Medicaid cuts shut only public outpatient oncology ward in NV.

April 6, 2009 8:53 AM

"We're a demonstration project, if you would, of all the things that can go wrong at once." "You know Yolanda, I think most people watching this interview think to themselves that if they get cancer and they don't have health insurance that somebody’s going to take care of them," Pelley remarked. "No, no, there's nobody to take care of you," she said.

On December 31, 2008, University Medical Center of Las Vegas--the only public hospital in the state of Nevada--suspended its outpatient oncology care program. Among the 2000 existing patients left to find care elsewhere are the uninsured and under-insured.

Working poor or middle class patients--the majority of the nation's uninsured--have the option, of course, of exhausting their assets until they are poor enough to qualify for Medicaid or Clark County medical assistance. However, these programs don't cover full costs and are only helpful if you can find a doctor who accepts them:

Roy Scales has been calling the private doctors from the list University Medical Center sent with its letter. He has been searching for someone who will accept payment from the county's medical assistance for the poor program, which he calls insurance. It has been five months since he was diagnosed.

He told Pelley he called at least 25 doctors and oncology practices trying to find care.

Asked what they told him, Scales said, "'What about that insurance? Well, we don't accept that insurance.'"

"What are you going to do if you can't find a doctor to take care of you?" Pelley asked.

"Die peacefully," Scales said.

One local oncologist has turned a storage room into a charity clinic serving 23 of those left without care.


Meanwhile, in France, cancer patients have 100% of their bills covered and guaranteed access to any drug necessary, and an emphasis on early detection/treatment leading to a survival rate that is the envy of Western Europe-- as part of a nationalized health care program that costs half of what the US spends per year on health care. (More stories in this series, from NPR, on the pros and cons of universal health care programs across Western Europe.)

posted by availablelight (85 comments total)

Those poor, dying cancer patients don't know it yet, but a life lived in a U.S.A. run by socialists isn't a life worth living.
posted by AzraelBrown at 8:57 AM on April 6, 2009 [9 favorites]

I cannot comment cogently on the health care system in our country without foaming from the mouth with uncontrollable rage. Thank you for the post. They more we highlight the sham it has become, the better. I know it seems like we're saying "how long must we sing this song" but it cannot be sung enough.
posted by KevinSkomsvold at 9:01 AM on April 6, 2009 [3 favorites]

And bravo to that oncologist!
posted by KevinSkomsvold at 9:01 AM on April 6, 2009

There is a genuine Republican argument which says that government is clearly no good at doing this sort of thing - look at what happened in Nevada for god's sake - so we shouldn't spend any more taxpayer's money on it. Republicans are bad at government so clearly we need less funding for government. Tax-and-spend-and-provide-vital-services Democrats don't get it.
posted by East Manitoba Regional Junior Kabaddi Champion '94 at 9:04 AM on April 6, 2009

At least you all have guns!
posted by Artw at 9:07 AM on April 6, 2009 [3 favorites]

And just imagine how much harder it will be for suffering cancer patients to kill themselves if the socialist Obama administration takes away their guns. We need Republican governance now more than ever.
posted by rusty at 9:13 AM on April 6, 2009 [2 favorites]

Now if only we could use our guns to steal another country's health care system...
posted by ChrisHartley at 9:15 AM on April 6, 2009 [3 favorites]

a life lived in a U.S.A. run by socialists isn't a life worth living

Not sure anyone is talking about nationalizing all forms of production, eliminating the stock market, and having government-mandated job tracks for citizens, here.

tired of the "universal health care = socialism" argument
posted by hippybear at 9:15 AM on April 6, 2009 [5 favorites]

So many of the people I talk to who are against some form--any form--of universalized health coverage aren't moved by talk about how our system is more expensive and less effective, brutishly unjust, etc. They're (currently) middle-class or upper middle class folks who are terrified of waiting an extra month for an elective surgery (no matter that there are possible models where one could pay privately for head-of-the-line care), and not picturing themselves as one of "those people" who "puts themselves in a position" (by getting laid off, becoming too ill to work, etc.) of having no health insurance at all while in the throes of a catastrophic illness.

Maybe the grim silver lining of this recession will be the realization that the line between "us" and "them" is wearing thinner and thinner, as more and more middle class people end up without insurance "through no fault of their own" and get to see how terrifying that can be. It might be the closest we get to coming up with a policy that might be what we'd all choose if we were behind some sort of Rawlsian "veil of ignorance."
posted by availablelight at 9:16 AM on April 6, 2009 [7 favorites]

It would be one thing if it were impossible or wildly moonshot-style impractical to save these people. But it isn't.

.
posted by anti social order at 9:17 AM on April 6, 2009

The Republican proposed budget would privatize Medicare.
posted by enn at 9:18 AM on April 6, 2009

Stan Brock is like a 21st-Century Florence Nightingale.

He started a charity - Remote Area Medical (RAM) - more than 20 years ago to bring relief to those cut off from healthcare.

Originally it was to help poor tribes in the former British colony of Guyana, South America.....
But now Stan spends most of his time bringing relief to the richest country in the world.

Some 60% of RAM's work is now carried out in the United States.


There is no debate amomgst rational people that the US healthcare system is broken. What surprises me is that, in the face of the evidence accrued from experiences in every developed nation over the last 60 years, there is still resistance to the concept of socialised healthcare as the solution. There are as many different flavours of socialised healthcare as there are countries that utilise it. There is no reason why a uniquely US-flavoured one cannot exist. It's a no-brainer for the majority of the population that this would be more affordable than the current system. The change will be resisted by he health insurance industry, who's raison d'etre will disappear, but it's inevitable, as the current system is getting close to collapsing under it's own costs.
posted by Jakey at 9:21 AM on April 6, 2009

The insured aren't doing all that much better than the uninsured, either. What good is insurance that covers nothing and has a $2000 deductible? Sure, if I get cancer or am hit by a car, maybe. But preventative healthcare is the ticket and the current system does everything it can to discourage anyone from ever seeing a doctor. And charging $1000/month only makes it all the more tempting to just drop it altogether.

We're getting a public option, right? Not single-payer, sigh, but at least something reasonable so we can dump the corporate leech machine?
posted by DU at 9:22 AM on April 6, 2009 [1 favorite]

How long until the term medical refugee becomes common?
posted by furtive at 9:33 AM on April 6, 2009

At least you all have guns!

