[webdevmark]

As a British person living in the UK reading stories like this seems so crazy. The very idea that when Americans are ill they need to negotiate with these huge institutions seems so utterly bizarre and messed up.

Surely if people know they could be fined thousands for simple treatments like stitches they avoid medical care altogether? Then things could get worse and even more expensive...

[jwr]

As someone from the EU, this reads like dystopian fiction. I pay about $120/month into the state (mandatory) health insurance system. In return, I get crappy first-contact healthcare, but I know I am covered in case anything bad happens.

Example: ending up in a hospital in Italy during a skiing holiday involves showing your insurance card (or simply giving the number). That's it: there is no payment, no negotiation, nothing — you just get healthcare services and you're done.

The EU gets criticized for many things, but universal healthcare across the entire union is something that should get more praise than it does.

[TuringNYC]

>> As someone from the EU, this reads like dystopian fiction.

As someone living in the US (thankfully well insured and decently paid), I can confirm dystopian reality. Everything works well 97% of the time, until you have something that falls out of the confines of the giant decision tree -- and then things go really wrong. I used to think everything was well until we had a difficult pregnancy/delivery. In such cases, there are professionals who's service is bill reconciliation!

[nojvek]

I had health insurance and still we were in a 10k shock for normal delivery. US healthcare is a mafia extortion industry.

US is the wealthiest nation but the deadliest nation too in terms of preventable deaths.

[thijsvandien]

Even if you don't have health insurance, in most of Europe you are fine. Especially in Central/Eastern Europe, where doctors in public hospitals work extra hours privately to make a better living.

[jwr]

Well, I think in all of the EU, you will be treated no matter what in an emergency. It doesn't matter if you have health insurance or not. That's the whole point of universal healthcare, something I've come to regard as a basic right in a civilized world.

[masonic]

Same case for emergency care in the USA, even for private hospitals.

[jwr]

Yes, but if I understand correctly, you do end up with a bill afterwards.

[lightbyte]

>Surely if people know they could be fined thousands for simple treatments like stitches they avoid medical care altogether?

This is what happened to myself. I've had persistent breathing problems and the last time I went to a specialist for it they charged me $3,000 to breathe in a tube for 15 seconds and say they don't have any ideas as to what was wrong. I haven't been back and try to ignore the fact that I have trouble breathing daily.

[heywire]

Same with me and these random chest pains I get. I've wiped out my HSA, still not close to meeting my deductible. Hooked up to an EKG for 15 minutes and monitored for an hour in the ER? That'll be $5k. 15 minutes on a treadmill with an EKG attached for a stress test? That's $2.2k. I would continue to pursue until I had an answer, but I simply can't afford it.

[gscott]

There are two options for you you can set up a fake business and buy health insurance for your employees as long as you have two such as you and your spouse. Another option is to visit a private urgent care clinic. The doctors and prices at urgent care are usually pretty good. Make sure the urgent care is not attached to a hospital.

[EForEndeavour]

Your anecdote reads like something out of a Neal Stephenson novel, writing style and all.

[Ntrails]

Also a Brit. I think about my various trips to hospital throughout my life and cannot imagine the difference if I was coping with money at the same time.

As a child, breaking my arm was upsetting, but imagine if it put additional financial strain on an already strained family?

My motorbike accident age 18 would have just been flat out medical bankruptcy (and potentially worse/incomplete recovery). I was pretty miserable anyway, adding that would've been demoralising in the extreme.

[umvi]

I mean, you are also seeing the extreme cases float to the top because articles like these attract anecdotes. It's hard to tell how widespread the problem is because people who pay a more reasonable amount for stitches don't comment in these kinds of threads. For all we know this only happens .1% of the time

FWIW, I've never had such extreme bills. The largest bill I've received in the last few years was $2000 for my wife's epidural, but I only paid about $400 of it (insurance paid the other $1600)

[shazow]

Nearly 100% of people spend some time in a hospital in their lives.

Unless you're claiming that hospitals only gouge some tiny subset of people and are benevolently generous to everyone else, that number is going to be much closer to 100% than 0.1%.

When I lived in the US, I have personally experienced this, even with top-tier insurance--from both ends: I've had insurance decline claims arbitrarily and pass on five-figure costs to me, and I've had hospitals misclaim things. In both cases, I had to spend dozens of hours on the phone to resolve it.

Most people in the US are far less privileged: Their insurance is not as good, and they don't have the luxury of spending dozens of hours on the phone.

