Comments

Health Affairs encourages readers to engage in discussion via comments on our Web site.

• To RESPOND to a particular article: Click on the link "Submit a response to this article" in the box at the top right-hand corner of the article.
• To READ responses to a particular article: Click on the link "View responses" in the box at the top right-hand corner of the article.

Comments to:

David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler, MarketWatch: Illness And Injury As Contributors To Bankruptcy, Health Affairs Web Exclusive, February 2, 2005 [Abstract] [PDF] [HTML Version] [Reprints & Permissions]

Comments:Submit a response to this article

Comments published:

Freedom and Health Care

Ivan L. Appelrouth   ( 3 February 2005 )

Medical Bills

Karen S. Ehnborn   ( 3 February 2005 )

Bad Things Happen to Good People...And Then You Declare Bankruptcy

Melissa K. Gallant   ( 3 February 2005 )

Natural Energy Solutions for Health and Wellness

Sallye M. Wentz   ( 3 February 2005 )

Medically Caused Bankruptcy Tip of the Iceberg

Barbara S Lee   ( 3 February 2005 )

Medical Bankruptcy

Pamela L. Curtis   ( 3 February 2005 )

Bankruptcy and Dementia

Gary Brient   ( 3 February 2005 )

Catch 22! No Matter What You Do...

LeeAnn Smith   ( 3 February 2005 )

Medical Bankruptcy and Long-Term Care

Wayne Deslattes   ( 3 February 2005 )

Unbiased?

Kevin D. Allen   ( 3 February 2005 )

Thank You!

Elizabeth H. Schulte   ( 3 February 2005 )

Reponse to Article on Medical Bankruptcy

ANGELA M LOMBARDI   ( 3 February 2005 )

How Does Long-Term Care Insurance Figure into This Study?

Dennis D. Flynn   ( 3 February 2005 )

Call It What You Will!

David Walker   ( 3 February 2005 )

Bankruptcy-Related Policy Issues

Christopher E Press   ( 3 February 2005 )

The Reponsibility of Us All

Wendy Shutts Bender   ( 4 February 2005 )

Long-Term Care Insurance

Dennis D. Flynn   ( 4 February 2005 )

Deregulation—Bah Humbug

Richard E. Lawrentz   ( 4 February 2005 )

Understanding and Rules

Michael H. Strong   ( 4 February 2005 )

Long-Term Care Insurance Isn't Always The Answer

LeeAnn Smith   ( 4 February 2005 )

Health Care Coverage: Of What, By Whom, to What Extent?

Neil Gardner   ( 4 February 2005 )

A Good Idea Gone Bad

John J. Perulfi   ( 4 February 2005 )

Response to Bankruptcies Due to Medical Care

Blanche E Glazier, NP-C   ( 7 February 2005 )

More Research in This Area Is Needed

Donna S. Smith   ( 7 February 2005 )

AFLAC To The Rescue

Andrew Waller   ( 7 February 2005 )

A Study With Predetermined Results

George W Liebmann   ( 9 February 2005 )

Retired and Broken by Health Care Costs

Larry R Smith   ( 11 February 2005 )

Authors' Conclusion Not Supported By Study Results

Kevin C. Fleming, M.D.   ( 16 February 2005 )

I'll Take My Irony Without The Starch

James R. Mauroff   ( 1 March 2005 )

Catastrophic Care Costs That Come from Nuclear Waste Contamination Problems

Leah Eselgroth   ( 2 March 2005 )

Multiple Causes, Failure of Long-Term Disability

Marcia B   ( 15 March 2005 )

Study Creates False Impressions

Gail L. Heriot   ( 15 March 2005 )

A Cautionary Note on the Number of Health-Related Bankruptcies

Jeff Lemieux   ( 13 April 2005 )

Bankruptcy And Health: The Authors Reply

David U. Himmelstein, Elizabeth Warren, J.D., Steffie Woolhandler, M.D., M.P.H.   ( 8 June 2005 )

