Medical debt vs. universal medical insurance: The interface between SBM and policy


The name of this blog is Science-Based Medicine, because we seek to champion medicine that is predicated on rigorous science because the safest and only medicine. Before the pandemic, much of what we used to write down about was the infiltration of pseudoscientific medicine and medicine based way more on prescientific or religious ideas than science, although a standard thread even for the reason that pandemic stays. These include, but should not limited to, the antivaccine movement, COVID-19 minimization/denial (very like germ theory denial that undergirds a variety of alternative medicine and antivaccine beliefs), resistance to public health measures, and, after all, the promotion of quackery, within the case of the pandemic (amongst many other things) the promotion of medication that were unproven but at the moment are disproven as effective treatments for COVID-19; i.e., ivermectin, hydroxychloroquine, and others.

Nonetheless, there’s more to SBM than rigorous basic and clinical science, a Bayesian approach to evaluating evidence that considers prior plausibility based on basic science, randomized clinical trials, and epidemiology. Probably the most effective science-based treatments will do no good in the event that they should not available to patients who need them, for whatever reason, and that is where, unavoidably, social sciences and politics are available. I’ve long said that we at SBM should not apolitical, although we do strive to be as nonpartisan as individuals could be given their biases. In any case, opposing the licensing of quacks, the continued sale of homeopathic products without the requirement by the FDA that they show safety and efficacy, and agreeing that physicians who spread medical misinformation should face sanctions from state licensing boards (for instance) are removed from apolitical. In some cases they aren’t even nonpartisan, given the way it was outstanding Democrats who championed the National Center for Complementary and Integrative Health (NCCIH) that we’ve long advocated dismantling, and nowadays the the Republican Party that’s promoting resistance to public health measures designed to mitigate the impact of the pandemic. That being said, SBM won’t ever be as effective in ameliorating human suffering if public policy considerations should not taken under consideration and likewise based as much as possible in science. What meaning is that SBM cannot—and I now argue, shouldn’t—avoid social science and politics. After all, as difficult because it is to deconstruct antivaccine misinformation, various alternative medicine pseudoscience, and false claims about COVID-19, I’m well aware that taking a look at SBM at a more macro level through which it interacts with society at large and its political and economic systems adds much more complexity to the combo, but we do need to contemplate these problems—and consider them more.

What got me fascinated about these issues, which I had been intending to bring up, were two news reports about studies. I listened to one in every of these on NPR on the approach to work on Thursday morning, a story about how 100 million people within the US live with medical debt (based on the KFF Health Care Debt Survey) that also featured transient stories about individuals who make up that figure. The second was a series of stories a couple of study that concluded that single payer universal medical insurance (which we within the US still wouldn’t have, “Obamacare” notwithstanding) could potentially have saved a whole lot of hundreds of lives throughout the pandemic. Obviously, the 2 stories are related, since the reason behind a lot medical debt within the US is clearly the shortage of universal medical insurance. Many families who’re uninsured or underinsured face financial catastrophe.

Medical debt: Deferring or foregoing SBM as a result of financial constraints

While on my approach to work last Thursday, I used to be flipping radio stations in my automobile and landed on NPR, only to listen to:

Elizabeth Woodruff drained her retirement account and took on three jobs after she and her husband were sued for nearly $10,000 by the Latest York hospital where his infected leg was amputated.

Ariane Buck, a young father in Arizona who sells medical insurance, couldn’t make an appointment along with his doctor for a dangerous intestinal infection since the office said he had outstanding bills.

Allyson Ward and her husband loaded up bank cards, borrowed from relatives, and delayed repaying student loans after the premature birth of their twins left them with $80,000 in debt. Ward, a nurse practitioner, took on extra nursing shifts, working days and nights.

“I desired to be a mom,” she said. “But we needed to have the cash.”

The three are amongst greater than 100 million people in America ― including 41% of adults ― beset by a health care system that’s systematically pushing patients into debt on a mass scale, an investigation by KHN and NPR shows.

The investigation reveals an issue that, despite recent attention from the White House and Congress, is way more pervasive than previously reported. That’s because much of the debt that patients accrue is hidden as bank card balances, loans from family, or payment plans to hospitals and other medical providers.

Again, SBM can do some truly amazing things and save lives that might have been lost even a few many years ago. Nonetheless, it may possibly’t help if people can’t afford to access it, and it would be much less effective if people suffer such major financial consequences for having accessed it.

