Many surprise medical bills are now illegal
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From what I can gather.there is some sinister game hospitals and medical insurance play, but you would think that, oh, I don’t know, it would save time and money for them both to just come up with some agreed upon pricing and save some administrator overhead.
So that's one reason why you might get a bunch of different bills from a bunch of different entities when you go to the hospital: all the doctors there may have the same hospital logo on their badges but some may be independent contractors.
Edit: for the curious, the final bill for 18 days in the NICU was ~$94,000. The insurance paid all but ~$10,000. We spent several months appealing that, arguing that "we had no choice", and they kept denying the appeals. Finally we gave up and called the rogue physician's group to arrange for a payment plan... and they told us the insurance had paid the balance.
My wife's dentist always puts in big bills to our insurance company. We then get a check in the mail along with records detailing how much the dentist billed, and then how much they are paying (though us). We then send the check along, and every time that we have then talked to them they say that we don't have to pay the remainder.
This is just a negotiation tactic between our dentist and the insurance company. They are just trying to make sure that they capture every dollar that the insurance company will possibly pay. They never expected to get everything that they billed, that was more like an opening position in bargaining.
I'm not saying that doctors have this goal. I am saying that this is what the system incentives are, and we all know how systems respond to incentives.
Hardly anybody is going to actually try to keep a patient sick, but there are many other ways to get the same result.
Does this patient have good insurance? Run lots of tests. All the tests. Do expensive procedures that might help regardless of their cost benefit ratio. Spending a quarter of a million dollars for something that has a 2% better result than an alternative that costs $20 is perfect, because the incremental improvement is real. It's just not worth a quarter of a million bucks. But the patient doesn't care about that when it's the insurance paying.
What might happen is a generous employer funded or government funded (such as Tricare) plan might offer more coverage for brand name drugs, or less requirements for pre authorizations. And a less generous plan such as Medicaid (state government) will try to minimize costs by only covering generics or requiring more pre authorizations.
But the people reviewing the claims at the managed care organizations are not looking at what kind of coverage a patient has to decide if they do or do not need a medical procedure or a lab.
Doctors love Medicare. It pays them nearly instantly, steady stream of clients, and known fixed rates commensurate with most private negotiated rates.
Medicaid is the one that has much stricter benefit rules and tighter price guidelines.
To which I would say that is wrong because the person working at the MCO reviewing the claim would not be evaluating the expensive procedure based on if the insured has Medicare or Medicaid, they will approve or deny it the same if they deem it medically unnecessary.
I agree that healthcare providers get paid differently based on the patient’s coverage, and that would influence the priority they give the patient. In fact, I would say the whole point of the convoluted MCO system (versus a simple taxpayer funded system like UK) is to give the government plausible deniability for segmenting the population into various groups of people getting different quality levels of healthcare.
If the patient has good insurance, they don't really care about providers doing a lot of expensive unnecessary things, because they're not paying.
If they have less good insurance, either the patient is paying more to you out of pocket and is more likely to balk, or you're waiving the patient's portion of the cost and you don't want to be doing unprofitable unnecessary procedures for them.
So the incentive is for providers to do lots of expensive unnecessary things on the patients with better insurance.
I guess doctors could be basing their diagnoses and recommendations on the out of pocket costs for the patient, but I like to think that is not the case, by and large.
Anyone getting rich in the insurance business or hospital administration, writing overpriced administrative tools or telehealth software, selling overpriced medical equipment, etc. is profiting from death and suffering, and should feel terrible for it every time they cash a check, but the thing is, they don't. There are too many exploiters milking health care due to inelastic demand and the extreme depravity of people eager for money that passes for virtue among the depraved.
Unless it either meets preselected criteria (or gets lucky with the RNG for orgs doing random spot review) for manual review, or is an appeal, the “people reviewing the claim” aren’t actually people in many cases.
But, people or not, they don’t care if the patient needs it (well, they do as one factor, but its not the ultimate question), they care whether it meets the plan’s coverage criteria. Outside of what is minimally mandatory under health insurance laws and regulations, the coverage conditions for certain treatments (and even certain tests) are often more restrictive in “less good” plans.
