American Health Care: Why It Sucks (according to Malcolm Gladwell)

Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world’s median of $2,193; the extra spending comes to hundreds of billions of dollars a year. What does that extra spending buy us? Americans have fewer doctors per capita than most Western countries. We go to the doctor less than people in other Western countries. We get admitted to the hospital less frequently than people in other Western countries. We are less satisfied with our health care than our counterparts in other countries. American life expectancy is lower than the Western average. Childhood-immunization rates in the United States are lower than average. Infant-mortality rates are in the nineteenth percentile of industrialized nations. Doctors here perform more high-end medical procedures, such as coronary angioplasties, than in other countries, but most of the wealthier Western countries have more CT scanners than the United States does, and Switzerland, Japan, Austria, and Finland all have more MRI machines per capita. Nor is our system more efficient. The United States spends more than a thousand dollars per capita per year—or close to four hundred billion dollars—on health-care-related paperwork and administration, whereas Canada, for example, spends only about three hundred dollars per capita. And, of course, every other country in the industrialized world insures all its citizens; despite those extra hundreds of billions of dollars we spend each year, we leave forty-five million people without any insurance. A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy—a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper—has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers.

The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions. Do you think that this kind of redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem.

excellent article. thanks for that.

And I'd rather go to an American doctor than a foreign one, especially a British one, where over half of their doctors aren't even trained there and have to be imported from other countries. Is it rocket science that when you pay more money you often times get a better service/good? Why is it Canadians come to American to use our private services but never the other way around?

Americans have fewer doctors per capita than most Western countries.

That is neither a good or bad thing. Isolated statistic. We could be more efficient or we could need more of them. Doesn't follow through with what that statistic is supposed to say. No causation/correlation for any theory.

We go to the doctor less than people in other Western countries.

Isolated statistic but not surprising. You'd be more likely to want to see a doctor for the most minor injury if it's on another person's dime, wouldn't you?

We get admitted to the hospital less frequently than people in other Western countries.

Doesn't even bother to mention how long it takes to get admitted compared to America. While prices may prevent people from getting treatment in America (53 percent of the cases of "unmet" needs) it is waiting lists that is the main deterrent in Canada (32 percent of cases).

We are less satisfied with our health care than our counterparts in other countries.

"Overall, Americans were more likely than Canadians to report that they were very satisfied with health care (53 percent compared to 44 percent)".

http://japan.usembassy.gov/e/p/tp-20040603-20.html

Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes?

In a cosmic sense, no, but in a realistic sense, yes. I'm not God and I'm not gonna pretend I can undo things like that. I do recognize that trying to undo the misfortunes laid upon people for reasons beyond their control by imposing on other people new burdens is both ironic and possibly much more damaging. It's unfair that black Americans have to grow up with a stigma of slavery that happened before they were born, but would it be fair to impose reparations and quotas on everyone else for a system of slavery that took place before they were born? It's social justice. Jim has x - 2 for reasons outside of his control, so let's make Mike pay 2 to make up for Jim's negative 2. Now Mike has had to give up 2 for something outside of his control in order to make up for Jim's misfortune (which was outside his control too). We haven't "solved" the misfortune that Jim originally had, we just made Mike pay for it. Now Mike is x - 2. Similar thinking is found in the "THE AMERICAN PEOPLE CANT PAY FOR HELATH INSURANCES!!! SO LETS MAKE A UNIVERAL SYSTEM THAT WILL BE PAID FOR BY.............THE AMERICAN PEOPLE!!11". Where does the "magic money" come from to pay for it that wasn't previously there? The logic here is kind of funny if it weren't kind of sad.

In the rest of the industrialized world it is assumed...

Anyone who starts of a sentence masking his personal opinion by trying to speak for the industrialized world is getting off on the wrong foot.

The first country to try socialized healthcare paid by the gov't was the Soviet Union and they eventually were one of the few countries that had a declining life span and a rising rate of infant mortality (the latter something the author seemed concerned about, I guess).

Phail.

all insurance systems ever spread the load of burden away from the person actually suffering - that's the point of insurance, and cunga's discovery that the wrong people are "burdened" is merely silly

principle of all insurance ever: jim = +2 and ten thousand mikes past and future each = -0.002

if the massed mikes are smart enough (and not obsessively greedy) they can collectively set up a health insurance system where everyone, past and future, spreads the load between them, so that the healthy, by hugely outnumbering the unhealthy, reduce their own burden to a microscopic level -- if the mikes however ingather more and more into a gated and luxury community, allowing a system where high-quality healthcare is unavailable outside this small community, they risk becoming a quarantined island of parasites set in a sea of the unwell --- unprotected in particular from new pandemics (which will devastate communities which have never gained adequate immunity as well as damaging the higher-immunity communities more rough-and-tumble masses outside the quaratined gates, whose general wellbeing is actually essential to the maintenance of full-on luxury within the gates) (= if all yr workers are off sick, yr corp will suffer)

ultimately since mike's wellbeing depends a little on jim's, it's only common sense that mike pay a little for jim's health upkeep

I think Belgium is in the top five at the very least. This is largely due to me, the biggest hypochondriac on this planet. ;-) (I think I read somewhere that Japan was highest, followed by Belgium.)

gabbneb -- Um, I can send you pictures of my grandpa, really.

