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.
> 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?
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.
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.
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.
"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.
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.
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.
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.
+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
This is definitely not true. A base model unequipped ambulance may be in that ballpark. A fully equipped ambulance will vary wildly in cost based on clinical level but will be about $250-500k in the US.
> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Maybe for BLS or non-emergency ambulances in a low-utilisation role? For ALS/Critical Care or higher in a busy jurisdiction it's going to be significantly higher.
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.
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.
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. It was also much closer to a van with a stretcher in it; the 911 ambulance was a mini hospital on wheels.
> 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 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.
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.
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.
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
Ambulance crews are almost never 2 paramedics. Most often they transport and do BLS only. If they are it’s because a local government is paying for that service. EMTs make minimum wage.
The people who own ambulances typically have a little cartel like business in a region and print money. They refuse to sign insurance contracts so they are almost always out of network and will not accept direct insurance payments.
When my wife had cancer, she ended up at a hospital that didn’t have the services she needed becuase the ER was full at the trauma center hospital. I was able to arrange a transfer, and paid $1800 for a drive that was approximately 12 city blocks. We had to do that to avoid a complication with hospital admission and coverage. The crew was cool and we did get to honk the siren.
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 need a regulatory body that can fine people for making analogies this bad
We need a communal agreement to apply social opprobrium upon people who reflexively propose to solve trivial problems by imposing their will on other people.
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?
They can't make money on some customers (medicare/insurance), so they have to make up the difference however they can. In practice this means screwing over the people who have assets to seize.
This thread is filled with strong arguments that ambulence operators do make money with medicare.
But even more, it's completely false that the reason an ongoing, working business charges a huge price to some people is that some other people are taking money from them. A business charge people huge prices when it can. Businesses make as much money as they can.
It is true that what health care providers charge individuals tends to be their "opening offer" to insurance companies so they do make this exact argument "we gotta make all our profits on you 'cause everyone else is denying us" but that doesn't make such arguments any more reasonable.
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.
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.
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.
"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.
I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you; no one is purchasing the right to see a movie regardless of how much it turns out to cost to show. It's the movie maker that would love to buy an option that makes you promise to buy a ticket, even if the movie turns out bad.
>I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you
I perfectly do know what an option is. It's just not relevant to the discussion, or at least not necessary. If you're selling a service that costs $2k of amortized costs to provide for $300, because that's all medicare/insurance companies are willing to pay, that's not a problem because you're offering options, it's an issue because you're charging too little. You're losing money because the numbers simply don't pencil out, not because you sold a bunch of options and sharp jane st traders cleaned you out. In any other situation where you're charging less than what it costs to provide, people just call it "bad business model", not "you're selling options" or whatever.
> 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.
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. If we move you without your approval, it's kidnapping or entrapment (not hit me up law arguers). To do that we either need implied consent (minor no parent, not A&Ox4, or Law Enforcement).
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.
> 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.
> 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.
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!
> 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.
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.
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 of perps in this context: 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.
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.
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.
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
if you wanna know why it's never gonna happen -- there is the list. they will spend more money than god on social media, bribes, and whatever else they need to keep the system the way it is
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.
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).
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.
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.
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.
Life expectancy shows that while the US is the best place to have stage 4 cancer, it's probably not the best place overall. Most places do the 80/20 stuff better.
But yeah, you are right that the US does some stuff well. Just not efficiently.
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 you really disagree (except maybe on whether you think it's the right call). That is where the money is, since the insurance company can be forced to pay. It's kind of good for the rest of the world though if the US wants to pay (in both money and other issues) to be early adoptors.
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.
Not "this woman died because of poor maternal care", but rather "this woman who died had been pregnant in the last year".
This change immediately doubled the number. The data was wildly overestimating maternal deaths and in fact the CDC and many states are revising data collection to improve the number.
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. The closest it comes is that there are interprovincial billing systems so you don’t have to do the paperwork to get covered for an urgent visit out of province, and not all provinces are signed on.
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 almost always talk about problems within a province. What's happening in the Maritimes has nothing to do with BC.
The feds set a minimum standard for a province to qualify for federal funding, and that's about the limit of their influence.
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."
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.
> 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.
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.)
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.
- the same as power but for roads. Traffic and congestion are now being actively managed by computerised systems because there are so many cars on the road.
- the same as power but for pollution. Another negative externality of driving up population for GDP reasons. Every person imported is more pollution generated in and by the local country.
It's important we have young people entering the workforce. But 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.
>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.
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
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.
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.
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"
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.
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.
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 it 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.
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.
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
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.
It's not a strawman. Ruining entire countries is literally what the parent comment said would happen if we do something as outrageous as making ambulances free.
> But those same people, through one false rationalization or another, are more than happy to ruin the entire country.
You may not have agued it yourself but your two sentence comment is rather lacking in alternate arguments, so I can only interpret you as supporting said parent comment and now engaging in a motte-and-bailey now that you realise you don't actually like what they said.
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.
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?
> 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.
Okay, so why don't we see this behaviour more in other countries?
In my jurisdiction, the incentives are actually weighted towards pushing people to ambulances, as there is a €100 fee for self-referral to ED which is waived if you're transported, but while there are time wasters and frequent flyers, the service is actually less abused than US ambulances under EMTALA.
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. Oh, and it was about a 10 minute ambulance ride.
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.
Treating medical care like this, similar to a racketeering scheme, should not be a thing anywhere.
Instead of punishing people for seeking medical care (or plainly requiring it), it would be preferable to have a robust protocol for rejecting patients that do not require care, whether at the hospital or before the ambulance ride.
For this, people would need to want medical care be a humanitarian right and basic pillar of a functioning society, not a business or a bureaucratic system to perform a selection process decreasing the life expectancy of less-affluent people.
Ironically, when there is free medical care and universal insurance, there are also perverse incentives. For example unneeded expensive procedures, prescribing patented, newer drugs where cheaper ones would work, providing ineffective or even detrimental services, etc.
But humanitarian values are out of fashion, because they were never achieved globally.
So the only right people care about increasingly is their right to own property.
For most nation states "should" in this case also corresponds to a certain treaty they are party to being highly inconsistent with treating health like a racket. Of course, the US is one of the few that never ratified said treaty. Too much like socialism I suppose.
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.
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.
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.
>> 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 only 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. Is it 900, or 9000? Will my insurance cover this? Is this outside my deductable? ... this is math that no person should have to do while bleeding beside a highway.
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
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".
>> 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.
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.
I think the idea is that if it's mandated, then the ambulance should be covered by some kind of insurance since it was medically necessary and not just Ol' Bob, the hypochondriac, calling because his tin foil hat fell off.
> 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 author does not understand how private equity extracts money. The high-liability and heavily scrutinized business is intentionally left with little profit: the actual profits are funneled up the supply chain. This is why private equity buys "nonprofit" hospitals - they can now control who that nonprofit buys services and equipment from.
I worked in private equity as an analyst in the 90's - we looked at an ambulance service that was up for sale - the underlying operating margins (before you load on debt) were pretty reasonable, although I don't remember the details.
I worked at a company which was doing medical billing for ambulances among other things.
Essentially, the bills are always inflated so when the settlement comes the providers get 20..50%. The crucial procedure is so called "medical coding" where medical notes (sometimes - scrawled on paper with a pencil) are being turned into bills - and that's where additional codes are getting added and more expensive codes are selected. There are books and guidelines on how to do the coding and some automated logic which "fixes" filled forms to bump the amounts a bit.
If the insurance (less frequently - the patient) pays more - that's just a bonus.
Billing itself gets a small fraction of the bill usually amounting to $20..50, they don't profit from inflated bills directly but the clients would select you on the basis of average settlements. Dispatchers also get little fractions. Things are very different when it comes to helicopter ambulances, where the bill could easily get to hundreds of thousands and everyone involved gets a lot. In fact, all the operators prefer to work with helicopters because of that, everyone involved references ground operations as "crap" or so.
Can't say for whole industry but that's what I've seen at one particular place working with several providers/dispatcher companies.
From what I can remember about the ground reality, a $12K bill would mean that they expected to actually get $3..4K.
A typical ground bill for some particular region the company operated at was settled at $500..$2K while an average helicopter bill was smth around $200K if I remember correctly, with spikes up to $500K.
> an average helicopter bill was smth around $200K if I remember correctly, with spikes up to $500K.
Those numbers made me blanch somewhat! Having been in a helicopter (aka Air Ambulance) in the UK, all of which operate as charities iirc, I was curious about their costs.
> The average cost of a helicopter mission is £4,748* and the average cost of a critical care car or rapid response vehicle mission is £2,054*[1].
In the UK maybe, but in the US you should expect higher bills for _ground_ transport. Like literally, the linked story is about $12K bill for short distance ground transportation not involving any complex procedures. The cases I vaguely remember did include long lists of medical codes.
I tried to find the asterisk there to see the details, but could not.
FWIW I think that HEMS cost is significantly under costed, as the London HEMS H135s run about £2,500 per flight hour on direct flight costs alone, so I suspect the £4,748 figure is referring to that alone.
I think a closer estimate is probably total annual operational costs divided by total shouts, (£18 MM / 2,000) or about £9,000 per shout.
Even that's an under costing, as the clinical personnel, equipment, and liability is shouldered by the NHS. A pure costing is probably closer to 2-3X that per clinical flight.
Still an order of magnitude less than the commercial US operators.
> I think a closer estimate is probably total annual operational costs divided by total shouts, (£18 MM / 2,000) or about £9,000 per shout.
That's a more useful estimate than merely the flight costs, agree - though the fixed operation costs don't change much in an 1800 vs a 2100 callout scenario.
> Still an order of magnitude less than the commercial US operators.
$500k? There entire helicopters you can just buy outright for less money than that. Does the $500k ride come with the helicopter itself included in the purchase?
I do vaguely remember seeing some bills with such figures. I've been literally developing various OCR and medical coding crap to process the cases and I've seen plenty of real cases. Some cases had eye-popping bills attached, yes.
The $500K spike was some sort of a highway accident response, can't recall any additional details apart from some serious head/brain trauma.
Keep in mind that everything gets significantly inflated, x2 multiplier is guaranteed, x5 is likely, x10 is not uncommon. Again, from what I can remember.
Also keep in mind that billed != settled. If I recall correct, that bill was settled at something around $55K. That was many years ago.
Uh, a new Bell 407 is north of $4 million and that's before it's equipped for medical flights. You aren't buying one of these for $500k used, at least not one that's air worthy. Eurocopter EC135 are a bit cheaper, but not by much.
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!
Note: My story is obviously kind of tangential to the actual article which explains why the cost is so high due to everyone who's being subsidized by what they're charging privately-insured patients. However, I have but the world's tiniest violin for those extremely profitable insurance companies who would obviously really like one of their costs of doing business to just go away. Yeah, I'd also like it if I could be paid my full salary, even though I refuse any work I find annoying.
> 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.
Be that as it may, the law in California forbids the insurance company from refusing to pay at the in-network rate in an emergency. As evidence, I'd submit the claim they immediately paid when called out on this.
If the insurance company weren't cynically exploiting people's lack of knowing their rights, they'd at least send a form letter to the patient saying "Please send us whatever proof from the hospital that you had a legitimate emergency and if approved, we'll pay <insert details> percent." Instead, they pay nothing, shove their fingers in their ears, and let the balance bill come to the patient, and hope nobody tells on them.
The only ambulance rides that should be billed like this are frivolous ones, like if someone is rear-ended at 1MPH, are unharmed, and they lay on the ground and fake an injury and demand to be transported to try to support a fraudulent legal case.
But isn't the California law requiring the insurance company to act as a sin-eater here? They seem to be the only people you were frustrated with, even though they are not the ones who charged you $1000.
They had the duty to pay and they try to trick every one of their customers into not realizing that, so that's why I'm only mad at them.
I acknowledge that the CA law is forcing them to, in the mechanism the article covers, causing them to subsidize other people's care, and this is happening in many areas of healthcare too.
Though those costs are surely accounted for when they set their premiums, which for 2025 amounted to just over $32,000 for my family.
