Sick Costs.
August 22, 2013 9:02 AM   Subscribe

John Green: "Why Are Americans Health Care Costs So High?" A quick, handy little overview of common misconceptions on the US healthcare system. (SLYT)
posted by The Whelk (73 comments total) 51 users marked this as a favorite

 
So this is the Jay Smooth of the white person world?

Ok, I'm listening...
posted by RolandOfEld at 9:19 AM on August 22, 2013 [2 favorites]


Why does everything need to be a goddamned video these days? If I wanted to sit there while a face talked at me, I'd watch the news.
posted by Steely-eyed Missile Man at 9:24 AM on August 22, 2013 [157 favorites]


Everything has to be a video because it is much easier for some people to express their ideas through talking, versus attempting to sit down and coherently write a sentence with proper grammatical and logical structure to convey the idea quickly.

If you were to transcribe everything he said, it would also take you twice as long to read it (and fully comprehend with near 100% accuracy). Not to mention the tone of voice and other stylistic things that do not carry over to text.

With all that said, I am kind of glad this is out there. Something to point to when people try to talk bullshit about the ACA or anything regarding health care costs. Some people just don't/won't read. So a video with this information is useful. Many people are trained to believe what they see versus what they read.
posted by daq at 9:31 AM on August 22, 2013 [4 favorites]



If you were to transcribe everything he said...


I'd be able to read it over my lunch break at work and maybe comment usefully on it.
posted by Pogo_Fuzzybutt at 9:32 AM on August 22, 2013 [75 favorites]


So this is the Jay Smooth of the white person world?

I had exactly the same reaction. I actually find the "Jay Smooth Video Affectation" annoying, particularly the cut to a new frame with each and every thought or sentence. I completely lose my focus when this happens. Can't you just sit still for 5 fucking minutes, talk to me, and assume that I have an attention span?

But OK. I think the message is accurate, and it is consistent with the conclusions drawn by that comprehensive analysis published in Time Magazine by Steven Brill. He also concluded that Medicare gets the best bang for the buck because it is large and has more leverage to negotiate prices down. In affect, he concluded that we should be making Medicare bigger instead of driving more people into the private insurance market, which has less and less leverage as hospitals and other health care centers are bought out creating corporate monopolies on points of access to the system in different geographic regions.
posted by Seymour Zamboni at 9:36 AM on August 22, 2013 [2 favorites]



It is much easier for some people to express their ideas through talking, versus attempting to sit down and coherently write a sentence with proper grammatical and logical structure to convey the idea quickly.

This is true, but I do not thing that John Green is one of those people.

(I like John Green. I am often annoyed by having to watch videos, though.)
posted by Jeanne at 9:42 AM on August 22, 2013 [5 favorites]


[Folks maybe watch the video or don't but don't turn this into a total derail about presenting information via video?]
posted by jessamyn at 9:43 AM on August 22, 2013 [16 favorites]


As an aside, if you don't mind his quick-cut, rapid-fire mannerisms, John Green is one-half of the Crash Course YouTube series, and his history series in particular is a pretty great introduction to world history if you never got beyond a mediocre High School history class.
posted by themadthinker at 9:44 AM on August 22, 2013 [13 favorites]


We do not negotiate as aggressively as other countries do with health care providers and drug manufacturers and medical device makers...

I think it's a mistake in political theory to think that one form of government or one way of organizing an economy is in general superior to others. It might be better to think of them as tools that are useful for different purposes. While I wouldn't want to live in a country that had a planned economy, central planning really does seem to be the most efficient way to deliver health care.

It's not hard to see why. When consumers are not able to make informed decisions about products (not being doctors) and are coerced by their circumstances into making purchases under life and death stress ("it's hard to put a price on not dying") there's no reason at all to think that market pressures will provide better, cheaper products.
posted by justsomebodythatyouusedtoknow at 9:44 AM on August 22, 2013 [13 favorites]


We do not negotiate as aggressively as other countries do with health care providers and drug manufacturers and medical device makers...

So maybe the soundbite for those Americans wary of socialism should be: "We want our government to treat medical suppliers the same way that Walmart treats its suppliers in order to get low, low prices for YOU!"
posted by maudlin at 9:50 AM on August 22, 2013 [18 favorites]


coerced by their circumstances into making purchases under life and death stress

Exactly. When you have a heart attack and call 911, the operator doesn't tell you that ambulance service X or ER Y is having a sale today for heart attack victims. And where would you like to go? You make the call and then everything is pretty much out of your control at that point. To call that a free market based system is a stretch.
posted by Seymour Zamboni at 9:55 AM on August 22, 2013 [11 favorites]


Seconding the recommendation for the CrashCourse YouTube series... and I'm a high school history teacher. I've used this in classrooms. Other teachers have, too. He does a wonderful job.
posted by scaryblackdeath at 10:00 AM on August 22, 2013 [1 favorite]


RolandOfEld: "So this is the Jay Smooth of the white person world?

Ok, I'm listening...
"

"Unless this is Ze Frank, you're stealing my bit!"