THAT IS WHAT INSURANCE IS FOR!!!

Does everyone who drives in the US have to have 3rd party car insurance?

32% of treatment-seekers having a lengthy wait sounds better than 53% not being able to afford to consider the option.

How many doctor's offices have you visited lately, if you're in the U.S.? There are lots of doctors that were trained elsewhere, or have immigrated to the U.S. You'd have to have your head in the clouds not to have noticed. But I suppose it's convenient for your argument.

And I'd rather go to an American doctor than a foreign one, especially a British one, where over half of their doctors aren't even trained there and have to be imported from other countries. Is it rocket science that when you pay more money you often times get a better service/good? Why is it Canadians come to American to use our private services but never the other way around?

So a 240% inflated cost is justified by a kind of fuzzy intuition you have that American doctors are somehow better than Sweedish or British or German doctors?

I'm sure your grandpa did, I'm sure he's not alone, and I'm sure Europeans have done so as well. But I posit that America vis-a-vis Europe has a greater per capita population that is rural or distant from major medical centers, which population is also more elderly and more prone to the I-don't-need-any-help attitude. Except for the latter (which you suggest that you have shared to some extent), this tells me nothing about the quality or distribution of health care in the urban and suburban areas where 4/5 of Americans live. Show me an outbreak of diy dentistry in the inner city and you've got something.

Relying on this excerpt, the article also seems to judge the health care system by its outputs while ignoring differences in inputs, i.e., America's poorer eating habits, greater automobile use, laxer environmental laws, etc.

The idea that per capita spending on medical cost is relevant is also ridiculous - so Americans, who have more disposable income, spend more on high-end, and non-medically necessary procedures. This tells us what?

And? We have less time than people in other Western countries. Next!

We are less satisfied with our health care than our counterparts in other countries.

And? We are more individualistic and demanding than our counterparts in other countries. I mean, we reportedly are more likely to believe in God than Europeans. Does that mean God is more likely to exist in America?

I think the article stated that American surgeons perform more "high-end medical procedures, such as coronary angioplasties" than other countries. It could simply be a matter of wealthy Canadians going to where the skilled doctors are. Assuming the American doctors and their skills are evidence of a good healthcare system is flawed. Maybe those people need their angioplasties because they never were diagnosed with high blood pressure and cholesterol so they need surgery. Maybe we have well-funded research hospitals. Neither of these mean that the average guy on the street is getting better standard medical care.

gabbneb massively OTM.

Still, I think that the healthcare issue is important regardless of Gladwell's feelings on it. At no point does he mention the malpractice lawsuit paranoia/rising insurance rates/prescription drug cost circle of badness that's raising the cost of care in the US. If anything, I would imagine that people are getting a lot less care for their money despite higher average expenditures.

We need to do a lot of things, starting with a more health-conscious populace that understands certain risks and knows how to self-diagnose. We need to encourage regular doctor visits as a preventative maintenance of sorts, more doctors and better access in rural areas and for the poor, better access to specialists when the need arises -- my family has had referrals that can take months, during which they're suffering symptoms. There are some parts of our system that work well. Both of my parents have had ruptured discs and have been able to have fairly timely surgery. To me, that's a treatable condition that, while not immediately life threatening, is going to destroy your quality of life and make you unable to do work. If we lacked insurance, they'd probably be popping ibuprofen and eventually dealing with digestion issues.

Some of these issues are more pronounced in the US, and some may be worse in countries where universal healthcare creates a longer wait for specialists. There has to be a way to learn from the mistakes elsewhere (and our own) and change the system more radically.

Also, to be clear, the pulling teeth with pliers line is a reference to an actual case described in a study that Gladwell references in his lead. And saying we spend more per capita because we're wealthier is just insane. We're not twice as wealthy as the rest of the industrialized world, and even if we were that wouldn't explain why we spend three times as much as Canada on administration and paper-pushing.

We have the best health care system in the world...for insurance companies.

Americans have fewer doctors per capita than most Western countries

i'm looking at 97 data showing that the US does in fact have fewer doctors per capita than Italy, Germany, Sweden, France and Denmark. But it has more physicians per capita than the UK, Canada or Australia. and when you add nurses to doctors, the only countries listed that score higher are Sweden, Germany and Australia.

most of the wealthier Western countries have more CT scanners than the United States does, and Switzerland, Japan, Austria, and Finland all have more MRI machines per capita

that's nice. there are only a handful of wealthier countries - Luxembourg, Norway, Switzerland, a couple of islands. the 90s data i'm looking at says the US, per 1 million persons, has more CT scanners than, and twice as many MRI machines as, any of the countries I listed in the previous response.

American life expectancy is lower than the Western average

per my 90s data, the same is true of the UK and Germany, both which have similar cancer mortality rates, and poorer heart disease mortality rates. could it be, perhaps, that these are the Western countries with the poorest diets and environments?

