What do Americans do if they have no healthcare?

[summeriscomingsoon]

Seeing posts on Reddit about the costs of routine medical visits and the astronomical breakdown of figures charged, but I'm assuming these are all covered by health insurance.

But what if you have no insurance. What happens if you get cancer etc. Are you left to die?

[quote mathanxiety]@Acovic
I'm in the US and had a fainting episode in January. I was taken to the local ER by ambulance as I had a gash on my chin. They did a CT scan to check for signs of stroke or other bleeding in my brain, fractured skull, etc - and discovered I had broken my nose. They also sewed up my chin and administered a saline drip. I was discharged, and felt fine. Went to my doctor for a follow up visit and got a Holter monitor to wear for a month to check for heart abnormalities. I need to get dental work done as I chipped a molar. (All paid for in full by my insurance, including the dental work).

The resistance to investigations is puzzling. I for one would really love to know if I have a heart condition or a carotid problem, or anything else actually, and I am glad to have found out I had broken my nose the day of my accident, not a week later. I can't see what the problem is if other conditions are found in the course of investigations for other problems, especially if those conditions might possibly be treatable if caught early, or need treating because they would cause problems. Waiting until a problem is obvious seems counter intuitive to me, particularly when one reason cited against finding out as much as possible involves life insurance.

IV Acetaminophen for pain management - a news report here:
www.washingtonpost.com/news/wonk/wp/2018/06/19/the-growing-case-against-iv-tylenol-once-seen-as-a-solution-to-the-opioid-crisis/[/quote]
The negative impacts of over-screening (not of screening per se, just of doing it when the clinical evidence does not suggest it's necessary) is, IIRC, largely economic - if we are paying for screening that is not well indicated that's money that's not being spent on something that is more likely to be effective. We see in the US the astronomical cost of health care compared to, well, everywhere else on earth. And that is partly because of inefficiencies like screening when it isn't called for. If people didn't insist on screening when it wasn't warranted, healthcare costs would fall somewhat (obviously not enough, but it's a part of it) and healthcare would be more affordable.

There are also issues with false positives - screening doesn't always produce the correct result. If you get screened a lot when the chances of something being found are small, the number of false positives will be higher than if people are only screened when clinically indicated, but the number of true positives that would not have been found by only screening where clinically indicated will be small. With some conditions, the impact of following up a positive screening result (a biopsy, say) can have some negative impacts. The negative impact of follow up on people who have false positive screening results over a large population can sometimes be worse than the impact of the few true positives that are missed.

There are some other issues with screening where not clinically indicated that have been fairly well researched but I cant recall them off the top of my head. Over all, it's better to follow the science than try the belt and braces approach.

[quote drspouse]@Acovic I'm so glad to hear you say that after my DS' treatment. I hope you agree a catheter for a urine sample in a nappy wearing 2 year old is not just unnecessary but cruel.[/quote]
Actually that’s based on fairly good evidence

One of the issues with over screening is finding a tiny tumour in an elderly person where the tumour would have outlived the person - that's why the breast cancer screening in the UK is age limited.

We see in the US the astronomical cost of health care compared to, well, everywhere else on earth. And that is partly because of inefficiencies like screening when it isn't called for.

Screening is recommended because population level statistics indicate it should be done. Hence pap smears, mammograms, colonoscopies at certain ages. Hence also screening for a broken nose and for bleeding in the brain and fractured skull when a patient presents after falling flat on her face on a tiled floor. Also heart monitoring. Yes, dehydration might have caused my fainting episode. But so also could a few other conditions, and some of them are serious.

It's the pricing model that is the problem. Screening itself is an excellent idea because it often identifies issues before they are medical problems requiring intensive and expensive treatment that is possibly going to be too late to be effective. Curing people before they become gravely ill is preferable to throwing the kitchen sink at an illness and still failing to prevent death. In stark terms, curing a patient is the only way not to waste money.

There are also issues with false positives - screening doesn't always produce the correct result. If you get screened a lot when the chances of something being found are small, the number of false positives will be higher than if people are only screened when clinically indicated, but the number of true positives that would not have been found by only screening where clinically indicated will be small. With some conditions, the impact of following up a positive screening result (a biopsy, say) can have some negative impacts. The negative impact of follow up on people who have false positive screening results over a large population can sometimes be worse than the impact of the few true positives that are missed.

You are talking about a tiny proportion of results, many of which can simply be retested, without a biopsy if there is any question about reliability. 'Some negative impacts' of a biopsy are not serious enough or widespread enough to warrant dropping, for instance, colonoscopies or pap smears or mammograms, from the list of highly recommended tests at certain points of one's life.

It seems to me that you are saying that for the sake of avoiding a tiny, tiny number of false positives and a tiny fraction of negative experiences in confirmation investigations, screening in general should be ditched.

You are allowing pricing issues to set aside the interests of science.

I also don’t understand the issues with screening. In fact, that’s the way some countries health systems work to save money on the basis of they catch things before they become problems then it’s a lot of $$ saved. The Japanese model is a great example of this and while it does seem odd to us (more like servicing a car that has not broken down rather than the mechanic fixing the broken car), it works.

