This is a far cry from the gravity of the post, but here's my personal anecdote about trying to navigate health care and insurance.
A month or two ago, I was trying to set up a pediatric dentist visit for my son. Not a medical emergency, but a matter of some urgency. I spent about three hours on a total of a dozen phone calls or so. Some to the insurer, and some to various dentist offices in the region to inquire about scheduling and logistics. I learned that I needed to switch my son's primary office before he would be eligible to receive care. This could only be done once per month. Fortunately, by luck, this would take effect at the close of business on that very day. Next I needed to find a covered provider. Of course, the insurer could not tell me which ones would have openings at short notice, so I had to call several. Then I learned that in order for a pediatric visit to be covered, it needed a referral from a general dentist. The pediatric office helped me find a dentist who could fill out this paperwork, which felt lucky. I verified that my policy worked with this dentist office. Several hours on the phone, but I had a sense of accomplishment for sorting it all out.
The day of the appointment came. The visit went smoothly. Then I found out that it wouldn't be covered because the insurance will not cover pediatric dentistry above the age of 6, but my son is 7.
I think I'm going to opt out of dental insurance altogether in the next enrollment. All the individual people seemed to be doing their best to help me, but the end result is a system that is impossible for me to use.
Insurance refused to cover imaging to identify my spouse's squamous cell carcinoma on an ovary because initial bloodwork didn't come back positive for ovarian cancer (squamous cell required different bloodwork, at least at the time).
It took a doctor offering to misdiagnose it as a dermoid cyst to get the imaging and hysterectomy ordered and approved, and that still took 2 months. By the time it happened, the cancer had metastasized.
The imaging would've cost a few thousand dollars. The hysterectomy would've cost about $20k-40k. Chemo was unsuccessful, and she died 9 months and about $2 million in medical bills later.
Fwiw, if one has a passport and some funds, one can travel abroad for cheaper surgery abroad. It won't guarantee an outcome, but it ought to be better than delaying it. Of course this in no way excuses the insurance firm.
Similar story for our youngest - excuse after excuse. We just bought two round-trip tickets to Warsaw and paid privately. It was a little more but my wife and son got to spend time with friends and family for that extra. The effort we had spent in US we never got back. I hope it worked-out okay for your family as well.
I've seriously considered opting out of health insurance altogether and stuffing away the obscenely priced monthly expense into an interest yielding account. Insurance is nightmarish, and I don't really want to deal with it much anymore.
I know this might appear foolish, but fighting with a corporation whose incentives are adverse to my own (both on the medical side and the insurance side) makes me a little sick to my stomach.
If you have enough money for that gamble to pay off over the long haul the cost of health insurance would be immaterial to you anyway. You might get away with it in your youth, or you might have a catastrophic loss and have your finances wrecked.
You're often able to negotiate discounts for cash payment from providers, but back when I had insurance that excluded a pre-existing condition I ran into providers who steadfastly demanded the full list price (under threat of collections). It only takes one of those standing pat on a high 5 or low 6-figure bill to cause you to lose on your "bet".
> you might have a catastrophic loss and have your finances wrecked.
If you have health insurance (in the US) and you have a catastrophic event, your finances are going to be totally wrecked anyway. You're likely to have to declare bankruptcy unless you are pretty wealthy. At least, that's how it's gone with every friend and family member of mine that had to navigate such an event. That's on top of the painful nightmare that is dealing with insurance company claims (which, to add insult to injury, you have to do when you're injured or sick).
The premiums are also so high that I'm very far from convinced that holding an actual health insurance policy is a better option than putting that premium money into an emergency fund.
I would agree that it's objectively terrible dealing with insurance companies, providers who are incredulous you care about the pricing of services, etc. There is no free market for healthcare services. Advocating for yourself is tremendously draining.
I'm happy with the ROI I've had with my insurance premiums over my life. I haven't had a catastrophic event but I've certainly had reasonably sizable claims. If I'd invested the last 20+ years of premium expense (about $400K to date) and had no claims I'd have a ton more money, but not enough to cover a catastrophic event later in life. The principal would also have been completely wiped-out a couple of times when I did have claims, however.
I pay the premiums because I'm not comfortable holding bets on both the market and on my health. I'm also unwilling to consider bankruptcy as a morally / socially acceptable solution.
This mixed socialized and capitalist "system" we've allowed to grow up feels like the worst possible one. Healthcare and health insurance expense are a mechanism to extract value from the middle class (i.e. everyone who has money but isn't wealthy enough to buy their way out of the "system").
My preference would be for a fully socialized system, built primarily around protection for catastrophic loss, where everyone contributes w/ no opting-out permitted.
Failing that I'll grudgingly take a fully capitalist system where people who can't afford to pay are left to fend for charity or die.
What we've got is a mix of the worst parts of both.
It's wild how differently the press release you linked to frames that.
> WASHINGTON, D.C. – Nearly half (49%) of cancer patients and survivors report being burdened by medical debt alongside some (13%) who report expecting to incur medical debt as part of their treatment plan, according to a new Survivor Views survey by the American Cancer Society Cancer Action Network (ACS CAN). Interestingly, nearly all (98%) were insured when medical debt occurred.
> Among those with cancer-related medical debt, nearly half (49%) have carried more than $5,000 in debt, a majority (69%) of whom have carried this debt for more than a year. Respondents also reported most commonly owing their medical debt to a hospital (76%).
...
> According to the survey, an individual with cancer-related medical debt was three times more likely to be behind on recommended cancer screenings in comparison to those who have been able to pay for their care without accumulating debt. Nearly half (49%) saw their credit score decrease with 30% having difficulty qualifying for loans.
> Cancer-related medical debt is also not felt equally and further deepens disparities. Black (13%) and Hispanic (14%) patients and survivors with medical debt were twice as likely as White respondents to report being denied care due to their debt. Black respondents were also more likely to report being contacted by collections agencies (66%) and to feel harassed by them (44%).
Look how many people in this thread are thinking about avoiding health insurance based on the premise that you’ll be financially wiped out by a catastrophic event even if you have insurance. That’s what happens when you put framing over facts. It’s important for people to understand the facts so they can make good decisions.
The collection laws also vary from state to state on this... in some states, medical collections are all but toothless, short of actually filing a lawsuit, which isn't likely, except some facilities actually have staff lawyers willing to harass and sue.
Well, you can try for sure to default on medical debts without suffering a hit to your credit, but goood luck obtaining future care from any provider that you’ve stiffed.
How many big medical systems/districts in your region can you run up a balance until none will serve you, except through the E.D.?
I have an 18yo bill for a medical lab, and I still get my regular bloodwork there... It gets brought up now and then on current visits, and I just say, "I'm not paying that bill."
As to the why, it's because I switched jobs and got my regular labs done and apparently was between coverage that week... they tried to charge me a large multiple of what they charged insurance for the same labs, so I refused to pay.
I also had several bills that were never paid from a week long hospital stay in my mid 30's... Most of them got paid if they'd agree to reasonable payments or settle for lower amounts when I had the money (tax return time, bonus, side work). After 7 years, they were all off my credit and I stopped bothering...
I'm essentially of the mindset of JohnFen (adjacent comment). If I have a health issue that crops up, I'm financially done anyway. Given this, I might as well control the money rather than throw it into a pit and hope something useful pops out in an emergency.
Catastrophic events seem to wipe people out financially regardless of insurance status. I keep hearing of people divorcing so their former spouse can keep some assets while they are battling cancer. There's just no winning unless you never need care.
I did that for much of my 20s and very glad I did. You are basically used parasitically by the Obamacare system as it caps the differential between young and elderly to the point it's well into the expected negative value, and you're young enough that the off chance of the bet going bad only results in declaring bankruptcy on a few years of professional salary.
Fortunately, out of pocket for relatively normal dental care isn't too bad... probably because Dental insurance doesn't really help much and often easier to just pay out of pocket.. though do shop around if you do so.
I’ve been through this situation with family members. I understand the frustration and agony.
I also understand the hesitancy to pay for two months at a “retreat-like inpatient psychiatric facility.”
In publicly funded system, it’s likely facilities like this would not exist or would be strictly private pay.