Did they know they were supposed to cover it, or did the provider make a billing error? Even if there's no error, why is a government-run ambulance service making this the patient's problem, if the law says that they definitely have to pay? Why did it cost $1000 anyway, is that a reasonable price?
- The "why $1000" part is the subject of the article (I assume COVID-era inflation has brought that up to about $1700 similar to everything else)
> why is a government-run ambulance service making this the patient's problem
Whether government or private, they just want their money, and the insurance companies shrewdly avoid conversations where they might have to actually pay money. Plus, the ambulance guys probably have barely any documentation they could submit to prove that it was a "real" emergency, without which the $1000 would be the correct bill for me.
Insurance company's "genius" here is just remaining quiet and saying nothing, guaranteeing the average person will either get sent to collections by the ambulance, cut a deal with the ambulance, sell their plasma and subsist on ramen to afford it, or charge it on a credit card. And none of those involve the insurance sociopaths at all.
The article really proves that a "network" doesn't even make sense for this particular service. The insane part to me is that the insurance companies are allowed to pretend it does, and that they even have any "network" and impose the in/out of network distinction at all.
It's like if your Internet service came with "unlimited data" but when you read the fine print everything is pay-per-MB besides one single unpopular website.
> isn't the California law requiring the insurance company to act as a sin-eater here?
American healthcare providers have done a pretty good job at transferring PR liability to insurers. Cost inflation, in America, is mostly a problem at the provider level.
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.
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.
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.
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 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!
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.
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.
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.
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.
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.
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.
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.
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?
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.
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.
Just a personal anecdote. I was living in China, my father was visiting and fell ill (anemia). We needed to go to the hospital and decided to call an ambulance vs. calling a car because it could enter the gated compound. For a 3 km ride the price difference wasn't even a concern. A car would cost ~$3 and an ambulance ended up about $30.
PS: An average net salary in that city was about $1700/month at the time.
I spent a lot of time in healthcare finance and across most medical service industries the Medicare rate is actually not a loss. It’s a common thing said as it’s not super profitable, but it’s usually not a huge loss. It’s pretty close to what the cost of care should be. It just doesn’t give the extra padding for extremely fancy clinics, hospitals, admin and executive compensation, and often PE investor margin expectations. It’s usually slightly positive on contribution margin and given the volume of Medicare in the mix there’s enough flow through to cover reasonable overhead and perhaps slim margins. But, whenever I see a claim that the true cost of service is 10x over the Medicare rate, it’s a huge red flag there’s some financial shenanigans at play. Saying that Medicare is a loss, leaves the impression that it leaves a huge hole to fill so other payers need to pick up the bag in a huge way. This kind of lazy analysis blindly perpetuates this misconception. If they wanted to add value here, they should have performed a “what should an ambulance ride cost?” type analysis. You have to really strip out costs that are unneeded, excessive, and account for profit margin similarly. There’s no way $13k makes any sense for the service described. We need sensible cost controls in this industry. The industry hands these people blank checks when they can hide behind out of network, etc. It’s still captive price gouging.
[if the article’s analysis is true] cost controls would reduce the supply of ambulances, since the article claims Medicare actually is a loss.
You have claimed it isn’t, but you haven’t really provided much evidence other than “there’s no way that’s true, trust me, I used to work somewhere in healthcare finance”
Thats fine, I'm a passerby making a comment on their work on a platform that they may not even be aware of. If you look closer I’ve done more than they have by simply raising the concern and I’m not authoring an article attempting to educate people on the industry. I think it’s perfectly fine to question someone’s assertion based on experience alone. Basically you’ll have to do more to convince me what you’re saying is true is what I’m saying. That’s the same feedback a teacher would give a student on their homework. It takes data that I don’t have to do the analysis which is probably also why they didn’t do it. But I don’t think it’s completely off the mark to mention that I’ve been an insider at multiple healthcare service companies that like to claim they lose money on Medicare yet they opt to accept Medicare patients. When we consider denying Medicare we realize they are such a large part of the mix that they allow us to be as profitable as we are. It’s almost always a misconception of what “losing money” means. Price gouging the few patients that can afford it, is only profitable if all your expenses are already covered and economies of scale are at play, which is what Medicare is good for.
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".
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.
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
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.
Very much so. We could fix this. We continue to choose not to, and will for some time into the future.
Tangentially (think in systems), much of the US exists off of volunteer emergency services (fire and emt), which is rapidly evaporating. Average age of these volunteers is mid 50s.
> For generations, volunteers have formed the backbone of the nation’s emergency response system. Roughly half of the U.S. population, some 170 million people, live in areas primarily served by volunteer departments. Unpaid firefighters comprise more than 60 percent of all U.S. firefighters, and more than 80 percent of the country’s fire departments are either all or mostly volunteer.
> 4.5 million people lived in an ambulance desert (AD); 2.3 million (52%) of them in rural counties.
Four out of five counties (82%) had at least one AD. Rural counties were more likely to have ADs (84%) than urban counties (77%). Areas with the highest share and number of people living in ADs include the Appalachian region in the South; Western states with difficult mountainous terrain; coastal areas across the U.S.; and the rural mountainous areas of Maine, Vermont, Oregon, and Washington.
Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
I don’t think it is reasonable to expect to have ambulance coverage across the entire United States. There is a lot of land with very few people.
Choosing to live far away from others is also choosing to live far away from help.
If a service is highly variable cost dependent and is unaffordable for the average individual to pay out-of-pocket it is unaffordable for the aggregate individual as well.
It's very often not a choice. But also, those rural areas are often the breadbaskets of the united states. Taking care of our farmers is important.
Trying to frame it as a choice also misses a lot. It technically is, but you have to recognize there's a huge cost in uprooting your entire life and moving to a new location.
We give our farmers absolutely insane subsidies already.
It is not the government’s job to “take care of” anybody.
Everything has a cost, staying has a cost, leaving has a cost. The question is how much should the public be taxed to pay for individuals suboptimal decision-making? Or conversely, why am I subsidizing some billionaires remote horse ranch to have daily Postal Service and an ambulance standing by?
Can I move to the wilds of Alaska and then demand the same level of service as New York City? No that would be ludicrous.
W.Australia has a land area three time that of Texas with the bulk of the 2.9 million in population clustered about the capital city Perth.
In the rest of the state there are volunteer Ambulance services subsidised by state and federal government and a fleet of Royal Flying Doctor air ambulances.
Australia is also going bankrupt just slightly faster than the United States. Looks like deficit spending and debt levels are only trending the wrong direction there as well.
I am all for flight for life as we call it here, but that is different than saying we should have a network of ambulances across massive swabs of mostly empty terrain.
I am willing to hazard that the Australian airlift response is slower than your average ambulance response in Sydney.
> Australia is also going bankrupt just slightly faster than the United States.
Dunno about that, there be weeds. Not to mention the US clown car demolition derby is still in office.
Still, the coronavirus pandemic and associated policy responses led to the largest deterioration in the Australian Commonwealth Government’s fiscal position since the Second World War. That was 2021.
The forecast national net debt has looked pretty shitty since then, but the arc has been one of improvement - last years 2025-26 National Fiscal Outlook has been claimed to be overly grim by the most recent KPMG assessment of the 2026–27 AU Budget and backs the estimates that the Federal Government net debt servicing will return to pre COVID levels by 2029-30.
Yeah, it's f-obvious it takes longer for a plane to cross 600km than it takes an ambulance to cross a Sydney suburb.
Sweet, open the borders then. It's not the government's job to take care of that (we had government long before we had 21st century style closed borders, so it's definitely not a requirement of government). More people = more money coming in.
> It is not the government’s job to “take care of” anybody.
That is literally the only job of government. The entire reason we have a government is to serve the citizens in some fashion or another.
Even for most libertarians, they'll view the government in having a role resolving disputes. That is "taking care of" citizens by resolving conflicts.
Subsidizing farmers so citizens continue to have cheap and consistent access to food is a great thing. Right up there with providing clean drinking water, sewage services, and building roads.
I think what I’m saying is being misinterpreted. I should have been more clear. Everybody’s definition of “taken care of” is different.
The government needs to balance the interest of the public with the interest of the individual. It is not intended to “take care of “people regardless of their asks.
Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
> Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
That's a false equivalence.
We aren't talking about giving people penthouses. We are talking about providing EMS. Heck, I can even grant "degraded EMS" maybe we don't ensure an ambulance is stocked with the latest and greatest tech because you are rural. Maybe the ambulance is a hand-me-down from a larger city.
But it's not a huge ask to say that rural communities deserve at least some level of emergency health medicine. Less people means less health incidents. That's the primary reason why so many rural locations today are able to get by with volunteer EMS (Something my family participated in. Calls happened roughly once a month at most in my town of 300).
> The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
I agree, it's smart to make sure the government isn't over spending on frivolous things. I just don't think "EMS" is frivolous. Everyone might need it, it doesn't ultimately cost that much to provide (especially if it were actually ran by the government and not private entities), and it's services buy a lot of good will with citizens. Additionally, it creates economic output. Someone dying or getting a lifetime disability because EMS wasn't available is someone that's not adding to the economy.
Since the 1980s the Republican party had adopted a position of starve the beast, of screwing up these very numbers so that people can make exactly the argument you have.
What happens when half of government acts is bad faith purely to poison the well, one half of government and an entire political party make it so that the numbers don't work (and via the fiscal policy they intentionally inflict/structure/design) purely so that they can promote their policy position of 'the numbers don't work'?
How many unfunded tax cuts have we had recently? Those aren't acts of nature. The numbers you speak of not matching aren't acts of nature. They are intentionally designed to 'starve the beast' in the 1980s Republican way, and in newer ways the party has come up with since. All so the exact argument you gave can be made.
The city with the most funds per capita in the USA is SF. It's entirely run by dems. They can't pull it together or make the numbers work any better than repubs
The farmers can go F themselves. US soybean industry destroyed by trump tariffs, all I see are news stories about the very same soybean farmers talking about voting for trump again despite the pain. Reap what you sow!
> Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
There are some good points above, but I think this one is a distraction. Many of those states on that list have low ambulance densities because they have low population densities.
Have you ever driven through Wyoming or Montana? They have less than 10 people per square mile on average. There are a couple clusters of cities and then miles of empty land.
These statistics need to be based on cities, or at least have population density taken into account. It doesn't compute to set a threshold for ambulances per square mile when the population density differs so much from state to state.
There is no reason why this should be a blocker to solving the problem though. 80% of the population still lives in an urban area. You could create a system that works for the majority of the country’s population and then can figure out the rest.
We choose not to, because most consumers of ambulance services don't have to pay for it. So those of us who pay out of pocket for an ambulance, like I did ($1700 to go 3/4 of a mile last year) are a tiny minority.
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.
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.
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".
>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.
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.
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.
Government subsidized sudent loan forgiveness is a regressive tax, though, which makes it quite unpopular in the non educated that on average earn less.
The root cause is still cultural. Nobody wants to pay taxes that are helping someone else. Whether that "other" is in a different economic class, different race, different gender, has different political beliefs, lives in a different state, it's always the same mentality: "I don't want my tax dollars to pay for people I have determined to be 'others' and culturally different from me." Heaven forbid someone who doesn't deserve it or doesn't need it, get help.
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.
> 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.
St. John's Ambulance service in Australia is a hybrid of core paid positions and volunteers (varying by region and demand).
In rural Australia most of the fire, ambulance, and emergency response service are volunteer manned and (locally) run, with federal and state assistance for equipment and costs.
Costwise AU Ambulances are either free (if you're a St. John's member - cheap per annum OR if covered by private / work insurance) or (a decade out of date number) a flat fee of $500.
Thanks for the response, it's been awhile since I used an ambulance. I've got to say, I was willing to believe, what with free Qld buses and all that jazz, but alas like WA it's "qualified":
There's no cost for ambulance treatment and transport for Queensland residents. This includes treatment and transport that takes place in other parts of Australia.
and
If you don’t live in Queensland, you’ll be charged for ambulance treatment and transport. If you have ambulance cover in another state it may cover the cost for you.
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.
