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Chapters

  • 06:31 Juanne from Ontario
  • 11:44 Insurance and surprise charges
  • 17:55 Insurance's humble origins
  • 20:06 Insurance competition raises costs
  • 24:40 Hospitals flex their power
  • 32:44 Joel from DC
  • 37:11 American medical coding oddity
  • 48:24 Emergency service private equity
  • 53:07 "Residency and training, or free labor?"
  • 56:29 Matt from Nashville
  • 1:03:57 What can we do?

Thank you Andrew Lenec for completing this transcript!


David Torcivia:

I'm David Torcivia.

Daniel Forkner:

I'm Daniel Forkner.

David Torcivia:

[0:04] And this is Ashes Ashes, a show about systemic issues, cracks in civilization, collapse of the environment, and, if we're unlucky, the end of the world.

Daniel Forkner:

[0:12] But if we learn from all of this, maybe we can stop that. The world might be broken, but it doesn't have to be.

David Torcivia:

[0:19] Daniel, we've got a very spooky show this week for October, the spookiest month of the year, and in fact it's part of a whole spooky series that we're covering throughout this month for the next 3 episodes, and in fact this is the most terrifying topic I can think of.

Daniel Forkner:

[0:35] What is it David is it? Is it, uhm...

David Torcivia:

[0:38] Spooky scary.

Daniel Forkner:

[0:40] I'm guessing it has to do with the bills that we're going to be receiving in the mail pretty soon related to our intellectual property show.

David Torcivia:

[0:47] Oh yeah. I had sort of pushed that into the back of my mind and...

Daniel Forkner:

[0:51] Well, I spooked ya.

David Torcivia:

[0:53] I'm trying not to think about it, but you're right, it is bill-related. It's just not exactly those bills that you think. I'm talking about healthcare, baby.

Daniel Forkner:

[1:03] That is spooky.

David Torcivia:

[1:05] We all have this huge fear of the doctor. It's something that a lot of us grow up with. When we're little, you go to the doctor, you get a shot, it's no fun. Like, 'Oof, I don't like this place.' The environment there is sterile, it smells weird, there's a bunch of sick people, those chairs in the waiting are uncomfortable. The magazines, they're all wrinkled and gross and old. It's not a fun place. But as we grow up and get older and experience the doctor firsthand as the person that brings ourselves to it, I think it gets much scarier for a lot of us. And I know I and many other people are terrified of being sick. Because being sick is not just about, 'Oh, I'm feeling bad, I'm going to go get help, they're going to make me feel better eventually and then I recover... hopefully.' But it's also this extra step where, after this conversation of, 'Okay here's this thing to help you feel better,' comes the really spooky question, 'Now how are you going to pay for this?' And it's really the center of this show, and of the next couple shows, how healthcare has turned from about helping people to about extracting as much money from each of us as possible.

Daniel Forkner:

[2:07] And healthcare in America, and that's what this show is, healthcare in America, gets a lot of attention. Obviously there's a lot of controversy in Congress about how to pay for healthcare, and a lot of people understand that it's out of control at this point. The spending, the costs... and many people relate, David, to exactly what you just said: the fear of, 'What's going to happen if I have to go into the hospital? What's going to happen if I get sick? Will I be able to pay for it? Will my family suffer?' This is truly a nationwide problem. 20 to 25% of our gross domestic product goes to healthcare spending, which is two to three times that of other countries, for no additional benefit. 20% of people under 65 that have insurance cannot pay their health bills easily, and half of everyone that is uninsured are struggling with healthcare bills. In the past 10 years, spending on health services for people with employer insurance increased 44%. But at the same time the burden of paying for these costs have increasingly fallen on individuals themselves. In 2007, only 5% of these insurance plans had high deductibles. By 2016, that number jumped to 29%.

David Torcivia:

[3:23] In fact, healthcare spending dramatically outpaces the growth of our economy. Every year, healthcare spending increases by almost double the rate that our GDP does, meaning that what little growth that we see in our GDP annually, well, much of it is made up of the fact that many of us are paying far more than we can afford in order to protect our health.

Daniel Forkner:

[3:42] We live in a system, David, where patients have no idea what the cost of a particular visit or operation will be, in part because costs vary wildly depending on the 'where' and the 'who.' Costs can literally vary by a factor of 10 for the exact same procedure or medication. And this really can't be exaggerated. In Elizabeth Rosenthal's book, An American Sickness, her first case study is a patient with psoriatic arthritis who gets billed well over $100,000 per visit every couple of weeks. For a 3-hour infusion of a drug that cost just $1,200.

David Torcivia:

[4:21] We are collectively paying more for healthcare than any other place on the planet. But we're not really getting anything additional for our money. For example, people diagnosed with cystic fibrosis in the United States live on median 12 years less than people diagnosed with the same condition in Canada. In the past 20 years, the price of insulin has gone up 1200%, causing many people to ration their use or simply go without it, as was the case for Alec Rashawn Smith, a 26 year old who died in May of this year because he simply could not afford his insulin.

Daniel Forkner:

[4:57] But David, this is a personal topic. Healthcare in America is something that impacts so many different people in so many ways, so we thought it would be appropriate in this show to incorporate some personal stories. Here's a written comment that someone wrote to us: "What really gets me is the fear of having to go to the doctor because of the cost. Certainly there are preventative measures one can take to keep from getting sick or injured, but often times we end up feeling like the chances of us getting food poisoning or slipping on a patch of black ice and injuring ourselves might as well have been dictated by a coin flip. People shouldn't be scared to go see a doctor. They should feel welcomed, and in good hands, and if a price tag is preventing that then we ought to reconsider how we approach healthcare."

David Torcivia:

[5:44] We agree that we ought to reconsider how we approach healthcare, and so this is part one in a three-part series on healthcare in America. In this first part we cannot go into every little detail of the system, nor, believe me, would anyone want us to. But we want to provide enough evidence that suggests the system of providing healthcare in the United States has been derailed from the tracks of social good, to one that Wall Street is well-acquainted with: profit and returns above all. And this is fundamentally a different narrative than the one that says high costs are what we pay to incentivize life-saving innovations in quality care. No, this is not a normal system. This is a broken system.

Daniel Forkner:

[6:27] We said we would incorporate some personal stories. Let's start with Jan.

Jan:

[6:31] My name is Jan and I currently live in Windsor, Ontario, Canada, and about 10, 12 years ago I went to California. I was going to a conference there, a screenwriters conference because I'm interested in script writing, and I was staying with a friend in Ventura.

[6:51] And we went to the first day of the conference and we had lunch in the hotel, and then on our way home we stopped at a Burger King to get a couple of Diet Cokes and then we got home. The next day we were both violently ill with food poisoning, and we were so sick we couldn't both go to the conference. We were really ill. But I was really, really ill for the next... this was on a, uh, Thursday.

[7:18] So Saturday night my friend and another friend of mine, they said, 'We're really worried about you, we think you should probably go see somebody.' And I was like, 'Yeah, probably a good idea.' So we ended up going to a hospital and there were two hospitals and I said, 'Well, why don't we go to, you know, Hospital A, which was right there, and they said, 'Oh no, no, that's a public hospital.' And I'm from Canada: to me I was like, 'Well, public hospital, what's the difference?' They said, 'No, you don't want to go to a public hospital, trust us. You don't want to go to a public hospital.' So they took me to a private hospital which, you know, I figured they knew best. So we went in there and it wasn't busy so I was seen pretty quickly and they said, 'Well, what's your problem?' I describe, you know, I'm throwing up, I'm constantly nauseous, I can't keep anything down. And they said, 'Okay, it looks like you have food poisoning.' So they gave me an IV for hydration because I was pretty dehydrated and they gave me anti-nausea meds, they did that by IV push, and I lay there for about an hour and a half, and sent me on my way. And I didn't think anything about it. So I'm back home in Canada about a month later. So then about 2 weeks later I get a letter from my travel benefits insurer.

