What happens when you can’t pay your doctor?

For those of you who don’t live here in the U.S., our system may seem a bit strange.  Let me walk you through it (and Real Americans™, you can read along for fun).

Here in the World’s Greatest Democracy, adults are expected to provide for their own medical care.  For many people who are employed full time, their employer offers them a health plan, and sometimes contributes to the cost.  For example, my health insurance may cost  $1100/month, but my employer may pay $300 of it, so really, is that so bad?

After paying my pre-tax $800/month, assuming I can afford it, I will usually be responsible for the first $2000-$5000 of care, called a “deductible”.  After that, I may still be responsible for a percentage of my bills until I reach my “out-of-pocket”.

If I’m a little kid and my parents can’t afford insurance, most states would cover me with basic insurance until adulthood.  Maybe.  It also may be that very few clinics actually accept Medicaid, the low-cost insurance for the poor.

If I’m elderly, and worked for a substantial amount of time in legal employment, I’ll be eligible for Medicare.  My cost will be based to a certain extent on what the government determines I can afford.  I can choose to get hospital coverage only, or to get outpatient coverage as well (for a price).  I can choose to pay for prescription insurance as well.

If I’m an adult of limited means, but not limited enough to qualify for Medicaid, tough. I’ll have to hope I don’t throw out my back trying to lift myself by my bootstraps.

If I’m an insured adult of limited means but can’t pay my bills, I may also be in for a hard time.

An emergency department (any that get federal monies, which is most) must provide emergency care for me—for anyone—until I am stable and can be safely turfed to someplace else.

So that’s how that works.  But what about regular doctor visits?

Sorry.  Unless you can find a clinic willing to treat you for a price you can afford, you’re out of luck.  If, for instance, you came to my hospital’s clinic, the financial representative would help you navigate the system.  The hospital receives some extra money to care for the poor, but will still take a loss, so chances are you’ll have to pay something.  If you go to a regular doctor’s office and you can’t pay because you are either uninsured and poor, or you haven’t met your deductible, you may also be out of luck.  Your doctor isn’t ethically required to work for free, as long as they care for any urgent issues and give you a written warning with phone numbers to other local clinics.

That last part is harsh, for the doctor and the patient.  Most doctors don’t want to turn anyone away.  We went into medicine, at least in part, to serve.  But not for free.

There is no mechanism in place to compensate us for free care.  I participate voluntarily in a local charity to provide pro bono care, but when it comes to patients who can’t pay their bills, well, I can’t afford that forever.

It’s a lovely system we have that does it’s best to separate doctors and patients from each other.

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  1. Again, incredibly well-written and honest. Thanks, Dr. Pal!

  2. R E G

     /  May 3, 2012

    The rest of the world is baffled. If you are poor, your health care is almost non-existant. If you are insured, your health care is held hostage to private insurer’s policies. And the cost! My American relatives are always struggling to fit it into their budgets.

    Even more baffling, Americans as individuals are generous people. Somehow the same spirit evident after natural disasters cannot be chanelled into universal healthcare.

    Just before they voted on Obamacare, I had a weird fantasy. I imagined Canadian flashmobs showing up in major American cities, wearing T-shirts listing medical procedures they had had for “free”. My own family would have included heart surgery, cancer treatment, brain tumor removal and many boring, screening tests. Yes, I know it is all paid for out of taxation, but somehow I just can’t find it in my heart ot begrudge equal access to medical care to people who earn minimum wage. Oddly enough, neither can Americans. They will be out on Saturday holding car washes to cover their neighbours’ medical bills.

  3. lumbercartel

     /  May 3, 2012

    I just can’t find it in my heart ot begrudge equal access to medical care to people who earn minimum wage. Oddly enough, neither can Americans. They will be out on Saturday holding car washes to cover their neighbours’ medical bills.

    Only because their neighbors are like them, not those others who can’t be trusted and who are merely parasites on Real Americans ™.

  4. I’ve been truly appalled at how ruthless some of my friends, family, and random ‘net acquaintances are about the idea of universal health care. So many of them are opposed to “paying for freeloaders”, even when those “freeloaders” are children. Personally, I favor a bare-bones single-payer universal coverage that provides pretty good care to everyone for free or a nominal (a couple bucks) co-pay. Of course, since funding wouldn’t be unlimited, there would have to be some decisions made about the most cost-effective use of available funds for the greatest benefit to society as a whole. Then, there could also be a network of private, fee-for-service care for those who want to pay extra (either at the time of care or in a supplemental private insurance plan) for the very super-duper top notch care that is just too expensive to realistically be provided to everyone. That way, there would still be funding and competition driving research and development of costly new drugs and techniques, which eventually would trickle down to the public system when the cost became affordable. People could still have the choice of paying for care the government deems cost-ineffective or too risky, but the costs of the public plan would be kept under control to some extent. Sure, it wouldn’t be a perfect system, so not everyone would get everything they want, but most people would get most of what they need — and that’s a heck of a lot better than what goes on now.

    Will this ever happen? I doubt it. Like I said, so many of my friends, who are normally generous and reasonable people, have a knee-jerk, visceral distrust — even hatred — of any universal health care plan. Personally, I’d like to see every man, woman, and child in this country have access to at least basic care, and I’m willing to put my tax money where my mouth is. Unfortunately, I can’t imagine the American public would ever go for it.

