What’s “broke” in the American health care system? Hospitals overcharging– and politicians who let them. The lobbyists are killing us — literally.

This  article, which appeared in The New Yorker, is a must-read for all American voters.

 Of course patients should know costs — so that they can be outraged enough to demand change.

The real elephant in the room isn't "should they know?" but "why do patients, communities, and elected officials allow medical money machines – i.e., the hospital corporations — get away with pirate costs on even the smallest items?" 

Time to go back to regulation. Better yet, Medicare for ALL.

When it comes to life, death, sickness and health, hospitals that charge 1,000 for a toothbrush should not be allowed to stand between you and the care you need.
DECEMBER 23, 2013 / (c) 2013 The New Yorker 




Two months ago, I moved into a new apartment. On the first night, in the dark, I tripped and fell. It felt like I had badly scraped my shoulder, but when I looked in the mirror there was no torn skin—my collarbone was simply jutting at a new, funny angle. When I tried to push it back into place, I got nauseated, so I decided to try to sleep. I’ll wake up soon, I thought, and just pretend this never happened.

When that didn’t work, I Googled “rotator cuff tear” and “asymmetric shoulder.” It seemed like a benign possibility; lots of people with rotator-cuff tears lead healthy and productive lives. No luck. I called my mom, who happened to be visiting for the night and was at a hotel two blocks away (and who, like me, happens to be a cardiologist). When she arrived, we made a video of my shoulder to send to my orthopedist cousin for a diagnosis—a clever idea except for the fact that he was sound asleep. Our delay tactics exhausted, we faced the inevitable: I needed to go to the emergency room.


Next thing I knew, I was standing with my pokey shoulder in front of an X-ray machine. My mother called out to me from the radiology reading room: “You broke your clavicle.”

“O.K.,” I called back.

After being diagnosed, the rational next step would have been to turn my attention toward treatment. Instead, when two additional X-rays were taken, an orthopedist was called to review the films, and two slings were provided instead of one, I wasn’t thinking about what I needed to do to get better. I was doing arithmetic: How much was all of this going to cost?

“You’re so tough,” my mom said, when I refused, for about the fifth time, to even take a Tylenol.

“It’s not that,” I said. I waited until the nice doctor walked away and whispered, “Did you not hear about the toothbrush?”

The thousand-dollar toothbrush, to which I was referring, had first gained notoriety in 2010, when featured, among other absurdities like twenty-three-dollar alcohol pads and fifty-three-dollar disposable gloves, in a CNN special on exorbitant health-care pricing. Three years later, the buzz around said toothbrush grew when the New York Timesreporter Tina Rosenberg published a widely circulated piece called “The Cure for the $1,000 Toothbrush,” which described how the lack of price transparency in health care contributes to its exorbitant costs, and financial ruin for many Americans. Those pieces, along with Elizabeth Rosenthal’s five-part Times series and Steven Brill’s twenty-eight-page Time cover story, “Bitter Pill: Why Medical Bills are Killing Us,” have made the lack of price transparency in health care an intensely debated topic for both policymakers and the public. And it’s why sitting perfectly still to avoid pain made more sense to me than accepting a Tylenol, which I feared would cost me a hundred times more than what I would pay at the CVS next door.

The obvious antidote to price opacity is price transparency, but such transparency may have a range of effects, depending on where it is applied in the many layers of health-care delivery. For instance, there is emerging evidence that when hospitals publish prices for surgical procedures, costs decrease without a loss of quality. The Surgery Center of Oklahoma, for example, has been publishing its prices for various procedures for the past four years. Because the center’s prices tend to be lower than those of other hospitals, patients started coming from all over the country for treatment. In order to compete, other hospitals in Oklahoma began listing surgical prices; patients were able to comparison shop, and hospitals lowered their prices.

The calls for price transparency, though, have now moved beyond the hospital walls. Intwo recent opinion pieces, Peter Ubel and colleagues argue that doctors ought to directly disclose to patients the costs of recommended treatments. Out-of-pocket costs, they argue, can “cause more distress in patients’ lives than many medical side effects, and patients can decide whether any of the downsides of treatment are justified by the benefits.”

We must find better ways to make affordable, high-quality health care available to everyone. But is injecting price transparency into the patient-doctor dynamic by asking patients to consider costs a step toward achieving those aims? Or will we end up hurting most those we are trying to help?

The first problem with financial disclosure from doctor to patient is a practical one. Doctors rarely know how much their patients actually pay. Patients are covered by a variety of insurers, all of whom offer several plans, for which any individual patient has a different copayment and deductible, which he may or may not have met.

Let’s say, though, with a click of a button, a patient’s out-of-pocket costs for any given recommendation are readily available to both doctor and patient. There will be some situations for which two treatments with similar risk-benefit profiles exist, but costs are clearly divergent. Patients with systemic lupus, for example, often choose between two drugs, Imuran and CellCept; the benefits and risks of the drugs are similar, but the latter costs ten times as much. Under these circumstances, asking a patient to consider price in their choices seems wise.

