N = 1 My Experience with the New Health Care System

“You look nice today. People don’t come to chemo in suits very often.”

The friendly and familiar receptionist mentioned as I was checking out, the always full jar of lemon flavored hard candy on the shelf between us. As I pocketed a few of the candies, I managed to swallow the nausea and metallic taste just enough to say, “Thanks. I have a job interview today.”

During my senior year in college, with medical school acceptance letter in hand, I was diagnosed with metastatic testicular cancer. Initially, life became planning surgery and meeting doctors, but early in my treatment course I received a letter that my health insurance had been exhausted and I would no longer receive any health benefits. This was after my first of four chemo cycles, with a major surgery still to come. Needless to say, this was a problem. My parents were both well educated, a lawyer and a chemist-turned-teacher, but this took everyone by surprise and presented a new crisis.

We responded by dividing up tasks. My parents quickly inventoried all the assets, including the family home, and my sister called around to all the hospitals to see what could be done.  She called the local and state governments asking for advice while I simply tried to eat food and get to class to graduate on time; I couldn’t have another tuition bill on top of my health expenses. I also started to look for a job, with a job came insurance – this much I knew.

I went to the interview, a job as a management trainee in a car rental agency, with hopes that this job would be something I could get, could do during treatment, and would provide the insurance that would save my family from financial ruin at my hands – my disease. I went to a Jesuit college and learned that truth and honesty are paramount.  So, I told the recruiter that I had cancer, I was in treatment, and that I would likely be done soon – all true.

I didn’t get the job. I still didn’t have insurance and my next chemo session, with its massive bill, was coming very quickly.
My sister learned that this would not be fun. One hospital said to her that they would treat me and then take us to court to get paid. Thankfully, I went to school in Massachusetts where a law was on the books that allowed me to enroll in health insurance without a pre-existing condition exclusion because my insurance being exhausted counted as a special qualifying event. I enrolled in an individual insurance plan, my care went uninterrupted, and I graduated on time. To this day, my sister and I remain grateful to Massachusetts for that single law, which is as much a part of my success as cisplatin and etoposide, the chemotherapy agents I received.

The bills still mounted, but were manageable. I survived, personally and financially. I pushed off medical school for a few years to get my life back in order, and moved on. I had many scary moments during my treatment, from the plastic surgeon telling me my arm might need amputation to my neutropenic fever to being discharged just in time for my college graduation.  However, what bothers me the most was, and stillis, the sense of abandonment from my society when my insurance ended.

I had insurance, my parents had good jobs and were highly educated, so how was I left in the breeze?

Now that I’m well past treatment, married to my then-girlfriend with two beautiful children, and currently a practicing physician at a major university, I still find myself troubled by the “Fogerty insurance debacle of 2002.”

With all the talk about health reform, I always kept quiet in the back as those around me in residency (which I completed in 2011) offered their opinions, and I realized that most of my colleagues were blissfully ignorant as to the financial burden of major illness. Between my own illness and my residency graduation, I also lost both my parents, got married, and had my first child.  By my early 30s, I’d experienced healthcare as a provider, patient, son, husband and parent. Generalizations are always dangerous, but I felt as though nobody around me understood the financial impact of this massive industry.

This gap in knowledge bothered me, so when I finished my training and joined the faculty, I dusted off my Economics degree and did something about it.

Residents and medical students that are still in-training are entering a new world of healthcare, one where financial ignorance is no longer permitted. My small part is to begin and remove the blinders, to expose them to the other stress in their patient’s experience. There are safety issues and financial waste throughout our system. Bringing these to light in an educational sense provides me with personal and professional satisfaction.

What did this Massachusetts law mean to me? When I recovered from my disease, my family and I had taken a physical and financial blow, but we could recover. Two years later, with my credit intact, I was able to borrow money to attend medical school. Without insurance, this never would have happened. There is more to surviving disease than outliving the pathology. The financial scars of medical care can be just as disabling to survivors of any disease, and as we grow and change as a profession, it is important that our providers of the future, today’s residents and medical students, have an understanding of the financial realities of their jobs.

Robert Fogerty, MD, MPH is a practicing Hospitalist in New Haven, CT and Assistant Professor at the Yale School of Medicine. The views here are his own. This piece originally appeared in Costs of Care.

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  4. Mike B, what type of doctor might you be? Care to give a stab at diagnosing me?

