> The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.
The cost isn't about the actual mileage though, it's having two paramedics each earning about 100k/yr per ambulance, while having coverage 24x7x365. So fully loaded, the labor for one ambulance might be in the high six figures to seven figures.
Even if we assume we need to cover their downtime between rides, at a conservative estimate of "we're the only call today" that's $2400 of labor at your rate (≈$400/d, 2 paramedics, 3 shifts). TFA suggests they're not paid well.
The piece is actually quite concise, but you're right in the other respect. You definitely didn't read it. Private equity as an explanation is explicitly rejected.
> The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue. That’s how it’s done in the rest of the rich world. Some places, like the United Kingdom or Japan, simply fund ambulance services directly out of taxes; others, like the Australian state of Victoria, sell memberships in “Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year per family.
One thing that's often overlooked is the cost of administering a billing system. If you're going to distinguish between the insured and uninsured you need a system that keeps track of who has insurance. You need paperwork (or digital equivalent). You need accounts payable staff to send invoices and chase up unpaid bills. It can, counter-intuitively, work out cheaper just not to charge anyone.
The company offering the ambulance surface. Similar to how a pool cleaning company will send you a bill if you call them and have them clean your pool.
Generally, people who want their pool cleaned do so when they are conscious and have their pool very close to their home address. People who need ambulances are usually in a very different condition. That makes it a different prospect trying to chase payment.
I don’t think that is the entire solution. Right now medical services are just much more expensive in America. Whether it is the average individual paying for them or the aggregate taxpayer individual, we will still go bankrupt if it’s too expensive for the average.
Government coverage is all well and good until the government (really you) is paying way above market rate.
I don’t think we get out of this by trying to regulate medical expenses either. That will just enrich another cadre of lobbyists and lawyers.
> “Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year
And even if you don't pay this it still isn't that expensive - US$12873 is more than a helicopter transport would cost here. US healthcare companies somehow get away with charging insured patients 10x more than civilised countries charge uninsured ones.
You don't have to pay them unless they're specific. I got a bill 3 years after being in an accident and I asked them for the documentation they legally have to provide me (itemization, the legal basis, detailed incident record, attempts on their part to contact insurance) of how they arrived at the sum. It's been a year since and they haven't given me anything.
The last thing I want at that time is to have to reason about any of this.
I think I’m realizing that what I cherish about the healthcare system up here is not just that I don’t pay bills, but that I don’t even see a bill. Not that the bankruptcy inducing costs aren’t wretched, but I just cannot even imagine being put into a fucked up bureaucratic hell while my family is in a life altering crisis.
Yea I think this is the bit thats easy to take for granted in nations with rational healthcare systems. Not only do I not get fleeced, but at no point does my healthcare feel like economic activity, a transaction, it feels like healthcare and that the provision of it is being done for the right reasons.
This applies to other things as well - retirement and education come to mind.
Anecdote: my uncle and BIL are auto mechanics. One in the US, the other in Scotland. Similar lifestyles - both own homes, have mechanical hobbies (vintage cars for one, Harleys for the other) - typical working class lives. The uncle in the UK just has much less mental overhead when it comes to major life planning.
And yet we have ICE and the FBI harassing “dissidents” every day, medical choices dictated by insurance companies, and on and on. They’ve been sold a bill of goods and just haven’t realized it yet, IMO.
It's from a fictional drama (The Newsroom) but this a great riposte to "freedom in the US".
You're going to say that we're the only ones in the world that has freedom?
Canada has freedom, Japan has freedom, the UK, France, Italy, Germany, Spain, Australia, Belgium has freedom.
Medicaid is actually like this incidentally. No copays really. Too bad the electeds don't want to roll it out. The a lot of the most expensive risk pools are already on medicaid or medicare.
Yeah, my family was hit by two ambulance bills in California in 2024, and tried to balance bill us contrary to the law.
It was a really frustrating experience trying to get them follow the law. One of the ambulance companies waited an entire year to even file paperwork and still tried to get insurance and me to pay.
Last view of life: slowly bleeding out in the back of a waymo that has gotten trapped in the traffic circle in front of the ER and won't unlock its doors until it reached its destination.
My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least. Wild.
> My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least.
Would your wife have been in a different location if you had made the call?
The law you've cited only applies for "emergency transport".
Falck has found a workaround: Bill emergencies as "non-emergency" so they can balance bill. This is, of course, fraud. I'm sure that enough don't understand the law that this makes them a lot of money.
We’re all pretending this is an unsolvable problem when really most of the world has solved it by making ambulance (EMS) funding similar to fire and police departments. Somehow in any emergency I’ve seen, all three show up, often EMS before police or fire dept, and somehow that’s a service that has to be supplemented by insurance billings.
The blog mentions it, but it’s one of those obvious things that somehow isn’t solved yet and blows my mind every time it comes up.
Sure, in a given public discussion, lots of people saying that show up. But substantial portion of those are shills, not necessarily people to say but who benefit from the scam. And some people who are paid, public relations people acting on the downlow, etc.
I think we are all villains here. Good healthcare coverage is just another status symbol to be attained. If the poor have it then it becomes less of a value. To some degree we are all wired this way and we all
suffer because of it.
>I think we are all villains here. Good healthcare coverage is just another status symbol to be attained.
Seriously? How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other? The extent I've experienced is stuff along the lines of "thank god I had my health plan, because otherwise it would have cost [6 figures]", but it didn't give the impression that they'd be mad if everyone didn't have to suffer that fate.
Not a one. But... I have had many conversations with people who feel they have "earned" healthcare because they "worked hard" and finally obtained a "job with benefits".
And this is exactly why those same people do NOT want universal healthcare.
Funny enough I have had this conversation during the ACA “Obama Care” national (US) debate in the early 2000s. I have had one of my colleagues say if we give healthcare to everybody then it will affect his care negatively. He would rather limit it to people who deserve it (through merit) so he can have his pick of quality doctors. These people absolutely do exist.
You're getting down voted, but there's substance here. A "job with benefits" is a badge of honor for some. That means they've "worked hard" and "earned it".
Do you really not understand the difference between the one you cited and the one to which I was responding?
The one to which I was responding was capricious. The one you cited has reasoning, even if you disagree with it.
And that was the whole point of my comment. That by reducing the other side to a farcical strawman, you diminish your own argument. It just becomes a yelling match.
I would rather debate the person you cited than sit complacently with the cynic to whom I responded.
Haven't yet seen a developed nation do worse than the US. If you prefer to compare against developing countries only, sure, winning by lowering the bar to the ground is an option.
What metrics are you using for that? The US ranks fairly close to the top for out of hospital heart attack survival, which is a good proxy for emergency medicine in general.
The US also has decent EMS response times. If you adjust for population density, the US has fantastic response times.
In retrospect, I think my wording might be misleading - I didn't mean to imply the US is doing significantly worse than developed world, just that none of the developed world does significantly worse than the US either.
I.e. I was responding to the original "in 'most of the world' EMS quality is ass.", trying to say that you only get that outcome if you compare apples and oranges (developed vs developing)
8-10 minutes in urban areas is pretty much universal (for the developed world). Rural areas are where differences come in, and even there standards for the developed world are somewhat on the same level.
US EMS quality isn't exactly something to be proud of. It's been private equityified. Just recently (last winter) I nearly lost an aunt because of our stellar EMS system literally doing a transfer from a hospital to a hospice. The company had only one person working, they parked the ambulance next to a snow bank, tried to wheel my aunt up the snow bank, and had her and the bed flip on them trapping them in the snow.
They were super lucky that someone from the hospice just happened to be leaving at the same time they flipped the bed.
> most of the world has solved it by making ambulance (EMS) funding similar to fire...
About 65% of the more than one million firefighters in the U.S. are volunteers, with nearly 19,000 fire departments being run completely by volunteers.
You know we can have volunteer supported services be very effective, right?
I volunteer to give blood. No one is paying me, and yet, someone's life is saved by that.
Some folks believe (in fact, this is the thesis statement of much of anarchist theory) that people would largely volunteer to care for one another if their basic needs were met.
Not everything has to be transactional, you can have a government setting up a scaffold that supports and encourages and organizes volunteers and run an effective service.
Many makes it seem like this is common. But it extremely uncommon in the US to get a bill after a fire. There are some rural volunteer fire departments that are funded through memberships and they will bill you if you aren’t a member. But these are not common.
Health care in general has been solved by state sponsored medicine in most industrialized nations. And when it isn't solved by directly state sponsored medicine, it's solved by formally and informally regulated monopolies. In fact, US health care in the 1960s was made reasonable by the Blue Shield regulated monopoly.
The thing about unfettered private health is that it finds "profit centers" and pumps them ruthlessly. But the problem when scheme/scam gets reigned in (say out-of-plan doctors), another appears (out-of-plan ambulances) and there's no end to the situation. Only actual state sponsored health care can end this.
I'm volunteering to help build out a nonprofit EMS authority that will tax residents and businesses in our local six boroughs to spread out the costs for ambulance transports.
We hope to set the rates such that folks won't have to pay at all if they have insurance or will only have to pay the gap amount insurance would have covered.
I'm collecting the data to figure out how many residents, how many businesses, and how many college students there are in the region and match that to the call volume for those same categories so that each group pays a fair share.
We're basing the legal structure in the MESA group from Lancaster PA. Public fee hearings with residents hopefully start this Fall, and then we're hoping to go live Jan 2027.
I will say I've been surprised how extremely expensive it is to run EMS. Even with 25% of our responders being volunteers, the costs are staggering. Insurance, equipment, medicines, payroll, billing, fuel, building maintenance, heating and cooling.
The vehicle maintenance would turn your hair grey. We have a vehicle in the shop almost every single day. And we have two volunteer mechanics trying to do fixes in house. But these ambulances just are absolutely beat to hell 24 hours a day. My partner is one of the mechanics, and she sometimes gets a half dozen vehicle maintenance reports a day! And we only have 7 vehicles!
And then you have to factor in deprecation on an asset that effectively drops to $0 after 5 years. And costs $300k to replace.
We pinch every penny we can think of, but the end effect is that we're trying to provide a service that's extremely expensive and so we hope this model will diffuse those costs across the whole population (which we expect will turn out to be something like $100/year per family).
Cross your fingers because this feels like our best option
Story up thread is about an ambulance ride by the San Francisco Fire Department charging a grand. So in essence the EMS funding is the fire department funding and it’s still unsolved.
So should we somehow recover roughly $127,000 from the victims of each fire?
Of course not. I and my neighbors pay taxes to maintain the Fire Department and have it ready when needed. Many may argue that we pay too much, but those unfortunate enough to actually need its services would probably say they got a great deal.
As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted. The article starts off by noting about how ambulance is an "option" for a rescue, but even though the analogy might vaguely work, it's not really needed to answer the question. That can be answered far more simply: "medicare and insurance companies pay them too little, so they have to charge everyone else more". Or, from the article:
>This meant that the payment structure and the cost structure were increasingly mismatched: and so ambulance services had to pay for their round-the-clock readiness by billing for individual rides. [...]
>And notably, the fees that Medicare sets run far below cost. The average ambulance transport costs $2,673 to provide; Medicare pays only about $329 of that. A typical ambulance ride for a Medicare patient, in other words, loses theambulance service thousands of dollars.
"Medicare pays too little" is based on the "fee for service" model; it only makes sense if you believe the group of people who actually use the ambulance should pay its full cost.
The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it. The former doesn't imply "everyone else should have to pay for my bad luck"; the latter does. It's effective persuasion.
>The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it.
There are plenty of services that have high fixed costs but low marginal costs, but we don't use the "options" framing. A movie costs tens to hundreds of millions to make, but otherwise costs very little to deliver. Their price are also fixed, rather than dynamically priced. Yet when a movie bombs, nobody is like "wow I guess they shouldn't have been selling an option for 2 hours of entertainment for $20!". It's a price problem, first and foremost, caused by insurance companies and medicare strongarming them.
Given you find this is _normal_ for a six mile ambulance ride: "and $11,670 as a “base rate.”"
What on earth would you consider normal for a helicopter ride from Exeter to London?
That's roughly 150 miles as the crow flies. Pilot, co-pilot and a medic, minimum crew for say 1.5 hours. Each way, so 300 miles of fuel and aircraft lifetime and three hours of crew cost, not to mention ground crew etc.
My dad got that on the firm when the shit hit the fan and he needed to be seen by specialists in the Royal Brompton and Royal Devon and Exeter decided that was his best shot at life. That was 15 years ago.
Anyway, the OP's bill looked pretty normal until the 11,000 base rate nonsense. How can that possibly be justified?
> The average ambulance transport costs $2,673 to provide
I think this ignores the 400 pound gorilla in the room. Why does an ambulance transport cost thousands for the operator? This is a short trip in an automobile, essentially a fancy uber ride. At first one might say that's flippant - obviously ambulances are specialized vehicles, and you have paramedics, and they need to get to locations quickly, and so forth, but let's consider those costs.
A new, fully equipped ambulance is about $150k. Of course this is more than a regular car, but by a factor of 5, not 50. Let's be generous and presume the ambulance fully depreciates in 2 years. Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr. Again, not orders of magnitude more expensive. Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year. Throw in money for gas and wear and tear, which should be quite comparable to other automobiles, and it costs about $1600 to own and operate an ambulance for 24 hours.
Now the other side of the equation is utilization. Taking the arbitrary example of Philadelphia Fire Department, they have 60 ambulances that handle on average 700 ems calls per day, and approximately 70% of ems calls lead to transport, so that's about 8 transports per ambulance per day. So distributing this all out, the actual cost to the ambulance operator, ignoring overhead, ought to be somewhere around $200.
I'm sure there are some additional costs I haven't included in this back of the envelope calculation, and maybe some of the numbers I pulled off google are off a bit, this should be taken as a very rough estimate. But even if you significantly increase the cost, the medicare payment amount seems quite reasonable to cover the expenses with a healthy profit margin. Unless you want to claim that operating an ambulance is less than 10% of the cost of ambulance transport, and that the estimators with Medicare are absurdly out of touch with reality, whence cometh $2,673?
+1. The base price for US healthcare is entirely removed from the cost of the service provided. And you can of course just look at other countries to figure out that the cost is much higher than it should be.
I think the main expense you are missing is medication and disposable equipment and insurance for the ambulance and medical malpractice.
Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.
That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.
Normal commercial insurance is much more expensive, let alone ambulances.
And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels
There’s the cost of supplies used during transport. Also the cost of maintaining potential supplies like blood even if they go unused. EMTs may make $23 but they are also getting benefits and have other overhead, making their real hourly cost probably closer to $50/hr minimum. There’s insurance, which I bet is out the wazoo expensive for ambulance. Ambulances have to be maintained and I would guess have much more regular service than your car at home. Ambulances have to be stored somewhere and secured-access parking isn’t cheap. Many ambulance rounds-trips can be well over an hour considering so many of us live far away from urban centers.