It's just a matter of time until you experience this.

[378fho]

> Unless you're claiming that hospitals only gouge some tiny subset of people and are benevolently generous to everyone else, that number is going to be much closer to 100% than 0.1%.

Actually, yes. Doctors and hospitals have relationships. When a hospital is aware that a good referral source referred them a patient, they will try to keep the patient happy to maintain that source of business.

They're very selective about who they try to screw.

Now if you walk in with no referral and no family doctor, then you're their source of profits and the party they'll try to milk.

[seandougall]

> Now if you walk in with no referral

You mean like, say, an ER visit?

Though, actually, the one time I've been referred to the ER by a doctor (he called ahead and everything), the billing was still a shitshow. Insurance delayed paying for months while they tried to work out a way to claim it was a pre-existing condition (this was pre-Obamacare), until the hospital gave up and tried to send me directly to collections for upwards of a quarter million dollars.

Given that most private practices (around here, anyway) usually have lucrative hospital affiliations, the incentive to keep doctors happy by keeping patients happy really doesn't exist.

[falcolas]

Most people hand it off to insurance and don't look at it twice. My parents have a story of looking at a paid by insurance bill that included $2,000 for two ibuprofen pills. They questioned it, and everyone involved (including the insurance company) said "why do you care, insurance pays for it?"

[mixmastamyk]

They don't pay list prices either, and have negotiated something much less. The list prices are basically a fantasy hoping to gouge the unknowing, while the rest of us feel like we got a discount.

[378fho]

It's simple fraud in many cases.

Patient has a 20% copay. The provider bills $100,000. The provider "pays" $80,000. The patient pays $20,000.

Provider then pays a $70k kickback disguised as a discount on other charges, fees for participation in the system, etc. (or never even pays the EOB amount). In fact a total of $30k is paid for the services, and 66% of that comes from the patient.

Insurance gets away paying $10k instead of $24k (80% of $30k). Provider gets the business by being on insurer's provider list. Patient thinks "I'm glad I paid $20k for Insurance. My health-care-spend ended up being $40k instead of $100k." In fact, they'd have been better off without insurance, which would have only cost $30k.

[DesiLurker]

are you claiming most people don't have deductibles and copays? or no in & out of network coverage. if so I'll call BS on this. I've had instances of being billed from out of network provider even though I went to in-network hospital. this is such a common occurrence that John Oliver did an episode on it.

[justinator]

I'm reading what you're saying, and it makes me sad - as if you don't believe that people without insurance are just liars. People are avoiding getting medical treatment because it may financially ruin them. Do please believe them.

[mindslight]

Take another look at that chain of bills. I would guess that if the initial bill was for $2000, the hospital only received $800 or so total. So insurance paid half, you paid half, but you think insurance paid for much more when really they just swatted away a fraudulent price.

Yes, very few here have been on the receiving end of a $143k magnitude extortion. The people who have are less likely to be writing HN comments and more likely to be slaving away in the mines of Rura Penthe. But these exceptional stories fit the exact pattern that anybody who has interacted with the healthcare racket has experienced, even though most ultimately dodge the (biggest) bullet.

[ezoe]

As a Japanese, It's crazy too. The government approved treatments are all strictly priced. No more and no less.

2k USD for a few stitchies? That's still insanely high.

[umvi]

> The government approved treatments are all strictly priced.

I kind of like Japan's system based on what I've read so far, but I'm still not sure of one thing:

Does regulated pricing have a chilling effect on drug companies?

It seems like it would be impossible for a Japanese drug company to be viable if the government gets to fix the price so that anyone can afford it seeing as new drugs can cost billions to develop.

[tristor]

No, it doesn't have a chilling effect because pharmaceuticals are a global market. The dirty little secret is that the US having crazy rates like "$2000 for two ibuprofen" as mentioned in another anecdote in this thread is exactly what enables price fixing in most of the rest of the world to be functional.

The disaster that is the US healthcare system is architected to eliminate any concept of price transparency to directly confound free market processes, and is costly to line the pockets of middlemen and pharmaceutical and medical/biotech firms, because their pockets aren't being lined elsewhere in what is an essential and large global industry. The US effectively subsidizes healthcare around the world by paying out the nose, and the entire thing is perpetrated against the American people by intentionally introducing smoke and mirrors to the process.

[Sir_Vival]

It would be astoundingly easy to fix. All you'd need is a law/regulation that says drug companies can't charge US customers more than the average price for the same drug in say, Canada, France, Britain, Australia, and Japan.

