Different Cultures, Different Rules

A story about an incident in 2006 is suddenly getting a lot of attention on social media. An American woman temporarily working in Iceland “went from feeling a lump in her breast to getting checked out and assured that it was benign in the space of a single day, and for $3.” She posted the story of her experience on Twitter.

This gets many people stirred up, asking: Why can’t we do this in the United States? Some politicians think we can and are promising changes, but the comparisons are not as straightforward as we’d like them to be.

Iceland is a small, island nation in the North Atlantic with a population of about 350,000. For comparison, the city of Minneapolis has a population about 425,000. The entire country is smaller than many American cities. 

But it’s not just a matter of scale. Taking it a step further, that population is very homogenous. About 91% of the residents of Iceland are Icelandic citizens and only 16% are foreign-born. Unlike the US, the population is concentrated. Ninety-nine percent live in urban areas and 60% live very close to the capital. Furthermore, about 72% belonged to the same religion, the state Evangelical Lutheran Church of Iceland.

Back to our comparison example – where Iceland has homogeneity, Minneapolis has diversity. Its population is approximately 64% white from various heritages, 19% African American, 10% Hispanic and 7% various other ethnicities. It is the home of more than 50 denominations and religions.

How important is this homogeneity in the smooth operation of a more socially oriented society? Denmark believes it is vital to maintain the order and necessary shared values. “Beginning at the age of 1, [mostly Muslim immigrant] ‘ghetto children’ must be separated from their ‘ghetto parents’ for 25 hours per week for mandatory instruction in so-called ‘Danish values,’ which includes learning about the language and the traditions of Christmas and Easter, The New York Times reported in July 2018.”

(Again for comparison Denmark is about 35% larger than Maryland in area with about 5% fewer people. These are much smaller countries whose people share a common background and history.)

But there is no free lunch and no $3 health service without a huge subsidy. Here is a simplified comparison to make the point.

After a $5,145 deduction, Icelanders pay 36.94% of income up to about $85,000 and 46.24% on income above that. On top of that is a value added tax (VAT) of 24% on most goods and services, but a few categories are subject to a reduced rate of 11% (e.g. food, hotels, newspapers, books, and utilities).

Everyone in Iceland pays at least at the same level as the highest tax bracket in the US, 36.94% compared to 37%. They don’t “soak the rich;” they take it from everyone. On the other hand, their corporate tax rate is among the lowest.

In Minneapolis a single taxpayer owes no more than 17% on the first $85,000 after a standard deduction of $12,200 and pays about 8% sales tax, but not on food. (Sales tax and VAT are not identical, but the economic burden of VAT falls on the final consumer.)

Using those numbers, a single taxpayer earning only $20,000 in the US pays $780, whereas for the same situation in Iceland the tax bill would be roughly $5,500. When the money is spent, it is taxed again at a rate up to 16% more.

On another point, access to doctors is slightly better. Iceland has a physician ratio of 3.62 doctors per 1000. In the US it’s 2.3 doctors per 1000.

These and many other considerations are ignored by those who want to make simplistic comparisons, comparisons that in reality are light-years away from apples to apples. It would be nice to have all the benefits and not have to make any of the sacrifices, not have to adapt to an entire new set of values and expectations, not have to live within a completely different culture. (The US cannot even agree to have one official language!) But there are no simple answers.

Medicare for All – Part 2

With all the campaign promises about Medicare for all, I took the opportunity about two months ago to explain how Medicare actually works. Politicians give the impression that it’s a totally free health insurance program. Just walk into the doctor’s office or emergency room, tell them your number, get fixed up and leave with no expectation of receiving a bill. 

Real Medicare today is not like that at all. Why would they spend time on TV and in mailings advertising supplemental insurance that “helps pay some of the health care costs that Original Medicare doesn't cover, like: Copayments, Coinsurance, Deductibles”? Those extra costs can only be avoided by paying money up front as a premium for the additional insurance.

From recent news, though, it’s clear that this misimpression is not the only problem. Medicare fraud is another big issue. Sometimes this is a critical thinking issue where patients are lured in as unwitting participants. Sometimes it goes deeper.

