[grogenaut]

He refused to go in an ambulance the first time. He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.

As an EMT if you're A&Ox4, alert to time, place, person and event, you make the choices. You do sign a release so we have proof we didn't abandon you, but you make the choice. If we move you without your approval, it's kidnapping or entrapment (not hit me up law arguers). To do that we either need implied consent (minor no parent, not A&Ox4, or Law Enforcement).

My department, a small rural one with a small tax base which happens to cover a lot of injuries because we have 20 miles of dangerous mountain pass freeway and a ski and mountain bike area, only charge for calls if we transport. I think a transport is around $900. Our minimum transport is 37 miles. We scale it down depending on income and type of event. We're not massive sticklers about it. We're just trying to cover wear and tear on big expensive vehicles for all the non-transports, winter driving, equipment, uniforms, training, etc. Most of our "business" comes from "transients" eg folks who don't live there, eg those skiing, hiking, biking, or driving over the pass.

This is also very much not the norm. But should explain a bit about those who do pay are covering those who don't.

We don't want a chilling effect on calling 911 for precautionary stuff. We'd rather show up 99 times and check people out and let them go than miss the impending cardiac event. And we get those. It's very interesting just how much going over a 4k foot pass stresses people on the edge. Many of our medica calls are people driving to seattle for deeper care and things exacerbating when they get to 4k feet.

[onion2k]

I don't think the question is "Should ambulances be a thing?" though. It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"

The (fairly obvious) answer to that no one should be in that situation. It's horrible. Society should find a better way to pay for ambulances. Most of the world has accepted that some system to spread the cost among everyone is better than putting people in that situation.

[otherme123]

> Society should find a better way to pay for ambulances

Society has this figured out, at least a decent solution that works until we find a perfect one. Only the US society seems to be unable to find a solution.

[x______________]

> Only the US society seems to be unable to find a solution.

Unwilling. It's absolutely feasible to find a solution, as seen everywhere else in the world.

[3D30497420]

Even some parts of the US have found solutions.

From the article:

> In Tulsa and Oklahoma City, meanwhile, the government buys staffed unit-hours from an ambulance operator, while households can prepay a few dollars a month on their utility bill and owe nothing if the ambulance ever comes.

[pornel]

billed for buying unit-hours from an operator... that's very carefully worded to make it sound like a corporation<>customer relationship and not socialism.

[toomuchtodo]

Lots of policy in the US is hacking around the lizard brain idea of "We cannot have nice things because someone who doesn't deserve it might get it."

My favorite example is universal school breakfast and lunch. Without fail, someone will argue that some kids don't deserve it. It doesn't matter that all of the data shows it is more economically efficient and the benefits to kids is overwhelming.

[andrew_lettuce]

Come on, across the world we prepay for the use of things regardless if we do or not. As described in the article it's an option, not a political system.

[red-iron-pine]

only parts of the US are unwilling

they happen to be in the Fortune 50, or top 10.

serious, go look at the F500 list and see how many of the largest, meanest companies in the US (and world) world also happen to be healthcare

if you wanna know why it's never gonna happen -- there is the list. they will spend more money than god on social media, bribes, and whatever else they need to keep the system the way it is

[lotsofpulp]

Why is Fortune the relevant list? Why not market cap, which also happens to correlate with net income, which means more cash to spend on political influence?

https://companiesmarketcap.com/

Mostly only pharmaceutical healthcare in the upper tiers of that, but these businesses still have market caps and net incomes literally one or two orders of magnitude separating them. Grouping top 10, 50, and 500 makes no sense.

[HelloNurse]

Unable to be willing. The combination of not knowing any better, political parties and media that don't care or exert a contrary pressure because they belong to billionaires, and powerful health sector businesses appears to be very effective.

[nkrisc]

The odds are stacked, but everyone still has free will and can choose to question what they’ve been told (especially what they’ve been told conflicts with what they can see with their own eyes).

Many choose ignorance because it’s comfortable.

[wisty]

And the US also pays a TON of tax dollars to a broken, overregulated system.

IIRC if you look at the cost of Medicaide, Medicare, VA, and other federal and state spending it's the same as most other countries per capita or as a percent of GDP. The US taxpayer pays about as much as Canadians to fund their public system, then pays the same amount again for private cover since it's not universal.

