Monday, February 14, 2011

American Healthcare System is Fucked Up

True story with not a hint of exaggeration:

This past weekend, the Korean Parents had their friends visiting from Korea -- a couple in their late 50s. Unfortunately, the wife of the couple suddenly suffered a stroke on the second night staying with TKParents. TKParents called 911 and rushed them to the nearby hospital. The doctor there recommended going to UCLA Medical Center immediately, because the larger hospital had more sophisticated equipments and better doctors.

The couple refused. Why? Because they had previously lived in America, and they knew that going to UCLA Medical Center without an insurance meant spending upwards of $10,000. (The bill from the nearby hospital was several thousand dollars already.) They were fairly well-off in Korea too -- they would easily qualify as a middle class in the U.S. also. But $10,000 on top of whatever they owed already was a lot of money. So they elected to immediately return to Korea when, for all they know, the lady could be having a brain hemorrhage. She could hardly speak, move her arm or walk. TKParents pleaded that their friends go to the hospital, but to no avail.

They spoke to their doctor in Korea before boarding the plane -- luckily, the doctor thought she would be safe to fly. When she landed, the doctor was waiting for them in an ambulance at the airport. Then she was taken immediately to Asan Medical Center, one of the finest hospitals in Korea, and received MRI scan and treatment. The whole thing -- your doctor waiting at the airport, ambulance, MRI, medicine to clear the clogged arteries at a top-5 hospital in the country -- cost less than $600.

Please, spare the Korean of the politics. If you think America's healthcare system is just fine after reading this story, please try and explain how it is normal for a middle-class woman who just went through a stroke would rather fly 13 hours to receive treatment instead of going to one of the best hospitals in the world. If you are callous enough to suggest that the couple should have purchased travel insurance, the Korean will have you know the lady had no prior instance of stroke and really was very healthy previous to this episode.

The Korean is fucking enraged right now. He is embarrassed and pissed off. This is America. We are the richest and greatest country in the world. And the family friends decided to board the plane after a stroke rather than to trust an American hospital to save her life while not bankrupting them. That shouldn't be too much to ask. It should not be too much to ask America to take care of people's lives as much as Korea does. This is fucking disgraceful, and we Americans should all feel embarrassed.

If you want to read more about Korea's healthcare system, please take a look at this post.

Got a question or a comment for the Korean? Email away at askakorean@gmail.com.

84 comments:

  1. I usually don't write on comments but I would like to give my humble perspective on your friend's situation. If it were me I would've been sent to the hospital and gotten all the necessary medical procedures along with fine quality care on par or at least comparable with the best American hospitals. I would not be charged any money, for my medical expenses are covered by taxpayer money. It's not the best care, but it is decent medical care which would be much better than none.
    Now, before everyone calls me a euro-Canadian-socialist marxist with calls for me to "go back to where I came from," I have to say that this scenario isn't in Canada, UK, or Korea. This care I speak of would be happening in the US of A. I'm not even a Canadian/euro citizen. I'm an American. To be specific, I'm a US veteran who's under the care of the VA medical system. To say that the US has a crappy healthcare system, I'd argue that the problem with our healthcare system isn't that we have no healthcare system. Actually, we have several types of healthcare systems working in the US. The system I'm under (VA) would be comparable to the UK's system (NHS). My medical history/information is stored electronically in the database and the military ID I still carry with me. This isn't even done with "superior" market based health insurance. Granted, it's not a perfect system. In fact, there are massive problems with the VA system. But the problems isn't a matter of the system itself, but of funding and management. Before you play the Walter Reed/enormous waiting period card, please consider that those issues arose because of lack of anticipation of military causalities and funding. Once a poster child for substandard medical care and incompetent management, VA's health care system now is considered by many to be the best in the country. Its ratings for quality of care and customer satisfaction have risen even as the patient load has increased. I can go on forever about this but I'm going to stop. The point is that Americans don't have to look abroad or have a deus ex machina moment to fix our healthcare. We use the UK's system (VA), we ICanada's and Taiwan's system (medicare), and we use for-profit market systems (just the US). TK's story happened because of our system and it's clear that there's much need of reform. But I guess that point's moot since we did pass health care reform last year. I do find it odd that people felt so strongly about reform. But with stories like these, I understand why the issue raises high emotions.

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  2. I'm sorry for your friends' ill health. A stroke is serious enough when healthcare is immediately available and affordable, let alone when complicated by issues such as these. It's good to hear things worked out relatively well in the end.

    If you are callous enough to suggest that the couple should have purchased travel insurance

    It's not callous, it's prudent. You really are taking a massive gamble with your life and/or life-savings if you travel without at least some level of travel insurance. Your Korean friends, like we here in Australia, enjoy completely free hospital cover, and (they even more so than we) low cost GP consults and medicines.

    We tend to take this for granted... if we get sick or injured, we just go to the hospital and they fix us right up, lengthy emergency room delays for non-life threatening conditions notwithstanding.

    It is sheer lunacy to travel without decent travel insurance, apart from countries with reciprocal health-care agreements, such as NZ and certain European countries for Australians. You simply are not covered and if life a threatening accident occurs, depending on where you are you will be either a) bankrupted, or b) wheeled out into the corridor to die. Those of us from countries with free universal health care need to be reminded of this.

    Being very healthy lessens this necessity not at all. Healthy people are just as likely to be assaulted or involved in a motor vehicle accident, etc.

    Your friends, unfortunately, learned this the hard way.

    That's the take home message here - not that the US healthcare system is an embarrassment (which it is) - but that traveling without proper travel insurance is maniacal.

    Best wishes for a speedy recovery.

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  3. This scenario is all too common. The system in the US is geared toward the pharmaceutical companies and the lawyers. If people would stop suing for no reason and take personal responsibility, the US could actual practice medicine.

    I'm glad I live in a country where I can walk directly into an orthopedist office, be examined in less that 15 minutes, get x-rays, PT, and medicine for less than $10.

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  4. I think the fact that the concept of "Travelling in US without travel insurance" is considered a lunacy in itself a testament to how fucked up the American healthcare system is.

    And I know horror stories of people who *have* gotten travel insurance and still got rammed in the ass with the astronomical hospital bill.

    When I tell relatives in Korea that my mom's hysterectomy would have costed $120,000+ without her insurance, they think I'm embellishing the truth. The truth is, it is fucked up to *that* degree, and as much as I disagree with Obamacare... It's still a significant improvement over either the status quo or the Republican "alternatives".

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  5. Totally agree. I'm scared just to get a cold while I'm visiting here in the States.

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  6. First, that really sucks about the stroke. I've had family members get strokes, and it is pretty darn scary. I can only imagine how much worse it'd be with the patient ostensibly refusing treatment.

    I think to say as a blanket statement that the US healthcare system is "fucked up" really isn't fair. Fact is, there are some things done right, and some things that aren't.

    First, there is no doubt that the US healthcare system produces the greatest advances in medical technology and treatments. The US also has virtually no waiting for anything. Finally, everyone who needs treatment gets treated.

    Now, I am not really interested in the good as much as what can be done to improve it. As a society, we've started using insurance for everything health-related. In the old days, surprise surprise, you paid the doctor for his services. The use of insurance for things other than catastrophic care has really blurred the supply and demand relationship that lowers prices and makes things more efficient. Many hospitals will offer you a discount of 40%-60% if you pay in cash (includes credit, debit, etc.) just to avoid the inefficiency.

    Insurance companies have monopolies on geographic areas. You probably know about not being able to buy insurance across state lines. Less competition, higher price.

    To all my fellow Californians with health insurance: Have you gotten a mammogram or acupuncture lately? Your insurance plan undoubtedly covers it regardless of your gender. Mandates on what a plan must cover increase costs.

    We have a ridiculous number of medical lawsuits. My dad, a physician, has to buy malpractice insurance. Why? He has a release form that patients sign. Doesn't matter. But the patient pays for that in the end.

    Somehow, our legislators think that mandating healthcare coverage and not allowing pre-existing condition screening for insurance companies will lower costs. Good luck with that. Just open it up to the free market, and watch the magic happen. The healthcare itself is great; we just have some cost issues. Getting the government involved more will only exacerbate any problems. Every problem that exists in healthcare today is inexorably linked to the government's meddling, not that I am accusing TK of suggesting that.

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  7. I had appendicitis at a time I was supposed to be in the US, and at the time I would almost certainly not have bought traveler's insurance, thinking my thirty-something self wouldn't need it.

    Thanks to an overly busy schedule, I was fortunate to be in Seoul with my Korea National Health Insurance card. The appendectomy and five-day hospital stay cost 1.2 million won, but only because I opted to stay in the nice, hotel-like single room for all those days. Otherwise it would have cost me 400K or 500K won.

    I have no idea how much I would have been billed had I gone to the US uninsured and had the surgery there, but ever since then, while living in South Korea, I always get two scoops of traveler's insurance when I visit relatives in California.

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  8. Dan, I think you are wrong on two points. First, making coverage mandatory and barring all insurance providers from blocking for pre-existing conditions gets them out of the business of denying coverage while expanding the risk pool. Consumers and insurance providers both avoid getting screwed for different reasons. Health Economics 101.

    Second, selling insurance across state lines, while it looks good on paper for the pro-competition crowd,
    tends to lead to a "race to the bottom" in terms of what is offered and affordable rates. The consumer will get screwed much in the same way credit cards went across the state line to Delaware, with health care ending up with the equivalent of 19.8 percent interest that shoots up if you so much as sneeze on the bill of some other credit card company.

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  9. What a heated discussion. I'd like to say that without insurance, both systems are pretty awful. Yes, Korean national insurance is better than many, many kinds of U.S. insurance, but if you don't have it, you can find yourself in just as tight a spot as your parents' friend, even in Korea.

    Case in point: I am currently living and working in Korea and am also pregnant. I have national insurance, so the birth of my baby will be free—even at the fancy-shmancy birth center we will be going to (we just have to pay for our private room which is less than 800,000 won).

    In the U.S., with insurance, many people have $5,000 (or higher) deductibles, so even with insurance, just to walk out of the hospital with your baby could set you back $5,000, So yes, with insurance, Korea wins hands down (and I was a teacher in the U.S.—I got the good insurance for government workers—my insurance here is still better).

    But—if I didn’t have insurance over here, the birth of the baby could cost anywhere from $3,000—$8,000 depending on the length of the stay and procedures used etc. Overall Korea’s system is better and fairer, but it’s not truly that much cheaper (at least in my case) for the uninsured.

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  10. @kushibo

    "Gets them out of the business of denying coverage while expanding the risk pool."

    Okay, first off, there is no "business" in the literal sense that can make money off of denying people service. Expanding the risk pool is essential to an insurance business, of course. But you know who knows a lot about the correct amount of risk to assume and how much the risk premium should be? Insurance actuaries. You know who wouldn't know the first thing about it? A government bureaucracy that pretty much can't do anything right and has created the problems in the risk pool in the insurance industry.

    With competition in the marketplace, no one would get denied. They would simply be charged more of a risk premium. Unless of course, they didn't want coverage that was pertinent to their disease. Though that is a specific decision that individuals would have to make. But guess what? You can't customize a plan like that, like you can with auto insurance.

    I'm sorry that an insurance company isn't going to cover you unconditionally in the same way you won't be able to buy fire insurance once you've lit your house on fire, but yeah, it's really not insurance then, is it?

    That's really the biggest problem here: people don't understand what insurance is. Why is it that so many 18-40 year olds have health insurance? Probably, the smart decision, economically speaking, is to save the money, maybe in a tax-free health savings account (if only the Government would allow it) so that when you're older and more likely to use it, you can buy a policy. And if it's allowed to be tailored and purchased from a myriad of companies, it's cheaper and more economically sound still. But that's not what we've got here in the US.

