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.
Some History
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 [2015])
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.
Medicare, Etc.
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.
Single Payer
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.
