This post was written after reading “Putting Profits Ahead of Patients,” by Jerome Groopman and Pamela Hartzband, which appeared in the New York Review of Books on or about July 13, 2017. The beginning anecdote and some of the information in the post were derived from the article. All quotes are in quotes, so to speak. The article referenced the book, “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back,” by Elisabeth Rosenthal (Penguin Books).
The Problem With Health Care
A lawyer in New York City gets chest pains during some kind of strenuous game. He is fully insured. He is taken to a hospital where he gets the standard medical responses to chest pains, an echo-cardiogram and a cardiac stress test. Tests show that he is not having a heart attack, and he is released from the hospital. The pains are judged to have been stress related. The bill is $8,000; his insurance agrees to pay $6,000 and the hospital begins to dun him for the $2,000 co-pay.
Luckily, he has a relative who is a doctor. (The relative is one of the authors of the article on which this blog-post relies.) The doctor/relative agrees that that seems high, and suggests that the lawyer call other medical providers similarly situated and check their prices for those procedures in that situation. The prices fall into the range between $1,500 and $6,000. The lawyer refuses to pay the extra money to the hospital, which immediately cancels the co-pay, settling for the $6,000 paid by the insurance company.
Reality Check: Something similar, but much less dramatic, happened to me recently. A very good and highly regarded “international” hospital in my Bangkok neighborhood charged me $240 for the very same stress test and echo, albeit not in the emergency room situation. No waiting, and no appointment. I walked in on a Sunday and within twenty minutes the doctor was getting started on the tests. This was all done with state-of-the-art equipment, by a fully qualified cardiologist and a nurse. The result was the same in my case: my heart is fine. I have the heart of a healthy three-year-old racehorse, but evidently my stress is getting to me. $240, put that in your pipe and smoke it. That cost is not a typo, the full charge for my visit, including both tests, was two hundred and forty dollars ($240; 7,900 Baht).
We all know that something has gone terribly wrong, we Americans.
Medicine was a primitive affair until the early Twentieth Century. There were no antibiotics, and anesthetics were basic and crude. What services could be provided were fairly cheap, all things considered. As medical knowledge increased over time, so did costs.
Hospitals were not in the business of making profits back then. They looked for ways to cover expenses. In the 1920s, Baylor University Medical Center in Dallas came up with a way to regularize their cash flow. It was a “subscription” service that people could join for $6 per year. If they ended up in the hospital, the sixth day of the hospital stay was free, all inclusive. (The regular price of a day in that hospital at the time was $5, which was almost a week's pay for most people at the time.)
This Baylor plan became Blue Cross, which was also a non-profit corporation.
Blue Cross begat Blue Shield, another non-profit outfit. They were called “the Blues.” By the 1960s, about fifty million Americans were covered by the Blues. They merged in 1982. Blue Cross/Blue Shield accepted all applicants, and there was one rate for all covered individuals. They retained their non-profit status until 1994, when industry pressure forced them to seek profits to remain competitive.
Employer Based Health Insurance came about almost by accident. A law was passed in 1943 making all of the money that companies spent to pay for employees’ health benefits tax free. Wartime wage controls were in place at the time, and companies jumped on health benefits as a way to attract workers. The government tax policy, and the companies’ habit of providing health insurance, stayed in place for some time.
From the 1960s to the 1980s, more and more for-profit health insurance companies came on the scene. Prices started to shoot up, which drove more people to seek insurance. Medicare and Medicaid came on the scene. All of these multiple payers had the effect of driving prices up, and up, and up. By the 1990s, many hospitals were still nominally non-profit, but they were chasing “excess revenues” and becoming rich without paying taxes. The for-profit insurance companies loved nothing better than NOT paying claims, so refusing payment became more common. The whole system of health care was becoming money crazy, and we were all becoming health-insecure. (“America’s Bitter Pill,” by Steve Brill )
Reach For The Stars!
Today we are stuck with a system where medical providers size us up and decide how much to overcharge us as a matter of course. Like the stress-test and echo that opened this post, providers know that they must reach for the stars if they want to end up with the moon.
Rosenthal tells a story about a plastic surgeon who did a small job on a girls face. Not like cosmetic surgery or anything, not a nose-job, nothing corrective, just three stitches on a cut. His initial bill was $50,000 (fifty thousand dollars). Why not? She had good insurance. Maybe they’ll pay it! A concerned medical association got the bill reduced to $5,000, which still seems astronomical for a few minutes work.
The problems with Medicare and Medicaid are under-reported, because those programs are well loved and generally work pretty well. Regarding Medicaid, the worst effect is on the standard of care that all Americans are due at the hospital. Per current law, anyone who presents at a hospital in distress must receive care. This is what Republican congressmen call, “nobody dies!” “You just go to the hospital!” And it’s true, if you are in acute distress, you will be treated. The hospital will then generate a bill, and they will explore ways of collecting on this bill. If the patient is homeless and bereft of resources, the debt is uncollectible. It is then presented to Medicaid, which will negotiate the bill and pay the agreed upon cost. If the patient is merely poor, the bill in collections becomes problematic pretty fast. Property can be seized, or wages garnished. An already marginally above water patient can be therefore pushed under the waves.
How about the standard of care? What level of care does the hospital owe a virtual beggar who just wanders in? If you show up at a hospital in a diabetic coma they must provide acute care sufficient to stabilize you, that’s it. Then they put you out in the street, with no medication and no follow up. That’s a problem. The law says that they owe you the same standard of care that everyone receives in the meantime, and that presents its own problem. The result has been that the general standard of care has been lowered, to avoid running up big bills treating the indigent.