    Your other point: I'm not really sure I get it, but here's my best attempt.

    "Race to the bottom" is exactly what you want. Well, you really want the ability for the customer to pick and choose what they want, but call it what you want. More stuff for less money. We call it economic efficiency.

    I'm not exactly sure how the credit card companies moving to Delaware is bad, but I think this is a great example of government meddling. Look at some of the lobbyists and family members of certain vice presidents of the United States, and it's clear that this is nothing but economically unsound that the government typically promotes.

    Credit cards are an amazing service. And no one forces you to buy them. Credit cards are another societally misunderstood thing. I am the only person I know who knows how to use a credit card "correctly." That is, have discipline. Don't buy anything you can't afford, pay on the first month always so as not to get charged interest, accumulate airline miles, and know that you have an added layer of security for your money. Many people think a credit card is a way to live beyond their means. It's not. I love my credit card, and think people are crazy who use it incorrectly.

    That's credit cards specifically, but the same societal problem applies to health insurance. People no longer understand it's insurance. They think it's a payment plan for health coverage. I'm not saying people are stupid. It's been legislated into their minds with all the mandates and all the employer-provided care.

    Sorry if the above sounds a tad...snarky...I totally don't mean it to sound that way.

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  11. ummm...you ain't know? no, seriously, my mom was a social service type worker helping people with various disabilities get the services they need. you'd think that a person who is truly disabled through absolutely no fault of their own would easily be able to find and receive services, right? not so. at any rate, during thanxgiving of 2009, mom suddenly couldn't read. come to find out, she had a brain tumor. that her regular doctor missed certain tell-tale signs for years is an issue unto itself. but there's also the fact that my mom obviously couldn't go back to work after the holiday and had to go on short-term disability. brain surgery, radiation, chemo... all this led to long term disability. after a few months of the long term, her company found some crazy loophole and basically fired her, leaving her with no insurance. so she worked with the disabled, but upon becoming disabled herself was fired. THIS is health care in the US. you look for those benefits when you apply for a job, right? don't you believe it. the insurance was crap to begin with, and this was blue cross! she's got 2 months til she can get medicare and while that's a whole new can of worms, it's better than nothing.

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  12. When commodity or service that is essential to human life is privatize, then you have the system like ours.

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  13. @David

    Just because you say a statement in a pseudo-profound way, doesn't make it true. A private system with minimal government intervention would be the most equitable, fair healthcare system. Sadly, it's not what we've got here in the United States. How can you even call it that between Medicare, Medicaid, the VA, and all the insurance mandates?

    And privatizing essentials is bad? Food is essential, right? It's also private in the US. I suppose that's why we've got people dying in the streets because of hunger too, right? While all those African countries with the food handouts and friendly, "always lookin' out for ya'" governments are just loaded with food for their people.

    Privatization is not the problem; it's the solution. Look at countries with both and you see it pretty clearly. Compare private hospitals here in the US with those run by Veteran's Affairs. Compare the NHS hospitals in England with the private practices that are often run on the side. Compare government hospitals with DONATION-SPONSORED missionary hospitals all over Africa and much of the developing world.

    Privatization isn't heartless. Just the opposite. It's compassion and trust for the individuals to make decisions for themselves. It allows the market, the most equitable solution, to prevail.

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  14. Food is privatized, but roads aren't. Homes are (typically) privatized, but fire departments aren't. I don't think healthcare really admits to analogies.

    America's healthcare problems are obvious: America spends twice as much money to get results that are, at best, the same as other industrialized countries.

    As awful and infuriating a case as this was, I don't think this really proves the inefficacy of the American system. Every now and then we hear about someone soliciting donations for a Westerner in Korea who is in need of thousands of dollars to pay off his medical bills.

    If this had happened to a Canadian in Korea, or a Korean in Canada, I don't know how different things would've been.

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  15. Every now and then we hear about someone soliciting donations for a Westerner in Korea who is in need of thousands of dollars to pay off his medical bills.

    Thousands, not tens of thousands.

    The aforementioned appendectomy I received would have cost about three or four million without insurance had I opted for a multi-person room instead. In the US, the average for an uninsured person is supposedly $23K to $35K.

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  16. In addition to Dan's complete faith that free markets will save medical care and that the nature of medical care (with inelastic demand, etc.) does not represent what economists would call a market failure, it appears he and I would also disagree on what is optimal medical service.

    Since most people are NOT medical practitioners, I guess I don't have the same amount of trust he has for the individuals to make decisions for themselves, and I see savings in people getting encouraged to get primary level preventative care, and greater public good in people getting treatment, vaccines, etc., such that they don't become disease vectors.

    I'd rather see people get treated whenever they're sick and get regular preventive care before they're sick, rather than have them make complicated calculations about whether or not it will be cost-effective for them to forego this treatment or that when they may not be entirely informed about the risks to themselves or others if they let such-and-such problem fester a while longer.

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  17. While living in the US I had no money for health insurance and as a result did not go to the doctor at anypoint, except when I got pregnant. Luckily I was healthy and so was my child. He has not had any care past his first few post natal visits because we could not afford it. This was one of the major reasons we left America and will probably never return. Now here in Finland atleast he can go to the doctor and dentist for free and I do not have to ponder, if I get hurt, weather it would be better for my family to just suffer and take my chances recovering at home, like I did on a few occasions in America. Or go to the hospital and banckrupt my entire family over something possibly minor.

    Choosing between financial destitution and health is no fair and I refuse to make that choice again. I still owe tens of thousands of dollars for the birth of my son but luckily the creditors can't find me.

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  18. Dear Korean Healthcare System,

    I want to thank you again for taking out my wisdom tooth, giving me x-rays, pain medication and subsequent follow ups all for a staggering cost of 16,000 won. American healthcare is a joke as that same procedure would have bankrupted me.

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  19. The US healthcare system (well, the insurance system more than the healthcare system itself) truly is embarrassing, and it's a big reason why after my stay in Korea this time is done I will think about ways to come back here or go to another country with universal coverage (most likely candidate being Canada). I am healthy, but the thought of how much I would have to lose if I suddenly wasn't healthy scares me (and that crossing from good health to poor health can happen in seconds, as your parents' friend's situation indicates). There are a lot of things I don't like about the US (as well as things I do, of course- after all it is home), but this insurance issue is at the root of so many other social ills, in my opinion.

    You parents' friend's situation was very unfortunate, but as others have pointed out, was not unique in that as a traveler costs could easily have climbed as high as $10,000 even in countries like Korea. (There are stories of expats in Korea all the time whose shady hagwon employees didn't enroll them in national insurance- or who were in Korea on tourist visas and not eligible for national insurance. In the case of emergency their costs can climb pretty high too). Saying after the fact that this woman should have had travel insurance IS a bit callous, but when I have traveled back to the US for a few weeks while living in Korea even I have bought travel insurance (as a US citizen, and healthy person in my 20s at the time). I think it is even more shameful that I need to buy travel insurance in the US as a US citizen!

    So, the moral of the story is that travel insurance is important, BUT the other moral is that yes, the US health insurance system sucks. And it is a matter of scale- if I suffer a catastrophic accident in Korea without insurance I may become bankrupt. If I suffer the same accident in the US without insurance I may be bankrupt times ten...

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  20. Ynotophobic,

    The Korean is a massive fan of the VA hospital system. If all (or even the majority of) American hospitals were under a similar system, the Korean wouldn't complain.

    Ryan,

    First of all, thank you for your concern.

    It is sheer lunacy to travel without decent travel insurance... You simply are not covered and if life a threatening accident occurs, depending on where you are you will be either a) bankrupted, or b) wheeled out into the corridor to die.

    That's just not true. Two of the Korean's (American) friends suffered life-threatening injuries while in Europe -- one a completely broken leg with massive bleeding because of a car accident in Sweden, the other a cracked skull because of a criminal assault in Ireland, both without any insurance. They both paid a fairly hefty sum for hospital fees, but still in the four digits, not five digits. They were hardly driven into bankruptcy.

    Overall, is it a good idea to carry travel insurance? Absolutely. Should you be driven into bankruptcy while traveling in the richest country in the world simply because you didn't carry travel insurance? No. Heck, you can travel in Korea without any traveler's insurance, suffer a life-threatening injury and not go bankrupt. It will certainly set you back a fairly significant amount of money. But the cost will never reach six figures, or even mid-five figures. That's what one would expect in a civilized country.

    shotgunkorea,

    That's a fair point, but the huge difference is -- it is very easy to have an insurance in Korea. Pretty much everyone can get it, including foreigners who stay long term.

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  21. Bonnie,

    if I suffer a catastrophic accident in Korea without insurance I may become bankrupt. If I suffer the same accident in the US without insurance I may be bankrupt times ten...

    That's a good way of putting it.

    Dan,

    Heartily agree on the med mal lawsuit point. The Korean thinks those suits can be significantly scaled down if healthcare was much more affordable, such that the damages figure from continued treatment becomes much smaller. That's what pretty much happens in Korea. But several respectful disagreements:

    everyone who needs treatment gets treated.

    This statement would be made much fairer if you said "everyone who needs treatment gets treated if they are willing to be driven into financial ruin."

    Privatization is not the problem; it's the solution. Look at countries with both and you see it pretty clearly. Compare private hospitals here in the US with those run by Veteran's Affairs. ...

    If you mean to say that U.S. private hospitals are nicer and spiffier, there is no question that you are correct. As the Korean recognized in the post, UCLA Medical Center is one of the best hospitals in the world, and it is a 20 minute drive from my parents' place. But the question is -- why did TKParents' friends refuse to go to the best hospital in the world and take a 13 hour flight instead?

    Further, Korea's health insurance system is decidedly NOT private. The bureaucrats whom you so despise run the NHIC board, and they do a damned good job keeping the healthcare cost low.

    Put it this way -- if the Korean's life depended on curing something that few people have even heard of (e.g. a rare brain condition,) he would much rather be in America. But if the Korean's life depended on curing something that is very serious but relatively common (e.g. stroke, cancer, heart conditions,) he would much, MUCH rather be in Korea.

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  22. @Dan
    So lets examine four commodities or services that is essential in our everyday life. Food in America is not completely privatized. Many of what we eat is heavily subsidize and for this reason food cost in America is affordable. Water in most cities is run by the city and the people in charge are elected by the citizens. Which is why our water bill is affordable. Electricity is under the umbrella of the public utility commission (PUC) and when a private electric company wants a rate hike, it must get approval from PUC. Because of this, our electric bill in most cases are affordable. But our health care is not govern by anyone. Drug companies, insurance company, doctors as well as the hospitals are free to charge whatever they wants. I do not know what the solution is but what I do know is if you leave health care up to the businessmen with no oversight, we will get screwed.

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  23. @TK
    "Put it this way -- if the Korean's life depended on curing something that few people have even heard of (e.g. a rare brain condition,) he would much rather be in America. But if the Korean's life depended on curing something that is very serious but relatively common (e.g. stroke, cancer, heart conditions,) he would much, MUCH rather be in Korea."
    I agree with you, but the problem is, many of us do not have access to the best doctors or hosipital here anyway. Therefore, I still rather be in Korea.

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  24. Well don't worry if you think its bad now the fundamentals dictate it will only get worse regardless of the system.

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  25. US healthCARE can be great, we have some of the best doctors, technology, hospitals......

    The US also has some of the best lawyers that drive up insurance rates up the wazoo and get huge settlements for unhealthy, unaccountable people keeping doctors afraid of being sued for "malpractice," but then these same doctors almost have to see medicaid/medicare patients with restrictions on how to treat them since they have to do things w/in their plan b/c no patient wants to pay out of pocket for anything; plus get reimbursed almost nothing! On top of that, if the visit/chart is not coded exactly right, then there's no reimbursement or even an audit, and the doc gets fined.