SF EMS is funded partially through the general fund and other bond measures, with additional billing to cover the rest. I believe it’s like $2K for a ride.
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.
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.
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.
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.
I live in Poland and despite being Europe from what I understand they don't have socialized healthcare. You need to buy insurance from the government, or private (I have both). If you don't have it, you don't have a right to healthcare.
Then, if you go to public doctors or hospital you still have to wait months for an exam or years for surgery. BUT, I've never heard of anyone going bankrupt from getting sick, or being scammed by their insurance not covering costs.
From what people make it sound, in the US you don't have socialized healthcare, getting doctors and exams is quick, but you also get scammed by insurance companies who will try their best to get out of paying, and I've definitely heard about people going bankrupt because they got sick.
I dislike sentences like 'you still have to wait months for an exam or years for surgery'. Depends on the exam or surgery.
- Blood test: wait time (after your 12 hour fast) is likely 15-30minutes in most of Europe (even eastern Europe. I should know, I do one every 3 month).
- pet-scan/x-ray: at most a few hours if your area is truly underserved, in my experience, less than an hour (but I needed it 4 times, so it might be small sample size).
Specialists will make you wait for sure if it doesn't sound life-threatening for deeper exams, and especially exams that requires surgery, but the only example I have on hand is my mother's boyfriend who got his in less than two weeks, and his cancer removal surgery was planned within 3 months after the tumor biopsy (you need to change your diet at least a month before surgery to prevent complications and improve healing, so the true delay caused by wait time is ~2 month). They also explicitly said that if his cancer was more aggressive they would have given him a month to prepare according to my mom.
But yes, in Europe especially, convenience surgery can take a year (my intern lips and teeth took 17 months) (and you pay a bit out of pocket), when in the US you can be done within days.
What I meant with "you have to wait months" is that if you go with the government-provided doctors and processes, they put you on a list and you have to wait for your turn. Getting an exam done can take months, and you can wait years for surgery, unless your condition is life-threatening.
If you go to a private clinic, of course you can get test results the same day and schedule any surgery within days.
Most people who can afford it go the private route. I had to do that too, which kind of pissed me off since I pay a hefty amount each month for insurance and I still have to go to private clinics. BUT, using the public infrastructure is just too inefficient. To get blood exams at a reduced price I had to schedule an appointment with my GP (days in advance), she'd send me to a specialist (about 1 week wait to get appointment), then a specialist would give me the paperwork required to get SOME of blood tests I needed covered by my insurance.
The point is that list isn't first-in-first-out. Public waiting lists are constantly reviewed by domain medical expert committees in the public system to triage priority patients.
If you're truly urgent, you will get bumped up. If you're not urgent, you can get bumped down as others go above you.
Unfortunately, individual QoL and urgency can sometimes be disconnected, which is why pensioners getting hip replacements can get bumped down despite having loss of mobility due to heaps of pain.
Cumulatively for lots of non-urgent activities (diagnosis tests etc) that drag can add up.
Much like any commons, is no perfect system, funnily enough.
To get standard blood exams (cortisol, insulin, triglycerids, HDL/LDL) reimbursed in France/Spain/Germany/Romania you only need a doctor note (and not even that if you test for STD).
Of course if you need specialized blood tests that need spectrometry or dna analysis or any expensive analysis you need a specialist appointment and that takes longer, but bureaucracy is the only way to make sure no one abuse the system. In worst case scenario, if the doctor thinks you should have priority, you will get it. And sometimes they are wrong. But it's a choice made to reduce overall cost, to avoid abuse.
You have free healthcare for children (up to 18 years old), pregnant women and registered unemployed. Moreover, any working person can (for free) add their spouse and parents. Plus people can apply for free health insurance if they have very low income.
Not sure, that's why I specified "from what I understand".
BUT, most people aren't children, pregnant, or registered unemployed/very low income, so from that point of view to me it's still an insurance-centric system.
I pay a hefty amount each month and I was sick in the past and the system was so inefficient that I had to go to private doctors and clinics just to figure out what was wrong with me. I see the public insurance payments as a tax and I have private insurance to cover the costs of private doctors/hospitals.
That’s not exactly right. You are eligible, you just need to do something to get it. Ie if you register as unemployed, you will get insurance. Same with university students.
> 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.
> “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.
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.
Hey man, don't worry about it, this is an international forum, English can be difficult. You seem kind of like a more junior/early in your career guy so, I'm happy to help out and explain.
Covered in this case means that they don't have to pay some third party to take that risk for them, they can just get the ambulance as part of the nominal fee everyone pays per year or whatever.
When you outline a problem statement, you want to map out what the person outlining the specs really mean. It takes practice.
There is no need to be condescending to me and be arrogant despite you being ambiguous over which definition of the word you were using. You could simply end the conversation, realizing we were talking past each other but instead you decided to take jabs such as implying I am ESL, implying I am bad at English, and assuming I'm early in my career in order to attempt to belittle me.
Foreigner from the socialist Nordics here, so perhaps I'm brain washed or something, but I don't get it. After some brief Googling it appears that you mean they have proposed a tax on a service that for some reason used to be tax-exempt.
Why was it tax-exempt? Why should it be?
What sets it apart from any other service where you pay someone to do something for you - such as cook you a meal, transport you somewhere or build you a house?
Virgina is easily one of the worst, most authoritarian states in the USA and it’s not even close
Worst driving laws in the USA by far. The entire existence of “the citadel”/VMI, the dog laws you mention, and a whole host of other authoritarian conservative nonsense.
I had to call an ambulance in Switzerland where ambulance prices are freely set by the operator (except in a few cantons which are enforcing reasonable flat rates)
A 5 minutes ride cost 1500.- (more or less the same in USD)
Because I had used a good broker to pick my insurance plan, I was left with “only” 500.- to pay out of pocket for the ride.
In Quebec, as a resident, going 3 blocks in the ambulance cost us about 500 CAD if I remember correctly.
Yeah, I had a Canadian friend who was in a motorcycle accident. He could see the hospital from where he crashed. He begged the paramedics to let him walk, but they judged he should not.
He was billed 600$.
The paramedics' judgment as to whether he should or shouldn't have isn't the debate here. They likely made the safe call.
To add, Switzerland is a little weird with accident vs disease.
If it’s an accident (ie sudden, unavoidable, unpredictable, more or less) it’s great because you have nothing to pay, you don’t even need to worry about the bill and there is no deductible and everything is covered no questions asked.
If it’s a disease, then it’s the regular insurance rules which can be quite arcane and you’re never sure what’s going to be covered and how much.
My transport was from adverse consequences of a surgery and so they deemed it not an accident, and that’s why I had to pay.
Oh wow. They were cool with me they said if we transport you it’ll be expensive. I didn’t have a car, I was living pretty high up a hill, it was midnight, and I had lost quite a bit of blood already so I thought “fuck it I’ll find out how expensive it is once I’m fixed”. But they wouldn’t have charged me if they hadn’t transported me (at least that’s what it sounded like)
I guess I made the right call because I fainted in the ER later from blood loss.
I don't get this US medical system. And the more I get to read about it the less informed I feel. Sounds like every involved medical service out there is just to rip the patient off.
Wait, being transported in an ambulance costs money? Man, every day I learn new things about how shitty the US health system is, and I'm more and more happy to not have to worry about deciding if I'd rather die or be broke in an emergency
His mistake was going to an American hospital at all. For what he paid, he could get a round trip ticket to literally anywhere in the world, then just get realistically priced medical care. The entire American medical establishment needs to end. It's cancer. I won't go. Not even if the alternative is my death. I just won't go. I should probably get some kind of dogtag to wear that explicitly states this if I'm ever knocked unconscious. Just leave me in the ditch man, American medical care is a fate worse than death.
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.
> 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:
“ 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).
> 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?
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.
Because America healthcare is stuck in the middle - it is semi socialized. You get both the negatives of socialized and free market ones. Either make it full socialized or remove all state money (this includes tax breaks and incentives) and allow competition.
It's simple. Ambs in the US are all private companies. Everywhere in the world private ambs are also extremely expensive and public ones free of charge. There is no truly public amb ride in the US.
This was a fun read, however, I feel that the actual essence is quite thin.
It can be summarized in a short sentence: The cost comes from being always prepared with teams and equipment, and few privately insured riders subsidizes everyone else, getting very high surprise bills - this can and should be a shared community tax which would effectively allow free ambulance rides to almost everybody.
It's an excellently written post though. I suspect people read this author for the experience, more so than actual information. I just wonder if they should just do prose and go wild with their skill instead of coating a few predictable facts with so many layers of color.
So what is the practical advice to avoid high costs? Also for foreigners, long ago had a friend visit from Asia and wave away ambulance after a potential serious injury (waiver not to be transported) knowing of the high medical costs.
Last year I had appendicitis in Italy, where I live. I called a cab to reach the nearest hospital, since I didn't feel so bad as warranting an ambulance. I got accepted, visited, transferred to the larger nearby hospital by ambulance, appendectomy, 4 nights stay, and I was provided with the drugs for the convalescence. When I was dismissed I took another cab back.
Total expense: ~25€ for the two taxi rides.
Very happy to pay my taxes, and very happy that when I don't need it myself, they go into financing the healthcare services for others that may or may not be able to pay out of pocket.
This sounds like a great deal if your annual taxes are less than your annual unsubsidized medical expenses, and a terrible deal if your annual taxes stretch into the six figure range as a young healthy person.
Doesn't this young person theoretically become older and less healthy as time passes? How many young people have six figures in taxes and not understand reciprocity?
Reciprocity is great when all parties contribute equal amounts, all parties receive an equal share of the benefit, and the arrangement is strictly voluntary. Think toll roads where everyone pays the same price, only the people using the road pay for it, and everyone using it benefits from it.
It's less great when some parties are expected to give more than they receive in return (in order to provide for those who give less than they receive in return), without their consent, enforced by the state's monopoly on lawful violence, and are demonized for so little as daring to express dissatisfaction with the involuntary arrangement.
I called 911 last year when my wife was unresponsive in Maryland. At least 10 vehicles arrived in under 10 minutes. EMTs worked to revive her for 30 minutes doing what they described as the same care she would have received at the emergency room.
She was transported to the hospital because she had a slight heart beat. Had she been declared dead at home, police and other staff would have helped process the death report and application for death certificate. I did not receive a bill or provide insurance information.
Can anyone explain why coverage networks even exist? What exactly makes it so expensive for an insurance provider to deal with an out-of-network health care provider? That same health care provider would not be expensive for an in-network insurance provider. I have no sense whatsoever for why the same health care provider would be expensive in one case and inexpensive in another case.
Usually, when some system is getting outdated, the system gets replaced or updated to fit the needs. Does this system work for the majority of USA, or not? Do I read it correctly, that the poor people have medicare/medicaid and therefore it's fine for them, the average person has some health insurance and don't mind spending a few thousands of dollars once in a while when his life is in stake?
If there is no emergency way to contact an ambulance in network then there should be no in- or out-of-network.
Calling 911 does not give you an in-network and there no way to know in advance unless calling your insurance (in business hours, giving that you are not dying... which you probably are)
I worked in private equity in the 90's and looked at one of the big regional ambulance service companies that was up for auction. The underlying operating margins were fairly reasonable - the private equity owned companies only have issues because of their debt load.
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?
Seems like rationalization - PE firms establish regional monopolies and jack up rates. They do it with every type of service. Just accept that we're all serfs under the billionaires who extract rents over every aspect of our lives.
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.
Great article. One item that it avoids touching even though it clearly insinuates it - the solutions.
And among the solutions, there's one that is briefly alluded to, but skipped around like a hot potato.
What if EMS were to refuse services for those who don't pay for the option on a monthly basis? And for the rest, if they choose to pay "on the spot" they can be OON like everyone is now? Why give out a free (or subsidized) option out, at all ? After all, I dont think it is illegal to turn away Medicare & Medicaid patients if you are not in-network with them.
We pay for other types of insurance. EMS insurance seems like a natural fit for a family.
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.
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.
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?"
