Common Sense Health Care: A Guest Post

Earlier this week, we ran a Q&A with Julie Salamon, author of the new book Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids. Given the richness of her book and the primacy of healthcare as a topic of interest, we’ve asked Julie to guest post here, and she has obliged.

(Disclosure: Julie once reviewed a book of mine; and yes, if it had been a bad review I would have remembered …)


Common Sense Health Care

A guest post by Julie Salamon

Last week a young friend, an international student at N.Y.U., received an upsetting call from a bill collection agency. She was told she owed a $1,089.50 balance on an emergency room visit, the part her insurance didn’t cover.

She had a high fever at night. The resident advisor in her dorm took her to the N.Y.U. emergency room, which accepts her student insurance. After a long wait, a doctor saw her, gave her Tylenol, and sent her home.

I called the insurance company, which had no record of any claim being filed or turned over to the collection company. On hearing this, the collection company told us “to sit tight” while the two companies deal with it.

“What does it mean, to sit tight?” the foreign student asked. “To do nothing,” I said. “To wait.”

“Crazy system,” she said.

As problems go, the $1089.50-plus tab for a quick fix was microscopic in the face of the $2.3 trillion spent on health care in the U.S. last year — about 16 percent of the GDP compared with 7 percent in 1965. But it was a big bill for my young friend.

Sitting tight in our crazy health care system doesn’t cut it anymore. A useful June election tracking poll from the Henry J. Kaiser Foundation reports that 25 percent of Americans see paying for health care costs as a serious problem — for them.

Our market economy approach to medicine has to change. There is “a fundamental illogic to trying to contain costs in a market-based system,” writes Dr. Marcia Angell in a thoughtful article about health reform in the April 21 issue of The American Prospect.

Dr. Angell, a senior lecturer at Harvard Medical School and a former editor-in-chief of The New England Journal of Medicine, was called “an unlikely muckraker” by The New York Times in 2004, when she published a powerful expose of the drug companies.

Her position on health reform appeals not to corporate interests but to common sense and the desire for good medical care, making it appear radical:

“The only workable solution is a single-payer system (there, I said it), in which everyone is provided with whatever care he or she needs regardless of age and medical condition,” she writes. “There would no longer be a private insurance industry, which adds little of value yet skims a substantial fraction of the health-care dollar right off the top.

“Employers, too, would no longer be involved in health care,” she continues. “Care would be provided in nonprofit facilities. The most progressive way to fund such a system would be through an earmarked income tax, which would be more than offset by eliminating premiums and out-of-pocket expenses.”

Until then, will state and federal lawmakers be willing to rein in a system that dishes out Tylenol at $1,089.50 a pop?

susan tripp

What people forget is that single payer not only covers the uninsured, but because it removes corporate costs and bureaucracy, it ends up saving money. The Lewin Report on the California single payer legislation, which passed the state legislature, proved that, and can be read on line.

At present at least 30% of the health care dollar goes into the bureaucratic costs of insurance companies, pharmaceutical companies, HMOs. And every doctor knows how much inefficiency in delivery this system produces. That's why US meical care is 37th in quality but twice as expensive as any other country. Shameful!


So who decides what is elective? I know people who believe abortion is elective.

And what basis is health care a guaranteed right? If I am not mistaken, health care is provided by other people to you. Rights are things that can't be taken away, they are not things that are given. Privacy can't be taken away, expression can't be taken away, and in the case of Heller, guns can't be taken away. This doesn't mean that the government has to give me guns, or a printing press. I have a right not to have my life taken from me by the government, that doesn't mean that government has to provide me with healthcare.

And what about the providers. What if, because of a single payer system that destroys competition, there is no incentive for people to join the healthcare profession. Would we force people to be doctors. Of couse, this is too absolute. There will always be people who would fill the jobs, some of them good, but others probably not as good as today's.



W Horter (#120), your numbers about pharmaceutical research vs. advertising are wrong. Yes, if you pull the income statements for the very biggest pharma companies, they spend a heck of a lot of money on advertising. And some of them do remarkably little research themselves. But they are paying for that research: You'll find it on the lines marked "acquisitions" and "joint ventures" and so forth. Every biotech they buy, every joint venture they start, every licensing fee they pay is, in practice, a research and development expense. They are buying the hundreds of millions of dollars of R&D that were performed by a private biotech. They have just figured out a way to call most of these depreciable "assets" instead of "expenses".


