
Post-apocalyptic life in American health care - primodemus
https://meaningness.com/metablog/post-apocalyptic-health-care
======
shrike
About 8 years ago I broke my leg and eventually developed a methicillin-
resistant infection where screws had been inserted. Fighting this type of
infection in the bone is difficult. I spent 11 months in a hospital bed plus
some time in a SNF. A total of 7 surgeries in the first 18 months and another
2 after that, the most recent 3 years ago.

I can second the experience of the author. All in I had contact with over 40
different providers. I was lucky in that I had to leave my job and could
concentrate on the administrative work required full time. I eventually
learned I needed to keep a detailed written narrative up to date with a tl;dr
at the top. Eventually I added appendixes that summarized lab tests and
surgery reports. This was the only way I could make sure each provider had the
details they needed. I would always send it advance, most of the time the
doctor hadn't read it so I brought paper copies and sat there while they did.

The billing and who covered what was hopeless. I had to fight with medical
insurance, the medical disability company and Medicare when I maxed both of
those out. I went through every bill line by line to identify mistakes, there
were many. Then I would make sure each had received a copy of each bill and
start figuring out who would cover what, sometimes line-by-line. This all had
to be done over phone and fax.

It's broken and I am sure it's killing people. I also don't see a technology
fix. Anything that requires more than two or three providers is an edge case,
this space is 90% edge cases.

~~~
grecy
A few years ago my brother broke his leg horribly. The Ambulance drivers said
it was the worst break they had ever seen.

Multiple surgeries, months in hospital, rehab, got addicted to morphine in the
process etc. etc.

At the end of it all was a handshake and "get well soon".

There was no bill.

Australia.

~~~
riverstones
I grew up in England. Same deal. In and out, no bill.

The Americans who decry "socialist" medicine have never used it. There has to
be a way to divorce health care and profit. English, Aussie, and Kiwi doctors
all make about the same pay as American doctors, but they work in a non-profit
system. Go figure...

Americans are largely opposed to a system where there is no profit. The
Americans are the Ferengi of medicine, this much is certain.

~~~
ido
American doctors make 6 figures $/year, sometimes _serious_ figures (like
$400k/year).

UK doctors don’t make near that much money.

~~~
inflagranti
Is this the average doctor or some specialist? The fact that some specialists
can hugely profit from the system the same way the hospitals, pharma companies
and insurance do, is likely port of the point of the previous comment. The
important takeway is the average doctor does likely also not see much of that
overhead money that goes to the pockets of a couple individuals and already
rich companies.

------
dbpatterson
It's amazing that someone can go through this and come to the conclusion, at
the end, that the solution is that this is a business opportunity that would
make a lot of money if someone could just make it more efficient. Trying to
make money off of healthcare is exactly how we have gotten the absolute mess
that is the American medical system. All the incredibly complex rules exist so
that health insurance companies can elect _not_ to pay for things that were
deemed necessary by a medical professional. If insurance companies would be
willing to pay for the services that were needed, there would be no 1600 page
rule books. Of course, a system that actually paid for the care that people
needed wouldn't be so obscenely profitable for them, and so they lobby
massively against it.

~~~
conanbatt
It isn't profit-seeking what makes healthcare what it is. Its the incredibly
burdensome regulation and restrictions.

If profit-seeking destroyed markets for profit, we would all be starving.

~~~
dragonwriter
Profit seeking destroys markets with large externalities or where utility
isn't readily discernable at low relative cost, and where for either or both
of those reasons the rational choice model doesn't reasonably approximate
actual behavior in the market.

Lots of real goods don't face that problem, but healthcare definitely does.

~~~
conanbatt
Whats the externality of providing healthcare, and in regards to the
diffuseness of utility, food has the same problem and its a relatively very
efficient market.

~~~
dragonwriter
> in regards to the diffuseness of utility, food has the same problem and its
> a relatively very efficient market.

Food is a frequently repeated purchase with significant immediately-apparent
utility and disutility, and so discovery of utilities is quick and the market
reasonably efficient in terms of immediate utilities. (There are long-term
utilities and disutilities that are less immediately experienced with
consumption, and the food market is hardly efficient in terms of those.)