I’m not aware of any country that makes such a thing available on short notice like this.
I also understand the frustration, as often times facilities like this are all that exist in terms of medium-term care. And often times some of their services are at least formally in-network.
The understanding is you pay for it by selling your house.
We’ve been tempted to do this (sell our house), but been advised against it - but the reasoning in our case is patient specific.
I wish insurance was clearer about what covered and what isn’t. I wish we had more mainstream (not retreat-like) medium term care places.
Maybe I’m misreading the phrase retreat-like.
But id this isn’t something a public system would pay for, it seems inappropriate to blame a private system to not pay for it, unless it’s clearly in the wording.
Regardless, mental health care in America stinks, and you can always argue over the details.
What gets me is that they probably could afford it out of pocket but didn’t want to deplete savings.
For a clear case like this, an insurance denial shouldn’t even be shared with the suicidal patient, their spouse should shield them from that and just pay from their checking account. The life of your spouse is worth more than a few more dollars in retirement.
Calling it a "few dollars" is probably disingenuous, although we don't know the personal circumstances. For many, this could be a "life-changing" quantity of money.
I will note that in a lot of places in the US, the role of medium term acute psychiatric care is taken by partial hospitalization programs, where patients go to a facility (usually a few conference rooms in an office building) during the workday for intensive therapy and medication management, but go home with family in the evenings. These programs are a lot cheaper than inpatient programs, and the standard workflow in my experience (with "good" insurance) at this point is 3-10 days inpatient, followed by 2-10 weeks in a PHP, and possibly some part time program after that. A lot of people skip the inpatient part if there's no acute danger.
I'm surprised the author makes no mention of those sorts of programs in the article. It makes it sound like the options were a luxury 8 week inpatient or nothing, when there's really a lot of stuff in between.
Me too! I’ve seen such good come from these sorts of programs!
I didn’t want to mentioned it my initial post, but these sorts of programs seem a happy combination of keeping costs down and maximizing autonomy, while focusing on full-time on mental illness.
Some is these are technically “in-patient” at home programs, which are growing in popularity in all fields on medicine.
But they’re not appropriate all the time, and I don’t want to “recommend” them. Talk to your doctor.
Sadly it seems these sorts of programs are simply unavailable in much of the country.
> I also understand the hesitancy to pay for two months at a “retreat-like inpatient psychiatric facility.”
> In publicly funded system, it’s likely facilities like this would not exist or would be strictly private pay.
In France, 80% is paid by the public healthcare if a psychiatrist greenlit you, which still make you liable for ~30€ per day in a room you share with another patient (and if you want a private room it's ~90€/day out of pocket) (maybe the prices around Paris are a bit higher though, i'm a country boy)
[edit] more accurate numbers, i had to check and correct them. Also, 30€ per day also covers medication if needed and a spa session
Yeah, happened a few months ago to my friend (who is leaving in August)(that's why I sort of knew the prices and living conditions). She waited a bit more of a month. It isn't often an issue from my understanding, but it is extremely frustrating for the person and the people around her. If you react poorly to anxiousness medication or antidepressants, you will be kept in a hospital before being admitted, and I believe in a higher category. Still a very frustrating situation.
It sounds like this guy needed around-the-clock, in-patient care. That's inherently expensive. While those facilities exist in countries with publicly funded healthcare, there's a huge shortage of in-patient beds, so there is some mechanism to funnel patients to outpatient care.
Usually beds in this context is a staffed operational bed. I was curious why they were complaining about beds back in the COVID era and looked into it. It means the physical object, the nursing staff, required clinician hours. They use the term “physical beds” in the rare contexts where those are significant.
Yes, there is something wrong with the insurance industry. But there is something wrong with the hospitals, doctors and drug companies too. The whole system is broken. Hospitals try to eke out the most out of insurance companies, often providing services that are unnecessary. Pharmaceutical companies charge US patients significantly higher rates than in other countries. Don't put all the blame on insurance companies.
>Randy needed immediate psychiatric care, and as an emergency physician I knew the options. We put our trust in the mental health team at a local crisis receiving unit, and they kept Randy overnight in temporary safe housing where he could be observed. By morning they had devised a plan to transfer Randy to a retreat-like inpatient psychiatric facility that was in-network with our insurance. The psychiatrist felt Randy was very high risk, but that he could heal with eight weeks of inpatient treatment. We were told our insurance would cover it.
>But six days into Randy’s eight-week hospital stay, our health insurance company denied any further inpatient care.
>The facility appealed Randy’s case, providing psychiatrist’s notes that clearly outlined his need, but the outcome did not change. Because Randy had no prior history of mental illness, the insurance company determined he shouldn’t need to be hospitalized and stopped paying for his care. A day later Randy was forcibly discharged.
This is definitely a case where the insurance company holds the majority of the blame.
> This is definitely a case where the insurance company holds the majority of the blame.
What facts are the basis of your conclusion? There is no health system in the developed world where a doctor's recommendation will guarantee expensive inpatient treatment without a layer of bureaucratic review.
You are right--Doctors absolutely share blame. Take my dentist's behavior, for example. When the oral hygienist is done doing all the real work, my dentist sits down for 10 minutes to count my teeth and say the words "You should floss more." She bills $85 for that sentence and calls it "Oral hygiene instructions". My insurance company (IMO rightly) denies paying for this. It's ridiculous and the dentist knows they're going to call bullshit on it, but they bill it anyway, and then I'm technically on the hook to pay for it. So far, the dentist has not yet attempted to balance bill that charge, and I will drop them like a bad habit if they ever do.
Doctors and dentists in the US are not bound by the same regulations (or even a similar stringency of regulation) involving billing practices and procedure codes.
I'd imagine you'd struggle to find a healthcare system in which a doctor's prescribed care is assuredly covered by insurance, by the insurance provider, and then later rescinded after care has already started.
The ACA made rescission of health insurance more difficult for insurers, but it absolutely happens. There are people at insurers tasked with looking for fraudulent omissions in policy applications for high loss ratio individual policyholders to target for rescission.
There are many health systems in the developed world, though, where the system doesn't make this the patient's problem. It shouldn't be possible to have a scenario where the provider believes eight weeks of treatment will be covered, the patient moves to an inpatient facility based on this understanding, and then the bureaucratic review layer decides six days layer that the provider was wrong.
The goal should be to provide every human being with the best care possible. If a system can't handle that, then we need to assess why and make changes.
Show me a country where that's the goal. Every other developed country has a goal that's something like: "provide the best outcomes for the population as a whole, at a cost the public is willing to pay."
Every player in the US healthcare / health insurance "system" has adapted to the regulatory niche they play in.
If Americans had the fortitude to have grown-up conversations about what should be socialized, how care should be rationed, etc, the public could exert some control over the design of the "system". As it stands, the "system" has mostly been shaped by corporate interests while the public has been distracted by inflammatory rhetoric pumped-out by all the entrenched players designed to play to partisan feelings about "fairness" and "freedom".
John Stossel explained in _Give Me A Break_ that the US once had a variety of pharmaceutical labs researching different cures and conducting trials. But US courts allowed a frenzy of frivolous lawsuits to extract astronomical payouts on behalf of former trial participants, even demanding payouts from the companies that stocked the supply and janitorial cabinets of research companies. One by one, we bankrupted our competitive machines of innovation until the few remaining pharmaceutical companies had grown large enough to defend themselves against injury claims. Big Pharma was created by lawyers.
> often providing services that are unnecessary
Thank a lawyer. "Patient with symptom X would have survived if only the doctor had tested him for Y". Now every patient with symptom X is issued a $5600 scan for Y -- not because of medical science, but because of liability.
Every time a courts awards 10 figure settlement because "that insurance company is good for it," all of society pays for it.
the problem is healthcare is run in a capitalist "free market" model, in which all actors are incentivized to increase their profits at the expense of the other actors, and where the patient is either a customer or a commodity
it's inherently the wrong model for providing a necessary feature of life (health), and combine it with a highly litigious society, and well, this is the result
The insurance companies are running the system more than any of the others — it is the finance "wizards" there who put the constraints on the rest of the system. I'll agree somewhat on the pharma companies too, who are also extractive.
