7 ms·

A Freelancer's Forty-Three Years in the American Health-Care System

39 points by mitchbob 5y ago

mitchbob 5y ago
Archived: https://archive.ph/K0Hbd https://archive.ph/K0Hbd
no_wizard 5y ago
As noted in this article, it’s insane that the wealthiest country in the world doesn’t have universal healthcare. I know Medicare is complex and not nearly as straightforward as I think too many people assume Toward the end of the article, to quote: > At any rate, when it comes to medical care, what’s wrong with socialism? The existing American system, with its dazzlingly inefficient mix of public and private insurers and its legions of redundant paper shufflers, is not a persuasive argument against it. Canada, which does have universal health care, spends roughly half as much per capita as we do, yet has better outcomes, including an average life expectancy that’s more than four years longer than ours. In fact, according to the World Health Organization, the U.S. ranks just fortieth, worldwide, in life expectancy at birth. That’s a little bit better than Ecuador and Poland but a little bit worse than Turkey and Croatia. I agree wholly with this. Arguably when one of the most complex government programs we have in the US is better than average than the options left with private insurance, even after all the political machinery that messes with Medicare and our system as a whole, it should be obvious by now we are doing it wrong
- refurb 5y ago
  Life expectancy is a crappy way to measure how effective your health care system is. It's way to blunt a tool and has many confounding factors that have nothing to do with your healthcare system.
- Gatsky 5y ago
  A fully socialised healthcare system a la Canada won’t fly in the USA (this is obvious?). There are models eg in Australia where there is pretty good socialised care, and also a private system where you either pay up or have private health insurance (with a lot of extra costs). It kinda works, and gives some choice to the user. There biggest problem with this system is that private healthcare isn’t a great business, and the hospitals and insurance companies often struggle. They also don’t provide anything near parity with public healthcare. The most complex and sophisticated care still happens in the public system, which in turn means that the best doctors still want to work in the public system as well.
  - gruez 5y ago
    >A fully socialised healthcare system a la Canada Is the canadian healthcare system even "fully socialized"? It's single payer, sure, but there's still private practitioners/clinics/providers. >There biggest problem with this system is that private healthcare isn’t a great business, and the hospitals and insurance companies often struggle. They also don’t provide anything near parity with public healthcare. The most complex and sophisticated care still happens in the public system, which in turn means that the best doctors still want to work in the public system as well. I've heard the opposite about public/private healthcare, at least in germany. Apparently there, the public insurance pays a pittance and is regulated, whereas with private insurance they can charge the market rate.
    - Gatsky 5y ago
      Very limited private services in Canada AFAIK.
- toastal 5y ago
  Medicare, the little socialized medicine we do have, is unusable if you go abroad too. No vouchers, no treaties with foreign healthcare systems, no tax exemptions. You will pay in to Medicare your whole life and be required to burn air fuel flying back to the US to redeem any care whatsoever. The worst part is that often it stills ends up cheaper with medical tourism or getting local care.
  - arbuge 5y ago
    I don't think that's a reasonable criticism of Medicare. Most other countries with universal healthcare do require you to be in the country to get that care. Europeans don't get much benefit from their universal healthcare when they leave Europe for example.
    - ggm 5y ago
      The EU is not a nation state, yet roaming in Europe between nation states they get universal healthcare. As do visitors from treaty nations outside the EU. There are no good bilateral health treaties with the USA For a reason. As an Australian, I have private health cover for longterm services like physio, optical and dental services. For life threatening emergencies I go public and can do so in bilateral treaty countries. That's how I understand the problem. Happy to be corrected.
      - aspenmayer 5y ago
