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Cancer Complications: Confusing Bills, Maddening Errors And Endless Phone Calls (npr.org)
265 points by thebent 20 days ago | hide | past | web | favorite | 349 comments



In Australia the Leftist government of Gough Whitlam introduced health-coverage-for-all in 1975 with a scheme called Medibank. In 1984 after a couple of governments, Bob Hawke's Leftist government created the Medicare scheme (Medibank became a government provider of private health insurance), which exists to this day.

The most interesting stat I ever heard about Medicare was this: prior to Medicare the number one cause of personal bankruptcy in Australia was medical bills.

So I'm with Bernie on this: health coverage for all is an incredibly important goal.

While we're at it, let's end the monopoly given to drug companies on the sale of pharmaceuticals in the US. You should be able to legally import them from, at the very least, any NAFTA country and any EU member.


We still cannot get a price list of medical procedures in the US thanks to the antitrust exemption provided in McCarran-Ferguson Antitrust Act of 1945.

I think repealing this would be a good start. All other industries are required to provide price lists. My friend went to the ER recently for a sprained thumb. They wrapped it in some bandage and he got a bill for $14,000.

His insurance is covering 80% but he is still on the hook for $2800 for a sprained thumb. Something is not right here.


Don't go to the ER for a sprained thumb.

Unless its an actual emergency, go to urgent care. I live in a pretty expensive area of California and they still only charge $95 per person they see. And our insurance covers it completely. And rightly so, they would much prefer a $95 bill to a $14,000 one.

With kids we go a couple times per year. They definitely have saved us a lot of money and time.


As other have said urgent care isn't everywhere and closes so it's not entirely by choice that people wind up in the emergency room for non emergency things. Beyond that it's hard to know sometimes what's emergency and what isn't until you have a doctor look at what's happening.


OK but a sprained thumb is not something that can't wait until morning. Take a couple of Advil and put some ice on it.


That assumes the patient _knows_ it's only a sprain.


It's likely the same for any break that is in the "not sure if is sprain or break" range.

Years ago I crashed my mountain bike and had a high suspicion that I had broken one of my fingers. Urgent care was closed by the time I got home and cleaned up and my college roommate was in town so I met up with him after taping my fingers together to prevent unnecessary/unplanned movement. Urgent care confirmed a break the next morning, and fixed everything for $300. Healed perfectly.

Anyway, anecdotes are just that, but the emergency room is not the place to go for "simple" things like a possible sprain, minor break.


Urgent care also closest. My closes urgent care is open from 8 am - 6 on. The rest close by 8.

Deep cut at 9pm... emergency room is only option.


Urgent care doesn't exist in some jurisdictions.


Urgent care might be a good option where it's available. Even here though, I've been told I just need to pay my copay, which I did up front, then been billed a couple months later for some additional amount. I was lucky that the amount wasn't high so I just paid it rather than dig in, but it's very unclear how or why I was billed extra. This happens all the time.


If you have a deductible you’ll be on the hook for the whole cost which could be $100-150. The bill would need to round trip to the insurance company first.

In contrast if you have not met your deductible and say you’re paying cash, it’s often cheaper as the cash price is something like $75.

I got in an argument once at an urgent care on this topic. I asked how much they would bill my insurance (“We can’t/won’t tell you) vs not having insurance and paying cash price ($75). They then proceeded to insist I give them my insurance information as “Sir- you must use your insurance. That’s illegal!”.


I had a hospital pull this on me when I was looking to get something done. They said we can't get the cash price because you can only get that if you don't have insurance, even if you know your insurance doesn't cover it, and it's illegal to not have insurance so we must have it, so no cash price.


Talking to people in the healthcare field about billing and money can make people murderous, logic, chain of reasoning, the English language is all in a state of flux.


This!

I've got family in health management and THEY can't reliably figure out what a procedure costs(not even something like a simple statistical characterization) much less what they should charge for it.


Interesting trivia - health insurers kind of don't care about these big bills, despite what most people think: https://www.propublica.org/article/why-your-health-insurer-d...


not sure it's trivia. it's pretty straightforward though:

higher bills means more money insurance companies can skim off the top without patients objecting. direct costs are basically pass-throughs to policy holders. the risks are higher but execs are in it for salaries and bonuses, so that exhibits the principle agent problem.


Our healthcare system is set up for the enrichment of doctors at the expense of patients. Here is a great article showing this yet again. When you go get a fast food hamburger for $1.49, you will only extremely rarely receive a poorly made burger or have a billing mistake or get food poisoning. So why are you virtually guaranteed to not get what you pay for and get overbilled anytime you visit a hospital? The doctors union has strictly prevented any kind of competition and innovation in healthcare.


Yes-- we need price information. A family member (US citizen) lives in Europe and has free government health care there, but you often have to wait several months to get treated. Instead of waiting, she thought she might just do needed cataract surgery in the US to get it done if it didn't cost too much. I called several medical centers that do cataract surgery for an estimate. Can't provide it. Can you give a ballpark range? No. Can you say if it's closer to $1k, $10k or $100k? No.


Instead of waiting, she thought she might just do needed cataract surgery in the US

Just about every country in Europe has private hospitals that will do non-emergency surgeries without wait if you pay. They'll also have no problem quoting you a fairly exact cost if you call them up.


Not universally true.

I can't get better care even if I pay for it, I'm only legally allowed to pay only for trivia; the only care available to me is the "free" (read: costing ~8% of my income in mandatory medical tax) one with, yes, months of waiting and nobody giving a damn about you.

It's almost certainly better than the US system, but it's not all roses in EU either.


I don't know where you are, but if nothing else there is nothing stopping you from getting on the next plane/train to Germany or wherever and having the operation done there.


Why did he go to the ER?


Thumb injuries are actually treated very seriously (at least more seriously than you might think) by medical professionals because thumb injuries can have very high consequences for quality of life. You can live a totally normal life without an index finger but a missing or disabled thumb is a much more significant impact.


I know. To elaborate (and reply indirectly to will_brown) I think it's impossible to say how egregious $14k is for billing without knowing how severe a sprain it is and how much they had to do to diagnose it. Maybe he walked out with a bandage, but maybe he got an x-ray or mri? And ERs are expensive because they have to handle anything from a MI, stroke, poisoning, massive trauma, or ID case. If you go to one, you have to pay for use of that very complex facility. Then you pay for diagnostics that they deem necessary. Then you pay for the attending/specialist(s)'s time. A thumb trauma could be super severe and it was probably a good call, and it's great he walked out with a bandage. But I don't think that a $14K er bill is that out of bounds given what they are intended for, nor do I think that a bill needs to be commensurate with treatment rendered.

edit: since this thread is about cancer, I will not reply more because it's OT in pretty fundamental ways. The US healthcare system has massive issues, but I am not sure this particular case relates to the thread or is a great example of the dysfunction in general. A price sheet is not possible for "my thumb really hurts" ... it will depend on a lot of situationally appropriate decisions being made by the attending that cannot be predicted.


> I think it's impossible to say how egregious $14k is

I live (well, lived. currently in the UK) in Australia, and the concept of a $14k bill for a sprained thumb is so out of my world. I cannot fathom how anyone would find that even remotely acceptable.


On the weekend my 83 year old mother in law fell and broke her ankle. One hour ambulance ride to a metropolitan ER. Examination and diagnosis by a trauma specialist and an orthopedist. X-ray. Moonboot applied, a night in hospital as community team were assigned to make her adjustments to her apartment for recovery period. Physiotherapist consultation and ongoing support. No insurance. Total cost zero dollars. In New Zealand and proud at times like this.


I am breaking my word replying, but madeofpalk and you highlight something I failed to distinguish in my comment. I'm talking about "bill" in the sense of summing up the cost of services rendered, like a check in a restaurant. Not policy talk about how is responsible for paying it. All that care for your grandmother (who I hope is okay) isn't zero dollars. It is thousands or tens of thousands of dollars, but she didn't directly pay it. And that is totally cool, and probably a good model. But I was justifying the cost of care the hospital rendered, without touching on who ended up reimbursing them.


I did understand your point, and I could have been clearer by using the word "bill" rather than "cost". Obviously there was cost. In New Zealand cost is not something that a person suffering sudden trauma has to worry about. I am glad you agree this is a good model.

I have another story that is cancer related. Four years ago I had cancer surgery, in the private system. The public system judged that I could wait a month or two (our system isn't perfect), but I was fortunate to have health insurance and elected to be treated immediately. After a few days at home I awoke in the most excrutiating pain imaginable. I was just able to stagger to the phone to call for an ambulance. I would judge it was less than five minutes before I heard the wonderful siren of an approaching ambulance with well trained paramedics and their lovely lovely morphine. It turned out I had a relatively rare complication, a urinoma, my resectioned kidney was leaking urine into my abdomen. Ambulance care (google "Wellington Free Ambulance" it's a wonderful thing), ER assessment, CT scan, stent insertion to help the kidney heal, five days in hospital. Total cost: Who knows, probably astronomical. Total bill: zero dollars.

I love capitalism, I'm a true believer. But I believe even more in a compassionate society and it seems to me that means not using capitalism as a solution to all problems. It makes total sense to have a model that relieves victims of sudden medical trauma from financial stress and spreads the cost across society. The victims are not well placed to play the role of rational economic actors.


> Total cost zero dollars.

You mean total bill zero dollars. Cost was much greater than this, it just wasn't covered by your mother.