You even said it yourself: "Hospitals try to eke out the most out of insurance companies...". Exactly! Because the hospitals and doctors are constrained to do "WHAT IS IN THE BEST INTEREST OF THE PATIENT" — that is their charter (and BTW, that is also the magic phrase to use whenever questioning what they propose to do for a patient or escalating a case). Perhaps a few hospitals or physicians occasionally overdo it, and there are some frauds, but your accusation overall is BS.
The insurance companies have no such constraint — if they do have such a mission goal, it is to OBTAIN MAXIMUM VALUE FOR THE SHAREHOLDERS. And the insurance companies are literally so amoral that they will reward agents for killing people for profit. That is not rhetoric, it is sworn testimony before congress of a person who cut off a patient's coverage, causing their death, and got promoted.
I have seen directly and personally an insurance company deny coverage for a test ordered for a close family member by the Chief Of Cardiology at Mayo Clinic. Mayo Clinic, and that physician are so overbooked they have ZERO motivation to order anything not necessary for the patient in front of them. It took days, and significant extra expense to get it reversed.
There is no way on the planet that anyone in an insurance industry should be able to override the doctors orders of the Director of Cardiology for Mayo Clinic. Or any physician, for that matter.
Medicine is one of the things that should never be run for a profit, and if I were on Luigi Mangione's jury I would acquit on Jury Nullification.
And you are saying overcharging an insurance company is on the same level as an insurance company denying medical care and directly killing the patient because they don't want to pay?
And your examples justify obviously incompetent insurance people vetoing doctor's orders, exactly how?
Doctors are generally forbidden to treat patients without directly examining them and knowing their cases. How is it that insurance companies are allowed to make life-and-death decisions over medical care —with less competent bureaucrats (who may or may not have a medical license)— without ever even seeing the patient? How is this good for the patient?
Of the 33 developed countries, 32 have figured out how to deliver medical care to all of their citizens, and do so for roughly half or less of the cost in the US. Moreover, those countries are seeing continued longer lifespans, while lifespans in the US are declining, again while spending twice the money. Clearly, for-profit medicine and insurance performs worse on every metric.
As it is, insurance rates are rising far faster than inflation rates. Have you checked how much insurance rates have gone on the last few years? It goes up 6% to 25% per year. Where is all this money going? Is it all going to insurance companies? Nope. The price increases are attributable to hospitals, doctors, pharmaceutical companies and so on. These price increases are a form of healthcare denial because a lot of people can't even afford health insurance at all, let alone worry about what is approved/denied by insurance companies.
Health insurers tripled their profits while covering 80,000 fewer people 2015-2025 [0]
What is the difference between the 32 developed countries who successfully deliver healthcare to all their residents, vs the wealthiest country of all of them who still fails, and yet spends twice what the rest spend?
Private Insurance runs the whole thing.
And it is a sh*tty business. Insurance company profits do not account for near the 2X difference in spending. That is in the massive waste and bureaucratic overhead of every party trying to keep their heads above water while jumping through the insurer's hoops.
Entire bureaucracies exist just to oppose the insurer's bureaucracies.
And feeding those bureaucracies consumes an insane amount of physician resources.
And exactly zero of it delivers any healthcare to patients.
In my experience, one can always continue care if one is willing to pay. Insurance companies do not deny care; they deny claims for care. In fact, numerous times they make mistakes and deny valid claims. Only the healthcare provider can choose to not provide care: either because they believe they will not get paid or they believe you don’t need it or some other such reason.
Considering this person has a high-paying job and it seems like a short-term intervention would have created a long-term positive outcome, it’s not clear to me why they didn’t simply insist on the care without insurance coverage.
My contingency plans for these situations are to pay out of pocket and figure out reimbursement later. In practice, paying out of pocket is just a promise to pay out of pocket. Often one isn’t charged until afterwards and I experienced sufficient mechanisms to delay payment until the whole thing had been sorted out.
Permanent conditions (like, say, brain death) are a different story. But in my case, the bill I was ostensibly facing was hundreds of thousands of dollars and I proceeded with it on the grounds that rapid intervention would yield results and I can figure out the payment structure later. If I were facing the worst case scenarios of a family medical bill bankruptcy or family member loss I think that usually I’d prefer the former. It’s hard to make a decision in the moment, but if the healthcare provider determines that more care is required and the insurance provider that it is not, I am more likely to follow the former though not without bound.
Let me amend it to indicate the uncertainty I intended here by saying “often”. Most of my experience with US healthcare is with San Francisco and Austin, so readers may wish to adjust their view based on that.
This article makes a good case for the abolition of health insurance. If everybody had to pay for medical care, medical care would need to be affordable to survive. It's hard for me to believe that a doctor couldn't afford medical care for her husband. She just couldn't get outside of the box and consider that the treatment was more important than the cost.
> It's hard for me to believe that a doctor couldn't afford medical care for her husband
Why's that? Between mortgage, repaying education debt, supporting children, recovering from a husband's failed business venture...what is hard to believe about having trouble paying for another expense, especially after you've been reassured that the expense would be at least partially recompensated and that turns out to not be the case?
Without assuming the specifics as you do, it’s possible and entirely believable that any buffer was wiped out by the husband’s business. Access to credit could also be affected.
As long as we’re throwing anecdotes, access to forbearance and deferment is shaky at best. I’ve personally had inconsistent success across various income levels.
I think for profit Health Insurance is a straight 100% scam. The only service where you pay a company for a service and when you need that service they spend as much money as possible to avoid giving you that service.
But... I've come to realize that it is impossible to make people understand it or change it.
So, I've been proposing a lesser change: In theory Insurance companies business model is to hedge against the risk of people getting sick ok? Well, let's make the bet fair and remove them the ability to decide who gets covered and who doesn't. In the case of the original article: Let a neutral third party panel of professionals be the ones that decide whether the Health Insurer has to cover or not the case.
Otherwise, Insurers are behaving like Casinos that decide to pay or not to pay to people who win a game.
The more interesting hypothetical is: would a NICU stay still cost $1M if the factors inflating that cost (namely, insurance subsidizing hospital revenue) were no longer in place?
I can assure you it wouldn't be $0, or anywhere near close to that.
My kiddos were born the day before the third trimester and spent two months in the hospital. Staff it at minimum wage, cap the costs at just the stuff used, and you're still talking a lot of money.
No one is making the claim that the cost of service would be $0. Quite obviously.
What you can't be sure of is the real cost in terms of resources, and how that would be accounted and paid for. The price of your childrens' stay, to you personally, could be far less than what you originally paid personally if healthcare was not reliant on private subsidy. You would also likely be subsidizing the costs of other children staying in the hospital through public subsidy using your tax dollars. I reckon that last point is where a lot of people in the US get hung up.
That's not the question I asked, but you're still heading down the road to being incorrect. The fact is that charitable giving, need-based aid, philanthropic donations, government assistance, and other forms of subsidy fund *roughly half of the sum total American healthcare costs.* That's trillions of dollars.
Maybe not according to your personal definition. Government welfare is a form of institutionalized or compulsory collective charity, although it is not “charity” in the private voluntary sense.
Regardless of whether or not you agree with any specific definition, the state of US healthcare is such that half of all spending needs to be subsidized in one form or another. To remove even the paltry billions that may fit under a strict category of “voluntary charitable giving” would be a disaster.
An alternative approach would be health care for all - with the caveat that there is NO private pay option. The unfortunate situation is that that ultra wealthy have greater influence over the political process due to citizens united, and are also the ones who would benefit from lower funding towards public health care. With their ability to access premium treatment via a private option, their incentive is to use their political influence to lower public health care spending, without any negative impact on their own health.
> with the caveat that there is NO private pay option
I don't think there is a society in the world that ever had that successfully executed in practice. I live in Norway, and even if the public heath system is probably as good as it gets here, I often use private providers for non-urgent things simply because waiting time can be up to six month otherwise.
And even if you somehow manage this on paper, you'll be very surprised on how markets work. They don't need legal recognition. They don't even need money. See: USSR. Health care was public and medics weren't even a particularly attractive profession because there were too much of them already. Still if you wanted to survive an appointment you'd better have a package of some deficit wares ready.