OK for those that seem to dislike the suggestion that pickup trucks and SUVs kill more than cars do here's a study from the BMJ.
Specifically, with regard to the shape of the front of the vehicle:
> A large recent study in the USA found that, as compared with the low and sloping front end of a traditional passenger car, the odds of pedestrian fatality increased by 45% if the striking vehicle had a tall and sloped front end; increased by 44% if the striking vehicle had a tall and blunt front end; and increased by 26% if the striking vehicle had a medium-height and blunt front end.
This problem just doesn't exist anywhere else in the world. Ambulance is just another truck. There are some fees involved with having priority on the road and some regulations, but it's just another truck. It won't cost (to anyone - i mean OF COURSE it is free for the actual patient) over a hundred euros or so to do a simple across-city ambulance ride anywhere in EU, maybe 2x the price of a cab.
That's corruption and nothing more. End it and imprison everyone who ever had a tangential relationship to this system, for life - to ensure no one will try to pull this sort of "regulatory capture" again.
I was handling my moms bills when, at an independent living home, she was sent twice by ambulance for minor falls.
As the article says, thousands of dollars for these 5 minute drives.
(Fuck "credit score") I sent a check for $20 for each of the two bills. And I then did the same the next month when the bills came again.
I repeated this $20-a-month routine for a few years before, in both cases, they ended up closing the accounts-billing after perhaps $500 or so was paid.
What a selfish society the US have. 900 bucks for a fn ambulance. I enjoyed my stay when I was there, but living there.... seems to be a fucked up, soulless, dog eat dog, sell your own mother for 3 pennies kinda devil ridden place.
This is the best article of HN ever, so detailed and explaining, and engaging. I have a message for all US readers, this is simply nonsense. Putting blame on the hurt in the moment of need, discussing money over his own health, is something demons do. I hope you will realize someday
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 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.
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 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.
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
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.
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.
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.
> 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?
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.
https://www.redcross.org/about-us/news-and-events/news/10-wa...
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.
EMTs are like veterinarians. Lovely people who get ruthlessly exploited. Benefits are garbage unless you’re a unionized public employee.
Yeah, every EMT I know was way underpaid for how crazy stressful it was. Especially considering how expensive the ride was
EMT now is often used as a stepping stone to a career with a liveable wage, like physician.
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.
https://www.cma.ca/resources/healthcare-real/answers/healthc...
Medical supply costs for transport are very small. The labor overhead costs are overhead. Insurance is included in the estimate.
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.
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.
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....
He wouldn't be much of an elevator repairman if it didn't go up considerably.
To be fair, if you pay the repairman, your elevator also goes up :)
Don’t they need to sign something legally binding, the moment they adjust even one minor internal part?
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.
A qualified elevator technician can definitely make an elevator fail dangerously spectacularly.
They wouldn’t be qualified if they couldn’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.
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.
Edit: spelling
> I just want every medical service to have this exact type of breakdown
Check out the "No Surprises Act"
https://www.cms.gov/priorities/key-initiatives/hospital-pric...
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.
edit: clarity
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.
For citizens or do you charge higher for tourists? In for example Sweden only eu citizens get the cheap price.
Seems reasonable and closer to American averages than I would have expected.
Replying to myself as a followup:
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".
You need more than the crew in the ambulance.
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).
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.
+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.
Insurance is included.
12k for insurance is not enough.
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
> A new, fully equipped ambulance is about $150k.
This is definitely not true. A base model unequipped ambulance may be in that ballpark. A fully equipped ambulance will vary wildly in cost based on clinical level but will be about $250-500k in the US.
> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Maybe for BLS or non-emergency ambulances in a low-utilisation role? For ALS/Critical Care or higher in a busy jurisdiction it's going to be significantly higher.
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.
The 12k per year includes medical liability insurance.
That number looks low.
An interesting take on the relative differences of manufacturing (and purchasing) an ambulance in the US and China: https://www.youtube.com/watch?v=8JcCISp5S64
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.
It may also be telling to figure out why no startup is offering $400 ambulance rides and dominating on volume.
Almost certainly regulations. Anything even vaguely medically-related tends to be very, very highly regulated.
I for one would love to see a startup called say, "Trauma Team International" or "Docwagon"...
Ambulnz by DocGo
Ambulance.ai
(Shudders)
You can get an ambulance for only $150k? A transit van with a few options is already $75k.
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. It was also much closer to a van with a stretcher in it; the 911 ambulance was a mini hospital on wheels.
> 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.
The fact that so many people some gleeful to work as EMT despite the shit pay is just insane!
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 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
"My LLM of choice" is like when the news reporter says "confirmed by someone not authorized to speak publicly". It's not a meaningful report.
Your point about LLMs aside, I'd trust the inside source over whatever carefully baked misrepresentation the PR department doles out.
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.
It's arguably more reliable than some rando above doing napkin math and zero actual experience or evidence
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.
I didn't forget the cost of insurance.
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.
IKON passes don't grow on trees you know.. Someone has to rent out in Aspen.
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.
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
Ambulance crews are almost never 2 paramedics. Most often they transport and do BLS only. If they are it’s because a local government is paying for that service. EMTs make minimum wage.
The people who own ambulances typically have a little cartel like business in a region and print money. They refuse to sign insurance contracts so they are almost always out of network and will not accept direct insurance payments.
When my wife had cancer, she ended up at a hospital that didn’t have the services she needed becuase the ER was full at the trauma center hospital. I was able to arrange a transfer, and paid $1800 for a drive that was approximately 12 city blocks. We had to do that to avoid a complication with hospital admission and coverage. The crew was cool and we did get to honk the siren.
Air ambulance is worse.
Nobody makes (federal) minimum wage these days. McDonalds employees make double that.
I don’t live in a red state so we have a bizarrely low minimum.
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.
You haven’t been to the shithole south if you believe this.
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!”
All in cost of the employee is probably double or more of your example $23 an hour wage, just to flesh out your napkin math
Which would increase the cost to $325, though I was deliberately excluding overhead.
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> This is a short trip in an automobile, essentially a fancy uber ride.
We need a regulatory body that can fine people for making analogies this bad
> We need a regulatory body that can fine people for making analogies this bad
We need a communal agreement to apply social opprobrium upon people who reflexively propose to solve trivial problems by imposing their will on other people.
Tsk-tsk.
People (like the guy from the article) literally take Uber rides instead of ambulances, so they are a reasonable substitute good in many cases.
i mean their job is transporting people.
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?
> How can that possibly be justified?
They can't make money on some customers (medicare/insurance), so they have to make up the difference however they can. In practice this means screwing over the people who have assets to seize.
This thread is filled with strong arguments that ambulence operators do make money with medicare.
But even more, it's completely false that the reason an ongoing, working business charges a huge price to some people is that some other people are taking money from them. A business charge people huge prices when it can. Businesses make as much money as they can.
It is true that what health care providers charge individuals tends to be their "opening offer" to insurance companies so they do make this exact argument "we gotta make all our profits on you 'cause everyone else is denying us" but that doesn't make such arguments any more reasonable.
Comparable UK costs: https://www.kingsfund.org.uk/insight-and-analysis/data-and-c...
Estimate for an ambulance call is about £450. I suspect the main reason the US costs more is wages.
Wages for which role?
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.
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.
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’s wrong. The poor people who don’t pay are Medicare and Medicaid patients, and both pay for medically necessary transportation.
Those calls essentially cover the base business expenses.
"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.
I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you; no one is purchasing the right to see a movie regardless of how much it turns out to cost to show. It's the movie maker that would love to buy an option that makes you promise to buy a ticket, even if the movie turns out bad.
>I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you
I perfectly do know what an option is. It's just not relevant to the discussion, or at least not necessary. If you're selling a service that costs $2k of amortized costs to provide for $300, because that's all medicare/insurance companies are willing to pay, that's not a problem because you're offering options, it's an issue because you're charging too little. You're losing money because the numbers simply don't pencil out, not because you sold a bunch of options and sharp jane st traders cleaned you out. In any other situation where you're charging less than what it costs to provide, people just call it "bad business model", not "you're selling options" or whatever.
I completely lost interest at the options part, it’s not that complicated of a concept. But substack writers have their type
Most of the cost is keeping crews, vehicles and equipment available for the call that may or may not come
> 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.
This is just insurance, dude
At the end of the day doesnt that just end up being universal healthcare but with more steps?
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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. If we move you without your approval, it's kidnapping or entrapment (not hit me up law arguers). To do that we either need implied consent (minor no parent, not A&Ox4, or Law Enforcement).
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.
> 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.
> Only the US society seems to be unable to find a solution.
Unwilling. It's absolutely feasible to find a solution, as seen everywhere else in the world.
Even some parts of the US have found solutions.
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.
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.
I'm so often disappointed in my own country.
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!
> 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.
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.
Christianity died in my country because people got tired of the judgemental, hypocritical cunts. The child abuse scandals that hit later only confirmed it.
It’s dying in the US too, just taking longer than other developed countries.
https://news.gallup.com/poll/697676/drop-religiosity-among-l...
https://news.ycombinator.com/item?id=46484284
Worse than the child abuse scandals of goverment: - public school teachers sexually abusing their students - The Epstein files ?
You’re attributing to government what is just the overwhelming population of perps in this context: 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.
> Women commit just as much sexual abuse as men, it's just not talked about by society.
Please provide a citation for this assertion. Here’s mine refuting it.
https://www.ussc.gov/sites/default/files/pdf/research-and-pu...
https://smart.ojp.gov/somapi/chapter-2-etiology-adult-sexual...
https://www.humanrights.unsw.edu.au/news/study-finds-one-10-...
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.
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.
only parts of the US are unwilling
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
if you wanna know why it's never gonna happen -- there is the list. they will spend more money than god on social media, bribes, and whatever else they need to keep the system the way it is
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?
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.
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).
Many choose ignorance because it’s comfortable.
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.
Canadians don’t get the same care as Americans.
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.
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.
Life expectancy shows that while the US is the best place to have stage 4 cancer, it's probably not the best place overall. Most places do the 80/20 stuff better.
But yeah, you are right that the US does some stuff well. Just not efficiently.
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.
https://www.thelancet.com/journals/lanonc/article/PIIS1470-2...
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 you really disagree (except maybe on whether you think it's the right call). That is where the money is, since the insurance company can be forced to pay. It's kind of good for the rest of the world though if the US wants to pay (in both money and other issues) to be early adoptors.
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/
> Now do maternal death rate
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.
Not "this woman died because of poor maternal care", but rather "this woman who died had been pregnant in the last year".
This change immediately doubled the number. The data was wildly overestimating maternal deaths and in fact the CDC and many states are revising data collection to improve the number.
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. The closest it comes is that there are interprovincial billing systems so you don’t have to do the paperwork to get covered for an urgent visit out of province, and not all provinces are signed on.
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 almost always talk about problems within a province. What's happening in the Maritimes has nothing to do with BC.
The feds set a minimum standard for a province to qualify for federal funding, and that's about the limit of their influence.
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.
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."
Most doctors and nurses are not overpaid.
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.
> 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.
[0] https://www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-...
[1] https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.h...
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.
[0] https://www.medicaleconomics.com/view/physician-pay-makes-up...
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.
That's what a government would be for. You vote neo-liberal, you get it... (I consider both the US democrats and republicans neo-liberal)
I think only the US consider the US Democrats as leftists.
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.)
The Democratic Party spans from slightly right to ragging left that even European leftists look at with confusion.
What's the name of the far left grouping?
Only the rightists do and among them really only the loud redfaced ones.
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The US has always been a nation of immigrants, but now its largely a nation of ignorance.
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.
- the same as power but for roads. Traffic and congestion are now being actively managed by computerised systems because there are so many cars on the road.
- the same as power but for pollution. Another negative externality of driving up population for GDP reasons. Every person imported is more pollution generated in and by the local country.
It's important we have young people entering the workforce. But 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.
Sorry, you're completely wrong.
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.
Pretty much the entire “New World” has birthright citizenship, so it’s not just the US thing and I don’t believe its origins are political at all.
>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.
Possibly reasonable point about labour supply ruined by an absurd analogy with slavery.
