In countries with well-designed national health, health insurance is not a profit center but is allowed only a very small margin. In our country, since Obamacare passed, health insurers have become profit bonanzas. Why are the CEOs of insurers, which are not health providers but middlemen, earning $100m per year? Medicare for all might be a step toward solving this problem.
It really puts things in perspective that my medical payments as an uninsured person visiting Taiwan were cheaper than my copays / co-insurance in the US with health insurance. Our system really is broken.
Really interesting, thank you, David. The comparison between US and UK maternity outcomes is shocking. I’m so glad to have the NHS here in the UK, much as people like to moan about it.
I’ve been reminded of Michael Moore’s 2007 documentary, Sicko, in which he compared US profit-driven healthcare with other systems around the world. It seems to have become even more polarised since.
In my post last Saturday, before the killing, I said I was going to write about this topic. A quote from my 11/30 post.
"Here’s what I now believe:
American healthcare should be a right available to everyone, not a privilege. It should be a public good, not a category of for-profit business.
That’s a huge topic and I don’t know how or if I might be able to shift the narrative to make a difference. But I want to try. Writing about it is a start.
To be continued next week––including transparency as to what privileged healthcare looks like to me."
David, my husband, a retired physician who practiced for 30+ years in DC, responded to the murder with some version of “I don’t condone murder, but this guy allowed the blatantly unethical behavior of United Health to continue… “ In other words, doctors as well as patients are horribly frustrated by the insurance companies denying claims, charging fees that are too high, etc.
The people who like these companies are the owners and the executives. That said, these companies are creatures of a lack of political imagination and a lot of political capture.
This issue is lying there for some political faction to pick up and run with.
I thought most CEOs answer to a board of directors. UHC is a publicly traded company. I think in Brian Thompson’s case it takes a village to deny health care.
agreed! my physician husband is highly critical of the profit-driven medical industrial complex; so he views the CEO and other execs as “complicit” (which they are, to some degree)
CK this is a benevolent view of BOD. Like they're going to say, oh no we need to make less money and be more ethical. That's just not the way a for profit Board operates. So much harm, unfortunately, all around the world, in the name of EBITDA.
Truth! My rheumatologist is ridiculously frustrated. During office visits, he routinely flips his computer screen to me and says, "See. I can't even order ..." Fill in the blank with some test or treatment he, in the past, could offer that now is "not in his wheelhouse." The system is siloed. And I have to figure out which doc can order which thing, get them to understand why and agree to it, and cross my fingers that insurance will agree. And truthfully, I've been very luck compared to others--in terms of eventually getting approvals for procedures and medications. But it has required an awful lot of work and follow-through and painful waiting periods on my part. And as I currently wait on insurance approval for a change in course of treatment my rheum strongly recommended, he's cautioned me that he's seen insurance change its minds last-minute with any number of "bullshit" excuses.
Ha! I didn't come here to complain. Like I say, I feel relatively lucky. But I did want to concur, Debbie. Along with my rheum, I have a few friends who work in the healthcare system, docs and PAs, who are beyond frustrated.
David, you've a gift for opening up conversations it seems.
I’m really glad your wife is doing better, David. That’s absolutely frightening.
I had a conversation with a friend just last night about the rise of concierge healthcare, and how if you don’t have it, or can’t afford it, and something goes terribly wrong medically speaking in the US, you are going to suffer greatly, even if you have a decent, expensive health insurance policy.
Another friend of mine recently received a cancer diagnosis, and insurance denied coverage for a pet scan needed to verify the cancer hadn’t spread. She could afford to pay for it out of pocket, but should she have to, especially for a cost that far surpasses what it would have cost in another country?
And as the gap between the haves and the have-nots continues to expand here in the US, I don’t see our healthcare systems improving in the short-term. And many will continue to suffer because of it. I believe this is evident in the reactions to the United Healthcare CEO shooting.
