It was about eleven years ago, and I was making an absolutely appalling living as a musician. This meant that I was able to cover the rent in my shithole apartment, but not much else. Health insurance, even the cheaper variety offered to a comparatively young guy like me, was simply not an option.
Come to think of it, if the insurers had any idea as to how I was treating myself, they surely would have raised the monthly premium rates. My diet basically consisted of black coffee, cheap bourbon, ramen noodles, and whatever terrible food available to me wherever I was playing, usually stuff that was fried in a bucket of oil.
One day, I found myself with a sore throat that kept getting worse and worse, and it eventually got to the point where I couldn’t swallow. After three x-rays, multiple prodding sessions by various doctors, and a fiber optic camera shoved up my nose and down my throat, I was given the diagnosis of an infected epiglottis.
The epiglottis, by the way, is a muscle that closes over your trachea when you swallow, thus preventing you from choking to death when you eat. Mine had gotten swollen to the point where it covered not just my trachea, but also my esophagus. The doctor described it as a “garage door that had rusted shut.”
They prescribed super powerful intravenous antibiotics, and put me in bed for three days. They put me on a liquid diet, which consisted of broth and jello, and for the pain they gave me Tylenol 3 with codeine crushed up in little cups of applesauce.
All of this cost me $17,000.
After explaining that they might as well have asked for $17 million from a penniless reprobate like me, they quite nicely allowed me to plead “financial hardship,” and knocked the price down to an entirely manageable $14,000.
It took me two years to pay it off. I was on a first name basis with the lady from the collections agency, so much so that I knew the names of her kids and how they were doing in school. And while I was in the midst of paying it off, I went down to do a show in Richmond, Virginia. While I was down there I ran into a guy I used to play music with. He quit playing when his wife got pregnant and went down the imminently sensible path of getting a real job, complete with health insurance benefits. I asked him how things were going, and he said they weren’t going so well because he had just gotten out of the hospital. I asked him what the problem was, and he asked me if I had ever heard of the epiglottis.
It turns out my friend had the exact same medical problem that I had, and he got almost the exact same course of treatment, complete with codeine crushed up in little cups of applesauce. But the problem was that his deductible (more on that later) was $5000, and also the insurance company had a problem with some of the charges. Like, what’s with the codeine? Why three X-rays when two would have been fine? For that matter, why the hell did the patient need to stay overnight for three days? According to the really awesome software that the insurance company had, all you really needed for something like that was two days, so they would be damned if they would pay for all that frivolous nonsense.
So, to recap, two guys had the same illness, one had insurance and the other one didn’t, and both of them ended up paying $14,000.
That’s how fucked the American healthcare system was in 2004. It’s better now, but not by much.
So Sorry, Fuck You, That’s Our Policy
An article of faith among conservatives in America is that we have “the best health care system in the world,” which is accurate as long as by “best” they mean “the most profitable.” Insurance companies, pharmaceutical companies, and HMO’s make cubic shit tons of money, and they make it in the most American way possible, which is by being totally unnecessary middlemen who have managed to insert themselves so thoroughly into the process that removing them seems like blasphemy.
So here’s how it is supposed to work: Every month, I pay a certain amount of money to an insurance company. If I come down with an infected epiglottis or get hit by a car, the insurance company covers the cost of my medical treatment by using the premium dollars of other policy holders who did not in fact come down with an infected epiglottis or get hit by a car. The idea is that if there are enough people in the insurance pool, then the occasional infected epiglottis or car wreck can easily be managed.
But that isn’t how it works at all. You pay into the system, and then there are all manner of other surplus charges that you get stuck with. There is the deductible, usually between $1500-$5000, which means that the insurance will only start paying for things once you get over your deductible limit. Meaning if I break my leg and my deductible is $5000 and my leg costs $5001 to fix, the insurance company will gladly cover that one dollar. If it’s $4999, so sorry, you have to pay, go fuck yourself, that’s just our policy.
There is also “co-insurance,” which is a fancy way for the insurance company to say “Sure, we’ll pay for that, but only around 80% of that.” So after you pay the deductible, you still end up paying for around 20% of the care.
And believe me, this is no guarantee that the insurance company will agree to pay. Insurers have an enormous amount of leeway in what they consider to be “medically necessary,” and if they believe that something is not medically necessary, then they will simply refuse to pay for it.
They also won’t pay for things if they have clerical errors. Medical billing to insurance companies is done by “code.” They are needlessly complex.
Let’s say an appendectomy code would be
but only in the first fiscal quarter of the year, and after that it changes to
“5+746+546865476358jfaoihytfheowiwh; asiaygf; aooeett885446581*558497.”