In the USA, what a hospital charges does not necessarily have any correlation with the cost of servicing your problem. In the same city, the price of a procedure from hospital to hospital can vary by up to 10x.


I think you are trying to make some point about wasting resource...but the ER is how accute injuries like this are generally treated. Sure there may be urgent care centers equipped for this, but that isn’t a guarantee and those often have more restrictive hours than an ER, especially acces to urgent care services like x-rays or mri/cat scans.

Sure in hindsight it’s a sprained thumb, but likely because of pain thought to be broken or worse...requiring x-ray and being set by a trained professional or maybe even surgery. It is a thumb so it would be less than ideal to lose feeling or mobility or the thumb itself (say there was nerve or circulatory damage).


And that's the essence of this: In the developed world, this is all but a US specific issue. Cancer and other life threatening diseases rarely bankrupt Europeans, Canadians, Australians, Kiwis, Japanese etc.


I don't know about the rest of the world, but bankruptcy in the USA is not really the catastrophe you might think it is.

You can keep a lot of your assets, generally including your retirement accounts, at least some equity in your home, your car, your personal property. Your credit is badly dinged and you'll have trouble borrowing money for a while, but even that is only a temporary setback.

I know people who have gone through it, in once case more than once, and at least from appearances they have a pretty normal lifestyle.

The recovery from a bankruptcy is probably a walk in the park compared to recovery from cancer (not speaking from experience). Ultimately it's just money.


If you read the article, you would note that Bankruptcy increases the risk of death significantly.


> Cancer and other life threatening diseases rarely bankrupt Europeans, Canadians, Australians, Kiwis, Japanese etc.

Sure, but they're also dramatically less likely to survive the cancer than Americans are at a population level. There have been multiple long-term studies on cancer survival rates that have demonstrated this.


The US is barely in the top among developed nations, and it's not much better than the next 10-15 countries: https://www.wcrf.org/dietandcancer/cancer-trends/data-cancer...

And it's notoriously difficult to compare. If cancer is registered as "discovered" early, because a for profit doctor starts treating it early, but the government hired doctor maybe doesn't, the early treated will statistically appear as living longer.


> The US is barely in the top among developed nations, and it's not much better than the next 10-15 countries: https://www.wcrf.org/dietandcancer/cancer-trends/data-cancer....

First, you're posting data that isn't relevant: that's the rate of cancer incidence, not the survival rates. That says nothing about how well the cancer is treated.

Secondly, it's nonsensical to compare aggregated cancer statistics between countries, because the demographics vary drastically, many cancer risk factors are highly hereditary, and the survival rates for different types of cancers vary so dramatically.

If you look at the actual survival rates, once adjusted for racial composition and type of cancer, the US comes out far ahead. https://www.ncbi.nlm.nih.gov/pubmed/18639491


Yes, I posted the wrong data. Sorry. See above :-)


1. The data you posted is 20 years old.

2. The data is talking about 5 year survival rates and not actual survival. The US Healthcare system is great at keeping people alive who should have stopped treatment long ago.

3. The US is behind on every other major health indicator, Infant Mortality, Life Expectancy, Cardiovascular Disease, Obesity etc. Cancer isn't the only expensive illness in the US.

This thread is overrun with Astroturfers.


> 1. The data you posted is 20 years old.

It's from a study published 10 years ago. The study was repeated more recently and republished less than a year ago, reaffirming the original results.

> 2. The data is talking about 5 year survival rates and not actual survival. The US Healthcare system is great at keeping people alive who should have stopped treatment long ago.

There is no such thing as "actual survival". 5-year survival rates are the global standard for cancer epidemiology.

> 3. The US is behind on every other major health indicator, Infant Mortality, Life Expectancy, Cardiovascular Disease, Obesity etc. Cancer isn't the only expensive illness in the US.

This thread is about cancer, in response to an article posted about cancer.

> This thread is overrun with Astroturfers.

From the HN guidelines: https://news.ycombinator.com/newsguidelines.html

> Please don't impute astroturfing or shillage. That degrades discussion and is usually mistaken. If you're worried about it, email us and we'll look at the data.


Aren't those 5 year survival rates from time of diagnosis?

If so, it is possible for two countries that have the same survival rate measured from actual onset of the cancer to have a different 5 year survival rate.


I think it's always from time of diagnosis. Determining the "actual onset" of cancer would be little more than a guessing game.


How does your link relate to your comment?


It didn't. Sorry. Clearly I shouldn't post from my phone while cooking. These were the comparisons I meant to post:

https://krugman.blogs.nytimes.com/2011/03/24/cancer-survival...

https://en.wikipedia.org/wiki/List_of_countries_by_quality_o...


You've failed to correct for over-testing, over-diagnosis, and over-treatment which all cause harm.

It's worrying that the US places so much emphasis on 5 year survival rates, and not on eg all cause mortality.


> You've failed to correct for over-testing, over-diagnosis, and over-treatment which all cause harm. It's worrying that the US places so much emphasis on 5 year survival rates, and not on eg all cause mortality.

I'm not, if you actually read the research I linked instead of speculating.


I have read the research. You're using 5 year survival rates, not all cause mortality.

This causes people to get tested, get treated, and sometimes get harmed by that treatment, but does not extend their life.


> You're using 5 year survival rates, not all cause mortality. This causes people to get tested, get treated, and sometimes get harmed by that treatment, but does not extend their life

This is discussed and addressed in each of the three instances of the study that have been conducted, so I recommend reading those for the response.


I think the current friction in free flow of medication across borders is not unwarranted. I'm thinking of Thalidomide as an example.

https://en.wikipedia.org/wiki/Thalidomide https://en.wikipedia.org/wiki/Frances_Oldham_Kelsey


> I think the current friction in free flow of medication across borders is not unwarranted. I'm thinking of Thalidomide as an example.

That's a completely different situation.

Currently, if an American pharmaceutical company produces a drug in the US and exports it to another country, people in the US cannot purchase it from foreign suppliers, even though it's both FDA-approved and produced by the same manufacturer. This dramatically raises the prices of drugs in the US.

Allowing imports of FDA-approved drugs from both domestic and foreign manufacturers would reduce prescription costs in the US greatly.


> [Allow] imports of FDA-approved drugs from both domestic and foreign manufacturers

I agree. I interpreted the OP's comment of "You should be able to legally import them from, at the very least, any NAFTA country and any EU member." to be too lax.


A fair chunk of what we in the US would consider “medical bankruptcy” is not the bills, but a consequence of chronic illness. If I’m living paycheck to paycheck, any disruption is going to hurt. That could be unpaid leave, but it could also be disability insurance that doesn’t replace 100% of your income. Regardless of how health insurance is paid for, those are going to happen.


Let me play devil's advocate.

What if living paycheck-to-paycheck is a consequence of having no health coverage?

Think about it. If you're on a low income that largely matches your outgoings, bills of thousands of dollars will wipe you out regardless of whether or not you save. So why save? You may just reduce any benefits you get from the state or Federal government (medical or otherwise) and those will be wiped out anyway. So you may as well spend now.

Consider, the Earned Income Tax Credit is one of the few times lower income households can make large purchases (and there's evidence of this in TV purchases and elsewhere).


Disability insurance, like other insurance, is motivated to find loopholes with which to deny you. Make sure to read the fine print while you're still well and able.


If health care for all reduces prices and total cost, then yeah. Otherwise, the cost will cripple the government, and by extension taxpayers. Right now they can declare bankruptcy and just don't pay (at a great cost, no doubt) but the government will have to pay. Cancer is a fact of life,38.4% will get it in their life https://www.cancer.gov/about-cancer/understanding/statistics and unless costs are dramatically lowered any plan will be bankrupt.


The federal government cannot be crippled because it can issue currency ad-infinitem. As AOC is wonderfully publicizing, the notion that government finance works like household and business finance is finally starting to be debunked and at least talked about openly. There maybe other problems with universal healthcare, but financing it is not one of them.


It's truly worrying that comments like these are made unironically.

Is there any amount of currency printing that you believe might be problematic? Or is the sky the limit?

Perhaps most importantly: What happens if we accept your claim, spend and print money ad infinitem, and then you're wrong?


MMT sounds awfully like the Magic Pudding [1]. If governments can just print any amount of money they like to pay for everything whence cometh hyperinflation?

1. https://en.m.wikipedia.org/wiki/The_Magic_Pudding


I don't understand why this discussion often turns to the Fed issuing more money, rather than the re-allocation of existing funds. It's pretty clear that the US is already spending more as far as %/GDP/per capita on healthcare than other countries that have socialized medicine. To me that just screams waste and inefficiency, er, I mean... profits!


Because it has become the magic solution to solving difficult problems. You don't have to make difficult choices between spending options, just buy everything and put it on the nations credit card.

Reforming the US healthcare system is incredibly difficult because everything is interconnected. If you try to reform it piecemeal things start to fall apart.


Thank you very much. This is precisely conversation we need to have. Exhibit A: Obama boom we hit 10% GDP deficits, the biggest since WWII resulting in no inflation and in fact slight deflation and GDP never averaged above 3% annually. Exhibit B: WWII, we hit around 22% GDP deficits. Full employment ( with a very high labor participation rate [rosy the rivoter, etc]) no hyperinflation and probably not much inflation.


The Obama boom was during the worst recession since the Great Depression so there was plenty of slack in the economy to absorb money creation.

