But it gets better: if they die after refusing care, you can blame them for being stupid.

Here's the problem: some on the right will look @ the Ashlock example, note that he lived, + say "look, the market worked perfectly." Whether or not this is true or- more accurately- he was merely *very* lucky is immaterial from a certain mindset.

-Z

Zorro has it right. This is what the right wing calls market-driven rationing, and they say it's so much better than the alternative, which is obviously Canadian-British-French-Swedish style socialized medicine.

Of course market-driven rationing is proper. Rich people deserve to be rich and get better healthcare. Poor people deserve to die. Your moral value can be determined by your passbook balance. Life is simple.

I was having severe foot pain last summer on the 4th of july, couldn't walk, went to the emergency room, after an x-ray and ace bandage they charged me $2,000. My insurance negotiated it down to $1,200, and because I am on a high deductible plan, I paid $1,200 out of pocket.

Nothing that was done was modern or requiring great skill, but because of the holiday, my doctor was not available. I think I was paying the price of my services+indigent care+those who don't pay their bills.

there has to be a better way...

I don't see what's so weird about this -- isn't this exactly how our Republicans and libertarians say our healthcare system should work? People look at the cost of treatments and decide whether or not to get them. If they can't afford them, they don't get them. If they die, so what? They should have been born rich.

All of this underscores a key failure of the democrats on this issue. They have not made the discussion of health care primarily one of morality. Sure they have discussed the uninsured, underinsured and situations such as this one, but they have not drilled down to a set of core moral assertions that can be repeated and spread through the media, such as: a) Sickness and disease shouldn't be treated as an opportunity for profit, b) No one "shops" for healthcare when given a potential lie threatening diagnosis (e.g.,breast cancer), and c) health care costs are high for the simple reason that people are frightened at the prospect of dying and/or suffering.

If folks can be constantly reminded of core issues such as these, "solutions" targeted at making the insurance industry slightly less profitable might not seem so reasonable.

My family's last visit to the ER will end up costing us about $4K out of pocket. And we have insurance.

James Kwak (from the Baseline Scenario blog) just posted this really nice concise post on why insurance works for things like houses but doesn't work for health care: Insurance and Health Insurance

From a 60's Mad magazine story about the USSR. Comrade goes to a Soviet ER and is told "Take two aspirin. If pain continue, DIE."

Dog eat dog, the other way around.

This all makes perfect sense. Its what has to happen under the current screwy system. We'd almost be better off if people couldn't buy any kind of health insurance and everyone had to pay the same cost out of pocket--then Hospitals would have to put up lists of actual costs of things and let people pick from the menu. At least that would make it pretty clear what treatment really means and we could storm our politicians houses and demand national health care.

I have pretty good health insurance but the disconnect between what doctor's prescribe and what the insurance will cover is huge. Every time I see my doctor she gives me a "freebie" asthma inhaler good for thirty uses. I hoard it because my insurance won't pay for it and if I needed to get one it would be 100 dollars for the same thirty doses. Its sweet of my doctor to try to help me out but its absurd that she has to know what my insurance covers/doesn't cover. And even more absurd that she doesn't know and prescribes for me something I can't afford.

Doctors who issue a set of expensive "orders for treatment" but who don't grasp that no one--NO ONE can afford to be on the hook for those payments--are part of the problem. If the AMA got 100 percent behind national health care we'd have it tomorrow.

aimai

What is really sad about all of this is that an insurance company would only pay a fraction of the "bill" that would have haunted Ashlock for the rest of his life.

Single payer is the only answer to eliminate this dilemma. I can relate. I rode out what I was pretty sure was a mild heart attack last year.

I had been laid off 6 months earlier, lost my employer sponsored healthcare and was prepared to die rather than become burdened with a huge hospital bill.

I'm OK now, but still unemployed for 16 months to date. With a single payer system, I would have been to the ER in a heartbeat....every pun intended.

We could solve this thing immediately with one act: Make every congressman and congresswoman deal with this bullshit the way the average American has to; take away their present health care and give them only the health care budget of the average American family. No spending more than that if you're in congress, period. Don't like it? Then quit.

Turn the Republican mantra on it's head, instead of healthcare being rationed out by the bureaucrats, the American people would ration it out to the bureaucrats.

We'd have a national healthcare plan in no time.