No I'm not making a typo. Medicare, Medicaide, and the US system is such a rip off that per capita Americans are paying similar tax dollars to their joke of a public system.

But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.

[refurb]

Canadians don’t get the same care as Americans.

McKinsey did a nice analysis of what is driving US healthcare costs. It compares category spending to OECD then compared price and volume.

Turns out the US pays a bit more for drugs (relative to total spend), a little more for inpatient care and a TON more for outpatient care but half of the increase is volume, not price.

As someone who works in healthcare globally, the difference in US care is stark. Americans get much early and more access to new technology than other countries.

If your lymphoma has returned and you have a 20% of living more than a few years the best care is CAR-T with cure rates close to 60%.

Check out CAR-T rates in the US versus Europe, it’s almost 3x. The US started using it in 2014 and Singapore just started paying for last year (11 years later). Even in Europe adopt only ramped up in the last 5 years.

So yes prices are higher, but a big part is more aggressive care with more expensive treatment.

[wisty]

The US healthcare system just upsells on unnessessary crap. It's junk volume or at best it's heroic high tech solutions mostly making up for the fact that people stay away from hospitals until it's too late.

Life expectancy shows that while the US is the best place to have stage 4 cancer, it's probably not the best place overall. Most places do the 80/20 stuff better.

But yeah, you are right that the US does some stuff well. Just not efficiently.

[refurb]

US care is highly aligned with international guidelines. Saying "it's junk volume" just tells me you're not that close to the data.

Life expectancy doesn't measure quality of healthcare, there are far too many confounding variables like genetics, diet, accidental deaths, etc. No serious study of healthcare quality relies on it.

Look at 5-year cancer survival rates. The US is better (significantly better) in many of them than other countries. A big part of that is access to the latest technology.

https://www.thelancet.com/journals/lanonc/article/PIIS1470-2...

[dghlsakjg]

A good tell that someone is utterly full of shit on Canadian healthcare is that they generalize all of Canada.

“Canadian health care” is not a thing. Each province administers its own completely independent system.

Someone on PEI is in a healthcare system that has as much to do with Alberta’s healthcare system as it does their neighbours in Maine. As a result, anyone referencing Canadian healthcare is talking about a dozen or so unrelated systems that do things very differently. The closest it comes is that there are interprovincial billing systems so you don’t have to do the paperwork to get covered for an urgent visit out of province, and not all provinces are signed on.

You can safely dismiss anyone that has reduced that complexity, or is completely ignorant of it. It’s a great way to tell when a foreigner is spouting talking points they picked up from an unreliable source and did not do even a minimal fact check on. “Canadian health care” as it is talked about in the US media is frequently fiction for propaganda purposes.

Canadians almost always talk about problems within a province. What's happening in the Maritimes has nothing to do with BC.

The feds set a minimum standard for a province to qualify for federal funding, and that's about the limit of their influence.

No idea if the rest of his statement is poorly sourced propaganda as the first sentence.

[refurb]

You’re ignoring the fact that provinces can’t fund technology that the federal government hasn’t reviewed and negotiated a price for.

So yes there may be differences between provinces in terms of when they fund what restrictions are put on it, the overall trend across Canada is pretty consistent.

And as I said Canadians don’t get the same care as Americans so concluding the higher cost is entirely higher prices for the same thing is false.

[nkrisc]

Most doctors and nurses are not overpaid.

Certain specialities probably are overpaid (orthopedics), but others like pediatricians or general practitioners usually aren’t.

And nurses!? From the nurses I know they are underpaid for what they deal with.

The ones making loads of many are willing to travel around the country and uproot their life once or more every year. Not exactly a lifestyle without its drawbacks.

[wisty]

Everyone is gonna say nurses are underpaid. It's a caring, female dominated profession, it's a motherlove sentiment. And they are not paid as well as doctors.

Yeah, most pink / blue collar workers in the US are badly underpaid, but IIRC ones in the health sector are some of the best off, relative to medium salaries.

Compare teachers and nurses. In most countries they make about the same AFAIK (and I'd say nurses do deserve more, telling a parent Billy did badly on a math test has got to be easier than explaining a bad medical test). But in the US it's about 75k vs 95k. There's a huge premium for working in health in the USA, EVEN in the underpaid blue collar end.

Doctors make out even better in the US, and the c suite in health can have salaries that are just insane.