    The US also has some of the most unhealthiest and obese people on the planet. Being a health care practitioner and having many friends in the industry, i constantly hear stories about so and so patient that is on medicaid, gets all these visits covered, BUT said patient has $$ to smoke 2 packs a day and already has 3 children at the age of 21. They ain't paying for their "health care," We ARE and we are paying for their health care when that smoking habit will turn into end stage diabetes and they will be on dialysis 3x a week. And unfortunately, it ends up driving up the cost for everything else for everyone else. (like me paying $450/month for health insurance for a single young healthy individual who has never even been in a hospital as a patient, who doesn't smoke, and who sees a doctor 1x/year for a yearly physical to ensure I stay on top of my health. I don't even have allergies! $450/month!!) That is not including dental or vision.

    The US needs the following

    1)more of its citizens to be more accountable for their own health and well being and not relying on the government or McD's to dictate how to lead a healthy lifestyle.

    2) more preventative education - much of the health issues we are dealing w/ today and which are sucking the $$ out of healthcare in the US is completely preventative!

    3) Obamacare is NOT the answer.

    4) Leave more of the decision making for the docs instead having insurance co's and lawsuits dictate what is standard of care or protocol. Sometimes, docs HAVE to overtest patients (mri's ct scans, etc etc...) to cover their bases in case they get sued, even if based on their experience, the diagnosis is something else entirely or something minor.
    and I can go on.....

    @TK - best of luck and health to your parents' friends.

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  26. Well, if you want America's healthcare cost to go down, do something about the trial lawyers. They're like vultures. They keep prices sky-high because doctors have to pay huge malpractice insurance fees.

    They also make it difficult if not impossible for hospitals to operate in the poorest areas. Take for example the one in Kingsville, Texas.

    The hospital almost never has a doctor for the ER these days. No doctor wants to work there. Their nursing staff is exhausted and if the nursing staff screws up the doctor is at fault.

    And when someone messes up because they're exhausted and way understaffed, the trial lawyers swoop in and bleed the hospital dry.

    Our trial lawyers system is what keeps our health care system sky-high. You want it cheaper, get rid of those leeches.

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  27. Random points:

    1) The American healthcare system isn't "inefficient." It's evil. It's a stain on our character. It's too bad the Democrats couldn't frame the debate accordingly.

    2) The cost of a particular procedure may differ for different patients (even at the same hospital) depending on what rates the hospital negotiated with the patient's insurance company. And for the uninsured (like your friends), the hospital jacks up the price. Why? Because they can.

    3) The VA is not only good for patients (VA has better outcomes, and let's face it - outcomes are what matter), they are good for doctors because they don't have to deal with multiple insurance companies. I have a friend who is a doctor at a VA hospital and he loves it because he doesn't have to deal with endless paperwork.

    4) It's not just the VA or Medicare that are "socialized." How about a system like Kaiser Permanente? They are an HMO, they have their own hospitals, employ their own doctors, have their own pharmacies. A patient can't see anyone outside the system without a referral. I have no complaints about KP - they seem perfectly respectable - but how exactly is it different from the British NHS?

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  28. everyone who needs treatment gets treated.

    I'm sorry but this is just bullshit and part of the whole bait and switch that goes on in this debate.

    Emergency rooms are required to stabilize anyone who walks through your door. But they aren't required to treat the underlying condition. If you develop brain, pancreatic or colon cancer, multiple sclerosis or any other long term, chronic and expensive disease, but you don't have insurance, you can't qualify for Medicaid and you're not charismatic enough to star in a telethon or community fundraising effort, you're screwed. Hospitals won't treat the underlying condition for free. They will just try to stabilize you if you have an attack. There is big difference between the two. Besides, who ends up paying for all this (at higher cost because the patient procrastinated until the condition was critical)? The insured. This is a bait-and-switch.

    Secondly, the malpractice red herring is just put out there to take away the few recourses patients have left with their doctors or insurance companies. Less than 3% of healthcare costs go to litigation and in most cases the final damages awarded aren't high. All so-called "tort reform" does is take away the rights of patients and give them to the companies. It won't fix healthcare. This is another bait-and-switch.

    Thirdly, the U.S. healthcare system suffers from long wait times, just like the Canadian and European systems, many of them are worse here than in these other systems. The difference is that the wait times are hidden by insurance companies so most Americans aren't aware that this is a widespread problem, whereas in Canada, Europe or Australia they are published on public websites for all to see. The only people who are exempt from wait times in the U.S. are ones who can pay for whatever treatment they want out-of-pocket. Most people can't do that. So we wait. This is another bait-and-switch.

    Fourth, we heard the same rhetoric about banks 15 years ago when they were deregulated. "If the law is changed so that banks can work across state lines we'll have more competition, better service and lower prices." So what happened? The big banks gobbled up the small ones and crushed any real competition through takeovers and mergers. They turned into oligopolies, more concerned about maintaining their marketshare than doing anything innovative for the customer. They became detached from local communities and from consumers and their costs and fees went up, not down while service got poorer. Does anyone think the banking industry is better for the costumer now than it was in the 1980s? I doubt many would. On top of that several became "too big to fail" holding all of us hostage. This is another bait-and-switch.

    Finally America's innovation in medical care doesn't come from the health insurance system but through university and government agency (CDC, NIH) research. Changing the way we pay for treatment isn't going to destroy innovation. They aren't linked. This is another bait-and-switch.

    Free markets aren't magic. The only time a free market works at all is if the buyer has free choice to purchase or not purchase a product. Free markets work fine when it comes to purchasing a TV, car or an iPod. You can shop around or wait for a better product or retailer to come along and give you a better deal. Healthcare isn't a voluntary purchase. Someone in health distress has no such free choice. If you have a heart attack, stroke, or cancer you can't shop around for the best price or wait for a sale. So the balance of power is shifted to these companies whose raison d'ĂȘtre isn't to treat patients but to maximize profits for shareholders.

    It is fucked up.

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  29. @toujoursdan
    I agree with 120 percent

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  30. For those who have insurance in US, they most likely wouldn't understand this story. I totally agreed if you left with no insurance in US and have a disease like TK said, you are only fucked up to die. It's very shameful to live as one of the Americans when to see republicans still opposing the Obamacare.

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  31. Gah. Stroke is one of those conditions where doctors talk about the "golden hour"- certain interventions only work RIGHT AFTER the stroke occurs. They say "time lost is brain lost." Hopefully your parent's friend caught the stroke on time (not always true) and the doctors at the local hospital stabilized your parent's friend enough to stop the immediate problem.

    "Finally America's innovation in medical care doesn't come from the health insurance system but through university and government agency (CDC, NIH) research."
    Thank you, thank you, thank you. Nearly every innovation in basic science and many in clinical science comes from research funded by governments. It's only when a treatment is relatively mature- ready for human implementation- that a professor goes off to form a company or some pharma company builds on published work to take it to market.

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  32. Wow, a lot of things to reply to…

    Not sure I will be able to reply further just because it's a large time drain to comment here. Here goes:

    So, one thing that a number of you (David, kushibo, et al) are attempting to point out is the macroeconomic concept of market failure. This is certainly an important concept and one which does occur and does require government action. However, healthcare doesn't fall into this category. Market failure is when the market fails to properly allocate resources. It usually occurs when parties not involved in a trade are affected by a trade. That would be the negative benefit from lots of pollution and things of that ilk. It does not have anything to do with demand being inelastic or being, in your opinion, too expensive.

    That said, I also agree that healthcare in the United States it too expensive. Many of you are conflating my defense of markets with the defense of the US healthcare system. I am not. The US doesn't have a free-market healthcare system. It is largely monkeyed with by the way insurance works here. In an ideal system, a patient would simply pay for the coverage they need and have a custom tailored insurance plan for catastrophic illness, most likely to be purchased when you are older. This would lead to lower prices. As I mentioned, many hospitals will give you a sizable discount for payment not by insurance or Medicare. In this sense, I agree with Bonnie, insurance is being used for things it's not meant for and isn't used for in any other industry.

    Now, some specific comments.

    @TK Absolutely, the healthcare in the US is way expensive. But your other point is about the health insurance in Korea. Essentially, Korea has a system like the ideal I described above with one main difference. So I reread your Korean healthcare post. Main routine care is paid for by the government and supplemented with insurance for the other stuff not covered. In a market system, with the individual paying, you essentially have the same thing with no middle man. Lower costs will follow.

    One other thing about the Korean healthcare system. I essentially only know what I know from your post, and while I have no crystal ball, I have bad news. The Korean healthcare system will go the way ours with high costs or insolvency if it stays its course. Again, no crystal ball, but here is probably how it will happen. You talk about a board that sets the prices of the procedures. In time, that committee will be lobbied to pay a higher reimbursement for procedures. Because there is no profit incentive for the government, they'll just do it. Drugs covered by Korean insurance will also lobby for a higher price. They will eventually expand their coverage to more procedures, including elective ones. All of this will lead to the government either having a broke program or it will cause the government, should it choose to keep the program solvent, it will mean higher premiums for Koreans. With the Korean population aging, this will be exacerbated. This happens every time a nationalized healthcare system exists. It will happen in Korea, so enjoy it while it lasts, I guess. A market doesn't require trusting a committee. It keeps prices fair regardless of how badly you need the service.

    Part 2 coming...

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  33. @David: Okay, lets go through your examples if that's what you want to do.

    Food: Yes, lots of food is subsidized and those subsidies represent nearly every ill with the food industry. Food would be affordable regardless. But lets examine some of the "unintended consequences" of one of those subsidies. The most famous one is corn subsidies. If you think this is to keep the price down, you're crazy. It's all about the lobby. This is obvious by the complementing sugar quota the US has. So what do we get as a result of this wonderful corn subsidy. Well, first we get the use of corn everywhere. We use it to feed cattle. That's disgusting. Cattle cannot process corn and so anti-rejection meeds are used on the cattle while feeding them corn as opposed to grass because corn is just so cheap. We use corn to make ethanol, a vastly inferior substitute for gasoline which ordinarily would cost more to do. This creates a bubble in the E-85 car market and ethanol market. And my personal favorite, High Fructose Corn Syrup. Evidence suggests that this sweetener might promote Type 2 diabetes, whereas cane sugar seems to not. Cane sugar is usually cheaper, but our protectionist government, bless the generous heart, is providing a corn subsidy and sugar quota to make food more affordable and to protect our farmers.

    Water is a case where the government is the most efficient party. They call these "natural monopolies." The reason though is different from why you think. The reason this is efficient is simply that private production of tap water would mean constantly having new water lines installed. This makes other forms of commerce difficult to do. Roads and electricity fall under the same category. These are true examples of "market failures." Healthcare isn't one. Healthcare can, unlike electricity and water, be allocated efficiently by a market. We don't have a free market in the US.

    @toujoursdan

    No, it's really true. Everyone gets treated. But I am not defending the cost of care. Simply the quality.

    Malpractice is a red herring? We can argue all day about what constitutes high costs. But that 3% figure, is really high in my view, especially if healthcare costs so much, right? Of course tort reform isn't a cure all, but there isn't just one thing that must be done. I'm not even saying you need to take away a patients rights, but for goodness' sake, if you sign a release and understand the risks, and the negative consequences you knew about happen, you shouldn't just have to be settled with just because you didn't get the outcome you want.

    Long wait times in the US. I can't say you're not right there. But here's the thing that you said that I almost couldn't believe. You said right after that you are exempt if you can pay. I hate to say "duh," but yeah, you get the service if you pay for it. It sucks that a lot of people can't afford out of pocket payment. They would if there were a free market. Not much else to say here.