  5. to: Mike B & Barry Carol: First, let me agree with Barry Carol, in that there is no “Board Certified Diagnostician” specialty and therein lies the rub to getting proper diagnosis as wella s proper treatment. hte res of this long post is to Mike B:
    A PARODY OR PSYCHOSIS?! This was in no way an “attempt” at parody/humor, NOR am I PSYCHOTIC, this is MY REALITY! Check my FB page from time to time. I may be speaking in a mordant manner, but I assure you, this is all REAL (come visit and I will show you reams of medical reports and EOB’s (explanations of benefits going back 78 pages to the 90’s.) and how I am being treated by the medical community at large, due to their inordinate FEAR of holding MRI GADOLINIUM CONTRAST at fault, for not only my own, but many people’s illnesses. Why the upsurge in “Fibromyalgia?,” ask all those patients how many MRI’s with contrast they’ve submitted to themselves. At approximately 30 million MRI’s per year, with even quarter of them being with contrast, this translates to billions of lost economical gains by a medical community brought up to believe, “We bring good things to light!” NO, it should read: WE BRING LIFE THINGS TO DEATH!”
    I answered this doctor’s article twofold. One to show the juxtaposition of what it took in his tenacity to fight cancer within his realm of what he had for insurance, versus MY OWN ORDEAL, HAVING a great insurance policy, that as long as i go to a preferred provider doctor, I pay but $10.00 and that seems to be all I am getting. $10.00 worth of treatment. No one will admit I have been poisoned by a product that is also poisoning many others. Doctors turning their heads the other way when some of us do enough of the research ourselves to figure out what it is that is harming us. In my own case, it was undiagnosed Lyme (OH, what controversy here taking 22+ years to diagnose my own Lyme) leading to many MRI’s with contrast (7) leading to toxic heavy metal poising, plain and simple. Now as such, doctors should do the next step in line and TREAT ME! BUT no one wants to! WOrds out, blacklisting me as a patient.

    At a recent appointment with Dr Lewis Nelson, a toxicologist at NYU/Bellevue, first I was asked to have my husband leave the room, so that TWO psychiatrists, along with Dr Nelson and his assistant Dr Lariss Laskowski, could come and OBSERVE me. Dr UH, NO DICE! I have some cognitive issues, so he stays, as my “memory.” Secondly, I was told by Dr Lewis Nelson, “You will need to come to GRIPS with what has happened to you, to deal with it. YOU WILLL NEVER ASSOCIATE WHAT HAS HAPPENED TO YOU WITH GADOLINIUM! YOU ARE NOT GETTING ANY TESTING WHATSOEVER!” NOTHING, NADA, ZIP! WHY?! What toxicologist, KNOWINGLY AWARE what a toxic heavy metal chelate such as what Gadolinium is, is doing to me, faced with results showing high amounts of a drug in me a full 6 years AFTER the last MRI with contrast, doesn’t want to do any further testing?Because word on the street is out on me that I am vocal about this being the cause of my issues and if I do not get a diagnosis, I do not get treatment. WIthout a proper diagnosis, I can’t get treatment paid for by my insurance company. I do NOT have the money to pay for my own treatment nor should I be expected to pay for something that happened to me because of the utter NEGLECT of the medical community to EXPOSE GADOLINIUM for what it truly is, a POISON! Are you a doctor, would you do all the proper testing needed to determine how high my body count of Gadolinium is, or do proper biopsies, then give me chelation treatment?

    A lot of my comments may be a bit facetious, cutting, but by no stretch of the imagination, are they psychotic nor a parody. Yes, it is sad, welcome to my LIFE, or what is left of it!
    Another reason I posted this to this particular comment, is this doctor is in the hallowed halls of Yale, stomping grounds and site of the NSF Registry, run by Dr Shawn Cowper,a dermatopathologist, in on the early days of NSF Research in 1997. IT took ten more years for the FDA to even put a warning on GADOLINIUM. Cowper’s office who refused to do any testing on me, because I didn’t have a diagnosis of NSF! Come send us your slides when you have a diagnosis of “nephrogenic systemic fibrosis” How ironic is that?! You don’t get to see any of our specialist doctors, because you don’t HAVE a diagnosis, so WHEN/HOW DO I/WE GET ONE? ( I am speaking here of the many, who like me are harmed, peddling in the oatmeal of our individual medical communities. It’s us and the insurance companies who suffer, but GE & BAYERshould shoulder the financial burden of harming us all.
    How do they look themselves in the bathroom mirror in the morning, knowing if NSF or Non-NSF happens to even one patient? AS I told Dr Lewis Nelson, “I will guarantee, if you ever hurt yourself, you will never ALLOW A CONTRAST MRI TO BE PERFORMED”
    Accountability, for the untold bodies who continue to mount…we are legion.

  6. If this isn’t a parody, it’s just sad.
    (Distinguishing parody from psychosis, on a site you don’t expect attempts at humor, is hard to detect.
    And having had to deal w/ patients like “CNP,” it’s hard to find it funny — if that was the intent — in any event.)

  7. It must be nice to be able to go into a doc’s office, get a PROPER diagnosis, then PROPER treatment, I applaud your tenacity, mine’s hanging by a thread; because your neck of the woods doesn’t even WANT to acknowledge that a NEW disease process exists , a ‘la “NON-Nephrogenic Systemic Fibrosis.” (see Cowper, down the block! & Kay, being late for an appointment after driving 500+ miles, because another Robinson doc kept me tied up-I was refused my appointment!)