But many common clinical scenarios are more complicated. Take heart-attack treatment, for which, Ubel and colleagues note, costs can approach forty thousand dollars per year. (The report from which the figure is derived actually suggests a range of three thousand dollars to forty thousand dollars, depending on the plan.) Heart-attack care typically begins when a patient comes to the emergency room with chest pain. A stent procedure to open a blocked artery is often life-saving, but only if done quickly. The longer you wait, the more heart muscle dies.

During my cardiology training, it was my job to describe the benefits and risks of this procedure to patients, and ask them to sign consent forms. I went over each risk in painstaking, non-jargon-y detail. You quickly learn, though, that certain risks are far more disturbing than others. Say “kidney damage,” which, while unlikely, is one of the more common complications, and most people seem relatively unfazed. Say “limb loss,” however—which, while possible, is unbelievably rare—and people panic. In weighing risks and benefits in these situations, it’s not the likelihood of the risk that matters but the ease of imagining it.

Now consider this same scenario and add to the list of potential risks, “Full disclosure: this might cost you as much as forty thousand dollars.” All of a sudden you have injected into a litany of the unfamiliar a “risk” that could not be more familiar: money. Who would not fixate upon this cost information in making medical decisions?

It’s also hard to quantify and convincingly describe the long-term costs of not getting treatment. So while it may be possible to tell someone the cost of a stent procedure, it will always be much more difficult to put a price on not getting the stent—which often includes frequent hospitalizations for heart failure, complicated medical regimens requiring intensive lab monitoring, devices to help the heart pump more efficiently, and sometimes even a heart transplant.

Everyone is prone to fixating on risks that come readily to mind while discounting those that may occur in the future. But the tendency to err in these predictable ways is magnified by how poor we feel in the first place. In their recently published book, “Scarcity,” the behavioral economist Sendhil Mullainathan and the cognitive psychologist Eldar Shafir describe the psychological consequences of feeling like you don’t have enough. The fundamental theme of the book is that scarcity, whether it’s from lack of money, time, or even human connection, “captures” the mind, depleting our mental reserves and giving us tunnel vision. As anyone on a deadline knows, such a mind-set can enhance focus and creativity. But more often, the feeling of scarcity, no matter its cause, leaves us more prone to making cognitive errors.

In one of the experiments described in the book, the authors asked people in a mall to consider hypothetical situations involving payments for a car repair. The subjects then completed tests for intelligence and impulse control. In the first scenario, subjects were asked to consider a relatively inexpensive car repair; afterward, there was little difference between high- and low-income participants on the intelligence tests. In the second scenario, however, the cost of fixing the car increases tenfold. When the same people repeated the tests, suddenly the poor fared far worse—the difference was akin to a thirteen-point drop in I.Q.

Based on this experiment and several others, the authors argue that the feeling of scarcity consumes the mind, causing us to behave in ways that are often attributed to personality, but may actually have more to do with context. No one, they argue, is immune.

I lead an undeniably privileged life, but the day I broke my clavicle, I was experiencing my own sense of scarcity. I had just moved, so I had spent lots of money all at once: the first and last month’s rent, cable and other utilities, and, most salient in my mind, a big wad of cash I had handed to the movers a few hours before the big break. And so I tunnelled. That’s why, after leaving the emergency room, while my mother read about treatment and recovery time for broken clavicles, I was frantically trying to understand my high-deductible health-savings-account insurance plan, unwilling to commit to further care until I knew how much I would pay. When it became clear that I would need surgery, and soon, as my mother tried to explain the various options—a big metal plate and screws versus a new technique, which would look better—I stopped listening after hearing the word “new” because “new,” in my mind, only heralded more expensive.

When I emerged from surgery a couple of days later, with the large, visible metal plate, I was delirious from the anesthesia, my heart rate was low, and my oxygen levels were falling. My surgeon insisted that I be admitted to the hospital overnight for monitoring and pain control. Though it was hard to remember to take deep breaths, it was not hard to remember that an overnight stay would cost thousands of dollars more than same-day care. “Take me home now,” I said to my mother.

Not surprisingly, I lost that battle. But in every other way, I won. I received outstanding care from a surgeon who is an expert in his field, ended up having far better insurance than I had initially understood, and have a mother who put her own life on hold to take care of me for a week. Though I will need a second surgery to take the metal plate out—which I wish I had thought about before—it feels like a win because rather than waiting two years, which was my surgeon’s initial estimate, I now have to wait only six months. But, most of all, I won because whatever scarcity had captured my mind was only temporary. For most people, it isn’t.

Transparency, as a concept, has tremendous visceral appeal. How can more information not be better? But information is not knowledge, and efforts to bring transparency to health care have previously failed, or caused unintended harm.