I will only be happy when we have both.
posted by adamdschneider at 9:34 AM on April 6, 2009 [1 favorite]

hippybear: anything which uses public money to help people is a Communist plot. Just look at what happened to Sweden; whole country is full of gosh-darned socialists, and the Swedish Bikini Team are the only ones to put up a fight against those godless Marxists.
posted by AzraelBrown at 9:34 AM on April 6, 2009

Fuck this. Fuck this with a post hole digger. You know what? Fuck this, and fuck anyone who defends it. I live in Ontario; a U.S. ex-pat. I'm a self-employed artist/photographer/printmaker. If I'm sick... I go to the doctor. That's it. If I'm sick, I go to the doctor. Simplest equation in the world. Do you people in the U.S. who argue about this have any clue about how different life is in a sane society? Living in the U.S. is like living in an apartment with bad plumbing on the floor above. You're always worried the ceiling is going to cave in on your head and douse you in cold, filthy water. There's always that worry, and no matter how much patching you do or plywood you put up, you still get drips, because the system itself is rotten. In civilized societies, you don't worry about it. You just don't worry anymore. Because it's a basic. fucking. right. China has state-run health care. Did you know that? CHINA. If you get sick in China, you go to the doctor. Jesus fucking Christ.
posted by seanmpuckett at 9:38 AM on April 6, 2009 [54 favorites]

Sadly, I doubt we'll see anything close to the sort of workable, universal plan enjoyed by the rest of the developed world. The sticking point, I think, is that to make any new system work, everyone is going to have to give (How much more the consumer can give, of course, is yet to be seen) Manufacturers, insurers and providers alike will have to take less. Controlling costs is key. And that where none of the big player are ever going to give. The consumer, of course, has been giving to beyond the breaking point for a long, long time now.

I was talking with my daughter's GP one day and we got onto the subject of Canadian healthcare. You would have thought I'd just killed a puppy before her eyes. She immediately lept into a rant about how Canada is a mess, how you can't get proper treatment in Canada, and how Canadians are literally streaming over the border into the US for everything from childbirth to vaccinations. The woman was practically screaming at me.

If she's any indication, I have a feeling we're going to have a hard time getting the medical community on-board with any change that might require them to give even just a little.
posted by Thorzdad at 9:46 AM on April 6, 2009 [1 favorite]

Here is a short, general comparison between Canadian and French health systems.

Basically, France keeps down costs by including copayments. France has more doctors per capita than Canada. The French system is still the third most expensive health system per capita in the world.

On a personal note, we just welcomed our second child about a week ago here in Canada. We showed up at the hospital, were admitted to a private room, and the doctors and nurses (the nurses were awesome) just did their thing. Our baby son experienced a few problems after the birth, and so had to stay in the ICU for a few days. We took him home yesterday, and a public health nurse is going to visit us soon, and we will also see our family doctor this week. The apparent financial cost to us? Nothing. I pay a $100 premium every month (my employer pays for that, actually). My taxes cover the rest.
posted by KokuRyu at 9:47 AM on April 6, 2009 [2 favorites]

She immediately lept into a rant about how Canada is a mess, how you can't get proper treatment in Canada, and how Canadians are literally streaming over the border into the US for everything from childbirth to vaccinations.

And yet cancer patients from any socio-economic background can still get treatment anywhere and at any time in Canada.
posted by KokuRyu at 9:49 AM on April 6, 2009 [3 favorites]

China has state-run health care. Did you know that? CHINA. If you get sick in China, you go to the doctor. Jesus fucking Christ.

I know what you mean, but it's hard to imagine a worse argument to try to convince someone who is reluctant to support a sane health-care system for the U.S. Because they believe you couldn't have the benefits of national health care without somehow making the US govt. more repressive and totalitarian, like China.
posted by straight at 9:51 AM on April 6, 2009 [1 favorite]

The sticking point, I think, is that to make any new system work, everyone is going to have to give (How much more the consumer can give, of course, is yet to be seen) Manufacturers, insurers and providers alike will have to take less. Controlling costs is key.

Single-payer healthcare costs less than the current system. The only people who will have to "give" anything is insurance companies. What they'll have to give is "up their stranglehold".
posted by DU at 9:51 AM on April 6, 2009 [6 favorites]

Azrael B. -- while I get the humor in your reply, it nevertheless remains difficult to have a rational conversation in the United States about providing universal health care without someone raising the specter of socialism. And it continues to be a straw man argument, as are so many of the Extrapolated Hypotheticals which the Right offers as a counter to reasoned, measured attempts at Actual Debate And Progress.

It's old, and it's tired. I haven't had health insurance in nearly 20 years, and it sucks, and thank goodness I haven't had anything REALLY awful go wrong *knock on virtual wood*. But I think my plight is equalled by the people I have known over the years who remain in a hellish workplace and crave to make a positive change, but cannot because their monthly maintenance medications cost them X per month WITH insurance, and would be X^2 without. And goodness knows, even if you DO find an employer who will offer you health insurance, which is becoming more and more rare these days, finding one which doesn't make you wait six months or a year before enrolling you is nearly impossible.
posted by hippybear at 9:54 AM on April 6, 2009 [1 favorite]

She immediately lept into a rant about how Canada is a mess, how you can't get proper treatment in Canada, and how Canadians are literally streaming over the border into the US for everything from childbirth to vaccinations.

Counterpoint.

Also, from Harper's Index (Sept 93): Ratio of the number of Canadians who favor a U.S.-style health-care system to those who believe Elvis is alive: 1:2


Anyway, that's an interesting comment from your kid's pediatrician-- I've heard other folks state that "any general practitioner will tell you the US system is irretrievably broken."
posted by availablelight at 10:00 AM on April 6, 2009

Insurance companies don't actually make much money. That's not the problem. Its costs everywhere else that are the problem. As well as idiotic statehouses that view healthcare funding as something they can reduce to make up for budget shortfalls.

Also there is a rather large implicit subsidy the American healthcare system gives to the rest of the world. The higher prices in the US help finance R&D the entire world benefits from.

What the US needs to figure out is how to deal with the middle group of people who lack the means for private insurance but are not poor enough to qualify for government programs.

