This question was prompted by reading comments related to the Simpsons episode “Homer’s Triple Bypass.” People posted comments such as:
“This is why it’s weird, as a non-American, to watch a plot like this (on any show). The very idea of having to pay tens of thousands of dollars for surgery is so unbelievable, it makes the plot almost unbelievable as well.”
“When I first watched this episode as a kid I got really worried about what would happen if a member of our family got sick because we weren’t exactly rich. My mom told me that was only in America, though. So… hurray!”
The impression seems to be that people thought if you didn’t have insurance, and couldn’t come up with the cash, you were just doomed to an early grave. Now, far be it from me to impugn the integrity of anonymous internet comments, but I can’t help but think these people are a little misinformed.
So what’s the straight dope - If you were in Homer’s situation (USA in the mid-90s, need triple bypass surgery or die, no wealth, no insurance), what were your options?
(Pre-emptive: I am genuinely, sincerely, seriously NOT interested in any political / nationalistic signalling that this kind of question is likely to prompt. That’s precisely the reason I couldn’t get a straight answer out of a Google search. Just the facts, Sir or Ma’am!).
As I understand it, part of the reason healthcare bills are so high in the US is because of the large number of people who can’t afford it (whether they be uninsured, or not able to afford the co-pay, or whatever else). The hospital generally recoups its losses from other, wealthier patients. Thus you get bonkers costs like $10000, when it’s really maybe a $1000 operation + recouping losses from a bunch of poor people.
Which isn’t to say such a thing isn’t a financial burden on the person who couldn’t pay, they’re still in debt, but it’s not like they immediately repossess your home to pay your 15 grand bill and make you live in a box for the honor of saving you from a heart attack.
So, basically the hospital would treat you even if it was very unlikely that you would be able to pay them, and their pricing structure took account of this?
Was this a legal requirement for hospitals? And, if so, did it apply to all treatment, or just to a restricted class of treatment (e.g. urgently-required, life-saving)?
Legally, the hospital only has to give immediate life saving care in an emergency room. In practice, I don’t know what they usually do when they have a patient who needs treatment and cannot pay. The Michael Moore movie had them callously letting a patient lose a finger when he could not come up with tens of thousands of dollars, cash, to pay for the surgery.
The messed up thing, of course, is that the fee the hospital wanted could not possibly be what it really cost them. So they are letting a guy lose a finger because the hospital can’t even demand a reasonable fee somewhat related to the actual cost of labor + supplies to sew it back on.
I mean, a hand surgeon is well paid, sure. 300k a year or so. Say it takes 1 day of his time total to reattach a finger - that’s only 1000-1500 bucks. The tray of instruments he needs can’t cost more than a grand or so for the sterilization fees + any disposable instruments.
Maybe another grand or so to rent the O.R., pay the support staff.
But that $5000 “actual cost” is of course not in any way at all related to what the hospital as an institution will demand.
So, if Homer needed a triple bypass but couldn’t pay for it, he would limp along until he was brought to the emergency room following a critical cardiac incident (assuming the incident didn’t kill him) and he would then get, regardless of his ability to pay, immediate life-saving care, but only such care as could be delivered in the emergency room (which presumably does not include bypass surgery).
If news stories like this one are to believe, if you are dying of a chronic or slowly progressing condition in the US and have no money to pay for the care, you are doomed. Or maybe you are only doomed in some states, I don’t know.
I assume it boils down to “what do you mean by ‘need’?” In The Good Old Days, if you had a heart attack, it was bed rest, aspirin, and antibiotics. Maybe an angioplasty to open up the artery again instead of a major surgery to chop you open, steal some artery from your leg, etc. At what point is a bypass the mandatory treatment?
The point of the lost finger story was that if there are extraordinary, but expensive, measures that might improve your future chances, the hospital is not required to go that extra golden mile unless you have the coverage to pay for it.
As I recall he was going to lose two, originally. The hospital even let him choose which one they would save. That’s what American healthcare’s about: choice.
Because Michael Moore movies are always so accurate and unbiased…
As another data point, there was a story in the newspapers in the 90s about a man who cam in with chest pains and no insurance. The hospital wound up putting stents in because it was considered emergent care and wound up writing off the entire $100,000 cost (and of course passing it on to people with insurance).
There’s an insurance pool for hospitals who run ER’s. They have to take in and treat everybody, but if the hospital gets stiffed for the bill, they’ll still get paid. The punch line is that it’s the tax payer who pays into the pool. I’m sure you’ve heard the cases where a poor mother takes the kid to the ER for the sniffles, can’t pay and the tax payer foots the bill. Urgent Care vs Emergency Room Costs, Differences and Options
I think it’s a great system because [deleted per OP’s request].
When I noticed visual field defects in my left eye my Blue Cross/Blue Shield plan would not let me go to a retinal specialist until I had been evaluated by an opthalmologist, who couldn’t get me in for four days.
I tried to get the retinal guy to see me, because I knew time is of the essence in detachments, which I thought I had. Even when I offered to pay out of pocket for the office visit, the retina guy refused to see me, because if it was a detached retina, the only fix was too expensive for me to pay, and having violated the policy by not going through the opthalmologist, BC/BS wouldn’t have paid, so there wasn’t any point in finding out it was something that couldn’t be fixed.