So whereas in France, let’s say, if you show up with a non-specific stomach ailment that has caused you to suffer a ridged abdomen, and x-rays do not show any condition that would cause that very serious, and very painful condition, you will be given an MRI. That’ll get to the bottom of things pretty quickly. Those are expensive, so as we speak they are part of the standard of care in France but not, I think, in America. They certainly didn’t do one on me when I presented with a ridged abdomen as a Medicaid patient. Luckily for me, the list of things that can cause a ridged abdomen consists of only fatal events, so they decided to do an “abdominal exploratory,” discovering after a full and comprehensive tour of my abdominal cavity that my appendix was way over in a strange corner and tucked behind a bone, and it had burst. An MRI would have displayed the appendix and its condition. I lived, thank God, but I’d have a much smaller scar if I’d gotten the MRI, and my recovery would have been much faster and easier as well.
Medicare helps, but it’s no great shakes. It’s pretty expensive; there’s nothing free about it. For Medicare A and B (doctors and hospitals), I pay about $1,200 per year, which is one month of my Social Security money. I’m beginning to wonder why I pay this fee at all, because I live in Thailand and there’s no real likelihood that I’ll ever move back to the States. Medicare does not make any payments at all for services rendered outside of the United States of America. There are many people like me who lived and worked all of their lives in America, paying taxes, raising children, contributing to communities, serving in the armed forces, and generally being good citizens, but are now denied the benefit of our bargain with our government, denied the benefit of Medicare that we are owed by the law. Isn’t that a little shameful? I find it so.
And what would Medicare pay anyway? It almost never pays 100% of the bill, evidently. Do you need a knee replacement? First you need to search for a doctor and hospital that will accept Medicare patients under any circumstances. Many just say, “nope, sorry.” Also, finding a doctor who will accept the Medicare money as full payment seems to be pretty rare, so you’re faced with negotiating a co-payment, which can be very expensive. In the case of a knee replacement, you will probably pay over $10,000 as a co-pay for treatment at a mediocre facility by a mediocre doctor, receiving a cheap implant that will only last ten years instead of one of the really good ones that last twenty years or more.
For me, between the cost of room and board and travel to and from America, and the co-pay, I’d save money just getting the implant in Thailand and paying out of pocket. And shut up with the “Third World” cracks. My medical experience would be as good as anything that you’re likely to receive in America, unless you’re a senator or something.
Of course, Americans with real insurance get the state-of-the-art implant and better treatment, even if they are not quite senators. They may have Medicare Supplemental Insurance. My ex-wife has that, through Kaiser. It cost her $500 per month the last time I heard. That’s on top of the $1,200 per year for A and B, and she’s probably paying for C and D as well. So she’s up to about $8,000 per year TO BE HEALTHY. Doesn’t that sound like a lot of money? Compare that to civilized countries, like France, or Canada, or Denmark, or Japan, or New Zealand, or South Korea, any of about twenty-five other countries where the government actually works for the good of their people, where her total bill for annual health care would be, of course, ZERO.
The solution to all of this is that we join the civilized world and provide all U.S. citizens with comprehensive single-payer health insurance, aka universal health care. America spends more per capita for health care than any other country in the world, much more, and we receive much less, much, much less. All of the extra money goes to a for-profit medical system, a for-profit hospital system, a for-profit pharmaceutical business, a for-profit health insurance business, and a network of for-profit hangers-on. It’s just bloody stupid.
There was a rush in the civilized world after World War II to move to a universal coverage system for medical care. The idea came up in our congress in Washington D.C., and the response was a deafening roar of, “oh, HELL no! That’s socialism!” That response was also stupid. I’m tired of being polite. That response was not only stupid, but also totally ignorant and quite insane.
So What Do We Do?
Americans have a blind spot when it comes to the word “socialism.” My big Oxford dictionary defines socialism as “a political and economic theory of social organization which advocates that the means of production, distribution and exchange should be owned or regulated by the community as a whole.” (Interesting that the “Oxford comma” that should appear between the words “distribution” and “and exchange” is missing from this Oxford Dictionary definition.)
That, my darlings, is a fine description of our American government, following the rules set forth in our own glorious Constitution! What part of “production, distribution and exchange” would not be part of interstate commerce? And all interstate commerce is regulated by the Federal government, which consists of representatives of the community, for the benefit of the community. Not to mention the socialistic aspects of many government programs, the Post Office, fire and police services, public roads and bridges, the armed forces, etc. Americans love socialism in its many manifestations in daily life. They even love Medicare and Medicaid. They just hate the word socialism!
This is based on an ignorant misapprehension of part two of the Oxford definition, which applies narrowly to a historical aberration:
“>(in Marxist Theory) a transitional social state between the overthrow of capitalism and the realization of communism.”
Virtually no one in the world still believes that Marxism is a thing, so we are left with the leading definition. It’s a bit late for “we don’t want socialism.” America's got socialism, in spades, and it works. To react so strongly to the mere word “socialism” is a childish, self-destructive tantrum with no arguable basis in reality. Honey, the Soviets are gone.
It’s time to wise up and move on to single payer. Ordinary citizens in America are waking up to this idea, as though from a dream. It’s going to take a while, though, because the usual suspects stand in the way of Americans who would prefer to have nice things. All of those profit centers that would be compromised would resist single payer to the death. All of our representatives in Washington will resist, because they share in the profits generated by the health care industrial complex. All of the running dogs everywhere from the conservative think tanks to the evangelical megachurches will resist based on one foolish excuse or the other. Maybe single payer will never happen. Oh, dear reader, I dread this part of every blog post that I write, where I have said my two cents already and have run stone out of ideas without really offering any useful suggestions for a remedy. I’m sorry for that. And I’m sorry for all of us, living in, or at least being a distant part of, a country that cares so little for our well-being. And after all we’ve done for America! Cruel fate, that.