There are always going to be rare cases of false positives and when things have gone awry but I’m not sure that’s a reason to ditch something that works well in the main.

Incidental findings were really common in my line of work. Say someone was hit by a car and had head injuries and we did an MRI. It shows a brain tumour that was unrelated to them being hit by the car. It hadn’t caused problems as yet but left it will (as advised by neuro) and is easier to remove at that point. Or bloods done when looking for a cause of current presentation but they indicate an issue in another regard that needs to be flagged to be dealt with in a non-urgent setting. This is all very common. I don’t see any issue with it personally.

@mathanxiety

We see in the US the astronomical cost of health care compared to, well, everywhere else on earth. And that is partly because of inefficiencies like screening when it isn't called for.

Screening is recommended because population level statistics indicate it should be done. Hence pap smears, mammograms, colonoscopies at certain ages. Hence also screening for a broken nose and for bleeding in the brain and fractured skull when a patient presents after falling flat on her face on a tiled floor. Also heart monitoring. Yes, dehydration might have caused my fainting episode. But so also could a few other conditions, and some of them are serious.

It's the pricing model that is the problem. Screening itself is an excellent idea because it often identifies issues before they are medical problems requiring intensive and expensive treatment that is possibly going to be too late to be effective. Curing people before they become gravely ill is preferable to throwing the kitchen sink at an illness and still failing to prevent death. In stark terms, curing a patient is the only way not to waste money.

There are also issues with false positives - screening doesn't always produce the correct result. If you get screened a lot when the chances of something being found are small, the number of false positives will be higher than if people are only screened when clinically indicated, but the number of true positives that would not have been found by only screening where clinically indicated will be small. With some conditions, the impact of following up a positive screening result (a biopsy, say) can have some negative impacts. The negative impact of follow up on people who have false positive screening results over a large population can sometimes be worse than the impact of the few true positives that are missed.

You are talking about a tiny proportion of results, many of which can simply be retested, without a biopsy if there is any question about reliability. 'Some negative impacts' of a biopsy are not serious enough or widespread enough to warrant dropping, for instance, colonoscopies or pap smears or mammograms, from the list of highly recommended tests at certain points of one's life.

It seems to me that you are saying that for the sake of avoiding a tiny, tiny number of false positives and a tiny fraction of negative experiences in confirmation investigations, screening in general should be ditched.

You are allowing pricing issues to set aside the interests of science.

No, not all screening is good, including at the population level. As mentioned, screening carries the risk of false positives (i.e. unecessary interventions and stress) and false negatives (i.e. a false sense of security). The extent of the false positives and false negatives depends on the test, the prevalence of the condition in the population being tested (the rarer it is , the more likely you are to have false positives for example) and the implications will depend on what is being tested for and the interventions which might result.

It is not somethign which is tiny and rare, it can be significant - especially at the population level. For example, mammograms in younger women lead to much higher false positive results - partly due to breast tissue in pre-menopausal women and partly due to the lower prevalence of cancer in younger women. That's why it's not recommended to do mammograms in younger women. The question is what is the optimal age? If you are taking a population level approach, you'll probably set that age higher than the individualistic approach as in the US

Having had two trips to A&E with both of my sons in the last 2 weeks (both have a broken wrist) I have spent some time each trip explaining to them the bill we would have got for the multiple xrays, casts, spleen ultrasounds, consultations from orthopedic specialists, wound experts, drugs, suturing, antibiotics etc etc etc had we lived in the US.

Frightening.

I mean, if the premise is that all screening is good and since anyone with breasts is at risk of breast cancer, why don't we start screening women for breast cancer at 20?

I mean, if the premise is that all screening is good and since anyone with breasts is at risk of breast cancer, why don't we start screening women for breast cancer at 20?

Because the cost of screening would not be beneficial given the likely incidence in 20yo’s. It’s a risk/benefit involving ‘return on investment’ so yo speak. Again, think of it as a car service. A 6mo car will not proactively require hoses replaced before they burst but a 5yo car may. So for the 5yo car you need to decide, should there be a recommendation to replace that hose at the 5yr service or would it be better to have mail be 20% of people with a broken down car on the road as the hose has burst and you can’t drive it. The answer depends on a lot of factors including cost of the hose and labour to replace vs inconvenience if breaking down (can mobile quickly do it there and then and you are in your way versus a tow job) etc. Same principles and there is no general rule, each case must be looked at independently on its factors.

@HoppingPavlova

I mean, if the premise is that all screening is good and since anyone with breasts is at risk of breast cancer, why don't we start screening women for breast cancer at 20?

Because the cost of screening would not be beneficial given the likely incidence in 20yo’s. It’s a risk/benefit involving ‘return on investment’ so yo speak. Again, think of it as a car service. A 6mo car will not proactively require hoses replaced before they burst but a 5yo car may. So for the 5yo car you need to decide, should there be a recommendation to replace that hose at the 5yr service or would it be better to have mail be 20% of people with a broken down car on the road as the hose has burst and you can’t drive it. The answer depends on a lot of factors including cost of the hose and labour to replace vs inconvenience if breaking down (can mobile quickly do it there and then and you are in your way versus a tow job) etc. Same principles and there is no general rule, each case must be looked at independently on its factors.