Happy and healthy holidays all. I had privileged healthcare in New York City in the late 80's and early 90's because my former husband was a resident at Mt. Sinai Hospital and again for years in Little Rock, Arkansas (he was an attending physician there about 1995-2010). If I stayed on the medical campus hubby worked at, there were no out of pocket deductions and medicine was free. Hubby could always access great pediatric medical people in those instances that just come with having children (stitches, hip bone scare what?, tummy issue here, tear duct procedure there, yada yada). We totally appreciated our medical fortune and wondered at how "normal" patients dealt with serious medical issues. My nephrologist has told me that patients have gone into kidney rejection, and returned to dialysis, because they could not keep up with the cost of the regimen of drugs required to fight rejection. Thank you for pointing out that, no matter what, privileged or not, the patient has to be formidable too. YAY FOR YOUR WIFE!
Thanks Sharon. It's great to have a doctor in the family for many reasons. Debbie's brother is an orthopedic surgeon and he was stumped as well. But it helped Debbie to be able to talk to him throughout.
Thank you for writing this. We need change—it is unworkable for most Americans. My brother is a surgeon, and many of the cases he sees are low-income working people who could not afford primary or preventative care and then need to have limbs amputated. My mother was an ER doctor for 35 years, and felt horrible at the fact that she often needed to prescribe patients care or medicine without knowing whether they could afford it.
I’m an American living in Italy, and have been very satisfied at the care I’ve received in the public system; even when you seek care in private hospitals, the prices are posted clearly at reception. I find it totally insane that Americans must get treatment and often do not know how much they will pay beforehand.
Thanks Clare for the comment. Do you follow Kirsten Powers? The cliche about an ounce of prevention being worth a pound of cure is a cliche because it's true!
A good friend who is a retired MD (pain specialist) recently shared this on a post about healthcare:
My soapbox: Insurance only pays to make us a C minus. According to insurance companies, That’s passing. That’s average. That’s adequate. That’s what they think. They don’t have to make you good. They just have to cover the basic minimums. They never pay to make you an A+. An A+ is often times possible. But because much of healthcare is not covered by insurance, you get C plus or C minus care. If you take the time and are willing to pay some out-of-pocket, hopefully you can find someone who’s willing to give you A+ care.  you don’t wanna just be passing, you want to be the best version of yourself that’s possible.
We all have our healthcare/healthscare stories. I shared about my son who has type 1 diabetes and how I often wonder how people with no or poor insurance handle such a disease. Autoimmune diseases are on the upswing - I believe in part due to our diet and lifestyles (read Casey Mean’s book “Good Energy” if you want a good scare) but our healthcare system survives on keeping us sick, billing for surgeries and keeping us on prescription medications for life. Some are needed (ie insulin) but others have side effects that are worse than the symptom.. Topic for another column I’m working on - how to take control of our health in spite of our healthcare system and unhealthy food supply.
I very much appreciate your open and honest conversation about healthcare costs in America. You strike me as a genuine individual in your approach to topics. Trying to explain healthcare costs to my young nursing student cohort, who have never paid out of pocket and still covered by mom and dad's insurance, is a challenge indeed. I will be showing this article to them, hopefully in the interest of them gaining understanding.
Yes, we in the UK complain about the NHS, which was funded insufficiently for a number of years and has had other countries (esp Australia and NZ, I believe) woo away our doctors. BUT BUT BUT Everyone has access to good care and good doctors, although the very rich can look after themselves by buying private care (and some of us can do so in small ways from time to time). We don't always get it instantly, which might shock rich Americans, but by and large people can get the treatment they need with no co-pay etc etc. We pay for it in our taxes and it is seen as fair. I am not a medical doctor, but have done masses of research about the NHS and it is very rare to hear people complain that they are paying for the ill health of other people. The need for health is seen as a boat we are all in together. I believe this is the common view of most Europeans, although the funding systems vary hugely.
We have lacked the political will to do something like the NHS in America. And also the myth of our "rugged individualism" seems to get in the way. Mostly so much money is at stake and the there's been political capture. Thanks as always for your comment.
‘Socialised medicine’ and a reluctance to pay for the guy down the road. Plus a well entrenched insurance system. Good luck. It won’t happen in my lifetime!
Here's my personal perspective, and I'm working on an essay to this effect.
