A basic (probably stupid) question about the current health care system

Factual Questions
1

I ask this only because I’ve never dealt with this type of thing and am too polite to ask people I know who may have faced it.

An adult, not eligible for Medicaid, Medicare, etc., with no insurance gets cancer. Assume the person is your garden-variety schlub making about $35K/ year.

  1. Can they get any kind of treatment (chemotherapy, etc.), even though they have no realistic way of paying all the bills, or will they just have to, well, die?

  2. Assume their medical bills total, say, $250,000. Can they agree to pay like $500 month (which would take decades to pay) or make some other arrangement, or do they generally have to pay off the whole enchilada within a few months of treatment (or declare bankruptcy)?

  3. For something like Parkinsons disease, which is going to require expensive treatments for the rest of their life, will treatment eventually be cut off due to lack of ability to pay?

I hate to ask something so basic, but I can’t seem to get a straight answer by searching the internet. Any guidance?

(FWIW- I haven’t been diagnosed with anything, and have insurance through my employer, so none of this applies to me directly. At least not yet.)

2

Since I’m Canadian, and have a small knowledge of the USA’s third-world system through relatives, I’ll take a stab at it: (All this would be covered in Canada)

-the hospital will possibly admit you for treatment. Depends on their policy; they may send you to a different hospital which accepts charity cases or high-risk patients. So you may find somewhere to treat you.

-better sell your house before you start treatment, and give the money away. In the end, it will be like any other debt. Pay all you can or go bankrupt… With the added bonus that you may instead die before you can do either. Plus, if you don’t accept their arrangements, they can put the debt out to a collection agency. Oh joy! More stress just when you need it!

-if you are seriously ill, odds are you stop earning; go on welfare, exhaust your savings. If you have no household income there’s welfare. Kiss the house goodbye, and any money the spouse made will have to do for the two of you and medical payments. At least on welfare, Medicare will pay for it. If the spoue makes too much for welfare/Medicare, you are both totally screwed. (However, if you both have decent incomes, odds are you have some sort of coverage).

  • Some hospitals(?) and doctors have policies that they will take charity cases and spread the cost by charging their regular patients more - somethng else driving up health care costs, since that basically becomes a form of health care where the able-to-pay support the uninsured.

  • A neighbour many years ago had 2 daughters who were nurses and went down to the USA to work. He said they came home within a few years, and said the hardest part of their job was telling people in the waiting rooms to go away they could not b admitted because they could not pay.

-Parkinsons’ is a different story. Even in Canada, all doctor visits are covered but medications are not (except during hospital stays). So prescription benefits (like health care benefits in the USA) are a much-desired employment benefit. A Parkinsons’ patient will need tons of drugs, none cheap. I suspect the same applies as in the USA - seniors and welfare recipients have their drugs covered, everyone else has to fend for themselves The USA has some bizzaro scheme of multiple seniors drug coverage dreamed up to enrich the big pharma companies. (Unlike Canada, those drug schemes in the USA are ***forbidden ***from negotiating lower prices with the pill makers!!)

3

Not until they have been made broke and homeless.

4

And divorced, unless they want their spouse broke and homeless, too.

5

I do know that any hospital that accepts Medicare payments (essentially all of them) cannot turn away a patient that needs care, regardless of their ability to pay. In my experience as a nurse in a large inner-city teaching hospital, the indigent get the same expensive treatments as the well-insured. I would imagine people who work, and don’t have insurance, get the same care too. They are just expected to pay their bill.

6

Hospitals can’t refuse treatment if you’re unable to pay. There are various programs that reimburse them, and they also get the money by building in the cost of treating such patients into their fee structure. In other words, part of your own hospital bill goes toward paying for them (one reason for the stories of $100 aspirin tablets).

You certainly can work out a payment schedule with the hospital if you don’t have the money, but $500 a month is going to be a small amount compared to the bill.

For long-term treatments, there are government programs and aid.

7

It was my understanding that “hospitals are required to treat them regardless of ability to pay” applies only to immediate life-threatening injuries or conditions. Once they’re stabilized (which does NOT mean “cured”…it means that they aren’t going to die from the immediate injury or trauma), the hospital has no further obligation legally. That does not mean long-term courses of medication or therapy or even surgery. Once the heart attack/head trauma/accidental amputation is taken care of, that’s when the “show us your insurance” decisions start.

Have I been misunderstanding the rules for this?

8

Eventually the patient would be broke or disabled enough to qualify for Medicaid. Some of his treatments prior to qualification would also be covered.