        I had Medicare on a temporary visa in Australia and had to go to the ER. I don’t think I ever got any bill at all. It was really amazing all the way around. The contrast made me feel ashamed to be an American, to be honest. I grew up in poverty, and have internalized not going to the doctor for any reason besides an actual, literal life threatening emergency. My folks were volunteer firefighters and first responders, as we lived in an isolated rural area on dirt roads, so we were the closest emergency services, now that I think of it. I’m back in USA now, and I still have to live that way, as I’m unemployed and trying to start a business. I have no assets and am nearly homeless. It’s no American Dream for everyone. I wrote a bit about my Australian medical emergency here: https://news.ycombinator.com/item?id=29719451 https://news.ycombinator.com/item?id=29719451
- TheJoeMan 5y ago
  Anyone trying to picture a US “universal healthcare”, I want you to think back to your last trip to the DMV. The experience dealing with almost any aspect of our government is fraught with paperwork, delays, forms to fill out, “oh you want this other department” circular loops. You can put up with this torture for the “privilege” to drive a car, but you don’t get to force me to deal with this so I can get healthcare when/how I want to. A while ago I went to an endoscopy clinic, and there was a woman crying and pleading with the secretary because her husband has cancer and couldn’t get treated on the day of his appointment because some medicaid paperwork didn’t go through regarding his diagnosis and thus medicaid wouldn’t approve the procedure yet.
  - andrewjf 5y ago
    Sounds like dealing with private insurance, as well. With the added benefit of getting bankrupted, even if insured.
  - csnover 5y ago
    Instead of telling people to make dishonest comparisons to unrelated bureaucracies, I’d recommend that they instead find someone who has actually used Original Medicare[0] (not Medicaid, which is a different thing) if they want to know what it is like to use Original Medicare. The amount of bureaucracy on the patient side is basically zero. My personal experience with Original Medicare + Medigap has essentially been this: Step 1. Need some health service. Step 2. Go get the health service. Step 3. There is no step 3, unless the provider fucks up and tries to bill the Medigap insurer as the primary insurer—which is a problem caused by the existence of private primary insurers, not Medicare. And with private insurers, this: Step 1. Need some health service. Step 2. Check if the provider is in-network. Step 3. Check if the facility is in-network. Step 4. Check if the service is covered by the insurance. Step 5. Submit a prior authorisation or else the insurer won’t pay anything at all. Step 6. Get denied for some asinine technicality. Step 7. Appeal and submit more documentation until they finally capitulate. (Also, you’re doing this while very sick.) Step 8. Triple-check with the facility that they are only going to use in-network doctors for things like anaesthesiology. Step 9. Go get the health service. Step 10. Get a half-dozen gigantic bills in the mail. There are certainly issues with Medicare, but I can’t think of any that aren’t the result of for-profit insurers or government abolitionists doing everything in their power to make the system intentionally terrible. [0] As mentioned in the article, Original Medicare is parts A & B. Part C—Medicare “Advantage”—is the government hand-out to private insurers.
- adamredwoods 5y ago
  It's insane that it took Obamacare to finally push for the rollout of electornic health records. Before this, less than 20% of hospitals were doing it: https://techcrunch.com/2016/07/27/how-president-obama-shaped-the-future-of-digital-health https://techcrunch.com/2016/07/27/how-president-obama-shaped...
  - IG_Semmelweiss 5y ago
    EMRs have been a handout of a fistful of dollars from actual doctors, to the software industry. Its insane that anyone would think that politicians could be wise and mandate something that an entire industry rejected, and have never needed since the advent of medicine. Result. Doctors spend time on screens instead of, seeing patients. The emr is basically an accounting system for insurances to receive claims in a format they can process. Anyone that tells you otherwise is making money from selling an emr to you or doesnt work in healthcare
- sandworm101 5y ago
  Yes but rich people in the US live far longer than the average american. We have to keep that dream alive, the dream that if you just work hard enough and/or buy enough lottery tickets anyone can live a long and healthy life. And access to company-provided healthcare is almost as important to workers as thier wages. Fear of losing healthcare motivates workers to work harder. Take that motivation away and they might quit or demand more money. The stock market cannot afford that sort of hit.
adamredwoods 5y ago