And saying we spend more per capita because we're wealthier is just insane. We're not twice as wealthy as the rest of the industrialized world

no, but we're roughly 1.5x as wealthy as the EU. and it's not just wealth - there are cultural factors (that are tied into wealth).

no wait, Luxembourg is the only country that is wealthier (by per capita gdp, which may be a totally stupid measure - is there a better one?)

Like what? I mean, are you seriously suggesting that our higher per-capita expense is not directly related to having to support an entire private insurance industry wedged between providers and patients? And the larger point isn't so much whether there are some countries we have more doctors or CT scanners than, it's whether our radically higher expense is in any way justified by our level of care or coverage. Is there any way to read the data that suggests the answer is "yes"?

And obviously the issue isn't whether we should adopt the Candian model, the British model, the Swedish model or whatever, but whether we should start from the same point as the rest of the world -- universal coverage with risk distributed across the entire population -- or continue with some further variation on our every-man-for-himself-and-HMOs-against-all system.

no, but i'm saying there are other directly related factors

the larger point isn't so much whether there are some countries we have more doctors or CT scanners than, it's whether our radically higher expense is in any way justified by our level of care or coverage

whose larger point? Gladwell is right of course that our system needs to be changed, but as Don notes that's almost a truism now, at least among the New Yorker's audience. Gladwell's repeating it in part so he can say America sucks.

The worst part about the article, which unsurprisingly transcends the predictable content, is that Gladwell doesn't bother with solutions. It's very easy to look at the problem (indeed, it's fookin' simple to look at healthcare and come up with a list of complaints, no matter what part of the system you've had personal experience in) and reduce the equation to, "It is, instead, about a few very simple questions." Gladwell intimates that we're missing the boat on this, that the people of this country are so busy coming up with bad solutions that they fail to see the forest for the trees. Which isn't true at all. The frankensteined solutions that come from the locked rooms of Hillarycare planning meetings or MSAs or the recent Republican drug giveaway all eminate from recognition of the problem. Gladwell chooses to ignore the larger cultural issues that are the essence of political solutions in this country. The buy-offs, compromise, and other grotesque politicking always transcend the simplitic assessments because in reality there's not a simple assessment of healthcare, other than the fact that the delivery system was not designed to provide unlimited treatment on demand for each citizen.

Very true, which is why I think it's likely that we'll see rationing long before we see any sort of workable long-term "solution" for what ails the health-care system.

Gladwell's a journalist. He's been researching and writing on science, medicine and culture since the mid-90s, well before the success of the decidedly mediocre Tipping Point full-length. Let's not turn this into a referendum on qualifications. Tired canard.

HEY LOOK! THE GOODYEAR BLIMP!

Full stop.

And this is where Gladwell strikes me as most OTM: A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy—a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper—has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers.

Where, oh where, is teh Invisible Hand when we need it most?

What Gladwell's advocating is a change of philosophy -- as he defines it, from actuarial insurance to social insurance. No, you're right, he's not presenting a point-by-point model. But we can't even get to all the ugliness of the trade-offs and compromises until we accept the basic idea that some kind of universal coverage makes sense. And saying it's "gospel" among New Yorker readers is kind of a dodge. So? There's a difference between having a general idea about something -- like, the American health care system sucks -- and reading a long, well-thought-out exploration of same.

The frankensteined solutions that come from the locked rooms of Hillarycare planning meetings or MSAs or the recent Republican drug giveaway all eminate from recognition of the problem.

Are you kidding? The Hillary plan was either too pragmatic or cowardly -- take your pick -- to take on the insurance companies, which means they punted on the biggest contributor to inefficiency in the system. (They thought they could buy the insurance companies off by building them in, but it's hard to buy off someone who's already making more money than you can possibly give them.) Medical Savings Accounts are -- as Gladwell notes -- ideological instruments, not medical ones. And the Republican drug giveaway was a classic sleight-of-hand, a straight-up corporate handout disguised as a health benefit. It had very little to do with recognizing or addressing real problems. (If it had, it would have started by encouraging Medicare to use its massive purchaging power to negotiate lower prices for drugs, instead of expressly forbidding it to.)

xpost to roger:
to crib from another New Yorker contributor, C. Barsotti, I think the Invisible Hand is giving us the finger.

Gladwell is a very smart guy, but, and perhaps understandably given the success of his work thus far, I think he does have a bit too much of a taste for the big idea (especially the big, counter-intuitive idea - think-by-not-thinking! efficiency-is-inefficient!) and the interesting anecdote, and this leads him play with the facts a little bit in this piece.

for some more interesting thoughts, here are Gladwell and Adam Gopnik on the US, Canadian, French, etc. systems a few years back. most intriguing (but perhaps again 'too' interesting) is the idea that the US system is built for men, and the Canadian system for women.

OTM, and he gets away with it much more in his articles, where he can pull a heyBIGIDEAgottago! than in book-length work, where the lack of a point becomes painful and embarassing.

Reading these posts depress me terribly. NY-ers what providers do you have?

Nothing. It'll be nice when Obamacare finally kicks in...

That's what I figured

Tipsy mothra, hadn't really clocked the 3-month premature bit of that, that must have been pretty terrible. Hope all is good with you guys.