The number is actually staggering, provided that the poll found that previously five years, greater than half of US adults report they’ve gone into debt due to medical or dental bills, with 1 / 4 of individuals with health care debt owing greater than $5,000 and about one in five with any amount of debt said they don’t expect ever to have the ability to pay it off. I’m sure that our European and Australian readers will facepalm at these findings, but they track. Because the poll and news story noted, regardless that the Reasonably priced Care Act (ACA) did dramatically reduce the proportion of Americans who’re uninsured, an unlucky problem with it’s that a variety of the medical insurance policies sold within the ACA marketplaces have high deductibles, making it very possible for less affluent people to go deeply into debt regardless that they ostensibly have medical insurance. It’s the deductibles that get them.


Perhaps most perversely, medical debt is obstructing patients from care.

About 1 in 7 individuals with debt said they’ve been denied access to a hospital, doctor, or other provider due to unpaid bills, in response to the poll. A fair greater share ― about two-thirds ― have delay care they or a member of the family need due to cost.

“It’s barbaric,” said Dr. Miriam Atkins, a Georgia oncologist who, like many physicians, said she’s had patients surrender treatment for fear of debt.

This last example strikes near home, given my surgical specialty. I’ll admit that it’s been rare in my practice for a patient to be reluctant to undergo surgery for breast cancer. Nonetheless, what is commonly not appreciated is that surgery is definitely likely the least expensive a part of the multidisciplinary care of this disease. Totalled up, the chemotherapy tends to cost so much more, particularly when newer drugs are used, reminiscent of immune checkpoint inhibitors or the newer HER2-blocking drugs.

Indeed, the story includes the instance of Cheyenne Dantona, who’s now 31 but was diagnosed with a blood cancer while in college:

The cancer went into remission, but when Dantona modified health plans, she was hit with hundreds of dollars of medical bills because one in every of her primary providers was out of network.

She enrolled in a medical bank card, only to get stuck paying much more in interest. Other bills went to collections, dragging down her credit rating. Dantona still dreams of working with injured and orphaned wild animals, but she’s been forced to maneuver back in along with her mother outside Minneapolis.

“She’s been trapped,” said Dantona’s sister, Desiree. “Her life is on pause.”

Desiree Dantona said the debt has also made her sister hesitant to hunt care to make sure her cancer stays in remission.

One other example:

Sherrie Foy, 63, and her husband, Michael, saw their fastidiously planned retirement upended when Foy’s colon needed to be removed.

After Michael retired from Consolidated Edison in Latest York, the couple moved to rural southwestern Virginia. Sherrie had the space to look after rescued horses.

The couple had diligently saved. And so they had retiree medical insurance through Con Edison. But Sherrie’s surgery led to quite a few complications, months within the hospital, and medical bills that passed the $1 million cap on the couple’s health plan.

When Foy couldn’t pay greater than $775,000 she owed the University of Virginia Health System, the medical center sued, a once common practice that the university said it has reined in. The couple declared bankruptcy.

The Foys cashed in a life insurance policy to pay a bankruptcy lawyer and liquidated savings accounts the couple had arrange for his or her grandchildren.

Most oncologists who practice in areas like Detroit (where I practice) have observed this phenomenon firsthand. I daresay that even oncologists who practice in additional affluent areas have also seen it.

One aspect of this problem not included within the story since it shouldn’t be about patients’ debt is the huge infrastructure devoted by insurance firms to prior authorizations. Again, prior authorization is an idea foreign to many other nations and refers back to the requirement by an insurance company that it authorize a proposed treatment before that treatment could be undertaken and reimbursed. Failure to get prior authorization will normally mean that the insurance company won’t pay for it; so providers’ offices and hospitals are very careful to acquire prior authorization to start treatment. Unfortunately, as any physician, NP, or nurse who has to cope with insurance firms’ prior authorization departments, obtaining prior authorizations can quickly descend into truly Orwellian depths of language denying them. The method is so bad that it’s often lampooned in cartoons and videos, for instance, the ever-amusing Dr. Glaucomflecken.

