The Parlous State of American Health Insurance

Yesterday, I received the bill for my heart intervention, hospital stay, and the imaging (echocardiograms and the like) that was done before the heart work.

The raw "retail" amount was $100,000. But all my providers are in the preferred network. They agree to accept about $35,000 from my insurer. My current insurance plan has a roughly $2,000 deductible each year, and then pays 75% for anything above that. I pay the remaining 25% up to an additional amount of $6,000 per year. The most I should be out of pocket in any given year is $2,000 (deductible) plus $6,000 (co-insurance payment) or $8,000 total. (That excludes the physician's fees. I was in the catheter lab for 90 minutes for the angiogram and stenting. I was in a standard, private hospital room for less than two days, and needed no special gear or care.)

I'd already used up my deductible, and these bills exhausted my out of pocket, so my share was $5500. (If I had had to pay 25%, it would have been over $8,000.) Healthcare during the rest of the year, for expenses covered in my plan, are thus 100% paid for. (What's nice is cardiac rehab is covered, so I will pay $0 for all of those appointments.)

The bill from the hospital said, call today to see if you qualify for a "prompt payment" discount. I did so, out of curiosity. I was planning to pay by credit card, as we pay our card off each month, and get airline miles plus the float.

The very nice person in billing said, "Let me see, yes, you do qualify, and it is ... 20% off ... that's $1,100." My mouth dropped open. I said, "Really? And I can pay by credit card." "Oh, yes." I immediately paid. I had heard that if you had terrible or no health care, you could call and negotiate and paying immediately could help. But I already had the benefit of halfway decent insurance.

So that was $100,000 retail. Negotiated to $35,000. My share was $5,500. Reduced on calling and paying immediately to $4,400. (The hospital received $30,000 from the insurer, too, of course.)

If I didn't have health insurance (for which we pay $800 a month as a family, and it's a very nice individual, not group, policy), I would have faced a $100,000 bill. Well, rather, they would have sent me home to arrange a future appointment as it wasn't life threatening, and I would have had a long talk with their finance department before I was admitted for the procedure.

I'm also now incentivized to go to healthcare providers for any little thing, no matter how expensive it is to treat, so long as it's medically necessary, as I will pay nothing for it. This is the moral hazard of care in which you pay a lot and then nothing.

Explain to me how this makes sense at any level? The raw cost, the billed cost, the premiums, the rest of it. The system is designed to have as many parties interceding to make profit as possible. It is not designed to produce the best care in the world; our care is fine. It does not exceed or meet comparable developed countries with national healthcare, and we pay vastly more and have steeply increasing costs. 

An Updated AirPort Book for 802.11ac

For those of you who use Apple's AirPort base stations (Extreme, Express, and Time Capsule), you may be interested to know that I've got a revised edition out of Take Control of Your 802.11n AirPort Network  — version 3.2 of the book now covers the new 802.11ac base stations (Extreme and Time Capsule) Apple released a few months ago, the updated features in AirPort Utility for Mac OS X and iOS, and Mountain Lion's Wireless Diagnostics utility.

(We had to keep the title the same for complicated reasons of how ebooks are listed! It can be baroque. We'll update the title for the next major release after Mac OS X 10.9 and iOS 7 ship.) 

What's the book good for? If you're trying to set up a network, swap out old base stations, or add new ones, I've got step-by-step instructions on how to do those and many other common configurations. I also explain all the security options available and using attached and internal disks. The 802.11ac update brings a ton of minor changes and issues, and I run through those from the spectrum and settings' standpoints.

I've been revising this book for nearly 10 years now through every base station and software and functionality change. It's always fun to dig down and see what little improvements were made (or major overhauls), and to figure out workarounds for places Apple missed the boat. 


The book is a $20 download, and has encryption/protection (DRM): you buy it, and it's in your account forever, and you can download it as many times as you like in PDF, MOBI (Kindle-compatible), and EPUB (general ereader compatible) versions. There are paid and free updates if you own a previous edition — if you own a previous edition, you should get email from Take Control, or contact them for details about upgrades.

Here's the full list of what's new in this update! 

This update takes account of several changes that have occurred since version 3.1 of the ebook came out in 2012:

This update takes account of several changes that have occurred since version 3.1 of the ebook came out in 2012:

  • New AirPort Extreme and Time Capsule: Introduced in June 2013, these new models feature 802.11ac, a newer (still in progress) version of Wi-Fi that offers higher data transfer rates and better coverage. The shape of the base stations was also changed. 802.11ac is now mentioned throughout the ebook.
  • More support for guest networks: Guest networking can now be set up on all base stations in a network, due to a change in AirPort Utility and updated firmware released in early 2013.
  • WPS for Wi-Fi printers: A Wi-Fi–enabled printer can be simply added to a network without entering an encryption key, due to the same early 2013 firmware update. This method of adding a printer relies on Wi-Fi Protected Setup (WPS), a no-entry system for connecting devices to a Wi-Fi network. (Apple once included WPS to connect computers and some other devices, but removed it in an earlier release. The ability to connect printers is new.)
  • Wireless Diagnostics utility: The Wi-Fi Diagnostics program found in the first release of OS X 10.08 Mountain Lion has been substantially changed yet again.
  • Windows 8: With Windows 8.1 expected in October 2013, I’ve inserted directions for adding a printer and connecting to a Wi-Fi network with Windows 8.1.