Is it $2600? Probably not. But I think you are low-balling pretty significantly.
Put another way, just getting a plumber to vibe to your house is gonna cost you $200 easy. It’s within reason that an ambulance ride might cost much more than that.
I don't disagree with what you're saying but I want to point out that it's rather unusual for (American) ambulances to carry blood, and probably more of them should.
Correct. The only ambulances that typically will stock blood are specialized NICU ambulances and HEMS (helicopter). Although more progressive agencies are looking more and more at part blood products.
TIL getting an elevator tech to just come out to look at your building's elevator is about $1600. If it's an easy fix, that's all you need to pay. If it's not, it goes up significantly....
I'm not going to claim that elevator malpractice isn't possible, but no elevator is designed with a single point of failure for any safety critical system, so I don't think it's easy or likely to make a mistake that would cause a safety issue.
This is fairly funny to me because I reckon most residents only had to do research to get in. EMT and tech experience are negative differentiators in getting into medical school, which is a shame.
Most people live in urban environments. Approaching zero are over an hour. As with most people being in urban environments most ambulance rides are in urban environments and go to the nearest hospital meaning that most rides should be under 10 minutes.
There is zero reason to compare cost of ambulance rides to a plumber and "vibe" on how much more expensive an ambulance ride instead of actually looking at the component costs. They aren't remotely related and one tells you nothing about the other.
Both the actual analysis you responded to and this one are also missing the fact that the ambulance is already subsidized and that usage fees aren't actually paying for the ambulance which makes the fees charged more onerous yet.
It might be instructive to look at what Canada charges non-residence as non-residents pay the unsubsidized rate of about $400-$600 Canadian.
If I charge $163 an hour for an electricians time, the cost to my job for one hour without material is between $130-140 depending on who it is. It only costs the plumber $20 if his time is free, which it isn’t.
"We mark it down based on [income]".. Obviously it's profit first (I don't mind if you don't pretend that profit is a cost). It unfortunately seems cheaper to be uninsured for many cases if you're willing to pick up a phone and discuss prices and take the risk that it may not always work out (but then again dealing with insurances has its own set of annoyances and steadily rising costs).. Not a recommendation but clearly my observation.
Ah, but you forgot private equity, that's about $2473 of profit per ride that needs to be accounted for. This high cost is what we must pay to keep our economy dynamic and efficient.
Probably an obvious/dumb thing to say on HN, but I just want every medical service to have this exact type of breakdown. And then we can at least somewhat pierce the veil of health care costs. The thing I can't figure out is why this doesn't already exist, or, if it does, why it's not more widely known amongst laypeople. Everything from ambulance rides to MRI's to surgeries can be baselined and then we can talk about unique situations that can push that baseline price higher, but at least have a baseline. Seems like a good thing for an LLM actually if you could trust it.
As to your specific $200 quote, which others have attempted to refine, it can't be a coincidence that you come up with that number and the Medicare number is $300+, which, if your $200 is even somewhat accurate, seems like a perfectly fair gross margin on what's being delivered. Imagine if the government actually reimburses for cost plus a decent profit margin! Unthinkable the gov could somehow be accurate in their reimbursements.
Hi there, I’ve used this for hospitals local to me but correct me if i’m wrong but those are only the prices for services. What I’m talking about is unit economics for the service. The difference being pricing is opaque (or rather pricing alone is not transparent enough) until you know the cogs and then you can evaluate how profitable the pricing is.
I agree. That number is bullshit. I Googled about it. It looks like 350K to 600K USD. Also, there is wild variance in vehicle sizes and the equipment you choose to carry.
At least one city I lived in it was well known that you wanted to only ask for the fire department, because they would call an ambulance company via cell directly, and that one was significantly cheaper than the one 911 would dispatch.
> Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr.
Paramedics and EMTs aren't the same thing. Private ambulance crews running "dual ALS (advanced life support, i.e. paramedics)" are _exceptionally rare_. Normal staffing is Paramedic and EMT, and most often there are crews that are dual EMT.
Average EMT wage is actually about $18/hr (and in much of the south you can be looking at $15-16/hr).
However where wages do go up, but not in a good way, is overtime. The agency I worked would happily schedule you for 36 or 48 hour _shifts_ and had no weekly hour limit beyond "You must take an 8 hour break after 60 hours of shift", I kid you not - and many people will regularly work 72-96 hour weeks.
The big thing is that private EMS writes off a lot of bills and pushes the balance on everyone else. The holy grail for private EMS agencies is "inter facility -out- of a hospital", as oftentimes the hospital pays the ambulance bill and charges the patient.
You also have to be careful looking at FD provided _transport_ as billing for this is often subsidized by property taxes. There are FDs who will charge for treatment and for transport, for transport only (not for treatment), or for neither (my FD did not charge - but there were also differing policies on when we transported, not by default, so you had people literally - and understandably - peeking out their window to see if it was a red FD ambulance/medic unit outside, or a white private ambulance).
Even above and beyond that, there are a LOT of disposable costs you never recoup. Bedding, blankets, gloves, etc.
> This is a short trip in an automobile, essentially a fancy uber ride.
That is a little flippant, as you acknowledge... good way to offend any paramedic or EMT. I've delivered babies en route to a hospital, including breeches. CPR. Emergency airways.
> A new, fully equipped ambulance is about $150k.
Not any more. Thanks, private equity. You can easily be looking at $400K. And they are vehicles that are driven hard, and cold, and maintenance sucks as a result. No warm up times for engines. Private ambulance, it's common to see rigs with 300,000+ miles on them.
> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Not for the medical treatment, no. You can get insurance privately as a paramedic but those policies are generally excess/umbrella style or are specifically "occasional only". The last private agency I worked at with a dozen paramedics and 50+ EMTs had at least mid 6 digit insurance bill.
> Throw in money for gas and wear and tear, which should be quite comparable to other automobiles
For a vehicle that can weigh 10,000lb+, that gets started and stopped often 30 times a day, a lot of time driven "foot to the floor" with an attitude of "it's got to get where it needs to go"? No, although one of the first thing any halfway decent sized agency quickly learns to build out is its own full shop and multiple mechanics (my friend is the Head Mechanic at a local county fire agency and oversees 8 FT mechanics and an auto electrician).
This jumped around a lot, I apologize, and I don't mean to shout you down, at all, but, lest you think I'm defending this state of affairs, I am not, in no way, shape or form.
Some of them are volunteers who do it because it’s about the calling to help their communities, not pay.
Some do it because they actually want to be firefighters but it’s helpful to be an EMT as well.
Others do it because it’s an easy entry point (in the US you only need a 3 month night course to be an EMT) in their medical career on their way to better paying jobs like MD and RN.
And yes, others are grizzled and burnt veterans out making little money.
But mostly people do it because they want to help.
You forgot the cost of insurance when you get sued by the passengers or when you get into an accident since you're racing down the road hoping people are paying attention and get out of the way. No idea what it costs but it's arguably more than an uber driver. 2x? 5x?
There are a ton of other costs. You're not paying for one employee. You're paying for many since ambulances run 24/7. They are also driven hard which means they require more maintenance. The ambulance is also full of expensive equipment and supplies.
My LLM of choice says it actually costs $1000-$2500 per ride to the company for operational costs on top of per-ride costs. You can probably ask one for a breakdown and see if it makes sense to you
Unfortunately that inside source is often coached by the PR department and are just there to say things they can't get away with saying publicly or don't want to have their exact words on record. I.e. just as much a misrepresentation as the official press releases. Or sometimes even more of a misrepresentation since nobody can actually be held accountable for their words.
Not in my experience. Most LLM answers are bullshit; and they almost never say they don’t know. Most people would just look at you and say ‘I don’t know’ instead of just making something up.
The U.S. Federal minimum wage is $7.25/hr. Some states or localities might have higher minimums, but it's been a long time since I've seen any jobs paying that little. McDonald's here is about $15/hr to start and jobs go begging. CoL here is not the lowest but it's not like a major urban center either.
We had to move my non-ambulatory[1] father from Mississippi to Virginia a couple of months ago. The vehicle probably didn't have all the staff and equipment of an ambulance but it did have an RN, a crash cart, and some other expensive crap that goes "ping". The cost was $3K for an 800 mile trip (slightly more because I included the "snacks and a DVD player" package).
[1] Oh, holy crap, I just got why ambulances are called that
Some of your estimates on this seem fine, but not this:
liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Insurance on my SUV is close to $3,000 a year, but with the understanding I drive it about 12k miles, and I'm not allowed to speed or run red lights whereas they're guaranteed to be speeding, and driving it around all day and maybe all night. And the ambulance is worth 5x as much as my car is. So I'd be shocked if the combo of their auto insurance + insurance against being sued for rescuing someone wrong is that cheap.
Looks like of the $1954 they estimate for a transport (already quite a bit below TFAs $2673), $1582 is salary. Given that we established the crew in the ambulance are taking home about $140 per transport between them, this seems bonkers. Capital, medical supplies, and fleet maintenance are a whopping 6% of the "cost".
As far as I can tell, your article is talking about total salary cost, divided by number of rides, not just the amount that the ambulance crew is being paid during an actual trip.
For that, $1500 seems pretty reasonable. In a place like the US, labor costs often dominate the total cost of many goods and services.
And remember, you have to pay the staff while they are sitting there waiting for a call that may never come. According to the OP's article, the ideal utilization is 30-50%, because you don't want a situation where there's a surge in requests and you don't have an available ambulance. So you're paying people to sit around and wait for a call, and, under normal conditions, you'll have 50-70% of that pool of people not ending up needing to take calls at all.
Also your article includes under salaries:
> Regular, overtime, vacation, and holiday pay for all EMS staff, including EMTs, paramedics, chiefs, 911 call technicians, dispatchers, and support staff
That's not just the 2-3 people on the ambulance during trips. That's a lot more people required to make the entire system work.
Here in the Netherlands it is 877 euro for an A1 call (emergency, no delays), and 384 for B1 calls (non emergency, planable). You also get a 4.83 euro per km cost. You pay up to 375 euro if you haven't had any medical cost that year, otherwise zero.
Stand by cost are about 154 euro/hour. E.g. for sport events.
ICU transport is about 2500. All are law mandated.
The total cost might be more as the insurers also put in undisclosed amounts and some cost is shared with the emergency departments at the hospitals.
The ambulance operator also gets stuck with the costs of all the ambulance rides which are never paid for - which is, statistically most - because of things like homeless folks, people giving false names, etc.
Which, notably, are so common, because it is financially ruinous to not do it.
They can’t decline transport for anyone with an emergency, regardless of ability to pay.
This is a fine example of coming up with some "plausible" numbers to support a conclusion, but all of the "plausible" numbers are actually wildly incorrect.
A new ambulance will probably run 2-4x what you quoted. Gas/maintenance will not be comparable to a regular automobile; it will be significantly higher. Paramedic wage (though there will probably be more "cheaper" EMTs out there than paramedics) seems right, maybe a little high for some markets. $12k for liability seems shockingly low; I wouldn't be surprised if you're off by an order of magnitude.
Regarding salaries, you're not just paying for the people in the ambulance. You're paying for dispatch, operators, support staff, administration, etc. You're also paying them 24/7, not just for the times that the ambulances are actually making trips.
You also left out the cost of medical supplies and equipment, both of which need to be maintained and replaced.
> As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted
Idk, my takeaway is ambulances look like a solid market for a subscription model. Ideally, one that taxpayers pay for. But also, potentially, as a private one that you can pay e.g. $50/month to know you won't be billed $12,000 by idiots.
One thing I'd like to point out, many of the Airlift companies, like Airlift Northwest, offer $60/year family insurance for Heli EMS. They'll bill your insurance and accept the insurer's payment as "Paid in full". They also tend to have reciprocal agreements with many other HEMS agencies.
You’re right. The cost of the service not matching the direct cost is something we’re familiar with - that’s just fixed cost and entirely normal (happens with books, movies, etc).
This just happens to be the case where you must transport people but most people are net losses. In this scenario, the only surviving companies would be those who charge the remainder sufficient enough that the blended population of clients causes a net pay-in. Everyone who doesn’t account for that will just go out of business.
Being available constantly could be helped with a retainer, it’s true, but even with that we should expect that some patients pay a lot if they’re rarer than the loss-makers.
That 150k figure I believe is quite outdated. New ones are running 300k or more. The ambulance vehicle providers have been bought up by private equity and the lead times are now years to get one.
UK – Newly Qualified Paramedics (Band 5): £28,407 – £34,581.
USA - $38,000 to $48,000: £28,323 – £35,777
Sure, there's a bunch of different tax treatments and work-benefits between the countries, but I don't think it's the cost-of-labour that is making the USA more expensive.
Check your insurance to make sure you have transport. It's the same in Switzerland - it's an extra line on your insurance.
My wife and also have Rega. They can't legally call it insurance but if we get injured in, for example, the USA they will send us a private hospital jet to bring us home.
This comment is confusing because it refers to the first paragraph and also assumes when you checked your insurance you didn't find transport there. Since the parent did have transport and good insurance and a second paragraph, it sounds like you're asking "And then do what after your hospital jet flies you home, quit your job and find better insurance?"
The article explains why; regulators sometimes can't foresee that their decision to consider something fee for service will eventually prevent it from being considered as a communal expense.
Fee-for-service doesn't prevent ambulances from being considered a communal expense, it just makes sticky. There is nothing preventing a government from making ambulances equivalent to fire or police except the will.
From the article: "The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue". In other words, taxation just like anything else we expect to be available to anybody.
"Sticky" is what I was saying. It currently can't be done because of path dependence from historical regulation to industry structure to attitudes. No broader reason. I felt your post was setting up "If there's no logical reason, it must be because people with property are greedy". Sometimes things are the way they are because they got that way.
I tell this story every time ambulance costs come up because it might be helpful to anyone. I once lived in San Francisco in the mid-2010s. In SF, the SFFD operates the vast majority of ambulances in the city. As in, 80%+. I once had the need to go to the hospital urgently and called 911. The ambulance that showed up was SFFD. They transported me and I recovered safely. I then got a bill from them saying that my insurance had refused to pay for it - apparently that insurance company (they're lucky I've forgotten which one, as naming and shaming health insurance people is one of my favorite hobbies) had refused to contract with SFFD, making them "out of network." Yes, an out of network ambulance. And remember, there's at least an 80% chance that an SFFD ambulance will show up, and I've never heard of them offering a menu of ambulance companies to the caller who's likely having a heart attack, bleeding, etc!
So of course, my insurance would only pay some small pittance, if anything, and I was sent a ~$1000 bill. I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.
So we have an insurance company which surely knows that law, surely knows what an ambulance is for, but has discovered the "life hack" of having an extremely inadequate network, simply refusing nearly every ambulance claim made in the City, and then only paying the small percentage who know the law and know how to file a complaint. And of course, there's no punishment, the punishment is just having to pay the few times they're caught.
