What happens in the US when an uninsured person needs health care?

Factual Questions
41

And psychologically, the reasons for that are obvious. “a little pain I can stand for a couple more days and it will go away on its own” versus " “unknown but HIGH costs”. In Melons case, it became “scarily, possibly life threatening condition” versus “unknown but HIGH costs”.

Do most middle class people in the US have any reasonable idea of costs for the treatment they are likely to incur? And the difference in those costs at other places then the ER? And can doctors give an estimate of costs of treatment? You never hear dr. House say: " we could do a lumbar puncture, but that will cost you 900 dollars" or “we need to get you back to the MRI, that will set you back 1200 bucks, do you agree?”

42

I think most people know that the ER is “expensive” in some nebulous way. I’m not sure many people have any reasonable way of estimating what that might be.

I mean, people aren’t doctors. They don’t know what’s wrong with them. They might think something is really minor when it’s actually really serious. And the reverse is also true. As far as getting an “estimate” – most times, even the doctors in the hospital have no idea what the hospital charges for their services.

ETA: Above, I’m talking about the emergency room. Doctors in their own practice normally know what they charge for the most common services, and can look up the rest.

Still, I think the problem remains, you can’t get an estimate because you don’t know what’s wrong with you, or how hard it will be to find out.

43

That is why iI asked if it is common for people to ask their docs about costs before agreeing with any treatment. Or if there is some kind of cultural taboo against that. Or if docs are not used to that question.

44

Anecdotally, I broke my left fibula and tibia very badly in 1997, 2 days before the insurance kicked in at my new job. I was only a few months out of grad school and had a semi-crappy admin job and essentially no savings.

The ER treatment to set the broken bone, one night in the hospital to make sure I was OK and hadn’t given myself a concussion in the fall, and the 10-minute ambulance ride cost about $4500 in 1997 dollars. The hospital wrote off about half, IIRC, and I paid the rest off very, very slowly for a couple of years. No threatening collections letters, though.

If my insuance hadn’t kicked in after a couple of days and covered the resulting 4 rounds of surgery, 2-week hospital stay, and hundreds of hours of therapy, though, I would have had to declare bankruptcy. Total medical expenses after insurance discounts were still north of $100k.

45

Weird, when that factor is crucial in getting people to agree to treatment. Nobody would trust a mechanic who would be unable to tell you how much the repair of your car would cost, right? Even if he didn’t know right away, he would do a diagnosis for which he would charge separately and then tell you on the phone how much treatment would be provided everything would go normally. So then you could decide on that information.

I recently went to a doc for self paid elective surgery (gastric bypass) and they had no trouble telling me how much it would cost if there were no complications.

46

A personal anecdote.

Back in 1989, I had a cyst on my jaw. It got infected and I went to a doctor to get it treated. He took care of it and then bandaged it up. He told me as follow-up I should get the dressing changed for the next three days. I asked if I should come back to his office for this. He said no, just go to the emergency room of the hospital next door.

So the next day, I went to the emergency room to get the bandage changed. Obviously, this was not an emergency so I ended up waiting for about an hour and a half. Finally a nurse removed the bandage I was wearing and replaced it with another.

I decided that rather than going through two more waits like this, I could handle this simple procedure on my own. So the next two days, I changed the bandage myself and never went back to the hospital.

Now, here’s where the insurance issue kicks in. I have good insurance but they refused to pay for the emergency room visit. They said it had not been a genuine emergency. The hospital therefore sent the bill to me.

The cost of having a bandage removed and replaced was over $1200.

(Which I didn’t have to pay. It took me several months to clear it up but I was able to get my insurer to pay because I was able to establish that the doctor, who was under the insurance plan, had directed me to go to the emergency room.)

47

Right. The thing is, that was not an emergency. In an emergency, they have to find out what’s wrong RIGHT NOW, due to the nonzero chance of immediate death. Remeber, if your life is not threatened the ER can refuse service. So a patient with no insurance being seen in the ER, is almost by default in life threatening danger.

It is very easy to find out what elective surgeries will cost. Even a basic, obvious, uncomplicated traumatic accident (like a broken wrist). Unexplained emergencies, not so much. Complex accidents, not so much. You can’t call up the ER and say “If I am in a car accident, what will it cost?”

48

What if you went to a really big garage with 20 mechanics? The guy behind the counter would give you a quote based on the job and hourly rate. The mechanic doing the repair would never see your bill at all. He would simply collect his pay from the garage a the end of the week.

As an aside, you folks in the U.S. really have a shitty system, no?

49

Yes, but we have all that freedom and liberty and stuff.

50

I didn’t know specifically how much it would be, no. I still don’t know how much I’ll wind up having to pay as I haven’t gotten the bill from the hospital yet, just the doctor. I don’t know whether it’ll be more or less than the doc’s bill.

51

It’s also hard to find out what something costs because it’s all contractors who don’t speak to each other. So a typical hospital stay will involve bills from the hospital, from the doctor(s), and from the lab(s). The doctor may be able to tell you what he charges, but he won’t know what the hospital charges or the labs charge.

52

Yes, the “twenty mechanics”-metaphor by Leaffan also made this point. Still, there could be some kind of price list for basic elements. One ten minutes consult with a surgeon, respectively nurse, or a basic unit of time in the OR, should give some estimate.
But that is IMHO, not GQ.

53

But that price list doesn’t exist: Everyone pays a different price for the same things.

With insurance, you usually get a notice from the insurance company that says “this is how much the charge was, this is what we actually paid (and often that number is zero), and you don’t owe the difference because we’re awesome”. I suspect that people without insurance rarely actually pay the full top-line number, but the insurance companies really negotiate it down, to the point that I expect the medical providers completely inflate the original charges to compensate.