[8:33] And it says, 'You know, we've received this from the hospital in California and we're just passing it on to you to let you know this is what the charges were and we've actually negotiated it down but we wanted you to have this for your records,' kind of thing, and I opened up the enclosed bill and I just about had a stroke! Because it was, it was for something like $2,000 and they had negotiated it down to something like $1,200 and this is for 3 hours. And the one thing I remember really, really clearly was, it was $600 for the IV. Now that's for a bag of saline water, basically, and it was $600. And then for the consult with the doctor and the nurses' time and all the rest, and then probably the administration fees were probably a chunk of money, too. For 3 hours. That's, I dunno, you do the math, but that's a lot of money for 3 hours. I feel very badly for anybody in the States who doesn't have any kind of insurance who has to make that decision, do I go to the ER or don't I, because I don't have $2,000 or whatever to pay for a, a three-hour visit.

Daniel Forkner:

[9:49] Jan makes a good point and, you know, $2,000 is not that much compared to-

David Torcivia:

[9:55] I was going to say, like, we are so jaded at this point I was, like, 'Eh, $2,000, that's not terrible.' I mean, I guess this was a decade or so ago, but still, like, in my messed up head I'm, like, '$2,000 after a visit to the doctor's, that's not crazy,' even though it's, like, they literally just gave her saline, like she mentioned, but...

Daniel Forkner:

[10:14] Right, because we've read stories about people that went to the doctor for various things and came home with a $600,000 bill, so obviously things can get a lot more expensive. But this is a great example of the uncertainty around going to the hospital in America, not knowing what you're going to get. And it's easy to see, you know, we've talked about, for instance in our episode "The Robot Is In" about automation and the threat to workers worldwide who are facing falling wages and how little people have in savings... $2,000 is a lot of money. There's many Americans that don't even have that much in savings.

David Torcivia:

[10:49] I think over 40% of Americans.

Daniel Forkner:

[10:51] Right, and so the idea that you could go to a restaurant, have a little food poisoning, and then your entire savings could be wiped out as a result, it makes sense that people live under a healthcare system that makes them afraid.

David Torcivia:

[11:04] Absolutely, Daniel. And I think especially noting that she, as a Canadian, just really isn't used to this, and so while we're balking at this $2,000 number, saying it's not so bad, it's so outside of her experience that you can even be billed this much for almost nothing, because there are alternatives that work, which maybe we'll discuss at some point. This is something that she would have had to pay more for parking in Canada than she would have for the actual treatment itself. But here we are, treating somebody for just dehydration and it's enough to bankrupt a huge percentage of Americans. And because of that reason, medical debt is the leading cause of bankruptcy in the United States, and it should come as no surprise to anybody already, but after the end of this episode you will definitely understand why.

Daniel Forkner:

[11:45] Well, to move on David, luckily for Jan she had health insurance that took care of it. And many Americans do have health insurance and likely wouldn't have to face the bill that she received.

David Torcivia:

[11:55] At least on paper.

Daniel Forkner:

[11:57] Right, and so let's talk about insurance for a moment here David, because even though on paper some of our bills may be paid, the fact that costs are rising so dramatically in the American healthcare system, the fact that services, pills, medical devices, ambulance rides, because all these things are so expensive, well, it's bad for everybody because it drives up insurance costs. It drives up the premiums we have to pay. It drives up the deductible limits that we're on the hook for, and it encourages these prices to keep climbing.

David Torcivia:

[12:29] And there's one word for healthcare insurance Daniel and it is: complicated. It's difficult to understand all that is going on behind the scenes, especially when you do everything you're supposed to do and still wind up with surprises. Here's a comment somebody wrote on a medical-related forum: "I once had to go to the emergency room, which is in-network. One of the doctors that came to me was out-of-network, so I was charged out-of-network charges, even though the hospital was in-network. Fabulous healthcare system we have. Really did a swell job of putting our heads together on this one, America." You laugh, Daniel, but this actually happens a lot. Now, what happened was this individual was likely seen by an emergency room doctor that was acting as an independent contractor, which the majority of ER doctors in this country now are.

Daniel Forkner:

[13:16] Yeah, that's right David. So let's break this down for a second. Most people with health insurance understand that there's a network of hospitals that will take their insurance. And in order to receive covered care they need to go to one of these hospitals. But the surprise comes when the doctors within those hospitals are not covered within their insurance network. So, just to clarify, the hospital you go to is covered by your insurance, but one or more of the doctors within that hospital that actually cares for you, they're not. So, how is that even possible? How is that legal, David?

David Torcivia:

[13:49] I mean, think about it this way: if you got into a car accident and then you went to get your car repaired, your auto insurance company says, 'Yeah, okay, this mechanic shop, it is covered,' so you go and get it repaired. But then you get this humongous bill because, while the shop was covered, the actual mechanic that worked on your car was an independent contractor. They came in from somewhere else, so you're on the hook for their work, even though the shop was just providing space. And, really, honestly not much more than that. It's crazy, but it's something that is standard and expected in the medical system. How this is all legal? Ehh, it's complicated and I'm not ready to explain it to you, but its possibility will make more sense when we get to medical coding and strategic billing. But for now, what's important to know is that fewer doctors than ever are actually employed by hospitals. Many are now independent contractors who sell their service on their own terms. This trend has been particularly pronounced among behind-the-scenes specialists. That is pathologists, anesthesiologists, radiologists, and ER physicians. Many of these people create their own practice and then sell their service to hospitals, refusing to do business with any insurance companies at all.

[14:57] Hospitals benefit because they are no longer liable for these practices, but who loses out? The patients. When you go to the hospital to get surgery, for example, and your surgery is in-network, and your hospital's in-network, you may think everything is covered until you receive that surprise bill a few weeks later that indicates that the anesthesiologist, who you never met, was out of network, is now demanding $10,000, or whatever figure they feel like charging.

Daniel Forkner:

[15:22] And so this arrangement results in a lot of surprise bills for patients and very expensive bills, as these doctors, the whole reason they don't want a contract with insurance plans is because those insurance companies don't want to pay the exorbitant fees they're charging. So a lot of these surprise bills patients get are also extremely expensive.

[15:38] But insurance is so complicated in so many ways. We heard from Winston, from the northeast United States, who used to work in a call center for a major insurance company that worked with mostly Medicare customers, so people over the age of 65. And then he worked for a legal marketing firm working with Social Security cases, and he told us a couple stories that were really heartbreaking. In one situation, he remembers speaking with a Medicaid patient who was trying to decide how to afford care for their children. And they were asking him questions like, 'Well look, if I get a divorce, will it make it more affordable for me to get my children covered?' because of the very complex ways that Medicaid restricts coverage based on how much money you make or how many assets you have. If you're a low-income family and you own two cars, that's actually going to negatively impact your ability to get coverage. But if you get rid of one of your cars and get that full coverage, now your income might suffer, as only one parent can get to work. On the other side, he tells stories about how many Medicare patients fall into what's known as the 'donut hole trap,' where Medicare agrees to pay for their medication after a certain deductible. But because of their multi-drug or generic drug combinations that they have to take, that deductible isn't reached within the year where the budget resets for their insurance plan, and so they end up paying a very large share of their retirement benefits on medication that is supposed to be covered by their plans, but they never reach that deductible level.