Pens, genetic disease, pregnancy, hacktivism discrimination, and Trek in the Park!

Whew, the latest issue of The Magazine is out for your reading and dancing pleasure. The Editor's Note detailing the contents is free to read as always, and Lisa Schmeiser's "Look Within" is this issue's free article.

Issue 24: August 29, 2013

Up on the Rooftop

Lynn and I were at the Olympic Sculpture Park on Saturday during a rare weekend date when the kids were at her parents overnight, and we happened upon Heather Hart's remarkable The Western Oracle: We Will Tear the Roof off the Mother. It's a temporary exhibit in which the artist and a team built the roof and attic of a house as if it were sunk into one of the hills that makes up the park.

Visitors are invited to climb the roof, all the way to the top. There are some warnings and a volunteer stationed to monitor: no children under 10, no flip-flops or sandals (widely abused), and one climbs at one's own risk. Still many people were at the apex, with an unbelievable view of the water. One could also crouch down and walk into the "attic" and look through a window at the Puget Sound.

This is one of the reasons to love the park, which is part of the Seattle Art Museum. Its setting is unique; design remarkable; art and installations fantastic. But the willingness to take this kind of risk? Beyond compare. It's temporary, too. It will be torn down in October.

While we were there, we noticed something being set up under the Calder sculpture, Eagle, opposite the house. The Calder is treated as something precious, and isn't supposed to be touched or climbed on. Which is funny for me, a Yalie, given that we had a Calder out in the middle of a quadrangle, and nobody ever worried about it. This was true when Eagle was in its old location up on Capitol Hill outside the Seattle Asian Art Museum (SAM's original home).

It was apparently some sort of outdoor production of Romeo & Juliet. I looked back at the house and saw a young woman standing near the chimney on Western Oracle, and someone down below photographing her. I asked another woman with a camera watching if these were publicity stills.  

No, she said, they were shooting her daughter's senior-class photo for high school, and the photographer was a world-renowned professional and a friend of the family! They had no idea Western Oracle was there. They had come for the site, not the installation. 

Top of the world, ma. 

 I coudn't see the photographer's face, so I asked the mother, is it Natalie Fobes? Natalie is extremely well known, though more for her wildlife photography, and I'd met her years before. The photographer heard me say that, turned around, and said, no, but I worked for Natalie 20 years ago! I said, Natalie took my picture back then for 24 Hours in Cyberspace! She remembered. I didn't catch her name.

The photo Natalie took around 1996 wound up as the cover of a French novel. The publisher asked my permission, because a) there was no model release and b) moral rights in European countries give those who create and participate in art the ability to nix use of work in some contexts (usually if it's derogatory to the original work). I said, yes, of course, but please send me a copy of the book.


Focus, Bless You: Advice on Smartphone Photography

 The wonderful Kirsten McKee, a physician and photographer in the UK who happens to be married to my friend Tom (and thus I get to also enjoy her photos on Facebook), wrote this straightforward and highly useful guide to taking reliably decent photos on a smartphone, such as the iPhone.  

Kirsten shoots film (instant and developed, small and large), DSLR, and smartphone, so when she offers advice, it's across the breadth of shooting, not just one aspect or technology.

I wrote an essay called "Focus, Damn It!" aimed at freelance writers, trying to explain why a smartphone isn't typically a good choice for documentary or profile photography, because it's difficult to get the right circumstances in which an iPhone, Android, or other device truly shines. You can take great photos with a smartphone, but not all the time. The consistency is the problem.

Kirsten provides the directly complementary view about how to make the right choices and set up shots whenever possible to achieve the best possible results — and how to get inspiration, too. We are yin and yang on this and I agree with all of her advice.

For instance: 

There is nothing as distracting as a wonky picture, particularly when you’re looking at pictures arranged in grids or streams on rectangular slabs of glass. If you shoot the image straight in the first place, you won’t have to straighten it later. And the discipline of checking the horizon lines will also make you more aware of composition and symmetry.  

Read the whole wonderful bit at Mortal Muses, a site in which 10 female photographers from around the globe offer advice for all comers (not just professionals) about taking great pictures.

My Sweet Boy Ben on His Ninth Birthday

Ben turns nine tomorrow. 