Healthcare products are infrequently purchased, and the relative utilities of
different options are far from apparent. It's not at all similar to the
aspects of the food market that can reasonably be described as relatively
efficient.

~~~
conanbatt
I would argue that food escapes its measure of utility because otherwise, we
would all be eating only the cheapest and healthiest option all the time, but
our constant hunger also makes us purchase things against our long term
interest. If so, you would expect the market to be really inefficient, but at
least in terms of satisfying demand, its very hard to make money producing
food.

Its true healthcare has less frequency so you cant be a sophisticated
consumer: but its more frequent than a car, which is also a necessity in many
cases, and the lack of sophistry does not make it an inefficient market.

Im not even sure healthcare is a special market, certainly not for
infrequency, or because you must pay with your life (i.e. that you make a
decision of life and death for resources). Not for restrictive application of
labor (lawyers have that), not for the high costs of technology in its
application (consumer tech? space exploration?).

I think at this point what makes the healthcare market unique is the common
belief of the people that it is unique. It forces the consumer to consciously
think of the cost of life, a question we are somehow bred all our lives to
hate to ask, but that we answer every day unconsciously.

~~~
dragonwriter
> I would argue that food escapes its measure of utility because otherwise, we
> would all be eating only the cheapest and healthiest option all the time

Economic utility is subjective; while it includes health effects, to be sure,
it also includes things like the taste and other enjoyment factors. It
absolutely is not the case that, were food a perfect example of rational
choice, we would only be buying options that cost-effectively optimized
healthiness.

> Its true healthcare has less frequency so you cant be a sophisticated
> consumer: but its more frequent than a car

“Healthcare” is a broad class of different products and services, many of
which are far less frequently purchased than autos (if you buy open heart
surgery more often than you buy a car, you are way out in a tail of frequency-
of-purchase distribution of at least one of those items.)

OTOH, cars are also a market in which purchasers take a number of steps to
counteract the low frequency. No one is test driving a variety of different
surgerical interventions before choosing one.

~~~
conanbatt
> Economic utility is subjective; while it includes health effects, to be
> sure, it also includes things like the taste and other enjoyment factors. It
> absolutely is not the case that, were food a perfect example of rational
> choice, we would only be buying options that cost-effectively optimized
> healthiness.

Sure, I agree completely, but at least nominally the argument that healthcare
is unique because its a necessity and it has irrational behaving actors is not
qualitatively different than the food market.

> “Healthcare” is a broad class of different products and services, many of
> which are far less frequently purchased than autos (if you buy open heart
> surgery more often than you buy a car, you are way out in a tail of
> frequency-of-purchase distribution of at least one of those items.)

Thats as practical a segregation as saying that the people that buy the same
model of a car the same year and with the same gas price tends to be 1 at
most, hence almost no car purchases are ever repeated!

> OTOH, cars are also a market in which purchasers take a number of steps to
> counteract the low frequency. No one is test driving a variety of different
> surgerical interventions before choosing one.

Not really qualitative differences, just quantitative. Many car purchases are
done without test drives (argentina doesnt do test drives often for example).

But again, even if you find some truly unique property of healthcare, which in
this debate i don't recognize yet, i dont know how it will show that it should
be private but public.

~~~
dragonwriter
> Sure, I agree completely, but at least nominally the argument that
> healthcare is unique because its a necessity and it has irrational behaving
> actors is not qualitatively different than the food market.

“Necessity” wasn't part of the argument, and the argument wasn't really of a
qualitative difference so much as them being different degrees of the same
issues (food is considerably regulated—even by the same agency involved in
much healthcare regulation in the US—for many of the same reasons, though the
degree of deviation from ideal market conditions is lesser than for
healthcare.)

------
testplzignore
In the software world, we would fork or rewrite, and deprecate the old
version. I think we should do the same for healthcare. The existing system is
unmaintainable spaghetti code that needs to be deleted.

Create a new single payer healthcare system that is completely separate from
anything existing now. Don't attempt to incorporate any existing insurance,
regulations, medical records, etc. Allow the new system to ignore any existing
drug patents. Get a few brand-new hospitals, a few hundred doctors fresh out
of med school/residency, and tens of thousands of people using it - probably
do this in a single city, a la Google Fiber. Spend a couple years working out
the kinks.

Once that is done, migrate everyone to the new system over the course of a
decade or so. Any existing hospitals, doctors, and patients are free to stick
with the existing system, but I suspect they'll learn to regret that decision.