Time ran a great article a few months ago about what hospitals charge for different services. And now this:

http://swampland.time.com/2013/05/08/an-end-to-medical-billing-secrecy/?hpt=hp_t3

Tipsy mothra, hadn't really clocked the 3-month premature bit of that, that must have been pretty terrible. Hope all is good with you guys.

Oh, it was years ago -- 2004. He's finishing up 2nd grade now. But thanks. Yeah, it was a rough start. And would've been a lot rougher if we'd had to worry about medical bills on top of it.

Reviving a separate old thread with a question— I’m curious as to what actual health care treatment is like, like, “on the ground” in other countries. It’s tricky enough to navigate getting care in Canada, I’m curious as to what people actually mean when they kvetch about HMOs and NHSs— and what things are like in the rest of the world

In Canada, you need to either inherit or come-by-chance upon a GP (family doctor), through research and/or waiting lists— long waiting lists. I never had one in Ontario (part 1), then I got one through nepotism in Quebec, then I got one by the books in Ontario (part 2) who remains my “official” family doctor (despite my recent move to BC).

If you don’t have a family doctor then it’s walk-in clinics and ERs for you. In BC, I just went to a walk-in clinic because the lesion on my face that my family doctor diagnosed as “a sun freckle” has at the very least revealed itself to be a basal cell and perhaps something more serious. I went to four walk-in clinics on a Saturday at 9am in Vancouver and was turned away— even almost like “are you kidding?” responses from one receptionist. On Monday I showed up at 6am at a walk-in clinic, and the lobby was already full (!) and I secured a spot and heard (at 6:10) the nurse tell the receptionist “no more walk-ins today”— I assume that this clinic normally takes appointments.

I got a referral for a dermatologist and I can expect to get a call for an appointment in four weeks.

I’ve never had a psychiatrist despite my mental health woes, they’re just too hard to find. I’ve never paid for anything in my life beyond (reasonably priced) medication, dental care (500 CAD a tooth to get wisdoms out, 250 CAD for a cleaning, thereabouts?), eye exams (I got LASIK many years ago bc my eyes were so fucked). I used to pay 150 CAD a week for therapy. Never for a hospital visit or a doctor’s visit.

In Canada, what dissuades from “seeking help” isn’t the cost of it but the wait times. If you go to an ER (especially in Quebec, where wait times are legendary), even with a broken leg you might expect to wait 4 to 8 hours. If it’s not serious you might wait longer.

It does legit seem like brain drain is a real thing— Canada’s care standards suffer because all our best doctors just move to US where they get paid more; my younger brother did exactly this, works in a hospital and basically has a palatial life.

Meanwhile I just would like someone to get an eyeball on this potential skin cancer that’d be nice

While I'm intimately familiar with all the problems facing health care in the U.S. (and getting worse with private equity, mergers, reductions in Medicaid that helps reimburse hospitals for treating un/underinsured patients, etc), I'm lucky to have excellent insurance. And the last 4 times that I or my wife have gone to the ER, we were triaged and roomed in less than 10 minutes (that could very well just have been luck with timing, but I've never had a long wait at the ER). I didn't pay anything out-of-pocket for cancer treatment or hospital stays, just reasonable co-pays for my meds.

Waits are definitely getting longer here (months out) to see primary care or specialists unless it's urgent (my wife was able to schedule neuro consults within weeks recently). But I was in the UK recently and the wait times for urgent care and appointments were beyond even what I was expecting.

I know I'm super privileged, although this health insurance is the main reason why I'm holding onto this job indefinitely, and I'm sure tons of people here have horror stories.

i've definitely had 4-6hr ER waits before in the states, incl for serious stuff. but tbh would probably still be happy to trade that as the norm if it meant not having to worry about losing my home if i get the wrong kind of illness.

maybe for another thread, but I am actually leaving the US for the next year at least b/c of this (while keeping residency #privilege)

my out-of-pocket went to $1150 a month which I simply can't afford, so I refuse to live in a country where I will go bankrupt and lose my house if I get injured or sick.

Nicaragua, our destination, does not have a great health care system but so far all my wife's interactions with it have been way more positive than in the US.

I got a referral for a dermatologist and I can expect to get a call for an appointment in four weeks.

It's more like six months plus in the UK, I've got psoriasis and my GP sent an "urgent" referral to the dermatology department in my local hospital... in July. Which is completely useless for psoriasis because it comes and goes, the last time I actually saw a dermatologist, which was well over a year ago, it wasn't that bad so it was a complete waste of everyone's time.

This is what is curious to me (about US health care)-- what is "the wrong kind of illness"? My older brother (now a permanent US resident, somewhat centrist in his views but a good guy) tells me that he vastly prefers US health care to what we have in Canada, that it is more precarious in terms of "surprise! you owe a lot of money!" but that the standard of care and speed of process far outstrips Canada's methods. I'm under the assumption that your average US citizen finds a joe job more attractive because of the insurance it offers (and in Canada, certain of my creative class friends enjoy the benefits of cushy full-time employment at fairly entry-level jobs as a supplement to their creative endeavours, as they now have optical, dental, massage and therapy all covered by their employer). What is offered to middle-to-lower class US workers? I guess I'm not entirely sure about how ACA works-- I know it requires that all citizens get ~some~ kind of insurance, but I'm unsure as to how that plays out.