WW2 is more complicated as there were price controls and rationing in place to prevent inflation. it is unlikely that you could impose such controls outside of a total war situation.

All the historical examples of hyperinflation have occurred when governments have printed far more currrency than they have raised in tax or via the debt market. Spending tens trillions dollars more than you raise in taxes is likely to end in tears.


Inflation! Why can't the conversation be "how far can we go before we hit inflation?" instead of "we can't afford it" because we of the household analogy ?


nope, doesn't work that way. USA issues a lot of debt, maybe more than it should, but issuing trillions of new dollars a year is not good policy.


People often don't even need to declare bankruptcy. Lots can get away without paying and the hospital will write off the charges without any ill effect.


doesn't matter who is president in 2020, if the senate isn't blue. And right now, it doesn't look like the senate will even hit 50/50.


Fortunately (ironically, sardonically), thanks to the precedents being set by the sitting president, future presidents will be free to declare healthcare a national emergency and divert funds away from, say, the defense department in order to pay for it. A slim majority in the senate and a minority in the house won't be near enough to stop them. The current senate dissolves the checks and balances at their own institutional peril (and no, this isn't a situation anyone ought to be celebrating, except for the authoritarians).


> future presidents will be free to declare healthcare a national emergency

Well, actually, maybe it is a national emergency? Definitely seems more of an emergency than some wall.


So is climate change. We have lots of emergencies to tend to. It is going to get interesting.


The political system in the US biases area over population. The Senate will remain conservative as long as rural states remain conservative, and that will never change.


I'm not sure I'd bet on that. Cities are almost universally liberal, and even rural states start to turn blue as they get their own big cities.


Unfortunately without proportional voting being mandated purple states like Texas remain solidly red due to vast gerrymandering purposefully made to deny people the right to their representation by diluting their vote. This is actually the main cause of polarization in the US as candidates need to play to their base instead of moderating to play to a moderate base.


So there's a lot I could say about this.

First is an example. As much as I, personally, liked (and continue to like) Obama as a person and as much as I agree with most of his policies, at the end of the day he was a pretty ineffective president. Why? Because he could get hardly any legislation passed (Obamacare aka the Affordable Care Act being the principle counterexample). He was a president who ruled by executive order.

The White House is the largest and loudest bully pulpit in the country, by far. You can point to Congress and call them obstructionist but the buck stops with you as president to move your policy agenda and change the national debate. And Obama just wasn't effective at that.

Again, with one exception. It used to be a fairly popular opinion in the US that health coverage was for those with jobs, basically. That still is the position of a significant portion of the population but it's not as popular as it used to be. Obama did change the national debate on this such that the question became how we should provide health coverage and not whether we should.

Go back a decade or more and the Bernie Sanders coverage-for-all policy platform would've relegated him to being a minor player in the primaries, not taken seriously. The fact that he was as prominent a figure as he was is in no small part due to Obama changing the debate on health care (IMHO).

The second thing I'll say is that nothing lasts forever. Demographics change. Opinions change. California voted for Reagan. Twice. It used to be a competitive state. Now it's safely Democratic. Florida used to be safely Republican but (largely due to migration from the Northeast) but now it's a battleground state.

Let's just say that at some point Conservatives get what they've been hoping for: Roe v. Wade overturned in the SCOTUS. It could happen. Largley though the "damage" has been done already. It won't be illegal. It'll just be a state issue. Many states will legallize it the next day. New York for example has already made moves to enshrine the legality of abortions in state law. Now this will suck for particularly poor people in Alabma but in a way Alabamans will get the state government they seem to want.

So let's say that happens. The problem then for Conservatives is they've lost a defining and unifying (for their base) issue. One can argue they're better off politically this way as they'll fracture in the aftermath.

I see the current Conservative bent as a desperate last gasp for what is a majority (in their respective states) that's in decline. A lot of damage can be done before this naturally remedies itself but we're not headed to a dystopian Handmaid's Tale future either.


> He was a president who ruled by executive order.

Do you hold this opinion due to the nature of his orders? His rate of orders issued doesn't make this look plausible, on its own. Lowest per-year average since well before WWI, by the look of things.


I'm all for universal coverage too. But reducing the profits of pharmaceutical companies well reduce the money they have for r&d dramatically.

This will slow down the speed of pharmaceutical development. So I think it needs to be paired with reforms to the FDA to reduce the go to market costs for drugs.


From https://en.m.wikipedia.org/wiki/Prescription_costs

“A study has placed the amount spent on drug marketing at 2-19 times that on drug research”

Maybe this should be reduced first?


The wikipedia article misstates the figure in the underlying paper. The underlying paper is talking about "basic research" not R&D. I.e. it doesn't count money spent on e.g. making improvements to use of known molecules, it doesn't count the cost of bringing a new molecule to market, it doesn't count the cost of testing, etc.

That's a non-sequitur. Companies have no incentive to spend any more on marketing than they have to. Tech companies also spend more on marketing than R&D--would innovation increase if the government forced that number downward?


Only in America and New Zealand are pharmaceuticals permitted to be marketed directly to consumers. Does the rest of the world not innovate?

We’ve tried the free market way, let’s try it the “rest of the developed world way” next.


> Only in America and New Zealand are pharmaceuticals permitted to be marketed directly to consumers.

Marketing does not only include direct-to-consumer advertising.

> Does the rest of the world not innovate?

Pharmaceuticals are a global market. As it turns out, European pharmaceutical companies make a disproportionate share of their revenues from pharmaceutical sales in the US.

But to answer your question: statistically, no, the rest of the world doesn't innovate. Half of all pharmaceutical R&D costs in the entire world are funded by the US. That share has dropped slightly in recent years, but not because the "rest of the developed world" has been increasing their funding: it's because India and China have been rapidly expanding their R&D.


> Marketing does not only include direct-to-consumer advertising.

The other flavor bribes doctors to overprescribe - it is much worse.


This is flawed thinking. But it's very popular flawed thinking, so you're certainly not alone. :)

If marketing has a return on investment (and it does) then marketing spend also increases money available for R&D.

Marketing and R&D are not pieces of a fixed pie. Marketing spend grows the entire pie and provides additional dollars for the company to spend on R&D.


It does provide a perverse incentive to research drugs with high market potential over those with live saving potential.


Of course it does. But until you can find trees that grow money, you need to invest in R&D that pays for itself.


> Marketing and R&D are not pieces of a fixed pie. Marketing spend grows the entire pie and provides additional dollars for the company to spend on R&D.

You're talking like marketing extracts money from the ground as if it's a raw resource. If 10x as much is spent on marketing as RD then the money spent on pharmaceuticals is <10% going to RD. That's not good for the consumer. It would be good if marketing was regulated and that pharmaceuticals were forced to compete by spending money on RD and making better drugs.


It doesn't matter how much gets spent on marketing in relative terms. If it were 99% of the budget, but R&D was larger in absolute dollars, then that'd be a net positive.

Marketing increases revenue. A portion of revenue goes to R&D. Ergo, more marketing means more revenue available for R&D.


There is no moral way for a pharma company to increase demand for its product.


That's silly.

If I have a cure for X. And if you have X but don't know about my cure -- perhaps you don't even know a cure is possible -- it's a net good for me to tell you about my cure for X. And how do I tell you if there are millions of yous I'm trying to reach? Via marketing.


That's an even sillier steel-man.

Consumers are not good at making informed pharmaceutical choices on their own, and the idea that magazine advertisements showing smiling old people does anything to inform them is laughable.

Also, pharma doesn't market cures, they prefer to market long-term treatments that are recurring funding streams.


Pharmaceutical companies spend way more on marketing than research.

If drug companies are willing to sell the exact same drug in Canada or the UK or Germany or France for less than a percent (in some cases) of what they sell it here for then why can't US insurance companies, hospitals and consumers buy it for that price? There's no reason other than an artificial monopoly.

You'll note that I didn't say "anywhere" and that was deliberate. India, for example, has decided that drug companies largely (it's complicated) don't get monopolies from patents and thus you can buy a lot of low-cost high-quality generics in India because no drug company is getting paid.

Obviously this is untenable at the global scale.

And before anyone lambasts India for not respecting patents here, countries do this sort of thing all the time. In the US, for example, you can't patent nuclear technology as a matter of national security.


> If drug companies are willing to sell the exact same drug in Canada or the UK or Germany or France for less than a percent (in some cases) of what they sell it here for then why can't US insurance companies, hospitals and consumers buy it for that price? There's no reason other than an artificial monopoly.

They're willing to do that because the US is a much larger market than any of those countries. Most pharmaceutical companies - including European companies - make the lion's share of their profits from the US market. If they couldn't, you'd certainly see the costs for essential medicines increase in European countries.

> You'll note that I didn't say "anywhere" and that was deliberate. India, for example, has decided that drug companies largely (it's complicated) don't get monopolies from patents and thus you can buy a lot of low-cost high-quality generics in India because no drug company is getting paid.

India has pretty solid reasons for not honoring drug patents that don't apply to the US or Europe.


They're willing to do that because the US is a much larger market than any of those countries. Most pharmaceutical companies - including European companies - make the lion's share of their profits from the US market. If they couldn't, you'd certainly see the costs for essential medicines increase in European countries.

"Willing" is a broken way to look at it. The drug prices are negotiated by the government in the single-payer systems.


> "Willing" is a broken way to look at it. The drug prices are negotiated by the government in the single-payer systems.