Three days into the wait for the opthalmologist the retina finished detaching and everything went dark. I haven’t seen anything with that eye in over a decade.
So, not dead, but half blind anyway, and I had insurance, just not good insurance. Would someone without insurance be allowed to die? All the time.
The key is “emergent”, which is generally thought of as “likely to kill you in the next 72 hours,” but may vary by hospital policy.
After that, it’s up to hospital policy, their indigent care programs (only non-profit hospitals have to provide indigent care outside the ER) and also to what individual doctors are willing to do. Sometimes you can get them to waive their fees, and then you can pay just the hospital fees (which isn’t a lot of help to the truly destitute, but can be of help to the struggling middle class uninsured.) Some sympathetic doctors will admit you from the ER onto the med surg floor, and all treatment under that admission period will be done now and billed later, and they’ll bring you applications for indigent care and any state medical plans you might be eligible for - some will cover you for that episode of care if you’re accepted onto the plan. But I live in a city with hundreds of hospitals, and I’ve literally only seen that happen at one (Swedish). Once you’ve been discharged, though, you’re fucked - even the same doctor will have to charge you upfront for future care related to whatever brought you into the ER. So if they’re reluctant to discharge you after an admission through the ER, it may be because they know that once they do, they won’t be able to help you again without payment.
I haven’t seen the Simpsons episode, but generally speaking, no, the hospitals are not bound to provide a triple bypass to an uninsured patient UNLESS they are so unstable that they will die without it in a few days and there’s no other treatment possible within the guidelines of the American Board of Internal Medicine or the surgeon’s relevant professional and regulatory bodies.
So what you want to do is wait until you think you’re about to die, *then *go into the ER. Hope you guessed your window correctly - not sick enough and you’ll be sent home “to follow up with your cardiologist” (with a list of cardiologists in the area you cannot afford), and too sick and you’ll die before the surgery or on the operating table.
Most hospital ERs will treat just about anyone that walks in the door which is why so many people with no insurance use the ER as their primary care doctor for colds and chronic illnesses. However, unless you’re dying, they aren’t going to admit you. Treat and street is most of their motto. I don’t recall why a person lost a finger in the film.
Unfortunately, if you need a procedure that is not life threatening (such as a herniated disk removal or knee replacement) you’re not going to get that without having the cash if you don’t have insurance. If you go to the ER, they will give you a couple of prescriptions and refer you to an orthopedist who won’t see you without prepayment.
Oh, and another thing - there’s a common misconception, both here in the US and on foreign shores - that Emergency Room treatment in the US is free. It is NOT. They will treat you, but they will send you a bill for it after the fact. Then they will send you a reminder, and eventually they will send you to a collection agency and it *will *bring down your credit score. (That last part has changed sometime in the last 30 years; I’m not sure when. It used to be that medical bills would not affect your credit score, but now they do.)
Emergent treatment isn’t FREE, it’s just done before billing, so it’s relatively easy to avoid paying it. It is not without consequence, however.
My 30 year old daughter broke her collar bone when she fell off a horse last year. She had no health insurance and no means to pay the hospital bill. The total bill was $40,000 (yes really) and she ended up paying a few hundred dollars.
I have no idea what her visit and surgery actually cost the doctors and hospital, but even if it was only $20.000 somebody else ended up paying for it since it wasn’t her.
She didn’t have to declare bankruptcy, but she had to prove in a sworn statement that she couldn’t afford to pay the bill, which she couldn’t. They could have put her on a $100 a month plan for the rest of her life, but instead they wrote it off. At least they couldn’t come after me for the money.
This is pretty common from what I’ve heard (and experienced, albeit through insurance). The “big money” you actually get billed initially is almost immediately dropped to something far less onerous (e.g. 80% off) if you show any willingness at all to work something out.
The original number has two purposes: (1) so that if you skip out entirely, they can send a big number to collections, and (2) so they can tell the insurance companies that they get a big discount off the going rate, because they’re not paying the big number either.
My brother was a pedestrian struck by a car around 1985. He was very lucky, and had no life-threatening injuries; he even broke no bones. But he required reconstructive surgery on his face, and they gave him an MRI because they could not believe he hadn’t injured his brain or skull, and they kept him in the hospital for three days just in case.
This left him with thousands of dollars in medical bills.
The driver’s insurance company would ultimately be responsible, but the collection agents were calling my brother, and he was absolutely in no position to pay: before the accident, he was so broke he had to walk to work, and then he was out of work for six months while he healed.
I have read several accounts of people seriously injured, in one case a bicyclist struck by a car where the article noted that his (quite generous) health insurance had been completely used up 25 minutes after he reached the emergency room.
As I understand it, it works like this: Doctors will not withhold lifesaving care just because you can’t pay. But they will still try to collect afterwards, and that can ruin you. As in, you wind up entering bankruptcy and lose your house.
There are some charities that might cover the bill for you, there are some doctors that will just mark it down as an unrecoverable debt, but you are rolling the dice and can’t be sure of such a kind outcome.
Oh, and there are some procedures that a doctor might find advisable but not necessary. So they aren’t required to do it to save your life, so you don’t get it unless you can pay.
Heck, I know from personal experience that if you are in a car crash and get taken to the emergency room, you are getting a bill for that ambulance.
Again, even if the crash was totally not your fault.