[nkrisc]

I don’t dispute this, but I also don’t think it matters. An underpaid profession being paid more then a severely underpaid profession doesn’t make the former overpaid.

[Sohcahtoa82]

> US doctors are overpaid. US nurses are over paid.

Median pay for a Nurse Practitioner is $132K/yr [0]. I think that's reasonable.

Average pay for physicians ranges from $220-450K depending on specialty. [1]

Personally, I think doctors should be paid more than software engineers, so I think those numbers are all reasonable, especially when you consider what it takes just to enter the field. Nurses require a Master's degree. Physicians need a Bachelor's degree PLUS another 4 years of med school AND THEN a residency program that lasts 3-9 years depending on specialty before they finally earn their medical license.

IMO, the idea that nurses and doctors are overpaid is quite simply ludicrous.

[0] https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-...

[1] https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.h...

[sgerenser]

You might find those salaries reasonable, but they’re probably double what those same occupations pay in many other (first world) countries with lower healthcare costs. Maybe the trade off is worth it, but it’s not something that can be ignored when people complain about how much more expensive healthcare is in the U.S. compared to Europe (for example).

[Sohcahtoa82]

> but they’re probably double what those same occupations pay in many other (first world) countries with lower healthcare costs

You'll find that salaries across the board are lower in other countries. Software developers in Europe make half of what they do in the USA. In exchange, they get far better benefits.

Also, physician salary only makes up about 8% of total healthcare costs [0]. Cutting salaries in half wouldn't significantly lower our healthcare costs.

[0] https://www.medicaleconomics.com/view/physician-pay-makes-up...

[master-lincoln]

That's what a government would be for. You vote neo-liberal, you get it... (I consider both the US democrats and republicans neo-liberal)

[bestouff]

I think only the US consider the US Democrats as leftists.

[opo]

This is a common claim, but it is a misleading simplification of US politics and European politics. (In simple terms, many of the economic positions taken by the Democratic Party would be considered centrist in Europe, but if you include positions that have been taken on immigration, identity politics, criminal justice, reproductive rights, etc. it would not.)

[refurb]

The Democratic Party spans from slightly right to ragging left that even European leftists look at with confusion.

[natebc]

Only the rightists do and among them really only the loud redfaced ones.

[cucumber3732842]

>But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.

17% of GDP is healthcare. So between 1:10 and 2:10 people in this country are making more than they otherwise would (note I did not say wealthier) because the system is screwed up and hoovers up more of everyone else's wealth than it ought to.

Slavery was 12% and (while obviously geographic concentration of industry plays a lot into it) it took a war for them to take a haircut.

[uoaei]

Earnings represented by GDP are not distributed evenly across a given population. That 17% of extra earnings goes to relatively few people in the States (I'm putting this very mildly, the concentration in reality is insanely lopsided).

[cucumber3732842]

The US healthcare industry is ~10% of the workforce. More if you include people affected by the supply distortions thereof (all those techbros working for agentic penis pump startups).

The fact that that pie is not sliced evenly does not change the fact that is an integer multiple larger than it ought to be.

[pjc50]

Possibly reasonable point about labour supply ruined by an absurd analogy with slavery.

[nekusar]

Not at all.

Systemic inertia is unimaginably strong.

I easily see that changing the USA to be more socialist, especially in areas where game theory indicates its the best solution, will likely take a civil war.

That also aligns with Marx's writings, that the capitalists will not acquiesce without a fight, and a big fight at that.

The slavery and Civil War connection is a comparison of similar economic magnitudes.

[refurb]

Canada doesn’t pay for ambulances unless it’s truly an emergency. Think you’re having a heart attack but you’re not? Time to pony up hundreds of dollars

[LtWorf]

You see, it's better to die than to help the coloured neighbour who lives across the highway. I don't believe in this but that's USA society.

[frenchman_in_ny]

I've been there before. I had a high deductible health plan, it was December & I hadn't used any of my premiums... I had a heart attack (I didn't know it at the time). And my mind went to "but my premium! I know, I'll walk myself to urgent care instead of taking an ambulance to the hospital"

[grogenaut]

Is this the common cost or is this an outlier blog story that hit it off. Talk real data to me. I don't get excited about any individual anecdote (unless it's me personally of course).

No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.

[lazide]

Well over a decade ago, it was $6500 for a couple mile ride to the nearest hospital, no emergency medical care necessary (just supervision). This was in the Bay Area, in California.