Most countries don't have single-payer systems, and even where that's the case, "negotiated" is the broken term. For essential medications, the supplier always has greater leverage than the purchaser.


"India, for example, has decided that drug companies largely (it's complicated) don't get monopolies from patents and thus you can buy a lot of low-cost high-quality generics in India because no drug company is getting paid."

The main incentive for the US to enforce patents is that it is at the forefront of technology development, so many patents are held by US companies.

As the lead the US has in technology lessens, as it has been predicted (and has already started) to do so for quite some time due to its poor education system and decreased funding and prioritization of science, other countries will catch up and overtake the US on the technology front, and they'll be the ones getting patents. Then it's quite possible that the US won't care quite as much about patents, and may even start "stealing" technology from other countries.


>Pharmaceutical companies spend way more on marketing than research.

Because who cares if you've made a breakthrough product and no one knows about it?

>why can't US insurance companies, hospitals and consumers buy it for that price

Because profits for future R&D has to come from somewhere? And if everyone is lined up for a discount, future R&D will suffer.


They'll do just fine. The money doesn't all go to R&D, it goes to execs and shareholders. If you force them to compete then you streamline cashflows.


I’ve never bought this argument about r&d for drug companies, and I have even less faith in the argument after learning recently that much of this r&d is used to modify an existing drug, not to make it better, but to essentially earn another patent on said drug and keep it out of the public domain for longer.

Couple this with the fact that there is a large focus on designer drugs, and dependency rather than curative drugs, and there’s snake oil being sold by drug companies that they absolutely need a regional monopoly to bring us new and life changing drugs.


One reason there isn't a focus on curative drugs is the current drug system won't pay for it. In an ideal world if it costs 10 million dollars to treat an HIV patient over ten years we should be willing to spend 5 million on a curative drug. But when this actually happens as seen with a hepatitis cure everyone freaks out about the price drug. And thus we can't have nice things.


In an ideal world, the creator would be happy with a fair salary for their work and stop trying to rent-seek a fortune to satisfy their own greed.


What kind of evidence do you have for this claim?


Evidence that if the profits of new drug drops significantly that the money spent on R&D on those new drugs will also drop?

Imagine the government decides to tax 80% of all revenue from all technology companies forever. Do you think funding for startups would increase, stay the same, or drop?

The obvious answer is drop, but what type of evidence would you expect to support this statement. A study of people taxing technology companies @ 80%? Or are you arguing with the premise that investment rates are correlated with profitability?


Worst straw man I saw in a long while.

PS: >The obvious answer is drop

No. You "feel" it is "right" and "obvious" even, and it might as well be if we really did that experiment, but humans are pretty bad at predictions.


What is your argument that it wouldn't affect R&D spending?


One scenario that might happen is that the increased competition might lead to more R&D spending as companies might try to make up for the "lost" profits of their current portfolio by bringing new (patented) drugs to market.

The idea that competition leads to innovation is not exactly new.


Why would a decrease in price drive an increase in competition?


Orphan drugs are a great example. Back in the 1970's, there was no research into orphan diseases because the return on investment wasn't there. The Orphan Drug Act (in the US), combined with a tolerance for very high prices (hundreds of thousands of dollar per year) resulted in an explosion of research into orphan drugs.


There is none. People just like to parrot that Big Pharma line because it "sounds like it makes sense, so I guess it does?!"

Big Pharma already abuses the patent system so much, like inventing something and then when the 20 year monopoly has passed they create a new patent that says "this same drug can be used for Y purpose, too" - and bam, another 20 year monopoly on the exact same or very slightly tweaked recipe.

Tens of thousands are already dying every year in the US because they can't afford healthcare. If the argument is that "if we reduce the Big Pharma profits then it would be even worse!", I'm sorry, I just don't buy it. If drugs were cheaper, a large portion of those people could be saved (yes, I realize there are problems with the healthcare system, too, but those would also be fixed by Medicare for all).


I wonder if, even with a reduction in new drug development, cheaper healthcare would nonetheless work out as a net win. If all the drugs that currently exist getting much cheaper would improve people's lives (both now and into the future) to a degree that outweighed the benefits of continuing R&D at the current pace.


We can supplement this by improving funding for research in public universities. This will probably provide a better bang for the buck than our current method anyway.


Why specifically public universities? Why not also universities such as Harvard, Stanford, MIT, Caltech, etc.?


So that the resulting patents are made available to the public for free. My impression is that those universities you listed make a great deal of money from the co-ownership of patents produced by their staff.

I'm not saying they should be excluded, but I don't think they would be willing to participate if it meant giving up a cash cow. I could be wrong though.


> My impression is that those universities you listed make a great deal of money from the co-ownership of patents produced by their staff.

So do public universities.


For sure and this is my point. Not that reducing pharmaceutical costs is bad, just that it isn't a free lunch.


Most basic research is funded by the government as there's no inherent profit motive. Research to make use of the foundational discoveries is funded by profit motive, as they get a monopoly on any working product. I'm pretty sure R&D is safe as there will always be profit to be made. You're also assuming congress isn't in bed with the industries, the ones who massively fund their campaigns and offer nice lobbying jobs afterwards.


Going by this logic, is there a limit to how extortionate drug pricing can get? After all, some fraction will go towards R&D!


The United States currently has the highest 5 year survival rate for all cancers combined. I think it's a fair question to ask if that would continue to be the case in a MFA system for 300 million patients.

Considering what a disaster the insurance marketplace was, I'm very skeptical.

Edit: what I mean by "disaster": when it launched, the site completely crashed for over a month and then, when it finally came back up, the policies offered weren't accepted by most doctors, because they had crazy restrictions.


5 year survival rate is poorly correlated with treatment efficacy. It's mostly correlated with how early a cancer is diagnosed.

In most cases it's a good thing to detect cancers early, but saying a country is good at detecting cancers is not near as strong of a statement as saying that a country is good at treating cancers.

And this gets complicated by prostrate cancer -- many would argue that mass screening for prostrate cancer causes more pain and suffering than it prevents.


So then it can be argued that, due to long wait times in MFA, the cancer survival rate would go down due to later diagnosis.


Nope, the reason it's diagnosed late is often due to many cancers being asymptomatic and aggressive. Your immune system literally cannot recognize the bad cells because of checkpoint inhibitors among other things.


That's a cherry-picked stat. Most health outcomes are worse in the US than other rich countries with universal healthcare. There are many studies and charts you can search for, here's one: https://jamanetwork.com/journals/jama/article-abstract/26746...


To be fair, most health outcomes are directly related to financial issues: controlling for all other variables, it's the single most consistent predictor.

If you look at pretty much any general population level outcome, a country with a high concentration of health insurance (as proxy for financial resource to get healthcare) is going to have bad "average" outcomes.

If you look at metrics that select a sample that tends to have access to healthcare (e.g., cancer tends to cluster in over-65s, who have access to Medicare and, at greater rates than the general population, Medicaid), you're going to get a look at "what the healthcare technology is like in that country for people with access to it."

It's entirely fair to point out that average outcomes suck for average people because "average" access to healthcare is "really shitty access to healthcare."

It's also fair to point out that if you change how the system operates, it's not unreasonable to ask whether you'll change the system's strong points, which may well be "technically sophisticated care for those that actually have access."

My position on this is a third, orthogonal position (which is that how you pay for care and the operations that produce that care are not unrelated, and fractured, free-market operations produce fractured care, and that operations have much more day-to-day impact on healthcare outcomes than technical sophistication.) But it's unrelated to the above.


1. This entire article and thread is about cancer, so I'm not cherry picking. If anything the broad "health outcomes" is a diversion from the main subject.

2. What percentage of poorer "health outcomes" are due to the US's ~33% obesity rate and overall horrid diet and have nothing to do with care or access?


You're right about 1, sorry.

Obesity and diet are very much related to care and access. If you can't afford to go to the doctor unless you're dying, nobody is going to tell you when your cholesterol is getting too high and you should adjust your diet, or your blood sugar is getting into the warning zone, or whatever.

We have such high obesity because we don't focus enough on preventative care, and lots of people can't afford preventative care even if they want it.


Thanks for acknowledging that. It's not something you commonly see in forums.

I have a hard time swallowing the idea that obesity and diet are related to access to medical care. Our great great grandparents undoubtedly had far less access to healthcare than even the average lower class, modern American, and yet obesity was almost non-existent for their generation.

Occam's razor would say that an epidemic of diet related illness is caused by a societal shift in diet. The simplistic boiling down of the complex answer from nutrition experts is that the massive increase in processed foods in the American diet, post WWII, along with the insane increase in sugar consumption, have led to the obesity and diabetes epidemics (and increasingly believed to be one of the main causes of cancer).

IMHO we could do exponentially more for the life expectancy of poor Americans by solving the problem of food deserts than by upending the entire medical system, that is functional for the majority, for a wholly bureaucratically controlled system - which, by the way, will eventually have to include decisions on which people do not get access to treatment.


Regarding obesity, there's a belief that's indicated by some studies that show obesity is related to causing cancer in younger people by clogging up the works and preventing your immune system from killing off the cancer cells.


I wonder how much of that is down to better/earlier diagnosis \* ? My experience with the NHS is that diagnostics in general isn't great because it's essentially a money-sink, you have to push very hard for a diagnosis a lot of people get a diagnosis privately before going back to the NHS for treatment.

Once diagnosed however I've never had any problem getting top quality treatment. This is an anecdote, of course, so I'd be interested to see the statistics.