Not at all.
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.
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
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In FY 2024, 0.3% of federal spending was by the US Agency for International Development ($21.7B)
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.
> Justifying stupid actions because you hate brown people isn't good for any of us.
What a strange non sequitur.
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.
You're arguing against a point I didn't make.
You see, it's better to die than to help the coloured neighbour who lives across the highway. I don't believe in this but that's USA society.
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"
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.
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.
I can’t imagine it’s gotten cheaper.
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.
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/
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.
He covered that in the article fairly thoroughly. Did you read it?
The anecdote illustrates the issue then he dives into the analysis.
It’s pretty common.
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
He’s a lightning rod only because some people get unnecessarily triggered by facts that don’t fit their world view.
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 it 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.
The time for this debate was 100 years ago. Now only people who can't be convinced aren't convinced, so there's no point convincing.
So why not make fun of them? There's no downside.
>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.
They will do that anyway. No amount of pandering will change their minds.
He’s a comedian that some people take too seriously.
You’re not supposed to shape your political views from entertainment.
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.
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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
"Just don't be poor!"
I feel like you have missed the entire point of the article.
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Your argument leads me to assume you think everything that causes to someone need an ambulance is the result of their choices.
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?!?
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.
Even the Soviets had a label for people who are a drain on society. You can’t run a country pretending everyone makes good choices.
And yet, somehow, not every country that has offered free ambulance rides has fallen into financial ruin.
Strawman. Ask any ER about “frequent flyers” who use ambulances as taxis
It's not a strawman. Ruining entire countries is literally what the parent comment said would happen if we do something as outrageous as making ambulances free.
> But those same people, through one false rationalization or another, are more than happy to ruin the entire country.
You may not have agued it yourself but your two sentence comment is rather lacking in alternate arguments, so I can only interpret you as supporting said parent comment and now engaging in a motte-and-bailey now that you realise you don't actually like what they said.
What do you consider financial ruin? Last time I checked most of those countries are desperately trying to contain their healthcare spending.
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.
> The increase in healthcare costs is more a function of an aging population, rather than people (mis)using ambulances too much.
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 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.
> I am not obligated to make your argument for you
Are you just uncomfortable with debate? How do you debate the merits of the argument without defining the terms being used?
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.
We should go further with this and require troops to pay for their own medevac. /s
Go ask SF troops what the PJs require from them if they get saved by a PJ (a branded tattoo on your ass).
I’m sure plenty of those soldiers would rather pay some money for the evac instead of a lifelong ass tat.
Well, if what I've read is true it's already sort of a practice in russian army.
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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?
> 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.
Okay, so why don't we see this behaviour more in other countries?
In my jurisdiction, the incentives are actually weighted towards pushing people to ambulances, as there is a €100 fee for self-referral to ED which is waived if you're transported, but while there are time wasters and frequent flyers, the service is actually less abused than US ambulances under EMTALA.
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. Oh, and it was about a 10 minute ambulance ride.
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.
Treating medical care like this, similar to a racketeering scheme, should not be a thing anywhere.
Instead of punishing people for seeking medical care (or plainly requiring it), it would be preferable to have a robust protocol for rejecting patients that do not require care, whether at the hospital or before the ambulance ride.
For this, people would need to want medical care be a humanitarian right and basic pillar of a functioning society, not a business or a bureaucratic system to perform a selection process decreasing the life expectancy of less-affluent people.
Ironically, when there is free medical care and universal insurance, there are also perverse incentives. For example unneeded expensive procedures, prescribing patented, newer drugs where cheaper ones would work, providing ineffective or even detrimental services, etc.
But humanitarian values are out of fashion, because they were never achieved globally.
So the only right people care about increasingly is their right to own property.
>rejecting patients that do not require care,
You end up just building the lawsuit against you.
I read a book once about doctors who went into the slums to treat cholera in the 19th century- noblesse oblige. We are now WORSE than the Victorians.
Should == I wish.
For most nation states "should" in this case also corresponds to a certain treaty they are party to being highly inconsistent with treating health like a racket. Of course, the US is one of the few that never ratified said treaty. Too much like socialism I suppose.
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.
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.
As someone who is not American, $10,000!!!!!! That's hard to conceive where I live. We even have a specifically free ambulance service here.
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.
This is exactly the part that makes "you can always refuse" feel a bit theoretical
>> 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 only 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. Is it 900, or 9000? Will my insurance cover this? Is this outside my deductable? ... this is math that no person should have to do while bleeding beside a highway.
I fainted once and my wife called an ambulance as I was unconcious due to Covid.
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
You do have to question why representatives of the people have not managed to address this
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
> but you make the choice
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’d argue nobody getting into an ambulance is making an informed choice.
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”?
Parent talked about conscious and aware.
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".
I think your department is probably closer to what people imagine ambulance billing looks like
>> 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.
By that logic no one can make choices for themselves, because people are never in the absolute theoretical optimal mental state.
The physician can mandate ambulance transfer.
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.
I think the idea is that if it's mandated, then the ambulance should be covered by some kind of insurance since it was medically necessary and not just Ol' Bob, the hypochondriac, calling because his tin foil hat fell off.
Except that's not how it works. Ambulances are almost always out-of-network, so subject to MUCH higher OOP expenses. It's spelled out in the article.
And what would they do if you refuse?
Who is "they" in your question?
> 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 author does not understand how private equity extracts money. The high-liability and heavily scrutinized business is intentionally left with little profit: the actual profits are funneled up the supply chain. This is why private equity buys "nonprofit" hospitals - they can now control who that nonprofit buys services and equipment from.
I worked in private equity as an analyst in the 90's - we looked at an ambulance service that was up for sale - the underlying operating margins (before you load on debt) were pretty reasonable, although I don't remember the details.
Thin operating margins don't really settle the greed question when the ownership structure is complicated
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Let's ask the thing whose mistakes I iron out all day to think for me.
I worked at a company which was doing medical billing for ambulances among other things.
Essentially, the bills are always inflated so when the settlement comes the providers get 20..50%. The crucial procedure is so called "medical coding" where medical notes (sometimes - scrawled on paper with a pencil) are being turned into bills - and that's where additional codes are getting added and more expensive codes are selected. There are books and guidelines on how to do the coding and some automated logic which "fixes" filled forms to bump the amounts a bit.
If the insurance (less frequently - the patient) pays more - that's just a bonus.
Billing itself gets a small fraction of the bill usually amounting to $20..50, they don't profit from inflated bills directly but the clients would select you on the basis of average settlements. Dispatchers also get little fractions. Things are very different when it comes to helicopter ambulances, where the bill could easily get to hundreds of thousands and everyone involved gets a lot. In fact, all the operators prefer to work with helicopters because of that, everyone involved references ground operations as "crap" or so.
Can't say for whole industry but that's what I've seen at one particular place working with several providers/dispatcher companies.
From what I can remember about the ground reality, a $12K bill would mean that they expected to actually get $3..4K. A typical ground bill for some particular region the company operated at was settled at $500..$2K while an average helicopter bill was smth around $200K if I remember correctly, with spikes up to $500K.
> an average helicopter bill was smth around $200K if I remember correctly, with spikes up to $500K.
Those numbers made me blanch somewhat! Having been in a helicopter (aka Air Ambulance) in the UK, all of which operate as charities iirc, I was curious about their costs.
> The average cost of a helicopter mission is £4,748* and the average cost of a critical care car or rapid response vehicle mission is £2,054*[1].
https://www.airambulancesuk.org/about-us/facts/
eesh
In the UK maybe, but in the US you should expect higher bills for _ground_ transport. Like literally, the linked story is about $12K bill for short distance ground transportation not involving any complex procedures. The cases I vaguely remember did include long lists of medical codes.
I tried to find the asterisk there to see the details, but could not.
FWIW I think that HEMS cost is significantly under costed, as the London HEMS H135s run about £2,500 per flight hour on direct flight costs alone, so I suspect the £4,748 figure is referring to that alone.
I think a closer estimate is probably total annual operational costs divided by total shouts, (£18 MM / 2,000) or about £9,000 per shout.
Even that's an under costing, as the clinical personnel, equipment, and liability is shouldered by the NHS. A pure costing is probably closer to 2-3X that per clinical flight.
Still an order of magnitude less than the commercial US operators.
> I think a closer estimate is probably total annual operational costs divided by total shouts, (£18 MM / 2,000) or about £9,000 per shout.
That's a more useful estimate than merely the flight costs, agree - though the fixed operation costs don't change much in an 1800 vs a 2100 callout scenario.
> Still an order of magnitude less than the commercial US operators.
It's wild!
Those are more sane numbers (unless you go by helicopter across the US).
Also found this intriguing in your source:
> London’s Air Ambulance crew made history in 1993 by performing the world’s first successful pre-hospital open-heart surgery at the roadside.
There are stories where the air ambulance sues patients who are still in ICU because getting paid depends on being first in line to file the lawsuit.
Personally, I've never seen anything like this. Usually it's billing company who sues, not providers dierctly - again, from my experience.
That's like saying "the fall doesn't kill you, it's the sudden stop".
I meant that I haven't seen such early lawsuits initiated by whoever.
$500k? There entire helicopters you can just buy outright for less money than that. Does the $500k ride come with the helicopter itself included in the purchase?
I do vaguely remember seeing some bills with such figures. I've been literally developing various OCR and medical coding crap to process the cases and I've seen plenty of real cases. Some cases had eye-popping bills attached, yes.
The $500K spike was some sort of a highway accident response, can't recall any additional details apart from some serious head/brain trauma.
Keep in mind that everything gets significantly inflated, x2 multiplier is guaranteed, x5 is likely, x10 is not uncommon. Again, from what I can remember.
Also keep in mind that billed != settled. If I recall correct, that bill was settled at something around $55K. That was many years ago.
Uh, a new Bell 407 is north of $4 million and that's before it's equipped for medical flights. You aren't buying one of these for $500k used, at least not one that's air worthy. Eurocopter EC135 are a bit cheaper, but not by much.
-> https://www.globalair.com/aircraft-for-sale/helicopters
There are many options very well over $1M. The 1975 one for 475K is unlikely to be used for medical transportation.
But you don't have to believe my story, you are totally entitled to consider that pure fantasy.
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!
Note: My story is obviously kind of tangential to the actual article which explains why the cost is so high due to everyone who's being subsidized by what they're charging privately-insured patients. However, I have but the world's tiniest violin for those extremely profitable insurance companies who would obviously really like one of their costs of doing business to just go away. Yeah, I'd also like it if I could be paid my full salary, even though I refuse any work I find annoying.
Be that as it may, the law in California forbids the insurance company from refusing to pay at the in-network rate in an emergency. As evidence, I'd submit the claim they immediately paid when called out on this.
If the insurance company weren't cynically exploiting people's lack of knowing their rights, they'd at least send a form letter to the patient saying "Please send us whatever proof from the hospital that you had a legitimate emergency and if approved, we'll pay <insert details> percent." Instead, they pay nothing, shove their fingers in their ears, and let the balance bill come to the patient, and hope nobody tells on them.
The only ambulance rides that should be billed like this are frivolous ones, like if someone is rear-ended at 1MPH, are unharmed, and they lay on the ground and fake an injury and demand to be transported to try to support a fraudulent legal case.
But isn't the California law requiring the insurance company to act as a sin-eater here? They seem to be the only people you were frustrated with, even though they are not the ones who charged you $1000.
They had the duty to pay and they try to trick every one of their customers into not realizing that, so that's why I'm only mad at them.
I acknowledge that the CA law is forcing them to, in the mechanism the article covers, causing them to subsidize other people's care, and this is happening in many areas of healthcare too.
Though those costs are surely accounted for when they set their premiums, which for 2025 amounted to just over $32,000 for my family.
The insurer is being forced to act as an insurer, by paying the $1000 they're supposed to cover.
Did they know they were supposed to cover it, or did the provider make a billing error? Even if there's no error, why is a government-run ambulance service making this the patient's problem, if the law says that they definitely have to pay? Why did it cost $1000 anyway, is that a reasonable price?
