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Joey Palmer Should Get A Damn Job That Pays
Palmer's a guy who had an expensive hospital bill after a motorcycle accident. Here's what happened, from an SFGate story by David Lazarus that starts out with those terse sentences clearly intended to tug at our heart strings (gag):

There are 47 million people in this country without health insurance. Richmond resident Joey Palmer is one of them.

He learned how costly this can be after fracturing a rib in a relatively minor motorcycle accident and subsequently being hit with a bill for more than $12,000 from San Francisco General Hospital.

"There's no way I could pay something like that," Palmer, 32, told me. "I'm not a bum, but I'm not making a lot of money right now. How is anyone supposed to pay a bill like that?"

Iman Nazeeri-Simmons, director of administrative operations at San Francisco General, said she sympathizes with Palmer's situation.

"It's not us," she said. "It's the whole system, and the system is broken. We need to look closely at making changes and at how we can deliver care in a rational way."

Palmer's story illustrates the broader problem of runaway health care costs in the United States and a system that leaves millions of Americans to fend for themselves.

Excuse me, but who should be fending for them? What ever happened to American individualism and self-determination? It can't be a total myth, because I have it, and know at least a few people who have it -- you know, that personal responsibility thing?

According to Lazarus' story, Palmer only earns $7,500 a year as "a woodworker who specializes in the decorative touches on wealthy people's yachts," and gets by "primarily with the assistance of relatives."

Dude -- that's called "a hobby." You could get by on much more if you got a job at Starbucks. And if you worked more than 20 hours a week at Starbucks, you'd have health insurance, too. And if you don't have health insurance, Mr. Genius, maybe you have no business riding around on a motorcyle (which a commenter here, I believe, recently noted that hospital emergency room doctors refer to as a "donorcycle").

The hospital administrator in Lazarus' story has the answer:

"Universal coverage would mean that a Joey Palmer doesn't get left out in the cold just because he was in the wrong county," Nazeeri-Simmons said

"Universal coverage"? Yeah, that's a nice name for it. It translates to "'U' do your woodwork hobby while the rest of us work long hours at real jobs to pay for your care."

Posted by aalkon at March 31, 2007 3:34 PM


This guy may be a worthless bum, but that doesn't mean that the system we have is any good. What about the person who works for twenty-five or thirty years, paying into the system the whole time, and then loses her job, only to find when her cobra runs out that she is absolutely, positively uninsurable due to her "preexisting condition." Even if that condition is work related, it doesn't get her into the insurables pool. Your smug assurances that people should be responsible and buy insurance in advance is reasonable advice for those who would be allowed to buy insurance under the current system, but your naivety about how the system works for lots of other people is disappointing. The problem isn't just with insurance of course, but there is a substantial element of luck involved in whether or not you can buy insurance after a certain age.

And by the way, the old joke among transplant surgeons about "donor cycles" was real, but the helmet laws are hurting the supply of available kidneys.

Posted by: Bob G at March 31, 2007 3:22 AM

What about the person who works for twenty-five or thirty years, paying into the system the whole time, and then loses her job, only to find when her cobra runs out that she is absolutely, positively uninsurable due to her "preexisting condition."

That sort of thing isn't what I'm talking about, and should be corrected.

I posted this because I suspect many of these people calling for "national health insurance" and the like really just want other people to pay for them.

What's hurting the supply of available kidneys is the fact people aren't allowed to sell theirs, a subject Virginia Postrel (who gave one of hers away) has written persuasively about.

Posted by: Amy Alkon at March 31, 2007 7:35 AM

Gotta love those (overpaid) hospital admins. "It's not us, it's the system". Yeah right. HOW padded do you suppose that $12,000 bill is, because they can get away with overcharging an individual in a way they can't with a health plan?

Posted by: Stu "El Inglés" Harris at March 31, 2007 8:15 AM

What's the big deal? Just stiff the hospital. It's their fault that they treated you without checking your financials. Had they done so you'd just have been shipped to a county hospital so the rest of us could support you; just like we are doing now. The comments on this page reflect what will happen with universal health care: they will run up huge costs treating warts with chemo, doing MRIs on hang nails, and refusing to furnish horny men with sex. You think costs are high now? Just wait.

