Good news, everyone! The U.S. healthcare system is a little bit less cruel and devious than it was a month ago!

The healthcare “system” of the United States is so deeply, unforgivably fucked up that it’s hard to put into words.


There is so much wrong with the system that even a layman like me could probably write several books on it, and barely scratch the surface. This is the result of running healthcare – or any other necessity for survival – for profit. There’s always going to be a fairly constant demand relative to the population, and people will do or pay everything they can to keep living. I’ll add that it’s even more fucked up when you consider that the corporate interests responsible for the massive amounts of pollution to which we’re exposed on a daily basis are also spending lots of money to keep people in power who will fight tooth and nail against the efforts to bring universal healthcare to the United States.

Until healthcare is treated as a right that can’t be used to extort money from people, the U.S. is going to keep having a system that profits off of death and misery.

That said, I’m a firm believer in the notion that the best way to get the people to empower themselves and bring about real democracy, is to do what we can to ensure their basic needs are met to the greatest degree possible, and to give them as much control over their limited time as possible. As the pandemic showed us, when people get a taste of what life could be like, they’re reluctant to go back to something worse. That means that while I think we absolutely should have universal healthcare that’s free at the point of service, I was glad to hear about the “No Surprises Act”, which goes a long way (though not all the way, as we’ll see) towards fixing one small part of what’s wrong with healthcare in the U.S.

For those unfamiliar with the complex array of bureaucracy and blood sacrifice that makes up what’s called a “healthcare system” in the United States, let me explain the need for this bill. Basically, if you’re not old enough to have Medicare (the kinda-universal healthcare that’s available to old people), you need some form of private insurance to make healthcare affordable. Most of the time, this insurance will not cover all the doctors or hospitals near where you live. It might not even cover most of them. Part of choosing a health insurance plan is looking through their lists of “in-network” healthcare providers to make sure that they’ll actually cover the costs of healthcare at a place near to you. Incidentally, it’s on you to actively look for the ways in which health insurance companies will try to force you to pay for your healthcare, despite sending them hundreds or thousands of dollars per month precisely to avoid those bills.

The problem is, even if you do get health insurance that covers your favorite hospital, that’s not a guarantee that everything in that hospital will be covered. Some of the individual doctors might be “out of network”, which means you are stuck with the bill. Again, it’s your responsibility, as the patient, to look out for that trap. The example scenario I hear a lot is one of surgery – you need an operation, and you know that your surgeon is covered by your insurance, but…

Is your anesthesiologist? Or are they out of network? Do you have a chance to check?

Or what if the entire operating room team is covered, but someone calls out sick, and their replacement isn’t covered?

So, it’s pretty common for Americans to get unexpected medical bills that can range from hundreds to tens of thousands of dollars, even for things they didn’t even know they had a say in.

This law, which went into effect on the first of January, fixes most of that (From the New York Times via Commondreams because paywall):

If you are having a medical emergency and go to an urgent care center or emergency room, you can’t be charged more than the cost-sharing you are accustomed to for in-network services. This is where the law’s protections are the simplest and the most clear for people with health insurance.

You will still be responsible for things like a deductible or a co-payment. But once patients make that normal payment, they should expect no more bills.


For scheduled services, like knee operations, C-sections, or colonoscopies, it’s important you choose a facility and a main doctor that is in your insurance plan’s network. If you do that, the law bars anyone else who treats you from sending you a surprise bill. This also addresses a large problem. Surprise bills from anesthesiologists, radiologists, pathologists, assistant surgeons, and laboratories were common before.

If, for some reason, you are having such a service and you really want an out-of-network doctor to be part of your care, that doctor typically needs to notify you at least three days before your procedure, and offer a “good faith estimate” of how much you will be charged. If you sign a form agreeing to pay extra, you could get additional bills. But the hospital or clinic can’t force you to sign such a form as a condition of your care, and the form should include other choices of doctors who will accept your insurance.

This is not the end. The entirety of the United States is set up to encourage people to find ways to make money, with no real concern for the harm done in the process. Even so, this is a legitimate win for the American people, against their corporate overlords. That said, as MSN reports, this bill does nothing to change the problem of Americans risking their safety to avoid ambulance bills:

The No Surprises Act, health care legislation targeted at preventing surprise medical bills, officially went into effect on Jan. 1, albeit with one major exclusion: ambulance bills.

A 2021 survey found that ambulance bills account for 8% of all medical debt. A big reason why is because 51% of emergency and 39% of non-emergency ground ambulance rides include an “out of network” charge from insurers, according to the Peterson-KFF Health System Tracker.

“I think part of the issue is that a lot of ambulances are run by the states, which makes it more complicated for them,” Matthew Rae, associate director at the Kaiser Family Foundation, told Yahoo Finance.

Furthermore, Rae added, you can “absolutely not” request a specific ambulance provider to ensure it’s in-network. Just 10 states have laws in place protecting consumers from being balance-billed by a ground ambulance provider.