David Torcivia:

[17:14] And that's even with good insurance, with something like Medicare. For many Americans who are forced to purchase health insurance because of the Affordable Care Act, where you can only afford the lowest level, catastrophic insurance, you might be paying thousands of dollars a year for this insurance, and insurance may have deductibles of $5,000 or $10,000, which is money you don't have in the first place. So even if you do get sick you're still going to be bankrupt despite already setting aside thousands of dollars for this insurance in the first place. This is very clearly a system that is sick. But to understand how insurance got this way, maybe we need to look back at where insurance came from.

Daniel Forkner:

[17:51] That's right. Let's take a step back David, cause I feel like we're getting a little bit in the weeds here.

[17:56] Insurance was not always this complicated. It has a very simple origin story that eventually went down a much different direction in the United States compared to other countries. The first form of American health insurance really took shape in the 1920s at a Texas hospital. To help cover costs, the hospital offered the Texas teachers union a form of insurance. Teachers could pay $6 a year, and if they were ever hospitalized, their entire stay was free up to 21 days, minus a copay of $5 a day for the first week. And this plan was so successful it was adopted all over the country, and it was called Blue Cross.

David Torcivia:

[18:36] So this plan was an individual thing. Like, you would come in and decide to contribute to it yourself and be part of it. And it quickly expanded beyond the teachers unions and people were signing up on it, and Blue Cross was devoted to being a non-profit system. It was solely there to protect people and to make sure that hospitals could still stay open, people, if they got sick, wouldn't be bankrupted by the process. Well, this all changed right after World War II. So at the time, the government had frozen all forms of wages, salaries, and bonuses, in order to spur the wartime economy, which made it hard for employers to attract workers. So many employers, in order to get around the freeze on wages, offered to pay for employee health insurance as a way to attract labor. As a result, the range of health coverage exploded. Blue Cross now had a friend called Blue Shield, and the majority of Americans signed up for this coverage. Now, insurance at this time was still non-profit. All rates were the same and no one was denied coverage.

[19:33] But the large market for insurance incentivized the creation of new private, for-profit companies to get into the insurance game. They could make money by marketing more attractive plans solely to fit and healthy segments of the population. And this eventually left the non-profit Blue Cross Blue Shield plans with the most risky and expensive clients. Of course this meant that BlueCross BlueShield had no choice but to eventually go down the for-profit route, raising rates and shedding its commitment to provide affordable healthcare for all in order to avoid bankruptcy.

Daniel Forkner:

[20:06] And this is really a story of how competition in the insurance market drove up prices and locked segments of the population out of affordable care. And this continues to go on to this day. And there are at least two important ways that I think we should point out, David, how competition among private insurers really harms everybody. So first you have regulation that requires insurance companies spend at least 80% of their money on paying for actual patient medical bills.

David Torcivia:

[20:37] Well that sounds like an okay thing.

Daniel Forkner:

[20:39] Yeah, it is, and it was one of the things that the Affordable Care Act fought hard to implement. You know, it means that, because insurance companies are paying 80% on care, they only have 20% left for marketing and other business activities. Never mind you, David, that Medicare spends 98% of all their money on actually paying for people's care, but let's stick to the private Market for just a second here. So David, picture this: you're a big bad insurance company. Alright?

David Torcivia:

[21:09] Awesome. I'm rich.

Daniel Forkner:

[21:10] And you know that in order to maintain a profitable slice of market share in your little corner of New York, you've got to spend a million dollars a year on marketing. That's just what you have to do to maintain market share. Any less than that and you lose customers. Your economies of scale will break down and you're going to start losing money. Well, here's the problem, David: your clients only racked up four million dollars worth of claims last year. Which means you're spending 25% of your money on marketing and advertising, which is over the legal limit. But then I walk into a hospital, David. I'm on your plan. And I've got this rare infertility disease that not many people have. And the hospital that I go see, because this is a rare disease, well they decide to charge you a million dollars. Now, I know it's a lot of money, David. You know it's ridiculous, I know it's ridiculous, but you sit down with your accountants and you realize, you know what, it actually makes sense to pay this, because now that puts your marketing budget below that 20% threshold, making it legal, and that's good for your bottom line because that's what you need to maintain your market share. So you do it! And that's the price of keeping you in business and profitable. That's the price that we all pay, slightly higher premiums for everyone else so that you can maintain your business.

David Torcivia:

[22:32] So instead of just negotiating this figure down to something that I know is reasonable, you know it's not a million-dollar treatment even if the hospital's trying to charge me that, I'd agree to accept this because it gives me that much more 20% for marketing or maybe, I don't know, my salary. It's something that I want. 20% of a larger number is 20% more for me to do whatever I need to. But of course I have to make up the difference for that extra million dollars because it's not in my budget. And like you said, how do I do that? By raising all of my members' premiums. Another way insurance competition raises prices for everyone else depends on the bargaining advantage of providers over insurers. Okay, so even if my budget was fine, Daniel, if I didn't need that extra 20% bump, I still might decide to eat the high cost of your medical bill because if I try and fight it, I'm a small enough insurance company that the hospital might choose to just drop me as a partner. And then I lose all my other clients to someone else, because who's going to want to use me if no hospitals are covered by my insurance plan?

Daniel Forkner:

[23:33] And then, because you accept that charge, and the hospital gets away with charging that huge sum, it becomes to standard that all insurers pay because now hospitals realize they can get away with it, and insurance companies again will compensate for these increased prices by raising premiums or raising deductibles across the board. So that's what contributes to a situation where it costs several hundred dollars to visit a physical therapist who is going to show you how to strengthen your wrist by picking up sand.

David Torcivia:

[24:03] This is one of these vicious cycles that continues to make things more and more expensive. So I, the insurance company, agree to pay this figure, the hospital's, like, 'Oh, they paid that. I'll increase it next time and see how much more we can get out of it.' Well, I don't want to challenge this and end up bargaining, or I need this extra money for whatever budget I need, so I agree to pay it again. And on and on this vicious cycle climbs and climbs, and this may be part of the reason why insurance premiums have climbed so rapidly over the past few years, with some states seeing increases of 50% over just one calendar year. Now let's talk about the other side of this equation. The hospital.

Daniel Forkner:

[24:40] Right. And hospitals have a lot of power. They're gaining power. In that last example, David, where the insurer chooses to eat a higher cost because negotiating with a more powerful hospital could lose out on business, this is something hospitals are trying to take advantage of. There's consolidation going on in the country right now. Hospitals are getting larger. In fact, there's a proposed merger right now which will become the largest health system in Texas. The Memorial Hermann provider plans to merge with Baylor Scott & White. It will affect over 73,000 people who visit these hospitals, and one of the big fears is that it's going to raise the cost of healthcare because this much larger provider will now have much greater leverage to negotiate higher prices with all the insurance providers in the area. But once again, David, hospitals have a much humbler beginning historically.

David Torcivia:

[25:31] For long-time hospitals and other medical providers were unconcerned with profit. Financial decisions beyond those necessary to stay afloat just weren't considered. They were often born out of large donations, and ran by charitable groups like religious organizations. In the same way that the American College of Surgeons used to vow, key word there is 'used,' to never charge patients beyond what they could pay, hospitals saw themselves as a public service to the local community. And part of their duty was to provide care for the poor and the ill at no cost. But the idea that hospitals should be run like a business changed all that, and really started taking off in the 1980s. Congress got rid of a law requiring hospitals to prove that there was a community need before investing in new facilities or machines. And hospitals started hiring MBA's and other business-minded people to emphasize their desire to improve... uh, am I going to say health? To improve patient health, Daniel?

Daniel Forkner:

[26:26] Maybe quality of care?

David Torcivia:

[26:27] Quality of care to success rate?

Daniel Forkner:

[26:29] Maybe lower-

David Torcivia:

[26:33] No.

