Blogging this tweet because this explains SO MUCH about the mindset of pretty much all the folks I’ve known who’re against single-payer, it’s not even funny…

This….

This never occurred to me. Not once. That Americans are against Health Care because they think it actually costs tens of thousands of dollars for a broken arm, hundreds of thousands for a complicated birth, millions for cancer treatment.

Because they’ve never known anything different. The idea that a broken arm is only a couple hundred bucks; a complicated birth a couple thousand; cancer treatment only tens of thousands; all easily covered by existing tax structures.

This explains a lot.  And it’s a good example of what I was talking about in my post on scarcity being used to prop up ableism – always question the idea that a resource is genuinely scarce.  Even if it seems obvious that it is, quite often that’s the result of careful manipulation and misconceptions that you’re not even aware of.  

And never think you’re too smart to be fooled by that kind of thing, it doesn’t work like that.  Similarly, don’t think people who are fooled by something are stupid.  Nobody can have all the information about everything, and nobody has the time and energy to investigate and put together conscious conclusions about every piece of information they’re given.  It doesn’t take being stupid, or even just gullible, to believe something like this.

I currently live in a country without free medical care and still, it’s enormously cheap compared to the USA. An American expat wrote a piece for our English language paper about how she paid more for parking at the hospital than giving birth to her baby that’s pretty interesting:

https://grapevine.is/mag/articles/2016/01/06/healthcare-in-iceland-vs-the-us-weve-got-it-so-good/

If price fixing was actually enforced against medical providers…

If this is difficult to assimilate, consider the humble aspirin. There are no aspirins on Earth that are worth the money that USA hospitals charge. Aspirin - a simple cheap form of salicylic acid - is worth less than pennies and the formulation doesn’t vary. You can buy packets of aspirin for less than a dollar and a lot of that is packaging. In market value, individual aspirins are worth fractions of cents. Hospitals in the USA will make a spirited attempt to charge you wild amounts for them. Ten dollars apiece! Twenty dollars? Thirty? Who knows! Hurray!

I … did not realize this

I do need to add here that part of the reason medications cost so much more in hospitals is because the cost includes helping to pay for the people preparing (the pharmacy staff) and administering them. It may sound like giving an aspirin to a patient isn’t a big deal, but it actually is, because aspirin is generally used these days as an anticoagulant rather than as a pain reliever. Which isn’t to say that drugs aren’t massively over-priced here in general. They are. But part of not having universal health care means paying out a lot of money to coders and billers, which takes money away from things like nursing care, which is way more important. Seriously, one of the biggest issues that we have here is how many people and how much money we have to spend to deal with the byzantine craziness that is all the different insurance companies–negotiating with them, following their guidelines for what they will & won’t pay for, etc. The money to pay nursing staff (and the patient care techs, the pharmacy techs, etc.) has to come from somewhere, and it’s the nurses who, with a lot of care and skill and background knowledge, administer the medications to the patients.

Oh see in the NHS, the nurses just cast a spell to materialize the aspirins from raw fundament, already in a little paper cup, and we pay them in acorns that we leave under toadstools.

Sorry, that was uncalled for, I just liked the mental image.

So we are actually agreeing with each other, I think you possibly got confused (probably my fault) and took a different angle.

Let’s say that the cost of making a burger is $5, and a restaurant burger costs $15. Everyone says, “hey, that’s pretty fair. Five dollars goes for the burger, five for restaurant overheads - salaries and electricity and decor and so on - and five for the restaurant to make a profit.”

In the UK, they said “okay, we’ve decided that burgers are a human right, not something you should squeeze profit from. We will charge $10 for a burger. That’s the cost of the ingredients, plus the admin fees of making and serving it and so on. It’s a nonprofit, a National Burger Service. but you can still pay $15 for a private one at a premium restaurant if you choose.”

America looked at that and said “burgers are $45.”

“But America,” everyone said, “but …why?”

“Because burgers cost a lot.”

“Er, could you show your math?” Everyone asked, except they probably said “maths.”

“Yes. $5 for the ingredients, $5 for salaries and electricities and the restaurant decor and whatnot. $20 for profit. And another $15 to collect the profit.”

Everyone else says “huh, how … interesting!” And continue to provide their citizens with $10 burgers, which somehow functions.

So then some American citizens say “oh, we like the look of the UK’s National Burger Service. Should we do that too?”

And America goes, “what, suddenly you can afford to hand out $45 burgers to every random fucker you know? Burgers are $45, you fools.”

And the citizens say “oh, you’re right, that sounds expensive, sorry. Let’s not do that.”

And this thread, including Elodie, says, “by the way - burgers themselves, as burgers, are worth more in the $10 range, which is what other countries charge.”