So, yes, the systems and people reviewing claims do look at what kind of coverage you have when deciding whether or not a medical procedure or test is covered (and to what extent it is covered) by your insurance.
(I know, I’ve been deeply involved in building and maintaining some of the involved systems for a public sector payer.)
This is what I am referring to when talking about determining what is and is not medically necessary. If there is clear evidence of a lab or medication being helpful, then it will be covered due to stipulations in the ACA regardless of how expensive the insurance coverage is, since it is proven medically necessary.
Of course this gets into shades of gray, but such is life. However, I have not seen a treatment or lab well supported by data to not be covered because someone was on a worse insurance plan and the treatment or lab happens to be expensive.
One example of a controversial medicine to cover off the top of my head is palivizumab (Synagis) for RSV in babies. There is very sketchy data on its efficacy and in what conditions
https://publications.aap.org/pediatrics/article/134/2/415/33...
But lots of health plans will have varying levels of coverage with varying pre authorization criteria for it because it is extremely expensive. So would it be classified as medically necessary? Probably not in most cases. But still some plans might cover it for whatever political reasons.
I’ve learned to seek this person out (around here, it tends to be mostly women, and usually in their late forties, or so). They can be acerbic and abrupt, but I’ve found that it’s well worth it to treat them respectfully.
These are the “rainmakers.” They know how to make bills disappear by simply recoding a procedure, or will tell you how to approach your insurance company.
They will probably be unhappy at the new law; mostly because it will force them to have to learn a new workflow. I have every confidence that they will learn it, inside and out, in time.
Of course I can! Obamacare requires that at least 80% of money must go to medical costs. Profits and administration come out of the rest. So the only way to keep profits rising for insurance companies is to arrange for payments to rise at a predictable rate. And therefore insurance companies are happy to be complicit in rising medical costs, so long as it is predictable and other insurance companies wind up with comparable rates.
I think people conflate two separate issues when considering health care costs in the US. The first is high costs. The second is increasing costs.
There is no doubt about it when it comes to high costs. We pay more than other first world countries for comparable levels of care.
When it comes to increasing costs though there isn't much difference between the US and many other first world countries. The US rates rise just a little faster than the rates in the other G7 countries, for example.
It's been this way for a long time. Here's how much various counties' costs went up from 2000 to 2018: US 2.3x, Germany 2.1x, France 1.8x, Canada 2.0x, Italy 1.7x, Japan 2.6x, and UK 2.6x. The US costs relative to 1980 were in 1990, 2000, 2010 2.6x, 4.4x, 7.7x, and 10.2x. For UK it was 2.0x, 4.1x, 7.5x, 10.6x. France did better: 2.2x, 4.1x, 6.1x, 7.5x.
Much of the focus on health care cost reform is on the high cost compared to other countries, with the assumption that we are doing something wrong that the others are avoiding and this is what leads to our high costs.
But our costs were about as much higher relative to the others 50 years ago as they are now. It is just that it wasn't as big a deal back then because costs were much lower as a percentage of GDP then both in the US and in the other first world countries.
In a sense then the US isn't actually doing much worse than the rest of the world (see note below). We are just farther ahead on the same curve they are all following, so we've reached the point where it is painful first.
This is not good. It means that fixing this is going to be a lot harder than most reform advocates think.
Note: when I say we aren't doing much worse this is just on costs. We are way behind in access.
Here are a couple of past comments with cites for the above numbers [1] [2].
As long as there are competing businesses, and/or sufficiently low barriers to entry, then this mechanism to earn ever increasing profits is mitigated by the fact that a competitor will come in and take your business. Managed care organizations (MCOs), i.e. health insurance, has many competitors, UNH/Anthem/Cigna/Humana/CVS/Molina/Centene, etc.
Either they are all colluding to keep prices going up, or they actually are trying to negotiate the best prices they can with healthcare providers for their customers in order to offer the best value to continue to win business.
Considering all of the above companies have many years of single digit profit margins, almost all 5% and below, I would say the business line is quite competitive, and barring evidence of collusion, it seems spurious to claim they are profiting off of regulations requiring minimum medical loss ratios.