9

I’ve been wondering how this applies to something like renal dialysis. It’s required 3 times a week and a patient needing it would likely die in fairly short timespan (say weeks, though it could be shorter or longer depending on how much residual function they have). So it’s not necessarily a medical emergency in the sense of death being in the next few hours, but sooner or later the patient will die. They also need to take all sorts of medications, some of which may not be cheap.

Do hospitals have an obligation to treat patients like this? I’ve been wondering about this for a while. Especially as it’s quite challenging for dialysis patients to work full-time, so presumably many of them don’t have insurance.

10

I remember being shocked to read about this a few years ago. Someone posted an anecdote about a guy who was shot by a pistol, and managed to get himself to the hospital. They bandaged him, stopped the bleeding, but did nothing more.They left the bullet inside him, and sent him home with no more treatment.
Is this typical?

(yeah, I know, it’s only an anecdote…but it was a Doper anecdote)

11

If a bullet is in soft tissue and not near a vital organ or structure such as a blood vessel and the patient has a normal exam otherwise (ie pulses and neurologic testing are intact), then there is no need to remove a bullet. It is VERY typical for a GSW to an extremity to go home with nothing more than some gauze.

12

Dialysis will qualify a patient for disability/Medicaid.

There seems to be a lot of confusion here over what is required legally with regards to patients without insurance (really for every patient). The EMTALA law requires that every hospital who accepts Medicare and has an emergency department provide a ‘medical screening exam’ and stabilization of any “emergent medical conditions” for patients who present to the Emergency Department. There are no provisions in this law regarding outpatient or inpatient care except as it pertains to stabilization. Here is a link to a great post on an Emergency Medicine forum that has a more detailed explanation:

The EMTALA Information Thread

13

A hospital is only required to treat you if you are in imminent danger of death. If you aren’t actively dying they can turn you away.

Of course, this is more likely some places than others. When I went through my first bought of poverty and lack of medical insurance word on the street was to go to a nearby hospital owned by the Catholic church who were pretty decent about taking on charity cases but that was in another state and a quarter century ago - I’m not certain where I’d go these days.

No, it won’t.

Medcare is only open to those over 65 and some disabled people. If you’re under 65 you MIGHT get medicaid, but it’s not guaranteed.

Not true anymore. It is possible to be earning a middle-class income and not have medical insurance.

14

A hospital can turn away any patient that it is not in an immediate life threatening situation. I had a kidney stone and found that out the hard way. They said, “No, it’s not a life threatening situation.” They sent me to Cook County (public hosptial) who told me “get in line.”

Now this doesnt mean they won’t treat you. I eventually found a hosptial that was willing to bill me to give me x-rays and pain meds. And fortunately a few days later the stone passed.

I also worked in the reception area of two ER in suburban Chicago hosptials and they do turn away patients. For example a heart attack comes in and they will stablize the patient and send him to Cook County the public hospital.

Another excellent trick is to turn yourself on bypass from ambulances. I saw this done much more than was needed. At the first hospital they’d announce a bypass every other night while the catholic hospital got it.

Of course this gets rid of paying as well as uninsured customers too.

Hill Barton hospitals are those who accept federal money unde r the Hill-Barton act. This used to be very helpful but now it’s not so much. In the old days, let’s say a hosptial borrowed 25 million under the act. The hospital was then required to provide so much “charity” care in return. The problem with Hill-Barton is that it doesn’t spell out the disbursement of funds.

For example, let’s make up some numbers for an example. If a hospital was required to provide one million dollars worth of charity services per year, for say 25 years, 'cause they have a Hill Barton loan, THE HOSPTIAL not you decides how to allocate it.

So if a heart attack comes in and this heart attack victim is a charity case and it runs $50,000 to treat. The hospital can allocate $10,000 to that particular victim and that is all he gets. Well if you’re $50,000 in the hole have $10,000 knocked off your bill ain’t helping much.

On the other hand some hospitals will do a flip around. In my example hospital let’s say they have to provide one million dollars of charity care per year and on January 2nd a cancer victim comes to him and it’s a rare cancer that will cost a million dollars to treat. The hospital can simply allocate the entire fund to cover this victim and be done with all their charity care for the entire year.

Now I oversimplified a bit in those above examples, there are more regulations and price charge guidlines, but you get the point.

Finally remember even if a hosptial treats you, you still OWE the money. It’s not free. As you saw in my example. Even though I found a hospital willing to treat my kidney stone, I still had to pay them over a period of about two years.

