
John Stockman’s Medical Bills Topped $1M – What Happened? - bookofjoe
https://www.wsj.com/articles/john-stockmans-medical-bills-topped-1-million-what-happened-11545934412
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dontreact
Let's back up and make this a statistic instead.

In 2016 there were 770,000 people who were bankrupted due to medical costs.

Around 45,000 people a year die from a lack of health insurance.

In every country that has universal coverage reform has started with a push to
ask a basic moral and ethical question: should we consider healthcare a basic
human right?

In the U.S. we pay 18% of our GDP on healthcare, yet we rank ~ 37th in terms
of death due to preventable causes, and 31st in terms of overall life
expectancy. If you look at how healthcare works in other countries there are
many different systems but what they all have in common is a commitment to
provide access to healthcare for all citizens. There are different mixes of
private and public, and we have already implemented most of them to some
degree:

There are 4 main systems 1. Beveridge (public health care providers and
insurance rolled into one, like the NHS in UK): The VA and healthcare systems
used for native americans use this system

2\. National health insurance (private healthcare providers and public
insurance funded by the government, like Canada's system): Medicare was copied
from the Canadian system (even the name!).

3\. Bismarck Model: (private healthcare providers and mostly private
insurance, along with an individual mandate and heavy regulation of insurance
companies: this is used in Germany and Japan). Obamacare was an incomplete
attempt to move more towards this model.

4 Out of pocket model: (fully private: a non-system used by most poor
countries in the world). This is what the uninsured fall back on.

The main piece that is missing is we haven't committed to scaling either
systems 1, 2 or 3 in order to provide universal access to healthcare and so we
have an incredibly fragmented and complex system with soaring costs. American
for-profit insurance companies are bloated by ~20% administration fees whereas
in most countries they are non-profit entities with 5% or less.

To back up and sum it all up the fundamental question we need to ask ourselves
is: do we want to provide universal access to healthcare?

~~~
paulddraper
A few comments:

First, US insurance companies are often pseudo non-profits, with profit caps.
[1]

Second, another model is Medicare Advantage where beneficiaries can choose a
private entity to administer their Medicare plan.

Third, most commercial insurance in the US is not actually underwritten by
insurance co's, but by "self-funded" employers. In this case, the insurance
company is merely a third-party administrator (TPA) for the employee plans,
using XYZ's bank account (and trying to save them money, offer health
incentive programs, etc., to secure repeat business). Most companies with more
than, say, 500 employees operate this way, though usually you won't even know
this is the case.

\---

Finally, if by

> do we want to provide universal access to healthcare?

you mean "do we want everyone to have healthcare?", the answer is an easy
"yes". We want universal access to housing, healthcare, employment, etc.

But if the question is "do we want _the government to use taxes_ to ensure
that everyone has healthcare?", the answer is far more divided. There's a lot
of interesting examples elsewhere. But as you've mentioned, the US government
has already dipped its toe into those waters with the VA, and I don't think
it's been perceived as a success.

[1] [http://thehealthcareblog.com/blog/2012/02/04/does-
obamacare-...](http://thehealthcareblog.com/blog/2012/02/04/does-obamacare-
limit-profits-for-health-insurance-companies-in-your-state/)

~~~
dontreact
I believe this article is about a provision in the ACA to limit administrative
costs to 20%, which is highly unimpressive when you look at the way non profit
insurance works in every other developed country.

~~~
paulddraper
Perhaps. Where are you getting the 5% administrative costs?

All numbers I've seen have been _far_ higher than that.

* Canada 12%

* Britain 16%

* Netherlands 20%

[https://www.commonwealthfund.org/sites/default/files/___medi...](https://www.commonwealthfund.org/sites/default/files/___media_images_publications_in_the_literature_2014_sep_himmelstein_comparison_hosp_admin_costs_ha_09_2014_itl_exhibit.png)

~~~
Steko
Your link is provider admin costs. IIRC insurer admin costs are 3% for UK and
5% for Canada.

~~~
paulddraper
You're correct; good clarification on which admin costs we're talking about.

~~~
dontreact
Right, I was only talking about insurance administrative costs.