There are no technical or medical roadblocks to this that I can see. The only
obstacles are political and legal, which can be overcome in one or two
election cycles.

~~~
thehardsphere
It's arrogant to assume that a new system will be better than the old one
merely because it was re-written from scratch. Many companies died because
someone said "let's rewrite this bit of software" and the project ended up
failing because people vastly underestimated the difficulty of the re-write.
Even though they were smart professionals who knew how to write software well.

Considering that software companies frequently fail to succeed at re-writes
with something as inconsequential as software, what makes you think society
can do it with something as consequential as healthcare? Especially
considering that healthcare is in many ways much harder and more poorly
understood than software?

~~~
pat2man
One advantage we have is that other countries have systems we could copy. Its
not a complete re-write.

~~~
thehardsphere
This is like saying that Netscape can re-write Navigator because they can copy
Internet Explorer. It ignores that Netscape and Microsoft had totally
different reasons for the choices they made, and that changing those choices
in a re-write was very non-trivial for Netscape, to the point where it ceased
to be a company.

You will likely find similar problems with this in attempting to replicate
other health care systems. Indeed, you could complain that the mess we are in
now is the result of doing a poor job replicating Switzerland's health
insurance laws.

------
crispyambulance
I've been through similar experiences with my mother.

The best thing you can do, before your parent gets too old, is to consult with
an elderlaw firm to get health care directives, wills and power of attorney
written up. Most importantly, be sure to fully talk through the possible
scenarios for what happens financially in the event of putting your parent in
an SNF (skilled nursing facility).

Private pay for SNF in the USA is about $10000/month. That's a steep rate for
middle class and even upper middle class folks. That's what your family will
pay until medicaid "kicks in" when the savings of the parent are depleted. If
your parent made the mistake of giving away part of their wealth to family
within 5 years of entering SNF, that money still counts and they have to pay
it to the SNF. The medicaid provider for your state will demand 5 years of
bank statements for all accounts as well as query ALL financial transactions.
You might have to hire a lawyer just to untangle the mess. Dealing with this
stuff is a nightmare in paperwork at the worst possible time you can imagine.

I have found that face-to-face communication with the bureaucrats helps a lot.
The HHS staff people who process medicaid long term care enrollments in SNF's
have massive, soul-crushing workloads. Of course they're going to just skim
the hundreds (not exaggerating) of pages of documents you send them. The
article is right. You have to watch out for your family. No one else will do
it.

Eldercare consultants cost several thousand dollars. We decided not to engage
one because the SNF provided a lot of support and we had previously worked
with an elderlaw firm, but it probably would have saved us some stress when
dealing with medicaid/HHS as I was on the hook for $100K+ until a property
sale from 4 years ago was sorted out. There are families that end up going
bankrupt needlessly just because a parent wanted to "leave something" to their
children and didn't know about the 5-year-lookback trap (Thank George W Bush
for that fuck-up, see Deficit Reduction Act of 2005). We were fully aware of
the basics and still narrowly averted a financial disaster.

------
maxxxxx
"There is, in fact, no system. There are systems, but mostly they don’t talk
to each other. I have to do that."

That's something I have noticed too. My girlfriend had to visit several
doctors for a problem. One was confused about the notes of the other doctor so
I proposed to call and figure it out together. The doctor seemed really
perplexed about this suggestion and instead ordered the same series of tests
again.

~~~
yborg
Because ordering a redundant set of tests generates revenue. Just consulting
another doctor wastes both of their time better spent ordering up redundant
tests and quickly moving on to the next victim that can have tests ordered.

~~~
rdtsc
Yap that's what I realized as well. It is a complicated beast in that some
things happen because there is a profit attached to it, some happen because
there is regulation requiring it.

Unnecessary tests are not even the worst, unnecessary face and nose surgery as
suggested by one of the doctors for a family members was really terrifying.
Good thing we decided to spend more money an time to get second opinions.

------
nathanaldensr
I love this article. I feel like it gets down to the real root of the problems
with the complexity of Western culture. I feel like this perspective applies
to a lot more than healthcare. It matches my own thoughts that technological
complexity is getting so high that eventually it will be beyond our own
understanding, both individually or in a group of any size. We as a species
simply won't be able to make use of our own tools and systems because they are
so complex.

Ah, the hubris of humanity...