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  34. @Dan
    "The US also has virtually no waiting for anything. Finally, everyone who needs treatment gets treated."

    First off, Dan, where do you live? Have you ever visited an NYC emergency room? I went to one last year and after waiting for two hours and seeing four people kicked out on the street for sleeping in the emergency room, I went home and slept before going to a different hospital in the morning where I waited for three hours for a five minute visit. Fortunately, I only had a dislocated jaw and nothing life-threatening. At least I was not like that woman in Brooklyn who had a stroke in a HOSPITAL WAITING ROOM and no one noticed!


    So the idea that hospitals in the US have no waiting is ridiculous. While I imagine that the ones that serve wealthier communities have shorter wait times, the same is probably true in the government run healthcare systems as well, just as public schools tend to be better in wealthier areas.

    "Why is it that so many 18-40 year olds have health insurance?"

    This isn't the problem. The problem is that our health care system is so overly weighted to treating problems after they appear with almost nothing spent on trying to prevent it in the first place. This is most likely why the poorer communities have longer waits in the emergency room, because a bigger percentage go there because they can't afford to go to regular preventative check-ups. Obviously, there are some emergencies that cannot be avoided like the friends in TK's post, or a car accidents, but when that happens, it's best not to have to deal with all of the people who did not have the resources to take care of their preventable health issues. I learned from my friend whose parents are doctors that only about 30% of ER bills are actually paid, which means that if you are paying for your ER bill, you are actually paying for two other people as well, which is why they are so expensive. Would it not be better to pay little by little when you're healthy, so that when you are sick, you can focus on getting well instead of whether your insurance will cover you and whether you have enough money to pay for what they won't?

    I have more problems with your posts, but I'll stop here because I'm rambling.

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  35. Not that anybody has not, but let's keep a civil tone here. In particular, thanks Dan for keeping it civil. It's harder to do that when being in a minority position.

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  36. Part 3:

    The banks were not deregulated. There is no point in arguing this with a faulty premise. They focus on maintaining market share rather than servicing customers? What? Like those things are opposites of each other? Damn Apple for mandating that their market share be bigger while all the other smartphone companies have to actually work for it! No. I'm sorry, it doesn't work that way. You can just make it so. Unless of course, you're a government. Is banking better than the 1980's? In some ways yes, and in others no. But yeah, those banks should have been allowed to fail. But then again, they shouldn't have had lending mandates set on them by the government, so I feel for 'em to a slight degree.

    Free markets are not magic. Well, I guess technically they're not magic, but they do bring down costs, create value, and make for a higher standard of living. Call it what you want.

    And no, they don't only work when you have a choice to purchase or not purchase. They only need competition to work. Again, look at food. You've got to purchase it. It's still cheap. And it'd be cheap without the government. Heck, screw the food. Let's take auto insurance. You have to purchase it. Even if it isn't a physical necessity like food, it's mandated that if you have a car, that you must purchase it. And it's affordable because there's competition and minimal government intervention. Even though you "need" it. But the core problem of health insurance doesn't exist with auto insurance. No one expects auto insurance to pay for a car wash, just for crashes and such. Can't say the same about health insurance.

    Whoops, forgot your innovation point. Yeah, I mean, follow the money is what I'd say. My dad, before being a clinical doctor, was a researcher at NIH, and I'd say that they have their function. But no, funding for the most useful studies is done by private money. Even at public universities, the studies are chosen and funded by private companies and interests. You think Pfizer is going to wait around for the NIH to do a study before they bring a product to market? You realize that would give the government prior art and make a patent almost impossible, right? Given how expensive a drug is to bring to market, they can't afford to not be able to get a patent. Professors at universities are hoping to make money. They don't feel a higher government calling. Sure, they can get government grants. And there is nothing wrong with that. Though private grants alone would probably be more efficient and be a lot less politicized.

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  37. Wanda,

    Hopefully your parent's friend caught the stroke on time (not always true) and the doctors at the local hospital stabilized your parent's friend enough to stop the immediate problem.

    Thanks for the concern, and that's basically what ended up happening. Apparently that's how the doctor in Korea could advise that she could get on a flight.

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  38. If you change the scenario just a little bit, you might arrive at a completely different conclusion. If your parent's friend was poor, and let's say suddenly diagnosed with cancer during her visit, her entire treatment at UCLA or any other major medical center in the US would have been free. At most major medical center, 20 to 60% of care provided is written off, because the patients cannot afford to pay. Hospitals in the US are not allowed to turn away patients based on their ability to pay. Doctors do not make judgement on whether to treat based on patient's ability to pay. None of this is true in Korea. Even with National Health Insurance, major medical illness such as cancer are not covered, or covered only up to a certain amount. If your parent's friend could not afford surgery or cancer treatment, she wouldn't be able to receive any care even though she is eligible for National Health Insurance. Although there are many shortcomings in health care in the US, the idea of treat first, collect payment later if you can, should not be faulted.

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  39. Even though I worked middle class jobs most of my adult life, it wasn't until I got to Korea that I had stable health insurance. I even worked for Blue Cross Blue Shield and saw how it works from the inside. Towards the end of my term there, my job was to write training materials for phone operators--teaching them all the loopholes they could use to deny people coverage.

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  40. The healthcare situation in the U.S. is diabolical and, needless to say, the Health Insurance industry has succeeded in almost completely defanging the current administration's lukewarm attempt to reform it.

    I read that the U.S. now has one of the highest infant mortality rates in the developed world. Consider that you might actually be better off flying to Korea to give birth - or to any other developed country.

    The problem, of course, is not the quality of healthcare but the grossly inflated cost, due partly to HMOs' dedication to profit but also to the gross inefficiency of the financial side.

    The solution: allow the government to use its purchasing power to negotiate prices with the drug companies. At the moment, it simply signs the cheques. And of course have a national health insurance scheme.

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  41. Don't forget that opposite of profit is a loss. Sustained loss means going out of business. Even if you shift it over to the government there will come a day when corrections will have to be made that no one will like.

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  42. J Man:

    The huge costs of the grossly inefficient current system are one of the main reasons the U.S. economy is in bad shape.

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  43. A woman left a country where she had no insurance to a country that she had insurance and is considered "well off" and was given good, cheap service. I think the same thing could be said if I was in Korea without insurance and decided to rush back to my home country where I did have insurance.

    Her being "well off" is a huge reason why the doctor met her at the hospital.

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  44. Apologies for resorting to hyperbole - it's an issue close to my heart. I have a string of tales about the heartache and pain (you see what I did there?) of being uninsured in a foreign country.

    The last of them: Unbeknownst to me at the time, my wife (then my girlfriend) did not have travel insurance when she first came to Australia. She had a string of personal injuries, in the weeks before she was due to return to Korea, culminating when she was flung through the air as a pedestrian hit by a car.

    Through some unfathomable turn of good fortune she broke no bones and suffered no serious internal injuries, but the cost of the various treatments and scans ran well into the thousands, even without any surgery and without actually admission. Things could have easily been orders of magnitude worse.

    Fortunately for us, Australia has compulsory third party insurance upon motor vehicle registration - when you register your car, you pay CTP right along with the registration costs - I'm believe many countries have similar policy in place.

    Anyhow, even though I'm young and healthy, I will never travel without insurance to a country that does not have a reciprocal health care agreement in place. My wife has private health cover here in case of future misfortune, which provides essentially the same level of care and coverage as the free public system, but in a nicer, better staffed, and less busy private facility. It costs less than a hundred bucks a month.

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  46. Well naturally the system is inefficient and is one factor in harming the economy. Reforms have been disjointed and have created a mess. If you want reforms to address that, that is fine, but if you really want to create a sustainable system cost controls are going to become important. I think if you look at the last thing to really cut down the inflation rate of health care, it was the beginning of HMOs, but that was only short lived because people didn't like the measures.

    One I think also would probably have to go more into the philosophy of health care. Who is the guarantor of your health? If you take a look at Dan's idea, it is more that you are. Other ideas makes it the government. Right now we are a bit in between with the various insurance programs. There are advantages and disadvantages to each.

    If you place it on the government you do run the risk of creating a moral hazard. This can be further encouraged by us often having an allopathic rather than a holistic view of health.

    No matter if you reform the system, there will be winners and losers. Health care is not like water, there are many different situations and many different needs. Creating efficiencies in the system may be your denial of service, but an unfunded system could also be your denial of service.

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  47. I do feel like I may be too aloof, but to The Korean I do feel for you. I would be pretty pissed and embarrassed too, and yes it is f'ed up. Even though there may be reasons why it is f'ed up, and to de-f it up would probably create other f'ed up situations. But lets call a spade a spade here, it is f'ed up.

    I'd be some combination of mad, worried, and frustrated to have someone visit, have a stroke, and go fly home on a plane before going to a more sophisticated hospital, because of the bill. When it comes to a stroke, "I think it will be ok" really isn't something that should sit well with a person, considering what one may have to live with. I hope all turns out well, and I'm sorry. No way I'd want to ever have to feel how you did in that situation.

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  48. No, it's really true. Everyone gets treated. But I am not defending the cost of care. Simply the quality.

    But this is factually false. Emergency rooms are legally required to stabilize you if you have a health crisis, but there is no requirement that a hospital treat an underlying condition that led to the crisis or treat long term chronic conditions like cancers, MS, etc. You can't go to the ER for ongoing chemo, etc. for free.

    I'm sorry but this is just a false assertion. So as a defence of healthcare quality this blows. Quality healthcare means ongoing care that prevents or treats underlying conditions. That doesn't happen in the ER for the uninsured.


    Malpractice is a red herring? We can argue all day about what constitutes high costs. But that 3% figure, is really high in my view, especially if healthcare costs so much, right? Of course tort reform isn't a cure all, but there isn't just one thing that must be done. I'm not even saying you need to take away a patients rights, but for goodness' sake, if you sign a release and understand the risks, and the negative consequences you knew about happen, you shouldn't just have to be settled with just because you didn't get the outcome you want.

    Sorry but that 3% figure isn't that high if doctors and insurance companies are truly screwing over patients and those patients are rendered disabled, etc. because of it.

    Secondly, if you read the article, you'll see that the malpractice figure is falling, not rising. This is due to the high cost of bringing suits to trial and because of caps states have already imposed on damages. Tort reform will do nothing to help reform healthcare. It merely takes away the right of a court to determine compensation to the victim based on the merits of the case itself.

    Long wait times in the US. I can't say you're not right there. But here's the thing that you said that I almost couldn't believe. You said right after that you are exempt if you can pay. I hate to say "duh," but yeah, you get the service if you pay for it. It sucks that a lot of people can't afford out of pocket payment. They would if there were a free market. Not much else to say here.

    No they wouldn't be able to afford it in a free market. What free market incentive is there to insure a middle class or poor person with an expensive chronic illness? How does that help create profit for shareholders?

    Free markets are fine in certain circumstances, but this "free market fundamentalism" which some Americans have rigidly embraced in recent years ignores that every economic system has strengths and weaknesses and may not be applicable in every circumstance.

    There isn't a country on earth that has adopted "free market" healthcare, simply because it doesn't work.

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  49. One more thing: I'm an HR Manager for a large commercial construction company.

    One thing that is discussed on HR websites is the cost of the system as it is. It's pretty obvious from the writing on the wall that many companies are going to cease subsidizing or even providing health insurance for their employees in the next 10-15 years.

    Most people don't know that their employer subsidizes their coverage. Most workers in large companies only pay 20%-33% of the cost. The company pays the rest as part of the compensation package. But with costs rising between 10%-40% annually, these costs are becoming too big for businesses to bear. So in 10-15 years time, they are going to push all the costs onto employees, who will suddenly see their health insurance premiums triple.

