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Health Care Reform and Caregivers Refusing Medicare Patients

Robert goes out on a limb and guesses that Lori Montgomery fell for (or is pushing) Republican spin in this article in the Washington Post
Report: Bill would reduce senior care
Medicare cuts approved by House may affect access to providers

A plan to slash more than $500 billion from future Medicare spending — one of the biggest sources of funding for President Obama’s proposed overhaul of the nation’s health-care system — would sharply reduce benefits for some senior citizens and could jeopardize access to care for millions of others, according to a government evaluation released Saturday.

The report, requested by House Republicans, found that Medicare cuts contained in the health package approved by the House on Nov. 7 are likely to prove so costly to hospitals and nursing homes that they could stop taking Medicare altogether.

Congress could intervene to avoid such an outcome, but “so doing would likely result in significantly smaller actual savings” than is currently projected, according to the analysis by the chief actuary for the agency that administers Medicare and Medicaid.

I have read the report (warning pdf) … well actually up to the passage stressed by Republicans and Montgomery. Montgomery’s article focuses on one paragraph deep in the report which begins “It is important to note that the estimated savings for one category of Medicare proposals may be unrealistic.” That’s some serious digging.

The paragraph goes on to discuss what seems to be new additional budgetary flimflam which is assuming that productivity in hospitals and nursing homes grows at the national average (measured productivity grows much more slowly and it doesn’t matter if this is due to unmeasured improved quality of care). That would be part of a large savings of $ 282 billion. The report doesn’t describe what the savings would be if Medicare rates were adjusted to a reasonable forecast of productivity growth.

Now I had assumed that Medicare cuts other than eliminating the Medicare advantage boondoggle were reductions in money effectively given to hospitals (and nursing homes etc) so they could afford to take care of the uninsured. Hospitals’ budgets will be affected by increased health insurance coverage, both by the increases in the total fraction of people insured and the fraction of people with pre-existing conditions insured. This means that the total effect on Hospitals’ budgets can’t be calculated assuming only Medicare payment rates change.

Importantly, the Foster (the author) assumes that reduced Medicare payments will cause hospitals to choose to refuse Medicare patients and not drive Hospitals bankrupt. It is true that relatively lower Medicare rates will cause more hospitals to refuse Medicare patients. How many currently do? I googled
“hospitals which refuse medicare” I got links to articles about physicians who refuse Medicare patients and this link to someone who works at a hospital where they talked about refusing Medicare patients.

Medicare rates are already low. There sure don’t seem to be many hospitals which refuse to treat Medicare patients.

OK so I tried the past tense and googled “hospital did not accept medicare”
This link to someone who says an anonymous hospital told her in 1998 that they didn’t accept Medicare patients.

Quite frankly this doesn’t seem to be a huge problem. The idea that it will get even bigger if Medicare rates fall further below other rates doesn’t seem to me to merit page 1 treatment.

I think Foster is saying that he believes that the new restrictions on Medicare compensation will be waived just as the existing restrictions are waived. He can’t say that Congress is flimflamming so he has to explain how this might be a natural response to unforeseen events in the future. My current guess is that the event will be the perfectly foreseeable complaints from hospitals and nursing homes and that the forecast that Congress will waive the rule is the only forecast a responsible actuary can make.

The Republican/Montgomery/ headline guy spin that elderly people will be denied care if the bill passes is absurd. If that’s the way things worked, the 1997 rule wouldn’t be waived year after year.

There don’t seem to be many reports of hospitals refusing Medicaid either.
No google hits for “hospital refuses medicaid” one for “hospital refused medicaid” to a publication of the National Center for Policy Analysis. Hmmm, where have I heard of that? It’s the so called think tank which fired Bruce Bartlett for heresy.

The document to which I link asserts that Veterans care is queue rationed and that the veterans administration does provide as high quality care as that available to people with private insurance. Non ideological sources rate the veterans administration as the best care provider — number one.

I think that “Hospitals will refuse Medicare and/or Medicaid” is a serious policy concern on a level similar to the “tax cuts cause increased revenues.” And here it is on the front page of

Update: Note I am writing about hospitals who refuse Medicare not doctors in private practice who refuse Medicare. My googling and questions were on hospitals which refuse medicare and/or medicaid. Of the first 7 comments, 5 discussed office based practices which refuse medicare. By my count letters “hospital” appear in that order 18 (eighteen) times in the post (sometimes followed immediately by an s). Somehow commenters seem to have overlooked all 18 (eighteen) of them.