Freedom and Health Care 3 February 2005
Ivan L. Appelrouth, Musical Instrument Repair Tech American taxpayer Send comment to journal: Re: Freedom and Health Care ivanappelrouth{at}earthlink.net Ivan L. Appelrouth	Given our commitments in Afganistan and Iraq, freedom seems to be very much a keyword of current politics. At the same time the president proposes overhauling Social Security, he appears to lay blame for rising health care costs solely on frivolous malpractice litigation rather than point towards the institutional greed of the insurance and pharmacutical industries. The president and Congress need to understand that real freedom for all Americans starts with National Health Care. Congress can strengthen our economy by not dumping responsibility for such a system onto employers and business. Americans should take responsibility for guaranteed, affordable, quality health care through taxes and co-pays. We would expect to see a decline in frivolous litigation, and the valid awards paid out would easily be absored by the huge numbers of people paying into the system. Freed from "the bottom line" and shareholder reports, we could expect to see advances in the use of experimental and alternative medicines. We would all be free to realize our dreams for the future and not be tied to an unfufilling situation solely for the sake of receiving the "benefits." Most importantly, no person would live in fear of losing everything should they or a family member become ill. Proposed Medical Savings Accounts are not a reality for the many American families struggling to just get by. Personally, I can think of no greater assault on personal freedom taking place in this country right now.
Medical Bills 3 February 2005
Karen S. Ehnborn, Accounting Assistant Send comment to journal: Re: Medical Bills k98683{at}aol.com Karen S. Ehnborn	I had surgery in March of 2003. One week later I had open heart surgery for a blood clot from complications of my first surgery. I now have monthly blood tests and DVT scans a few times a year. My employer decided to change health plans because of the high cost of insurance. The first year all of my monthly and yearly tests were covered. I had a $20.00 copay for office visits. In 2004 my insurance changed so that I had to cover the first $1,500 of my testing. After that I had to pay 10% of the cost for the next $2,000. This year I again get to pay the first $1,500 and then I pay 20% of the costs for the next $2,500. I was told by the insurance broker that companies are going to this type of insurance because workers do not realize the high cost of medical bills. I paid out in 2004 $3,000 that I never had to pay before. My salary did not increase to cover the new costs. I have had to borrow money and have three jobs to pay for my rising health care costs.
Bad Things Happen to Good People...And Then You Declare Bankruptcy 3 February 2005
Melissa K. Gallant, Arts Educator Send comment to journal: Re: Bad Things Happen to Good People...And Then You Declare Bankruptcy mkgood2go{at}yahoo.com Melissa K. Gallant	Thank you for printing some of the results of this medical debt/bankruptcy study. I met with a bankruptcy attorney last week after deciding to file chapter 7 bankruptcy due to the extent of my medical bills. Over the last 7 years I have struggled to not only face my bipolar diagnosis, but I have been drowning in bills from hospitals, psychiatrists, doctors, labs, pharmacies, therapists, and more. It's expensive to be treated for suicidal depressions and psychotic, frightening manias (sometimes they were even "mixed" together) while the medical establishment tries to find the right combination of medications and therapy to help you function as a whole, rational person. First come the bills. Then the realization that bipolar, as a "mental" illness, is often treated as the crazy cousin of physical illness and is only paid at 50% for many of the medical services received, instead of the expected 80%. Then, I left my steady job on the grounds of "disability," which paid me 50% of my usual paycheck. I tapped out as much as legally possible from my 401K for medical hardship in order to avoid bankruptcy at that time, and I prayed for a quick turnaround of my health. That did not happen. I applied for and received Social Security Disability Benefits, which helped me limp along both mentally and financially when added to my company-paid disability. All of this time, I faithfully paid as many of my medical bills as possible, or at least made a minimum payment every month. Soon, the bills went into collections. Some of the collectors refused to accept less than $50-$100 a month, which I could not afford--unless I gave up something like food or utilities. A friend told me to continue to pay a little each month even if the companies said they wouldn't accept that little. I did...the collection agencies sent the checks back. They called constantly. I received reprint after reprint of the same bill along with new ones. I gave up trying to figure out what I actually owed to some of the medical groups. I constantly felt discouraged and I carried a weight around my neck that I knew wouldn't go away for probably decades at the rate I was paying. I wanted to pay for the services I had received, but I couldn't afford it. I had to pay outragous medical insurance premiums just in case I went into the hospital again. My company did pay the actual inpatient costs at 80/20 and I couldn't take the chance of losing that benefit. It became a lose/lose situation. Also, my credit became worse and worse. Now, my credit is so bad that I decided a bankruptcy might actually be an improvement. I have been stable on my current medications for five months, which is three months longer than any block of time in the last 7 years. I don't foresee any large inpatient expenses in the near future. It's time to throw off the weight around my neck and start over. I have nothing left to lose. And this entire financial disaster has been caused by a devastating medical diagnosis. I have zero credit card debt. I hold a Masters of Fine Arts with a major in Theatrical Directing and I have no student or personal loans. Well, actually I owe my parents several thousand dollars, but that is also related to my medical bills. I did not blow my money on anything obscenely frivolous. I do not own anything of value to anyone but me anymore except a fairly used, but very sturdy car. Oh, and the entire amount of my debt is under $15,000. This is all very similar to the statistics quoted in the study today. It's so good to know that I'm not alone and there are others that are trying to do the "right thing." And that "right thing" for us right now is to declare bankruptcy and to get on with our lives as productive, American citizens with inadequate and vastly over-rated and over-priced health insurance.
Natural Energy Solutions for Health and Wellness 3 February 2005
Sallye M. Wentz, Wellness Consultant Send comment to journal: Re: Natural Energy Solutions for Health and Wellness SallyeWentz{at}aol.com Sallye M. Wentz	The American health care system is not only broke, it is broken. And now we are experiencing personal monthly medical bills, primarily from the cost of pharmaceutical drugs, that equal or exceed mortgage payments, leading to a rise in personal bankruptcies. Medical costs are spiraling out of controal while health is on a rapid downtrend. What will it take for America to wake up to the fact that we are not chemical bodies, we are energy bodies. That is why medications can't fix us. The more we put into our body, the more we become chemical soup with the medications merely masking the symptoms and causing negative side effects, both short term and long term, while the root cause is never addressed. Once we look at the wellness puzzle as an energy challenge rather than a chemical shortage, we can find the solution. No medical condition has ever been caused by the lack of a pharmaceutical drug. Energy balancing is the answer, and natural energy technologies are the catalyst. The Japanese compnay that is the world leader in global wellness makes technologies that are simple to use to allow the body the right environment to repair and rejuvenate itself. Cost-effective as well as nontoxic, and noninvasive with no negative side effects, the benefits are powerful. Their use requires no major lifestyle change which is appealing to those seeking wellness. Isn't it time to change our paradigm and give the body the natural energies it needs to do the job it was created to do, which is take care of itself? Simple, efficient, and cost effective...a winning combination.
Medically Caused Bankruptcy Tip of the Iceberg 3 February 2005
Barbara S Lee, retired Send comment to journal: Re: Medically Caused Bankruptcy Tip of the Iceberg blee718589{at}aol.com Barbara S Lee	There are millions of other citizens who are adversely affected by these same costs. Some, like me, have used their retirement savings to care for chronically ill children, and other family members. If bankruptcy is avoided, there still may be real poverty issues because of the side effects of family illness. The social, physical and mental ramifications of paying for health care are onerous to many of us, even though one may have had good education, good jobs, and good management of resources.
Medical Bankruptcy 3 February 2005
Pamela L. Curtis, I.T. Operator Send comment to journal: Re: Medical Bankruptcy arms223{at}aol.com Pamela L. Curtis	I became financially ruined after being diagnosed with MS. Insurance co-pays and numerous prescription costs caused a great financial strain on my single-parent budget, which was already strained. The layoff from my job after filing a Chapter 13 was the final straw. Now I have no choice but to file a Chapter 7. I was always able to get by as a single parent until my health problem. All my years of hard work washed away due to medical costs.
Bankruptcy and Dementia 3 February 2005
Gary Brient, Journalist Independent Send comment to journal: Re: Bankruptcy and Dementia sgbrient{at}comcast.net Gary Brient	Do you have any statistics indicating the percentage of dementia patients that are driven into bankruptcy by their ailments. Whether they are caused by Alzheimer's, Parkinson's, alcohol, etc., almost all long-term dementia patients, unless independently wealthy, witness the annihilation of their estates. As a member of a public policy committee on the west coast for an Alzheimer's Association, I have found that almost all families with an Alzheimer's member are subjected to ultimate bankruptcy or zero balance estates. At such time, Medi-Cal (California Medicaid) becomes the alternative financing for the long-term care. Any information you have that illustrates the draconian reality of dementia and estate-loss would be appreciated. And, one further request, what say you to the following: LEGISLATION FOR THE PROTECTION OF THE CALIFORNIA ESTATE: FOR ALL PEOPLE CLINICALLY DIAGNOSED WITH ALZHEIMER’S DISEASE, HUNTINGTON’S DISEASE, PARKINSON’S DISEASE (WITH DEMENTIA), A MYOTROPHIC LATERAL SCLEROSIS, LUPUS, OR ANY OTHER DEMENTIA RELATED DISEASE NECESSITATING LONG TERM CARE, A $500,000 PRE-DEATH EXEMPTION SHALL BE ESTABLISHED FOR THE PROTECTION OF THE AFFLICTED PERSON’S ESTATE THEREBY PERMITTING FULL QUALIFICATION FOR MEDI-CAL AND FULLY FUNDED LONG-TERM CARE. Thank you for your attention; I'll look forward to a response. Sincerely, Gary Brient