Millions of dollars, for example, have been invested getting restaurants to post calorie counts. Despite the fact that there is no evidence to suggest that these labels have decreased calorie consumption, and even some concern that low-income consumers may choose higher-calorie items, the Affordable Care Act mandates this approach for large restaurant chains. Another failed transparency effort, launched in New York State, involved using “report cards” to publish cardiac surgeons’ performance so that consumers would have better information. In this case, it was physician behavior that changed: the sickest patients, more likely to die and thus reflect poorly on the physicians’ performance, were increasingly turned away. Racial and ethnic disparities, which continue to plague all of health care, worsened.

In the weeks after surgery, stymied by dictation software and limited in what I could do, I spent a lot of time slowly wandering around New York City. In the same way that I had fixated on beautiful hair during times in my life when I had a regrettable haircut, I became enchanted by the loveliness of the clavicle—its symmetry and the amazing way it curves, which is unlike any other bone. But I also started noticing all the people who were broken—in slings like me, or limping along in awkward orthopedic shoes—a whole outbreak of hardship I had previously failed to register. One woman, when our paths crossed early one morning in Central Park, was wearing a sling just like mine. She smiled at me sympathetically and shook her head. “There’s a whole lot of that going around,” she said.

I wondered, but didn’t ask: Did she feel that she had enough to invest in getting fixed? Or was she still hoping, as I had so briefly, that with a little luck, she would mend?

Lisa Rosenbaum is a cardiologist, a fellow at the Philadelphia V.A. Medical Center, and a Robert Wood Johnson Foundation Clinical Scholar at the University of Pennsylvania.

(c) 2013 New Yorker Magazine



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Two health insurance articles you MUST read. Then go call Congress and tell it to support Obamacare, or your vote goes to someone who does.


The two articles, below explain the immediate effects of Obamacare on your health insurance costs. 

The first is from the New York Times. The second is from the New Yorker.

Here's the bottom line, folks. Until now, we've been at the mercy of health insurers who raised their rates at whimsy and for profit and greed. Their batallion of lobbyists paid off the best Congress money can buy. But with the passage of this health reform initiative, which requires that everyone participate — and allows for policies to be shopped around, even with "pre-existing conditions" —  patients/consumers have more choices, and aren't stuck with policies that cost too much while offering too little–let alone increase so egregiously each year.

The only thing more ideal than that is the Public Option, which would be the equivalent of Medicare for every citizen, not just those over sixty-five. Just imagine: you're in your twenties, and you can finally go to a doctor, without it costing you the equivalent of a month of rent!  Ask the citizens of Canada, the United Kingdom, and any other First World country who has it: it works. It's the most important service provided by their hard-earned taxes. It's fair for everyone.

Will Americans one day join their ranks? I hope so. I hope to see it in my lifetime, but I'm not so optimistic.

Not until all the lobbyists get out of the way.

Or until the citizens of the U.S. make it clear to their elected officials that they deserve the same heathcare plans provided to Congress and its families.

Yep, that's right: our elected officials gets it for free or for a pittance–and for life no less.

If they have it, you should, too.

Contact your U.S. senators, and tell the to support ALL platforms within the Affordable Care Act, because they will mandate patient healthcare reform.

Contact your Congressperson, to also support  the Affordable Care Act because it lowers your healthcare costs, as opposed to protecting the health insurers' profits. In fact, challenge him/her to write a bill that  provides you the same coverage as what they are getting for themselves.

Most importantly, contact your state's governor, and tell him future votes to him and his party are predicated on his expanding Medicaid in your state, which allows the Federal program to work for those most needy, and gives funds to your state to cover them.

— Josie


Health Plan Cost for New Yorkers Set to Fall 50%


Published: July 16, 2013 

Individuals buying health insurance on their own will see their premiums tumble next year in New York State as changes under thefederal health care law take effect, Gov. Andrew M. Cuomo announced on Wednesday.

State insurance regulators say they have approved rates for 2014 that are at least 50 percent lower on average than those currently available in New York. Beginning in October, individuals in New York City who now pay $1,000 a month or more for coverage will be able to shop for health insurance for as little as $308 monthly. With federal subsidies, the cost will be even lower.

Supporters of the new health care law, the Affordable Care Act, credited the drop in rates to the online purchasing exchanges the law created, which they say are spurring competition among insurers that are anticipating an influx of new customers. The law requires that an exchange be started in every state.

“Health insurance has suddenly become affordable in New York,” said Elisabeth Benjamin, vice president for health initiatives with the Community Service Society of New York. “It’s not bargain-basement prices, but we’re going from Bergdorf’s to Filene’s here.”

“The extraordinary decline in New York’s insurance rates for individual consumers demonstrates the profound promise of the Affordable Care Act,” she added.

Administration officials, long confronted by Republicans and other critics of President Obama’s signature law, were quick to add New York to the list of states that appear to be successfully carrying out the law and setting up exchanges.

“We’re seeing in New York what we’ve seen in other states like California and Oregon — that competition and transparency in the marketplaces are leading to affordable and new choices for families,” said Joanne Peters, a spokeswoman for the Department of Health and Human Services.