~~~
jerf
I'm as guilty as some people of just citing "excessive regulations" as a
problem without mentioning the mechanics that make that a problem, since so
many people see "regulation" as a good thing by just thinking of it as
"regulating away the bad outcomes". But this article gets to one of the
mechanisms I think of when I cite regulation as a problem; regulation casts in
concrete a particular way of doing business, and makes it _literally illegal_
to do it any other way. Can't even try something new as a one-off; it's
illegal to do anything else. Doesn't matter how brilliant your idea is; it's
illegal. Doesn't matter if you've got a startup with the software all ready to
go; it's illegal. Are two regulations either interacting poorly, or outright
contradictory? Not only is it illegal to not conform to both of them, now
we've introduced an adhoc meta-regulatory regime with regard to how to address
the overlaps, with the _de facto_ force of law behind this unwritten
metaregulation, and/or impedance mismatches between two bits of the industry
resolving them in different ways.

Even if we stipulate that The Hypothetical Medical Regulation Act of 1983 was
somehow the miraculous embodiment of perfect medical regulation for 1983, it
would be causing major problems for the medical system today. Mere time would
be enough to cause problems with medical regulations, and alas, they aren't
perfect to start with, and they seem to be ever-growing in size, and there's
no way the complexity growth is merely O(n). We've almost certainly passed the
point where regulations are appearing for the sole purpose (if one did a full
cause analysis) of dealing with the fact that regulations are blocking the
system up.

(My biggest objection to "national healthcare" is that unless you find me some
different authors to write it than our current Congress and current regulatory
state, I have approximately 0.001% confidence that "nationalizing healthcare"
will fix this. Advocates of nationalizing healthcare would have a much easier
time convincing me if Obamacare had _simplified_ health care, instead of
massively adding to the pile of regulations and massively empowering more
regulations going forward.)

~~~
NoGravitas
Obamacare complicated health care because it was designed to preserve the
existing system of insurance companies, employer-provided insurance, and
patchwork regulations. So, of course, it introduced more patchwork
regulations, along with subsidies to the existing players.

A single-payer system (Canadian style) would greatly simplify the health care
system, largely by cutting out the insurance-company layer for most people. A
British NHS-style system would arguably be even simpler, but is even more of a
political non-starter in the US.

~~~
jerf
I think you sort of misunderstood my point. My point was that you'd have an
easier time of selling me on it if Obamacare had actually simplified things.
Which was one of the promises it made, after all. Explaining _why_ it failed
to do so does not contradict my point, it reinforces it.

In terms of Obamacare not simplifying things, my engineering answer is "Then
why did we implement it?" If a goal is impossible for some reason, then the
correct solution is not to try to obtain it, not to just cruft up the system
harder anyhow. How many people can tell the same story of failure in their
engineering jobs? Since this is the same set of people who want to bring us
nationalized healthcare and want to write all the regulations for it, it does
not encourage me to think well of their judgment in doing so.