Daniel Forkner:

[26:33] ... the amount of-

David Torcivia:

[26:35] No.

Daniel Forkner:

[26:35] ... the infection rates...?

David Torcivia:

[26:36] No. It's the bottom line. And at the same time, consulting companies started advising hospitals on something called strategic billing, and the final blow, Wall Street, stepped in to finance new investments to pay for all this that could generate guaranteed returns for their financial investors.

Daniel Forkner:

[26:55] Among all this new interest in turning healthcare into big business, David, hospitals began stripping and outsourcing whole departments that were not generating enough profit. One of the most notable examples of this is dialysis. And David, you mentioned a few weeks ago on how so many of the topics we cover contribute to diabetes. Well, as the number of people with diabetes has increased and the ability for hospitals to squeeze profit out of dialysis centers has plateaued, and even declined in some cases, these hospitals responded by shedding these services and selling their patients to large, for-profit companies like Fresenius and DaVita. Today more than 90% of dialysis patients are treated by these profit-making companies who have turned these enormous profits by cutting costs, over-billing government insurance, and marketing dangerous products. Both Fresenius and DaVita have paid hundreds of millions of dollars in settlements as a result.

[27:55] And as you would expect, these trends don't support patient health. Compared to nonprofit dialysis centers, patients have between 19 and a 24% higher risk of death at these large, for-profit centers than the nonprofit ones. And in general, people who undergo dialysis in the United States have the highest mortality rates in the world. And even so, or perhaps because of this reality, DaVita and Fresenius made a combined $1.8 billion in profit in 2017 alone.

David Torcivia:

[28:27] You know, reading about the way that these patients are treated in dialysis centers, it's really, honestly horrifying, Daniel. Hospitals basically sell, and that's the word I'm choosing to use, they basically sell patients for like 70 to $80,000 to these dialysis centers. Passing it over, it's a guaranteed revenue for the dialysis centers from the insurance that's coming in, and they just trade bodies. Like not too different than a slave labor thing, but instead of labor that they're purchasing, they're purchasing the fact that this person is sick, and needs treatment to survive, and insurance is going to foot the bill. But it quite literally is a trade of bodies, and there is a dollar sign applied to every individual body in that process.

Daniel Forkner:

[29:10] Well, you know what I think is really interesting about the fact that hospitals, in order to be more financially attractive to investment, is they shed these departments that aren't making money. And maybe that makes sense to us now, like we've become normalized to this, like, 'Oh, it makes perfect sense! If the hospital isn't making money on something, it shouldn't do it.' But think about what we're talking about here, David. We're talking about healthcare. We're talking about providing someone care for a disease or an illness, and traditionally this is what hospitals have been about: helping people who can't afford care, helping people receive care. It's not something that was ever meant to be profitable. Because what profit is there in disease, David? It's a negative thing. It's a cost to society no matter what. There's no profit to be made from someone getting sick in our society.

David Torcivia:

[30:00] Or there shouldn't be.

Daniel Forkner:

[30:02] Well, yeah, I mean, if someone is making money off of it, it means we're all losing out in some way, because it's already a loss. And we should be... I guess the question is, 'Does it make sense to consider disease and illness as a business opportunity, or should it simply be a cost to society that we all pay for, and focus our attention on the quality of care and on prevention, so that that cost can be as minimal as possible?'

David Torcivia:

[30:29] Well, bringing up preventative care I think is important here, and this is one of the major departments that was slashed by this process to try and strengthen the bottom line. Because preventative care is hugely not profitable for these facilities. I mean, think about it this way: if you have somebody coming in and they need something stitched or they need a medication or they need treatment or surgery or something, the hospital can bill a lot of money for that. And we'll talk about coding and upcoding and stuff in a moment. That's where the story sort of really gets dirty, if it isn't already. But preventative care is something that we should all be aspiring to. Like, this is the most important part of the healthcare process, because the better that we can keep people healthy and out of these hospitals, the better off society and all of us are. For a huge variety of reasons: one, just because quality of life in general is improved, for both individual and for all the people around them. You're not burdened by somebody who's sick, you're not burdened by their medical bills, you're not burdened by treating for them, caring for them, worrying about them. The loss of a loved one is something that could be prevented by this preventative care. All these things are important and hard to assign external cost to, but they're hugely, hugely valuable. Of course, those costs don't show up in the bottom line, and even if you want to get economical with it you could assign something with lost work or productivity gains by keeping people healthy, the cost of Medicare eventually when it does get to that societal cost, if you can keep people healthy longer then you're not going to be paying as much money for them when they do eventually get sick. But general preventative care, things like exercise, things like eating right, basic check ups and physicals, these things are discouraged. And we are encouraging people to get sick, to live unhealthy lives, because ultimately that's more profitable for the healthcare system itself.

Daniel Forkner:

[32:10] Well, when we do get chronically sick, David, we become the ultimate consumer, right? I mean, if the for-profit dialysis companies are making, you know, close to $2 billion a year in profit, that's surplus money. Then they are directly benefiting from one of the most deadly chronic diseases in the world right now, diabetes. And so does it make sense for these for-profit companies treating this disease to support anything that would actually prevent it? Maybe not. But David, enough from us. Let's hear from another personal story.

Joel:

[32:45] Hi my name is Joel from Washington D.C.

[32:48] I used to deliver pizza, and I got assaulted and robbed one day, and I ended up with a stab wound, which was possibly from a screwdriver or an ice pick. They're not sure which. I needed (help) bad and so, 10 minutes later. So, I was kind of in a daze after that... I remember getting in the ambulance and making some calls to my family, and I, I think at one point I said to the EMT that, uh, 'I don't have insurance, I don't know how I'm going to pay for this.' And he's, like, 'Oh, that's fine, don't worry about it.' Then I go to the hospital, and they checked me out, and they did an MRI, and they... Sorry, I'm a little bit traumatized by this... Uh, anyway, I had the MRI, and then they, like, examined the area, and the wound, and, uh, they put in a catheter, and they, uh, I don't know how to describe this... checked my anal cavity. Umm... it was very uncomfortable. And then so all this happened, and I was there for four hours, then they said, 'You don't need stitches. We're going to give you some bandages and tell you how to dress the wound.' And then they came and they were, like, 'Oh, so, how are you going to be paying for this?' And then I'm, like, 'I don't have anything. I don't have insurance. I don't know how I'm going to pay for this.' And he said, 'Oh, we're going to work out a payment plan,' or something. And then what ended up happening is my work had this, like, ghetto insurance if there were, like, injuries or the store was robbed or something, so I guess I fell under that. And I was able to get them to pay for the majority of it, which was almost $10,000. They didn't really do that much... and then I had a tetanus shot, and then (a nurse) give me some advice. I got about five separate bills. I got one for, uh, the doctor, one for the MRI, one for the shot, one for the ambulance, and there was another one that I don't remember. It was, like, maybe for administration or something? And the one I had, the major one was like $6,700, and that was for being given a bed, basically, and sitting in the hospital, waiting for them to tell me what to do. So I don't know exactly what I was paying for there, or being charged for.

David Torcivia:

[35:12] You know, pizza driving is like one of the most dangerous jobs, actually. They get robbed and attacked all the time. Salute to pizza drivers, y'all are in way more danger than cops, so, like, hats off to y'all.

Daniel Forkner:

[35:24] David, let's summarize this story really quick from Joel. [He] was on the job, got attacked, gets sent to the hospital, he's there for, what, three, four hours, they teach him how to dress his wound.

David Torcivia:

[35:37] The whole time complaining that he can't pay for any of this.