The new premium rates do not affect a majority of New Yorkers, who receive insurance through their employers, only those who must purchase it on their own. Because the cost of individual coverage has soared, only 17,000 New Yorkers currently buy insurance on their own. About 2.6 million are uninsured in New York State.

State officials estimate as many as 615,000 individuals will buy health insurance on their own in the first few years the health law is in effect. In addition to lower premiums, about three-quarters of those people will be eligible for the subsidies available to lower-income individuals.

“New York’s health benefits exchange will offer the type of real competition that helps drive down health insurance costs for consumers and businesses,” said Mr. Cuomo.

The plans to be offered on the exchanges all meet certain basic requirements, as laid out in the law, but are in four categories from most generous to least: platinum, gold, silver and bronze. An individual with annual income of $17,000 will pay about $55 a month for a silver plan, state regulators said. A person with a $20,000 income will pay about $85 a month for a silver plan, while someone earning $25,000 will pay about $145 a month for a silver plan.

The least expensive plans, some offered by newcomers to the market, may not offer wide access to hospitals and doctors, experts said.

While the rates will fall over all, apples-to-apples comparisons are impossible from this year to next because all of the plans are essentially new insurance products.

The rates for small businesses, which are considerably lower than for individuals, will not fall as precipitously. But small businesses will be eligible for tax credits, and the exchanges will make it easier for them to select a plan. Roughly 15,000 plans are available today to small businesses, and choosing among them is particularly challenging.

“Where New York previously had a dizzying array of thousands upon thousands of plans, small businesses will now be able to truly comparison-shop for the best prices,” said Benjamin M. Lawsky, the state’s top financial regulator.

Officials at the state Department of Financial Services say they have approved 17 insurers to sell individual coverage through the New York exchange, including eight that are just entering the state’s commercial market. Many of these are insurers specializing inMedicaid plans that cater to low-income individuals.

North Shore-LIJ Health System, the large hospital system on Long Island, intends to offer a health plan for individuals as well as businesses for the first time. Some of the state’s best-known insurers, UnitedHealth Group and WellPoint, are also expected to participate. Insurers may decline to participate after they receive approval for their rates, but this is unlikely.

For years, New York has represented much that can go wrong with insurance markets. The state required insurers to cover everyone regardless of pre-existing conditions, but did not require everyone to purchase insurance — a feature of the new health care law — and did not offer generous subsidies so people could afford coverage.

With no ability to persuade the young and the healthy to buy policies, the state’s premiums have long been among the highest in the nation. “If there was any state that the A.C.A. could bring rates down, it was New York,” said Timothy Jost, a law professor at Washington and Lee University who closely follows the federal law.

Mr. Jost and other policy experts say the new health exchanges appear to be creating sufficient competition, particularly in states that have embraced the exchanges and are trying to create a marketplace that allows consumers to shop easily.

“That’s a very different dynamic for these companies, and it’s prodding them to be more aggressive and competitive in their pricing,” said Sabrina Corlette, a professor at Georgetown University’s Center on Health Insurance Reform.

But some consumers may still find the prices and plans disappointing. Jerry Ball, 46, who owns a recycling business in Queens, said the cost of covering his family increased so rapidly in the last few years that he had to scale back their coverage. Still, he pays nearly $18,000 a year for a high-deductible policy for a family of three.

He said he would be reluctant to part ways with his insurer, Oxford, and was disappointed that even the least expensive Oxford plan being offered next year would cost about as much as he pays now.

With another plan, he said: “Will I be able to maintain my doctors? I’m concerned that some of the better doctors aren’t going to take health insurance.”

He acknowledged that the new law would allow him for the first time to easily switch plans, but it is still hard for him to believe it guarantees coverage for pre-existing conditions. “I have to be careful. I can’t be denied coverage, right?” he asked.

(c) 2013 New York Times


JULY 17, 2013


POSTED BY  / New Yorker 


Politically, these are rocky days for Obamacare. A couple of weeks ago, the Administration announced that it wassuspending for a year the employer mandate that will oblige businesses with fifty or more employees to offer health coverage or pay a fine. Instead of going into effect next January, as was originally planned, the mandate will apply beginning January 1, 2015. In seemingly trying to bury the news by putting it out just before the July 4th holiday, the Administration only made things worse. In Congress, gleeful Republicans seized upon their opponents’ discomfort, calling for theindividual mandate to be postponed as well.

The Administration rejected that idea, and plans are going ahead to get the insurance exchanges at the heart of the health-care reform up and running within six months. It’s a monumental task, in part because many G.O.P.-led states have refused to coöperate, but progress is being made. Following recent announcements in other states, including California and Oregon, confirming that a wide range of insurers have applied to sell individual and family plans through the exchanges, officials in New York are presenting some details of how the new insurance market will work here.

According to a front-page story in the Times on Wednesday, one important piece of news is that the cost of individual plans, which from Staten Island to Buffalo have long been astronomical, will come down substantially on the new exchange. In Manhattan, for example, people who have been paying well over a thousand dollars a month for individual coverage will be presented with a choice of plans that start at less than five hundred dollars a month. Those who make a modest income will be eligible for generous federal subsidies that will bring the cost down much further—perhaps as low as a hundred or two hundred dollars a month.