\* Or even over-diagnosis? It's "easy" to have a high 5-year survival rate if you push removal of tumors that may well have been benign.


As a person with cancer going through treatment, even with fully paid for by my employer healthcare and making a good amount of money, this is super expensive and if I didn't have a job where I could work remote, I'd probably be bankrupt by now with all the time I have to spend in treatment and the initial surgeries.

5 year survival rates vary by the type of cancer, while cancers like leukemia, prostate, and breast cancer have made progress, most of those survival rate numbers are based on catching the cancer early, which, unfortunately most aren't caught early leading to a poor prognosis, my prognosis for example is 5% overall survival for 5 years with a significant drop off after 3 years. The survival rate is also heavily dependent on comorbidities, or other things that impact your health, this can leave things like surgery off the table.

Another fun fact is that we really still suck at cancer treatment because we don't know how it functions, and as previously stated there's over 100 different types of cancer, each with their own mechanisms and subtypes.

So to your main point, no unless there's some massive breakthrough in immunotherapy that's pan-cancer responsive for most patients (right now immunotherapy only works for roughly 20-30% of patients), the costs aren't going to go up dramatically as the primary option is surgery if it's early and if it's late you're probably still going to be dead within 5 years. The number of patients surviving each year only goes up by about roughly 2% per year.


It sounds like you are implying that cancer survival rates are affected by the way Americans pay for healthcare. What specific mechanisms do you think are the cause? Total spending, ability to see doctors, insurance company approval of certain treatments...? Or something else?


There is actually evidence to show that while the coastal blue states and Texas have better (not great but better) survival outcomes, the ability to get diagnosed earlier is tied to access to preventative healthcare because if you have good health insurance and money you're more likely to go to the doctor if something doesn't seem severe, like most initial cancer symptoms, this causes patients to only go to the emergency room for health care which is often too late for a surgical option as the cancer has metastasized to your lymph nodes, which generally means it's in your other organs as well. This leaves chemotherapy and radiation as the resulting therapies, which while these can be effective, it's basically only life prolonging as radiation has a limit on how much you can due and damages other healthy tissue in the area and chemotherapy comes with side effects, organ damage, etc. and the cancer will eventually mutate, or the treatment could only slow the cancer or do nothing. Unfortunately doctors mostly don't know why the same treatment that works for the most patients doesn't work for all patients. Other treatments such as clinical trials can be either, unavailable for patients due to distance, trial rules, or a lack of expression of the marker that the medicine is hoping to exploit. While these are typically of no cost to the patient, it still means you have to be lucky enough to be near the location, be able to have the time off from work for the treatments which can take half a day at a time, and be able to have reliable transportation that isn't you driving yourself as the treatments can cause unpredictable side effects.


The U.S. actually has worse health outcomes overall than Japan and France who both have universal coverage (through different systems)


What are "health outcomes"? "5 year cancer survival" is a definable metric. "Health outcomes" is very vague. Is there a scoring system? Are different illnesses/conditions ranked?


Lifespan Deaths due to preventable causes

On both of these the US is somewhere in the 30s in terms of rank among countries. But we are #1 in terms of cost per capita :)

5 year cancer is too low level in my opinion to give an overall picture


And how much of that is due to the obesity epidemic in the US and has nothing to do with the healthcare system?


I don’t know for sure what the breakdown is.

Right now our overall system does little to discourage the obesity epidemic, but in a universal coverage system there would be massive financial incentive to fight it (either the government or insurance companies being forced to provide coverage for all)


Is there perhaps a better way to use resources to fight the obesity epidemic, and massively impact "health outcomes", than a ~$40 trillion complete overhaul of the medical system and hoping that the epidemic is solved by proxy?


I don't know where you get 40 trillion from.

As I mentioned, our costs are significantly higher and our outcomes are worse than 30 other countries who have universal coverage. We should be learning something from the systems in place in other countries. I think you are focusing too narrowly on obesity in particular, when there are many reasons why this is happening.

I would suggest reading this book: https://www.amazon.com/Getting-Health-Reform-Right-Performan...

It was written by William Hsiao, who was hired by the Taiwanese government to advise them on modernizing/reforming their health care system. It does a lot to compare health systems in various countries. I think one underlying thread is how much health systems improve once there is a commitment to universal coverage.

I work in this space and am trying to see what can be done about changing behaviors to make people healthier but it is incredibly difficult, especially when there is so much financial incentive in getting people to behave in unhealthy ways.


"5 year cancer survival" is unfortunately a very weak metric. Consider this easy way to boost 5 year cancer survival rates - do prostate screening tests for everyone in the country every year. You will undoubtedly detect more cancers and thus increase 5 year survival rates, but this is also undoubtedly a net negative for society.


This is the only solution. Every other developed country in the world has healthcare for its people. Politicians that don't support this are monsters who'd rather kill millions and ruin millions' more lives. They are disgusting, inhuman, immoral scum who would rather enrich their billionaire backers than help people live and recover from illness. These are the people that we should use the death penalty on because they have killed and will kill millions unnecessary. All out of greed and hate for their fellow Americans.


I think that's just a corollary of "63% Of Americans Don't Have Enough Savings To Cover A $500 Emergency":

https://www.forbes.com/sites/maggiemcgrath/2016/01/06/63-of-...

EDIT: My comment is in reference to the old thread title, which was something like "More than 42 percent of the 9.5 million people diagnosed with cancer from 2000 to 2012 drained their life's assets within two years"


Not with cancer. I know people who had cancer and there was a never ending inflow of bills for 5000 here, 10000 there until they were wiped out. Add to that the fact it’s very hard to fight your insurance while you are very sick.


Even with insurance, folks often wind up with six figures of bills out of pocket treating cancer. That's a huge amount for the even most frugal of the lower or middle class.


When my son was born he fit in my hand and spent his first three months in NICU. I guess the nurses thought his survival was questionable so they entered in his name into the computer as “Baby Boy”. A few months later I started getting bills (eventually around $3 million) because there was nobody named “Baby Boy” on my insurance. Calling the insurance to try and correct was a nightmare - wait on hold for an hour, get 3rd degree interrogation about my identity, wait on hold, explain that son was on insurance but not called literally “Baby Boy”, wait on hold, get interrogated for his details on son’s identity, wait on hold, long series of questions to determine Baby Boy isn’t real and let me know about penalties for fraud. Three hours later done, that covers the first $50. Decided I would never do that again, let it go to collections and explain it to the judge. Turns out that before it goes to collections it goes to someone with a brain who realizes “Baby Boy” is in-fact the infant boy with identical birth date on my policy, notices stop coming. No telling how much money they spent sending me all the nasty payment due letters in the mean time.


As someone who works in healthcare software, I wouldn't interpret "Baby Boy" that way. Different hospitals process information in different ways and it is very common for newborns to all be entered under the same, generic name. Sometimes different departments within the same hospital have different systems, especially as they get more specialized (see: NICU). Maybe the birth name you chose got entered in one place and not the other.

Just thought I'd shed some light on the issue.


I wonder what percentage of insurance companies' profits are from fraudulent collection attempts like this.


That was my initial thought, and it's definitely related, but the term used here is assets which people generally have a lot more of then just raw cash savings.


The abstract to the paywalled study cites the average expenditure being about $92k per person in the study. While it is still ridiculous that people should have to pay that much to fight off an illness, that is a disturbingly low value for an "entire life's assets", particularly considering the study was restricted to people who are 50 or older (with an average age of 68.6).


cancer treatments in USA are several orders of magnitude more expensive than $500. I know a breast cancer survivor with $100k of medical debt.


Let's see, since starting treatment in October, even with awesome healthcare we've spent over $5k in treatment. I absolutely believe the $100K statement as I've seen what the insurance pays.


Certainly, but the person in the article was a woman with enough savings that she had planned to retire early.

If it can hit her that hard, it would be devastating to someone without $500.


Not really, if you don't have money you likely don't have insurance and you are moved to hospice care. Maybe you can get a round of palliative chemo when tumor burden is high enough to cause symptoms (shortness of breath, gastric outlet obstruction, liver dysfunction, etc). So it's less of a financial devastation and more of a life ending diagnosis.

If you have money and insurance then a hospital and insurance company will gladly work together to take what money you do have. Sort of like a chicken wishbone.


None of the surveys linked in this article go over age distribution of savings -- something I'd expect to be inversely proportional to incidences of cancer.


It's such an absurd expense that I wonder if I get diagnosed with cancer, I would just deny treatment, accept death, and hand my assets to loved ones. Not sure if anyone else thinks the same way.


That is rational thinking through and through. Part of the reason that medical costs are so high is because some people will pay any price, to themselves or to society, to get/stay healthy.

A rational person says "some costs are too extreme and thus we must allow some to die".

A flip side of the argument is that very high cost(read profit margin) of treatment incentivizes others to fund research for treatments and cures.


I don't think anyone can think about it realistically until they are in that situation. How much is another year of your life worth to you? And to your loved ones for that matter? (assuming we're talking terminal cancer here, which it might not be)

I have family that suffered from cancer and spent a good lot of money prolonging their life by about eighteen months. They were not pleasant months, but I don't think for a second that the family would have preferred to take the lump sum instead.

In short, every decision is horrible.


My mom fought cancer at great expense and with everyone's support, and just ended up prolonging her suffering. When my dad was diagnosed with cancer a few years later, remembering that experience, he fought pretty much everyone and declined treatment, and died swiftly. If my turn comes and my odds are about as bad as theirs, I may well prefer to follow his example.