I am abundantly confident that our current ruling class would find _some_ way
to muck it up. Even if we handed them The Pristine National Healthcare System
Act of 2018, they'd have regulated it to death in just a handful of years. Our
current ruling class doesn't seem to be able to sneeze in anything less than
50 pages of legislation and several hundred pages of accompanying regulations.

~~~
nradov
That's not how politics works. Everyone has a different opinion and
priorities. Obamacare made the overall system better by providing more people
with affordable access to healthcare, at the cost of increased complexity in
some areas. It was a good trade-off. If everyone had insisted on perfection
then nothing would have been changed at all.

------
jf
I switched to Kaiser after my own dealings with the kafkaesque world of
healthcare that this article describes.

Kaiser is amazing in comparison.

With Kaiser, I no longer have to stare into the abyss of the "post-systematic
atomized era" of healthcare. I don't have to use CPT codes to compare prices
on bills with Medi-Cal rates, study legal agreements to find discrepancies, or
repeat myself to every different medical provider I visit. Instead, I can go
about my life and focus on the things I care about. Kaiser isn't perfect by
any means, but it's astonishingly better than the alternative.

------
JimboOmega
I'm living this situation right now. In my own life.

I'm transgender, and transgender care is a VERY complicated beast. I'm a
Kaiser member, and Kaiser NorCal (though not SoCal, so I hear...) is about as
good as you can get for Transgender care.

Do you know how hard it was to find someone who had some idea what Kaiser (or
any insurance) did actually did cover? And even when I did find that out, it
was (of course) changing. It took me talking to multiple member services reps
and people at both of the regional transgender facilities before I found
someone who could refer me to the person who knew.

What resonates most about the article - the "communal" aspect of it all - was
around a specific surgery I need - facial feminization. Kaiser has one
provider, basically. Great guy. Horribly backlogged - 2 year wait they told
me.

Through lots of redditing I found the one person who knows exactly how to work
this system. How to file the right grievances with the right language to put
everything in order. Things like - you need an appointment with another
provider so they can't merely claim there isn't a provider who can't do it.
This person has basically walked me through the entire process.

A fun and related fact is that California has a board that handles disputes
and does "Independent Medical Review". For facial feminization surgery, this
amounts to them deciding if given traits of a face fall within feminine norms
(which would make the surgery aesthetic, and not covered) or not (which would
make the surgery reconstructive, and covered). I've read a bunch of them that
go both ways. A really weird experience (the decisions are publicly
available!)

The ability to "work the system" is entirely too necessary - never mind the
cost, hassle, and everything else about it. You need "bureaucratic
perseverance". You _absolutely_ need to be ready to call, mail, file papers,
whatever it takes to kick up a fuss. And if you have somebody who knows how it
works on your side it's SO much easier.

------
bawana
Corporations increase complexity as they grow - each department needs to
maximize its revenue - thus complexification is justification for increased
budgetary needs. Healthcare is becoming increasingly corporatized. All the
talk about outcomes is just that. TALK. It has been so difficult to actually
understand how to improve efficiency because there is no good measure for it.
Everyone is arguing about outcomes and what actually is a meaningful measure.
The net result is laughable - everyone is looking at Press-Ganey scores
(basically a popularity contest as to how their 'customers' feel). Real
outcomes take decades to measure and for-profit healthcare systems are run by
CEOs who want to maximize their quarterly bonus(BTW the CEO of AETNA got a
$500million bonus for retiring-that came from premiums) It is criminal to
profit from the unintended misery of the unfortunate. The practitioners should
be paid. But everyone else who is pushing paper, massaging electrons or
jawboning about the share price is just dead weight on the system.

Ironically, the author found peace by hiring a consultant - back to square one
- a one on one transaction between two humans without a middleman.

~~~
bogomipz
>"Healthcare is becoming increasingly corporatized."

Hasn't healthcare been corporatized since the dawn of HMOs almost 50 years ago
though?

~~~
bawana
HMOs were a minor player 50 years ago. They are a euphemism for the corporate
cancer that maximizes profits at the expense of the sick. Even when I started
working in Mass 25 years ago, it was one of the few states with HMOs. They
have continued to morph and are now ripe for purchase by the more profitable
corporations (pharma) CVS buying Aetna is the first shot. Although Aetna is an
insurance company, they offered many stripped down 'products' = HMO like
plans.

------
Florin_Andrei
> _the biggest failing of the American health care system is its
> fragmentation_

This flaw will be extremely difficult to fix for as long as its nature is
perceived as "freedom" or "choice".

~~~
SN76477
I am always looking for the most fundamental answer, I think this is it.

------
carapace
> In 2017, software is conspicuously not eating the cost-disease economic
> sectors: health care, education, housing, government. They are being
> eaten—by communal mode tribalism.

Software can't fix political problems...

Bucky Fuller predicted that we would describe our problems to the computer and
it would calculate the optimal deployment of resources to solve them. He
estimated that we would have the technology to supply everyone on Earth with a
decent standard of living by sometime in the 1970's, provided that we used our
resource and technology _efficiently_. In other words, if you accept Bucky's
point, all of our problems now are _psychological_ rather than technological.
(We have all the technology we need.)

Standard of living problems have mathematical solutions, psychological
problems don't.[1]

> hire an independent health care administration consultant

"Add another layer of abstraction."

But now the consultant has a clear _disincentive_ ($150/hour!) to fix the
problem.

The U.S. health system is pathetically broken, and I have no idea how to fix
it. This seems like a poor solution, even though I can understand why the
author would do it.

I really feel for the author. My mother has dementia and is slipping away
fast. Thankfully my sister has the time and energy to move back in with our
mother and care for her. She's also with Kaiser-Permanente which seems to let
us avoid the worst of the systemic problems. So, in a way, we're really
_lucky_.

