Luke Messac

Thankfully, Your Money or Your Life was written by a doctor. Dr. Luke Messac is an Emergency Department doctor. He could honestly report he did not know what his hospital charged for his services, since he was on salary. And anyone he asked didn’t know either, so he could never answer patients’ desperate, worried questions about how much it was going to cost to be repaired. Nor could he know how many of his patients his hospital sued, or how it crippled their families and lives in their neverending greed for profit. But Messac knows research. And that’s what this book is about: the facts on non-profit hospitals putting millions of Americans in irreversible debt. For profit.

The simple facts and statistics speak to insanity: “As early as 2013, hospitals and health care providers were the largest group of customers for collection agencies and agencies’ largest source of recoveries in dollar terms,” he found. By 2020, they provided $1.5 billion in revenues to 7000 collection agencies. Over 100 million Americans carry some amount of medical debt. People with zero or negative net worth hold 79% of medical debt obligations in the USA.

Naturally, carrying all that medical debt means the sick do not or cannot seek the treatment they need. People with such debt think they must change doctors, out of humiliation if they aren’t refused service altogether. Hospitals refuse them any additional or followup treatment. Such patients have learned to just live with it and not seek help at all. This is madness.

Hospitals will do anything to collect a few hundred dollars. They will attach customers’ bank accounts. They will put a lien on their homes and foreclose, putting the family on the street. Yale New Haven Hospital had liens on 7.5% of owner-occupied homes in New Haven, CT. It foreclosed on the hospital’s own employees, working for minimum wages from the hospital while needing treatment.

This also includes veterans, who came by their injuries in the service of the nation. Think about that. You get injured serving your country, then are forced into bankruptcy and/or homelessness dealing with those injuries back home. The biggest single block of the homeless is veterans.

Hospitals will go after parents and spouses for medical bills, long after the patient in their supposed care has died. Messac begins the book with the story of an elderly woman who works in the hospital laundry for free to try to pay off the debt run up by her deceased husband. This is debtors’ prison in the USA. And hospitals are proud of this “innovation”, supposedly tying them ever more closely to the local community. Think U.S. airlines are money-grubbing, selfish and cruel? Try U.S. non-profit hospitals.

The invention of high deductible insurance plans, far from being a solution, has led to insureds “more than twice as likely to report health care-related financial burdens.” It is always about more profit for the hospital corporations. But it also costs hospitals more to deal with high deductibles because more customers can’t pay the full amount they must just to get started. There is more paperwork, more legal work, and more harassment to mete out. By 2022, Messac says, 58% of private sector US workers were on high deductible plans. But already by 2017, the average single American with a high deductible plan was responsible for $1,820 in annual deductibles. How is that health insurance?

It gets sicker. Messac says in 2019 the Providence network of 51 hospitals paid McKinsey $45 million to devise a plan to prevent low-income patients from learning about charity care the systems was legally required to provide as a non-profit. Hospitals routinely do not offer help, and make applying for it all but impossible. They demand all kinds of proof for every line on the forms, requiring dozens of pages of backup or the application will be flat out rejected. Yet all they have to do is determine if the patient is on welfare, or food stamps, or Medicaid to know if they would qualify. But that would be too generous for these not for profits (though some are finally doing this today).

The situation has become so perverse that there are other non-profits out there buying up the debt of non-profit hospitals simply in order to cancel it all. It typically costs a few pennies per dollar of debt, but can be as low as half a cent. This means millions of dollars in debt can be cleared for a few tens of thousands of dollars. Then, the patients are contacted and told their debt has been cleared. Mackenzie Scott, ex-wife of Jeff Bezos, has been donating heavily to this cause. Messac points to one of the biggest players: “By 2020, RIP Medical Debt had purchased and forgiven $2.7 billion in medical debt, aiding more than 1.8 million individuals.” This is an intensely stupid way to run a healthcare system. If hospital services are worth one hundredth of what they charge, then they are overcharging by a factor of 100. No wonder medical debt is the most common ingredient in personal bankruptcy in the USA.

I knew in advance I would be aggravated reading this book. But it was much worse than I braced for. As I read, I kept thinking: this is insane. This man is writing about insanity as if it were regular, normal business practice. Hospitals need billions in profits, don’t they? They should avail themselves of every tool in the box to get those billions, right? They should sue their customers by the thousands. They should seize their customers’ bank accounts and sell their houses out from under them to satisfy the bill, even if it is only a few hundred dollars (as most are). After harassing their customers, they should bundle the remaining unpaid bills and sell them off in a package to collection agencies that will torture the hospital’s customers again, without the hospital’s knowledge or approval. Or so they will later claim if someone (like Messac) reports it publicly. And then report every one of them to the national credit agencies to destroy their credit going forward. They should have the ability to refuse service to anyone, particularly the poor.

In the meantime, these same hospitals routinely spend millions marketing themselves on billboards and in mailers and radio and tv commercials touting their close ties to the community, how they are always there to serve and help, and how they are proud of how the community receives them. These same millions could have gone to paying off charity bills, but that would make too much sense. Instead, it appears to outsiders like a giant scam.

All this is acceptable behavior for hospitals in the USA. But this is also insanity. As I must, I kept reading anyway. Nothing Messac says ever convinced me this whole thing wasn’t totally insane. If you read the book, and it is worthy of it, you must keep that in mind throughout. Or you will become one of them. And think this is normal.

The biggest thing missing from the book is the Catch-22 for patients. Because not only do they get trapped in debt from unplanned Emergency Department visits, but even if they had a planned treatment, they could not know what the final bill would be. Because in the USA the government does not set or even monitor rates. Estimates are not required, and if they were, not adhered to. Hospitals can charge what they want, when it suits them. They can charge two different people different amounts for the same treatment on the same day. The billing department decides, with no reference to anyone else. They routinely charge the poorest the highest rates for everything. They will charge outrageous amounts for every tissue and Q-tip they use, and no one can predict that price in advance. If you call to find out what the cost will be, you will hang up totally unsatisfied with the non-answer.

Some hospitals now list some procedures and their approximate cost, hidden in their websites. But no one can rely on those figures to be accurate or applied to their own case. In other words it is not possible in the USA to comparison shop among hospitals when customers know they will need a procedure done. This is just more insanity that Americans are required to consider moral, acceptable and accepted business practice.

The US federal government spends some $1.5 trillion on healthcare, but it does not set standards, monitor prices or make requirements of hospitals it gives money to, to treat those who can’t afford it, except to maintain non-profit status before the IRS. Instead, non-profits pay their CEOs tens of millions a year, build extravagant palaces with 20 foot ceilings like railway stations, grand pianos to soothe those with good insurance and advance appointments, and turn away the poor as their first instinct. This is institutionalized insanity.

I fully understand hospitals are a fat target for a book. I understand only about a third of Americans think their healthcare system is good. But I’m also pretty sure most don’t know how bad it is, and how hospitals work politicians to keep it this way, because they’re making fortunes out of people’s health issues. That’s racketeering – a RICO offense. That’s why Your Money or Your Life is worth reading.

David Wineberg… (altro)