When I lived in San Francisco, I worked freelance for a number of years and had no health insurance. It was too expensive. Over time, I started having sever pains that shot through my abdomen and groin. I could barely walk. I had tried to go to the SF General hospital, but it took about a month to be seen by a general practitioner. I finally did get seen and they thought it could be a hernia, but were unsure. They scheduled more tests, which was about a 6 month wait. (I should note that SF General gets a lot of unusual people and the staff gets slowed down from dealing with the more difficult patients.) Desperate, I found a small hospital clinic and asked them to see me. I told them I had to pay out of pocket. Oddly, the doctor who saw me gave me a huge discount. He diagnosed that I had sciatica from bad ergonomics. Sure enough, changing how I sat improved my pain! I was lucky. Very lucky. Now, my sister is currently struggling with a serious issue, and as a Medicare patient (being under the poverty level), she wasn't able to be seen for months, and even now they are unable to diagnose properly due to delays in getting her referrals or tests (CT scans, etc). I can't stress enough how uneven and cruel the US healthcare system is. I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage.
- zamfi 5y ago
  > I can't stress enough how uneven and cruel the US healthcare system is. Yes, and there is no doubt healthcare is expensive. I won't rehash the reasons it's particularly expensive in the USA; they're well-known, though there isn't strong consensus. But: > I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage. "Obamacare" tried to remedy this by capping healthcare costs at 8.5% of income. Yes, there are holes (in particular, before 2021 this only applied to those earning under 400% of the federal poverty line FPL) and healthcare is even more egregiously expensive in those special cities where 400% of the FPL is below the local poverty line. But whether you get subsidized by the state, a union, or your employer, the thing to keep in mind is that the costs of healthcare are ultimately still borne by "you": really, we, collectively, employees, union-members, taxpayers -- yes some of us are privileged enough to work for companies that are not financially constrained, but for most employers an extra $1000-3000/mo going to healthcare (you did say "family-level premiums") just feeds in to their total cost of employing you. Offering that benefit to employees means the pay they can offer you as an employee is constrained by its cost as well. If having employer-based care is the only way to survive, then what that really means -- since money is fungible, really -- is that having the privilege of being well-compensated is the only way to have effective healthcare. I think that's worse, honestly.
egberts1 5y ago
Too bad that there is not a website that can let us plug-in our economic scenarios and advise us of which plan to get under SSA/Medicare such as: - Medicare A/B - Medicare D - Medicare C - Medigap - HMO Advantage (Medicare) And more. This is the Internet! Surely there must be one out there somewhere???
- refurb 5y ago
  So everyone gets Medicare A (hospitalization) who qualifies for Medicare (~40 quarters of SSI taxes). You get Medicare B (hospital or physician administered drugs like chemotherapy) if you pay the premium. Everyone should get Medigap, as Medicare A + B only pay 80% (or 90%?) of costs, so Medigap covers most of your obligation under A+B. Those with very low incomes can get a LLS (low income supplement where the government covers the gap). Medicare C is Medicare Advantage is HMO Advantage. It's basically the government paying premiums to an HMO Medicare plan instead of providing the benefit directly themselves. It covers Medicare A+B+Medigap. Medicare D is prescription drugs (drug you take home and give yourself). Your premiums are paid by the government but offered by private insurers. The choice here (and there are calculators) are more complex as there are multiples plans to choose from and they are updated each year and it depends on what drugs you're on or think you'll be on.
  - egberts1 5y ago
    Thank you for detailed outline. But it computes nothing for us. We all like to plug in our personal socio-economic numbers of what we have and get result … rather instantly. This here is the Internet! Not everyone is good at math. Much less on SSA/Medicare/HMO policy and procedures. (But I am, as I compute this labyrinth for my senior citizen family members, each, repeatedly)
    - refurb 5y ago
      I think the problem is the calculation is too complex (as it is too personal) and too local. Imagine a calculator that said “Please list all drugs you currently take or may take next calendar year”. That alone is a massive undertaking for most seniors.