I'm on the downward side of 50. My best years (physically) are in the past. My kids are nearly adults. I'd rather pass on my assets to them and set them up for a better life than piss it away on medical treatments that don't have much hope of working.


My point is that your kids might not agree with you, and it is difficult, to say the least, to negotiate that situation. I'm not saying you're wrong, just that everyone has a different answer.


Take that lump sum or in another way of looking at it have that lump sum taken from them. Depending on the family situation this could cause knock on effect leading to financial burdens that who knows, could lead to suicide? Is that worth 18 months of a doomed persons life?


They wouldn't have the lump sum taken from them if they consented to it. And many do, sometimes with more enthusiasm than the person technically giving the money.


A lot of cancers have good a prognosis, especially if diagnosed early. Would you still do so if your chance of long-term survival and full remission, with treatment, is 50% or higher?


Problem is, the treatment provider offers no hard guarantees: full remission or your money back. The claimed success rates could be based on research studies, which have a reputation to be systemically flawed.

> Over a 10-year stretch, he said, Amgen’s scientists had tried to replicate the findings of 53 “landmark” studies in cancer biology. Just six of them came up with positive results.

https://slate.com/technology/2016/04/biomedicine-facing-a-wo...


I think it depends on cost. Maybe if the cost is 5x my yearly income, then it's probably not worth it for me to continue going on.


I'm not even in US and I'm considering the same.. if the expenses go above some reasonable threshold, I don't see the point of me living enough to see my family dragged into poverty. I don't delude myself - it's not easy to do.


Part of the problem is that, especially with an illness with as complicated a treatment process as many cancers, there's no way to even estimate the expenses. Even once you get treatment, the expenses might not be accessible until the bill comes in and you find out what your insurance company will pay for.

After that, there's a sunk cost issue: once you've dropped (N*your current net worth) on treatment, what's the harm in continuing?


That was actually one of the cornerstones of the HSA for everyone plan that Ben Carson was pushing. The government would pay into your HSA and when you got a diagnosis like that, you’d have the option of not continuing treatment and passing the balance of the HSA to your family.


I think your family would spend that money and more to get more time with you.


How much time? Two weeks? This is how long some of these advanced, very expensive, cancer meds give you. https://www.bmj.com/content/357/bmj.j2097


Still not rational. Just because people want to do something, does not mean it is the best decision for them.


I think that route is unpopular because we no longer have a sane relationship with death as a society. Religion, at least in theory, should help, but rates are declining there too. We'll pay any price to avoid the inevitable. We'll spend hundreds of thousands to get one more year of poor quality time with family, yet neglect to spend that time in better quality when health is taken for granted.

If you had no family, you could save many more lives for cheaper and easier to treat sicknesses, plus donating your healthy organs.


This is precisely my plan. I gave away upwards of $1 million USD last year. I have no assets remaining, no career, parents, spouse or pet. I’m almost out of money finally.

40 something white American male college drop out with no social connections. Tinnitus and hyperacusis long term.

The biggest part is figuring out how to maximize the donation of my organs to the medical school by coordinating self termination in a country where suicide is still largely frowned upon.

I have no insurance and just yesterday I had serious chest pains for the first time on the right half. This is almost certainly the result of not taking care of my body. Better to self terminate and spare suffering and resources, and to donate the organs.


As it turns out, there is no way to donate most organs unless you pass in an appropriate medical setting, to keep the organs alive.

The next best option seems to donate body to medical school.


When societies began moving on, philosophically, from dogmatic religions and into the current era of empiricism, we lost the ability to put death in context. Empiricism tells us that when you die, there is nothing, and the objectively rational thing to do is whatever it takes to live as long as possible. Empirical thought patterns tend towards extremes. What society needs to do, and possibly is in the process of doing, is recognizing empiricism as an incomplete model of reality. Hopefully that will lead us back towards a healthier relationship with our mortality.


If you've got kids and a family, they may not agree. It's a terrible situation to be in.


So it's definitely something that goes through your mind, however I've had the discussion with my wife. There's also the possibility that you'd be cured. It's entirely going to depend on your diagnosis, which you literally don't know until after you've gone through a CT scan, PET scan, and possibly surgery to determine tumor staging. I can say based on numerous conversations with other people, if you think you're going to die, you're going to die. Cancer is also extremely painful physically for some people with or without treatment. Best bet? Get life insurance.


I have two friends who have survived cancer. Both of them have said that they would skip treatment if they could relive the experience. I lost another friend to an agonizing one year battle with glioblastoma.

If I ever receive a cancer diagnosis it will probably be the end of me. I have great life insurance and my survivors will be well taken care of. Even with the modern, immune-based chemo(which my friend had for melanoma), there are severe and permanent side-effects. After watching my friend with GBM die, I realized the medical industry is more than happy to take any money you have even if there is no chance they can help.


I would consider this seriously for myself.

I've been thinking about my own death since ~2003. I have established what I want to happen to my body; I have yet to determine an official will, medical attorney, &c and that great fault is on me.

I recommend following "Order Of The Good Death" for the "US alternatives on Death". It is good times. Yes, talking about Death counts as "good times"; it is not difficult to imagine your survivors arguing over your body... about your body... about your assets... about your legacy... about your estate... and so forth.


This is a very good reason to make sure one has a living will.


My doctor and I had a conversation about this and that was his position, though not for reasons of expense. He says it's a fairly popular position amongst his peers, as well. Those who get to see first-hand what treatment looks like don't want to go through it themselves.


That's any easy statement to make when being diagnosed with cancer is some small probability potential future event.

Not that I really disagree with the sentiment, but I find it difficult to judge people actually staring death in the face based on my comfortable position of, well, not.


I always thought this was the way to go. People routinely punch the numbers to figure out if they can 'afford' to have a child, why is it so strange to do the same for end of life?


It always seems any American that is against Universal Healthcare quickly changes their tune as soon as they or their loved ones are hit with bankruptingly large bills for things they have no control over.

What a shame they can't see outsides themselves and realize they're only an inch away from financial ruin.


That’s how it is in other aspects too: unemployed? Must be lazy. Homeless? Must be mentally I’ll or a druggy. Lost the houses? Must have been living paycheck to paycheck. People are quick to judge others until that thing happens to them and all of a sudden the tune changes.


This is honestly one of the things that most stresses me out as I get older. I don't use my insurance much now because I'm pretty healthy, but I know my cancer risk will just go up over time.

I've considered that if something like this ever did happen, I'd move to Lithuania and do it there paying in cash over trying to do it in the US system. Universal health care can't come fast enough.


When you get old you presumably qualify for Medicare.


Why not just make it so that you always qualify for Medicare?


Because it would go bankrupt and then no one would get Medicare.


But why not make it not go bankrupt?


Because "I got mine", or maybe not yet, but someday I hope to get mine and you better keep your grubby hands off my imaginary money.


A lot can happen before age 65, and cancer doesn't wait!


> Universal health care can't come fast enough.

What do you mean by "Universal healthcare"?


For the haters out there. I was genuinely asking a clarification question because "Universal Healthcare" can often mean compulsory insurance purchase, Single payer, single provider or other means too ...

As with many things I think the details of how is critically important...

more info: https://en.wikipedia.org/wiki/Universal_health_care


I'd like to know where the patient with the $870 MRI bill was seen. My last MRI was billed at over $7500. Before I started treatment for my brain tumor I got divorced for purely financial reasons and gave all my remaining money to my children. USA is so fucked.


For non-emergency imaging studies it's worth shopping around. Prices really can vary by a factor of 10× between facilities in the same area. For those with private insurance, most major insurance companies offer some sort of cost estimator on their web sites which allow members to see which radiology centers are cheaper.

(I do appreciate that this is a bad experience for patients.)


I needed an MRI a few years ago, and my insurance provider actually called me to tell me about insurance-preferred imaging centers, and how much the out-of-pocket cost would be at those centers vs. the one my MRI was initially scheduled at.


Yes some payers will check the stream of incoming X12 278 Prior Authorization messages for expensive procedures and then attempt to steer members toward lower cost options. This helps to hold down costs for the healthcare system as a whole.


Other than cash, how do you give money over $15k without being nailed by the gift tax? Keeping as much money in retirement savings seems wise as those are exempt from liens.


On top of the yearly exemption, you have a lifetime exemption in the US of $11.18M.


Currently you do. At a recent visit to my estate planning attorney he said it's likely that will be cut in half in the next few years. I don't recall whether it was because there's a time limit on that particular part of the law that's going to run out, or because it was likely the ruling parties would switch and they would vote it back down. But either way just remember that it can change in either direction at just about any time.


IRAs are not exempt from creditors in all states, FYI. Texas has solid unlimited protection at least, though.


Some of the cost difference is likely due to different procedures and materials(i.e. contrast agents).


We've got private MRI clinics in Canada, and Googling prices for my city gives a number of clinics with prices in the 700 CAD range.


57% of Americans cant handle a surprise bill of $500 without going into debt. [1]

I don't doubt cancer is probably the most expensive hit that we have a good chance of receiving, but I'd be inclined to point to the lack of "life's assets" being fluid as the first problem to tackle.

[1] https://www.cbsnews.com/news/most-americans-cant-afford-a-50...


It's amazing that you got down voted so much. Do people not like facing reality or something?