Posted by: Howard Veit at March 31, 2007 8:37 AM

Stu, two things to keep in mind:
1) When you have insurance, you're part of a giant risk pool. Risk is spread throughout the pool. People pay approximately the same amount for services. Some end up needing more, some less. The reason that the "some less" people are willing to pay more than "their share," presumably, is that often we have no way of knowing who will be in the "some less" group ahead of time. The individually insured don't get the benefit of this...and the fact that healthier individuals are less likely to seek insurance raises the average risk for insured individuals even further.
2) Insurance companies represent huge groups of patients and therefore represent millions or billions of dollars in business. Therefore, they can negotiate lower rates than can individuals. This is the case in just about every industry out there - the more buying power you represent, the lower the rates you can achieve.

Is that bill "padded"? Maybe. Or maybe $12,000 is what it really costs the hospital for those services, and this guy doesn't have the benefit of an insurer negotiating discounted rates for him.

I agree with Amy, though. Starbucks will give you health insurance if you work there at least 20 hours a week, and no obstacles are put in place to prevent you working 20 hours a week. I am fully aware that there are people with limited options, but this guy is mooching off of his relatives so that he doesn't have to get a real job, and is riding a motorcycle to boot. HOWEVER, on the flip side, I note that the article says that he asked to be taken to Contra Costa Hospital, where he knew he could get treated for much less, but the paramedics pushed him to go to a trauma center. If there's not something in place to let a patient sign a waiver dismissing liability for taking said patient to the hospital he asks for, there should be, assuming it could hold up in court.

I still think Bill Bradley had one of the best ideas for dealing with all this that I've heard of - allow the uninsured to participate in the largest government employee health insurance program. That's a HUGE risk pool, and the larger it gets, the lower the costs. But, until you can get Americans to agree not to sue when doctors refuse to intubate their 98-year-old grandmothers with dementia or when they refuse to rescuscitate babies born at 21 weeks of gestation, a European/Canadian-style single-payer system isn't going to work here. I'm not saying that doctors are blameless saints, God knows, but Europeans and Canadians are used to a very different approach to the medical system than we are, with fewer diagnostic tests, longer waiting periods for procedures, and more acceptance of what they're given as options. You need that mindset for single-payer to work.

Posted by: marion at March 31, 2007 8:39 AM

Howard, is that scenario happening in the universal care for seniors (medicare) program? I always thought that one worked pretty well.

Posted by: Rojak at March 31, 2007 8:42 AM

P.S. Anyone interested in seeing what happens when you attempt to establish a single-payer system in the U.S. might want to Google "TennCare." Short answer: Tennessee decided to use its Medicaid funding to insure ALL of the uninsured and uninsurable (i.e. the people who have, say, had cancer and are in long-term remission). The program eventually was bleeding huge amounts of money because whenever administrators tried not to cover something like, say, methadone, activists went to court and convinced judges that the program shouldn't "discriminate." What eventually happened was that new Gov. Phil Bredesen said that, if the activists wouldn't agree to limits on coverage, he'd end the program. The program survives, but in a reduced form that doesn't cover anyone. (On a side note, keep an eye on Bredesen - he's a Democrat and a lawyer from New York who managed to get elected and re-elected as governor in the very red state of Tennessee...initially by refusing to implement a state income tax, a promise that he kept. He's quite popular among both parties. No idea how good he is libertarian-wise, but I'm expecting him to seek higher office at some point.)

Posted by: marion at March 31, 2007 8:45 AM

There must be tons of information missing from that story. If Mr. Palmer truly makes only $7,500 a year then he is probably elgible for Medicaid and also eligible for the 60 day retroactive period. Any hospital that deals with emergency cases would make the paperwork available.

If the extent of Nazeeri-Simmons knowledge is to call for universal coverage then one can only wonder how many other publicity starved idiots work at SFGH.

Posted by: Pat Patterson at March 31, 2007 9:12 AM

Dropped a paragraph. Also there was no mention of what kind of coverage his own insurance, for the motorcycle, carried. That is a requirement in California, which is verified each year when renewing your registration.

Posted by: Pat Patterson at March 31, 2007 9:17 AM

Thanks for your contributions, Marion, you write a lot of good sense there. I'm exactly one of those people you describe -- a fairly healthy person with very modest expectations from the health system, thanks to growing up with the British NHS.

I write from the perspective of ONE WHO KNOWS in the matter of hospital billing, though. I'm now insured in California, but when I wasn't, I had a 3-day hospital sentence with pleurisy. $12,000 was exactly what my bill came to, as well -- and going through it line by line, I found much of it was sheer invention. I paid the part of it that represented genuine goods & services delivered. So much for the myth that the uninsured don't pay their bills.

Try this some time. Just before you're the recipient of a medical service, ask the doc/nurse/admin what the cost of the service is. They won't have a clue -- and if they did happen to have a clue and were honest, they'd reply "It depends on who's getting the treatment".