New Yorkers purchasing family plans will also get a break. For example, Empire Blue Cross currently charges Manhattanites $4,755 a month for a standard family plan. (Yes, that’s close to sixty thousand dollars a year.) On the new exchange, the monthly rate for a comparable plan will be $1,573, a difference of $3,182. Over twelve months, that adds up to more than thirty-eight thousand dollars. Elsewhere in the state, where current rates are a bit (just a bit) cheaper, the savings will be less, but they will still be considerable. And these numbers don’t even account for the new federal subsidies, which reflect a political decision to extend private health-care coverage to millions of Americans who couldn’t otherwise afford it. (I’ve long thought that the subsidies are so large that they may eventually encounter political opposition, but that’s not the issue here.)

How is this possible? The savings outlined in the previous paragraph reflect a chronic failure in the private health-care industry which Obamacare will help to correct. As such, they provide a timely reminder of why radical reform was necessary in the first place.

The first task of any health-care system is to provide readily available coverage for the sick, especially those with chronic conditions, such as heart disease or cancer. As it operates at the moment, the U.S. system doesn’t meet this standard. In many states, particularly in the South, health insurers refuse to sell individual coverage to people with serious illnesses on the perfectly logical grounds that they are likely to need a lot of costly care and attention.

In New York and other progressive states, the authorities require insurers to offer coverage to people with preëxisting conditions, but that has simply forced up the prices of individual plans to extortionate levels. As the cost of premiums rose, many young and healthy folks who didn’t have group plans chose to go without any coverage, at least until they got ill. That further biased the risk pool for individual plans toward sick people, and the insurers responded by raising the price of coverage even further, making it even more difficult to obtain for those who needed it most.

Economists refer to this problem as “adverse selection,” and the individual mandate was designed to address it. By obliging even healthy people to take out insurance, the government can change the nature of the risk pool, which should allow insurers to charge lower premiums. In New York, at least, the initial signs are encouraging. Today, the cost of individual insurance plans is so high that fewer than twenty thousand people buy them. Under the new system, state officials project, the number of people enrolled in individual plans will expand to more than six hundred thousand. In a state with a population of nearly twenty million, that isn’t an enormous number, but it is a significant one.

It’s too early to say how Obamacare will shake out. New York is just one state. In other, less regulated, places, where insurers are currently able to offer cheap plans that provide very limited coverage, the cost of individual plans may well go up—but so will their quality.

And expanding individual coverage is just part of a bigger picture. Without making the employer mandate work effectively, containing the cost of small-business plans and persuading more G.O.P.-run states to expand Medicaid, the whole thing won’t hang together.

Even if Obamacare does get up and running nationwide, there will still be questions about its cost, and about whether it wouldn’t have been cheaper and more effective to cut out the private insurers and adopt the public option.

But don’t let anyone tell you that the current health-care system is working well, or anything close to it. In Manhattan, where the median household income is about sixty-seven thousand dollars, it costs some families upward of fifty thousand dollars a year to purchase health coverage. That’s nuts, and it’s about to change for the better.

 (c) 2013 The New Yorker

Maternity Delivery: US is the COSTLIEST country in the world–by far.

This article, from the New York Times, should give pause to anyone who is having a baby–or has had a baby–in the United States. If this doesn't make the strongest case for health care reform in our country, then I don't know what does.

— Josie


American Way of Birth, Costliest in the World

Photo: Josh Haner/The New York Times

"I feel like I'm in a used-car lot." Renée Martin, who, with her husband, is paying for her maternity care out of pocket.

By  | Published: June 30, 2013

As you read this article, please share your experiences by responding to the questions that will appear. Your responses will inspire future articles in this series.

Elisabeth Rosenthal, reporter


What do you think the total cost of a woman’s pregnancy should be, from prenatal checkups through delivery and newborn care?




LACONIA, N.H. — Seven months pregnant, at a time when most expectant couples are stockpiling diapers and choosing car seats, Renée Martin was struggling with bigger purchases.

At a prenatal class in March, she was told about epiduralanesthesia and was given the option of using a birthing tub during labor. To each offer, she had one gnawing question: “How much is that going to cost?”

Though Ms. Martin, 31, and her husband, Mark Willett, are both professionals with health insurance, her current policy does not cover maternity care. So the couple had to approach the nine months that led to the birth of their daughter in May like an extended shopping trip though the American health care bazaar, sorting through an array of maternity services that most often have no clear price and — with no insurer to haggle on their behalf — trying to negotiate discounts from hospitals and doctors.

When she became pregnant, Ms. Martin called her local hospital inquiring about the price of maternity care; the finance office at first said it did not know, and then gave her a range of $4,000 to $45,000. “It was unreal,” Ms. Martin said. “I was like, How could you not know this? You’re a hospital.”