- The "why $1000" part is the subject of the article (I assume COVID-era inflation has brought that up to about $1700 similar to everything else)
> why is a government-run ambulance service making this the patient's problem
Whether government or private, they just want their money, and the insurance companies shrewdly avoid conversations where they might have to actually pay money. Plus, the ambulance guys probably have barely any documentation they could submit to prove that it was a "real" emergency, without which the $1000 would be the correct bill for me.
Insurance company's "genius" here is just remaining quiet and saying nothing, guaranteeing the average person will either get sent to collections by the ambulance, cut a deal with the ambulance, sell their plasma and subsist on ramen to afford it, or charge it on a credit card. And none of those involve the insurance sociopaths at all.
The article really proves that a "network" doesn't even make sense for this particular service. The insane part to me is that the insurance companies are allowed to pretend it does, and that they even have any "network" and impose the in/out of network distinction at all.
It's like if your Internet service came with "unlimited data" but when you read the fine print everything is pay-per-MB besides one single unpopular website.
> isn't the California law requiring the insurance company to act as a sin-eater here?
American healthcare providers have done a pretty good job at transferring PR liability to insurers. Cost inflation, in America, is mostly a problem at the provider level.
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.
> or cabulance
I'm sorry, are insurance companies now demanding that people use Ubers to get to the hospital?
... do they reimburse those charges? Because wtf.
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.
Oh, ok. When I posted that I genuinely thought they wanted people to call Ubers, etc.
This is less terrifying, thank you for clarifying!
I mean in real life, that is EXACTLY what many people do every day.
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.
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.
Was this Cigna? Same thing happened to me in SF in the same timeframe.
It took 5 times of me calling and explaining that they can’t charge it as out of network before they adjusted it.
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.
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!
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.
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.
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.
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.
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.
Many here will say that that's the cost of the freedom of choice and speech in the US.
It's from a fictional drama (The Newsroom) but this a great riposte to "freedom in the US".
https://youtu.be/wTjMqda19wk?t=95And 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.
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.
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.
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?
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.
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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.
Bring a window hammer.
Cleaning fee
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.
Just a personal anecdote. I was living in China, my father was visiting and fell ill (anemia). We needed to go to the hospital and decided to call an ambulance vs. calling a car because it could enter the gated compound. For a 3 km ride the price difference wasn't even a concern. A car would cost ~$3 and an ambulance ended up about $30.
PS: An average net salary in that city was about $1700/month at the time.
I spent a lot of time in healthcare finance and across most medical service industries the Medicare rate is actually not a loss. It’s a common thing said as it’s not super profitable, but it’s usually not a huge loss. It’s pretty close to what the cost of care should be. It just doesn’t give the extra padding for extremely fancy clinics, hospitals, admin and executive compensation, and often PE investor margin expectations. It’s usually slightly positive on contribution margin and given the volume of Medicare in the mix there’s enough flow through to cover reasonable overhead and perhaps slim margins. But, whenever I see a claim that the true cost of service is 10x over the Medicare rate, it’s a huge red flag there’s some financial shenanigans at play. Saying that Medicare is a loss, leaves the impression that it leaves a huge hole to fill so other payers need to pick up the bag in a huge way. This kind of lazy analysis blindly perpetuates this misconception. If they wanted to add value here, they should have performed a “what should an ambulance ride cost?” type analysis. You have to really strip out costs that are unneeded, excessive, and account for profit margin similarly. There’s no way $13k makes any sense for the service described. We need sensible cost controls in this industry. The industry hands these people blank checks when they can hide behind out of network, etc. It’s still captive price gouging.
[if the article’s analysis is true] cost controls would reduce the supply of ambulances, since the article claims Medicare actually is a loss.
You have claimed it isn’t, but you haven’t really provided much evidence other than “there’s no way that’s true, trust me, I used to work somewhere in healthcare finance”
Thats fine, I'm a passerby making a comment on their work on a platform that they may not even be aware of. If you look closer I’ve done more than they have by simply raising the concern and I’m not authoring an article attempting to educate people on the industry. I think it’s perfectly fine to question someone’s assertion based on experience alone. Basically you’ll have to do more to convince me what you’re saying is true is what I’m saying. That’s the same feedback a teacher would give a student on their homework. It takes data that I don’t have to do the analysis which is probably also why they didn’t do it. But I don’t think it’s completely off the mark to mention that I’ve been an insider at multiple healthcare service companies that like to claim they lose money on Medicare yet they opt to accept Medicare patients. When we consider denying Medicare we realize they are such a large part of the mix that they allow us to be as profitable as we are. It’s almost always a misconception of what “losing money” means. Price gouging the few patients that can afford it, is only profitable if all your expenses are already covered and economies of scale are at play, which is what Medicare is good for.
Here in Australia, you can be 2,000km in the bush and an ambulance will fly out to you and fly you back to the city for free.
That being said, we also have private ambulance companies here that will sting you for a huge bill if you don't have private ambulance cover.
We're getting taken to the cleaners in NZ!! I think it's $50 for a westpac chopper ride...
Yay for the RFDS.
If only ground ambulances were as universally awesome
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".
Sharing costs generates institutional incentives to keep costs down. Individualizing costs generates institutional incentives to charge more.
Perverse incentives are the essence of what is wrong with US medical systems.
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.
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
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.
Very much so. We could fix this. We continue to choose not to, and will for some time into the future.
Tangentially (think in systems), much of the US exists off of volunteer emergency services (fire and emt), which is rapidly evaporating. Average age of these volunteers is mid 50s.
https://www.nfpa.org/news-blogs-and-articles/nfpa-journal/20...
> For generations, volunteers have formed the backbone of the nation’s emergency response system. Roughly half of the U.S. population, some 170 million people, live in areas primarily served by volunteer departments. Unpaid firefighters comprise more than 60 percent of all U.S. firefighters, and more than 80 percent of the country’s fire departments are either all or mostly volunteer.
https://www.ruralhealthresearch.org/publications/1596
> 4.5 million people lived in an ambulance desert (AD); 2.3 million (52%) of them in rural counties. Four out of five counties (82%) had at least one AD. Rural counties were more likely to have ADs (84%) than urban counties (77%). Areas with the highest share and number of people living in ADs include the Appalachian region in the South; Western states with difficult mountainous terrain; coastal areas across the U.S.; and the rural mountainous areas of Maine, Vermont, Oregon, and Washington. Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
I don’t think it is reasonable to expect to have ambulance coverage across the entire United States. There is a lot of land with very few people.
Choosing to live far away from others is also choosing to live far away from help.
If a service is highly variable cost dependent and is unaffordable for the average individual to pay out-of-pocket it is unaffordable for the aggregate individual as well.
There _should_ be some ambulance deserts.
It's very often not a choice. But also, those rural areas are often the breadbaskets of the united states. Taking care of our farmers is important.
Trying to frame it as a choice also misses a lot. It technically is, but you have to recognize there's a huge cost in uprooting your entire life and moving to a new location.
We give our farmers absolutely insane subsidies already.
It is not the government’s job to “take care of” anybody.
Everything has a cost, staying has a cost, leaving has a cost. The question is how much should the public be taxed to pay for individuals suboptimal decision-making? Or conversely, why am I subsidizing some billionaires remote horse ranch to have daily Postal Service and an ambulance standing by?
Can I move to the wilds of Alaska and then demand the same level of service as New York City? No that would be ludicrous.
W.Australia has a land area three time that of Texas with the bulk of the 2.9 million in population clustered about the capital city Perth.
In the rest of the state there are volunteer Ambulance services subsidised by state and federal government and a fleet of Royal Flying Doctor air ambulances.
RFD(WA) comes in at ~ $80 million AUD / annum in state support (for better or worse - https://www.abc.net.au/news/2024-07-24/rural-gp-slams-royal-... )
They assert to have a "value" to the state of $4.1 billion AUD over 30 years - https://www.flyingdoctor.org.au/wa/
Australia is also going bankrupt just slightly faster than the United States. Looks like deficit spending and debt levels are only trending the wrong direction there as well.
I am all for flight for life as we call it here, but that is different than saying we should have a network of ambulances across massive swabs of mostly empty terrain.
I am willing to hazard that the Australian airlift response is slower than your average ambulance response in Sydney.
> Australia is also going bankrupt just slightly faster than the United States.
Dunno about that, there be weeds. Not to mention the US clown car demolition derby is still in office.
Still, the coronavirus pandemic and associated policy responses led to the largest deterioration in the Australian Commonwealth Government’s fiscal position since the Second World War. That was 2021.
The forecast national net debt has looked pretty shitty since then, but the arc has been one of improvement - last years 2025-26 National Fiscal Outlook has been claimed to be overly grim by the most recent KPMG assessment of the 2026–27 AU Budget and backs the estimates that the Federal Government net debt servicing will return to pre COVID levels by 2029-30.
Yeah, it's f-obvious it takes longer for a plane to cross 600km than it takes an ambulance to cross a Sydney suburb.
Any other insights?
> It is not the government’s job to “take care of” anybody.
That is actually the only legitimate function of government.
Sweet, open the borders then. It's not the government's job to take care of that (we had government long before we had 21st century style closed borders, so it's definitely not a requirement of government). More people = more money coming in.
> It is not the government’s job to “take care of” anybody.
That is literally the only job of government. The entire reason we have a government is to serve the citizens in some fashion or another.
Even for most libertarians, they'll view the government in having a role resolving disputes. That is "taking care of" citizens by resolving conflicts.
Subsidizing farmers so citizens continue to have cheap and consistent access to food is a great thing. Right up there with providing clean drinking water, sewage services, and building roads.
I think what I’m saying is being misinterpreted. I should have been more clear. Everybody’s definition of “taken care of” is different.
The government needs to balance the interest of the public with the interest of the individual. It is not intended to “take care of “people regardless of their asks.
Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
> Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
That's a false equivalence.
We aren't talking about giving people penthouses. We are talking about providing EMS. Heck, I can even grant "degraded EMS" maybe we don't ensure an ambulance is stocked with the latest and greatest tech because you are rural. Maybe the ambulance is a hand-me-down from a larger city.
But it's not a huge ask to say that rural communities deserve at least some level of emergency health medicine. Less people means less health incidents. That's the primary reason why so many rural locations today are able to get by with volunteer EMS (Something my family participated in. Calls happened roughly once a month at most in my town of 300).
> The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
I agree, it's smart to make sure the government isn't over spending on frivolous things. I just don't think "EMS" is frivolous. Everyone might need it, it doesn't ultimately cost that much to provide (especially if it were actually ran by the government and not private entities), and it's services buy a lot of good will with citizens. Additionally, it creates economic output. Someone dying or getting a lifetime disability because EMS wasn't available is someone that's not adding to the economy.
Do you think a beachside penthouse is really an equivalent example to life-saving medical care?
Since the 1980s the Republican party had adopted a position of starve the beast, of screwing up these very numbers so that people can make exactly the argument you have.
What happens when half of government acts is bad faith purely to poison the well, one half of government and an entire political party make it so that the numbers don't work (and via the fiscal policy they intentionally inflict/structure/design) purely so that they can promote their policy position of 'the numbers don't work'?
How many unfunded tax cuts have we had recently? Those aren't acts of nature. The numbers you speak of not matching aren't acts of nature. They are intentionally designed to 'starve the beast' in the 1980s Republican way, and in newer ways the party has come up with since. All so the exact argument you gave can be made.
The city with the most funds per capita in the USA is SF. It's entirely run by dems. They can't pull it together or make the numbers work any better than repubs
The farmers can go F themselves. US soybean industry destroyed by trump tariffs, all I see are news stories about the very same soybean farmers talking about voting for trump again despite the pain. Reap what you sow!
Why should there be ambulance deserts but not postal deserts?
Directionally, I am also fine with postal deserts or at least different delivery expectations for very rural areas.
But also because Postal Service is much cheaper than an ambulance service?
> Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
There are some good points above, but I think this one is a distraction. Many of those states on that list have low ambulance densities because they have low population densities.