And insurance companies wonder where all that anger (Delay, Deny, Depose, was it?) comes from.
Anyway, practical moral of the story: don't let them get away with doing that if it happens to you or someone you know!
> discovered the "life hack" of having an extremely inadequate network
The article covers this. Ambulance providers are strongly incentivized not to join insurance provider networks, and as a result more than 80% of ambulance rides in the US are “out of network”. So the inadequacy of the network is probably not the insurer’s fault.
As an ex-paramedic and EMT, both with County Fire and private, there are absolutely those. But many-a-time, some of the blame falls on the physician. Medicare has, for one example, a lovely little form to fill out, just a few fields, mostly checks and multiple choice, to explain why the need for a "fully equipped BLS (or ALS) ambulance" was required, versus POV (private owned vehicle) or cabulance.
The number of times we'd have to hang out at the charge nurse's desk because the physician had scrawled a signature at the bottom of the form and nothing else, etc., was ... staggering.
If that doesn't give that reasoning (unable to stand steady, fall hazard, need for continuous O2, etc., etc., etc.) then no pay. And many insurers would use that same paperwork, not just Medicare. Could we fill it out ourselves? No. I'm not risking my EMS career to be at the center of a "ambulance company employees charged with medicare fraud" news story.
Cabulance - "wheelchair transport", often staffed by a EMR (emergency medical responder, a lower level than EMT). Someone who needs assistance and support getting where they're going, but is not in need of or likely to need medical treatment or support during the trip.
And they are reimbursed, or actually generally billed to insurance.
Not surprising. They clearly care(d) a LOT about the regulators asking questions. I was actually shocked that this mechanism was surprisingly effective at reining in abuses from insurers.
It could have been Cigna -- I've cycled between probably every possible insurer during my career. Dirtbags, the lot of them.
I had a very similar experience. Except unlike you I wasn't aware of that requirement at the time, and ended up paying all of it. I did complain to the insurance company that the amount I owed didn't seem right, and they told me it was my fault for using an out of network ambulance.
> I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.
First: Hats off -- nice work.
What annoys me the most about this story: There should be a disportionately large penalty that the insurance must pay to the health care regulator for cases like this. It would discourage this kind of illegal behaviour.
Agree. I would be utterly shocked if this exact same scam didn't play out for every ambulance call in San Francisco (And according to this article, it's actually completely normal that the "networks" are nonexistent, so multiply that by every city and town!)
What percentage of patients are likely to be taking ANY action that leads to insurance paying? Either spending (as someone else shared) 5 phone calls trying to convince them, or knowing what regulator to file a complaint with - those are the only options. All other options involve someone else eating that cost. I bet less than 10% get them to pay, so the fine should start at $10,000 - and escalate if they show no improvement.
Another solution: Each year, require health insurance companies to self-report (via third party auditor) the number of violations. Then they need to refund all illegal collections with penalty and pay a large penalty to the regulator. This kind of shitty illegal behaviour would disappear overnight. After the Global Financial Crisis in 2008/2009, some new laws were passed to regulate trading by investment banks. Many of the rules work this way and they work!
Unreal you have to go through this in the richest country in the world.
Family members have been in ambulances a few dozen times over the decades. There is no concept of a bill or paperwork for it. Like borrowing a book from the library.
Branded GPL-1s cost $1-1.5K a month in the States without insurance coverage, $25 with coverage. Something's rotten, I doubt big pharma eats the difference, they'll get theirs.
I think the answer is very simple. Regulation. If there was no regulation or very little then anyone could open up an ambulance service and the cheapest costs and the best service would win.
Unfortunately that’s not the case. It’s like day care. Day care is expensive because the government mandates it to be expensive. Otherwise you’d have grandmas down your street would gladly watch your kid but it’s generally not allowed for more than a couple kids.
Same thing with houses. I have half an acre. Could easily put 2 affordable tiny homes on it. Good income for me, cheap rent for someone else, but, unfortunately it’s legally blocked
Again, if you are busy dying, you (or, more likely, the bystander who calls EMS on your behalf) do not have time to check how much the bill will be, or who has the best response time to your location at that moment, or the best equipment, or the best training.
Again, if people are doing it cheaper, how could a 13k per ride company stay in business? 911 services would have to be steering them to an insanely bloated expensive company. That wouldn't happen. Competition brings better service and much cheaper prices, always does, without exception.
There's a distinction between 911 emergency ambulance service (respond to people calling 911) and interfacility transfer service (transfer stable patients between hospitals and medical facilities).
When you are an ordinary person calling 911, you can't meaningfully shop around in that emergency situation. The competition that exists is between the possible organizations you local government could contract to run the system. The safety regulations and medical standards they set are part of them choosing what they feel is the best "deal" for their population. (In some places, all 911 calls are run by public fire departments; in others, the government contracts with private companies.)
At the IFT level, again it's not generally possible for patients to choose their service, because (as explained in the article) ambulance services inherently need extensive infrastructure with large fixed costs at every location they serve. You're not going to fit 20 ambulances from 20 competing companies in one hospital's ambulance bay, and those 20 competitors aren't going to be able to afford to pay employees to sit around for hours at that hospital on the off chance that maybe today patients will pick them and not the other guy. The costs for the ambulance company are not primarily per-call, most of the expense is to stand ready for a call whether it happens or not. Instead, competition generally happens when the hospital chooses which ambulance service(s) to contract with.
Again, as I keep explaining, if companies were free to compete then even 911 is not going to redirect you to a 13k ambulance service. Why would they unless they are getting payoffs. It doesn't cost anywhere near that to transport you.
The idea that everything gets better if we remove all regulation is one we know doesn't work. It's the model we've tested repeatedly, before each piece of regulation, and it always leads to negative outcomes.
I think one of the most aggravating things about interacting with the health care system is losing control of cost/risk/reward tradeoffs. The mandatory transfer and ambulance ride in the linked story are an excellent example. I think I'd have walked out against medical advice in that circumstance, but there is the constant danger of being subjected to similar costs, both monetary and physical, when I am less conscious or at a serious informational disadvantage. The need to bring a patient advocate with you to the hospital whose role echoes both doctor and lawyer is becoming quite serious.
The genius part is that the negotiations that determine how much they can get away with charging completely excludes the consumer. Two for-profit entities, with no mandate to actually provide care, decide how much they should pay each other.
Years ago i slid down a bannister at a dance club, caught my foot, flipped over backwards, and landed on a barstool. Having grown up poor as dirt, i knew that calling an ambulance would be at least a grand if not double that. I called an uber to take me the 15 blocks to the hospital.
Total cost was 70 bucks (10 bucks for the uber, 60 for the er copay).
The number of people here in the US who use uber as an ambulance is waaay higher than you would think.
There is a gigantic business called "NEMT" "Non-Emergency Medical Transport" that has been filled by taxis and rideshares for decades. I first discovered this service when I broke my leg in 2006, and Medicaid was paying for taxi vouchers so that I could travel to far-flung orthopedic appointments over the span of 9 months. Otherwise I'd be on the bus, on crutches: ouch!
So NEMT can cover a lot of use cases where people are stable and just going to PCP or specialist visits. Or even behavioral health appointments. There are now dedicated NEMT providers, like Veyo out of San Diego.
In fact, when I broke my leg, there was talk of calling an ambulance. But I was only about 3 miles from the destination hospital, and there were many wise people nearby, so several of them suggested I just call a cab and take the cab to the E.D. instead, because that was far more efficient. So that's what we did, because really, I didn't need any life support, or blood transfusion, or rescuscitation on the way there.
Since the billing SNAFU last Thanksgiving I also learned about the difference between BLS and ALS. For some reason the ambulance provider billed for ALS even though none of that was necessary. Of course, ALS costs more and bills more and probably profits them more. I should have contested this stupid account trick, but whatever. They haven't even billed me for the "co-pay" yet, so we still need to wait and see how this shakes out.
I had an ambulance ride on Thanksgiving Day last year. And the punchline was that with my ACA insurance, the "ambulance run" co-pay was $1,200. (Of course my total ambulance bill was around $1,310.)
There was a long period of back-and-forth with calls and website visits, where they were insistently billing the wrong insurance, and so forth. But I'm grateful that I used the ambulance at that point in time.
The key advantage to an ambulance ride is bypassing the Triage Nurse. If you're going to an E.D. and you take a ride-share or a friend drives you, then you'll go to the registration desk and then meet the triage nurse. And the Triage window is pretty good at conserving hospital resources, and de-prioritizing you if your issue could be handled by Urgent Care or your PCP on a weekday.
But if the ambulance gets called to your home, it's a foregone conclusion that you really, really want to go to the E.D. and the ambulance crew will Keystone Kops their way to a successful hospital drop-off. They'll take some vitals and ensure that you're stable, because if you're not, they can save lives, and keep you alive during transport. But if you're conscious then they ask that $64,000 question: "do you want to go to the hospital?"
Once a few years ago, a nurse in a clinic had called 9-1-1 on my behalf and it was actually difficult to refuse a hospital transport. The EMS crew put me on the phone with a hospital attending physician and I had to emphatically refuse transport several times, after being advised of all the risks. (My only issue was elevated blood pressure. C'mon, guys.)
One of the troubles with ambulances is that they are really overkill for many calls. If some homeless dude goes unconscious on the curb, they get called. Some neighbor was going to call 9-1-1 because I laid down briefly near the pool. The ambulance and its crew is highly equipped to save lives and respond to the worst trauma cases: multi-GSW, car accidents at 70mph, etc. But I called them because I had a bad headache. And that's why they got to bill so much: they cost a lot! And I bet that a lot of uninsured deadbeats default on their ambulance bills, and the City gets to eat all those costs.
But the times I've transported myself to the hospital, I kinda got blocked by Triage, and it was for my own good. This last time over Thanksgiving, I had a lot of issues, and isn't it always the way that they hit at the beginning of a holiday weekend? So, it was good I went to the hospital.
But I was flabbergasted that my "co-pay" was 92% of the ambulance bill. I don't know why, but that plan has terminated anyway, so there's no arguing about it. At least, my actual hospital bills were well-covered by that plan.
Yeah I would bet the vast majority of ambulance rides are never paid for. Homeless, street people, the impoverished, the uninsured, the unemployed... none of them will ever pay a dollar much less thousands for an ambulance ride. And in many areas those are the people who disproportionately use ambulance services.
> The key advantage to an ambulance ride is bypassing the Triage Nurse.
This is going to depend on where you live/the particular hospital. A lot of "frequent fliers" figured out this loophole and started abusing it where I previously lived, so there was no way around the triage nurse.
I've treated people with panic disorder who, if there were no cost involved, would probably have called an ambulance monthly for suspected heart attacks.
I wonder how countries with universal healthcare coverage deal with the lack of a (dis)incentive here. Maybe they just eat the cost?
Aside from the funding mechanism being a premium that everyone pays, the other part of the motivating story here that seems downright silly is:
- the patient was _forced_ to take an ambulance to another hospital, but not to be treated for anything in particular.
- the post goes into how the EMS system is expensive b/c you need trained paramedics and expensive medical equipment and such -- but sometimes they really do just need to move a patient, not treat anyone in the field or en route. Saying that you pay for the paramedics even when you're effectively just being moved between facilities _also_ seems wasteful.
Yes, we should share the cost. But once we all share the cost, maybe we should try to spend the public dollars effectively by only using ambulances when they're needed, and distinguishing between "transport patient who can't sit upright and buckle a seatbelt" and "try to stop their arterial bleeding as you speed towards the hospital".
> There are parts of the U.S. that do this already. Ambulance rides are already subsidized by taxpayers in most places, thanks to public funding for fire departments; and a growing number of places have taken this further.
Indeed, in my county that's the case along with a $60/year subscription program to indemnify yourself against further costs:
i think i read many warnings or jokes about this: when go to usa, dont call an ambulance because it's so fucking expensive..to compare, in china, it usally cost less than 100USD.
> In 2020, Congress passed the No Surprises Act, which banned surprise balance bills for most parts of emergency care. But by necessity, it exempted ground ambulances from the law: actually restricting the practice would have rendered much of the EMS industry insolvent.
Right, but air ambulances are subject to the No Surprises Act, and we somehow still have those.
Also, ERs are subject to the No Surprises Act, and they do some pretty damned expensive things. Plus, if you're seen by an out-of-network practitioner in an in-network hospital or ER, no you weren't: No Surprises Act forces them to accept QPA and not balance bill. Somehow all of those out-of-network anesthetists and radiologists are still in business.
This isn't sustainable. You really want every person who is dealing with this bureaucracy to manage negotiating between their insurance and their EMS? After they've just had a significant accident/health issue?
“ This time he didn’t have a choice. He was loaded into an ambulance for a six-mile transfer, evaluated without additional treatment, and sent home the same night.”
This is weird, why didn’t he have a choice? I have literally walked out of a hospital with IVs still attached to my arms when I disagreed on course of treatment that included hospitalization for a case of white coat syndrome. They also wanted me to wait one hour to sign a waiver, which I unkindly refused.
Yeah you're always free to decline medical services. Nobody can make you go to the hospital (unless you're unconscious or in delirious but then you aren't deciding anything).
He refused to go in an ambulance the first time. He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.
As an EMT if you're A&Ox4, alert to time, place, person and event, you make the choices. You do sign a release so we have proof we didn't abandon you, but you make the choice.
My department, a small rural one with a small tax base which happens to cover a lot of injuries because we have 20 miles of dangerous mountain pass freeway and a ski and mountain bike area, only charge for calls if we transport. I think a transport is around $900. Our minimum transport is 37 miles. We scale it down depending on income and type of event. We're not massive sticklers about it. We're just trying to cover wear and tear on big expensive vehicles for all the non-transports, winter driving, equipment, uniforms, training, etc. Most of our "business" comes from "transients" eg folks who don't live there, eg those skiing, hiking, biking, or driving over the pass.
This is also very much not the norm. But should explain a bit about those who do pay are covering those who don't.
We don't want a chilling effect on calling 911 for precautionary stuff. We'd rather show up 99 times and check people out and let them go than miss the impending cardiac event. And we get those. It's very interesting just how much going over a 4k foot pass stresses people on the edge. Many of our medica calls are people driving to seattle for deeper care and things exacerbating when they get to 4k feet.
I don't think the question is "Should ambulances be a thing?" though. It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"
The (fairly obvious) answer to that no one should be in that situation. It's horrible. Society should find a better way to pay for ambulances. Most of the world has accepted that some system to spread the cost among everyone is better than putting people in that situation.
Is this the common cost or is this an outlier blog story that hit it off. Talk real data to me. I don't get excited about any individual anecdote (unless it's me personally of course).
No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.