I had a short hospitalization in may, and due to a communication mix up, I got one bill as if I didn’t have insurance, and it was “$600, but we’ll cut it in half if you pay within 30 days”. A friend of mine was being treated for a broken collarbone and needed a piece of equipment that was “$3000 if you go through insurance, but if you do it without insurance, we’ll give it to you for $300”.

The point is, if you’re thinking there’s a “master price list”, even one that only exists in someone’s head, you’re wrong. The revenue collection component of the American health care system is, to put it mildly, “complex”.

54

It’s like what Churchill had to say about democracy. It’s the worst system except for all the others that have been tried.

55

But our system is not democracy. Our system here in the United States completely and utterly sucks. We pay more and get less for it. The American public would rather have a single payer system that covers everyone. We don’t get it. Instead we get the anti-Democracy system. Our wishes are ignored because it suits insurance companies profits.

It is the worst possible system. Especially when compared with most others.

56

It’s not hugely different from the Ontario dental system, as far as I can tell.

By the way, in my experience Canadian dentists will also charge you differing amounts depending on whether you have insurance or not.

57

I’m absolutely FOR National Health Insurance.

Many visits to the ER are feet-first: people brought in by ambulance. They aren’t exactly in a position to ask about costs. If you are NOT in a life-threatening state, the hospital will call an ambulance to have to transported to the nearest County hospital (that’s the taxpayer-supported one).

If you ARE treated by the ER, you will be asked if you are conscious or your friends/family will be asked if you are not, what insurance do you have? They want the info NOW. The ER will negotiate with the insurance company over how much will be paid. The difference between the hospital rate and the negotiated insurance rate is absolutely mind-bending. Sometimes, we’re talking ten cents on the dollar. When you get your Explanation of Benefits from the insurance company, you’re likely to say, “Thank GOD I have insurance!” You may or may not have a copay depending on your coverage. Two people can have Aetna insurance, and one may have a $25 copay for the ER, the other could have a $150 copay for the ER. The folks in Human Resources are the ones who haggle with the insurance companies about premiums and copays and deductibles.

The poor uninsured slob will get hit with the whole freakin’ bill. Some people simply throw the bill in the trash. You are throwing your credit rating in the trash, too. A smart, desperate person will call or visit the hospital billing office and say, “We need to talk.” The hospital can reduce the bill to the negotiated charge that insurance companies pay, the hospital can work out a payment plan, or for a very few favored folks, the hospital has a certain amount of leeway to “forgive” all or part of the debt. These options are not automatic, though. You have to contact the hospital and do a fair amount of groveling.

A lot of people stay at really crappy jobs, because they desperately need the insurance for themselves or a family member. If a single person in a group racks up a huge amount of claims to the insurance carrier, in some small companies, the carrier can cancel the company-wide coverage, and the person with the big bills can be denied coverage by any new carrier.

Some policies have a really low coverage max ceiling. Most people don’t pay attention to it, because to them, a $100,000 max payout seems like a huge amount of money they’ll never need. A baby born with birth defects, a horrendous accident, or cancer needing radiation/chemotherapy/surgery can max out a policy in no time. The insurance carrier will gladly pay the bills until the ceiling is reached and then say, “Sorry, we’re out of the game.”

The sick person is literally up shit creek.

Then you have “the working poor.” These are folks barely scraping by with minimum wage jobs, and either the employer doesn’t offer health insurance, or the premiums would decimate the take home pay. For those people, the babies with the ear infections, the woman with too-heavy periods, and the guy with chest pains that may or may not be chronic heartburn simply suck it up and continue to keep going.

The “Obama-care” which is so vilified by many people is merely a start.
~VOW

58

The main differences there being that the amount one can spend on dental care is somewhat more finite than what can be spent on medical care, and people rarely die from dental problems.

59

I have absolutely no idea. I’ve never had to go in for high blood sugar, I’ve always been able to treat it at home.

I’ve had to go in because of breathing problems, though. I don’t remember what the total was, but I had to pay $500 because I wasn’t checked into the hospital. My insurance covers weird stuff. I would have had to pay less out of pocket if I’d had to be checked in, even though the total cost would be greater.

[QUOTE=VOW]
If you ARE treated by the ER, you will be asked if you are conscious or your friends/family will be asked if you are not, what insurance do you have? They want the info NOW.
[/QUOTE]
Not true, in my experience. I went in, was obviously having difficulty breathing, and while the staff wanted to know who I was and what medical problems I had, they were completely uninterested in learning what insurance I had, or even if I had insurance. They wanted to get me breathing easily again.

60

When I was taken to the hospital by ambulance on Memorial Day they actually took my insurance information in the ambulance on the way to the hospital, but while I was in pain I was coherent and able to answer questions so it may depend on your situation.

My husband and I had a plan that after our baby was born I was going to quit my job and start my own business since we had such excellent coverage through his work. Then he lost his job and now my business idea is on the back burner until he finds another job with that kind of health benefit. Since I’m adding my husband and our soon-to-be child onto my health plan at work our monthly premium after my employer’s contribution is going to be more than I pay in rent in NYC and is going to take up 50% of my paycheck. If I worked for a larger company that employed more than 50 people our rates would be about half of what they are now. My working for a small business is going to leave us completely fucked money-wise after the kid is born, but given that my husband is diabetic and they discovered cancer cells at my last doctor’s visit neither of us will ever qualify for an individual policy at any kind of affordable rates so we don’t have a better option at this time.