Have you ever driven through Wyoming or Montana? They have less than 10 people per square mile on average. There are a couple clusters of cities and then miles of empty land.
These statistics need to be based on cities, or at least have population density taken into account. It doesn't compute to set a threshold for ambulances per square mile when the population density differs so much from state to state.
There is no reason why this should be a blocker to solving the problem though. 80% of the population still lives in an urban area. You could create a system that works for the majority of the country’s population and then can figure out the rest.
We choose not to, because most consumers of ambulance services don't have to pay for it. So those of us who pay out of pocket for an ambulance, like I did ($1700 to go 3/4 of a mile last year) are a tiny minority.
But if we fixed it, that might help people who can't afford the ride otherwise. And we cannot have that.
But do they really? Can you point a real, evil villain saying that?
Here you go: https://news.ycombinator.com/item?id=48857068
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.
You shifted the goalposts quite a lot there; first you wanted an example of evil, and now you want an example of unreasoning evil.
Evil is often very reasonable; pretending otherwise is a 'farcical strawman' of your own.
Do you believe the example given was evil? I believe they are wrong not evil. That's what I mean that I will not be a cynic.
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'm not sure I agree. Poor health is not always obvious and your health insurance provider is not conspicuous in most interactions.
I have had VASTLY better free health coverage (OHP, Portland OR via Providence) than the current Kaiser dreck I and employer pay significant sums for.
Healthcare is not a flex, and it my experiences on the west coast, it's an inverse correlation to wealth. :/
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".
>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.
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.
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.
> 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
Do imaginary conversations in the shower count?
See everyone who decries student loan forgiveness as an example.
Government subsidized sudent loan forgiveness is a regressive tax, though, which makes it quite unpopular in the non educated that on average earn less.
The root cause is still cultural. Nobody wants to pay taxes that are helping someone else. Whether that "other" is in a different economic class, different race, different gender, has different political beliefs, lives in a different state, it's always the same mentality: "I don't want my tax dollars to pay for people I have determined to be 'others' and culturally different from me." Heaven forbid someone who doesn't deserve it or doesn't need it, get help.
But that is not the topic being discussed. Is it?
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.
> 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.
A pretty large number of EMS is also volunteers. Basically wherever you have a volunteer fire department, you'll have volunteer EMS (if it's there).
St. John's Ambulance service in Australia is a hybrid of core paid positions and volunteers (varying by region and demand).
In rural Australia most of the fire, ambulance, and emergency response service are volunteer manned and (locally) run, with federal and state assistance for equipment and costs.
Costwise AU Ambulances are either free (if you're a St. John's member - cheap per annum OR if covered by private / work insurance) or (a decade out of date number) a flat fee of $500.
I don't think this is true everywhere. Queensland has the QAS[1], operated and funded by the state government. There are no (direct) fees.
[1]https://www.ambulance.qld.gov.au/
Thanks for the response, it's been awhile since I used an ambulance. I've got to say, I was willing to believe, what with free Qld buses and all that jazz, but alas like WA it's "qualified":
and https://www.ambulance.qld.gov.au/our-services/emergency-ambu...Yeah. In many countries, EMS is also heavily volunteer-based.
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.
The ambulance that billed me in San Francisco after my accident was run by San Francisco Fire Department.
Many fire departments in the US send bills, whether responding to medical emergencies or fires.
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.
SF EMS is funded partially through the general fund and other bond measures, with additional billing to cover the rest. I believe it’s like $2K for a ride.
Well, thank goodness we don't price Fire Department response the same way.
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.
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.
the reverse side of that medal is that in 'most of the world' EMS quality is ass.
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.
I think this argument is very disingenious for two reasons:
- 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.
If you limit it to say the top 20 developed countries how does it look?
Just a quick Google indicates the UK, Germany, US, and Japan all have urban response times in the ballpark of 10 minutes.
And even then they do worse than the average half brained private driver on trauma calls, since for many medical issues speed trumps capability.
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.
UK has had some atrocious response times.
Google is telling me that’s not the case… 7 minute target for life-threatening calls, with 90% actual within 15 minutes.
Well, here it is often ass AND expensive. I'd take ass and free over ass and expensive.
I live in Poland and despite being Europe from what I understand they don't have socialized healthcare. You need to buy insurance from the government, or private (I have both). If you don't have it, you don't have a right to healthcare.
Then, if you go to public doctors or hospital you still have to wait months for an exam or years for surgery. BUT, I've never heard of anyone going bankrupt from getting sick, or being scammed by their insurance not covering costs.
From what people make it sound, in the US you don't have socialized healthcare, getting doctors and exams is quick, but you also get scammed by insurance companies who will try their best to get out of paying, and I've definitely heard about people going bankrupt because they got sick.
I dislike sentences like 'you still have to wait months for an exam or years for surgery'. Depends on the exam or surgery.
- Blood test: wait time (after your 12 hour fast) is likely 15-30minutes in most of Europe (even eastern Europe. I should know, I do one every 3 month).
- pet-scan/x-ray: at most a few hours if your area is truly underserved, in my experience, less than an hour (but I needed it 4 times, so it might be small sample size).
Specialists will make you wait for sure if it doesn't sound life-threatening for deeper exams, and especially exams that requires surgery, but the only example I have on hand is my mother's boyfriend who got his in less than two weeks, and his cancer removal surgery was planned within 3 months after the tumor biopsy (you need to change your diet at least a month before surgery to prevent complications and improve healing, so the true delay caused by wait time is ~2 month). They also explicitly said that if his cancer was more aggressive they would have given him a month to prepare according to my mom.
But yes, in Europe especially, convenience surgery can take a year (my intern lips and teeth took 17 months) (and you pay a bit out of pocket), when in the US you can be done within days.
I'm not sure we're talking about the same thing.
What I meant with "you have to wait months" is that if you go with the government-provided doctors and processes, they put you on a list and you have to wait for your turn. Getting an exam done can take months, and you can wait years for surgery, unless your condition is life-threatening.
If you go to a private clinic, of course you can get test results the same day and schedule any surgery within days.
Most people who can afford it go the private route. I had to do that too, which kind of pissed me off since I pay a hefty amount each month for insurance and I still have to go to private clinics. BUT, using the public infrastructure is just too inefficient. To get blood exams at a reduced price I had to schedule an appointment with my GP (days in advance), she'd send me to a specialist (about 1 week wait to get appointment), then a specialist would give me the paperwork required to get SOME of blood tests I needed covered by my insurance.
The point is that list isn't first-in-first-out. Public waiting lists are constantly reviewed by domain medical expert committees in the public system to triage priority patients.
If you're truly urgent, you will get bumped up. If you're not urgent, you can get bumped down as others go above you.
Unfortunately, individual QoL and urgency can sometimes be disconnected, which is why pensioners getting hip replacements can get bumped down despite having loss of mobility due to heaps of pain.
Cumulatively for lots of non-urgent activities (diagnosis tests etc) that drag can add up.
Much like any commons, is no perfect system, funnily enough.
To get standard blood exams (cortisol, insulin, triglycerids, HDL/LDL) reimbursed in France/Spain/Germany/Romania you only need a doctor note (and not even that if you test for STD).
Of course if you need specialized blood tests that need spectrometry or dna analysis or any expensive analysis you need a specialist appointment and that takes longer, but bureaucracy is the only way to make sure no one abuse the system. In worst case scenario, if the doctor thinks you should have priority, you will get it. And sometimes they are wrong. But it's a choice made to reduce overall cost, to avoid abuse.
that's not true, access to the emergency medicine (and transport) is a constitutional right in Poland, you don't need NFZ coverage for that.
Same as in the USA. They are legally required to treat you in emergency situations there, too.
BUT, they will charge you for their services afterwards--both in the USA and in Poland.
Although I suspect that the bill from the American hospital will be A LOT more...
> they don't have socialized healthcare
You have free healthcare for children (up to 18 years old), pregnant women and registered unemployed. Moreover, any working person can (for free) add their spouse and parents. Plus people can apply for free health insurance if they have very low income.
Not sure, that's why I specified "from what I understand".
BUT, most people aren't children, pregnant, or registered unemployed/very low income, so from that point of view to me it's still an insurance-centric system.
I pay a hefty amount each month and I was sick in the past and the system was so inefficient that I had to go to private doctors and clinics just to figure out what was wrong with me. I see the public insurance payments as a tax and I have private insurance to cover the costs of private doctors/hospitals.
But maybe that's just me.
Here is a nice summary of Polish health care: https://www.oecd.org/content/dam/oecd/en/publications/report...
That’s not exactly right. You are eligible, you just need to do something to get it. Ie if you register as unemployed, you will get insurance. Same with university students.
> 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.
So there is a solution.
> “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.
>from everyone the service stands ready to rescue
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.
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.
That is not required complexity. You can just send the bill to the customer.
Who is the “you” in this scenario?
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.
So everyone's covered unless you explicitly opt-out?
Everyone is covered and you have the ability to pay someone to take on the risk of having to pay for an ambulance.
what happens to the people who don't pay someone to take that risk when they need an ambulance?
Then they pay for the ambulance.
Well then not everyone is covered.
To me covered means that the ambulance will drive to your location.
Hey man, don't worry about it, this is an international forum, English can be difficult. You seem kind of like a more junior/early in your career guy so, I'm happy to help out and explain.
Covered in this case means that they don't have to pay some third party to take that risk for them, they can just get the ambulance as part of the nominal fee everyone pays per year or whatever.
When you outline a problem statement, you want to map out what the person outlining the specs really mean. It takes practice.
There is no need to be condescending to me and be arrogant despite you being ambiguous over which definition of the word you were using. You could simply end the conversation, realizing we were talking past each other but instead you decided to take jabs such as implying I am ESL, implying I am bad at English, and assuming I'm early in my career in order to attempt to belittle me.
But that’s socialism!
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Foreigner from the socialist Nordics here, so perhaps I'm brain washed or something, but I don't get it. After some brief Googling it appears that you mean they have proposed a tax on a service that for some reason used to be tax-exempt.
Why was it tax-exempt? Why should it be?
What sets it apart from any other service where you pay someone to do something for you - such as cook you a meal, transport you somewhere or build you a house?
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Virgina is easily one of the worst, most authoritarian states in the USA and it’s not even close
Worst driving laws in the USA by far. The entire existence of “the citadel”/VMI, the dog laws you mention, and a whole host of other authoritarian conservative nonsense.
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I had to call an ambulance in Switzerland where ambulance prices are freely set by the operator (except in a few cantons which are enforcing reasonable flat rates)
A 5 minutes ride cost 1500.- (more or less the same in USD)
Because I had used a good broker to pick my insurance plan, I was left with “only” 500.- to pay out of pocket for the ride.
In Quebec, as a resident, going 3 blocks in the ambulance cost us about 500 CAD if I remember correctly.
Yeah, I had a Canadian friend who was in a motorcycle accident. He could see the hospital from where he crashed. He begged the paramedics to let him walk, but they judged he should not.
He was billed 600$.
The paramedics' judgment as to whether he should or shouldn't have isn't the debate here. They likely made the safe call.
Similar story here in Switzerland, with a 0 minute ride (they decided I didn’t need to be transported) that resulted in a bill of about 600-800 CHF.
To add, Switzerland is a little weird with accident vs disease.
If it’s an accident (ie sudden, unavoidable, unpredictable, more or less) it’s great because you have nothing to pay, you don’t even need to worry about the bill and there is no deductible and everything is covered no questions asked.
If it’s a disease, then it’s the regular insurance rules which can be quite arcane and you’re never sure what’s going to be covered and how much.
My transport was from adverse consequences of a surgery and so they deemed it not an accident, and that’s why I had to pay.
Oh wow. They were cool with me they said if we transport you it’ll be expensive. I didn’t have a car, I was living pretty high up a hill, it was midnight, and I had lost quite a bit of blood already so I thought “fuck it I’ll find out how expensive it is once I’m fixed”. But they wouldn’t have charged me if they hadn’t transported me (at least that’s what it sounded like)
I guess I made the right call because I fainted in the ER later from blood loss.