“Most places you may not have a choice over who’s the ambulance that shows up,” Rae said. “This is absolutely a place where someone who is having an emergency has to make a call and they don’t have control picking their provider and then they are potentially subjected to a surprise bill.”

According to the Peterson-KFF Health System Tracker, citing data from seven states, “more than two-thirds of emergency ground ambulance rides had an out-of-network charge for ambulance-related services.”

Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, told Yahoo Finance that there is “only one [provider] who has a monopoly contract for the region you live in. There’s literally no choice. Not that you really have a choice of emergency physicians, barely have any choice over an anesthesiologist, but it’s even more extreme. We think of ground ambulance services as if it should be like a municipal fire department type of service.”

Adler noted that “something like 80%” of ground ambulances are out-of-network.

“It’s fundamentally broken … it’s not like the ambulance has as much power because they don’t get to choose who they pick up,” he said. “Neither side has a lot to stand on here. And then you’re getting a lot of one-off fights between the insurers and the ground ambulances which is not great for the patients stuck in the middle.”

And those who are without any health insurance and in need of an ambulance are responsible for footing the entire bill, though Rae noted that they do have the ability to negotiate.

“This is a place where people can incur big expenses,” he said.

Off the top of my head, I can think of two times when I should have taken an ambulance ride to get checked out, and opted not to because of the cost. The first was a simple bike accident. I hit a curb too hard, and went over sideways. I hit my head hard enough on the pavement to crack my helmet, and my neck hurt. The abysmal insurance I had at the time (this was before the Affordable Care Act, when it was even worse) didn’t cover any of the nearby urgent care clinics, and I didn’t want the cost of an ambulance ride, so I put an ice pack on my neck and tried not to move much for a couple days. I was fortunate that I could afford to do that, rather than having to go to work. I was also fortunate in that there seemed to be no serious damage done.

The other time, I was biking back from work, had the right of way, and a woman turning left hit me. We were both going fairly slowly, but her car destroyed my bike, and I skinned a knee and badly jarred my wrists. It was outside a CVS pharmacy, so I hobbled in and bought myself some medical supplies rather than availing myself of the ambulance that showed up.

In hindsight, I probably should have taken the ambulance ride and gotten checked out, but I would have had trouble affording it. My wrists never fully recovered from that.

It was, as I’ve said before, damned near miraculous how much our quality of life improved when we got to Scotland, and just simply… knew that our costs would be covered. If we felt sick, we could just call the doctor. If we needed medicine, we just got the medicine. When Tegan got shingles in the United States, we thought it was poison ivy at first, and didn’t even consider going to the doctor, because of the cost. The result of that was she went untreated for the first week or two, and suffered a lot for it.

When I got shingles in Scotland, I called the doctor as soon as I noticed the rash, because why wouldn’t I? It was a short walk away, and no matter what it was covered by the money we had already sent to the NHS (it was £600 for each of us for a full year of coverage). I got an appointment the same day, stopped by the pharmacy on my way back, and started taking antiviral medication immediately. I had a much easier time with it than Tegan did.

Here in Ireland, the healthcare situation is worse than Scotland, but better than the United States, at least from our perspective. Irish citizens have universal coverage, as I understand it, but immigrants like Tegan and I do not. That said, our private insurance covers most hospital costs, with the highest single charge for something that’s not covered being €80. For example, it’s possible that a set of x-rays, multiple blood tests, and specialist visits, the bill could climb to hundreds of Euros, but it’s capped at €970 per year. That costs us €80 per month, compared to $300 per month with MUCH worse coverage, back in Massachusetts.  We pay out of pocket for GP visits and prescriptions, but that is also far cheaper than the deal we had in the US. I should also mention that this is literally the cheapest plan we could get and still be allowed to live in this country – if you want frills like a private hospital room, pregnancy coverage (which seems like it shouldn’t be extra), and so on, you can get a more expensive plan for better service.

I will probably never stop being angry about the cruelty and injustice of the U.S. health insurance system, for as long as it exists in anything close to its current form. Even so, I am overjoyed that my friends and family will now be a bit better protected from the greed that ravages that country. It’s a real step in the right direction that will materially improve a lot of people’s lives.

Thank you for reading. If you find my work interesting, useful, or entertaining, please share it with others, and please consider joining the group of lovely people who support me at Life costs money, alas, and owing to my immigration status in Ireland, this is likely to be my only form of income for the foreseeable future, so if you are able to help out, I’d greatly appreciate it. The beauty of crowdfunding is that even as little as $1 per month ends up helping a great deal if enough people do it. You’d be supporting both my nonfiction and my science fiction writing, and you’d get early access to the fiction.


  1. says

    This is the kind of writing that the US system deserves but never ever gets from mainstream journalism. Even the most pissed off partisan in the op-eds of local papers has to tone it down somehow. Blood sacrifice is right.

  2. klatu says

    Yes, well… How could this possibly ever have happened in the first place?