I know that John Oliver is a bit of a “lightning rod,” for many folks, but he (or his staff, really) does his homework. He did a segment on it, some time ago: https://youtube.com/watch?v=Ezv8sdTLxKo
There’s a thin line between satire, which can convince, and sneering, which can only turn off. John Oliver, unfortunately, does end up on the wrong side of the line from time to time, and can (together with his core audience) be something of a bully when he does.
I’d also be careful about his facts: they’re usually well-researched, but by the nature of the format he only ever presents those which fit his argument, and that’s just not good epistemology. I can think of a few times when the show made me feel safer about my beliefs than I should have been feeling.
>So why not make fun of them? There's no downside.
...except the populist right backlash, triggered in part by their resentment at coastal "elites" (think yuppies, not people who fly to davos annually) sneering at them.
The "coastal elites" they resent are made up by conservative media. No behavior changes by the yuppies can affect the ever-increasing resentment people feel in response to this sneering bully, because the bully is made up and the tendency of RW media to use ever-more-dire portrayals of supposed societal ills.
As an aside, I think the culture which produces this result is related to people in the US always thinking crime is increasing, regardless of actual crime trends.
Well over a decade ago, it was $6500 for a couple mile ride to the nearest hospital, no emergency medical care necessary (just supervision). This was in the Bay Area, in California.
That's wild. According to the website of my local ambulance organisation, a full on ambulance ride with all medical supervision etc runs between 400 and 900 euros. Typically this would be reimbursed by the (mandatory in this country) health insurance. This is in a large city in western Europe, I would expect it's cheaper in places with lower cost of living.
Yeah my mom got billed 9k a few months ago from SFO to one of the south sf hospitals. Neck brace and supervision was all that was needed. Basically an expensive uber ride.
> Society should find a better way to pay for ambulances
Society has this figured out, at least a decent solution that works until we find a perfect one. Only the US society seems to be unable to find a solution.
And the US also pays a TON of tax dollars to a broken, overregulated system.
IIRC if you look at the cost of Medicaide, Medicare, VA, and other federal and state spending it's the same as most other countries per capita or as a percent of GDP. The US taxpayer pays about as much as Canadians to fund their public system, then pays the same amount again for private cover since it's not universal.
No I'm not making a typo. Medicare, Medicaide, and the US system is such a rip off that per capita Americans are paying similar tax dollars to their joke of a public system.
But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.
All nations are nations of immigrants other than maybe the cradle of humankind. They stop being that generally when the state and benefits get so expensive that administrating them and paying for them becomes a huge burden. The original immigrants to America fought the land and many died to tame it. Coming now to take is not the same thing. Particularly when you can fly in, give birth to an American, and fly out again.
Immigrants provide a net economic benefit on average. If they work here, they spend here. They tend to be younger and with our aging demographics it’s really important that we have more young people entering the workforce.
This is just GDP, which isn't that relevant. If you add a million people and only one of them works, GDP will still go up. It doesn't take into account the following:
- no-one's talking about immigration in general. They're talking about mass immigration. So any general "look how immigration can be good" is not addressing the issue
- mass immigration means that housing becomes scarce, driving up prices. This again makes GDP look good, because stamp duty revenue goes up and so do estate agent fees. But all the many negative externalities, such as everyone is now buying houses 10 years later, and leaning on their parents, and their dwellings are all being subdivided because even a tiny place is now worth renting out or selling, are totally ignored. The housing costs drive every other cost up. Minimum wage / living wage needs to skyrocket just to combat this one thing, both because people need more money to pay for their own accommodation, and people need to afford goods and services that are all also being made more expensive because their salary costs need to increase for the same reason.
- mass immigration spikes up demand for power. Power is often a large capital investment, which means that the country borrows a load of money from Macquarie Group to build it, with lots of interest paid back over decades. Seems to generate GDP as people are being paid to build things; actually a net negative all told over the lifetime of the investment.
- the same as power but for water.
It's important we have young people entering the workforce. But it's just incredibly obvious that adding more people from external sources is not sustainable. When they all get old do we import more people? Or should we just be repurposing the millions of young people who are doing less important but less icky jobs to do the jobs that we're currently getting immigrants to do. "Who will pick the cotton?" is not a good question.
Net economic benefit is not only GDP, it includes net tax over government spending. Immigrants are younger so they have more regular taxable income (vs capital gains), while spending more of it (vs saving) and drawing less government benefits.
The housing shortage is driven by NIMBY and regulatory capture. You are right that perpetual growth is unsustainable but we are not remotely near the possible carrying capacity of our land and resources. We have had periods of much greater population growth that were accompanied by greater prosperity overall.
Immigrants are not the problem, they are the convenient scapegoat of the business interests that have systematically hollowed out the middle class over the last 50 years.
My entire region has been overrun by Mexican immigrants. There are more Mexicans here than Mexico. They are poor, and they bring their poverty with them, driving down wages and sales prices everywhere and turning the place into a slum. The locals (natives) aren't the beneficiaries of this arrangement. Only the governments and businesses.
Since when is the constitution leftist? Birthright citizenship isn’t a left or right question at all in Europe. It’s not a thing there. Neither left nor right wants it.
This is a common claim, but it is a misleading simplification of US politics and European politics. (In simple terms, many of the economic positions taken by the Democratic Party would be considered centrist in Europe, but if you include positions that have been taken on immigration, identity politics, criminal justice, reproductive rights, etc. it would not.)
>But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.
17% of GDP is healthcare. So between 1:10 and 2:10 people in this country are making more than they otherwise would (note I did not say wealthier) because the system is screwed up and hoovers up more of everyone else's wealth than it ought to.
Slavery was 12% and (while obviously geographic concentration of industry plays a lot into it) it took a war for them to take a haircut.
Earnings represented by GDP are not distributed evenly across a given population. That 17% of extra earnings goes to relatively few people in the States (I'm putting this very mildly, the concentration in reality is insanely lopsided).
The US healthcare industry is ~10% of the workforce. More if you include people affected by the supply distortions thereof (all those techbros working for agentic penis pump startups).
The fact that that pie is not sliced evenly does not change the fact that is an integer multiple larger than it ought to be.
I easily see that changing the USA to be more socialist, especially in areas where game theory indicates its the best solution, will likely take a civil war.
That also aligns with Marx's writings, that the capitalists will not acquiesce without a fight, and a big fight at that.
The slavery and Civil War connection is a comparison of similar economic magnitudes.
Certain specialities probably are overpaid (orthopedics), but others like pediatricians or general practitioners usually aren’t.
And nurses!? From the nurses I know they are underpaid for what they deal with.
The ones making loads of many are willing to travel around the country and uproot their life once or more every year. Not exactly a lifestyle without its drawbacks.
Everyone is gonna say nurses are underpaid. It's a caring, female dominated profession, it's a motherlove sentiment. And they are not paid as well as doctors.
Yeah, most pink / blue collar workers in the US are badly underpaid, but IIRC ones in the health sector are some of the best off, relative to medium salaries.
Compare teachers and nurses. In most countries they make about the same AFAIK (and I'd say nurses do deserve more, telling a parent Billy did badly on a math test has got to be easier than explaining a bad medical test). But in the US it's about 75k vs 95k. There's a huge premium for working in health in the USA, EVEN in the underpaid blue collar end.
Doctors make out even better in the US, and the c suite in health can have salaries that are just insane.
I don’t dispute this, but I also don’t think it matters. An underpaid profession being paid more then a severely underpaid profession doesn’t make the former overpaid.
McKinsey did a nice analysis of what is driving US healthcare costs. It compares category spending to OECD then compared price and volume.
Turns out the US pays a bit more for drugs (relative to total spend), a little more for inpatient care and a TON more for outpatient care but half of the increase is volume, not price.
As someone who works in healthcare globally, the difference in US care is stark. Americans get much early and more access to new technology than other countries.
If your lymphoma has returned and you have a 20% of living more than a few years the best care is CAR-T with cure rates close to 60%.
Check out CAR-T rates in the US versus Europe, it’s almost 3x. The US started using it in 2014 and Singapore just started paying for last year (11 years later). Even in Europe adopt only ramped up in the last 5 years.
So yes prices are higher, but a big part is more aggressive care with more expensive treatment.
A good tell that someone is utterly full of shit on Canadian healthcare is that they generalize all of Canada.
“Canadian health care” is not a thing. Each province administers its own completely independent system. Someone on PEI is in a healthcare system that has as much to do with Alberta’s healthcare system as it does their neighbours in Maine. As a result, anyone referencing Canadian healthcare is talking about a dozen or so unrelated systems that do things very differently.
You can safely dismiss anyone that has reduced that complexity, or is completely ignorant of it. It’s a great way to tell when a foreigner is spouting talking points they picked up from an unreliable source and did not do even a minimal fact check on. “Canadian health care” as it is talked about in the US media is frequently fiction for propaganda purposes.
Canadians talk about problems within a province.
No idea if the rest of his statement is poorly sourced propaganda as the first sentence.
You’re ignoring the fact that provinces can’t fund technology that the federal government hasn’t reviewed and negotiated a price for.
So yes there may be differences between provinces in terms of when they fund what restrictions are put on it, the overall trend across Canada is pretty consistent.
And as I said Canadians don’t get the same care as Americans so concluding the higher cost is entirely higher prices for the same thing is false.
I lived in Ontario for 20 years then I lived in Seattle for the next 17, I assure you that the healthcare I receive and received is pretty much the same - except in Ontario it's way cheaper.
You're talking about cutting edge technologies available to the tiniest sliver of people - I'm not even able to get access to much of them with my private FAANG insurance - and drawing a false comparison.
Nope. I've not only lived in both countries, I work in healthcare so I'm very close to who gets access to what.
And it's not "the tiniest sliver of people", we're talking about disease like cancer. Check out the CAR-T rates in the US vs. Canada, the difference is stark. And CAR-T is standard of care in some types of lymphoma.
Hell, ask parents with autistic kids what kind of early intervention is available to them in Canada. I had a coworker who moved to the US so he'd have much better access for his kid at a time when it had a big impact.
Look at access to the cystic fibrosis therapy that effectively cures it (e.g. Orkambi). It was paid for by insurance (and Medicaid!) from the day it was launched and avaiable to everyone it could help. In Canada some provinces just started paying for it, but only kids, adults are shit outta luck.
And I don't know the details of your FAANG insurance, but my US insurance (typical corporate insurance) pays for all these new technologies.
Canada is great if you have a routine issue. If you need something specialized you're going to be treated with therapies that are a decade or more old. Hell, even the CBC wrote a whole story about 2 friends with breast cancer and the differences in treatment.
"Then I found out that this other country — which I thought had a healthcare system that was so superior to the U.S. — doesn't test for the tumour marker that saved my life, and doesn't cover this drug that is responsible for pushing my cancer into remission after traditional chemotherapy failed to do that."
The US healthcare system just upsells on unnessessary crap. It's junk volume or at best it's heroic high tech solutions mostly making up for the fact that people stay away from hospitals until it's too late.
US care is highly aligned with international guidelines. Saying "it's junk volume" just tells me you're not that close to the data.
Life expectancy doesn't measure quality of healthcare, there are far too many confounding variables like genetics, diet, accidental deaths, etc. No serious study of healthcare quality relies on it.
Look at 5-year cancer survival rates. The US is better (significantly better) in many of them than other countries. A big part of that is access to the latest technology.
Now do maternal death rate. Like I said, a good place to have cancer but they aren't good at stuff that matters.
The US leans aggressive on tests and heroic end of life care. I doubt youreally disagree (except on whether you think it's a good call). That is where the money is, since the insurance company can be forced to pay.
Read "When doctors die", the US is the total opposite - everything goes to the big ticket aggressive (and yes, modern and cutting edge) treatment where it's hitting diminishing returns. https://pmc.ncbi.nlm.nih.gov/articles/PMC6179868/
Turns out the CDC changed the way it counts maternal deaths, while other countries didn't, so you're comparing different measures.
The old US measure was deaths that occurred during birth or shortly thereafter, now it's within six months and they added a check box only asking if the woman had been pregnant in the last year.
> US doctors are overpaid. US nurses are over paid.
Median pay for a Nurse Practitioner is $132K/yr [0]. I think that's reasonable.
Average pay for physicians ranges from $220-450K depending on specialty. [1]
Personally, I think doctors should be paid more than software engineers, so I think those numbers are all reasonable, especially when you consider what it takes just to enter the field. Nurses require a Master's degree. Physicians need a Bachelor's degree PLUS another 4 years of med school AND THEN a residency program that lasts 3-9 years depending on specialty before they finally earn their medical license.
IMO, the idea that nurses and doctors are overpaid is quite simply ludicrous.
You might find those salaries reasonable, but they’re probably double what those same occupations pay in many other (first world) countries with lower healthcare costs. Maybe the trade off is worth it, but it’s not something that can be ignored when people complain about how much more expensive healthcare is in the U.S. compared to Europe (for example).
> but they’re probably double what those same occupations pay in many other (first world) countries with lower healthcare costs
You'll find that salaries across the board are lower in other countries. Software developers in Europe make half of what they do in the USA. In exchange, they get far better benefits.
Also, physician salary only makes up about 8% of total healthcare costs [0]. Cutting salaries in half wouldn't significantly lower our healthcare costs.
No, certainly just cutting physician salaries wouldn’t make a big difference. But cutting salaries for everyone involved, including physicians, nurses, and administration would. I’m not saying we should do that, but just that people seem to ignore how much higher salaries are in the U.S. when they compare healthcare costs to other countries.
> In Tulsa and Oklahoma City, meanwhile, the government buys staffed unit-hours from an ambulance operator, while households can prepay a few dollars a month on their utility bill and owe nothing if the ambulance ever comes.
billed for buying unit-hours from an operator... that's very carefully worded to make it sound like a corporation<>customer relationship and not socialism.
Lots of policy in the US is hacking around the lizard brain idea of "We cannot have nice things because someone who doesn't deserve it might get it."
My favorite example is universal school breakfast and lunch. Without fail, someone will argue that some kids don't deserve it. It doesn't matter that all of the data shows it is more economically efficient and the benefits to kids is overwhelming.
You essentially described the Republican and Libertarian perspectives in the US.
The Republicans seem to see it as immoral to potentially give a few people support they don't need even if that means that most of the people who need the support actually get it. And, instead, they believe that having an inconsistent array of private interests will somehow be more able to service an enormous population than having an organization (like government...) that is large enough to match that population's needs.
The Libertarians seem to either genuinely not care about the rest of the world or, more often than not, seem to be naive about how life can be for the less privileged.
It's the lie of the "rugged individualist" in America. Most "successful" people come from successful families. Social mobility, in the US, is part of that lie. Here, we celebrate the person who rises from poverty to become wealthy as a member of a sports team, or as an actor, or similar, while disregarding that these massive successes are outliers.
Sorry 'bub but the Democratic party is as much to blame as republicans. Neoliberalism has infected both parties and let us finally shed this fake reality that the democratic party is the party of labor and not corporations.
Good news is that if you want the democratic party to become the party of labor, now is the absolutely best time to have a real impact in your community.
