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February 21, 2013 8:12 AM   Subscribe

Bitter Pill: Why Medical Bills Are Killing Us. Summary: Inside the Cover Story. Related video: The Exorbitant Prices of Health Care

Time is soliciting reader stories about their experience with the high cost of US healthcare. CNN has been investigating the story with the magazine.

Comments on the article.
posted by zarq (85 comments total) 40 users marked this as a favorite

 
*shakes fist, deletes bookmarks*
posted by the man of twists and turns at 8:25 AM on February 21, 2013 [4 favorites]


I'm going to read this at lunch and I will probably cry because this is the sort of thing that affects my family directly and I will not be able to believe that my home country is okay with medical care being a "crapshoot."
posted by Kitteh at 8:30 AM on February 21, 2013 [2 favorites]


I'm not even halfway through the article yet and there's no way it's ending on a good note.
posted by dobi at 8:35 AM on February 21, 2013


The results of national study (pdf) of bankruptcies released last year noted that 62.1 bankruptcies filed in 2007 were tied to medical expenses. Three-quarters of those who filed for bankruptcies in 2007 had health insurance. Most medical debtors were well-educated and middle class. The share of bankruptcies due to medical problems rose 50% between 2001 and 2007.
posted by zarq at 8:42 AM on February 21, 2013 [5 favorites]


I'm not even halfway through the article yet and there's no way it's ending on a good note.

That's an accurate description of the US Health Care System.
posted by Brandon Blatcher at 8:58 AM on February 21, 2013 [5 favorites]


WP - Ezra Klein: Why an MRI costs $1,080 in America and $280 in France
There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher.
posted by Golden Eternity at 9:00 AM on February 21, 2013 [2 favorites]


OK, i'll bite...Why are the prices higher?
posted by joecacti at 9:03 AM on February 21, 2013


“Other countries negotiate very aggressively with the providers and set rates that are much lower than we do,” Anderson says. They do this in one of two ways. In countries such as Canada and Britain, prices are set by the government. In others, such as Germany and Japan, they’re set by providers and insurers sitting in a room and coming to an agreement, with the government stepping in to set prices if they fail.

In America, Medicare and Medicaid negotiate prices on behalf of their tens of millions of members and, not coincidentally, purchase care at a substantial markdown from the commercial average. But outside that, it’s a free-for-all. Providers largely charge what they can get away with, often offering different prices to different insurers, and an even higher price to the uninsured.

posted by Golden Eternity at 9:13 AM on February 21, 2013 [4 favorites]


How many of us will ever, in a lifetime, earn enough to save enough to pay for treatment of a catastrophic injury or chronic debilitating or rare disease? this is the fundamental problem in western healthcare.
posted by OHenryPacey at 9:16 AM on February 21, 2013 [3 favorites]


Me to my father-in-law's dialysis nurse: "What happens to people who can't afford this obnoxiously priced medication that he HAS to be on?" Nurse: (with a knowing look and sigh): "Honestly? They die."
posted by cdalight at 9:23 AM on February 21, 2013 [6 favorites]


-- If they're going to die, they'd better do it, and decrease the surplus population!

Michael Caine's delivery of that line in MCC is forever etched in my mind.
posted by seanmpuckett at 9:26 AM on February 21, 2013 [1 favorite]


This article, (and maybe it's the intent) scares the crap out of me. My wife and I have reasonably good insurance and savings. And yet I'm pretty sure one major illness would wipe us out financially. How the hell do you prepare for something like that?
posted by Thistledown at 9:29 AM on February 21, 2013 [2 favorites]


You move to another country.
posted by seanmpuckett at 9:30 AM on February 21, 2013 [7 favorites]


There is no reason any patient should pay a 400% markup on the cost of healthcare services, and it's obscene that we expect uninsured sick people to bargain prices down as a matter of course. Anyone making an unqualified claim that US has the best health care system in the world has clearly forgotten that the billing process is part of the system.

I've posted this link before, and I'm posting it again. The Debt Resistor's Operations Manual. If you're already saddled with medical bills that are in collections, pay special attention to page 27 and Appendix C, which describes how you can challenge the debt by asking for a fee breakdown, which is almost impossible to provide without violating HIPAA.
posted by compartment at 9:30 AM on February 21, 2013 [35 favorites]


Astonishing beyond belief.

In the UK, even if you go for the most fancy private hospital treatment and pay with a credit card, the costs are a twentieth of these. A thirtieth. A hundredth.

I know someone who wanted the latest robot surgery and paid privately because the National Health Service wouldn't provide it (debatable whether it was a better treatment).

Cost of 5 nights in The London Clinic (probably London's top cancer centre for this type of op), including all aspects of the before and after care from 3 hours of robot-assisted surgery by the best dude in the country: around 15,000 GBP.

No wonder there were several guys on the ward who had flown in from the US.
posted by colie at 9:33 AM on February 21, 2013 [2 favorites]


That was an excellently written article. My wife just broke her arm and had surgery last week, and two things that really struck me were the "keep it in the family" treatment approach from the hospital and an almost complete lack of any price transparency.

When she was first hurt we went to the local ER, which is run by a big healthcare company. After initial treatment, they ran our insurance and checked with our primary doctor (who was affiliated with the hospital) before giving us a name and number of an orthopedic specialist (who was also affiliated with the hospital). The orthopedic doctor recommended surgery and set a date at their outpatient surgery center (which is affiliated with the hospital). Then we went to follow up care at the medical offices (which are affiliated with the hospital) and got an order for PT, which for our convenience can be done in the office right next door by a physical therapist (who is affiliated with the hospital). So when she walked in the door with a busted up arm, she was not a 2-hour revenue generator for the hospital group. She was a three-month revenue generator, across 4 medical offices and 3 care providers. As more hospital systems consolidate, that will only grow in frequency. With less competition comes higher prices, and as the article notes less willingness to negotiate with health insurers and end customers.

