Sunday, August 30, 2009


That was the bill for my wife's hospital stay during and after the delivery of our second child, a daughter, at a major teaching hospital in Washington, DC. It seemed extreme even to us (two family doctors who are used to navigating the byzantine, overpriced health system on behalf of our patients) especially since my daughter was delivered by a nurse midwife, without anesthesia or other drugs, and my wife labored in the hospital for only 2 hours and was discharged after less than 30 hours. Curiously, when we requested an itemized bill, the hospital could only account for $6562.47 of the tab, of which our health insurance (a program for federal employees) ended up paying $4352.32 and we paid $100.

I might use this absolutely true story as an example of the complete lack of transparency and common sense in health care costs, or as a morality tale about greedy hospital executives or cheapskate health insurers. But instead, I'd like to make two other points: 1) You are not the customer. 2) You're subsidizing care for the uninsured already, but in the worst possible way.

What does it mean when I say that you, the patient, are not the customer? For insured people, it means that medical bills are a complex negotiation between insurers and providers of care (hospitals, physicians, outpatient facilities, etc.), where actual costs mean very little to patients. Sure, my wife and I felt our hospital bill (which included mysterious charges such as a separate $163.90 "daily supply charge" on top of the $1115.00 daily room fee and $1074.70 "recovery first 2 hours" when my wife shivered under a cheap blanket, her lunch never arrived, and she ended up lunching on a reheated hamburger I purchased in the hospital cafeteria) was excessive, but what did it matter to us since our insurance was footing all but $100 of the bill? When we, the real consumers of care, are completely disconnected from what that care actually costs, most of us are inevitably tempted to request too much care, which hospitals and physicians are usually happy to provide but which does nothing to improve our health.

The other reality illustrated by our bill is the hospitals, like all medical institutions, already use insurance payments (your money) to subsidize care for the uninsured. When a patient without insurance and no other means to pay comes to the hospital to deliver a baby or in the throes of a heart attack, who pays? You do - in the form of higher insurance premiums that pay for artificially inflated bills.

This is why it makes no sense to advocate for limiting health care to U.S. citizens, or legal immigrants. Illegal immigrants get sick too, and they end up going to U.S. emergency rooms when their health problems become too serious to ignore. The high-risk premature delivery that could have been prevented by routine prenatal care, and the heart attack that could have been prevented by controlling blood pressure and cholesterol levels (which primary care does very well and cheaply, given the opportunity), instead become expensive, catastrophic emergency visits, which are charged to your hospital, and therefore your health insurance, and therefore, you. Immigration policy is an important and divisive issue, but it should be separated from the issue of public health and the health reform debate.