39 points by mitchbob 5y ago

Archived: https://archive.ph/K0Hbd https://archive.ph/K0Hbd

As noted in this article, it’s insane that the wealthiest country in the world doesn’t have universal healthcare. I know Medicare is complex and not nearly as straightforward as I think too many people assume Toward the end of the article, to quote: > At any rate, when it comes to medical care, what’s wrong with socialism? The existing American system, with its dazzlingly inefficient mix of public and private insurers and its legions of redundant paper shufflers, is not a persuasive argument against it. Canada, which does have universal health care, spends roughly half as much per capita as we do, yet has better outcomes, including an average life expectancy that’s more than four years longer than ours. In fact, according to the World Health Organization, the U.S. ranks just fortieth, worldwide, in life expectancy at birth. That’s a little bit better than Ecuador and Poland but a little bit worse than Turkey and Croatia. I agree wholly with this. Arguably when one of the most complex government programs we have in the US is better than average than the options left with private insurance, even after all the political machinery that messes with Medicare and our system as a whole, it should be obvious by now we are doing it wrong

refurb 5y ago
Life expectancy is a crappy way to measure how effective your health care system is. It's way to blunt a tool and has many confounding factors that have nothing to do with your healthcare system.
Gatsky 5y ago
A fully socialised healthcare system a la Canada won’t fly in the USA (this is obvious?). There are models eg in Australia where there is pretty good socialised care, and also a private system where you either pay up or have private health insurance (with a lot of extra costs). It kinda works, and gives some choice to the user. There biggest problem with this system is that private healthcare isn’t a great business, and the hospitals and insurance companies often struggle. They also don’t provide anything near parity with public healthcare. The most complex and sophisticated care still happens in the public system, which in turn means that the best doctors still want to work in the public system as well.
- gruez 5y ago
  >A fully socialised healthcare system a la Canada Is the canadian healthcare system even "fully socialized"? It's single payer, sure, but there's still private practitioners/clinics/providers. >There biggest problem with this system is that private healthcare isn’t a great business, and the hospitals and insurance companies often struggle. They also don’t provide anything near parity with public healthcare. The most complex and sophisticated care still happens in the public system, which in turn means that the best doctors still want to work in the public system as well. I've heard the opposite about public/private healthcare, at least in germany. Apparently there, the public insurance pays a pittance and is regulated, whereas with private insurance they can charge the market rate.
  - Gatsky 5y ago
    Very limited private services in Canada AFAIK.
toastal 5y ago
Medicare, the little socialized medicine we do have, is unusable if you go abroad too. No vouchers, no treaties with foreign healthcare systems, no tax exemptions. You will pay in to Medicare your whole life and be required to burn air fuel flying back to the US to redeem any care whatsoever. The worst part is that often it stills ends up cheaper with medical tourism or getting local care.
- arbuge 5y ago
  I don't think that's a reasonable criticism of Medicare. Most other countries with universal healthcare do require you to be in the country to get that care. Europeans don't get much benefit from their universal healthcare when they leave Europe for example.
  - ggm 5y ago
    The EU is not a nation state, yet roaming in Europe between nation states they get universal healthcare. As do visitors from treaty nations outside the EU. There are no good bilateral health treaties with the USA For a reason. As an Australian, I have private health cover for longterm services like physio, optical and dental services. For life threatening emergencies I go public and can do so in bilateral treaty countries. That's how I understand the problem. Happy to be corrected.
    - aspenmayer 5y ago
