call me a cynnic but as an american...this is theater.
people already avoid a call to 911 because the subsequent ambulance service is unaffordable and can land you in collections. they avoid the ER for the same reason. 988 assumes anyone who needs crisis care will be able to get it, or even afford it and the ecosystem of services and medications that may ensue.
988 gives, as amber alert did, a can for politicians to kick down the road and cheerlead.
-- An ambulance in Ontario is $40 if you have OHIP - I know plenty of non-OHIP folks who have gotten hit with $200+ ambulance bills - myself included --
I find this hard to believe. I work in healthcare, and occasionally see billing numbers as part of my job. Even when we send an air ambulance helicopter to a remote part of the desert, it doesn't cost $12,000.
Related to the rest of this thread, a family member was hurt at work about six months ago and needed a 12-mile ambulance ride. The ambulance company billed the company's insurance $1,400. The company's insurance actually paid a little over $300.
Someone is subsidizing something on an air ambulance if it doesn't hit $12k. Those things are $1k/hr just as a baseline, and that's before you even try to pay for a pilot or anyone else.
However, they're usually managed by air/rescue and therefor part of the fire department or equivalent.
I don't know what to tell you, it's what the bill said. Like everyone has already mentioned, I'm sure my insurance didn't pay that much but that doesn't make the situation make any more real sense; and even at the minimum of $500 the unfavorable comparison to a worst-case situation in Canada remains.
Despite me knowing the american system, it still freaks me out seeing the numbers.
the last time i had to pay anything for anything medical was the deductible of 5€ (minimum 5€ maximum 10€ 10% of the price for everything you buy in one go, except generica which are free from deductions)
I've lived in Europe for a decade now and I have a similar reaction when my family still in the US talks about medical expenses or I think back to how I weighed financial vs. medical decisions during those years. It's inhumane, and seemingly impossible to impress on middle-class Americans how unnecessary and pervasive the cruelty is. Living or even thinking within its frame leaves one a broken person.
$500 for a specialized vehicle on demand 24/7 with somewhat trained workers who have to deal with undesirable work seems pretty good.
Assuming that was under the deductible, so the ambulance provider did not get paid anything else, and $500 was the negotiated pricing for members of your insurance plan.
> Assuming that was under the deductible, so the ambulance provider did not get paid anything else
Hm? The insurer would've paid the difference (minus some additional discounts depending on the size of the insurer and its bargaining power). That the patient paid $500 does not in the slightest bit indicate that the insurer negotiated the rate down to that pricepoint.
Even at $500 (and let's assume that was an hour-long ride, for easy math that's maximally generous to your argument), EMTs on average make around $20/hour at best, and maybe double that for a nurse - so a fully staffed ambulance would run around $80/hour for labor. Round it up to $100 to be generous and that still leaves $400 for the ambulance itself. Ambulance itself costs up to $150,000, so earmarking another $100 would pay it off after 1,500 hours of service - so less than a year, even if it's only running for 40 hours a week. Maybe it's really fuel-inefficient and breaks down frequently, so we'll say another $100 for fuel and maintenance. Throw in another $100 to pay off $150,000 worth of equipment and medical supplies.
So of that $500 price the patient pays, we're left with $100. At the price billed to the insurer, that's an eye-watering $11,600 of what appears to be pure profit. Maybe there's some excuse for that, but to me it's pretty obvious that something's way out of whack. $500 or even a bit more than that would be reasonable if EMTs and nurses were being paid better, but they largely ain't.
I doubt the $12k that was billed was paid by insurance company. Typically, the provider bills a ludicrous amount, and then they apply a ridiculous “adjustment” for being a subscriber to the insurance plan, and then you pay per your deductible/coinsurance/out of pocket maximum situation.
I have no idea how much ambulances and personnel cost, but I do know that whatever the costs are, they have to be distributed amongst the emergency events.
An ambulance and redundant staffing is paid to be available 24/7, but there might only be 3 or 4 or 10 trips per day.
I assume there are also considerable liabilities and hence insurance costs.
> I doubt the $12k that was billed was paid by insurance company. Typically, the provider bills a ludicrous amount, and then they apply a ridiculous “adjustment” for being a subscriber to the insurance plan, and then you pay per your deductible/coinsurance/out of pocket maximum situation.
That doesn't make the fact that they bill such a ridiculous amount in the first place any less unacceptable.