> The Libertarians seem to either genuinely not care about the rest of the world or, more often than not, seem to be naive about how life can be for the less privileged
No, they just put boundaries on what services they want handled by the government. Government programs are the least efficient and most wasteful way of getting a job done, and there are endless examples of this.
Churches were historically the places people went to for assistance, and churches held people accountable and would push them to fix their underlying issues.
Government programs have none of this, you can keep making the same bad decisions and nobody will hold you accountable and the benefits will keep coming in.
Christianity died in my country because people got tired of the judgemental, hypocritical cunts. The child abuse scandals that hit later only confirmed it.
You’re attributing to government what is just the overwhelming population: predatory men. Sometimes teachers, very often religious institution participants; positions of power, trust, and/or authority used to control.
I am not.
School teachers are predominantly women (around 90%), single parent homes are primarily run by women, women play the largest roles in the raising of children in genetal, and also make up about 35% of domestic abuse reports (not accounting for all the cases where men are too ashamed to report the abuse).
Women commit just as much sexual abuse as men, it's just not talked about by society.
The government is in a bad position to be that kind of paternal - any sort of large machine is the worst possible judge of the difference between "shit happened" and "I am systemically making incorrect life choices".
I agree that what you need here is someone(s) with leverage and respect in your life to interfere with systemic bad behaviors if they exist, but that takes community, government merely gets leverage, and churches are often not a welcoming place to many people's eyes, rightly or wrongly, around the US.
As I get older, I'm increasingly of the opinion that the best you can do is unconditional support from the government (because it's the only kind you can rely on no humans in the chain acting in bad faith to condition), and well funded local support structures for people to subsist while fucking up their lives and also help them get out of that spiral if they want to.
Not because I believe in some fundamental good in man or something, but because I think that's the only way you can design this that isn't subject to people's bad faith manipulation, and I've personally seen too many cases go wildly differently for "objective" criteria where the main difference seemed to be whether the person reading it went into it assuming you were lying or not.
It's interesting to note that very often these same Republicans have no issues at all with large tax-based incentives when they help their employers or knock some dollars off they yearly property tax bills.
It just boggles my mind how the poor are supposed to be continually punished just for being poor and should always be denied, almost by rote, any sort of government aid because, you know, did you hear that story about that fentanyl addict who was found with THREE active EBT cards in his wallet?
Yeah for sure...how dare some dirty addict should be able to eat!
Come on, across the world we prepay for the use of things regardless if we do or not. As described in the article it's an option, not a political system.
Unable to be willing.
The combination of not knowing any better, political parties and media that don't care or exert a contrary pressure because they belong to billionaires, and powerful health sector businesses appears to be very effective.
The odds are stacked, but everyone still has free will and can choose to question what they’ve been told (especially what they’ve been told conflicts with what they can see with their own eyes).
Why is Fortune the relevant list? Why not market cap, which also happens to correlate with net income, which means more cash to spend on political influence?
Mostly only pharmaceutical healthcare in the upper tiers of that, but these businesses still have market caps and net incomes literally one or two orders of magnitude separating them. Grouping top 10, 50, and 500 makes no sense.
> Only the US society seems to be unable to find a solution.
US society has been spending a fortune on USAID funding the world's social action projects, NIH funding the world's medical research, and the US military keeping shipping lanes safe (at least until recently), and taking in a million or so people a year from other countries. That vast generosity means other countries can just spend on their own citizens and feel superior for doing so. That's why all that stuff has dried up - what's the point in spending on others when they look down on you for doing so?
Surrounded by the barbarian warmonger nations of Canada and Mexico, the US has to increase its military budget to close to a trillion to pay for wars it definitely hasn’t been single-handedly starting since the 1970s while the USAID budget which is 5% of the military’s which tries to eradicate tuberculosis and malaria needs to go. Makes total sense.
The war in Iran in MAY was reported at 29 billion dollars. It's probably been a bit more since then. Justifying stupid actions because you hate brown people isn't good for any of us.
Canada doesn’t pay for ambulances unless it’s truly an emergency. Think you’re having a heart attack but you’re not? Time to pony up hundreds of dollars
Even with insurance all these companies will fight with each other to find excuses to say it’s not their responsibility and send you letters non stop saying things like “oh you paid for the van, I’m just the nurse, it’s separate” or “oh yeah you paid for the hallway in the hospital but the ct scan person is a contractor, you owe them 3k”. System could not be more broken
>It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"
Yes, you want to make that choice rather than shirk it off. Anything else is a perverse incentive. Making poor medical choices that prioritize your own well-being over the financial solvency of those you care for, those around you, is a shitty thing to do. But, some people like to pretend that if they can just make sure those people are the 300 million Americans rather than a more immediate circle of family, that the problem goes away. It doesn't, it becomes worse.
Most decent people would rather croak than ruin their own family. But those same people, through one false rationalization or another, are more than happy to ruin the entire country. Even if doing so won't result in net benefit. If I'm going to live, it's because the cost of keeping me alive is less than the net benefit of my increased lifespan. That calculation has to be the same no matter how you want to "spread the cost among everyone" or it all falls to shit. And since you're incapable of making rational decisions when it's spread further than your own family, well... things are going to continue to go downhill.
Well, you don't know how rotten the industry is.
Your moral social-darwinism just enriches a couple of suits, nothing more, instead of spreading the costs you could very well start by making sure the costs are not inflated.
x2..x5 multiplier is always applied to any ambulance bill as far as I'm aware. I worked in that industry.
This shit is exactly the problem with capitalism and capitalists.
I've seen as long as I've been alive, "Communism killed hundreds of millions!!!" breathless claims.
When Capitalism kills, oh wait, it never does! Its always "bad individual choices", and never a review of the terrible for-profit system that caused it to begin with.
> Making poor medical choices that prioritize your own well-being over the financial solvency of those you care for, those around you, is a shitty thing to do.
And there it is. The system is highly predatory as intentioned. But the system is just part of capitalism, so its OK. But 'YOUR CHOICES' are the one that's bad, aka blame redirection.
And guess what? More and more people are seeing behind this facade that capitalism is good. Socialism is better. We're tired of being extracted, used up, and thrown away. Its why I'm also part of DSA. I'm done with this individual blame for systemic shit.
The increase in healthcare costs is more a function of an aging population, rather than people (mis)using ambulances too much. However in these countries, although the rates are fairly low, misuse of ambulances is often heavily linked to poor levels of health literacy or lack of transportation options - though the caller often genuinely perceives it as an emergency - both of which can be improved through other programs such as education and public transport provisions. It’s almost as if providing good public education and transportation makes the population more productive and less wasteful.
I refuse to play these games. If you wish to make the argument that universal healthcare (including cheap or free ambulance coverage at point of use) necessarily leads to financial ruin you are free to make that argument, along with all the necessary support such a position requires. If you do not wish to do so, then I have no issues and thus decline to make any argument otherwise.
I am not obligated to make your argument for you, and I am not inclined to calibrate your motte-and-bailey merely because you feel like interjecting your support for a position you would call a strawman when called out.
No, I just don't see any point in debating anything when you presumably agree that nobody is being bankrupted by free ambulance rides given that you called it a strawman. If you wish to defend what you called a strawman, which I didn't think people normally did in good faith but could be convinced otherwise, then I am willing to let you set the definitions you wish and make a case, as is standard for those instigating a discussion, while reserving the right to decline further participation if my disagreement with the position is below a certain threshold and/or any other reason I might find the discussion unproductive.
I'm amazed that in ~450 comments, the word "capitalism" is mentioned in just one - yours - and you've been downvoted for criticizing it!
It seems even a group that purports to be rational critical thinkers don't want to be rational critical thinkers to the extent of looking into the root causes.
The problem with capitalists is that if you wanted, they'd let you go do your little commune thing somewhere. The problem with communists is that if you're not a communist and you can't be reeducated into becoming one, you must die. Or if you're the wrong kind of communist. Or if you're the same kind of communist, but you also want power. Or if you don't want power, but they think you might some day. Or if you're related to someone who might want power some day.
But no, I won't be a communist with you. And if you insist, things could get ugly. Fortunately for me, you're still in your hipster-college-champagne stage of communism, and you're both scared of violence and worried about the PR backlash of being found out to be a bloodthirsty savage.
In November when it becomes apparent that the Democrats won't win back seats, you'll all start to panic. But the real fun will come in 2028 or 2030, when Obamacare will be dismantled. I can hardly wait.
> It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"
Only a complete moron would think the answer to this is no. If there's no personal cost to using an extremely expensive service, every one is going to use it regardless of whether it's actually necessary. It will quickly turn into a free taxi service for anyone who wants to go anywhere near a hospital.
The only way a free ambulance system could work is if there were harsh penalties for people who abuse the system. Unfortunately, the American Democrat party has shown countless times that they have no interest in preventing fraud. Prominent Democrats like Tim Walz and Gavin Newsome have spent more time in the last year pushing laws to protect fraudsters than prosecuting them.
So in your eyes, the population of several western countries is (and has been for decades) dominated by complete morons, resulting in free or almost free ambulance rides?
And what does the Democratic party have to do with all that? Your whole comment just seems like a thinly veiled and insulting political rant. Going by your account name, this seems to be a pattern.
So people should be getting financially ruined to god-forbid prevent some abuse of the system? As long as there is no abuse everything else is hunky-dory?
I've been there before. I had a high deductible health plan, it was December & I hadn't used any of my premiums... I had a heart attack (I didn't know it at the time). And my mind went to "but my premium! I know, I'll walk myself to urgent care instead of taking an ambulance to the hospital"
I remember this came up during COVID. The government was worried that homeless people and illegals would be afraid to report symptoms. GPs are specifically free and don't have to ask for papers or insurance to combat these health crises.
Under distress, yes. But honestly, I did piloting a little (airplane and various soaring aircrafts), and think that thinking there is also under distress, and that's ok, you still need to make decisions, that's life.
You’re getting in an ambulance, not calling a cab. You’re probably unconscious, maybe at least disoriented, overwhelmed, concerned about what’s happening more than doing math. Also you’re there on the floor bleeding, what’s your alternative? “Nah don’t worry, I’ll figure out this exposed fracture in the uber, I got points with them so it’s cheaper”?
I had fractures several times, and I did think about the costs. In fact, the last one was pretty bad, andy first thought was "good thing I'm in a country with good medical care, even though expensive".
Really? Where I live a patient is always able to refuse any medical procedure or treatment, unless they’re unconscious or otherwise mentally unable and the procedure is considered necessary to save their life. They certainly can opt for a non-ambulance transfer, though here it would be free even though a regular ambulance service typically isn’t.
Consent for treatment is a core principle of medical practice.
>> We scale it down depending on income and type of event. We're not massive sticklers about it.
That touches on another very american problem. The injured person now does not know how much the tansport/treatment will cost. And the persons on the ground cannot quote a price. If they say yes they enter into that zone of having another random health care bill comming in the mail.
I had an accident where I had a concussion and other injuries that put me in a lot of, and the people I was with called an ambulance for me, and I wasn't really in a state to decline, but if I had been, and knew how much it would cost, I would have. The ambulance ride was, of course, out of network. As were some of the doctors that treated me once I got to the hospital. It was the first time I dealt with a major medical expense as an adult, and it came as quite a shock when the bills came several months later, that said I was responsible for about $10,000 for the ambulance (plus a lot more for the hospital), and a good chunk of it didn't even count towards my deductible because it was out of network. I later learned I should have contested that since it was an emergency, and insurance is supposed to cover out of network service in an emergency, but I was young and inexperienced with dealing with health insurance companies.
I guess my point is, sometimes you don't have a choice, but you still end up with a massive bill. And also, that experience definitely had a chilling effect on me calling 911.
I can literally buy a nice house with that just outside the city. And we somehow have universal healthcare despite the average salary is not even one-tenth of American.
Being concussed should count as not being fully aware. And making someone pay something that he was made to accept while not fully aware should be denounced as a scam.
Can't you simply argue: I never agreed to this, so I'm not obliged to pay this.
Americans love to pretend that healthcare can somehow be a free market (it can't), but a free market requires voluntarily entering into a transaction. Costs that can be forced upon you without your agreement need to be tightly regulated and subject to clear caps.
My insurance says ambulance rides are covered 100%. Apparently most are out of network though, which the people have no choice of choosing (obviously).
I was sent a post insurance $8000 bill. After months and months of arguing they said it was an error on their side and dropped the charge. Absolutely ridiculous
>> He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.
Disagreed. Someone who is cogent and not intoxicated and not a stroke victim can't always make the best choices. Your decision making can be compromised by I dunno the fucking pain of a broken toe bone.
Seeking help should not be interpreted as a sign of weakness and made into a maze where only the most rational can escape with minimal bills. The longer we leave this cognitive dissonance where the land of the free roughly translates to land of the free to get fucked we are going to continue to have instability.
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[ 3.4 ms ] story [ 141 ms ] threadthe writer really went into depth about the problem and...surprise...the answer is almost embarrassingly simple.
Everyone in the country needs to read this.
> The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.
(Yes, there is some other stuff, much, much, much later that maybe cuts into that …)
So there is a solution.
So compelled health insurance to use an ambulance? You could just as well make it optional and charge people without the insurance the full price.
Government coverage is all well and good until the government (really you) is paying way above market rate.
I don’t think we get out of this by trying to regulate medical expenses either. That will just enrich another cadre of lobbyists and lawyers.
And even if you don't pay this it still isn't that expensive - US$12873 is more than a helicopter transport would cost here. US healthcare companies somehow get away with charging insured patients 10x more than civilised countries charge uninsured ones.
Besides this kind of billing is banned in California now https://leginfo.legislature.ca.gov/faces/billHistoryClient.x...
The insurers just pay the in-network fee and you call it a day.
I think I’m realizing that what I cherish about the healthcare system up here is not just that I don’t pay bills, but that I don’t even see a bill. Not that the bankruptcy inducing costs aren’t wretched, but I just cannot even imagine being put into a fucked up bureaucratic hell while my family is in a life altering crisis.
Anecdote: my uncle and BIL are auto mechanics. One in the US, the other in Scotland. Similar lifestyles - both own homes, have mechanical hobbies (vintage cars for one, Harleys for the other) - typical working class lives. The uncle in the UK just has much less mental overhead when it comes to major life planning.
Would your wife have been in a different location if you had made the call?
Falck has found a workaround: Bill emergencies as "non-emergency" so they can balance bill. This is, of course, fraud. I'm sure that enough don't understand the law that this makes them a lot of money.
The blog mentions it, but it’s one of those obvious things that somehow isn’t solved yet and blows my mind every time it comes up.
Seriously? How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other? The extent I've experienced is stuff along the lines of "thank god I had my health plan, because otherwise it would have cost [6 figures]", but it didn't give the impression that they'd be mad if everyone didn't have to suffer that fate.