As far as the lack of willingness to create a single-payer system - as long as the majority of Americans still have private insurance there is no willingness to make the sacrifices that would be inevitable. Like everything else there is tremendous inequality of care in the US. The 65% of people who benefit from that aren't exactly going to be big fans of seeing the availability of treatment decline - even if the net effect is a positive for the population as a whole. Its pretty easy to be selfish about your health.
posted by JPD at 10:01 AM on April 6, 2009

Single-payer healthcare costs less than the current system. The only people who will have to "give" anything is insurance companies. What they'll have to give is "up their stranglehold".

Most, if not all, single-payer systems rely upon price controls for all players. That's largely how the lower cost is realized.
The providers will have take lower compensation for services, manufacturers (like big pharma, for instance) will have accept lower prices for their wares, too. And, of course, insurers would have to say goodbye to their endless river of cash.

Single-payer may cost less, but there's a functional reason for that. Cost controls. None of the big players in the US are going to sit still for that, and neither will their political allies for whom "cost control" = "socialism".
posted by Thorzdad at 10:01 AM on April 6, 2009

Anyway, that's an interesting comment from your kid's pediatrician-- I've heard other folks state that "any general practitioner will tell you the US system is irretrievably broken."

That's the funny part of it. She admits that the current system is broken. That's when I mentioned Canada and all hell broke loose.
posted by Thorzdad at 10:04 AM on April 6, 2009

Single-payer may cost less, but there's a functional reason for that. Cost controls.

We have cost controls now. They are called "closing Medicare oncology wards" and "raising private healthcare premiums to the point where nobody can afford them" and "shutting out anyone with a 'prior condition' from getting new insurance".

Oddly, all of those things end up raising costs, when emergency rooms get flooded with uninsured people who had to wait until their conditions became too serious to ignore, rather than getting early or preventative care. Those indigent patient costs are passed off to paying / insured patients throughout the rest of the hospital, who then find their insurance premiums rising to cover the increased costs...

It all comes out in the wash, it just depends how many have to die from delayed treatment.
posted by hippybear at 10:10 AM on April 6, 2009 [8 favorites]

Single-payer healthcare costs less than the current system. The only people who will have to "give" anything is insurance companies. What they'll have to give is "up their stranglehold".

This is wrong. Not only is it wrong, but it kind of encapsulates why we go around and around on universal health care in this country without ever getting anywhere: on one side, you have people screaming that it would cause huge lines and rationing and all sorts of poorer-quality care, and on the other side you have people making totally ridiculous claims like insurance company overhead is the only reason that health care makes up 17% of our GDP. You can't even begin to coalesce political support around a single workable alternative when both sides are so totally disconnected from reality and unwilling to let little things like facts and empirical evidence sully their ideological beliefs.

You wanna know who is gearing up the PACs and smear organizations to oppose this round of health care reform? Here's a hint: it's not AHIP, who were the big source of opposition the last time health care reform looked like a real possibility, in 1994. It's not the AMA, who killed health care reform in the 1940s under Truman. This time around, it's the drug and medical device makers, who are literally some of the only players left who are going to make much less money if we institute serious reform.

If you're an American who wants to see health care reform actually pass this time around, I think it may be worth taking the time to educate yourself about the issues and the real opposition, and not lazily decide that it's got to be insurance companies just because they're the most visible pain-in-the-ass you personally encounter in the health care system.
posted by iminurmefi at 10:12 AM on April 6, 2009 [3 favorites]

I was talking with a friend last night who lives in Alabama. During the call she noted that she thought she might have broken a bone in her hand, but that she couldn't afford to go to the doctor; at least the swelling was going down, and she thought it would be okay. I cannott tell you how this appalls me. What is this toxic throw the weak to the wolves American ethos? I don't understand it.
posted by jokeefe at 10:26 AM on April 6, 2009 [1 favorite]

My super conservative (listens to Rush Limbaugh and Fox) co-worker is divorcing his wife right now because she has cancer. It's not because he's a jerk, it's because she's uninsured.

He has health insurance through work, but to add her to his policy would cost too much. Our company does not cover any portion of a family member's insurance. (to add my daughter would cost $400 or nearly a quarter of my take home pay.) Because they are divorcing, she's now indigent and can get coverage through our state health insurance. (and she is able to get treatment as well.)

My husband asked me if he thought my coworker's divorce would change his mind about a single payer system. That would be the only silver lining to this situation, but I don't have much hope.
posted by vespabelle at 10:49 AM on April 6, 2009

Canadians are literally streaming over the border into the US for everything from childbirth to vaccinations.

That's funny. There was a new OHIP (Ontario Health Insurance Plan) photo id introduced about a decade ago specifically to stop American's from defrauding our system using the old photo-less cards.
posted by srboisvert at 10:52 AM on April 6, 2009

Azrael B. -- while I get the humor in your reply, it nevertheless remains difficult to have a rational conversation in the United States about providing universal health care without someone raising the specter of socialism.

I was trying for humor in my original post, too, trying to mock the perjorative "socialism", because it's like calling accusing somebody of supporting the terrorists for not buying American, or firing movie stars because they have Communist friends. It's an insane and useless accusation, and I was pulling it to the extreme, that the conservative anti-socialist attitude would be that dead citizens are better than socialist citizens. In fact, and this may surprise you: I identify as a socialist; I'm just not as funny as I think I am.
posted by AzraelBrown at 11:06 AM on April 6, 2009

In fact, and this may surprise you: I identify as a socialist; I'm just not as funny as I think I am.

No, I do too, and wow you are dry!
posted by hippybear at 11:13 AM on April 6, 2009 [1 favorite]

I watched this last night and after the interview with Yolanda I got seriously upset.

People don't just loose things like jobs, 401k's, homes, etc. in a recession. Some of them. Fucking. Die. That shit that rolls down hill? Ya, Sometimes it takes people over the fucking cliff with it.

To anyone on Wall Street looking for sympathy...go face to face with one of these cancer victims or anyone else who is facing a terminal diagnosis due to medical cutbacks and tell them how rough it is for you.
posted by Smarson at 11:22 AM on April 6, 2009 [3 favorites]

I had an up-close-and-personal look at how messed up our health care system is a few weeks ago: A friend got up in the middle of the night to use the bathroom; she passed out and bonked her head on the floor. She was also having severe abdominal pain. Crying from the pain, she's moaning, "I don't know what's wrong... I think I need to go to the hospital... but it's going to cost soooo much!!"