      I had Medicare on a temporary visa in Australia and had to go to the ER. I don’t think I ever got any bill at all. It was really amazing all the way around. The contrast made me feel ashamed to be an American, to be honest. I grew up in poverty, and have internalized not going to the doctor for any reason besides an actual, literal life threatening emergency. My folks were volunteer firefighters and first responders, as we lived in an isolated rural area on dirt roads, so we were the closest emergency services, now that I think of it. I’m back in USA now, and I still have to live that way, as I’m unemployed and trying to start a business. I have no assets and am nearly homeless. It’s no American Dream for everyone. I wrote a bit about my Australian medical emergency here: https://news.ycombinator.com/item?id=29719451 https://news.ycombinator.com/item?id=29719451
TheJoeMan 5y ago
Anyone trying to picture a US “universal healthcare”, I want you to think back to your last trip to the DMV. The experience dealing with almost any aspect of our government is fraught with paperwork, delays, forms to fill out, “oh you want this other department” circular loops. You can put up with this torture for the “privilege” to drive a car, but you don’t get to force me to deal with this so I can get healthcare when/how I want to. A while ago I went to an endoscopy clinic, and there was a woman crying and pleading with the secretary because her husband has cancer and couldn’t get treated on the day of his appointment because some medicaid paperwork didn’t go through regarding his diagnosis and thus medicaid wouldn’t approve the procedure yet.
- andrewjf 5y ago
  Sounds like dealing with private insurance, as well. With the added benefit of getting bankrupted, even if insured.
- csnover 5y ago
  Instead of telling people to make dishonest comparisons to unrelated bureaucracies, I’d recommend that they instead find someone who has actually used Original Medicare[0] (not Medicaid, which is a different thing) if they want to know what it is like to use Original Medicare. The amount of bureaucracy on the patient side is basically zero. My personal experience with Original Medicare + Medigap has essentially been this: Step 1. Need some health service. Step 2. Go get the health service. Step 3. There is no step 3, unless the provider fucks up and tries to bill the Medigap insurer as the primary insurer—which is a problem caused by the existence of private primary insurers, not Medicare. And with private insurers, this: Step 1. Need some health service. Step 2. Check if the provider is in-network. Step 3. Check if the facility is in-network. Step 4. Check if the service is covered by the insurance. Step 5. Submit a prior authorisation or else the insurer won’t pay anything at all. Step 6. Get denied for some asinine technicality. Step 7. Appeal and submit more documentation until they finally capitulate. (Also, you’re doing this while very sick.) Step 8. Triple-check with the facility that they are only going to use in-network doctors for things like anaesthesiology. Step 9. Go get the health service. Step 10. Get a half-dozen gigantic bills in the mail. There are certainly issues with Medicare, but I can’t think of any that aren’t the result of for-profit insurers or government abolitionists doing everything in their power to make the system intentionally terrible. [0] As mentioned in the article, Original Medicare is parts A & B. Part C—Medicare “Advantage”—is the government hand-out to private insurers.
adamredwoods 5y ago
It's insane that it took Obamacare to finally push for the rollout of electornic health records. Before this, less than 20% of hospitals were doing it: https://techcrunch.com/2016/07/27/how-president-obama-shaped-the-future-of-digital-health https://techcrunch.com/2016/07/27/how-president-obama-shaped...
- IG_Semmelweiss 5y ago
  EMRs have been a handout of a fistful of dollars from actual doctors, to the software industry. Its insane that anyone would think that politicians could be wise and mandate something that an entire industry rejected, and have never needed since the advent of medicine. Result. Doctors spend time on screens instead of, seeing patients. The emr is basically an accounting system for insurances to receive claims in a format they can process. Anyone that tells you otherwise is making money from selling an emr to you or doesnt work in healthcare
sandworm101 5y ago
Yes but rich people in the US live far longer than the average american. We have to keep that dream alive, the dream that if you just work hard enough and/or buy enough lottery tickets anyone can live a long and healthy life. And access to company-provided healthcare is almost as important to workers as thier wages. Fear of losing healthcare motivates workers to work harder. Take that motivation away and they might quit or demand more money. The stock market cannot afford that sort of hit.

