The American healthcare system damages your *thinking* not just the public health

This whole country is a scam

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65% of people on Medicare do not receive dental coverage according to the Kaiser Family Foundation.

As a result “almost half of all Medicare beneficiaries did not have a dental visit within the past year (49%), with higher rates among those who are black (71%) or Hispanic (65%), have low incomes (70%), and are living in rural areas (59%), as of 2016.”

The numbers are bad for everyone else across the board too. In 2016 around 74 million Americans had no dental coverage whatsoever. In 2017 36% of adults aged 18-64 did not go to the dentist in the previous year.

That all seems bad right but don’t worry because the Democrats are here to save the day with a plan to include dental coverage in Medicare (not for the rest of us of course) starting in… seven years.

Jeff Stein @JStein_WaPo

Looks like House Dem bill includes only starting new Medicare dental benefits in 2028 -- way after the White House wants WH wants to send new Medicare dental benefits out to millions of seniors as soon as next year, not at the very end of Biden's potential second term

This is almost the platonic ideal of Some Democrat Shit. These people need help. Our plan is to give it to them well over half a decade from now.

It makes no sense. They don’t even seem to want to reap the immediate political benefits of such a move!!! Old people as you may have heard tend to vote. They can’t even work in their own self interest never mind everyone else’s.

(For what it’s worth as it currently stands the plan is to have hearing and vision coverage expanded under Medicare in the next year or two. Perhaps those fields don’t have powerful enough lobbies to slow things down?)

I covered a lot of these gaps in dental coverage for seniors and Americans in general a couple years ago in this piece in which readers shared some of their dental nightmare stories which you should read if you haven’t.

luke @lukeoneil47

I asked people to share their dental care nightmares. Whether it was putting off treatment for years because of the cost, having to pay many thousands even with insurance, or the shame and fear that comes with poor dental hygiene. Here's what they said.

luke.substack.comI was rigid in the chair crying from both fear and shameIt was so bad I would sit on a cold winter basement floor in pain swigging whiskey to dull the pain like I was a cowboy

Sharing that story again yesterday on Twitter prompted a discussion about how fucking fake dental insurance is in this cursed country.

“I have what is supposedly the ‘best dental insurance’ and I have to get a crown replaced. It will cost me $1200, which of course will not count toward my medical out of pocket maximum for the year since teeth are not part of medical insurance!” one person said.

“I just had $500 worth of dental work done and because I had dental insurance I only owe $485 of it,” added another.

And a few more:

“It’s awesome going to the dentist and having them explain to you how basic treatments like teeth cleaning aren’t covered by your insurance and you’re going to have to pay $600 dollars to get it done.”

“[I’ve had] approximately $50,000 on dental work/surgeries in the past 10 years. Insurance covered maybe $4,000. It’s a large contributing factor why I am poor with no savings.”

“I have fancy employee dental insurance, but still have to pay a bunch for crowns and root canals with the added bonus of being really limited in dentists who accept the insurance. Instead of paying $1,000 for a crown I pay $300. So I’m basically paying $30 a month for a discount card.”

It then progressed from there to stories of people travelling abroad for dental work or being surprised while living in or visiting other countries at how cheap it was there.

“I had such culture shock as an American living in Taiwan when my emergency root canal (3 visits + surgery + medication + 3D x-rays emailed to me the next day) cost $20 US total,” one person said. “I wish I had never had to move back to the US (where I worked as a hospital admin.)”

That got me thinking about how much cheaper receiving any type of medical care is in other countries. (And to be clear elsewhere dental care also counts as medical care not its own separate thing like it is here for some insane reason. Teeth as we all know are considered “luxury bones” in America).

So I asked people to tell me stories about getting hurt or getting sick abroad and how much it cost. You will probably not be surprised to hear the way we do things in the U.S. is absolutely fucked by comparison. Read what they told me down below.

If you’re not a paid subscriber to Hell World you will have missed a couple of “good ones” in the last week or two. In this one David Anthony wrote on what it was like growing up in a funeral home and how it changed the way he thinks about how we process death in America.