Speaking as a Canadian, neither I, nor anyone in my extended family has ever been the victim of health care "rationing". Nor have I ever been told which doctor to see. Whenever anyone in my family needs healthcare we go to see a doctor, no questions asked, no thought of money. Yes there is a shortage of GP's and some specialists up here. What that means is that those unable to find a family physician are forced to go to a walk in clinic, and those trying to see a specialist where there is a shortage are triaged. That being said, I have rarely heard of these problems resulting in the loss of life. If there were real issues with people dying due to "rationing" it would be all over the media. It is not.

Is the system here perfect? No. But it's a damn site better than trying to decide between food on the table and your life.

It is, in effect, patient-driven rationing.

Mnemosyne said:
People look at the cost of treatments and decide whether or not to get them. If they can't afford them, they don't get them. If they die, so what?

Except that the disease doesn't end there. People in rural Mexico traditionally use home remedies, and then over-the-counter antibiotics -- neither of which was effective against the H1N1 virus. By the time they sought medical help many people were desperately ill and had spread the disease to others.

Even worse is when someone stops a course of antibiotics before it's finished. The result is that the weaker germs are killed off, leaving the stronger, more resistant germs to multiply. This is how we get drug-resistant forms of diseases like tuberculosis.

As usual, conservatives are thinking like teenagers -- not considering consequences beyond the immediate moment.

The doctor on duty dismissed Ashlock's questions about cost, telling him she was "a physician, not an accountant," he said.

Having helplessly watched a good friend die unnecessarily because he adamantly refused to seek medical care for a freak infection (he was terrified of the bills eating up every limited cent he had and putting him in heavy debt forever), I read this and literally want to beat this stupid, arrogant woman to a bloody pulp with a pile of her patients' unpayable medical bills.

Here is something else to consider. In most states spouses are responsible for the necessaries (like health care) incurred by their spouses. Death might not have relieved Mr. Ashlock's family of liability for the outrageous bill that he was sure to receive. See the comment above from the guy who thinks he had a mild heart attack.

Choosing glasses over eye surgery is patient driven rationing. Forgoing treatment for a heart attack or a concussion isn't.

Yes, we have a 'problem'. It is absolutely shameful to have healthcare in this country tied to your job. You lose your job (as 5 million have done since this 'recession' began) and you are 'healthcare destitute'. We'd better get something done about this or there's going to be another American Revolution!!

Mom opted for early retirement, but couldn't afford the insurance offered. Too young by a year or two to qualify for Medicare/Medicaid. Diagnosed with a rare form of Lupus. One (experimental) treatment ran roughly $30K, and there were not other options. She made a deal with the doctor & hospital to be some sort of experimental guinea pig for the drug's trial. Hospital renegged and started hounding her for payment.

With her fixed income, she had to declare bankruptcy. She's doing okay now, living in a low-income comlex, even though we offered to have her move in with us. But situations like this are unconscionable.

Hasn't anyone read the news today? Obama is apparently content to let the health insurance people take care of the problem themselves--which means more of the above. Can't someone get him to realize we have a crisis in healthcare out here in the real world? Let's at least get single payer back on the table. It is not even represented in the administration's gamut of solutions to the problem, nor do its advocates have any luck in getting a hearing at all from the Obama administration. It's disgusting.

I realize that the doctors in this scenario aren't the bad guys, and I'm not trying to make them so, but there are real consequences when physicians are completely divorced from medical expenses. They refer people for procedures, sometimes probably overcautiously in anticipation of malpractice suits, they have no idea what any of it costs, and the patient may be unable to make a determination as to whether this is a needed recommendation or a CYA type recommendation and may also be unable to determine what the costs are going to be ahead of time. (I'm not saying these were CYA recommendations, but e.g. my husband was sent for something that he really did not actually need and other people in his situation do not routinely get, and the cost with pretty decent insurance was over $500. If this had been someone uninsured who really thought they needed this procedure for their health and got stuck with the full $5000 bill, they might be very turned off and/or financially unable to get medical treatment that was necessary.)

Who cares... It's an ownorsh*t society. If you control lot's of capital than you can waive insurance and deduct your healthcare expenses. If you are the typical middle class American and you don't have insurance or a pre-existing condition than you are up sh*t's creek.

A liberal is a conservative who has been sick.

