"Unless you're Bill Gates you're just one serious illness away from bankruptcy."

--Dr. David Himmelstein, Associate Professor of Medicine at Harvard and lead author of a 2005 study on the relationship between medical bills and banruptcy


You've probably heard it before: medical costs here in the U.S. are way out of control.

I mean, way, way out of control. If you don't have health insurance in this country, you are at risk of financial and physical ruin. And, based on census reports, over 40 million people in the U.S. don't have it.

Much of this is because insurance prices along with health care have been rising double-digit percentages each year. For instance, according to an ABC News report, in 2002 Kaiser Permanente (a major insurer) increased premiums for consumers in East Coast states by as much as 75%. My own health insurance company hiked their rates 36% in 2003, right in the middle of a deflated economy.

Furthermore, a 2004 survey revealed that U.S. hospitals routinely charge uninsured patients four times what they ultimately bill insurance companies for the same procedures. How they expect people who can't afford coverage in the first place to be able to pay a 400% markup is beyond me.

Even those with health insurance, particularly those in HMOs, are sometimes denied beneficial care because an insurance agent rather than their physician ultimately decides what care they should receive.

For instance, a 2003 study conducted by the Institute for Ethics at the American Medical Association asked 700 doctors how often they had withheld information about a "useful service to a patient because of health plan rules." 23% of the U.S. doctors surveyed said they sometimes did this, and 8% said they frequently failed to tell their patients about all treatment options because of the rules imposed by the patients' health plans. Those who served Medicaid patients were especially likely to not share information with patients.

The situation is slightly better than a few years ago when HMOs could regularly enforce "gag clauses" that barred doctors from even mentioning treatments that the HMOs weren't willing to pay for. Bad publicity convinced most health companies to drop such clauses, and most (but not all) U.S. states have subsequently banned such clauses.

According to Blue Cross Blue Shield of Hawaii, people in the U.S. spent $1.3 trillion on medical expenses in 2000; this was more than they spent on housing and food ... it's even more than the government spent on national defense. Many organizations expect U.S. health care costs to soar to $2.6 trillion by 2010. The Centers for Medicare and Medicaid Services estimates that American medical expenditures will equal almost 16% of the nation's Gross Domestic Product.

But broad statistics are a little abstract, aren't they? They get quite a bit more compelling when your friends and loved ones can't pay for insurance or health care.

Take Braunbeck, for instance. Like many professional writers, he doesn't make Rowling/King level paychecks. He's often lucky to make what he'd get at a minimum-wage job. The frustrating part is, that even though he's sold close to 200 stories and 10 books and is an excellent teacher, he has no college degree and thus he can't get a gig as a writing instructor at a college. The only other types of jobs he's had are as janitors and orderlies and such, and he really can't do manual labor any more due to back and joint problems.

I, with two college degrees, have only been able to find a very low-paying part-time job after a year and a half of searching. Braunbeck, with his ten years as a full-time fiction writer and high school diploma and bad back, has had of course no luck whatsoever in finding anything else.

So, health insurance for Braunbeck -- which would cost over $250 a month due to his age and history of health issues -- has been way out of reach.

Also like many writers, he has carpal tunnel. Last year, he had a bad flare-up that caused him excruciating pain ... couldn't move his hand, couldn't sleep. This happened around 9 p.m. after all the walk-in clinics closed. The only option you have for after-hours care in this city is to go to the emergency room.

So we went to the ER of a hospital with an inexpensive, charitable reputation, where we waited around for a couple of hours. A doctor came by, looked at his hand for about thirty seconds, wrote him a script for anti-inflammatories and painkillers, told him he needed surgery, and had a nurse bring him a wrist splint of the sort that can be purchased at a drug store for $15-$20

The bill? $500 for the 30-second ER doctor consultation, and $120 for the $20 wrist splint. I'm guessing the nurse didn't make $100 for the three minutes it took her to walk it down the hall. She'd handed it to him like it was a freebie; if he'd known the exorbitant charge, he'd have declined the brace, you can be sure.

Braunbeck's subsequent surgery took place at an outpatient center and took about half an hour from prep time to the nurses' assistant escorting him to the curb behind the clinic. It was classic drive-through surgery, the kind that's supposed to be ultra-economical. It would have cost him $5000, but the surgeon took pity on Braunbeck's lack of insurance and knocked his fee down to $2500. The anaesthesiologist didn't care and charged his full $800.