What denies public healthcare money isn't "wealthy trying to cut public spending down". It's bureaucrats wanting their share of the pork barrel.
As someone who just recently was re-diagnosed for active major depression after a major back surgery this article hits very hard. I recently discussed inpatient treatments with my psychiatrist too. I can understand what the husband was feeling... that the nothing of death was greater than the feelings of life. It's difficult to work with healthcare in general - add a mental issue on top of that and it feels impossible. You have to constantly advocate for yourself since each doctor will only do what is required for their subspecialty and you also have to fight insurance on the other side.
Specifically regarding mental related items are treated as lesser than physical issues. I have Kaiser who has actively been punished by the US Department of Labor [1](2026) [2](2021) for delays in behavioral health care and pushing for out of network therapist. They tried to push these therapist on me twice, both through RULA and it was really a terrible experience. The therapist literally ended my meeting 10 minutes into our discussion when I told him I hadn't finished reading the book he recommended. I am now with an in-house kaiser therapist that is working well. I worry about the psychiatric side of the house as well, they set me up to only meet with my psychiatrist once every three months. That doesn't feel frequent enough to get my medication tuned right.
I don't see this getting better in the future with the current leadership in the US advocating for a "return control to the patients" by reducing SSRI prescriptions. [3]
My only advice for people out there is to take their mental health seriously, if you are having suicidal thoughts talk to your doctor. It may end up being a difficult journey but its better than being alone.
I recommend if you're looking into inpatient treatment and you're not an acute danger to yourself or others, look into partial hospitalization programs and intensive outpatient programs instead. I know Kaiser covers some at least in Virginia.
In my experience with family members, inpatient hospital stays at many hospitals in the US are one of the least therapeutic environments possible, and once you've gone through an ER or psych ER (which most of them make you do), you have no control over which hospital you end up at. In the end your stay is unlikely to be any more than 7 days.
PHP programs on the other hand tend to fill the role that work had previously taken in someone's life for a few to several weeks. They're typically 9-3, held in office parks, and are mostly quality group therapy with a daily or weekly psych visit.
I've had to go through this with treatments for my eyes... that I haven't been able to see a doctor on for about a year and a half because as a contractor my insurance sucks and even when I've had good insurance it was often problematic... wierd codes and then a back and forth call the insurance, call the provider only to ever get answers if I 3-way called them both and held them both to account.
More than once I was on the hook for a $15k set of injections that I had to run on a credit card. At this point, I'm maxed out, paying out of pocket for what I can and it sucks... I'm hoping to convert to a City employee (temp) vs contractor which at least gets decent medical, but my own experience has me doubtful even then. I've worked my whole adult life, didn't even take vacation time through my 20's and 30's... and never planned to retire... I don't want to, but I'm facing a reality that may not give me a choice in the long run.
I don't think shifting to public healthcare is the answer in the US... but would like something similar to fiduciary safeguards around medicine and insurance.
The goal of their insurance company is to make a large return for their shareholders. And, thus, a large bonus for the C-suite execs. Their goal is not to provide care.
In this particular instance, the insurance company saved money to give to shareholders and their C-suite by not treating the patient further. They lose no money by allowing him to die.
I wish that rather than the closed govt medical programs we have... we simply funded a public, non-profit health insurance provider that is motivated by fiduciary responsibility, but not profit driven. While this may seem heartless as some would fall through the cracks, such as cases like tfa that wouldn't be covered, at least there would be more competition against the private insurance companies.
I'm not a fan of fully socializing medicine, but having a non-profit with negotiating power in the mix could only help.
I nominally agree with this sentiment. BCBS does have issues like this happen, but not at the same level others, in my experience.
Anecdotally though, I've found that my current insurer (United) denies and delays care far, far, more often than when I had a similar plan with BCBS. And I'm not talking about small bills, my son was in the NICU for 41 days, at a cost of ~$150,000. Through BCBS I paid like a grand of that. United denies the most random things, a referral to a specialist, meds for on brand usage while they'll pay for other meds that are off brand, for instance.
I do have a platinum level plan, I am _extremely_ lucky to have this. I know the vast majority of Americans, most of my friends and family, fight with their insurance companies for far less than my complaints.
She doesn't mention the root issue; her and her colleagues absurdly high salaries and the tight limits on new doctors in the US that make medical care scarce and unaffordable but keep their salaries high.
Anyone who moans about the state of healthcare in USA should be required to reveal their voting habits. Collectively, America gets the healthcare system it desires, and deserves.
I've said a similar sentence on here in the past, but there's a large anti-tax sentiment in the US because their government is one of the most inefficient per dollar.
People are against paying for nothing, not against paying for services. There's just no confidence that the amount of services rendered can change away from "as little as they can get away with", so there's no enthusiasm for paying at all.
The government is very efficient at redistributing your SS money from young broke workers to old more well off SS recipients. And at converting $ into guided missiles that blow up Iranian girls' schools. It's just that it's not practically possible to have "representatives" that actually represent the people in muh democracy in USA. See the massive unprecedent money that got poured in to make Massie lose his primary when he acted against the interest of Israel and to expose pedophiles in power.
> I am an emergency physician living in the U.S., and we had one of the top commercial health insurance plans.
You see, dear, your critical error was in believing that psychiatry is “medicine”, and that mental health treatment is “health care”.
Oh for sure, they present you “doctors” and “nurses” with the same credentials, wearing white lab coats, ties, scrubs, and even stethoscopes. They can prescribe “drugs” and run “hospitals”.
From the outside, they are indistinguishable from physicians who treat the physical body, but it is all a satiric cosplay. It is done this way for reasons, chiefly not to scare people too much.
Mental health should be considered more of the “Pre-Crime Division” or Department of Corrections For Stuff That’s Not Your Fault.
Don’t ever believe they’re in “Health Care”. This is a fatal category error.
This is a far cry from the gravity of the post, but here's my personal anecdote about trying to navigate health care and insurance.
A month or two ago, I was trying to set up a pediatric dentist visit for my son. Not a medical emergency, but a matter of some urgency. I spent about three hours on a total of a dozen phone calls or so. Some to the insurer, and some to various dentist offices in the region to inquire about scheduling and logistics. I learned that I needed to switch my son's primary office before he would be eligible to receive care. This could only be done once per month. Fortunately, by luck, this would take effect at the close of business on that very day. Next I needed to find a covered provider. Of course, the insurer could not tell me which ones would have openings at short notice, so I had to call several. Then I learned that in order for a pediatric visit to be covered, it needed a referral from a general dentist. The pediatric office helped me find a dentist who could fill out this paperwork, which felt lucky. I verified that my policy worked with this dentist office. Several hours on the phone, but I had a sense of accomplishment for sorting it all out.
The day of the appointment came. The visit went smoothly. Then I found out that it wouldn't be covered because the insurance will not cover pediatric dentistry above the age of 6, but my son is 7.
I think I'm going to opt out of dental insurance altogether in the next enrollment. All the individual people seemed to be doing their best to help me, but the end result is a system that is impossible for me to use.
Insurance refused to cover imaging to identify my spouse's squamous cell carcinoma on an ovary because initial bloodwork didn't come back positive for ovarian cancer (squamous cell required different bloodwork, at least at the time).
It took a doctor offering to misdiagnose it as a dermoid cyst to get the imaging and hysterectomy ordered and approved, and that still took 2 months. By the time it happened, the cancer had metastasized.
The imaging would've cost a few thousand dollars. The hysterectomy would've cost about $20k-40k. Chemo was unsuccessful, and she died 9 months and about $2 million in medical bills later.
Which insurance firm was this?
Fwiw, if one has a passport and some funds, one can travel abroad for cheaper surgery abroad. It won't guarantee an outcome, but it ought to be better than delaying it. Of course this in no way excuses the insurance firm.
Similar story for our youngest - excuse after excuse. We just bought two round-trip tickets to Warsaw and paid privately. It was a little more but my wife and son got to spend time with friends and family for that extra. The effort we had spent in US we never got back. I hope it worked-out okay for your family as well.