Catch 22! No Matter What You Do... 3 February 2005
LeeAnn Smith, Disabled Send comment to journal: Re: Catch 22! No Matter What You Do... lsmith2660{at}aol.com LeeAnn Smith	I am writing in reference to your article on bankruptcy. I was a middle-class American, until I had to claim bankruptcy. At that point you feel like you have sunk to the lowest part of your life. My story begins as a fairy-tale romance. I found the man of my dreams, and we found love at first site. We moved in together after one month and we were married within six months. We both had very good jobs, and started with our family right away. We now have three children and have been together for 15 years. Our lives started to change when after five years of marriage, I was diagnosed with Multiple Sclerosis. I continued to work full time and continued with all of my children's extra activities for the next five years. No one would have ever known that anything was wrong with me, because I did not want to believe there was anything wrong with me, either. I was hiding my secret very well, until my balance started to change, I became extremely exhausted, I was in pain every day. Now you could see there was something wrong with me, and it seemed like everything hit at once. I was no longer able to keep a full-time job, and didn't have the energy to do it anymore. I went out on disability, and that is where our nightmare began. Disability does not start or is not approved until Social Security decides that you are entitled. It is a long and frustrating task. You think that now you can take care of yourself and your disease, because you are now home and you no longer have the stress of working or feeling sick during the day, or of coworkers who feel you are not pulling your own weight at the job. So one Catch 22 is that you want to work and keep supporting your family, but you are physically not able to do it anymore every day of the week. On the other hand, if you do stay home and try to take care of yourself, you feel worthless a lot of the time, and other people think that because your disease is not obvious by looking at you, that you are faking or just lazy. The next Catch 22 is when you call all of your creditors to let them know that you are no longer in the same financial situation and you ask if there is any way that they can help you make a payment arrangement to settle your debt. You explain how you are no longer able to work, and the $50k salary you used to get will no longer be coming into your household. You explain how all of this happened, about getting sick, trying to work but not able to do the job at 100%. You ask for help from them, and the only answer you get is "We cannot help you because you are current with your payments, we cannot help you unless your payments are late or you do not pay them." I did not want to be late or not pay my bills; all I wanted was some understanding and a payment arrangement with the balance I currently had with each of them, without adding more interest. I told them that my situation was not going to change, that I had a disease that did not have a cure, but I wanted to keep my credit in good standing. There was no one who would help us. I tried three different companies to consolidate the bills. One collected the monthly payment, but did not send any of the payments to the creditors. I asked to get out of it, and they told me that I would lose all the money I had already sent. Then within 2-3 months they went bankrupt so I lost it all anyway. Another one I tried seemed to be so helpful and friendly, until you pay the fee, then the company's phone gets disconnected. Here you are with some kind of letter writing campaign, and in the mail you are receiving letters from attorneys representing the credit card companies stating that you are going to be sued for balances, interest, and court costs. At the same time as all of this is going, on your family is now falling apart, because you don't know how you are going to buy food or keep a roof over your head. Now the credit card companies have definitely moved to the bottom of the list of people to pay. Your belief in yourself or in others really drops lower than you could have ever imagined. Especially when your family falls apart, and your husband turns to alcohol to drink away the problems. Then when you become sober again all of your financial problems are still there; you have only ruined the relationship between your wife and children. You tried to do the correct thing, by asking for help to get your debts paid, but in the end the only thing that creditors care about is the almighty dollar, and their INTEREST. Bankruptcy can make you feel embarrassed and ashamed, but when it is the only way to save your family and home, I am extremely thankful that this was available as an option. You never know what will happen in your life, and everything could be taken away in an instant. This disease and financial hardship has made me realize that the most important things in life are your husband, children, and family. The embarrassment of bankruptcy will go away in time. I am very happy to say that now my husband is sober and we are working on putting our family back to the way it used to be, without using credit cards for impulse purchases and making the banks richer with high interest payments. By the time you pay off your credit cards, you have paid for the same item you put on the card over five times. I hope my story will help someone else realize how important it is not to buy everything on credit, because you could be the next person to claim bankruptcy because of a health issue or disease you never expected. What is truly important is not money, but your family. Thank you for allowing me to share my story.
Medical Bankruptcy and Long-Term Care 3 February 2005
Wayne Deslattes Send comment to journal: Re: Medical Bankruptcy and Long-Term Care LAltc4u{at}aol.com Wayne Deslattes	If you take a real close look, I think you'll find that out of those bankrupt due to medical costs, most are associated with long-term care costs, especially among the elderly. This cost is going to explode in coming years with people living longer, more sustaining disablitites, and havng to pay $50K+ nationally for one year of care. It's no wonder many seniors who are bankrupt, it is for this reason! The easiest and best solution is long-term care insurance and a federal goverment that offers an "above the line deduction" for everyone who carries this insurance. The risks for this are great! Statistics show 40% of all people getting some kind of care now are under the age of 65! That's working-age people. Approximately 60% of those over 65 will need some kind of care before they die. This coverage is as important as health insurance, if not more, because only one out of every 15 will have a major hospital stay. We have to change the way we look at our insurance coverage. Health insurance is for short-term, acute care. For anything longer than three months, outside a hospital, long-term care coverage is a must. Our Medicaid systems can't handle more nursing home patients. What is going to happen as more baby boomers retire, live longer, and incur disabilities? How long will their money last? Can their families take off work from their jobs, live on less money, because they have to take care of a parent?
Unbiased? 3 February 2005
Kevin D. Allen, President Consolidated Insurance Agency, Inc. Send comment to journal: Re: Unbiased? kdallen{at}sbcglobal.net Kevin D. Allen	Just curious...did ANY of the respondants to your study carry ANY form of employer-provided Disability Insurance? If not, the socio-economic level of survey participants must have been on the very lowest end of the employment spectrum. Was that the case? If so, why weren't high wage earners surveyed as well? Highly paid people are just as likely (maybe MORE likely) to file bankrutcy. Were the five judicial districts (out of 77) truly representative? Or just the poorest? I don't pretend to have detailed data to prove the point, but anecdotal evidence acquired over 27 years of work in the field of business insurance has shown me time and again that many employers provide this type of protection to their employees. Even those on the lower end of the wage scale are often given a disabilty benefit. Was any of that uncovered in your work? Or did you even look? And if the worker was injured on the job, his/her income is ALWAYS replaced by a Workers Compensation benefit equal to 65-70% of average weekly wages-TAX FREE. Any data on that issue? Please tell me this was NOT another foundation-funded excuse for promoting government sponsored health care. Or was it? Lastly, what was the logic behind the Pope Gregory tale? Bizarre. That, combined with your "...Bible(s)...are exempt from (bankruptcy) seizure" line, a comment dripping with condescension, makes me wonder about your biases in areas unrelated to the study.
Thank You! 3 February 2005
Elizabeth H. Schulte, Executive Director Northern Ohio Breast Cancer Coalition Send comment to journal: Re: Thank You! lschulte{at}nobcc.org Elizabeth H. Schulte	Thank you so much for doing this study. The Northern Ohio Breast Cancer Coalition has been engaged in breast cancer advocacy for the last 4 years and began calling attention to this problem some time ago. We feel lack of health insurance and lack of a financial support system during treatment for breast cancer actually contributes to mortality when many patients delay seeking care or fail to complete active treatment and follow up care. Perhaps some day we'll have sufficient evidence to show poverty as a risk factor for breast cancer mortality. Thank you so much for this important work. It will be sent immediately to our local, state, and federal elected officials. Bless you and keep up the good work!
Reponse to Article on Medical Bankruptcy 3 February 2005
ANGELA M LOMBARDI, NA Send comment to journal: Re: Reponse to Article on Medical Bankruptcy ANGART5{at}AOL.COM ANGELA M LOMBARDI	I read your article on bankruptcy with high interest. I was wondering after your research, did you know or know how to put me in contact with any information that helps avoid this due to high medical bills. I am one of the examples used in the article where I am married, have insurance, etc., but due to medical problems (denied by disability) I can no longer afford the percentage balance of the medicines and/or the copayments considering I can easily have more than five doctor appointments a week. Can you advise? Thank you.
How Does Long-Term Care Insurance Figure into This Study? 3 February 2005