Separately, at no time during her care was there ever any sort of price sheet or discussion of payment other than the ubiquitous "we will bill your insurance but you swear you're good for it too" paperwork and calculation of copays. At past treatments, I have asked about prices and was told "we will bill your insurance" and "that is calculated after everything is finished." It really struck me that here we were being treated for something that will surely have a list price greater than any other thing we've ever purchased other than our house (no exaggeration there), and we had no idea how much it would cost. Because we have good insurance through my work it doesn't directly matter in this case, and I think that's the biggest problem. We'll pay something like $250 all in, and she received excellent care along the way. But for those working for themselves, or without a job, even something basic like a broken arm would have meant thousands and thousands of dollars, incurred without any opportunity to negotiate or even KNOW the price. That is just not sustainable.
posted by AgentRocket at 9:40 AM on February 21, 2013 [29 favorites]


Same shit, different day.
posted by Ardiril at 9:50 AM on February 21, 2013


Excellent article, but is it really news at this point?

As usual, it's good to remember that the American healthcare system isn't broken, it's working exactly as intended.

How many of us will ever, in a lifetime, earn enough to save enough to pay for treatment of a catastrophic injury or chronic debilitating or rare disease? this is the fundamental problem in western healthcare.

No, this is the fundamental problem of American healthcare. Other countries deal with it very simply by socializing the costs, thereby balancing the power between buyers and sellers.

You can't have a free market without price discovery, but price discovery is completely absent in the American system unless you're in the big boys club.
posted by unSane at 9:52 AM on February 21, 2013 [22 favorites]


The word apparently got out to the "smart money" some time back that America has become a nation of suckers. And we've all been doing our best (from defending the undisclosed use of cheap fillers in meat products to quietly acquiescing to outsourcing practices that have poisoned our pets and children) to earn that reputation for years now. Of course we're overcharged for medical services. We're overcharged and nickle-dimed at every turn these days, ostensibly in the name of market efficiency and increasing shareholder value.
posted by saulgoodman at 9:53 AM on February 21, 2013 [7 favorites]


What astounds me is that people still, with a straight face, are able to argue that the US has a "free market" health care system. It's not. In a free market you can shop around, you can figure out what something costs and find suppliers, and there's competition. I am not permitted to be an informed consumer, so how can I possibly play that role in a market to bring down prices?
posted by Tomorrowful at 9:54 AM on February 21, 2013 [16 favorites]


And this, children, is why libertarian laissez faire market solutions are a fantasy that only benefit the wealthy and do nothing to actually address the costs of health care.
posted by klangklangston at 9:58 AM on February 21, 2013 [6 favorites]


So, I have a question: What tangible changes to this will Obamacare produce, as it is written now?
posted by jbickers at 9:58 AM on February 21, 2013


No one ever, ever mentions that maybe something to do with the high cost of health care is that our medical training requirements are far higher than any other country's, and therefore our doctors are paid 2-3x as much. Expensive drugs and equipment explain a little bit of the cost difference, but expensive providers explain much more of it.
posted by miyabo at 9:59 AM on February 21, 2013


~How the hell do you prepare for something like that?
~You move to another country.

Hardly.
Moving to another country is just as financially out-of-reach to most people as is paying for healthcare.
posted by Thorzdad at 10:02 AM on February 21, 2013 [10 favorites]


our doctors are paid 2-3x as much

They have an around 200k debt to pay off from medical school I think.
posted by colie at 10:03 AM on February 21, 2013


colie: "our doctors are paid 2-3x as much

They have an around 200k debt to pay off from medical school I think.
"

Right: "that our medical training requirements are far higher than any other country's"
posted by boo_radley at 10:08 AM on February 21, 2013


By "training requirements", do you mean "tuition fees"?
posted by jeather at 10:14 AM on February 21, 2013 [2 favorites]


OK, i'll bite...Why are the prices higher?

Profits.
posted by jokeefe at 10:22 AM on February 21, 2013 [3 favorites]


Assuming you can control the costs for imaging, ancillary, and lab services in the private sector, and lower overhead costs, the remaining issues would be to:

Train a generation of doctors to accept stable but lower incomes in exchange for a good long term career.
Train a generation of Americans to accept rationing and evidenced based medicine and to have less influence over their health care workups.
Remove legal fears that drive defensive medicine.
Accept that access will be lowered if doctors are not compensated in proportion to the volume of patients they see. This is not a bad thing, per se, but is a reality. In most clinics that are not owned by private entities like hospitals, access is much better for patients because doctors are paid substantially more to see more patients. Without that incentive a doctor that sees 25-30 patients in a day will see 18-20, and wait times will increase proportionally.

There's a lot of issues at stake here. The system is a mess. Everyone will need to accept some changes and pain, but ultimately, a single-payer system is probably the only thing that will ever be sustainable.
posted by docpops at 10:22 AM on February 21, 2013 [9 favorites]


"It doesn't specifically say the words 'tuition' or 'fees' or 'school'!"