Any inquiry seriously aimed at finding reasonable conclusions should attempt to explain the data we have rather than the data we think there should be. In the case of health care, our (the US) system has created the most expensive and worst system in the industrialized world. We pay three times the per capita health care costs as the UK, double than of France, etc, and have worse health care outcomes. Any argument that does not address this basic fact on the ground is an exercise in wishful thinking.

It is also obvious from the posts here that few people have any medical background. You cannot provide health care once someone has a crisis or acute event and expect to save money. The most cost effective treatments are preventative. Putting a patient with hypertension on a thiazide diuretic (cost:


I like the idea of universal (taxpayer-funded and absolutely mandatory) health insurance for catastrophic costs: a $10K deductible, and pay three-quarters afterwards? Maybe a $25K deductible and pay 95% afterwards? It depends on how much people are willing to pay in income taxes.

Note that I'm not trying to improve America's health with this system. I'm trying to prevent two things:

* People going bankrupt over $100K hospital bills, which is really not something that the typical family can pay, no matter how good their intentions.

* Hospitals closing because there are too many people not paying their bills.

Bankruptcies and hospital closures are bad for the economy and bad for the people who paid their hospital bills. Why should my medical emergency not receive appropriate care, just because someone else didn't pay his fair share of the bills?

I might, to be honest, pick a different system for kids. We're already providing free or nearly free health care for a very sizeable number of kids; it wouldn't be that hard to "level the playing field" and pay for them all. But for adults -- you can skip your blood pressure meds and die if you'd *really* rather buy pizza instead of your $4 prescription (most hypertension drugs are *very* cheap generics). All I want is for you not to hurt the local economy when you do that.

So far, uninsured people have a pretty strong track record for demanding life-saving care, even if the need for the care is due to their own poor choices. Frankly, I would too: dying of a heart attack is painful and frightening. If you won't voluntarily pony up for some level of health insurance to pay for the expensive health care that you will eventually demand as a "human right", then I'm willing to force you to do so with a straightforward income tax. There is, after all, no human right to force someone else to work for you for free. Slavery was outlawed a long time ago.


steve haus

Why not have "universal health care" acting as a safety net for emergency and basic care, that anyone should really have a right to (just like being looked after by the police, firemen, etc.) and that would come out of your taxes. I'm saying something efficient but simple.

However, if you want to have the very latest technology, speed, hospitals, transfers, amenities, you'd pay for a health insurance that would compete for a more efficient service than the basic government provided one. Let them compete for you just like DHL, FedEx and UPS. See who gives you the most bang for your buck. Let them chase after you.

Isn't that simple common sense?

If you say a gov't-controlled health service would never work in a country the size of a continent, well.. decentralize. give some of that responsibility to the states. Let them shape the health program the best way suited to their state. After all, a, operating model (no pun intended) that's best suited to California won't necessarily work as well in Wyoming.

The difficult thing is not so much to implement it, as it's to contain influence from health care lobbyists.



I wonder why not many people even realize there are international health insurances out there giving much better value for your money—It's one of the good sides of Globalization.

I recently did the move to a Danish international health insurance, with no complaints so far.

If at one hand it makes me sad to take my hard-earned cash abroad, at the other, it makes me sadder that the ones I used to pay the semi-criminal premiums at Oxford did not cover (most of) the care I needed.

Hey.. it's the free market, right?

Dale S.

I constantly hear about how for-profit companies provide lesser coverage at greater cost, while the government can reduce the overhead costs of marketing and bureaucracy and provide better care.

So, let's prove it. Allow the government to open Medicaid to those who wish to be a part of it, but ONLY pay for it with the taxes of those who participate in the program.

We need proof that government can adequately manage health coverage without running up huge deficits that those with private care do not have to pay for.

There is no reason that we shouldn't de-regulate healthcare to the point of having health clinics that operate as freely and efficiently as Wal-Mart. *gasp!* This is the only way to truly affordable and economic healthcare.