Midway through her pregnancy, she fought for a deep discount on a $935 bill for an ultrasound, arguing that she had already paid a radiologist $256 to read the scan, which took only 20 minutes of a technician’s time using a machine that had been bought years ago. She ended up paying $655. “I feel like I’m in a used-car lot,” said Ms. Martin, a former art gallery manager who is starting graduate school in the fall.


Like Ms. Martin, plenty of other pregnant women are getting sticker shock in the United States, where charges for delivery have about tripled since 1996, according to an analysis done for The New York Times by Truven Health Analytics. Childbirth in the United States is uniquely expensive, and maternity and newborn care constitute the single biggest category of hospital payouts for most commercial insurers and state Medicaid programs. The cumulative costs of approximately four million annual births is well over $50 billion.

And though maternity care costs far less in other developed countries than it does in the United States, studies show that their citizens do not have less access to care or to high-tech care during pregnancy than Americans.

“It’s not primarily that we get a different bundle of services when we have a baby,” said Gerard Anderson, an economist at the Johns Hopkins School of Public Health who studies international health costs. “It’s that we pay individually for each service and pay more for the services we receive.”

Those payment incentives for providers also mean that American women with normal pregnancies tend to get more of everything, necessary or not, from blood tests to ultrasound scans, said Katy Kozhimannil, a professor at the University of Minnesota School of Public Health who studies the cost of women’s health care.

Financially, they suffer the consequences. In 2011, 62 percent of women in the United States covered by private plans that were not obtained through an employer lacked maternity coverage, like Ms. Martin. But even many women with coverage are feeling the pinch as insurers demand higher co-payments and deductibles and exclude many pregnancy-related services.

From 2004 to 2010, the prices that insurers paid for childbirth — one of the most universal medical encounters — rose 49 percent for vaginal births and 41 percent for Caesarean sections in the United States, with average out-of-pocket costs rising fourfold,according to a recent report by Truven that was commissioned by three health care groups. The average total price charged for pregnancy and newborn care was about $30,000 for a vaginal delivery and $50,000 for a C-section, with commercial insurers paying out an average of $18,329 and $27,866, the report found.

Women with insurance pay out of pocket an average of $3,400, according to a survey byChildbirth Connection, one of the groups behind the maternity costs report. Two decades ago, women typically paid nothing other than a small fee if they opted for a private hospital room or television.


What aspects of maternity care or its costs were unexpected for you?

Only in America

In most other developed countries, comprehensive maternity care is free or cheap for all, considered vital to ensuring the health of future generations.

Ireland, for example, guarantees free maternity care at public hospitals, though women can opt for private deliveries for a fee. The average price spent on a normal vaginal delivery tops out at about $4,000 in Switzerland, France and the Netherlands, where charges are limited through a combination of regulation and price setting; mothers pay little of that cost.

The chasm in price is true even though new mothers in France and elsewhere often remain in the hospital for nearly a week to heal and learn to breast-feed, while American women tend to be discharged a day or two after birth, since insurers do not pay costs for anything that is not considered medically necessary.



If you gave birth outside the United States, what was your experience with medical testing, procedures and costs?


Only in the United States is pregnancy generally billed item by item, a practice that has spiraled in the past decade, doctors say. No item is too small. Charges that 20 years ago were lumped together and covered under the general hospital fee are now broken out, leading to more bills and inflated costs. There are separate fees for the delivery room, the birthing tub and each night in a semiprivate hospital room, typically thousands of dollars. Even removing the placenta can be coded as a separate charge.

Each new test is a new source of revenue, from the hundreds of dollars billed for the simple blood typing required before each delivery to the $20 or so for the splash of gentian violet used as a disinfectant on the umbilical cord (Walgreens’ price per bottle: $2.59). Obstetricians, who used to do routine tests like ultrasounds in their office as part of their flat fee, now charge for the service or farm out such testing to radiologists, whose rates are far higher.

Add up the bills, and the total is startling. “We’ve created incentives that encourage more expensive care, rather than care that is good for the mother,” said Maureen Corry, the executive director of Childbirth Connection.

In almost all other developed countries, hospitals and doctors receive a flat fee for the care of an expectant mother, and while there are guidelines, women have a broad array of choices. “There are no bills, and a hospital doesn’t get paid for doing specific things,” said Charlotte Overgaard, an assistant professor of public health at Aalborg University in Denmark. “If a woman wants acupuncture, an epidural or birth in water, that’s what she’ll get.”

Despite its lavish spending, the United States has one of the highest rates of both infant and maternal death among industrialized nations, although the fact that poor and uninsured women and those whose insurance does not cover childbirth have trouble getting or paying for prenatal care contributes to those figures.

Some social factors drive up the expenses. Mothers are now older than ever before, and therefore more likely to require or request more expensive prenatal testing. And obstetricians face the highest malpractice risks among physicians and pay hundreds of thousands of dollars a year for insurance, fostering a “more is safer” attitude.