    Most middle class people aren't going to be able to pay the full price of an insurance package. So most middle class people will do without. And if you think wait times are bad now in the ER, just wait.

    So the defenders of the status quo (or proposing "free market" solutions, which will just further disincentive insurance companies from covering anyone who isn't the creme of the crop) are defending a system that won't exist in a decade or so. It is in a state of collapse now. Some kind of public system will have to pick up those that can't afford insurance and the insurance companies can't insure at a profit, otherwise people will be dying in the streets again.

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  50. Sorry didn't see the rest of this:

    The banks were not deregulated. here is no point in arguing this with a faulty premise.

    There was a partial deregulation, whereby banks were allowed to operate across state lines for the first time in the 1980s. This is what you advocate for insurance companies. It didn't lead to more competition and lower costs. It led to the creation of oligopolies. This is one example where a real world example doesn't match the ideology.

    They focus on maintaining market share rather than servicing customers? What? Like those things are opposites of each other? Damn Apple for mandating that their market share be bigger while all the other smartphone companies have to actually work for it!

    Wait!? I thought we were talking about banks and insurance companies which provide a service for customers rather than a company that is making a product (in a field where there is both domestic and international competition and a low thresh hold for entry into the market.) You're going off on a tangent that has nothing to do with the topic here.

    No. I'm sorry, it doesn't work that way. You can just make it so. Unless of course, you're a government. Is banking better than the 1980's? In some ways yes, and in others no. But yeah, those banks should have been allowed to fail.

    Again, this misses the point. My point is that the dropping of banks working across state lines didn't lead to more competition and better service for the consumer. It led to higher fees, worse service and a detachment from local communities. I haven't seen anything from you that contradicts this assertion.

    But then again, they shouldn't have had lending mandates set on them by the government, so I feel for 'em to a slight degree.

    The crash of 2008 had nothing to do with government mandates on banks. It had to do with the banks themselves choosing to lend to people who were not qualified. The government mandate in the Community Reinvestment Act helped poor people in the inner city. Those who were caught in the foreclosure crisis were middle and wealthy people. Source

    And no, they don't only work when you have a choice to purchase or not purchase. They only need competition to work. Again, look at food. You've got to purchase it. It's still cheap. And it'd be cheap without the government.

    Not really. The government spends billions in food programs for low income people (school lunches, food stamps, etc.) and on subsidies for farmers who grow the food. But again, you're off an tangents that have nothing to do with the topic.

    Heck, screw the food. Let's take auto insurance. You have to purchase it.

    No. I don't have car insurance. But I don't own, or need, a car because I live in a downtown area close to work. Millions of Americans don't have auto insurance. You don't have to purchase it. You can live in an area where you don't need a car and/or use public transportation to get around instead.

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  52. I forgot to mention in your food example that the government also supports cheap food by spending trillions on infrastructure that makes farming cheap in the first place (damns, levees, irrigation projects, hydroelectric schemes, groundwater pumping schemes, reservoirs, transportation infrastructure, etc.). If farmers had to pay for this out of pocket food would be far more expensive. It's also unlikely there would be much farming west of the Mississippi at all. The government owned California Aqueduct project brings water to the Central Valley and the government owned Hoover Dam and Colorado River Project brings water to the Imperial Valley and Southern Arizona, two of the largest breadbaskets in the world.

    Even if it isn't a physical necessity like food, it's mandated that if you have a car, that you must purchase it.

    IF you have a car. Many Americans don't have cars. So it isn't a mandate on everyone.

    And it's affordable because there's competition and minimal government intervention. Even though you "need" it.

    I can't think of an area where there is more government intervention to make insurance cheap for the consumer.

    The government builds the roads, bridges, guardrails, tunnels, and provides the signage to make roads safe. The government licenses drivers who must achieve a certain skill level to receive and keep their driver's license. And the government actively (police/courts) pulls bad drivers off the road. The government also mandates that auto insurance companies insure everyone, even those in high risk pools making the pool as wide as possible. All this government intervention makes it possible for auto insurance rates to be cheap because the number and scope of accidents is minimized.

    Also only people who need and can afford a car will buy one. So this isn't universal like health insurance needs to be.

    But the core problem of health insurance doesn't exist with auto insurance.

    Exactly. For the reasons I gave above. Not everyone needs auto insurance, but everyone does need health insurance. You don't have to have a car to make a living. Millions of Americans don't have a car. Everyone needs health care at some point in their lives.

    This is apples and oranges. It doesn't work.

    No one expects auto insurance to pay for a car wash, just for crashes and such. Can't say the same about health insurance.

    If you don't wash or repair your car and it ends up on the junkyard, you buy another car. Not a big deal. If you don't receive regular exams and checkups and a tumour or clogged artery isn't caught and treated, you die. Surely people are more valuable than things.

    Whoops, forgot your innovation point...

    Here you confuse health insurance profits with all private money. It's hard to know where to even start to break this apart. If you can show me that a substantial portion of innovation is driven by health insurance profits per se, I'd be happy to see it.

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  53. @toujoursdan

    You can't go to the ER for ongoing chemo, etc. for free.

    Well, I mean, I think doctors should be paid for their services. And of course, I can only speak about hospitals that I know, but if you asked to be treated for something like cancer, they'd treat you even if you couldn't pay. I had an acquaintance have to get a cyst operated on. She couldn't afford it all at once out of pocket and she didn't have insurance. She worked out a payment plan with the hospital.

    That said, it was still a huge rip-off of a procedure. And so I must say again because I don't really think it's getting through: I am not defending the status quo in terms of the way payments for healthcare are made, nor am I defending the current role of the insurance companies.

    Sorry but that 3% figure isn't that high if doctors and insurance companies are truly screwing over patients and those patients are rendered disabled, etc. because of it.

    As I said, this is totally subjective as to what's a lot. Here's my figuring based on the docs I know. The doctors I know make legitimate, suable mistakes, maybe once out of every maybe 10,000 patients. If that, and again, these are the docs I know. I know a lot of them. If 3% of their costs are a result of something that is relevant about .01% of the time, is a disproportionately high cost. Of course this calculation is stupid, but so is just willy-nilly calling 3% not a lot. But I'm sorry, maybe this is my bias because of all the doctors I know. Sure these guys want to make money, but they genuinely care about patients and really just want to make them better. And so often they get sued over nothing. And all this does is scare the doctors into not recommending all the options. I know for a fact that my dad will not recommend certain surgeries to people simply if he thinks they are the lawsuit type, even if they are a candidate and it might be the best procedure. Doctors totally are privy to this, and are while they'd love to fix someone and make them well again, they've had the fear of God put into 'em by these lawsuits and they try to screen out this type of patient. Not sure how this doesn't negatively impact healthcare.

    No they wouldn't be able to afford it in a free market. What free market incentive is there to insure a middle class or poor person with an expensive chronic illness?

    There's not a "guarantee" per se, any more than there isn't a guarantee that you are going to get a car. But if I must explain it: The reason they'd be able to afford it is that the hospitals want the business. If they can treat the illness at or above the cost that they will charge the consumer, they'll do it. They won't just turn down money. That's the "shareholder incentive." You're again assuming that what we have in the US is a free market and that prices are representative of what they would be.

    Again, it's like an iPhone. What's Apple's incentive to allow middle class people to buy iPhones? More iPhones sold. Simple.

    There isn't a country on earth that has adopted "free market" healthcare, simply because it doesn't work.

    No, the reason it hasn't been implemented anywhere is because that would be a problem for the legislators in that area if they can't have their hooks in it. You would be making some very powerful people less able to interfere in people's lives and take away their freedom, and they just won't have that.

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  54. Now I want to address what you called "free market fundamentalism." I know exactly the character you are referring to. It's really a shame that people like myself, who are simply in favor of individual rights and liberties are being labeled as essentially anarchists. We're not. And so let me just spell some things out.

    Of course the government has a place. Their job is to enforce contracts and to protect the rights set out in the constitution. That would be spelled out in the amendments.

    Now as for the government providing services, because that's the relevant bit here: Essentially, the government should provide a service when the service will basically not be provided privately. It doesn't mean provided for free; just provided. These include goods which are non-excludable and non-rivaled in consumption. The government can either provide it or set up a regulated monopoly. These are things like water, power, roads, and parks.

    Healthcare would be provided by the private sector, for other citizens without any mandates. It is also excludable and rivaled in consumption. Ergo, not public. And another thing: this idea that somehow it's holy because it's healthcare is ridiculous. Again, food is a necessity, and the government isn't needed to provide it reasonably.

    Your whole bit about how the cost is rising. Yes, it is a really big problem. I can imagine the issues HR types are going to have in the future. So here is what I would suggest as a whole fix to the healthcare thing. I feel I've been maybe a bit too abstract.

    1. Tort reform. I know you don't think it's going to do much, but it's a good thing to do for the cost cutting. Even socialized medicine countries don't have the issues we have with this. It's just ridiculous.

    2. Insurance needs to change. It needs to not be viewed as a payment plan for healthcare. I say again that we as a society have the wrong idea about insurance. It really is like expecting car insurance to pay for washes and all repairs. I'm not saying there is anything wrong with plans like that being offered, but they should not be the only plans mandated to exist. Care costs will drop, and it will enable all this other stuff. Buying insurance across state lines is a nice way to increase competition for catastrophic coverage. Hospital competition will lower the cost of primary and continuing care.

    The fact that insurance has become a norm for primary care coverage blurs the line between the cost of healthcare and the demand. Not to mention this nonsense about the hospital "accepting" only certain insurance for routine care. This limits your choices significantly and makes inter-hospital competition non-existant in our current system.

    3. Tax exempt health savings accounts: This isn't 100% necessary unless the government wants to really get this to work fast. If you could save money towards healthcare tax free that maybe would expire yearly, people would be incentivized to save that money and use it on healthcare.

    That's a pretty good start right there. If only those things are done, the US will probably have the most efficient and equitable healthcare around.

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  55. Wait!? I thought we were talking about banks and insurance companies which provide a service for customers rather than a company that is making a product (in a field where there is both domestic and international competition and a low thresh hold for entry into the market.) You're going off on a tangent that has nothing to do with the topic here.

    Before I am accused of going off on a tangent, let's not forget who brought up banking. The thing with Community Reinvestment, is just another act of meddling. If you can't afford a home, you shouldn't buy one. Sure private banks made loans. I would too if I could offload it to a GSE, and I would be stupid not to. But yes, this is a bit of a tangent.

    As for my comparison to car insurance, of course I admit that it isn't a perfect analogy. But a lot of the reason it's not a perfect analogy is because people have misunderstood what insurance is. It is an opt-in service which covers eventualities and doesn't act as a payment plan. Not all kinds of insurance are mandated, but there is a reason why car insurance is if you own a car. The reason is that car insurance isn't for your benefit; it's for the guy you hit with your car.

    Your "response" to my food thing does not contradict anything I've said. Things like roads are in the category of public goods because the private sector would not supply them otherwise. This is not why food is cheap, though. It's just why food is able to travel farther. This is a lowering of transaction costs.

    I can't think of an area where there is more government intervention to make insurance cheap for the consumer.

    The government builds the roads, bridges, guardrails, tunnels, and provides the signage to make roads safe. The government licenses drivers who must achieve a certain skill level to receive and keep their driver's license. And the government actively (police/courts) pulls bad drivers off the road. The government also mandates that auto insurance companies insure everyone, even those in high risk pools making the pool as wide as possible. All this government intervention makes it possible for auto insurance rates to be cheap because the number and scope of accidents is minimized.