This is not a quibble. The provision of the bill which Foster suspects will not be actually applied concerns “institutional” providers of health care not physicians in private practice. I quote from his report

H.R. 3962 would introduce permanent annual productivity adjustments to price updates for institutional providers (such as acute car hospitals, skilled nursing facilities, and home health agencies) using a 10-year moving average of economy-wide productivity gains. [skip] end participation in the program (possibly jeopardizing access to care for beneficiaries).

That’s why I asked about Hospitals refusing medicare patients. There is a big difference between squeezing the entities which can’t be squeezed and squeezing those which can be squeezed (provided they are getting a lot more money due to increased insurance coverage so they won’t go bankrupt).

Fox Noise on Canadian private insurance boom

By: Divorced one like Bush

This is a heads up. Fox news has a report out that there is a rise in private insurance activity in Canada. The article suggests that it is because of all the wait time that people are tired of do to a shortage of doctors and possibly the low fees. And, that may be true, especially being there was a Quebec Supreme Court ruling on it.

If you google the headline, you will find many a posting touting this article as a sort of proof that the Canadian system really is bad stuff.

But, and with Fox there is always a butt, what they do not tell you is that their article is based on a report in the CMAJ – JAMC article from 2008: Canada Health Act breaches are being ignored, pro-medicare groups charge

Private for-profit medical clinics are proliferating across the country, according to a detailed report by pro-medicare groups.
The number of such clinics has increased significantly over the past 5 years and there’s evidence “to suspect that 89 for-profit clinics in 5 provinces appear to be in breach of the Canada Health Act,” states the 169-page Eroding Public Medicare: Lessons and Consequences of For-Profit Health Care Across Canada report.
But federal and provincial officials “have fallen down in their responsibility to protect patients against extra billing and 2-tier care,” says report author Natalie Mehra, director of the Ontario Health Coalition.

The Fox article quotes the same Natalie, but not those quotes.

The CMAJ article continues:

Researchers also found evidence of physicians practising in hospitals but referring patients to their private for-profit businesses, where medically necessary services would be provided more quickly, for an out-of-pocket fee…

So, some illegal stuff is going on (boom in private activity), the government was suppose to do something about it, but it didn’t. Can you say “conservative, Milton Freedmon governance”?


In 1995, then-federal health minister Diane Marleau issued a policy interpretation letter calling on provinces to introduce “regulatory frameworks” to govern the operation of private clinics, and make illegal the “facility fees” charged by private clinics which provide publicly-insured services.

Basically as I read the real article, the boom is actually starting to create what we have here in the USA. A two class society regarding health care access with rising expenditures as doc’s have the market opportunity to charge more via cash deals. Kind of a black market situation? Is the solution to be more like us, or is the solution to solve the bottle neck of not enough doctors? Or maybe the problem is that once you let people who can pay for them self do so (choice?), you begin the destruction of what was a system that treated everyone equally. That is, for a basic human need such as health care, everyone is of the same stature.

We have a great opportunity here with Canada. What happened in our banking system is what has happened to Canada’s health care funding system. Same ideology implimented, same distruction for the benefit of the few.

We are seeing the effects of what happens when the ideology of individual freedom is made predominat in an economic system that assured equality regarding basic needs. That is the key: Basic Needs. Not wants, not money beyond autonomous consumption, but money at autonomous consumption. It is libertarian economics vs Jefferson democracy economics. Personal economic freedom for needs funnels down the benefits of human progress to fewer people instead of expanding the benefits to every more people.

There was one letter responding to the CMAJ article. An open letter to the minister of healthPaul C. Hébert, MD MHSc, Editor-in-Chief

After more than a decade, the health system has not fully recovered from the last round of federal cuts in the mid-1990s. The large reduction of about 10% in federal funding for health forced provincial governments to axe many health care programs, close some hospitals and reduce the number of beds in the remaining institutions, as well as slash training positions for physicians and other health care providers… Provincial governments have become much more autonomous and, in many instances, unwilling to adopt new programs and standards in the interest of all Canadians. The ongoing jurisdictional battle between federal and provincial governments, whether over First Nations health, public health, access to care and expensive medications or the setting of national standards, suggests that the federal government has little influence on Canada’s health systems. The ability of the provinces to offer private services1 and mount administrative barriers to portability of services without consequences is a constant reminder of this weakened federal authority…Canada’s health care systems seem to be moving further and further away from fulfilling the promise of the Canada Health Act.