Background: I was born into poverty with a congenital heart defect. Poverty and disability are terrible bedfellows. In the U.S. over 25% of the homeless population have some sort of disability. By sheer persistence and the blessing of a decent intellect, I was able to claw my way out of poverty, get a college degree, and have a career with decent pay, until my heart finally quit and I needed a heart transplant. I had to move across the country to a transplant center where I received a heart transplant. Years of working a good career allowed me to save enough money in my 401k that I was able to fund my move and expenses. I know other people who have not been as fortunate and they died waiting for a heart at other, smaller hospitals. In that way, I recognize that I had a privilege they did not. Conversely, if I had not been so poor in my early life, perhaps I could have received the necessary medical care to keep my heart healthy enough to avoid the need for a transplant. This is something I will never know.
I enjoyed this substack and what a relief/blessing that your wife knows what is going on with her body, has a great Dr., and that you are able to afford her treatments.
I am 61 and am a part of let’s say a COOP or Sharing plan. I signed up after I got laid off during the Covid madness which permanently changed so many lives. The plan pays EVERYTHING except the first $400 for any incident. Nothing has ever been denied. I can decide what Drs I go to, get second opinions etc! (I don’t know what the payout is on meds but I am only on thyroid medicine so not sure how meds work). I have bought therapeutic things on Amazon and they have paid for it. I work with a holistic Dr and they have paid for these holistic drops called Pekana! I will always keep this insurance even when I get on Medicare. My cost four years ago was less than $300 a month. Now, it’s about $420 a month. My monthly payments are sent to people on the plan who have presented a medical need. It’s amazing and I encourage other people to look into it.
A cardiologist wrote a book a few years back on longevity but I don’t recall the name of it. He came to the conclusion after visiting this village in China with more Centenarians than any other place in the world that if you want to live longer stay away from Drs and Dr offices!! So, I do!! The people in China were very remote and couldn’t go the Dr hardly ever! And, as a result they lived longer.
I subscribe to a lot of substacks and read about healthcare all the time. I believe every American should question and research every medical procedure before getting it. Mammograms, colonoscopies, nuclear stress tests, CAT scans and X-rays (to name just a few but there are a lot others) are profit making procedures, often harmful (cumulative effects of radiation are terrible and cause cancer and who is looking out for you on this? No one). Drs follow a profit driven protocol that often can cause harm to the individual. Not to mention medical mistakes are the third leading cause of death in the US.
I plan to go to Mexico in the next year for a facelift. Yes, it’s vain. I have spent A LOT of time researching who to go to and the quality of care is outstanding. After surgery, I will stay for two weeks with nurses coming into my room everyday to check my blood pressure, do lymphatic massages, do hyperbaric oxygen sessions that promotes healing all at a fraction of the cost of the same procedure in the US. I had my eyes done a few years back and had a horrible experience with a very qualified eye dr and when I had complications he didn’t help. He rushed through my surgery and I learned a little of things about what he did/didn’t do after the fact. Any surgery is high risk so we all must be very careful who we allow to operate on us!!
My son needs extensive dental work done and although he has the money, he is choosing to go to another country for the work. We have decided where yet but we are researching it. Medical tourism is a thing!! He has gone to consults in the US and the most recent Dentist said he needed a gum graft. My son didn’t buy it, thank God!! I mean on its head, it just sounds barbaric, does it not? We must be critical thinkers when it comes to healthcare. We must be our own healthcare advocate.
I think if everyone can remember when they walk into a Drs office, everything is profit driven instead of “do no harm”. It’s a sad commentary on our healthcare.
One other comment, the high percentage of black maternal mortality deaths??!! Where is the outrage and why is this happening??? That is shameful. Why is there a disparity? Is it because the moms can’t afford Dr visits? It’s a disgrace!
The future is now
That's true, or it should be.
In countries with well-designed national health, health insurance is not a profit center but is allowed only a very small margin. In our country, since Obamacare passed, health insurers have become profit bonanzas. Why are the CEOs of insurers, which are not health providers but middlemen, earning $100m per year? Medicare for all might be a step toward solving this problem.
I think some version of that could make sense.
Thank you for this. As Kirsten Powers' piece did for you, this did for me.
It really puts things in perspective that my medical payments as an uninsured person visiting Taiwan were cheaper than my copays / co-insurance in the US with health insurance. Our system really is broken.
Really interesting, thank you, David. The comparison between US and UK maternity outcomes is shocking. I’m so glad to have the NHS here in the UK, much as people like to moan about it.