I am conflicted. Last year I ran up an $800,000.00+ health care bill, but my insurance covered most of it. Before incurring the expenses, I did a lot of work making sure that all of the appropriate paperwork was filed and as much as possible would be covered. This included filing a letter with the hospital stating that I refused service from anyone who was not included on my insurance plan. I also made a note of this on my admission paperwork.

Inevitably, after everything was said and done, I had doctors coming out of the woodwork asking for payment who were not on my insurance. I thanked them for their 'donation of services' (because in choosing to work on me against my wishes) and basically explained that they could go fly a kite.

I was totally disabled for three months and simply did not have any more money to pay. Learning to breath on my own and walk again was my full time job.



I have never seen so many long comments. So many comments for that matter. Great post.


#122 and #123,

People come to the ER for non-emergencies for two reasons. The first is lack of insurance coverage, as the ER is required to provide a screening exam by EMTALA (The Emergency Medical Treatment and Active Labor Act). The second is convenience. Some private practice physicians are simply unable to provide "urgent" appointments. Americans also love the convenience of 24/7 anything. Clearly a single-payer system will eliminate the first problem. It can also eliminate the second, as EMTALA was passed to prevent hospitals from refusing to treat uninsured patients. With proper protocols and the knowledge that a primary care doctor is actually available, emergency rooms will be able to refuse non-emergent patients and refer them for an urgent (within 24 hours) appointment.


W Horter 162: "the chance of someone having to go to an emergency room, as opposed to a GP, will be lessened. Everyone would have access to healthcare like I do, I have never gone to the ER for an aspirin, if I’m sick, I call my Doctor."

Most colleges and universities have health clinics. When I was a grad student, that's where I went, not to the emergency room. Why didn't the grad student in the story go the university's health clinic first?

My point is not having to go to the emergency room versus going to a GP. My opinion is that the author is not complaining about the cost but complains that else should pay for it. Which, as I mention, violates the separation theorem -- it is valued destroyed no matter who pays for it and society would still be worse off under a single payer. Do you not think that if one goes to a GP (at a lower cost) for an aspirin would still be a waste of time and money?

Single payer systems still have to ration. An example: In my community Canadian stations often have better reception than the local U.S. stations. One weekend the first winter I lived here of the 27 hospitals in Toronto 21 had closed their emergency rooms because of lack of funds. A person died because the ambulance went first to a hospital with a closed emergency room. (Yes, I know that is a single incidence is not proof.)



At #75:

"People should not become doctors to get rich; they should become doctors because they wish to help people be well and are attracted to the medical/biological sciences."

Yes and no. I would say most doctors didn't choose their profession for the money, however they need to be reimbursed for their training—ask some doctors of their social life in the third decade of their life.

Marc Brown

121 -

Speaking as someone in England I can comment:

'Some drugs are very expensive, so you can’t get them free. These decisions are made by N.I.C.E(National Institute of Health and Clinical Excellence). If you do pay for drugs that haven’t made the list, you then become liable for the full cost of your treatment including hospital stay and doctors’ fees.'

This is about treating people equally and not allowing well off people to get treatment denied to the poor. The new cancer drugs are very expensive and largely experimental - the trials simply haven't been completed for some of the them. However, I expect in England that there will be a speeding up of approvals and an end to the postcode lottery soon. But to imagine that thousands of people are not getting what is standard care is wrong - they are. What some aren't getting is last ditch experimental therapy, but neither are many in the US or in most other countries.

'There are other reasons for not being treated. One is obesity. Officials have decided in many UK regions that fat people deserve to be suffer, so they must lose weight before they get treated. Smokers are treated as unworthy of treatment because their disease is self inflicted.'

You're reading too many right wing newspapers - this is not true. The example you quote clearly says that smoking would cut the chances of the surgery being successful. If the man does what clinical - not bureaucratic - advice says then he gets his op.

And let's celebrate - the NHS is 60 years old today and made an extraordinary transformation of the lives of British people.



One of the big problems is that healthcare consumers are kept in the dark about costs, are encouraged not to think about costs, and then get socked with the bill. Why can't taking your body in for service be more like taking your car in for service?

So much of the things people see doctors for, like routine exams, well-child visits, etc. are or should be charged at a fixed price. That price ought to be openly available to the consumer.