Suddenly we'd be paying a lot less and if we are subsidizing the cost it'll for them to raise prices in those other countries.

[ZeroGravitas]

I'm pretty sure "we're subsidizing foreigners" is one of those smokescreens.

It's almost Trumpian in its vague, implausible and detail-free appeal to the baser instincts in order deflect from clear and obvious fraud.

[mook]

The government gets to fix a price doesn't mean the drug company has to make it (or exist), right? So presumably the price would be set at some point where there is still a profit to be made.

[gingabriska]

On the other man I am making the kind of money I can never ever make in UK, so US is optimized for individual gains and high health care cost are side effects this bal game.

[craftinator]

Do you run a hospital, by any chance?

[nameless912]

They do. And we wonder why our medical costs are completely out of control.

[378fho]

The hullabaloo over "If you like your doctor, you can keep your doctor" goes a long way to explaining how health-care used to work in the US. Most simply it was a free market and free markets work.

In more detail: Independent doctors (and their staff) functioned as buyers' agents would refer patients to specialists. "Doctor-Patient Relationship" and "Referrals" were the two main components of the system. Knowing that DR. JONES referred PATIENT SMITH to them, the specialist would treat PATIENT SMITH well and charge a reasonable amount.

It was unfortunate in that you had to "get in" to the system by finding a good doctor. It was (and more now than ever is) hard to "find a good doctor." Most are no longer accepting new patients, but it served all those parties. Doctors would have repeat customers. It'd reduce their work of learning new patients. Etc.

Without such a family doctor, you would go to a provider without a referral. The provider would then know it could gouge you without risking a referral relationship.

However this system was sub-optimal for insurance company profits and large scale providers. Which is exactly who pushed Obamacare, and lead to the break-up of so many of these relationships.

As background, Health Insurance has lists of "approved providers" which they carefully curate. The most straightforward method of breaking up relationships is to exclude providers. They also put these "good doctors" (from the patients' perspective) into plans with expensive premiums. They also churn. By raising prices selectively between plans with different providers insurance companies can encourage patients to "try out" a new doctor this year. They also churn provider lists.

This means Insurance companies are now a more powerful source of referrals. They also prefer institutional providers. Between both of that, fewer providers care about where their patients are coming from. The patients often don't have much choice where they go (one of 9 different locations of the same conglomerate) and don't know enough to make an informed decision anyway (as their family doctor used to do for them).

All of this is brought about by the individual mandate. It's not a free market if you're not free to abstain. By being forced in, cash buyers became a smaller segment of the market. Cash buyers were the very people holding it all together by selecting doctors of their choosing and forming these relationships. With these doctors going out of business (largely retirement) and being replaced by institutional providers it's just getting worse.

[wkearney99]

There was also the scare-mongering associated with "keeping your insurance plan". Failing to realize that a great many people had been diligently paying for a plan that was NEVER going to pay out for any reasonable expenses. Plans so bereft of decent coverage that it would have bordered on criminally negligent had the ACA offer something like them. But how do you make that argument? You can't keep that because it's shitty and we can't offer something worthless? They should have made this point but it was honestly not on their radar, that something so miserably bad would be out there.

[peter422]

In the free market what is the incentive for any doctor to take on a patient that has a condition so expensive the patient can't afford the treatment?

You are completely ignoring the insurance part of health insurance.

[seandougall]

> All of this is brought about by the individual mandate

Some of us are old enough to remember dealing with healthcare before Obamacare, and can testify to this having been the status quo long before there was an individual mandate.

[ebiester]

How do you negotiate with providers while having a heart attack?

Free markets depend on leverage.

[hnick]

I think their assumption is that you do all that thinking and negotiation while picking an insurance provider so it's covered.

But then you get carted unconscious to a hospital you are covered for but looked over by an "out of network" doctor, whatever that is.

Being an American seems like a full time job. You have to watch your back so society doesn't eat you. The frequent obsession over credit scores I see on Reddit is another one that baffles me.

[ebiester]

Credit scores don't matter in the way it sounds. If you're trying to do tricky things like rotate through credit cards for their benefits (like airline miles), then it requires closer monitoring, and it helps to watch in case some sort of fraud is going on, but that's about it.

That said, keeping up with looking after your own back in America does feel like a full time job at times. :/

[wkearney99]

And leverage depends on clarity regarding price/performance. Neither of which is readily accessible for health providers. Way too many variables, of course, but some basic price facts would go a long way toward improving the situation.