~ falls down sobbing ~
posted by boo_radley at 10:23 AM on February 21, 2013


I really question if you can save very much by lowering doctor salaries, though maybe for some specialists. You pay a family doc or internist or pediatrician any less and you are just absolutely going to see an absence of coverage across most of the non-urban USA. That may be OK if you supplant with midlevels, but anything more than routine diagnoses will start to be missed. You tell someone to spend 7-8 years of post-collegiate education on a career paying under 150K and add in 6 figure debt and your available pool of people for medicine shrinks even more than it is now, at least as far as primary care goes.
posted by docpops at 10:28 AM on February 21, 2013


How many of us will ever, in a lifetime, earn enough to save enough to pay for treatment of a catastrophic injury or chronic debilitating or rare disease? this is the fundamental problem in western healthcare.

I know I'm at least the second person to say this, but no: This is a problem with American health care. Which isn't really health care at all, but a machine to monetize illness. Like other Canadian or Australian or English Mefites, I can chime in with my story: last year I had major surgery, was hospitalized for a week, underwent all sorts of diagnostic tests involving blood and CT scans, etcetera. The final cost to me was about $20.00 (twenty dollars) because I asked for a private or semi-private room, which was almost entirely covered by my extended health (insurance through work). If I'd stayed in the room shared with three other people, I would have paid nothing at all.

Fun fact: I shared the semi-private room with a genuine Italian mobster who had also had liver surgery; his phone calls were amazing to listen in on, and it wasn't just the drugs.
posted by jokeefe at 10:28 AM on February 21, 2013 [14 favorites]


How many of us will ever, in a lifetime, earn enough to save enough to pay for treatment of a catastrophic injury or chronic debilitating or rare disease?

That's not the plan. The healthcare industry's ultimate goal is to take the last dollar out of your pocket (or from your family, if possible) when you take your last breath. If they don't, that's money left on the table.
posted by RobotVoodooPower at 10:28 AM on February 21, 2013 [4 favorites]


Can I just ask, from my perch of not really understanding the clusterfuck that is the US medical industry, why isn't Medicare just expanded to cover everyone? Is it just the entrenched interests of the hospitals and insurance companies that prevent it?
posted by jokeefe at 10:31 AM on February 21, 2013


This is an astoundingly well written and comprehensive article for Time Magazine. There is no groundbreaking news in this article, but it is good and necessary that this sort of thing get republished and republished and republished. The website TrueCostofHealthCare covers some of this information in video form...and exhaustive articles on the incredible ineptitude of the US healthcare system are a google search away...but what continues to astound me every time this merry-go-round completes a loop is why we don't do anything about it? The state of affairs for our healthcare system is even more deplorable in light of the reams of evidence pointing to exactly WHY it is failing...yet as a society we kind of just shrug.

The US Healthcare system is a perfect representation of a failure of capital - insofar as the myth is concerned that a market-driven system is the most effective solution for benefiting the majority of society. As this article points out...if you are Capital - a stakeholder in the healthcare industry - things are working out just fine...but if you are anyone who actually needs care...too bad F*ck you. It really makes me angry.

No one ever, ever mentions that maybe something to do with the high cost of health care is that our medical training requirements are far higher than any other country's, and therefore our doctors are paid 2-3x as much

No one ever mentions this because as a line-item on most healthcare costs the cost of a doctor, even an expensive one like here in the US, is far below that of procedures, tests and fees that are by and large a result of inefficient insurance company billing.

Take a look at T.R. Reids Healing of America or these links for more relating to this issue:

link
link
posted by jnnla at 10:31 AM on February 21, 2013 [8 favorites]


As I've noted elsewhere on the site previously, my partner received a liver transplant a few weeks back. For shits and giggles, thanks to this thread, I decided to log on to see how much my total billed amount for this plan year was, even though I had planned on ignoring it at least until we were back home. As of today:

$121,805.93

(Yes, the plan year in question started 1/1/2013.)

But looking at it in more detail, I realize they haven't even done a claim for the actual surgery or his hospital stay yet, just prescriptions.

Granted $70,000 of this was for a TIPS shunt they put in just 5 days before a donor was found to hopefully alleviate some of the symptoms of the bad liver we thought he'd be stuck with for longer. When I asked the transplant surgeon what they did with the stint they had just put in the previous week when they gave him the new liver, she grinned ruefully and said 'Yeah, I just ripped that right out."*

And even though that was a big waste of money, and even with insurance, it's not like the expenses won't be a major thing to take care of, I'm glad we were able to make that choice and have not been bogged down in worrying about every nickel and dime through this last year or so.

Everyone should be so lucky. EVERYONE.

* Obviously, this was an unexpected post-surgical complication. Why? Because even though she had just probably saved my partner's life so our relationship would continue as planned for just the two of us, the surgeon's immediate response of "Yeah, I just ripped it right out" after a six hour surgery meant a small-but-not-insignificant part of my heart would always belong to another.
posted by MCMikeNamara at 10:32 AM on February 21, 2013 [4 favorites]


"It doesn't specifically say the words 'tuition' or 'fees' or 'school'!"

"Training requirements" is quite different in meaning from "tuition fees". One is about the classes you take, the internships, etc, the other is how much you're paying. The US has higher tuition fees, but I'm not convinced that it has hugely higher training requirements than other countries, which is what you claimed.
posted by jeather at 10:34 AM on February 21, 2013


why isn't Medicare just expanded to cover everyone

Because SOCIALISM.

Also, in the main article, since 1998 the healthcare industry has spent over three times as much as the defense industry on lobbying Congress. Healthcare is the #1 lobby in DC.