I’ve been reminded of Michael Moore’s 2007 documentary, Sicko, in which he compared US profit-driven healthcare with other systems around the world. It seems to have become even more polarised since.
Sure
Why didn’t you write this before the execution of the UHC executive?
He has previously written about this subject, actually.
Well it’s all very opportunistic at this point.
Read more of David’s posts. You’ll see.
In my post last Saturday, before the killing, I said I was going to write about this topic. A quote from my 11/30 post.
"Here’s what I now believe:
American healthcare should be a right available to everyone, not a privilege. It should be a public good, not a category of for-profit business.
That’s a huge topic and I don’t know how or if I might be able to shift the narrative to make a difference. But I want to try. Writing about it is a start.
To be continued next week––including transparency as to what privileged healthcare looks like to me."
Ok I stand corrected
David, my husband, a retired physician who practiced for 30+ years in DC, responded to the murder with some version of “I don’t condone murder, but this guy allowed the blatantly unethical behavior of United Health to continue… “ In other words, doctors as well as patients are horribly frustrated by the insurance companies denying claims, charging fees that are too high, etc.
The people who like these companies are the owners and the executives. That said, these companies are creatures of a lack of political imagination and a lot of political capture.
This issue is lying there for some political faction to pick up and run with.
Thanks for the comment Debbie.
I thought most CEOs answer to a board of directors. UHC is a publicly traded company. I think in Brian Thompson’s case it takes a village to deny health care.
agreed! my physician husband is highly critical of the profit-driven medical industrial complex; so he views the CEO and other execs as “complicit” (which they are, to some degree)
CK this is a benevolent view of BOD. Like they're going to say, oh no we need to make less money and be more ethical. That's just not the way a for profit Board operates. So much harm, unfortunately, all around the world, in the name of EBITDA.
Truth! My rheumatologist is ridiculously frustrated. During office visits, he routinely flips his computer screen to me and says, "See. I can't even order ..." Fill in the blank with some test or treatment he, in the past, could offer that now is "not in his wheelhouse." The system is siloed. And I have to figure out which doc can order which thing, get them to understand why and agree to it, and cross my fingers that insurance will agree. And truthfully, I've been very luck compared to others--in terms of eventually getting approvals for procedures and medications. But it has required an awful lot of work and follow-through and painful waiting periods on my part. And as I currently wait on insurance approval for a change in course of treatment my rheum strongly recommended, he's cautioned me that he's seen insurance change its minds last-minute with any number of "bullshit" excuses.
Ha! I didn't come here to complain. Like I say, I feel relatively lucky. But I did want to concur, Debbie. Along with my rheum, I have a few friends who work in the healthcare system, docs and PAs, who are beyond frustrated.
David, you've a gift for opening up conversations it seems.
I’m really glad your wife is doing better, David. That’s absolutely frightening.
I had a conversation with a friend just last night about the rise of concierge healthcare, and how if you don’t have it, or can’t afford it, and something goes terribly wrong medically speaking in the US, you are going to suffer greatly, even if you have a decent, expensive health insurance policy.
Another friend of mine recently received a cancer diagnosis, and insurance denied coverage for a pet scan needed to verify the cancer hadn’t spread. She could afford to pay for it out of pocket, but should she have to, especially for a cost that far surpasses what it would have cost in another country?
And as the gap between the haves and the have-nots continues to expand here in the US, I don’t see our healthcare systems improving in the short-term. And many will continue to suffer because of it. I believe this is evident in the reactions to the United Healthcare CEO shooting.
True long term self interest for the "haves" is to support reform. Otherwise more people and institutions are going to snap.
Thanks for the comment, Heather. And no, your friend should not have had to pay for it out of pocket!
Happy and healthy holidays all. I had privileged healthcare in New York City in the late 80's and early 90's because my former husband was a resident at Mt. Sinai Hospital and again for years in Little Rock, Arkansas (he was an attending physician there about 1995-2010). If I stayed on the medical campus hubby worked at, there were no out of pocket deductions and medicine was free. Hubby could always access great pediatric medical people in those instances that just come with having children (stitches, hip bone scare what?, tummy issue here, tear duct procedure there, yada yada). We totally appreciated our medical fortune and wondered at how "normal" patients dealt with serious medical issues. My nephrologist has told me that patients have gone into kidney rejection, and returned to dialysis, because they could not keep up with the cost of the regimen of drugs required to fight rejection. Thank you for pointing out that, no matter what, privileged or not, the patient has to be formidable too. YAY FOR YOUR WIFE!