[1] "psychological problems don't [have mathematical solutions]" Although...
There is something called Neuro-Linguistic Programming (the other NLP) that is
a kind of model of psychology that does admit of algorithm-like protocols for
therapy. E.g. the "Five-Minute Phobia Cure" which is an algorithm that cures
phobias.

------
poppingtonic
[https://equilibriabook.com/molochs-
toolbox/](https://equilibriabook.com/molochs-toolbox/)

~~~
tvanantwerp
I read this a few weeks ago when it was linked from comments on a different HN
discussion. Definitely describes well the problems facing health care.

------
hectorr1
The need to hire a 'consultant' is extremely depressing. That is what doctors
(primary care managers in particular) are supposed to do.

But their pay is terrible compared to specialists, especially when you
consider medical school debt and that they don't start earning until years
later than most. They have diminishing power in the hospital organizations
unless they go into management. There are exceptions, but most medical
students with options don't choose Primary Care.

For specialists, the model is just as broken. If you do procedures, you are
incentivized to do procedures. Sometimes this is the best option for the
patient, sometimes it's not, but you are going to get paid one way and not the
other. And there is a good chance that unless you are at a top-tier academic
hospital, there will not be anyone around to second guess you unless you
realllllly screw up.

There is also tremendous pressure to produce, which is why doctors triple book
fifteen minute appointments, and you end up in freezing the waiting room with
no LTE for two hours. A good doctor would love to spend more time with you
directly, and a lot more time managing your care, but that's not what the
system incentivizes. And tying compensation to quality ratings is hugely
problematic when the job is to often tell people they are fat alcoholics who
need to quit doing opiates.

My wife is a doc, and it breaks my heart when she says she wouldn't recommend
it for our kids.

------
toomuchtodo
> For complex health care problems, I recommend hiring a consultant to provide
> administrative (not medical!) guidance.

This is called a patient advocate. Think of them as your healthcare guardian.

Sometimes you hire one, sometimes one will be assigned to you in more
progressive healthcare systems. If you are fighting a chronic or potentially
lethal disease, I highly recommend one.

Edit: Your patient advocate is usually covered by insurance if they work for
the hospital or the insurance company, but not if you hire them directly. Take
that for what you will.

~~~
gt_
Does American insurance cover this? I have inquired about something like this
before when I was getting conflicting diagnoses and treatment plans. Everyone
I asked (at my insurance company) acted like they didn’t know what I was
talking about. I did not size the phrase “patient advocate” but if one were
available, I think my need for them would have been clear.

~~~
pc86
If insurance denies claims for life-saving medical procedures because they
happened out of network, I have a hard time believing they'd pay for someone
to give you advice.

~~~
lukeschlather
The article gives a good example of why it's in the insurance companies'
interest to pay people to give you advice. It was obvious to everyone on the
ground that the insurer would save money if they just sent the author's mother
to an out-of-network physical therapist rather than keeping her in the
hospital. But the insurer didn't have anyone who could quickly make that cost-
saving judgment call.

Really, the biggest problem in a lot of cases is not that insurers deny claims
for life-saving procedures, it's that they prioritize expensive and
ineffective treatments over inexpensive and effective treatments.

------
mattchew
Best article I've read this year. (Haha, but it's very good, if a little
burdened with weird terminology.)

I have been through some similar experiences myself. Not as bad, but enough to
find OP's story not-really-remarkable.

This is what we've got for healthcare in the USA. I wish it was fixable, but I
do not believe it is. Powerful interests will resist or subvert any
substantive change. (I do expect new "reforms" that will promise fixes and
then pump even more money into the broken system, though.)

