Monday, June 8, 2015

A Sick Business

The other day I ran across an article in the Atlantic Monthly that perfectly illustrates something that seems could happen only in America. I literally had to shake my head.

The writer, Olga Khazan, explains how the convoluted American insurance-based health care system is rife with pitfalls even for folks who have what is normally considered adequate insurance. For someone like me, who doesn’t have to deal with this sort of thing, it was an eye-opening read.

The main thrust of Khazan’s story was that fully covered Americans can still face unexpected medical bills, hassles with hospitals, and legal tussles with their insurers, all due to the byzantine nature of the American system.

One of the cases Khazan cites involves a Texas woman with a history of heart disease who began to have chest pains one day. When she and her husband became alarmed enough to seek medical help, they first shopped around. Finns reading this might be puzzled, but that is exactly what the couple did. They used a smart-phone app provided by their health insurance company to find a local health-care provider that would accept the woman’s insurance.

This is the approach reportedly advocated by some health-care experts and high-profile conservatives. Jeb Bush, the stealth GOP candidate for president, recently touted the “there’s an app for that” approach as the optimal alternative to Obamacare. The thinking is that what works best is a completely market-based system, where choosing medical treatment, even emergency treatment, is just like any other consumer choice – just like finding the shampoo or deodorant that suits you best. 

With the help of her phone app, the woman in Texas settled on a particular “stand-alone” emergency room, not a hospital, to treat her chest pain. Stand-alone ERs didn’t exist when I still lived in the US, and I’m sure we don’t have them here in Finland. I recall seeing one in a shopping center in my hometown on one of my more recent visits to Georgia. It’s like a branch of a bank, a smaller facility conveniently located for suburbanites. As such, I guess it’s not a bad idea, but they seem to share some of the unfortunate business practices of much larger facilities.

Luckily for the woman in Texas, there was nothing wrong with her heart, as was borne out by an EKG and some blood tests. Her visit to the stand-alone ER was short, but it came with a hefty price tag. When totaled, the bill came to $4600 (€4100), which seems staggering enough to me. Only half of that was for any kind of medical procedure (for example, the EKG was $300). The other half ($2258, or €2030) was just for the use of the ER itself, “facility fees” similar to those charged by full-fledged hospitals.

While her insurance covered most of the invoice, she was still on the hook for $500, which she was evidently able to reduce by negotiating a lower sum with the bill collection agency (hired by the ER to get its money). 

Apparently, when you’re sick in America, it helps to be a persistent haggler, as well as a smart shopper.

Another story Khazan shared in her article involves a Dallas man who suffered two strokes within a period of six months. The hospitals he was taken to in both cases were “in-network” for his insurance plan, meaning they had existing agreements to accept the man’s insurance. There was no worries about whether his treatment would be covered. Or, so he thought.

Apparently, individual doctors working in American hospitals often can charge separately for the care they provide to the hospital’s patients. And, they don’t have to necessarily accept the same insurance plans accepted by the hospital itself. This appears to be why the Dallas stroke victim received completely unexpected bills for “out-of-network” care not covered by his insurance. Three years later, the man is still in the midst of taking legal action over the extra charges.

I’ve heard of many stories similar to these. For many people, coming home from the hospital is often just the beginning of the next hardship to overcome, a protracted fight with insurance companies and bill collectors.

The very idea of this way of doing things seems alien to me after living so long in a country with a completely different approach to health care. Perhaps the best way to show what I mean by this is through a little example of my own.

Three years ago, I experienced a very minor health scare. Normally, I don’t like to share such personal (and let’s face it, trivial) details, but I’m trying to make a point here.

It was a Monday in July. I had just had an ocular migraine, in which your vision is temporarily obscured by shimmering “lights”. This in itself was no big deal. I have these ever so often. It’s not painful, but you essentially lose much of your vision for a few minutes due to something happening inside your brain.

This time, however, immediately after the migraine subsided, my left arm went completely numb and I had some pain in my chest. I was not even able to lift my arm above my head. That had never happened before, though in the past I have had occasional numbness in my arms due to pinched nerves.

I was sufficiently freaked out by this combination of events that I decided to see a doctor right away.

I didn’t shop around first, but I did need to make a call to decide where to go. The default choice would be the Palohein√§ Tervyskeskus, the city-run health-care center closest to my home (about a mile away). Palohein√§ is closed in July, however, when many services are scaled down in mid-summer when Helsinki almost turns into a ghost town, so I called a central health-service number to find out which other nearby clinics were operating. I was directed to go to Maunula, less than three miles away. I know the place well, since that's where I usually see the dentist. 

When I got there, a nurse checked me out and did an EKG, which showed nothing alarming. As it was near closing time, she asked me to come back the next day, a Tuesday, for blood work. On that second visit, she performed a second EKG (which seemed a bit unnecessary, to be honest). No change from the day before.

On Wednesday, I got a phone call from a doctor at Maunula with the results of my blood test. Nothing to worry about there, either. Still, he wanted to see me and booked a time for me the next afternoon. When we met, he explained that whatever had caused my symptoms, it wasn’t heart-related (a relief) and was most likely due to the kind of neck problems I had needed surgery to correct back in 2005. Thinking that this previous condition might have again deteriorated, he made an appointment for me with a neurosurgeon at Meilahti Hospital.