And you’re like “NO ELODIE BURGERS ARE $45 BECAUSE YOU NEED TO PAY FOR THE CARPETS, AND THE BURGER BILLING DEPARTMENT, AND THE COLLECTIONS AGENCIES, OTHERWISE HOW WILL WE PAY THE POOR SERVERS?.”

But that is not QUITE what we are talking about. Healthcare costs in countries with socialised medicine do not include the paying for the cost of the salaries of the billing departments because billing doesn’t work that way under socialised medicine.

So one way we could start working towards that is by saying “the $10 burger is possible, and indeed it is practiced in many economies.” Then, I think, people will feel more relaxed about it, and will start to consider it without panicking.

There’s a bit more to it than this, related to the effect of health care outcomes on the cost of providing health care.

In the US, clients who are known to be able to pay subsidize those who are not able to pay. This is because of a law that requires hospitals to provide emergency care to anyone regardless of means. 

However, emergency care is actually one of the most expensive types of health care to get. For a fewreasons: 

All of that ^^^ is to say that the way the US currently delivers health care to its poorest citizens is literally the least efficient way you possibly could do it, which means it’s the most expensive. US critics of single payer systems are right about one thing: Someone has to pay for the ER visits of poor people who can’t pay themselves. In the US, it’s everyone else, and that’s part of why hospitals hyper-inflate the cost of things like bandages and medicines (the other part is price-fixing and profit-seeking). 

What US critics don’t realize - or refuse to acknowledge, depending on the critic - is that single-payer systems aren’t as expensive because not as many people get to the point of needing emergency care. And, furthermore, those who do don’t tend to get to that point as often. Part of how single-payer systems save money is by trying to catch problems as early as possible, before someone shows up at the ER on death’s doorstep. Is it perfect? No. But does it help? Hell yes. 

Again working off the asthma example because that’s what I’m familiar with: When my asthma got bad and I was going to the ER on a regular basis, the single-payer system in my province recognized I was an ER “frequent flyer” because of my poor asthma control. So I was referred to a specialist by my doctor (note: I had to do nothing in way of paperwork or approvals to get in with the specialist, and I did not have to fight with an insurance agency that I really needed a specialist. My doctor had complete authority over whether I got the referral) and an asthma education clinic (likewise) for more in-depth instruction on how to manage my asthma. The specialist identified the cause of my poor control (an allergic asthmatic with a severe cat allergy living with two cats isn’t exactly the best arrangement for health… The specialist was able to diagnose my allergy and that led to me needing to find new homes for my cats because my cat allergy is so bad that owning cats could literally kill me) and the asthma education clinic taught me tools to compensate for the fact that my breathing had been shitty for so long I’d literally forgotten what good breathing felt like and didn’t know how to recognize when I was getting bad until it was an emergency. 

In the US system, because I would not have been able on a grad student’s salary to pay for a specialist, I would’ve continued getting sicker and sicker and costing hospitals more and more money for more and more ER visits until such time as my asthma became disabling and I got Medicare or an attack finally killed me.

In the Canadian system, everyone saved money by having me get the care I needed when it first became apparent I needed it, not when my condition progressed to the point of permanent damage. I saved money on taxes and missed work time. The single-payer system saved money by having to pay for way fewer ER visits. And other taxpayers saved indirectly by not having to pay as much for my care. While I haven’t been able to completely avoid the ER since completing the education course and seeing a specialist, I’ve gone form having twice-monthly ER visits to averaging an ER visit once every two years or so, six years on. 

In Canada, an average asthma attack ER visit costs the province about 75K Canadian. The cost of visiting a specialist and my asthma education was about 6K Canadian. By sending me to a specialist and asthma education clinic and enabling me to cut down on my ER visits by well over 90%, the province saved itself over ten and a half million dollars in the six years since I was referred to the education clinic. That’s for one person. 

And that is the unspoken difference between a single-payer system and a profit-driven mixed-model system like the US. Single payer systems are motivated to improve health care outcomes in order to save money. The US system has no such motivator, because what they lose on ER frequent fliers they can just make up on everyone else.  

ACA Enrollment Cheat Sheet!

so it’s open enrollment time, which means you need to pick a health insurance plan from the exchanges!  it can be daunting as shit, for sure, especially if you don’t live in the filthy weeds that are the business side of our garbage health care industry like yours truly does.  

so!  here’s a quick rundown of some of the vocabulary:

premiums: this is what you pay per month for the glorious honor of having insurance coverage.  it does not count towards your deductible or out of pocket maximum.  depending on your income, you may be eligible for a subsidy or other financial assistance to make your premiums more affordable.  