The reason for limited progress is an erosion of national leadership in health. Successive federal governments have either decreased investments or, through inaction, allowed health to be a purely provincial matter. Despite the importance of health in the minds of the voting public, we remain very concerned that health has slipped entirely off the federal agenda.

Get it? What is actually happening in Canada is the results of the Grover Norquist training manual for conservative governance, the goal of which is the drowning of anything that suggests a social conscience.

Deja Vu Health Care Reform: Hillary Care is the wrong feeling

by: Divorced one like Bush

Ok folks. It’s real, this familiarity with the health care reform debate. It is a real memory you are experiencing, that deja vu feeling. Only, the reason it seems so much as deja vu is because what your being told is the trigger of the deja vu is not the real memory. Hillary Care is not the correct memory for the current debate and thus it “feels” like you have been there before: deja vu. However, you really have been there before, and thus it is a real memory, not a similar feeling. It was Nixon, 1971. And, the experience of the mind games that are being tempted upon you are as real and cautioning a memory as having burned your hand on a hot pan, or caught a knief falling.

February 17, 1971

Ehrlichman: We have now narrowed down the vice president’s problems on this thing to one issue, and that is whether we should include these Health Maintenance Organizations like Edgar Kaiser’s Permanente thing.
Nixon: Now let me ask you…You know I’m not to keen on any of these damn medical programs.
Ehrlichman: This is a private enterprise one.
Nixon: Well that appeals to me.
Ehrlichman: Edgar Kaiser is running this Permanente deal for profit. And the reason that he can, the reason he can do it…I had Edgar Kaiser come in, talk to me about this. And I went into some depth. All of the incentives are toward less medical care. Because the less care they give them, the more money they make.
Nixon: Fine
Ehrlichman: …and the incentives run the right way.
Nixon: Not bad.

February 18, 1971
Nixon’s Special Message to Congress proposing a National Health Strategy

I’m going to start with his last paragraph:

Nineteen months ago I said that America’s medical system faced a “massive crisis.” Since that statement was made, that crisis has deepened. All of us must now join together in a common effort to meet this crisis–each doing

Going forward, I only excerpted the parts related to insurance because the truth now as then is that the real issue when this nation talks about health care reform, is that we are only talking about how the money will travel to pay for it. Cost controls are always second and presented as a results of how the money will travel. Improved outcomes are always third and a result of how the money will travel. Tort reform equals how the money will travel. More people having access? Again a result of how the money will travel.

What follows are Nixon’s arguments for keeping a private system. The points should all sound very familiar. There are a few items however that might surprise you as to him being a republican compared to today’s “republican”. In the end, it is still the republican (and now also DLC) ideology of free market rhetoric supporting a discussion of what I consider the false market in “health care reform”: The third party, the middleman.

This is long after the jump. Please take the time to read Nixon’s words. Reading such history first hand is the only means we have for growing a more mature social personality.

As you read, pay attention to the reasoning and expected results, then compare them to today. Today, is the actual results. The results are what we are living.

Recognize the sales pitch. Recognize the appeal to humanistic needs as part of the pitch for the product. Nixon was not trying to sell a better America. That was just jive talk to sell HMO’s. Recognize such in today’s presentation.

Continuing Nixon’s presentation:
Our record, then, is not as good as it should be. Costs have skyrocketed but values have not kept pace. We are investing more of our nation’s resources in the health of our people but we are not getting a full return on our investment.

This new strategy should be built on four basic principles.
1. Assuring Equal Access
2. Balancing Supply and Demand.
3. Organizing for Efficiency. There are two particularly useful ways of doing this:

A. Emphasizing Health Maintenance. In most cases our present medical system operates episodically–people come to it in moments of distress–when they require its most expensive services. Yet both the
system, and those it serves would be better off if less expensive services could be delivered on a more
regular basis… In short, we should build a true “health” system-and not a “sickness” system alone. We should work to maintain health and not merely to restore it.
B. Preserving Cost Consciousness. As we determine just who should bear the various costs of health care, we should remember that only as people are aware of those costs will they be motivated to reduce them. When consumers pay virtually nothing for services and when, at the same time, those who provide services know that all their costs will also be met, then neither the consumer nor the provider has an incentive to use the system efficiently.