If you go to the hospital and get treated for a heart attack and you have no income, no job etc, they’re STILL going to bill you. And some companies, such are very aggressive about collecting.

There was a story in the Chicago Tribune a bit back about Adventist Health System in Chicago Suburbs, where a woman who gave birth at one of their hosptials had a son who turned 18 and she still hadn’t paid for it yet. She was making payments and caught up and such but with interest and the fact she could only give the hospital like $10/month 'cause she made so little, it pointed out the irony, the fact the kid was now an adult and not yet paid for :slight_smile:

15

You are not wrong here.

And the key to really understanding this is, if you’re under 65 you have to have a PERMANENT disability. It can’t be something that will knock you out for a year then allow you to be cured during that year.

16

Not just a permanent disability, but a severe one that really keeps you from working at all. For example, being blind in one eye is disabling in a sense, but not enough to get you on Medicare.

17

What if the situation is similar to the dialysis example, but requiring expensive surgery. Suppose an uninsured person needs a heart valve replacement. There’s no immediate emergency, but without the surgery he’ll die a slow, lingering death. Is the hospital obligated to perform that surgery once the diagnoses is made? How about later, when his condition deteriorates to the point of being life-or-death?

18

Thanks, everyone appreciates your posting from a position of ignorance with some wild stabs in the dark in General Questions. Following some of your advice would lead one to some fantastically stupid decisions about how an uninsured person in the United States should handle a major medical illness. Again, your efforts to maintain the sterling factual quality of the factual-questions section of the board are appreciated.

Others have addressed issues such at EMTALA better than I could. Also, others have mentioned that hemodialysis dependent renal failure as well as several other conditions automatically qualifies one for Medicaid. Unfortunately even this creates a gap for people such as illegal immigrants that are unable to qualify for Medicaid. These people can often receive hemodialysis from public hospitals that maintain dialysis units at enormous expense, but public funding for such facilities is declining and there have been some wrenching issues with this recently. However, I would note that I am not aware of Canada offering any programs provide hemodialysis treatments for illegal immigrants from Latin America or the United States either.

More on the topic of the urgent crises in dialysis for immigrants in Atlanta:
http://topics.nytimes.com/top/news/health/series/the_breaking_point/index.html?scp=1&sq=dialysis%20grady&st=cse

The best factual answer to the broad question is that health-care for the uninsured in the United States is a catch-as-catch-can patchwork of public funds, various local, regional, or programs for uninsured care, and large amounts of care rendered by hospitals which is not reimbursed that either becomes “charity care,” or a large, likely impossible to address debt which the recipient somehow just deals with by not paying and taking the credit hit or declaring bankruptcy. Very rarely are strongly indicated treatments absolutely withheld from someone actively seeking care.

A large proportion of the people who are uninsured that face major medical illness do eventually qualify for Medicaid. At my current institution, I often see marginally employed people of modest means and no insurance come in for something like cholecystitis, get their gall-bladder removed, and qualify for Medicaid in the same visit, and Medicaid will cover the admission during which they qualified.

For people without insurance or with bad insurance that leaves a large gap unpaid, debt collectors are not fun people to deal with, but they must abide by the same laws and restrictions that someone trying to chase you down for your credit-card debt. They can’t just kick you out of your house, they can only garnish a portion of your wages, and the option of bankruptcy is often a reasonable one for people in such a position.

I am not posting this to downplay the importance of expanding healthcare in the United States. Although someone that needs a foot amputation in this country is overwhelmingly going to get one, I think most everyone would prefer if people had the chance to control their diabetes through drugs, diet, and exercise with a primary-care provider before they had a need for a foot amputation, and doing so is vastly harder for someone working at a $10/hour Wal-Mart job without health insurance who cannot qualify for Medicaid. Our current system is not ideal, but it is not as barbaric as some might imagine.

19

In certain circles (legal ones), this is known as “fraudulent conveyance” and if the hospital has reason to believe you’ve disposed of assets to avoid paying (or in anticipation of) your just debt, they will sue you, whoever you sold your house to and whoever you gave away money to.

Just sayin’.

20

This is the best thing I have seen in GQ for months. Thank you for saving me the time and possible moderator action for calling out the sort of wild ass guessing that apparently passes GQ muster these days.

I only wish that everyone who posts in GQ would have the discretion to follow your posting advice, instead of feeling obliged to offer their unsupported opinion.