In my dad’s minivan there was a cot with a gray cloth cover that was always there, just in case, while we were out, we had to stop and pick up a body, either from the local morgue or on a house call. Once after a Little League game my dad gave another kid a ride home and he absolutely freaked out that a dead body had once been reclining on the cot in our van. I remember not being able to understand why this was such an alien concept to him. While I can appreciate that not every eight-year-old has watched people be embalmed on a regular basis, the fact that death was so abjectly terrifying even in this most tangential context has always stuck with me. 

After that I reflected on the r/HermanCainAward the Reddit group in which people share screenshots of Covid- and vaccine-denying people succumbing to the virus that has a lot of people feeling conflicted about whether or not it’s ok to look on with something like glee or schadenfreude.

I don’t want anyone to die but if they are determined to do so what the fuck can I do about it? It all reminds me very much of substance abuse. You can give all the grace and guidance in the world to a friend who is suffering but they won’t hear it until they want to change themselves.

A weird thing about a lot of these people though is that even at what you might think is rock bottom for them — the death of a parent or spouse or child from a virus they were cavalier about contracting — it doesn’t even seem to be their actual bottom. (There have been over 100,000 Covid orphans created in the U.S. alone placing us at number four in the world by the way). It’s like an alcoholic who crashes their car off the side of the road and instead of taking stock of their life blames the road crew who they say painted the yellow lines incorrectly. Not only that but they think the mayor and the governor were in on the scheme too. After the crash they’re even more determined to drive recklessly to teach everyone a lesson.

As a reminder subscribers also get access to the Discontents collective Discord. Let me know if you want to learn how to sign up for that it’s a lot of fun.

Ok here are a bunch of stories about getting medical treatment in other countries. Enjoy (?)

• I lived in South Korea and once had a doctor's appointment that ran me $4, which ended up with a $4 prescription for a run of antibiotics. Some of my Korean friends apologized for it being so expensive because I was a foreigner. It was an ear infection because I’m the idiot that uses Q-tips to clean out his ears. The doctor at the ER, in very solid English, told me: “If you try to clean out your ears with a chopstick again don’t go so deep or don’t come back.”

• When my spouse and I were in Peru they got a sinus infection and walked into a pharmacy where the pharmacist diagnosed them and gave them antibiotics no problem. It was the first time I was like...oh wow this doesn't have to involve a billion phone calls because every in-network doctor (though I don't think I even had insurance at that point) is booked for months out. I can't remember how much it cost but it can't have been more than I'd spend for Tylenol here.

• A Japanese friend was diagnosed with cancer. The best cancer hospital in California told her to go back to Japan for treatment because it would bankrupt her here. Complete treatment was $0, out of pocket, and $250 USD for ‘cosmetic’ breast implants. I believe her insurance even offset her flights. She literally flew to/from the U.S. to Japan for her treatments and surgery, stayed with family (or hospital) while there and spent less than it would cost for one day in a U.S. hospital.

• This was over a decade ago, but I was mountain biking in Cape Town South Africa a few years after college and flipped over my handlebars, gashed my chin, got taken to the ER at a private hospital, and needed stitches. I was freaking out about how many thousands of dollars I was going to owe and was charged $125 total. Stitch removal was free. I was absolutely shocked.

• I went to Husavík, Iceland for vacation and got a bad upper respiratory infection that settled in my ear, making me dizzy and nauseous. Vomiting, the whole deal. It didn’t even occur to us we could go to a doctor because, you know, it wasn’t an emergency (The American healthcare system damages your *thinking,* not just the public health). The guy running our guesthouse had to tell us we could go to a clinic.

  So we go. They *apologize* to us(!) because they have to charge us (about $25) to see a doctor.  We were in and out in 30 minutes, prescriptions in hand. Total cost for antibiotics and Tylenol with codeine: $20. 

• I’ve lived in Denmark for around 10 years. Last year I was having persistent headaches and I went through the full gamut of treatment: local doc, referral to a specialist and even a CT scan. In the end, it was chalked up to stress. All of this was covered by the system. I paid nothing. It gave me great peace of mind to know there was nothing wrong physically and even though the doctors suspected as much all along, they wanted to be sure. Hard not to think that the costs of not strictly necessary tests would have been a consideration in the US, possibly stopping the process in its tracks, or that I’d have to justify the tests to an insurer, which would have just piled on the stress.