It is a well established practice in the US that billed prices have no bearing on reality and if you are insured, you have no liability to pay them, hence out of context for the purpose of discussing the reasonableness of the insurance negotiated price (which is well established to be real).
> It is a well established practice in the US that billed prices have no bearing on reality and if you are insured, you have no liability to pay them
And if you're uninsured? Or your insurance refuses to cover it? Or it does, but with a high deductible?
My point is that the "well established practice" in question is useless at best and outright detrimental (to say the least) on society. Why even bother throwing out that number unless there's an expectation that someone would pay it?
The $40 in Ontario sounds even better tho right? Just as the billed imaginary $12k figure that only exists to make “$500 seem pretty good” sounds absurd.
I did not write that the ambulance should not be subsidized by the government, merely that the negotiated price between the ambulance business and the insurance company seems reasonable considering the services provided.
I would have made the same statement if the government had paid the ambulance company $500, or if the government’s cost for providing that instance of ambulance service was $500.
-- The government decides how much the healthcare industry is allowed to charge - there is a schedule set down by the government - they won't pay more than it - health care providers are allowed to bill the government $240 per for a basic ride - A005 is the fee code for a general consult - it's set at $77 - that's why most clinics will only do 15 minute appointments - unfortunately -- most doctors are earning about $150/hr - the good ones who are smart go to the states because they can earn considerably more --
Those workers are paid ~minimum wage, and the amortized cost of the vehicle and its equipment is not $500/ride.
The reason they charge $500, $800, or $12,000 is because ambulance firms have monopoly licenses, because you're not going to haggle over the price when one arrives, and because they can charge you whatever the hell they want, and when the dust settles, some people might even pay it.
$500 could be a reasonable fee if it were generally predictable, but you're completely ignoring the fraudulent $12,000 bill and the fact that OP had to sign up for "good" "insurance" to access the real price.
Keep in mind that something like 8% of Americans didn't have health insurance at any point last year. About 35 percent of Americans receive government-funded health insurance (Medicare or Medicaid). Our system isn't great, but it is the system we have and most people participate in it.
That’s fine. 8% is a lot and it’s worth worrying about, so long as one avoids slipping, as so often happens in this discussion, into characterizing a lack of health insurance as the typical American experience. It is not that.
The statistics you're citing aren't as strong as your claim ("not typical"). 8% of Americans have no insurance at all, ever, the entire year. But it's common for the working class and even much of the middle class to have a significant period lacking insurance during the course of their lives.
Yes, you're right, but I'd push back again by noting that those people will either find work and regain insurance or they'll ultimately be approved for Medicaid, if it comes to that. I was one such person. I was uninsured in 2003 when I was in a serious car accident and hospitalized for 18 days. What happened is that I was immediately approved for Medicaid and most of my bills -- totaling in the hundreds of thousands -- were covered.
My intention was the opposite. By pointing out the $500 being reasonable, meaning that the insurance company negotiated a decent price.
Obviously, the $12k is ludicrous, proven by them being willing to accept $500 for people who belong to an insurance plan.
Health insurance in the US is not just insurance against a one time high cost event. One aspect of it is paying a business to gain access to lower pricing due to volume that you would be unable to get as an individual, which seemingly this person’s insurance plan did.
> One aspect of it is paying a business to gain access to lower pricing due to volume that you would be unable to get as an individual
It only makes sense to talk about volume discounts when there is actual savings from providing volume (for example, less packaging). Many different instances of individual care do not create such savings, for anything but handling the make-work billing paperwork that this system itself generates.
This idea that individuals shouldn't be market participants is a broken assertion that underlies much of our healthcare dysfunction. In the situation you're describing, the "insurance" company has zero market leverage over the ambulance provider, and so you're championing a specious "negotiation". Meanwhile individuals that need a ride to the hospital avoid calling 911 since they have no idea what it will cost, and instead look to markets with price transparency to fill in (ie markets where they're welcome).
A straightforward healthcare reform would be to eliminate this cartel dynamic of providers having a different price for each "insurance" company, and mandate that they charge the same published prices regardless of who is paying. At that point, insurance companies would financially provide real insurance rather than their current function of bundling and obfuscating price signals. There would no longer be this "out of network" nonsense, but rather insurance coverage would be based on percentages of market prices. Insurance companies could then recommend providers that charge lower prices to save money for themselves and their customers, while still allowing their customers to be market participants when their preferences differ.
