The crime of being alive

And other healthcare stories.

A friend in Iowa sent me this Gazette story about Andre Rockett, a Davenport man accused of using aliases to obtain medical treatment at University of Iowa hospital. He was charged with first-degree theft, which carries a penalty of up to 10 years in prison.

You probably can guess that I think this story is a disgraceful indictment of American society. It’s disgusting that a person might end up in prison, and all the horror that entails, for obtaining medical treatment. Everything about this is fucked. I could go on and on about the depths of evil here, but I want to talk about it in a little more detail, beyond the obvious moral outrages.

The bills for Rockett’s treatment, over two visits, totaled $108,258, according to the paper. Readers of this newsletter will know that medical bills often bear little to no relation to the actual cost of care. Uninsured people are charged the ‘list price’ for procedures, which are often multiples of what insurance will end up paying for identical treatments; those prices are, in turn, much higher on average than what the government pays. The prices are made up. We know this because different hospitals will charge wildly varying amounts for the same treatment, differences in the tens of thousands of dollars, and also sometimes they just admit it. Hospitals are quick to note that most people don’t pay these list prices; just look at almost any hospital’s posted chargemaster list and you’ll see that sort of disclaimer. A similar thing goes on with drug prices: Insurance plans pay far less than the exorbitant list price, and then the industry defends these high prices by saying “well, no one really pays that,” but that doesn’t stop uninsured patients from being stuck with the fake price. Turns out someone really does pay that.

This is crucial in a case like this, where a man apparently lied about his identity in order to seek care. First, it matters because the ‘value’ of the care he obtained affects what charge he faced; in Iowa, theft of property valued over $10,000 is a first-degree felony. And so the state just accepts a hospital’s out-of-its-ass calculation of the prices of all its procedures, treatments, drugs, and so on, as it does when patients are sued for medical bills—like the Virginia woman whose $164,000 bill for emergency surgery led to the University of Virginia hospital suing her and putting a lien on her house, a bill double what even commercial insurers would pay. According to the Washington Post, that bill “included $2,000 for a $20 feeding tube.”

Chargemaster lists are notoriously impossible to understand, but I downloaded the University of Iowa hospital’s list, and searched for something simple: “ibuprofen.” The listed price for Advil is $186, which would get you about 1,800 Advil at CVS. Generic fluoxetine? That’s $270, please. These are pretty normal charges for hospitals. We don’t know what medical procedures Rockett underwent; it’s certainly likely that a ‘reasonable’ accounting of the treatment he got would still ring in at over $10,000. Still, it’s important to remember how made-up these charges are when they are being used to determine how heavily the state can come down on a person whose crime is trying not to die.

The issue of prices inevitably leads to the question of hospital profits and operating margins. The hospital industry as a whole will routinely cry that hospitals are always on the edge of financial peril, operating on razor-thin margins, and therefore that any sort of healthcare reform that would set reasonable prices is actually extremely dangerous, because this is the only way they can survive. Certainly, hospitals that primarily serve the poor have been closing across the nation at alarming rates, for years. At the start of the Covid-19 pandemic, hospitals and their representatives in Washington warned that many would be at threat because of a lack of elective procedures, which is where they make all their money. The University of Iowa hospital system, for example, said it expected to lose $100 million just through June 2020 due to the pandemic.

But in April this year, UIHC’s CFO reported that the hospital was actually doing much better than most hospitals nationally, with an operating margin of 4.1 percent to a national average of 1.1 percent. They’re determined to go ahead with the building of a $230 million new facility, a plan that was recently rejected by the Iowa Board of Regents as duplicative of existing services and unnecessary. I would think spending $230 million on a new building is not something you do if you’re so strapped for cash that you need to chase an obviously desperate man for $100,000, and get the state involved in sending him to prison for up to 10 years.

Who is harmed when someone uses a false name to illicitly obtain healthcare? Yes, it means the hospital cannot collect the fraction of that $100,000 that they could otherwise expect to obtain from the average uninsured patient. If everyone started lying about who they were to steal healthcare—again, this is such a stupid concept and I cannot believe we have to talk about it—hospitals would experience a bigger-scale version of the existing problem of “uncompensated care,” where they can’t charge anyone for the care of uninsured people who will never pay. Who would pay?