If the code is wrong, the insurance company will both refuse to pay and will make absolutely no effort to help fix the error. Fuck them, it’s their problem, not ours, that’s just our policy, so sorry.
There is also the matter of whether or not the doctor, hospital, or surgeon is “in network,” meaning that they have come to an arrangement with your particular insurance company. If they aren’t, the insurance company won’t pay. So if I get hit by a car and the hospital they take me to is one that my insurance company doesn’t do business with, they won’t pay. Fuck you, so sorry, that’s just our policy.
Hospitals Are Also Complete Assholes
I would like to say that the doctors and hospitals are blameless victims here, but they really aren’t. The Hippocratic Oath has a second line here in the States. “First, Do No Harm. Second, Daddy Needs a New Pair Of Shoes.”
I once knew a guy who had a lot of money, but dressed up like a complete fucking hobo when he had to take his dog to the veterinarian. He was under the impression that the costs of treatment went up when it looked like the owners of the various animals had a healthy bank account. I’m not sure if that was actually the case, but that premise absolutely applies when hospitals are dealing with insurance companies. If treatment took place in a vacuum, there would be no conceivable way that an aspirin could cost $12. But once United Health Care, Kaiser, or Blue Cross/Blue Shield is footing the bill, hospitals are completely comfortable with overcharging for EVERYTHING. Pick any procedure available in New Zealand, and then determine its cost. Now add one or even two zeros to that price, and that’s how much it costs in America. And just so you know, there isn’t any Robin Hood-type shit going on here. If the insurance company won’t pay for this or that, the hospitals just bill the patient for the difference, and if the patient can’t pay it, then the hospital can at least sell the debt for maybe a dime on the dollar to a collections agency, and at least make something out of the deal.
Hospitals also don’t have a separate menu for the uninsured. They keep those costs just as high when they deal with people without insurance. And to make things even worse, insurance companies are able to negotiate lower prices for procedures, while the uninsured are not. So an MRI might cost Blue Cross/Blue Shield $9000, and will cost a homeless guy $10000.
It Actually Used to Be Worse
There used to be all manner of other ways for the insurance companies to fuck you over, sometimes fatally. There used to be such a thing as a “lifetime limit,” meaning that there was only so much that the insurance company would be willing to pay over the course of your life. These limits seemed like a lot until you realized how damned expensive everything was in a hospital, and lifetime limits could be reached after three days in an Intensive Care ward.
Insurance companies would also do a practice called “rescission,” in which they would dig through every aspect of your life in order to find a reason to drop your coverage. And the reason could be something as simple as neglecting to mention that you had acne as a teenager when you filled out a form, or being wrong about the day you quit smoking, regardless of whether or not said zits or said smoking had anything to do with why you were in the hospital in the first place.
If someone needed costly treatment or a procedure and would die without it, insurance companies would slow-walk everything and hope that the patient would die while all the delays were going on. Problem solved.
And then there is the “Pre-Existing Condition” dilemma, which fucked over millions of Americans. Here’s the scenario: John Liberty Freemarket has an insurance policy and gets cancer. John Liberty Freemarket’s insurance company says “Fuck You, So Sorry, That’s Just Our Policy, Don’t Let the Door Hit Your Chemo Drip on the Way Out.” Johnny Liberty Freemarket then goes down the street to another insurance company to exercise his right as a consumer, and is told that they can’t help him because he has cancer, which is a “pre-existing condition.”
This is all emblematic of the problem with for-profit health care. I certainly get the idea of cutting costs and raising profitability and all of this is fine when you are talking about the making and selling of Frisbees, toasters, cars, pencils, tablecloths, dildos, or whatever. But this same formula cannot be applied to people’s healthcare. What ends up being cut to increase profitability for the shareholders is the actual care itself, and also the insurance company’s willingness to pay for that care. This lowers the standard of care and also passes the extra costs on to the patients, hence my friend getting charged $14,000 despite actually having insurance, hence people getting nickeled and dimed to death, hence the idiotic “coding” system, etc. etc.
So the Affordable Care Act (AKA “Obamacare”, AKA “Blood-Soaked Communist Tyranny,”) fixed all this, right? Well, some of it. There aren’t any lifetime limits anymore, and there aren’t any pre-existing conditions limitations. But the costs are still ridiculous, and there are still huge deductibles, and nothing is really stopping insurance companies from refusing to pay for all manner of things, and nothing is really stopping hospitals from over-charging, and nothing is really preventing the code system from continuing, and nothing is really preventing slow-walking from insurance companies, and people are still getting fucked over when they find out that the person who performed emergency surgery on them wasn’t “in network,” and the list goes on and on and on, but other than that, everything is fine, thanks. You guys might call it “having all of your medical bills rejected,” but it’s called “Freedom, Liberty, and Respecting the Free Market” over here.