Well I can't speak for all countries, but here in the UK I haven't paid a penny toward my cancer treatments.

I also kept my job despite being off work for nearly a year going through chemo, and I even got sick pay for all of that time. (Not at full wage, but still a very generous proportion of it).

Post-treatment I went back to my same workplace, doing the same job, and found out that I had even acrued annual leave at full rate during the 9 months I was off sick, so had 25 "extra" vacation days that I wasn't expecting.

Yes, this is more than the legal baseline, but even the legal baseline would let me keep my job, acrue leave, get some sick pay (although the statuatory sick pay isn't huge), but most importantly, have completely free treatment, so I wasn't spending the little energy I had worrying about medical bills or insurance.


I wonder what the downstream effects of this are on building generational wealth. 100 years ago, when your parents died, you might inherit a home or a small amount of money. That then helped uplift the next generation. Now, if your assets are drained, you have a reverse mortgage, etc, there's nothing to pass on except for the very wealthy.

Cancer sucks.


This was definitely the case with my grandparents, but it wasn't even cancer it was just the long term cost of care for people who live well into their 90s.


>Cancer Complications: Confusing Bills, Maddening Errors And Endless Phone Calls

Hell that's just insurance in America... if you just use it.

I've been dealing with a bill where the insurance company decided that my kid's pediatrician was out of network all of a sudden. All the other visits to the same pediatrician have been covered, but they can't seem to fix this one bill....

There's no incentive for the company to be helpful as what am I going to do? Change insurance companies? That's not my choice.


A cynical viewpoint might add that if the patient has a terminal illness, and if they are overcharged, then the process can be dragged out past the patient's lifespan and their estate just might not get around to it.


I think they just expect I'll get tired of it and pay.


File a regulatory complaint. Boom, now they have incentive to fix things.


This is a 2019 article covering a study that covers 2000 to 2012 and doesn't mention the Affordable Care Act signed into law in 2010. Insurance landscape has changed quite a bit in the USA since ACA, which makes this not very interesting. What I would be interested in is repeating the study now and comparing results.


I would expect the results to be no different - the article was talking about people who already have insurance. I've been through the incredible medical-bill maze that results from cancer treatment since then; it's just the same. The ACA was explicitly designed to perpetuate the current insurance system, why would you expect the situation to have improved?


Before ACA, there were lifetime benefit limits. After ACA, there is no limit, so it will have greatly changed the situation that people facing years of very expensive treatment faced. Now, you are spending a max of $10k per year on in network providers, or whatever your annual out of pocket max is. Before the insurance company had the option of telling you that you've maxed out your benefits and you're on your own, and/or not offering health insurance coverage for you in the future period.

The removal of lifetime benefits, ability to deny pre-existing conditions, and setting a maximum range between the lowest premium that can be offered and highest premium that can be offered greatly improved access to health insurance benefits for everyone. At the expense of making it more expensive for the young and healthy, but obviously someone has to pay, and we as a nation don't want it to be via taxes.


I got cancer in 2018. Very little has changed. It's still very expensive.


This came up last year when it was discovered that Leon Lederman had to sell his Nobel Prize to pay for cancer treatments. But there is more moral complexity to this issue than people appreciate. Cancer treatment is inherently expensive; it just doesn't seem that way in some other countries because the government pays from the outset.

But I don't think that's necessarily moral, compared to something like Medicaid, which requires people to spend down their assets first before the government will pay. The median net worth for someone between 65-74 is $225,000. Why should the government spend tax dollars to protect those savings for people unfortunate enough to get cancer, when there are many people unfortunate enough to never enter the middle class and be in a position to save that kind of money in the first place? Isn't it unfair to spend tax dollars protecting the inheritance of an upper-middle-class kid when that money could be given to a kid that never had a hope of an inheritance?

Put differently, there is a huge moral difference between the government ensuring that everyone can get cancer treatment, and the government intervening to protect the financial and social status of people fortunate enough to have significant assets.


I would think the average person would feel slimy/predatory buying someone else’s Nobel prize. Unless it’s the case of a friend offering to help out, but then why not just lend the money without the collateral?


Could have been a museum or something.


Maybe it was a pharma exec?


I cannot even imagine the toll this would take.

I have a very simple set of recurring claims against my healthcare provider that I'm handling myself (out of network, no problem, I thought). Due to job changes I had successfully had my charges reimbursed by my previous 2 insurance companies over the past year.

The current one has taken 6 months to finally start reimbursing me -- and actually, they're almost caught up! Every goddamned time, the helpful phone persons sees the problem: "Your provider was entered as an XYZ type of provider instead of a ZYX provider, so it was being sent to the wrong unit. I'll re-enter him correctly, delete the old entry, and resubmit your claims marked as urgent. They should be processed within 7-10 days..." Very helpful staff. They seem to get it. They seem to figure it out. They seem to fix it. And it's never. fucking. fixed. And so you wait 7 days. You want 10 days. Still in process (if the horrible online system even allows you to login today). You wait 14 days, thinking maybe that was 10 BUSINESS days. Then you call back. Again, and it's the same thing. Over and over again.

My reimbursements came totally out of sequence. The claim numbers don't match. The dates on the claim number don't match the dates on the EOB, they're paying me back for the wrong visits!

But somehow, somewhere, on the backend, someone is reconciling it. Amazingly, the amounts are adding up. I think the processors are REALLY GOOD at not accidentally double-paying, so even though they're paying me for the wrong dates here, the next time they avoid double-paying, and find ANOTHER date to pay for (properly). It actually looks like it'll somehow all get paid back. Again, all one insurance company and one health care provider. And it's my insurance. And it's top tier private tech company employer PPO type stuff.

My wife was in the hospital after a car crash. The first EOB I got for $200,000 saying "Denied", and that number didn't even include the surgery. I just laughed. It went to the wrong insurance, a simple call and it was sorted.

But I can't fathom having less than perfect insurance (and I don't even know how to manage to maintain good insurance while having cancer and potentially being out of work and having a partner who might not be able to work while they're helping you), and having millions of dollars in bills, and having them come in from countless different providers.. sheer misery.


Moving to Switzerland, you'll be compelled by law to get health insurance and you will be covered no matter what for roughly 500 bucks a month with a 300$ deductible.


When I was in my early 20s, I got myself a beefy life insurance policy that covers suicide after some waiting period that has expired many years ago. I know that in case of crippling illness I can always take the easy way out while preserving my assets plus the life insurance payout. My family would be taken care of.


>My family would be taken care of.

And possibly traumatized that you killed yourself so they could have money.


In case of being stricken by an incurable disease, I'm going to die anyway. I'm sure my people will understand my choice to make a graceful exit before illness takes away any shred of my dignity.


It's interesting to me that life insurance policies exist that cover suicide. I assume it means that people over-estimate their eventual willingness to commit suicide.


I didn't know this was a thing (life insurance policy that covers suicide), very interesting.


Ummm...maybe buy Aflac instead (cancer insurance).


This a good solution that scales.


It's not just the billing that sucks. It's also the care, or lack thereof, in the health care system.

I remember taking my friend to a Dr. visit when he had a brain tumor. The parking was confusing, with signs threatening fines of hundreds of dollars for parking anywhere near the building(this was at UCSD in La Jolla). This was at a cancer center, where you'd expect they'd prioritize access for patients. He went in for an eye exam, and the doctor was getting extremely agitated because my friend had problems communicating and performing a few tasks as quickly as the doctor wanted. Very few people in the hospitals seemed equipped to handle someone who had problems seeing, walking and communicating.


"But none of these is her most gnawing, ever present concern.

That would be the convoluted medical bills that fill multiple binders, depleted savings accounts that destroy early retirement plans and so, so many phone calls with insurers and medical providers."

Is it like this in other OECD countries? I ask because I'm told that we in America have "the best health care system in the world."


My father fought cancer for the last 8 years of his life, and was on 2 boxes of Glivec a month for all those years(in US Glivec treatment costs about $146,000/year[0]). He also had 2 operations to remove some tumors, plus bi-monthly MRI to check if the cancer came back. He has never paid a single penny towards the treatment. In fact, the hospital would always reimburse him for taking the train every month to get his drugs and check-ups done. There were no bills to pay, I think he only had to sign one piece of paper every month to say that he picked up his medicine and we could go home. There were never any calls to any insurers or medical providers, simply because as patient over here you don't care who is paying for the treatment. You turn up to the hospital for whatever treatment is planned and that's about it. You don't even know how much the hospital is paying and to whom. It doesn't even matter if you are currently employed/unemployed and if you're paying towards the national health service - if you are not employed(say as a result of your illness) you are still 100% covered anyway.

After he passed away(the cancer unfortunately came back and not much could have been done at that point) his savings account was definitely not affected by 8 years of illness.

That's in Poland btw.

[0] http://www.ascopost.com/issues/may-25-2016/the-arrival-of-ge...


I ask because I'm told that we in America have "the best health care system in the world."

I'm going to assume that you're asking an honest question, but I'll tell ya that (and I can not emphasize this enough) from my perspective the question is so naive that I seriously think I'm missing the sarcasm.

But in good faith I shall carry on...AFAICT, "US=='best'" is propaganda, or ignorance at best. We (I am an American) have poorer outcomes for more money spent. Now, many excuses will be offered as to why that is, but I'm not here to argue; as best as my research can do, that appears to be fact. On top of that, for a less capable and more expensive product, we have a byzantine system of forms and providers.