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maxxxxx
When I read these stories it always strikes me how arbitrary the system is.
You can have insurance but you still may lose everything. There really is no
way to do it right. It's a pure gamble.

~~~
zozbot123
"Insurance" can't solve the issue of sky-high healthcare costs. In fact, the
closest thing to a quick solution (a _real_ solution would require draining
the swamp altogether, by reforming the entire healthcare sector essentially
from the ground up) is its very opposite, namely _price transparency_ , with
the end-user paying directly for their health care. This doesn't mean doing
away with insurance entirely, but it will have to be _catastrophic_ insurance,
the main purpose of which will be dealing with truly rare health
conditions/medical emergencies, albeit with a sub-component of subsidizing
cheap preventive care.

~~~
amoorthy
I'm not sure why you conclude insurance cannot solve healthcare. Private
insurance, where there's a profit motive, may be inappropriate but insurance -
as a concept of spreading risk over a large population - seems logical for a
generally healthy population with occasional health issues.

The problem with healthcare is it's not a good like others which are insured.
Even with price transparency the patient isn't qualified to decide what
treatment to get at what price (your doctor is), and often the patient isn't
at their best physically or mentally when treatment decisions need to be made.

Comparing the US healthcare cost to other countries is slightly misleading as
much of the world free-rides off US pharma research.

If we want affordable insurance we should let people with chronic or
debilitating diseases die rather than treat them with expensive
medications/procedures that increase cost on us all. But when it's your loved
one that's sick it's extremely hard to be this cavalier about the decision to
not treat at any cost. I know I couldn't make that call.

~~~
maxxxxx
"Comparing the US healthcare cost to other countries is slightly misleading as
much of the world free-rides off US pharma research."

I want to see hard numbers on this. I strongly believe that this is just self-
serving propaganda to justify ripping off people in the US.

~~~
amoorthy
Fair request on hard data. I don't have it and don't want to suggest this is a
well-researched point on my part by simply Googling some random report.

I was going off comments from some post-doc friends who immigrated to the US
because they said medical research funding here is much better than elsewhere.

(As an aside I think some replies to my comment misunderstood my point. I
believe government insurance is highly appropriate for a good like healthcare.
Just that it's not without it's downsides and being Canadian I've seen those
first-hand).

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jchw
2 entities with asymmetric information and shockingly little oversight are in
a constant race to increase pricing. It cost $2900 for me to enter an ER and
leave it an hour and a half later after no treatment and no medication
whatsoever.

~~~
pasbesoin
Perhaps no longer surprising, but of note especially to people in other
countries, with regard to health care in the U.S.

People are frankly -- and justifiably -- scared of going to the emergency
room. To the point of declining transport from the scene of an accident or
other medical event, etc.

They actively ask people _not_ to call an ambulance.

It's not necessarily that they fear the doctor or the treatment. They fear
_the bill._

And yes, often enough these are people _with insurance._

A couple of years ago, I faced bills north of three grand, because someone
called the paramedics when I didn't need them. I'd purchased the best
insurance plan available to me, that year, and I was told at the time that
service should be covered. Nope: Insurance failed to pick up the majority of
it.

Fortunately, I could afford to cover the expense. And the paramedics -- part
of the local fire department rather than privately owned -- forgave the
balance of their charges when they learned that insurance had crapped out on
all but a couple of hundred. (It cost, at that time, about a grand just to
"roll the bus", with surcharges added to that for actual service and
transport.)

That last was another reminder that _public,_ non-profit safety can be a lot
kinder than private, for-profit.

~~~
maxxxxx
Somebody hit me at a red light a few years ago and the firefighters suggested
I take their ambulance to the hospital. I was really scared that this would
turn into a huge bill and almost declined but wasn't in good enough shape to
go home so I went but was stressed for days. In Germany I would just have
hopped on without worry.

At a minimum the US needs regulation so people can go through most medical
situations and know what they are getting into financially.

~~~
plink
If the at-fault party to your accident had auto insurance or you had uninsured
or underinsured coverage, you should have felt no compunction at riding the
ambulance. Auto insurance would have covered your damaged vehicle and your
health care costs after which your lawyer would be able to demand from the at-
fault party's insurer a cash settlement for the identical costs already paid
to the hospital, EMTs, et cetera (essentially paying out twice). Your attorney
would take 30 percent and you would deposit a check for the remainder. U.S.
health insurance doesn't have the monopoly on insanity.

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HarryHirsch
Wait, what? The article says that eventually, after a year of talks involving
a hostage negotiator^W^Wpatient advocate, the patient from the story paid only
his in-network deductible of 13 kUSD. Good for him, but you can afford that
kind of legal defense only when you are wealthy to begin with. Someone who
isn't a retired 1%-er would likely have declared medical bankrupcy, had he
faced the same circumstances.

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rootusrootus
[https://outline.com/4KRWuK](https://outline.com/4KRWuK)

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davidw
A root cause analysis would probably look at why the US didn't end up with one
of the various European-style health care systems.