Flash forward to two weeks ago. Braunbeck broke his lower left canine tooth on a granola bar, and discovered it had gone bad. He didn't feel the rot setting in because a few weeks before that he'd had a severe back spasm and had to see his regular doctor ($70) to get a script for anti-inflammatories, muscle relaxants, and Vicodin.

So. Off to the dentist ($46) who referred him to an endodontist for a root canal for the rotted canine. The endo charged him $650 for the root canal (based on my research at dentistry sites, the going rate nationwide ranges from $400 to $750, depending on if a dentist or an oral surgeon does it) and temporary filling on the tooth, then told him he'd need to get his regular dentist to put a crown on it.

He called his dentist today to make an appointment, and found out they want $750 to put a crown on the tooth. Ack. He's calling around to see if any of the other dentists friends have referred us to can give him a better price, but I fear he's stuck, unless he can sign up to be a guinea pig at the OSU dental school.

That's going to make $1450 to fix One. Single. Tooth. That's more than what it cost me to get all four impacted wisdom teeth cut out of my jaw back in 1992.

How are we, with my $8/hour McJob and his 5-cents-a-word checks from publishers who regularly pay months after they've promised to, supposed to afford this?

And all this has been fairly minor stuff from a treatment standpoint. Heaven forbid one of us should really get hurt, or have something major go wrong.*

What good are all these amazing medical advances if regular people can't afford them?

I can completely see how the U.S. has turned into such a lawsuit-happy society. Imagine you have an accident or get sicker when treatment doesn't go as expected, and as a consequence you face enormous medical bills you have no way of paying. You can either go bankrupt ... or you can sue somebody (the guy who couldn't brake in time to keep from hitting you, the doctor who misjudged your infection) and at least have a hope of getting the money to pay your bills. You wouldn't have sued, otherwise, because you know people make mistakes ... but you need the money to pay for your treatment and keep the collection agencies from hounding you all day.

So you sue, and win, and after the lawyer's fees have enough to stay out of bankruptcy court. In the meantime, all the lawsuits from people like you drive malpractice insurance up and up, which drives medical costs up, up, up, thus spurring on more lawsuits and bankruptcies and on and on.

The winners? The law firms and the insurance companies, which get to play both sides of the field. The losers? Doctors and patients and everybody else.

Congress, of course, is composed of millionaires. Our President has lived a pampered, privileged existence from Day One. These folks have no concept of what it's like to have to watch a loved one suffer through pain because you can't afford a doctor; they're high on conservative ideology and flush with campaign donations from the insurance companies. They've apparently got no motivation whatsoever to try to improve the situation.

morven says Totally and utterly agreed. I especially agree with the point you make that I've made a bunch of times: the lack of affordable health care and any kind of social safety net in the U.S. is what makes the place such a sue-happy society. Why? Because the costs of any kind of medical problem can be immense. Even if you have health insurance. It constantly amazes me that people in the U.S. do not get just how much the lack of universal heathcare in the US actually costs, both in cold hard cash, and in terms of human suffering. Universal healthcare would be too expensive? Then explain why the current U.S. system costs more, as a percentage of GDP or anything else one cares to name, than the health care systems of any other nation on Earth.

TheBooBooKitty says I am 25 years old. I haven't seen a doctor or dentist in over 15 years. I probably won't ever get to see one. A nice side effect is that I also have to go to work when I am sick, since I can't afford to call off (haven't missed a day since 1998).

cbustapeck says I just graduated from college, so I am no longer covered by my parents' health insurance, and now I have to figure out what the heck I am going to do. I pay $90 a month for Adderall (or a few dollars less for the generic, which no pharmacies ever seem to have), and I have $120 visits to a shrink (who doesn't seem to do much) every four months. Most health insurance doesn't seem interested in covering anything else, either. And as an artist, with the work I do, I know I'm going to end up in the emergency room sooner or later. Either that, or I'll end up performing stitches on myself again. (not fun). Sigh.

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Insurance is inherently a poor investment. When you buy an insurance policy, odds are that in the long run you'll pay your insurance company more than they'll pay you. It has to be that way, else insurers would never be able to stay in business. Insurers profit from the laws of probability in the same manner as casinos - consider an insurance agent as a bookie who lets you place long-term bets on your own misfortune.