    Yes, and the insurance company can actually use their actuaries to assess your risk. That's why young drivers pay more. Now we've got people talking about pre-existing condition denial in healthcare as some kind of evil. Without the mandates of certain coverage types in healthcare, even a mandate that they cover everyone would be okay as long as the insurance company can charge what they deem as the risk premium. But I must state again: Insurance is not a payment plan. It's a risk pool, as you acknowledge.

    Here you confuse health insurance profits with all private money. It's hard to know where to even start to break this apart. If you can show me that a substantial portion of innovation is driven by health insurance profits per se, I'd be happy to see it.

    No, health insurance companies do not fund research. Sorry if it came across that way. I was referring more to pharma and biotech money.

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  56. I had a similar experience with an elderly relative of mine who developed cancer. Universal health care is one of myriad reasons why I cannot identify with the American right. They are simply dishonest about the costs and risks associated with nationalized health care, which does not supercede the private sector in any country where it is properly implemented (see France, Switzerland, Germany, etc.).

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  57. Damn, I have better things to throw money away on like high school graduates dribbling a ball, Central Americans who lie about their ages but hit a ball a whopping 3 times out of 10, or NFL millionaires thinking about sitting out a season for more millions. Sadly, this is more important to Americans than fixing a broken system and paying doctors what they are worth for actually "saving" lives.

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  58. Actually it would probably be easier to "fix" something if everyone just cared about sports. Frankly the only reason why a program got through was because it got rammed through. Unfortunately if everyone is saying, "do whatever, but don't touch this" then it really doesn't matter what you do we will just be facing the same problems. If you say, "ahh well if that happens, I'll be S.O.L., but thats ok," then your maybe getting somewhere.

    Sure maybe you can realize some efficiency, but that is only going to get you so far. You can come up with one aspect that could save money, but the problem is not just one aspect that is causing the problem. If the future funding of Social Security and other such programs seems laughable, how is health care going to be financed when you see on the horizon lots of old people coming and growing problems such as obesity and diabetes? We can put more funding into the health care system, but that is going to have to come from other things such as education, security, transportation, infrastructure, and the value of the dollar.

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  59. Well, I mean, I think doctors should be paid for their services.

    And under a universal public or single payer system that would happen. They would be paid.

    And of course, I can only speak about hospitals that I know, but if you asked to be treated for something like cancer, they'd treat you even if you couldn't pay.

    They would treat the symptoms, not the underlying condition.

    I had an acquaintance have to get a cyst operated on. She couldn't afford it all at once out of pocket and she didn't have insurance. She worked out a payment plan with the hospital.

    At this point I'd advise you to dig deeper. You seem to confuse stabilizing a patient with full medical care.

    Under current law, if you show up at an ER with a gangrenous leg due to diabetes, the ER will treat the gangrenous leg, but they will not treat the diabetic condition that underlies it. Without threating that underlying condition, that patient isn't getting quality healthcare. They will continue to suffer the same symptoms and their health will deteriorate.

    It's great that the patient worked out a plan with the hospital, but many people can't do that. Many hospitals aren't willing to make such arrangements. Many people end up declaring bankruptcy and suffering from a 10 year hit on their credit report. This is unnecessary.

    Using the ER is not a solution to the healthcare problem. Stabilization and treatment of symptoms doesn't constitute quality healthcare.

    As I said, this is totally subjective as to what's a lot. Here's my figuring based on the docs I know. The doctors I know make legitimate, suable mistakes, maybe once out of every maybe 10,000 patients.

    But those mistakes can be very serious for the patient (i.e, chronic disability or death.) The stakes are higher for healthcare than in other services. This affects their lives.

    If that, and again, these are the docs I know. I know a lot of them. If 3% of their costs are a result of something that is relevant about .01% of the time, is a disproportionately high cost. Of course this calculation is stupid, but so is just willy-nilly calling 3% not a lot.

    You are confusing the number of mistakes made with the seriousness of the mistake and its impact on the life of the patient.

    But I'm sorry, maybe this is my bias because of all the doctors I know. Sure these guys want to make money, but they genuinely care about patients and really just want to make them better.

    Sure. But the impact on the patient can still be very serious. If a doctor, even honestly, makes a mistake that results in lifetime paralysis for the patient, that patient through no fault of their own, has to live with that doctor's mistake. Shouldn't the patient get some kind of compensation for the suffering they will have to endure for the rest of their lives? Shouldn't the patient get some kind of assistance (wheelchairs, etc.) to help adapt?

    And so often they get sued over nothing.

    And those cases are generally thrown out of court.

    Not sure how this doesn't negatively impact healthcare.

    It is not a factor in the inflation of healthcare costs. The cost of litigation is going down while healthcare costs are going up.

    There's not a "guarantee" per se, any more than there isn't a guarantee that you are going to get a car.

    Your analogies make no sense.

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  60. But if I must explain it: The reason they'd be able to afford it is that the hospitals want the business.

    Why would a hospital or insurance company want a patient who is going to cost them more money in health costs than they can pay in premiums?

    If they can treat the illness at or above the cost that they will charge the consumer, they'll do it. They won't just turn down money.

    This doesn't make sense. Why would a hospital or insurance company treat a patient who will cost them more than they'd receive in return?

    Again, it's like an iPhone. What's Apple's incentive to allow middle class people to buy iPhones? More iPhones sold. Simple.

    Again. Doesn't make sense. Healthcare is not like an iPhone. iPhones cost very little to make. Healthcare is too expensive for middle class people. Treatments can cause between $1000s-100000s or higher. Most people can't afford these treatments out of pocket. This is an apples to oranges comparison.

    No, the reason it hasn't been implemented anywhere is because that would be a problem for the legislators in that area if they can't have their hooks in it. You would be making some very powerful people less able to interfere in people's lives and take away their freedom, and they just won't have that.

    No. I'd advise you to look deeper. Some countries like Taiwan were able to plan a healthcare system from scratch. They didn't choose the U.S. system.

    who are simply in favor of individual rights and liberties are being labeled as essentially anarchists. We're not. And so let me just spell some things out.

    But your liberties are rights (like the right to your life) are threat under the current system.

    non-excludable and non-rivaled in consumption. The government can either provide it or set up a regulated monopoly. These are things like water, power, roads, and parks. Healthcare would be provided by the private sector, for other citizens without any mandates.

    Then insurance companies will merely choose the healthiest and most profitable people and discard the rest.


    It is also excludable and rivaled in consumption. Ergo, not public. And another thing: this idea that somehow it's holy because it's healthcare is ridiculous.

    This makes no sense. Healthcare is "holy" because it is essential to life and treatments (unlike food) are generally too expensive for people to afford out of pocket.

    Again, food is a necessity, and the government isn't needed to provide it reasonably.

    Because food is cheap. Health treatment isn't.

    That's a pretty good start right there. If only those things are done, the US will probably have the most efficient and equitable healthcare around.

    No. It doesn't address the problems at all. You ignored several points I already made. It will create a system of "haves" and "have nots."

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  61. And under a universal public or single payer system that would happen. They would be paid.


    They would treat the symptoms, not the underlying condition.

    They would treat the symptoms, tell you why you have them, and if you wanted the underlying condition treated, they wouldn't say no based on your ability to pay. But of course, this can raise costs for the rest of us if they simply skip out on the bill. That's why do the things I suggested in my previous comments to make it easier for costs to come down.

    But those mistakes can be very serious for the patient (i.e, chronic disability or death.) The stakes are higher for healthcare than in other services. This affects their lives.

    I'm actually relieved you said this. I keep saying that you can't just decide that 3% isn't high, just in the same way I wouldn't say that 1 in 10,000 mistake isn't big or important to the patient. The point in this example was to say that the 3% being not high is totally subjective. But I imagine the figure is much higher, and I will get to that later.

    Shouldn't the patient get some kind of compensation for the suffering they will have to endure for the rest of their lives?

    Umm...most of these things are settled out of court. And you can go to lawyer's websites essentially bragging about how much they settled for. Millions, often tens of millions of dollars. That doesn't mean that they were ruled in their favor. Just that they managed to harass the hospital enough. Again, as I was saying about subjectivity, who am I to say that millions of dollars isn't fair?

    Personally, in my model of insurance for catastrophic care with customizable policies, you would probably be able to add a malpractice protection to your plan. The insurance company would essentially be placing a bet on the ability of the doctor.

    But I want to talk about this 3% figure and how malpractice relates to costs. I really doubt that 3% figure, and here's why. Again, I am going off the doctors I know. But one huge thing that creates inefficiency and really drives up costs is defensive medicine. Doctors, and I mean almost 100% of doctors, will make sure they order extra tests to be 100% sure so as not to be sued. Even if the tests are unnecessary, they are in the habit of doing so that if they miss a condition, it is documented that they've exhausted all the means of screening. This, suffice it to say, raises costs, gums up the works with patients who don't need the tests, drives up the cost, and of course subjects the patients to extra tests which can involve things like radiation.

    In TK's example of his parents' friends, the woman's doctor in Korea said it would be okay to wait it out and take a flight. Even if the stroke was just a TIA, an American doctor would NEVER suggest something like that. The potential liability would be huge for that doctor and they'd lose a court case in the US hands-down. Doctors see patients all day and they know probably what will happen and how serious things are, but can't really act on it.

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  62. They would treat the symptoms, tell you why you have them, and if you wanted the underlying condition treated, they wouldn't say no based on your ability to pay.

    Yes they do say "no" because you're not having a health crisis. There is no law that requires a hospital to treat the underlying condition. There isn't.


    But of course, this can raise costs for the rest of us if they simply skip out on the bill. That's why do the things I suggested in my previous comments to make it easier for costs to come down.

    But none of those things work.

    I'm actually relieved you said this. I keep saying that you can't just decide that 3% isn't high, just in the same way I wouldn't say that 1 in 10,000 mistake isn't big or important to the patient. The point in this example was to say that the 3% being not high is totally subjective. But I imagine the figure is much higher, and I will get to that later.

    You keep avoiding the point. The 3% isn't a factor in the inflation of health care prices. Taking away the right of the courts to settle cases based on their merit as opposed to an arbitrary cap won't help solve the healthcare issue and it will hurt patients.

    Shouldn't the patient get some Umm...most of these things are settled out of court. And you can go to lawyer's websites essentially bragging about how much they settled for. Millions, often tens of millions of dollars. That doesn't mean that they were ruled in their favor. Just that they managed to harass the hospital enough. Again, as I was saying about subjectivity, who am I to say that millions of dollars isn't fair?

    Do they ever really show what those patients look like when they brag their websites? No. They don't.

    Try this scenario:

    You are a plumber. Over a period of time you start feeling fatigue. You go to the doctor. She runs tests and determines that you have a benign tumour on your thyroid. It needs to be removed. You schedule surgery.

    During the surgery, the nurse accidentally slips, bumps the doctor on the arm. The doctor's scalpel goes into the cartilage between your vertebrate and severs the nerve. You're now a quadriplegic.

    It was a completely innocent mistake. The nurse wasn't negligent and the doctor couldn't do anything to stop it. It was all an accident. Still the damage is done.

    Your life is changed forever. You can't walk or move your arms. You can't work as a plumber anymore, so that income is gone. You'll need training to work in another profession because you can't be a quadriplegic plumber. If you're lucky you'll find something else that can work with your skill level and handicap. You'll need tens of thousands of dollars in new equipment: electric wheel chair, ramps, etc. Your house will need be retrofitted for a handicapped person. You'll need therapy to learn how to live as a quadriplegic. How to use the toilet. How to take a shower. You can't drive anymore. You can't go grocery shopping, or go to a movie or see a concert without assistance. You'll need around the clock care for the first few months and, if you're lucky, daily care after that.

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  63. Why would a hospital or insurance company want a patient who is going to cost them more money in health costs than they can pay in premiums?