  Also, we had one child in the US and the second in Denmark. Big differences in both service level (better in US) and the payment/insurance aspects (infinitely better in Denmark). Suffice it to say the combo of no paid paternal leave and super complicated insurance led to an ultimatum from my Danish wife: “I’m not having another kid in this country, so if you want another one we’re moving to Denmark.” We did, and when our second was born (by c-section) it was smooth and simple, although we both agreed that the service was better in the US, in terms of the birthing suite, attention from staff, etc. But while the actual short time in the hospital was better there, the long term was much, much better in Denmark: no bills to wrestle with, no insurance companies to argue with, and most importantly, a year of paid leave to split between us. (She had to fight tooth and nail to get her US employer to agree to six months *unpaid* leave after our first was born). Things aren’t perfect here by any means, but the US healthcare system seems broken by comparison.

•  I am flying next week to Costa Rica for dental work. In America it’s $6,600 for one tooth. And this is with “great dental insurance” as stated by my normal dentists. In Costa Rica it’s $2,200 for two teeth. With no insurance. It’s an utterly broken system.

• I’m in Japan. I’m on the national health insurance. Dental included. In America I avoided the dentist. Here I get a cleaning every 4 months for $20. I needed a root canal in February. The dentist did the procedure and checked on it weekly for a month before capping. $80. I put off the root canal for an extra week out of basic fear of physical pain but also because I generally didn’t trust dentists back home. I remember the dentist in America telling me to get my wisdom teeth out every visit even though they came in clean and caused no pain. It would have been $1,000.

• The first time I went to a doctor here in Australia was after I was in a minor car accident but hit my head a bit. I went to work anyway. They made me go to the doctor which I resisted and then it was just... free. They gave me a certificate for the day off with a minor concussion, told me take Advil.

  I went to the reception on the way out to pay and they, slightly bemused, had to explain that because I had Medicare nothing cost anything today. I'd lived in Australia for a bit over a year. I knew about Medicare, even as a visa holder I was entitled to it, etc, knew it took care of medical, etc. I moved here in 2008 so before the ACA. I went through hospitals in America a couple of times, those bills, ambulance bills...

• When I needed an emergency root canal in Finland in 2010 — my face was alarmingly swollen — I was able to get a same-day emergency appointment at the municipal health center on a Sunday. The procedure cost me €50 plus whatever it was for the antibiotics. After that, I went to a regular dental clinic (still in Finland) for follow-up care, and over the course of three months got all my teeth fixed, uninsured, for about a third of what it would have cost in the US at the time.

• Both of my kids both broke their left arms in random sports accidents this summer. They both got two months of weekly treatment at a local orthopaedic hospital. How much would that cost in the States?! Here in rural Japan it cost us nothing. I’m not even kidding. Normally health insurance in Japan covers 70% (of the very low) cost of medical care, but due to the low birth rate, small towns in the countryside have incentives like free healthcare for children. It blows my mind.

• I had a motorbike accident in Thailand in 2012. I had a pretty bad scrape on my ankle. A hospital visit and five different prescriptions altogether totaled less than $10.

• I lived and worked in Japan for 3 years. Everyone there gets enrolled in their national health service that, at worse, covers 75% of all medical and dental bills. If you've got a job, it just comes from your check automatically but I didn't even notice as I was making more money there than I had ever made in the U.S. I needed to get a wisdom tooth removed that was becoming troublesome and knew I should definitely get it done there before returning to the states but I didn't anticipate just how staggering the price difference would be. When I went to get it looked at, my dentist did a thorough cleaning and also noticed a couple cavities he wanted to clear out and fill. He booked me for a series of visits only expected to last about 45 minutes each to do each cavity and the wisdom tooth pull individually (this is normally how dental work is done in Japan I believe).