Which is sort of the problem, ultimately: How are we paying for healthcare in this country? If the whole thing can fall apart because someone says their name is John Johnson, you might not really have a healthcare system. America is reasonably unique in making individuals responsible for wildly unaffordable healthcare costs, and this is a very stupid way to do things for innumerable reasons, some of which include: It means sick people are financially punished, and sick people already tend to be poorer; hospitals can’t even collect most of the cost they’re owed from these people precisely because they are too poor to be insured; it means people end up in jail for being sick; it contributes to these wacky prices, higher than anywhere else in the world; and it is evil. Any one of those alone would be enough reason not to do it this way. The fact that it routinely leads to situations where no one pays for the cost of treating someone is just one more.

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So here we are, with America treating Andre Rockett as the criminal, not the hospitals that make up prices. The problem is the man who stole healthcare, not every other point of failure and negligence in the whole rotten system. And I don’t think there’s a better encapsulation of that warped mindset than the fact that the Gazette accompanied this article with Rockett’s mugshot. Not just the mugshot, in fact, but a little graphic featuring his full name too.

Media outlets are just now starting to rethink the awful practice of illustrating articles about crimes with the alleged perpetrator’s mugshot, with many deciding to cease publishing galleries of mugshots. It’s a vile practice that projects criminality onto someone who has almost always not even been convicted of a crime, and that reinforces racial biases. The AP recently changed its policy, saying it would “no longer name suspects or transmit photographs of them in brief stories about minor crimes when there is little chance the organization will cover the case beyond the initial arrest.” The Hartford Courant, in a January editorial, said it would “dramatically [scale] back its use of mug shots on crime stories,” and only use them in “exceptional circumstances,” including if the case gets widespread national attention or “if there is a particular and exceptional reason to believe printing a mugshot is necessary for public safety.”

I emailed the reporter of the Gazette piece—who I’ll note is an intern—to ask about the use of this mugshot, and she provided me with a statement from her editor, Craig Gemoules:

“Use of police mug shots is always a concern and they are not or have never been a major component of our public safety coverage. It is worth noting that The Gazette has never run mugshot slideshow galleries like some others have. Frequently – but not always -- when newspapers say they have stopped using police mug shots this is what they are referring to.

It’s also worth noting that we are one of the few newspapers anywhere that has a process linked from our home page for people to request a public safety-related article be removed from continued online publication.

In many other countries, it wouldn’t even have been possible for him to commit the crime he’s charged with. Instead, he lives in America, where you can end up choosing between dying a preventable death on the street, or going to prison for stealing healthcare and ending up with your mugshot in the paper; where the villain and the thief is the poor man who needs medical treatment, and not the one who asks him to pay for it.

Briefly, some other healthcare news that caught me eye:

  • Congressional Democrats are trying to figure out how to expand Medicaid in the holdout non-expansion states, which would cover an additional 2.2 million people. According to Politico, they’re torn between letting people below the poverty line get free (i.e. subsidized) private plans on the ACA exchange; creating a second, non-Medicaid Medicaid; or a “hybrid” of the two, where the poor could get free plans until the government can make another program for them. It’s just very stupid, and likely to involve billions more in subsidies to the insurance industry, which is apparently the only way we’re allowed to expand healthcare anymore.

  • ProPublica and the Palm Beach Post tracked harmful pollutants released by sugar cane burning in the Florida Glades. The ash causes asthma that sends kids to hospital; in 2015, Palm Beach County had the highest percentage of uninsured kids in South Florida, at 10.5 percent.

  • A good, quick piece for Current Affairs on how the phrase “universal healthcare” became so meaningless in American politics. Along with “healthcare is a right,” these phrases are routinely deployed by Democratic politicians who are adamantly opposed to policies that would actually establish universal healthcare as a right for all.

That’s all for now, since I have to watch England collapse against Italy in the Euro cup final soon. See you next week.