Daniel Forkner:

[35:41] Right. They don't give him stitches and then they send him on his way, and then he gets a bill for $10,000. That's insane. You know, luckily his company paid for a majority of it. I wonder how much he was he was on the hook for, though. And imagine if he hadn't been working for the pizza company and this had happened when he was just driving home from a movie. Would he have been stuck with that $10,000 bill himself as an uninsured person, and what might that have done for his future?

David Torcivia:

[36:09] Medical bankruptcy, Daniel. The answer is medical bankruptcy. Actually, I know a guy who was in a car accident and he broke both his arms, I think. And he went to the hospital and they treated him and took care of him and then he had this, at the end of it this medical bill that was reaching six figures. And he was just, like, 'You know what? Screw this.' And he just dropped out of society and now he rides around the country as a hobo, hitching on trains because he can't afford to do anything else. For some reason he didn't declare medical bankruptcy, probably because it's complicated and a lot of people don't realize that's an option in the first place. And so he hasn't held a single job for years besides just, like, for-cash migrant work where they can't dock his wages or collections come and find him. And he's literally living the life of a hobo because of this medical impact, and if Joel hadn't had that worker's insurance then he very likely might have ended up in a similar situation. Maybe not traveling on trains, but certainly with no hope with what to do and how to pay for this.

Daniel Forkner:

[37:11] Well all of these stories, David, that we've heard, they involve confusion over the amount that is charged. Joel received five separate bills in the mail. And this is a common experience for millions of people in the United States. You go to the hospital thinking that you're going to receive a routine procedure, next thing you know you get a 20-page bill in the mail with a list of expensive charges that you don't understand. And part of the reason for this is the way the United States uses medical codes, which is different from any other country. And so first let's explain, David. What is a medical code?

David Torcivia:

[37:44] That's a great question, Daniel, and the origins of modern medical coding began way back in 1893 when French physician Jacques Bertillon, along with several others, created the Bertillon Classification of Causes of Death. This was commissioned by the International Statistical Institute to standardize all the known causes of death, so that they could be identified in any country and tracked across borders. The World Health Organization took over the system in the 1940s, allowing even greater standardization around the world, and it became known as the International Statistical Classification of Diseases, Injuries, and Causes of Death. That's a mouthful. So let's simplify it: the ICD. While the purpose of this global effort is to provide a public good for tracking and understanding global health patterns, the United States increasingly use medical codes not just for announcing cause of death, but for financial reasons, adopting more and more complex codes for insurance and business purposes. What that means is that codes are used to inform financial value. The code for heart failure, for example, is 428. And the code for acute systolic heart failure 428.21, is a billing difference of thousands and thousands of dollars.

Daniel Forkner:

[39:02] This has led to the emergence, about three decades ago, of an entirely new profession: the medical coder. And huge Industries have sprung up to support these coders with opposing goals. There are coders that work for hospitals and other providers that try to figure out how to bill a patient from maximum profit. While there are coders that work for insurance companies that then try hard to reject the codes hospitals charge, and also, you know, they try to lobby regulators for lower value codes. And it's crazy how much this back-and-forth search for profit has ballooned out of proportion, and how complex the practice of billing patients has become. There's a big industry dedicated solely to educating physicians, hospital staff, and these medical coders themselves on how to maximize their profits and avoid losing money. It's part of something called revenue cycle management. Here's some copy, David, from one of these companies called Billing Paradise.

David Torcivia:

[40:00] That is a dystopic name.

Daniel Forkner:

[40:03] [Laughs] "As a physician, you need reliable and efficient business intelligence systems which provide automated revenue reports of your practice. Unless a physician is ready to lose large sums of money, understanding medical billing reports and using the right software to provide automated revenue reports is a must." And so what their software does, in part, is it tracks every single medical code a provider uses. It tracks the revenue they make from these codes and how long it takes patients to pay the provider back. It then makes recommendations on how the provider can ascribe different codes to make more money, or change the way it bills, all so that the doctor or hospital can maximize the amount of money they make from patients.

David Torcivia:

[40:50] Hold up. Stop right there. Record scratch. So this software is literally designed, not in order to help the health care of the patient or to maximize their quality of care or anything else, it solely exists to maximize how much they can charge that patient. That is the entire purpose of this software. They say, 'Okay, we could have a 428-point-whatever, but if weill increase it to this 428.21, well that's more profit for the hospital and ultimately for the doctor, which we will talk about in a moment.

Daniel Forkner:

[41:22] Well, a lot of these medical coders, David, they don't work alongside the doctor, they don't follow you around when you go to the hospital. You know, a lot of them work from home, you know, they're mobile, they get paid hourly. And so it can create some interesting situations where patients are billed for things that never happened. There are examples of patients that, that give birth and then they receive a bill for, you know, something like circumcision, which they never had the doctors perform. But these medical coders, they look at the situation, they say, 'Okay, this is what the patient went through. These are likely all the procedures that happened. We can make more money if we bill for this versus that. The insurance company likely can't refute that because they don't know exactly what happened.' I mean, it gets complex, and to be fair, David, it's not like the businesses selling these services are inherently malicious.

David Torcivia:

[42:07] Yeah. Right.

Daniel Forkner:

[42:08] They're trying to help hospitals and doctors streamline their administrative tasks, avoid errors, while at the same time increasing revenue. But the fact that this industry is necessary in the first place is a symptom of an overly complex system. It's a financially-driven system, and the money these companies make is coming straight out of the pockets of the American people. We are the ones paying for this.

David Torcivia:

[42:32] But hold up, you're thinking, 'Why would my doctor, someone who's taken the Hippocratic oath to do no harm, allow the hospital to alter the codes a patient is billed for?' You might be wondering, 'Why does a doctor not simply write down exactly what they needed to do to provide you the right care, and then have the hospital, their staff, or whoever just bill you exactly for that?' Well, I mean, number one: many doctors never see the bills. They have no idea exactly what you're being charged for. But beyond that, and here's where it gets really dirty, there are additional perverse incentives going along with these medical codes that incentivize the doctors themselves to engage in a process called upcoding. Hospitals have a long history of demanding physicians to bring in more revenue, from converting them into those independent contractors, to paying them based on the amount of revenue they bring in. That's right, you probably didn't know this, but your healthcare is commission-based. Just like when you buy a used car at that shady car lot. In fact, today over 70% of all physician practices are paid in some way based on their "productivity." What that means is that when a patient comes in and describe a symptom, the doctor has a choice: we can perform a basic service like a steroid injection, which is just a quick shot, or use an unnecessary ultrasound machine to assist the injection which of course will add a few hundred dollars to the service If the physician chooses not upcode, but their colleagues do, they'll be punished with a lower income.

Daniel Forkner:

[44:02] Well that's from the hospital's perspective, David, but you mentioned earlier in this episode about those out-of-network doctors, the anesthesiologists, the pathologists, the ER doctors, that are contracting with hospitals and then billing patients who have insurance, and then refusing to contract with the insurance the patients have, resulting in higher charges. Well, the explosion of these types of physician-owned specialists, and the centers that they open, this has been driven in part by the profitability of these codes.

[44:34] When Medicare created a system that's used for determining how much it would pay for these medical codes, it turned the management of that system over to the American Medical Association which is made up of physicians themselves. And these physicians then lobby the association to improve the value of codes specific to their practice. So imagine there's one pie of money, David, that Medicare's willing to pay each year to physicians as a whole. And then how that pie gets split up is determined by the American Medical Association. You know, if it raises the value of one code, it has to lower the value of another one. But because of the way that this process is structured, specialists get a lot more power and leverage to negotiate and lobby for their codes than the generalists, which has led to extremely profitable specialist practices like radiology, and like physical therapy, at the relative expense of other physicians. And so there are really two broad forces going on here that are driving the bills up related to these codes.