    How about those who HAVE GREAT insurance, yet who are irreparably harmed by 22+ years of undiagnosed Lyme Disease, additionally poisoned by Retained Barium, Creon Induced FIbrosing Colonopathy, topped with Empty Nose Syndrome, aggravated by Fluoroquinolone induced Peripheral Neuropathy, etc., Macroglobulinemia, Glycine Encephalopathy, Lupus, Sjogren’s, all topped with, are you ready, Thyroid Cancer? and with minorly high ANA’s no one will acknowledge the Scleroderma that one report says I have via blood tests, it might mean I WAS RIGHT ALL ALONG: what did I tell you? http://www.auntminnie.com/index.aspx?sec=prtf&sub=def&pag=dis&itemId=106037&printpage=true&fsec=sup&fsub=mri
    what’d I tell u?GE/BAYER=POISON

    No one in the entire medical community wants to admit that Gadolinium is causing patients with no known Kidney disease”, a Gadolinium Induced Focal Dermal FIbrosis w/increased mucin, as my most recent biopsies (#’s 7 & *8) reveal. Gadolinium found almost 6 years post last MRI! WHY? too much money to be lost for GE & Bayer, all the imaging centers will do ONLY half their previous business,; afterall, who wants to have brain damage AND have their organs turn to stone (fibrosis) , certainly NOT ME, if I had KNOWN better, with INFORMED CONSENT! I’d have told tehm to stick the Gadolinium (Magnevist in all cases) where the sun don’t shine!

    Be Forewarned all, Gadolinium is POISON and if you allow it to enter your bodies, in the GUISE of medical imaging care, and the environment, you will wind up like me! Standing in front of just about every Eastern Seaboard doctor, with one hand on the doorhandle, doing a combination MIchael Jackson Moonwalk/Rodney Dangerfield shrug, when confronted with test results PROVING all of the above, but NO REAL DIAGNOSIS! Care to give it a shot? It will look darn good on your resume, “Healed Doc Discovers Pogorzelskitis!”

    The midical community has known this since at least 1997 if not before and it has been covered up; time to do some scratching in the litter box, you will be surprised at waht you might find.

    By the way, Dr Fogarty, have you had any MRi’s with contrast lately?

  8. Sandra & Barry,

    I can speak to how Canada does it. The provinces administer their own health insurance “federal” plan with universal budgets, but the federal government also uses transfer payments to control compliance – much the same way the U.S. uses highway dollars to regulate state standards. But of course there are no “private” hospitals – an easier system to regulate.

    The U.S. will never get control of health costs with so many private interests working at cost purposes to cost control and the ability to find loop holes.

    More info here:

  9. The rest of Europe uses insurance, not a top down approach. And the UK isn’t as prescriptive as it sounds. They use a supply side approach – fewer ICU beds and dialysis spots; number of physicians that are trained; number and size of hospitals. There are interesting approaches to supply and costs – trained nurses colonoscopies, and, as one primary care physician in the UK said, “If you’re asking if we let someone with kidney failure die, the answer is yes, but everyone who needs dialysis gets it.” It seems to be playing out a bit here – some recent news reports say that “Hospital X is saving $$ by reducing/eliminating unnecessary blood product transfusions, saving $250 per transfusion, and this has improved outcomes as well as saving $$ because it’s reduced adverse reactions to transfusions.” Over the past couple of years we seem to be moving slowly in that direction – I bet it would happen faster with a global budget. Perhaps we’d have a slowdown in hospital construction.

  10. Sandra –

    I don’t see how you could impose a regional global budget when providers are controlled by different corporate entities. I also think it would be hard to get doctors to practice more efficiently, especially regarding the ordering of diagnostic tests, when the hostile litigation environment hasn’t changed. If there is a public perception that doctors aren’t allowed to miss anything or should have known that an extra test might have led to a timely diagnosis, they are going to practice defensive medicine. It pervades the medical culture.

    It’s different in the UK where the NHS pretty much runs the whole show and the propensity of patients to sue medical providers is presumably much less. In the U.S., if I see Kaiser start to operate successfully within a global budget that stabilizes or even shrinks its per capita spending, then I’ll believe we can get there at least for large provider organizations that cover the whole continuum of care.

  11. Does it make sense to have global budgets for hospitals rather than an overall global budget for the country or region by region? What happens if it’s a global budget for a provider type, costs just get shifted to another provider (note rehabs and TCUs that take care of post-op care, with hospitals still getting their DRG payment that used to include much more time in the hospital). There are ways to manage an overall global budget – that does require rationing as it’s commonly understood, but what also happens is providers start to understand the “scarce resources” approach and begin to figure out how to deliver care in a more cost-effective manner.

  12. “Reducing unnecessary testing” brings us back to the to the threat of tort liability. Each patient is, at least in court, a unique individual, with individual needs, not a cypher in a protocol digest. Under existing law, the courts frame the issue in terms of foreseeability. All the plaintiff is required to show is that the physician “should have known” that the test deemed “unnecessary” under protocol would have averted the outcome complained of. As for changing the existing laws relating to “negligence,” I see little likelihood of that.

  13. Peter1 –

    The trend is to move away from the fee for service payment model in favor of bundled payments for surgical procedures, shared risk / shared savings models for hospitals, and, eventually, capitation or global budgets for hospitals. The Accountable Care Organization structure would lend itself to this approach pretty well, by the way. For hospitals, to the extent that they get paid largely based on DRG’s (case rates), reducing unnecessary testing would save money for the hospital without reducing case rate revenue. Eliminating the entire DRG, though, because it’s unnecessary or marginally useful is a different matter.