Posted by: Stu "El Inglés" Harris at March 31, 2007 9:18 AM

The Canadian health care system is actually pretty good. I got a free abortion when I needed it, and I only had to wait one week. Annual physicals are allowed once a year (they are strict about that), but once you're in there, you can get tested for EVERYTHING, which I do. Drugs aren't paid for, and neither is dental, but that's what employer health insurance is for.

They are working on the longish waiting times for operations, but in the meantime, they just ship people down to the US and the government pays for it.

I don't know how long the system will last before it collapses in on itself, but I'm hoping at least another 50 years, and then it's not my problem anymore!

Posted by: Chrissy at March 31, 2007 9:36 AM

> The Canadian health care system is
> actually pretty good. I got a
> free abortion when I needed it,




Posted by: Crid at March 31, 2007 9:47 AM

"They are working on the longish waiting times for operations, but in the meantime, they just ship people down to the US and the government pays for it."

Yes. I know. My father is a U.S. physician and occasionally would have Canadian patients with, say, brain aneurysms who had been put on waiting lists for operations. Any neurosurgeon in the U.S. who did that would be sued for malpractice, and rightfully so...however, the ratio of neurosurgeons to total population is much higher in the U.S. than in Canada. These people were lucky - the Canadian government wasn't paying for their trip down to the U.S., but they had the funds to do so themselves.

Stu, I admire your initiative...but keep in mind that the hospital you went to likely serves a lot of illegal immigrants without health insurance, and balances its books on the backs of those who can pay. I'm all for doing something to address that particular issue, especially given that I also live in a border state, but I don't think the padding was so the hospital CEO could replace his Mercedes with a Porsche.

If you want an example of what I'm talking about, Google "dooce Leta MRI" and you can read a tale about a popular blogger and her young daughter who didn't want to start walking. The kid was given TWO MRIs to rule out the small possibility that she might have a brain tumor or something similar. TWO. I feel safe in guessing that in another country she wouldn't have gotten either. Now, would I want the same for my kid if I thought she might have a problem? Yes, because I'm used to the U.S. medical system. But the higher level of health-care spending here isn't just because doctors are paid's because kids who don't want to walk get multiple expensive medical scans to rule out serious problems that are unlikely in the first place (among other things).

Posted by: marion at March 31, 2007 10:38 AM

I said: "What about the person who works for twenty-five or thirty years, paying into the system the whole time, and then loses her job, only to find when her cobra runs out that she is absolutely, positively uninsurable due to her "preexisting condition."

Amy Alkon replied: "That sort of thing isn't what I'm talking about, and should be corrected."

Thanks for the clarification; now mine: The current system does not provide for universal access to health insurance, which ought to be a prerequisite for any system we might wish to design. The problem is that it is hard to come up with a system guaranteeing universal access under the current model in which a few giant companies limit public enrollment. Proposals usually fall into two categories: First is some sort of legal requirement that everyone have insurance. Second is a government mandate that the private insurance companies offer insurance policies to everyone who asks. Both proposals have problems: Neither deals with the fact that the U.S. healthcare system spends a whale of a lot of money to deliver less care than other modern systems. With all due respect to the economic ideologues, I don't think that universal coverage can be instituted without some rational approach to cost containment, and I wonder how well universal access would play out.

The question I raised was more limited and might be thought of this way: If you pay into a life insurance policy for some number of years, at a certain point you are vested and they can't cancel it. The health insurance system is exactly the opposite -- insurance companies look for reasons to cancel you or raise your rates through the roof, and you have no rights under the system. This is one consequence of employer-based systems without portability, to use the current jargon. Part of this could be fixed simply by creating a vesting right after a certain number of years of uninterrupted coverage -- people who leave corporate and government jobs would have the right to continue coverage at a comparable overall cost, and this could be administered as the equivalent of the applied risk pool for auto insurance.

Conservatives have a reflexive antipathy to moving the insurance system over to the government, but I might be willing to endure the inefficiency of a government agency in lieu of the efficiency with which the private insurance companies give us the shaft. Government does certain things well (collecting money and writing checks), and it could be made to do the same in terms of health insurance. This isn't the only possible option, but the current system is not acceptable.

Posted by: Bob G at March 31, 2007 10:42 AM

Oh man, where to start?

Years ago, I had (what turned out to be) a massive asthma attack. It felt like (what I had heard) a heart attack feels like. I did the right thing, and called 911. After the ER, ambulance, etc. I ended up with - what I felt was a reasonable - bill for about $4000. Being single, self-employed and stupid, I did not have health insurance at the time. Such did not obviate my responsibility for paying the bill, thus I paid the bill.