[45:39] On the one hand medical coders are looking for ways to apply as many codes and what the highest value is possible to your particular visit, and then the physicians themselves are incentivized to perform as many steps as possible to add as many ancillary services to their process to qualify your visit for those higher charges.

David Torcivia:

[46:01] This process is so slimy. And ethically dubious and disgusting, and we're not the only people that think so. In fact the American College of Surgeons, as we mentioned, changed their ethics code to get rid of the part that said, "I will never charge patients beyond their ability to pay" from their pledge. The American Medical Association's code of ethics used to say that their physicians fees "should be commensurate with the services rendered and the patient's ability to pay." It sounds nice, but that latter bit, the one about the patient's ability to pay? Well that was later removed in the 1980s. These groups have realized, and have changed their own ethical standard to include the ability to exploit us for the care that we are provided. To charge us as much money as they possibly can in order to profit off our disease, our sickness, our lack of health. When did we turn our hospitals into used car lots, where doctors are working on commissions depending on how much they can charge us, how many tests they can run, what expensive drugs, which we'll talk about in the next episode, what expensive treatments, care, anything they can possibly imagine to click on in order to make more profit? Like, this is so gross! How did we get so far from the idea that healthcare itself should be non-profit, should be provided for as little as possible, even free those who cannot pay.

[47:22] I mean, we're so far gone at this point. There is no saving this system. And the Affordable Care Act attempted to do that, but in many ways made things worse, like we talked about with the catastrophic insurance, people being forced to pay for insurance that still will bankrupt them when the bills come due. The entire system is sick. It cannot be cured. And we need to put it down and start with something else. But who is really to blame for this process? We all know, and those are the people who are paying the closest attention to the bottom line.

Daniel Forkner:

[47:51] Well David, someone might criticize us as being a little bit too idealistic here. I mean, we're saying how the profit incentive that has infected this system of healthcare is wrong, and maybe someone will see that as, 'Look, it's just not realistic. We live in a world where things have gotten more complex. Disease has gotten a little bit more complex and we need to spend more to treat it and we need to incentivize all these doctors and these providers to innovate a solution, and if that means they get paid then that's just the cost that it takes.' But let's examine real quick another startling trend that might suggest something else.

[48:30] And that's the increasing role that Wall Street private equity is playing in this giant equation. You see, in the wake of the financial crisis, private equity firms swept into many sectors of the economy to purchase distressed assets and investments for pennies on the dollar, and then used techniques for cutting cost, filing suits, increasing prices, and lobbying for regulation in order to make money. That's the goal of a private equity firm, whether they're using the money from pensions, banks, or investor cash, the goal is to purchase an asset at a discount, squeeze the asset for more money, and then dump it, or sell it, or enjoy the returns after stripping it of pesky things like employee benefits or employees themselves.

[49:16] And although Wall Street's most infamous roll after 2008 involved the housing market, firms also approached cash-strapped municipalities and bought up things like fire departments, where they made money by introducing really clever innovations like billing people for showing up to their burning homes. The New York Times reported in 2016 how one of these private fire departments sued a man for $15,000 after showing up to his house once it had already burned to the ground. But the same article also reveals how firms bet on emergency services as a good investment, and bought a number of services like ambulances. When the money they thought they'd make didn't pan out these, firms either filed bankruptcy, which disrupted ambulance response time, or slashed costs by laying off EMTs, or in one case even encouraging paramedics to steal medical equipment to keep their ambulances stocked. But private equity or not, just about every ambulance company now charges a fee to deliver people to the hospital. And in the same way that hospitals use strategic billing to maximize the amount they can get from patients, ambulance companies do the same thing.

David Torcivia:

[50:28] From Rosenthal's book, An American Sickness, she writes, "As in all the other sectors of medicine, ambulance companies progressively unbundled their bills. In Los Angeles, with sets charges for all ambulance providers, the base rate for an ambulance ride in 2014 was $1,033.50, or $1,445 if an advanced life support team is on board. Plus $19 per mile, $51 for every 15 minutes of waiting, and that didn't include extras such as to $84.75 if it's after 7 p.m., the $65.75 for the use of an oxygen tank, $27.25 for each ice pack, bandage, or oxygen mask. And because insurance companies often refuse to pay for these specific types of charges, most people are stuck with the bills out of pocket."

Daniel Forkner:

[51:17] Once again here's Joel on his experience.

Joel:

[51:20] Because the ambulance took me to a different hospital than the one that is closest, and I don't know why, I don't know... I don't understand what the point of that was. I think the ambulance ride was like $600. I think that was the last bill I received. That shouldn't even be a thing. It's not like I had any choice in the matter. If you're in that condition, you can't bring yourself to the hospital. It's just insane that you're being charged for things that you have no control over.

David Torcivia:

[51:45] You know what's especially crazy about these ambulance charges, Daniel?

Daniel Forkner:

[51:48] What's that, David?

David Torcivia:

[51:50] Is that the EMTs themselves who are riding in these ambulances or driving them, they make almost nothing. So, I mean, we can understand maybe the extremely high amounts of money that we pay for healthcare coverage within a hospital, where the doctors are making six figures or a quarter million dollars, or whatever it is, comfortably. It's expensive. It's expensive to have a lot of doctors like that. And then we'll get to residency labor in a moment. It's easy to think about this: nurses, doctors, it's expensive. But EMTs, they make, on average, maxing out about $40,000 annually. And that's after years of doing this. But a single ambulance ride can rack up bills for thousands of dollars. Who's profiting off this? It's not the people actually doing the work. It's a companies that own these ambulance systems, and the investors behind those.

Daniel Forkner:

[52:34] And hospitals take advantage of the low pay that these EMTs make. So Joel mentioned in his story how the ambulance didn't take him to the closest hospital but took him somewhere else, and it's likely because he was uninsured. These ambulance teams, they often have the freedom to take patients to any provider, and hospitals find ways to incentivize them to bring in the insured patients, which they can make more money off of, and keep the uninsured somewhere else. But as you alluded to, David, there's also other ways hospitals are taking advantage of low-wage labor.

David Torcivia:

[53:08] That's right, David. It's not just ambulance companies taking advantage of the low wages that they can pay the employees doing much of the work. But hospitals themselves are more than happy to exploit the labor of doctors-to-be in the form of their residency programs. And these residency programs are an important part of the American medical system. It's where a doctor-to-be is trained, in actual practice, to become a doctor. They get hands-on experience actually working with patients, doing different treatments, learning from people who've been there for years, and become familiar with the practice that they'll soon be joining. It's a long, arduous process: it's three years, usually, but they work very, very, very long hours, typically 36-hour shifts and it's grueling. It makes sure they have no social life and devote their entire life for years to this process with the hope that eventually they'll become a full doctor and be able to pay off their quickly-growing medical school loans.

[54:00] Now, they are compensated for this practice: most salaries for residents range from about 50 to $80,000 a year, and with additional health care benefits, employee benefits, things like that, the actual average compensation is about $130,000 annually. Now, hospitals make, somebody calculated this, about a quarter million dollars from every resident. And that's before federal subsidies for each of these residency positions of amounts over $100,000. Meaning that for every resident a hospital brings on, they're making, on average, close to a quarter million dollars in pure profit. No wonder that hospitals are scrambling to get as many residents as possible on to their staff. And because of this, the federal government has set limits on how many residencies can be at each system. And increasingly they've also set limits on how much these residents can actually be worked, cutting down on some of the very dangerous hours that they were working for years, which is something we talked about in our sleep episode where, you know, staying up for 36 hours is going to lead to long-term health effects but also, problems in the way that you're actually performing your duties during your shift. This has caused hospitals to panic.