Doctors will tell you that "they can't know what to charge you because they might find a problem that would cost more." Haven't they ever heard of an ESTIMATE?

When you take your car in, there's a big sign on the wall that tells you what the mechanic charges for different routine services: so much for brakes, so much for plugs and points, so much for changing the fluids, etc. That's required by law. If he finds a problem the routine service doesn't cover, he has to give you a WRITTEN ESTIMATE to fix it. That's also required by law. If the problem is worse than he thought and it goes over the estimate, he has to get your approval for any additional costs. That's also required by law.

Why can't a similar law apply to healthcare providers? Because doctors think their social prestige will be in jeopardy if they have to account for themselves the way ordinary working stiffs do.

And as for the idea that doctors deal with life-and-death stuff and mechanics don't, ever have your brakes go out on a busy main road during rush hour? AFTER you'd just had them serviced?



@122 and others,

The reason people head for the emergency room for $1000 aspirins is because they have no medical insurance. At least here in California, emergency rooms can't turn away patients for lack of insurance while any private physician would. So, if you have no money, but don't feel well, you go to the emergency room. This is just one of the ways that lack of insurance increases costs for us all.

Freakonomics teaches us that people's decisions should be driven by data, and in this case the data is incontrovertible. Government supported health care system provide superior health results by all measures. It's getting so that the US is down with South Korea and Portugal despite paying the highest prices in the world.

It seems so obvious that one must wonder why presumably intelligent people would argue so strenuously against this obvious fact. My belief is that it's the slippery slope argument; if socialized medicine works better than free market medicine, then perhaps the free market is not a magic panacea. So despite all evidence, right-wingers believe they cannot let socialized medicine succeed even if their own loved ones are at risk; otherwise the emptiness of their belief system will be exposed.



How is a single payer system going to make things better when people already head to the ER for conditions which only require a few Tylenol to care for?

People already head to the doctor/hospital for things which people in the old days would have just stayed in bed for. Take away even the small co-pays people have, people will be heading to the ER every time they get a hang nail.

Healthy skeptic

How is it possible that the US has the most expensive and least effective health care in the world? Among OECD countries, we rank near the bottom on quality of care and at the top in expense. In the US, we get the right treatment for our conditions just 55% of the time (RAND study). Hospitals and doctors still get paid for cutting off the wrong leg--name me another industry where outrageous defects are paid at the same rate as perfection. How well would Toyota be doing if they sold defective cars?

To its credit, CMS will stop paying in October for certain events that should NEVER happen in a hospital, like cutting off the wrong leg or giving people infections while they're in the hospital. It's a start.

To understand the problem one must look at the link between quality and cost. Two prominent features of our healthcare system are waste and error, which are expensive and lead to unsafe conditions. Addressing quality is the only enduring way to address cost, no matter who's paying for health care. If we go to a single payer system without looking at what we're paying FOR, it'll break the bank and nobody will be healthier.


Ian Jones


In the UK system, healthcare provision is decided by an ever growing army of officials who have to decide on prioities.

Some drugs are very expensive, so you can't get them free. These decisions are made by N.I.C.E(National Institute of Health and Clinical Excellence). If you do pay for drugs that haven't made the list, you then become liable for the full cost of your treatment including hospital stay and doctors' fees. This is so unbelievable I must provide a link:

There are other reasons for not being treated. One is obesity. Officials have decided in many UK regions that fat people deserve to be suffer, so they must lose weight before they get treated. Smokers are treated as unworthy of treatment because their disease is self inflicted.

A builder is refused treatment for his broken ankle because he is a smoker.A spokesman for the hospital trust said: "Smoking has a very big influence on the outcome of this type of surgery, and the healing process would be hindered significantly".

So hopskotch. Don't just worry about right-wingers regulating your health care for political reasons. Any official can do that.



"Why not take the medical educational system out of the market economy of free enterprise, select the best and the brightest, pay their education, then regulate their income?"

First, we'll need to train a lot of morticians to handle the avalanche of "best and brightest" who die laughing at the idea of going into a profession where their income is regulated by the government.

"Doctors conspiring with affluent patients to evade income taxation"

Huh? Paying in cash is conspiring to avoid taxes?