deductible: this is how much in health care costs you have to pay before your insurance starts really kicking in.  for example, my insurance through work had a $1,500 deductible, so the copays and coinsurances and lab costs that i had to pay early in the year, before i had another surgery, were fully my responsibility until i’d paid out $1,500; after that, my insurance started covering a flat 80% of everything, including copays.  basically, the deductible is how many actual dollars you have to pay out for medical costs before your insurance takes over.  

out of pocket maximum: this is the cap on how much– aside from premiums– you should have to pay in health care costs in a year.  most plans on the exchanges right now have a high deductible and higher OOP max.  

network: this is the collection of providers (doctors, surgeons, urgent care facilities, imaging facilities, etc.– any clinical medical care or medical service provider) that are contracted with the insurance plan.  this means that they have an agreement with the plan to accept payment from that plan for services.  you can still see out of network providers, but your plan may have a separate out of network deductible that is higher and that you pay separately from your main deductible (for example, if your plan deductible if $5,000, you might have a separate out of network deductible of $5,500; even if you’ve already paid of $4,950 of your regular deductible, if you see an out of network doctor, you’re going to have to hit the $5,500 deductible in copays and whatnot before the insurance covers them fully).  

copay: this is a flat fee you pay to a provider when you see them.  it’s like the cover charge at a bar: you pay $20 to get in the door, and then you get the dubious honor of also paying for the drinks and food you buy inside on top of that.  

coinsurance: this is a percentage charge for seeing a provider.  instead of a $20 copay for the cost of the visit to see doctor bob, you’re charged, say, 10% of the total cost of all charges associated with you visit to see doctor bob.  if you don’t get much done, this may only like $10; if you get a full metabolic panel run and a bunch of xrays, it might be $100.  

and the plan types:

hmo: health management organization.  the concept of this plan is that you have a pcp (primary care provider - your regular doctor) who functions as your primary point of contact for all medical care.  if you want to see a non-pcp doctor, you have to first see your pcp, who will write you a referral to see said specialist.  specialists include orthopedists, physical therapists, neurologists, ob-gyns,  etc. - any provider who isn’t your pcp, basically.  

ppo: preferred provider organization.  this plan is a free for all: if they’re in network, you can go to whomever you want.  they tend to be a bit pricier (almost always on premiums, 50/50 on deductibles) than hmo plans, but you’re basically paying for ease of access.  you can make an appointment directly with any specialist you so choose.  these plans are ideal for people like me, since i have to see orthopedists and hematologists and physical therapists pretty regularly, and going through a pcp for each of those would be a pain.  

epo: exclusive provider organization. this is the bastard child of the hmo and ppo and is also an increasingly common option on most of the exchanges.  like a ppo, no pcp or referrals are provided; however, the network tends to be narrower and you have less choice of in-network providers and, crucially, they don’t tend to cover any out of network providers except for emergencies 

high deductible/catastrophic: these are exactly what they sound like– plans for healthy young people who are pretty much only going to wind up with medical costs if something terrible and, well, catastrophic, like a car accident, happens.  they have low premiums and very high deductibles (often approaching ~$10,000).  these are only available to people under the age of thirty, because clearly as soon as you turn thirty you must turn into a total drain on all healthcare resources :|

so what does all of this boil down to for you and your enrollment?

start by figuring out what financial help you’re eligible for!  the exchanges generally have an option at the front end of the process for you to identify your annual income and number of dependents on your plan.  this will let you know if you’re eligible for a subsidy or other financial help, and, if so, how much; you should also have an option when searching through plans on the exchanges to input estimated financial help, which will adjust the premiums in the search engine.  

after that, start digging into the individual plan options.  every exchange plan should provide a summary of benefits and coverage.  it’ll be a pdf and will look like this:

that red circle in the top right there? that’s where you can identify what type of plan you’re looking at.  the first page in the summary of benefits will always look the same– it’s the basic overview of the costs and definitions.

this document will also list excluded services.  it’ll generally be somewhere in the middle/back half of the document and will have a clear header like this:

for me, this is the first thing i look for after verifying premium and deductible amounts.  as the above picture indicates, you can find more information in the plan documents.  these aren’t always directly linked to on the exchange website, but you can generally find them on the insurance providers website.  these will be a lot more detailed and can be anywhere between twenty and 200 pages.  ctrl + f your heart out: as frustrating and complicated as insurers can be, they can’t actually fail to disclose if they, for example, don’t cover all forms of contraceptives.  they’ll disclose it in the plan documents, even if they don’t, unfortunately, have to be clear and up front about it.