    Could it maybe have something to do with how profits are just simply more important (at the end of the day!) than people? (At least, to those peope who actually HAVE political power?)

    Insurance will only cover what is stochastically profitable. Same way a casino will only allow the games that are stochastically profitable.

    Like, let’s keep hospitals always running at capacity, doing only the same three “profitable” surgeries, over and over again. This is what I would decide. If I were a sociopath.

    Again, could it maybe have something to do with how profits are just simply more important (at the end of the day!) than people?

    No way, right?! That’s nuts! First world bragging rights and all that! No way are we as shit as Africa!

    The fact that your country has bills like the “No Surprises Act” is all you ever need to know about it.

    “Clever” politicians keep getting back to the same idea: Let’s cut social spending. Too much money is going to the underserving/degenrates/lgbtqia! Never ever do they stop to wonder at what actually happens to a society that keeps getting conditioned to be as uncharitable and self-serving as possible (in the long run).

    Could that kind of trained anti-solidarity maybe have a role to play in our (as of yet still singular) pandemic? Probably.

    Could it maybe maybe have disatrous effect in our (ostentibly) collective fight against extinction brought on by climate breakdown. Sure.

    But helping people is for losers, right? Only an idiot would sacrifice part of his crazy-ass millions and billions of personal wealth to actually help people.

    But, anyway. I’d like to mirror Satan and commend you on all your writing. I haven’t been commenting much recently, but I do read all your stuff and I appreaciate every single entry. Please keep it up, if you can!

  3. StevoR says

    The nightmare for me personally is that our LNP coalition misgovt is following the USA’s horrific example healthcare~wise. They’d destroy our medicare if they could get away with it… & I’m not putting it past them to deliberately break the system tothen say it doesn’t work as an excuse to do just that. I fear that prospect smcuh closer than many Aussies now realise.

    I also presume you have seen seen already Mike Moore’s Sicko doco* – you may very well have already posted on it too,tho’ I’m afraid i don’t remember if so.

    * See :

  4. K says

    I’ve had a bunch of “how is this even legal?” insurance, but two stick out in my mind:

    1) cost $1000/month for 4 people (me, spouse, 2 kids). Any medical encounter had to be documented and sent off to a “middleman” company in Florida (red flag) who would then approve or disapprove. If they approved, they forwarded it to the insurance company, who then paid some amount of it. You never knew from time to time how much they would pay or not pay. They made the whole process so painful that we almost never used it. The egregious part came when I needed a minor procedure in a doctor’s office–I was in-and-out in 20 minutes, but had I let it fester, it could have been catastrophic. The Florida people refused to authorize it. The doctor called them (great doc!) and they whined that they didn’t understand the procedure and “were not medical”, at which point the doctor asked them why they were in this business. They replied, “to make money”.

    2) Another job I worked turned out to have a privately-managed “medical pool”, where all the employees paid in and the owner decided what bills got paid from the “pool”. This of course was not explained to the employees and the insurance *seemed* to be legit…until you needed it. The wife of the owner got cancer and suddenly nobody else’s bills got paid (cancer treatment is very, very expensive).

    To repeat, “How is this even legal?”

  5. K says

    Also, I am celebrating the “no out of network” bills because I understand them so well. A couple of decades ago, I was really ill and went to my doctor’s office, where I passed out in the waiting room. They called an ambulance and I was taken to a hospital, where I was kept for several days until they figured out what was wrong and put it right.

    For the next decade, random bills from random doctors and random services kept popping up from that one event. The insurance company kept refusing to pay anything because I didn’t make certain that everything was in my network. I was unconscious–I did not call the ambulance or choose the hospital or any of the doctors there. It appeared that all of them were out of network, plus the facility.

  6. Dunc says

    As someone who’s lived all his life with universal healthcare free at the point of use, this is, of course, all completely bizarre-sounding – but I think perhaps the most bizarre-sounding part is the idea that somebody might have a “favorite hospital”… Surely you just go to the hospital that is (a) best-placed to offer whatever care you need, and (b) closest? How on Earth are you supposed to form preferences for something like that? Read TripAdvisor reviews or something?

  7. says

    It’s the “in-network” thing. Basically, your insurance plan might not cover any doctors in the closest hospital – that’s a matter of private negotiation between whatever company owns the hospital, and the insurance company. Some insurance companies WILL cover all hospitals, but only if you pay more per month for a better plan. It gets very, very complicated. As bad as the costs are, the time and energy spent trying to navigate the paperwork and so on is often just as bad, and you have to deal with THAT whether or not you get sick.

    So people go to the best/nearest hospital when they can afford to do so. Some hospitals also charge more than others for the same services, which can affect how much YOU have to pay out of pocket. It also may be a matter of finding a particular doctor that you feel comfortable with, I guess.

    And I don’t know about TripAdvisor, but people do read and write Yelp reviews of hospitals, and people also may choose based on word of mouth, personal connections, and so on.

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