This was actually an interesting take and I'm glad he got the malpractice and other common complaints out of the way first.
posted by boo_radley at 10:00 AM on August 22, 2013 [1 favorite]


Luckily, John Green has a post on his site related to this video, and he includes this:
For a much more thorough examination of health care expenses in America, I recommend this series at The Incidental Economist: http://theincidentaleconomist.com/wordpress/what-makes-the-us-health-care-system-so-expensive-introduction/
The Commonwealth Fund's Study of Health Care Prices in the US: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/May/1595_Squires_explaining_high_hlt_care_spending_intl_brief.pdf
Some of the stats in this video also come from this New York Times story: http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html?pagewanted=all

This is the first part in what will be a periodic series on health care costs and reforms leading up to the introduction of the Affordable Care Act, aka Obamacare, in 2014.
I would ask him why he didn't make those links, you know, links, but that's another discussion for another time. (I made them links for ease of use.)
posted by filthy light thief at 10:02 AM on August 22, 2013 [11 favorites]


Slightly annoying presentation, but the essential analysis is excellent. This is, inter alia, one of the ways in which Obamacare, once it is up and running properly, will help drive down healthcare costs. Not only does it increase the bargaining power of the insurance companies (yes, that is a good thing--low medical prices are one of the areas in which the interests of insurance companies and patients completely coincide), but it reduces the pool of those uninsured who are getting treated at the highest possible rates (emergency room care). But even more importantly, because of the subsidies for the poor it exerts pressure on the government to get involved in regulating healthcare costs in order to reduce the burden on middle class taxpayers.
posted by yoink at 10:03 AM on August 22, 2013 [1 favorite]


We want our government to treat medical suppliers the same way that Walmart treats its suppliers...

No, no, the whole point is that we don't want people to be treated inhumanely.
posted by justsomebodythatyouusedtoknow at 10:04 AM on August 22, 2013 [4 favorites]


I would ask him why he didn't make those links, you know, links,

Those links (as links) are all in the "about" section of the video.
posted by yoink at 10:05 AM on August 22, 2013


Dang it he mentioned having a physical need for the next season of Sherlock and then all I could think about was Benedict Cumberbatch talking and then I got all dreamy and couldn't pay attention for a little bit.

But yeah...that's a really good video. What's unfortunate is that all the points he makes will go right over the heads of anyone who does not agree with his point of view.

Especially because I have heard many people say that having healthcare is not a right. That it IS exactly like "needing" a new MBA or the next season of Sherlock.

I'd like a video or primer on arguing effectively against people who think things like that rather than another video/FAQ/report on why universal healthcare is great.
posted by sio42 at 10:10 AM on August 22, 2013 [4 favorites]


yoink: Those links (as links) are all in the "about" section of the video.

Ah, thanks. YT is blocked here for me.
posted by filthy light thief at 10:10 AM on August 22, 2013


"So you might say John Green is talking about..."

*removes sunglasses*

"The Fault in Our ERs..."

*YYYYEEEEAAAAARRRRRRGGGGGGGHHHHHHHH*

BWOUM. BWA-BWOUM!
posted by robocop is bleeding at 10:12 AM on August 22, 2013 [9 favorites]


Not only does it increase the bargaining power of the insurance companies

But I wonder if it matters how big an insurance company is if hospitals and other providers continue to merge into larger entities. It becomes like an arms race for leverage between insurance companies and hospitals. And wouldn't the hospitals always win that race because they are the ones providing the care that people want access to?
posted by Seymour Zamboni at 10:13 AM on August 22, 2013


Transcript, for those who prefer reading to video.
posted by ocherdraco at 10:13 AM on August 22, 2013 [22 favorites]


To add to the discussion about economic models as tools:

/caveat: I am not an economist, however I have read extensively on historical economics and modern economic theory. Nor am I a doctor, however I have spent an inordinate amount of time utilizing the health care system, due to several health issues over the years.

One of the biggest failures of supposed "free market" methods of managing health care is asymmetrical information. Almost every proponent I have ever read or heard talk about how grand the "free market" is for anything economic always forgets that the only way for that model to work at it's peak efficiency is for all parties to have perfect information. With medical/healthcare treatments, no one has perfect information. Not the doctors, not the patients, not the insurance companies, not the government. No one. It is a very fuzzy field, with many diagnosis made through inference and monitoring of symptoms. Until we get nanobots living symbiotically in our bodies reporting on everything from the cellular level, we will never have perfect knowledge of our health. Yes, you could implement many levels of controls and testing to minimize the amount you don't know, but even then, you will end up with so much information, that it would be impossible to process in a timely manner to make a fully informed decision.

Hell, I would say that the main reason we ended up in the situation we currently have (in the U.S., regarding healthcare costs) is because of this asymmetrical information. The insurance and healthcare providers know that their customers do not have as much information as they do. So they are always at an advantage in regards to pricing costs. If you were to map out every minute of a doctors time and the costs associated with them earning enough money in a day to cover their cost of doing business with a 10% profit, but with a realistic supply/demand curve, the actual healthcare costs would be a fraction of what they are today. Instead you have inelastic demand with asymmetric information about the real costs of care, which means that those who have any access to the supply side can set whatever price they want.

I know I'm an rehashing several of the things said in the video and from other sources like the Time article someone referenced above. But seriously, this is stuff that needs to be debunked, and hard.
posted by daq at 10:23 AM on August 22, 2013 [6 favorites]


John Green is excellent but given that some people don't or can't watch a video and don't care to check his website or the Youtube "about" section here's my best effort at a summary of the points he makes in this one:

  • The US spends more tax money (public expenditures) per capita on healthcare than other social democracies like Canada, Germany, the UK, Japan, the Netherlands or Australia.
  • The US also spends more private expenditures (private employers, out of pocket) than anyone else.
    So a higher percentage of US taxes go to healthcare compared to other countries with socialized healthcare systems and the US doesn't even get good healthcare out of it it. Therefore the biggest overall problem with the US healthcare system is that costs are significantly higher than anywhere else (he gives a number of specific examples of this for various procedures/treatments.)