In fact, when McKinsey, aided by a Bank of America survey, pulled together all hospital financial reports, it found that the 2,900 nonprofit hospitals across the country, which are exempt from income taxes, actually end up averaging higher operating profit margins than the 1,000 for-profit hospitals after the for-profits’ income-tax obligations are deducted. In health care, being nonprofit produces more profit.
posted by the man of twists and turns at 10:34 AM on February 21, 2013 [3 favorites]


The healthcare industry's ultimate goal is to take the last dollar out of your pocket (or from your family, if possible) when you take your last breath.

To be fair, they or the collection agency any bills go to will be happy to also take money from your spouse or children after you've already died.
posted by nTeleKy at 10:35 AM on February 21, 2013


By "training requirements", do you mean "tuition fees"?

Several things: posted by miyabo at 10:36 AM on February 21, 2013


So, I have a question: What tangible changes to this will Obamacare produce, as it is written now?

As it's written now, it's a shell game. Everyone's still trying to game it, and milk as much money as possible in as little time as possible. Whereas before, it was only the insurers that were playing that game. If, as many hope, it's step 1, and actual enforcement with penalties and incentives becomes possible... and the focus shifts to the insurers failings and not the providers, well, it's step 1. There will be a lot of winners and losers.

The insurance companies answer only to their shareholders. Not the patients.
posted by DigDoug at 10:37 AM on February 21, 2013


What astounds me is that people still, with a straight face, are able to argue that the US has a "free market" health care system. It's not. In a free market you can shop around, you can figure out what something costs and find suppliers, and there's competition. I am not permitted to be an informed consumer, so how can I possibly play that role in a market to bring down prices?

Seems to me the medical billing fraud system and other aspects of healthcare could benefit from transparency and free market brutality. $75 gauze? And I could see how fully socialized healthcare could cause big problems - not enough physicians willing to provide high quality care because the price is too low and they would have to take a loss. But a fully free market health system would be a nightmare. How much would some people be willing to pay to add 5 years to a parent's life? or 50 years to their child's life? What if they only have a few hours to make a decision or it's too late? Health providers have kind of an upper hand in these sort of negotiations making "government" protection and insurance necessary.
posted by Golden Eternity at 10:42 AM on February 21, 2013 [2 favorites]


OK, i'll bite...Why are the prices higher?
The chief executive of the Carolinas HealthCare System received $4.76 million in wages, bonuses, and benefits in 2012, and nine other executives with the North Carolina-based network earned at least $1-million, reports the Charlotte Observer ..... Carolinas HealthCare, the second-largest public hospital system in the country, operates 38 hospitals in North and South Carolina and has raised its annual revenue from $4.1-billion to $7.5-billion in the last five years.

- - - -

A new survey finds more than one in five CEOs at non-profit hospitals in California make more than $1 million a year. How about $7.7 million a year? That's what Kaiser Permanente's CEO George Halvorson made in 2010.

- - - -

Rhode Island Hospital’s parent company paid its CEO $9.5 million in 2009, but the industry’s top lobbyist says that doesn’t mean Providence’s hospitals can afford to start contributing money to the city budget. Local hospital chain Lifespan’s CEO George Vecchione earned $9.5 million in fiscal 2009, after getting paid $3.2 million in 2008 and just under $3 million in 2007.

Two guesses where those millions of dollars are coming from.

I remember not too many years ago seeing a donation cup at our gas station for a local kid's surgery. Some days I feel like we're living in Zimbabwe.
posted by crapmatic at 10:50 AM on February 21, 2013 [7 favorites]


Very limited number of medical school slots -- there has been an explosion in the number of slots for other professional programs, keeping salaries relatively low, but this hasn't affected medical programs

...primarily due to pressure from the AMA, which consists of doctors who don't want to see their future earnings deflated by a glut of physicians arriving on the market en masse in five years' time.

The system is so irrevocably fucked that nothing will ever change unless the political will for single-payer coverage emerges. Massive mounting evidence for the hopelessness of the American system hasn't been enough to generate that political will, so I'd say this will happen shortly after the corpse of the GOP cools to room temperature.
posted by Mayor West at 10:53 AM on February 21, 2013 [6 favorites]


Yup. Someone like, say, an aerospace engineer probably has a similar level of discipline specific knowledge and academic skills as a doctor. But there is absolutely no shortage of aerospace engineering programs -- every medium-sized university has one, there's no real competitive admission, and tuition is heavily subsidized. You don't have to have a BA in something else before you even start. And aerospace engineers can move in freely from other countries under work-visa programs. That's why a top-notch aerospace engineer is making $100k, and an average doctor is making $250k.
posted by miyabo at 11:05 AM on February 21, 2013 [2 favorites]


why isn't Medicare just expanded to cover everyone

As a relative put it, "I work hard for my health insurance, and I don't think lazy people should get what I have for nothing."

Or, in other words, "Fuck you, got mine."

There are enough people like that, people who would rather see their whole family in financial ruin than to know someone who didn't "deserve" healthcare got it, people who practically squeal in delight at hearing about some poor person's hardship, that there will never be sane healthcare in this country. Never. We are far more likely to lose Medicare than to gain a sane healthcare system.
posted by dirigibleman at 11:16 AM on February 21, 2013 [24 favorites]


why isn't Medicare just expanded to cover everyone
I know this has been asked and answered a couple of times already but yeah... to a significant number of people in the US, providing universal healthcare is SOCIALISM and makes baby George Washington cry. This type of person would rather that everyone else in the country work three jobs to pay for cripplingly expensive private health insurance than endure the thought of someone, somewhere GETTING A FREE RIDE.