4. Building on Strengths. We should also avoid holding the whole of our health care system responsible for failures in some of its parts. There is a natural temptation in dealing with any complex problem to say: “Let us wipe the slate clean and start from scratch.” But to do this-to dismantle our entire health insurance system, for example–would be to ignore those important parts of the system which have provided useful service…

One of those strengths is the diversity of our system–and the range of choice it therefore provides to doctors and patients alike. I believe the public will always be better served by a pluralistic system than by a monolithic one, by a system which creates many effective centers of responsibility–both public and private–rather than one that concentrates authority in a single governmental source.


In recent years, a new method for delivering health services has achieved growing respect. This new approach has two essential attributes. It brings together a comprehensive range of medical services in a single organization so that a patient is assured of convenient access to all of them. And it provides needed services for a fixed contract fee which is paid in advance by all subscribers.

Such an organization can have a variety of forms and names and sponsors. One of the strengths of this new concept, in fact, is its great flexibility. The general term which has been applied to all of these units is “HMO”–“Health Maintenance Organization.”
The most important advantage of Health Maintenance Organizations is that they increase the value of the services a consumer receives for each health dollar. This happens, first, because such organizations provide a strong financial incentive for better preventive care and for greater efficiency. A fixed-price contract for comprehensive care reverses this illogical incentive. Under this arrangement, income grows not with the number of days a person is sick but with the number of days he is well. HMO’s therefore have a strong financial interest in preventing illness, or, failing that, in treating it in its early stages, promoting a thorough recovery, and preventing any reoccurrence. Like doctors in ancient China, they are paid to keep their clients healthy. For them, economic interests work to re-enforce their professional interests.

…So is this administration. That is why we proposed legislation last March to enable Medicare recipients to join such programs. That is why I am now making the following additional recommendations:
2. To help new HMO’s get started-an expensive and complicated task–we should establish a new $23 million program of planning grants to aid potential sponsors–in both the private and public sector.
At the same time, we should provide additional support to help sponsors raise the necessary capital, construct needed facilities, and sustain initial operating deficits until they achieve an enrollment which allows them to pay their own way. For this purpose, I propose a program of Federal loan guarantees which will enable private sponsors to raise some $300 million in private loans during the first year of the program.
(In 2009 dollars that’s: $1,594,443,347.32 using the Consumer Price Index, $1,270,112,394.52 using the GDP deflator, using value of consumer bundle, $1,572,128,637.06 using the unskilled wage, $2,589,331,122.17 using the nominal GDP per capita, $3,796,805,962.20 using the relative share of GDP)

In my State of the Union Message, I pledged to present a program “to ensure that no American family will be prevented from obtaining basic medical care by inability to pay.” I am announcing that program today. It is a comprehensive national health insurance program, one in which the public and the private sectors would join in a new partnership to provide adequate health insurance for the American people.

In the last twenty years, the segment of our population owning health insurance has grown from 50 percent to 87 percent and the portion of medical bills paid for by insurance has gone from 35 percent to 60 percent. But despite this impressive growth, there are still serious gaps in present health insurance coverage. Four such gaps deserve particular attention. (Ok, well this has definitely been reversed.)
First–too many health insurance policies focus on hospital and surgical costs and leave critical outpatient services uncovered… Because demand goes where the dollars are, the result is an unnecessary–and expensive— overutilization of acute care facilities. The average hospital stay today is a full day longer than it was eight years ago. (Yup, fixed that one.)

A second problem is the failure of most private insurance policies to protect against the catastrophic costs of major illnesses and accidents. Only 40 percent of our people have catastrophic cost insurance of any sort and most of that insurance has upper limits of $10,000 or $15,000. This means that insurance often runs out while expenses are still mounting. For many of our families, the anguish of a serious illness is thus compounded by acute financial anxiety. Even the joy of recovery can often be clouded by the burden of debt–and even by the threat of bankruptcy.
A third problem with much of our insurance at the present time is that it cannot be applied to membership in a Health Maintenance Organization–and thus effectively precludes such membership. No employee will pay to join such a plan, no matter how attractive it might seem to him, when deductions from his paycheck–along with contributions from his employer–are being used to purchase another health insurance policy.

The fourth deficiency we must correct in present insurance coverage is its failure to help the poor gain sufficient access to our medical system. Just one index of this failure is the fact that fifty percent of poor children are not even immunized against common childhood diseases. (We are above 80% now.) The disability rate for families below the poverty line is at least 50 percent higher than for families with incomes above $10,000.