About six weeks later, I had an MRI done at the hospital. People who have undergone this procedure know that patients often have choice of music to listen to while encased in the incredibly noisy MRI machine. As it was a Sunday afternoon, I asked the technician to tune the sound system’s radio to Yle Mondo, which I knew at that time of day would be broadcasting National Public Radio from the US. Lying inside that huge machine, in a space the size of a coffin surrounded by powerful magnetic fields, I listened to the familiar soothing voice of Garrison Keillor on “Prairie Home Companion”. That is how I like to spend my Sunday afternoons.

The consultation with the neurosurgeon a few days later was short and sweet – no drastic changes showed up in the MRI. Nothing to worry about, and in fact, a similar episode of sudden numbness has not occurred since. Knock on wood.

A few weeks after all this happened, the bills started rolling in. The first was for the visits to the Maunula clinic. It was €13.80. The next, from the hospital where I’d had the MRI and neurosurgeon consultation, was almost double that, €27.50. The total came to €31.30 (about $40 at the time).

These two bills were basically office fees, comparable in some sense to the 2000-dollar-charge levied on the Texas woman for her brief visit to the stand-alone ER. For the EKGs, blood tests, doctor consultations, even the MRI, I was charged nothing. Zilch. This is what we pay taxes for.

Thinking back to my own experience on that July day, the differences to the American system could not be more glaring.

I didn’t have to shop around for the health center that would take my insurance. It’s a moot point. I don’t have insurance. I don’t need insurance.

I didn’t have to worry about sticker shock from unexpected bills because some of the professionals providing me care don’t accept my particular insurance plan. As said, I don’t have insurance. Don’t need it.

I didn’t have to haggle with an insurance company or collection agency to get my unexpected out-of-pocket fees reduced. There would be no insurance company to haggle with anyway, and besides 30 euros was something I could manage to pay without undue hardship (duh!).

To be sure, it is possible to buy health insurance in Finland, and there are private health-care providers here for folks who prefer that and are willing to pay the higher costs. Most people I know don’t use them, unless paid for by their employers. Most Finns I know usually use the public, single-payer system.

As it happens, the US Supreme Court is set to make a ruling any day now that could be a major blow to many Americans who finally have health insurance thanks to what Republicans, out of ignorance or naked ideology, love to call "socialized" medicine (a.k.a. Obamacare). It's not, not by a long shot.

Even though Obamacare is an improvement over what came before it -- and I do hope that the nine justices leave it untouched -- it’s good to remember that many liberals consider it, in reality, to be a half-assed compromise that relies on keeping the private insurance industry intact. 

I’m sure many of us would have wished that in 2010 Congress had instead enacted a single-payer system like Finland has. I'd like to think most Americans, if they actually thought it through, would prefer the same.

Or maybe they just prefer making things really, really difficult.


  1. Could the second EKG be for comparison? You know, for differences of features that normally wouldn't be problems?

    You know, it might be worth seeing a physiotherapist about that numbness if it's still a problem. It could be muscles or spine slightly pinching a nerve. I mean it doesn't sound like a problem, but you could get advise on a stretch or massage regimen that helps to prevent it in the future.

    1. Thanks. I'm sure you're right about the EKG, and it does make sense to do a follow up for comparison. Stretching is definitely something I could do with more of. I've even been thinking of trying yoga this autumn. Couldn't hurt.

    2. Those people are amateurs. Physiotherapists are professionals with a degree who know about anatomy and can tell you a lot about your body and what to do to get rid of problems. Some yoga poses may actually aggravate any issue you might have especially if e.g. your spine is settled in a slightly wrong position.

  2. We would have had single-payer here in the USA if it had not been for the slimy sack of garbage, Joe Lieberman.

    You guys in Europe have an excellent health-care system. However, your own version of the 1% are doing their damndest to take it away from you. I see the calls for it to be rolled back or even eliminated. Such attempts are strongest in the UK, but it's going to spread like a pandemic because, well...that's how it works.

    I have what is considered great insurance here in the USA since I am an employee of the Federal government. But I still have accumulated onerous medical bills when I have had serious health problems and surgeries. Even with insurance you can find the system putting you into jeopardy.

    1. It’s a shame that even with good insurance you’ve had to face big medical bills. It shouldn’t be that way in a modern country.

      Somehow, I can’t imagine a single-payer system ever making it through US Congress, no matter what, especially considering how the Democrats were barely able to get passed what is essentially a market-friendly system inspired by an conservative think tank. (Newt Gingrich himself pushed a similar idea back in 1993, for Christ sakes.) The level of opposition from the right to Obamacare still boggles my mind. It’ll be interesting to hear how the Supreme Court rules on King v. Burwell and what happens then.

      Myself, I’m not so fatalistic about the future of health-care on this side of the pond. Every Brit I know thinks highly of the NHS, and no one in Finland talks about drastic changes to the system here. I suspect any politician who strongly advocated for doing away with the system would probably have a short career.