> the solution to most social ills in America is to simply not be poor

American healthcare works well if you have money and better than anywhere else in the world if you have money and a chronic condition. If you get in an accident, however, particularly while away from your posh neighbourhood, you’re getting the same overworked, hyper-indebted surgeon as the homeless man. (If you’re a billionaire or head of state, that’s different, but that’s different everywhere.)

> better than anywhere else

Spoken like a salesman!

It's mostly false. Last time I did a deep dive on this, the US had a genuine but small edge in treatment for diabetes and breast cancer, but that was it -- and the edge was nowhere near proportional to price.

That's something I've always been very curious about as someone who doesn't live in the US and was very unimpressed by the healthcare there when he lived there and had to deal with issues with my Asthma.

What documentation/studies did you find in your deep dive?

> US had a genuine but small edge in treatment for diabetes and breast cancer

You’re looking at gross statistics. On average, American healthcare is average. If you zoom into the top 10%, it outperforms other countries’ top 10% (in general; of course there are exceptions). This goes from virtually instant imaging with concierge medicine to the Cleveland Clinic’s global medical evacuation jets and helicopters.

Not just if you have money. If you have a lot of money. The majority of the country is one major accident away from being completely wiped out. It's the number one cause of bankruptcy.

I had an emergency this year within a very tiny insurance gap between employers and now all of my savings and retirement are gone.

I'm really not sure who it works out better for versus universal healthcare, but I can't imagine it's a whole lot.

You weren’t able to use COBRA? Or was the coverage just very poor even with it?

My probably naive understanding was that COBRA can be activated retroactively if you get in an accident during the coverage gap.

Yeah, I tried all of that. I'll spare you the details, but things just lined up in a way that made me ineligible for COBRA, but the insurance that I had at my previous employer was absolute trash and they wouldn't have covered a single thing anyway. It was the only option given aside from Kaiser (my Kaiser saga is an even longer story), and even before this emergency it covered almost nothing.

My prescriptions seemed kind of high so I checked with GoodRx and they were cheaper! Cheaper without insurance than with, like how does that even make sense?

Right now I'm trying to negotiate on my last and only unpaid bill, the hospital won't negotiate with 1st parties so I've been trying to go through a newer company called Goodbill or something. I can't vouch for them yet as it's still in process, but just trying to get this all out of the way so I can just move on. Honestly, this whole thing has been so terrible that I'm just like, nope you're not even going in the worry pile. I'll go through the motions, pay it as best I can, and move on. I'll save the worry for the next totally normal work meeting coming up :)

I'm just very fortunate that I don't have a family to support or a mortgage to pay, even though I've been very close to breaking my lease and moving in with my parents until I can get back on my feet. I mean, I make good money too, I never thought I'd be in this situation.

I will absolutely go through the insurance options with a fine toothed comb when I interview again. Mama mía, aye yay yay

> hospital won't negotiate with 1st parties

Talk to an FCRA lawyer. There are certain notices that if you send them and they are ignored can let you remove the lines from your credit report should they mark them as defaulted on. They will likely also help if the hospital chooses to sue.

I very much appreciate the tip, I'll check that out. Thank you! It's amazing how much time and work I've put into this and more info just keeps coming up. Crazy thing for people to navigate.

I don't know about poster, but offering COBRA isn't required for companies below a certain size. (I had to unexpectedly obtain private insurance to cover a gap in the pre-Obamacare era because the co I worked for only had a few employees.) It is a qualifying event for using the exchanges, but no idea about that being retroactive.

That shit is so expensive. I think I paid nearly $800 a month for a good short term policy during my gap.

Fun Fact: COBRA coverage doesn’t exist when your startup shuts down and you’re laid off.

This did not stop my insurance company from cashing my premium payments for over three months, even though they silently canceled my policy (no email, mail, or phone call). I only learned I had no coverage when I actually tried to have a dental appointment. Refunds of these premium payments took another another 3 months to be returned!

COBRA is fuxking expensive. I have no desire to pay for it again on a low salary.

Sigh. This isn't your fault. But COBRA is retroactive. EG. You have 60 days to find new insurance with a new employer. So you don't have to ever pay for COBRA. IF / when something happens - you pay all the missed bills and you are covered. That is the entire point of COBRA. People paying for COBRA are using it wrong or can't find employment in 60 days.

> So you don't have to ever pay for COBRA.