Pretty much no businesses have that percentage fixed by legislation.
If you make hammers and your customers are willing to pay $10 for a hammer and your costs are $9, your profit margin is 10%. If you can lower your costs to $8, you can still get $10, so now your profit margin is 20%. You have an incentive to reduce costs. And maybe even to reduce prices, because the higher number of hammers you sell at $9 might make up for the lower margin.
The main exception are utility companies and government contractors and it leads to the same perverse incentives there as in heath insurance.
> As long as there are competing businesses, and/or sufficiently low barriers to entry, then this mechanism to earn ever increasing profits is mitigated by the fact that a competitor will come in and take your business.
The way this works is that the lower cost insurer denies coverage for medically unnecessary procedures and the higher cost one doesn't. Then medical providers find someone who got denied and bring the story to the press that Discount Medical Insurance Co is intentionally murdering people by denying their health insurance claims! They must be stopped!
Then the bad PR loses them more customers than the lower price gained them, and the higher price makes them more money anyway. This continues until nobody is offering the lower price anymore.
Setting a minimum medical loss ratio is not setting a minimum profit margin.
>The way this works is that the lower cost insurer denies coverage for medically unnecessary procedures and the higher cost one doesn't. Then medical providers find someone who got denied and bring the story to the press that Discount Medical Insurance Co is intentionally murdering people by denying their health insurance claims! They must be stopped!
>Then the bad PR loses them more customers than the lower price gained them, and the higher price makes them more money anyway. This continues until nobody is offering the lower price anymore.
That is not how it works at all. MCOs do not have a team of doctors and pharmacists scheming to approve medically unnecessary procedures. The business is extremely competitive and much of the denial/approval criteria is in the hands of the payer, for example Medicaid/Medicare/Tricare/CMS.
It's setting a maximum profit margin.
We don't have problems with businesses trying to minimize their own profit margin.
> MCOs do not have a team of doctors and pharmacists scheming to approve medically unnecessary procedures.
All their competitors have to do is convince one of their patients that one of the procedures they're denying is medically necessary and they still get the bad press.
Is this a problem? As demonstrated by audited financial reports, there are many competing MCOs with many years of very small profit margins. These businesses clearly do not have pricing power, and are not businesses you get into to pocket lots of profit.
>All their competitors have to do is convince one of their patients that one of the procedures they're denying is medically necessary and they still get the bad press.
There is bad press about every single MCO out there, and they are processing millions of claims per day. I would need evidence to see that the bad press even means anything. Majority or at least plurality of people do not even get to choose their MCO.
You're arguing against yourself there. If the market is really competitive then there is no need to set a maximum profit margin because anyone who tried to charge that much would lose business.
Meanwhile, suppose that one provider was much better managed than the others. The mismanaged ones would simultaneously have high prices and low margins, because they're wasting the money. The well managed one could then have much higher margins even at the same or lower price.
But if there is a profit cap and you're already at it, searching for further efficiency improvements costs you profit. If your margin is 20% and that's the cap, but you can get a 10% cost reduction, what do you do? If you lower prices, your competitors lower prices, and then you still have a 20% margin and they drop to a 10% margin. You gain no customers and reduce your absolute profits by 10% by making the same 20% margin on a 10% smaller total. If you burn the efficiency improvement on purpose, or don't look for it to begin with, you make more money.
> Majority or at least plurality of people do not even get to choose their MCO.
Somebody is choosing for them and that person doesn't want to take the blame for choosing one that denies claims.
This is part of the reason why it works -- some HR drone making the decision isn't spending their own money, but they're the one who takes the blame for choosing the disreputable discount provider if there are problems.
However, since current profit margins are no where near 100% minus minimum medical loss ratios, I do not see how the existence of the minimum medical loss ratios would cause any MCO to be less incentivized to seek further efficiencies.
This also lines up with the PR benefit in being able to claim a low profit margin and overhead on paper.
https://www.investopedia.com/terms/t/transfer-pricing.asp
I also do not see what the gain for shareholders would be in reporting lower profit margins.