    When hospitals start to get paid for keeping people healthy and out of the hospital, they will stop rewarding their salaried doctors for relative value units billed. If we want to reduce unnecessary utilization, the savings can’t all go to insurers and taxpayers. Providers need to be rewarded as well.

    We also need good price and quality transparency tools so referring primary care doctors can identify the most cost-effective high quality providers in real time and send their patients to them.

  14. “if it did, we could get some useful experience to see whether or not such protection would actually reduce defensive medicine, at least over a period of five or more years as doctors gained confidence in the law’s protections.”

    Yes Barry, I’d be willing to test as well. You’re assuming that docs are chomping at the bit to reduce health costs overall through evidence based medicine.

    I suspect that docs in hospitals will have a harder time as it will reduce hospital revenue. Hospitals may just increase charges elsewhere to keep the billing machine fed.

  15. “It is questionable whether Congress even has the lawful authority to abrogate rights well established in the common law.”

    archon41 –

    I don’t agree. What right does a patient have to sue a doctor for not diagnosing cancer three months sooner because the doctor failed to order that one more test that evidence based guidelines and protocols didn’t call for?

    There was a time in the 1980’s and early 1990’s when lawyers were bringing many class action suits against publicly traded companies basically because their stock went down when sales and earnings results fell short of expectations. It was often cheaper for the companies to just pay off the lawyers by settling the case rather than fight it in court. Lawyers cleaned up while shareholders got pennies per share or nothing at all from the settlements.

    Congress then passed the Securities Litigation Reform Act of 1995 which gave companies safe harbor protection from these suits if they warned shareholders at the start of earnings conference calls and presentations to investors that actual results may differ materially from expectations and that the company’s business is subject to numerous risks and uncertainties that are enumerated in its SEC filings. The number of suits declined substantially after that but were not eliminated entirely

    The same principle can be used, in my opinion, to protect doctors from suits alleging the failure to diagnose the patient’s disease or condition on a timely basis as long as evidence based guidelines and protocols were followed.

    Unfortunately, since trial lawyers are one of the three key constituencies for Democrats, it’s not likely to happen at the federal level anytime soon. At the same time, since numerous states have both Republican governors and Republican controlled legislatures, it could happen in at least some states and, if it did, we could get some useful experience to see whether or not such protection would actually reduce defensive medicine, at least over a period of five or more years as doctors gained confidence in the law’s protections.

  16. Given the chokehold lawyers and their accomplices have on us, providers can expect no meaningful relief from the existing tort liability scheme. It is questionable whether Congress even has the lawful authority to abrogate rights well established in the common law. Denying the relation between “defensive medicine” and the threat of tort liability, however, was essential to the passage of Obamacare. This denial made plausible, to a crucial segment of the electorate, the claim that the high cost of health care is due primarily, if not exclusively, to the “greed” of insurers. This gave rise to the agreeable notion that insurers could be forced to fund the medical needs of the indigent and uninsurable without untoward consequence to others. “We have to pass it,” she simpered, “to see what’s in it.” Well, now we know, and it’s not pretty.

    Seems like the ACA, as written, is fast becoming, like military defeat, an orphan. I think we all have a pretty good idea of the firestorm gathering out there.

  17. A person comes to this thread and reads what, more of the rigid zealot ideology that drives either abandonment or dependency.

    Oh, and the usual antiphysician drivel that tried to hide as being “sensitive” and allegedly focused on the needs of the public.

    Yeah, well “bunk” to you antiphysicians, although many who know they are just project their selfish and special interest agenda on doctors as a whole.

    MD as Hell, you know this mob who trolls here and what they want.

    Us to wear black and white collars and embrace that vow of poverty.

    Just so the antagonists can take more money and power.

  18. ” It’s safe harbor protection for doctors who follow evidence based guidelines and protocols where they exist. To my knowledge, no state has implemented such safe harbor protection nor has the federal government.”

    Precisely, this is why docs cannot and will not likely follow protocols. A “jury of our peers” will not tolerate this as a reason for not ordering a test.

  19. I’ll make three points on this.

    First, as a prior commenter noted, the writer’s dilemma would not happen under ACA rules that go into effect next week. Even a catastrophic insurance plan purchased by a young person would cover most of the cost of a serious illness and there would be no lifetime limit on the amount of claims that the insurer would have to pay under the policy.

    Second, regarding defensive medicine, the problem isn’t the botched surgeries. It’s the failure to diagnose suits that drive excessive testing. The perception among the public is that doctors aren’t allowed to miss anything. While lawsuits that claim the doctor failed to diagnose the patient’s disease or condition on a timely basis account for only about 20% of all malpractice cases, they probably drive at least 80% of defensive medicine. The fix isn’t caps on non-economic damages. It’s safe harbor protection for doctors who follow evidence based guidelines and protocols where they exist. To my knowledge, no state has implemented such safe harbor protection nor has the federal government.