~~~
dontreact
I really recommend this book: [https://www.amazon.com/Healing-America-Global-
Better-Cheaper...](https://www.amazon.com/Healing-America-Global-Better-
Cheaper/dp/0143118218)

It goes into comparing health systems around the world and understanding the
history of why they went into effect.

There is a cheeky answer to your question: we have _all_ the main systems that
are used in Europe and other places in the world.

There are 4 main systems 1\. Beveridge (public health care providers and
insurance rolled into one, like the NHS in UK): The VA and healthcare systems
used for native americans use this system

2\. National health insurance (private healthcare providers and public
insurance funded by the government, like Canada's system): Medicare was copied
from the Canadian system (even the name!).

3\. Bismarck Model: (private healthcare providers and mostly private
insurance, along with an individual mandate and heavy regulation of insurance
companies: this is used in Germany and Japan). Obamacare was an incomplete
attempt to move more towards this model.

4 Out of pocket model: (fully private: a non-system used by most poor
countries in the world). This is what the uninsured fall back on.

A less cheeky answer involves looking at the common factor in the rise of
systems 1, 2 and 3 in countries around the world. The fundamental political
driving force behind this was a moral and ethical decision that healthcare is
a human right that the government should provide. When Clinton attempted
healthcare reform in 1994 he couched the politics of it in economic terms
saying that we need to reduce costs, and it failed. Obamacare only began to
make some headway once the politics and debate around it started focusing more
on the basic moral and ethical question of whether our society should provide
universal access to healthcare.

So it's this weird situation where maybe some people want it for economic
reasons (our system is by far the worst in terms of costs per outcome), but
politically the best thing is to make this a fundamental moral question of
healthcare as a human right. Most constitutions written in the second half of
the century include some kind of reference to healthcare as a human right.

~~~
mynameishere
You keep saying "human right" and I don't think you realize this undermines
the persuasiveness of whatever else you might be saying.

It may well be for the overall good to expand Medicare to everyone. But it
isn't some sort of "human right" in the same way free speech is. It never will
be, as that implies we have the "human right" to demand services from others.
We don't--that's nonsense to anyone who actually considers it for five
seconds.

~~~
dontreact
Yeah I think for someone more libertarian like you appear to be the argument
is more about how bad our system is in terms of costs and outcomes and how
good everyone else’s is. We should look at those other systems and see why
they work well. The common factor seems to be a commitment to providing
universal coverage.

My point is that an argument in economic terms historically has been
ineffective for actually getting reform to happen, whereas an argument based
on healthcare as a right is effective (I get why it’s not effective for
someone like you)

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Tomminn
A point I can't help repeat: the US already _has greater public healthcare
spending_ than almost all countries that have universal public healthcare [1].

To fix the damn system:

Step 1. Decide on an amount you want to spend on public healthcare.

Step 2. Fund an external body (for an example see [2]) to figure out which
treatments will result in the most bang (roughly speaking QALY's) for your
chosen buck. This will result in some hospitals and some treatments not being
funded because they are too expensive.

Step 3. Watch the private insurance market become sane private and hospital
cost disease reverse because they have to compete with fairly decent public
health coverage.

[1]
[https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...](https://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita#/media/File:OECD_health_expenditure_per_capita_by_country.svg)

[2] [https://www.pharmac.govt.nz/about/your-guide-to-
pharmac/fact...](https://www.pharmac.govt.nz/about/your-guide-to-
pharmac/factsheet-01-introduction-to-pharmac/)

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aurizon
Looks like they measured his financial resources and grabbed because they
could.

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HillaryBriss
when people repeat, ad nauseam, that "America is the richest country in the
world", i reflect on stories like this one and think "really?? how many people
are benefiting from all these 'riches' when this kind of thing can happen to
just about anyone in America?"

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theredbox
Can anyone even measure the impacts of the US going full "free" healthcare on
other countries ?