Yes, exactly my point. Not all screening is good and a lot of it can be unecessary Another example is prostate cancer screening. The US screens for it, UK doesn't. There are A LOT of false positives leading to biopsies. Also there is an issue of overdiagnosis and treatment because many men will have prostate cancer but not die from it but interventions to treat it can have serious consequences like incontinence.

@mathanxiety

We see in the US the astronomical cost of health care compared to, well, everywhere else on earth. And that is partly because of inefficiencies like screening when it isn't called for.

Screening is recommended because population level statistics indicate it should be done. Hence pap smears, mammograms, colonoscopies at certain ages. Hence also screening for a broken nose and for bleeding in the brain and fractured skull when a patient presents after falling flat on her face on a tiled floor. Also heart monitoring. Yes, dehydration might have caused my fainting episode. But so also could a few other conditions, and some of them are serious.

It's the pricing model that is the problem. Screening itself is an excellent idea because it often identifies issues before they are medical problems requiring intensive and expensive treatment that is possibly going to be too late to be effective. Curing people before they become gravely ill is preferable to throwing the kitchen sink at an illness and still failing to prevent death. In stark terms, curing a patient is the only way not to waste money.

There are also issues with false positives - screening doesn't always produce the correct result. If you get screened a lot when the chances of something being found are small, the number of false positives will be higher than if people are only screened when clinically indicated, but the number of true positives that would not have been found by only screening where clinically indicated will be small. With some conditions, the impact of following up a positive screening result (a biopsy, say) can have some negative impacts. The negative impact of follow up on people who have false positive screening results over a large population can sometimes be worse than the impact of the few true positives that are missed.

You are talking about a tiny proportion of results, many of which can simply be retested, without a biopsy if there is any question about reliability. 'Some negative impacts' of a biopsy are not serious enough or widespread enough to warrant dropping, for instance, colonoscopies or pap smears or mammograms, from the list of highly recommended tests at certain points of one's life.

It seems to me that you are saying that for the sake of avoiding a tiny, tiny number of false positives and a tiny fraction of negative experiences in confirmation investigations, screening in general should be ditched.

You are allowing pricing issues to set aside the interests of science.

It isn’t a matter of letting pricing issues set aside the interests of science. Cost is an integral part of scientific decision making when you don’t have infinite resources.

Pap smears, etc are recommended at a certain age because age is part of the clinical criteria that mean that testing is a good use of resources. Outside those limits (absent other criteria) testing isn’t
worthwhile, not because it will never find a positive case but because it uses up too many resources for too little return.

Another example is prostate cancer screening. The US screens for it, UK doesn't. There are A LOT of false positives leading to biopsies. Also there is an issue of overdiagnosis and treatment because many men will have prostate cancer but not die from it but interventions to treat it can have serious consequences like incontinence.

I’m not in the UK (but worked in NHS for many years) or the US but our system has prostrate cancer screening. Just because it’s positive doesn’t mean treatment, there are many factors taken into account and a great proportion are not treated for the reasons you note. Diagnosis doesn’t necessarily translate to treatment. It’s not as black and white as you think. Even so, in the case of prostrate cancer screening we have determined a pivot point where screening all at a certain age (voluntarily obviously but it’s an item the Govnt funds) is still more beneficial for early treatment for those where it’s deemed appropriate vs later more costly treatment if required.

@Iamblossom

Having had two trips to A&E with both of my sons in the last 2 weeks (both have a broken wrist) I have spent some time each trip explaining to them the bill we would have got for the multiple xrays, casts, spleen ultrasounds, consultations from orthopedic specialists, wound experts, drugs, suturing, antibiotics etc etc etc had we lived in the US.

Frightening.

For their balance, did you explain the French, German, Spanish, Canadian or Australian health systems?

@HoppingPavlova

Another example is prostate cancer screening. The US screens for it, UK doesn't. There are A LOT of false positives leading to biopsies. Also there is an issue of overdiagnosis and treatment because many men will have prostate cancer but not die from it but interventions to treat it can have serious consequences like incontinence.

I’m not in the UK (but worked in NHS for many years) or the US but our system has prostrate cancer screening. Just because it’s positive doesn’t mean treatment, there are many factors taken into account and a great proportion are not treated for the reasons you note. Diagnosis doesn’t necessarily translate to treatment. It’s not as black and white as you think. Even so, in the case of prostrate cancer screening we have determined a pivot point where screening all at a certain age (voluntarily obviously but it’s an item the Govnt funds) is still more beneficial for early treatment for those where it’s deemed appropriate vs later more costly treatment if required.

I don't think it's black or white at all, that was exactly the point I'm making. But to choose NOT to have a screening programme isn't always just to save money but makes sense at the population level. And in other programmes or in other countries, certain ages are targeted for those reasons. It's always going to be a balance and depend on what is prioritized. I'm all for screening when it makes sense!