Our National Health Insurance Partnership is designed to correct these inadequacies–not by destroying our present insurance system but by improving it. Rather than giving up on a system which has been developing impressively, we should work to bring about further growth which will fill in the gaps we have identified. To this end, I am recommending the following combination of public and private efforts.

1. I am proposing that a National Health Insurance Standards Act be adopted which will require employers to provide basic health insurance coverage for their employees. (Guess that answers the question of why we have an employment based system. Oops! Hey, no Walmart then either.)

2. I am also proposing that a new Family Health Insurance Plan be established to meet the special needs of poor families who would not be covered by the proposed National Health Insurance Standards Act–those that are headed by unemployed, intermittently employed or self-employed persons.
Accordingly, I propose that the part of Medicaid which covers most welfare families be eliminated. The new Family Health Insurance Plan that takes its place would be fully financed and administered by the Federal Government. It would provide health insurance to all poor families with children headed by self-employed or unemployed persons whose income is below a certain level. For a family of four persons, the eligibility ceiling would be $5,000.
(I’ll say it for Fox News: Democrat President Nixon today proposed…)

Our program would also require the establishment in each State of special insurance pools which would offer insurance at reasonable group rates to people who did not qualify for other programs: the self-employed, for example, and poor risk individuals who often cannot get insurance. Did I hear something about co-ops?)

I also urge the Congress to take further steps to improve Medicare. For one thing, beneficiaries should be allowed to use the program to join Health Maintenance Organizations. (Well it took 30+ years, but they got that: Medicare Advantage.)

…To begin with, there simply is no need to eliminate an entire segment of our private economy and at the same time add a multibillion dollar responsibility to the Federal budget. Such a step should not be taken unless all other steps have failed.
More than that, such action would be dangerous. It would deny people the right to choose how they will pay for their health care. It would remove competition from the insurance system–and with it an incentive to experiment and innovate…There is a better way–a more practical, more effective, less expensive, and less dangerous way–to reform and renew our nation’s health system.

38 years since this speech. A speech that has all the same talking points regarding a private, free market based system as we heard with Hillary Care and today. We did the employer based HMO version of private insurance after the other version (BCBS employer based) did not work including the HMO medicare experiment in this decade. We are worse off than ever by all reports from all parties. It was not “ a better way–a more practical, more effective, less expensive, and less dangerous way…”. It has failed. People are in more danger today. All other ways have failed: a no health insurance system, an employer based non-profit private system, an employer based for profit private system and privatizing a single payer, government run system. The time has come. We have met the exception that Nixon gave the nation. We can now prove or disprove that there is such a creature as the “rational consumer”.

Ehrlichman: Edgar Kaiser is running this Permanente deal for profit. And the reason that he can, the reason he can do it…I had Edgar Kaiser come in, talk to me about this. And I went into some depth. All of the incentives are toward less medical care. Because the less care they give them, the more money they make.
Nixon: Fine
Ehrlichman: …and the incentives run the right way.
Nixon: Not bad.

Here’s your Medicare Part D

by Divorced one like Bush

Time for some real numbers. This example is also an example for people to understand the need for fixing our system of paying for health care. Because, even in the senior years, the cost can bankrupt you.

My parents, 2008 adjusted gross income $43,291. $19,745 is capital gains from a one time sale of land. This land was taken by the state of RI via eminent domain law. See, Fidelity didn’t have enough land (300 acres via a low rent to the state in exchange for some jobs) if Dow Chemical was going to put a plant there. Dow never built. The land was worth around $400K on the open commercial market. They got $180K divided by 3. The land was in the family for centuries.

$15,502 in SS not taxed.

My step-father is in the nursing home. Mom is currently paying the bill because they own the house. It’s around $6500/m. He’s on a few meds. 9 to be exact.

The Plan: No deductible. $2700 in total drug costs (co-pay plus plan pay) covered before the “coverage gap”.

Total expense as of 4/30: $2804.20. Coverage Gap: $4350. Amount toward the Gap: $1098.06 Balance of TrOOP (true out of pocket): $3251.94.

After the “Coverage Gap” he enters Catastrophic Coverage. The cost is $2.40/generic, $6/brand name.

So, he’s in the nursing home. He might be able to get off of 1 maybe 2 of these if we can get him home. Still, the cost of his meds have been running $370/m. Now that he has entered the “Coverage Gap” the cost will be $700/m. That is 4.6 months of paying before the rest of the insurance kicks in sometime in September 2009.