    So, why are costs so high?

  • Do we get better care for our money? No US outcomes are generally worse than other countries'.
  • Overutilization of healthcare? No, the data doesn't support this. Americans use less healthcare than other countries (by some metrics).
  • Obesity/Americans are unhealthy slobs? No actually disease prevalence it turns out doesn't affect costs that much AND while the US has higher obesity it has lower alcohol and smoking rates than European countries, so that's something of a wash.

    So not those then what? Truth is complex (surprise surprise) but involves the following:
  • If you don't have insurance you still get care but you might go bankrupt or otherwise avoid paying so society as a whole has to bear costs of your healthcare plus the cost of the hospital's efforts to get you to pay. Plus you're bankrupt so that's a bummer. Exacerbating the above problem if you don't have insurance you are more likely to only get emergency care, which is known to be the most expensive way to do healthcare.

    OK now we're around 3:50 in the video and John takes a look at comparing our costs to other countrie sto see what might be keeping costs high.
  • Malpractice/defensive medicine? - data says pretty small effects here, judging by difference in states which passed tort reform.
  • Adminstrative/marketing overhead of insurance is a factor
  • Drugs cost more here (more on why in a minute)
  • BUT the biggest factor by far is the overall cost of inpatient and outpatient care, which together is $500 billion more than you would expect given the size of our economy in comparison with other countries.

    WHY?
    John argues that this is largely because in the absence of a centralized national healthcare system negotiation over prices is much less aggressive because smaller groups have less leverage. He points out that the single largest group negotiating costs in the US is Medicare and not coincidentally it gets the lowest prices for care.
    This segues into a discussion of how demand for healthcare is inelastic (If I need a pill to stay alive I will likely pay 5, 50, or 500 dollars regardless because the alternative is death).

    The video ends with a qualification of his point about lack of a centralized system that this is not a simple problem and a lot of factors feed into why the system is the way it is so there are no simple answers. Further he argues that healthcare costs are the single biggest drag on the US economy and must be grappled with in a meaningful way and not as political theater.

    As mentioned upthread more info and his references are linked on his site and in the info for the video.

  • posted by Wretch729 at 10:26 AM on August 22, 2013 [41 favorites]


    Aww shoot ocherdraco I forgot they did those transcripts. That would have been easier, lol.
    posted by Wretch729 at 10:27 AM on August 22, 2013 [3 favorites]


    Thanks, ocherdraco.

    From the transcript:
    [US citizens] pay more in taxes for healthcare than you would if you were British, and in exchange for those taxes, you get... no healthcare.
    ...
    private healthcare spending -- most of Americans are privately insured through their employers -- is WAY higher than anywhere else in the world.
    'Murrika, fukk yah! Y'all hate us for our freedoms! The freedom for a few people to get obscenely wealthy from a lot of sick people!
    Okay, and now for the big one. I'm going to lump in-patient and out-patient care together because in the US we do a lot of thigs as out-patient procedures -- like galbladder surguries -- that are often in-patient procedures in other hospitals. So we're just going to make a big ball. That big ball is 500 billion dollars more than what you would expect given the size of our economy. Per year. Why? Well because in the United States we do not negotiate as aggressively as other countries do with healthcare providers and drug manufacturers and medical device-makers.
    Free market! Woo-hoo! Competition! The invisible hand of the market works!

    IN FAVOR OF THE MEDICAL PRODUCTION COMPANIES.
    posted by filthy light thief at 10:28 AM on August 22, 2013 [3 favorites]


    Hell, I would say that the main reason we ended up in the situation we currently have (in the U.S., regarding healthcare costs) is because of this asymmetrical information.

    You're in this situation because Dickensian conditions are the default. Anything else requires deliberate choice and political action. There's a reason why surveys deem Tommy Douglas the "greatest Canadian." ("I felt that no boy should have to depend either for his leg or his life upon the ability of his parents to raise enough money to bring a first-class surgeon to his bedside.") An efficient socialist health care system doesn't just spontaneously appear.
    posted by justsomebodythatyouusedtoknow at 10:36 AM on August 22, 2013 [14 favorites]


    But I wonder if it matters how big an insurance company is if hospitals and other providers continue to merge into larger entities.

    Yeah, sure, there are countervailing forces that don't help--but it's still enormously helpful for insurance companies to be able to bargain with the healthcare providers on a large scale. Insured people pay far, far lower amounts to hospitals, pharmaceutical companies, doctors et al. than uninsured people do, and that's because the insurance companies have the leverage to bargain for lower prices. Bring more people under their umbrella and they have more leverage still. In the end, of course, it will take further government intervention and regulation in the healthcare market to really drive costs down, but I think that Obamacare makes that intervention far more likely in the medium term because it makes our collective exposure to rampant healthcare inflation more visible.
    posted by yoink at 10:43 AM on August 22, 2013


    Your summation is still very effective, Wretch729, thanks.
    posted by George_Spiggott at 10:46 AM on August 22, 2013


    I am quite seriously going outside of the United States for some cosmetic surgery, after comparing prices. At this point, all of the "other countries have hideous healthcare and there's nobody to sue if they sew monkey glands into your faaaace" stuff has begun to sound like FUD from rent-seekers.
    posted by adipocere at 10:46 AM on August 22, 2013 [1 favorite]


    adipocere:
    I actually know of several trans-individuals who went out of country for their last bit of sex reassignment surgery. For what they would have spent in the U.S., they were able to go visit Japan for a week on the way to (can't recall the exact country, somewhere in southeast asia, I believe), and were given 5-star accommodations at the clinic for their 2 week stay (sex reassignment surgery is very complicated and requires a whole lot of recovery time as well as after care). So, um, yeah. For a lot of things, going out of the country is very much worth the trip.
    posted by daq at 10:50 AM on August 22, 2013


    Why does everything need to be a goddamned video these days? If I wanted to sit there while a face talked at me, I'd watch the news.