I was applying sunscreen to him this morning, and noticed a tiny scar, one I know well. When Ben was one or two days old, one of his long fingernails grown in the womb scratched his face and removed a slice of skin from one cheek.

We cut the fingernails, and I thought, baby skin is the best skin in the world. It will heal and we will never see a trace of it. 

He was born via caesarean after a long, long, long few days of labor. This is when one thanks medical science and all its advancements.

Ben crying and Lynn, exhausted, singing to him. 

Mother and child were united moments after birth, in the sweet song of a baby's cries as he learns to use his lungs, previously unavailable to him for the purposes of producing sound, and the woman who incubated him singing and soothing and telling him the world he has just entered is all right because she is there. It was just after midnight that he was born, and I remember every detail.


A very happy, rather tired (kind of young looking) me with Ben. 

It did heal as a tiny, tiny scar. Whenever I see it, I remember that day when I met Ben nine years ago (shy five hours as I write this).

I was happy to meet him, just as I was Rex, after his far-easier birth (a scheduled C), in which everyone was much less exhausted until after the birth.

A recent photo of the handsome fellow.

The Magazine #23 Is Out: Bees, Nudists, and More

Another fun and complicated issue. Restaurants can't keep track of customers, nudist camps have sagging enrollment, where have the bees gone, how can you concentrate pot (it's so hard to concentrate, man), and the greatest video game sequel ever made can never be released.

Issue 23: August 15, 2013

An Insurer's "Cheap" Pharmacy Partner? Ha

Years ago, my insurance company offered a small prescription drug benefit on the plan we had as a family — $250 per year with lots of provisos about brand names and such and no co-pays. Over time, the plans changed and even the modest benefit disappeared. However, the insurer partnered with a mail-order pharmacy that, originally, offered significant discounts by using them for 90-day supplies of recurring drugs, and had negotiated deals with retail pharmacies to reduce cost for ones you had to get on the spot.

I knew the discounts weren't great, but some drugs I needed were brand name (Lipitor) and others were very cheap. I didn't price check that often, but I thought I was paying reasonable prices. Lipitor went off-patent, and the generic was much cheaper. I turned to Canada for one drug before it also went off-patent. But then I hit the wall when I had a stent put in recently.

After the diagnosis and intervention for my artery issue, I needed to add four new medications and continue one I'd started a few months ago for what seemed to be gastric issues. Aspirin is cheap. The rest vary. When I was discharged from the hospital, I went to the pharmacy, and they assembled all the meds I needed. One of the pharmacists went over all the drugs with me and said, "We gave you the discharge pricing; your insurance plan has terrible coverage." (I had technically been discharged by a different branch of the same hospital group, but the nearby one I was in didn't have Sunday pharmacy hours.) "You should really check out Costco for refills. It will be much less for many of these."

While still in my hospital room, I had priced one of the drugs, Plavix (an antiplatelet medication that keeps the stent clean): $2,500 a year for the brand name and $1,000 a year for the generic equivalent. I had a little sticker shock. Lynn said, "Don't look up the price of drugs while you are in the hospital recovering from a heart intervention." She was right.

A few days later, I did more research. My insurance company's partner, Express Scripts, offered a price that was always more (except, oddly, for one generic drug) than Costco's prices. Costco is a vast buyer, of course. And Express Scripts is enormous, too, and only handles prescriptions. It's absurd to think that a generally available generic drug should cost 10 times as much from Express Scripts than from Costco. [Update: I originally said one has to be a Costco member for these prices. That's apparently untrue. Not clear on the site.]

The total is $3928 per year for my new drugs and existing ones from Express Scripts and $953 for the identical generic drugs from Costco. (I have a query in to Costco about its Synthroid pricing, too.) I'll be sending a letter to the state insurance commissioner asking about this. The markup is absurd, assuming that Costco isn't losing thousands on my orders.

Is it legitimate for an insurer to refer its subscribers to a pharmacy that has such high prices relative to a legitimate, in-country retailer? It smells, but may be perfectly legal. I would like my insurer to require that its partners provide an up-to-date list of drug pricing databases and offer comparisons among major retailers.

DrugExpress ScriptsQtyPer dayCostco PharmacyQtyPer day
Pantoprazole (Protonix) 40mg$298.4890$3.32$21.7490$0.24
Carvedilol (aka Coreg) 3.125mg (2x/day)$156.24180$1.74$9.99180$0.11
Clopidogrel (aka Plavix) 75mg$197.8990$2.20$28.71100$0.29
Ramipril 2.5mg$130.4690$1.45$23.46100$0.23
Levothyroxine (aka Synthroid) 75mcg$22.1890$0.25$86.43100$0.86
Atorvastatin (aka Lipitor) 40mg (cut in half)$85.5390$0.95$26.4990$0.29
Montelukast (aka Singulair) 10mg$77.7290$0.86$51.9390$0.58
Yearly total$3,927.81$952.61