A perhaps interesting anecdote: from age 16 I would sporadically suffer from cripplingly painful headaches, stabbing pain that would cause me to wince. The pain would, after the stab, immediately abate; at its worst I could actually feel my body releasing dopamine following every stab and it became this weird awful thing. I couldn't function in English class and my teacher sent me to the ER. The doctor who examined me surmised that it was a build-up of earwax, and I spent the next 13 years under this assumption, flushing my ears, doing dumb stuff like candling, but always still suffering this recurring horrible situation. (My high school friends had a field day with this, that I went to the ER "because of earwax".)

I had an attack while travelling in USA, and went to a walk-in (as it was so bad that I felt there was no other option). The doctor saw me immediately, talked to me for maybe ten minutes, and completely changed my view of my personal health: not earwax at all, but an inflammation of one of the three nerves that crisscross my scalp, and easily treated with an anti-inflammatory (i.e. Motrin). Such a stupid simple issue. The doctor was great. I'm appalled that I went so long without a "correct" diagnosis. My bill for the 10-minute visit was $500. This happened in California.

In contrast, I woke up in Belgium one day, elected to run on the treadmill before getting in the car to drive to Paris. I was running one of those interval programs and set it to a "difficult" setting as I was in good shape. I got distracted by the television, and wasn't monitoring my heart rate. After about fifteen minutes, I suddenly became aware that I was really sweating profusely, and my heart rate going like mad. I checked my heart rate on the sensors and it was 180. I was like "omg wtf" and I slowed down and eased back into normal. Then, as is my custom, I drank four or five cups of coffee with breakfast.

We started driving to Paris with my travelling companion behind the wheel. Pulling out of a rest stop, she incorrectly misread a yield sign (and thought we had right of way). A tractor-trailer slammed on the horn as it was barrelling by and missed us by inches. I gasped violently and my heart contracted into a tight, painful fist. I said to her, "something is very wrong. We need to go to a hospital right now." We did so, outside of Lille. With my crypto-French I was able to communicate to the nurses what was going on-- 180 bpm treadmill moment, 2L of coffee, near miss on the highway-- and they immediately removed my shirt and hooked me up to sensors to test what was going on. No underlying issue, just circumstance, apparently, but they gave me diazepam to keep on hand in the event that it should happen again.

As all this was happening, I was frowning a big frown, remembering my $500 visit to a Californian clinic about that neuralgia thing. "This is going to cost a fortune". After it was all done, they told me it was to cost 105 Euro (including the diazepam) and that I could pay by mail, and they mailed me an invoice and I dutifully paid it. Whenever I see those lists of "every country's health care, ranked", and see France consistently at #1, I remember that day.

t is more precarious in terms of "surprise! you owe a lot of money!" but that the standard of care and speed of process far outstrips Canada's methods.

yeah I think this is true, sadly the first part of that is a dealbreaker for me

I'm not entirely sure about how ACA works-- I know it requires that all citizens get ~some~ kind of insurance

The original legislation included a delayed phase-in of tax penalties imposed on those who chose to forego 'bare bones' medical insurance, the so-called 'bronze' plans, as opposed to 'silver' or 'gold'. This was a critical component designed to bring the population as near to 100% insured as possible. Of course the Republicans stripped out this requirement as soon as they had the power to do so. They stripped out some other critical parts, too.

In case it wasn't clear, the only consequence for having no medical insurance in the USA today is... you have no medical insurance. There is no requirement any more.

the ACA, while obviously goodhearted in its intention, is pretty horrific and kinda always has been imo -- you pay a high monthly premium for access to care that is extremely limited in terms of who are you able to see in network, and the plans are usually still high deductible even w/ crazy monthly premiums. the subsidies helped some but even still in my experience was nowhere close to being worth the money. how boxed in you become from a pricing and access aspect really encapsulates everything bad about the american healthcare system

i've been uninsured for like 1.5 years now. i've luckily avoided anything that has required a hospital visit, repeated visits to a doctor etc. i have also avoided routine care that i otherwise would have sought with insurance. however, i have found that doctors are sympathetic to people who don't have insurance and what the system puts them through and will work with patients to provide care at a cost that is affordable, manageable etc. it's actually an eye opening experience to go to a doctor's office and say "i don't have insurance and have to pay for this out of pocket" and find out what price they offer for their services. it's often way less than the cost of one monthly insurance premium payment, to say nothing of what the procedure/care itself would "cost" the patient on top of the insurance premium. it's important to remember that if you're insured and go to a doctor and ask how much xyz will cost you the individual that they can't actually tell you -- all they can tell you is how much they will bill your insurer, but how much your insurer will charge you is out of their hands. erasing this shell game by removing the insurer from the equation altogether will change your understanding of what american health care actually "costs" in real terms.

