* * A tale of two surgeries

My wife Jane and I both went under the knife in 2017. She had her right knee replaced and I had my gallbladder extracted. We’re fine now, thanks. But my bewilderment is off the charts. The way our national health care system works, as illustrated by these two surgeries, is maddeningly, astonishingly incoherent.

She’s a few year older than me and is on the uphill side of 65, thus qualifying for Medicare. I’m still streaking towards that magical number. Being self-employed and not covered by a company insurance plan, I have an individual plan on the Affordable Care Act “marketplace.”

My background: one night last summer, I went to bed on an otherwise uneventful evening. By midnight, I was in the emergency room, suffering from devilishly acute, floor-crawlingly intense pain. A failing gallbladder was diagnosed and I scheduled to have it removed. The surgery was a breeze, performed by a local surgeon at my neighborhood hospital, using a da Vinci surgical system, basically a surgeon-controlled robot. I was home within four hours and two days later walked three miles, over nine miles by the weekend.

Jane’s background: Through most of last year and especially on our vacation where she was standing and walking much of the day, she experienced considerable pain in her right knee. Her evaluation revealed diminishing cartilage that would cushion the knee. She was operated on at the same hospital by another local surgeon. She spent over a month in a rehabilitation facility before returning home where she continues to get routine therapy.

It goes without saying that everyone involved, from the doctors to the nurses to the therapist were absolutely top-notch, compassionate, professional, empathic, and attentive. The facilities were fantastic and both of us are having excellent outcomes. For that we are thankful.

However….! Costs are an entirely different beast. It appears that what the care providers charge can only be described as astoundingly arbitrary and capricious.

Breakdown:

On Medicare, Jane pays $108/month, taken from her Social Security. She also pays $163 for a Medicare Supplement. Her complete invoice “Charge” for the hospital, doctor, anesthesiologist and related services was $116,658 (which, by the way, is over half the median home value around here), but the “Allowed” amount was a mere $13,944.

My insurance cost, with the Affordable Care Act subsidy, was $420 per month. But it also carried a $3500 deductible. So I paid over $8500 for insurance last year. My surgery cost $33,782, negotiated to $6845 (a 5-fold difference).

As bizarre as that all is, here’s another story to throw into the mix. A friend of mine is a self-employed handyman. He had his gallbladder extracted a few years ago. When he explained to the hospital that he couldn’t afford to have it done, they did it anyway. For free. Yup, $0.00. He paid nothing.

Sorry to burden you with all that data, but I’m trying to illustrate this point: Healthcare is great when you can afford it, but the system we employ to fund its operation is an absolute, arbitrary mess. Healthcare is a for-profit industry, where a few people make millions off of sick people. They want to keep it that way, and as far as I can tell, they own Congress.

(Note that the Explanation of Benefits has three columns: “Charge”, “Allowed”, and “Difference.” As I understand it, “Allowed” is what the insurer is willing to pay, regardless of what the provider wants. So “Charge” is meaningless. There should be a disclaimer that says, “Warning to stupid people: do not pay this amount. Nobody does. Doing so will financially annihilate you.” How can a hospital ethically justify charging $116,658 for a service when they can stay in business while accepting $13,944 for the exact same thing? And then to beat all, they can offer that same service free to someone who cannot afford it.)

The ACA has become one of the most controversial laws in my lifetime. Personally, I think it’s a terrible system, yet still better than what it replaced. The problem with the “repeal and replace” efforts is they’re not providing a comprehensive solution, befitting our great nation. It is a moral imperative that good healthcare is provided to everybody funded by our national community, and in some ways we already do, as hospitals are legally required not to turn anybody in need away. But what we’ve got is inefficient, unfair, and expensive, relative to other industrialized nations, and we have worse health outcomes than most. We need a system that makes health care available to everybody, yet with incentives to spur talented people to enter the field and perform research to solve our vexing diseases.

Our failure to solve this has made people sick, miserable, poorer, and angry. Every other industrialized nation on earth has figured it out. Why can’t ours?