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I've seriously considered opting out of health insurance altogether and stuffing away the obscenely priced monthly expense into an interest yielding account. Insurance is nightmarish, and I don't really want to deal with it much anymore.
I know this might appear foolish, but fighting with a corporation whose incentives are adverse to my own (both on the medical side and the insurance side) makes me a little sick to my stomach.
If you have enough money for that gamble to pay off over the long haul the cost of health insurance would be immaterial to you anyway. You might get away with it in your youth, or you might have a catastrophic loss and have your finances wrecked.
You're often able to negotiate discounts for cash payment from providers, but back when I had insurance that excluded a pre-existing condition I ran into providers who steadfastly demanded the full list price (under threat of collections). It only takes one of those standing pat on a high 5 or low 6-figure bill to cause you to lose on your "bet".
> you might have a catastrophic loss and have your finances wrecked.
If you have health insurance (in the US) and you have a catastrophic event, your finances are going to be totally wrecked anyway. You're likely to have to declare bankruptcy unless you are pretty wealthy. At least, that's how it's gone with every friend and family member of mine that had to navigate such an event. That's on top of the painful nightmare that is dealing with insurance company claims (which, to add insult to injury, you have to do when you're injured or sick).
The premiums are also so high that I'm very far from convinced that holding an actual health insurance policy is a better option than putting that premium money into an emergency fund.
Depends.
I got $300,000 in coverage for a catastrophic event and wound up paying $ 3,100.
But I did have good insurance with United Healthcare.
I had a catastrophic event and it was not particularly wrecking to my finances. Judge for yourself: https://wiki.roshangeorge.dev/w/Motorcycle_Accident
I had quite a few not-bills of the sort you see there totaling more than a few hundred thousand. Insurance coverage did work in my case.
I would agree that it's objectively terrible dealing with insurance companies, providers who are incredulous you care about the pricing of services, etc. There is no free market for healthcare services. Advocating for yourself is tremendously draining.
I'm happy with the ROI I've had with my insurance premiums over my life. I haven't had a catastrophic event but I've certainly had reasonably sizable claims. If I'd invested the last 20+ years of premium expense (about $400K to date) and had no claims I'd have a ton more money, but not enough to cover a catastrophic event later in life. The principal would also have been completely wiped-out a couple of times when I did have claims, however.
I pay the premiums because I'm not comfortable holding bets on both the market and on my health. I'm also unwilling to consider bankruptcy as a morally / socially acceptable solution.
This mixed socialized and capitalist "system" we've allowed to grow up feels like the worst possible one. Healthcare and health insurance expense are a mechanism to extract value from the middle class (i.e. everyone who has money but isn't wealthy enough to buy their way out of the "system").
My preference would be for a fully socialized system, built primarily around protection for catastrophic loss, where everyone contributes w/ no opting-out permitted.
Failing that I'll grudgingly take a fully capitalist system where people who can't afford to pay are left to fend for charity or die.
What we've got is a mix of the worst parts of both.
> If you have health insurance (in the US) and you have a catastrophic event, your finances are going to be totally wrecked anyway.
For most people, this is not true. Half of cancer patients and survivors say they have medical debt, and of those half have less than $5,000: https://www.fightcancer.org/releases/survey-finds-majority-c....
It's wild how differently the press release you linked to frames that.
> WASHINGTON, D.C. – Nearly half (49%) of cancer patients and survivors report being burdened by medical debt alongside some (13%) who report expecting to incur medical debt as part of their treatment plan, according to a new Survivor Views survey by the American Cancer Society Cancer Action Network (ACS CAN). Interestingly, nearly all (98%) were insured when medical debt occurred.
> Among those with cancer-related medical debt, nearly half (49%) have carried more than $5,000 in debt, a majority (69%) of whom have carried this debt for more than a year. Respondents also reported most commonly owing their medical debt to a hospital (76%).
...
> According to the survey, an individual with cancer-related medical debt was three times more likely to be behind on recommended cancer screenings in comparison to those who have been able to pay for their care without accumulating debt. Nearly half (49%) saw their credit score decrease with 30% having difficulty qualifying for loans.
> Cancer-related medical debt is also not felt equally and further deepens disparities. Black (13%) and Hispanic (14%) patients and survivors with medical debt were twice as likely as White respondents to report being denied care due to their debt. Black respondents were also more likely to report being contacted by collections agencies (66%) and to feel harassed by them (44%).
Yes, facts are more important than framing.
Look how many people in this thread are thinking about avoiding health insurance based on the premise that you’ll be financially wiped out by a catastrophic event even if you have insurance. That’s what happens when you put framing over facts. It’s important for people to understand the facts so they can make good decisions.
The collection laws also vary from state to state on this... in some states, medical collections are all but toothless, short of actually filing a lawsuit, which isn't likely, except some facilities actually have staff lawyers willing to harass and sue.
Well, you can try for sure to default on medical debts without suffering a hit to your credit, but goood luck obtaining future care from any provider that you’ve stiffed.
How many big medical systems/districts in your region can you run up a balance until none will serve you, except through the E.D.?
I have an 18yo bill for a medical lab, and I still get my regular bloodwork there... It gets brought up now and then on current visits, and I just say, "I'm not paying that bill."
As to the why, it's because I switched jobs and got my regular labs done and apparently was between coverage that week... they tried to charge me a large multiple of what they charged insurance for the same labs, so I refused to pay.
I also had several bills that were never paid from a week long hospital stay in my mid 30's... Most of them got paid if they'd agree to reasonable payments or settle for lower amounts when I had the money (tax return time, bonus, side work). After 7 years, they were all off my credit and I stopped bothering...
I'm essentially of the mindset of JohnFen (adjacent comment). If I have a health issue that crops up, I'm financially done anyway. Given this, I might as well control the money rather than throw it into a pit and hope something useful pops out in an emergency.
Catastrophic events seem to wipe people out financially regardless of insurance status. I keep hearing of people divorcing so their former spouse can keep some assets while they are battling cancer. There's just no winning unless you never need care.
I did that for much of my 20s and very glad I did. You are basically used parasitically by the Obamacare system as it caps the differential between young and elderly to the point it's well into the expected negative value, and you're young enough that the off chance of the bet going bad only results in declaring bankruptcy on a few years of professional salary.
Fortunately, out of pocket for relatively normal dental care isn't too bad... probably because Dental insurance doesn't really help much and often easier to just pay out of pocket.. though do shop around if you do so.
I’ve been through this situation with family members. I understand the frustration and agony.
I also understand the hesitancy to pay for two months at a “retreat-like inpatient psychiatric facility.”
In publicly funded system, it’s likely facilities like this would not exist or would be strictly private pay.
I’m not aware of any country that makes such a thing available on short notice like this.
I also understand the frustration, as often times facilities like this are all that exist in terms of medium-term care. And often times some of their services are at least formally in-network.
The understanding is you pay for it by selling your house.
We’ve been tempted to do this (sell our house), but been advised against it - but the reasoning in our case is patient specific.
I wish insurance was clearer about what covered and what isn’t. I wish we had more mainstream (not retreat-like) medium term care places.
Maybe I’m misreading the phrase retreat-like.
But id this isn’t something a public system would pay for, it seems inappropriate to blame a private system to not pay for it, unless it’s clearly in the wording.
Regardless, mental health care in America stinks, and you can always argue over the details.
What gets me is that they probably could afford it out of pocket but didn’t want to deplete savings.
For a clear case like this, an insurance denial shouldn’t even be shared with the suicidal patient, their spouse should shield them from that and just pay from their checking account. The life of your spouse is worth more than a few more dollars in retirement.
Calling it a "few dollars" is probably disingenuous, although we don't know the personal circumstances. For many, this could be a "life-changing" quantity of money.
You are probably misusing disingenuous. It implies dishonesty (so intention).
Yeah. "Misleading" is maybe better.
I will note that in a lot of places in the US, the role of medium term acute psychiatric care is taken by partial hospitalization programs, where patients go to a facility (usually a few conference rooms in an office building) during the workday for intensive therapy and medication management, but go home with family in the evenings. These programs are a lot cheaper than inpatient programs, and the standard workflow in my experience (with "good" insurance) at this point is 3-10 days inpatient, followed by 2-10 weeks in a PHP, and possibly some part time program after that. A lot of people skip the inpatient part if there's no acute danger.