If you get sick, hope that it is something utterly routine that your
applicable system will process without a hiccup. Failing that, expect this
kind of craziness and prepare for it. Defensive record keeping and navigating
bureaucracies will be necessary skills in 21st century USA.

~~~
aeorgnoieang
> weird terminology

That's due to several factors but one of them is that some of the terms are
specific 'concepts' described elsewhere on the same site, which is itself a
'book'.

------
communalnotes1
The author concludes that communal or relational modes of interaction will
become more common as systems fail. It would have added a lot to the article
if he gave some tips on talking to the various providers and bureaucrats in
the system (the only advice is working in a medical office and "having
charm").

Once you've seen it, the communal/relational mode of interaction is
immediately easy to spot and is actually a very rewarding way to interact with
people. Although it doesn't happen as often in large cities except among large
families or tight-knit ethnic groups, I think a well-functioning workplace
should have some of it. People helping others out, getting to know each other,
and so on. The problem is the conflict between the way the health care system
presents itself and is organized (systematic/transactional) and the way it
really works.

Tips on seeing the communal mode and maybe practicing a bit: Note how your
group of friends relates when they're camping or otherwise on a trip of some
kind. Spend some time in a smaller town where you know at least a couple
people. Spend time with lower-income people from a similar background to you,
who have to rely on each other more versus their bank accounts. Outside large
cities, ask people at the stores or wherever how they're doing and actually
care about what their response is.

------
jbob2000
I know this is going to be controversial, but at this point:

> My mother’s mild dementia began accelerating rapidly a year ago. I’ve been
> picking up pieces of her life as she drops them. That has grown from a part-
> time job to a full-time job. In the past month, as she’s developed unrelated
> serious medical issues, it’s become a way-more-than-full-time job.

I would have kept my mother out of the healthcare system and let her pass at
home or in a hospice. You can't save someone from dementia and old age, don't
even try, you are just prolonging their pain. Let her drop the pieces of her
life and leave them there. Lymphedema treatment? She's 84 years old with
dementia, she isn't going to get up a run a marathon, why would you treat
this?

I say this having never have dealt with a dying parent, so this may be
ignorant on my part. I am sure it is difficult standing by while a loved one
fades. I think it would be better to spend a few stress-free, happy months in
a hospice than years running around between the confusing, painful, stressful
mess that is the healthcare system.

~~~
ams6110
I don't think it's controversial at all. Nobody gets out of life alive. If I
make it to 65 or so, I feel I've had my share. It's all downhill after that
point anyway, why would I want to prolong the misery?

~~~
AnIdiotOnTheNet
An easy statement to make when you're nowhere near 65. I've spent a lot of
time in my life thinking about death, and as a result I've come to certain
philosophical conclusions regarding it. But I know that philosophy is
something that exists comfortably in mind of someone without a gun to their
head.

------
EliRivers
_It appears that 73% of the labor cost of a health care organization is spent
on trying to communicate with other health care organizations that have no
defined interface._

So if it worked properly, US healthcare would cost one quarter if what it
does. Less, once the people engaged in trying to talk to each other are no
longer required. That's quite a statement.

~~~
ashark
Considering that (IIRC) other OECD states typically sit between 40% and 60% of
US spending on healthcare per-capita, and they presumably haven't actually
_eliminated_ these sorts of inefficiencies (so some percentage even of that
40% is still communication overhead) I'd say 73%'s at least plausible (could
still be wrong, of course).

------
maxander
If someone has a reasonably high-level position in a major medical services
organization, and wants to help us advance as a species, here's something to
push for; get your company to throw out all its fax machines.

Every office in the world _can_ use non-fax communication technologies; they
just have policies that prevent them. If they encounter a sufficiently large
healthcare entity that simply shrugs at them and says "we don't do faxes,"
_those policies won 't matter_, for precisely the reasons stated in the
article. People will do what needs to be done to get things to happen, policy
or no (if they care; if they don't, it won't get done, regardless of the
number of fax machines involved.)

One organization making a stand could start the process of getting us past
that particular perverse element of the medical system.

------
frgtpsswrdlame
I really can't agree with this paragraph:

 _Are the confused rules Anthem’s fault? I imagine that the 1600 pages try to
reconcile federal, state, and local legislation, plus the rules of three
federal regulatory agencies, nine state agencies, and fifteen local agencies.
All those are vague and conflicting and constantly changing, but Anthem’s
rule-writing department does their best. They call the agencies to try to find
out what the regulations are supposed to mean, and they spend hours on hold,
are transferred from one official to another and back, and eventually get
directed to a .gov web site that says “program not implemented yet.” Then they
make something up, and hope that when the government sues Anthem, they don’t
get blamed for it personally._

Anthem doesn't do their best to help people navigate their insurance and get
solid answers. Individuals within the company may do their best but the
company itself chooses how to fund those departments, how to run them, etc.
Healthcare is confusing because 'healthcare explainers' and 'insurance
navigators' are cost centers and so our privatized system places no real
emphasis on them.