  When I went out to pay, I had no idea what to expect and was shocked to hear the visit was about 600 yen. That's about $5. I thought surely the next visit when I get a filling will be the real cost. $8. And each visit after that was the same, never more than $8 to get great dental work done. After it was all said and done, two cavities cleared and filled and a wisdom tooth procedure cost me a total of about $40. FORTY DOLLARS. And my dentist also loaned me some CDs he thought I would like based on all the friendly conversations we had at the visits. I'm still to this day floored by this, it's unbelievable. This was in 2018!

• I was in Vienna in the spring and got very bad food poisoning. After about ten days of shitting blood, I figured it was time to see someone. Austria doesn’t technically have universal health care. Everyone is required to be insured. But my girlfriend (I was visiting her on her Fulbright) scoped out a free clinic for the uninsured and we went there. Before I even saw a doctor my blood was drawn, and 90 minutes later a doctor was going over my complete blood work with me and relaying her consult with the staff gastroenterologist at the hospital about my labs. They sent me home with two vials to do further stool analysis and had me come back the next day, where another doctor went in depth with me about the possibilities and took my samples. Wait times were negligible, and the first time I went was a national holiday and they were short staffed. They were reluctant to fuck with my gut by giving me antibiotics they didn’t know if I needed yet. Three days later they confirmed I had Campylobacter, which doesn’t respond to antibiotics that well anyway. 

  It was $0 for the most thorough and caring and pragmatic health care I’d ever received as an adult. Almost every day I imagine what it would have been like to go to an Urgent Care here in the States instead and get pumped for cash and full of Z-pack and uncertainty from some very justifiably tired and annoyed clinician. 

  I’ve been uninsured before, and was when I got sick in Vienna. Now I am finally insured again, and staring down a scary barrel of only now just starting to get some stuff checked out that I've been putting off for a year or so because how am I going to afford it?

• I got a lung infection on tour in the UK around 2002. The trip to the ER and subsequent prescription cost me 6 quid. Which at the time was like 12 bucks. My asthma meds in the States every month cost me like $180. This was pre Affordable Care Act. Insurance was a nightmare then. 

  What also shocked me was when they asked me at the ER what my address was, I was like, “I’m on tour. I don't have an address.” Then they asked me where I played last night, so they put my address down as Joseph’s Well in Leeds. Then they zipped me off to get a nebulizer treatment and pumped me full of steroids. I grabbed a prescription at a pharmacy. No proof of insurance or NIH card needed. They were like, “We understand. That’ll be 6 pounds” and sent me on my way. The ER was no cost to me.

  I just had to go to the ER last week on a trip to LA because I had an eye infection and they sent me out with a bill for $500 that I have to remit to my insurance or pay in full because I'm from out of state. Garbage system

• I suffered a stress fracture of my hip that an orthopedist in Ft. Lauderdale misdiagnosed as tendonitis. He told me to go ahead on a planned trip to Brazil but just to lay off the running for a while. After a week of walking on a broken hip I was in agony and sought treatment in Salvador de Bahia. There I was informed that the ball of my femur had separated. Surgery to insert two screws to fix the bone led to a week long hospital stay. It cost me about $8,000, which is not nothing, but pales in comparison to the $40,000+ it would have cost in the States. And I ate fresh papaya everyday in the hospital, and when I buzzed for the nurse it took 5 minutes to be attended to, not 45. My surgeon found me a hotel after I was released and came to the hotel room to administer heparin shots. You’d never get that kind of care here.

• I am an American citizen who was living in Chicago, but traveling to London for work. I went out for a run and needed to keep my phone in my hands for navigation. I didn't see a small curb, so my foot didn't hit the ground as I figured it would. I fell forward hard and landed on my hands. With my phone in hand, two of my fingers got caught underneath. Both broken. At the hospital I got an x-ray, 10 minutes with a real doctor, and some good painkillers for only the cost of the painkillers. They didn't even take my information whatsoever. Total cost 6 pounds ($10 USD). 

  I live in the UK now.