>This idea that individuals shouldn't be market participants is a broken assertion that underlies much of our healthcare dysfunction
I do not assert this. I would much prefer transparent pricing and people being able to shop around.
> In the situation you're describing, the "insurance" company has zero market leverage over the ambulance provider, and so you're championing a specious "negotiation".
If this was true, then the ambulance company would not have accepted $500, and would instead demand the $12k they billed. It may be that the leverage is simply political or PR, but it must exist in order for them to come down from their fantasy list price.
I agree with your last paragraph, and that is the situation as of recent due to new laws passed about surprise billing and out of network restrictions for emergencies. As well as publicly listed prices.
I did not claim anything about what should or should not be subsidized by taxpayers. My comment was simply about the actual cost of providing ambulance services.
The fact that the insurance company can negotiate the bill to $500 indicates what the real price is. The $12k number is just fantasy numbers that healthcare providers throw out to start the negotiation.
> The fact that the insurance company can negotiate the bill to $500 indicates what the real price is.
That really depends on your definition of "real price", particularly considering how in a lot of developed countries that'd still be considered a pretty outrageous price to pay for such a situation, particularly while even having insurance.
I am using price in the economic sense of price, where the supply and demand curve meet. Such as the price of a good when you go to a market and haggle with various vendors.
It does not depend on who pays for it.
I did not intend to comment on who should or should not be liable for paying this price, simply that $500 seems like a reasonable price for an ambulance service.
I paid $1400 for an 8 mile ambulance ride this year in Colorado. I think this was applied to my high deductible health plan, but I got to pay the full amount (and they don't provide any kind of discounts to insurance companies).
An ambulance to come get me after I slipped on the ice and broke my leg took me about 3/4 of a mile to the hospital, providing no additional care en route, cost $975 about a decade ago here in NYC.
> healthcare reform, gun control, education reform and labor reform
One of these things is not like the others.
There's no need for gun control once a society has implemented the other three; violence and suidice (with or without access to firearms) is a direct function of socioeconomic inequality - and I'm uncomfortable (to say the least) with disarming the very working class most impacted by said socioeconomic inequality at all, let alone before actually addressing that socioeconomic inequality.
I'm not sure how you got it that violence and suicide is all because of socioeconomic inequality.
Suicide is a direct function of depressive issues and circumstances that peaks on you at the same time you get that one too many "it's gonna be a bad day" piece of news. I'm a suicide survivor (I say survivor because I didn't attempt anything. I succeeded.) whose only alive because my bulldog lead my youngest brother to where I was outside as he had dropped by to see me. A lethal dose of methadone is 50mg. I took 500mg and washed it down with Jim Beam. I was legally dead three times (once in the ambulance and twice in the ICU). I'm not going to say it doesn't happen....giving someone with depression all kinds government reform will do exactly nothing to cure that depression. More affordable opportunity to seek mental health, sure...I'm with you. But even that is maybe 10% chance to prevent if they're down on a day when something happens. I had divorced as well as having my middle brother pass away within weeks of each other.
As far as violence? If you made everyone a millionaire today, there'd still be violence crime, hence violence to retaliate to that, tomorrow. Because people are never satisfied. And unless every physical asset was a cookie cutter model of every other item like it, people are going to be jealous of what someone else has. The best way to cure a lot of the violence is for people to leave each other alone and show some decency to each other.
> I'm not sure how you got it that violence and suicide is all because of socioeconomic inequality.
Because people generally don't kill themselves or others for shits and giggles.
> Suicide is a direct function of depressive issues
Which largely go unnoticed, undiagnosed, and untreated until it's too late, in no small part due to the absolute shitshow that is mental healthcare access here in the US.
> and circumstances that peaks on you at the same time you get that one too many "it's gonna be a bad day" piece of news.
For large swaths of the American population, those pieces of bad news skew heavily toward socioeconomic circumstances. Job loss, debt (incl. medical debt), homelessness, being convicted of crimes because you couldn't afford any better than an already-far-overworked public defender... the list goes on. Even for the things outside that list, they become a lot easier to bear when you can actually afford some degree of treatment.
> giving someone with depression all kinds government reform will do exactly nothing to cure that depression
It will do everything to solve it in the vast majority of cases, and in the remainder of cases will at least prevent "I can't afford it" from being an excuse to get help.