This winter I slipped on ice and hurt my shoulder. After a couple of days of no improvement, I went to my doctor. The clinics xray center was closed so he sent me to the emergency room to check for a dislocated shoulder etc. So after they do xrays, the emergency room decides to give me an EKG. I know pain in the arm is a sign of a heart attack but this pain was 100% attributed to my fall. But I was in so much pain that I didn't want to argue with the Dr. So they did the EKG and charge about $800 for the service. I wish I had told them to no, but the reality is it is extremely difficult to say no.

It may be partially due to malpractice concerns, but my sense is it is just a way for them to make more money if there is any possibility.

But next time I have a medical emergency, I'm going back to the same ER, because it is close to where I live and I'm not going to value shop everytime there is an emergency.

I came close to engaging in patient-driven rationing in 1997. Was taken to ER with severe upper back pain. The dr. found nothing on x ray and said he needed to see a CAT scan. My company's insurance administrator was notorious for declining payment on a whim and I was tempted to ask him to skip the CAT but decided not to object. Turned out the CAT scan showed a dissected aorta (sound familiar? Think John Ritter). I spent 10 days in Cardiac Intensive Care and obviously survived. The mortality rate on untreated dissections is 95%. I'm glad I held my tongue for once.

this is bad framing and progressives should avoid it. This isn't "patient-driven". It's insurance company profit-driven rationing.

Word. And it's the Republicans' favored outcome.

When patients are more afraid of medical bills than life-threatening ailments, there's a problem.

And that problem isn't going to be solved by allowing the Health Care Industry Trojan Horse into the tent.

People are asking the wrong questions.
I say follow the money.

When I was a child, Doctors still came to your house if you were sick. Even if you didn't have insurance a person of 'modest' means could afford hospital treatment. If you didn't have money, there was a county-run hospital where you would be treated.

We need to ask... what changed and why?

Billions of dollars are flowing into somebody's pockets. Whose Pockets? Why does a basic room in a hospital cost $10,000 per day?

If this is [allegedly] supply and demand, why is the supply of medical care constrained?

Given that money controls our political system, solving this problem likely isn't going to happen until there are literally people at the barricades.

Public campaign financing is where it all must start... Progressive people should focus 100% of their attention on that issue. Good things will follow.

My late exwife died in this fashion:

She had been becoming erratic and more "eccentric" since before she lost her job in 1998. With the job loss she lost our families insurance: I was an artist, who had always done minor construction when the art wasn't selling, and I went to work with a series of contractors, building log homes. I was 42 in that year.
She developed an antiques business (starting in flea markets) and did ok: and I became aware she was carrying on a series of affairs, one with a former coworker. I must say on my part, I confronted her, and she told me I should find an outside interest. I loved the woman and didn't want to divorce, and was able to come to terms with my own same sex attraction, with steady lover in another town.
In 2001 I got a job managing a small bookstore that was essentially a rich gay couples' tax shelter: never quite profitable, but I tried. Also in that year, she had a series of strokes, and ended up at the Georgia Medical center in Augusta. We were able to arrange payments, and with my 25K salary (supplemented with an occasional art sale and some money from freelance writing) and her antiques business we did ok. Our marriage became an arrangement. She also has untreated diabetes, and would get off the diet by early '04. She bounced back, but was more erratic, had occasional seizures, became a hoarder, filling our house floor to ceiling with stuff (some of it antiques) and being abusive to me and the kids frequently.
In the fall of 2004, she complained of feeling bad frequently, and in November she was hospitalized locally with gastric pain. She would stay three day, and make me check her out, saying the treatment she got was awful because she had no insurance. She told me she had gall stones, and would go to a gastroenterologist. She also asked for a separation. I moved into the house of my employers (who were frequently gone on travel), and tried to keep my son with me (my daughter was in a nearby college).
She would take the $1200 of saving we had to go to the doctor (although I would find later she had gone to Harrah's Cherokee and blown the money gambling), and started 'home remedies' for gallstone. She dropped a lot of weight fast, and there is reason to think she used meth to do so.
Christmas day she really felt bad, and I offered to take her to the emergency room. "WE can't afford it, and I'm not going back to be treated like trash by those bastards."
The next day she was really ill. Our house had been heated by wood, and I had to put out a small chimney fire first thing in the morning, and my daughter interrupted me to say "mom is really feeling bad." I attempted to force her to go with me, we tried to pick her up, she went limp, cussed and raved, and refused. "WE CAnt Afford it!" was her refrain. We gave up, my daughter went to her job, and I hung out, thinking I might need to call an ambulance. I then got a call from my daughter who had locked her keys in her car. I told my now-ex that I was going to unlock my daughter's door, got her the water she requested, and left. When I got back perhaps an hour later, she was dead. The cat was still curled up there and 'Law and Order' was playing. I tried resuscitation but it was too late.
The autopsy said the cause of death was congestive heart failure, with a stroke and a perforating duodenal ulcer. We also found liquor bottles under her bed. She didn't have to die. I will always feel guilty about not getting her to the hospital, although my daughter says "She had it her way..."
It was the day of the great Tsunami. I imagine she was furious about standing inline at the Pearly Gates.