Lest you’re thinking that that the nice doctor is exaggerating, I included a response with a video of an actual prior authorization call:

Given how difficult and bureaucratic all the approach to prior authorizations has change into, hospitals now have significant infrastructure devoted simply to prior authorizations, and small, private practice offices find yourself devoting ridiculous amounts of time that could possibly be dedicated to patient care just attempting to make certain they could be paid for his or her services. I won’t dwell on this any more—nor will I even mention it again on this post—because our inconvenience as physicians coping with insurance company bureaucracy pales in contrast to the suffering of patients who’ve difficulty accessing care or face the specter of going into major debt in the event that they change into ailing. I merely mention it briefly to bolster the purpose that the present medical insurance system within the US is designed to not facilitate SBM care, but to profit, and one approach to profit is to disclaim costlier care at any time when possible. (Thus endeth the whining about this.)

To get an idea of what people surrender due to medical debt, here’s a graph included with the story:

What people forego due to medical debt within the US.

As well as:

However the medical debt on credit reports represents only a fraction of the cash that Americans owe for health care, the KHN-NPR investigation shows.

  • About 50 million adults ― roughly 1 in 5 ― are paying off bills for their very own care or a member of the family’s through an installment plan with a hospital or other provider, the KFF poll found. Such debt arrangements don’t appear on credit reports unless a patient stops paying.
  • One in 10 owe money to a friend or member of the family who covered their medical or dental bills, one other type of borrowing not customarily measured.
  • Still more debt finally ends up on bank cards, as patients charge their bills and run up balances, piling high rates of interest on top of what they owe for care. About 1 in 6 adults are paying off a medical or dental bill they placed on a card.

Not only is the present system apparently designed to slow or deny SBM care, it’s also a medical debt machine. In reality, one thing that I hadn’t appreciated that was reported on this story is how medical debt has change into big business within the US. The story first notes that previously, medical debt on this scale was unheard of due to two reasons. First, previously doctors and hospitals often made informal arrangements for patients to repay medical debts; for instance within the nineteenth century male patients at Latest York’s Bellevue Hospital needed to ferry passengers on the East River and recent moms had to wash floors to pay their debts. Second, and more importantly, physicians often wrote off debts that patients couldn’t afford to pay, as historian Jonathan Engel was quoted saying, “There was no notion of being in medical arrears.”


Worse, efforts to gather often have horrific effects:

Edy Adams, a 31-year-old medical student in Texas, was pursued by debt collectors for years for a medical exam she received after she was sexually assaulted.

Adams had recently graduated from college and was living in Chicago.

Police never found the perpetrator. But two years after the attack, Adams began getting calls from collectors saying she owed $130.58.

Illinois law prohibits billing victims for such tests. But regardless of how again and again Adams explained the error, the calls kept coming, each forcing her, she said, to relive the worst day of her life.

This form of horror is the results of a system that has sprung up that makes medical debt—and collection of that debt—big business. It’s a business that hospitals, including university hospitals and nonprofits, now partake of:

Now, a highly lucrative industry is capitalizing on patients’ inability to pay. Hospitals and other medical providers are pushing tens of millions into bank cards and other loans. These stick patients with high rates of interest while generating profits for the lenders that top 29%, in response to research firm IBISWorld.

Patient debt can also be sustaining a shadowy collections business fed by hospitals ― including public university systems and nonprofits granted tax breaks to serve their communities ― that sell debt in private deals to collections firms that, in turn, pursue patients.

“Persons are getting harassed in any respect hours of the day. Many come to us with no idea where the debt got here from,” said Eric Zell, a supervising attorney on the Legal Aid Society of Cleveland. “It appears to be an epidemic.”

I realize that a few of our readers may be unhappy that I ventured into this territory or perhaps think that it’s an inappropriate subject for SBM. I’m also sure that somebody will likely be unhappy that I didn’t include their favorite issue with our healthcare system as currently constituted (e.g, for-profit big pharma firms distorting clinical trial results and driving up costs). Fair enough, but that shouldn’t be the subject for today. Possibly in the longer term.