Not technically true when I used it last. I did have to pay for it.

"Employers may require individuals to pay for COBRA continuation coverage. Premiums cannot exceed the full cost of coverage, plus a 2 percent administration charge." But yes, the American Rescue Plan act allocated funds to make COBRA free. I wouldn't doubt that I was using cobra wrong at the time either prior to the passage of the act. Small pdf warning: https://www.google.com/url?sa=t&source=web&rct=j&url=https:/...

Was retroactively electing cobra not an option for some reason?

Longer story, but the timing of the emergency and recovery period fell within an ineligibility window for COBRA. My previous insurance company wouldn't have covered it anyway. It was the worst Blue Shield plan that I didn't even know could be legal. Also, I got the first few bills, was like okay, I'll just pay these off and move on and not even bother. These were the only bills I could find in their patient portal at the time. Then I got hit with the massive ones that made my head spin. By that time I had started at my new employer, my new insurance hadn't kicked in and I was outside of the COBRA window, not that it would have covered it anyway.

From now on I'm making sure I have good insurance, which requires a crazy amount of due diligence, but not something I'll take for granted anymore. It's one of reasons I'm currently trying to move to another country. Quality of healthcare is important, but how much does it matter if you're in massive debt, lost nearly everything, and don't have a retirement anymore?

What ineligibility window are you talking about?

You have 60 days to file (in writing by mail, in my case) once you leave your previous job, I didn't have enough time between jobs to really need it, emergency happens + a few weeks of recovery time where I'm incapable of basically doing anything, I get a few bills, I pay them, start working at my new job, get more and much larger bills, now I'm ineligible for Cobra. Not that it would have mattered with that insurer anyway in my case.

> better than anywhere else in the world if you have money and a chronic condition.

Which isn’t saying much. Even for wealthy people in the US, chronic conditions get you labeled anywhere from annoying to chronic drug seeker to mentally ill. Many doctors simply don’t believe that conditions that thousands to millions of people have are real, and no amount of money will change their minds. You do however get targeted for all kinds of scams!

also: when wealthy you become a customer instead of a patient.

So they will do all kinds of useless tests and treatments because that is what they earn money on.

You will never really know if this treatment is good for you or good for the hospital.

This might be true initially. But such people have networks who know people, pull strings, and move them pretty quickly to "the best" hospital in the area. You know, the Mayo Clinics, the Johns Hopkins, the Cedar Sinais of the world. It makes the hospitals happy, too because they run fundraisers and happy rich patients tend to give a lot, for just this reason.

> American healthcare works well if you have money and better than anywhere else in the world if you have money and a chronic condition.

Citation needed.

Disagree. A friend who had dual citizenship moved from Canada to the US because Medicaid covered her kids rare disease drug but Canada didn’t.

Medicaid is actually very good coverage.

With rare diseases this is always the case. Here in NW Europe we have the same issue with some one in a million diseases. The main issue is the insane prices charged by the companies to recouperate in a few years time to appease shareholders instead of several decades, which results in the cold truth it is not worth the effort looking at the grand scheme of things.

That’s the thing. The US system is expensive not only due to inefficiency but also due to a willingness to pay for things other countries don’t.

If you happen to have a kid with a rare disease, that matters.

> Medicaid is actually very good coverage.

As the saying goes, "it's the best insurance money can't buy".

Bullshit.

> No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it.

Those people deserve it. I mean, some people chose to be born to wealthy parents; if you were too lazy to do that why should I have to reward your laziness by paying to look after you? Really, some people can be so selfish!

> It is very nice indeed to be a VIP in an American hospital

My gf had a life threatening illness and went to Stanford hospital. They gave her the special blanket just for Stanford Faculty so she'd get the VIP treatment. Which in practice meant nothing. Thankfully she survived; now I wonder if I should be glad or not that VIPs get the same shitty health care there as everybody else.

VIP treatment means a private room and doctors who personally really actually pay attention to your treatment because the administrator has reminded them to do that, or your friend from med school/business school has asked them to do that. It is not conferred by a blanket.

BTW there is a carrot and a stick going on. Yes, the hospital admin wants to make VIP patients happy for donations, but they also want to avoid making the patient unhappy because they have resources to sue, and win. All of this is highly motivational.