    Hey, if that's what makes The Damn Kids Today pay attention, I'm all for it. Especially since conservatives are trying to sabotage Obamacare by swindling young people out of learning how they can benefit, GOP elected officials are refusing to inform their constituents about the law (while eagerly taking filthy socialist money behind the scenes). And let's not forget their current plan is to take the world economy hostage over it, which makes last week's idea of just shutting down the government look positively rosy by comparison.
    posted by zombieflanders at 10:53 AM on August 22, 2013 [13 favorites]


    Even New Zealand is a major medical tourism hotspot for Americans who are effectively without coverage -- and it is one of the most expensive places to fly to in the developed world, for fairly obvious reasons. Anecodotally, I recall an article by a guy who basically said for his surgery he was still up $60,000 on the deal over what he would have paid for his (necessary non-elective) procedure in the US even after airfare and weeks of recuperation at a topnotch hotel and generally having a pretty good time while he was there.
    posted by George_Spiggott at 10:54 AM on August 22, 2013 [1 favorite]


    (ISTR it was a hip replacement. And he described the quality of hospitals and care as "magnificent".)
    posted by George_Spiggott at 10:57 AM on August 22, 2013


    And let's not forget their current plan is to take the world economy hostage over it, which makes last week's idea of just shutting down the government look positively rosy by comparison.

    It's at the point of being hilarious how utterly terrified they are that the people will see a "socialist" program give them tangible benefits and won't be quite as quick to listen to their fearmongering in the future. And the more they fight it, the more they'll look like assholes when the sky doesn't fall, but they're just too committed now to back out. I really think that when people see a program as flawed as the ACA benefit them the impulse will be to fix the flaws instead of losing the benefits, and that way lies single payer and a death blow to the socialist strawman, and the Republicans bet all their chips on that strategy to distract from the reality that they ceded the center and a fair bit of the right-of-center to the Democrats. The threat of losing due to alienating minorities is peanuts next to the threat of everyone seeing that their entire thing is sound and fury signifying nothing.
    posted by jason_steakums at 11:16 AM on August 22, 2013 [4 favorites]


    The Devil's greatest trick was convincing republicans that socialism is a bad thing.
    posted by freakazoid at 11:35 AM on August 22, 2013 [2 favorites]


    But I wonder if it matters how big an insurance company is if hospitals and other providers continue to merge into larger entities.

    The insurers have a fix for that problem.
    posted by Thorzdad at 11:35 AM on August 22, 2013 [1 favorite]


    Elisabeth Rosenthal (a former doctor turned journalist) was recently on Fresh Air talking about her recent series of articles in the New York Times about exactly why we pay so much for health care. The interview and articles are incredibly well detailed and insightful.

    Still, though, I'm kind of sick of hearing about health care costs. It's been plainly obvious to anyone who's been paying attention that, as a whole, the US spends far more on health care for worse outcomes. I remember hearing about it in 2006. Still nothing changes. The ACA is a watered-down half-measure based on a plan from a conservative think tank, and even that gets a startling amount of violent opposition. After a while, the whole mess makes you doubt the ability of our institutions to actually solve any problems.
    posted by heathkit at 11:39 AM on August 22, 2013 [3 favorites]


    But I wonder if it matters how big an insurance company is if hospitals and other providers continue to merge into larger entities. It becomes like an arms race for leverage between insurance companies and hospitals. And wouldn't the hospitals always win that race because they are the ones providing the care that people want access to?

    I've read that a big trend in recent years has been for Insurance companies to outright buy hospitals--a lot of insurance companies now also own hospitals through various business relationships. Doesn't that confuse the incentives picture considerably? If we had any anti-trust protection with real teeth, maybe I wouldn't worry, but I do... In our state, the legislature's determined not to make the AHCA implementation work. In fact, they recently took away their own power to review health insurance rate increases just to make it that much easier for insurer's on the state exchange to use the implementation as an opportunity for shenanigans. Even though the feds are on the hook to run the exchanges here (due to the intransigence of our political body) they don't have authority to review/reject rates.

    So as expected, they're trying to create an impossible climate for the plan's success here.
    posted by saulgoodman at 11:48 AM on August 22, 2013


    The Devil's greatest trick was convincing republicans that socialism is a bad thing.

    And in convincing both republicans and democrats that "Welfare" programs are un-American intrusions of the Communism into our otherwise unspoiled laissez faire economic system, despite the fact that the very name used around the world for such programs comes from right there in the preamble to the US constitution.
    posted by saulgoodman at 11:54 AM on August 22, 2013 [2 favorites]


    Thanks justsomebodythatyouusedtoknow for the Tommy Douglas link. There's also a very good CBC (radio = BEST OF BOTH WORLDS) documentary about the 1962 Saskatchewan doctor's strike. I was six at the time and vaguely remember listening to Tommy Douglas on the radio. Listening to the documentary is unsettling because of the intensity of the rhetoric on both sides, and because I get the feeling that if Douglas hadn't been such an effective and impassioned speaker we might not have Medicare in Canada today.
    posted by sneebler at 12:00 PM on August 22, 2013 [1 favorite]


    It's at the point of being hilarious how utterly terrified they are that the people will see a "socialist" program give them tangible benefits and won't be quite as quick to listen to their fearmongering in the future. ... when people see a program as flawed as the ACA benefit them the impulse will be to fix the flaws instead of losing the benefits, and that way lies single payer and a death blow to the socialist strawman

    All of which was predicted by Bill Kristol, right for once in his life, back during the Clinton effort to reform health care.