Dennis D. Flynn, Dentist Send comment to journal: Re: How Does Long-Term Care Insurance Figure into This Study? DRDNMIZP{at}aol.com Dennis D. Flynn	Actually, the title for my letter is the question I want to ask. I noticed on the Web site that 96% of the polled believe the health care system should be changed in order to cover us all. Well, that isn't going to happen because Uncle Sam is wanting to get out of the long-term care business. I live in the Commonwealth of Virginia; this week the Governor sent all citizens between 50 and 70 a letter regarding the need for us to take charge of own long-term needs. The name of the program is, "Own Your Future." Virginia is one of five states in which this pilot program is being tested. The secret to preventing bankruptcy due to debilitating illness is to purchase long-term care coverage. Remember, as my wife said to me when we were deciding to purchase, "The question in not, what if we get sick and die; the question is, what if we get sick and LIVE?"
Call It What You Will! 3 February 2005
David Walker, Currently unemployed Send comment to journal: Re: Call It What You Will! DWalker245{at}aol.com David Walker	What about us ? I am 49 years old and an unemployed, divorced single father with custody of 3 children ages 13 to 18. I am a homeowner with a large mortgage. I worked steadily for over 25 yrs and supported my family and always paid taxes. I believe in saving for retirement. However I also believe that people should have access to their money (401K) when hardship arises and have those funds available without penalty. Things were going smoothly and on plan until the year 2000. Circumstances occured in my life that would change everything. Divorce, job loss and other issues had forced me into insurmountable debt. The tax and penalties on my distributions have forced me into bankrupcy. I was unable to pay this and also support my children, keep my home etc. ... So what happens to people like me who needed that money to stay afloat until things turn around? The government took almost $40,000 that I had invested in my company stock. That money was mine, and I would not be facing bankrupcy if that had not happened. As a result, I am suffering, my children are suffering, and it appears Uncle Sam is laughing all the way to the bank. No wonder people are sick!! There's more to this, but I am sure you get my drift. Bankrupt in Florida, David W
Bankruptcy-Related Policy Issues 3 February 2005
Christopher E Press, Partner Morgan Healthcare Consulting, LLC Send comment to journal: Re: Bankruptcy-Related Policy Issues press{at}mindspring.com Christopher E Press	My remarks differ from some other correspondents who recount individual hardships that inevitably accompany bankruptcy. My comments apply to the article and policy matters. The news release I received heralded “Middle-Class Workers With Health Coverage Represent Most Medical Bankruptcies In America, Health Affairs Article Says.” Later on it reads “Most of those filings were middle-class workers…” The authors’ data in Exhibit 1 do not describe the "middle class." According to the Census Bureau, 2001 median household income was $42,228 (all races and ages). The 2001 median household income was $53,320 for 35-44 year olds, the age cohort nearer the median age of the sample (41 or 42). In 2001, 29.2% of households earned less than $25,000. In March 2001, 77.4% of the population older than age 15 was described as having attained "less than a bachelor’s degree," a description that would seem to be the same as the authors’ "at least some college education." 72.1% of the population ages 40 to 44 attained "less than a bachelor’s degree." The US home ownership rate has been above 62% continuously since 1960, and in 2001 the rate was 67.8%. Low incomes, low educational attainment, and low home ownership rates are not the middle. That is not to say that your findings aren’t important, or that members of the middle class aren't among the affected—they almost assuredly are, but the statistics that describe the bankrupt population do not describe the middle class. As to the content of the article, I could not agree more with your observation that "many health insurance policies prove to be too skimpy in the face of serious illness. We doubt that such underinsurance reflects families’ preference for risk; few Americans have more than one or two health insurance options." This suggests that people are OVER insured for rudimentary coverage (with low deductibles) and UNDER insured at the upper end ($1 million lifetime coverage). We might agree that employer-controlled health insurance is a problem and contributes to bankruptcy by a chain of unintended events: dependency on the employer for coverage; illness; loss of job; loss of insurance; heightened economic exposure; bankruptcy. As another reader has noted, going bare for disability insurance can accelerate this vicious cycle. I infer that the authors see universal coverage as a solution from the lament that "even" it might not solve the problem. The first "policy" change is that a product should not be cancelable at the moment of need. It’s like paying for a house and, upon arriving to move in, being told you can’t. When the utility of the insurance is needed, it must be available. Interstate sale of policies also merits examination. Employer-controlled health insurance is the rate-limiting barrier to creating competition and innovation in health INSURANCE that might redress these deficiencies and enlarge the market for health insurance (i.e., make it of interest to the uninsured). Such competition might open the door to an array of products that would give consumers more than "one or two...options." In no category of health care is access more limited than one's choice of insurers (federal employees excepted). We laud unfettered access and freedom of choice with respect to one's doctors, hospitals, and nurses, but not the insurer? As the kids say, "What's up with that?" Today’s health insurance paradigm prohibits anyone from owning their health insurance coverage—we all just rent it, month-to-month. This creates innumerable dislocations (and your study has added to the fund of knowledge with respect to one of them). If health insurance were available outside the company store, who knows what innovative policies would arise that extend and stabilize coverage, increase choice, reduce cost, and increase value—and reduce the likelihood of illness-induced financial ruin.
The Reponsibility of Us All 4 February 2005
Wendy Shutts Bender, Social worker Prevent Child Abuse New York Send comment to journal: Re: The Reponsibility of Us All wendysbender{at}aol.com Wendy Shutts Bender	Thank you so much for this information. We need to help our country understand this very challenging issue and relate to it in a manner that acknowledges that this is a problem for us all. This is not just an issue that affects the poor in America. Too often, I hear the response; "Why should I have to pay more, or settle for less, just to help those that don't want to work for their share." Your report offers us more information to support the fact that this is a problem for us all. It is also the responsibility of us all to make a change.
Long-Term Care Insurance 4 February 2005
Dennis D. Flynn, Dentist Send comment to journal: Re: Long-Term Care Insurance DRDNMIZP{at}aol.com Dennis D. Flynn	Dr. Himmelstein et al.: Yesterday I submitted an eLetter that said that the answer to the bankruptcy problem is long-term care insurance coverage. When I came back online to read some of the other responses to your article, I was quite taken aback by the fact that many of the respondents expect Uncle Sam to foot the bill. This is not going to happen; in fact, Medicare pays only a pittance, and Medicaid is moving toward getting out of the long-term care business. Health insurance policies were never meant for long-term care, and disability policies take care of things like the house and car payments, food, utilities and the like; they do not provide additional, sufficient funds for a long-term situation. The answer has been as close as a phone call to a long-term insurance specialist. Long-term care policies can be quite affordable, especially if you are younger than I when I took mine out at age 59--and even at my age, it was affordable because my health was still good. But one day my wife was looking at our annual retirement income and our assets, and she came to the conclusion that a long-term illness could wipe us out financially. She convinced me to buy our policies with the following comment: "Flynn, the question is not, what if one of us becomes seriously debilitated and dies; the question is, what if one of us becomes debilitated and LIVES?" The answer to preventing bankruptcy due to medical costs: long-term care insurance coverage.
Deregulation—Bah Humbug 4 February 2005
Richard E. Lawrentz, Freelance The Employment Law Center Send comment to journal: Re: Deregulation—Bah Humbug rlawrentz{at}charter.net Richard E. Lawrentz	I had to file bankruptcy due to medical bills. This is not something I ever dreamed would be necessary. It points to a larger problem, however. Since the insurance companies were deregulated we have lost real insurance. If the insurance companies lose money on the stock market, your rates go up. If you have to use your car insurance, your rates go up. There is no real "insurance" being offered. What you pay them is treated as profit with no meaningful amount being set aside to pay off claims as there was when we had regulation.
Understanding and Rules 4 February 2005
Michael H. Strong, Ordinary Person KC Dance Information Send comment to journal: Re: Understanding and Rules dancer{at}kcdance.com Michael H. Strong	This is a response triggered by Kevin from the insurance industry. Kevin, You clearly don't understand it. I have to guess that you have not been through this personally nor perhaps your friends. Most people do manage to luck out. However, you should read the letter by LeeAnn Smith, a couple of postings down from your posting. Her letter is more typical of the people I know and their situations. Honest efforts and playing by the rules don't work if you don't control those rules. Over the past 15 to 20 years I have had worse and worse experiences with insurance companies — more rule bound, rigid, unyielding, and unavailable when needed. Less human. I have begun to think the last true humans in the insurance industry and their related industries began dying out after the 60s and more noticeably into the 80s as the WWII and Korean War vets began thinning out and retiring. The people I knew were family friends and members of the community — people well known by everyday contact throughout that community. I think that was a time when the population still remembered the experience of common struggle across many classes and life situations. This sense of being together seems to have paled greatly. Instead, those who are more fortunate see others not as people with a struggle but as lesser, even less moral. In enterprises begun for human needs, the rules become merely business rules, which in turn become justified as if they were morality rules. Hardly the first time in history this has occured, but it is a dark shame each time. I think this is at the heart of the resistance to finding truly helpful and caring solutions to health care. Private solutions always have a drop-dead limit beyond which the private interest of the business does not extend, for a variety of reasons, including the loss of the business. Private interests are just that, private. A government is defined by the people within its geographic borders and should be their representative. This is the social contract which the current crew seems to have forgotten — a set of people united as human beings in common cause. As far as the challenge to the Pope Gregory XIV reference goes, I cannot imagine how one would see bias in this. I think this is an obvious example to show at least three basic ideas: 1) that anyone regardless of wealth can be wiped out, 2) that, if possible, we will expend all our treasures in desperation for a cure for catastrophe, and 3) that even if you are the very top rule-maker in your society, you can be overwhelmed by something beyond your power to make a rule to fix. If you are still in the "let them eat cake" mode, I can only hope neither you nor your friends and relatives will find themselves in a medical catastrophe - without community.