    They wouldn't, but I am not advocating insurance as-is. It's a payment plan now, and it shouldn't be. I'd say day to day care should be out of pocket with tailored insurance for catastrophic coverage. This makes health insurance analogous to every other kind of insurance, which works pretty well and is affordable.

    Again. Doesn't make sense. Healthcare is not like an iPhone. iPhones cost very little to make. Healthcare is too expensive for middle class people. Treatments can cause between $1000s-100000s or higher. Most people can't afford these treatments out of pocket. This is an apples to oranges comparison.

    Costing little to make is a function of the competition in the space and the simple supply and demand relation that doesn't exist with healthcare because of the way insurance has been changed to act as a payment plan. They will, in a free market, be able to afford treatments. You're expecting me to have a crystal ball about healthcare exactly, and I can't. But what I can point to is every other commodity for which the price goes down with competition. This is the point of the iPhone analogy. Obviously they're not exactly the same.


    No. I'd advise you to look deeper. Some countries like Taiwan were able to plan a healthcare system from scratch. They didn't choose the U.S. system.

    I said this to TK about Korea, and I don't know much about Taiwan other than what I briefly read on Wikipedia, but again, more bad news coming:

    Any system where the government sets the price of something will lead to necessary rationing or a shortage. If the Taiwanese system is truly nationalized and single-payer, the politicians will be lobbied for more money for treatments. This supply and demand connection will be blurred and there will be inefficiency. The government will not be able to pay for it, and will either need to raise the tax for it beyond what it would cost all out of pocket, or need to shut down the program. I assure you, any government-run healthcare system will have its day of reckoning unless they turn it lose to the market. It's starting in the US (yes, I know we don't have single-payer, but the intervention thing still applies), it will happen in Korea and Taiwan.

    But your liberties are rights (like the right to your life) are threat under the current system.

    Your right to life is not the same as an entitlement to free healthcare. Just the same, I think people should be able to get healthcare and it should be affordable. But since the market has a way of doing just that: giving stuff to people as cheaply as possible, I'd say that the fastest and best way to promote liberties is to make it a free market. Again, I think you think that I am defending the status quo. As I said, the US is going to have its day of healthcare reckoning. If it's not a free market solution, all you've done is postponed the inevitable.

    Then insurance companies will merely choose the healthiest and most profitable people and discard the rest.

    Well, I suppose that could happen, but why guess when we have examples of the contrary all over. It'd be like any other insurance: they'll just charge you a higher risk premium. You might think this is heartless, but you don't realize is how insurance prices will drop if they are not treated as payment plans and instead as actual insurance: a risk pool. If the current companies don't want supply it, new ones will spring up, specializing in high-risk consumers. They aren't going to ignore money to be made in the market. With the ability to tailor the plans, you can take out things you don't think they're at risk for, lowering price further.

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  64. So just to readjust your life will cost several hundred thousand dollars. But what about the other loses: the pleasure you got out of playing the piano, or surfing, or hiking. They are all gone, forever.

    Who's fault is that? Yours? No. You didn't do anything wrong. So why should you pay out of pocket to adjust to your new life?

    I don't think you'd take that lying down if it happened to you.

    The bait and switch here is that the gullible actually believe that those who win these large settlements are perfectly healthy people who got a big award, instead of people whose lives have been altered forever through no fault of their own. Most of these big judgments are appealed (read the fine print on those websites) and reduced anyway.

    Tort reform does nothing to stop frivolous lawsuits. The caps that are proposed ($250,000 in CA) don't even cover the cost of therapy and equipment. Those who are catastrophically harmed, suffer a second time because they have to pay out of pocket for something that they didn't cause.

    There is reason we have a court system to look at these cases individually.


    Personally, in my model of insurance for catastrophic care with customizable policies, you would probably be able to add a malpractice protection to your plan. The insurance company would essentially be placing a bet on the ability of the doctor.

    What if you can't afford it? What if you can't afford insurance at all, like most of the working poor?

    How is someone who makes $12 an hour working in a call centre, or as a plumber's apprentice, or as a hotel worker able to afford an individual policy that costs at least $100/mo? What possible incentive would a for-profit insurance company have to give someone a cheaper policy, yet cover all their basic healthcare needs when they could easily cost more than the policy premiums itself?

    Scenario #2.

    You work as a electrician's apprentice. You makes $12/hr. You live in Chicago or LA with a couple roommates in a $1200/mo apt. You need to have a car to do your job, which costs a couple hundred more in payments, insurance, gas and maintenance. You need to buy food, have a cell phone for calls, pay utilities, etc. How much money is left over for health insurance or a Flexible Spending Account? Not much. Why would a for profit insurance company insure a person that can't afford more than $40/mo?

    Say this person wakes up one morning with tingly fingers and toes. They go to the ER and find out they have multiple sclerosis. This is a progressively serious disease that costs thousands to treat monthly. They must take expensive medications. They will eventually need a wheel chair and therapy. Eventually they'll need round the clock care as the disease progresses.

    Even if this person could afford insurance, what "free market" incentive is there for a for-profit insurance company to keep this person on as client without a legal mandate? They are a drag on their profits. What shareholder is going to invest in a company that willingly chooses such a financial inefficiency?

    What hospital is going treat this person free for the rest of their [shortened] lives?

    I'm sorry. Free markets are fine for voluntary purchases like auto insurance and iPods, but they don't work when the need is universal and the costs can bankrupt people. There is no free market reason to cover unprofitable people and all the free market fundamentalism in the world isn't going to change that.

    You're not freer under a private for-profit system. It just appears that way when you don't need the system. Once you do, you'll find that you don't have much freedom at all. And the cruel truth is that with healthcare, anyone can end up on the wrong side very easily.

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  65. This makes no sense. Healthcare is "holy" because it is essential to life and treatments (unlike food) are generally too expensive for people to afford out of pocket.

    A bit of heartlessness here: Everyone is going to die. Even the richest man in the world, with all the healthcare he can get, is going to die. Because of this, the definition of healthcare almost becomes subjective. I mean, let's take this to its logical extreme. Let's say there was a pill. And if you took it yearly, you'd live forever. But here's the rub: it costs $1,000,000/year. Many people, including many millionaires, won't be able to afford it. I'm sure almost everyone will want it, but not everyone can afford it, even though it is, more so even than healthcare, a distillation of life. Should everyone get it for free? I would say no.

    But, if there were a market for it, the price will come down, and eventually the millionaires, then the 6-figure folks, then the middle-class, and even the poor will eventually be able to afford it.

    Before you tell me this analogy is ridiculous because it doesn't exist, I will say that the above analogy is more of direct correlation to "the right to life" than is healthcare.

    Because food is cheap. Health treatment isn't.

    It will be with my above suggestions.

    No. It doesn't address the problems at all. You ignored several points I already made. It will create a system of "haves" and "have nots."

    I've pretty painstakingly addressed all the relevant points you've made. The problem is that you keep conflating the current system with a free market. It's kind of hard to address concerns that aren't related to my solutions.

    As for a system of haves and have nots. Well, a free market system is the most equitable way. It's shown with countless goods and services. It has elevated the standard of living of the world over the centuries in spite of government intervention. Conversely, the government creates these have/have not gaps. This is done by putting blocks in the way of people who want to make money in the form of onerous taxes and regulations, and promoting of a lack of initiative and robbing people of their humanity through entitlement programs.

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  66. They wouldn't, but I am not advocating insurance as-is. It's a payment plan now, and it shouldn't be. I'd say day to day care should be out of pocket with tailored insurance for catastrophic coverage. This makes health insurance analogous to every other kind of insurance, which works pretty well and is affordable.

    No. It is analogous for voluntary forms of insurance. This is an apples to oranges comparison.

    Costing little to make is a function of the competition in the space and the simple supply and demand relation that doesn't exist with healthcare because of the way insurance has been changed to act as a payment plan. They will, in a free market, be able to afford treatments. You're expecting me to have a crystal ball about healthcare exactly, and I can't. But what I can point to is every other commodity for which the price goes down with competition. This is the point of the iPhone analogy. Obviously they're not exactly the same.

    No. Prices only go down to the actual costs of providing care. Efficiencies can only go so far. It isn't magic. And health insurance isn't a commodity. It's a necessity. It isn't an iPhone.

    There are many working poor who can barely afford the necessities of life, much less spend hundreds on a family policy. This punishes the poor. It's only freedom for some, not for all.

    Your right to life is not the same as an entitlement to free healthcare.

    And this is where we are different. I, like most of the world, believe that the right to life does include the right to services that preserve and maintain life, viz., healthcare.

    It's a cruel, cruel system that punishes people because they are too poor to afford healthcare, or lose their job, or are made to suffer because of the mistakes of others, however innocent they may be.

    It's a form of social Darwinism that has no place in my value system. Unfortunately social Darwinism is at the centre of so-called free market thinking.

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  67. A bit of heartlessness here: Everyone is going to die. Even the richest man in the world, with all the healthcare he can get, is going to die. Because of this, the definition of healthcare almost becomes subjective.

    And now the truth comes out. People's lives have no value. If you can't afford it, you die. Simple.

    I'm willing to bet that if was your life, you wouldn't just sit around and say "I'm going to die eventually anyway, so I might as well now."

    Because food is cheap. Health treatment isn't.

    It will be with my above suggestions.


    None of your solutions help reduce costs. Costs will continue to rise because we have an ageing population with greater need, more expensive technology, and a for-profit system which is innately inefficient because their goal is to maximize profits for the shareholder, not serve the consumer.

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  68. This is done by putting blocks in the way of people who want to make money in the form of onerous taxes and regulations, and promoting of a lack of initiative

    Funny. There are countries with far higher taxes than the U.S. whose citizens are better off than ours.

    In fact, IN the U.S. the states with the highest tax burdens have far higher per capita incomes and create more wealth than states with lower tax burdens (compare median income in MA with MS, or NY with NV, or CA with WV, or CT with AL.)

    But that's just one more example of how the real world doesn't fit with the ideology.

    and robbing people of their humanity through entitlement programs.

    I wonder how many senior citizens feel like their humanity has been robbed by Social Security. Or, how many want to go back to the 1920s when seniors literally died of starvation in poor houses.

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  69. But none of those things work.

    Not going to bother here. It's like arguing with a child. Examples of how these things work are everywhere. Can't do much with denial.

    You keep avoiding the point. The 3% isn't a factor in the inflation of health care prices. Taking away the right of the courts to settle cases based on their merit as opposed to an arbitrary cap won't help solve the healthcare issue and it will hurt patients.

    Oh, so you're point is that malpractice doesn't lead to inflation of cost. No, that's probably more the mandates. Point taken. However, arbitrary cap? Well, yeah. But what's so wrong with those? We have them for all sorts of offenses in courts. Maybe 250k is not enough for certain things. If it's not, then just have categories of malpractice based on severity of the mistake and put individual caps.

    There is a lot of stuff that you said after this point, but since you can't seem to understand what I think the role of insurance ought to be, and because we don't operate in a free market, the out of pocket prices aren't known. There is no sense in really restating this over and over, as it seems I have to.

    This applies to all your plumber scenarios. The incentive is simple. They want the plumber's money. The plumber can't afford a certain plan? He buys a different one. It doesn't have everything the plumber wants or even needs in terms of catastrophic coverage? He can cut back on something else. Does being poorer have disadvantages? Yes, but if it didn't everyone would just opt to be poor. I say again that there is nothing holy about healthcare. I refer again to my $1,000,000 pill. But only the free market will lower the costs of the insurance and the treatments. Mandates won't. This is the thrust of everything I am saying.

    And now the truth comes out. People's lives have no value. If you can't afford it, you die. Simple.