    Third, a lot of Medicare and Medicaid fraud could be stopped or at least mitigated by the implementation of better analytics. If a claim looks suspicious, don’t pay it without further documentation to satisfy the payer that it’s legitimate. This is what the private insurers do. Medicare pays quickly and then tries, usually unsuccessfully, to chase crooks later to collect improper payments that shouldn’t have been made in the first place. Of the $65 billion Medicare paid to physicians in 2011, 2% of doctors billed Medicare $500,000 or more and accounted for 25% of all claims. There were 303 doctors who billed Medicare $3 million or more. A lot more attention should be focused on them including thorough audits.

  20. “What you want is “free” health care, keeping the doctors lined up as “sitting ducks.””

    That would be no more sustainable than the present system.

  21. You are nattering about matters you know nothing whatsoever about.

    What you want is “free” health care, keeping the doctors lined up as “sitting ducks.”

  22. No nation on the planet has completely figured out the access-quality-cost dilemma in healthcare

    However most civilized nations (unlike the US ) have some form of basic single payer safety nets

    I say that human flesh and human souls are not commodities (like smart phones, e-tablets and flatscreen TVs) and therefore should not be bought and sold in the marketplace of commodities.

    If your a Doc with an MBA quit medicine and go into business with my full blessings.

  23. 41, I guess I should add I’m no fan of the lawyer class, which as you know is self regulated. Most people think they don’t play fair, but of course when you’re the plaintiff people want the shark, not the dolphin.

  24. No smarter except that I try to look at evidence and not ideology with a good dose of people experience. My wife has also been a nurse for 35 years with a stint as head nurse and has had many, many interactions with doctors – good, bad and ugly. They are people first with the usual self preserving faults.

  25. 41, the costs of expensive litigation also damper lawyers, who work on contingency, from venturing too deeply into false suits. It works both ways, except that contingency also gives the poor access to legal remedy.

    Assuming that doctor peers will police their colleagues is just naive. As a group, doctors always circle the wagons in defense of their “peers”, because of the, “there, by the grace of god go I” fear.

    When we let banks police themselves how did that turn out. How about letting the police police themselves.

    In Texas when tort reform was passed the state stiffened the “peer” review process with more oversight, it wasn’t long before docs revolted against that as well.

    The number of mega suits is small but are used to cover the real problem – doctors behaving badly who are not “peer” reviewed.

  26. Tort reform has never changed the threshold for being sued in the first place. So the costs of care remain unaffected.

    I must be immune from law suits for me to save you money.

    I could save half your budget if you would shield me from litigation.

  27. Central organized rationing.

    No coverage for scooters and lift chairs would be a wonderful start.
    No dialysis for cocaine positive people would be another.
    No Medicaid for Iphone 5s owners.
    No dialysis if your Hemoglobin A1C is over 9.

    Doesn’t sound so bad.

  28. I think it strange to bring morality into the discussion. How many people die from any number of technologically preventable causes? Take auto accidents for example – people die tragically and violently all the time in accidents that technology exists to prevent. Why is dying from disease worse than dying from and accident or whatever? It doesn’t seem quite as moral an issue in myriad other ways to die. Unless death itself is immoral, which seems to be the case when we talk about banning soda, etc. Oh wait, that’s a “cost to society” issue, which of course takes it out of both the human rights and morality arenas.
    I might agree that a civilized society should provide health care along with the other civil services you listed. But do you really have that hard of a time explaining why we don’t privatize fire, police, sanitation, and civil defense. Really? So why should health care be the carve out – the one that government is incapable of – the one that must and can only be provided with so called insurance? Philosophy does matter, and if more people would engage a few brain cells in philosophy first, we wouldn’t waste so much time and money on poorly conceived programs that fail to accomplish even half of what they promised (or, what the politician, funded by the industry that will benefit, promised).
    Medicare Part D, PPACA are classic examples. And plain old medicare itself is extraordinarily wasteful – it has been proven quite successfully that it raises health care costs more than it lowers them. If someone had taken the time to have a coherent philosophical underpinning in the 1960’s we might have put the health care question behind us long ago.

  29. I can’t imagine an exercise more frivolous than using judgments in malpractice suits as a guide to assessing the influence of the threat of suit on “defensive medicine.” A good 95% of all personal injury claims are settled before trial, and the costs of defense, in complex litigation, generally exceed the amount of the settlement.

    It’s a continuum: the more you protect the doctor, the more you compromise the right to sue him. Placing “caps” on the damages recoverable doesn’t get the job done. I think physicians should be judged by their peers: other physicians, familiar with the specialties involved. The plaintiff should be required to show, by clear and convincing evidence, that what the defendant did or did not do fell outside the realm of the reasonable. Jurors hauled in from the “peanut gallery” are too easily manipulated by “testifying doctors” hired by lawyers. There should be no “jackpot” awards of punitive and non-economic damages.

  30. 41, I’ve never disagreed that over treatment is a problem, but it has not much to do with tort fear – read McCallen TX or Miami FL, two states with tort reform.

    Rather than the pseudo cleaver quips or false claims from the peanut gallery tell us what you would like to see.