It is as hard for me to imagine living in a country whose populace believes in providing each other with universal healthcare as it is for outsiders to believe it could be so completely screwed up in the US.
posted by usonian at 11:45 AM on February 21, 2013 [8 favorites]


Huh. Relevant reading, by an American visiting England:
This is how you healthcare. It’s care of those clinging to life and care of those spinning and reeling in their orbit, struggling to adapt to life in a new airless atmosphere, a place with its own physics. There's no division. At one end, there is a malfunctioning heart, so you give it the right dose of the right drugs. At the other end is an exhausted relative, so you give her toast.

By now I am convinced that the NHS – and I hyperbolise, but only slightly – is the greatest achievement of humankind, the nearest we get to a benevolent deity, a goddamn superhero. It is an imperfect manifestation of a beautiful ideal – free care based on need, free care for all, without judgement, without reservation.

However long this goes on for, they'll continue throwing resources at this individual and never show a single sheet of figures to any of his relatives. Not because they'll get anything back, but because this is what the NHS does. It’s free care for throat cancer sufferers who only gave up smoking four years afterwards, for drinkers who were told 35 years ago that if they didn’t quit drinking they’d die. Free care for American immigrants, for jerks and gents. Free care for parents whether they showed up or not. Free care for guys who tried to try. Free care for the only father I will ever have.
posted by jokeefe at 12:11 PM on February 21, 2013 [9 favorites]


Missed the edit window-- the writer is English, but her father is American.
posted by jokeefe at 12:16 PM on February 21, 2013


Doctors List Overused Medical Treatments - "A coalition of healthcare provider associations says many common practices are costly, often unnecessary and sometimes even harmful."
Breast Practices: The Mammogram Dilemma - "Your annual screening may cause you more harm than good."
A Cardiac Conumdrum
Jones argues that the predominant explanation of what causes heart attacks—obstructions in the coronary vessels that need to be cleared—is primarily to blame, because it leads to an erroneous emphasis on the highly visible plaques looming on angiogram screens. In fact, these plaques are not heart attacks-in-waiting; smaller, often invisible lesions in the heart vessels are now understood to cause most heart attacks. The problem isn’t so much that bypass surgery or angioplasty or stents aren’t working, Jones explains, but that in some cases, the interventions target the wrong lesions. “Instead of trying to stent every possible lesion, we need to realize that there are certain risks—small plaques—and that we cannot manage them all with stents or bypass. We need interventions, especially lifestyle changes or medications, that address the causes of atherosclerosis, and not just the largest plaques. And we need to accept that there are some large plaques that might not need intervention. What we really need to do, if we want to change the way we make decisions about these procedures, is to change both the culture among physicians and the culture among patients so that they accept a slight increase in risk tolerance.”
posted by the man of twists and turns at 12:25 PM on February 21, 2013


This article, about healthcare, is making me sick.
posted by ropeladder at 12:28 PM on February 21, 2013


Read the first two pages of the article and could not go further. I've been struggling with my medication for a chronic health problem, worried that the side effects could force me to a new treatment (last 10-15 years, still heavily patented) that would probably cost $10K+ per year less whatever my insurance would cover.

My doctor let me roll back the dose to manage side effects and this morning I woke up feeling human for the first time in weeks. I wanted to weep from sheer relief and half of it wasn't the knowledge that I might feel better, it was the knowledge that my illness might not destroy everything my husband has put together for us.

I lived in England in the 1980s as a teenager and had a bad experience with the NHS (a bad doctor prescribed my mother medication she was listed as allergic to). It colored my impression of the NHS for years. Only as an adult did I come to understand the sheer terror of being unable to get healthcare and how the supposedly greatest nation in the world supposedly cannot afford to take care of its own and what a great accomplishment the NHS really is.
posted by immlass at 12:30 PM on February 21, 2013 [1 favorite]


The USA can more than afford to take care of its own; it is, however, too proud to do so.
posted by seanmpuckett at 12:32 PM on February 21, 2013 [5 favorites]


“But when you see the limits expressed in the thousands of dollars, it looks O.K., I guess. Until you have an event.”

This also applies to injuries in a car accident if you're at fault. When Geico sells you the legally mandated minimum of $15,000 body injury liability in California professing to save you 15% on your car insurance in 15 minutes they're opening you up to a legal black hole. A veritable money pit that you could be tossing cash into for the rest of your life.

If your insurance is paying for it you can be sure the hospital is going to throw everything including the kitchen sink onto the bill. Make sure your coverage is in the seven or even eight digits if you can afford it, people.
posted by Talez at 12:44 PM on February 21, 2013


OK, for those of you who were too depressed by the heartbreaking stories in the first half of the article to finish it (I read the beginning in short chunks, which helped):

This is the most detailed and damning piece I've ever seen about our health care system in a mainstream US publication. I'm surprised and pleased Time gave Steven Brill that much space to work with, and I really, really hope it helps us.
posted by asperity at 12:52 PM on February 21, 2013 [1 favorite]


What tangible changes to this will Obamacare produce, as it is written now?

Well, for one it is aiding in the employment of phalanxes of lawyers and underwriters, working feverishly to find loopholes and alternate payment methods in order to safeguard insurance company profits.

For instance...Recently, Anthem suddenly stopped paying on our son's depression counseling. For ages, a visit to the counselor was a co-pay for us, and the counselor bills the adjudicated rate to Anthem, which they pay. After getting a bill for hundreds of dollars from the counselor, my wife spend several angry, tear-filled hours on the phone with Anthem.