I'm surprised the author makes no mention of those sorts of programs in the article. It makes it sound like the options were a luxury 8 week inpatient or nothing, when there's really a lot of stuff in between.
Me too! I’ve seen such good come from these sorts of programs!
I didn’t want to mentioned it my initial post, but these sorts of programs seem a happy combination of keeping costs down and maximizing autonomy, while focusing on full-time on mental illness.
Some is these are technically “in-patient” at home programs, which are growing in popularity in all fields on medicine.
But they’re not appropriate all the time, and I don’t want to “recommend” them. Talk to your doctor.
Sadly it seems these sorts of programs are simply unavailable in much of the country.
> I also understand the hesitancy to pay for two months at a “retreat-like inpatient psychiatric facility.”
> In publicly funded system, it’s likely facilities like this would not exist or would be strictly private pay.
In France, 80% is paid by the public healthcare if a psychiatrist greenlit you, which still make you liable for ~30€ per day in a room you share with another patient (and if you want a private room it's ~90€/day out of pocket) (maybe the prices around Paris are a bit higher though, i'm a country boy)
[edit] more accurate numbers, i had to check and correct them. Also, 30€ per day also covers medication if needed and a spa session
The trade-off appears to be[0]:
> Le délai d’attente d’un lit disponible est en moyenne de 3 à 4 semaines
3 to 4 weeks vs. the next morning in the article. Interesting. I wonder what would have happened in the intervening weeks.
0: https://clinique-du-parc.ramsaysante.fr/vous-%C3%AAtes-patie...
Yeah, happened a few months ago to my friend (who is leaving in August)(that's why I sort of knew the prices and living conditions). She waited a bit more of a month. It isn't often an issue from my understanding, but it is extremely frustrating for the person and the people around her. If you react poorly to anxiousness medication or antidepressants, you will be kept in a hospital before being admitted, and I believe in a higher category. Still a very frustrating situation.
Maybe i missed the part of the article that suggested a public system would have paid for a 2 month retreat?
It sounds like this guy needed around-the-clock, in-patient care. That's inherently expensive. While those facilities exist in countries with publicly funded healthcare, there's a huge shortage of in-patient beds, so there is some mechanism to funnel patients to outpatient care.
Don't leave out jails, without insurance and significant funds, that's what democracy has decided for you.
For psychological care it isn't that bad. Probably because people will first get on anxiousness/depression pills, and convince themselve they are ok.
My state has the beds available, but no staff.
Usually beds in this context is a staffed operational bed. I was curious why they were complaining about beds back in the COVID era and looked into it. It means the physical object, the nursing staff, required clinician hours. They use the term “physical beds” in the rare contexts where those are significant.
Yes, there is something wrong with the insurance industry. But there is something wrong with the hospitals, doctors and drug companies too. The whole system is broken. Hospitals try to eke out the most out of insurance companies, often providing services that are unnecessary. Pharmaceutical companies charge US patients significantly higher rates than in other countries. Don't put all the blame on insurance companies.
>Randy needed immediate psychiatric care, and as an emergency physician I knew the options. We put our trust in the mental health team at a local crisis receiving unit, and they kept Randy overnight in temporary safe housing where he could be observed. By morning they had devised a plan to transfer Randy to a retreat-like inpatient psychiatric facility that was in-network with our insurance. The psychiatrist felt Randy was very high risk, but that he could heal with eight weeks of inpatient treatment. We were told our insurance would cover it.
>But six days into Randy’s eight-week hospital stay, our health insurance company denied any further inpatient care.
>The facility appealed Randy’s case, providing psychiatrist’s notes that clearly outlined his need, but the outcome did not change. Because Randy had no prior history of mental illness, the insurance company determined he shouldn’t need to be hospitalized and stopped paying for his care. A day later Randy was forcibly discharged.
This is definitely a case where the insurance company holds the majority of the blame.
> This is definitely a case where the insurance company holds the majority of the blame.
What facts are the basis of your conclusion? There is no health system in the developed world where a doctor's recommendation will guarantee expensive inpatient treatment without a layer of bureaucratic review.
You are right--Doctors absolutely share blame. Take my dentist's behavior, for example. When the oral hygienist is done doing all the real work, my dentist sits down for 10 minutes to count my teeth and say the words "You should floss more." She bills $85 for that sentence and calls it "Oral hygiene instructions". My insurance company (IMO rightly) denies paying for this. It's ridiculous and the dentist knows they're going to call bullshit on it, but they bill it anyway, and then I'm technically on the hook to pay for it. So far, the dentist has not yet attempted to balance bill that charge, and I will drop them like a bad habit if they ever do.
Doctors and dentists in the US are not bound by the same regulations (or even a similar stringency of regulation) involving billing practices and procedure codes.
I'd imagine you'd struggle to find a healthcare system in which a doctor's prescribed care is assuredly covered by insurance, by the insurance provider, and then later rescinded after care has already started.
The ACA made rescission of health insurance more difficult for insurers, but it absolutely happens. There are people at insurers tasked with looking for fraudulent omissions in policy applications for high loss ratio individual policyholders to target for rescission.
This one is pre-ACA but the insurer focused on an "omission" to justify the rescission: https://www.cnn.com/2009/POLITICS/06/16/health.care.hearing/...
There are many health systems in the developed world, though, where the system doesn't make this the patient's problem. It shouldn't be possible to have a scenario where the provider believes eight weeks of treatment will be covered, the patient moves to an inpatient facility based on this understanding, and then the bureaucratic review layer decides six days layer that the provider was wrong.
The goal should be to provide every human being with the best care possible. If a system can't handle that, then we need to assess why and make changes.
Show me a country where that's the goal. Every other developed country has a goal that's something like: "provide the best outcomes for the population as a whole, at a cost the public is willing to pay."
We should make it the goal as a species. We have the resources and technology. We decide to be limited by economics.
No, economics is just how we describe resource limits and tradeoffs in a methodical way.
>We decide to be limited by economics.
And closed-minded accounting rules, such as the rule that debits must equal credits in every transaction. And physics.
Every player in the US healthcare / health insurance "system" has adapted to the regulatory niche they play in.
If Americans had the fortitude to have grown-up conversations about what should be socialized, how care should be rationed, etc, the public could exert some control over the design of the "system". As it stands, the "system" has mostly been shaped by corporate interests while the public has been distracted by inflammatory rhetoric pumped-out by all the entrenched players designed to play to partisan feelings about "fairness" and "freedom".
John Stossel explained in _Give Me A Break_ that the US once had a variety of pharmaceutical labs researching different cures and conducting trials. But US courts allowed a frenzy of frivolous lawsuits to extract astronomical payouts on behalf of former trial participants, even demanding payouts from the companies that stocked the supply and janitorial cabinets of research companies. One by one, we bankrupted our competitive machines of innovation until the few remaining pharmaceutical companies had grown large enough to defend themselves against injury claims. Big Pharma was created by lawyers.
> often providing services that are unnecessary
Thank a lawyer. "Patient with symptom X would have survived if only the doctor had tested him for Y". Now every patient with symptom X is issued a $5600 scan for Y -- not because of medical science, but because of liability. Every time a courts awards 10 figure settlement because "that insurance company is good for it," all of society pays for it.
Our country is run by lawyers for the benefit of laywers. This explains much of what we see around us.
the problem is healthcare is run in a capitalist "free market" model, in which all actors are incentivized to increase their profits at the expense of the other actors, and where the patient is either a customer or a commodity
it's inherently the wrong model for providing a necessary feature of life (health), and combine it with a highly litigious society, and well, this is the result
NO
The insurance companies are running the system more than any of the others — it is the finance "wizards" there who put the constraints on the rest of the system. I'll agree somewhat on the pharma companies too, who are also extractive.
