Illustration by Sibel Ergener

Paul Ryan Will Live to Regret Gutting Medicare

A surgeon explains why even the House Speaker needs the program he plans to destroy

Paul Ryan — what can we say about Paul Ryan? Paul Ryan is rich. Paul Ryan is young, or youngish: From a medical standpoint, 46 is fairly young. Paul Ryan is very powerful, and Paul Ryan, like most rich, young, powerful people, apparently thinks he is never going to die. Paul Ryan appears to be laboring under a misapprehension.

Alternatively, Paul Ryan is completely deluded.

It would be difficult not to arrive at the latter conclusion after reading his remarks to the Milwaukee Journal Sentinel yesterday, when he expressed his desire to “bring relief to people who are suffering from Obamacare” — i.e., by repealing Obamacare. To be fair, Paul Ryan is wealthy enough not to use Obamacare himself, so he need not think too hard about how terrifying his promise to replace it with a nebulous “something better” sounds to the millions of Americans who previously had no insurance and are now covered under the Affordable Care Act.

But Ryan also, on Sunday, reiterated his longstanding dream of privatizing Medicare, thereby making life much more difficult and expensive for senior citizens. Perhaps he thinks he’s never going to be one.

Bad news, Paul Ryan! You are one hundred percent definitely going to get old and sick, and when you do — not if you do — the high-quality, aggressive, capitalist American health-care system is going to eviscerate your bank account, unless you’ve got functional, low-copay, no-ceiling health insurance that will actually, you know, insure you.

Almost everyone I know is frightened by the specter of astronomical medical bills. People put off going to see the doctor; they put off having procedures. Things that seem like they should be cheap are not and no one knows how much anything is going to cost. As a doctor, particularly as a young surgeon, I only feel remotely less terrified of a monster bill because these people are my community, and they will figure out a way to take care of me for free if they have to. I don’t know some special way to game the system; there is none.

Of course, I don’t know very many millionaires. (I know a few. They all use their copious cash to buy extremely comprehensive health insurance.) If you have enough money, I suppose you think you can get away with anything. Paul Ryan evidently thinks that his net worth, estimated by The Seattle Times at “between $2.1 million and $7.8 million” in 2012, will be enough to protect him when he gets sick — when he gets thyroid cancer, or rectal cancer, or kidney failure. When he gets hit by a car. When his heart gives out; when his immune system rebels against him. It is not.

Remember when Lamar Odom was found unresponsive at a brothel in Nevada and transferred to Cedars-Sinai in L.A., and stayed there for months? A health-care costs expert was quoted in Entertainment Tonight saying that, “your basic hospital stay runs about $10,000 a night,” and Cedars-Sinai is not basic care. She estimated the inpatient bill at around $30,000 to $50,000 per day. Despite this, many wealthy people still opt out of commercial insurance plans, preferring to pay their bills themselves; it seems thrifty, until something terrible happens.

Look: Something terrible is going to happen. Something terrible is going to happen to all of us. It’s just that the terrible thing often waits until we are older than 65 and on Medicare — and then the government foots the bill.

One of Medicare’s most important features is its “catastrophic” coverage, which is exactly what it sounds like: Once a Medicare beneficiary has spent $4,950 out of their own pocket (according to 2017 rates), then Medicare steps in to cover all but a negligible amount of the remaining hospital bills for that calendar year.

This is very different from commercial insurance plans, many of which have “maximums” on the amount they will pay per year — and will consequently refuse to pay your $1 million medical bill. In fact, there are a lot of ways for your commercial insurance to avoid paying your bills (because otherwise your insurance company would never make any money, and that is all it wants to do).

For example, many reasonable-quality commercial insurance plans also have something called “coinsurance,” which is a percentage the insured party has to pay, usually in the 20 percent range. That means the insured party will pay 20 percent of their health care costs, whatever they are. The Affordable Care Act currently has language in place to attempt to address both of these issues—but then, we know what Paul Ryan has in mind for the Affordable Care Act.

One final thing about insurance rates: Medicare runs the show. Every American over 65 uses Medicare, because why wouldn’t they? The wealthy among them can buy additional, better commercial insurance, but when it comes to negotiating fees for services, Medicare has the most bargaining power.

The problem is that Medicare, in an effort to reduce costs, has a habit of telling hospitals that it will only pay a percentage of the fee for a given visit or procedure. Hospitals have in turn developed a habit of charging a lot more for things, so that they get the amount of money they want or need. This leads to a situation where, as The New York Times reported in 2013, a colonoscopy bill can start out at $19,438; after “insurers negotiated down the price, the final tab… was more than $3,500.” Large insurance companies will do the same thing.

This system works until you don’t have any insurance, or your insurance sucks. Using “a conservative definition,” a study in the American Journal of Medicine estimated that 62.1 percent of all bankruptcies in 2007 were the result of medical bills. The bills are the same whether they go to you or a high-end insurance company or a profoundly terrible insurance company, although you can apply for leniency if you have no money.

Paul Ryan has a lot of money. Paul Ryan seems to think that the insurance vouchers that he’d like the government to provide in lieu of the current single-payer Medicare system will be enough for patients to buy insurance that will actually help them. Paul Ryan seems to think that none of this applies to him anyway, because he is wealthy and healthy and neither of those things will ever change.

When Paul Ryan gets rectal cancer — which lots of people get, which a fair number of people his age even get — and he needs preoperative chemotherapy and radiation, and the chemotherapy includes one of the new, revolutionary VEGF or EGFR inhibitors, it will cost around $10,000 to $15,000 per treatment. He will get eight treatments, at least. The radiation, depending on the center, costs anywhere from $1,000 to $3,000 per 15-minute treatment. He will get radiation every day for six weeks. Then he will have surgery. He will stay in the hospital for days afterward, almost a week. Then he will have another few months of chemotherapy; then he will be readmitted to the hospital with dehydration, with failure to thrive, with pain and nausea. He will have an infection, maybe. Maybe he will get a drain tube put in though his skin and left there for weeks. He will recover. The drain will be removed.

Then he will have another surgery, which was always planned. Then he will have surveillance with an MRI every six months and a high-tech ultrasound colonoscopy — far fancier than the basic $19,000 colonoscopy — every six months, staggered so that one happens every three months. He will do that for one or two years. Then he will get to spread the surveillance out to biannually, then annually. He will do this for five years, at least. At the end, maybe his cancer will be cured. The survival rates for rectal cancer in the U.S. are quite good.

At the end, he will not have a lot of money anymore. Two million dollars is not enough to protect you from serious illness. Seven million dollars is not necessarily enough. Fifty million dollars is enough, but even Paul Ryan doesn’t have $50 million.

Medical professionals know the system is broken. We know. When surgeons are operating, we say things like, “No, I can work without that. It costs, like, $500.” We know that the treatment plans we create will lead to years of bills, hundreds and hundreds of thousands of dollars’ worth of bills. When a man posted on Reddit about the $1 million bill he got for a five-day hospital stay, Zubin Damania, a physician and vocal critic of the costs of the American health care system, was quoted as saying that it didn’t surprise him — “although… it is especially exorbitant. A million bucks? Those are heart transplant prices.”

They are. That’s how much a heart transplant costs, Paul Ryan.

I hope you don’t need a heart transplant.