Do imaginary conversations in the shower count?
And this is exactly why those same people do NOT want universal healthcare.
Healthcare is not a flex, and it my experiences on the west coast, it's an inverse correlation to wealth. :/
The one to which I was responding was capricious. The one you cited has reasoning, even if you disagree with it.
And that was the whole point of my comment. That by reducing the other side to a farcical strawman, you diminish your own argument. It just becomes a yelling match.
I would rather debate the person you cited than sit complacently with the cynic to whom I responded.
Evil is often very reasonable; pretending otherwise is a 'farcical strawman' of your own.
The US also has decent EMS response times. If you adjust for population density, the US has fantastic response times.
I.e. I was responding to the original "in 'most of the world' EMS quality is ass.", trying to say that you only get that outcome if you compare apples and oranges (developed vs developing)
8-10 minutes in urban areas is pretty much universal (for the developed world). Rural areas are where differences come in, and even there standards for the developed world are somewhat on the same level.
- If you’re comparing to developed nations (or some non developed ones with functioning agencies), the argument doesn’t hold true.
- If you’re comparing to the bottom of the barrel EMS (quality being ass like you said), you’re still not going bankrupt for an ambulance ride.
They were super lucky that someone from the hospice just happened to be leaving at the same time they flipped the bed.
About 65% of the more than one million firefighters in the U.S. are volunteers, with nearly 19,000 fire departments being run completely by volunteers.
I volunteer to give blood. No one is paying me, and yet, someone's life is saved by that.
Some folks believe (in fact, this is the thesis statement of much of anarchist theory) that people would largely volunteer to care for one another if their basic needs were met.
Not everything has to be transactional, you can have a government setting up a scaffold that supports and encourages and organizes volunteers and run an effective service.
The thing about unfettered private health is that it finds "profit centers" and pumps them ruthlessly. But the problem when scheme/scam gets reigned in (say out-of-plan doctors), another appears (out-of-plan ambulances) and there's no end to the situation. Only actual state sponsored health care can end this.
We hope to set the rates such that folks won't have to pay at all if they have insurance or will only have to pay the gap amount insurance would have covered.
I'm collecting the data to figure out how many residents, how many businesses, and how many college students there are in the region and match that to the call volume for those same categories so that each group pays a fair share.
We're basing the legal structure in the MESA group from Lancaster PA. Public fee hearings with residents hopefully start this Fall, and then we're hoping to go live Jan 2027.
I will say I've been surprised how extremely expensive it is to run EMS. Even with 25% of our responders being volunteers, the costs are staggering. Insurance, equipment, medicines, payroll, billing, fuel, building maintenance, heating and cooling.
The vehicle maintenance would turn your hair grey. We have a vehicle in the shop almost every single day. And we have two volunteer mechanics trying to do fixes in house. But these ambulances just are absolutely beat to hell 24 hours a day. My partner is one of the mechanics, and she sometimes gets a half dozen vehicle maintenance reports a day! And we only have 7 vehicles!
And then you have to factor in deprecation on an asset that effectively drops to $0 after 5 years. And costs $300k to replace.
We pinch every penny we can think of, but the end effect is that we're trying to provide a service that's extremely expensive and so we hope this model will diffuse those costs across the whole population (which we expect will turn out to be something like $100/year per family).
Cross your fingers because this feels like our best option
For my city of Ann Arbor, Michigan from https://www.a2gov.org/media/4glhvywf/2025-aafd-annual-report...
FY2026 budget: $20,810,234 Structure Fires: 58 Cooking Fires: 75 Vehicle Fires: 30
So should we somehow recover roughly $127,000 from the victims of each fire?
Of course not. I and my neighbors pay taxes to maintain the Fire Department and have it ready when needed. Many may argue that we pay too much, but those unfortunate enough to actually need its services would probably say they got a great deal.
>This meant that the payment structure and the cost structure were increasingly mismatched: and so ambulance services had to pay for their round-the-clock readiness by billing for individual rides. [...]
>And notably, the fees that Medicare sets run far below cost. The average ambulance transport costs $2,673 to provide; Medicare pays only about $329 of that. A typical ambulance ride for a Medicare patient, in other words, loses theambulance service thousands of dollars.
The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it. The former doesn't imply "everyone else should have to pay for my bad luck"; the latter does. It's effective persuasion.
There are plenty of services that have high fixed costs but low marginal costs, but we don't use the "options" framing. A movie costs tens to hundreds of millions to make, but otherwise costs very little to deliver. Their price are also fixed, rather than dynamically priced. Yet when a movie bombs, nobody is like "wow I guess they shouldn't have been selling an option for 2 hours of entertainment for $20!". It's a price problem, first and foremost, caused by insurance companies and medicare strongarming them.
What on earth would you consider normal for a helicopter ride from Exeter to London?
That's roughly 150 miles as the crow flies. Pilot, co-pilot and a medic, minimum crew for say 1.5 hours. Each way, so 300 miles of fuel and aircraft lifetime and three hours of crew cost, not to mention ground crew etc.
My dad got that on the firm when the shit hit the fan and he needed to be seen by specialists in the Royal Brompton and Royal Devon and Exeter decided that was his best shot at life. That was 15 years ago.
Anyway, the OP's bill looked pretty normal until the 11,000 base rate nonsense. How can that possibly be justified?
I think this ignores the 400 pound gorilla in the room. Why does an ambulance transport cost thousands for the operator? This is a short trip in an automobile, essentially a fancy uber ride. At first one might say that's flippant - obviously ambulances are specialized vehicles, and you have paramedics, and they need to get to locations quickly, and so forth, but let's consider those costs.
A new, fully equipped ambulance is about $150k. Of course this is more than a regular car, but by a factor of 5, not 50. Let's be generous and presume the ambulance fully depreciates in 2 years. Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr. Again, not orders of magnitude more expensive. Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year. Throw in money for gas and wear and tear, which should be quite comparable to other automobiles, and it costs about $1600 to own and operate an ambulance for 24 hours.
Now the other side of the equation is utilization. Taking the arbitrary example of Philadelphia Fire Department, they have 60 ambulances that handle on average 700 ems calls per day, and approximately 70% of ems calls lead to transport, so that's about 8 transports per ambulance per day. So distributing this all out, the actual cost to the ambulance operator, ignoring overhead, ought to be somewhere around $200.
I'm sure there are some additional costs I haven't included in this back of the envelope calculation, and maybe some of the numbers I pulled off google are off a bit, this should be taken as a very rough estimate. But even if you significantly increase the cost, the medicare payment amount seems quite reasonable to cover the expenses with a healthy profit margin. Unless you want to claim that operating an ambulance is less than 10% of the cost of ambulance transport, and that the estimators with Medicare are absurdly out of touch with reality, whence cometh $2,673?
Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.
That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.
Normal commercial insurance is much more expensive, let alone ambulances.
And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels
"...nearly all of [their cost] goes to standing ready—the stations, the vehicles, the crews waiting around the clock for a call that may never come."
The ride isn't expensive. Waiting for it is.
Is it $2600? Probably not. But I think you are low-balling pretty significantly.
Put another way, just getting a plumber to vibe to your house is gonna cost you $200 easy. It’s within reason that an ambulance ride might cost much more than that.
https://www.redcross.org/about-us/news-and-events/news/10-wa...
They wouldn’t be qualified if they couldn’t.
There is zero reason to compare cost of ambulance rides to a plumber and "vibe" on how much more expensive an ambulance ride instead of actually looking at the component costs. They aren't remotely related and one tells you nothing about the other.
Both the actual analysis you responded to and this one are also missing the fact that the ambulance is already subsidized and that usage fees aren't actually paying for the ambulance which makes the fees charged more onerous yet.
It might be instructive to look at what Canada charges non-residence as non-residents pay the unsubsidized rate of about $400-$600 Canadian.
https://www.cma.ca/resources/healthcare-real/answers/healthc...
A plumber charges you $200 to come to your house, it costs the plumber $20 to come to your house. The latter value is what we're discussing here.
As to your specific $200 quote, which others have attempted to refine, it can't be a coincidence that you come up with that number and the Medicare number is $300+, which, if your $200 is even somewhat accurate, seems like a perfectly fair gross margin on what's being delivered. Imagine if the government actually reimburses for cost plus a decent profit margin! Unthinkable the gov could somehow be accurate in their reimbursements.
Edit: spelling
Check out the "No Surprises Act"
https://www.cms.gov/priorities/key-initiatives/hospital-pric...
edit: clarity
We need a regulatory body that can fine people for making analogies this bad
Paramedics and EMTs aren't the same thing. Private ambulance crews running "dual ALS (advanced life support, i.e. paramedics)" are _exceptionally rare_. Normal staffing is Paramedic and EMT, and most often there are crews that are dual EMT.
Average EMT wage is actually about $18/hr (and in much of the south you can be looking at $15-16/hr).
However where wages do go up, but not in a good way, is overtime. The agency I worked would happily schedule you for 36 or 48 hour _shifts_ and had no weekly hour limit beyond "You must take an 8 hour break after 60 hours of shift", I kid you not - and many people will regularly work 72-96 hour weeks.
The big thing is that private EMS writes off a lot of bills and pushes the balance on everyone else. The holy grail for private EMS agencies is "inter facility -out- of a hospital", as oftentimes the hospital pays the ambulance bill and charges the patient.
You also have to be careful looking at FD provided _transport_ as billing for this is often subsidized by property taxes. There are FDs who will charge for treatment and for transport, for transport only (not for treatment), or for neither (my FD did not charge - but there were also differing policies on when we transported, not by default, so you had people literally - and understandably - peeking out their window to see if it was a red FD ambulance/medic unit outside, or a white private ambulance).
Even above and beyond that, there are a LOT of disposable costs you never recoup. Bedding, blankets, gloves, etc.
> This is a short trip in an automobile, essentially a fancy uber ride.
That is a little flippant, as you acknowledge... good way to offend any paramedic or EMT. I've delivered babies en route to a hospital, including breeches. CPR. Emergency airways.
> A new, fully equipped ambulance is about $150k.
Not any more. Thanks, private equity. You can easily be looking at $400K. And they are vehicles that are driven hard, and cold, and maintenance sucks as a result. No warm up times for engines. Private ambulance, it's common to see rigs with 300,000+ miles on them.
> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Not for the medical treatment, no. You can get insurance privately as a paramedic but those policies are generally excess/umbrella style or are specifically "occasional only". The last private agency I worked at with a dozen paramedics and 50+ EMTs had at least mid 6 digit insurance bill.
> Throw in money for gas and wear and tear, which should be quite comparable to other automobiles
For a vehicle that can weigh 10,000lb+, that gets started and stopped often 30 times a day, a lot of time driven "foot to the floor" with an attitude of "it's got to get where it needs to go"? No, although one of the first thing any halfway decent sized agency quickly learns to build out is its own full shop and multiple mechanics (my friend is the Head Mechanic at a local county fire agency and oversees 8 FT mechanics and an auto electrician).
This jumped around a lot, I apologize, and I don't mean to shout you down, at all, but, lest you think I'm defending this state of affairs, I am not, in no way, shape or form.
Some do it because they actually want to be firefighters but it’s helpful to be an EMT as well.
Others do it because it’s an easy entry point (in the US you only need a 3 month night course to be an EMT) in their medical career on their way to better paying jobs like MD and RN.
And yes, others are grizzled and burnt veterans out making little money.
But mostly people do it because they want to help.
(Shudders)
There are a ton of other costs. You're not paying for one employee. You're paying for many since ambulances run 24/7. They are also driven hard which means they require more maintenance. The ambulance is also full of expensive equipment and supplies.
My LLM of choice says it actually costs $1000-$2500 per ride to the company for operational costs on top of per-ride costs. You can probably ask one for a breakdown and see if it makes sense to you
There plenty of idiots there making 2 dollars an hour and tips and thinking they’re doing well because “at least my CoL is low!”
[1] Oh, holy crap, I just got why ambulances are called that
liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Insurance on my SUV is close to $3,000 a year, but with the understanding I drive it about 12k miles, and I'm not allowed to speed or run red lights whereas they're guaranteed to be speeding, and driving it around all day and maybe all night. And the ambulance is worth 5x as much as my car is. So I'd be shocked if the combo of their auto insurance + insurance against being sued for rescuing someone wrong is that cheap.
https://digitechcomputer.com/costs-of-ems-readiness/
Looks like of the $1954 they estimate for a transport (already quite a bit below TFAs $2673), $1582 is salary. Given that we established the crew in the ambulance are taking home about $140 per transport between them, this seems bonkers. Capital, medical supplies, and fleet maintenance are a whopping 6% of the "cost".
Dispatch, maintenance, janitors, HR, managers.
They also need continuous training, and that is also a large salary cost for training staff (you have to pay them and the trainer).
For that, $1500 seems pretty reasonable. In a place like the US, labor costs often dominate the total cost of many goods and services.
And remember, you have to pay the staff while they are sitting there waiting for a call that may never come. According to the OP's article, the ideal utilization is 30-50%, because you don't want a situation where there's a surge in requests and you don't have an available ambulance. So you're paying people to sit around and wait for a call, and, under normal conditions, you'll have 50-70% of that pool of people not ending up needing to take calls at all.
Also your article includes under salaries:
> Regular, overtime, vacation, and holiday pay for all EMS staff, including EMTs, paramedics, chiefs, 911 call technicians, dispatchers, and support staff
That's not just the 2-3 people on the ambulance during trips. That's a lot more people required to make the entire system work.
Stand by cost are about 154 euro/hour. E.g. for sport events.
ICU transport is about 2500. All are law mandated.
The total cost might be more as the insurers also put in undisclosed amounts and some cost is shared with the emergency departments at the hospitals.
Which, notably, are so common, because it is financially ruinous to not do it.
They can’t decline transport for anyone with an emergency, regardless of ability to pay.
A new ambulance will probably run 2-4x what you quoted. Gas/maintenance will not be comparable to a regular automobile; it will be significantly higher. Paramedic wage (though there will probably be more "cheaper" EMTs out there than paramedics) seems right, maybe a little high for some markets. $12k for liability seems shockingly low; I wouldn't be surprised if you're off by an order of magnitude.
Regarding salaries, you're not just paying for the people in the ambulance. You're paying for dispatch, operators, support staff, administration, etc. You're also paying them 24/7, not just for the times that the ambulances are actually making trips.
You also left out the cost of medical supplies and equipment, both of which need to be maintained and replaced.
Idk, my takeaway is ambulances look like a solid market for a subscription model. Ideally, one that taxpayers pay for. But also, potentially, as a private one that you can pay e.g. $50/month to know you won't be billed $12,000 by idiots.
This just happens to be the case where you must transport people but most people are net losses. In this scenario, the only surviving companies would be those who charge the remainder sufficient enough that the blended population of clients causes a net pay-in. Everyone who doesn’t account for that will just go out of business.