IIRC, in Germany and Switzerland medical insurance is mandated non-profit, and can only meet the costs of running the company. The insurers could just give themselves high salaries, but to cover those premiums would need to be higher, which could cause the insured folks to seek out lower priced coverage.
SF General isn’t in network for any insurer. Let that sink in. Why? They mostly treat indigent, so shit, insurance has nothing to do with it most of the time. Otherwise it’s revenue maximizing. And this is a government run hospitals. Let that point sink in too.
And I wouldn’t give physicians such an easy pass. I had conversations with a few community oncologist practices and they know the game very well. Ask them to take a 1% cut in revenue and you’d think you were throwing them in the poorhouse.
They could e.g. force hospitals to publish pricing information so that it becomes common knowledge and a market is created with accurate pricing.
Or offer to replace overpriced medical supplies used by doctors on their own, which they acquire separately from the manufacturer and in bulk.
Or - worst-case - start buying hospital stock at up to 2x market value so the profits accrue to them, and use investor pressure to start replacing hospital administrators with their own efficient bean counters.
These are public companies, if they could get that 3% quarterly growth cutting costs from somebody "milking" them, why isn't that priority #1?
Maybe not an explicit goal, but I think it's pretty easy for say an anesthesiologist who blows into the OR, talks to the patient (maybe) for 30 seconds, then powers through the surgery and on to the next one to lose touch with the core motivations for why they are there. In fact anyone who works with sick and hurt people needs to develop this dettachment as a survival mechanism. The administrators who create and operate these money machines are never connected with the patients in the first place. Not unlike a lot of software developers in this aspect!
The problem is that patients are being pulled into BS that normally they wouldn’t with other insurance.
When my car got damaged, I just brought it to a garage and gave them my insurance details. If they didn’t get paid it wasn’t on me.
Hospitals don't. Patients are.
I most certainly have options for my in-network healthcare provides and no, a crappy auto repair can certainly include an element of risk of death or permanent disability. Maybe not to the same degree, but if some shop forgets to reconnect the brakes it ain’t good.
In the case of an automobile repair, this is virtually never the case. Tow services if you've broken down on the road might be an exception, but few if any auto-repair issues (standard maintenance, component failure, collission repair) *will not suffer additional harm if repair is delayed by hours, or days, even months or years in many cases.
That's not the case for medical treatment.
This is fully independent of the quality or appropriateness of treatemnt / repair itself.
I do hope I've made the distinction sufficiently clear.
If you need surgery for your back, you can take the time to evaluate different doctors and hospitals, get their opinions and make a choice.
In the US healthcare system, "patients are being pulled into BS that normally they wouldn’t with other insurance". Without choice. And as numerous others have noted in this thread, sufficiently often in cases where the consequence of delay is critical. The newborn requiring NICU treatment is a case in which care is both urgent and consent or shopping by the patient is a complete impossibility (https://news.ycombinator.com/item?id=29766079).
I stand by my point. I'm a bit confused why you're arguing against your own earlier position.
I just happened to have paid a bill with that! Here it is, right out of the trash:
These guys wanted a $708 "emergency room" payment for an urgent care visit (it was not an ER! We saw a physician's assistant, not even a real doctor!) plus $157 for a lab test. The insurance gave them $140, the remaining $690 is considered a contractual write-off.
The maximum benefit amount is usually $1k to $2k. Maybe $3k at a generous employer. So if you ever had a really bad dental problem that exceeded those amounts, you are not insured from having to spend on dental problems that cost a lot of money.
Contrast with health insurance, where due to out of pocket maximums, you can suffer a very expensive healthcare event, and you are insured against having to pay $500k for the bypass surgery or NICU stay.
1) >>>>>>>> and every time that we have then talked to them they say that we don't have to pay the remainder.
This is actually in default of the contract between doctor and insurer. However, lots of physicians do it anyway. The minimum legal requirement is that physician must attempt to bill difference 3 times. If insurance audits and finds a pattern of these "writeoffs" it will claw back insurance claims. IN short, insurance doesn't want to pay more than the patient. Of course, the doctor will side with the patient, and then lose a bunch of money during an audit.
