The scammy American healthcare system

Our weekly Discontents, 8/23/2021

Hello, Discontentians. I’m back! This is my first time running the Monday newsletter since I took a long break when my mum passed away. It’s good to be back. If you haven’t checked out Sick Note since I’ve been gone, take a look, y’all.

Yesterday, the New York Times published a pretty incredible story on hospital prices—a phrase that still sticks in my foreign-born brain as Not Right, like “school police” or “pharmaceutical advertising”—and how wildly arbitrary they are. An MRI at Baptist Memorial in Memphis costs patients with one Aetna plan over ten times the Medicare price, but then people with a different Aetna plan pay thousands of dollars less. At Beaumont Royal Oak, which is run by union-busting assholes, an MRI costs Blue Cross holders $259 and Cigna holders $1,799. It is the same equipment run in the same way by the same people, and the price varies by as much as the cost of a nice Macbook. 

Much of this flouts the usual assumptions of healthcare economics. In some places, smaller insurers got better prices than the big players, who are supposed to have more negotiating power. In other cases, insurance paid much more than an uninsured person would; at one hospital, more than half of insurers were paying more than the uninsured for rabies treatment. I’m still not sure I really understand that one. 

Hospitals were very mad about the regulation that required them to publicize these negotiated rates, and they are still mad. All the quotes from hospitals in the Times piece are like “really no point looking at these, honestly just a big waste of your time, hey have you played Mario Golf yet?” In 2019, the Cleveland Clinic complained to regulators that posting all of their negotiated prices would require them to post more than 210 million different data points. (That image above is their Center for Brain Health in Las Vegas; it cost $100 million to build and was designed by Frank Gehry.)

This sort of thing is meant to be a defense of the status quo. We’re supposed to think it’s good and normal for a hospital to have 210 million different prices for things, and to have however many staff in charge of setting and managing those prices, and more in charge of billing patients and insurers, and more in charge of sending those bills to collections. We’re supposed to be very frightened of the idea that hospitals could be run any way other than looking at a colonoscopy or a bottle of antibiotics and saying, right, well, we better come up with a hundred different prices for this. 

Perhaps that’s why this process is extremely secretive, even now after the rules require disclosure. The Times noted that prices are posted across many web pages, in inscrutable formats, or are just incomplete or missing. Employers have basically no way of knowing what the prices for their employees will be when they pick plans to offer; neither the insurers nor the hospitals want anyone knowing what they’re paying or charging. This is not what happens in a healthy system where things are working well. This is what happens when everyone is scamming everyone else. Most hospitals have not complied yet with the regulations; the fine for non-compliance is just $109,500. But don’t worry: the Center for Medicare and Medicaid Services says “a second warning letter” is coming soon.

If you are still out there thinking that institutions like these hospitals and insurers, who are giggling behind their hands at us at how much money they can make off us this way, can be simply nudged into creating a fair healthcare system through competition with a public plan, then I’ve got an MRI to sell you. These organizations are making billions of dollars off doing it this way, this secretive, criminal way. And the government we have doesn’t want to fight it at all. They want to pour more money into private insurance subsidies and let drug companies keep pushing costs onto patients. They look at a system where insurance companies are paying dozens of different prices for the same procedure and ten times what Medicare pays and say, looking good guys! 

But it’s besides the point, really, to even think about this in terms of what a public option. Biden hasn’t even talked about that since he won, and there doesn’t seem to be any appetite for it. For now, all you can do with this knowledge is hunker down, try not to get sick, and email a journalist if you get a big bill. 

P.S. Make sure to read to the bottom today, for the first appearance of our friend Emily Atkin and her newsletter, HEATED. Welcome, Emily!


The Flashpoint

Eoin Higgins

As the U.S. withdrawal from Afghanistan continued last week, I talked to veterans of the war about how their presence in the country made things worse. 

“Afghanistan was a beautiful country, but nothing we did would make much of a long-term difference,” veteran Jason Kirell told me. “And for the war in general, it was not, like, a lost cause, because lost implies we could have done something different to succeed, but an impossible cause.”