Of course I have no idea what's wrong -- hell, maybe a burst appendix for all I know. Or maybe it's just really bad gas. Do I take her to the ER and saddle her with a fat bill, or do I stay put and watch her literally die in my arms??

We ended up going, and she spent the night in the ICU and got an MRI before being released the next day. Total bill = $7500. (One single Oxycontin pill for the pain = $800) No diagnosis, no idea what was wrong.

This girl works two jobs, 60+ hours a week, but they're both service industry (wait staff) and neither one offers insurance. I haven't asked her salary, but it's less than $30k. She won't be able to pay that bill back for years. Lesson learned: next time stay home and hope really hard.
posted by LordSludge at 11:23 AM on April 6, 2009 [3 favorites]

I lived in the States for a while, and the health care system was definately one of the major factors in why I left.

Unfortunately I don't think much will change until the mindset of the American gov't changes. The amount currently spent on the "defense" department could easily pay for health care with enough left over for a world-class military. Sadly your country cares more about killing serfs in foreign lands than just about anything else.
posted by blue_beetle at 11:28 AM on April 6, 2009

And FWIW, *everybody* here in my area (South Carolina) calls it "socialized medicine", which raises the spectre of government cheese lines and substandard gray soviet housing. I don't think I've ever heard "universal health care" around here. (Mention "single payer system" and you're get a really good impression of Nipper, the RCA dog.)
posted by LordSludge at 11:32 AM on April 6, 2009

The amount currently spent on the "defense" department could easily pay for health care with enough left over for a world-class military.

You do of course realize that the US already spends more as a % of GDP on healthcare then any country in the world? Right? Money isn't the problem here.
posted by JPD at 11:33 AM on April 6, 2009

I cannot comment cogently on the health care system in our country

You call that a system?
posted by Mental Wimp at 11:34 AM on April 6, 2009

Mental Wimp: "I cannot comment cogently on the health care system in our country

You call that a system?"

System of a Down.

sorry..bad metal reference
posted by KevinSkomsvold at 11:40 AM on April 6, 2009 [1 favorite]

Insurance companies don't actually make much money.

Well, United Health Group is doing okay (pdf; check out p. 19).

Actually, there are a lot of reasons our health care costs more, and one of those is our very expensive insurance system. As Bill Clinton put it, in our health insurance system, we have a million people whose job is to keep from paying another million people whose job is to get paid. That is a huge expenditure. And everyone shaves a little off down the line, so it's hard to point to one person in the chain and say, this, this is the person who's costing us all the money. We also have a government that is run under laws passed by folks beholden to the medical insurance and medical products industries. Not only is the utter failure of the Clinton-era attempt at reform evidence of how pernicious this is, but also note that the medicare drug bill forbids the federal government from negotiating drug prices. So, yes, we fund R&D (mostly D) through our drug prices. But again, that's only a fraction of the increased costs, as are physician and other personnel costs, insurance costs, etc., etc.

And, I submit, there is no system for health care, only for making some dough.
posted by Mental Wimp at 11:50 AM on April 6, 2009

How much the share price has gone up is NO indication of if a company makes money. Secondly nearly all of the appreciation in that graph has been erased as the cycle for health care companies has turned over. UNH now trades at 2002 prices.

Additionally its a very cyclical business and we just came through the top part of the cycle. You can't just look at one health insurer to make your point. Look at the entire industry. It is a commodity business. There are people to blame (drug companies, for profit hospitals. overpaid specialists, etc) it isn't the insurance industry.
posted by JPD at 12:08 PM on April 6, 2009

Insurance companies don't actually make much money. That's not the problem. Its costs everywhere else that are the problem.

Cost control outside of insurance companies is definitely a problem, but I don't think it follows that insurance companies aren't a problem either. Whether or not they're profitable, their overhead may be a real issue.

Also there is a rather large implicit subsidy the American healthcare system gives to the rest of the world. The higher prices in the US help finance R&D the entire world benefits from.

How does this work? Are the R&D dollars really built into the cost of service, or is the funding for the R&D really coming from entirely different public and private grants?
posted by weston at 12:10 PM on April 6, 2009

Look at Cigna. It took them 31billion dollars in capital last year to make 438 mil dollars. That is less the a 2% return. That's not making money.
Oxford went bankrupt and got itself bought by UNH.
posted by JPD at 12:13 PM on April 6, 2009

How does this work? Are the R&D dollars really built into the cost of service, or is the funding for the R&D really coming from entirely different public and private grants?


Prices paid for Drugs and Med Devices are significantly higher in the US then they are in the rest of the world.

Whether or not they're profitable, their overhead may be a real issue.


It is such a competitive business, and the only way you can make yourself cheaper is by controlling overhead. If don't have the cheapest cost to serve you can't offer a competitive product in the long-term- so you probably end up getting bought (all the insurers in the US are roll-ups). And the value propsition behind deals is basically eliminating the adminstrative side of things in the acquired businesses.

Insurers do occasionally attempt to ration care and be total jackasses about reimbursements - but its not as material as actually handling the paperwork and everything.

Of course having a single administrator would have even greater economies of scale...
posted by JPD at 12:18 PM on April 6, 2009

Insurance companies don't actually make much money.

Could you flesh out this claim a bit? You and I must have different definitions of "much" or "actually".
posted by odinsdream at 12:18 PM on April 6, 2009

It takes a lot of money to run an insurance company. To just look at the absolute profit number is folly. Look at the Cigna example I posted above. In theory you would have been better off putting your into a CD.
posted by JPD at 12:24 PM on April 6, 2009 [1 favorite]

To be fair, Mental Wimp, the fact that UNH has doubled their revenues over a period of 5 years has everything to do with the consolidation in the health insurance industry generally, of which they're one of the biggest players--it's not like they've been achieving a higher and higher profit margin, they've just been insuring more people as they (and every other national insurance company) bought up a bunch of the regional insurers. Of course, the consolidation of the insurance industry has been hand-in-hand with the consolidation of the hospital industry into big regional chains. Smaller insurers don't really stand a chance of negotiating discounts against big hospital chains that are the only game in town--and the lack of negotiating power is what results in a $7,500 hospital bill for one night of observation.

