. Which gives you (1-z) as I mentioned."

Let's make a little thought experiment. Let's imagine that 98% of people were vaccinated with a vaccine with 90% efficacy. Since the efficacy is not 100%, some people will still get the disease and some will still get hospitalised. Since very few people in this scenario are unvaccinated, most of the people who end up in hospitals will be vaccinated. Let's imagine that 50% of those who get the disease get hospitalised. Since only 10% of those vaccinated that get infected contract the disease, only 5% of the vaccinated population will get hospitalized. OTOH (in this scenario) 50% of the infected unvaccinated people get hospitalized, but since only 2% of the people are unvaccinated, this means only 1% of the infected unvaccinated population get hospitalized; 99% of the hospitalized people are thus vaccinated.

    v = 98
    h = 99

    "People from our scenario are 98/2 vaccinated/not vaccinated. Among the hospitalised 99/1 are vaccinated/not vaccinated. So you have 99/98 = 1.01 and 1/2 = 0.5 Therefore the ratio of risks is 1.01/0.5 = 2.02. Which gives you -1.02 as I mentioned."

That formula doesn't seem to make sense.

It does make sense from the numbers 99% of hospitalised vaccinated, 98% of the population vaccinated you should conclude that the vaccine increases the risk of hospitalisation. That is why the number comes out negative. It would be the same in https://en.wikipedia.org/wiki/Vaccine_efficacy if you swapped the numbers for vaccine / placebo. The number would come out negative if in a trial the vaccine worked worse than the placebo. In your scenario you confuse yourself by calculating with percentages, I think.

> you should conclude that the vaccine increases the risk of hospitalisation.

Not really. It just means that since in that scenario the vast majority of people are vaccinated the break-through cases (people who despite being vaccinated end up hospitalised) outnumbers the small percentage of unvaccinated people who end up hospitalised *despite* the fact that the vaccine efficacy rate remains constant.

I'm not sure if we're talking past each other, so let me take one step back and make another attempt:

I made an extreme example to make it easy to see. Let's make an even more extreme example without any numbers nor percentages:

Let's imagine that everyone, literally every single person in a population gets vaccinated. How many hospitalised people do you expect to see?

Since the vaccine is not perfect and some people get severely sick despite the vaccine, you'd expect to see some number of hospitalised people.

How many of those hospitalised people would be vaccinated?

Well, we just said that in this scenario everybody in the population has been vaccinated, thus everybody who got hospitalised is vaccinated!

Can we conclude that vaccines cause hospitalization? We clearly cannot conclude that from these numbers alone.

Can we agree on this before continuing to talk about which crucial metric we're ignoring in this discussion?

I'm honestly not sure, maybe we are really just talking past each other. If there are no unvaccinated people left the relative risk reduction would be zero, that just follows from the definition. The absolute number of hospitalisations would still be meaningful. In the perfect world that everyone was vaccinated you would still see an age dependent decrease of effectiveness over time and relative to alpha. The real data from Israel seems to show that two vaccine doses in a very compliant population are not enough to effectively prevent the number of cases, hospitalisations and deaths to rise without additional other measures (boosters, masks, etc.).

I'm not arguing against what data from Israel may show in general, I didn't go into that rabbit hole.

What I'm arguing is that the argument as presented in this thread cannot support this conclusion since they only focus on the vaccinated/non vaccinated ratio of hospitalised cases, which by definition goes up as more people get vaccinated. The effect is also compounded by a skewed distribution in favour of older people "getting severely sick" (and thus hospitalized) versus the general lower "getting sick" bar set to measure vaccine effectiveness.

This is a bit counterintuitive and makes for an easy topic for journalists to create a sensationalistic piece.

Unfortunately that's how most articles of the subject that I see cited look like. Perhaps there are better articles that make a stronger case, with all the relevant number (such as hospitalizations / infected people in general population). Can you share one if you know about it?

The israeli data has issues because it was during the initial surge of delta which was predominantly in cities with high vaccination rates, which drives the VE down if you compare it against the population-wide ratio of vaccinated to unvaccinated.

Most studies of VE also do statistical modelling of how many of the unvaccinated have been infected and are actually recovered. This was the case of the CDC study from yesterday which had the headline number of only 66% efficacy against delta, but if you dig into the data they didn't test for antibodies or anything but modeled viral spread and had a 95% CI on that number of 26% to 84%.

That is literally garbage data.

The actual value could be closer to the higher end due to them underestimating community spread (pretty plausible) and due to selection effects where their unvaccinated population was higher risk for prior infection than they thought.

I thought that study might change my mind on the situation since they had done a much better job than the Israeli data on controlling for age, comorbidities, etc. But when you get down to it the VE data was still crap. And the mention of waning immunity seemed to be just tacked on with no supporting evidence other than the lower number VE number against delta.

Similarly, its now been found that the studies which equated similar Ct values to viral load are bad because there's less culturable virus in vaccinated individuals, and the Ct values drop faster which indicates vaccinated individuals are producing more viral debris at peak Ct and clearing the virus faster. So they would therefore be expected to have less transmission. Since they're staying out of the hospital and Ct values correlate somewhat with symptom severity that also suggests less transmission (the people who wind up hospitalized most likely transmit more before they get there).

Then there's that silly study out of China which found the odd result that viral-load-as-measured-by-Ct where 1,000 times higher against delta than against original Wuhan strain data from the pandemic when measured at the onset of symptomology (so not peak data, not average data, and compared against the earliest PCR results against the original pre-D614G virus). That quietly disappeared from scientific discussions, but the media keeps on citing it as the truth without any qualifications.

We know that vaccination reduced actual transmission and attack rates against Alpha and its very likely that it does the same against Delta. No data has contradicted that yet.

And I can't explain why so many scientists are so eager to undermine the message of vaccine efficacy. I guess they think it'll be easier to get vaccinated people to mask up than it is to get the unvaccinated to get vaccinated, and some of them are presumably just as addicted to bad news on facebook and twitter as the rest of the population is.

Ok thanks, that is informative. From a policy perspective I think it is a bad idea to basically promise everything can return to normal after vaccination, if this appears to not have worked out in places like Israel. In Germany they are phasing out free antigen tests and they are not required for vaccinated. Both seem like really short-sighted policies.

Expanding on a sibling comment's reference to Simpson's paradox is the following analysis of the data:

https://www.covid-datascience.com/post/israeli-data-how-can-...

Basically, Israel is doing quite well even still. Yes, there's a reduction in efficacy, and yes there's breakthrough infections, but your risk of serious outcomes is still reduced by ~80%+, even in older populations _when correctly compared to unvaccinated older populations_.

Isn't what you ultimately care about in terms of policy the effectiveness on a population level? Of course you hit diminishing returns, when you start vaccinating people that were not at risk in the first place. I'm not arguing against getting the vaccine btw., I'm vaccinated myself. It is just disappointing that it alone won't solve the problem.

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