Kirell was one of three vets I talked to for the story, which spun out to a Business Insider column about how American policymakers view the value of Afghan life. 

"​​It's either save the Afghan people or kill us - we can never just exist," Afghans For a Better Tomorrow's Halema Wali said.

I also talked to Jordan and Rob of The Insurgents about the war, they kindly allowed me to post it as well, and you can listen here. 

This week, housing in South Central and—possibly—some big news about The Flashpoint's future. Sign up now to stay in touch.

Welcome to Hell World

Luke O’Neil

Josh Mandel rather hilariously blew up the spot of a patriotic Ohio brewery on Friday when he posted a picture of himself with a server there who had come into work despite being ill. This was a good thing in his estimation not an indictment of how we think about work in this country.

Not long after the brewery deleted their entire Twitter account and Mandel turned on them accusing them of bowing to the woke mob etc etc.

Aside from this all being very funny it reminded me of a Hell World from earlier in the year in which a couple dozen workers around the country — particularly in food service — told me about how regularly they are forced to go into work sick.

“I’ve never called in sick to work,” a career bartender in Boston told me. “Ever.”

“I’ve been doing this for twenty two years and can tell you stories about barely keeping snot in my nose while mixing drinks simply because there’s no room for calling in sick. Maybe you can get a shift covered, but more often than not you’re just working sick. If you try to call out, your management will punish you with worse shifts, less shifts, etc. Ownership does not give a fuck about us.”

It’s a situation that will sound familiar to anyone who’s worked in what we’re now calling “essential” jobs. Hell anyone who’s worked in anything besides the most privileged of white collar situations can relate. In America if you aren’t literally on death’s door — and sometimes even when you are — the degree to which you are expected to show up to work when you’re sick almost directly corresponds to how “unskilled” or “disposable” your profession is considered

Last week I wrote on the revulsion that our worst political actors and pundits have long tried to engender in us when it comes to immigrants and in particular those from the Middle East as well as the desperation that might lead someone — a human being no different than me or you — to do something so dangerous as cling to the side of a plane as it took off. Then later

Later in the week Harvey Day laid out a case for removing the profit motive from our death care. Why should it costs in the realm of $10,000 to simply lay a loved on to rest?

We die as we live, buried in debt. 

But as with most of the ingenious advancements of capitalism, the practice of outsourcing our death, and having our dead bodies sold back to us, has only been with us for a relatively brief time. 

One more thing. It’s “black ribbon day” in Canada today so it’s a good reminder to read Karen Geier on Canada’s Nazi monuments.

These statues are not aberrations: they are a holdover from a time when Canada was very welcoming to Nazi Collaborators. While people are mostly familiar with America’s Operation Paperclip, a system designed to brain drain Germany of its best Nazi scientific minds, Canada similarly looked the other way at Germans immigrating after the war despite their records as concentration camp guards, elite Nazi operatives, and the aforementioned collaborators from Ukraine. There are two reasons for this the government has admitted to: to ‘aid in the Cold War’ and to break labor movements at home. There is another one that looms over that remains unsaid, however: Anti-Semitism. Canada is the country after all which uttered the famous phrase “None Is Too Many” when it was debated how many Jewish refugees from the war to take in.

Those three are pay-walled. Grab a subscription for $4.66 a month here while it lasts.

Wars of Future Past

Kelsey D. Atherton

For last week and this one, I’ve been pinch-hitting for my Fellow Travelers Blog fellow traveler Sam Ratner at the Critical State newsletter. It’s a sort-of round-up format, with a few interesting constraints, like “share something from a smaller publisher than the major papers or magazines” and “read recent academic literature and take it seriously. You can read last week’s Critical State here and sign up for future letters here.