Within the meantime, I understand, but now disagree that considering the more “meta” problems with how a political system regulates and provides SBM to its residents is any less of a subject for this blog than discussing why the newest trial for homeopathy is bogus. Over the previous couple of years I’ve increasingly realized that, as improbable as SBM is at alleviating suffering, saving lives, and restoring health, it’s no good if people can’t access it without worrying about being bankrupted or incurring debts that that take years to repay. Furthermore, guess who’s most affected by medical debt? While the story does note that just about half of households making $90,000 or more a 12 months have incurred medical debt within the last five years, it also notes that it’s the poor and disadvantaged who most fall prey to this method and suffer probably the most under it. Quite simply, the strongest predictor of medical debt is the prevalence of illness. Indeed, US counties with the best share of residents with multiple chronic conditions, reminiscent of diabetes and heart disease, are likely to have accrued probably the most medical debt. That makes illness a stronger predictor of medical debt than either poverty or insurance. This method also exacerbates racial disparities in health and medical care as well, with Blacks 50% more likely and Hispanics 35% more likely than whites to owe money for care. My cancer center is home to a superb Population Studies and Disparities Program; so I even have been aware of racial and socioeconomic disparities in cancer outcomes and burden for quite a while, having increasingly appreciated the problem over the 14 years since I accepted my current employment. I now due to this fact argue that understanding disparities in SBM care and methods to eliminate them is an element of SBM.

This brings me to 1 area for change and improvement. Definitely, there are other needed changes to make SBM more available to all, but I’m going to start out with this one.

Medical health insurance and the pandemic

The story that I just discussed includes this quote:

“The No. 1 reason, and the No. 2, 3, and 4 reasons, that individuals go into medical debt is that they don’t have the cash,” said Alan Cohen, a co-founder of insurer Centivo who has worked in health advantages for greater than 30 years. “It’s not complicated.”

Put this fashion, the explanation for the issue may not be complicated, but the answer is. Again, that is where the interface between SBM and society gets messy. Still, let’s look to a PNAS study published per week ago by a bunch led the Center for Infectious Disease Modeling and Evaluation, Yale School of Public Health, and including investigators from the University of Florida, University of Massachusetts, Amherst, and Syracuse University. The study asked the query: What would the effect of universal medical insurance have been on mortality within the US from the pandemic? Its conclusion is that universal medical insurance is pandemic preparedness, and it concludes that ~212K who died of COVID-19 might have been saved in 2020 alone and that, overall, from the pandemic’s starting until mid-March 2022, universal health care could have saved greater than 338K lives from COVID-19 alone. As well as, the study estimates that single payer universal health care would even have saved the US government roughly $106 billion in health care costs related to hospitalizations from COVID-19—plus an estimated $438 billion that could possibly be saved in a nonpandemic 12 months.

The methodology of the study was as follows. The authors calculated elevated mortality attributable to lack of employer-sponsored insurance and to background rates of being uninsured, summing with increased COVID-19 mortality attributable to low insurance coverage. Demographics and age-specific mortality rates as a result of COVID-19 were estimated, in addition to prepandemic mortality, leading the authors to estimate that 338K deaths from COVID-19 alone might have been prevented over the 2 12 months period from March 2020 to March 2022. They then argue that Medicare-For-All could have saved these lives through a mixture of:

  • Improved access to primary care and reduction in comorbidities.
  • Early diagnosis and access to life-saving medical care.
  • Facilitation of COVID-19 preventative measures (e.g., vaccination).
  • Alleviating pressure on hospitals during a pandemic.

There’s a big evidence base supporting the conclusion that health outcomes are likely to be higher with universal health care. Nonetheless, I are likely to agree with this evaluation by Dylan Scott that points out various issues with the study above, not the least of which is its assumption that a single-payer universal health care system is the be-all and end-all of systemic solutions for improving health outcomes, decreasing disparities, and eliminating medical debt. As an illustration, it is rather much true that COVID-19-associated mortality was very high within the US. Now we have 4% of the world’s population, but suffered 16% of the mortality burden as a result of COVID-19. Additionally it is true that COVID-19 mortality was lower in countries with universal medical insurance, in some cases so much lower. Nonetheless, there’s the outlier of the UK, which, despite having single-payer universal health care (in the shape of the National Health Service, or NHS), had a COVID-19 mortality rate almost as bad because the US.


All of those countries do have universal health care, but they don’t all have a single-payer system within the vein of Sanders’s Medicare-for-all proposal. Taiwan does. But Australia utilizes a hybrid program where some people rely on public medical insurance and other people use private plans. The Netherlands and Germany depend on private medical insurance, heavily regulated and subsidized by the federal government. The UK’s National Health Service goes beyond single-payer and is fully socialized: The federal government not only pays for look after everyone but in addition runs hospitals and employs doctors directly.