You even said it yourself: "Hospitals try to eke out the most out of insurance companies...". Exactly! Because the hospitals and doctors are constrained to do "WHAT IS IN THE BEST INTEREST OF THE PATIENT" — that is their charter (and BTW, that is also the magic phrase to use whenever questioning what they propose to do for a patient or escalating a case). Perhaps a few hospitals or physicians occasionally overdo it, and there are some frauds, but your accusation overall is BS.
The insurance companies have no such constraint — if they do have such a mission goal, it is to OBTAIN MAXIMUM VALUE FOR THE SHAREHOLDERS. And the insurance companies are literally so amoral that they will reward agents for killing people for profit. That is not rhetoric, it is sworn testimony before congress of a person who cut off a patient's coverage, causing their death, and got promoted.
I have seen directly and personally an insurance company deny coverage for a test ordered for a close family member by the Chief Of Cardiology at Mayo Clinic. Mayo Clinic, and that physician are so overbooked they have ZERO motivation to order anything not necessary for the patient in front of them. It took days, and significant extra expense to get it reversed.
There is no way on the planet that anyone in an insurance industry should be able to override the doctors orders of the Director of Cardiology for Mayo Clinic. Or any physician, for that matter.
Medicine is one of the things that should never be run for a profit, and if I were on Luigi Mangione's jury I would acquit on Jury Nullification.
An itemized bill from the hospital for about four weeks of his hospital stay. It came to a little over $4 million. https://www.cbsnews.com/news/covid-19-deaths-families-60-min...
Woman charged $143,396.66 for a breast biopsy https://www.marketwatch.com/story/a-doctors-prescription-to-...
Numerous studies have found that when doctors have a financial stake in a hospital, they tend to order more tests and procedures, raising costs for Medicare and other insurers. https://www.nytimes.com/2011/12/13/health/policy/republican-...
And you are saying overcharging an insurance company is on the same level as an insurance company denying medical care and directly killing the patient because they don't want to pay?
And your examples justify obviously incompetent insurance people vetoing doctor's orders, exactly how?
Doctors are generally forbidden to treat patients without directly examining them and knowing their cases. How is it that insurance companies are allowed to make life-and-death decisions over medical care —with less competent bureaucrats (who may or may not have a medical license)— without ever even seeing the patient? How is this good for the patient?
Of the 33 developed countries, 32 have figured out how to deliver medical care to all of their citizens, and do so for roughly half or less of the cost in the US. Moreover, those countries are seeing continued longer lifespans, while lifespans in the US are declining, again while spending twice the money. Clearly, for-profit medicine and insurance performs worse on every metric.
As it is, insurance rates are rising far faster than inflation rates. Have you checked how much insurance rates have gone on the last few years? It goes up 6% to 25% per year. Where is all this money going? Is it all going to insurance companies? Nope. The price increases are attributable to hospitals, doctors, pharmaceutical companies and so on. These price increases are a form of healthcare denial because a lot of people can't even afford health insurance at all, let alone worry about what is approved/denied by insurance companies.
Health insurers tripled their profits while covering 80,000 fewer people 2015-2025 [0]
What is the difference between the 32 developed countries who successfully deliver healthcare to all their residents, vs the wealthiest country of all of them who still fails, and yet spends twice what the rest spend?
Private Insurance runs the whole thing.
And it is a sh*tty business. Insurance company profits do not account for near the 2X difference in spending. That is in the massive waste and bureaucratic overhead of every party trying to keep their heads above water while jumping through the insurer's hoops.
Entire bureaucracies exist just to oppose the insurer's bureaucracies.
And feeding those bureaucracies consumes an insane amount of physician resources.
And exactly zero of it delivers any healthcare to patients.
[0] https://healthcareuncovered.substack.com/p/2025-big-insuranc...
In my experience, one can always continue care if one is willing to pay. Insurance companies do not deny care; they deny claims for care. In fact, numerous times they make mistakes and deny valid claims. Only the healthcare provider can choose to not provide care: either because they believe they will not get paid or they believe you don’t need it or some other such reason.
Considering this person has a high-paying job and it seems like a short-term intervention would have created a long-term positive outcome, it’s not clear to me why they didn’t simply insist on the care without insurance coverage.
My contingency plans for these situations are to pay out of pocket and figure out reimbursement later. In practice, paying out of pocket is just a promise to pay out of pocket. Often one isn’t charged until afterwards and I experienced sufficient mechanisms to delay payment until the whole thing had been sorted out.
Permanent conditions (like, say, brain death) are a different story. But in my case, the bill I was ostensibly facing was hundreds of thousands of dollars and I proceeded with it on the grounds that rapid intervention would yield results and I can figure out the payment structure later. If I were facing the worst case scenarios of a family medical bill bankruptcy or family member loss I think that usually I’d prefer the former. It’s hard to make a decision in the moment, but if the healthcare provider determines that more care is required and the insurance provider that it is not, I am more likely to follow the former though not without bound.
> One isn’t charged until afterwards
This is not a universal billing practice, often clinic visits are billed upfront before meeting with the provider.
Let me amend it to indicate the uncertainty I intended here by saying “often”. Most of my experience with US healthcare is with San Francisco and Austin, so readers may wish to adjust their view based on that.
This article makes a good case for the abolition of health insurance. If everybody had to pay for medical care, medical care would need to be affordable to survive. It's hard for me to believe that a doctor couldn't afford medical care for her husband. She just couldn't get outside of the box and consider that the treatment was more important than the cost.
> It's hard for me to believe that a doctor couldn't afford medical care for her husband
Why's that? Between mortgage, repaying education debt, supporting children, recovering from a husband's failed business venture...what is hard to believe about having trouble paying for another expense, especially after you've been reassured that the expense would be at least partially recompensated and that turns out to not be the case?
At a high income level, you should have more buffer for life’s events if you’ve made good decisions in your life. Generally speaking.
For example, that mortgage, did you stretch the very limit of your income or did you buy something reasonable?
Nobody forced you to buy a house, you could also rent or commute longer.
I lived in a crappy rental for five years and commuted and was able to fully pay off my student loans at the beginning of my career. As an example
Education debt can be put on forbearance or deferment under many life circumstances.
Given high income level, you also have many options available to you like personal loans.
Without assuming the specifics as you do, it’s possible and entirely believable that any buffer was wiped out by the husband’s business. Access to credit could also be affected.
As long as we’re throwing anecdotes, access to forbearance and deferment is shaky at best. I’ve personally had inconsistent success across various income levels.
I think for profit Health Insurance is a straight 100% scam. The only service where you pay a company for a service and when you need that service they spend as much money as possible to avoid giving you that service.
But... I've come to realize that it is impossible to make people understand it or change it.
So, I've been proposing a lesser change: In theory Insurance companies business model is to hedge against the risk of people getting sick ok? Well, let's make the bet fair and remove them the ability to decide who gets covered and who doesn't. In the case of the original article: Let a neutral third party panel of professionals be the ones that decide whether the Health Insurer has to cover or not the case.
Otherwise, Insurers are behaving like Casinos that decide to pay or not to pay to people who win a game.
> This article makes a good case for the abolition of health insurance.
Yes.
> If everybody had to pay for medical care, medical care would need to be affordable to survive.
How would people with zero income afford it?
The way they used to before medical insurance took over that industry: charity
So everyone had their healthcare needs addressed in the 1800s?
Which charities have the funding to cover a $1M NICU stay?
The more interesting hypothetical is: would a NICU stay still cost $1M if the factors inflating that cost (namely, insurance subsidizing hospital revenue) were no longer in place?
I can assure you it wouldn't be $0, or anywhere near close to that.
My kiddos were born the day before the third trimester and spent two months in the hospital. Staff it at minimum wage, cap the costs at just the stuff used, and you're still talking a lot of money.
No one is making the claim that the cost of service would be $0. Quite obviously.
What you can't be sure of is the real cost in terms of resources, and how that would be accounted and paid for. The price of your childrens' stay, to you personally, could be far less than what you originally paid personally if healthcare was not reliant on private subsidy. You would also likely be subsidizing the costs of other children staying in the hospital through public subsidy using your tax dollars. I reckon that last point is where a lot of people in the US get hung up.
> No one is making the claim that the cost of service would be $0. Quite obviously.
I am making the claim that the cost will be prohibitive to handle via charity, especially as a national healthcare strategy, as proposed upthread.