Regardless of how one may feel about $40 tylenol being dispensed at the hospital, one is seeking a service and one should pay for said service. I would no more stiff the hospital than I would expect my clients to stiff me. All parties know going in that they are required to give/receive services and remuneration is expected.

Unless the guy in question was so handicapped in such a manner as to preclude him obtaining employment which gives a better compensation, he should not be complaining about the bill he received due to his actions. Sell the bloody motorcycle.

With the type of work he does and the clients he has, one would expect him to make a lot more. My impression is that he is a bloody lazy slob who feels he is entitled...No sympathy whatsoever for the idiot...

Posted by: André-Tascha at March 31, 2007 10:50 AM

> one is seeking a service and one should pay for said service.

Yes, but again, one can ask up front what the cost of that service will be, or even is likely to be, and one will not be told.

Posted by: Stu "El inglés" Harris at March 31, 2007 2:04 PM

Precisely... The genius of the American consumer for finding the best deal has been disabled throughout these transactions.

Posted by: Crid at March 31, 2007 2:57 PM

While riding in the front of the ambulance (my son was in the back still not coming out of an hour-long seizure), the last thought on my mind was which hospital would have the "best deal" for services rendered. Expecting people with no medical training and often no advance notice prior to having to make critical medical decisions to research medical services the same way they research before buying a car isn't realistic in a lot of situations. An x-ray is cheaper than an MRI, but will it provide the information needed to diagnose a problem? And which radiologistis the best at interpreting test results? It may not be the gal who works at the hospital with the best surgical team, etc. I think it's a bit naive to expect the "genius of the American consumer" to come to the fore when dad might have had a stroke or you are told you have melanoma and need to have surgery tomorrow.

Posted by: deja pseu at March 31, 2007 4:38 PM

Ahem. My family owned a marina in Florida for 32 years. If this guy makes only $7500 a year, it's because he's hiding it from the IRS.

Yes, his motorcycle insurance should step up. That's the smart way for anyone to minimize their insurance bills.

And don't you find it amazing that people will think about paying for a car via payments for years, but it never occurs to them to settle their other financial obligations this way?

This needs to be institutionalized , by law, as a private obligation to pay, perhaps with a break on the interest on the outstanding balance. A government agency standing in line with its hand out is not going to reduce costs.

Note to nitwits:No matter who pays, you cannot be made whole again in the case of serious injury. Don't get in line with your hand out again if the doctors can't fix your dumb, broken ass.

Posted by: Radwaste at March 31, 2007 4:42 PM

"While riding in the front of the ambulance... the last thought on my mind was which hospital would have the "best deal" for services rendered."

There is elective surgery and routine visits where we could (should?) do some price shopping.

Posted by: doombuggy at April 1, 2007 4:49 AM

Here's one of the biggest things broken in our ridiculous system: people with insurance get lower bills than people without it.

Come again?

True. I spent 104 days hospitalized in critical condition 2 years ago. My doctor charged me $360 for the daily lovefest with him (any bleeding? any cramping? no? see you tomorrow). My insurance company brokered that down to $48. Times 104 days. Anyone have a calculator?

If the barely-employed motorcycle rider had spent some portion of his ridiculously meager earnings on health insurance, his total bill would have been lower.

Someone please explain that to me...

Posted by: Tess at April 1, 2007 7:14 AM

Since most health insurance policies either do not cover a lot of elective surgeries (or cover them only minimally), I'm sure that individuals are already researching costs. I knew when I had my thyroidectomy (non-elective) last year that the surgeon I wanted for the procedure didn't adjust his rates down for insurance and that I'd be liable for whatever they didn't cover.

I agree that Joey the motorcycle rider is either a slacker or not telling the truth about his income, and should be liable for his medical costs. But Bob G is correct that health insurance is not as universally available to individuals as some might think.

Posted by: deja pseu at April 1, 2007 7:44 AM

"Here's one of the biggest things broken in our ridiculous system: people with insurance get lower bills than people without it."

That's the way that insurance works. People with car insurance typically pay much less when their cars get seriously wrecked or totaled than people without. You pay less for a few reasons: 1) you've been making regular monthly payments for coverage, so while you're paying less for *that specific procedure*, the procedure's price doesn't take into account those previous payments; and 2) since you're part of a large group of potential patients, your insurance company negotiates discounted rates with health-care providers, just like every group out there in any industry that represents a large number of people negotiates lower rates than individuals can achieve when it can. The idea of large groups paying less than individuals is repeated throughout multiple industries. When you represent significant buying power, you have more power over pricing than when you represent individual buying power.