Being available constantly could be helped with a retainer, it’s true, but even with that we should expect that some patients pay a lot if they’re rarer than the loss-makers.
Those calls essentially cover the base business expenses.
Estimate for an ambulance call is about £450. I suspect the main reason the US costs more is wages.
UK – Newly Qualified Paramedics (Band 5): £28,407 – £34,581. USA - $38,000 to $48,000: £28,323 – £35,777
Sure, there's a bunch of different tax treatments and work-benefits between the countries, but I don't think it's the cost-of-labour that is making the USA more expensive.
My wife and also have Rega. They can't legally call it insurance but if we get injured in, for example, the USA they will send us a private hospital jet to bring us home.
From the article: "The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue". In other words, taxation just like anything else we expect to be available to anybody.
So of course, my insurance would only pay some small pittance, if anything, and I was sent a ~$1000 bill. I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.
So we have an insurance company which surely knows that law, surely knows what an ambulance is for, but has discovered the "life hack" of having an extremely inadequate network, simply refusing nearly every ambulance claim made in the City, and then only paying the small percentage who know the law and know how to file a complaint. And of course, there's no punishment, the punishment is just having to pay the few times they're caught.
And insurance companies wonder where all that anger (Delay, Deny, Depose, was it?) comes from.
Anyway, practical moral of the story: don't let them get away with doing that if it happens to you or someone you know!
The number of times we'd have to hang out at the charge nurse's desk because the physician had scrawled a signature at the bottom of the form and nothing else, etc., was ... staggering.
If that doesn't give that reasoning (unable to stand steady, fall hazard, need for continuous O2, etc., etc., etc.) then no pay. And many insurers would use that same paperwork, not just Medicare. Could we fill it out ourselves? No. I'm not risking my EMS career to be at the center of a "ambulance company employees charged with medicare fraud" news story.
I'm sorry, are insurance companies now demanding that people use Ubers to get to the hospital?
... do they reimburse those charges? Because wtf.
And they are reimbursed, or actually generally billed to insurance.
This is less terrifying, thank you for clarifying!
It took 5 times of me calling and explaining that they can’t charge it as out of network before they adjusted it.
It could have been Cigna -- I've cycled between probably every possible insurer during my career. Dirtbags, the lot of them.
What annoys me the most about this story: There should be a disportionately large penalty that the insurance must pay to the health care regulator for cases like this. It would discourage this kind of illegal behaviour.
What percentage of patients are likely to be taking ANY action that leads to insurance paying? Either spending (as someone else shared) 5 phone calls trying to convince them, or knowing what regulator to file a complaint with - those are the only options. All other options involve someone else eating that cost. I bet less than 10% get them to pay, so the fine should start at $10,000 - and escalate if they show no improvement.
Family members have been in ambulances a few dozen times over the decades. There is no concept of a bill or paperwork for it. Like borrowing a book from the library.
Unfortunately that’s not the case. It’s like day care. Day care is expensive because the government mandates it to be expensive. Otherwise you’d have grandmas down your street would gladly watch your kid but it’s generally not allowed for more than a couple kids.
Same thing with houses. I have half an acre. Could easily put 2 affordable tiny homes on it. Good income for me, cheap rent for someone else, but, unfortunately it’s legally blocked
When you are an ordinary person calling 911, you can't meaningfully shop around in that emergency situation. The competition that exists is between the possible organizations you local government could contract to run the system. The safety regulations and medical standards they set are part of them choosing what they feel is the best "deal" for their population. (In some places, all 911 calls are run by public fire departments; in others, the government contracts with private companies.)
At the IFT level, again it's not generally possible for patients to choose their service, because (as explained in the article) ambulance services inherently need extensive infrastructure with large fixed costs at every location they serve. You're not going to fit 20 ambulances from 20 competing companies in one hospital's ambulance bay, and those 20 competitors aren't going to be able to afford to pay employees to sit around for hours at that hospital on the off chance that maybe today patients will pick them and not the other guy. The costs for the ambulance company are not primarily per-call, most of the expense is to stand ready for a call whether it happens or not. Instead, competition generally happens when the hospital chooses which ambulance service(s) to contract with.
How is that possible?
Total cost was 70 bucks (10 bucks for the uber, 60 for the er copay).
The number of people here in the US who use uber as an ambulance is waaay higher than you would think.
LAFD has already called Ubers for non-emergency transport to hospitals.
https://www.cbsnews.com/losangeles/news/la-county-changes-am...
So NEMT can cover a lot of use cases where people are stable and just going to PCP or specialist visits. Or even behavioral health appointments. There are now dedicated NEMT providers, like Veyo out of San Diego.
In fact, when I broke my leg, there was talk of calling an ambulance. But I was only about 3 miles from the destination hospital, and there were many wise people nearby, so several of them suggested I just call a cab and take the cab to the E.D. instead, because that was far more efficient. So that's what we did, because really, I didn't need any life support, or blood transfusion, or rescuscitation on the way there.
Since the billing SNAFU last Thanksgiving I also learned about the difference between BLS and ALS. For some reason the ambulance provider billed for ALS even though none of that was necessary. Of course, ALS costs more and bills more and probably profits them more. I should have contested this stupid account trick, but whatever. They haven't even billed me for the "co-pay" yet, so we still need to wait and see how this shakes out.
There was a long period of back-and-forth with calls and website visits, where they were insistently billing the wrong insurance, and so forth. But I'm grateful that I used the ambulance at that point in time.
The key advantage to an ambulance ride is bypassing the Triage Nurse. If you're going to an E.D. and you take a ride-share or a friend drives you, then you'll go to the registration desk and then meet the triage nurse. And the Triage window is pretty good at conserving hospital resources, and de-prioritizing you if your issue could be handled by Urgent Care or your PCP on a weekday.
But if the ambulance gets called to your home, it's a foregone conclusion that you really, really want to go to the E.D. and the ambulance crew will Keystone Kops their way to a successful hospital drop-off. They'll take some vitals and ensure that you're stable, because if you're not, they can save lives, and keep you alive during transport. But if you're conscious then they ask that $64,000 question: "do you want to go to the hospital?"
Once a few years ago, a nurse in a clinic had called 9-1-1 on my behalf and it was actually difficult to refuse a hospital transport. The EMS crew put me on the phone with a hospital attending physician and I had to emphatically refuse transport several times, after being advised of all the risks. (My only issue was elevated blood pressure. C'mon, guys.)
One of the troubles with ambulances is that they are really overkill for many calls. If some homeless dude goes unconscious on the curb, they get called. Some neighbor was going to call 9-1-1 because I laid down briefly near the pool. The ambulance and its crew is highly equipped to save lives and respond to the worst trauma cases: multi-GSW, car accidents at 70mph, etc. But I called them because I had a bad headache. And that's why they got to bill so much: they cost a lot! And I bet that a lot of uninsured deadbeats default on their ambulance bills, and the City gets to eat all those costs.
But the times I've transported myself to the hospital, I kinda got blocked by Triage, and it was for my own good. This last time over Thanksgiving, I had a lot of issues, and isn't it always the way that they hit at the beginning of a holiday weekend? So, it was good I went to the hospital.
But I was flabbergasted that my "co-pay" was 92% of the ambulance bill. I don't know why, but that plan has terminated anyway, so there's no arguing about it. At least, my actual hospital bills were well-covered by that plan.
This is going to depend on where you live/the particular hospital. A lot of "frequent fliers" figured out this loophole and started abusing it where I previously lived, so there was no way around the triage nurse.
I wonder how countries with universal healthcare coverage deal with the lack of a (dis)incentive here. Maybe they just eat the cost?
- the patient was _forced_ to take an ambulance to another hospital, but not to be treated for anything in particular.
- the post goes into how the EMS system is expensive b/c you need trained paramedics and expensive medical equipment and such -- but sometimes they really do just need to move a patient, not treat anyone in the field or en route. Saying that you pay for the paramedics even when you're effectively just being moved between facilities _also_ seems wasteful.
Yes, we should share the cost. But once we all share the cost, maybe we should try to spend the public dollars effectively by only using ambulances when they're needed, and distinguishing between "transport patient who can't sit upright and buckle a seatbelt" and "try to stop their arterial bleeding as you speed towards the hospital".
Perverse incentives are the essence of what is wrong with US medical systems.
Indeed, in my county that's the case along with a $60/year subscription program to indemnify yourself against further costs:
https://www.wake.gov/departments-government/emergency-medica...
Right, but air ambulances are subject to the No Surprises Act, and we somehow still have those.
Also, ERs are subject to the No Surprises Act, and they do some pretty damned expensive things. Plus, if you're seen by an out-of-network practitioner in an in-network hospital or ER, no you weren't: No Surprises Act forces them to accept QPA and not balance bill. Somehow all of those out-of-network anesthetists and radiologists are still in business.
Here's a PDF about the No Surprises Act:
https://www.cms.gov/files/document/a274577-1a-training-1-bal...
Tell the insurance company to wait to release the funds until you talk to the ambulance company or to release the funds directly to you.
Tell the ambulance company they can take the $9,967 or get zero.
That seems needlessly cruel to do to people.
This is weird, why didn’t he have a choice? I have literally walked out of a hospital with IVs still attached to my arms when I disagreed on course of treatment that included hospitalization for a case of white coat syndrome. They also wanted me to wait one hour to sign a waiver, which I unkindly refused.
I am shuttled to the airport at 4 am and paid $30.
It did not cost 20k per ride. So ambulance providers charge that much because they can. There is no real competition.
As an EMT if you're A&Ox4, alert to time, place, person and event, you make the choices. You do sign a release so we have proof we didn't abandon you, but you make the choice.
My department, a small rural one with a small tax base which happens to cover a lot of injuries because we have 20 miles of dangerous mountain pass freeway and a ski and mountain bike area, only charge for calls if we transport. I think a transport is around $900. Our minimum transport is 37 miles. We scale it down depending on income and type of event. We're not massive sticklers about it. We're just trying to cover wear and tear on big expensive vehicles for all the non-transports, winter driving, equipment, uniforms, training, etc. Most of our "business" comes from "transients" eg folks who don't live there, eg those skiing, hiking, biking, or driving over the pass.
This is also very much not the norm. But should explain a bit about those who do pay are covering those who don't.
We don't want a chilling effect on calling 911 for precautionary stuff. We'd rather show up 99 times and check people out and let them go than miss the impending cardiac event. And we get those. It's very interesting just how much going over a 4k foot pass stresses people on the edge. Many of our medica calls are people driving to seattle for deeper care and things exacerbating when they get to 4k feet.
The (fairly obvious) answer to that no one should be in that situation. It's horrible. Society should find a better way to pay for ambulances. Most of the world has accepted that some system to spread the cost among everyone is better than putting people in that situation.
No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.
I know that John Oliver is a bit of a “lightning rod,” for many folks, but he (or his staff, really) does his homework. He did a segment on it, some time ago: https://youtube.com/watch?v=Ezv8sdTLxKo
I’d also be careful about his facts: they’re usually well-researched, but by the nature of the format he only ever presents those which fit his argument, and that’s just not good epistemology. I can think of a few times when the show made me feel safer about my beliefs than I should have been feeling.
So why not make fun of them? There's no downside.
...except the populist right backlash, triggered in part by their resentment at coastal "elites" (think yuppies, not people who fly to davos annually) sneering at them.
As an aside, I think the culture which produces this result is related to people in the US always thinking crime is increasing, regardless of actual crime trends.
You’re not supposed to shape your political views from entertainment.
I can’t imagine it’s gotten cheaper.
EDIT: their own website states "If the ambulance only comes and stabilizes you on the spot but you don’t need to be transported, there are no costs." https://ambulanceamsterdam.nl/information-in-english/
The anecdote illustrates the issue then he dives into the analysis.
Society has this figured out, at least a decent solution that works until we find a perfect one. Only the US society seems to be unable to find a solution.
IIRC if you look at the cost of Medicaide, Medicare, VA, and other federal and state spending it's the same as most other countries per capita or as a percent of GDP. The US taxpayer pays about as much as Canadians to fund their public system, then pays the same amount again for private cover since it's not universal.
No I'm not making a typo. Medicare, Medicaide, and the US system is such a rip off that per capita Americans are paying similar tax dollars to their joke of a public system.
But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.
- no-one's talking about immigration in general. They're talking about mass immigration. So any general "look how immigration can be good" is not addressing the issue
- mass immigration means that housing becomes scarce, driving up prices. This again makes GDP look good, because stamp duty revenue goes up and so do estate agent fees. But all the many negative externalities, such as everyone is now buying houses 10 years later, and leaning on their parents, and their dwellings are all being subdivided because even a tiny place is now worth renting out or selling, are totally ignored. The housing costs drive every other cost up. Minimum wage / living wage needs to skyrocket just to combat this one thing, both because people need more money to pay for their own accommodation, and people need to afford goods and services that are all also being made more expensive because their salary costs need to increase for the same reason.
- mass immigration spikes up demand for power. Power is often a large capital investment, which means that the country borrows a load of money from Macquarie Group to build it, with lots of interest paid back over decades. Seems to generate GDP as people are being paid to build things; actually a net negative all told over the lifetime of the investment.
- the same as power but for water.
It's important we have young people entering the workforce. But it's just incredibly obvious that adding more people from external sources is not sustainable. When they all get old do we import more people? Or should we just be repurposing the millions of young people who are doing less important but less icky jobs to do the jobs that we're currently getting immigrants to do. "Who will pick the cotton?" is not a good question.
The housing shortage is driven by NIMBY and regulatory capture. You are right that perpetual growth is unsustainable but we are not remotely near the possible carrying capacity of our land and resources. We have had periods of much greater population growth that were accompanied by greater prosperity overall.
Immigrants are not the problem, they are the convenient scapegoat of the business interests that have systematically hollowed out the middle class over the last 50 years.
My entire region has been overrun by Mexican immigrants. There are more Mexicans here than Mexico. They are poor, and they bring their poverty with them, driving down wages and sales prices everywhere and turning the place into a slum. The locals (natives) aren't the beneficiaries of this arrangement. Only the governments and businesses.
17% of GDP is healthcare. So between 1:10 and 2:10 people in this country are making more than they otherwise would (note I did not say wealthier) because the system is screwed up and hoovers up more of everyone else's wealth than it ought to.
Slavery was 12% and (while obviously geographic concentration of industry plays a lot into it) it took a war for them to take a haircut.
The fact that that pie is not sliced evenly does not change the fact that is an integer multiple larger than it ought to be.
Systemic inertia is unimaginably strong.
I easily see that changing the USA to be more socialist, especially in areas where game theory indicates its the best solution, will likely take a civil war.
That also aligns with Marx's writings, that the capitalists will not acquiesce without a fight, and a big fight at that.
The slavery and Civil War connection is a comparison of similar economic magnitudes.
Certain specialities probably are overpaid (orthopedics), but others like pediatricians or general practitioners usually aren’t.