Apparently, Anthem has changed billing for mental health services to a two-step arrangement...We pay the $40 co-pay for the office visit, but then also pay out-of-pocket for the "treatment". That is, they now consider the therapy session as a "treatment" separate from the office visit. Fucking evil shit.
posted by Thorzdad at 1:00 PM on February 21, 2013 [1 favorite]


My health-care plan has just changed. Now it goes something like this:

Get a DNR for my uninsured ass.

Keep reading articles like this about the American (alleged) health-care system.

Stroke the fuck out from the anger, and never have to think about it again.

because it takes too long to die from regular old annoyance
posted by hap_hazard at 1:14 PM on February 21, 2013


FYI, the author of this article is on The Daily Show tonight ...
posted by jbickers at 1:35 PM on February 21, 2013 [1 favorite]


"That's why a top-notch aerospace engineer is making $100k, and an average doctor is making $250k."

Huh. I had a buddy who got $100k as an entry salary as an aerospace engineer some six, seven years back, so I always assumed that was average. I do know that he had crazy security check stuff, couldn't talk about what he was doing at all, and that after three years, Lockheed laid him off, which was the best thing that ever happened to him. But the money put his wife through her masters to become a nurse practitioner, and helped him start a brewery in Madison.
posted by klangklangston at 1:47 PM on February 21, 2013


One very, very small silver lining in this whole shitstorm is that it actually makes it easier to bargain over healthcare costs with providers if you're paying out of pocket.

Yes, this means tons more phone calls, letters, paperwork--it quite literally can be a part-time job for a while. But when you're talking about thousands, or even tens of thousands of dollars...?

By simply going to the provider and saying, basically, "I can't pay what you're charging me," you'd be surprised at what can happen. Remember, they'd rather get a little than none, and they often do get none (see: medical bankruptcy).

I've seen friends reduce their medical bills by 90% by just being pleasant, firm, and above all persistent. Escalate, escalate, escalate--if you're not getting the answer you want, request to talk to their supervisor, then their supervisor, then theirs. Find the person who really makes the billing decisions. Get a VP on the line. Leave messages. Follow up. Get that flag in your file. Be the squeaky wheel. Document everything--names, titles, dates, what they said, etc. Does the hospital have a patient advocate? Payment plan? Financial aid system?

Remember, no fixed price works both ways.
posted by gottabefunky at 1:52 PM on February 21, 2013 [1 favorite]


Let me give you a contrasting example of a for-profit system elsewhere. I picked up a nasty case of bronchitis in Nepal, and stupidly avoided seeing a doctor there because I was going back to Bangkok in a few days. Back in Bangkok I went to a hospital that specialises in Westerners and makes a lot of money by doing discretionary surgery and so forth. The place was gorgeous, much nicer than most hospitals I've visited in the USA or Australia. I saw a doctor and had a chest x-ray to confirm, I guess, that I didn't have pneumonia or TB or whatever. So I used the services of at least one doctor, a couple of nurses, a radiologist and a radiologist's assistant.

The total cost for my walk-in visit was around $120. OK, that was 10 years ago, and labor costs in Thailand are much lower than in the USA, but still. $120. I think the medication might have been $5 more. I just searched for them on Google; they have a web page that lists the typical costs for procedures. It not only gives the median, but gives you an idea of upper and lower typical costs. It's quite amazing to see a hospital that's being so open about their charges.

I'm a big fan of Australia's public medical system, but I have no problems with this private hospital. They're doing their best to help patients make a decision and they're being totally transparent. This is what a real free market is like, one where costs inform your choices. In contrast, the USAn system is purposefully opaque and they make their money by manipulating and controlling desperate people. That's not a free market: that's robber baron capitalism.
posted by Joe in Australia at 2:29 PM on February 21, 2013 [6 favorites]


Oh, I should say: the prices on that page are in Thai baht: divide by around 30 to convert to US or Australian dollars. So the median price of a total hip replacement is 575,834 baht = around US $19,200. Plus the cost of a prosthesis (the joint?) which is $3,000 to $6,300. And I stress that this is for-profit medicine in a really nice hospital, with English-speaking staff.
posted by Joe in Australia at 2:38 PM on February 21, 2013 [1 favorite]


How Brill’s Health-Care Opus Jumped From The New Republic to Time
posted by homunculus at 2:45 PM on February 21, 2013 [5 favorites]


gottabefunky, escalating is the last thing on your mind when you've been diagnosed with a serious illness. I know you aren't advocating it as a long-term solution, but I've met people who think it is-- that if you aren't that "squeaky wheel" during your treatment, you don't deserve the care.

I ended up in a hospital with stage IV lymphoma less than a year after becoming too old for my mother's insurance plan. I was getting bills for 10s of thousands of dollars before my treatment was even halfway over, and they went straight to collections because we didn't apply for charity care fast enough. I guess if we were real Americans we wouldn't have been so preoccupied with that silly "cancer" stuff.

I don't qualify for anything except that charity program-- not Medicaid, not Medicare, not disability. I still have years left of followup exams, and I have to fight tooth and nail to remain eligible for the alleged "charity" at my hospital of choice-- or rather, the only hospital that still lets me in the doors, knowing I have no money to pay for the expensive scans I need. And this is only for billing directly from the hospital; it doesn't cover the myriad separate bills being sent to me as the hospital breaks up its services into separate entities in order to dodge their societal charge to help the less fortunate. I certainly haven't been able to argue any of these down to a manageable level, and mostly just get told that they "don't do that".

This was my introduction to adulthood, and my situation is better than that of countless others. I had family to care for me and give me a place to stay when I couldn't afford my apartment anymore; many are not so lucky.