But that doesn't mean insurance is never worth having. The casino gambler places bets, against the odds, on something that he hopes will happen - not in ten years when he might really need his winnings, but in a few short seconds. The insurance gambler, on the other hand, bets on something he hopes will never happen, so that he'll be able to afford it if it does. Thus the purpose of insurance is one of security - to reduce risk to an acceptable level. A corollary is that it's not worth insuring something you can easily afford to pay for yourself. People who do such things are generally the same sort of people who play lotteries.

Unfortunately, most health insurance policies seem to be designed by devout Powerball followers. By involving middlemen in virtually every transaction involving medical treatment, they increase costs to both the patient and the practitioner. The only winners are the insurance companies, and presumably the elected officials whose campaigns they funded.

For purposes of analogy, suppose you own a house. Further suppose that your house is worth a lot of money - far more than you have in your savings account. If the house burns down, you're out of luck. You'll never be able to buy another one. So Bob the insurance salesman makes you an offer: if you pay him a hundred dollars a month, he'll buy you a new house in the event that yours burns down. Maybe you accept the deal - you'd rather make a poor investment than face the possibility of having to live at that scary motel down the street where fat cockroaches and skinny junkies scurry about all hours of the night.

But Bob's out to make as much money as he can, of course. Catastrophe policies like yours are profitable, but they're not the sort of thing that will enable him to retire to Tucson in ten years and live out his days in golfing bliss. So he also offers you the "deluxe complete home coverage package." If you pay him five hundred dollars a month, he'll still replace your house if it burns down, And now, for the price of a much higher premium, he'll pay to fix just about anything else that might go wrong with it. Roof leaking? Find a roofer approved by Bob's company, file a claim, and Bob'll pay the roofer to fix it. You don't have to negotiate the roofer's rate - Bob takes care of all of that. He might not be getting the best deal for the money, but you already paid him, so what do you care? Even routine maintenance is covered - every few years, your house is painted and your gutters cleaned at Bob's expense. Cat clawed the furniture? Drunken party guests vomited all over the carpet? You don't have to worry about such trivialities. You're covered. And Bob is shopping eagerly for a new set of clubs.

Then Bob starts to raise his rates. Pretty soon, you can no longer afford his "coverage," and you go back to your original disaster insurance. The next time your roof needs fixing, you pick up the telephone book and decide to shop around.

You soon find that the rates roofers are charging nowadays are astronomical. You try to negotiate, and they just laugh at you. They've been dealing with insurance companies for so long that the notion of getting paid by a customer instead of an insurer is practically foreign to them. For years, Bob and his friends have been telling roofers what they can do to fix people's roofs, and how much they'll be paid for it. The upshot is that roofers don't really have to compete any longer to offer their customers lower prices. In the long run, people lose more than money by purchasing too much insurance. They lose choice as well.

Most individuals aren't foolish enough to purchase the sort of insurance I've described on their homes. And come to think of it, most people who actually purchase health insurance don't buy such bloated policies either. I know I didn't - my deductible is a few thousand dollars. I'd be a fool to want to file insurance claims for something like penicillin or eyeglasses, which I could easily write a check for and be done with the matter.

But many people have such wasteful insurance coverage anyhow. It's become standard practice for an employer to add health insurance as a "benefit" when hiring someone for any job designated as "full-time." The employee usually doesn't have any choice in the matter - in most cases, he can't simply request the right to take care of his own medical needs in return for an increase in salary commensurate with his employer's cost for the unwanted insurance. It isn't really the employer's choice either, as long as companies receive tax benefits for funneling their staff into the gaping maw of the health-care bureaucracy. If the guy with the gun and the handcuffs tells you he'll take less of your money if you do things his way, you'll do it if you want to keep your business afloat.

The overall effect is a vicious cycle - the overhead and waste of insurance companies increase medical costs to the point where people without conventional, 9 to 5 jobs can't afford treatment, and are thus forced into entering the rat race, which means more money for the insurance industry and higer medical costs for people working outside of corporate structures. This makes it ever more difficult for self-employed artists, writers, programmers, farmers, cab drivers, strippers, etc. to earn a living on their own. That can't be a good thing.

Socialized health care is most emphatically not the answer. The prospect of the Federal government taking over, employing all the physicians and telling them what they can and can't do to treat your illnesses ought to be enough to scare you to death - perhaps, in the long run, literally. The Federal bureaucracy makes even the worst of the insurance companies look honest and efficient. Socialized medicine means an increase in pencil-pushers at the expense of practitioners. It's a mountain of red tape for a surgeon to tunnel through before he can even lift a scalpel to begin a life-saving operation unapproved by the Powers Above.