2) >>>>>This is just a negotiation tactic between our dentist and the insurance company. They are just trying to make sure that they capture every dollar that the insurance company will possibly pay.
You get half right. Its not a negotiation tactic. Its straight up capturing 100% of the potential reimbursement. Doctors have an extremely hard time maintaining different pricing for every contract, by CPT code. If doctors could easily maintain different pricing for different services, they would, because it would "true up" their AR Aging. Therefore they instead have 1 price, the highest possible, and just work to writeoff any underpayments. This is why healthcare costs keep going up. Doctors have no market incentive, they only have a maximizing incentive. That's why an increasing number of doctors do not take medicare or medicaid.
Something as simple as making doctor visits ("fee for service") payable via pre-tax dollars would probably make a big dent in the insurance game. HSAs were a step in the right direction, but its incredibly expensive from the employer perspective. You can have an stellar insurance plan and an avg one that offers HSA, and the premiums for the latter will be more expensive!
Source: Working in a healthcare startup that lets doctors not play these games. Former exec for brick and mortar healthcare companies.
I think it was the economist Kenneth Arrow that used situations like this as an example of why health care cannot be treated like other markets. Free Markets™ require information by buyers, and there tends to be asymmetry in this regard in medicine more than in many other markets.
* https://web.stanford.edu/~jay/health_class/Readings/Lecture0...
Usually when buying a product or service you know the price ahead of time, but with medical treatment this is often impossible for non-elective / emergency procedures.
I was verbally quoted about $2500 out of pocket expenses. I have a really good hdhp plan that covers $1500 hdhp before a 10k max coverage at 90% coinsurance.
I ended up costing close to $7000 out of pocket anyhow...
The medical insurance system is really stupid in America. It's basically fraud.
Coinsurance coverage doesn't work as intended because the hospital can charge any amount they want, meaning your forced to pay close to your max coverage even if you have a high % coverage.
Your forced to sign a "please bill me on anything you want" to get medical services rendered.
I got billed $400 per post visit just for a camera to be shoved up my nose.
The anesthesia was out of network and didn't get covered by insurance
This actually is specifically illegal, it's a pain in the ass to fight it against both the hospital and your insurance but if you insist hard enough they will cover it and you'll only pay what you would normally through your insurance. As long as the hospital itself is in network they aren't allowed to play "gotcha" with specific doctors/providers just not being in network all the sudden.
Unfortunately, hospitals will never be able to consolidate or pass-thru bills from all providers, because admins would want a cut of the amount paid, plus they would know what everyone is charging and use that info strategically. So no provider in their right mind would go for it. Sending bills directly cuts out any middleman and increase their margins.
If you are insured, supposedly there are measures to limit costs due to out of network providers, but I am not sure if you are entitled to find out the costs beforehand. I presume you are entitled to get a “good faith estimate”.
https://www.cms.gov/nosurprises/consumer-protections/What-ar...
If you are not insured, healthcare providers are obliged to give you a “good faith estimate” upfront now:
https://www.cms.gov/nosurprises/consumers/understanding-cost...
https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bill...
I'll be calling them Monday and telling them that unless they send me an itemized bill detailing what doctor (or other medical professional) she saw, what the treatment date was, and what service was provided, I'm not paying squat.
Frankly, she's got more important things to worry about than an account getting sent to collections, and I'm legally responsible for how I spend her money. I'm not going to pay bills from any rando who feels like sending one. Not gonna happen.
We kept digging and had to threaten the facility with a referral to the Medicare inspector general to get information. Turned out that the guy prescribed some random drugs and billed for a “3 hour evaluation”, which supposedly took place on a day where my dad was accompanied by family members or in physical therapy for the entire day. (Context: he had a stroke and was unable to speak)
The doc just showed up and wrote random scripts. We didn’t get the feds to care, but the state medical licensing people did censure the doctor.
Good luck. These facilities aren’t very forthright and will retaliate against your helpless relative.
It may even be legit. But I don't know that.
Edit: at least yours had a doctor's name! This bill doesn't even have that.