I don't get this US medical system. And the more I get to read about it the less informed I feel. Sounds like every involved medical service out there is just to rip the patient off.
Wait, being transported in an ambulance costs money? Man, every day I learn new things about how shitty the US health system is, and I'm more and more happy to not have to worry about deciding if I'd rather die or be broke in an emergency
His mistake was going to an American hospital at all. For what he paid, he could get a round trip ticket to literally anywhere in the world, then just get realistically priced medical care. The entire American medical establishment needs to end. It's cancer. I won't go. Not even if the alternative is my death. I just won't go. I should probably get some kind of dogtag to wear that explicitly states this if I'm ever knocked unconscious. Just leave me in the ditch man, American medical care is a fate worse than death.
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.
> 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:
https://www.wake.gov/departments-government/emergency-medica...
Finding out about this program was such a relief. I haven't worried about the prospect of having to call 911 since signing up.
“ 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).
This is amazingly coherent and explanatory article!
the writer really went into depth about the problem and...surprise...the answer is almost embarrassingly simple.
Everyone in the country needs to read this.
> 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.
Here's a PDF about the No Surprises Act:
https://www.cms.gov/files/document/a274577-1a-training-1-bal...
If you remove the $11,000 extortion “fee”, the remaining $1,000 is about the price found in the Western world countries.
"On appeal, his insurance agreed to cover $9,967 of the charge—better than nothing, but it still left him on the hook for about $3,000."
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.
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?
That seems needlessly cruel to do to people.
In a market where competition isn't relevant, the price of things is whatever you can get someone to pay for it.
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.
And they decide that you'll pay a percentage of what they pay each other. Which you also have no say in.
Because America healthcare is stuck in the middle - it is semi socialized. You get both the negatives of socialized and free market ones. Either make it full socialized or remove all state money (this includes tax breaks and incentives) and allow competition.
Uber for ambulances, got it. Claude, get to work. We will submit for Apple app review at EOD.
"Honest EMT — not just rides, but better"
It's simple. Ambs in the US are all private companies. Everywhere in the world private ambs are also extremely expensive and public ones free of charge. There is no truly public amb ride in the US.
We don't even have public toilets. We do have laws criminalizing homelessness though!
This was a fun read, however, I feel that the actual essence is quite thin.
It can be summarized in a short sentence: The cost comes from being always prepared with teams and equipment, and few privately insured riders subsidizes everyone else, getting very high surprise bills - this can and should be a shared community tax which would effectively allow free ambulance rides to almost everybody.
It's an excellently written post though. I suspect people read this author for the experience, more so than actual information. I just wonder if they should just do prose and go wild with their skill instead of coating a few predictable facts with so many layers of color.
So what is the practical advice to avoid high costs? Also for foreigners, long ago had a friend visit from Asia and wave away ambulance after a potential serious injury (waiver not to be transported) knowing of the high medical costs.
Last year I had appendicitis in Italy, where I live. I called a cab to reach the nearest hospital, since I didn't feel so bad as warranting an ambulance. I got accepted, visited, transferred to the larger nearby hospital by ambulance, appendectomy, 4 nights stay, and I was provided with the drugs for the convalescence. When I was dismissed I took another cab back.
Total expense: ~25€ for the two taxi rides.
Very happy to pay my taxes, and very happy that when I don't need it myself, they go into financing the healthcare services for others that may or may not be able to pay out of pocket.
This sounds like a great deal if your annual taxes are less than your annual unsubsidized medical expenses, and a terrible deal if your annual taxes stretch into the six figure range as a young healthy person.
Doesn't this young person theoretically become older and less healthy as time passes? How many young people have six figures in taxes and not understand reciprocity?
Reciprocity is great when all parties contribute equal amounts, all parties receive an equal share of the benefit, and the arrangement is strictly voluntary. Think toll roads where everyone pays the same price, only the people using the road pay for it, and everyone using it benefits from it.
It's less great when some parties are expected to give more than they receive in return (in order to provide for those who give less than they receive in return), without their consent, enforced by the state's monopoly on lawful violence, and are demonized for so little as daring to express dissatisfaction with the involuntary arrangement.
> annual taxes stretch into the six figure range as a young healthy person
At that point you're in the, what, top 2% of salaries? Especially for your age band.
I called 911 last year when my wife was unresponsive in Maryland. At least 10 vehicles arrived in under 10 minutes. EMTs worked to revive her for 30 minutes doing what they described as the same care she would have received at the emergency room.
She was transported to the hospital because she had a slight heart beat. Had she been declared dead at home, police and other staff would have helped process the death report and application for death certificate. I did not receive a bill or provide insurance information.
Can anyone explain why coverage networks even exist? What exactly makes it so expensive for an insurance provider to deal with an out-of-network health care provider? That same health care provider would not be expensive for an in-network insurance provider. I have no sense whatsoever for why the same health care provider would be expensive in one case and inexpensive in another case.
Usually, when some system is getting outdated, the system gets replaced or updated to fit the needs. Does this system work for the majority of USA, or not? Do I read it correctly, that the poor people have medicare/medicaid and therefore it's fine for them, the average person has some health insurance and don't mind spending a few thousands of dollars once in a while when his life is in stake?
Anywhere else in the world it’s possible to do this orders of magnitude cheaper.
But yes, it’s because of “options” and not because of greed.
Some group of people tries to extract as much money as possible. You can call this capitalism. I think it’s a big scam.
Where I live (NJ) you don't pay if your picked up by a town run rescue squad. But you don't always know who's responding... Such a strange system.
If there is no emergency way to contact an ambulance in network then there should be no in- or out-of-network.
Calling 911 does not give you an in-network and there no way to know in advance unless calling your insurance (in business hours, giving that you are not dying... which you probably are)
I worked in private equity in the 90's and looked at one of the big regional ambulance service companies that was up for auction. The underlying operating margins were fairly reasonable - the private equity owned companies only have issues because of their debt load.
In India, there's a quick commerce company (Blinkit) which offers free ambulance service, under 8 minutes TAT. Just broken systems, I guess.
Its a collective emergency service, which can save lives.
If by law this service is required and you bill only the rides, you get this, high bills per ride.
It would be nice to see a chart of countries with cost of ambulance rides, cost for the patient and average response times.
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?
They eat the cost, at least in my country.
Seems like rationalization - PE firms establish regional monopolies and jack up rates. They do it with every type of service. Just accept that we're all serfs under the billionaires who extract rents over every aspect of our lives.
I don't understand why taxes can be used to save property but not a person.
because of the moral values of elected law makers and thus indirectly because of the moral values of voters
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.
Because we like property.
Sure you do. Most people don’t own property. Most of the taxes are paid by people who do. And elections are decided by people with property.
You've got it. Who makes the decisions? Primarily the folks with the most property.
Great article. One item that it avoids touching even though it clearly insinuates it - the solutions.
And among the solutions, there's one that is briefly alluded to, but skipped around like a hot potato.
What if EMS were to refuse services for those who don't pay for the option on a monthly basis? And for the rest, if they choose to pay "on the spot" they can be OON like everyone is now? Why give out a free (or subsidized) option out, at all ? After all, I dont think it is illegal to turn away Medicare & Medicaid patients if you are not in-network with them.
We pay for other types of insurance. EMS insurance seems like a natural fit for a family.
> The standard answer is greed
The article is interesting, but it doesn't actually sufficiently dismiss this; it's the route cause of it all.
Cost in Bulgaria: $0
Same in Poland. Even uninsured junkies get a free ride.
Why won't EMS providers strip down their services to the level where Medicare/Medicaid rates completely cover their costs?
Yet "the payment model is broken" and "some prices are absurd" can both be true
There should be an "Uberlance" - discount emergency pickups by Uber, at Uber prices.
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.
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.
Uber is already “Uberlance”. Most people take Ubers to the hospital unless they are literally dying (and some even then).
Unlike an ambulance, an uber driver won't be able to keep a hemodynamically unstable patient alive for a 30 minute transport.
LAFD has already called Ubers for non-emergency transport to hospitals.
LACFD, and they encouraged the patients to call ubers, didn't call them themselves (I couldn't find the cite).
https://www.cbsnews.com/losangeles/news/la-county-changes-am...
Taxi / shuttle service also needs trained professionals, high fixed cost investment on specialized equipment, 24/7 availability.
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.
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.
And then do what, precisely? Quit your job and find one with better insurance options?
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?"
its horrible to think when u are caught up in something serious that calling an ambulance could ruin your life later.
better to live in uk where nhs takes care of all this compassionately for free.
What are the margins on an ambulance ride?
> a car hit him; he did, in his words, “a little flip” over the vehicle, landed in the road
He was lucky he was hit by a car.
A slab fronted SUV or pickup would have dragged him underneath and so it goes.
OK for those that seem to dislike the suggestion that pickup trucks and SUVs kill more than cars do here's a study from the BMJ.
Specifically, with regard to the shape of the front of the vehicle:
> A large recent study in the USA found that, as compared with the low and sloping front end of a traditional passenger car, the odds of pedestrian fatality increased by 45% if the striking vehicle had a tall and sloped front end; increased by 44% if the striking vehicle had a tall and blunt front end; and increased by 26% if the striking vehicle had a medium-height and blunt front end.
https://injuryprevention.bmj.com/content/32/1/16
This problem just doesn't exist anywhere else in the world. Ambulance is just another truck. There are some fees involved with having priority on the road and some regulations, but it's just another truck. It won't cost (to anyone - i mean OF COURSE it is free for the actual patient) over a hundred euros or so to do a simple across-city ambulance ride anywhere in EU, maybe 2x the price of a cab.
That's corruption and nothing more. End it and imprison everyone who ever had a tangential relationship to this system, for life - to ensure no one will try to pull this sort of "regulatory capture" again.
To be precise, a minibus.
I was handling my moms bills when, at an independent living home, she was sent twice by ambulance for minor falls.
As the article says, thousands of dollars for these 5 minute drives.
(Fuck "credit score") I sent a check for $20 for each of the two bills. And I then did the same the next month when the bills came again.
I repeated this $20-a-month routine for a few years before, in both cases, they ended up closing the accounts-billing after perhaps $500 or so was paid.
Same from Argentina to Canada? Wow
3rd world country.
What a selfish society the US have. 900 bucks for a fn ambulance. I enjoyed my stay when I was there, but living there.... seems to be a fucked up, soulless, dog eat dog, sell your own mother for 3 pennies kinda devil ridden place.
This is the best article of HN ever, so detailed and explaining, and engaging. I have a message for all US readers, this is simply nonsense. Putting blame on the hurt in the moment of need, discussing money over his own health, is something demons do. I hope you will realize someday
My fun ancedotal story about US healthcare:
Kaiser transported me 4hrs in a ambulance to get surgery and I think I just paid the $200 ER fee
But then they would never cover an MRI for an issue with the same leg.
It's like we're almost done with this project guys, come on.
You guys pay for an ambulance ride?
Why? Because fuck you, that's why.
Welcome to America. It's a business. Gimme my money.
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 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.
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tldr: greed
TLDR: private equity
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 article argues the exact opposite:
> 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.
That paragraph is somewhat incoherent at that point in the article: margins are razor thin — at a price tag of $12,000 per 6 miles or $2,000 per mile.
(Yes, there is some other stuff, much, much, much later that maybe cuts into that …)
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.
Except the paramedics are actually making mcdonalds wages.
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
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.
So the argument is that any piece of regulation will always lead to a positive outcome?
How is that possible?
Can you name some?
When you are bleeding out on the street, you don't have time to shop around for the best deal
Wont matter because nobody is going to be paying 12k for a ambulance ride if there are people doing it significantly cheaper.
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.
I would absolutely not tolerate and unregulated ambulance responding to my emergency.
You don’t have to. You do what you want. I’d prefer to hire a company where the workers make more money. Right now they make a pittance.
Someone who's having a medical emergency is certainly in no position to go comparison shopping for ambulance services.
You would do it before hand of course
Let me just schedule in plans for my future heart attack and car accidents.
Yes because you don’t have health insurance until you have a heart attack right? You never pick that before hand do you?
When you get your bill, you could just double that as a tip.