Late last month, thirty-five individuals associated with dozens of telemedicine companies and laboratories were charged with fraudulently billing Medicare more than $2.1 billion for expensive cancer genetic tests. Nine of the defendants are medical doctors. “In addition, the Centers for Medicare & Medicaid Services, Center for Program Integrity (CMS/CPI), announced…adverse administrative action against cancer genetic testing companies and medical professionals who submitted more than $1.7 billion in claims to the Medicare program.”

One of the defendants in this case, who cost taxpayers more than $1 billion in illegal Medicare reimbursements, “has been under near-constant federal scrutiny for the past five years and was supposed to have been deported more than a decade ago.” That was billions lost to fraud as a result of only one investigation, due in part to government inaction.

Meanwhile, the U.S. Department of Health and Human Services Office Inspector General has issued an alert to the public about other genetic testing schemes. Medicare eligible patients are offered a free genetic screening for undetected conditions, but the real motive is to get their Medicare information “for identity theft or fraudulent billing purposes.” The screenings are unnecessary and are usually denied by Medicare. When they are, the individual could be responsible for the entire cost of these useless tests, sometimes thousands of dollars. 

They get nothing but the promise of some new information about their health with the selling point that, as Medicare recipients, it may be free to them. This promise of something for nothing – free testing or free devices all paid for by Medicare – is used so often it’s beginning to sound stale, but it must be working.

Advice from the Inspector General is to not volunteer any information to these genetic testers, don’t stop at their booths at health conferences, ignore their ads, and return unopened any testing kits received in the mail.

Medicare fraud is a huge problem. The AARP reported in March of last year “roughly 10 cents of every dollar budgeted for the giant health insurance program is stolen or misdirected before it helps any enrollee. Looked at another way, about $1,000 is lost per Medicare member through theft or waste each year.” That estimate is based on government reports, but a leading expert from Harvard University believes the real number could be much higher, 20% or more.

AARP used the figure of $60 billion in fraud for the 2018 calculations cited above. Other sources show exactly the same estimate for 2015 and 2011. The number hasn’t changed in eight years. Apparently as fast as they can lock people up or put them out of business, more fraudsters spring up to take their place.

Would the general public as a whole be less likely to become victims of Medicare-for-All fraud schemes? That’s doubtful, and it leads to so much waste. 

Shopping for Healthcare

Suppose you walk into a sporting goods store to buy a pair of gloves.  At the checkout the clerk told you that the manager is an expert in outerwear and to ensure every customer is properly attired, you are not allowed to buy gloves without also buying a winter jacket.  You also know that if you walk out without the gloves or the jacket, you will be charged for the time spent serving you.  Outrageous!  How would they expect to stay in business – unless all their competitors acted the same way?

Almost that exact thing happened to me a couple of years ago, except in a doctor’s office.  I had my annual checkup and one aspect of the blood work was slightly elevated, so I was asked to return in six months to retest and monitor the possible problem.  When I returned and sat down to have the blood drawn, two test tubes appeared.  I commented that it was a lot of blood just for one test.  No, I was told, the doctor’s policy was to order a full set of tests each time.  (Can’t buy your gloves without buying a jacket; it’s the rule.)  I explained that I was on a high-deductible insurance plan, that it only pays for one preventive screening per year, and that I did not want to pay out of pocket for the extra, unnecessary tests just to placate the doctor.  While I sat there with my sleeve rolled up, the technician left to get permission to order the single test.

Under a different insurance plan I may have been paying a $20 co-pay either way and would not be concerned how much blood they took or how many tests they ordered.  How are we supposed to be good consumers and try to control the cost of healthcare under this current system?  Under today’s system you walk in without knowing what services you will be getting or what each will cost.  Often the doctors don’t even know or care about the costs.  Even the components of a routine physical vary from one provider to the next.  Weeks after the fact you receive an explanation of benefits from your insurance company telling the cost of each, what they will cover and what you owe.  Many people, too busy to check the accuracy of these, just pay what they are told.  (Mine was a comparatively minor example, but see this article about how preventive care can turn into diagnostic without you even knowing about it and cost you money.)

We can’t be smart consumers of healthcare, when we have so little information about the total costs or the intentions of the providers, and remain a third party to the financial transaction.  I’m not against universal healthcare as a concept, but providing everyone with insurance will do nothing to change the upwardly spiraling cost.  Under the current system it would only increase the number of people who have to deal with the headaches of working through the insurance providers instead of working directly with their healthcare providers.