my boyfriend had to get an emergency root canal a few years ago w/ no insurance and it cost him several thousand dollars out of pocket. it was a tough pill to swallow out of nowhere but the dentist and dental surgeon that he had to see both took pity on his situation and greatly reduced the stated out of pocket costs for the procedures in order to not bankrupt him over something that was completely out of his control. i, of course, don't want to paint being uninsured as any sort of utopia, it's very scary and deeply fucks with the way you interpret signals from your own body, but when push comes to shove i think most doctors are still good hearted people who want to provide care to those in need and will work w/ patients to provide that care at a reasonable cost. having to do this has both given me more faith in american healthcare, at its core, while also further exposing the ridiculousness of what we are forced to endure normally.

the other thing w/ medical bills is that you can just choose to not pay them and roll the dice on whatever happens next. i feel like i'm dancing w/ the devil even talking about this but, in my experience and hearing from other uninsured people, in many cases, it just disappears. i would not say that this is a regularly recommended option, but it is an option

Wow thanks for sharing J0rdan. Sounds super Wild West.

I loved being unemployed and having access to great healthcare in MN. Now that I've had a job for the last few years, I can't afford health insurance

fwiw I have def had the same experience as J0rdan w/r/t people just writing off bills. more than once in fact. but I can't rely on that as I turn 60 this year, and I don't wanna gamble for 7-8 years until I retire and (hopefully) get Medicare like my wife. it's been rough since she retired and I lost my job w/health insurance 3 years ago, but at least I could afford the premiums for what amounted to catastrophic coverage only. In 2022 I think I had like $6K of medical bills alone, not counting dentist stuff.

I didn't get the policy canceled until January 2nd, so Regence sent me a bill for $72 covering those two days...

Just to add two horrible anecdotes about our healthcare system is the U.S...

First, I recently caught up with a friend from home and we talked about a mutual acquaintance we knew who passed away from cancer years ago. What I didn't know until now was that she was on Medicaid - it was a sad situation where she basically lost her position at a school (and hence her healthcare) and soon after discovered she had cancer. So she got on Medicaid in order to receive treatment, and after things went in the wrong direction, she let everyone in her family know about Medicaid's "estate recovery" policy, which is probably old news to some but I was completely unaware of it:

State Medicaid programs must recover certain Medicaid benefits paid on behalf of a Medicaid enrollee. For individuals age 55 or older, states are required to seek recovery of payments from the individual's estate for nursing facility services, home and community-based services, and related hospital and prescription drug services. States have the option to recover payments for all other Medicaid services provided to these individuals, except Medicare cost-sharing paid on behalf of Medicare Savings Program beneficiaries.

After she died, she had no estate left, every last dime was taken away. She wasn't wealthy but still it was a shock for her surviving relatives to see everything she owned of monetary value picked clean in cold and brutal fashion.

Which brings me to a worse story, told to me about six and a half years ago when I moved into a new neighborhood and got acquainted with my new neighbors. One of them worked for a hospital - forgot which - and she explained to me (with a bit embarrassment) that her department basically recovered payment for treatment when patients die - in blunt terms, when the hospital fails to keep someone alive, they still want payment in full and go after the next of kin as the responsibility is now on them. It wasn't a job she liked discussing - I'm guessing it was something she didn't intend to do for long - but I got the impression it was very harsh and depressing to do.

Anyway, my partner has floated the idea of us moving to her home country someday, and while it wasn't something I gave serious consideration before, in the last few years, it's impossible to shake off as something we may need to do even if, say, MAGA collapses and things go back to "normal." It's really shitty how things are done in the U.S.

i've luckily avoided anything that has required a hospital visit

pro tip: when I was uninsured and had an ear injury, I went to a doctor in the back of a latino bodega in Oakland. He was a real doctor, spoke perfect english, and there was his medical license right on the wall. Anyway, he figured it out and wrote me a prescription for some drops and I think I paid $50 cash? I would totally go that route again for minor stuff

Re: not paying bills and having them get written off - this is what I was referring to with Medicaid. Margins are thin in health care, and my understanding is that there's some combination of state and government funding to reimburse hospitals for care that they provide to uninsured/underinsured patients, and this is has gotten worse with Trump's bill.

I'm not an expert by any means, but idk, being uninsured in the U.S. and betting on good health seems crazy to me. Personally I wouldn't even want to be a freelancer at this point, unless my spouse had an employer-sponsored plan.

that's what I keep hearing: people are afraid to quit and start a business or something like that, because the situation around healthcare is so precarious

Bernie knows the answer, and we know he's right, but what can you do ¯\_(ツ)_/¯

The GOP has no real plan whatsoever other than to dismantle the (decidedly problematic) ACA.. and then replace it with nothing; or some trump cookie jar where you can save spare nickels for your next serious illness

If you don't have a job that provides decent healthcare, that must be YOUR fault

Most Canadians I know who make six figures supplement their public coverage with additional private coverage. I tried it for a year or so— funnily enough, and I don’t remember what I was seeing the doc about, but I once shared a waiting room with Conrad Black, who was mutteringly complaining to every nurse/receptionist he could accost that he needed to be treated immediately or at least given a private place to wait

I’ve been in a hospital in Thailand for five weeks now. I’m fortunately on my wife’s insurance but will still be paying the deductible and 20%. I almost had a heart attack when they made me sign a bill for the first ten days. It would have destroyed our savings. Then I realized it was in Thai baht (not USD) lol, so I did the conversion and felt better until it sunk in that that’s still a fuck ton of money!