Censure? In the sense that he's doing five-to-ten stamping license plates for wire fraud?
If you have a heath insurance card, you just pick one and you are done.
If you are paying by cash, you ask for a price. Then you price shop all hospitals. There are no "surprises" as hospitals expect customers to pay upfront the cost of procedure and or a deposit for room/incidentals.
The good thing with this is, you say "hey hospital A, how much for a cataract surgery", same for all hospitals. The bad thing is, if you don't have the cash, you either have to borrow or sell off property which throws people into poverty faster.
Recently government made a public insurance scheme where every family is covered for like 1200 procedures and is cashless. The good about it is, even poorest of poor can get private healthcare and hospitals get a steady revenue stream, albeit at a lower profit but in the long run they are expected to turn a profit.
In India, health insurance and insurance in general is missold. Agents sell " return of premium" and "money back" instead of risk cover because they get a fatter commission. I have talked to dozens of agents and they dislike term life insurance like the plague. "Why would you do that, its stupid. Yuck. Ew". Same for medical, the result being only rich could afford good care till now.
Basically "list" vs "actual" pricing depending on what "discounts" you are eligible for.
"How much you got?"
Mobsters.
They also talk about how they are making it more affordable for everyone.
You pay more, you get higher probability of access to MDs. You pay less, you get higher probability of access to PA/NP. And many other variations of that.
You can accomplish the goal of politically expanding access to healthcare, but without the costs of getting everyone access to the same healthcare.
Edit: we could also generally waste less human potential and train more people by you know, having college kids go to school 48 weeks a year instead of 36, like real adults who enlist in the military or trades.
Whoever or whatever was preventing supply of doctors from increasing for the past few decades really did the doctors who worked 1980s to 2010s a big favor, but a big disservice to pretty much all future doctors.
Hello. I'm from the rest of the world, and I or my family have never received a bill from a hospital. The idea seems crazy. Just providing a perspective.
But I’m kind of surprised that hospitals don’t try and get ahead of it. If I had two options for hospitals and one provided financial management (say guaranteed a final cost) and the other was like “fuck off, call your insurance”, I’d opt for the former easily.
Any other business in the country would just have products / services and prices without any of these games.
Had the same experience as you, FWIW.
No, because the status quo allows the various providers to extract every penny of value that they can out of you.
This also really bothers me:
> Out-of-network doctors also must inform patients about what their care might cost, and they may ask patients to sign a form that waives their protections. (Be leery of signing this, consumer rights experts say.)
It's a very weak law when you can still sign away your rights to someone who has the stronger end of a power/information imbalance. Emergency care is supposed to be covered by this law, but if you're in bad shape and show up at the ER, you might sign anything just to get care.
Then if you do say no, could the hospital then charge you for cancelling surgery at late notice? Especially given insurance generally doesn't cover such fees.
Honestly any law that doesn't say "if the facility is in network, the insurance company must cover all costs as in network" and get rid of this bullshit concept of "out of network" people in an in network facility is fundamentally insufficient.
https://www.cms.gov/nosurprises/consumer-protections/What-ar...
>Ban out-of-network charges and balance billing for ancillary care (like an anesthesiologist or assistant surgeon) by out-of-network providers at an in-network facility.
If not signing that waiver means your surgery gets canceled (especially in an emergency situation), most people will feel coerced to sign. Hell, most people will probably feel coerced to sign in most situations.
https://www.cms.gov/files/document/standard-notice-consent-f...
Which instructs the provider to list the "good faith estimated cost" on page 4. Presumably, this will then bind the provider to having to deal with you via the dispute resolution process:
https://www.cms.gov/nosurprises/consumers/medical-bill-disag...
Of course, the effectiveness of all of this remains to be seen, and will depend on what kind of teeth this dispute resolution process has:
>If after getting your bill you realize that any of your providers or facilities billed you for an amount that’s $400 or more than what’s on your good faith estimate, you can use a new dispute resolution process to request that an independent third-party, called a dispute resolution entity, review your case and determine an appropriate payment. This process is referred to as “patient-provider dispute resolution.” The dispute resolution entity will review the good faith estimate, your bill, and information submitted by your provider or facility to determine if you should pay the amount on your good faith estimate, the billed charge, or an amount in between the two. There’s a $25 non-refundable administrative fee to start this process.