[55:05] And so to compensate for the reduced working hours that they can get out of these residencies, they've cut down on the actual educational portion of the residency programs. Meaning less time watching procedures, less time attending lectures, and instead more time doing routine medical procedures like blood draws or looking at charts. Things that make the hospital money. We are sacrificing the education of our future medical professionals in order to increase the bottom line right now. And this has effects on patient health at the moment, and it will have drastic effects on patient health going forward in the coming decades, as these residents become full-fledged doctors but with much less education than those from the years.

Daniel Forkner:

[55:45] We've heard a couple stories, David, about how this broken system affects people personally, how navigating it can be like navigating a bureaucracy nightmare in a Kafka novel, and the high charges that people receive, and so here's a final story for us that kind of highlights the absurdity of a number of intersecting parts of this system, from the ambulance to the charges to the lack of choice. And for those of you who may be disturbed by stories of depression, suicidal thoughts, this particular story has those themes in it if you would like to skip ahead about two and a half minutes to avoid that, we would encourage you to do that now.

Matt From Nashville

Matt:

[56:30] My name's Matt, I am from Nashville, Tennessee. Now this happened actually in Boulder, Colorado when lived over there. But it was a very low point in my life. I moved to Boulder, Colorado to live with this girl. Terrible idea, I know. But after 2 years, everything just fell apart. I mean, I was like, 'Fuck it. I am just going to kill myself.' So I attempted to hang myself, and soon as everything kind of started blacking out, I was, like, 'I can't do this.' So I immediately, like, [shudders].

[57:02] You know, I'm crying, all of this shit, and I call the suicide hotline. You know, cause I see it all of the time online, like, 'Oh, if you're going through trouble call The Suicide Hotline.' And the person on the other line really did help. But about 15 minutes in they asked me, 'Do you mind if we send someone to go check on you?' I, of course, was, like, 'Please, I need some kind of compassionate human interaction at this point.' So 30 minutes into the call I get a knock on the door. And I go over there and it's two police officers. They want to check my neck, then they take me outside. They're, like, 'Put your shoes on, we're going to take you to the hospital.' I tried to talk my way out of it and they're, like, 'No, you're going no matter what.' And a couple paramedics came over and they saw it and they're, like, 'Alright, you're either going to go in the ambulance or they're going to take you in the cop car. Ambulance you're going to have to pay for.' And I was, like, "Alright, I am not doing that. I'll go in the cop car.' And they're, like, 'We don't trust you necessarily in the cop car, so we're going to put handcuffs on.' And I'm, like, 'Fine.' They took me down to the hospital, kept me there for about 4 hours, they brought a counselor in from one of the local detox centers. And he talked to me, and it helped. He was there for about 45 minutes and while he was there, he's, like, 'This entire consultation or whatever is free.' But I jumped to the conclusion that the entire visit would be free.

[58:26] Alright, 4 hours in, they asked me if I was good to go home or if I wanted to stay the whole night. I was, like, 'Yeah, I'm good to go back.' So I had a friend come pick me up. The next day they called me, and asked me to come in again, so I did. And they gave me a bill for $3,600 for the visit. Yeah... and I was, like, 'Well, shit. I'm already paying bills out the ass, I'm depressed as fuck, and now I have this on top of me.' I had no idea what to do. Like, I still haven't paid it off. I was definitely way more depressed afterwards, and I told a lot of people about it of course. Like, 'Oh, The Suicide Hotline? It's great.' And I'm, like, 'No, it is not, and here's why: they will arrest you because you're a danger to yourself and then charge you for that.'

David Torcivia:

[59:13] What a traumatic experience that is, Daniel. I mean, somebody who's in that situation where they're forced to make that kind of call... and then you find yourself, next thing you know, in the back of a police vehicle. Make it to the hospital, finally, and then get basically no help. And be billed for that whole experience.

Daniel Forkner:

[59:31] Right. And I know this is, this topic, David, is about healthcare, but to me this story's just such a great example of how we as a society feel that it's so important to outsource everything that makes us uncomfortable, everything that we should be handling ourselves, and instead handing that off to professionals. We have a society now where if people among us are depressed, are unhappy, lack connections with other human beings, we tell these people, 'Look, just call this professional hotline. They'll handle you, because we don't want to.' And this is the type of thing that can result, is a very impersonal, cold, calculating system that looks at someone who's vulnerable and says, 'Well, you know, fine. We'll take care of you, but here's your bill. Would you like to set up a payment plan?' Is that really the best system for people who are in this kind of vulnerable state?

David Torcivia:

[1:00:26] I mean, the obvious answer, of course, is 'No.' It's only a crazy, sick society that could look at something like this and say, 'Well, yeah. Of course we're going to bill you thousands of dollars for this traumatic incident.' But getting in that situation in the first place, like you mentioned, our pathological nature to try and pass off everything to a professional, is definitely exacerbating this problem.

[1:00:46] I mean, Suicide Hotline... it's staffed primarily by volunteers, they're not paid for this, so they're doing a good job but it is something that is wholly impersonal. They have training to know how to deal with people who might be suicidal, who might be feeling this way, but that's really the limit of their ability. They don't know this person. They can't reach out in a personal way. But we have these these lines, you see them all the time, people are sharing, 'Oh, if you're feeling bad, here, Suicide Hotline please call these things.' You see people online constantly posting huge, huge links of suicide hotlines in every country, like, "Oh, if you're feeling upset about this thing please call, please call.' But how impersonal has our society gotten that this is what we have to do? And the Suicide Hotline absolutely does provide a purpose. They're the person who will always pick up, and it's important. But we should be able to call those around us as well. Now, I've been on the receiving end of these types of calls before, of people that I know, of friends. And I fortunately had had a little bit of training and I knew what to do when somebody's calling you, talking to you suicidal. How to talk to them, what to say, what things you need to do in the real world outside of this phone call at the same time, and because of this and because of people like Daniel we're able to help people who needed that, who were asking, crying out for help at the moment.

[1:01:58] But how many people have that training? It's something that doesn't take that long, it's an hour or two, really, and it should be something that we have in every single school. It should be part of our standard healthcare system that extends not just to the for-profit hospitals and emergency rooms that we have right now. But into the very nature of how we teach health to children and to each of us, in our communities and in our schools. If we were better prepared to help each other, in this situation, if we know what to say when somebody calls us asking for help, these types of tragedies, and fortunately this didn't end in tragedy but it very well could have, could be avoided or helped or made less terrible. And the financial burden that evolves from it can be completely avoided. When we all know how to answer this phone call, what to say, how to help people, we're that much more likely to get that call in the first place. And this is important because things like suicide, depression, they are climbing. They are exploding at rates that we've never seen before especially, unfortunately, among the very young. Middle schoolers, high schoolers. And it's important now that we start teaching people how to handle these situations, how to respond to these calls, and the fact that it's okay to make the call in the first place. And this is well beyond the topic of this episode but it's something that I feel is important to get across here.

[1:03:13] But the professionalization and the financialization of our healthcare systems has moved away this care from individuals helping each other out, from communities providing things collectively, to these cold, impersonal situations that invariably end up with enormous bills that themselves destroy people's lives just as much as a disease or health issues that cause them to go and ask for help in the first place.

[1:03:40] Like we said, we've barely scratched the surface of the problem here. We have more episodes coming up on this for the following 2 weeks, but even then there's only so much you can say about the deep, deeply rooted systemic issues that are torturing all of us in this financialized healthcare system. But even then there are some things that we think we can do.