    But this time, while Kristol's insistence on killing reform outright worked in the Clinton era, it didn't this time. Republicans are now faced with the prospect of Kristol's predictions coming true for once in his life now that their "kill the bill" strategy has failed (they should be thanking their lucky stars that the so-called "liberal media" rarely mentions that Obama adopted a Republican plan).
    posted by Gelatin at 12:06 PM on August 22, 2013


    despite the fact that the very name used around the world for such programs comes from right there in the preamble to the US constitution

    And, as I've pointed out before, in Article 1, giving Congress enumerated authority to raise taxes and spend money to provide for the common defense and general welfare.
    posted by Gelatin at 12:10 PM on August 22, 2013


    I've read that a big trend in recent years has been for Insurance companies to outright buy hospitals--a lot of insurance companies now also own hospitals through various business relationships.

    UPMC and Highmark have been in a huge contract dispute for years because Highmark, an insurance company, bought some hospitals to set up a competing network (UPMC, meanwhile, also runs its own insurance plan). We've gotten inundated in recent months with inane attack ads from both sides. It should be noted that both organizations are "non-profit".

    But hey, better to have your ability to afford healthcare get taken away by giant rent-seekers than to have The Government kill you all the time from everything like they do in Communist Canada or Socialist Europe, or to know that somewhere some poor black person got healthcare they didn't "earn".
    posted by dirigibleman at 12:27 PM on August 22, 2013 [2 favorites]


    Previously, and arguably this too.

    There seems to be a post about this type of thing about every .5-1 weeks by that pattern...
    posted by emptythought at 12:59 PM on August 22, 2013


    Adminstrative/marketing overhead of insurance is a factor

    Administrative overhead is fully 20% of our health care costs. It's byzantine and insane. They employ an army of people whose only job is to try to find - and often invent - any reason to deny your claim and stick you with the insanely high bills despite your having faithfully paid your premiums for years and years; then comes the first time you actually need the insurance, and then they find a way to swindle you. Charming.

    For all that money spent on administrative overhead, you get a horrendous product in return - as in, mistakes, double-triple-quadruple billing, absolute incompetence and inability to correct egregious errors and so forth. It's really a microcosm of our entire healthcare system: a ton of money spent for an inferior product.

    I'm generally a very healthy person, as is my wife. However, we do like to get a checkup from time to time, and my wife needed to have her eyes checked, and I came along for a checkup at the suggestion of my primary doc, since I have not had my eyes examined in 25 years, and I was starting to have mild age-related presbyopia. That was my first mistake - unless you are bleeding out of your eyes, you should not put yourself willingly into the clutches of the UCLA health system and their billing department(s).

    Both my wife and I are on the same insurance, and we handed in our cards, and it came time to pay our co-payment of $35 each - and then we made a truly horrific mistake... I just let my wife pay for the both of us on her credit card.

    Well. That was the start of a months-long odyssey, that ended up in my utter defeat and unconditional surrender to the UCLA medical billing department. They simply could not - no way, no how, understand that my $35 co-pay was taken care of the very day I was examined. No matter how many times I called - after receiving yet another bill for $35 for that visit - and explained that the reason they don't have a record of my payment is because my wife paid for us both, and I have the receipt... "OK, I'll fax it again, but I already faxed it four times in the last six weeks!". I've asked for supervisors. I've written letters. I've called and gone through every person in that department. Every time I have to start over, explaining, telling the story from the beginning, faxing, checking re-checking and every time after the confused person finally grasps what is happening, I am issued firm promises that it'll be taken care of. And then I get the bill again. "Ignore it!" "But I'm afraid!" "Ignore it!" "But it says 'final notice'!" "Ignore it!" "OK... I guess...". And then there's a message on my answering machine from a collection agency looking for the $35. In the end, I am defeated. I pay the $35, not because I couldn't keep fighting, but because I simply have neither the time nor the energy to deal with this. It's only $35 and "the principle of the thing!!!!UNO!!!" has just gotten too expensive.

    Of course, I have never gone back to the "world renowned" Jules Stein Eye Institute - I'd rather go blind, than fall into their clutches again. I've increased my eye-healthy vegetable portions instead. And I hope my 0.5-in-one-eye glasses last me long enough, so that on my next European vacation I can go to a doctor over there and have my eyes checked and pay on the spot for any new glasses.

    Fortunately, like I said, we're both pretty healthy. I have managed not to need care for quite a while. But of course, I live in fear of ever needing to go to a doctor. I exercise and keep on top of the latest medical news and prevention strategies.

    But I still need checkups. Being of northern-euro extraction, living in southern cali, well, I thought I should have that suspicious mole examined. That was a big mistake. The doctor was fabulous. I paid my $35 dollars, with my own credit card, my wife wasn't even with me, because what if somehow her very presence confuses the billing department. I carefully put away the receipt.

    Two weeks later I received a bill for $230 for physician services - and they helpfully noted that I already paid $35, so I now owe $195. I immediately sprung into action. I was prepared - after all, I first went to my physician who sent me to the dermatologist, I received the authorization from the insurance company, and I noted all that at the time of check in at the dept., the physician is in the network and so forth. I laid it all out, and calmly spoke to the person in the billing department. They were very nice, and explained that they didn't send the bill to my insurance "by mistake, and now made a note in my account". Just to be sure, I made xerox copies of all the paperwork including my authorizations and so forth and sent it to them, and called my insurance company to prepare them.