Do you not agree that charity/philanthropy is already an essential part of the US healthcare strategy?
US healthcare costs are $16k/person/year.
I do not think charity makes up a particularly signficant portion of that cost, no.
That's not the question I asked, but you're still heading down the road to being incorrect. The fact is that charitable giving, need-based aid, philanthropic donations, government assistance, and other forms of subsidy fund *roughly half of the sum total American healthcare costs.* That's trillions of dollars.
> government assistance
That's not charity!
Maybe not according to your personal definition. Government welfare is a form of institutionalized or compulsory collective charity, although it is not “charity” in the private voluntary sense.
> Maybe not according to your personal definition.
Not according to any common definition.
I, too, can win every argument if I get to make up the definitions.
> compulsory collective charity
Compulsory makes it not charity. That's a tax.
Regardless of whether or not you agree with any specific definition, the state of US healthcare is such that half of all spending needs to be subsidized in one form or another. To remove even the paltry billions that may fit under a strict category of “voluntary charitable giving” would be a disaster.
An alternative approach would be health care for all - with the caveat that there is NO private pay option. The unfortunate situation is that that ultra wealthy have greater influence over the political process due to citizens united, and are also the ones who would benefit from lower funding towards public health care. With their ability to access premium treatment via a private option, their incentive is to use their political influence to lower public health care spending, without any negative impact on their own health.
> with the caveat that there is NO private pay option
I don't think there is a society in the world that ever had that successfully executed in practice. I live in Norway, and even if the public heath system is probably as good as it gets here, I often use private providers for non-urgent things simply because waiting time can be up to six month otherwise.
And even if you somehow manage this on paper, you'll be very surprised on how markets work. They don't need legal recognition. They don't even need money. See: USSR. Health care was public and medics weren't even a particularly attractive profession because there were too much of them already. Still if you wanted to survive an appointment you'd better have a package of some deficit wares ready.
What denies public healthcare money isn't "wealthy trying to cut public spending down". It's bureaucrats wanting their share of the pork barrel.
As someone who just recently was re-diagnosed for active major depression after a major back surgery this article hits very hard. I recently discussed inpatient treatments with my psychiatrist too. I can understand what the husband was feeling... that the nothing of death was greater than the feelings of life. It's difficult to work with healthcare in general - add a mental issue on top of that and it feels impossible. You have to constantly advocate for yourself since each doctor will only do what is required for their subspecialty and you also have to fight insurance on the other side.
Specifically regarding mental related items are treated as lesser than physical issues. I have Kaiser who has actively been punished by the US Department of Labor [1](2026) [2](2021) for delays in behavioral health care and pushing for out of network therapist. They tried to push these therapist on me twice, both through RULA and it was really a terrible experience. The therapist literally ended my meeting 10 minutes into our discussion when I told him I hadn't finished reading the book he recommended. I am now with an in-house kaiser therapist that is working well. I worry about the psychiatric side of the house as well, they set me up to only meet with my psychiatrist once every three months. That doesn't feel frequent enough to get my medication tuned right.
I don't see this getting better in the future with the current leadership in the US advocating for a "return control to the patients" by reducing SSRI prescriptions. [3]
My only advice for people out there is to take their mental health seriously, if you are having suicidal thoughts talk to your doctor. It may end up being a difficult journey but its better than being alone.
1. https://www.dol.gov/newsroom/releases/ebsa/ebsa20260210
2. https://calmatters.org/health/2023/10/kaiser-permanente-cali...
3. https://www.pharmacytimes.com/view/announcing-new-initiative...
I recommend if you're looking into inpatient treatment and you're not an acute danger to yourself or others, look into partial hospitalization programs and intensive outpatient programs instead. I know Kaiser covers some at least in Virginia.
In my experience with family members, inpatient hospital stays at many hospitals in the US are one of the least therapeutic environments possible, and once you've gone through an ER or psych ER (which most of them make you do), you have no control over which hospital you end up at. In the end your stay is unlikely to be any more than 7 days.
PHP programs on the other hand tend to fill the role that work had previously taken in someone's life for a few to several weeks. They're typically 9-3, held in office parks, and are mostly quality group therapy with a daily or weekly psych visit.
I've had to go through this with treatments for my eyes... that I haven't been able to see a doctor on for about a year and a half because as a contractor my insurance sucks and even when I've had good insurance it was often problematic... wierd codes and then a back and forth call the insurance, call the provider only to ever get answers if I 3-way called them both and held them both to account.
More than once I was on the hook for a $15k set of injections that I had to run on a credit card. At this point, I'm maxed out, paying out of pocket for what I can and it sucks... I'm hoping to convert to a City employee (temp) vs contractor which at least gets decent medical, but my own experience has me doubtful even then. I've worked my whole adult life, didn't even take vacation time through my 20's and 30's... and never planned to retire... I don't want to, but I'm facing a reality that may not give me a choice in the long run.
I don't think shifting to public healthcare is the answer in the US... but would like something similar to fiduciary safeguards around medicine and insurance.
https://archive.ph/nLvxS
The goal of their insurance company is to make a large return for their shareholders. And, thus, a large bonus for the C-suite execs. Their goal is not to provide care.
In this particular instance, the insurance company saved money to give to shareholders and their C-suite by not treating the patient further. They lose no money by allowing him to die.
This is all by design.
I wish that rather than the closed govt medical programs we have... we simply funded a public, non-profit health insurance provider that is motivated by fiduciary responsibility, but not profit driven. While this may seem heartless as some would fall through the cracks, such as cases like tfa that wouldn't be covered, at least there would be more competition against the private insurance companies.
I'm not a fan of fully socializing medicine, but having a non-profit with negotiating power in the mix could only help.
Yes, that's what people are referring to when they say "wrong".
This happens with (theoretically) non-profit insurers, too. Like the BCBS networks.
I nominally agree with this sentiment. BCBS does have issues like this happen, but not at the same level others, in my experience.
Anecdotally though, I've found that my current insurer (United) denies and delays care far, far, more often than when I had a similar plan with BCBS. And I'm not talking about small bills, my son was in the NICU for 41 days, at a cost of ~$150,000. Through BCBS I paid like a grand of that. United denies the most random things, a referral to a specialist, meds for on brand usage while they'll pay for other meds that are off brand, for instance.
I do have a platinum level plan, I am _extremely_ lucky to have this. I know the vast majority of Americans, most of my friends and family, fight with their insurance companies for far less than my complaints.
She doesn't mention the root issue; her and her colleagues absurdly high salaries and the tight limits on new doctors in the US that make medical care scarce and unaffordable but keep their salaries high.
Anyone who moans about the state of healthcare in USA should be required to reveal their voting habits. Collectively, America gets the healthcare system it desires, and deserves.
I've said a similar sentence on here in the past, but there's a large anti-tax sentiment in the US because their government is one of the most inefficient per dollar.
People are against paying for nothing, not against paying for services. There's just no confidence that the amount of services rendered can change away from "as little as they can get away with", so there's no enthusiasm for paying at all.
The government is very efficient at redistributing your SS money from young broke workers to old more well off SS recipients. And at converting $ into guided missiles that blow up Iranian girls' schools. It's just that it's not practically possible to have "representatives" that actually represent the people in muh democracy in USA. See the massive unprecedent money that got poured in to make Massie lose his primary when he acted against the interest of Israel and to expose pedophiles in power.
> I am an emergency physician living in the U.S., and we had one of the top commercial health insurance plans.
You see, dear, your critical error was in believing that psychiatry is “medicine”, and that mental health treatment is “health care”.
Oh for sure, they present you “doctors” and “nurses” with the same credentials, wearing white lab coats, ties, scrubs, and even stethoscopes. They can prescribe “drugs” and run “hospitals”.
From the outside, they are indistinguishable from physicians who treat the physical body, but it is all a satiric cosplay. It is done this way for reasons, chiefly not to scare people too much.
Mental health should be considered more of the “Pre-Crime Division” or Department of Corrections For Stuff That’s Not Your Fault.
Don’t ever believe they’re in “Health Care”. This is a fatal category error.
By chance, are you a Scientologist?