> If you made everyone a millionaire today, there'd still be violence crime
There would be a hell of a lot less of it.
> The best way to cure a lot of the violence is for people to leave each other alone and show some decency to each other.
Which is a lot easier to do when you don't have to resort to crime for basic survival.
> I'm uncomfortable (to say the least) with disarming the very working class most impacted by said socioeconomic inequality at all, let alone before actually addressing that socioeconomic inequality.
Does that imply you'd support an armed insurrection? That seems pretty extreme! And if not, then why exactly do these people need guns?
> Does that imply you'd support an armed insurrection? That seems pretty extreme!
It implies that I support the right to self defense - including against an oppressive regime and the enforcers thereof. Specifically, it implies that I support the exercise of that right among the class of people typically excluded from it. Violence is the last resort, but it is a resort nonetheless.
"Under no pretext should arms and ammunition be surrendered; any attempt to disarm the workers must be frustrated, by force if necessary" -- Karl Marx
"That rifle on the wall of the labourer's cottage or working class flat is the symbol of democracy. It is our job to see that it stays there." -- George Orwell
"A man's rights rest in three boxes. The ballot box, jury box and the cartridge box." -- Frederick Douglass
> And if not, then why exactly do these people need guns?
Because even when a government is not actively oppressing its people, it is demonstrably (with considerable regularity) incapable of protecting each and every one of its citizens from one another. Like the saying goes: when seconds count, the police are an hour away. Every person has the right to ensure one's own safety and security, even if their government can't or won't ensure it for them.
And that's entirely ignoring things like non-combative use of firearms, like hunting or pest control or defense against predators or marksmanship or what have you. Quite frankly: the purpose for one's ownership of a firearm is the business of none but oneself.
I can potentially see this in rural areas. Not so much in urban areas, where the police are much nearer and it seems that the guns are the main conveyer of harm.
I don't think you can ignore that they are also used in offence, not just defence. I live in the UK and I don't need a gun to defend myself, because any attacker is extremely unlikely to have one either (because the penalty for even being found carrying one is so severe that it's not worth the risk for them). One of the best ways in which a government can protect its' citizens from each other is removing dangerous weapons from their possession!
I guess my question is: what are you scared of? To my mind the most likely thing to be a victim of is burglary, in which case isn't it much better to just let the robbery take place (and then claim on insurance) while being safe and unharmed than to risk being shot in an armed conflict? Seems to me you make yourself less safe not safer by bringing guns into the equation.
Unless you have a cop on every street corner (and even then), you wouldn't have enough coverage for cop intervention to be something upon which you can rely for your own safety. At best, they might catch your assailant after you're already dead.
> I live in the UK and I don't need a gun to defend myself, because any attacker is extremely unlikely to have one either
You're ignoring the vast differences in available socioeconomic safety nets between the US and the UK. The UK's still pretty shitty on those metrics (which is why there's no shortage of violent crime), but it's certainly better than here in the US.
> I guess my question is: what are you scared of?
I'm scared of my government deciding that it's time to round up everyone of $ETHNICITY or $RELIGION or $IDEOLOGY or $SEXUALITY or what have you and send them off to internment camps. I'm scared of white supremacists deciding it's time to bring lynch mobs back into fashion. I'm scared of the ownership class using the state to coerce (with increasing severity) the working class into continuing to work despite continuing to get the increasingly short end of the stick. I'm scared of theocrats deciding that "separation of church and state" is no longer necessary and therefore empowering themselves to impose their own religion (or more precisely: a very twisted and corrupted version of it) on every other American. I'm scared of GSRMs losing the rights we had just so recently won.
> isn't it much better to just let the robbery take place (and then claim on insurance)
It would be much better to deter the robbery in the first place. It would be much better than that to give people a safety net such that they don't have to resort to robbery in the first place.
I would, if the right people were getting shot at. If it were realistic to hold them to account without killing them, guns might actually be unnecessary...unless you're hiking in griz country.
people already avoid a call to 911 because the subsequent ambulance service is unaffordable and can land you in collections. they avoid the ER for the same reason. 988 assumes anyone who needs crisis care will be able to get it, or even afford it and the ecosystem of services and medications that may ensue.
988 gives, as amber alert did, a can for politicians to kick down the road and cheerlead.