I am disgusted with a country and a faith I grew up believing in and loving. We claim to be the greatest nation in the world, but we are too psychologically insecure to stop buying bombs and start looking after those of our own who are unable to care for themselves. So many proudly claim that we are a nation founded on the Christian faith, but they are too blind and self-impressed to compare their ways with the ways of Christ. The Christ I read about would be incandescent with rage at the plight of the American poor, languishing as they do in a nation so wealthy and powerful as ours.

And rather than agreeing that we have a problem to address, we blame those of us least able to advocate for themselves, simply because it is easiest-- because the reality of our own cruelty and moral impoverishment is too great to face, and solutions "too complicated" to implement. Those who maintain this status quo are small-hearted, shortsighted, and contrary to their claims, profoundly un-Christian, and I can only hope that some day far in the future this point in history will be regarded as a dark, dark time, to which we couldn't possibly return.
posted by the liquid oxygen at 3:05 PM on February 21, 2013 [32 favorites]


Each paragraph of this story lifts me to a new height of rage and disbelief. How should I protest this? Where are people organizing to protest?
posted by Rustic Etruscan at 3:58 PM on February 21, 2013 [3 favorites]


I think it is profoundly unethical, immoral, and evil for anybody to become massively wealthy on the backs of desperate dying people. It is sick. And yes...I am talking about you big hospital administrators.
posted by Seymour Zamboni at 6:03 PM on February 21, 2013 [1 favorite]


A year and change ago, I passed out cold while eating lunch. It turns out there was nothing seriously wrong, but the restaurant staff understandably flipped out and called 911. I woke up in the ambulance on the way to the ER. They kept me around for an hour or two then released me.

That couple of hours ended up costing $1700. I bitch and moan as I pay it off, but I have to keep reminding myself, "There was nothing wrong. If there had been (or if I had been unlucky in some other way) I could have been royally fucked."

Jesus, this is infuriating.
posted by brundlefly at 6:04 PM on February 21, 2013


How Brill’s Health-Care Opus Jumped From The New Republic to Time

That's fascinating. Thanks for linking to it.
posted by zarq at 6:18 PM on February 21, 2013


After working briefly at a psychiatrist's office in a rust-belt town in the 1990s, I became convinced that at some point in the near future we'd all be working in the health care industry and all our income would go back to medical costs.

Even in the mid 1990s, the two hospitals in town -- since we needed one on each side of the freight railroad tracks -- were the biggest employers. Add in all the associated businesses (medical lab, medical equipment, clinics, etc) and I figured the town almost had a self-sustaining perpetual motion machine (well, with the help of Medicare/Medicaid funds).

It's like that sci-fi short story in which asphalt -- freeways, parking lots, streets -- had completely taken over the American landscape. But we'd be ok because the government was building a giant Howard Johnson by the freeway interchange for all of us to live in and we’d eat all our meals at Denny’s or at the drive-in diner.
posted by spamandkimchi at 9:43 PM on February 21, 2013 [2 favorites]


My pregnancy costs in Canada:
* monthly, then weekly prenatal visits: $0
* various visits to hospital due to braxton hicks contractions that were ridiculously painful: $0
* some kind of injection for baby's lungs because the contractions were so strong that they were worried the baby might come early: $0
* emergency c-section (95% percentile head, didn't want to come out properly): $0
* Semi-private room for 3 nights: $90, which I submitted to my extended health plan

I always wondered why so many women were planning home births on all the pregnancy boards. Now that I think about it some more, it's because it's cheaper to buy a swimming pool for your living room than to go to the hospital for a delivery.

One of DH's US colleagues said that it was $5k for a normal delivery in the US, and couldn't even guess what a c-section would be.
posted by wenat at 11:44 PM on February 21, 2013 [3 favorites]


The Daily Show: Steven Brill details the irrational market forces that drive the American health care industry.
posted by homunculus at 12:12 AM on February 22, 2013 [3 favorites]


A friend who's a retired surgeon once told me something to the effect of, 'It will be like this until white people start dying in the streets. There are already black people dying in the street and that's not enough."
posted by jon1270 at 5:04 AM on February 22, 2013


A friend who's a retired surgeon once told me something to the effect of, 'It will be like this until white people start dying in the streets. There are already black people dying in the street and that's not enough."

Poor white people are already dying in the streets. Look at the crowds who come to the stadiums when they distribute free medical care. It's not all black and brown people. The white people who are dying aren't (upper) middle-class enough yet to get any action.
posted by immlass at 8:07 AM on February 22, 2013


Slate on the Time article
posted by bq at 1:42 PM on February 22, 2013


Slate is dum.

If Brill had concluded "Medicare!", Republicans would be able to dismiss the article as socialism mongering. Since he has presented a blue state friendly solution (which no he /doubt knows is inadequate), a cross-aisle discussion can be had.
posted by seanmpuckett at 2:50 PM on February 22, 2013 [1 favorite]


Well I forget what the colours are down there.
posted by seanmpuckett at 3:00 PM on February 22, 2013


Yeah, it's not intuitive at all.
posted by Rustic Etruscan at 3:08 PM on February 22, 2013


Steven Brill's cover story in Time on hospital pricing is quite brilliant, but also extremely long. If you want to seem well-informed this weekend without reading over 20,000 words, here's what you need to know.

Key word for Slate: "seem."
Brill, in beautiful classic style, has led his readers to the obvious conclusion without SHOVING IT AT THEM, so they can think they came up with it all by themselves (and love it all the more).