adamredwoods 5y ago

When I lived in San Francisco, I worked freelance for a number of years and had no health insurance. It was too expensive. Over time, I started having sever pains that shot through my abdomen and groin. I could barely walk. I had tried to go to the SF General hospital, but it took about a month to be seen by a general practitioner. I finally did get seen and they thought it could be a hernia, but were unsure. They scheduled more tests, which was about a 6 month wait. (I should note that SF General gets a lot of unusual people and the staff gets slowed down from dealing with the more difficult patients.) Desperate, I found a small hospital clinic and asked them to see me. I told them I had to pay out of pocket. Oddly, the doctor who saw me gave me a huge discount. He diagnosed that I had sciatica from bad ergonomics. Sure enough, changing how I sat improved my pain! I was lucky. Very lucky. Now, my sister is currently struggling with a serious issue, and as a Medicare patient (being under the poverty level), she wasn't able to be seen for months, and even now they are unable to diagnose properly due to delays in getting her referrals or tests (CT scans, etc). I can't stress enough how uneven and cruel the US healthcare system is. I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage.

zamfi 5y ago
> I can't stress enough how uneven and cruel the US healthcare system is. Yes, and there is no doubt healthcare is expensive. I won't rehash the reasons it's particularly expensive in the USA; they're well-known, though there isn't strong consensus. But: > I feel the only way to survive long-term is to have a career that enables access to jobs (or unions) that offer health care as a benefit. Without it, paying for family-level premiums is similar to a mortgage. "Obamacare" tried to remedy this by capping healthcare costs at 8.5% of income. Yes, there are holes (in particular, before 2021 this only applied to those earning under 400% of the federal poverty line FPL) and healthcare is even more egregiously expensive in those special cities where 400% of the FPL is below the local poverty line. But whether you get subsidized by the state, a union, or your employer, the thing to keep in mind is that the costs of healthcare are ultimately still borne by "you": really, we, collectively, employees, union-members, taxpayers -- yes some of us are privileged enough to work for companies that are not financially constrained, but for most employers an extra $1000-3000/mo going to healthcare (you did say "family-level premiums") just feeds in to their total cost of employing you. Offering that benefit to employees means the pay they can offer you as an employee is constrained by its cost as well. If having employer-based care is the only way to survive, then what that really means -- since money is fungible, really -- is that having the privilege of being well-compensated is the only way to have effective healthcare. I think that's worse, honestly.

egberts1 5y ago

Too bad that there is not a website that can let us plug-in our economic scenarios and advise us of which plan to get under SSA/Medicare such as: - Medicare A/B - Medicare D - Medicare C - Medigap - HMO Advantage (Medicare) And more. This is the Internet! Surely there must be one out there somewhere???

refurb 5y ago
So everyone gets Medicare A (hospitalization) who qualifies for Medicare (~40 quarters of SSI taxes). You get Medicare B (hospital or physician administered drugs like chemotherapy) if you pay the premium. Everyone should get Medigap, as Medicare A + B only pay 80% (or 90%?) of costs, so Medigap covers most of your obligation under A+B. Those with very low incomes can get a LLS (low income supplement where the government covers the gap). Medicare C is Medicare Advantage is HMO Advantage. It's basically the government paying premiums to an HMO Medicare plan instead of providing the benefit directly themselves. It covers Medicare A+B+Medigap. Medicare D is prescription drugs (drug you take home and give yourself). Your premiums are paid by the government but offered by private insurers. The choice here (and there are calculators) are more complex as there are multiples plans to choose from and they are updated each year and it depends on what drugs you're on or think you'll be on.
- egberts1 5y ago
  Thank you for detailed outline. But it computes nothing for us. We all like to plug in our personal socio-economic numbers of what we have and get result … rather instantly. This here is the Internet! Not everyone is good at math. Much less on SSA/Medicare/HMO policy and procedures. (But I am, as I compute this labyrinth for my senior citizen family members, each, repeatedly)
  - refurb 5y ago
    I think the problem is the calculation is too complex (as it is too personal) and too local. Imagine a calculator that said “Please list all drugs you currently take or may take next calendar year”. That alone is a massive undertaking for most seniors.