Long-Term Care Insurance Isn't Always The Answer 4 February 2005
LeeAnn Smith, Disabled None Send comment to journal: Re: Long-Term Care Insurance Isn't Always The Answer lsmith2660{at}aol.com LeeAnn Smith	For the people who think long-term care insurance is the answer, it does not always work out that way. Who at 30 years old with three young children is thinking about long-term care insurance? You are just starting your family and buying a house. I did have disability insurance through my employer, and they would only cover the short-term disability for my multiple sclerosis. Since I was not diagnosed until age 30, they looked back in my medical history and determined that this is a pre-existing condition. Because I had had different symptoms prior to diagnosis, they could not determine when the start of my medical condition began. I had optic neuritis at the age of 19, and I was not informed at that time that I had a 50-50 chance of acquiring MS, so I went with the diagnosis at that time. But the long-term care insurer determined that my disease probably started with that incident, so now it is a pre-existing condition. All the money you paid for long-term disability is lost, because no disability insurance companies will pay for pre-existing conditions. I guess the only option is for our parents the day we are born to buy us disability insurance, because insurance companies will always try to find a way to not be responsible for covering someone's disabilities or injuries. I am sure that if you bought the insurance at birth, they would figure out a way that your disability started while in the mother's womb. It seems like you are never going to win. The best option is to live every day to the fullest and enjoy life, as you never know what can happen from one day to the next.
Health Care Coverage: Of What, By Whom, to What Extent? 4 February 2005
Neil Gardner, Public health adviser Send comment to journal: Re: Health Care Coverage: Of What, By Whom, to What Extent? nginpa2000{at}yahoo.com Neil Gardner	I noticed that a few of the responses so far relate to long-term care costs and resultant bankruptcies. I agree that this is indeed a problem for some, especially the elderly, and I have absolutely no good comment here how best to handle that issue. I wish to comment on what I think most of us feel is the main health care system's mission. We hope for a system whose mission is to be there for us to help keep us or return to us a decent quality of life health-wise without decimating us financially. Because of the loss of life or quality of life that illness or injury can cause to us or our families, we rightfully wish to do everything possible to prevent loss of or restore quality to life. Most of us have no adequate knowledge (information asymmetry) of evidenced-based standards of care and the effectiveness, efficiency, or necessity of various care procedures. When bad things happen, we will do almost anything to prevent loss or restore quality of life, but can any system afford to do anything and everything for everyone? Because of this dilemma, the latest mantra is for self-directed health care through Health Savings Accounts (HSAs) and catastrophic insurance coverage. However, that does nothing to deal with the info asymmetry at the individual level, and the associated catastrophic insurance plans are not going to cover anything that the former "first-dollar plans" did not covered. In fact, HSAs make caveat emptor (buyer beware) problems even more likely, as possibly overly aggressive providers try to get these individual pots of money without any consultant, like an insurance company, to act as initial screeners of recommended treatments. There is also the continued problem of who can afford to participate in the system and what about the care for those who do not! It would therefore seem that we need ideally a systematic way to measure and describe what works and how well it works, such as viable evidence-based standards of care. Then we need a system that can provide such care where indicated to people on some basis, either to those that can pay in the end, or to everyone. The point of this article is that our current system does not provide for coverage in many areas and cases, either because people had no coverage, or the coverage was denied, or because the coverage was insufficient. If a national health system or single-payer system of basically full coverage is going to be the answer, what to cover and what not to cover will be a critical area to define and redefine so that people can get the care they need without going bankrupt. We still will have to say no to treatments that don't measure up to standards at the time even to those desperate for miracles or who want to try low-effectiveness procedures! Defining these provided treatments and what will not be provided will be a constant battle in any universal system. There will also still be the question of adequate access to care, and questions about what to allow people to spend their own money on in the health care area.
A Good Idea Gone Bad 4 February 2005
John J. Perulfi, Retired Send comment to journal: Re: A Good Idea Gone Bad jperulfi{at}earthlink.net John J. Perulfi	With the abstract seeming to portend analytical problems, there was little hope for the usefulness of the journal article. Why the change in metric from families to number of people in bankruptcy? What is your definition of "middle class"? The article, at least on line, should provide the questionnaire. The study uses mean or median values, but a more accepted method would be bankruptcy frequency by household income quintiles, which is the usual presentation of houshold income distribution. Are the readers to assume that medical debts are the only debts of the bankruptcy filers? Do the authors really think that $1,000 of medical debt coupled with, say, $20,000 of other debt causes the bankruptcy to be "medically related"? The reader can make no informed judgement because the authors provide no data regarding other debt. In general, one would expect more from educated professionals. I found the comment "even the most comprehensive plan available to us through Harvard University leaves faculty at risk for out-of-pocket expenses as large as those reported by medical debtors" to be disingenuous at best.
Response to Bankruptcies Due to Medical Care 7 February 2005
Blanche E Glazier, NP-C, Nurse Practitioner VA and Drexel Univ student Send comment to journal: Re: Response to Bankruptcies Due to Medical Care blancheglazier{at}yahoo.com.au Blanche E Glazier, NP-C	I am using citations from your study as part of a research study I am doing on whether primary care providers don't enroll their patients in programs that are for the uninsured/underinsured because they don't know about the programs, because they don't know their patients' financial constraints, or because they don't have time to enroll them in the programs or refer them to providers of the programs. Your study confirms what so many of us already know but had nothing to back up that knowledge. Your study came at the most fortuitous time for my study. I have forwarded it by e-mail to my professor at Drexel University so she can use it as a topic of discussion for Health Promotion and Health Policy and Politics classes. Thank you so much.
More Research in This Area Is Needed 7 February 2005
Donna S. Smith, Reporter Send comment to journal: Re: More Research in This Area Is Needed dsmith{at}spe.midco.net Donna S. Smith	I applaud the article written about medical bankruptcies and especially the information on the insured who end up broke. Another study is needed of how and when medical providers push insured individuals to the brink of bankrupcy with aggressive deductible and copayment collections, court actions, and garnishments. It makes it seem as though being uninsured and therefore not expected to have resources to pay would be a better option for many families. In our case, we also found that the providers associated with our only hospital/clinic system charge much more to those of us with insurance for services and equipment and say it's because the uninsured cost them so much. Having insurance is a double-whammy at best. I have a blog at hcfa.blogspot.com to discuss just these types of issues. Thank you.
AFLAC To The Rescue 7 February 2005
Andrew Waller, District Sales Coordinator AFLAC Send comment to journal: Re: AFLAC To The Rescue Andrew_waller{at}us.aflac.com Andrew Waller	Finally, empirical evidence to put the quack in the AFLAC duck. AFLAC is the leading provider of supplemental income protection, and our policies are designed to pay cash to families to avoid exactly the scenario described in this article. AFLAC is a voluntary employee benefits provider that markets supplemental policies through employers to employees on a voluntary, payroll-deducted basis. Our 8-10 products do exactly what these numbers say that people need to do, which is either save seriously (which they won't) or pay for suppplemental income protection, which will pay cash to the family to (1) offset lost income of one or both family income earners and (2) cover out-of-pocket medical expenses. We are in the reality-based financial "safety-net" business in that the reality is that most people do not have adequate savings or resources to financially survive a serious accident or illness, even with great medical insurance. We have the difficult job of explaining to people that even with both short and long-term disabilty coverage, Workers Comp, and good health insurance, people are still exposed. Thank you, Harvard and the researchers and writers, for bringing to light what we have been trying to get the duck on the commercials to say for some time now.