"Medicare for all, I'm a genius!"
posted by the man of twists and turns at 9:09 PM on February 22, 2013 [1 favorite]


So, I have a question: What tangible changes to this will Obamacare produce, as it is written now?

As it's written now, it's a shell game. Everyone's still trying to game it, and milk as much money as possible in as little time as possible.


The Urban Institute Health Policy Center - Despite Criticism, The Affordable Care Act Does Much to Contain Health Care Costs (Stephen Zuckerman and John Holahan)
It appears from Centers for Medicare & Medicaid Services (CMS) actuaries and Congressional Budget Office (CBO) projections that the rate of growth in health care spending has already slowed, in part because of the economy, but also because of provisions of the Affordable Care Act.5
[...]
These measures, and a variety of other factors, are already reducing projections of future health expenditures. The CMS actuaries recently projected health expenditures to increase by only one percentage point above GDP growth. They cite the shift to high deductibles in private insurance plans and the development of fewer blockbuster drugs, the adoption of tiered formulas, and greater use of generic drugs. But the actuaries also cite mandated reductions in Medicare fee-for-service rates, lower payments to Medicare Advantage plans, a shift of coverage from employer plans to Medicaid and health insurance exchanges, and the excise tax on high cost plan as reasons to expect lower health spending per capita.34
posted by Golden Eternity at 3:54 PM on February 24, 2013


For all of the flaws in the US system, you can qualify for state aid for birth/pregnancy which drives costs down. Of course, if you make too much to qualify for aid but don't have insurance... THEN you're fucked. I have friends with copays that range from $600-$6,000.

The bill I got for my son's birth (hospital, 48hr stay, epidural, vacuum extraction) was $15,000. I paid zero. I was lucky enough to have insurance that covered my entire birth. Oddly, my private Blue Cross insurance I had before getting pregnant would have only covered part of the cost... but my boyfriend's mandatory cheapo grad school insurance paid for 100% of birth and prenatal costs. Which is how he legally became my husband several months before our actual wedding.

Homebirth is tricky. Insurance won't cover it as in many states it's actually illegal. Just sticking to the financial risks - if you do have insurance, having a home birth to save money makes no sense. If you don't, yes, it's cheaper than a hospital birth provided everything goes well... in an emergency, you end up in the hospital anyway. There are a lot of pros and cons around home birth, and money definitely factors into it - but I've more often heard the other side, women with insurance who wish they could birth at home but can't afford to pay a midwife out of pocket when their insurance covers 80-100% of a hospital birth.
posted by sonika at 8:48 PM on February 24, 2013


In other news: High Debt and Falling Demand Trap New Vets
posted by homunculus at 4:21 PM on February 25, 2013


And this, children, is why libertarian laissez faire market solutions are a fantasy that only benefit the wealthy and do nothing to actually address the costs of health care.
A "true" lasses-faire free market healthcare system would not require doctors to have any kind of certification, so anyone could open up a medical practice in a strip mall and charge $500 for a heart transplant, instead of $70k (BYOH, but no questions asked)

Also, you wouldn't have the student debt issue either, as "doctors" could just learn everything they need on Wikipedia, for free!

This would clearly dramatically lower the price of healthcare in the US. It would also kill millions of people, but hey, freedom isn't free.
Can I just ask, from my perch of not really understanding the clusterfuck that is the US medical industry, why isn't Medicare just expanded to cover everyone? Is it just the entrenched interests of the hospitals and insurance companies that prevent it?
Yes. It's just the entrenched interests of the hospitals and insurance companies that prevent it.

Also, the central thesis of the article isn't that doctors are overpaid, but that hospital administrators are overpaid.
After working briefly at a psychiatrist's office in a rust-belt town in the 1990s, I became convinced that at some point in the near future we'd all be working in the health care industry and all our income would go back to medical costs.
In the future we'll all have Prometheus style med-pods in our homes.
Slate is dum.

If Brill had concluded "Medicare!", Republicans would be able to dismiss the article as socialism mongering. Since he has presented a blue state friendly solution (which no he /doubt knows is inadequate), a cross-aisle discussion can be had.


Hmm, I used to read Matt Yglesias's RSS feed I read before he moved to slate (I stopped because there's no way to get just his feed anymore).

And actually Brill did say on one of the Sunday shows that lowering the Medicare age would actually save money overall, because while you would pay more in taxes you'd pay a lot less in total because you wouldn't have to pay insurance premiums. He talked about lowering it to 60, but the same logic applies to lowering it to zero.

Also, I don't think you can really argue that simply telling the truth is "dum" because it's politically inconvenient. I would argue that the reverse is actually stupider.
posted by delmoi at 1:59 PM on February 26, 2013


Well, of course you can argue it.

Whether your argument is convincing or not depends on the reference frame.

If your aims are political then obviously you should refrain from saying something politically inexpedient.

Reportage loses its power when it becomes polemic. Most journos have EXTREMELY strong opinions which they manage to keep to themselves more or less, unless gonzo or Matt Taibbi.
posted by unSane at 9:47 PM on February 26, 2013 [1 favorite]


If your aims are political then obviously you should refrain from saying something politically inexpedient.

Reportage loses its power when it becomes polemic. Most journos have EXTREMELY strong opinions which they manage to keep to themselves more or less, unless gonzo or Matt Taibbi.
Yes, but choosing not to say something because it's politically inexpedient is also a form of polemic.
posted by delmoi at 5:12 PM on February 27, 2013


On Purposely Getting Arrested, to Get Life-Saving Surgery: Sometimes going to prison can be an unfortunately rational health care decision.
posted by homunculus at 5:41 PM on February 27, 2013


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