Daniel Forkner:

[1:04:02] First, in terms of practicality, I would encourage anybody who is dealing with medical-related issues and feels confused, feels out of the loop, pick up Elizabeth Rosenthal's book, An American Sickness. It'll go a long way in helping you to understand some of the things going on behind the scenes. But in addition she offers some chapters in the later half of the book on actual practical things you can do as you talk to your doctor, as you receive bills, ways to spot instances where hospitals are overcharging you, how to dispute those, how to negotiate for better contracts. I mean, it's unfortunate that we live in a system where, in our most vulnerable moments, the moments where we are sick, the moments where we are facing death, potentially.... Where we're making decisions about the future of our lives, dealing with chronic illnesses, those are the moments when we have to navigate a complex bureaucracy looking at every turn to confuse us, to take our money. But it is the reality at the moment, and the more we can understand, the more power we have to navigate that and to avoid being taken advantage of.

[1:05:09] And for all of us, we should be looking and supporting and educating ourselves on a better system. As healthcare insurance is framed to us in America as a marketplace, we're told that having all these choices is good for us. It's good that we have so many different insurance companies competing for our business. But as we've seen, that competition can actually raise prices and harm all of us. At the end of the day, what people want when it comes to their health is not the choice, not a marketplace of insurance programs that they can choose from, not an endless roster of deductible plans and benefit plans and payment options. What we want is the choice of our doctor. We want the choice of our hospital. We want the freedom to choose the type of care we receive. We don't want the endless choices about money and business decisions and treating our life as if it's a trade-off between health and financial disaster. And so looking at some kind of single-payer system where we can cut out so much of these middle men simply taking advantage of openings in markets and ways to make profit could go a long way in helping to alleviate some of this wasted time and heartache that so many people in America have to go through.

David Torcivia:

[1:06:32] This is not a political issue. Despite what you've been tricked into thinking by the media and the Democrats and the Republicans. Single-payer healthcare, or Medicare For All, or whatever term you want to call it at this moment is a bipartisan issue. People across the aisle, on the far right, on the far left, and everyone in the middle, want this. A huge majority of Americans want this. There is no lack of support for these ideas. People are fed up with the healthcare system. Rightly so. And we want something that's different. We want to change of this. And a change is there, ready for us.

[1:07:14] But our politicians, they are not interested in this system. And though some have realized that they can come around to this because this is something with so much support from both sides of the aisle, it is something that we are having to drag them kicking and screaming across, because they are financially invested in the continuation of the financialization of our healthcare systems. They profit off of this, and the people who lobby them profit off of this, as well. The healthcare industry is approaching 20% of our GDP. That's money we're spending to try and stay healthy. But we're not the ones who end up with that money, those are going into a concentrated small amount of insurance companies, of hospitals and of Wall Street investors. And though some of us get the end results by our stocks that we might hold along the way, that is not where we should be profiting. We should not be profiting off the sickness of others. And the people who are most impacted by this, of course, are the poor, are the minorities, who are far more likely to not be able to afford this care. Far more likely to not have insurance. Who are far more likely to get sick in the first place because of the way our systems come down on them that much harder than those who have the means to avoid these problems in the first place. The United States has amazing of medical care. We have some of the best technology, some of the best doctors, some of the best training in the entire world. But it's only available for a very small amount of people.

[1:08:37] The rest of us, who live outside this, can only look inside and say, "I could be healed right now. I could be cured by this. But it will ruin me. I will be bankrupt. My savings will be gone."

[1:08:50] There was a Nobel Prize winner who just died, who had to sell off his Nobel Prize for three-quarters of a million dollars in order to pay for his healthcare expenses as he died. That is the nation that we're living in right now. Where even the most wealthy of us - that prize comes with a million-dollar prize - are forced to pay everything, and still not find the health that they're looking for. This is a system that's sick and cannot be cured. We are not customers. We are patients. And driving home the distinction is so important. I'm not usually one to advocate for legislative change, but we have no choice here. We have to step in and say, "Medicare For All, single-payer, whatever you want to call it, is not an option. Any politician who does not support these plans who doesn't actually work towards enabling them and making them a reality is not our ally. They are there to profit off of our suffering, our pain, and our misery, and they do not deserve our support no matter what other policies they have.' There is no option going forward. This is a matter of life and death for a huge amount of Americans, and anybody who does not support this is willing to profit off the death and pain of others and that is wholly unacceptable. And I will not stand for it, and I encourage you to do the same.

[1:10:14] Beyond that, you can actually shop around for your health treatments. You can call up hospitals, ask them how much something's going to cost, and they'll give you a price list. You'll spend a long time on the phone, you'll have to talk to a lot of people, but you can get these costs. So when your doctor prescribes something or says you should get some tests, ask around and you can end up saving tens of thousands of dollars because you took the few hours it takes to make these calls. Of course, again, that's a luxury that only those of us with enough time in order to spend hours on the phone calling around, shopping around for medical care can do, but that is the reality of our situation at the moment.

[1:10:51] I hope for a day that the healthcare system can return to its not-for-profit, and truly not-for-profit system. There are plenty of not-for-profit hospitals that exist right now, but they are profiting just as much as the private ones today by these upcoding practices, by clever financial accounting. They are there just as much to suck the money out of us as any other. But a truly not-for-profit healthcare system, where profit doesn't even enter the conversation or equation, where we're solely concerned with patient health, welfare, and a healthier society and culture at all, is what we need globally. Not just in the United States, but here more than anywhere we can really feel the pain of when we are not given this. We're just not going to take anymore at this point. This is not an option. We need something better. We're not going to fix this broken system, so it's time to ask for, to beg for, or ultimately to take and create something new, something better.

Joel:

[1:11:47] I just really want to get involved in, like, the drive for universal healthcare when I get back. This is something that's really important to me because of what I've experienced, so I definitely want to volunteer or something, and try to help to build a system in place that will help others, so that they don't have to experience what I've experienced. Because no one deserves that.

Matt:

[1:12:08] I thought it was all going to be free. I didn't have health insurance. I haven't had health insurance since I was in the military. So... yeah, there's no way of paying it off. To this day I still don't have, like, TennCare, Medicaid, whatever you want to call it... health insurance? There's no way I'm able to afford that. And I have medical problems to this day. Ya know? It... sucks. But... whatever.

Jan:

[1:12:35] And I will mention as well that, because single-payer here in Canada, A: the administration costs are much lower because you're dealing with one insurer, which is the government. And B: because it is a single-payer and because it is a single negotiator, the government negotiates with all the providers. The providers for IVs, the providers for drugs, all the rest of it, and so the costs are lower. We do have a problem in terms of doctor-to-patient ratio, but for things like, if you have cancer, you go to the front of the line. If you present the ER with a heart attack, you're in surgery. I guess the question is, 'Do you want to have to wait six months to get your knee operated on, or do you want to never get your knee operated on cause you can't afford it?'

Daniel Forkner:

[1:13:25] As always, that's a lot to think about.

David Torcivia:

[1:13:28] You can read so much more on all of this, and we really encourage you to check out that book, An American Sickness, by Elisabeth Rosenthal. It goes into so much detail and really, very clearly explains all these issues, but in the meantime you can read much more on our website as well as a full transcript of this episode, at AshesAshes.org.

Daniel Forkner:

[1:13:47] A lot of time and research goes into making these episodes possible, and we will never use ads to support this show. So if you like it, and would like us to keep going, you, our listener, can support us by giving us a review and recommending us to a friend. Also, we have an email address: it's contact@ashesashes.org, and we encourage you to send us your thoughts. We'll read them and we appreciate them.

David Torcivia:

[1:14:12] You can also find us on your favorite social media network, @ashesashescast. Next week, we continue our health care coverage, but turn towards the world of pharmaceuticals. We hope you'll tune in. Until then, this is Ashes Ashes.