NOTE: MINIMUM VALUE STANDARDS

towards the end of the summary of benefits document will be a page that looks like this:

minimum value standards roughs out to basically meaning that at least 60% of all medical charges are covered.  if the plan you’re on does not meet minimum value standards, you might be able to get a tax credit to help you buy another marketplace plan.  always check for this verification when you’re researching plans.

what does all of this shit mean? 

it means start here and then find your state’s exchange from there.  the garbage carrot in chief established “maintenance times” on this website throughout the open enrollment period (sunday afternoons, i believe), so schedule around that.  sit down on a monday or wednesday or saturday with some snacks and a cup of your favorite beer/wine/tea/whathaveyou and crank up some good music to jam to and do some research:

as always, i’m here for any questions you might have!  

if i don’t know the answer, i can point you towards someone or some resource that will.  don’t be afraid to ask me or anyone else for help!  this is a complicated situation and even though the current administration is trying really hard to make it worse, there are still always resources available to you for help and guidance.  all you have to do is ask :)   

If anyone needs any help please ask me! I am a tax professional and can translate what might be confusing.

(via Birth control actually is (or can be) healthcare 👏🏼👏🏼👏🏼 : TrollXChromosomes)

PS - preventing unwanted pregnancy as a consequence of enjoying sex is also health care.

A doctor discovers an important question patients should be asked

This patient isn’t usually mine, but today I’m covering for my partner in our family-practice office, so he has been slipped into my schedule.

Reading his chart, I have an ominous feeling that this visit won’t be simple.

A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath.

He suffers from both congestive heart failure and renal failure. It’s a medical Catch-22: When one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.

Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can’t blame him.

Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.

With us is his daughter, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.

After 30 years of practice, I know that I can’t possibly solve this man’s medical conundrum.

A cardiologist and a nephrologist haven’t been able to help him, I reflect,so how can I? I’m a family doctor, not a magician. I can send him back to the ER, and they’ll admit him to the hospital. But that will just continue the cycle… .

Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it’s useless to try.

Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?”

I pause, then look this frail, dignified man in the eye.

“What are your goals for your care?” I ask. “How can I help you?”

The patient’s desire

My intuition tells me that he, like many patients in their 80s, harbors a fund of hard-won wisdom.

He won’t ask me to fix his kidneys or his heart, I think. He’ll say something noble and poignant: “I’d like to see my great-granddaughter get married next spring,” or “Help me to live long enough so that my wife and I can celebrate our 60th wedding anniversary.”

His daughter, looking tense, also faces her father and waits.

“I would like to be able to walk without falling,” he says. “Falling is horrible.”

This catches me off guard.

That’s all?

But it makes perfect sense. With challenging medical conditions commanding his caregivers’ attention, something as simple as walking is easily overlooked.

A wonderful geriatric nurse practitioner’s words come to mind: “Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function.”

Suddenly I feel that I may be able to help, after all.

“We can order physical therapy — and there’s no need to admit you to the hospital for that,” I suggest, unsure of how this will go over.

He smiles. His daughter sighs with relief.

“He really wants to stay at home,” she says matter-of-factly.

As new as our doctor-patient relationship is, I feel emboldened to tackle the big, unspoken question looming over us.

“I know that you’ve decided against dialysis, and I can understand your decision,” I say. “And with your heart failure getting worse, your health is unlikely to improve.”

He nods.

“We have services designed to help keep you comfortable for whatever time you have left,” I venture. “And you could stay at home.”

Again, his daughter looks relieved. And he seems … well … surprisingly fine with the plan.

I call our hospice service, arranging for a nurse to visit him later today to set up physical therapy and to begin plans to help him to stay comfortable — at home.

Back home

Although I never see him again, over the next few months I sign the order forms faxed by his hospice nurses. I speak once with his granddaughter. It’s somewhat hard on his wife to have him die at home, she says, but he’s adamant that he wants to stay there.

A faxed request for sublingual morphine (used in the terminal stages of dying) prompts me to call to check up on him.

The nurse confirms that he is near death.

I feel a twinge of misgiving: Is his family happy with the process that I set in place? Does our one brief encounter qualify me to be his primary-care provider? Should I visit them all at home?

Two days later, and two months after we first met, I fill out his death certificate.

Looking back, I reflect: He didn’t go back to the hospital, he had no more falls, and he died at home, which is what he wanted. But I wonder if his wife felt the same.

Several months later, a new name appears on my patient schedule: It’s his wife.

“My family all thought I should see you,” she explains.

She, too, is in her late 80s and frail, but independent and mentally sharp. Yes, she is grieving the loss of her husband, and she’s lost some weight. No, she isn’t depressed. Her husband died peacefully at home, and it felt like the right thing for everyone.

“He liked you,” she says.She’s suffering from fatigue and anemia. About a year ago, a hematologist diagnosed her with myelodysplasia (a bone marrow failure, often terminal). But six months back, she stopped going for medical care.

I ask why.

“They were just doing more and more tests,” she says. “And I wasn’t getting any better.”

Now I know what to do. I look her in the eye and ask:

“What are your goals for your care, and how can I help you?”

-Mitch Kaminski

Source

THE important question.

This.