$43,291 – $19,745 (cap gains) + 15,502 (SS) = $39,048 to live on.
$39,048 – 4350 (Coverage Gap) = 34,698.00 to live on.

Of course, some things have changed since the “crash”. $8149 of that $34, 698 was dividends. They cashed out this year. So, that leaves $26,549 to live on. We could have waited the crash out, but see, dad’s in a nursing home. Either the home takes it, or the economy takes it. Either way, it’s not there to generate money from money.

$26,549 – $5989 (property tax) – $3922 (utilities) – $3038 (Insurance) – $5230 (auto expenses) = $8370 to live on.
Last year there was $8328 in medical expenses EXCLUDING meds. I don’t expect that much this year, but there could be at least half that. Mom needs some stents for the renal arteries before her vascular system pops from the very high Bp.

Total medical, out of pocket expenses, 2008: $9484. Potential this year: $8,000 to12,000 approximately not including the nursing home costs. That is $26,680 to date. Even if he is home, there will be cost for home care help.

What does someone do who is not in their position? Of course, if the medical is as last year, they will be in the hole financially.

Health plans

Robert was hiding this link over at his Stochastic site, where he allows himself to have unsophisticated but very readable translations of Angry Bear at times. Here is the link to an analysis of McCain’s plan for health insurance. The link to Stocastic Thought is on the left sidebar.

Also in that Health Affairs posting, this attempt to deal with the Obama plan and Mark V. Pauly on the whole kit and kaboodle.

FYI on National Health Insurance

Science Friday aired a show on 12/14/07 discussing national health insurance.

Guests were:
Uwe Reinhardt James Madison Professor of Political Economy,
Princeton, New JerseyJ.
Fred Ralston, Jr Chair, Health and Public Policy
Committee American College of Physicians, Fayetteville, Tennessee
Donald Berwick President and Chief Executive OfficerInstitue for Healthcare Improvement, Cambridge, Massachusetts
Here is a real example (as of 12/17/07) of just how convoluted the payment system has become:

Just got an EOB back from Humana. I am out of network with Humana but in-network with Multiplan (b/c they bought PHCS). Humana discounted my services stating that “I am not in-network with Humana but I have accepted a discount because of another contract”. Then after this discount they applied the out of network deductible and out of network co-insurance (60%). Had front desk call Humana to find out what contract they were discounting from. Humana told us Multiplan. Called Multiplan, they said that Humana is using Multiplans fee edits but they shouldn’t be applied to this patient b/c it is not a Multiplan member. Confused? Me too. Last I heard from my Front desk was that “they” will correct it if we send: new HCFA, invoices, insurance card, and EOBs

EOB = explanation of benefits

The American Medical System – One Person’s Experience With Heart Surgery in the US… and Brazil

A week ago, my sister, while traveling in Natal, a city in Northeastern Brazil, experienced some heart trouble. Heart trouble is nothing new for her; she’s had a defibrillator in her for well over a decade now, and has undergone heart surgery a few times. Long story short, a taxi driver rushed her to the hospital, and on Tuesday she underwent heart surgery. Luckily for her, there’s a new heart hospital in Natal, so they knew what they’re doing. It also allows her to compare care under specialists in the US (she’s been through this in LA, Houston, and North Carolina) to her care under specialists in a city most people have never heard of in Northeastern Brazil.

A few interesting facts:

1. Needless to say, despite the plummeting value of the dollar relative to the Brazilian real, the cost of this surgery and everything related to the hospital stay is much, much cheaper in Brazil. (Thank goodness – her insurance company will reimburse her for most of the expenses, but since it was done abroad, she has to pay for it first and submit a bill later.)
2. My sister says that from her perspective, this surgery went more easily than the many surgeries she had in the US. In plain English, the pain, upon awakening, was much, much less, and she was up and about much more quickly. Whoever was in charge of sedation and anesthesia did one heck of a job. (I should also note – this surgery was something of an emergency – I believe each time she’s had surgery in the US, they had time to plan and the surgery was scheduled months in advance.)
3. The pre- and post- op care has been first rate. My sister uses words like “fabulous” and “incredible” to describe how she’s been treated. She’s talking about buying a place in Natal and moving there, and I suspect she’s only half joking. Maybe less than half.

Health care is more expensive and often of lower quality in the US than in developing countries like Brazil, even when you’re dealing with exotic problems which is what American care supposedly excels at dealing with. Someone tell me again about the greatness of the American medical system.