I’ve often said elsewhere that universal medical insurance doesn’t need to be single-payer to be effective, and that was the major thing that irritated me about this Yale study; it assumed that only Medicare-For-All could be the reply to save lots of all these lives from COVID-19, an assertion that it didn’t back up with evidence, mainly since it didn’t really seriously consider or compare other universal medical insurance systems. (Also, one notes that even Medicare, which was examined on this study, only covers 80% of costs—after the deductible is met—unless one gets a Medigap policy or signs up for a Medicare Advantage plan.) Germany, for example, has one in every of the oldest universal medical insurance systems that dates back to the Eighties and survived the Nazi regime. It’s what’s called a universal multi-payer health care system and encompasses each statutory medical insurance for individuals who earn lower than a certain salary, in addition to private medical insurance for many who earn more and decide to purchase their very own. Furthermore, clearly there have been other aspects besides just universal medical insurance.

As Scott notes:

Other aspects may be in play beyond the particular kind of health care system. As Damien Cave wrote for the Latest York Times in Australia, social trust seems to have been a decisive difference between the American and Australian experiences throughout the pandemic. The 2 nations share a variety of sociocultural DNA, but Aussies have much deeper trust in people normally, and their health care system specifically, than Americans do, Cave wrote. After I was reporting on South Korea’s successful Covid-19 response, Korean sources pointed partially to people there having a generally high level of trust in the federal government.

This also makes some intuitive sense. It follows that individuals in societies with more trust could be more prone to wear masks or stay home or get vaccinated not just for their very own profit but for the health of the people around them and society at large.

This brings us to the ultimate point. SBM alone shouldn’t be enough.

SBM versus values and politics

I’ve lost track of how again and again when, as I discussed potential randomized controlled clinical trials (RCTs), I identified that sometimes the important thing value of SBM, namely doing best science possible to find out if a treatment works (a double-blind, placebo-controlled RCT) shouldn’t be all the time possible since it conflicts with one other value, specifically values of fairness and clinical equipoise as laid down by medical ethics. For instance, I’ve long identified how doing a double-blind placebo-controlled RCT of the childhood vaccination schedule in the shape of a “vaxxed/unvaxxed” study that some antivaxxers have periodically called for to “prove” that vaccines cause autism could be completely unethical since it would go away the control group unprotected against common childhood vaccines. Consequently, we’ve to depend on epidemiological studies to indicate that vaccines should not related to autism.

The identical principle operates on a much larger scale in relation to a rustic’s willingness to institute public policies designed to bring SBM to as many individuals as possible, as Scott points out quite well:

Universal health care is a alternative, a mirrored image of a rustic’s values. When reporting the Everybody Covered series, I discovered this quote from Princeton health care economist Uwe Reinhardt. It was in his most up-to-date book Priced Out, which was published after he died in 2017:

Canada and virtually all European and Asian developed nations have reached, many years ago, a political consensus to treat health care as a social good.

Against this, we in america have never reached a politically dominant consensus on the problem.

While traveling in Taiwan or the Netherlands, people would ask me about US health care and I might need to tell them that tens of millions of Americans were uninsured and that individuals could possibly be charged hundreds of dollars for medical care. That was unfathomable to the people I met. They lived in a rustic where people agreed such things should never be allowed to occur.

America has never made that collective commitment to providing everyone with health care. The country paid the value for that shortsightedness throughout the pandemic, as this recent study helps show. Whatever form it took, a universal health system would have likely prevented tens of hundreds of deaths from the novel coronavirus.

As necessary as demonstrating how harmful medicine based on bad science and pseudoscience has been to patients and to the healthcare system normally, in addition to the way it has degraded standards of evidence in a way that (I argued) facilitated the promotion of, for instance, ivermectin as a miracle treatment for COVID-19, SBM in isolation shouldn’t be enough. The system through which SBM is utilized is an element of SBM, for higher or worse. It will possibly’t be repeated enough that SBM is far less useful if people can’t access it or the fee of accessing it’s prohibitive. I’m due to this fact coming to the conclusion that not only is SBM necessarily political. It should be political, with a view to find ways to vary the dominant values in our political system with a view to find ways to spark change that permits SBM to be accessible to all without ruinous cost. Unfortunately, nowadays we appear to be getting in the improper direction.


Please enter your comment!
Please enter your name here