All of this is kind of derail, though, because the linked article is all about the financial stress that safety-net hospitals are under, which doesn't really have anything to do with insurance companies. In fact, insurance companies pay higher rates than Medicare and Medicaid for the same procedures, and hospitals often claim that it's this cross-subsidization that allows them to continue accepting Medicare and Medicaid patients at all. Safety-net hospitals can be particularly stressed by this arrangement, because the higher the proportion of your patients that are on Medicaid or Medicare, the lower your margins are. Safety-net hospitals (and other safety-net providers, like community health clinics) that exclusively serve the poor end up in bad shape for lack of patients insured by big health insurance companies. That's why you don't see a hospital administrator in that article bemoaning the evil insurance companies--their problems arise in a context that is probably as close as you get to single-payer exclusively government-funded care outside of the VA. Obviously, cutting insurance companies out of the system and relying instead on government funding hasn't led to some sort of magical utopia for this hospital.
posted by iminurmefi at 12:28 PM on April 6, 2009

Or look at WLP which is supposed to be "best in class" earned on average since its IPO and 8% return on capital. Means it was probably just about worth it to put your money into the business. Yeah they made 2.5 bil in profit last year but they spent about 1.8 bil of that reinvesting in the business. And in aggregate its taken them 34 billion dollars to build their business.
posted by JPD at 12:28 PM on April 6, 2009

insurance companies pay higher rates than Medicare and Medicaid for the same procedures, and hospitals often claim that it's this cross-subsidization that allows them to continue accepting Medicare and Medicaid patients at all

Isn't that what happened here - doctors set up their own infusion centers which creamed off the privately insured who had been cross-subsidizing the un/underinsured at the hospital? So when the hospital had to cut costs the outpatient oncology biz was just hemmoraging cash with no hopes of getting back to breakeven?

One more example of something to be cleaned up. Reimbursement inefficiencies.
posted by JPD at 12:32 PM on April 6, 2009

JPD, that's a related but slightly different issue. There's two types of cross-subsidization that occur in hospitals:

(1) from patients with higher-reimbursing payers (self-pay and insurance companies) to those with lower-reimbursing payers (Medicare, which is low, and Medicaid, which is even lower), and

(2) from higher-margin services (anything related to cardiac care) to lower-margin or negative-margin services (in particular, psychiatric units and burn centers are almost always money-losers--note that the hospital in the linked article specifically said they were trying to keep their burn center open, which is important because hospitals in general are getting rid of them)

Oncology is actually traditionally one of the higher-profit areas for hospitals--although there has been a shift towards oncologists treating more patients in their office for reasons related to Medicare reimbursement rules--so this hospital's choice to jettison it is probably more related to #1, not having enough privately-insured patients to subsidize charity care.
posted by iminurmefi at 12:56 PM on April 6, 2009

A few months ago, there was a great This American Life (I know, I know) that was part a memorial for a man who made his career in news radio for many years, and that segment of the show was devoted to interviews this guy did with survivors of the Great Depression. There was a common thread among many of them that started with shame, continued to a hypercritical questioning of every economic decision they made before the crash, before finally coming to the realization that it was a Depression and things were pretty much fucked all over.

Which is I think the big cognitive barrier behind the health care crisis. The Socialist ideological insight that the working class are the backbone of the economy and have the right to organize for a basic quality of living never really sunk in, and the belief that people are poor or lack health care because of some deep moral flaw is really hard to shake. And I really don't know what will shatter the equilibrium on this.
posted by KirkJobSluder at 1:00 PM on April 6, 2009 [1 favorite]

Guys, the issue of the costs of insurance to the system isn't whether they are making profits or not, because their costs are costs to the system. You're paying money to the company to do whatever they do and it is added to the money you pay to the drug company, to the physician, or to the hospital.

But, that said, in 2007 the return on shareholder equity for UHG was something like 22%.
posted by Mental Wimp at 1:03 PM on April 6, 2009 [1 favorite]

Dear Canada:

Please send us a copy of your health-care system. And maybe your banking system and vote-counting system, if you don't mind. Just add the copying and shipping costs to our tab.

Thanks,

The United States

P.S. Please do not send us Stephen Harper. We regret any inconvenience this may cause.
posted by oaf at 1:08 PM on April 6, 2009 [8 favorites]

Guys, the issue of the costs of insurance to the system isn't whether they are making profits or not, because their costs are costs to the system. You're paying money to the company to do whatever they do and it is added to the money you pay to the drug company, to the physician, or to the hospital.

Right but they provide a service - underwriting the risk pool, handling the billing and negotiating pricing. If we eliminated them we would have to replace them. I'm not saying that's a bad thing - but don't pretend they are just leeches.

You complain about costs - they complain about costs. Its in their interest to see medical expenses decline.

2007 the return on shareholder equity for UHG was something like 22%.
Top of the cycle, best performer in the industry. ROIC is massively superior to ROE as a metric becuase it illiminates the impact of leverage. ROIC was 9.4% - which is quite good - but not as standout good as 22% ROE.
posted by JPD at 1:13 PM on April 6, 2009

Right but they provide a service - underwriting the risk pool, handling the billing and negotiating pricing. If we eliminated them we would have to replace them. I'm not saying that's a bad thing - but don't pretend they are just leeches.

They do all of those "services" badly, and on top of that they have a financial incentive to deny people health care. Underwriting is not a feature, it's a bug. They're worse than leeches: They're extortionists.

Health insurance companies may not the entire problem, but once we're rid of them the rest of the problems will be easier to solve.
posted by vibrotronica at 1:44 PM on April 6, 2009 [6 favorites]

vibrotronica, I'm not an apologist for the insurance companies (my kid has kidney problems) but getting rid of an industry employing a lot of people is bound to have a lot of unintended consequences.
posted by Michael Roberts at 2:08 PM on April 6, 2009

Right but they provide a service - underwriting the risk pool, handling the billing and negotiating pricing...

that the federal government does for a fraction of the price.
posted by Mental Wimp at 2:13 PM on April 6, 2009

Those poor, dying cancer patients don't know it yet, but a life lived in a U.S.A. run by socialists isn't a life worth living.