I can’t imagine it’s gotten cheaper.

[WJW]

That's wild. According to the website of my local ambulance organisation, a full on ambulance ride with all medical supervision etc runs between 400 and 900 euros. Typically this would be reimbursed by the (mandatory in this country) health insurance. This is in a large city in western Europe, I would expect it's cheaper in places with lower cost of living.

EDIT: their own website states "If the ambulance only comes and stabilizes you on the spot but you don’t need to be transported, there are no costs." https://ambulanceamsterdam.nl/information-in-english/

[culopatin]

Yeah my mom got billed 9k a few months ago from SFO to one of the south sf hospitals. Neck brace and supervision was all that was needed. Basically an expensive uber ride.

[Esophagus4]

He covered that in the article fairly thoroughly. Did you read it?

The anecdote illustrates the issue then he dives into the analysis.

[ChrisMarshallNY]

It’s pretty common.

I know that John Oliver is a bit of a “lightning rod,” for many folks, but he (or his staff, really) does his homework. He did a segment on it, some time ago: https://youtube.com/watch?v=Ezv8sdTLxKo

[master_crab]

He’s a lightning rod only because some people get unnecessarily triggered by facts that don’t fit their world view.

[mananaysiempre]

There’s a thin line between satire, which can convince, and sneering, which can only turn off. John Oliver, unfortunately, does end up on the wrong side of it from time to time, and can (together with his core audience) be something of a bully when he does.

I’d also be careful about his facts: they’re usually well-researched, but by the nature of the format he only ever presents those which fit his argument, and that’s just not good epistemology. I can think of a few times when the show made me feel safer about my beliefs than I should have been feeling.

[ajuc]

The time for this debate was 100 years ago. Now only people who can't be convinced aren't convinced, so there's no point convincing.

So why not make fun of them? There's no downside.

[refurb]

He’s a comedian that some people take too seriously.

You’re not supposed to shape your political views from entertainment.

[PearlRiver]

I remember this came up during COVID. The government was worried that homeless people and illegals would be afraid to report symptoms. GPs are specifically free and don't have to ask for papers or insurance to combat these health crises.

[thayne]

I had an accident where I had a concussion and other injuries that put me in a lot of, and the people I was with called an ambulance for me, and I wasn't really in a state to decline, but if I had been, and knew how much it would cost, I would have. The ambulance ride was, of course, out of network. As were some of the doctors that treated me once I got to the hospital. It was the first time I dealt with a major medical expense as an adult, and it came as quite a shock when the bills came several months later, that said I was responsible for about $10,000 for the ambulance (plus a lot more for the hospital), and a good chunk of it didn't even count towards my deductible because it was out of network. I later learned I should have contested that since it was an emergency, and insurance is supposed to cover out of network service in an emergency, but I was young and inexperienced with dealing with health insurance companies. Oh, and it was about a 10 minute ambulance ride.

I guess my point is, sometimes you don't have a choice, but you still end up with a massive bill. And also, that experience definitely had a chilling effect on me calling 911.

[moritzwarhier]

Treating medical care like this, similar to a racketeering scheme, should not be a thing anywhere.

Instead of punishing people for seeking medical care (or plainly requiring it), it would be preferable to have a robust protocol for rejecting patients that do not require care, whether at the hospital or before the ambulance ride.

For this, people would need to want medical care be a humanitarian right and basic pillar of a functioning society, not a business or a bureaucratic system to perform a selection process decreasing the life expectancy of less-affluent people.

Ironically, when there is free medical care and universal insurance, there are also perverse incentives. For example unneeded expensive procedures, prescribing patented, newer drugs where cheaper ones would work, providing ineffective or even detrimental services, etc.

But humanitarian values are out of fashion, because they were never achieved globally.

So the only right people care about increasingly is their right to own property.

[PearlRiver]

I read a book once about doctors who went into the slums to treat cholera in the 19th century- noblesse oblige. We are now WORSE than the Victorians.

[WarmWash]

>rejecting patients that do not require care,

You end up just building the lawsuit against you.

[lazide]

Should == I wish.

[Alpha3031]

For most nation states "should" in this case also corresponds to a certain treaty they are party to being highly inconsistent with treating health like a racket. Of course, the US is one of the few that never ratified said treaty. Too much like socialism I suppose.