Thanks Sharon. It's great to have a doctor in the family for many reasons. Debbie's brother is an orthopedic surgeon and he was stumped as well. But it helped Debbie to be able to talk to him throughout.
Thank you for writing this. We need change—it is unworkable for most Americans. My brother is a surgeon, and many of the cases he sees are low-income working people who could not afford primary or preventative care and then need to have limbs amputated. My mother was an ER doctor for 35 years, and felt horrible at the fact that she often needed to prescribe patients care or medicine without knowing whether they could afford it.
I’m an American living in Italy, and have been very satisfied at the care I’ve received in the public system; even when you seek care in private hospitals, the prices are posted clearly at reception. I find it totally insane that Americans must get treatment and often do not know how much they will pay beforehand.
Thanks Clare for the comment. Do you follow Kirsten Powers? The cliche about an ounce of prevention being worth a pound of cure is a cliche because it's true!
I do! I find her writing very compelling.
A good friend who is a retired MD (pain specialist) recently shared this on a post about healthcare:
My soapbox: Insurance only pays to make us a C minus. According to insurance companies, That’s passing. That’s average. That’s adequate. That’s what they think. They don’t have to make you good. They just have to cover the basic minimums. They never pay to make you an A+. An A+ is often times possible. But because much of healthcare is not covered by insurance, you get C plus or C minus care. If you take the time and are willing to pay some out-of-pocket, hopefully you can find someone who’s willing to give you A+ care.  you don’t wanna just be passing, you want to be the best version of yourself that’s possible.
We all have our healthcare/healthscare stories. I shared about my son who has type 1 diabetes and how I often wonder how people with no or poor insurance handle such a disease. Autoimmune diseases are on the upswing - I believe in part due to our diet and lifestyles (read Casey Mean’s book “Good Energy” if you want a good scare) but our healthcare system survives on keeping us sick, billing for surgeries and keeping us on prescription medications for life. Some are needed (ie insulin) but others have side effects that are worse than the symptom.. Topic for another column I’m working on - how to take control of our health in spite of our healthcare system and unhealthy food supply.
Thanks for another great Substack.
Thank MM for the comment. I like that grading way of evaluating what insurance sets out to do. Our health is not pass/fail!
I very much appreciate your open and honest conversation about healthcare costs in America. You strike me as a genuine individual in your approach to topics. Trying to explain healthcare costs to my young nursing student cohort, who have never paid out of pocket and still covered by mom and dad's insurance, is a challenge indeed. I will be showing this article to them, hopefully in the interest of them gaining understanding.
Thanks for the comment Darrin.
Yes, we in the UK complain about the NHS, which was funded insufficiently for a number of years and has had other countries (esp Australia and NZ, I believe) woo away our doctors. BUT BUT BUT Everyone has access to good care and good doctors, although the very rich can look after themselves by buying private care (and some of us can do so in small ways from time to time). We don't always get it instantly, which might shock rich Americans, but by and large people can get the treatment they need with no co-pay etc etc. We pay for it in our taxes and it is seen as fair. I am not a medical doctor, but have done masses of research about the NHS and it is very rare to hear people complain that they are paying for the ill health of other people. The need for health is seen as a boat we are all in together. I believe this is the common view of most Europeans, although the funding systems vary hugely.
I'd love an NHS in America, and I think if you waved a magic wand tomorrow and created an American NHS, most people would be happy.
Ann,
We have lacked the political will to do something like the NHS in America. And also the myth of our "rugged individualism" seems to get in the way. Mostly so much money is at stake and the there's been political capture. Thanks as always for your comment.
I thought the issue was something called
‘Socialised medicine’ and a reluctance to pay for the guy down the road. Plus a well entrenched insurance system. Good luck. It won’t happen in my lifetime!
Here's my personal perspective, and I'm working on an essay to this effect.