    Two weeks later, I received another identical bill for physician services - I owe $195, because after all, I already paid $35, otherwise it would be $230. I call again - I tell them the name of the person I spoke to before, the date and the time and go through the whole thing again. She's swearing up and down that it was just a small computer glitch and I can fully ignore the bill. Oh boy. I tell her all about my dire experiences with "ignore the bill", but she's firm. I send the paperwork again, and again call my insurance company. This time for sure, SURE, I'm told the problem will go away. I will never receive a bill for the same thing again.

    Today, three weeks later, I received a bill for physician services - I owe $195.

    At this point, my plan is to simply not use any services unless it's an emergency and I'm struck down in the street. I don't even want to walk close to any hospital or pass by a medical building, lest the billing department issues a bill by osmosis through the walls.

    Instead, I will schedule my European vacations in such a way as to include any checkups and needed medical procedures over there.

    I just hope I don't have any emergencies here. Meanwhile, I try to stay as healthy as I know how to. The only doctors I plan to meet here, are at parties "so, what do you do?" "I'm a doctor" "Oops, nice to meet you, but I need to refill my water - see ya!".
    posted by VikingSword at 1:11 PM on August 22, 2013 [15 favorites]


    Administrative overhead is fully 20% of our health care costs. It's byzantine and insane. They employ an army of people whose only job is to try to find - and often invent - any reason to deny your claim and stick you with the insanely high bills despite your having faithfully paid your premiums for years and years; then comes the first time you actually need the insurance, and then they find a way to swindle you. Charming.

    Neither of your anecdotes, however, are anecdotes of insurance company incompetence or malfeasance. The insurance company, in both cases, did its part; it's the physicians that screwed up. Now it is true that public health systems make the whole billing part of the system a lot easier and cheaper. The fact that hospital billing departments have to deal with hundreds of different insurance plans with different rules and codes and copays and what not does make the whole thing unnecessarily complex and promotes the kind of chaos you're talking about. Single payer has the huge advantage that the rules are always the same and the procedures, even if complex, are familiar. Still, even in a national-health country, hospitals are big messy bureaucracies that can drive you mad with administrative fuck-uppery (I speak from first hand experience as well as a ton of second-hand family experience). Converting to single-payer would certainly help trim the difference between the US medical costs and the rest of the first world, but it isn't the major factor.

    The specific complaints you have in the passage I quote above are all addressed pretty directly by Obamacare, by the way. Under Obamacare, insurers lose the ability to boot you off your insurance for preexisting conditions (one of the main tools they used to use for weaseling out of coverage) and there's a hard cap on how much of your premiums they can spend on admin/overhead/profit; 85% of the money has to be spent on medical care or they have to refund it to their customers. It's also worth noting, by the way, that we do want our insurers to spend some time investigating claims and being skeptical about their necessity: I, for one, don't want my insurance premiums going to fund either medically unnecessary or medically inappropriate treatments or lining the pockets of fraudsters; that raises the costs for all of us.
    posted by yoink at 1:42 PM on August 22, 2013


    Yep, yoink, I'm aware of that - it's the provider's billing department that's at fault in my case as I outlined above. My point was that the chaos is everywhere in this system, and the insurance companies are not the only part - though a very prominent one.

    People who are in the Canadian system or ones like it, and never see a bill, have no idea how good they have it.

    Paying more does not buy you better service - and administrative overhead is a prime example.

    It's the system that's designed very, very poorly, or perhaps we should say, was allowed to evolve into a horrible mess only partly through design.
    posted by VikingSword at 1:51 PM on August 22, 2013


    Neither of your anecdotes, however, are anecdotes of insurance company incompetence or malfeasance.

    Given that VikingSword repeatedly provided the insurance company ample documentation (the customer service rep going so far as to admit one bill was in error) that it later claimed never to have heard of, I'd say "incompetence or malfeasance" are absolutely appropriate, and not necessarily mutually exclusive, terms.

    Which doesn't detract from the point that yes, single payer would be vastly more efficient. I look at the fact that it'd largely be at the expense of private insurance companies as simply a welcome bonus.
    posted by Gelatin at 1:51 PM on August 22, 2013


    Given that VikingSword repeatedly provided the insurance company ample documentation (the customer service rep going so far as to admit one bill was in error) that it later claimed never to have heard of, I'd say "incompetence or malfeasance" are absolutely appropriate, and not necessarily mutually exclusive, terms.

    He's not dealing with the insurance company in these anecdotes, Gelatin, he's dealing with the hospital billing departments. The insurance company has approved the payments and, so far as I can tell, has paid them. The hospital is just fucking up about who it is supposed to be dunning.
    posted by yoink at 1:53 PM on August 22, 2013


    To clarify: I see that the round-and-round was with the billing department, but since VikingSword mentioned a co-pay, presumably insurance is involved somewhere. If the insurance company paid the bill, it's hard (but not impossible) to imagine the billing department continuing to chase a bill that's already been paid.
    posted by Gelatin at 1:53 PM on August 22, 2013


    People who are in the Canadian system or ones like it, and never see a bill, have no idea how good they have it.