  5. Karen

     /  May 3, 2012

    I’ve found the same result as alicia7q; many people in my extended family don’t want to pay for health insurance for “them”. They’re never too sure who “they” are, but “they” surely must be freeloaders of one sort or another. These aren’t stupid people, either; the attitude baffles me.

  6. DLC

     /  May 3, 2012

    Hey, you could always trade a chicken for an office visit. or a box of cookies… or . . . hey how about I trade you a bacon cheeseburger for some simavastin ? you get cholesterol, fat and proteins and I get a pill to lower my cholesterol . . .

  7. Barbarella

     /  May 4, 2012

    Very well said, and those figures were just about perfect. Mr. Barbarella has an acute AND chronic disease, very rare, which has been eating up his kidney tissue since he was about 35. We spend about 20,000 a year on that (our share, according to insurance people). However, his doctor says he ought to be dead, so we figure we are lucky. I am healthy except for mental illness, which is finally covered by insurance. All I can say is, you try to balance your checkbook while you are hallucinating. And then there’s Barbarella Jr., male, 22 years old, working two 30-hour week jobs with no insurance, so we pay his bills. Our deductible is 4,000 yearly. We all also go to the dentist, not covered by our insurance. And we all wear glasses, ditto. And I am in that age group where we ladies have to be tested just about everywhere.

    Vacations? Forget about it. We don’t even have cable TV.

  8. saffronrose

     /  May 4, 2012

    Many people consider the things which government does for them to be social progress but they regard the things government does for others as socialism. Chief Justice Earl Warren, April 1952

    This is one of my sigs. It seems to be highly appropriate now.

  9. Dianne

     /  May 5, 2012

    Oddly enough, the state of Pennsylvania does acknowledge that there are some diseases that can’t be treated profitably because the patient population is too poor and the diseases too complex and expensive to treat. Therefore, they have a program by which hospitals and offices that treat a large number of these patients are compensated. Guess what the current (Republican) government is doing to these programs just now?

    Yep, cutting them. Despite the extremely clear data that show that cutting these programs will result in more public money being spent to care for the same patients (they’ll just end up in the hospital more if they can’t get preventative care). I guess it could be worse: they haven’t cut them off altogether, but the decrease in funding is increasingly problematic and only ends up costing the state more and more. Aren’t the Republicans supposed to be the hard headed fiscal conservatives? No longer, it seems.

    • Welcome to the world we live in. On the one hand, people on the far left wonder why we can’t cure everything. (Remember activists wondering why it was 1988 and we still hadn’t cured AIDS? You’d laugh if people weren’t dying.) On the other, people on the right (not even the far right really) wonder why we can’t cure everything at a profit.

      My genes aren’t so bad, but I had a cousin who contracted HIV from a reused syringe in prison. (It was 1982.) My grandfather died of liver cancer due to alcoholism. Neither of them would’ve been able to afford their medical expenses.

      “Fiscal conservatism” is a funny thing. A tax break is the exact same thing as giving money away. But a tax break is more ideologically acceptable. Also, nobody’s a fiscal conservative anymore. You’d have to go back to Hoover to see a true fiscal conservative.

  10. Lady Day

     /  May 6, 2012

    Great post!

  11. It’s a job that requires 8 additional years of school, and you’re basically working 24 hours a day.

    I should think expecting a decent payment is the least you can get.

    Of course, the quacks will use this to say it’s all about money…while charging you $300 for a tiny bottle of water.

    • alicia7q

       /  May 8, 2012

      Yes, I’ve always wondered why it’s considered “dirty” for doctors to worry about litte things like getting paid (while exposing themselves to huge liability risk despite often not getting compensated while on call for the ER), while “alternative” quacks usually demand payment up-front.

      • Long post ahead.

        For the same reason “the FDA is biased toward Western [sic] medicine” while DSHEA exists. (Whenever someone says “Western medicine”, I remind them that Lakota medicine holds that disease is caused by tiny invisible animals called mni watu.)

        For the same reason homeopathy isn’t listed as “Western medicine”, and “Western” is a snarl word. (Interestingly enough, during Nazi Germany, homeopaths claimed scientific medicine was “Judaized” and homeopathy was “Aryan medicine”. Seriously.)

        For the same reason that in spite of what I just last wrote, alties frequently invoke Godwin’s law.

        For the same reason “Western medicine” “focuses on the symptoms”, even if the entirety of homeopathy is the symptoms.

        For the same reason that alties use the IHS (Indian Health Services) coercive sterilization scandal of the late 20th century (It was first reported in the 70s, probably began in the 20s, and the last reported sterilizations were Norplant and Depo-Provera experiments in the 80s and early 90s.), while most American Indians…still don’t go to the health food store (when they can afford it because of the aforementioned price) and still vaccinate their children. (In fact, New Zealand is now using the Indian Health Services model to vaccinate the Maori.) We still don’t trust OBGYNs because of the coercive sterilizations, and most of us don’t trust a scalpel anywhere around the genital region, but we KNOW about immunological naïveté.

        (As an aside on that last part, can I just say this is the problem with the fringe? Like, I know a dude who as a teenager was molested on the psych ward, but he can’t come forward, because every group that handles this is connected to a certain church started by a science fiction writer that I won’t mention for legal reasons. Call it woospam: Any actual malpractice is difficult to report because the interested parties are run by woo peddlers.)

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