Getting sick/hurt really sucks. I can’t imagine what uninsured ppl who get bills like this would do

jeez heez, hope they're taking care of you there! That sounds like a wild experience

Getting out Sunday or Monday but won’t be able to walk without support for a while, if ever. Lots of PT in my immediate future. I now own a wheelchair, a walker and crutches. Haven’t seen the bill for those yet.

It would have destroyed our savings

for so many people, this is just one unforeseen malady away

being uninsured in the U.S. and betting on good health seems crazy to me

it is crazy! but i'll tell you what's crazier -- being on a basic ACA plan and looking at a list of in network providers in your "area" and trying to find a single option that you find acceptable in terms of distance from home, quality of care, availability of appointments etc. it's the sort of thing that makes rolling the dice seem like an attractive option by comparison.

when i lost a job many years ago and switched to an ACA plan, i had to drop my PCP at the time because he was no longer in network and instead found a doctor's office in manhattan that, to me, felt basically like a patient mill. they took in people on ACA plans, did routine care for them, etc -- it was a fine office, the people were nice, the doctor who cared for me there seemed to take the job seriously etc but it was not a place where i had a genuine doctor to patient relationship in the way i had with my original PCP. when i lost my most recent job and decided to not even bother w/ the ACA, i went to my new PCP of several years (different person than the previous two) and told him that i didn't have insurance anymore. and what he told me is that he was there for me and would help me get the care i needed even w/o insurance. he started filling my prescriptions at a local pharmacy that depressed out of pocket costs. he provided care to me through direct messaging to avoid unnecessary trips to his office. this to me felt far better than having insurance through the ACA at the cost of being pushed into a system where you again begin to drown in red tape, bureaucracy, in network/out of network etc

i'd also say this -- if i had to choose to be in medical debt to any sort of entity, i would choose a hospital or doctor's office directly over an insurance company 1 million times out of 1 million. you never read stories in the newspaper about how someone is being bankrupted by a singular dental surgeon, or is being denied urgent treatment because they can't find a doctor who will treat them. but what you do read about all the time is people being bankrupted by their insurance companies, or being denied urgent care because their insurance company refuses to approve a procedure. in my experience, doctors take the approach of "we need to get this fixed and we'll figure out the cost later. i'll talk to the billing desk and we'll get it figured out." when you build choose to maintain these kind of relationships w/ people who care for you instead of giving yourself over to the insurance industry, you are treated with so much more humanity, dignity, and respect.

sadly I think you're correct

It’s a fair point but we would be completely fucked if our insurance wasn’t covering 80% of this. I think the gamble between an emergency root canal and a multi week stay in a hospital is pretty significant

a multi week stay in a hospital without insurance sounds terrifying and i hope to never have to experience that. but i wonder if you had an enormous bill from a hospital -- hundreds of thousands of dollars that you could never come close to paying back -- and said to them, "well look there's no way i can ever pay you guys this amount of money" what they would settle on with you vs what it would cost to hit all of your out of pocket maximums + your insurance premiums for the year. especially if you're on a high premium/high deductible/high out of pocket max ACA plan. i think the numbers would be a lot closer than you think

Well the point is you don’t have a 6 figure bill when you have insurance. Again I hear your point but you may rethink it when you hit your mid-forties. I’ve had two other outpatient surgeries in the last two years. I’m 46

a multi week stay in a hospital without insurance sounds terrifying and i hope to never have to experience that. but i wonder if you had an enormous bill from a hospital -- hundreds of thousands of dollars that you could never come close to paying back -- and said to them, "well look there's no way i can ever pay you guys this amount of money" what they would settle on with you vs what it would cost to hit all of your out of pocket maximums + your insurance premiums for the year. especially if you're on a high premium/high deductible/high out of pocket max ACA plan. i think the numbers would be a lot closer than you think

We went through this with my father-in-law about 15 years ago. He got very sick (after years of smoking and heavy drinking and generally being a POS, his whole system kinda collapsed on him) and had to go to the ER, which sent him to a rehab center, then when he got even worse they put him back in the hospital on a ventilator, which was where he died. The bills were pretty enormous, so my wife had to spend many long days talking to what they called "charity care" back then, and they wound up writing off basically the whole thing, because he was unemployed and destitute (though we were living with him) and none of the bills came back to land on us.