Besides it's not like these rules emerge from the ether either, they exist as
a response to shady tactics by insurance companies. Surely we're not so far
removed to have forgotten all the abuses of pre-existing conditions by
insurance companies?

I might be able to say this isn't the fault of healthcare and insurance
companies only so far as it's the fault of government for not just ending the
charade and making the whole thing public.

~~~
conanbatt
No matter how much money in lobbying anthem might have spent, the ultimate
responsiblity for the law as written is of government.

Government should fix the current problems it has before asking for more
responsibility.

~~~
frgtpsswrdlame
I don't understand how your comment relates to mine. Care to elucidate?

~~~
conanbatt
"Anthem should do their best to explain the complex rules set forth by
government"

------
justinhj
She retired in 97 and still has health coverage by her employer. Is that
typical in the US? Is it very expensive to insure someone in perpetuity like
that?

~~~
InitialLastName
I assume it's tied to some kind of pension (which is tied to the former
employer), so the premium would be ongoing and taken out of the pension
payout.

Otherwise, I'd imagine yes permanently insuring someone would be
extraordinarily expensive.

------
dredmorbius
This is a systems interface essay. The lede is buried very deeply:

 _It’s like one those post-apocalyptic science fiction novels whose characters
hunt wild boars with spears in the ruins of a modern city. Surrounded by
machines no one understands any longer, they have reverted to primitive
technology._

 _Except it’s in reverse. Hospitals can still operate modern material
technologies (like an MRI) just fine. It’s social technologies that have
broken down and reverted to a medieval level._

 _Systematic social relationships involve formally-defined roles and
responsibilities. That is, “professionalism.” But across medical
organizations, there are none. Who do you call at Anthem to find out if
they’ll cover an out-of-state SNF stay? No one knows._

The author recommends hiring a consultant. I'd like to suggest an alternate
approach.

In complex disputes between parties, we have several systems or dispute
resolution. One is to engage the services of an alternative administrative
system: the courts.

While Anthem may be governed by 1,600-page rule-books, a judge is not. Or
rather, a judge has a _different_ set of rule books _and considerable autonomy
to make decisions independently_.

(With provisions for review.)

One way of considering this is as a collapsing of complexity: where a system
becomes _too complex_ to function reasonably, a third party is called in.

 _The U.S. healthcare "system" has become vastly too complex to function with
any semblance of sanity._ It is in desperate need of a complexity constraint
being applied to it. What we might in other political contexts call a
revolution. Perhaps a reform.

But it seems vastly beyond the realm of incremental change.

------
yodsanklai
I'm wondering, is the American health care bad for (upper) middle-class too?
let say you have a good job in a big corporation, do you have to worry about
healthcare? can you go to a decent hospital for any problem you may have and
get appropriate care without spending any dime?

~~~
mnm1
Yes, it's horrifically terrible. The hospitals/doctors you can go to are
dictated by your insurance. Having a good job does not equal having good
insurance. It's hit or miss. Having a good job does not guarantee you have
someone to help you out with the paperwork and the stress from that can and
will kill you even if you survive the actual hell that is the healthcare
itself (topic of the article).

If you get injured on the job, you have to go through the worker's
compensation system which can take months to years just to be seen for certain
conditions like RSI. And if you change states, you're fucked because there's
literally no one who knows how the systems should work together. The more
history you have, the worse. Sometimes you have to lie and omit medical
history just to get your foot in the door.

I worry about healthcare and whether I will be able to do my job (writing
software) next year, let alone ten or thirty years from now because I simply
cannot get the care I need for a problem that's 100% caused by work. This is
supposed to be covered 100%. Now imagine how bad people without insurance or
people who have otherwise not-covered conditions have it. It's a fucking
nightmare for everyone who is not part of the upper class and can afford good
insurance and the ability to hire assistants to actually make the insurance
work for them, so much so that certain companies have contracted out for such
services for their employees. It's a perk of employment that very few
employers offer. I'm sorry, but horrific doesn't even begin to describe the
situation ... I'm actually at a loss for words in describing how bad
healthcare is in the US.

~~~
bradknowles
But if you have a bad job, or maybe just one that is less than perfect, it can
be almost impossible to get good insurance.