Socialists?

Effective dehumination must preceed the anihilation of a hated group.
This falls short.

We should get back to referring to socialism as "a cancer upon the earth". Or something... It's annoying not to have a better label than "Socialist" for these germs. It sounds so -- sociable. And they're growing everywhere, you know? France is full of them. So's Canada. I'll bet they're even in Algiers.
posted by RoseyD at 2:16 PM on April 6, 2009

Prices paid for Drugs and Med Devices are significantly higher in the US then they are in the rest of the world.

I'm not sure this is the strongest example. For one thing, I seem to recall that drug companies tend to spend much more money on marketing than on R&D, and that a good portion of the R&D is in fact financed from public sources.

It is such a competitive business, and the only way you can make yourself cheaper is by controlling overhead.

From my perspective, it looks like competition in the business is inherently hobbled. As soon as you find you need insurance payouts for a given condition, you're a poor risk that will pay premiums at a higher rate if you'll be insured at all. That's if you're in the unfortunate position of personally shopping for insurance rather than having it provided through a group. Either way, if there's some kind of problem with the service, you can't exactly just pick up and choose another insurer.

I suppose, though, that this might lead to the point where the only end differentiator for businesses and consumers is price, especially given that data on quality of care and satisfaction isn't easily available, and that's competitive environment of sorts.

Look at Cigna. It took them 31billion dollars in capital last year to make 438 mil dollars. That is less the a 2% return.

The last year or two would be a bit of an anomaly, wouldn't it? A 2% return may be historically poor and not particularly compelling for a field that has high growth prospects in general, but it seems decent in comparison to a number of other recent investments we could look at...

Right but they provide a service - underwriting the risk pool, handling the billing and negotiating pricing. If we eliminated them we would have to replace them. I'm not saying that's a bad thing - but don't pretend they are just leeches.

This is an interesting point overall -- someone has to do the risk underwriting if you're going to have a risk pool at all. But with billing in particular, the necessary work seems largely multiplied rather than managed. And pricing...

You complain about costs - they complain about costs. Its in their interest to see medical expenses decline.

It's in their interests to see their share of costs they cover decline. Unless we're talking about plans where they accept responsibility for all charges, this is far from the same thing. That's not to say they *should* be 100% responsible for all charges, nor that they bear most of the responsibility for runaway costs (providers have their own problems and probably will continue to unless we can get some kind of episode-of-care arrangement going), just that there are inherent limits to how far their self-interest alone helps.
posted by weston at 2:53 PM on April 6, 2009

Dear USA c/o MeFite Oaf,

Happy to send you the systems you request.

Please change your mind about Mr. Harper. We'll throw in new snow tires and a 2-4 of Moosehead.

Yours, etc....
posted by angiep at 2:55 PM on April 6, 2009 [3 favorites]

I have long made the prediction that the USA will only get national health care when there is a worldwide pandemic caused by terrorism. Anthrax, smallpox, influenza, you name it. The deaths in the US will be disproportionate to the rest of the developed world (even when weighted for total national population) because of our uninsured.

Health care will become a matter of national security (not that the Bush administration was that competent at national security).
posted by bad grammar at 3:08 PM on April 6, 2009

Cancer Patients Die While “New Democrats” Help Bankers Get Billions
posted by homunculus at 3:09 PM on April 6, 2009

The pandemic, also because there will be no escape for the rich (cf. Black Death) unless they flee to live inside bubbles inside gated communities patrolled by armed guards.

I'm sorry if I'm feeling apocalyptic, but that's how I feel upon reading this thread. My parents are getting old. An old family friend has cancer.
posted by bad grammar at 3:14 PM on April 6, 2009

Yeah, but we're number one at some things. Figuring out new and better ways to blow people up. How best to imprison large segments of the populace. We're great at those things. I've encountered a fair number of people who seem to be pretty content with that state of affairs. Nothing but anecdotes, there; but near fifty years of anecdotes should count for something.

We have yet to figure out how to access the better sides of our nature. Everything else grows from that. Other countries have come to reconcile themselves, to one point or another, that they have an investment in the wellbeing of their fellows, ultimately. Here in the states that kind of thinking often gets you called a bleeding heart liberal, even if your own particular beliefs tend to diverge significantly from those of the Democrats.

This situation of medical care is just one more manifestation of this. If I can't make a buck off your ass you're not worth a damn to me. The saddest aspect of all this to me is that I suspect that no matter what kind of medical (or other) system we managed to get set up in the U.S. we would still find a way to fuck it up, only to say something like 'see, that way doesn't work.'

The U.S. of A: a tragic and shameful waste of resources covered by a lot of high-flown and noble-sounding rhetoric. I asked my brother what that word 'rhetoric' meant when I was a kid. He told me it meant bullshit. He was right.

Best of health to everyone in this thread.
posted by metagnathous at 4:04 PM on April 6, 2009 [1 favorite]

It is interesting that we can immediately find billions to throw at bankers and yet we can't fix our health care system, which would be a fraction of that.
posted by maxwelton at 6:45 PM on April 6, 2009 [1 favorite]

Getting back to the original article, maybe I'm cynical, but I've seen this kind of thing before when it comes to public funding.

For instance, when voters are getting restive about school taxes and refusing to vote for increases to support the schools, then the school administrators will say, "tut tut, if you don't vote for this then we'll have to cut things, like school football." Football is very popular, and the result is that the voters do end up passing the tax increase.

Is football the only thing the district could cut if the tax increase fails? Of course not; it's small beans compared to the whole budget. But it's always high on the list of things that the administrators threaten to cut, because they're trying to extort more money from the voters. (Whether that's justified is in the eye of the beholder. I'm not talking about whether the end is justified, I'm talking about the tactics that get used in these kinds of cases.)

I've seen the same thing with cities. Polls show the voters are unlikely to vote for a tax increase asked by the city council, so the mayor announces that if it doesn't pass, the city will drastically reduce the budget of the police and fire departments. Not that they make up the whole budget, of course, and there are a bunch of things which could be cut which the majority of voters wouldn't mind at all. It's all gonna come out of the budgets of the police department and fire department -- because that's intolerable to voters. So they knuckle under and vote for the tax increase anyway.