A Study With Predetermined Results 9 February 2005
George W Liebmann, U.S.Bankruptcy Trustee Liebmann and Shively, P.A., Baltimore, Md. Send comment to journal: Re: A Study With Predetermined Results george.liebmann2{at}verizon.net George W Liebmann	I have been a member of the panel of bankruptcy trustees in Maryland since since 1981, and have reviewed schedules and questioned debtors in approximately 10,000 cases. The methodology of the study was calculated to produce misleading results, and does not conform to my experience. I would judge that medical bills are the primary cause of bankruptcy in about 10% of cases, certainly not more than 15%. The judicial districts chosen are unrepresentative, and to describe medical costs as a "major cause" of bankruptcy where $1,000 in uninsured costs were incurred within two years of bankruptcy is an absurdity. The typical bankruptcy case today involves $25,000-30,000 in credit card debt, and the existence of $1,000 in medical costs does not justify the researchers in characterizing them as a "major cause"; this definitional decision was driven by a desire to pproduce a dramatic 50% plus result. Prof. Warren has declared her belief that debtors shold be permitted to retain a middle-class lifestyle; this skewed study reflects her mindset. There is a case for creating a new stigma-free procedure for part payment and discharge over time of medical debts, but distortion and sentimentalism will not lead to its enactment.
Retired and Broken by Health Care Costs 11 February 2005
Larry R Smith, Retired Send comment to journal: Re: Retired and Broken by Health Care Costs dsmith{at}spe.midco.net Larry R Smith	I read with great interest your study on bankruptcy. I believe it's a great start, and I hope you continue to do more studies along this line and get them to the American public. I too had to file bankruptcy in 2004 mainly because of medical bills, and I had medical insurance. I had long talks with many people before filing, including our former U.S. Senator Tom Daschle. He and several other senators signed a "Sense of the Senate" resolution to help improve our health care coverage in America, which I and others thought was a great idea. Unfortunately, due to the 2004 election results and our naive, to say the least, voters here in South Dakota, this resolution may never reach the point of further legislative action. I am now 60 years old. My working career is over, and I am on Social Security disability due to many serious health issues, including peripheral artery disease, coronary artery disease, etc. There's a catch, though. I can't get on Medicare insurance for two years, so I still have the fight of paying medical insurance. I recall 40 years ago that my medical insurance premium was $17.50 per month for excellent family coverage, and it paid 100 percent of everything the majority of the time. Now insurance premiums are $500 per month (or more), and it certainly does not cover everything. In fact, the coverage is short of covering everything by about $500 per month. I'm not a mathematician, but I calculate that 1,000 divided by 17.50 is about 57. So my medical costs are 57 times higher than 40 years ago. Even given room for inflation, my wages have not kept pace. I made about $300 a month 40 years ago. The year before I went on Social Security disability, I was making slightly less than poverty-level wages of $8.84 an hour or about $1,500 per month. Wages for me have gone up five times in 40 years while health care costs have gone up 57 times as much for me. In 1992 President Clinton said that health care and medical issues were the No. 1 priority in the nation. He turned over the issue to Hillary Clinton, and the Republicans told her to go to hell. More than 12 years later, guess what? We still have the same problem, only it's even more serious for more people. I live in western South Dakota, and we know that the wages here are poverty level or lower. If we can't make employers pay more wages, then they have to do something about the benefits or none of us can live here. I may be a bit out of the loop now, because of my age, to be able to help with health care reform, but my wife, my six children, and my 12 grandchildren are not. I hope everyone will continue to bring health care reform and problems that cause bankruptcy to the present administration, which so far has swept the health care subject off the table. Social Security reform talk seems to be dominating the domestic discussion for now, but issues of health care coverage and reform must somehow be addressed.
Authors' Conclusion Not Supported By Study Results 16 February 2005
Kevin C. Fleming, M.D. Mayo Clinic, Minnesota Send comment to journal: Re: Authors' Conclusion Not Supported By Study Results fleming.kevin{at}mayo.edu Kevin C. Fleming, M.D.	The authors offer data that may or may not support their titled contention that medical care accounts for half of all bankruptcies. It is unlikely that any single person or family could manage the enormous bills arising from an illness, leading to bankruptcy in some. However, as many responses have already suggested, the data offered in this study do not support the conclusion that the bankruptcies studied here arose due to medical expenses. The very definition of "medical bankruptcy" in this study is a poor one, including gambling and alcoholism, and met by "noncatastrophic" medical expenses of just $1,000. In addition, at the end of the article the authors add, "The low rate of medical bankruptcy in Canada suggests that better medical and social insurance could greatly ameliorate this problem in the United States." This conclusion is only one of several options, however. While it is true that few individuals would be bankrupted by medical care when the government pays for health care, recent experiences with Medicaid (e.g. Tenncare) demonstrate that government management of all health care may instead bankrupt an entire state. Instead, the study, however flawed, might have concluded that (a) all persons should be required to have catstrophic medical coverage or (b) the "stop at nothing" approach to medical diagnostics and therapy is too costly, and people may have to settle for a range of options by cost, similar to the range of choices available for food, shelter and clothing. This is clearly demonstrated in the reference to the pauperization of Pope Gregory XIV. Even with such riches available, he spent away his own wealth, and the Church's wealth as well. It's an old lesson: one can always outspend one's income.
I'll Take My Irony Without The Starch 1 March 2005
James R. Mauroff Send comment to journal: Re: I'll Take My Irony Without The Starch jmauroff_02{at}comcast.net James R. Mauroff	There is no middle class; many Americans are living beyond their means (for a variety of reasons); and too much economic activity, hence profit, is in health care. Furthermore, any significant shift in any direction could break the economy. To debate this study's methodology and conclusions overlooks the real question: How many of us are just one illness away from poverty?
Catastrophic Care Costs That Come from Nuclear Waste Contamination Problems 2 March 2005
Leah Eselgroth, n/a Send comment to journal: Re: Catastrophic Care Costs That Come from Nuclear Waste Contamination Problems leah.eselgroth{at}comcast.net Leah Eselgroth	Thank you for publishing the report on the effect of health care costs as a factor in emerging bankruptcies. I honor the authors’ courage and integrity for bringing this problem to the media’s attention. And I thank you for publishing this report so all Americans can become more enlightened. Like many of your respondents, I too suffered an unplanned accident with serious economic repercussions. As a former resident of Richland, Washington, who lived near the Hanford Nuclear Reservation, I became exposed to radiation leaks that contaminated the surrounding air, water, and soil. This radiation poisoning ran havoc with my body and put me in the hospital for almost a year, followed by 6 additional hospitalizations of shorter duration. I lost my job, income, savings, and home. Friends lovingly opened their home to me, and I used their guest room as a home base of operation, until I could return to work and get my own place again. I got a new job in Boston and worked successfully for a few months when 9/11 happened. As you know, the stock market was seriously impacted, and this forced many firms to downsize to compensate for lost investment income. I lost my job. The stress from this loss of employment, coming as it did within my overall recovery, generated a relapse, and I could no longer return to work. My attorney suggested that I apply for Social Security Disability benefits, and they were granted to me about 14 months later. During the period I had to wait for SSDI to become available, I was forced onto welfare and received $338.00 a month plus food stamps. I had some debt in place, a car loan, auto insurance premiums, and minor credit card debt. So when this relapse occurred I was in danger of losing my car, my credit worthiness, etc. I have been blessed in having a couple of church-based organizations share their benevolence fund with me, helping me to stay afloat. But it’s a horrible situation to be in, to have to rely on charity in order to eat, have a place to live, etc. It requires great humility and forgiveness. The SSDI benefit I received was $806.00 a month with no food stamps. I have continued to apply for and receive benevolence as needed. I hope to return to work, but I can’t do that quite yet. Litigation is pending regarding the Hanford contamination problem. I am one of about 4,000 plaintiffs injured. It takes time to move through the court system. I’ve learned a great deal from this tragedy. I think our federal system of SSDI benefits needs serious revamping. I think the state welfare system needs serious revamping too. How can anyone live on $338.00 a month and maintain the very basic necessities needed in order to regroup in dignity? What wisdom and intelligence led to this conclusion? With the wealth our country embodies, and with its ability to fund a war of choice, not of necessity, this system should be embarrassing to everyone. If it were not for the church based benevolence I have received, I would have been forced into bankruptcy. I anticipate a generous settlement, but how do I live from day to day until that is realized? The pressure and indignity I live within each day is ntolerable. No one should have to experience this. My hope is to bring the media’s spotlight on this very serious problem. Thank you again for all you are doing.
Multiple Causes, Failure of Long-Term Disability 15 March 2005