Someone will reply: Medical costs are responsible for X% of personal bankruptcies in America.
Someone will reply: Most Americans don't have to worry about medical bills because they have coverage through their employer.
Someone will concur: Yeah, I have fantastic benefits with my company.
Someone will provide a counter anecdote: I also have great benefits with my employer. But I still have to pay a $5000 deductible before coverage kicks in.
Someone will reply to the parent with: The US has the best health care in the world. Why do you think people fly from overseas to receive treatment in the US?
Then someone will reply: The US has the best health care ... if you can afford it. The last time I saw my doctor, he looked at me for five minutes and prescribed me a bottle of aspirin.
Someone will reply: You need a new doctor. I once had an experience like yours. I found a new doctor, who truly cares about my health and well being.
Someone else will reply to the comment two spots above:
> The US has the best health care ... if you can afford it.
"No, the US has the best health care in the world, including for middle class people and poor people. I once injured myself in [insert first world country] and their health care system was practically third world."
_______
I know it's real people suffering and because of personal relationships with US citizens I feel for them.
Yet it's a fascinating lesson in how complex social problems can be acknowledged by pretty much everyone while at the same no-one is able to implement a workable solution.
PS: I'm glad there will always be someone who reminds me that here in central Europe I can not choose my doctor, have to wait months for an appointment and that we don't have health insurance here because it's covered by taxes. Since that's not how it works at all I always forget ;)
PPS: Obviously it's not all sunshine and roses here either and we have our fair share of problems but large unexpected bills for scheduled or emergency procedures just don't happen frequently enough to matter in the grand scheme of things.
One of my app ideas was to make it so you can have that "graph" for every issue, and then instead of rehashing the same debate every time, you just tell people to find where their argument is in the graph, and they can link it or improve what's there.
It's the middle class that takes it in the neck.
Not all of them have, of course. Without going through every single state, Texas allows you to make up to $25,503 for a household of one and still be eligible for Medicaid.
Those who make more are eligible for free or subsidized Obamacare plans.
What do you mean by "cripplingly poor", and what state was this?
For example, in Florida, to be eligible for Medicaid, you must be below the poverty line AND:
> You must also be one of the following: Pregnant, or Be responsible for a child 18 years of age or younger, or Blind, or Have a disability or a family member in your household with a disability, or Be 65 years of age or older.
Expanded Medicaid in states that accepted it cuts people off at 100% to 138% of the FPL, meaning if you make more than $12k to $16k a year, you're ineligible for Medicaid.
If you have more than $2k worth of assets, you must sell them before being eligible for Medicaid.
And if you live in certain states, they throw in all sorts of impossible restrictions and surprises. Sometimes they’ll suggest that you move.
Not sure that you could get that past the Supreme Court, or run it competently over the long term given our depressing partisan split on health care, but you know. If this were Canada, that would be the way to make this work.
That isn't at all what they were saying.
They were saying that instead of Congress trying to make rules through the legislative process (which moves to slow to work), Congress needs to create and authorize a federal agency to make these rules (like the FAA or FCC.) The portion about the supreme court is regarding whether such an agency would be deemed constitutional.
Extremely different mechanisms protect a hospital from a patient lifting a box of bandaids and some OTC pain reliever vs a hospital unlawfully billing them zillions of dollars.
The real court case to upend this country would be one that limits or nullifies the delegation capability.
But at least we’ll have small government again lol.
Clarence Thomas has this bit where he says "you guys are doing all these crazy contortions to do stare decisis on these old New Deal decisions that enable the modern administrative state, but the real answer is that they were never constitutional to begin with and should be reversed." This would clearly be a giant disaster, but I think his argument is probably correct.
We don't really do constitutional amendments any more though, so I'm not sure if there are any answers other than court packing to ensure continuous Constitutional Calvinball.