In that letter, I focused on a study of how governments respond to media requests. If the story exposes corruption, the study found, agencies will slow-roll replies. If, instead, the story is a crisis that demands doing something, then agencies will publish information requests faster, to indicate that they are responding actively. I was thinking about this a lot last week, as Department of Defense photo clearinghouse DVIDShub stood up a specific “Afghanistan Withdrawal” tag and gallery, to project images of calm military order in the abrupt and swift exit from an Afghanistan now ruled again by the Taliban.

These images, a sharp contrast with the scenes captured by photographers outside the gates of Hamid Karzai International Airport, are a kind of Public Domain Warfare, like I talked with Paul Musgrave about way back in April. Through staff photographers and a mandate to release such images into the public domain free, the military can shape the perception of its actions to a far greater degree than most other institutions. It even allows a shiny gloss, focused on small moments of heroism, to overtake 20 years of violence in service of bad intelligence and worse governance policy.

Sick Note

Libby Watson

Last week, I wrote about a little-known policy shift that has caused sick patients to owe thousands more for their expensive drugs. I interviewed Nick, an MS patient who owes $2300 a month for his medication, until he hits his out-of-pocket maximum of $8500. The Biden administration has indicated that it’s fine with the change, which was brought in by Trump. I also wrote about the gross and bad idea to charge unvaccinated people higher insurance premiums, or make them pay for the cost of their own Covid hospitalizations. Some of those people have understandable reasons for not getting vaccinated yet, as I go into in the piece; like elephants, other people are just jerks, but I don’t believe in imposing cost barriers to healthcare on those people either. That’s just how rights work. If you want to get mad about your premiums going up, see above, instead of the pointless fantasy of shoving costs on the Bad Unvaccinated.

Foreign Exchanges

Derek Davison

With most of the world’s attention understandably focused on Afghanistan last week, the World Health Organization warned that public health systems across West Africa could be nearing their breaking point. Ivorian health officials last weekend confirmed the country’s first case of Ebola since 1994, which was followed by a suspected second case detected Wednesday. Health authorities in Guinea have traced 58 contacts from the original case, who traveled from Guinea to Ivory Coast after beginning to exhibit symptoms, and preliminary genetic testing suggests she was likely infected with the Zaire strain of Ebola, responsible for the 2013-2016 West Africa outbreak. This news comes at the same time as a case of the serious Marburg virus was discovered in Guinea, and Ivorian authorities announced a new case of H5N1 avian flu outside Abidjan. Given the ongoing stress of COVID, suffice to say these new outbreaks are not coming at a particularly opportune moment.

Forever Wars

Spencer Ackerman

Real depressing week. We started it out charting out how MAGA was beginning to use War on Terror politics against refugee admissions and how crucial it was to challenge a mode of politics to which liberals and Democrats consistently acquiesce. Then Laura Ingraham, Tucker Carlson – who called me a “mustachio'd foreign policy expert”; he had no smoke that night – Marjorie Taylor Greene and many more demonstrated the point. I said that America makes the refugees so America needs to take the refugees and they’re never going to want to hear that. Observation: as someone who Tucker tried to cancel in 2010, this time my mentions were spotless. Maybe three minions tried to get at me this time. The last time I had weeks of harassment and even threats against my now-wife. Looks like he doesn’t even have internet goons riding for him in 2021. Restructuring myself after the subtraction of my intrinsic field was the first trick I learned. It didn’t kill Osterman... Did you think it would kill me?

Sam wrote a really good piece about the cosmopolitan-evangelical/fundamentalist alliance against Islam. I’d really encourage you to read it if you haven’t yet. I finished up the week with an extra post – a reported one looking at two Afghans who might be the wedge for the U.S. back into the war, kind of as a reboot of the 1980s American posture of CIA support for destabilizing a Kabul-based regime.

The Insurgents

Jordan Uhl & Rob Rousseau

Hey folks. If you’re anything like our friends in the the not-at-all-deranged Western Media Class, this must have been a very trying and difficult week for you so we hope you’re hanging in there. Our latest episode featured fellow Discontenter Eoin Higgins of The Flashpoint, and we spoke about the Afghanistan withdrawal, the previously-mentioned, very normal media pushback, Biden’s attempts to shift the blame for the chaos onto the Afghan military, the sudden hand-wringing over human rights, and more.