And it opens the door to abuse on a massive scale - a legal monopoly of the knowledge and equipment needed to repair bodies and save lives, held by the people responsible for the War on Drugs and the War on the Bill of Rights. Picture yourself in the following scenario:

"Sure, we'll fix your ankle right up. Just pee in this cup here and sign that loyalty oath."

I, for one, would hightail it (or in this case, probably limp!) to the nearest black market clinic. But if your condition were critical or you couldn't afford to pay cash to an underground doc, you'd have to choose between your freedom and your life. And all but the most zealous libertarians would choose the second - who wants to be a martyr to something as unromantic as a welfare state?

It's clear that medical costs are becoming outrageous. And it ought to be clear to anyone whose head isn't buried in the sand that the commonly proposed alternative is just a recipe for disaster. Centralization of power in the health care industry has had such deleterious effects that only a fool would seriously consider increasing it by handing it over to Washington.

I don't claim to have any magic pill to solve the whole problem. Anyone who does is probably lying. But there are a few ways to cut your own medical costs - the first and most obvious being if you don't have mandatory coverage from your employer, look for insurance yourself to get the best deal with the highest deductible you can reasonably afford. When you can, patronize self-employed physicians, dentists, chiropractors, etc. and make it known that you'll be paying your bill yourself. Small practices naturally have lower overhead, and are typically far more willing to deal with their patients individually in matters financial as well as medical. What's more, they generally don't have full-time "dealing with the insurance people" people on staff, so they'll welcome patients with less paperwork. You may be able to negotiate costs; if you can't, consider shopping around.

If you're unfortunate enough to have a major medical condition requiring continual, high-priced treatment, there's another route worth considering. I would never have thought of it myself until my mom went to work at a hospital a few years ago. In retrospect, it should've been obvious - just as a restaurant will give its employees free meals, a hospital might take care of its employees' medical treatment. Chemotherapy is expensive stuff, but when it's all done in-house and there are no claims and referrals to process, apparently the cost drops enough to make a hospital with an oncology department willing to provide it as a fringe benefit to a valuable employee. I can only speculate how great the difference is between the price hospitals charge insurance companies for chemotherapy drugs, and what it's actually costing my mom's employer to keep her healthy. But the markup has to be substantial.

On a related note, there used to be small towns where the local dentist would fix a poor farmer's teeth in exchange for fresh eggs every week. Such quaint Norman Rockwell-isms are long gone, but in principle there's nothing stopping someone from exchanging medical services for goods or services of some other sort. Such an exchange would almost invariably be "off the books," which is why politicians hate barter economies - they're much harder to tax. If you're an auto mechanic and your neighbor is a dentist, trading a timing belt and a tune-up for a filling or two just might be a better deal for both of you than "over the table" transactions that would have to be recorded and reported to the IRS. Come to think of it, insurance companies don't get a piece of the pie either. This is starting to sound better and better!

My last comment concerns a more long-term strategy to avert government takeover. There's an organization known as "The Shrine" whose members, known as Shriners, wear funny hats while marching in parades and incidentally operate a network of children's hospitals.Free children's hospitals, but they tend to be limited in scope. If your kid has a bunch of awful third-degree burns, though, the Shriners will help if they can, for no charge. Doesn't matter if you're unemployed and living out of your van, or working 60 hours a week deciphering old COBOL code. There's no "government assistance" involved - the Shriners are an entirely private organization.

I like the Shriners. The found something they considered worth doing, developed an effective way of doing it without impinging on anybody's freedom, and set about doing it. If you've just cashed in a bunch of stock options, I can't think of a more worthwhile way to keep that extra money out of politicians' hands than to fund people like the Shriners so they can fix up crippled kids. The Shriners' organization provides a model for what may ultimately be the best way for reducing government dependence and the taxation, graft, waste, and (some would say) war that inevitably follow. The philanthropist seems a dying breed, slowly squeezed out of existence by the taxman and his ever-replenished barrel of pork. The Shriners are still at it, though, operating with an efficiency that puts Medicare to shame. The chief fallacy of the welfare state is that to help the genuinely unfortunate get back on their feet, it's necessary to enact laws that engender a whole class of parasites. The Shriners, and those like them, prove welfare statists wrong every day. I see no reason why the tide can't be turned.

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