    Many of us do. I'm aware enough about the issues and problems with the US system that I say a grateful thanks to Tommy D et al. every time I need to us it. I just wish more people in the US had an idea of how good they could have it. Enough at least to get the political will and powers to do it. Any complaints I might have about our system just pale in comparison to what you guys have to go through.
    posted by Jalliah at 2:00 PM on August 22, 2013 [2 favorites]


    Even our primary care providers do this. Our pediatrician routinely ends up trying to bill us multiple times for the same office visit already covered under our insurance.

    Systems this complex also provide very convenient cover for fraud. I don't doubt that actual fraud in health care administration is also rampant and costly in America. Fraud really is unbelievably pervasive and deeply embedded in our society nowadays. A fact not helped by the prevalence of weak enforcement mechanisms that generally allow guilty parties above a certain pay-grade to walk away Scott-free.
    posted by saulgoodman at 2:01 PM on August 22, 2013 [2 favorites]


    RE: VikingSword's billing dilemma...
    It could also be a situation where the insurer has changed how it pays for the service being billed (possibly changing it from a copay to an out-of-pocket) and simply kept rejecting the claim from the hospital, which, in turn, bills it to the patient. We went through the very same issue with Anthem over counselor's fees. Used to be copay, was changed to out-of-pocket, and Anthem didn't tell us or or the provider about the change. Provider kept accepting copays, and Anthem kept rejecting the bill for service, and we ended up with hundreds of dollars in bills to the counselor.

    It was only after spending several hours over on the phone a period of a week with various Anthem CSRs and their managers that we finally got an explanation. Even some of the CSRs weren't aware of the change. And our online policy still said "copay".
    posted by Thorzdad at 2:08 PM on August 22, 2013 [1 favorite]


    The insurance company has approved the payments and, so far as I can tell, has paid them. The hospital is just fucking up about who it is supposed to be dunning.

    Unfortunately, it's not 100% clear what is going on. First I was told that the hospital didn't actually submit - by mistake - the bill to the insurance company. But then, one of the reps claimed that actually it was submitted, and paid, but the hospital doesn't realize it was paid. Then (just got off the phone) I'm hearing that the hangup is the insurance company didn't pay in full because of how it was submitted separately somehow - I didn't fully understand what (presumably the hospital was late somehow or submitted improperly), even though I'm covered totally for this, but it has to be submitted properly.

    Bottom line I don't fully understand the dermatology thing. The eye thing I think was more a hospital provider issue (I suppose?).

    Anyhow, this thing is going nowhere good - I'm seriously considering paying the $195 and just never ever going anywhere near a hospital in the U.S.. But I'm also pissed off, so I think I'll just keep fighting. But I am absolutely not joking about getting care abroad, including things like preventive care and checkups.

    The irony to me is that getting checkups seems the responsible thing to do and should save everyone money in the long run - no? It's better than to be scared and not get any and let stuff fester until it explodes in cost.
    posted by VikingSword at 2:10 PM on August 22, 2013


    Especially because I have heard many people say that having healthcare is not a right.

    Here's the thing, it doesn't matter if it's not a right. The fact is that we already use more tax dollars on health care than we need to. If socialized health care is a way for us to spend less tax money on health care then we should do it.

    It doesn't matter if you think health care is a human right or if you just want to government and yourself to save money. The solutions are the same.
    posted by VTX at 2:33 PM on August 22, 2013 [2 favorites]


    I thought it weird that the statistics about us spending more tax under our current healthcare system than anyone with socialized medicine weren't blared from the rooftops 24/7 during the ACA debate, but then I realized that's asking a bit much of the Democrats' messaging machine. No matter which team has the ball, they're always on defense.
    posted by jason_steakums at 2:56 PM on August 22, 2013 [2 favorites]


    It doesn't matter if you think health care is a human right

    "Rights" are actually a poor framework within which to think about healthcare. If we were to say "everyone has a right to healthcare" and put that in the constitution, what would that actually mean? Does that mean that if a treatment gets developed for, say, the flu which works every time, reducing the average flu from a two week illness to a two day illness--but costs $100,000 a pop--that every one has a right to have that treatment provided free of charge? Because that would almost certainly bankrupt the government to no very great ultimate gain in overall public health. If all it means is "everyone has a right to a certain minimum level of healthcare" then you could arguably say that the US already provides that.
    posted by yoink at 3:08 PM on August 22, 2013


    By that argument, though, lots of "rights" aren't a useful framework. What is the minimum standard for the right to a fair trial? Until the 1960s, it didn't include the right to an attorney in a criminal case in a state court. This led to a need for public defenders. But how many public defenders do we need? How much time should they be required to spend with their clients? How much training should they have had? This is also a question of allotting limited public resources, but we don't just say, "it's not a right" or "it's not worth talking about it in terms of rights," we try to hash it out.
    posted by naoko at 3:23 PM on August 22, 2013 [1 favorite]


    Oh, I'm wirh those who think instead of rights we Americans should talk about our responsibility .... but we'll never get anywhere.
    posted by Lesser Shrew at 3:34 PM on August 22, 2013 [1 favorite]


    Especially because I have heard many people say that having healthcare is not a right.

    It frustrates me to no end that the opponents of health care reform never seem to mention the Emergence Medical Treatment and Active Labor Act of 1986. That law requires all hospitals which accept payments through Medicare to provide emergency treatment to anyone that needs it, regardless of ability to pay.

    So we've already decided that we, as a society, have an obligation to provide medical services to those that really need. It's just that we can only do it in the most expensive, last-minute way possible.
    posted by heathkit at 3:53 PM on August 22, 2013 [4 favorites]


    What would it actually mean if we put "the pursuit of happiness" into the constitution as a basic right? We've already got an explicit right to life that should cover basic needs like food, water, and critical care (but conveniently, those kind of complex, nuanced and pro-public rights are seldom invoked in legal reasoning these days)...