[shaky-carrousel]

Being concussed should count as not being fully aware. And making someone pay something that he was made to accept while not fully aware should be denounced as a scam.

[mcv]

Can't you simply argue: I never agreed to this, so I'm not obliged to pay this?

Americans love to pretend that healthcare can somehow be a free market (it can't), but a free market requires voluntarily entering into a transaction. Costs that can be forced upon you without your agreement need to be tightly regulated and subject to clear caps.

[geoffmunn]

As someone who is not American, $10,000!!!!!! That's hard to conceive where I live. We even have a specifically free ambulance service here.

[martheen]

I can literally buy a nice house with that just outside the city. And we somehow have universal healthcare despite the average salary is not even one-tenth of American.

[veunes]

This is exactly the part that makes "you can always refuse" feel a bit theoretical

[sandworm101]

>> We scale it down depending on income and type of event. We're not massive sticklers about it.

That touches on another very american problem. The injured person now does not know how much the tansport/treatment will cost. And the only persons on the ground cannot quote a price. If they say yes they enter into that zone of having another random health care bill comming in the mail. Is it 900, or 9000? Will my insurance cover this? Is this outside my deductable? ... this is math that no person should have to do while bleeding beside a highway.

[hnthrow10282910]

I fainted once and my wife called an ambulance as I was unconcious due to Covid.

I was fully aware when the ambulance arrived and refused. They peer pressured me very hard anyways. It was a 1 mile drive and cost me $14,000

[mikeodds]

You do have to question why representatives of the people have not managed to address this

[hnthrow10282910]

My insurance says ambulance rides are covered 100%. Apparently most are out of network though, which the people have no choice of choosing (obviously).

I was sent a post insurance $8000 bill. After months and months of arguing they said it was an error on their side and dropped the charge. Absolutely ridiculous

[deepsun]

> but you make the choice

No US doctor would ever tell you how much any procedure would cost (even though they know, at least "in-network" doctors).

But if in your EMT you inform the patient of the potential costs of the ride, then yea, I agree they make an informed choice.

[tonyedgecombe]

I’d argue nobody getting into an ambulance is making an informed choice.

[deepsun]

Under distress, yes. But honestly, I did piloting a little (airplane and various soaring aircrafts), and think that thinking there is also under distress, and that's ok, you still need to make decisions, that's life.

[culopatin]

You’re getting in an ambulance, not calling a cab. You’re probably unconscious, maybe at least disoriented, overwhelmed, concerned about what’s happening more than doing math. Also you’re there on the floor bleeding, what’s your alternative? “Nah don’t worry, I’ll figure out this exposed fracture in the uber, I got points with them so it’s cheaper”?

[deepsun]

Parent talked about conscious and aware.

I had fractures several times, and I did think about the costs. In fact, the last one was pretty bad, andy first thought was "good thing I'm in a country with good medical care, even though expensive".

[veunes]

I think your department is probably closer to what people imagine ambulance billing looks like

[getpokedagain]

>> He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.

Disagreed. Someone who is cogent and not intoxicated and not a stroke victim can't always make the best choices. Your decision making can be compromised by I dunno the fucking pain of a broken toe bone.

Seeking help should not be interpreted as a sign of weakness and made into a maze where only the most rational can escape with minimal bills. The longer we leave this cognitive dissonance where the land of the free roughly translates to land of the free to get fucked we are going to continue to have instability.

[Ferret7446]

By that logic no one can make choices for themselves, because people are never in the absolute theoretical optimal mental state.

[milleramp]

The physician can mandate ambulance transfer.

[sitharus]

Really? Where I live a patient is always able to refuse any medical procedure or treatment, unless they’re unconscious or otherwise mentally unable and the procedure is considered necessary to save their life. They certainly can opt for a non-ambulance transfer, though here it would be free even though a regular ambulance service typically isn’t.

Consent for treatment is a core principle of medical practice.

[true_religion]

I think the idea is that if it's mandated, then the ambulance should be covered by some kind of insurance since it was medically necessary and not just Ol' Bob, the hypochondriac, calling because his tin foil hat fell off.

[alistairSH]

Except that's not how it works. Ambulances are almost always out-of-network, so subject to MUCH higher OOP expenses. It's spelled out in the article.

[chrisra]

And what would they do if you refuse?

[criddell]

Who is "they" in your question?