Marcia B, Disabled Send comment to journal: Re: Multiple Causes, Failure of Long-Term Disability marcia_bcd{at}yahoo.com Marcia B	Looking at the result of the study, although the authors seemed to differentiate between types of medical causes of bankruptcy, I am not sure that they accounted for multiple causes that are medical and nonmedical. If I was filing today, and seriously am thinking of doing so, I don't know how I would have answered the survey. My story is that my husband and I were both in professional positions in health care, with a household income of about $100,000. I became ill 12 years ago and had to leave work on short-term disability. I was exhausted all the time, but tried to go back to work after 6 months. I tried all sorts of alternative arrangements, but they didn't work -- I couldn't do the job anymore. My eventual diagnosis was chronic fatigue syndrome. I went back out on short-term disability, and after 6 months, I believe, my long-term policy, for which I had been paying about a dollar a week, kicked in. Very shortly after the long-term disability began, the insurance company forced me to apply for Social Security disability, and after two years, tried to get me off its rolls, stating that chronic fatigue syndrome wasn't covered beyond that. Although I fought it, they had "experts" that felt I didn't have enough documentation, and dropped me. I knew from groups on the Internet that it wasn't worth it to fight them -- they have very well known reputations for skillfully trying to "catch" people doing things they said they couldn't do. For instance, a person carrying a bag of groceries will be deemed "capable of carring 5 lbs or more on a sustained basis" and thus able to work. Another point is that many long-term policies are for return to work in your profession, whereas with Social Security, it is any type of work. So even though I am highly educated, if I can type, all things being equal, I can be deemed capable of working. Back to my story. Meanwhile, my husband had increased his drinking, and continued to spend like we had the same income as before. Between him and my disability, we were now down to about $60,000 per year. To keep up the mortgage, etc., I started buying groceries and monthly items with credit cards. First I paid everything off each month, as usual. Then as cards started maxing out over a couple of years, I paid the minimums every month. Because we had great incomes before, we had great credit lines -- $25,000, $10,000, etc. My husband could not handle my illness and the financial implications; we separated four years later. Things dragged for a year; then we both retained lawyers -- more money. Then in the middle of the divorce, he filed for bankruptcy. All the joint debts went to me, and there was nothing I could do about it. So here I am on Social Security, still trying to pay off these debts. No one will give me any credit, as his bankruptcy is forever linked with my name. So I have been trying to do the right thing, but I can't climb out of this pit. He was supposed to pay me for his share of the debts, but he left the state, and although I have a judgment against him, I would have to hire marshalls to bring him back. So even though we started off as a professional couple, once one thing happens, it is like a stack of dominos. If one thing happens, sometimes it is recoverable. After two or three, it is nearly impossible to turn back. The three take-home points of all this are: (1) What the article does not seem to mention is that there might be multiple causes for bankruptcy, as catastrophic illnesses affect not only you but others in your environment; (2) it does not happen to just working- or middle-class people; and (3) having a long-term disability policy, as someone suggested, sounds more protective than it really is. That being said, I am very glad this article was written. It makes me feel more validated, and maybe not feel so bad if I am forced to apply for bankruptcy myself.
Study Creates False Impressions 15 March 2005
Gail L. Heriot, Professor of Law University of San Diego Send comment to journal: Re: Study Creates False Impressions gheriot{at}sandiego.edu Gail L. Heriot	A study touted by its authors as evidence that “[a] broken health care finance system is bankrupting middle class America” [See Harvard Law School web site] should be about bankruptcies caused by medical bills. This one is not; it is about bankruptcies that the authors somehow considered to be medically related. But that is just the first of many concerns that a careful reader might have after reading it. In arriving at their conclusion that half of all bankruptcies have a “medical cause,” the authors include in their definition of bankruptcies with a “medical cause” several dubious case categories, including bankruptcies caused by chronic gambling and alcohol or drug addiction as well as bankruptcies in which the debtor had paid more than $1,000 in medical bills over the course of the two-year period leading up to the bankruptcy (regardless of whether the debtor himself or herself considered those bills to have caused the bankruptcy). That’s only $500 a year –- hardly an unusual sum for a family and not indicative of "[a] broken health care finance system.” Many families no doubt spent even more than that on groceries. Yet it would be misleading to say that their bankruptcies were caused by groceries. As a result of the broad definition of “medical cause,” the reader is left with a false impression about how frequently crushing medical debt leads to bankruptcy or illness or injury leads to bankruptcy.
A Cautionary Note on the Number of Health-Related Bankruptcies 13 April 2005
Jeff Lemieux, SVP, Center for Health Policy and Research America's Health Insurance Plans (AHIP) Send comment to journal: Re: A Cautionary Note on the Number of Health-Related Bankruptcies jlemieux{at}ahip.org Jeff Lemieux	This paper tackles an important and troubling issue: personal bankruptcies caused by or related to an underlying health issue. However, the authors made many assertions and leaps of logic that were unjustified by their research, especially in subsequent statements to the media. The authors' research showed that roughly 50 percent of the bankruptcies they studied had some sort of health issue as a contributing or associated factor. However, the research did not support the conclusion that these bankruptcies were "caused" by medical issues, let alone that they were "caused" by medical debts. Nevertheless, the authors' summations, choices of terms (like "medical bankruptcy"), and press statements clearly tried to create an impression that half of personal bankruptcies were caused by medical debts, and that insufficient health insurance was to blame. They pointed to the peer review process at Health Affairs for justification. As an occasional reviewer for Health Affairs, I think this episode provides an example of how the peer review process can be misused. Authors have the ultimate responsibility to characterize their research accurately. It raises a very difficult question: In extreme cases, should the journal or its volunteer reviewers publicly rebut authors who attempt to use the journal's peer review process as validation for unjustified publicity statements? In this case, the mismatch between the research and the press statements seems very obvious. First, the authors' definition of a health issue was very broad, ranging from uncovered medical bills over $1,000 within the last two years, to a two-week loss of work-related income due to illness or injury, to simply citing illness or injury as a "specific" reason for bankruptcy. In fact, the authors stretched this already broad definition to include birth of a child, death of a family member, addiction, or uncontrolled gambling in order to boost the percentage of “medical” bankruptcies over the media-critical threshold of 50 percent. Second, the fact that a health issue was associated with a bankruptcy does not indicate causation. The authors declared that any bankruptcy with one of these health issues present constitutes a "medical bankruptcy." This is a highly misleading characterization. Instead, the authors could have asked households if they had tax liens over $1,000 within the last two years, or credit card debts over that amount. Would they then have defined those bankruptcies as "tax bankruptcies" or "credit card bankruptcies?" Would households reporting a divorce or separation within the last two years have been declared "marital bankruptcies?" The authors never demonstrated that a health issue was the primary cause of bankruptcy rather than simply one factor associated with it. They failed to examine other critical factors that could lead to bankruptcy -- such as lack of savings, divorce, overspending, other family needs, or unemployment unrelated to health -- and they did not ask respondents to rank the relative contribution of various factors to their bankruptcy. The authors noted that even people with health insurance had so-called medical bankruptcies. Then they made another unjustified logical leap: that inadequate health insurance must be the cause of these bankruptcies. Yet the authors also noted that debtors' "out-of-pocket medical costs were often below levels that are commonly labeled catastrophic." Of course, if the real reason for many of these bankruptcies was a sudden loss of income and lack of savings, it really doesn't matter whether a household had health insurance -- their debts were still going to pile up. It seems fair to assume that many personal bankruptcies are triggered by a sudden loss of income, as the authors acknowledged near the end of the article. This loss of income could result from job loss, illness or injury, business failure, childbirth, divorce, alimony or child-support problems, caring for a sick parent or relative, or any number of root causes. The U.S. savings rate is low, and many households have significant mortgage, credit card, and auto loans without much savings to cushion a sudden income loss. A loss of a job or income can make health coverage seem like a luxury. Moreover, health insurance is usually associated with employment -- when workers are unemployed and can no longer rely on employers to help pay for health coverage, the full cost can be quite a shock. Clearly, higher rates of disability coverage are needed. The nation also needs a robust program of "transitional health coverage" for unemployed workers. People with a sudden loss of income need help maintaining their health insurance coverage. But this research article does not come close to supporting the implication that half of all bankruptcies are caused by medical debts. The authors' protestations to this effect are not valid -- despite the peer review process at Health Affairs -- and their recommendation for a no-copayment, single-payer health system does not follow logically.
Bankruptcy And Health: The Authors Reply 8 June 2005