  31. For starters, you could acknowledge the truth that “defensive medicine,” “overtreatment,” and abuse are serious problems, and desist from promoting the fiction that half of every dollar insurers collect is pure profit, to be squandered in some way. But that wouldn’t advance the agenda, would it?

  32. “hen what is the purpose of insurance, if after you become ill an insurer decides you are a “disfavored policy holder” and dumps you into the government program while keeping all the premiums you paid them for years?”

    Well now, interesting point Bob, what if in order to dump you, the insurance company were required to refund all your past premiums, with interest, and penalties? And what if there were always state-run high-risk insurance available for, say, no more than 2x the rate for the healthy???

  33. The experience described here appears to be a problem of the particular insurance policy design – namely a low cap on benefits. If it was employment based insurance, then the employer knowingly put in the cap to save on premium costs. If it was purchased in the individual market, then the cap was probably non-transparent and the author was a victim of misleading marketing. Most healthy individuals buy insurance to insure against financially catastrophic events, which is actually the purpose of insurance. However, socialized or collectivized insurance, like that practiced in the US, combines the catastrophic and chronic with subsidizing routine or relatively minor expenses, along with annual policy underwriting and price changes. The subsidies, along with tax and employer subsidies, entice healthy individuals to participate. However, it also highly non-transparent, inviting fraud, waste, over-pricing, and over-consumption at all levels.

  34. Lies? Certainly you know how insurance works, the healthy subsidize the sick, and many people’s rates have decreased, not increased. The government should take care of those who can’t qualify for insurance? Then what is the purpose of insurance, if after you become ill an insurer decides you are a “disfavored policy holder” and dumps you into the government program while keeping all the premiums you paid them for years?

  35. I know from research that no state can show lower costs from tort reform.

    What would have in mind?

    Conservatives love to point to Medicare’s fraud problem on how “guvment” can’t do anything, I would have thought the private sector did a better job – guess not.

    Again, what would you like to see?

    Would the 50% include those conservatives on Medicare and Social Security? Or the ones running to FEMA every time a hurricane or flood rolls in?

  36. No state has enacted the reforms necessary to give physicians any real peace of mind about judicial second- guessing, but you know that.

    Insurers, being themselves ever in the cross hairs of the lawyers, are very limited in what they can do about abuses. You knew that, too.

    I was interested to see that even Comrade Margalit is now conceding that “single payer” isn’t a viable option, having concluded, rather dourly, that 50% of the electorate is too “conservative.”

  37. “What is a right?” We DECIDE. And, your “rights” exist to the extent that society will uphold and defend them. Moreover, rights are not unilateral; they imply reciprocal obligations to the very social order that defends them. One shouldn’t even have to point this out.

  38. Show us the numbers in tort reform states.

    Aren’t insurance companies supposed to prevent provider fraud?

  39. Many of the proposals about “prices” I see here seem to be refracted through a hidden agenda. On a scale of 1 to 10, concern about “defensive medicine” and its relation to tort liability seems to rate about 1.5. But there is no great mystery here, given the incestuous relationship between liberals and the trial lawyers. When it comes to preserving the ability to “hit the jackpot” in court, the Democratic Party is but the political action arm of the personal injury industry. As for downright provider fraud, and what might be done to suppress it, I’m not hearing much but crickets.

  40. “I received a letter that my health insurance had been exhausted and I would no longer receive any health benefits.”

    “I went to school in Massachusetts where a law was on the books that allowed me to enroll in health insurance without a pre-existing condition exclusion because my insurance being exhausted counted as a special qualifying event.”

    Both of these have been solved by the ACA, what has not been solved is how to pay for it without cutting prices. We are still expecting people of moderate means to pay for a system that requires un-moderate incomes and subsidies.

  41. You are not going to shut down discussion about acceptable levels of health care by mawkish and peremptory appeals to emotion.

  42. To further clarify Dan, I am not suggesting it’s not worth it, merely asking that we acknowledge its worth or cost. Because to divorce discussion about access without cost will lead you to some contradiction some point in time.

  43. The stakes are indeed high Dan. And MD Anderson type care for all will cost, and cost more than the cost curve. And so it won’t reduce the national debt, as promised. It can’t.

    Perhaps what healthcare debate needs most is honesty. And what you are seeing expressed in the comments are atoms of honesty, even if such expressions are fundamentally distasteful.

  44. One sees many people in resplendent Arab dress in the waiting rooms there. Part of the “balancing act,” I suppose.

  45. So much bluster in these comments. This story is simple: Dr. Fogerty explains why health care matters. Everything else is secondary, and much of it is purely ideological, not a serious discussion of health care. We know what a good health care system requires. And Fogerty’s piece shows the stakes and benefits.

  46. What retirement?

    Everyone will be working to pay off the federal debt. There will be no retirement.

  47. I must CHARGE the same price to every patient. I may ACCEPT a different amount as payment in full. Therefore I may (or must) accept a lesser amount from an insurer or payor, i.e. Medicare…definitely less.

    Every insurer and patient receives the same charge for the same CPT code. It is illegal for me to charge a private pay patient less (or more) than I charge a Medicare patient. It is illegal for me to accept “insurance only” from anyone. (There are ways around that, but that should not surprise you, since it is a law written by lawyers.)