When patients are more afraid of medical bills than life-threatening ailments, there's a problem.

No, that's the invisible hand inevitably and with flawless exactitude finding the true value of a human life. It's not a bug, it's a feature.

</republican>

Another horror story:

A former friend of mine had a degenerative joint/muscle disease (it was not RA or MS, but I do not remember the name of the disease). Periods of activity made him ache to the point where he couldn't even get out of bed. Eventually, he was forced to quit his job as a line cook and go on disability. Fortunately, he was able to go on Medicare. Unfortunately, he also go trapped in the donut hole. He was prescribed morphine pills for his pain and would ration out the pills in order to stretch the prescription as far as possible. His wife worked a couple of jobs to try to support both of them. Eventually, the cost of the prescription became so prohibitive, that he would occasionally sell a few of the pills in order to have enough money for the next refill. Our healthcare system is truely broken.

maybe beside the point -- but i know woodhull medical center, and the guy probably did himself a favor by not sticking around.

other than for the gunshot and stabbing wounds they routinely cater to, i'm told they are NOT a go-to place.

I don't really want my doctors to know the cost of treatments. It would be great if hospitals and urgent-care clinics and such were required to have lists and someone capable of navigating the list with a patient, but given that the numbers change every month I don't want that stuff cluttering up the brain of someone who already has their head full with the stuff needed to diagnose and treat.

As a recipient of the "Canadian/British/French/Swedish style 'socialist' medicine" model, I have puzzled for years
Why do US citizens tolerate the lack of a basic right?

We've got a great piece illustrating the problem with emergency room care and how the billing is handled. Written by Kirk Nielsen, it recounts his journey after passing out and ending up in the emergency room. It's here: http://www.miller-mccune.com/health/fainting-in-america-1107

During the winter, my wife had an episode with pneumonia where we had to take her to emergency. She is covered under a medical plan. She was under observation for almost 4 hours, responded to IVs and was released. During that time, one supervising doctor entered the area and spoke with her for a few minutes. He spoke with her for about five minutes about her condition. Almost in passing, he mentioned the benefits of stopping smoking. When she reviewed her bill, she discovered that there was a $450.00 charge for Smoking Counseling from the doctor. This was, in addition, to his overseeing fees. File this under Fees Run Amok. She has refused to pay this portion which the insurance company will not pay.

But Mr Bill is being way too hard on himself. She probably stopped caring about him long long long before she died. If she was truly acting in this way, there was nothing he could do. And to sound harsh, not the worst thing that could happen. When someone becomes such a huge self destructive black hole to everything around them, maybe she got what she wanted.

Bills of sale trump the Bill of Rights. I would like to believe that everyone is entitled to live free of medical extortion; but then we would be too European and there would be no erectile drug bonanzas. Shameful. As bad or worse than torture since good people live in pain and terribly reduced circumstances.

I don't really want my doctors to know the cost of treatments. It would be great if hospitals and urgent-care clinics and such were required to have lists and someone capable of navigating the list with a patient, but given that the numbers change every month I don't want that stuff cluttering up the brain of someone who already has their head full with the stuff needed to diagnose and treat.

I don't think anyone is suggesting that doctors memorize the exact current prices of every treatment. But having some idea of what things cost -- or what severe financial hardship having some treatments costs the average patient, including those with insurance -- is critical to the effective practice of medicine in this system we have. Simply dismissing the whole discussion of cost, as Ashlock's physician did, is inexcusable.