Background: I was born into poverty with a congenital heart defect. Poverty and disability are terrible bedfellows. In the U.S. over 25% of the homeless population have some sort of disability. By sheer persistence and the blessing of a decent intellect, I was able to claw my way out of poverty, get a college degree, and have a career with decent pay, until my heart finally quit and I needed a heart transplant. I had to move across the country to a transplant center where I received a heart transplant. Years of working a good career allowed me to save enough money in my 401k that I was able to fund my move and expenses. I know other people who have not been as fortunate and they died waiting for a heart at other, smaller hospitals. In that way, I recognize that I had a privilege they did not. Conversely, if I had not been so poor in my early life, perhaps I could have received the necessary medical care to keep my heart healthy enough to avoid the need for a transplant. This is something I will never know.
Dawn,
That's an incredible story. I'm about to subscribe to your perfectly named Substack because I want to know more. Thanks for the comment.
Thank you for supporting my work! I'm very happy whenever I know that my writing gives people something to think about or the words they need to hear.
I enjoyed this substack and what a relief/blessing that your wife knows what is going on with her body, has a great Dr., and that you are able to afford her treatments.
I am 61 and am a part of let’s say a COOP or Sharing plan. I signed up after I got laid off during the Covid madness which permanently changed so many lives. The plan pays EVERYTHING except the first $400 for any incident. Nothing has ever been denied. I can decide what Drs I go to, get second opinions etc! (I don’t know what the payout is on meds but I am only on thyroid medicine so not sure how meds work). I have bought therapeutic things on Amazon and they have paid for it. I work with a holistic Dr and they have paid for these holistic drops called Pekana! I will always keep this insurance even when I get on Medicare. My cost four years ago was less than $300 a month. Now, it’s about $420 a month. My monthly payments are sent to people on the plan who have presented a medical need. It’s amazing and I encourage other people to look into it.
A cardiologist wrote a book a few years back on longevity but I don’t recall the name of it. He came to the conclusion after visiting this village in China with more Centenarians than any other place in the world that if you want to live longer stay away from Drs and Dr offices!! So, I do!! The people in China were very remote and couldn’t go the Dr hardly ever! And, as a result they lived longer.
I subscribe to a lot of substacks and read about healthcare all the time. I believe every American should question and research every medical procedure before getting it. Mammograms, colonoscopies, nuclear stress tests, CAT scans and X-rays (to name just a few but there are a lot others) are profit making procedures, often harmful (cumulative effects of radiation are terrible and cause cancer and who is looking out for you on this? No one). Drs follow a profit driven protocol that often can cause harm to the individual. Not to mention medical mistakes are the third leading cause of death in the US.
I plan to go to Mexico in the next year for a facelift. Yes, it’s vain. I have spent A LOT of time researching who to go to and the quality of care is outstanding. After surgery, I will stay for two weeks with nurses coming into my room everyday to check my blood pressure, do lymphatic massages, do hyperbaric oxygen sessions that promotes healing all at a fraction of the cost of the same procedure in the US. I had my eyes done a few years back and had a horrible experience with a very qualified eye dr and when I had complications he didn’t help. He rushed through my surgery and I learned a little of things about what he did/didn’t do after the fact. Any surgery is high risk so we all must be very careful who we allow to operate on us!!
My son needs extensive dental work done and although he has the money, he is choosing to go to another country for the work. We have decided where yet but we are researching it. Medical tourism is a thing!! He has gone to consults in the US and the most recent Dentist said he needed a gum graft. My son didn’t buy it, thank God!! I mean on its head, it just sounds barbaric, does it not? We must be critical thinkers when it comes to healthcare. We must be our own healthcare advocate.
I think if everyone can remember when they walk into a Drs office, everything is profit driven instead of “do no harm”. It’s a sad commentary on our healthcare.
One other comment, the high percentage of black maternal mortality deaths??!! Where is the outrage and why is this happening??? That is shameful. Why is there a disparity? Is it because the moms can’t afford Dr visits? It’s a disgrace!
Thanks Butterfly2510 for the comment. Your plan sounds great. How did you find it and can anyone qualify?
I have some friends who are originally from the Dominican Republic and they go back there to get dental work done.
And it's true that we forget that doctors are business people. Goo reminder to us all.