    Each provider may have different charges from me, but I must be consistant and so must they. I also cannot tell you what I charge and I cannot reveal what I accept. That would violate the Stark laws. i also cannot refer patients to my outpaitent clinic from the ER…also a violation of Stark.

  48. There were charitable organizations picking up the slack long before governemnt came along. All those St. someone hospitals were not named for senators and presidents.

    But this country does not want it called “Charity”. In New Orleans there is a hospital named Charity. People do not want charity. They want entitled.

    This law was never about providing care.

  49. Now, this is interesting: “Emergency manager Kevyn Orr has suggested that the city’s [Detroit’s] arrangements for providing post-bankruptcy health care to its employees and retirees depend heavily on the availability of coverage mandated by the ACA. Other municipalities at risk of being dragged under by legacy health care costs may see their options similarly circumscribed if the ACA founders.” (Brian Dickerson: The Affordable Care Act on the Brink of Doom, Detroit Free Press, 12-22-13)

  50. In a civilized society, healthcare is as much a right as police protection, fire protection, food safety, drinkable water, military defense, or to be appointed a lawyer if you cannot afford one. Someone can wax philosophical about, “What is a right?” but it is morally wrong for a society to let a member die because she doesn’t have enough money, or to allow her to live because she is more wealthy. Of course, some will then debate, “What is moral?” while letting thousands of people die all around them, for the sake of an argument.

  51. “It is the law for each provider to charge every entity the same thing”

    It most certainly is not. That, right there, makes me wonder if you have any clue at all what you’re talking about.

  52. Yes there would be problems. I doubt MD Anderson would exist if the government did not regulate the health insurance to mitigate the “lemon” problem.

  53. Would anyone seriously propose that “single payer” would not result in a deterioration of the quality of care received by the vast number of voters presently insured under group plans? Have you really persuaded yourselves that they share your obsession with eliminating disparities in the quality of care? Would not the imposition of such a scheme play havoc with existing physician-patient relationships? Who would decide who gets to go to MD Anderson (by way of example) and who doesn’t? As for the “Medicare for all” crowd, I suspect they are innocent of any real understanding of the inadequacy of that benefit. Perhaps they are purveyors of “Medicare supplement” plans.

  54. My daughter was the recipient of compassion that was at once “centralized” and personal. Don’t conflate disdain with “bitterness” Mr Mad as He’ll.

  55. That’s too binary for me.

    Healthcare has too many shades of gray to perforce a clear cut winner between market & government.

    The idea that everyone can have exactly the care they are willing & able to purchase, just like ordering a meal, is practically unimplementable

  56. I could see your point if we didn’t so closely tie healthcare and essentially involuntary emergency care. No one demands proof of ability to pay when there’s a car accident or injury from fire. I saw in a London historical museum a medallion that was displayed on houses that had paid for fire protection. And when in Ecuador, there were guards with machine guns at grocery stores and gas stations. We in the U.S. have come to accept public fire protection, emergency care, police protection… Is healthcare really that different? No, I’m not talking about preventive care, which can end up draining any treasury. But care for serious disease and injury? It doesn’t make sense to me that someone in their late 50’s, walking around the mall, suffer a cardiac arrest and receive emergency care so are resusitated but require surgery and rehab. Not unlike the n of 1 story in this piece, but with no time to recover and go to medical school under any circumstances. Does this really make sense to people? If there were charitable organizations picking up the slack, I would not say anything, but I don’t see that happening. I’ve seen too many patients deeply regret, sometimes to the point of committing suicide, that their injury or disease caused their family to suffer financial catastrophe.

  57. Single payer does reduce costs if accompanied by a global budget. That is certainly necessary when government is paying for it – at least in any reasonably constrained government that can’t borrow infinitely. It does work in many parts of the world – a lot of attention to cost-benefit.

  58. No it is not.

    Or yes it is, if the single payor is the patient and not the government.

    If it is the government, then we are merely pets, not citizens.

  59. This was never about and adequate level of care.

    This was always about centralized power over the population to provide political cover for the necessary Medicare nd social Security cuts to come.

  60. No.

    It is the law for each provider to charge every entity the same thing. They do not however have to accept the same thing as payment in full.

    Always negotiate for a better deal.

  61. I read your daughter’s story and am very sorry for her pain and your pain. I would have given everything I have to help. Your bitterness keeps you from hearing me.

    You cannot expect centralized compassion. They are trying to build the wrong kind of compassion and support. It can never touch those who need it..

    The good doctor’s story simply does not justify this monstrosity of monolithic meddling.

  62. By reducing administrative complexity and introducing a tax “single payer tax”. Businesses, particularly medium sized ones, will not have to worry about how much bleeding from health of employees. At the margins, of course.

    No doubt, it’s possible to make a dog’s dinner out of single payer, so on a realistic front, your incredulity may be affirmed.

  63. Saurabh:

    Not following you. How does single payer reduce uncertainty vs. any other system?

  64. MD as Hell:

    I understand completely what the author means when he says he felt abandoned by society and I think his comment is quite accurate.