But less than 25 percent of America’s high payments for pregnancy typically go to obstetricians, and they often charge a flat fee for their nine months of care, no matter how many visits are needed, said Dr. Robert Palmer, the chairman of the committee for health economics and coding at the American College of Obstetricians and Gynecologists. That fee can range from a high of more than $8,000 for a vaginal delivery in Manhattan to under $4,000 in Denver, according to Fair Health, which collects health care data.

Rather it is the piecemeal way Americans pay for this life event that encourages overtreatment and overspending, said Dr. Kozhimannil, the Minnesota professor. Recent studies have found that more than 30 percent of American women have Caesarean sections or have labor induced with drugs — far higher numbers than those of other developed countries and far above rates that the American College of Obstetricians and Gynecologists considers necessary.

During the course of her relatively uneventful pregnancy, Ms. Martin was charged one by one for lab tests, scans and emergency room visits that were not included in the doctor’s or the hospital’s fee. During her seventh month, she described one week’s experience: “I have high glucose, and I tried to take a three-hour test yesterday and threw up all over the lab. So I’m probably going to get charged for that. And my platelets are low, so I’m going to have to see a hematologist. So I’m going to get charged for that.”

She sighed and put her head in her hands. “Welcome to my world,” she said.

Extras Add Up

Though Ms. Martin has yet to receive her final bills, other couples describe being blindsided by enormous expenses. After discovering that their insurance did not cover pregnancy when the first ultrasound bill was denied last year, Chris Sullivan and his wife, both freelance translators in Pennsylvania, bought a $4,000 pregnancy package from Delaware County Memorial Hospital; a few hospitals around the country are starting to offer such packages to those patients paying themselves.

The couple knew that price did not cover extras like amniocentesis, a test for genetic defects, or an epidural during labor. So when the obstetrician suggested an additional fetal heart scan to check for abnormalities, they were careful to ask about price and got an estimate of $265. Performed by a specialist from the Children’s Hospital of Philadelphia, it took 30 minutes and showed no problems — but generated a bill of $2,775.

“All of a sudden I have a bill that’s as much as I make in a month, and is more than 10 times what I’d been quoted,” Mr. Sullivan said. “I don’t know how I could have been a better consumer, I asked for a quote. Then I get this six-part bill.” After months of disputing the large discrepancy between the estimate and the bill, the hospital honored the estimate.

Christopher Gregory/The New York Times

"Most insurance companies wouldn't blink at my bill, but it was absurd." Dr. Marguerite Duane, who questioned line items on her hospital bill.


Mr. Sullivan noted that the couple ended up paying $750 for an epidural, a procedure that has a list price of about $100 in his wife’s native Germany.

Even women with the best insurance can still encounter high prices. After her daughter was born five years ago, Dr. Marguerite Duane, 42, was flabbergasted by the line items on the bills, many for blood tests she said were unnecessary and medicines she never received. She and her husband, Dr. Kenneth Lin, both associate professors of family medicine at Georgetown Medical School, had delivered babies in their early years of practice.

So when she became pregnant again in 2011, she decided to be more assertive about holding down costs. After a routine ultrasound scan at 20 weeks showed a healthy baby, she refused to go back for weekly follow-up scans that the radiologist suggested during the last months of her pregnancy even though medical guidelines do not recommend them. When in the hospital for the delivery of her son Ellis in February, she kept a list of every medicine and every item she received.

Though she delivered Ellis with a midwife 12 minutes after arriving at the hospital and was home the next day, the hospital bill alone was more than $6,000, and her insurance co-payment was about $1,500. Her first two pregnancies, both more than five years ago, were fully covered by federal government insurance because her husband worked for the Agency for Health Care Research and Quality.

“Most insurance companies wouldn’t blink at my bill, but it was absurd — it was the least medical delivery in history,” said Dr. Duane, who is taking a break from practice to stay home with her children. “There were no meds. I had no anesthesia. He was never in the nursery. I even brought my own heating pad. I tried to get an explanation, but there were items like ‘maternity supplies.’ What was that? A diaper?”

Ms. Martin is similarly well positioned to be an expert consumer of health care. She administered the health plan for a large art gallery she managed in Los Angeles before marrying and moving to Vermont in 2011 to enroll in a year of pre-med classes at the University of Vermont. She has a scholarship this fall for a master’s degree program at Vanderbilt University’s Center for Medicine, Health and Society, and then she plans to go on to medical school. Her father-in-law is a pediatrician.


Video by Dave Horn; Photography by Cheryl Senter for the New York Times

Statement after delivery without any discounts; not an official bill:
Hospital charges
Bills for prenatal care:
Emergency visit
Genetic testing


She and her husband, who works for a small music licensing company that does not provide insurance, hoped to start their family during the year they were covered by university insurance in Vermont, she said, but “nature didn’t cooperate.”

Then they moved to the New Hampshire summer resort of Laconia, her husband’s hometown, for a year before she started the grind of medical training. But in New Hampshire, they discovered, health insurance they could buy on the individual market did not cover maternity care without the purchase of an additional “pregnancy rider” for $800 a month. With their limited finances and unsuccessful efforts at conceiving, it seemed an unwise, if not impossible, investment.