And so I bet it is here. I really am wondering whether the hospital cut this cancer treatment program -- and then made sure that lots of sob stories about it hit the newspapers -- as a way of putting pressure on the state legislature.

In a good cause? Again, maybe so and maybe not. I pass no judgment on that. I'm just suggesting that this is a cynical tactic being used to try to force the legislature to give the university more money.
posted by Chocolate Pickle at 6:53 PM on April 6, 2009 [1 favorite]

It might help if conservatives stop associating socialism with communism. They're two different things.
posted by kldickson at 7:20 PM on April 6, 2009

Also, that makes me want to round up all those cancer patients and deposit each one on the front step of a conservatard. Because I want them to feel guilty. I will freely admit I want them to hurt. They probably won't, of course.
posted by kldickson at 7:25 PM on April 6, 2009

This is what happens when you fuck up an economy.

Sorry, I'm in rage mode tonight, folks.
posted by kldickson at 7:26 PM on April 6, 2009

I find it entirely laughable that they also find the survival of a useless little ball of cells important than the life of someone who is a fully-developed human being.
posted by kldickson at 7:28 PM on April 6, 2009 [1 favorite]

Chocolate Pickle -- Finally! Someone talking sense. Why is everyone accepting this story at face value? I work at an American hospital. Nobody gets turned away to die. Of course, providing charity care and forgiving unpaid bills costs us a couple hundred million dollars a year. But it's part of the business. And if you show up, you get cared for.
posted by Faze at 7:28 PM on April 6, 2009

The current healthcare system in the United States will continue until a sufficient number of companies are bankrupted by it. Until then, good luck everybody.
posted by LastOfHisKind at 8:51 PM on April 6, 2009

This posting, which I think came from Metafilter, is good reading - with interesting insights on how health systems in other countries came to be. As an Australian who lived in the US for 3 years (thankfully with a hugely well funded health scheme coz otherwise no expat would work there), I was continually horrified by the US "Health System", and I worked with really well paid people.
posted by ozjohn at 4:45 AM on April 7, 2009 [1 favorite]

Nobody gets turned away to die. Of course, providing charity care and forgiving unpaid bills costs us a couple hundred million dollars a year. But it's part of the business. And if you show up, you get cared for.

...and you may well be financially ruined by the care. That's a really powerful incentive to not seek care at all, and just hope the medical situation goes away on its own -- which it might, in which case you've saved several thousands of dollars. Then again, you might DIE.

BTW, my friend called the hospital business office to apply for "hospital sponsorship" (a "charity" program to lessen or eliminate hospital costs for those who can't afford them). But whaddya know, she was told that with all the budget cuts, she's very unlikely to be approved.

Then again, maybe they were just trying to scare her.
posted by LordSludge at 8:26 AM on April 7, 2009

You want to know something messed up? In the moment, when my friend was curled into the fetal position from her mysterious abdominal pain, I was quietly trying to convince her NOT to go to the hospital, that she would probably just be fine if she just waited it out. She, not me, was the one who insisted that she go. I feel bad about that; I could have gotten her killed. But in hindsight, given the outcome, and given our present health care system, I was right -- she really should have just waited it out, because now she's financially screwed.

You wanna know something even MORE messed up? She STILL utterly opposes "national health care" because, to her, "national health care" = "socialized medicine" = "government doctors, incompetent care, and long lines" ...just like everybody else in this right-wing city.

FUCK everybody who insists on spreading these lies. You are inflicting pain and suffering on your fellow Americans.
posted by LordSludge at 10:24 AM on April 7, 2009

The elephant in the room in virtually all discussions of nationalized/public healthcare, at least in my experience, and the biggest issue that supporters of it seem to hand-wave away, is the one thing that the current privatized system provides: insulation from politics.

If you want to sell public healthcare to voters, you have to deal with this issue in a transparent and convincing way. How do you effectively nationalize the healthcare system -- and let's be blunt, that's what's really up for discussion, it's really just the degree of nationalization that's at question (whether it's basically nationalizing the function currently performed by the insurance companies, or some bigger or smaller slice) -- and make it part of the government, while still insulating healthcare from becoming a political weapon?

It's easy to brush off concerns by claiming that "better government than insurance companies" or "better politicians than executives," but that's shortsighted: today's government and politicians aren't necessarily going to be tomorrow's, or next decade's, government and politicians.

There is a very wide, and very ugly, authoritarian streak in U.S. politics that (as far as I can tell or have seen demonstrated), doesn't seem to exist in many of the countries that people are pointing to as examples for a future healthcare system. If you want to make a European-style or even Canadian-style system work in the U.S., you have to figure out how to make it withstand the inevitable assault by people who will see it as a means to their own closely-held ends. This is not trivial, it's not something that can be left to be hammered out later, it's not something that can be blithely hand-waved away: it is, and ought to be, a potential deal-breaker.

Let's just envision the nightmare scenario: Obama manages to pass a complete nationalized healthcare package. Imagine anything you want, the whole enchilada -- go nuts. But he doesn't end the recession, his other reforms fail, and the populist base he's whipped up to force them through Congress turns on him. Palin/Jindal 2012.* A new social-conservative renaissance. A narrative that explains the Depression as the result of moral decay.

What do you think a health-care system run by a government like that would be like? I doubt it resembles what today's boosters of such a system would like. We'd probably have the only system in the world that would cover prenatal care but not abortions ("it's a child not a choice!") or aftercare ("if you can't feed 'em, don't breed 'em!"), stay-hard pills but not contraceptives ("life begins at conception!"), and would hand out oxycodone but not cover addiction treatment ("your problem is that you're weak!"). Certainly not AIDS.

And I think that's only the beginning. Think of what kind of political hay someone could make with a story like the Octomom, if all her expenses were picked up by the taxpayer. One example like that, with the right kind of yellow journalism, and it'd be better than every "welfare queen" anecdote ever invented. Think free clinics and hospitals in the inner cities, or wherever the minority neighborhoods are (maybe the exurbs) will last? I don't.