David U. Himmelstein, Associate Professor of Medicine, Harvard Medical School, Elizabeth Warren, J.D., Steffie Woolhandler, M.D., M.P.H. Send comment to journal: Re: Bankruptcy And Health: The Authors Reply dhimmelstein{at}challiance.org David U. Himmelstein, et al.	Several of the letters poignantly recount experiences akin to those we encountered in interviewing families suffering medical bankruptcies. We have been overwhelmed by a flood of similar stories in e-mail, phone calls, and letters that were sent directly to us. A few correspondents parrot critiques that have been circulated by a network of conservative politicians and think tanks seeking to discredit our study and justify the indefensible bankruptcy reform bill passed by Congress at the behest of the credit card industry. We would respond in the following manner: Our study was based on a survey of 1,771 families filing for personal bankruptcy in five states. We also examined the detailed court records for each of these filings and completed in-depth follow-up interviews with 931 families. This is by far the largest and most comprehensive study of medical bankruptcy ever carried out. We found that illness and/or medical bills contributed to about half of all bankruptcies, involving about two million people in 750,000 families in 2001. Let’s be clear from the outset: Every number, every percentage, and every variation in how to interpret the data that the critics seize upon in attempting to dismiss our work came from the paper itself. We concealed nothing, reporting detailed breakdowns in the numbers precisely so that others could draw their own conclusions about what constitutes a medical bankruptcy. Drs. Himmelstein and Woolhandler have each published more than seventy scientific articles in leading medical journals and are senior faculty at Harvard Medical School. During twenty-five years of academic scholarship they have published numerous controversial findings, yet no important scientific or data error has ever been found in their research. Professor Warren holds an endowed chair at Harvard Law School, is the author of more than 100 books and articles, and is the leading legal researcher on bankruptcy. She was appointed Chief Advisor to the National Bankruptcy Commission by Chief Justice Rehnquist. Despite the fact that her work has often angered a well-financed credit industry, no one has every found an important scientific or data error in her work, either. Dr. Deborah Thorne, a sociologist from Ohio University, also has a sterling record on her data work. While the authors hold strong opinions on social policies, they receive no financial backing or other reward from any corporate or other interest with an axe to grind on these issues. Press releases regarding the article were issued by Health Affairs, Harvard Medical School, and the Cambridge Health Alliance (the Harvard-affiliated hospital where Drs. Himmelstein and Woolhandler practice), and the research was featured on the home page of Harvard University and Harvard Law School. All press releases included a Web address for the full article and reported the finding accurately. The press releases, as do virtually all such press releases, included quotations from the authors interpreting their findings. The five judicial districts studied were chosen to be representative nationally on the basis of geographic distribution, a selection of states with high versus states with low bankruptcy filing rates, and states with more stringent versus less stringent rules about exempt property (i.e., how much home equity is protected in bankruptcy). The statement that these venues were chosen based on where judges would cooperate (as Heriot stated in a critique on her organization’s Web site) is untrue. Moreover, the demographic profile of the sample surveyed was closely matched to the demographics of bankruptcy filers nationally. Liebman’s claim that our sample is unrepresentative is not backed up by anything but his own opinion. Cluster sampling of the type used in this study is a standard method used in survey research, and extrapolation from such samples is a common practice, employed by the National Center for Health Statistics, among others. The extrapolation method assumes that medical bankruptcy accounts for the same share of all bankruptcies in each state -- an assumption warranted by the uniformity actually observed across the five states studied. However, the wide state-to-state variability in overall bankruptcy filing rates is incorporated into the estimates for individual states (estimates that were provided to the press). The methods used to make the estimates were clearly explained on the table in question. Some critics dispute our definitions of medical bankruptcy. One could quibble about a few of the cases we classified as medical bankruptcies. Some may want to eliminate the families that bankrupted themselves providing rehabilitation treatments for a drug-addicted child or a woman filing for bankruptcy after her husband sunk the family with uncontrolled gambling debt (a condition classified as a psychiatric illness by the American Psychiatric Association). These cases have little effect on the overall numbers. The vast majority of cases are very clear. Moreover, many people ruined financially by medical care do not file for bankruptcy because they are too sick, destitute, or demoralized to go through the lengthy legal process of bankruptcy. Hence, our study likely underestimates the financial toll of illness and injury. Some complain that we used too broad a definition of medical bankruptcy –- including uncontrolled gambling, drug addiction, alcohol addiction, birth or adoption of a child -- falsely classifying many people as medically bankrupt who were not. In fact, we used two different definitions of medical bankruptcy. One was a relatively expansive one that included these items because many people do consider a family that bankrupts itself putting a teenager through extended rehabilitation, for example, as a medical bankruptcy. But the paper also include a more constricted definition that virtually all reasonable people would classify as indicating a medical cause of bankruptcy. Interestingly, the two definitions did not yield very different results -- 54.5% were classified as medically bankrupt using the broader definition and 46.2% using the stricter definition -- because most of the cases were completely clear. Of course, both of these results –- and detailed breakdowns that allow readers to make their own assessments of each of the contributors to medical bankruptcy -- are clearly stated in the paper. No matter how the data are cut, they show that a broken health care system is bankrupting middle-class America. As we stated in our paper, survey research in this area is complex. Many of the debtors we surveyed listed things like “aggressive collection efforts by creditors” or “may lose home” as the immediate reasons for their bankruptcy. Yet, an illness or injury had piled up the medical bills that triggered the aggressive collection effort or the fear of losing their home. A number of debtors had taken out second or third mortgages on homes in order to pay medical bills, yet did not cite illness as the reason for their bankruptcy in our initial survey. (Indeed, 15% of all debtors who had taken out second or third mortgages had done so in order to pay medical bills). In such cases, it is clearly correct to classify a bankruptcy as triggered by illness. Lemieux argues that people reporting more than $1,000 in out-of-pocket medical bills in the past two years should not necessarily be considered to have undergone medical bankruptcies, and wonders how people without recent high out-of-pocket expenditures could be classified as medically bankrupt. First, most people who had more than $1,000 in medical bills also gave other answers that would have classified their bankruptcy as “medical” regardless of their answer to this question -- e.g., they had taken out a mortgage to pay medical bills. Second, many debtors had struggled with debts for years before seeking bankruptcy protection. Medical debts incurred more than two years before filing for bankruptcy would not show up in our assessment of recent medical debts. Third, it became apparent from our in-depth interviews that many individuals with large expenditures for prescription drugs had not included these under the rubric “medical bills” when responding to our survey. Moreover, the average out-of-pocket costs of $11,854 that we found indicates that most families had incurred far more than $1,000 in out-of-pocket costs Contrary to Press’s assertion, our debtors’ educational attainment was virtually identical to that of the average American adult (52.6% had attended at least some college in 2003, according to The Statistical Abstract of the U.S., vs. 55.8% of medical debtors). While home ownership rates in our sample were modestly below the nationwide average, more than half of the debtors in our sample were homeowners. Debtors’ occupational prestige scores, closely indicative of their position in society, place them squarely in the middle class. The fact that income in our sample was substantially lower than the national average reflects the setbacks that led to bankruptcy (e.g. illness that caused job loss), not their class status before the onset of financial disaster. Data from Canada, where medical bankruptcy is rare, argue convincingly that universal, comprehensive coverage does indeed cut medical bankruptcy rates. Moreover, Canadian employers spend far less on health benefits than do their U.S. counterparts. Indeed, in our paper we called for the severing of the link between health insurance and employment, because too often illness leads to job loss and consequent loss of coverage. In sum, our paper presented the first in-depth data on medical bankruptcy and included sufficient detail to allow other scholars to assess the severity of the problem. One can debate the precise number of bankruptcies that are attributable to illness and injury, but our data leave no doubt that it is very large. Moreover, surveys on medical debt carried out by the Commonwealth Fund and the Henry J. Kaiser Family Foundation indicate that our figures are very conservative. For example, a Commonwealth Fund survey released January 27 found that at least 14% of all working-age adults (26 million people) had been contacted by a collection agency about medical bills within the past year; one-third (60 million) reported problems paying medical bills. Such surveys demonstrate that a huge number of American families are saddled with unaffordable medical bills that leave them stressed financially and afraid to seek the care they need. Only a small fraction of these families ever file for bankruptcy. Many more face financial ruin without the protections of the bankruptcy system. No matter how you slice it, huge numbers of people -– most of whom have coverage -- are being bankrupted by illness and medical bills. This, and the incontrovertible evidence that millions of Americans don’t get care because they can’t afford it, argue persuasively that our current health care system is broken and that we need new solutions. Ad hominem attacks cannot make these facts go away.