    Oh, I'm wirh those who think instead of rights we Americans should talk about our responsibility .... but we'll never get anywhere.

    It's not an either/or. We have responsibilities because we have rights that we have to exercise responsibly. There are no responsibilities in the absence of rights, as without the autonomy our rights afford us, there's no moral basis for holding us responsible for our actions.
    posted by saulgoodman at 4:10 PM on August 22, 2013 [1 favorite]


    And that's also why people who hide their irresponsible or fraudulent behavior behind the shield of exercising their rights deserve absolutely no consideration.
    posted by saulgoodman at 4:12 PM on August 22, 2013


    I work in costing for the NHS in the UK, and this spreadsheet from this page is a fairly easily deciphered list of what everything costs in the NHS (mainly it's on the sheet named 01. APC & OPROC (Admitted Patient Care and Outpatient Procedures)).

    These are the costs of procedures (in GB £, obviously) with all management overheads included. I don't know if there are any other healthcare systems which have costs published all in one place for comparison, but the one that will be most surprising to people in the US is NZ11B: Normal delivery [birth] without CC [complications] - £1,477 or $2,300.

    Not that I'm suggesting anyone goes around haggling, but I just feel that the more people in the US know that there is, somewhere, a baseline cost for medical procedures that's pretty much comparable, the more their outrage can be focused and the sooner things will improve.
    posted by ambrosen at 4:21 PM on August 22, 2013 [5 favorites]


    If you were to transcribe everything he said, it would also take you twice as long to read it

    Give some people credit for being able to read/skim faster than a video. Given a choice between reading and watching something, I would much, much rather read.

    But the same argument applies for having stuff also available as a video. Different people learn better in different ways, or combinations of ways.
    posted by Foosnark at 4:23 PM on August 22, 2013 [2 favorites]


    Ambrosen, Australia has a nice searchable website with the costs of all their procedures called MBS Online.
    posted by Static Vagabond at 5:45 PM on August 22, 2013 [2 favorites]


    By that argument, though, lots of "rights" aren't a useful framework. What is the minimum standard for the right to a fair trial? Until the 1960s, it didn't include the right to an attorney in a criminal case in a state court. This led to a need for public defenders. But how many public defenders do we need? How much time should they be required to spend with their clients? How much training should they have had? This is also a question of allotting limited public resources, but we don't just say, "it's not a right" or "it's not worth talking about it in terms of rights," we try to hash it out.

    But the decision to add public defenders to the meaning of a "right to a fair trial" was a once-in-a-lifetime watershed move. In healthcare those decisions happen almost every day. The very notion of what we mean by "health" and "healthcare" is immensely fluid. Do we include all kinds of potential ameliorations of "wellbeing" in the notion?

    I doubt, in the end, we're very far apart on what we think the idea responsibility of the society towards the unwell should be (some kind of national health system, in other words), I'm just not convinced that the language of "rights" in the US constitutional sense would actually be very useful in bringing that about or in maintaining it if we once get it. For additional evidence I would point out that it has not, in fact, been the pathway by which National Health schemes have been implemented in those many countries that have them.
    posted by yoink at 5:59 PM on August 22, 2013


    We should be able to agree that some minimum baseline of critical and preventative care are sufficient to satisfy the right. Obviously, non-critical elective treatments might not always be on offer, but to grant with one hand a right to life (which btw we invest far more money ostensibly in protecting with our various forms of security policy and/or theater) while with the other, denying access to the very services (medical care, medicines) and minimal necessities (food, shelter) a life requires.

    The rights we supposedly already enjoy are a meaningless legal fiction so long as people can still be economically coerced by the threat of hunger or lack of access to life-saving care. If our "rights" are so weak they can be dangled in front of us like carrots to force us to accept disadvantageous economic arrangements, then what's the point of declaring them rights?
    posted by saulgoodman at 6:53 PM on August 22, 2013


    Er, "to grant... while (etc.).. a life requires, is perverse."
    posted by saulgoodman at 7:03 PM on August 22, 2013


    Saulgoodman, I agree entirely that we should provide healthcare to all, I'm saying that the language of "rights" per se is not particularly useful in arriving at that goal. Given that other nations have achieved universal healthcare without resorting to the language of fundamental political rights--at least at a constitutional level--in order to achieve that end, I think history tends to support my claim.
    posted by yoink at 9:50 PM on August 22, 2013


    I get that, yoink, and I'm not necessarily disagreeing. What I'm saying is that I think a right to basic health care (and food and shelter) is already implicitly embedded in one of the rights we've considered a natural right since day one, so it's strange that we make so much fuss about this question at all.
    posted by saulgoodman at 5:45 AM on August 23, 2013


    From the Universal Declaration of Human Rights:

    Article 25.

    (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
    (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.


    Note the "medical care" piece as a basic human right. The US is a signatory. Obviously we need to figure out the limits of what care we should cover, but I think the US should adopt a similar statement (Constitutional amendment?) to clarify this as a priority.

    How crazy is it that in the US, we have the right to stockpile the silly man-toys called guns, but not the above? Not trying to derail, but for me it's useful in thinking about our priorities and how crazy they seem to me.
    posted by freecellwizard at 7:04 AM on August 23, 2013 [3 favorites]


    Nothing makes me laugh louder that the phrase "health care".
    posted by telstar at 9:10 PM on August 29, 2013


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