Most of the New Deal was gutted by the courts in the 1930s and 1940s and everything else that remains from it just has never been challenged, mostly from a lack of inspiration, lack of awareness, or distraction by other causes.
I would be skeptical of anything we’ve just assumed is American that came about from the New Deal.
I’ve got a couple full agencies in my crosshairs, and I’m excited about that.
Sure, its going to be a disaster, and I’m empathic about people losing other civil rights they have gotten used to that this court is going to re-evaluate, but I’m glad I can leave and that my particular causes will give me the openings I want.
What prevents this from becoming standard practice as a part of all the other stuff you have to sign?
I think as the understanding of the health system continues to spread, it will become more and more difficult for certain unethical practices to survive the backslash.
Isn't it only relatively recently they've even had to show us prices? And so draw attention to the $15 bandaids, etc?
(I've never had any actual hospital stays while living in the US so have never seen a receipt, and so don't know the progression)
It just so happened that the meteoric rise in healthcare costs came to a head when the social media and the internet was also blowing up.
Even without the internet, it was still well known enough to be a sufficiently important political flashpoint to actually result in Affordable Care Act passing. But I remember Clinton debating about healthcare costs in the 90s on national TV, it just had not effected sufficient number of voters yet to become a big enough issue.
I also assume it has something to do with baby boomers reaching the age where they start experiencing healthcare costs and so you have a huge portion of the US population gaining experience for the first time of how much money they will have to spend on healthcare.
I still carry a high end insurance plan because if I break my leg on the ski slopes I don’t want to end up being triaged into the “indigent” bucket at the ER (this happened to me once, luckily with something less serious than a broken leg). Likewise it’s hard to get into some specialists unless you are in network. This isn’t a case when a call from my primary can’t get me an appointment (that call has gotten me seen even by docs who are “not accepting new patients”) but because the hospital administration doesn’t like cash payers even though they are charged the most.
The real differences lie elsewhere. For example my primary doctor simply doesn’t accept insurance of any sort. I see her, I pay the bill as I leave. She chooses tests and therapies based on whether she thinks they are worth it (risk vs informative value), and has the time to discuss with me. The longest I’ve had to wait for an appointment was once when I called in the morning and couldn’t be seen until the afternoon. She seems to be friends with the heads of various departments of a few local hospitals which cuts through red tape.
The wealthy 1%ers and 0.1%ers have special areas of high end hospitals and various sherpas who can make sure the patient gets the attention they want. I wonder how that system is operating these days in light of what COVID has done to the hospital infrastructure.
Apart from my primary care physician, I’ve had better care from more egalitarian systems in Europe and Australia. Even there though, the informal networks are quite valuable.
I like the US for obvious reasons; nature, freedom, startups, VCs but without this fixed, I would never consider it and that's a shame. I would love to live with the many people I know there and build companies.
Why is it even possible to have forms that allow dodging laws?
I hope to see the day when nobody avoids care - preventative and acute - due to cost. It costs lives, and in other cases diminishes lives. I avoid care myself, despite having health insurance and being relatively high income, because you can mysteriously get a $1250 "room fee" added onto a $300 bill to stick a camera up your nose for 5 seconds when an ENT casually suggests it, which actually happened to my partner during a simple consult recently (you can buy a similar camera to hook up to a smartphone display for $10). This sort of "surprise bill" and outsized costs for trivial diagnostics with almost no cost to the providers needs to end. When I made less money and had no insurance, I didn't just avoid care, I went without it entirely for years. We should avoid that as a society, it comes with high costs - the cost of more significant care later, the loss of labor force, and the loss of quality of life and family.
We asked for a bill. They refused. Finally they somehow calculated it and said it was about 900$, we payed. BUT then they send another bill for 3000$ more (guess just for the registration at the hospital), on the bill we payed it was stated that it is not the final bill.
To be precise the insurance payed. But it is obviously a rip off.
Seriously though, stop trying to patch a broken system... There's a better way...
There is some policy I didn't agree to that allows them to bill me 6+ months later
My policy is your request for payment is denied. Damn the costs
The people behind many representatives don’t know or care enough.
This helps more of them know and care.