And the clincher is that all this will happen in an environment where the Planned Parenthoods and few remaining free clinics (e.g. Shriners Hospitals) we have now will have disappeared, since they weren't necessary during the early days of such a system. They exist today because they're necessary; they will disappear as soon as they're not -- but they'll be difficult to magic back into existence when the winds of political change shift and suddenly they're necessary again, because the electorate has decided they're tired of paying for some people's medicine. If the system is not adequately insulated against political manipulation, a lot of people will be left in the vacuum as it is pulled back and forth by changing governmental priorities.

The United States has had major shifts in political temperament just in the past half-century, and that was during a period of time when things were going very well for the nation as a whole; there's reason to believe the 21st century will be much more interesting, and that the political forces at work will be correspondingly stronger, and shifts more violent.

This completely ignores, by the way, an entirely separate class of problem: all the legislation that will spring up once people realize their neighbor's heretofore-private behaviors are suddenly affecting their tax bill in a direct way. Even without invoking a completely repugnant and malicious elected government, there's still a lot of room for nastiness. There are a lot of very -- to put it kindly -- vanilla people in the country, who don't smoke or drink, have a very small number of sexual partners, don't have any hobbies more dangerous than driving to the movies, who will not appreciate the idea of paying for the bills incurred by those whose lifestyles include more risk. We will be lucky if engaging in such behaviors only makes you ineligible for healthcare and simply isn't flat-out illegal.


That there are people literally dying on the street and "socialized medicine" is still a career-killing phrase in Washington shows the distance that anyone has to go, if they want to sell the concept to the public. Part of that sales pitch needs to deal with how to prevent politicization of the system in the future, since a necessary consequence of shifting the burden from the private to the public sector is a greater exposure to demagoguery.^** Another part needs to deal with how the new-found transparency and accountability of such a system won't lead to a rash of restrictive legislation in an effort to pinch pennies.

Nationalized healthcare systems seem to work well in civilized countries. I remain skeptical about how it would work in the United States.

* If this is too hard to believe, make it Clone-Palin/Cyborg-Jindal 2040, or however far you need to go to get beyond the currently-predictable political horizon.

** Lest anyone accuse me of putting out too many problems and not enough solutions -- an accusation I admit to -- I'll put one idea out there, as the only one I think provides anything close to the necessary level of 'tamper resistance': Constitutional amendments.
posted by Kadin2048 at 11:02 AM on April 7, 2009 [5 favorites]

Obvious followup question to Kadin2048's excellent post: How is this handled in other countries?
posted by LordSludge at 1:20 PM on April 7, 2009

Since when is someone making $20,000 a year middle class?
posted by QIbHom at 1:36 PM on April 7, 2009

the one thing that the current privatized system provides: insulation from politics.

Some insulation from some public politics. It's a good point, though.

There are a lot of very -- to put it kindly -- vanilla people in the country, who don't smoke or drink, have a very small number of sexual partners, don't have any hobbies more dangerous than driving to the movies, who will not appreciate the idea of paying for the bills incurred by those whose lifestyles include more risk.

And there would be merits to these kinds of concerns.

This isn't to say said concerns would be without problems -- there's certainly the potential to make these proxy fights over moral issues. And there's room to disagree over what burdens any given activity might present to the risk pool. I've seen people line up to spit on mountain climbing as a high risk activity right here on metafilter, and yet if you take a sample of sedentary folks and a similar sample of mountain climbers, would the number of illness/death episodes among sedentary folks be smaller than the number of injury/illness/death episodes among climbers?

But it's a legitimate question to ask how certain kinds of activities that really boil down to lifestyle choices might change your contribution to the risk pool in proportion to measurable risks (a better alternative than limiting coverage).
posted by weston at 5:00 PM on April 7, 2009

the one thing that the current privatized system provides: insulation from politics.

No, no, no. Y'all can't be oblivious to this, can you? I don't see much insulation in our current system.
posted by Mental Wimp at 10:42 PM on April 7, 2009

Mental Wimp: That's kind of my point. That sort of crap is what we have now, with a system that's at least ostensibly private, and the three entities involved are the patient, the doctor, and their insurance company (whose interest is typically focused purely on the cost aspect). Given that the pro-lifers and others with an agenda have managed to squeeze their way in there, a system where the government plays a much larger role can only be more subject to manipulation by the same folks.

Rather than having to argue their case on strict ideological grounds -- 'abortion is wrong so let's make it illegal' -- they'd be able to argue a much easier case to people who are on the fence: "you don't want your tax dollars being used to pay for abortions, do you? It's your money they're using; you're a baby-killer; you're an accessory." Rather than arguing in favor of "banning abortions," they'd only have to succeed in winning voters over in favor of "banning taxpayer-funded abortions." Since the whole health system would be taxpayer-funded it's potentially the exact same end result, but the argument is a lot easier. Historically, the pro-life crowd has had much more success in limiting taxpayer-funded expenditures on family planning, contraception, and abortion than in banning it outright. There are a lot of middle-ground voters who are OK, or at least reluctantly tolerate, abortion/contraception/whatever, but start to get annoyed when they're told that they're bankrolling it.

That's where I think the increased risk of politicization comes in. (And that's just one example; I think there are probably a lot more avenues by which politics could invade the health sphere depending on how a system was set up.)

Right now we have a system that is primarily run by bean-counters and only occasionally invaded by politicians; we are potentially talking about reversing that relationship and I don't think there's been nearly enough discussion about the long-term consequences.
posted by Kadin2048 at 11:56 AM on April 8, 2009

"you don't want your tax dollars being used to pay for abortions, do you? It's your money they're using; you're a baby-killer; you're an accessory."

Yeah, I hear what you're saying, but I think the most success the slut-haters have had has been in local government. A single-payer system would put those decisions on a national level and the slut-haters would have to win national support for their policies, support that just isn't there.

I think a significant majority of the American voters believe that abortion should be rare but an option and medically available. They would be denying it to their own flesh and blood if they voted it out of single-payer coverage, something I suspect they won't do.

The present system is so wasteful of resources that there isn't enough money for even life-saving procedures for many people, so the fear of a minority cutting out abortion altogether has to be put in perspective. We can't be sure that the slut-haters might gain the upper hand temporarily, but I'm pretty sure in the long run they'd lose to the majority.
posted by Mental Wimp at 12:37 PM on April 8, 2009

…it's not like it would be illegal to pay, outside the insurance system, for abortions.
posted by oaf at 12:54 PM on April 8, 2009