Also, when you're insured with a health policy, you're part of a risk pool and your payments are based on the overall level of risk. Some pay "more" than they should, some "less"...but eventually, we either die prematurely or we get older and sicker and our risk level rises. The difference between health insurance and car insurance, if you get health insurance through your employer or via some other group, is that you pay the same monthly rates and copays that everyone else does, whereas with car insurance, since it's done individually, your rate depends on your perceived level of risk.

Insurance works by getting you to pay something up front that you wouldn't otherwise pay in order to pay less in case Something Bad happens. If you never wreck your car or need any medical care whatsoever, it's a bad deal. If you do wreck your car or need any medical care whatsoever, insurance suddenly seems great. The system has a built-in bias toward rewarding those who plan ahead and leaving those who decide not to pay in advance in stickier straits. If you don't like it, fine, but this is how ALL insurance works. The only real alternative to this particular aspect of insurance is a single-payer system funded entirely by taxes. I've already stated why I don't think this would work given the American psyche, but I'll add another reason: do you really see people in the U.S. cheerfully accepting Canadian or European-level taxes? I was raised in a state (Tennessee) that recently rejected, again, the notion of a state income tax. I don't think you're going to be able to tax Americans enough to fund anything like a workable single-payer system.

As for shopping for lower be fair to Joey the motorcycle rider, the story says that he did tell the paramedics that he wanted to go to a nearby hospital that would offer him discounted care because of his low income, and they persuaded him to go to the farther-off, larger SF hospital on the chance he might need a trauma center. The paramedics need to be told not to do that unless someone is, say, slipping in and out of consciousness. But we live in a country in which people who can do skilled work with their hands are rare. How can this guy not be leveraging his ability into more money per year? And what does it say that this columnist had to latch onto a guy who's mooching off of his relatives in order to make a point about health insurance?

Posted by: marion at April 1, 2007 8:35 AM

He could have also done four years in the military, as I did, then at least, you'd have some kind of coverage for those times in between jobs. It's not the best of insurance plans, but it would cover a fractured rib without socking you with a bill.

Universal Health Care...that's all we need right now: yet another means for some indigent or homeless person to fake an illness for the sake of getting a bed and a meal for a night. Maybe even two.

Posted by: Patrick at April 1, 2007 6:46 PM

Crid, I figured you'd latch onto the abortion thing, out of everything else in my comment. Kind of Fred Flintstone-ish of you, but what I've come to expect. I guess it would be a lot more fair for a guy to give a woman a kind of security bond for around $1,000, just in case she needs an abortion, prior to having sex. That way at least he has take responsibility for his actions up front.

I think that's one thing that should be completely free for all women, considering the cost to society of unwanted and underparented kids.

Posted by: Chrissy at April 2, 2007 6:14 AM

> I guess it would be a lot
> more fair...

Look, people old enough to fuck shouldn't whine about "fairness". Or cartoon characters (did Fred Flintstone have a position on abortion?). Final responsibility for conception will always rest with the woman. Not just because of hardware issues or policy issues, but just because of horse sense. By all means, if you want your partners to post a surety bond before you get sexual, it's your own business. Men are dogs.

But we've known for many years now how babies get made. I grew up feminist and have been stunned, stunned see how rarely women get pregnant when they really don't want to. Women who have babies almost always have a hole in their heart that they need to patch through motherhood. They don't often patch it responsibly.

Nothing anywhere is "completely free". If you think other people should pay for your abortions, especially when they believe them to be murder, you're going to be really disappointed. You can insist that the broader society take an interest in traffic within your trousers. But you won't be happy when they do

Posted by: Crid at April 3, 2007 11:02 AM

Whoops! Don't often should be often don't.

It was a break at work. I was distracted by something shiny. No misogyny here, nosiree!

Posted by: Crid at April 3, 2007 3:32 PM

'You can insist that the broader society take an interest in traffic within your trousers. But you won't be happy when they do.'

There is already way too much interest in how women conduct their sex lives, with the intent of controlling it somehow (religion's raison d'etre). If there weren't so many people interested, nobody would care about such a simple medical procedure which takes all of 5 minutes. If they cared about life some much, wouldn't they be standing outside abortion clinics offering to adopt the kid and pay for its upkeep for 16 years?

Even in a very modern society, it is still safer for women to be very discrete about their sex lives, they are still judged, with very negative consequences.

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