And nurses!? From the nurses I know they are underpaid for what they deal with.
The ones making loads of many are willing to travel around the country and uproot their life once or more every year. Not exactly a lifestyle without its drawbacks.
Yeah, most pink / blue collar workers in the US are badly underpaid, but IIRC ones in the health sector are some of the best off, relative to medium salaries.
Compare teachers and nurses. In most countries they make about the same AFAIK (and I'd say nurses do deserve more, telling a parent Billy did badly on a math test has got to be easier than explaining a bad medical test). But in the US it's about 75k vs 95k. There's a huge premium for working in health in the USA, EVEN in the underpaid blue collar end.
Doctors make out even better in the US, and the c suite in health can have salaries that are just insane.
McKinsey did a nice analysis of what is driving US healthcare costs. It compares category spending to OECD then compared price and volume.
Turns out the US pays a bit more for drugs (relative to total spend), a little more for inpatient care and a TON more for outpatient care but half of the increase is volume, not price.
As someone who works in healthcare globally, the difference in US care is stark. Americans get much early and more access to new technology than other countries.
If your lymphoma has returned and you have a 20% of living more than a few years the best care is CAR-T with cure rates close to 60%.
Check out CAR-T rates in the US versus Europe, it’s almost 3x. The US started using it in 2014 and Singapore just started paying for last year (11 years later). Even in Europe adopt only ramped up in the last 5 years.
So yes prices are higher, but a big part is more aggressive care with more expensive treatment.
“Canadian health care” is not a thing. Each province administers its own completely independent system. Someone on PEI is in a healthcare system that has as much to do with Alberta’s healthcare system as it does their neighbours in Maine. As a result, anyone referencing Canadian healthcare is talking about a dozen or so unrelated systems that do things very differently.
You can safely dismiss anyone that has reduced that complexity, or is completely ignorant of it. It’s a great way to tell when a foreigner is spouting talking points they picked up from an unreliable source and did not do even a minimal fact check on. “Canadian health care” as it is talked about in the US media is frequently fiction for propaganda purposes.
Canadians talk about problems within a province.
No idea if the rest of his statement is poorly sourced propaganda as the first sentence.
So yes there may be differences between provinces in terms of when they fund what restrictions are put on it, the overall trend across Canada is pretty consistent.
And as I said Canadians don’t get the same care as Americans so concluding the higher cost is entirely higher prices for the same thing is false.
You're talking about cutting edge technologies available to the tiniest sliver of people - I'm not even able to get access to much of them with my private FAANG insurance - and drawing a false comparison.
And it's not "the tiniest sliver of people", we're talking about disease like cancer. Check out the CAR-T rates in the US vs. Canada, the difference is stark. And CAR-T is standard of care in some types of lymphoma.
Hell, ask parents with autistic kids what kind of early intervention is available to them in Canada. I had a coworker who moved to the US so he'd have much better access for his kid at a time when it had a big impact.
Look at access to the cystic fibrosis therapy that effectively cures it (e.g. Orkambi). It was paid for by insurance (and Medicaid!) from the day it was launched and avaiable to everyone it could help. In Canada some provinces just started paying for it, but only kids, adults are shit outta luck.
And I don't know the details of your FAANG insurance, but my US insurance (typical corporate insurance) pays for all these new technologies.
Canada is great if you have a routine issue. If you need something specialized you're going to be treated with therapies that are a decade or more old. Hell, even the CBC wrote a whole story about 2 friends with breast cancer and the differences in treatment.
https://www.cbc.ca/news/canada/british-columbia/a-tale-of-2-...
"Then I found out that this other country — which I thought had a healthcare system that was so superior to the U.S. — doesn't test for the tumour marker that saved my life, and doesn't cover this drug that is responsible for pushing my cancer into remission after traditional chemotherapy failed to do that."
Life expectancy doesn't measure quality of healthcare, there are far too many confounding variables like genetics, diet, accidental deaths, etc. No serious study of healthcare quality relies on it.
Look at 5-year cancer survival rates. The US is better (significantly better) in many of them than other countries. A big part of that is access to the latest technology.
https://www.thelancet.com/journals/lanonc/article/PIIS1470-2...
The US leans aggressive on tests and heroic end of life care. I doubt youreally disagree (except on whether you think it's a good call). That is where the money is, since the insurance company can be forced to pay.
Read "When doctors die", the US is the total opposite - everything goes to the big ticket aggressive (and yes, modern and cutting edge) treatment where it's hitting diminishing returns. https://pmc.ncbi.nlm.nih.gov/articles/PMC6179868/
Sure!
https://archive.is/rMVJ0
Turns out the CDC changed the way it counts maternal deaths, while other countries didn't, so you're comparing different measures.
The old US measure was deaths that occurred during birth or shortly thereafter, now it's within six months and they added a check box only asking if the woman had been pregnant in the last year.
This change immediately doubled the number.
Median pay for a Nurse Practitioner is $132K/yr [0]. I think that's reasonable.
Average pay for physicians ranges from $220-450K depending on specialty. [1]
Personally, I think doctors should be paid more than software engineers, so I think those numbers are all reasonable, especially when you consider what it takes just to enter the field. Nurses require a Master's degree. Physicians need a Bachelor's degree PLUS another 4 years of med school AND THEN a residency program that lasts 3-9 years depending on specialty before they finally earn their medical license.
IMO, the idea that nurses and doctors are overpaid is quite simply ludicrous.
[0] https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-...
[1] https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.h...
You'll find that salaries across the board are lower in other countries. Software developers in Europe make half of what they do in the USA. In exchange, they get far better benefits.
Also, physician salary only makes up about 8% of total healthcare costs [0]. Cutting salaries in half wouldn't significantly lower our healthcare costs.
[0] https://www.medicaleconomics.com/view/physician-pay-makes-up...
Unwilling. It's absolutely feasible to find a solution, as seen everywhere else in the world.
From the article:
> In Tulsa and Oklahoma City, meanwhile, the government buys staffed unit-hours from an ambulance operator, while households can prepay a few dollars a month on their utility bill and owe nothing if the ambulance ever comes.
My favorite example is universal school breakfast and lunch. Without fail, someone will argue that some kids don't deserve it. It doesn't matter that all of the data shows it is more economically efficient and the benefits to kids is overwhelming.
The Republicans seem to see it as immoral to potentially give a few people support they don't need even if that means that most of the people who need the support actually get it. And, instead, they believe that having an inconsistent array of private interests will somehow be more able to service an enormous population than having an organization (like government...) that is large enough to match that population's needs.
The Libertarians seem to either genuinely not care about the rest of the world or, more often than not, seem to be naive about how life can be for the less privileged.
It's the lie of the "rugged individualist" in America. Most "successful" people come from successful families. Social mobility, in the US, is part of that lie. Here, we celebrate the person who rises from poverty to become wealthy as a member of a sports team, or as an actor, or similar, while disregarding that these massive successes are outliers.
I'm so often disappointed in my own country.
Good news is that if you want the democratic party to become the party of labor, now is the absolutely best time to have a real impact in your community.
No, they just put boundaries on what services they want handled by the government. Government programs are the least efficient and most wasteful way of getting a job done, and there are endless examples of this.
Churches were historically the places people went to for assistance, and churches held people accountable and would push them to fix their underlying issues. Government programs have none of this, you can keep making the same bad decisions and nobody will hold you accountable and the benefits will keep coming in.
https://news.gallup.com/poll/697676/drop-religiosity-among-l...
https://news.ycombinator.com/item?id=46484284
Women commit just as much sexual abuse as men, it's just not talked about by society.
https://smart.ojp.gov/somapi/chapter-2-etiology-adult-sexual...
https://www.humanrights.unsw.edu.au/news/study-finds-one-10-...
I agree that what you need here is someone(s) with leverage and respect in your life to interfere with systemic bad behaviors if they exist, but that takes community, government merely gets leverage, and churches are often not a welcoming place to many people's eyes, rightly or wrongly, around the US.
As I get older, I'm increasingly of the opinion that the best you can do is unconditional support from the government (because it's the only kind you can rely on no humans in the chain acting in bad faith to condition), and well funded local support structures for people to subsist while fucking up their lives and also help them get out of that spiral if they want to.
Not because I believe in some fundamental good in man or something, but because I think that's the only way you can design this that isn't subject to people's bad faith manipulation, and I've personally seen too many cases go wildly differently for "objective" criteria where the main difference seemed to be whether the person reading it went into it assuming you were lying or not.
It just boggles my mind how the poor are supposed to be continually punished just for being poor and should always be denied, almost by rote, any sort of government aid because, you know, did you hear that story about that fentanyl addict who was found with THREE active EBT cards in his wallet?
Yeah for sure...how dare some dirty addict should be able to eat!
Many choose ignorance because it’s comfortable.
they happen to be in the Fortune 50, or top 10.
serious, go look at the F500 list and see how many of the largest, meanest companies in the US (and world) world also happen to be healthcare
https://companiesmarketcap.com/
Mostly only pharmaceutical healthcare in the upper tiers of that, but these businesses still have market caps and net incomes literally one or two orders of magnitude separating them. Grouping top 10, 50, and 500 makes no sense.
US society has been spending a fortune on USAID funding the world's social action projects, NIH funding the world's medical research, and the US military keeping shipping lanes safe (at least until recently), and taking in a million or so people a year from other countries. That vast generosity means other countries can just spend on their own citizens and feel superior for doing so. That's why all that stuff has dried up - what's the point in spending on others when they look down on you for doing so?
https://usafacts.org/explainers/what-does-the-us-government-...
The war in Iran in MAY was reported at 29 billion dollars. It's probably been a bit more since then. Justifying stupid actions because you hate brown people isn't good for any of us.
What a strange non sequitur.
I feel like you have missed the entire point of the article.
Yes, you want to make that choice rather than shirk it off. Anything else is a perverse incentive. Making poor medical choices that prioritize your own well-being over the financial solvency of those you care for, those around you, is a shitty thing to do. But, some people like to pretend that if they can just make sure those people are the 300 million Americans rather than a more immediate circle of family, that the problem goes away. It doesn't, it becomes worse.
Most decent people would rather croak than ruin their own family. But those same people, through one false rationalization or another, are more than happy to ruin the entire country. Even if doing so won't result in net benefit. If I'm going to live, it's because the cost of keeping me alive is less than the net benefit of my increased lifespan. That calculation has to be the same no matter how you want to "spread the cost among everyone" or it all falls to shit. And since you're incapable of making rational decisions when it's spread further than your own family, well... things are going to continue to go downhill.
Victim of a violent crime? You shouldn't have left your house.
Run over by someone else? You shouldn't have left your house.
Caught an infectious disease? You shouldn't have left your house.
Fell down the stairs? Why were you in your house!?! Don't you know how dangerous it is?!?
I’m sure plenty of those soldiers would rather pay some money for the evac instead of a lifelong ass tat.
x2..x5 multiplier is always applied to any ambulance bill as far as I'm aware. I worked in that industry.
I've seen as long as I've been alive, "Communism killed hundreds of millions!!!" breathless claims.
When Capitalism kills, oh wait, it never does! Its always "bad individual choices", and never a review of the terrible for-profit system that caused it to begin with.
> Making poor medical choices that prioritize your own well-being over the financial solvency of those you care for, those around you, is a shitty thing to do.
And there it is. The system is highly predatory as intentioned. But the system is just part of capitalism, so its OK. But 'YOUR CHOICES' are the one that's bad, aka blame redirection.
And guess what? More and more people are seeing behind this facade that capitalism is good. Socialism is better. We're tired of being extracted, used up, and thrown away. Its why I'm also part of DSA. I'm done with this individual blame for systemic shit.
Sure, but increasing healthcare costs are due to a number of factors like new technology adoption, not just an aging population.
So while I would agree that no one is going bankrupt from overuse of ambulances, it all adds up.
I am not obligated to make your argument for you, and I am not inclined to calibrate your motte-and-bailey merely because you feel like interjecting your support for a position you would call a strawman when called out.
Are you just uncomfortable with debate? How do you debate the merits of the argument without defining the terms being used?
We’re talking about financial ruin of the government.
It seems even a group that purports to be rational critical thinkers don't want to be rational critical thinkers to the extent of looking into the root causes.
But no, I won't be a communist with you. And if you insist, things could get ugly. Fortunately for me, you're still in your hipster-college-champagne stage of communism, and you're both scared of violence and worried about the PR backlash of being found out to be a bloodthirsty savage.
In November when it becomes apparent that the Democrats won't win back seats, you'll all start to panic. But the real fun will come in 2028 or 2030, when Obamacare will be dismantled. I can hardly wait.
Only a complete moron would think the answer to this is no. If there's no personal cost to using an extremely expensive service, every one is going to use it regardless of whether it's actually necessary. It will quickly turn into a free taxi service for anyone who wants to go anywhere near a hospital.
The only way a free ambulance system could work is if there were harsh penalties for people who abuse the system. Unfortunately, the American Democrat party has shown countless times that they have no interest in preventing fraud. Prominent Democrats like Tim Walz and Gavin Newsome have spent more time in the last year pushing laws to protect fraudsters than prosecuting them.
And what does the Democratic party have to do with all that? Your whole comment just seems like a thinly veiled and insulting political rant. Going by your account name, this seems to be a pattern.
No US doctor would ever tell you how much any procedure would cost (even though they know, at least "in-network" doctors).
But if in your EMT you inform the patient of the potential costs of the ride, then yea, I agree they make an informed choice.
I had fractures several times, and I did think about the costs. In fact, the last one was pretty bad, andy first thought was "good thing I'm in a country with good medical care, even though expensive".
Consent for treatment is a core principle of medical practice.
That touches on another very american problem. The injured person now does not know how much the tansport/treatment will cost. And the persons on the ground cannot quote a price. If they say yes they enter into that zone of having another random health care bill comming in the mail.
I guess my point is, sometimes you don't have a choice, but you still end up with a massive bill. And also, that experience definitely had a chilling effect on me calling 911.
You end up just building the lawsuit against you.
Americans love to pretend that healthcare can somehow be a free market (it can't), but a free market requires voluntarily entering into a transaction. Costs that can be forced upon you without your agreement need to be tightly regulated and subject to clear caps.
I was fully aware when the ambulance arrived and refused. They peer pressured me very hard anyways. It was a 1 mile drive and cost me $14,000
I was sent a post insurance $8000 bill. After months and months of arguing they said it was an error on their side and dropped the charge. Absolutely ridiculous
Disagreed. Someone who is cogent and not intoxicated and not a stroke victim can't always make the best choices. Your decision making can be compromised by I dunno the fucking pain of a broken toe bone.
Seeking help should not be interpreted as a sign of weakness and made into a maze where only the most rational can escape with minimal bills. The longer we leave this cognitive dissonance where the land of the free roughly translates to land of the free to get fucked we are going to continue to have instability.
better to live in uk where nhs takes care of all this compassionately for free.