So, no, it would appear that other OECD countries do not have this issue, partly/mainly because all but a few (and I would be hard-pressed to name those few) socialize their medical care.


No, my family in Canada and UK don't deal with any of this. In the US, it's not even worth your time figuring out how much your treatment will cost, other than whether or not the provider is in network or not. Assume it's the out of pocket maximum for your insurance, because when you go to a provider, you sign a blank check that says you will be responsible for whatever chargers they make up during the course of your treatment. So your only ally is the insurance company, who has the power to deny payment for things like $15 worth of linens (which was actually a few pieces of paper towel).


" whatever charges they make up during the course of your treatment"

That's the worst. Pricing is totally arbitrary. You may spend 5000 or 100000 for the same thing and there is no way to know upfront.


You can't figure out whether your provider is in or out. Just yesterday I got a bill from someone I've never heard of who turns out to be a "Medication Safety Specialist" who allegedly rendered services to me worth $392. You'd think such a person would just be a functionary of the hospital who in any case bill me $27k every day, but actually they are some kind of mercenary who bill patients directly.


Yes, it's crazy how difficult these little things are.

During birth, should one stand outside their wife's delivery room and ask each provider to wait outside while you look up if they are in network or not on your insurance company's app? At least we have apps to do that nowadays.


Yes, you should. When my wife gave birth the first time there was an endless parade of idiots who uselessly entered the room for a moment and then left and later sent a huge bill. We also got a bill from the anesthesiologist who was not present because my wife didn't want it and for the supposed attending obstetrician who, although they were paged, never showed up. We had to go through disputes of all those things and even though we prevailed on all of them, my attorney had to get paid.


I would definitely recommend actually doing that, but I kind of meant "should we do that" in a sense of "should we be behaving like this in a civilized society"?


No, this side of it is definitely better in other countries.

My late wife passed away of cancer a few years ago, we lived in Australia. She went through rounds of intensive treatment. We had private health insurance which kicked in, limiting our up-front costs. Not all was covered, but what wasn't covered was capped through public health care. It might have cost us $10k AUD, but not more.

We spent little to no time worrying about paperwork and billing, it was almost all auto-handled for us.


The administrative/insurance side of American healthcare is probably one of the worst, if not the worst in the developed world. But the quality of the care itself (the actual treatments) is very high, probably one of the very best. I think the American health care is especially good in terms of treatment availability: many drugs are simply not available in other countries (or are available but not covered).

Some people are genuinely concerned than touching the former (administrative side) will result in lowering the level of the latter (quality/availability of care, drugs, etc.). That it's the inherent high cost of the current US system that somehow makes it so good in terms of availability/quality of care. I disagree, but can somehow understand the line of thought.

EDIT: I have no idea to what extent care is really better in the US than elsewhere, but know first hand of someone who had to pay for interferon out of pocket in Japan because it was not yet covered at that time. It's not rare for the newest US drugs to take many years to cross the Pacific ocean...


No, it is definitely not. Whoever tells you that is either lying, ignorant, or in denial.


My question was slightly sarcastic, but primarily sincere, in that I want to hear first-hand accounts from cancer patients in other OECD countries.

Rudy Guliani said this in a campaign ad [1] when he was running for U.S. president in 2007-2008. I also recall him saying this in one of the Republican debates. When my (now) wife, who is German and has also lived in Denmark, heard this she couldn't help laughing.

[1] https://www.cbsnews.com/news/giuliani-ad-chances/


> "Their high-deductible insurance policy meant they had to spend $6,000 before their insurance started covering her treatment expenses. They hit their annual out-of-pocket maximum of $10,000 well before the year was over."

The article mentions a variety of causes but I'm having a hard time figuring out which ones are most important. In the example above with a $10k out-of-pocket maximum, how much money did these patients actually end up paying? Is that the main reason for their bankruptcy, or is it their loss of income? Does disability insurance cover things like cancer, and if not, are there similar programs that do?


I published a piece on debt in America last week and touched in the subject of medical debt. When you look at it from a broader perspective, most Americans are in a financially dire situation. 42% sounds lower than I would have expected.

Americans are Drowning in Debt: https://thenib.com/americans-are-drowning-in-debt


Yep, paying off my debt (except mortgage, which is affordable and only 15-year term) has been the most liberating thing I've done. Learning to live below my means was difficult (still is), but absolutely worth it.


I remember the radiolab episode on worth[0]. Is another month of life with cancer worth x amount of dollars? Who should pay 100k for a medication that might let you live a month longer with pancreatic cancer. I imagine most Americans don't look at it that way.

[0]https://www.wnycstudios.org/story/worth


Has anyone tried flying to another country for more affordable treatment after the diagnosis?

Countries like Germany and some south american countries have much more affordable treatment even factoring in the lodging and flying.


Having to fly to receive treatment seems like it might significantly affect the likelihood of a full recovery. Cancer patients tend to have compromised immune systems and airplanes are filthy.


As a cancer patient, wear a mask. I travel for work all the time, even right after chemo. I'm not older, which makes for a stronger immune system in the first place, but planes just require hand sanitizer and a face mask. The real problem would be you would have to be able to pay out of pocket for lodging, translation services, treatment, etc. and in most cases overall survival is better in the US for late stage cancer.


This same issue exists for autoimmune disease as well as many other diseases. My understanding is that the hospitals were going to post the costs for treatments and make the process more transparent. Has this happened?


I’m confused. If you have medical insurance, shouldn’t you only pay up to your deductible? Is this saying people’s life assets don’t cover the deductible? Or, people are uninsured?


The deductible might be huge, and there's also this magic new thing I've just discovered (or United invented out of nowhere) called "co-insurance" and "maximum out of pocket" which I call "deductible #2."

Then when you actually try to use the insurance you pay monthly for (but don't get to use until you reach the deductible #1 and #2?) they may just send the bill to you with a lot of legalese that amounts to "we don't cover this, or we do but we have better lawyers, get fucked peasant."

Luckily the debt collection industry is incompetent so all you gotta do is keep replying with "please mail proof of debt" and you're golden!


All of the terms you listed are easily understandable concepts clearly explained on healthcare.gov or any health insurance company's website, and they've been a thing for decades.

How much clearer can maximum out of pocket be?

Edit: I do think in network and out of network should be easier/faster to figure out though.


There are plenty of times when in/out network is an impossible thing to determine or plan for.

I had an out patient surgery about a year ago and while my doctor and every admin I talked said that everything would be in network, I still had someone sneak in who was supposedly out of network.

Then came the bill of what should have been ~$300 was around $2500. I got that BS waived only by called my doctor's office and talking with them about it. Once we talked it all through, the nurses called the _head management of company that ran the out patient surgery clinic_ in order to get it removed. It feels like people have to do you favors in order to get your actual correct billing.

Our health care system is so royally f'ed in the U.S. It desperately needs fixing and I hope it does before something serious happens to myself or my wife because it's currently feels like gambling with ruination. No $2.5k isn't ruination but health care is the only thing in this country where I go in knowing NOTHING about what my final bill will actually be.


If you tell everyone who admits you "I don't consent to any procedures or care from out of network providers", could you sue any out-of-network providers who operate anyway for malpractice?

Or I wonder if a similar "HIPAA trap" could be constructed by categorically revoking consent to share your PMI with any out-of-network individuals and companies?


Typically the people performing the operations don't know if they are out of network. That's handled by a separate billing department.


Sure. I'm lazy, I care more about being a better programmer than learning the esoteric rules around insurance. I probably could pay less taxes if I managed to Learn that, or get better return on my index funds. Or I could add another programming language to my tool belt, or learn more git commands, read a book on management... It's all choices I've gotta make. And I have the privilege of a high paid job and a 15 minute commute.

As for what's covered by my insurance, I strongly disagree that this is "clearly explained." It is not, some of it is outright "and other services," most of it is buried in pages of medical terms I don't understand.


Isn't there also a maximum lifetime benefit most US insurances stipulate, that isn't that hard to reach (like $1M or so ?)

My understanding is that past that point, you become mostly uninsurable, but maybe I'm wrong.


Apparently, this has been outlawed. "Under the current law, lifetime limits on most benefits are prohibited in any health plan or insurance policy."


There's a huge spectrum of what's covered under US insurance plans. Mine, for example, is a "good" plan for the size of company we are, but if I was rushed to a hospital that wasn't in-network in an emergency, or a hospital visit was later deemed "unnecessary" by the insurance company, I could be subject to huge bills.


I see. Are doctors unable to tell you which treatments are defined as “necessary” ahead of time? Or, do you have to do this research yourself?

Also, do ‘good’ insurance plans typically deem any signicantly life saving treatment as necessary?

Sorry, I’ve always been healthy so have never taken the time to understand this but my parents are getting old.


My understanding is "necessary" is determined by the insurance company, after the fact, and is subject to negotiation.


They were insured, and insurance covered treatment, but they lacked savings to begin with, so they drained assets to make up for lost income. Most Americans don’t save and only have “savings” in their house, which is usually mortgaged.

From the article: Since she's unable to work, the family lost her nursing salary.


From the article:

"Their high-deductible insurance policy meant they had to spend $6,000 before their insurance started covering her treatment expenses. They hit their annual out-of-pocket maximum of $10,000 well before the year was over."

Even with a lower deductible, many plans have annual and lifetime limits.


Ok, so basically the article says most ppl don’t have 20k in savings?


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