    I got caught without insurance as I did not have the money to pay for it and got a bad diagnosis requiring surgery. Not having surgery would have resulted in death.

    I had a customer that decided not to pay me, no one would lend me money, friends disappeared, etc.

    I ultimately got insurance, but had to fight like hell to get it which is tough when you’re sick.

    So it is what it is, but the bottom line was that I felt like society was telling me to F off and die.

  65. I am afraid the horse has long bolted that stable, when we believed that reason alone would solve everything.

  66. Agree single payer won’t reduce costs. But it would reduce uncertainty. According to one economic theory at least, I think it is the rational expectation theory (happy to be corrected), uncertainty leads to loss of animal spirits and is bad for free market.

  67. Inscription from Hittite artifact:

    We live in evil times. The old ways are not followed, children do not respect their parents, and every man would play the Philosopher King.

  68. The promise of a single payer system assumes that govt would run it efficiently and fairly, but more importantly that they would rein in costs. Given lobbying unclear that this would happen. If one looks at ACA it is a huge giveaway to big HC players like pharma, insurance, etc.

    So if one got to single payer would the govt. squeeze pharma or other large players to get costs down? No idea.

  69. Of course, whether healthcare is a right or not has no bearing on the obscene charges by hospitals, something that remarkably seems to have escaped reformers’ attention, until recently.

    A single payer system may be the only answer to the contradictions of American healthcare, regardless whether one believes healthcare is a right.

  70. I’d be happy to if society had a square deal that dealt everyone a fair shake. I’m more a progressive liberal on many topics, but I’m also a fiscal conservative. There’s better ways to take care of people with respect to healthcare. Better systems that are both cheaper, don’t bankrupt people, and lead to better health outcomes. I’ll be happy to pay higher taxes for a single payer system so you don’t have to pick and choose between your livelihood and dignity in retirement vs. getting healthcare. This isn’t something anyone living in a first world country should have to deal with, but we do.

  71. If this is intended as a justification of the lies that have been told here, it doesn’t work for me. Had there been a frank disclosure of the fact that the needs of the uninsured were to be financed by jacking up the premiums of others, the ACA would not have become law. It now lies under a miasma of partisan falsehood and deception, stripping its advocates of all credibility. Providing an adequate level of care to those who can’t afford or can’t qualify for insurance is properly the function of government, not insurers, and certainly not of disfavored policyholders.

  72. Dr. Mike. That is one of the best I have read on the contradictions of “healthcare is a right”.

    There is one more thing to add to the cauldron of contradiction. What is healthcare?

  73. Anecdotes serve a useful purpose, as this story proves. They help to take what is a philosophical belief and make it practical, applicable. But there is still a philosophy underpinning it, and that is where many struggle. It would appear to me that the philosophical underpinning to this story is healthcare as a right, or at least insurance as a right. Let’s say that it is a right. Is it a US right, or a universal right? Surely it is a universal human right if it is a right at all. So why stop at our borders? Certainly pregnant twin sisters, one who swam the Rio, one who stayed behind, both deserve the same right to care at the time of delivery? Do not we have an obligation to go at get that other sister? Ah, but you say there are practical considerations. By that you mean money of course. Are you going to let the limited supply of money stop you from opening the way to what is another person’s human right? Aren’t “practical” considerations the reason why the hospital said it would collect what was due? So which is it – a universal human right unbound by money, or a service made possible by money? And are you sure you have it right that insurance is the means to ensuring the right to health care? Is it not possible that the right is truly to health care, not to the financial instrument that pays for health care? And thus we all should provide it one to another. If I individually am to strive to provide you with dignity, equality, justice, etc then should I not also strive to give health care? Impossible you say? Then we must arrange for someone else to provide it – hire someone? That would bring us back to the “practical” consideration – that it is a right subject to available resources. Maybe compel someone to give health care on our behalf – to relieve ourselves of the burden of individually giving someone their due rights. But what about the rights of the compelled person – freedom from slavery is also a basic human right is it not?
    If you don’t find the philosophy of all this interesting, worthy of discussion, then what right do you have to “make up” or parrot what you have heard someone else say about rights? Or do you just prefer finding the anecdote that most closely matches the philosophy you pulled from wherever and use that to press for an agenda that has no sound philosophical underpinning?

  74. It seems to me that, in fact, the medical system to provide you financial support did, indeed, work. I am sure it was terrible to go through the details at the same time going through treatment and Mass General response should have been to help you find the alternative you did find rather than threaten you.

  75. My late daughter was given a 4+ effort by her doctors and hospitals for the 26 months of her cancer ordeal. She had no insurance. Absent Medi-Cal she’d have died in about 1-2 months.

    Which would have saved YOU a good bit of money, Mr. Perpetually Aggrieved.


  76. The business of medicine is cruel to those in need. Those leaders are ruthless businessmen whose modus is to ring the cash register, and ring it extra hard on those without insurance. Thye bill much more than they would otherwise get from the insurance carriers, and then go to court to collect it.

    Is that not a violation of some law?

  77. “Abandoned by your society”. Really? How about your house of worship? How about applying for Medicaid? Didn’t you really mean abandoned by your government?