• I'm involved in my university's study abroad program. I was in Namibia of all places. A student had a pre-existing problem that he was worried was exacerbated by the 30-hour flight over there. I took him to the fanciest hospital in town,  not the public one, the one run by Catholic nuns. He was there all day and got an MRI and some blood tests. We just walked in and saw a doctor right away. I went to pay, and they said "300 dollars". I was absolutely shocked and asked "Namibian Dollars or American Dollars?" and they looked at me like I was a moron. It was Namibian dollars, of course, which is about $20 USD. I spent more on lunch at their shitty cafe than I did on the dude's MRI and bloodwork.

  Another time I was with students in Iceland, and a student needed something (I forget what). We went to a doctor who said "You have to go see a specialist" and I asked if we needed a referral or anything. He stared at me like I had a tit growing out of my forehead and said "I am referring you to go see the specialist". The specialist was just in a room down the hall. The student ended up needing a prescription, and I forget the details, but it was like ten bucks

  By comparison, three years ago I fractured my foot. An X-ray, a cheap plastic boot, and ten minutes of a doctor looking at it going "yep that a fracture, put on the boot and stay off it" cost me $2,500

  Anyway this whole shit country we have is one big scam.

• I have a fake incisor because of some dumb stuff I did as a child and it broke off when I was in Italy. I scrambled to find a dentist in the little town we were visiting. He didn’t speak any English and I didn’t speak any Italian so we communicated entirely through yes/no questions typed into Google Translate on my phone. When I left, he charged me €200 in cash. The dental work was great (Italy is, like, the second highest rated country by the WHO in dentistry.) No one ever asked medical history. No one even asked for my name. I think the dentist might have taken it as an easy way to make a little extra. Oh, and the dentist’s name? Dr. Mario.

• My first son was born in Seattle, when I was a grad student at UW. My wife was a public high school teacher with decent insurance. But she had no paid maternity leave and instead had to use her accumulated sick leave and vacation days to cover about 40 days of leave. My son was born two weeks early, and my wife was working literally the day her water broke, which happened that evening while we were preparing three pans of lasagnas to eat after he was born. 

  Anyway, we rushed to the hospital, only to be told that she wasn't progressing fast enough, which was about four hours after we got there. So they jacked her full of pitocin (artificial oxytocin) to stimulate contractions. This resulted in her having too strong contractions and my son's head getting stuck in her pelvis. 

  She tried her best to have a natural birth, but after twenty hours of labor, they insisted that she needed a C-section. Normally it takes about ten minutes after the surgery starts to get the baby out, but it took about an hour because he was so stuck. Luckily he made it out (but he has significant behavioral deficits that I've always wondered if they're due to his complicated birth). The recovery was fine. Three days in the hospital and then we were on our way. We got one at home visit from a nurse, and much of that visit was obviously focused on whether we're able to provide a safe and healthy environment for our new baby. By the way, the surgeon told us that my wife should never try to have a natural birth if she should decide to have another child. The cost for everything was about $2,000, not enough to break the bank but a significant expense for a grad student and teacher. 

  Four years later we're in Germany where I got a job as a scientist, and my wife got pregnant with my second son. She has a job as a high school teacher at an international school, and she'd only been there for a few months when she got pregnant. She got to see her OB/GYN about every six weeks at no cost. Nearly every visit, they give her an ultrasound, no cost. Her doctor reassures her that there's nothing wrong with her anatomy and that she can try to have a natural birth.

  At some point at about six months pregnant she is connected to a midwife (they call it a hebamme), who makes in-home visits to check on progress about every other week. At six weeks prior to her due date she is required to stop working to prepare for the delivery, at full pay. In the two weeks before the due date, the hebamme comes to the house almost every other day.  When my wife started having contractions, the hebamme came multiple times that day. She worked with my wife on how much time should be between contractions to determine when we should go to the hospital. At about 8pm, we head to the hospital, and the hebamme and her assistant deliver our second boy in about four hours with no complications whatsoever. We are told that we could stay at the hospital for up to five days if we want, or we could go home since everyone is healthy. We decided to go home. Total time at the hospital was about eight hours, by our choice. 

  Next morning the hebamme shows up to check on us and comes again that evening, then a few more times over the next couple of weeks. My wife gets two month more of maternity leave at full pay, and then ten months leave at 60% pay. 

  Total cost for all that healthcare? Zero euros.