I don't really think the Mr/Mrs Moneybags "VIP patient" compares remotely to a board-certified member of La Cosa Nostra Medical Mafia with an iphone full of colleagues and professional acquaintances with a friend-of-an-attending across all specialties

When you are a doctor, you're part of the club. Skipping the line and getting a consult in 30 seconds? Well, that is 15 seconds too long. Got a laceration on your child, and want a 3 layer closure by the head of Plastics? No issue there. Want to convene a board on your rare medical issue? Well, there is a doctors only Facebook group for that, with about 500 docs ready to chime in on their breaks.

It goes way behind this too. Indepth knowledge and advice about who the actual locally best doctors and surgeons are, across specialties (not the popularity contest or bought magazine ones either). Early tracks on new promising studies. Handouts of non-scrip medical supplies like event swag. Pharma-reps wanting to market their novel products and spread the info on them. The amount of free stuff is off the charts.

I've seen exponentially more over the top professional courtesy "Good Old Docs" club from my Dr. wife and the associated professional network, than I have in any other profession by far.

I think the abortion case is more problematic than this. The laws raise a high barrier to entry, not just financial, but logistical and social. You can leave to get an abortion if you have the money, but there will be a fine on you, and you have to make travel arrangements for a very uncomfortable medical procedure. Poor people still have other, riskier options available.

"No, the solution to most social ills in America is to simply not be poor. If you are poor, stop "

In healthcare not being poor is sufficient. You actually have to be quite well off in order to not worry about cost.

Yes! My salary is twice the local average and still worry a medical event could wipeout my life savings.

There are annual out of pocket maximums. Mine is something like $7000 last I checked. Its a lot of money, but not an amount that would bankrupt most people.

Talk to somebody who has a chronic illness or multi year cancer. There are plenty ways to charge people way more than their out of pocket maximums. People also get worn down by constant mistakes and weird bureaucratic hurdles by hospitals and insurance.

I always wonder about those. Are they real? Or will insurance companies find exclusions or ways to mark things as out of network and the maximums don't apply?

Right, my insurance company tries to weasel out of paying for things all the time. I have zero confidence in the maximums.

Me. too.

cancer treatment costs can make anyone poor. just sayin'

That's why AFLAC offers cancer insurance.

https://www.aflac.com/individuals/products/cancer-insurance....

Probably you still be broke

> The out-of-pocket expenses displayed are estimated at 40% of the total medical cost, assuming that average major medical plans cover approximately 60% of the expense. Your major medical coverage may be more or less, and if an individual or family incurs expenses for non-covered benefits, these out-of-pocket expenses may increase potential unexpected costs. You will also need to pay for any limits or exclusions on your benefits which may include the number of refills for certain drugs, visits to certain specialists, or days covered for certain benefits.

How do I figure out if I need something like this and how well my current insurance covers me?

I'm trying to find a case study but nothing turns up. A story - someone got a major injury, cancer, or other life-threatening hard/impossible-to-cure condition, and how exactly the events had unfolded financially. I.e. how many tens of millions the treatments were worth, how much insurance had covered, and how much was still left to pay and why. So maybe I could see what my insurance covers and see if I need another insurance to fill some obvious gaps.

All that my naive search attempts produce are mentions about people without coverage or with insufficient cheap coverage, which is a problem but a different one from what I'm trying to research. Oh, yes, and lots of mentions of out-of-network ambulance drives' crazy costs - I get this one.

Do they offer poverty insurance?

Having two different forms of medical insurance can be worse than one. I’ve not had such an experience, but I’ve heard horror stories of the two providers pointing fingers at each other and refusing to pay.

My spouse is on a very expensive treatment. For the first 5 years or so, the insurance company would call us every six months to ask if we had other insurance because they do not like paying for it. I think they’ve finally stopped asking. Next, they started harassing our doctors telling them to switch her Rx over to their (fucked up) internal pharmacy. Luckily the doctor knew they couldn’t be forced to do it and called us about it. We had to call the insurance company and tell them we aren’t changing pharmacies and to stop calling us or our doctors about it. They continued to call for a few months but have apparently relented.

The other solution is simply not to be sick. If you're sick, stop it. Welcome to America.

Or don't be racist and rebuild the social safety net

Americans desocialized because of equal rights.

What does racism has to do with broken medical health care system in the US?

Privatization since the 60s is a reaction to equal rights and "welfare queens"

> the solution to most social ills in America is to simply not be poor

No, the solution is to be either poor or well off. The lower middle class are the people that have the most to worry about in the US healthcare system.