    I'd encourage people to read the pill example and see how truly ridiculous claim that everyone is entitled to everything in terms of healthcare is. As I said, everyone will die. Your life is made less enjoyable in thousands of ways by being poor. But only the freedom for markets to lower prices and for the poor to better their situation will ever change that.

    To provide it as a single-payer service will require there to be rationing and worse care regardless of how hard you've worked. I don't see how I am heartless by comparison.

    Costs will continue to rise because we have an ageing population with greater need, more expensive technology, and a for-profit system which is innately inefficient because their goal is to maximize profits for the shareholder, not serve the consumer.

    If you knew anything about technology and its trends you'd know how ridiculous your tech statement is.

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  70. This almost needs no answer. Aging population will create more demand for healthcare, yes, and doctors and hospitals, in a free market, will spring up to meet the demand. The health sector grows, the economy grows, more jobs. So terrible. For-profit systems for the "shareholders" are the most efficient. The goals of the company align perfectly with those of the customers. The providers must provide good service to compete. Having a competitive edge makes shareholders and consumers happy. Happens in every commodity. It's why the companies with the products that make consumers happiest are usually the most successful with their shareholders getting more benefit. It is the government which has incentives misaligned with consumers. The incentive of the government, not having to turn a profit, is to simply have each bureaucrat increase people under him, making things more inefficient and himself harder to dispense. It's why we have teachers being underpaid in a city like LA, and yet we have a 4:1 Admin:Teacher ratio.

    It's why in a place like DC with crappy public schools that the average per-student spending is 14k, which would, if just paid directly by consumers could get you into the best private schools with all the rich kids where I live (California). To tell me that the government would be more efficient is absolutely laughable.

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  71. To provide it as a single-payer service will require there to be rationing and worse care regardless of how hard you've worked. I don't see how I am heartless by comparison.

    The current system ALREADY rations. The current system rations based on ability to pay. You even admitted that. A single payer system rations based on need. Which is more just?

    And save the ad hominems for someone else. I'm not a child. None of the examples you provide are anything like healthcare. Don't project your inability to find anything similar onto me.

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  72. They want the plumber's money. The plumber can't afford a certain plan? He buys a different one. It doesn't have everything the plumber wants or even needs in terms of catastrophic coverage?

    This still doesn't make sense. Why would an insurance company take on a policy that will cause them to LOSE net income?

    If the plumber can only afford $40 a month but his doctor visits, prescriptions and catastrophic treatments cost an insurance company $100/mo then a for profit insurance company wouldn't want the plumber's money. It would be losing proposition. He could cost more than he is worth.

    He can cut back on something else.

    So you'd rather have people give up food, or the ability to make a living to preserve an ideology?

    Wow. That is a fundamentalism by definition. And the apathy about human life and suffering just caps the whole thing.

    I guess we're on different pages and we'll have to leave it at that.

    If you knew anything about technology and its trends you'd know how ridiculous your tech statement is.

    I read about the technology all the time. My sister has her PhD in nursing at teaches as Arizona State University. We talk about this all the time. Treatments are becoming more expensive, not cheaper.

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  73. In fact, IN the U.S. the states with the highest tax burdens have far higher per capita incomes and create more wealth than states with lower tax burdens

    Chicken and egg. Rich people want to live in California. Taxes came later after they realized they could get it. Over time, people will move themselves and their business away from these places. The recent 2010 census data bears this out. Look at the "apportionment data" if you just want the big picture from the recent census.

    I wonder how many senior citizens feel like their humanity has been robbed by Social Security. Or, how many want to go back to the 1920s when seniors literally died of starvation in poor houses.

    I wonder how they feel that they're essentially operating on an unaffordable Ponzi scheme that relies on more young people, and how they feel about their kids' inheritance being depleted by a lie. It can't be afforded. Even a smiley-face name like "social security" can't change that.

    Social security can be viable if people pay into it what they take out. And if they don't, then the least the government could do is invest it instead of sticking it in the mattress. But then again, I really shouldn't hold Uncle Sam to any standards of fiscal intellect.

    As for my ad-hominem. You got me, I was out of line there. Sorry about that. I still believe my examples and analogies, while not perfect, show the general point. I believe these sorts of changes would allow healthcare to be more like any other commodity, and which point, I believe we can expect its price to act like anything else.

    Free-market rationing: Yes, there is rationing in a free market. But it is based on people's ability/willingness to pay for things. AKA, the value they place on it. AKA, the most equitable way. I don't think promising to give it to everyone, which is impossible, is compassion. I just don't. I think it's lying.

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  74. @toujoursdan

    Sorry, one other thing. It saddens me to say, though I am sure you are in the same boat, that these comments have been eating up a lot of my time. I am not sure I'll be able to respond to any more. Maybe if it's quick, but I'm sure we can go at this for weeks.

    Just the same, it's been fun debating with you, and if I came across as personally attacking you, I totally didn't mean it. I'm sure you're a gentleman. Haha! See ya' 'round the other posts on the blog, I guess.

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  75. I wonder how they feel that they're essentially operating on an unaffordable Ponzi scheme that relies on more young people, and how they feel about their kids' inheritance being depleted by a lie. It can't be afforded. Even a smiley-face name like "social security" can't change that.

    I don't think you know what a ponzi scheme is. Social Security by definition isn't a ponzi scheme and it isn't unaffordable.

    It has run a surplus, which has been raided by the government to pay for other programs for decades. That raid was started by Reagan to make his deficits look lower than they actually were.

    If this raiding hadn't been done, there would be more than enough money to handle the demographic bubble indefinitely at current levels of benefits.

    Yes, working people of every age pay into it via a payroll tax. They can draw from it when they retire.

    The Social Security "crisis" is deliberately manufactured by people who don't like government and can't stand the idea of a government program being effective.

    Social Security can be viable if people pay into it what they take out.

    It isn't a savings account. It is an insurance scheme. "Security" = insurance. If someone wants to create a savings account they can invest in a 401k or IRA. If those collapse or they make an investment mistake and lose their money, they can still rely on Social Security, instead of being a burden on others.

    And if they don't, then the least the government could do is invest it instead of sticking it in the mattress.

    This would turn it into a ponzi scheme, since that is exactly what modern stock market is nowadays. Investments aren't guaranteed. They entail risk. What happens if that risk is realized?

    But then again, I really shouldn't hold Uncle Sam to any standards of fiscal intellect.

    Nor are many of Uncle Sam's media critics.

    I'm still not sure how this dehumanizes people.

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  76. As for my ad-hominem. You got me, I was out of line there. Sorry about that. I still believe my examples and analogies, while not perfect, show the general point.

    No. You can't compare a universal need with a voluntary purchase or a consumer product. There is no comparison. They are completely different.

    I believe these sorts of changes would allow healthcare to be more like any other commodity, and which point, I believe we can expect its price to act like anything else.

    But health care isn't a commodity and quality healthcare isn't going to become affordable for the working poor no matter how many efficiencies are realized.

    Free-market rationing: Yes, there is rationing in a free market. But it is based on people's ability/willingness to pay for things. AKA, the value they place on it. AKA, the most equitable way.

    Obviously people place high value on their lives. But many still can't afford to buy health insurance. You can't call a system successful if people are expected to give up necessities like food and shelter to receive healthcare.

    I don't think promising to give it to everyone, which is impossible, is compassion. I just don't. I think it's lying.

    But every other developed country has found a way to give quality healthcare to all of its citizens. They use different models, but they all work. Many of these systems have far far better patient outcomes than the U.S.

    Allowing people to suffer and die because they can't afford to pay is cruel.

    And I guarantee that allowing the current to continue isn't going to work either. People are not going to stand by while they, or their children suffer and die when the treatments are there but out of reach because of affordability. That's how revolutions starts.

    Health care will be reformed and it won't follow free market principles because free market principles can't be applied to a area that has to serve everyone equally.

    Chicken and egg. Rich people want to live in California. Taxes came later after they realized they could get it. Over time, people will move themselves and their business away from these places. The recent 2010 census data bears this out. Look at the "apportionment data" if you just want the big picture from the recent census.

    This doesn't make sense. California has had relatively high taxes since the 1960s yet it continued to grow. The last census showed CA growing by 10%.

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  77. The comments on this post are many and most of them lengthy so I skipped most of them. So, I'm sorry if these points have already been made:
    1. The health care in the US may be good to great depending on the specialty area.
    2. The health care SYSTEM in the US is very broken and "embarrassing" as the Korean noted.
    3. The debate isn't about quality of care but access and affordability to that care. And, many in our country do not have access nor can afford care.
    4. The argument about how we should let the doctors decide on treatment is a bit flawed. Like all services we purchase, the consumer should do homework. There are studies to prove that when fee schedule of procedures are changed, doctors change their behavior (fee for procedure x gets dramatically reduced, rate at that procedure being performed goes down dramatically).
    5. My entire career has been in health care and health care systems (both) and while Health Care Reform passed last year can hardly be called "reform", it is one step in the right direction.

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  78. I believe it's the crippling nature of the cost to companies of insuring their workers that will, in the end, bring the current system down. The current system is an enormous drain on the resources of companies with a workforce in the U.S. That's why it's at last getting some attention in Washington.

    It would be nice if Washington had paid attention to the majority of Americans who look favourably on some form of National Health Service for at least the past 30 years, but they're only actually starting to pay attention now because it's so expensive for American industry. The public just votes, it doesn't have lobbyists or lawyers, or make multimillion dollar campaign contributions. And the American public has been steeped in anti-'socialized medicine' propaganda for decades too.

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  79. I believe it's the crippling nature of the cost to companies of insuring their workers that will, in the end, bring the current system down. The current system is an enormous drain on the resources of companies with a workforce in the U.S. That's why it's at last getting some attention in Washington.

    As someone said, companies are going to look for ways to get out of providing health insurance pretty soon.

    It would be nice if Washington had paid attention to the majority of Americans who look favourably on some form of National Health Service for at least the past 30 years, but they're only actually starting to pay attention now because it's so expensive for American industry. The public just votes, it doesn't have lobbyists or lawyers, or make multimillion dollar campaign contributions. And the American public has been steeped in anti-'socialized medicine' propaganda for decades too.

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  80. Why is this even an issue? I know they flew 13 hours for medical attention, but if my insurance was in America and I was travelling in Korea when I had a stroke - I would go to America if my doctor said I could! I don't think the bankrupt 10 times thing is valid - Medical attention here in Korean CAN be cheap but if you go to better hospitals and want good doctors and "good service" you are going to spend lots of money too!

    Medical procedures cost lots of money without insurance ANYWHERE! That is why they have insurance!

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  81. This is because Reagan thought it would be a fucking fantastic idea to let PRIVATE companies handle healthcare coverage by offering insurance. Profit is profit to these sadists. Bankruptcy, death, denying coverage, and inadequate care are all part of what goes into making a profit.

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  82. dan = fail. toujoursdan FTW.

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  83. The Korean National Health Care is only good for basic colds. Every Korean I know purchases their own private insurance, which these people certainly did. That is the reason they chose to come back. If they were smart, they would have purchased travelers insurance in case of an accident.

    A friend of mine had the national health care which was provided by his job, but that has not helped his insane bill. Not to mention it was voided when his school fired him for being sick. In the first week he incurred 10,000,000 won worth of medical bills which the NHS would not cover. They would not even admit him without all the money in his account and his credit card. Now he has no more money and they have stopped treating him for his on going condition because he can't pay for his 40,000,000 won bill. Also, they won't let him leave the country to get the help that he needs until he pays the bill. It's truly sick they way they have been treating him. I won't even mention the horrible care that he has had to endure while in their "care".

    He is a poorly written article on the situation.
    http://www.nydailynews.com/life-style/health/south-korean-hospital-won-transfer-american-home-40g-bill-paid-article-1.1438566

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