Soon after buying insurance coverage without the rider for $450 a month, Ms. Martin discovered she was pregnant. Her elation was quickly undercut by worry.

“We’re not poor. We pay our bills. We have medical insurance. We’re not looking for a handout,” Ms. Martin said, noting that her husband makes too much money for her to qualify for Medicaid or other subsidized programs for low-income women. “The hospital is doing what it can. Our doctors are taking wonderful care of us. But the economics of this system are a mess.”

Not knowing whether the pregnancy would fall at the $4,000 or $45,000 end of the range the hospital cited, the couple had a hard time budgeting their finances or imagining their future. The hospital promised a 30 percent discount on its final bill. “I’m trying not to be stressed, but it’s really stressful,” Ms. Martin said as her due date approached.


How would you describe the ideal scenario for insurance coverage during pregnancy?

Package Deals

With costs spiraling, some hospitals are starting to offer all-inclusive rates for pregnancy. Maricopa Medical Center, a public hospital in Phoenix, began offering uninsured patients a comprehensive package two years ago. “Making women choose during labor whether you want to pay $1,000 for an epidural, that didn’t seem right,” said Dr. Dean Coonrod, the hospital’s chief of obstetrics and gynecology.

The hospital charges $3,850 for a vaginal delivery, with or without an epidural, and $5,600 for a planned C-section — prices that include standard hospital, doctors’ and testing fees. To set the price, the hospital — which breaks even on maternity care and whose doctors are on salaries — calculated the average payment it gets from all insurers. While Dr. Coonrod said the hospital might lose a bit of money, he saw other benefits in a market where everyone will have insurance in just a few years: mothers tend to feel allegiance to the place they give birth to their babies and might seek other care at Maricopa in the future.

Laura Segall for The New York Times

"Making women choose during labor whether you want to pay $1,000 for an epidural, that didn't seem right." Dr. Dean Coonrod, chief of obstetrics and gynecology at Maricopa Medical Center in Phoenix


The Catalyst for Payment Reform, a California policy group, has proposed that all hospitals should offer such bundled prices and that rates should be the same, no matter the type of delivery. It suggests that $8,000 might be a reasonable starting point. But that may be hard to imagine in markets like New York City, where $8,000 is less than many private doctors charge for their fees alone.

One factor that has helped keep costs down in other developed countries is the extensive use of midwives, who perform the bulk of prenatal examinations and even simple deliveries; obstetricians are regarded as specialists who step in only when there is risk or need. Sixty-eight percent of births are attended by a midwife in Britain and 45 percent in the Netherlands, compared with 8 percent in the United States. In Germany, midwives were paid less than $325 for an 11-hour delivery and about $30 for an office visit in 2011.

Dr. Palmer of the American College of Obstetricians and Gynecologists acknowledged the preference for what he called “medicalized” deliveries in the United States, with IVs, anesthesia and a proliferation of costly ultrasounds. He said the organization was working to define standards for the scans.


To control costs in the United States, patients may also have to alter their expectations, including the presence of an obstetrician at every prenatal visit and delivery. “It’s amazing how much patients buy into our tendency to do a lot of tests,” said Eugene Declercq, a professor at Boston University who studies international variations in pregnancy. “We’ve met the problem, and it’s us.”

Starting next year, insurance policies will be required under the Affordable Care Act to include maternity coverage, so no woman should be left paying entirely on her own, like Ms. Martin. But the law is not explicit about what services must be included in that coverage. “Exactly what that means is the crux of the issue,” Dr. Kozhimannil said.

If the high costs of maternity care are not reined in, it could break the bank for many states, which bear the brunt of Medicaid payouts. Medicaid, the federal-state government health insurance program for the poor, pays for more than 40 percent of all births nationally, including more than half of those in Louisiana and Texas. But even Medicaid, whose payments are regarded as so low that many doctors refuse to take patients covered under the program, paid an average of $9,131 for vaginal births and $13,590 for Caesarean deliveries in 2011.

Insured women are still getting the recommended prenatal care, despite rising out-of-pocket costs, according to a recent study. But that does not mean they are not feeling the strain, said Dr. Kozhimannil, the study’s lead author. The average amount of savings among pregnant women in the study was $3,000 to $5,000. “People will find ways to scrape by for medical care for their new baby, but are young mothers taking care of themselves? And what happens when they need to start buying diapers?” she asked. “Something’s got to give.”

Ms. Martin, who busied herself making toys as her due date neared, could not stop fretting about the potential cost of a complicated delivery. “I know that a C-section could ruin us financially,” she said.

On May 25, she had a healthy daughter, Isla Daisy, born by vaginal delivery. Mother and daughter went home two days later.

She and her husband are both overjoyed and tired. And, she said, they are “dreading” the bills, which she estimates will be over $32,000 before negotiations begin. Her labor was induced, which required intense monitoring, and she also had an epidural.

“We’re bracing for it,” she said.

(c) 2013 The New York Times.


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