Currently I live in Montana and am very fortunate w/r/t health care. Because I am an unemployed freelance writer I am on Medicaid, so all my doctor's visits and medications (I am diabetic and take two different pills and two different types of insulin, one fast-acting and one long-acting) are free, and because there are no people here - the whole state has a population of 1.1 million - when I do go to the doctor the wait time is about 10 minutes, if that.

hospitals and doctors know that the cost of healthcare in america is completely fucked up simply because of the presence of insurers. they all know that if they could just deal w/ patients directly that the prices for everything they do would be dramatically lower. so when you actually give them the opportunity to operate that way, it's a far more sane experience than when you have insurance. again i'm not trying to say that this is utopic, it is quite stressful. but it is possible to receive care in the way that i.e. fgti received in other countries ("i randomly went to the doctor and they charged me $125 and i went on my way") in america if you offer medical providers the opportunity to conduct business in that fashion, especially if it's a place that has cared for you regularly as a patient

Oh for sure. The U.S. system is egregiously expensive due to insurance. I hope I don’t sound like I’m defending that. The whole point of my story was just how quickly you can find yourself deep in debt, with or without insurance, because your body decides to break one day

californian, feel lucky to have been with the same hmo for most of my life. hunting around for doctors and referrals and prior authorizations has always sounded really awful and antiquated to me.

The first time I dealt with any insurance issue was in Los Angeles - I needed care and went to UCLA and to my surprise they refused to see me. I knew nothing of insurance, only that I was covered (I'm pretty sure I was no longer a minor, but just barely), but they had to explain to me that they didn't take HMO, which is what I had. I walked out of there thinking 1) I had shitty useless insurance and 2) fearing what would happen to me because apparently I wasn't "covered" (though I was). Fun times.

The irony of this situation is that I had a friend then who was studying trauma medicine AT UCLA, and when I told him what had happened, he basically agreed to see me outside of the hospital at home and all turned out well, but still, it really seemed fucked up.

I've lived for long periods in the UK, France and Australia and have had dealings with all three health systems. Australia is the best, France not too far behind, UK a distant last. Here in Sydney I can usually see my GP the same day, or if not the next day. I don't pay, as he charges the government reimbursement rate, although GPs can charge more if they want and many do. My brother in London, on the other hand, has never even seen his GP and has only had phone consults. Last couple of occasions I wound up in ER, I was triaged more or less immediately and probably waited an hour to see a doctor. I'm in a wealthy part of Sydney though, it's probably worse elsewhere.

The lack of universal healthcare is one reason (the other being guns) that I could never live in the US.

xp that sucks! but i'm a total idiot and maybe i don't understand, you had coverage under an HMO but instead of going to the HMO for care you went to UCLA where you had no coverage?

i hear you Heez. btw my point is not that not having insurance is better than having insurance, i don’t think that’s true. the last time i was insured i suffered a minor foot injury playing basketball which necessitated an x ray, MRI, multiple visits to a sports medicine doctor, and multiple months of twice weekly physical therapy. all told it cost me a few hundred bucks and it fixed my foot. there’s no way i could have received that level of care without insurance, nor would i have sought it. and it’s really that “i can live with this pain but i don’t know what it portends for the future” avoidance of care that i dislike the most about being uninsured

i think my point is more that having seen both sides of the equation it’s much more of a “pros and cons to either situation” or “selecting from two sets of bad options” than it is black and white, especially if you’re talking about not having well subsidized employer insurance and are looking at the marketplace options

xp So this was my first time going to a doctor or hospital on my own. (Up until then, I had gone to my school's health center a number of times.) I was having allergy issues and given previous experiences, I wanted to get it treated before it turned into something serious. I wasn't a student at UCLA, but I was staying in their housing for the school term. Since the school's medical center was right there, I thought "hey, why don't I just go there?" I didn't even walk in even though it was close, I called first, and as soon as I gave them my insurance info over the phone, they slammed the brakes and said I couldn't come see any of their doctors. I was thoroughly confused - I had insurance, I had been using it for a while now and I had gone to hospitals before, including for emergencies...and all of a sudden this hospital is telling me not to come in? I called my insurance and they said even though I was not in-state at the moment, they'd still cover it, that I should be fine. So I called the hospital again and relayed the info and then two, maybe three different people got on the phone with me and said unless I was, like, DYING, they couldn't see me. Since I was green about insurance, I can't remember everything they told me because I didn't understand it at the time. but I think UCLA only took PPO insurance, no HMO insurance whatsoever, and since I had HMO coverage, they would not take it unless it was an emergency situation (and I shudder to think what that bill would've looked like - they would've admitted me, but how much of the visit would actually be covered?) I had no idea what PPO insurance was at the time, I just thought health insurance was all more or less the same.

Yeah avoidance of care is a big deal. Before I left the states I purposefully went and had all sorts of check ups done so I could avoid the situation I’m in now. I would not have done that without health insurance. Unfortunately my back was not one of them and here I am.

Btw I am in a very good hospital in Thailand. Unfortunately my family, including a 6 and 9 year old, are at home in Cambodia. I was told that under no circumstances should I get surgery in Cambodia. It’s been an extra layer of torture not being able to see them and also see how frayed my wife is due to handling all the childcare on her own. Hope to be back home on Sunday

ouch what an ordeal, birdistheword. it should all be much simpler!

Man Heez I'd love to read a thread about you talking about how things are in Cambodia. I have a friend who went once for a couple months because he needed to get a shit-tonne of creative work done and he wanted to eat cheaply and not be distracted but I'm like... Cambodia would be THE most distracting place in the world, for me

^ seconding this, would love a thread

Ok will do! It def not all positive