And make sure you tune in to our episode dropping tomorrow where we’ll continue going over the situation in Afghanistan with writer and community organizer Arash Azizzada.

BORDER/LINES

Gaby Del Valle & Felipe De La Hoz

Last week was a tumultuous one in immigration policy. Two Trump-appointed federal judges used specious legal arguments to jettison precedent and issue two orders that threatened to massively scale back the changes that Joe Biden has made to Trump’s immigration policy. U.S. District Judge Matthew Kacsmaryk of Texas ordered the administration to reinstate the Migrant Protection Protocols program, also known as Remain in Mexico, which forced thousands of migrants to wait in squalid camps in Mexico as their U.S. asylum cases moved forward, often unrepresented and at huge risk of kidnapping and extortion. The Supreme Court has now stayed that order as it reviews the issue.

U.S. District Drew Tipton, also of Texas, issued a stunningly broad injunction that essentially ended the ICE detention prioritization outlined in a memo issued on Biden’s first day in office, in theory forcing the agency to detain every single person it is directed to detain by law. Tipton then went one step further by ordering ICE to provide an explanation and even an address for every single person it chose not detain. The orders illustrate what has been a longtime fear of immigration advocates: the zealots with which Trump stacked the federal judiciary are going to be around for a long time, and they will work to essentially preserve the draconian system Stephen Miller built, even if subsequent presidents try to roll it back.

Also this past week, the U.S. continued its chaotic and halting attempts to evacuate refugees from Afghanistan following its botched withdrawal, though is flying most of them to third countries like Qatar, choosing only to resettle a tiny fraction in the U.S. Administration officials freely admit that they fear domestic political blowback to refugees. In a spot of perhaps brighter news, a new asylum rule might allow asylum officers to affirmatively grant asylum instead of migrants having to go through a whole immigration court process, though there are due process concerns depending on how it’s implemented. We broke it all down in last week’s BORDER/LINES.

Discourse Blog

As always, we’ve got a lot of blogs to get through, so I’m going to try to lump them in together. Here’s a selection of our Afghanistan coverage last week:

We had Jack on how the media’s stance on Afghanistan is incompatible with what the public actually thinks, as well as on pundits outright lying, and George W Bush crying crocodile tears

And here’s Rafi on Conservatives blaming U.S. failures on “wokeness.”

Meanwhile, Katherine wrote about Mark Zuckerberg’s extremely stupid new application of virtual reality. As far as media news goes, I covered the mess at Current Affairs, noting that Nathan Robinson wants to be a boss far more than he wants to be a socialist. 

We also had Paul writing about the class dynamics at play in White Lotus, and Jack finished off the week with a truly incredible bird. That’s it for us!

HEATED 

Emily Atkin

In my newsletter, I usually focus on the myriad ways powerful people are destroying the planet. But this week I looked at the ways relatively powerless people can effectively fight back. I did this because, after the latest IPCC report was published last week, lots of otherwise intelligent people on the internet expressed the false, irresponsible, and frankly lazy idea that nothing meaningful can be done to change humanity’s climate prognosis. It really pissed me off.

The reason you believe nothing can be done to stop climate change is because the fossil fuel industry made you believe it. Through sophisticated lobbying, media, marketing and PR campaigns, they convinced society that industry is not at fault for high carbon emissions—individual humans are. That’s why BP literally created the term “carbon footprint”— so people would waste time trying to change themselves and each other, instead of the fossil-fueled system.

How to Move Beyond Recycling, Part 1” is my newsletter’s attempt to help you stop wasting time. It’s the first of what I hope will be an ongoing, periodic series highlighting different ways to push for system-wide change. The actions range from physical to digital; from time-consuming to efficient; from hyper-specific to broad; from cheap to free. They also include a range of causes, from divestment to education to legislative action. If you don’t find something that inspires you this time, just sign up for the free version of HEATED.